Trends and Differences in Infant Mortality Rates in Rural and Metropolitan Counties in the United States, 2021-2023

NCHS Data Brief No. 534, July 2025

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Danielle M. Ely, Ph.D.

Although infant mortality has declined in the United States over time, previous research shows that differences persist across geographic areas and by maternal and infant characteristics (1-6). An earlier report based on 2014 vital statistics data examined differences in infant mortality by urbanization level (1). This report presents trends in infant mortality among rural, small and medium metropolitan, and large metropolitan counties in the United States from 2014 through 2023, and infant mortality rates by age at death, mother's age, and maternal race and Hispanic origin for combined years 2021-2023.

Keywords: maternal age; race and Hispanic origin; urbanization level; National Vital Statistics System

After declining in all urbanization levels from 2014 to 2020, infant mortality rate trends varied from 2020 through 2023.

• In large metropolitan counties, the infant mortality rate declined 10% from 2014 to 2020, from 5.44 infant deaths per 1,000 live births to 4.91. The rate then increased 5% from 2020 to 2023 (5.13) for an overall decline of 6% from 2014 to 2023 (Figure 1, Table 1).
• In small and medium metropolitan counties, the infant mortality rate declined 3% (nonsignificant) from 2014 (6.20) to 2020 (6.00). The rate was essentially unchanged from 2020 to 2021 (5.84) and rose 6% from 2021 to 2023 (6.19), resulting in no change for 2014 to 2023.
• In rural counties, the infant mortality rate declined 5% from 2014 (6.55) to 2020 (6.24). The rate then increased 5% from 2020 to 2022 (6.56) and was essentially unchanged from 2022 to 2023 (6.27), resulting in no change from 2014 to 2023.

During 2021-2023, total, neonatal, and postneonatal mortality rates were higher in rural and small and medium metropolitan counties compared with large metropolitan counties.

• For 2021-2023, the total infant mortality rate was 27% higher in rural counties (6.45 infant deaths per 1,000 live births) compared with large metropolitan counties (5.06). The rate for small and medium metropolitan counties (6.06) was 20% higher than that of large metropolitan counties (Figure 2, Table 2).
• The neonatal (0-27 days of age) mortality rate was 15% higher in rural (3.85) and 16% higher in small and medium metropolitan (3.86) counties compared with large metropolitan counties (3.34).
• The postneonatal (28-364 days of age) mortality rate was 50% higher in rural counties (2.57) compared with large metropolitan counties (1.71). The rate was 28% higher in small and medium metropolitan counties (2.19) compared with large metropolitan counties.

The mortality rate was higher in rural and small and medium metropolitan counties compared with large metropolitan counties for infants of mothers of all ages.

• In 2021-2023, for infants of mothers younger than age 20, the infant mortality rate was 14% higher in rural (10.39) and 17% higher in small and medium metropolitan (10.62) counties than in large metropolitan counties (9.10) (Figure 3, Table 3).
• For infants of mothers ages 20-29, the infant mortality rate was 8%-9% higher in rural counties compared with large metropolitan counties and 9%-10% higher in small and medium metropolitan counties compared with large metropolitan counties.
• For infants of mothers ages 30-39, the infant mortality rate was 35%-45% higher in rural counties compared with large metropolitan counties and 19%-27% higher in small and medium metropolitan counties compared with large metropolitan counties.
• For infants of mothers age 40 and older, the infant mortality rate was 49% higher in rural (9.07) and 29% higher in small and medium metropolitan (7.84) counties compared with large metropolitan counties (6.09).

Mortality rates were higher in rural and small and medium metropolitan counties compared with large metropolitan counties for infants of mothers of most race and Hispanic-origin groups.

• In 2021-2023, the infant mortality rate was higher in rural counties compared with large metropolitan counties for infants of mothers of most race and Hispanic-origin groups: Asian non-Hispanic (subsequently, Asian) mothers had a rate of 4.80 infant deaths per 1,000 live births compared with 3.25; Black non-Hispanic (subsequently, Black), 12.23 compared with 10.10; White non-Hispanic (subsequently, White), 5.78 compared with 3.56; and Hispanic, 5.65 compared with 4.64. For infants of American Indian and Alaska Native non-Hispanic (subsequently, American Indian and Alaska Native) mothers, differences between rural and large metropolitan counties were not significant (9.19 compared with 8.08) (Figure 4, Table 4).
• The infant mortality rate was higher in small and medium metropolitan counties compared with large metropolitan counties for infants of mothers of most race and Hispanic-origin groups: Asian mothers had a rate of 4.70 compared with 3.25; Black, 12.02 compared with 10.10; White, 4.97 compared with 3.56; and Hispanic, 5.30 compared with 4.64. For infants of American Indian and Alaska Native mothers, differences between small and medium metropolitan and large metropolitan counties were not significant (7.89 compared with 8.08).
• The smallest differences between rural and large metropolitan counties were among infants of Black mothers (21% higher in rural) and the largest differences were among infants of White mothers (62% higher).

Summary

The infant mortality rate varied by urbanization level and key maternal and infant characteristics. From 2014 through 2020, the mortality rate declined for infants in counties of all urbanization levels. In large metropolitan counties, the rate increased from 2020 to 2023. In small and medium metropolitan counties, the rate was essentially unchanged from 2020 to 2021 and increased from 2021 to 2023. In rural counties, the rate increased from 2020 to 2022 and was essentially unchanged from 2022 to 2023. From 2014 through 2023, in large metropolitan counties, an overall decline of 6% was seen in the infant mortality rate. Essentially no change was observed in the rate for small and medium metropolitan and rural counties. The infant mortality rate was higher for rural and small and medium metropolitan counties compared with large metropolitan counties for each year from 2014 through 2023. For combined years 2021-2023, total infant, neonatal, and postneonatal mortality rates were higher in rural and small and medium metropolitan counties compared with large metropolitan counties, as well as for infants of mothers in all age groups and all maternal race and Hispanic-origin groups except American Indian and Alaska Native (nonsignificant difference).

