Municipality-Level Variation in Severe Maternal Morbidity and Association With Municipal Expenditures in New Jersey | Emergency Medicine | JAMA Network Open | JAMA Network
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    Original Investigation
    Public Health
    November 18, 2021

    Municipality-Level Variation in Severe Maternal Morbidity and Association With Municipal Expenditures in New Jersey

    Author Affiliations
    • 1Rutgers, The State University of New Jersey, New Brunswick
    • 2Columbia University, New York, New York
    • 3New Jersey Department of Health, Trenton
    JAMA Netw Open. 2021;4(11):e2135161. doi:10.1001/jamanetworkopen.2021.35161
    Key Points

    Question  Are expenditures at the municipal level associated with severe maternal morbidity (SMM), a major determinant of maternal mortality?

    Findings  This cross-sectional study including 1 001 410 births from 2008 to 2018 used birth files linked to maternal hospital discharge files from New Jersey and found that municipal expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM, whereas expenditures on police were positively associated with SMM.

    Meaning  These findings suggest that budget allocation decisions made by municipalities may have consequences for SMM rates and potentially maternal mortality.


    Importance  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.

    Objective  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.

    Design, Setting, and Participants  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.

    Exposures  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.

    Main Outcomes and Measures  SMM was identified using diagnosis and procedure codes developed by the Centers for Disease Control and Prevention to measure SMM.

    Results  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]).

    Conclusions and Relevance  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.