Associations Between State and Local Government Spending and Pregnancy-Related Mortality in the U.S.

  • Dovile Vilda
    Address correspondence to: Dovile Vilda, PhD, Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2210, New Orleans LA 70112.
    Mary Amelia Center for Women's Health Equity Research, Tulane University, New Orleans, Louisiana

    Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health & Tropical Medicine, New Orleans, Louisiana
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  • Brigham C. Walker
    Department of Health Policy and Management, Tulane University School of Public Health & Tropical Medicine, New Orleans, Louisiana
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  • Rachel R. Hardeman
    Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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  • Maeve E. Wallace
    Mary Amelia Center for Women's Health Equity Research, Tulane University, New Orleans, Louisiana

    Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health & Tropical Medicine, New Orleans, Louisiana
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Published:January 17, 2023DOI:


      There is limited evidence on how government spending is associated with maternal death. This study investigates the associations between state and local government spending on social and healthcare services and pregnancy-related mortality among the total, non-Hispanic Black, Hispanic, and non-Hispanic White populations.


      State-specific total population and race/ethnicity-specific 5-year (2015–2019) pregnancy-related mortality ratios were estimated from annual natality and mortality files provided by the National Center for Health Statistics. Data on state and local government spending and population-level characteristics were obtained from U.S. Census Bureau surveys. Generalized linear Poisson regression models with robust SEs were fitted to estimate adjusted rate ratios and 95% CIs associated with proportions of total spending allocated to social services and healthcare domains, adjusting for state-level covariates. All analyses were completed in 2021–2022.


      State and local government spending on transportation was associated with 11% lower overall pregnancy-related mortality (adjusted rate ratio=0.89, 95% CI=0.83, 0.96) and 9%–12% lower pregnancy-related mortality among the racial/ethnic groups. Among spending subdomains, expenditures on higher education, highways and roads, and parks and recreation were associated with lower pregnancy-related mortality rates in the total population (adjusted rate ratio=0.90, 95% CI=0.86, 0.94; adjusted rate ratio=0.87, 95% CI=0.81, 0.94; and adjusted rate ratio=0.68, 95% CI=0.49, 0.95, respectively). These results were consistent among the racial/ethnic groups, but patterns of associations with pregnancy-related mortality and other spending subdomains differed notably between racial/ethnic groups.


      Investing more in local- and state-targeted spending in social services may decrease the risk for pregnancy-related mortality, particularly among Black women.
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