Malaysia has successfully reduced maternal mortality through several efforts which, in the broad sense, include (i) the overall socio-economic development of the country; (ii) strengthened health services; and (iii) specific efforts and initiatives for the reduction of maternal mortality, one of which is the audit of maternal deaths by the confidential enquiry into maternal deaths.
The phases of maternal mortality reduction in Malaysia
Maternal mortality reduction can be broadly classified into three phases (Figure 1). The first phase was from 1933 to 1957 when Malaya was under British rule until the nation gained independence in 1957. Maternal mortality was high and was identified as a major health problem to be given priority. This led to a strong political commitment from the founding fathers and the Government of Malaya. The foundations were laid for the development of maternal and child health services. The professionalisation of midwifery had its foundations in the passing of the Midwives Ordinance in 1954 and its subsequent revisions. Midwives were regarded as professionals and received a high standing in society, especially in the rural areas. The key role of these care providers in remote areas was therefore ensured.1-3
The second phase was from 1958 to 1975. The maternal mortality ratio (MMR) was moderately high but was rapidly declining. The health system was strengthened by improving better access for all but especially for disadvantaged people, in particular the rural poor, and a more enabling environment was created by the concomitant programmes for improved water and sanitation, disease prevention, nutrition etc. Partnerships with Traditional Birth Attendants (TBAs), including training, were also strengthened, as an interim short-term measure while adequate numbers of skilled birth attendants (community nurses and midwives) were being trained.4, 5
The third phase can be traced from 1976 to the present day. The relatively low MMR underwent further decline, and despite the difficulty of attaining yet further declines, continued efforts are in place to try and achieve this. This third phase saw the consolidation of past gains, by further capacity strengthening and introducing several specific initiatives to further lower MMR, such as the meticulous auditing of maternal deaths using confidential enquiry into maternal deaths (CEMD), which began in 1991. The origin of the CEMD system in Malaysia can be traced to a landmark meeting of top policy makers from the Ministry of Health, obstetricians and gynaecologists, and Family Health officers held in 1987.6 At that time it was felt that the existing system of maternal mortality audit, then held at the local and state levels only, needed to be escalated to a full formal national audit with involvement of the policy makers who were in the position to make system changes whenever required.7
Lessons were learnt—that maternal deaths can be reduced! Success breeds success and there was motivation to continue the gains through both strong political commitment and sound technical advice.
The role of family planning
These two lessons drove continued emphasis on the Family Planning Policy in Malaysia, which changed from family ‘limitation’ to family ‘spacing’ with effective contraception. There was full integration of family planning services into every community health clinic in Malaysia. Today, the focus of the policy for Malaysia is not on the demographic interest of population control (which may be the main goal for some countries), but on the health perspective—to ensure both maternal and child health, and by extension, family wellbeing, through optimal child spacing. In the initial years of the programme, the focus was, and to a large extent still is, on coverage (measured by acceptance or contraceptive prevalence rates). Family planning has since begun to examine the (unmet) needs and quality of the service. This includes the issues of ensuring an adequate range of method choice, women-friendly approach and more involvement of men.
The range of contraceptives provided has been extended over the last 4 years through the efforts of the National Drug Committee.
