Rutgers, The State University of New Jersey, New Brunswick.
Columbia University, New York, New York.
JAMA Netw Open. 2021 Nov 1;4(11):e2135161. doi: 10.1001/jamanetworkopen.2021.35161.
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.
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.
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.
严重产妇发病率（SMM）是产妇死亡率的一个主要危险因素，但人们对 SMM 的地域差异或与地方一级地域差异相关的因素知之甚少。市政府承担着提供服务的大量支出，这些服务是居民生活的重要组成部分，但市政支出与 SMM 之间的关联尚未得到检验。
调查新泽西州各市镇 SMM 发生率的差异，个体特征和市政支出对这种差异的贡献，以及市政支出与 SMM 之间的关联。
设计、地点和参与者：本横断面研究分析了 2008 年至 2018 年新泽西州出生档案，这些档案与产妇住院记录和美国人口普查市政支出数据相关联。出生档案包含了新泽西州的所有出生记录，住院记录包含了研究期间新泽西州所有住院患者的信息。出生记录与产妇出院记录和支出数据相匹配。数据于 2020 年 8 月至 2021 年 8 月进行分析。
个体特征和人均市政支出在教育；公共卫生；消防和救护车；公园、娱乐和自然资源；住房和社区发展；公共福利；警察；交通；和图书馆。
使用疾病控制与预防中心制定的诊断和程序代码来衡量 SMM，确定 SMM。
在 2008 年至 2018 年期间在新泽西州医院分娩的 1001410 人中（平均[SD]年龄 29.8[5.9]岁；108665 名亚洲人[10.9%]；147910 名黑人[14.8%]；280697 名西班牙裔[28.0%]；447442 名白人[44.7%]），有 19962 人（2.0%）患有 SMM。SMM 在市一级存在着大量的差异，这些差异不能完全用人口特征来解释。消防和救护车、交通、健康、住房和图书馆方面的市政支出与 SMM 呈负相关；每年人均支出增加 1000 美元，SMM 的可能性降低 35.4%至 67.3%（比值比，0.33[95%CI，0.15-0.72]至 0.65[95%CI，0.46-0.91]）。警察支出与 SMM 呈正相关（比值比，1.15[95%CI，1.04-1.28]）。
本研究中关于各级服务支出与 SMM 之间的关联的发现，在控制了各级支出、人口规模和社会经济地位等总体支出的情况下，表明市政预算分配决策与 SMM 率有关，并指出未来研究调查潜在因果关系的重要性。
