Fatal, pedestrian-involved, motor vehicle collisions are increasing in the United States yet remain lower in rural states such as West Virginia. This study's purpose was to investigate the overall risk factors of pedestrian fatalities by rurality and sex in West Virginia. Data were obtained from the Fatality Analysis Reporting System. The fatality had to occur within West Virginia between 1 January 2009 and 31 December 2019. Risk factors of rural vs. urban and male vs. female crashes were determined using multivariable logistic regression models. Clustering of crash locations was analyzed using kernel density estimation and Ripley's K. Among the 254 fatalities, most victims were male (70%). Most crashes occurred at night (76%), on highways (73%), on level (71%), non-curved (84%), dry (82%) roads during fair weather conditions (82%). Nearly 34% of the victims tested positive for alcohol. Men were 2.5 times as likely to be hit in a rural area (OR = 2.5; 95% CI 1.2, 5.4), on curved roads, and 57% less likely (OR = 0.43; 95% CI 0.2, 0.9) to test positive for drugs compared to women. Crash characteristics, including location, were similar between the sexes. As many risk factors were modifiable behaviors, public health interventions to ensure pedestrian safety may be necessary.