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 people hospitalized for a delivery experience SMM. In addition to adverse health outcomes, SMM can lead to disruptions in mother-infant bonding, which can compromise children’s social and emotional development, and confers substantial economic costs to families, communities, and insurers including Medicaid. While existing data show associations between state and county government expenditures and infant health, associations between expenditures at any level of government and maternal health outcomes have not been investigated. And because the services provided by municipalities tend to be part of residents’ daily lives, municipal government expenditures can have both direct and indirect impacts on health outcomes. In a study recently published in JAMA Network Open, Muchomba et al. estimate associations between municipal expenditures and SMM in the state of New Jersey.


Using 2008-2018 birth records in New Jersey linked to maternal hospital discharge records and US Census municipal expenditures data, the authors identified SMM cases using diagnosis and procedure codes developed by the Centers for Disease Control and Prevention to measure SMM. They focused on nine categories of expenditures associated with population health outcomes: education; public health; fire protection and ambulance; parks, recreation and natural resources; housing and community development; public welfare; police; transportation; and libraries and found:

  • There was substantial municipality-level variation in SMM that was not fully explained by demographic characteristics.
  • Municipal expenditures on fire and ambulance, transportation, public health, housing and community development, and libraries, were associated with 35.4%- 67.3% lower odds of SMM.
  • On the other hand, municipal expenditures on police were associated with 15% higher odds of SMM.

Implications for Policy and Practice

Associations between spending on various types of services at the municipal level and SMM, controlling for municipal spending, population size, and socioeconomic status, indicate that municipal budget allocation decisions are linked to maternal health outcomes. The finding that SMM was associated with many types of municipal expenditures that are not directly related to public health underscores the need for a holistic and multi-sector approach for improving maternal health outcomes. The findings from this study also inform current local/state policy debates wherein lawmakers are simultaneously having to make decisions about spending cuts but also needing to position budgets for improved population health.