An economic evaluation of the Safe Motherhood programme in Guangxi, China

Maternal and infant mortality is a global health issue with a significant social and economic impact. Each year, over half a million women worldwide die due to complications related to pregnancy or childbirth, four million infants die in the first 28 days of life, and eight million infants die in the first year. Ninety-nine percent of maternal and infant deaths are in developing countries. Reducing maternal and infant mortality is among the key international development goals. In China, the national maternal mortality ratio and infant mortality rate were reduced greatly in the past two decades, yet a large discrepancy remains between urban and rural areas. To address this problem, a large-scale Safe Motherhood Programme was initiated in 2000. The programme was implemented in Guangxi in 2003. Interventions in the programme included both demand-side and supply side-interventions focusing on increasing health service use and improving birth outcomes. Little is known about the effects and economic outcomes of the Safe Motherhood Programme in Guangxi, although it has been implemented for seven years. The aim of this research is to estimate the effectiveness and cost-effectiveness of the interventions in the Safe Motherhood Programme in Guangxi, China. The objectives of this research include: 1. To evaluate whether the changes of health service use and birth outcomes are associated with the interventions in the Safe Motherhood Programme. 2. To estimate the cost-effectiveness of the interventions in the Safe Motherhood Programme and quantify the uncertainty surrounding the decision. 3. To assess the expected value of perfect information associated with both the whole decision and individual parameters, and interpret the findings to inform priority setting in further research and policy making in this area. A quasi-experimental study design was used in this research to assess the effectiveness of the programme in increasing health service use and improving birth outcomes. The study subjects were 51 intervention counties and 30 control counties. Data on the health service use, birth outcomes and socio-economic factors from 2001 to 2007 were collected from the programme database and statistical yearbooks. Based on the profile plots of the data, general linear mixed models were used to evaluate the effectiveness of the programme while controlling for the effects of baseline levels of the response variables, change of socio-economic factors over time and correlations among repeated measurements from the same county. Redundant multicollinear variables were deleted from the mixed model using the results of the multicollinearity diagnoses. For each response variable, the best covariance structure was selected from 15 alternatives according to the fit statistics including Akaike information criterion, Finite-population corrected Akaike information criterion, and Schwarz.s Bayesian information criterion. Residual diagnostics were used to validate the model assumptions. Statistical inferences were made to show the effect of the programme on health service use and birth outcomes. A decision analytic model was developed to evaluate the cost-effectiveness of the programme, quantify the decision uncertainty, and estimate the expected value of perfect information associated with the decision. The model was used to describe the transitions between health states for women and infants and reflect the change of both costs and health benefits associated with implementing the programme. Result gained from the mixed models and other relevant evidence identified were synthesised appropriately to inform the input parameters of the model. Incremental cost-effectiveness ratios of the programme were calculated for the two groups of intervention counties over time. Uncertainty surrounding the parameters was dealt with using probabilistic sensitivity analysis, and uncertainty relating to model assumptions was handled using scenario analysis. Finally the expected value of perfect information for both the whole model and individual parameters in the model were estimated to inform priority setting in further research in this area.The annual change rates of the antenatal care rate and the institutionalised delivery rate were improved significantly in the intervention counties after the programme was implemented. Significant improvements were also found in the annual change rates of the maternal mortality ratio, the infant mortality rate, the incidence rate of neonatal tetanus and the mortality rate of neonatal tetanus in the intervention counties after the implementation of the programme. The annual change rate of the neonatal mortality rate was also improved, although the improvement was only close to statistical significance. The influences of the socio-economic factors on the health service use indicators and birth outcomes were identified. The rural income per capita had a significant positive impact on the health service use indicators, and a significant negative impact on the birth outcomes. The number of beds in healthcare institutions per 1,000 population and the number of rural telephone subscribers per 1,000 were found to be positively significantly related to the institutionalised delivery rate. The length of highway per square kilometre negatively influenced the maternal mortality ratio. The percentage of employed persons in the primary industry had a significant negative impact on the institutionalised delivery rate, and a significant positive impact on the infant mortality rate and neonatal mortality rate. The incremental costs of implementing the programme over the existing practice were US $11.1 million from the societal perspective, and US $13.8 million from the perspective of the Ministry of Health. Overall, 28,711 life years were generated by the programme, producing an overall incremental cost-effectiveness ratio of US $386 from the societal perspective, and US $480 from the perspective of the Ministry of Health, both of which were below the threshold willingness-to-pay ratio of US $675. The expected net monetary benefit generated by the programme was US $8.3 million from the societal perspective, and US $5.5 million from the perspective of the Ministry of Health. The overall probability that the programme was cost-effective was 0.93 and 0.89 from the two perspectives, respectively. The incremental cost-effectiveness ratio of the programme was insensitive to the different estimates of the three parameters relating to the model assumptions. Further research could be conducted to reduce the uncertainty surrounding the decision, in which the upper limit of investment was US $0.6 million from the societal perspective, and US $1.3 million from the perspective of the Ministry of Health. It is also worthwhile to get a more precise estimate of the improvement of infant mortality rate. The population expected value of perfect information for individual parameters associated with this parameter was US $0.99 million from the societal perspective, and US $1.14 million from the perspective of the Ministry of Health. The findings from this study have shown that the interventions in the Safe Motherhood Programme were both effective and cost-effective in increasing health service use and improving birth outcomes in rural areas of Guangxi, China. Therefore, the programme represents a good public health investment and should be adopted and further expanded to an even broader area if possible. This research provides economic evidence to inform efficient decision making in improving maternal and infant health in developing countries.

