Malaysia

Disclaimer: Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels.^[1] 

 

Indicators (United Nations)

 

5.1 Maternal mortality ratio (MMR):

a.    2000: 41^[2]

b.    2005: 62^[3]

c.    2007:

A maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.”^[4] According to the 2005 WHO/UNICEF/UNFPA maternal mortality estimates, most of the countries in the Asian region have not reduced the maternal mortality  by three quarters as stated in the MDG Goal.^[5] 

Malaysia’s maternal mortality ratio is one of the lowest in the 12 Asian countries. According to the 2005 WHO/UNICEF/UNFPA maternal mortality estimates Malaysia records a maternal mortality ratio of 41 per 100,000 live births in 2000, and 62 per 100,000 live births in 2005. The national estimates the maternal mortality in 2000 was reported to be 30 according to the Ministry of Health Annual Report 2004.

 

According to a UNDP Malaysia report in 2004, Malaysia approached the reduction of maternal mortality through six key elements. These include, (i) improved access to, and quality of care of, maternal health services, including family planning, by expanding health care facilities in rural and urban areas; (ii) investment in upgrading the quality of essential obstetric care in district hospitals, with a focus on emergency obstetric care services; (iii) streamlined and improved the efficiency of referral and feedback systems to prevent delays in service delivery; (iv) increased the professional skills of trained delivery attendants to manage pregnancy and delivery complications; (v) implemented a monitoring system with periodical reviews of the system of investigation, including reporting of maternal deaths through a confidential enquiry system; and (vi) worked closely with communities to remove social and cultural constraints and improve acceptability of modern maternal health services^[6].

 

Critical indicators to comprehensively monitor maternal mortality

5.1.1 Lifetime Risk of Maternal Death

 

The concept of adult lifetime risk of maternal death measured as the probability of dying from a maternal cause during a woman’s reproductive lifespan^[7], is more holistic in comparison to maternal mortality ratio (MM Ratio) and maternal mortality rate (MM Rate). Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the MMRatio or MMRate as a summary measure of the impact of maternal mortality^[8].

 

The lifetime risk of maternal death in Malaysia is 1 in 560, as compared to 1 in 1 300 in China. 

 

5.1.2 Maternal deaths due to unsafe abortion

In Malaysia, unsafe abortion accounts annually for one to five deaths in the last 10 years according to the Confidential Enquiry into Maternal Deaths by the Ministry of Health.^[9] It is important to understand that providing access to safe abortion services is a critical intervention to reduce maternal deaths in these contexts.

 

Actual Voices from the Ground

Study:

 

1. ‘A Study of Knowledge, Attitudes and Understanding of Legal Professionals about Safe Abortion as a Women’s Right’ was conducted by ASAP in 2008-2009. The study was conducted with local partner in Malaysia Reproductive Rights Advocacy Alliance Malaysia (RRAAM). The court is a powerful arena to effect changes in society. Through the avenue of the courts, restrictive laws may be stricken down as invalid; failure to implement the law by state agents, may hold these state agents liable, in their official as well as personal capacity; refusal to heed the requirements of the law, may also compel the courts to enforce compliance by these state agents. Legal profession, when used in this study, however, does not simply refer to those who have had formal schooling in law and are bestowed the titles as such. This study adopts an expanded definition of the legal profession and includes also legislators, high ranking police personnel, jailers, medical practitioners, head of hospitals, and other persons who are tasked with the implementation of the law, as well as those whose opinion and experience may be given weight in legal and policy advocacy. While the members of the legal profession are important agents of change in society, they cannot effect lasting change on their own. We recognize that these changes in the field of law and policy need to be propelled and informed by the experiences and wisdom of those at the ground level in the implementation of the law. The study findings are expected to help in a greater understanding of the perspectives of this group and will inform future capacity building, attitude reconstruction efforts and the development of advocacy tools for action. This study is unique in its attempt to move beyond the women/community-provider interface and look at gatekeepers outside the service provision field.  To read the study, please click here

 

5.2 Proportion of births attended by skilled health personnel:

Proportion of births attended by skilled health personnel:  

a.    2001: 96.6^[10]

b.    2006: 98^[11]

c.    2007:

A skilled attendant, according to WHO, refers to “an accredited health professional-such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained or untrained are excluded from the category of skilled health workers.

Skilled attendants at birth reached a full 100% in 2006 in Malaysia^[12]. Another UN estimate on skilled attendants at birth point to 98%. This data points to the fact that almost all the deliveries in Malaysia are attended by skilled health personnel.

Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic and comprehensive emergency obstetric care services and post-partum care 

The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important^[13].

Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a functioning health system with a basic and comprehensive level of obstetric care, including surgery and blood transfusions in case of complications. The key to maternal death reduction is universal access to emergency obstetric care which is a major challenge in most of the Asian countries.

It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b) postpartum care so as to reduce maternal deaths meaningfully.

5.2.1 Access to emergency obstetric care

Malaysia’s investments in its health delivery system started as early as 1960, and have been systematic and based on community needs with the aim of ensuring that basic health services are available, accessible, and affordable to all. The development of basic health infrastructure through the rural health service programme during the 1960s and 1970s, with links to district hospitals, provided for the availability of basic health care to the rural population of which maternal and child health care was the major component. The conversion of the three-tier to the two-tier system in the mid-1970s improved availability and coverage, increased accessibility to a broader range of health services, including curative care, and improved quality of MCH services provided by higher trained personnel at the first level of contact^[14].

 

The conversion of the midwife to the community nurse from 1975 illustrates this.

