Abstract
Severe maternal morbidity (SMM) is a major risk factor for maternal mortality, yet little is known about geographic variation in SMM or factors associated with geographical variation at the local level. Municipal governments incur substantial expenditures providing services that are an essential part of residents' lives, but associations between municipal expenditures and SMM have not been previously examined. To investigate variation in rates of SMM across municipalities in New Jersey, the contributions of individual-level characteristics and municipal expenditures to that variation, and associations between municipal expenditures and SMM. This cross-sectional study analyzed 2008 to 2018 New Jersey birth files linked to maternal hospital discharge records and US Census municipal expenditures data. The birth files contain all birth records for New Jersey, and hospital discharge records contain information from all in-patient hospitalizations in New Jersey over the study period. Birth records were matched to maternal discharge records and expenditures data. Data were analyzed from August 2020 to August 2021. Individual-level characteristics and per capita municipal expenditures on education; public health; fire and ambulance; parks, recreation, and natural resources; housing and community development; public welfare; police; transportation; and libraries. SMM was identified using diagnosis and procedure codes developed by the Centers for Disease Control and Prevention to measure SMM. Of 1 001 410 individuals (mean [SD] age, 29.8 [5.9] years; 108 665 Asian individuals [10.9%]; 147 910 Black individuals [14.8%]; 280 697 Hispanic individuals [28.0%]; 447 442 White individuals [44.7%]) who gave birth in New Jersey hospitals from 2008 to 2018, 19 962 individuals (2.0%) had SMM. There was substantial municipality-level variation in SMM that was not fully explained by demographic characteristics. Municipal expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM; $1000 higher annual expenditures per capita in these categories were associated with 35.4% to 67.3% lower odds of SMM (odds ratios, 0.33 [95% CI, 0.15-0.72] to 0.65 [95% CI, 0.46-0.91]). Expenditures on police were positively associated with SMM (odds ratio, 1.15 [95% CI, 1.04-1.28]). The findings in this study regarding associations between spending on various types of services at the municipal level and SMM, holding constant overall spending, population size, and socioeconomic status at the municipal level, indicate that municipal budget allocation decisions were associated with SMM rates and point to the importance of future research investigating potential causal connections.
Highlights
The United States has one of highest rates of maternal mortality among high-income countries.[1]
Municipal expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with Severe maternal morbidity (SMM); $1000 higher annual expenditures per capita in these categories were associated with 35.4% to 67.3% lower odds of SMM
Expenditures on police were positively associated with SMM
Summary
The United States has one of highest rates of maternal mortality among high-income countries.[1] Severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention (CDC) as unintended outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health,[2] is a major determinant of maternal mortality.[3] In 2015, 146.6 of every 10 000 women hospitalized for a delivery experienced SMM.[4] Besides being an important women’s health outcome, SMM can lead to disruptions in mother-infant bonding, which can compromise children’s social and emotional development.[5] SMM confers substantial economic costs to families, employers, insurers, and communities.[6]. Rates of SMM are generally reported at the national, census regional, or state level,[2,4] with few available robust prevalence estimates at more local levels. One study of New York, New York, neighborhoods found place-based disparities in SMM and highlighted priority communities for intervention efforts.[6] To our knowledge, there have been no previous studies of within-state geographic variation in SMM
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