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


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 scorewere 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: Ourfindings 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)
Article numberjech-2020-214260
JournalJournal of epidemiology and community health
StateAccepted/In press - 2021

Bibliographical note

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


  • health inequalities
  • infant mortality
  • urbanisation

PubMed: MeSH publication types

  • Journal Article


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