NATIONAL STRATEGIC PLAN OF ACTION TOWARDS ACHIEVING MILLENNIUM DEVELOPMENT GOALS (MDG) 4 & 5

By:

DIVISION OF FAMILY HEALTH DEVELOPMENT MINISTRY OF HEALTH MALAYSIA JANUARY 2011

CONTENTS Tables ............................................................................................ Figures ........................................................................................... Foreword ........................................................................................ 1 2. Background .................................................................................... Millennium Development Goal 4: Reduce Child Mortality .............. 2.1 Situational Analysis ................................................................ 2.1.1 Infant Mortality Rate (IMR) .......................................... 2.1.2 Under-5 Mortality Rate (U5MR) ................................... 2.1.3 Proportion of One-year olds Immunised Against Measles ....................................................................... 2.2 Past and Future 2.2.1 Trend of IMR and U5MR with Interventions 2.2.2 Projection of IMR and U5MR 2.2.3 Targets for IMR and U5MR by States for 2015 3. Millennium Development Goal 5: Improve Maternal Health............ 3.1 Situational Analysis ................................................................ 3.1.1 Maternal Mortality Ratio (MMR) ................................... 3.1.2 Contributing Factors for the Maternal Death................ 3.1.3 Proportion of Births Attended by Skilled Health Personnel ................................................................... 3.1.4 Contraceptive Prevalence .......................................... 3.1.5 Adolescent Birth Rate ................................................. 3.2 Past and Future 3.2.1 Trend of MMR with Interventions ................................. 3.2.2 Projection of MMR ....................................................... 3.2.3 Targets for MMR by States for 2015 ........................... 4. 5. 6. 7. Conclusion ..................................................................................... The Way Forward ........................................................................... References ..................................................................................... Contributors .................................................................................... TABLES Table 1: Goals, Target and Indicators for MDG 4 and MDG 5 9-10 2 3 4 9 11 11 11 13 15 16 16 17 18 19 19 19 21 22 22 24 25 25 25 27 28 28 29 30

Table 2: Table 3:

Under-5 death, IMR by States, 1990 and Targets for 2015 Maternal death, live births and MMR by states, 1998, 2000 and 2007

18 20

Table 4: Table 5:

Causes of Maternal Death 1997 and 2007 Targets of MMR by States for 2015

21 27

FIGURES Figure 1: Figure 2: Infant and Under-5 Mortality Rates, Malaysia, 1970-2008 Infant and Neonatal Mortality Rates in Malaysia,1990-2007 11 12

Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Figure 10: Figure 11: Figure 12: Figure 13: Figure 14: Figure 15: Figure 16:

Top 6 causes of Infant Death (government hospitals) IMR by states 2002-2006 Causes of Under-5 Death (government hospital) Proportion of under-5 Deaths for hospitals and non hospitals Under-5 Mortality Rates by States, Malaysia 2002-2006 Proportion of 1 year-olds immunised against measles Intervention and Trend of infant and under-five mortality rates 1955-2007 Projection of infant and under-five mortality rates by 2015 Maternal Mortality Ratio, 1950-2008 Safe delivery and antenatal care Contraceptive Prevalence Rate in Malaysia Age Specific Fertility Rate among women aged 15-19 years by ethnic groups Intervention and Trend of MMR, 1933-2005

12 13 14 14 15 16 16 17 19 22 23 24 25

Maternal Mortality Ratio 2000-2008 and Projection for 2015 26

FOREWORD
OPENING MESSAGE BY Y.BHG. TAN SRI DATO SERI DR. HJ. MOHD ISMAIL BIN MERICAN DIRECTOR GENERAL OF HEALTH MALAYSIA 25th June 2010 9:00am 12noon Bilik Gerakan, Level 4, Block E7, Putrajaya MEETING ON MILLENNIUM DEVELOPMENT GOAL (MDG) 4 DAN 5: HOW IS MALAYSIA FARING

1.

INTRODUCTION The Millennium Development Goals (MDG) was agreed upon by 189 world leaders at the United Nations Summit in September 2000. It consists of 8 goals, 21 targets and 60 indicators, with special relevance to population, development and health. The target year for achieving the MDGs has been set for 2015, with 1990 being the baseline. Of these 8 MDGs, only MDG4, 5 and 6 are directly related to health, though the health sector has a stake in the other MDGs as well. Malaysia has set to achieve the various MDGs by 2015. MDG4 & 5 are of concern because, although Malaysia has made remarkable progress in the reduction of both child and maternal mortalities since independence, from the year 2000 both mortalities have been more or less stagnant. If we do not intervene now, Malaysia will not be able to achieve the set target for MDG4 & 5 by 2015.

2.