Professional care at birth
Every delivery should be a safe one. The safe delivery rate in Malaysia, i.e. delivery conducted by a trained person, is close to 98.5%. The reduction in maternal mortality has mirrored the rise in the safe delivery rate. The biggest contribution to maternal survival is ‘safe’ delivery—a delivery conducted by trained personnel. The best possible setting for this is the hospital, where there are facilities for emergency procedures. Therefore one of the earliest strategies of the MCH programme was to encourage more hospital deliveries, with priority for ‘high-risk’ pregnancies. The introduction of a government midwife for home deliveries, which has been in place since the 1950s, ensured safe delivery for rural Malaysian women. By the mid-1970s, the cadre of ‘community nurse’ was introduced who, besides midwifery, is also trained in other aspects of maternal and child care.8 Taking into consideration the popularity of TBAs and their relevance in some areas, the government forged a partnership between TBAs and government midwives. The TBAs were given training (in particular in avoiding harmful practices), provided with a delivery kit, registered in a special registry and were required to report to the government midwife the deliveries conducted. The registration of TBAs was allowed for a period of 10 years under the Midwifery Act provided these conditions were met. This was one of the important lessons of the Malaysian experience, i.e. working together with the TBA and not isolating them.9, 8, 10
Many women with a ‘low’ or ‘moderate’ degree of risk who should deliver in a hospital may refuse to do so. Instead of allowing the delivery to occur at home such women are delivered in an alternative birthing centre, usually located in an extension of the health centre, which may be more acceptable to the woman. This means that trained midwifery personnel, doctors and transport are available and that emergency measures can be instituted.8, 10
Most maternal deaths occur in the postpartum period (Figure 2). Several changes have been introduced so that there is now individualised nursing care for high-risk mothers. The midwives who cared for the mother in the antenatal period are informed so that they follow-up the mother postnatally and detect any problems early.11, 12 Checklists have been introduced and supervisory visits have been increased. There have also been efforts to involve the private sector using the provision of the Private Healthcare and Facilities Act of 1998 and its Regulations (2006) which require private doctors to provide the required feedback as dictated by circulars from the Director-General of Health to the health sector.13
Evolution of the CEMD system
The chairmanship of the CEMD national committee passed from the Director of Family Health to a senior obstetrician. After that change, it was occasionally found that recommendations and remedial actions were delayed in their implementation. The Director-General of Health initiated a system of maternal death reviews, with every maternal death reviewed in the presence of the State Director of Health and the State Obstetricians. This ensures a focus on health system issues, where prompt remedial actions are required. With this system in place, dissemination and implementation of decisions are promptly carried out.
The cost of the CEMD is absorbed under the Ministry of Health. Budgetary constraints have never been a problem and all CEMD activities are supported and take place.
The term ‘substandard care’, which was initially used from 1991 to 1997, was changed to ‘remediable factors’, which is indicative of a more positive impact on the care givers. This was also in line with the patient safety movement, which emphasised that many remediable factors are systemic in nature rather than individual in nature.14
Currently, only direct and indirect maternal deaths of citizens of Malaysia are included in the statistical calculation of the MMR for Malaysia but all deaths including fortuitous deaths of non-citizens are reviewed by the CEMD system. This was important because there are important lessons to be learnt from every death.
Identification of maternal deaths
There have been noticeable improvements in the reporting systems for maternal deaths. Data are now collated between the Vital Statistics, run by the Department of Statistics, Malaysia and the Family Health Division of the Ministry of Health, which serves as the secretariat for the CEMD system. Congruence in data between Vital Statistics and Ministry of Health data has now occurred. This was in contrast to 1991 when the CEMD data showed a doubling of the MMR compared with that reported by the Department of Statistics, Malaysia.
To overcome the disparity in reported rates, efforts were made to improve reporting by encouraging the active capture of maternal deaths. Soon after the introduction of the CEMD, the Department of Registration was requested to include on the death certificate of every woman who had died, information as to whether she was pregnant, or had delivered in the past 42 days.
The benefits of CEMD
The CEMD reports provide evidence-based information to support budget requests in the Ministry of Health. This has resulted in budget allocations for areas of services that need strengthening, including provision for alternative birthing centres in rural and urban settings, provision of communications systems for remote areas and provision of equipment for haemoglobin estimation to provide for effective management of anaemia in pregnancy.
A budget was also provided for home-based, patient-carried maternal records so that there was better continuity of care by the primary health and hospital sectors (both public and private). These cards also encouraged the mothers to have responsibility for and ownership of their health and provided health education because these records carried important health messages on nutrition and frequency of antenatal visits and warning signs of obstetric emergencies.
A budget was also provided for human resource skill improvement through training. Training modules were developed for the most important causes of maternal mortality—postpartum haemorrhage, hypertensive disease of pregnancy, heart disease in pregnancy—and more recently a guide on management of venous thromboembolism was developed.
