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By Dr. Jasvindar Kaur , Dr. Harpal Singh
Corresponding Author Dr. Jasvindar Kaur
Instiute for Public Health, - Malaysia 50590
Submitting Author Dr. Jasvindar Kaur
Other Authors Dr. Harpal Singh
World Health Organization (Representative Office for Brunei Darussalam, Malaysia and Singapore), 1st floor, Wisma UN, Block C, Kompleks Pejabat Damansara, Jalan Dungun, 50490 Kuala Lumpur. - Malaysia

PUBLIC HEALTH

Maternal Mortality Ratio, Millennium Development Goal 5, Malaysia, Maternal Health

Kaur J, Singh H. Maternal Health in Malaysia: A Review. WebmedCentral PUBLIC HEALTH 2011;2(12):WMC002598
doi: 10.9754/journal.wmc.2011.002598

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Submitted on: 19 Dec 2011 07:59:02 AM GMT
Published on: 19 Dec 2011 03:33:51 PM GMT

Abstract


Introduction: Maternal health in Malaysia has been in relatively good standing compared with its neighbours in South East Asia. This paper looks at the progress made in the achievement of target 5A of MDGs in Malaysia and makes recommendations for sustaining and accelerating progress towards the achievement of MDG 5A.

Methodology: Data on maternal mortality health indicators from Ministry of Health, Malaysia and the Statistics Department from 1990 to 2008 was reviewed.

Result & Discussion, The maternal mortality ratio stood at 44 per 100,000 live births in 1990 and declined to 29 deaths per 100,000 live births in 2007.  Since 2000, the MMR has remained relatively stagnant at around 28-30 per 100,000 live births. It appears that further reductions in the maternal mortality ratio would be more difficult to achieve given the fairly low levels achieved thus far and would require a different strategic thrust.

In three large states, Johor, Sabah and Sarawak, maternal mortality increased between 1997 and 2007. In 2007, the highest maternal mortality ratio was experienced by Other Malaysians and Other Bumiputra (67.3 and 40.8 maternal deaths per 100,000 births respectively) and   the lowest by the Chinese (12.9 births per 100,000 births). Maternal mortality among older women aged 40-44 years was higher compared to women in the prime childbearing age group.

The most common causes of maternal deaths are the direct causes; obstetric embolism (17.4%), postpartum hemorrhage (17.4%) and hypertensive disorders of pregnancy (18.1%). The proportion of births attended by health personnel increased from 92.9% in 1990 to 98.6% in 2008. Antenatal care coverage (first visit) has been increasing from 78% in 1990 to more than 90% since 2006.

Conclusion: Implementation of more comprehensive strategies may enable further reduction of MMR to achieve Malaysian MDG target of 11 per 100,000 populations by 2015.

Introduction


At the turn of the millennium, maternal health in Malaysia was in relatively good standing compared with its neighbours in South East Asia. A review of past trends of maternal mortality conducted by Pathmanathan and others (1) held the Malaysian approach to the delivery of health services to women as an example to be emulated. Past declines in the maternal mortality ratio in Malaysia have been attributed to improvements in access to quality health services, increased professional skills of trained delivery attendants to manage pregnancy and delivery complications, investments in upgrading the quality of essential obstetric care in district hospitals, improved efficiency of referral and feedback systems to prevent delays, close engagement with communities to remove socio cultural constraints, improved acceptability of modern maternal health services and improved monitoring system. These efforts instituted over a period since the 1960s have been sustained till the present time.
In the new millennium, investing in maternal health was seen as one of the crucial elements in the development agenda of countries. As a result the Millennium Development Goals (MDGs) that were adopted by Member States of the United Nations in 2000 included “improving maternal health” as one of its eight development goals. The MDGs are a framework for measuring progress in development and focuses on improvement of people’s lives. MDGs focus on improving maternal health. There are 2 targets to achieve to improve maternal health. One is to reduce maternal mortality by three quarters between 1990 and 2015. And the other, introduced at 2005 World Summit, is to achieve universal access to reproductive health by 2015.
This paper looks at the progress made in the achievement of target 5A of MDGs in Malaysia and makes recommendations for sustaining and accelerating progress towards the achievement of MDG5A. Target 5A, as indicated above, is to reduce, by three quarters, the maternal mortality ratio between 1990 and 2015. The MDG document recommends the use of three indicators to measure the progress made towards the reduction of maternal mortality. One is the maternal mortality ratio which is the number of maternal deaths per 100,000 live births in a given years. The second is the proportion of births attended by a skilled health professional, and third is the proportion of women who made at least one antenatal visit and those that made at least 4 antenatal visits during pregnancy.