MDG 4 AND 5 2.1 MDG 4 is to reduce child mortality by two-thirds, between 1990 and 2015 and the three indicators for monitoring the progress are: Infant mortality rate (IMR) which steadily declined from 40.8 per 1,000 live births in 1970 to 13.1 in 1990 (reduction of 68% in 20 years), and it further reduced to 6.5 in 2000 (reduction of 50% in 10 years). The IMR in 2008 was 6.4 (reduction of only 1.5% in 8 years). The target by 2015 is 4.4 (based on two thirds of 1990 data i.e 13.1).

Under-5 mortality rate declined from 57 per 1,000 live births in 1970 to 16.8 in 1990 (reduction of 70% in 20 years) and it further reduced to 8.9 in 2000 (reduction of 47% in 10 years). In 2008, the rate was 8.1 (reduction of 9% in 10 6

years). The target by 2015 is 5.5 (two thirds of 1990 data i.e 16.8). Proportion of 1 year old children immunized against measles increased from 70% in 1990 to 94.3% in 2008. The target is for more than 95% coverage by 2015. Among the above three indicators mentioned, immunization against measles is achievable. The major cause of IMR and Under-5 are linked with the neonatal period (55%). The most common cause of neonatal deaths are immaturity, lethal congenital malformation and asphyxia neonatarum. 2.2 MDG 5 is to improve maternal health. There were two indicators initially for this goal; maternal mortality ratio (MMR) and safe deliveries. In 2005, another four indicators were added for universal access to reproductive health. The two indicators that have been showing good progress are: Proportion of birth attended by skilled health personnel, which has increased from 92.9% in 1990 to 98.6% in 2008 (target - to achieve more than 90%). Antenatal coverage which has increased from 78% in 1990 to 94% in 2008 (no target set) However, there is poor progress since last decade in the following indicators: Maternal mortality ratio (MMR) declined from 140 per 100,000 live births in 1970 to 20 in 1990 (reduction of 85% in 20 years). However, with the establishment of Confidential Enquiries into maternal deaths (CEMD) in 1991, the MMR was 44 per 100,000 live births. MMR declined from 44 in 1991 to 28.1 in 2000 (reduction of 32% in 19 years). Since 2000, MMR has plateauted and was 28.9 in 2008. The target by 2015 should be 11 (reduction of three quarters based on 1991 data), however, the target has been adjusted and agreed to 20. Even though there is no target set, the contraceptive prevalence rate (CPR) has declined from 54.5% in 1994 to 51.9% in 2004 (CPR in Sri Lanka 70, Singapore 62 in 2004). The other two indicators without any targets set are: Adolescent birth rate declined from 28 in 1990 to 13 in 2008 Unmet needs for family planning 3. SUMMING UP I look forward to todays discussion to see the big picture from the public healths perspective and the specific interventions in obstetric and pediatrics services that can narrow the gaps and give maximum impact in the next five years. 7

OPENING MESSAGE BY Y.BHG. TAN SRI DATO SERI DR. HJ. MOHD ISMAIL BIN MERICAN DIRECTOR GENERAL OF HEALTH MALAYSIA 1st November 2010 9:00am 1.00pm Bilik Gerakan, Level 4, Block E7, Putrajaya MESYUARAT PROGRES PERLAKSANAAN KE ARAH MENCAPAI SASARAN MILLENNIUM DEVELOPMENT GOALS MDG 4 dan 5 1. WHERE ARE WE? This meeting is a follow up of the 1st meeting, which I chaired on 25th June 2010. During that meeting, it was informed that Malaysia has committed to achieve the 8 MDGs by 2015, however, MDG4 & 5 are of concern because, both child and maternal mortalities from the year 2000 have been more or less stagnant. Maternal and child mortality tragedies can be easily averted. We know how to prevent these needless deaths and effective interventions exist. This is what makes these deaths doubly tragic.
2.

CALL TO ACTION I have been informed that following the 25 th June 2010 meeting, several other meetings have been held to discuss in depth the strategies required to attain MDG4 & 5. The presentations today from the public health, obstetric and pediatrics services will show us the approach and direction which we will be heading in the next five years. The specific interventions discussed should narrow the gaps and give maximum impact by 2015.

3.

SUMMING UP

We have another 1,886 DAYS (5 years, 2 months) left. No child below five years old should die and no woman should die giving life in Malaysia. We must hold each other accountable. We have a tremendous responsibility to do what we must do - now!

TALKING POINTS Y.BHG TAN SRI KETUA PENGARAH KESIHATAN MESYUARAT KPK KHAS BIL. 5/2010 22 NOVEMBER 2010 Millenium Development Goals (MDG 4&5) 1. Malaysia telah memberi komitmen untuk mencapai sasaran MDG menjelang 2015, namun MDG 4&5 dikhuatiri sukar untuk dicapai kerana tren kematian ibu dan kanak-kanak didapati mendatar semenjak tahun 2000. Semua negeri perlu sedia Pelan Tindakan dan pencapaian akan dipantau pada setiap Mesyuarat KPK Khas. Mulai tahun 2011, MDG 4&5 dijadikan sasaran dalam SKT Pengarah Kesihatan Negeri.