Subsequent upgrading of the health delivery system from the 1980s includes measures such as creating separate blocks for maternal and child health services; upgrading human resources; expanding the scope of maternal and child health services, with specific strategies to reduce maternal mortality; building nucleus concept district hospitals; implementing flexible referrals and availability for emergency obstetric care; increasing accessibility to remote areas and underserved population groups through outreach services; developing the Health Management Information System and Quality Assurance programmes to improve data collection and utilization; and monitoring and upgrading quality of care^[15].

 

Malaysia has progressed in the 1990s with further upgrading of physical infrastructure of health centres, klinik desa (rural health clinics), and district hospitals to allow for wider coverage in urban and rural areas; expanding the scope of services in curative and diagnostic aspects; and development of new programmes for health promotion for all women, the elderly, and adolescents. In the 1990s, low-risk maternity centres were established in urban areas in response to women’s preference for institutional delivery, as a result of efforts to provide safe deliveries closer to communities^[16].

 

5.2.2 Post partum care

 

A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.

 

The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital setting.^[17] 

Malaysia’s investments in its health delivery system started as early as 1960, and have been systematic and based on community needs with the aim of ensuring that basic health services are available, accessible, and affordable to all. The development of basic health infrastructure through the rural health service programme during the 1960s and 1970s, with links to district hospitals, provided for the availability of basic health care to the rural population of which maternal and child health care was the major component. The conversion of the three-tier to the two-tier system in the mid-1970s improved availability and coverage, increased accessibility to a broader range of health services, including curative care, and improved quality of MCH services provided by higher trained personnel at the first level of contact.^[18] 

 

5.3 Adolescent birth rate (per 1000 women):

a.    2000: 12.0^[19]

b.    2005: 12.6^[20]

c.    2007:

 

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19^[21].

The adolescent birth rate in Malaysia remained almost stagnant at 12.6 in 2005.  

Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive morbidity and mortality. Early childbearing  also impedes the overall development of teenage girls and their access to education and labour force participation.

 

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage, the legal age at marriage and access to sex and sexuality education

5.3.1 Median age at marriage

 The singulate mean age at marriage among females (an indirect measure based on the proportion never married at each age group) increased from 18.5 years in 1947 to 25.1 in 2000. Chinese women are marrying later, at about age 27.0, compared with Malays (24.8) and Indians (25.4)^[22].

5.3.2 Legal age of marriage 

The legal age at marriage is 18 for women and 18 for men. There are also pre-conditions for parental approval in some countries. In Malaysia, for example, individuals aged 18–21 need written parental consent to get married.

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.^[23] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.^[24] 

Malaysia has not yet started a comprehensive provision of sex education in schools as part of the school curriculum

5.3.4 Access to reproductive health services for adolescents within the public health system

Data is not easily available, but anecdotal evidence suggests that married adolescents, compared to unmarried adolescents, have easier access through the public health systems. 

Voices from the ground:

News/Magazine articles:

a.    This article focuses on a 17 year old girl, and how she abandoned her baby because she was afraid of condemnation from her parents and teachers. It also mentions the large numbers of teenage pregnancies and the abandonment of babies and this is blamed on the lack of reproductive and sexual health education especially in secondary schools. Read the article here

b.    This article blames the ignorance of youth on sex mainly on the minimal attention paid to this issue. It also has links to other stories such as that of a young girl who was arrested because she did not know what to do with her dead newborn baby. Read the article here

 c.    This article talks about dangers young people may face due to lack of sexual education. It emphasizes on the importance of sexual education and the fact that young children need it as they are all vulnerable to rape, abuse and incest but they may not know what is happening to them or what they should do.Read the article here  

Malaysia’s ICPD+15 Country Case Study

a.    The Malaysia country study aims to monitor the extent to which the specific ICPD agreements made by the Malaysian government have been achieved in the areas of: reducing unwanted pregnancies, the unmet need for contraception,and the barriers to contraceptive use; comprehensive and rights-based sex education and more available SRHR services for young people; increasing access to legal abortion, decreasing repeat abortions and improving provider training. Read the Case Study here

 

5.4 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:

a.    2000:

b.    2005:

c.    2007: 54.5^[25]

In Malaysia, the CPR in 2007 was estimated at 54.5.  The CPR has remained rather stagnant over the past 2 decades.

 

 

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

 

5.4.1 Range of contraceptive methods available.

Access to modern methods seems to be an issue as 45.32% of all contraceptive users rely on traditional methods.

 

5.4.2 Provision of informed choice service provision. 

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods.^[26] However, data is not readily available for Malaysia for this indicator.

 

5.5 Unmet Need for contraception:

 

a.    2000:

b.    2005:

c.    2007:

 

Data is not available for unmet need in Malaysia.

Generally women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to ensure access to contraception to all groups of women.^[27] 

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”^[28] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.^[29] 

 

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

 

5.5.1 Total and Wanted Fertility Rates

 

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need.

Wanted fertility rates compared to Total Fertility Rates

 

a.    Total Fertility Rate (2005): 2.9^[30]

b.    Wanted Fertility Rate (2005)

c.    % difference

 

Data is also not available for wanted fertility rates in Malaysia.^[31]

 

5.5.2 Reasons for non-use of contraception

 

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in Southeast Asia.^[32] Despite a stagnating, average CPR data is not available on the reasons for non-use of contraception in Malaysia.

 

5.6 Antenatal care coverage

a.    At least one visit (%):

Ø  2003: 73.6^[33]

Ø  2007: 78.8^[34]

Ø  After 2005:

b.    At least four visits(%):

Ø  2003:

Ø  2007:

Ø  2007: