Severe maternal morbidity (SMM)—defined by the Centers for Disease Control and Prevention as unintended outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health—is a major determinant of maternal mortality. Each year 15 of every 1,000 women hospitalized for a delivery experience SMM. Besides being a significant women’s health outcome, SMM can lead to disruptions in mother-infant bonding, which can compromise children’s social and emotional development. SMM also confers substantial economic costs to families, insurers including Medicaid, and communities.
Rates of SMM are generally reported at the national level. Consequently, little information about within-state geographic variation of SMM is available. Identification of geographic patterns in SMM at finer levels of geography is needed for pinpointing problem areas, identifying structural determinants, and targeting of interventions.
Further, while expenditures by state and county governments have been associated with infant health, associations between government expenditures at any level and SMM have not been investigated. Because the services provided by municipalities tend to be part of residents’ daily lives, municipal governments are arguably closer to the people. Consequently, to the extent that government expenditures are associated with SMM, the associations may be more readily observed at the municipality level than at the county or state level.
To address this gap, we documented the variation in SMM rates across municipalities in the state of New Jersey (NJ), evaluated the contributions of individual-level characteristics and municipal expenditures to that variation, and estimated associations between specific types of municipal expenditures and SMM. Despite being a state with one of the lowest poverty rates and highest median incomes in the U.S., NJ has the 4th highest maternal mortality rate and one of the highest SMM rates.
We linked 2008-2018 NJ birth records to maternal hospital discharge records and U.S. Census municipal expenditures data (n=1,005,240) and estimated multi-level logistic regression models to evaluate contributions of individual-level characteristics and municipal expenditures to that variation and investigate associations between types of municipal expenditures and SMM. We focused on nine categories of municipal expenditures that have been associated with population health outcomes: education; public health; fire/ambulance; parks/recreation and natural resources; housing/community development; public welfare; police; transportation; and libraries.
We found significant municipality-level variation in SMM rates that was not fully explained by demographic characteristics. Municipal expenditures on fire/ambulance, transportation, public health, housing/community development, libraries, and public welfare were associated with lower odds of SMM. Municipal expenditures on police were associated with higher odds of SMM.
Conclusions and Implications:
Expenditures at the municipality level were strongly associated with SMM. The findings from this study indicate that place matters for maternal health, that determinants at the municipality level are important, and that interventions to prevent SMM should be geographically targeted.