Rurality, racial marginalization, and severe maternal morbidity risk in California, 1997-2019.

Abstract

The compounded impact of racialization and rurality on risk of severe maternal morbidity (SMM) remains underexplored. We aimed to examine how residence in rural neighborhoods may shape differential SMM risk by racial marginalization. Data were from all live births in California born at 20-45 weeks' gestation between 1997 and 2019 (N = 10,681,950). Census-tract (neighborhood) rurality was defined using Rural-Urban Commuting Area codes. We used race/ethnicity stratified generalized estimating equation models accounting for neighborhood clustering, sociodemographic factors, clinical characteristics, and neighborhood poverty to estimate risk ratios (RR) of SMM comparing those residing in rural versus urban neighborhoods. Population attributable fractions (PAF%) were also calculated to estimate the contribution of rural residence to SMM risk. Residing in rural compared to urban neighborhoods was associated with increased risk of SMM for each racial/ethnic group in fully adjusted models. Associations were strongest among Pacific Islander individuals (RR = 1.63; 95% Confidence Interval (CI): 1.19,2.24) and weakest among White individuals (RR = 1.04; 95% CI: 1.00,1.09). The highest PAFs were observed for American Indian/Alaska Native (PAF% = 6.30; 95% CI: 2.01,10.63) and Pacific Islander (PAF% = 1.84; 95% CI: 0.43,3.32) individuals. Findings highlight the need for targeted interventions that alleviate rural-urban disparities in maternal health within the context of racial marginalization.