Food Insecurity, Walkability, and Social Determinants of Health: A Cross-Sectional, County-Level Study of Associations with Maternal and Infant Mortality in the United States.

BACKGROUND: Compared to other high-income countries, US women face higher maternal and infant mortality rates. METHODS: This study used structural equation modeling (SEM) to examine cross-sectional, county-level associations between structural and intermediary social determinants of health (SDOHs) and maternal and infant mortalities, based on the World Health Organization's Commission on Social Determinants of Health framework. RESULTS: Our findings suggest maternal mortality may be linked to increased food insecurity, food assistance, distance to obstetric care, and decreased walkability and marriage rates. Our modeling also points toward a connection between infant mortality and increased food insecurity, food assistance, Black race, mental distress, and decreased walkability, education, and income. SEM revealed significant direct and indirect effects of these SDOHs. Notably, food insecurity and walkability had direct associations with both maternal and infant mortality in both SEM models. CONCLUSIONS: The findings underscore the need for policy, practice, and research efforts to address key SDOHs and reduce mortality disparities in the US.