Differences of Maternal Mortality Rate Between Shanghai and New York City from the Perspective of Regulatory Policy

Maternal mortality remains a significant global health challenge, with many deaths being preventable through effective healthcare systems and regulatory policies. This study examines the differences in maternal mortality rates (MMRs) between Shanghai (SH) and New York City (NYC) from 2006 to 2017, focusing on the role of regulatory policies (RPs) in shaping maternal healthcare systems (MHCS) and their impact on MMRs. Both cities are first-class international metropolises, yet they exhibit stark differences in MMR trends over the study period. By 2017, Shanghai achieved a significantly lower MMR of 3.0 per 100,000 live births compared to New York City’s 21.5 per 100,000 live births. This study explores how differences in regulatory policies contributed to these disparities.

Background and Context

Maternal mortality, defined as the death of a woman during pregnancy or within 42 days of termination, is a critical indicator of healthcare system performance. Despite global efforts to reduce MMRs, significant disparities persist, often linked to the quality of maternal healthcare systems. Regulatory policies play a pivotal role in ensuring the effectiveness of these systems by defining responsibilities, accountability mechanisms, and the scope of healthcare services.

Shanghai and New York City provide an interesting comparison due to their similarities in urban development and economic status, yet their divergent MMR trends suggest underlying differences in healthcare regulation. In 2006, both cities had comparable MMRs (SH: 26.2 per 100,000; NYC: 23.1 per 100,000). However, by 2017, Shanghai’s MMR dropped dramatically to 3.0 per 100,000, while New York City’s remained high at 21.5 per 100,000. This study investigates whether differences in regulatory policies contributed to these outcomes.

Methods

The study employed a quantitative evaluation model to assess and compare maternal health regulatory policies in Shanghai and New York City from 2006 to 2017. Data were collected from publicly released policy documents, including laws, regulations, strategies, and guidelines. The evaluation focused on four high-priority maternal health issues: screening and management of high-risk pregnancies, prenatal care, intrapartum safety, and postpartum care.

Three quantitative indicators were developed to measure the comprehensiveness and effectiveness of regulatory policies:

Regulatory Elements Coverage Rate (RECR): Measures the extent to which essential regulatory elements are covered in policy documents.
Departmental Responsibility Clarity Rate (DRCR): Assesses the clarity of responsibilities among stakeholders involved in maternal healthcare.
Accountability Mechanism Clarity Rate (AMCR): Evaluates the clarity of accountability mechanisms for ensuring policy implementation.

Statistical analyses, including Pearson correlation, principal component analysis, and linear regression, were conducted to examine the relationship between these indicators and MMRs in both cities.

Results

Comparison of Regulatory Policy Indicators in 2017

By 2017, significant disparities in maternal health regulatory policies were observed between Shanghai and New York City. Shanghai achieved a 100% RECR, indicating comprehensive coverage of essential regulatory elements, compared to New York City’s 77.0%. In terms of effectiveness, Shanghai’s DRCR (38.9%) was lower than New York City’s (45.1%), but its AMCR (29.2%) was higher than New York City’s (22.5%). These findings suggest that while New York City had clearer departmental responsibilities, Shanghai excelled in establishing accountability mechanisms.

Trends in Regulatory Policies and MMRs (2006–2017)

From 2006 to 2017, Shanghai demonstrated significant improvements in all three indicators. RECR increased by 8.7%, DRCR by 53.2%, and AMCR by 45.2%. In contrast, New York City showed slower growth: RECR increased by 25.0%, DRCR by 12.5%, and AMCR by only 2.9%. These trends indicate that Shanghai prioritized enhancing the comprehensiveness and effectiveness of its maternal health regulatory policies, while New York City made fewer advancements.

Correlation Between Regulatory Policies and MMRs

The study found strong negative correlations between the three indicators and MMRs in Shanghai (RECR: -0.831, DRCR: -0.833, AMCR: -0.909), suggesting that improvements in regulatory policies significantly contributed to the reduction in MMR. In New York City, only RECR and DRCR showed negative correlations with MMR (RECR: -0.736, DRCR: -0.683), while AMCR had no significant correlation. This indicates that while regulatory comprehensiveness and departmental clarity played a role in reducing MMR, the lack of a robust accountability mechanism limited New York City’s progress.