A new species of Genus Triplophysa (Nemacheilinae: Balitoridae), Triplophysa longipectoralis sp nov, from Guangxi, China

A new species, Triplophysa longipectoralis, is described from Liujiang River, Guangxi, China. The new species is distinguished from other species of Triplophysa by the following combination of characters: pectoral fin highly developed, reaching beyond pel

A new species of genus Pseudogyrinocheilus (Teleostei: Cyprinidae) from Guangxi, China

A new species, Pseudogyrinocheilus longisulcus, was discovered from a tributary of Pearl River in Jingxi Co., Guangxi, China, The new species can be distinguished from other species of Pseudogyrinocheilus by the following combination of characteristics: prolonged post-labial grooves, and extended antero-medially close to anterior end of middle lower lip, but not meeting with its counterpart; posterior margin of lower lip free; scales of abdomen from thorax to pectoral-fin base embedded under skin; lateral-line scales 40-42; dark stripe longitudinal along lateral line on flank. The key to the species of Pseudogyrinocheilus is provided.

Metzia longinasus, a new cyprinid species (Teleostei: Cypriniformes) from the Pearl River drainage in Guangxi Province, South China

Metzia longinasus, a new cultrine cyprinid species from the Hongshui-He River of the Pearl River drainage in Guangxi Province, southern China, is described here. It can be distinguished from all other congeners by having a combination of the following characters: a superior mouth, 43 or 44 lateral-line scales, a long head (length 27.2-30.8% of standard length), a long snout (length 31.7-37.0% of head length), 10 or 11 branched anal-fin rays, and no longitudinal black band extending along each side of body from the extremity of the gill opening to caudal-fin base.

Bibarba bibarba: A new genus and species of Cobitinae (Pisces : Cypriniformes : Cobitidae) from Guangxi Province (China)

A new genus of Cobitinae, Bibarba gen. n., and a new species, B. bibarba sp. n., were discovered and are described for the Chengjiang River, a tributary of the Hongshuihe River in Guangxi Province of southern China. This river region is characterized by a Karst landscape, and the river that is inhabited by the new genus is a slowly moving stream with arenaceous and cobblestone beds. The new genus resembles Cobitis Linnaeus, 1758 (subfamily Cobitinae) in the shape and pigmentation pattern of their body, the absence of scales on their head, and the presence of a suborbital spine, but differs from it by a single Lamina circularis on the third pectoral fin ray instead of on the base of the second pectoral fin ray; two pairs of barbels (one rostral pair and one maxillo-mandibular pair) instead of three pairs of barbels (one rostral pair, one maxillary pair, and one maxillo-mandibular pair); a relatively thick and short suborbital spine with a strong medio-lateral process instead of a suborbital spine without or with a weakly formed medio-lateral process as in Cobitis; and the lack of a black stripe extending from the occiput through the eye to the insertion of the rostral barbel. The first two characters have not been reported in any other genus of the subfamily Cobitinae. A morphometric character analysis based on PCA reveals differences between B. bibarba and C. sinensis in body size, barbel length, interorbital width, pectoral fin length in males, and the position of the dorsal and ventral fins. Type specimens of the new species are kept in the Freshwater Fishes Museum of the Institute of Hydrobiology at the Chinese Academy of Sciences in Wuhan, Hubei Province. (c) 2007 Elsevier GmbH. All rights reserved.