2.

Strategi sedia ada perlu disemak untuk penambahbaikan dan cabaran dalam penjagaan kesihatan ibu dan kanak-kanak perlu dikenalpasti dan diatasi. Perkara berikut perlu diberi keutamaan; - Combined clinics - Red Alert system - Klinik Pra-kehamilan - Menyediakan perkhidmatan perancang keluarga di hospital - Memaklumkan klinik kesihatan berkenaan bagi setiap kes yang di discaj dari hospital agar lawatan postnatal boleh dijalankan - Membuat semakan dan mengukuhkan perkhidmatan retrieval services Pengarah Kesihatan Negeri juga perlu memastikan tindakan berikut diambil; mempengerusikan mesyuarat Kematian Ibu dan kanakkanak peringkat negeri. Unit Kawalan Amalan Perubatan Swasta disarankan menjadi ahli tetap mesyuarat , kerana terdapat kematian ibu dan anak di hospital swasta dan rumah bersalin. Pegawai Kesihatan Daerah menjalankan mesyuarat Kesihatan Ibu dan Kanak-kanak pada setiap bulan. Semua doktor dan anggota kesihatan primer menjalani kursus dalam perkhidmatan bagi pengendalian kecemasan obsterik. Semua doktor dan jururawat baru di credentialed dalam perkhidmatan obstetrik dan pediatrik sebelum dihantar ke peringkat kesihatan primer. 9

3.

 Pengarah hospital hendaklah membuat audit dan pemeriksaan mengejut ke wad, dewan bedah, wad bersalin dan persekitaran. Pakar Perunding O&G dan pediatrik Negeri mesti menjalankan ward round setiap hari dan sentiasa dapat dihubungi. Mereka hendaklah membimbing pegawai-pegawai dibawah seliaan mereka supaya kompeten dan mahir. Memastikan pakar O&G bertugas di wad bersalin 24 jam dan memberi perkhidmatan kaunseling perancang keluarga Semua jururawat yang telah menjalani latihan post basik ditempatkan mengikut disiplin Memperkukuhkan aktiviti lawatan rumah mengikut jadual yang ditetapkan Ketua Jururawat Kesihatan Daerah mengaktifkan kembali aktiviti lawatan ke hospital yang berdekatan setiap hari untuk mendapatkan maklumat terkini berkaitan dengan ibu mengandung, kanak-kanak bawah 5 tahun, kematian dan kelahiran

10

1. BACKGROUND
In September 2000, 189 Heads of State endorsed the United Nations Millennium Declaration. The declaration was translated into eight Millennium Development Goals (MDGs) to be achieved by 2015. Progress towards achieving the MDGs is monitored through measurable targets and indicators for each MDG. Table 1: Goals, Targets and Indicators for MDG 4 and MDG 5 Goals and Target Target in 2015 (MALAYSIA)

Indicators for Monitoring Progress Goal 4: REDUCE CHILD MORTALITY Target : Reduce by two-thirds, between 1990 and 2015, the under 5 mortality rate i. Under 5 mortality rate ii. Infant mortality rate iii. Proportion of oneyear-old children immunized against measles.

5.5/1000 live births

4.4/1000Livebirths >95.0%

Goal 5: IMPROVE MATERNAL HEALTH Target 5A: reduce by three quarters, between 1990 and 2015, the Maternal Mortality Ratio i. Maternal mortality ratio 11/100,000 Live births (reduction of based on 1991 data) >95.0%

ii. Proportion of births attended by skilled health personnel i. ntraceptive prevalence rate ii. Ad olescent birth rate 11 Co

Target 5B : Achieve by 2015, Universal Access To Reproductive Health

60% (for modern methods)

7/1000 female population 1519 years

Goals and Target

Indicators for Monitoring Progress iii. Ant enatal care coverage (at least one visit and at least four visits) iv. Un met need for family planning

Target in 2015 (MALAYSIA) > 95.0 %

25.0% (modern methods) 36.2% (2004) for modern methods

12

2. MILLENNIUM DEVELOPMENT GOALS (MDG 4): REDUCE CHILD MORTALITY

2.1 Situational analysis Malaysia has shown good progress with MDG 4. The progress made is evidenced by the reduction of the under-5 mortality rate (U5MR) and also IMR. 2.1.1 Infant Mortality Rate (IMR) The infant mortality rate has reduced from 39.4 per 1,000 live births in 1970 to 13.0 per 1,000 live births in 1990 and then to 6.2 per 1,000 live births in 2008.The infant mortality rate was halved from 1990 to 2000. It has since stabilised around 6 per 1000 live births. (Figure 1.) Similarly the neonatal mortality rate (deaths in the first 28 days after birth) has been halved from 1990 to 2008, from 8.5 per 1000 births to 4.0 per 1000 births (Figure 2). Figure 1: Infant and Under-5 Mortality Rates, Malaysia, 1970-2008

