Pregnancy and childbirth can carry risks for both the mother and the baby.
The biological function of women is to perpetuate the human race without which the human race will be extinct.
Pregnancy and birth are not without risk and many have stated that the most dangerous journey any person undertakes is when being born.
Yet, mothers die undertaking the risky process of giving humanity new lives, when their lives can be saved.
Mothers die not because of conditions that cannot be prevented or treated but because societies have not decided that their lives are worth saving.
According to the World Health Organization (WHO), about 300,000 women die annually because of pregnancy or childbirth, and about two million babies die in their first month of life and millions more are stillborn.
Based on current trends, the WHO expects that four out of five countries are not on track to meet global targets for improving maternal survival by 2030.
Maternal mortality ratio (MMR)
Maternal mortality is widely accepted as a vital indicator of health and socioeconomic development.
It is reflective of the whole national health system and represents the outcome of various other characteristics like developmental status, intersectoral collaboration, transparency and disparities.
There is also a view that it reflects the socio-cultural, political and economic philosophy of a society.
The MMR is defined as the number of maternal deaths per 100,000 live births.
A maternal death is a death from pregnancy-related causes during pregnancy or within 42 days of giving birth.
Malaysia’s MMR decreased dramatically from 1946 to 1996 when it reached 15.6 per 100,000 livebirths, after which it increased to 16.8 and 29.1 per 100,000 livebirths in 1997 and 1998 respectively.
Since then, the MMR has stagnated in the 20s per 100,000 livebirths except for 2021 when it was 68.2 per 100,000 livebirths because of Covid-19.
In absolute numbers, there were between 103 to 157 maternal deaths annually since 2000. (https://data.gov.my/data-catalogue/deaths_maternal)
The 2019 Confidential Enquiries into Maternal Deaths (CEMD) reported that the main causes of maternal deaths were postpartum haemorrhage; associated medical conditions; hypertensive disorder in pregnancy; sepsis; pulmonary embolism; amniotic fluid embolism; and ectopic pregnancy.
Of deaths, 83.5% comprised Malaysians and 16.5% were non-citizens with legal documents; 51.7% of the deaths were direct, 11.3% indirect and 37.1% fortuitous; 65.2% of the deaths occurred in a government healthcare facility, 5.9% in a private healthcare facility, 12.7% at home and 14.4% were brought in dead to a healthcare facility; 81.6% of the maternal deaths in Malaysia were preventable and 18.4% not preventable
A maternal death is not just a number – it has significant negative impacts on the mother’s spouse or partner and more importantly, on her children left behind.
The birth weight, maternal hypertension and instrumental delivery are significantly associated with preventable stillbirths and neonatal deaths. — Photos: Unsplash
Severe maternal morbidity
The true extent of maternal morbidity is unknown, but it has been suggested that for each maternal death, 20 or 30 women suffer from maternal morbidity.
The WHO defines maternal morbidity as “any health condition attributed to and/or complicating pregnancy, and childbirth that has a negative impact on the woman’s well-being and/or functioning”.
The 2022 National Health and Morbidity Survey, published in 2023, reported that 27.1% of pregnant women had diabetes, 6.5% high blood pressure, 19.3% anaemia, and 11.2% post-partum depression (but nine in 10 were unaware of their condition).
There is no universal definition of significant pregnancy complications, often termed severe maternal morbidity (SMM), which result in significant short and/or long term health consequences and are a significant challenge for healthcare providers, health systems and for all pregnant women.
There is no Malaysian data of SMM.
However, a 2014 study at the Raja Perempuan Zainab II Hospital and Universiti Sains Malaysia Hospital in Kelantan reported that the risk factors for SMM in 353 women were maternal age older than 35 years, previous pregnancy complications, Caesarean section deliveries and preterm delivery.
Neonatal mortality and stillbirths
The neonatal mortality rate (NMR) is the number of newborn deaths in the first 28 days of life per 1,000 live births.
According to WHO, Malaysia’s NMR improved from 31 in 1951 to five in 2000 and 4.4 in 2022 (in absolute numbers, there were 1,789 neonatal deaths in 2022).
The NMR in Asean countries ranges from 0.9% in Singapore to 21.1 in Myanmar.
Like the MMR, Malaysia’s NMR has stagnated in the last quarter century.
According to the 2020 Malaysian National Neonatal Register, published in 2023, 10.7% of all livebirths were delivered preterm (less than 37 completed weeks), of which about three quarters were delivered at late preterm gestation (34-36 completed weeks).
A stillbirth is a baby who dies after 28 weeks of pregnancy but before or during birth. Malaysia’s stillbirth rate in 2000 was 2.1 per 1,000 livebirths and 4.8 per 1,000 live births in 2023.
In absolute numbers, there were 2,193 stillbirths in 2023.
In a review of 15,444 cases between 2015 and 2017, of which 55% were stillbirths and 45% neonatal deaths, a team from Universiti Sains Malaysia found that 21% were preventable.
The birth weight, maternal hypertension and instrumental delivery were significantly associated with preventable stillbirths and neonatal deaths.
Among the 3,242 cases of preventable stillbirths and neonatal deaths with a complete documented level of adequacy and quality of healthcare, the most frequently identified factors were due to insufficient antenatal care (20.4%), non-compliance with medical advice (12.3%) and unsuitable place of delivery (8.6%). (Med J Malaysia Vol 78 No 1 January 2023)
Poor quality care
World Health Day, which is celebrated on April 7, 2025, is the beginning of a year-long campaign on maternal and newborn health.
The campaign theme “Healthy Beginnings, Hopeful Futures”, will urge governments and the health community to ramp up efforts to end preventable maternal and newborn deaths, and to prioritise women’s longer-term health and well-being.
The campaign goals are:
> To raise awareness about gaps in maternal and newborn survival and the need to prioritise women’s longer-term well-being;
> To advocate for effective investments that improve the health of women and babies;
> To encourage collective action to support parents as well as health professionals who provide critical care;
> To provide useful health information relating to pregnancy, childbirth, and the postnatal period.
The 2022 United Nations Population Fund (UNPA) report Enhancing Human Capital Through Sexual and Reproductive Health Investments and Family Support Policies in Malaysia stated: “It is not really insufficient access that prevents greater maternal health in Malaysia but poor-quality care.
“For example, ‘maternal near-miss’ i.e. when a woman nearly dies but survives a complication during pregnancy, childbirth or within 42 days of termination of a pregnancy – is higher in Malaysia compared to higher-income countries, and this is due to poor quality care.
“Poor quality care includes misdiagnosis, long waiting time, inefficient care during pregnancy check-ups, disrespectful care and lack of clear communication from healthcare providers during delivery.”
The UNPA recommended “continuing and strengthening high quality maternal health services, including CEMD and investigating maternal near-miss cases to identify health system quality issues”.
Improvements in newborn health will follow improvements in maternal health.
Will the health ministry adopt WHO’s campaign goals?
What definitive actions will be implemented?
Mothers and mothers-to-be certainly expect an end to preventable maternal and newborn deaths.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