Methods


The maternal mortality ratio
Long term trends of the maternal mortality ratio (MMR) for Malaysia show impressive declines. The ratio has declined from 530 deaths per 100,000 live births in 1950 to just 28 in 2009, a decline of 94% or 1.6 percentage points a year on average. The success in reducing MMR from such high levels has been attributed, in part, to early and massive efforts in competency-based training and placement of midwives in rural areas. 1 By 1990, the initial reporting period for the MDGs, the maternal mortality ratio stood at 44 per 100,000 live births, a decline of 91 per cent from the level in 1950. Since then, the ratio has declined to 29 deaths per 100,000 live births in 2007, a decline of 34 per cent short of the target of a decline of 75 per cent (11 per 100,000 births) by 2015 (see inset to figure 1). Most of the decline in the maternal mortality ratio took place during the decade of the 1990s. Since 2000, the MMR has remained relatively stagnant at around 28-30 per 100,000 live births. It appears that further reductions in the maternal mortality ratio would be more difficult to achieve given the fairly low levels achieved thus far and would require a different strategic thrust.
The rarity of maternal deaths is illustrated by the number of maternal deaths for Malaysia as a whole which has declined from 169 in 2001 to 133 in 2008 with a corresponding decline in the number of live births from 515,985 in 2001 to 473,200 in 2008. Thus, state level maternal mortality ratios are sometimes based on a very small number of deaths that fluctuate from year to year. Nevertheless, some conclusions could be drawn about the distribution of maternal mortality ratios among the states of Malaysia. Table 1 shows maternal mortality ratios, the number of deaths and the number of births by states for 1997, 2000 and 2007. The ratios marked in bold are those that are based on 5 or fewer maternal deaths in the year. In 1997, Kedah, Pulau Pinang, Selangor, Pahang, Terengganu and Sabah had maternal mortality ratios of above 30 per 100,000 births. By 2007, five states, Pulau Pinang, Johor, Sabah, Sarawak and Melaka had ratios above 30 per 100,000. Melaka had only 5 deaths in 2007.
Nine states had more than 5 deaths in both 1997 and 2007, thus allowing the study of trends. In five States (Kedah, Perak, Selangor, Pahang and Kelantan) the maternal mortality ratio declined during that period. The ratio remained unchanged in Pulau Pinang, while in three states, Johor, Sabah and Sarawak maternal mortality increased between 1997 and 2007. Johor, Sabah and Sarawak all have a sizeable rural population. In Sabah and Sarawak, in particular, rural hinterlands make access to higher level hospitals that are well-equipped to deal with emergency obstetric care difficult.
In 2007, the highest maternal mortality ratio was experienced by Other Malaysians and Other Bumiputra (67.3 and 40.8 maternal deaths per 100,000 births respectively). The lowest ratio was experienced by the Chinese who, in 2007, had a ratio of just 12.9 births per 100,000 births followed by Malays at 28.4 deaths per 100,000 births. This difference is striking because the Malay ratio is more than twice that of the Chinese and the Other Bumiputra ratio is more than three times as high. The Indians had a maternal mortality ratio of 23.6 deaths per 100,000 births but the number of deaths among the Indians was just seven. High maternal mortality ratios could be due to various factors such as accessibility of healthcare services and lack of knowledge of complications by patients and inadequately trained staff to handle the complications. Such reasons may be relevant in the case of maternal deaths among Other Bumiputras, one third of whom lived more than 20 km from the nearest hospital. There is an unmet need for contraception as 60 per cent of Other Bumiputra had never practiced any form of family planning. About one third of deliveries were conducted by traditional birth attendants that may have resulted in unsafe deliveries. The difference between the Chinese ratio and those of the other ethnic groups probably reflects the lack of access to and/or utilization of services as well as the quality of services and health professionals. Lower fertility among the Chinese probably has an effect as well in that they are more likely to be urban residents, thus have more access to specialist facilities.
Maternal mortality among older women aged 40-44 years was three times as high as that among women in the prime childbearing age group of 25-29 years and twice as high as among women aged 30-34 years (Figure 3). The high ratios at older ages are a reflection of the risk to childbearing that is age-related and also parity-related (Table 2). Older women who have many children are also more likely to live in rural areas, and are more likely to be poor. Thus aside from the proximate factors that elevate risks of childbearing, the distal factors of education, poverty and rural residence also play a part.