13

Figure 2: Infant and Neonatal Mortality Rate Malaysia, 1990-2007

Source: Department of Statistics, Malaysia

Among the leading causes of infant mortality are the broad class of conditions classified as certain conditions originating congenital in the perinatal period, followed by and malformations, desformations

chromosomal abnormalities (Figure 3). Figure 3 : Top 6 causes of Infant Death (government hospitals)

14

Source: Health Informatics Centre, MOH

Figure 4 shows the states that have achieved higher IMR for 2006 in comparison to the national average of 6.2 per 1,000 live births. Figure 4: Infant Mortality Rates (IMR) by states 2002-2006

6.2

1 6
Source: Health Informatics Centre, MOH

1 4
15

1 2

2.1.2 Under-5 Mortality Rate (U5MR) There was a large reduction in U5MR from 57 per 1,000 live births in 1970, to 16.8 per 1000 live births in 1990 (Figure 1). Since 1990, the U5MR has declined at a slower pace to reach 8.1 in 2008.The leading causes of under-5 mortality are those arising in the perinatal period followed by congenital malformation, infectious and parasitic diseases, respiratory diseases, and circulatory diseases (Figure 5). More than three quarters of underfive deaths occurred in hospitals. Data from the underfive survey shows an increase in the number of deaths taking place in hospitals (Figure 6), thus increased use of healthcare facilities, but also suggesting that there may be delays in seeking treatment.

Figure 5: Causes of Under-5 Death (government hospitals)

Source: Health Informatics Centre, MOH

Figure 6: Proportion of Under-five Deaths for Hospitals and NonHospitals

16

10 0%

9% 0
Source: Under-5 Mortality Study 2006

8% 0
. Under-5 mortality rates vary in different states, with some states consistently above the national figure of 7.9 per 1,000 live births. (Figure 7) Figure 7: Under-5 Mortality Rate by States, Malaysia, 2002-2006

7% 0

7.9

1 6

6% 0

1 4

5% 0

17

1 2

4% 0

source: Health Informatics Centre, MOH

2.1.3 Proportion of one-year olds immunised against measles Malaysia has achieved almost full coverage of

immunisation of one year-olds against measles. In 2008, 94 per cent of one year-olds were immunised for measles, in combination with mumps and rubella (MMR), up from 70 per cent in 1990. Figure 8 improved immunisation coverage by shows the state. The

apparently low rates for W.P. Kuala Lumpur can be explained by parents seeking immunisation from the private sector and by parents taking their children to the neighbouring state, Selangor, to be immunised. There is weakness in the reporting system of immunisation coverage from the private to the public sector, leading to the inaccuracies. States showing more than 100% coverage was due to immunisation given to children from other states, under registration of live births and coverage of foreigners. Besides routine Immunisation, a catch-up program of measles vaccination to all school children was carried out in 2006. This is essential in providing universal protection against measles in the community. Figure 8: Proportion of 1 Year- Olds Immunised Against Measles

18

2.2

Past and Future 2.2.1 Trend of IMR and U5MR with Intervention Factors contributing to the success in the reduction of child mortality are summarised in Figure 9.

Figure 9: Interventions and Trends of IMR and Under-5 Mortality 19552007

10 0

9 0 INTERVENT

1 5 's 90
Source: Family Health Development Division, MOH

8 0 1 6 's 90 7 0
) % (

2.2.2 Projection of IMR and U5MR Figure 10 shows projection of infant and under-5 mortality rates for 2015. The target is to reduce further IMR and Under-5 Mortality Rate to 4.3 and 5.5 19 - B o t n i c a v G C - D o t n i c a v T P

6 0

5 0

4 0

respectively and this is translated to 2460 infant deaths and 2009 under-5 deaths by 2015. The targets are calculated based on the estimated number of live births for each state, using 2008 data. Figure 10: Projection of Infant and Under-5 mortality rates by 2015

Source : Department of Statistics

8 0
2.2.3 Targets for IMR and U5MR by States for 2015 Table 2 below shows the target for 2015 by states.