Definitions

Infant mortality rate: Number of infant (younger than 1 year) deaths per 1,000 live births.

Neonatal and postneonatal infant deaths: Neonatal infant deaths occur within the first 27 days after birth. Postneonatal infant deaths occur from 28 to 364 days after birth.

Urbanization level: County classification as urban or rural is based on the county of maternal residence (3). Counties were classified according to their metropolitan status using the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme, by merging the county of maternal residence geographic federal information processing standard (FIPS) codes with county-level FIPS codes from the 2013 NCHS Urban-Rural Classification Scheme data set (3). Metropolitan counties include large central counties, the fringes of large counties (suburbs), medium counties, and small counties. Nonmetropolitan counties include micropolitan statistical areas and noncore areas, including open countryside, rural towns (populations of less than 2,500), and areas with populations of 2,500-49,999 that are not part of larger labor market areas (metropolitan areas). Due to the variation in metropolitan county sizes, metropolitan counties were put into two levels, large (large central and the fringes of large cities) and small and medium (including medium and small cities), for comparisons in this report. In this report, rural counties include micropolitan and noncore counties.

Data source and methods

This report contains data from the period linked birth/infant death file, which is part of the National Vital Statistics System (7). The period linked birth/infant death file includes all infant deaths younger than age 1 year reported on death certificates and all live births reported from birth certificates (7). The period linked birth/infant death file is the primary data set for analyzing infant mortality trends and patterns in the United States and is the only source for examining infant mortality by maternal race and Hispanic origin and other factors related to birth (7). Data for 2021-2023 were combined to produce more reliable rates for subgroups with a small number of annual deaths. Linked birth/infant death data sets are available from: https://www.cdc.gov/nchs/data_access/vitalstatsonline.htm.

The race and Hispanic-origin groups shown in this report follow the 1997 Office of Management and Budget standards and differ from the bridged-race categories in reports before 2017 (8).

The NCHS Urban-Rural Classification Scheme data provide geographic FIPS codes and NCHS Urban-Rural Classification Scheme information for all counties in the United States. The NCHS county classification scheme data are available from: https://www.cdc.gov/nchs/data-analysis-tools/urban-rural.html?CDC_AAref_Val=https://www.cdc.gov/nchs/data_access/urban_rural.htm.

References to differences in rates indicate that differences are statistically significant at the 0.05 level based on a two-tailed z test. References to trends in rates across years for Figure 1 were evaluated using the Joinpoint Regression Program (9). A maximum of one joinpoint was allowed during the 2014-2020 period, which is the default setting. The default settings were also selected for the other parameters of the analysis (10).

About the author

Danielle M. Ely is with the National Center for Health Statistics, Division of Vital Statistics.

References

1. Ely DM, Driscoll AK, Matthews TJ. Infant mortality rates in rural and urban areas in the United States, 2014. NCHS Data Brief. 2017 Sep;(285):1-8. PMID: 29155685.
2. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health. 2014 Apr;91(2):272-92. PMID: 24366854. DOI: https://www.dx.doi.org10.1007/s11524-013-9847-2.
3. Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties. Vital Health Stat 2. 2014 Apr;(166):1-73. PMID: 24776070.
4. Meit M, Knudson A, Gilbert T, Yu AT, Tanenbaum E, Ormson E, Popat S. The 2014 update of the rural-urban chartbook. Rural Health Reform Policy Research Center. 2014 Oct;10.
5. Eberhardt MS, Pamuk ER. The importance of place of residence: Examining health in rural and nonrural areas. Am J Public Health. 2004 Oct;94(10):1682-6. PMID: 15451731. DOI: https://www.dx.doi.org10.2105/ajph.94.10.1682.
6. Peck J, Alexander K. Maternal, infant, and child health in rural areas: A literature review. Rural healthy people. 2003:85-96.
7. Ely DM, Driscoll AK. Infant mortality in the United States, 2023: Data from the period linked birth/infant death file. Natl Vital Stat Rep. 2025 Jun;74(7):1-20. DOI: https://dx.doi.org/10.15620/cdc/174592.
8. National Center for Health Statistics. User guide to the 2023 period/2022 cohort linked birth/infant death public use file. 2025. Available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/period-cohort-linked/23PE22CO_linkedUG.pdf.
9. National Cancer Institute. Joinpoint Regression Program (Version 5.0.2) [computer software]. 2023.
10. Ingram DD, Malec DJ, Makuc DM, Kruszon-Moran D, Gindi RM, Albert M, et al. National Center for Health Statistics guidelines for analysis of trends. Vital Health Stat 2. 2018 Apr;(179):1-71. PMID: 29775435.

Suggested citation

Ely DM. Trends and differences in infant mortality rates in rural and metropolitan counties in the United States, 2021-2023. NCHS Data Brief. 2025 Jul;(534):1-9. DOI: https://dx.doi.org/10.15620/cdc/174609.

Copyright information

All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

National Center for Health Statistics

Brian C. Moyer, Ph.D., Director
Amy M. Branum, Ph.D., Associate Director for Science

Division of Vital Statistics

Paul D. Sutton, Ph.D., Director
Andrés A. Berruti, Ph.D., M.A., Associate Director for Science