Racial Disparities in Pregnancy-Related Mortality across Different Classification Systems of Rurality/Urbanicity Open Access

Abstract

Objective: A retrospective cohort study was conducted to determine whether the racial disparity

in pregnancy-related death varies between rural and urban areas and whether there is interaction

between race and rurality, based on different classification systems of rurality and urbanicity.

Methods: Data on pregnancy-related deaths from 12 states participating in the Maternal

Mortality Information Application (MMRIA) were abstracted. Data on live births in states and

years where pregnancy-related deaths occurred were obtained from NCHS natality records. 2013

NCHS Urban-Rural Classification Scheme for Counties, the 2010 U.S. Census County Codes,

and the 2013 USDA Rural-Urban Continuum Codes, were used as the basis for assigning ruralurban

designations to counties. MMRIA data, NCHS natality records, and county designations

were linked by FIPS codes. Negative binomial generalized estimating equation (GEE) regression

models were fit separately to compare incidence density ratios (IDRs) for non-Hispanic black vs.

non-Hispanic white women and estimate the interaction between race and rurality.

Results: The adjusted IDR for pregnancy-related death among non-Hispanic black women

compared to non-Hispanic white women was similar for the USDA classification, moderately

higher for rural compared to urban counties using the NCHS classification, and higher for rural

compared to urban counties using the U.S. Census definition. The interaction between race and

rurality was significant for the model using the U.S. Census definition but not for the NCHS and

USDA definitions.

Table of Contents

Chapter I. Literature Review.........................................................................................................1

Maternal Mortality in the United States ........................................................................................1

Measurement: NVSS ...................................................................................................................1

Measurement: Pregnancy Mortality Surveillance System ..............................................................3

Measurement: Maternal Mortality Review Committees ..............................................................4

Causes of Maternal Mortality/Risk Factors .................................................................................5

Racial Disparity in Pregnancy Outcomes .....................................................................................6

Rural /Urban Continuum ............................................................................................................10

Chapter II: Manuscript ...............................................................................................................15

Introduction ................................................................................................................................15

Methods ......................................................................................................................................19

Data Sources ......................................................................................................................19

Statistical Analysis .............................................................................................................22

Results ........................................................................................................................................23

Discussion ..................................................................................................................................24

Chapter III: Discussion ...............................................................................................................27

References .....................................................................................................................................31

Tables ............................................................................................................................................35

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	Racial disparity Rurality/urbanicity Maternal mortality
Committee Chair / Thesis Advisor	Michael Kramer, Emory University

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