7 0

6 0

Table 2: Under-five and Infant Mortality by state, 1990 and target for 2015

5 0

4 0
20

3 0

Calculation were made based on 9.0 % reduction per year from 2008

STATES

U5MR per 1,000 live births 1990 Target for 2015 Number of deaths for 2015 (Target) 2009 254 178 196 66 74 135 156 23 81 110 170 7 342 135 80

IMR (per 1,000 live births) 1990 Target for 2015 Number of deaths for 2015 (Target) 2460 308 224 218 89 95 154 183 27 105 142 208 12 427 173 95

Malaysia Johor Kedah Kelantan Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Sabah Sarawak W.P Labuan Selangor a Terengganu W.P. Kuala Lumpur
a

16.8 16.6 18.8 17.6 13.8 15.6 20.7 17.7 20.7 12.2 21.4 12.7 NA 14.6 20.2 12.0

5.5 5.7 6.2 6.3 5.0 4.8 5.9 4.9 7.2 6.5 8.3 4.6 9.7 3.3 6.0 4.9

13.1 13.4 14.6 13.5 11.1 12.7 15.9 13.2 16.9 10.2 16.3 10.0 NA 11.7 15.3 9.6

4.4 4.6 4.9 4.5 4.2 3.7 3.4 4.4 5.6 3.4 5.6 3.3 3.5 1.5 5.1 1.3

: Including Putrajaya N.A.: Not Available

3.

MILLENNIUM DEVELOPMENT IMPROVE MATERNAL HEALTH

GOALS

(MDG

5):

21

3.1

Situational Analysis 3.1.1 Maternal Mortality Ratio (MMR) Long-term trend of the maternal mortality ratio for Malaysia shows impressive declines (Figure 11). The MMR has undergone a most remarkable transformation in the countrys medical history; a decline from 530 per 100,000 live births in 1950 to 28.9 maternal deaths per 100,000 live births in 2008 (Dept. of Statistics, 2010). A steep decline occurred in the MMR in the decade between 1970 and 1980 when it fell from 141 to 56 per 100,000 live births, a decline of 40 per cent. The rapid decline continued throughout the 1980s such that by 1990 the MMR was just 19 per 100,000 births. Since 2000, the MMR has remained relatively stagnant at around 28-30 per 100,000 live births (Figure 11). Further reductions in the maternal mortality ratio will be more difficult given the fairly low levels achieved thus far and will require a different strategic thrust. Table 3 shows the status of maternal mortality by states.

Figure 11: Maternal Mortality Ratio 1950-2008

Ma rnal m rtalityr tios Mala s 1 5 -2 0 te o a , y ia 9 0 0 8
600 s h 500 t r i b e v i 400 l 0 0 0 , 300 0 0 1 r e 200 p s h t a e 100 D 0 1940 1950 1960 1970 1980 1990 2000 2010 2020 45 35 25 15 1990 1995 2000 2005 2010

S ource: 19 50-1990D ; 1991-2008C MD MOH. OS E ,

Table 3: Maternal deaths, Live Births and Maternal Mortality Ratios by State, 1998, 2000 and 2007

22

State
Number of Maternal Deaths

1998
Live Births (LB) MMR
(per 100,000 LB)

2000
Number of Maternal Deaths Live Births (LB) MMR
(per 100,000 LB)

2007
Number of Maternal Deaths Live Births (LB) MMR
(per 100,000 LB)

Johor Kedah Kelantan Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Sabah Sarawak Selangor Terengganu WPKL
Malaysia

19 15 13 7 2 13 8 1 8 21 8 20 4 14
153

57,091 39,814 45,123 15,951 19,142 29,156 47,956 4,692 26,039 54,738 46,083 81,354 24,995 32,844
524,978

33.3 37.7 28.8 43.9 10.4 44.6 16.7 21.3 30.7 38.4 17.4 24.6 16 42.6
29.1

12 10 9 2 1 7 12 0 1 68 7 28 5 6
168

67,907 41,263 40,641 15,672 19,394 29,724 48,786 4,656 26,826 56,352 50,689 90,514 25,502 31,617
549,543

17.7 24.2 22.1 12.8 5.2 23.5 24.6 0 3.7 120.7 13.8 30.9 19.6 19
30.6

29 11 9 2 5 7 9 2 5 20 11 20 4 3
137

56,865 33,630 33,646 13,260 16,866 24,725 35,990 3,927 22,196 47,535 41,840 94,324 22,213 25,031
472,048

51 32.7 26.7 15.1 29.6 28.3 25 50.9 22.5 42.1 26.3 21.2 18 12
29.0

Source: Department of Statistics

3.1.2 Contributing factors for the Maternal Death

23

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. The number of deaths by causes from the Confidential Enquiry into Maternal Deaths (CEMD) for 1997 and 2007 are shown in Table 4.

