Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

Bridget Basile Ibrahim, Julia D Interrante, Alyssa H. Fritz, Mariana K Tuttle, Katy Backes Kozhimannil

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample’s (n = 93) median SVI score [IQR] was 0.55 [0.25–0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88–0.98] compared with 0.38 [0.19–0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13–0.97), midwifery care (aOR 0.35, 95% CI 0.12–0.99), doula support (aOR 0.30, 95% CI 0.11–0.84), postpartum support groups (aOR 0.25, 95% CI 0.09–0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01–0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.

Original languageEnglish (US)
Article number1077
Issue number7
StatePublished - Jul 2022

Bibliographical note

Funding Information:
The authors gratefully acknowledge assistance from the American Hospital Association in supporting outreach to rural hospitals in this study. The authors appreciate input from the University of Minnesota Rural Health Research Center Expert Workgroup and the rural hospital administrators and clinicians that participated in pilot testing. None of these individuals or organizations received financial compensation for their input. The authors also appreciate research assistance from Mary Gilbertson, MPH and Phoebe Chastain as well as data collection support from Maria Bertrand, MPH. Gilbertson, Chastain, and Bertrand are affiliated with the Rural Health Research Center, University of Minnesota School of Public Health, and received salary support from the above-named grant (Cooperative Agreement No. 5U1CRH03717).

Funding Information:
The authors declare no conflict of interest. Kozhimannil, Interrante, and Tuttle reported support from the Health Resources and Services Administration PHS Cooperative Agreement No. 5U1CRH03717. Kozhimannil and Basile Ibrahim reported support from the National Institutes of Health National Center for Advancing Translational Sciences, grant UL1TR002494.

Funding Information:
This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS) under PHS Cooperative Agreement No. 5U1CRH03717. This research was also supported by the NIH National Center for Advancing Translational Sciences, grant UL1TR002494. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Publisher Copyright:
© 2022 by the authors.


  • birth
  • breastfeeding
  • evidence-based care
  • health equity
  • infant mortality
  • maternal health inequities
  • maternal morbidity
  • maternal mortality
  • midwifery
  • obstetric
  • rural
  • social vulnerability

PubMed: MeSH publication types

  • Journal Article


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