The leading causes of maternal deaths can be classified into two broad categories: direct and indirect deaths. “Direct obstetric deaths are those resulting from obstetric complications of the pregnant state (i.e. pregnancy, labour and the puerperium), from interventions, omissions or incorrect treatment, or from a chain of events resulting from any of the above. Indirect obstetric deaths are those resulting from a previously existing disease or a disease that developed during pregnancy and which was not due to direct obstetric causes but which was aggravated by the physiological effects of pregnancy.”2. In developing countries’ the most common causes of direct maternal death are obstetric haemorrhage, sepsis, pregnancy-induced hypertension and complications of unsafe abortion. The most common causes of indirect maternal death are anemia, HIV/AIDS and malaria3. In Malaysia, the most common causes of maternal deaths are the direct causes.
The number of deaths by causes from the Confidential Enquiry into Maternal Deaths (CEMD) for 1997 and 2007 are shown in Table 3. In 2007, the direct causes of maternal deaths were obstetric embolism (17.4%), postpartum hemorrhage (17.4%) and hypertensive disorders of pregnancy (18.1%). The main indirect cause was “Associated Medical conditions” which made up 14% of maternal deaths. That category of indirect causes of deaths declined over the ten-year period from 22.7% in 1997 to 14% in 2007. It is interesting to note that between 1997 and 2007, the percentage of maternal deaths due to the preventable causes of postpartum hemorrhage and hypertensive disorders of pregnancy has been more or less constant. This may, in part, explain the stagnation in the maternal mortality ratios as the preventable causes are easier to address. The indirect causes, although on the decline, may explain some of the deaths in malaria and tuberculosis endemic areas such as in Sabah and Sarawak.
Proportion of Births attended by skilled health personnel
Skilled attendants at delivery are one of the fundamentals necessary to reduce maternal mortality, particularly mortality due to direct causes. The proportion of births attended by health personnel increased from 92.9% in 1990 to 96.6 per cent in 2005 and to 98.6% in 2008 (Table 4). The data cover all public and private institutions who report to the Ministry of Health. Some omissions may occur in the case of deliveries in private institutions, but those are assumed to be negligible.
All states had shown an increasing trend in safe deliveries. However, Sabah has a lower proportion of births attended by skilled health personnel as compared to the other states, ranging from 74% to 89% (1990 to 2005). Since 2006, Sabah has shown an improvement, achieving more than 90% of births that were attended by skilled health personnel.
Antenatal care monitors the well being of the mother and the unborn child. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing. The WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. The WHO guidelines are specific on the content of antenatal care visits, which should include:
blood pressure measurement;
urine testing for bacteriuria & proteinuria;
blood testing to detect syphilis & severe anemia; and
weight/height measurement (optional)
Four antenatal visits will ensure that the pregnant women receive important services, such as tetanus vaccinations, screening and treatment for infections and health promotion and prevention advice on warning signs during pregnancy. Thus, antenatal visits help identify and treat illnesses which place pregnant women at high risk of maternal death due to indirect causes and is therefore considered a proxy indicator for safe deliveries.
Although Malaysian women make more than on visit for antenatal care, antenatal care is monitored for only the first visit. Antenatal care coverage (first visit) has been increasing from 78% in 1990 to more than 90% since 2006 (Figure 5). Antenatal care coverage (first visit) by states shows that Johor, Perlis, WP Kuala Lumpur, WP Labuan, WP Putrajaya have full coverage in 2008.
Postnatal period is within 6 weeks after birth. Almost two thirds of all maternal deaths occurred in the postnatal period. Postpartum care is provided by primary health care staff from the health clinics. Ministry of Health Guidelines for home visits are a total of 8 visits, 1st,2nd,3rd,4th,6th,8th,10th and 20th postnatal days and on the 42nd postnatal day for a routine examination for mother and baby which is done at the clinic by the doctor. Regular postnatal visits can detect complications early and cases can be referred for further care. More than 70% of deaths occurred in hospitals or en route to hospitals. This could be due to the late referral of cases or ignorance on part of patient and family as well as weakness in the referral system.


