Structural racism, racial inequities and urban–rural differences in infant mortality in the US

Dovile Vilda, Rachel Hardeman, Lauren Dyer, Katherine P. Theall, Maeve Wallace

Research output: Contribution to journalArticlepeer-review

24 Scopus citations


BACKGROUND: While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban-rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas.

METHODS: Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013-2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR.

RESULTS: In urban counties, structural racism indicators were associated with 7%-8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism.

CONCLUSIONS: Our findings highlight the complex relationship between structural racism and population health across urban-rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

Original languageEnglish (US)
Pages (from-to)788-793
Number of pages6
JournalJournal of epidemiology and community health
Issue number8
Early online dateJan 27 2021
StatePublished - Aug 1 2021

Bibliographical note

Funding Information:
Funding This study was supported by Robert Wood Johnson Foundation Center for Health Policy (Interdisciplinary Research Leaders program), Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD092653) (R01HD096070) and National Heart, Lung and Blood Institute (R01HL085631) (R01HL085631-S2) (R01HL085631-S3).

Publisher Copyright:
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.


  • health inequalities
  • infant mortality
  • urbanisation


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