Table 4: Causes of Maternal Death, 1997 and 2007

Causes Postpartum Haemorrhage Hypertensive Disorders in Pregnancy Obstetric Embolism Associated Medical Conditions Obstetric Trauma Antepartum Haemorrhage Puerperal Sepsis Abortion Ectopic Pregnancy Unspecified Complications of Pregnancy & Puerperium Associated with Anaesthesia Others Total
Source: Ministry of Health, Malaysia

No. 31 24 18 36 9 3 3 5 2 7 5 15 158

1997 Percentage 19.6 15.2 11.4 22.7 5.7 1.9 1.9 3.2 1.3 4.4 3.2 9.5 100

No. 23 25 24 20 6 2 3 6 7 8 1 11 136

2007 Percentage 16.9 18.4 17.7 14.7 4.4 1.5 2.2 4.4 5.1 5.9 0.7 8.1 100

24

3.1.3 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 per cent in 1990 to 96.6 per cent in 2005 and to 98.6 per cent in 2008 (Figure 12). The data covers all public and private institutions reporting to the Ministry of Health. Some omissions may occur in the case of deliveries in private institutions, but those are captured by the Department of Statistics and verified with the Ministry of Health. Figure 12: Safe Delivery and Antenatal Care

3.1.4 Contraceptive Prevalence The National Population Board conduct and Family Planning Life

Development

National

Family

Surveys (NFLS) on a 10 yearly basis, starting from 1974. A baseline study on family planning in 1966 in Peninsular Malaysia estimated contraceptive prevalence rate (CPR) at 8.8 per cent for married couples. In 1984, the NFLS 25

recorded a prevalence of 51.4 per cent and the most recent survey, in 2004, estimated prevalence was at 51.8 per cent. (Figure 13) Figure 13: Contraceptive Prevalence Rate (CPR) In Malaysia

60 ) % ( e g a t n e c r e p 50 40 30 20 10 0 CPR 1966 8.8 1974 34.4 1984 51.4 year 1994 54.5 2004 51.8

Source: Population profile, Malaysia 1999 National Family Life Surveys 2004

For modern methods, prevalence has remained almost unchanged at around 30 per cent since 1984. The use of traditional methods declined from 22 per cent in 1984 to 16 per cent in 2004. The pill is the most popular method of contraception. However, the percentage of married women in the reproductive age using the pill declined from 18 percent in 1974 to 13 percent in 1994 and 2004. There has been a noticeable increase in the use of IUD, condom, and injection as well as female sterilization since 1974. The rhythm method is by far the most popular traditional method, with a prevalence rate of about 9 per cent in 1994 and 2004. The practice of other traditional methods such as jamu, majun, other herbs, exercise and incantation has declined substantially since 1984 (National Family Life Survey 2004).

26

3.1.5 Adolescent birth rate 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. High birth rates among young women pose risks of maternal mortality and health. Adolescent mothers also have their access to higher education curtailed or have had to terminate their secondary education. Those who are unmarried face a variety of social and economic challenges and problems. Figure 14 shows the age-specific fertility rates among women aged 15-19 years by ethnic groups in Malaysia. Figure 14: Age-specific fertility rates among women aged 15-19 years by ethnic groups

Source: Department of Statistics, Malaysia Others includes non citizens

27

3.2

Past and Future 3.2.1 Trend of MMR with Intervention

Figure 15: Interventions and Trend of Maternal Mortality Ratios, 19332005

3.2.2 Projection of MMR Further reductions in the maternal mortality ratio will be more difficult given the fairly low levels achieved thus far and will require a different strategic thrust (Figure 15). It is targeted that by the year 2015, the MMR will be 11 per 100,000 live births (based on estimated live births in 2008) and this is translated to an estimated 54 deaths. (Figure 16 and Table 5)

28

Figure 16: Maternal Mortality Ratio 2000-2008 and projection for 2015

29

3.2.3 Targets of Maternal Mortality Ratio (MMR) by States for 2015 Table 5: MMR by States for 1991, 2000, 2008 and target for 2015 STATES 1991 2000 2008 2015 (Target) MMR Perlis Kedah P. Pinang Perak Selangor F. T Kuala Lumpur F. T Putrajaya N. Sembilan Melaka Johor Pahang Terengganu 63 62 23 30 30 13 NA 58 49 56 85 27 0 20.3 4 26.1 21.9 20.8 0 29.3 58.2 37.4 40.2 29.3 30 24.7 26.4 36.2 30.9 23.6 20.5 0 42.3 46.0 19.9 36.4 4.4 0 11.0 12.7 10.6 6.8 11.0 0 11.0 13.8 11.8 11.2 12.5 Number 0 4 3 4 7 3 0 2 2 7 3 3

Kelantan Sabah F. T Labuan Sarawak Malaysia

52 57 NA 19 44

33.8 27.9 NA 27.9 28.8

38.7 32.1 0 36.0 28.2

10.7 13.0 0 11.08 11

4 7 0 5 54

Source: Department of Statistic Malaysia and CEMD, Malaysia

4. CONCLUSION
Malaysia has thus made important progress towards the MDG 4 and MDG 5 targets, but a lot more needs to be done, including: improving service provision especially referral, feedback and retrieval systems; and increasing the coverage of maternal and child health services to marginalized groups such as aborigines, the urban poor, immigrants and unmarried women. No significant progress has been made on MDG 4 and 5 since the last decade in Malaysia. The decline is very limited and slow. MDG 4 and 5 requires reducing child and maternal mortality at a much faster rate than the current state. 31

Five years remain until the 2015 decline to achieve the MDGs. Progress is possible, if child and maternal health are sufficiently prioritized at the implementation level and supported by strong political commitment. The strategies need to be streamlined and our challenge now is to scale up the time tested interventions with regular monitoring and evaluation by the middle (state) and high level (ministry) programme management team.