Conclusion


Strategies need to be developed and strengthened to further reduce the MMR which has currently reached a plateau. Local models of care that are successful should be identified and scaled up to be implemented on a large scale, especially amongst the vulnerable groups. Special attention should be given to the ethnic and indigenous groups that experience high maternal mortality. All forms of barriers; physical, social and financial, should be removed to improve access to effective maternal care. This would ensure efficient and effective health services easily accessible to all, especially the vulnerable groups in remote interior areas. Inaccessibility may cause unavoidable delays in transferring patients to hospitals that have specialists. Establishing temporary homes, early admission into healthcare facilities and availability of transport to send patients to the nearest hospital for deliveries are some solutions to reduce maternal mortality among the indigenous groups. Emergency obstetrical care should be readily available and accessible to all who need it. There should be contingency plans to transfer patients early and quickly by involving community participation.
Quality services should be provided by improving the clinical level of care and health service delivery. Education and empowerment of women is essential to increase their demand for such services. Emphasis should be given to family planning practices and pre conception care to the couple, especially among the high risk groups. Increased use of family planning to delay and limit child bearing and better access to high quality obstetric care will further reduce maternal deaths. It was noted that increased contraceptive prevalence, increased skilled birth attendants, and improved emergency obstetric care were some of the strategies to reduce maternal mortality in India by nearly 80%. 6
The health personnel should be equitably distributed to meet the health needs of mothers and newborns. Strategies to reduce MMR among immigrant mothers include advocacy and strengthening cooperation of neighboring countries.
The National Health and Morbidity Survey 3 (NHMS3) made the following recommendations for identified subgroups of population requiring attention to enhance their health status. The existing rural health services provided by the Ministry of Health such as the Maternal and Child Health Services should be strengthened. Allocation of resources should be need based, depending on the community of urban or rural areas. Health services should be developed at the community level, even beyond the existing infrastructure of the Ministry of Health.
Data on antenatal care coverage is collected from government health facilities. Because the private sector is playing an increasing role in provision of healthcare, it would be timely to start collecting data from the private sector, so as to get a comprehensive picture of the total healthcare provided by the healthcare system. The Ministry of Health should strictly enforce the Private Healthcare Act for the private health facilities to comply with providing timely and accurate feedback to the Ministry.
Disaggregated data by states, strata, sex should be compiled to identify the disparities in healthcare for the different population subgroups. This would enable definitive actions to be taken to step up health care for those groups who need it the most. Disaggregated data for the MDG indicators would facilitate more accurate trend analysis of the indicators in the subsequent MDG Report. Sub national monitoring and evaluation systems including targets need to be established to identify gaps and analyze trends. Since 1998, there has been reconciliation of data from the Department of Statistics and CEMD regarding the maternal mortality in the country. This has led to improved surveillance and registration of the all maternal deaths. However, there may still be some underreporting or misreporting as seen in States with low MMR. The registration of all maternal deaths should be mandatory,
Qualitative research needs to be conducted on specific target groups and pockets of the population, such as the poor, marginalized and the lesser educated groups with unmet need for contraception. Health education and promotion activities should focus on the negative impact of unplanned pregnancies, religious issues affecting family planning and fear of the side effects of family planning. A rights-based approach should be utilized to confront the unmet needs of the high risk population and vulnerable groups. The role of the males should be stressed, both in utilizing the family planning methods and reducing their barriers to family planning practice. Users of traditional methods are a potential target group for modern methods of contraception. The unmet needs of family planning must be addressed with enhanced reproductive health services that target married and unmarried individuals especially adolescents.
Implementation of more comprehensive strategies may enable further reduction of MMR to achieve Malaysian MDG target of 11 per 100,000 populations by 2015.