Principal Component and Linear Regression Analysis

Principal component analysis extracted a single component for each city, explaining 87.96% of the variance in Shanghai and 84.18% in New York City. Linear regression analysis showed that the principal components had a significant impact on MMRs in both cities, with a stronger effect in Shanghai (R = 0.914, R² = 0.836) compared to New York City (R = 0.854, R² = 0.357). This further supports the conclusion that differences in regulatory policies contributed to the disparities in MMRs.

Discussion

Comprehensive Regulatory Policies in Shanghai

Shanghai’s success in reducing MMR can be attributed to its comprehensive and effective regulatory policies. The city’s 100% RECR by 2017 reflects its commitment to covering all essential regulatory elements, including service procedures, department coordination, and assessment standards. For example, Shanghai implemented a pregnancy risk warning assessment system in 2012, which integrated prenatal, intrapartum, and postpartum care. This system significantly improved maternal health outcomes by ensuring timely interventions for high-risk pregnancies.

Shanghai also established a joint conference of public health involving 34 departments, fostering collaboration on maternal health issues. Additionally, the city created a maternal emergency aid network with five centers, each responsible for specific regions. This network facilitated rapid response to obstetric emergencies, contributing to a 98% success rate in treating critically ill pregnant women.

Accountability Mechanisms in Shanghai

Shanghai’s higher AMCR underscores its emphasis on accountability. The Department of Health (DOH) was designated as the external accountability agency for maternal healthcare providers, with clear penalties for preventable maternal deaths. Hospitals faced downgraded performance evaluations and reduced government funding for such cases, incentivizing high-quality care. In contrast, New York City lacked clear accountability mechanisms for maternal health providers, which may have hindered efforts to reduce MMR.

Limitations in New York City’s Regulatory Policies

Despite having clearer departmental responsibilities, New York City’s regulatory policies were less comprehensive and lacked robust accountability mechanisms. For instance, the city’s policy documents did not adequately address service procedures, coordination, or assessment standards. The absence of a well-defined accountability mechanism meant that healthcare providers faced no penalties for preventable maternal deaths, reducing the incentive to improve care quality.

Trends in Policy Improvements

Shanghai’s rapid improvements in regulatory policies from 2006 to 2017 reflect its prioritization of maternal health. The city launched a series of initiatives, including the Three-Year Action Plan for Strengthening Public Health System Construction, which significantly enhanced its MHCS. In contrast, New York City’s slower progress suggests less emphasis on maternal health regulation during this period. However, recent efforts, such as the 2017 Perinatal Standards Expert Panel, indicate a growing focus on maternal health in New York City.

Implications for Policy and Practice

The findings highlight the importance of comprehensive and effective regulatory policies in reducing maternal mortality. Shanghai’s success demonstrates the value of integrating service procedures, fostering departmental coordination, and establishing robust accountability mechanisms. Policymakers in other regions can learn from Shanghai’s approach to enhance their maternal healthcare systems.

Conclusion

This study provides valuable insights into the role of regulatory policies in shaping maternal healthcare systems and reducing maternal mortality. The significant differences in MMRs between Shanghai and New York City can be attributed, in part, to disparities in the comprehensiveness and effectiveness of their regulatory policies. Shanghai’s comprehensive coverage of regulatory elements, clear accountability mechanisms, and rapid policy improvements contributed to its remarkable reduction in MMR. In contrast, New York City’s slower progress and lack of robust accountability mechanisms limited its ability to achieve similar outcomes.

The quantitative evaluation model developed in this study offers a practical tool for assessing regulatory policies and their impact on maternal health outcomes. Future research should explore additional factors influencing MMRs, such as health literacy, financial resources, and organizational structures, to provide a more comprehensive understanding of maternal healthcare system performance.

doi.org/10.1097/CM9.0000000000000741

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