5. THE WAY FORWARD

Plan of Action developed for achieving MDG targets by 2015 are available in the appendices attached. 5.1 National Strategic Plan of Action (Public Health) Appendix 1 5.2 National Strategic Plan of Action (Obstetric) 5.3 National Strategic Plan of Action (Paediatric) Appendix 2 Appendix 3

6. REFERENCES
Yearbook of Statistics 2007, Department of Statistics 2. A Study on Under Five Deaths in Malaysia in 2006, Ministry of Health 3. The Third National Health and Morbidity Survey 2006 Volume 1 and Volume 2.
1.

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6. 7.

The Millennium Development Goals Report 2005, United Nations at http://unicef.org/rightsite/sowc/statistics.php 5. The Millennium Development Goals Report 2009, United Nations Report : National Seminar Towards Achieving The Health Millennium Development Goals (MDGs),13-14 June 2005, Kuala Lumpur (MOH) Report on The Public Forum on The Right to Health: Achieving Health MDGs, Human Rights Commission of Malaysia 8. Malaysia Achieving The Millennium Development Goals 2005, UNDP 9. Report on the Confidential Enquiries into Maternal Deaths in Malaysia 1997-2000, Ministry of Health 10. Report on the Confidential Enquiries into Maternal Deaths in Malaysia 2001-2005, Ministry of Health 11. Annual Report, Ministry of Health 2007 12. Annual Report, Ministry of Health 2005 13. Annual Report, Family Health Development Division (FHDD), Ministry of Health 2009 14. Vital Statistics Malaysia Special Edition (2001- 2006) 15. National Health and Morbidity Survey 111 (Volume 1) 16. http://www.who.int/making_pregnancy_safer/topics/mdg/en/index.htm 17. National Adolescent Health Plan of Action, 2006 to 2020 18. Malaysias Health 2006, Ministry of Health 19. FFPAM-RRAAM Consultation, Increasing Access to the Reproductive Right to Contraceptive Information and Services; Progress at ICPD 15, 21st October 2008 20. The MDGs and Beyond: Pro Poor Policy in a Changing World Number 19, January 2010. International Policy Centre for Inclusive Growth, Poverty Practice, Bureau for Development policy, UNDP
4.

7. CONTRIBUTORS
(alphabetical order)

1. 2. 3.

Dr. Asits Sanna Pegawai Kesihatan Keluarga Negeri, Jabatan Kesihatan Negeri Sabah Dr. Arpah Ali Ketua Penolong Pengarah, Bahagian Perkembangan Perubatan Dr. Che Asiah Bt Taib Pegawai Kesihatan Keluarga Negeri, Jabatan Kesihatan Negeri Pahang

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4. 5. 6. 7. 8. 9.

Dr Chin Choy Nyok Pakar Perunding Kanan Pediatrik, Hospital Tengku Ampuan Afzan, Pahang Pn. Dasimah Bt Ahmad Ketua Penyelia Jururawat, Bahagian Kejururawatan, KKM Dr. Faridah Abu Bakar Pegawai Kesihatan Keluarga Negeri, Jabatan Kesihatan Negeri Perak Dr. Ghazali Ismail Pakar Perunding Kanan O&G, Hospital Sultan Ismail, Johor Bahru Dr. G. Thavamalar Pegawai Kesihatan Keluarga Negeri, Jabatan Kesihatan Negeri Selangor Dr. Hussain Imam Haji Mohammad Ismail Pakar Perunding Kanan & Ketua Disiplin Pediatrik, Institut Pediatrik Hospital Kuala Lumpur Dato Dr. H.S.S Amar Pakar Perunding Kanan Pediatrik , Hospital Permaisuri Bainun, Ipoh Dr. Hamimah Bt Saad Pakar Perubatan Keluarga, Klinik Kesihatan Putrajaya Pn. Habesah Bt Ab. Latif Ketua Penyelia Jururawat, Jabatan Kesihatan Negeri Pahang Dr. Irene Cheah Pakar Perunding Kanan Neonatologi, Institut Pediatrik Kuala Lumpur Prof. Dr. Jamiyah Bt Hassan Pakar Perunding Kanan O & G, Pusat Perubatan Universiti Malaya (PPUM) Dr. J.Ravichandran Pakar Perunding Kanan O & G, Hospital Sultanah Aminah, Johor Bahru Dr. Jasvindar Kaur Pembangunan Kesihatan Komuniti, Institut Kesihatan Umum Dr. Jafanita Jamaludin Ketua Penolong Pengarah, Bahagian Perkembangan Perubatan, KKM Pn. Jamaiah Bt Alang Abd Rais Ketua Penyelia Jururawat ( Perubatan), Jabatan Kesihatan Negeri Pahang Dr. Kamaliah bt Mohamad Noh Timbalan Pengarah ( Kesihatan Primer), Bahagian Pembangunan Kesihatan Keluarga (BPKK), KKM Dato Dr. Mukudan Krishnan Pakar Perunding Kanan O&G dan Ketua Disiplin Obstetrik & Ginekologi Hospital Raja Permaisuri Bainun, Ipoh Dr. Mymoon bt. Alias Timbalan Pengarah (Kesihatan Keluarga), BPKK, KKM

