Perinatal & Pediatric
Rural-Urban Differences and Racial Disparities in Maternal Syphilis in the United States, 2023 Clara Busse* Clara Busse Danielle Gartner Katy Backes Kozhimannil
Cases of syphilis during pregnancy (hereafter, “maternal syphilis”) have risen dramatically in the United States. National trends in maternal syphilis have not been disaggregated by rurality, despite the availability of this information and its importance for directing resources for prevention and treatment. Using 2016-2023 United States natality data for live births available from Center for Disease Control and Prevention’s Wide-ranging ONline Data for Epidemiologic Research, we compared maternal syphilis rates among rural and urban residents, stratifying by race, age, timing of prenatal care, and state. We observed that maternal syphilis rates in urban areas tripled from 2016 to 2023 (90 vs. 317 cases per 100,000 live births) while rates quintupled in rural areas over the same years (69 vs. 365 cases per 100,000 live births) (Figure 1). Since 2021, rural rates have exceeded urban rates, and the rural/urban gap has widened over time. Maternal syphilis rates were extraordinarily high among American Indian or Alaska Native (AIAN) birthing people: in 2023, the rate among rural AIAN birthing people was 1.6 times the rate among urban AIAN birthing people (2,089 vs. 1,272 cases per 100,000 live births), and 8.8 times the rate among rural White birthing people (2,089 vs. 239 cases per 100,000 live births). From 2020-2023, birthing people ages 35-39 years had rates of maternal syphilis that exceed those of their urban peers. Rates by trimester of prenatal care initiation were similar in rural and urban areas, with the highest rates in the no prenatal care group. Of the 34 states that reported maternal syphilis for both rural and urban areas in 2023, 14 had higher rates in rural areas compared with urban areas (13 states had suppressed case counts, 3 states and the District of Columbia do not have rural areas). These findings are essential for identifying rural populations most in need of resources and health care to prevent and treat maternal and congenital syphilis.