Acknowledgements


We would like to thank the Director General of Health, Malaysia for his permission to publish the review findings.  We would like to thank Dr Vasanta Kandiah for her invaluable contribution.

Discussion


1. Indra Pathmanathan et al (2003) Investing in Maternal health : Learning from Malaysia and Sri Lanka. The World bank, Human Development Network, Health, Nutrition and Population series.
2. Suzanne Cross, Jacqueline S. Bell and Wendy J. Graham (2010) “What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries” in Bulletin of the World Health Organization 2010; 88:147-153.
3.KS Khan, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF (2006) WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367:1066-1074.
4. Bunyanjargal Yadamsuren et al ( 2009) Tracking Maternal Mortality Declines in Mongolia Between 1992 and 2007: The Importance of Collaboration. Bull World Health Organ 2010:88:192-198.
5. Maternal Mortality for 181 Countries, 1980-2998: A Systematic Analysis of Progress Towards Millennium Development Goal 5. http://www.thelancet.com/journals/lancet/issue/vol375no9723/PIIS0140-6736%2810%29X6122-0 (accessed on December 10, 2010)
6. Goldie SJ, Sweet S, Carvalho N, Natchu UCM, Hu D (2010) Alternative Strategies to Reduce Maternal Mortality in India: A Cost –Effectiveness Analysis. PLoS Med 7(4): e10000264. Doi:10.1371/journal.pmed.1000264.

References


1. Indra Pathmanathan et al (2003) Investing in Maternal health : Learning from Malaysia and Sri Lanka. The World bank, Human Development Network, Health, Nutrition and Population series.
2. Suzanne Cross, Jacqueline S. Bell and Wendy J. Graham (2010) “What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries” in Bulletin of the World Health Organization 2010; 88:147-153.
3.KS Khan, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF (2006) WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367:1066-1074.
4. Bunyanjargal Yadamsuren et al ( 2009) Tracking Maternal Mortality Declines in Mongolia Between 1992 and 2007: The Importance of Collaboration. Bull World Health Organ 2010:88:192-198.
5. Maternal Mortality for 181 Countries, 1980-2998: A Systematic Analysis of Progress Towards Millennium Development Goal 5. http://www.thelancet.com/journals/lancet/issue/vol375no9723/PIIS0140-6736%2810%29X6122-0 (accessed on December 10, 2010)
6. Goldie SJ, Sweet S, Carvalho N, Natchu UCM, Hu D (2010) Alternative Strategies to Reduce Maternal Mortality in India: A Cost –Effectiveness Analysis. PLoS Med 7(4): e10000264. Doi:10.1371/journal.pmed.1000264.

Source(s) of Funding


This project was funded by World Health Organization (WHO) Grant.

Competing Interests


The authors declare that they have no competing interests.

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