maternal mortality malaysia

1. MATERNAL MORTALITY

2. One woman dies every minute somewhere in
the world because of a complication related to
pregnancy or childbirth - and 80% of these
deaths could be prevented.
THE REALITY

3. MATERNAL DEATH
 The death of a woman while pregnant or within 42 days of
termination of pregnancy:
 irrespective of the duration and site of pregnancy
 from any cause related to or aggravated by the pregnancy
or its management
 From other causes not related or caused by the pregnancy
 Termination of pregnancy:
 Normal delivery
 Miscarriage
 Ectopic/Molar

4. CLASSIFICATION
 Direct
 Deaths resulting from obstetric complications in pregnancy,
labour and puerperium
 Indirect
 Deaths resulting from previous existing disease or diseases that
developed during pregnancy and which was aggravated during
pregnancy
 Fortuitous
 Deaths from other causes not related to or influenced by
pregnancy
 Late
 Death after 6 weeks until 1 year after delivery

5. Classifiction Examples
Direct Thromboembolism
Haemorrhage
Ectopics
Hypertensive disease of pregnancy
Sepsis
Amniotic fluid embolism
Indirect Cardiac disease
Suicide
Epilepsy/CNS haemorrhage
Infections
Respiratory/gastrointestinal diseases
CLASSIFICATION

6. MMR
(MATERNAL MORTALITY RATIO)

7. (MATERNAL MORTALITY RATIO)
 Maternal mortality ratio (MMR) is the number of
women who die from pregnancy related causes during
pregnancy and within 42 days of childbirth, per 100,000
live births.
 Excluding accidental or incidental causes
 No of women dies
100,000 live births

8. MDG 5
(MILLENNIUM DEVELOPMENTAL GOALS)
MDG 5: improve maternal health
 Target 5.A. Reduce by three quarters, between 1990 and 2015, the
maternal mortality ratio
 Target 5.B. Achieve, by 2015, universal access to reproductive health

9.  National MMR have reached a plateau between 28-
30/100,000 LB the last 10 years
 State MMR showing a decreasing trend the last 4 years….
 MMR for 2010 (21.3) & 2011 (19.9) – reaching a plateau?
 MDG 5 target for state by 2015 – 11.08/100,000 LB

10. OUR STATE….
 There is marked reduction in MMR in our state
YEAR MMR ( per 100,000 live births)
2008 30.8
2009 26
2010 21.3
2011 21.7
2012 26.6
2013 9.3 (*** achieve MDG 5 target)

11. CEMD
(CONFIDENTIAL ENQUIRIES INTO
MATERNAL DEATH)

12. SUMMARY FROM CEMD REPORT 2006-2008
 772 pregnancy related deaths were reported from 2006-2008
 MMR in 2008 was 27.3 per 100,000 live births
 Principal cause of maternal deaths are obstetric embolism, medical
disorders in pregnancy, PPH & hypertensive disorder
 >60% of the maternal death occurred during postnatal period
 The risk of maternal death was higher in woman aged >40 years & in
mothers who had >6 childrens
 Maternal death tagged with the green code increased from 26.6% in
2006 to 32.3% in 2008

13. TABLE: NUMBER OF PREGNANCY RELATED DEATH
FROM 2001-2008
YEAR 2001 2003 2005 2006 2007 2008
No of
deaths
316 236 255 247 258 267

14. TABLE: MMR ACCORDING TO STATE
STATES 2006 2007 2008
Death MMR Death MMR Death MMR
Perlis 0 0 2 50.9 1 24.1
Kedah 8 23.7 10 29.7 9 25.6
P.Pinang 4 18.4 8 36 8 35.1
Perak 7 19.3 6 16.7 11 30.1
Selangor 24 26.4 22 23.6 22 22.7
K.Lumpur 5 20.2 2 8.0 5 19.7
Putrajaya 0 0 0 0 0 0
N.Sembilan 4 24.3 4 23.7 7 40.9
Melaka 5 39.1 5 37.7 6 44.6
Johor 21 37.6 24 42.2 11 19.3
Pahang 9 36.5 6 24.3 9 35.3
Terengganu 7 32.1 5 22.5 1 4.3
Kelantan 7 20.8 8 23.8 13 37.5
Sabah 15 34.1 21 45.7 15 30.3
Labuan 0 0 0 0 0 0
Sarawak 11 26.1 13 31.1 15 35.0
Malaysia 127 27.3 136 28.8 133 27.3

15. TABLE: CAUSES OF MATERNAL DEATHS
CAUSES 2006 2007 2008
PPH 24 (18.9%) 23 (16.9%) 26 (19.5%)
HPT DISORDER 22 (17.4%) 25 (18.4%) 14 (10.5%)
OBSTETRIC
EMBOLISM
18 (14.2%) 24 (17.7%) 40 (30%)
MEDICAL ILLNESS 24 (18.9%) 20 (14.7%) 24 (18%)
APH 5 (3.9%) 2 (1.5%) 2 (1.5%)
PUERPERAL
SEPSIS
2 (1.6%) 3 (2.2%) 4 (3.1%)
ABORTION 3 (2.3%) 6 (4.4%) 3 (2.3%)
ECTOPIC 9 (7.1%) 7 (5.1%) 3 (2.3%)
UNSPECIFIED
COMPLICATION
OF PREGNANCY &
PUERPERIUM
5 (3.9%) 8 (5.9%) 2 (1.5%)
ASSOCIATED
WITH
ANAESTHESIA
0 1 (0.7%) 1 (0.8%)
OTHERS 9 (7.1%) 11 (8.1%) 9 (6.7%)