The CEMD allowed for improvement in healthcare provision based on the remedial factors identified in the audit. Examples of these included the use of partograms in the health setting and at home, protocol development (such as for anaemia), conduct of combined interdisciplinary clinics for medical disorders in pregnancy and the creation of the red alert system in hospitals, which allowed for rapid mobilisation of specialists in obstetrics and gynaecology as well as anaesthesia and support staff for obstetric emergencies such as postpartum haemorrhage, eclampsia and collapse.15, 16
Medical causes of maternal deaths
We are now witnessing a changing trend in maternal deaths from direct obstetric causes to indirect maternal deaths and fortuitous deaths (Figure 3, Table 1). This change emphasises the fact that efforts in training as well as improvements in the quality of obstetric care have had an impact.
- Data are given as n (%).
Deaths related to termination of pregnancy have not featured prominently in the CEMD. Each year, there are on average five deaths related to termination of pregnancy (Figure 1). There is under-reporting of abortion data in the CEMD but we are confident that the number of deaths related to termination of pregnancy is reported with the robustness of the system. Following an amendment to the Penal Code in 1987, Malaysia permits the termination of pregnancy by a medical practitioner if the pregnancy would endanger the woman's physical or mental health. In September 2012 a termination of pregnancy guideline was developed and released by the Ministry of Health for use in public hospitals.17
The introduction of training manuals in the management of hypertensive disorders in pregnancy, postpartum haemorrhage and cardiac disease in pregnancy have made it possible for all involved in maternal care to be constantly trained and updated. Furthermore, work is in progress to finalise a training manual for the management of obstetric embolism.11, 12
The increasing caesarean section rate has resulted in an increase in the repeat caesarean section rate. This has led to a worrying trend in the incidence of morbidly adherent placenta. To best manage this dreaded complication, a guideline on the management of adherent placenta was developed.18
Empowerment of midwives was a key component of the CEMD activities. This included a colour-coding system used during antenatal care that was designed to streamline referrals by midwives to the hospitals. A woman given a red code by a midwife could be admitted to a specialist hospital immediately without any hindrance or question.19
Midwives are now allowed to continue heparin for thromboprophylaxis, give antenatal steroids to mothers with preterm labour and give intramuscular magnesium sulphate under guidance from protocols from the Ministry of Health.16
An improved career structure for midwives has also been discussed at the highest levels of the civil service in Malaysia and we hope to see a positive impact in the near future. Some labour wards in the public hospitals allow midwifery-led care for appropriately selected women in specialist hospitals.16
Factors ensuring success of the CEMD in Malaysia
- Political will and top management commitment to the reduction of maternal mortality and improving the status of women.
- A multi-sector approach by including all stakeholders in women's health, and adopting other ‘newer’ paradigms, such as the patient safety movement using the systems approach.
- Commitment to organisation and management with skills upgrading of health personnel.
- Investing in facilities and manpower for maternal health.
- Optimising the basic health system that already exists with the principle to build on what exists and not create new structures.
- Making special efforts for maternal health and reduction of maternal mortality, including maternal death audit at local, state and national level (CEMD).
- The evolution of key performance indicators in public service that integrate major factors from the CEMD so that improvement is sustained. This has included target setting for massive obstetric haemorrhage, recurrent eclamptic fits and deaths from heart disease.
Many lessons can be learnt from the Malaysian success story of reducing maternal mortality in a sustained way over the last 50 years. There must be an organised effort to analyse the cause of maternal deaths and a systematic effort to address the remedial factors. The journey has not been smooth or easy but hiccups have been quickly overcome because of a common shared vision.
Malaysia has shared its experiences of its CEMD with its neighbouring countries and at international meetings. The country was able to change the status of maternal health by ensuring professionalisation of its midwifery services, expanding access to deliveries by trained personnel, ensuring a reliable and rapid referral system, providing mothers with necessary medicines, equipment and support; ensuring the availability of emergency obstetric care throughout the nation and focusing efforts on sustaining quality of care. One important lesson learnt has been that the CEMD must remain a confidential and nonpunitive system to ensure its success in achieving systems improvement.
Disclosure of interests
JR and JR are members of the Confidential Enquiries into Maternal Deaths, Malaysia and are employees of the Ministry of Health, Malaysia.
The authors wish to thank the Director-General of Health, Malaysia for granting permission to publish this article.