Municipal Social Expenditures and Maternal Health: Implications for Health Disparities

Background and Purpose:

The United States has one of the highest rates of maternal mortality among high-income countries as well as high rates of severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention as “unintended outcomes of labor and delivery that result in substantial short- or long-term consequences for a woman’s health.” SMM is the leading risk factor for maternal mortality and rates have been increasing. There are also large racial/ethnic and socioeconomic disparities in SMM.

The social determinants of health literature suggests that addressing SMM and disparities in SMM will require intervening beyond the healthcare system to address poverty, housing, and other socioeconomic and structural factors that affect maternal health. Because these factors can be shaped by government policies through the provision of social services and benefits, social expenditures—i.e., government spending on housing, transportation, education, and other society-wide needs— are tools that policymakers can potentially use to improve maternal health outcomes in their jurisdictions. However, empirical evidence on links between social expenditures and maternal health, particularly at local levels of government, is scant.

It is not clear a priori how social expenditures would affect health disparities. The effects on disparities would depend on the extent to which expenditures are disproportionately targeted to economically or socially marginalized populations or the health benefits of resources made broadly available to the population are greater for marginalized populations. However, whether social expenditures are associated with narrowing or widening of racial/ethnic and socioeconomic disparities in maternal health has not been investigated.

We addressed these gaps by estimating associations between municipal social expenditures and SMM by race/ethnicity and socioeconomic status in the state of New Jersey-NJ. NJ has the fourth highest maternal mortality rate and one of the highest SMM rates in the nation as well as large maternal health disparities and wide variation in social expenditures across its 564 municipalities. We hypothesized that living in municipalities with higher per capita social expenditures would be associated with lower odds of SMM and that the associations would be stronger for more marginalized groups.

Methods:

We linked 2008-2018 NJ birth records to maternal hospital discharge records and U.S. Census municipal expenditures data (n=1,003,974). We estimated associations between municipal-level social expenditures per capita and SMM using multilevel logistic models. We considered the following minoritized racial-ethnic groups, comparing each to non-Hispanic White: non-Hispanic Black, non-Hispanic Asian, and Hispanic. We focused on educational attainment as an indicator of socioeconomic status.

Results:

Residing in a municipality with higher social expenditures was associated with significantly lower odds of SMM across all racial/ethnic groups and education levels. The associations were greater for individuals with less than a high school education than for those in the other educational groups in both relative and absolute terms.

Conclusions and Implications:

Municipal-level spending on social services is associated with narrowing socioeconomic disparities in SMM. Narrowing racial/ethnic disparities in maternal health will likely require intervening beyond the provision of services to addressing historic and ongoing structural factors.