16. 0
5
10
15
20
25
30
35
2006
2007
2008

17. TABLE: DEATH BY CITIZENSHIP STATUS
CLASSIFICATION 2006 2007 2008
Malaysian citizens 186 (76.1%) 202 (78.2%) 197 (73.8%)
Non citizens with
legal documents
24 (9.7%) 28 (10.9%) 31 (11.6%)
Non citizens without
legal documents
35 (14.2%) 28 (10.9%) 39 (14.6%)

18. TABLE: CLASSIFICATION OF PREGNANCY RELATED DEATHS
CLASSIFICATION 2006 2007 2008
Direct 100 (47.2%) 115 (50%) 110 (48.2%)
Indirect 27 (12.7%) 21 (9.1%) 23 (10.1%)
Subtotal 127 136 133
MMR 27.3 28.8 27.3
Fortuituos 85 (40.1%) 94 (40.9%) 95 (41.7%)
Grand total 212 230 228

19. TABLE : MATERNAL DEATH BY AGE SPECIFIC GROUP
AGE 2006 2007 2008
< 19 32 18.5 16.9
20-24 26.6 19.4 17.6
25-29 12.5 20.5 17.9
30-34 27.2 30.8 26.7
35-39 44.4 48.3 44.8
40-44 81.8 67.8 81.3
>45 56.1 112.5 114.6

20. TABLE : MATERNAL DEATH BY PARITY SPECIFIC
PARITY 2006 2007 2008
Primigravida 8.4 17.1 11.5
Multiparity 32 30.5 32.6
Grandmultipara 80.3 70 64.5

21. TABLE: MATERNAL DEATH BY FAMILY PLANNING PRACTICE
FAMILY
PLANNING
2006 2007 2008
Ever user 30 (23.6%) 25 (18.4%) 24 (18.3%)
None user 68 (53.5%) 86 (63.2%) 82 (62.6%)
Don’t know 29 (22.9%) 25 (18.4%) 27 (19.1%)
TOTAL 127 136 133

22. TABLE: MATERNAL DEATH BY STAGE OF
PREGNANCY
STAGE OF
PREGNANCY
2006 2007 2008
Antenatal 27 (21.3%) 26 (19.1%) 32 (24%)
Intrapartum 19 (15%) 13 (9.6%) 11 (8.3%)
Post partum 69 (54.3%) 84 (61.8%) 83 (62.4%)
Early pregnancy
deaths
12 (9.4%) 13 (9.5%) 7 (5.3%)
TOTAL 127 136 133

23. TABLE: MATERNAL DEATHS BY COLOUR CODING
COLOUR CODING 2006 2007 2008
Red 15 (11.8%) 18 (13.2%) 13 (9.8%)
Yellow 17 (13.4%) 24 (17.7%) 17 (12.8%)
Green 34 (26.7%) 45 (33.1%) 43 (32.3%)
White 12 (9.5%) 7 (5.1%) 12 (9%)
No information 49 (38.6%) 42 (30.9%) 48 (36.1%)
TOTAL 127 136 133

24. KEY RECOMMENDATIONS
 Ectopic pregnancy should be ruled out in any woman in the
reproductive age who complains of abdominal pain.
 Pre-conception care should be provided for women with pre-existing
medical conditions.
 Combined care to the women with current or previous medical
conditions
 Awareness on thromboprophylaxis & postnatal depression among
Health professional
 To follow Obstetric protocols and guidelines and to organise regular
obstetric drills

25. STEPS TO REDUCE MMR
 Greater effort should be made to provide family planning services to
high risk women
 Existing referral system should be strengthened through supervision
and communication
 Regular obstetric drills should be organised for health staff
managing obstetric patients
 All home deliveries must be conducted by trained personnel
 Home visits and defaulter tracing must be done by health staff
 Hospital staffs must inform the health clinic once patient discharged

27. DELAYS CAUSES DEATH
 Delays in deciding to seek care
 Delays in reaching appropriate care
 Delays in receiving care at the health / hospital facility

28. PATIENT FACTORS
These are factors attributable to the attitude of
women and/or their relatives, which prevented
appropriate care being received by the patient

29. PERSONNEL OR FACILITY FACTORS
These are factors related to inadequacies in the
number, types or availability of personnel or
facilities

30. REMEDIABLE CLINICAL FACTORS
These are specific interventions or approaches to
management that would have reduced the
likelihood of death of the mother.

31. REMEDIABLE CLINICAL FACTORS
1. Failure to diagnose
2. Failure to appreciate severity.
3. Inadequate, inappropriate or delayed therapy.
4. Failure of adherence to protocols
5. Inappropriate delegation of duties.
6. Failure to inform seniors.
7. Failure to inform other specialists.
8. Failure of combined care.
9. Failure of communication.
10. Delay / failure of referral.
11. Failure of home visits / defaulter tracing.

32. More than 50% of patients who
died had some degree of
unsatisfactory management
‘Substandard care’
‘Remediable clinical factors’

33. ** INCREASE MATERNAL MORTALITY
** INCREASE PERINATAL MORTALITY