10 . 11 . 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 .

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22 . 23 . 24 . 25 . 26 . 27 . 28 . 29 . 30 . 31 . 32 . 33 . 34 . 35 . 36 . 37 . 38 . 39 . 40

Dr. Muhaini Othman Pakar Perunding Kanan Perubatan, Hospital Serdang, Selangor Dr. Mohamed Rouse Bin abd Majid Pakar Perunding Kanan O&G, Hospital Tengku Ampuan Afzan, Pahang Pn. Mahawa Manan Ketua Penyelia Jururawat Kesihatan, BPKK, KKM Dr. Majdah bt Hj. Mohamed Ketua Penolong Pengarah (Kanan), BPKK, KKM Dr. Norliza Ahmad, Pengarah Bahagian, Lembaga Penduduk dan Pembangunan Keluarga Negara (LPPKN) Dr. Nik Rubiah Nik Abd. Rashid Ketua Penolong Pengarah Kanan, BPKK, KKM Dr. Norsiah bt Ali Pakar Perubatan Keluarga, Klinik Kesihatan Tampin, Negeri Sembilan Dr. Noridah Bt Mohd. Salleh Ketua Penolong Pengarah Kanan, BPKK, KKM Dr. Nooraziah Bt Zainal Abidin Ketua Penolong Pengarah Kanan, Bahagian Perkembangan Perubatan, KKM Pn. Noorakidah Bt Shamaan Penyelia Jururawat, Jabatan Kesihatan Negeri Perak Pn. Norizan Mashttah Bt Mardan Penyelia Jururawat Kesihatan, BPKK Dr. Paramjothi P. Pakar Perunding Kanan O&G, Hospital Selayang, Selangor Dr. Rohaizat Bin Haji Yon Timbalan Pengarah Kanan Caw Pembangunan Profesion Perubatan,Bahagian Perkembangan Perubatan, KKM Dr. Rachel Koshy Ketua Penolong Pengarah (Kanan), BPKK, KKM Dr. Rohana Ismail Ketua Penolong Pengarah (Kanan), BPKK, KKM Pn. Rokiah bt Don Pengarah, Bahagian Pemakanan, KKM Dr. Rosila Yahaya Ketua Penolong Pengarah (Kanan), BPKK, KKM Dr. Rozita Ab Rahman Ketua Penolong Pengarah (Kanan), BPKK, KKM Dr. Safurah Jaafar

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Pengarah, Bahagian Pembangunan Kesihatan Keluarga, KKM 41 . 42 . 43 . 44 . 45 . 46 . 47 . 48 . 49 . 50 . 51 . Dr. Soo Thian Lian Pakar Perunding Kanan Pediatrik, Hospital Wanita dan Kanak-Kanak Likas, Kota Kinabalu Dr. Soon Ruey Pakar Perunding Kanan O&G, Hospital Wanita dan Kanak-Kanak Likas, Kota Kinabalu Dr. Safiah Bahrin Ketua Penolong Pengarah (Kanan), BPKK, KKM Dr. Sahaini Hassan Ketua Penolong Pengarah Kanan, Cawangan Kawalan Amalan Perubatan Swasta, KKM Pn. Tan Phaik Simm Penyelia Jururawat Kesihatan, BPKK, KKM Pn. Tumerah Bt Swandi Ketua Jururawat Kesihatan, BPKK, KKM Dr. Wong Swee Lan Pakar Perunding Kanan Pediatrik, Hospital Tuanku Jaafar, Seremban Dr. Wan Hamilton Wan Hassan Pakar Perunding Kanan O & G, Hospital Serdang, Selangor Dr. Yogeswary Sithamparanathan Pakar Perunding Kanan Pediatrik,Hospital Tuanku Ampuan Rahimah, Kelang Dr. Zaleha bt Abd. Hamid Ketua Penolong Pengarah (Kanan), BPKK, KKM Pn. Zainun Bt Yahaya Penyelia Jururawat, Jabatan Kesihatan Negeri Selangor

We would also like to thank all those who sent feedback and suggestions during the various workshops and meetings for the preparation of this document.

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