Assessing the relationship between census tract rurality and severe maternal morbidity in California (1997-2018)

Rachel L. Berkowitz, Peiyi Kan, Xing Gao, Elleni M. Hailu, Christine Board, Audrey Lyndon, Mahasin Mujahid, Suzan L. Carmichael

Research output: Contribution to journalArticlepeer-review


Purpose: Recent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census-tract level. This study assessed the relationship between census-tract-level rurality and SMM for birthing people in California. Methods: We used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural-Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2-category) and at 4 levels (4-category). Covariates included sociocultural-demographic, pregnancy-related, and neighborhood-level factors. We ran a series of mixed-effects logistic regression models with tract-level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines. Findings: Of 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2-category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4-category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%). Conclusion: The observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality-related inequities in the risk of SMM.

Original languageEnglish (US)
JournalJournal of Rural Health
StateAccepted/In press - 2023


  • health inequities
  • morbidity
  • neighborhood
  • rural
  • severe maternal

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


Dive into the research topics of 'Assessing the relationship between census tract rurality and severe maternal morbidity in California (1997-2018)'. Together they form a unique fingerprint.

Cite this