OBESITI

Malaysian Health and Healthcare
Performance Report
General Health Status
Maternal and Child Mortality
2014
MALAYSIAN HEALTHCARE PERFORMANCE UNIT
Authors:
Seet Wymen
Ariza binti Zakaria
Joseph Ng Soon Heng
Mohd Kamarulariffin bin Kamarudin
Editors:
Jamaiyah binti Haniff
Theyveeka Selvy a/p Rajoo @ Balusamy Radia

General Health Status, Maternal and Child Mortality
Disclaimer:
Findings in this report maybe different from other published reports. This is because
analysis for this report was done based on the latest dataset obtained from the
Department of Statistics Malaysia and Family Health Development Division, Ministry
of Health Malaysia.
Acknowledgement of Funding:
This report is supported by National Institutes of Health (NIH), Ministry of Health

Malaysia.
Published by:
Malaysian Healthcare Performance Unit

National Institute of Health,
c/o Deputy Director General (Research and Technical Support) Office
Ministry of Health Malaysia
Block E7, Federal Government Administrative Centre
62590 Putrajaya,
Malaysia.
Tel : (603) 8000 8000

Fax : (603) 8888 6187
Email : contactmhp@crc.moh.gov.my, kkm@moh.gov.my
This report is not copyrighted. Therefore it may be freely reproduced with the
permission of the Malaysian Healthcare Performance Unit. Acknowledgement would
be appreciated. All enquiries should be directed to the editors of this report.
Suggested citation is: Malaysian Health and Healthcare Performance Report 2014.
Malaysian Healthcare Performance Unit. Ministry of Health Malaysia.
ii
ACKNOWLEDGEMENTS
We wish to thank YBhg. Datuk Dr Noor Hisham bin Abdullah, Director General of
Health and Dr Shahnaz binti Murad, the Deputy Director General of Health
(Research & Technical Support) for their guidance. A special mention is dedicated to
the Director of National Clinical Research Centre, Dr Goh Pik Pin for her strong
support. Acknowledgement also goes to all our stakeholders as listed below:-
Y.Bhg. Datuk Dr Lokman Hakim bin Sulaiman

Timbalan Ketua Pengarah Kesihatan (Kesihatan Awam)
Kementerian Kesihatan Malaysia
Y.Bhg. Dato' Dr Hj Azman bin Abu Bakar

Pengarah
Bahagian Perkembangan Perubatan
YBhg. Datuk Dr Haji Abdul Rahman bin Hasan

Ketua Perangkawan
Jabatan Perangkaan Malaysia
Dato’ Dr Ahmad Razin bin Dato’ Haji Ahmad Mahir

Pengarah
Jabatan Kesihatan Negeri Kelantan
Y.Bhg. To’ Puan Dr Safurah binti Hj Jaafar

Pengarah
Bahagian Pembangunan Kesihatan Keluarga (BPKK)
Datuk Dr Zulkifli bin Jantan

Pengarah
Jabatan Kesihatan Negeri Sarawak
Dato’ Dr Norhizan bin Ismail

Pengarah
Jabatan Kesihatan Negeri Kedah
iii
Dr Haji Mohammad bin Omar

Pengarah
Jabatan Kesihatan Negeri Terengganu
Dr Zaini bin Hussin

Pengarah
Jabatan Kesihatan Negeri Perlis
Dr Md. Khadzir bin Sheikh Hj. Ahmad

Timbalan Pengarah
Pusat Informatik Kesihatan (PIK)
SPECIAL THANKS FOR FINAL REVIEW
Professor Niek Klazinga

Health Care Quality Indicator Project Directorate for Employment, Label, and
Social Affair (OECD)
iv
THE EDITORIAL BOARD
Editors:
Dr Jamaiyah binti Haniff

Ketua Unit
Dr Theyveeka Selvy a/p Rajoo @ Balusamy Radia

Pakar Bedah Umum
Contributors:
Y.Bhg. Dato' Dr Hussain Imam bin Haji Mohammad Ismail

Pakar Perunding Kanan & Ketua Jabatan Pediatrik
Hospital Kuala Lumpur
Dr Ravichandran a/l Jeganathan

Pakar Perunding Kanan & Ketua Jabatan Obstetrik dan Ginekologi (O&G)
Hospital Sultanah Aminah, Johor Bahru
Dr Roslinah binti Ali

Pengarah
Institut Penyelidikan Sistem Kesihatan (IPSK)
Dr Christina Rundi
Pengarah
Jabatan Kesihatan Negeri Sabah
Dr Kamariah binti Hussain

Timbalan Pengarah Kesihatan (Kesihatan Awam)
Jabatan Kesihatan Negeri Perlis
Dr Hayati binti Mohd Radzi

Timbalan Pengarah Kesihatan (Kesihatan Awam)
Jabatan Kesihatan Negeri Kedah
Dr Jamilah binti Hashim

Timbalan Pengarah Kesihatan
Jabatan Kesihatan Negeri Sarawak
v
En. Ahmad Jessree bin Kamaruddin

Timbalan Pengarah
Bahagian Perangkaan Penduduk dan Demografi
Dr Sharmala Devi Karalasingam

Pakar Perunding Kanan Obstetrik dan Ginekologi (O&G)
Pusat Penyelidikan Klinikal Kebangsaan
Datin Dr Siti Hajar binti Daud

Ketua Penolong Pengarah Kanan (Perubatan)
Jabatan Kesihatan Negeri Terengganu
Dr Mahani binti Abdul Hamidy

Ketua Penolong Pengarah Kanan
Bahagian Perancangan
Dr Siti Sara binti Yaacob

Cawangan Kualiti Penjagaan Perubatan
Dr Arpah binti Ali

Cawangan Perkembangan Perkhidmatan Perubatan
Dr Jafanita binti Jamaludin

Cawangan Perkembangan Perkhidmatan Perubatan
Dr Zul Azuin binti Zulkifli

Bahagian Pembangunan Kesihatan Keluarga
vi
Dr Yeong May Luu

Bahagian Pembangunan Kesihatan Keluarga
Dr Junaideen bin Mohamad Zain

Pegawai Kesihatan Daerah
Jabatan Kesihatan Negeri Kelantan
En. Mohd Sofi bin Ali

Ketua Penolong Pengarah
Bahagian Perangkaan Penduduk & Demografi
vii
SOURCES DATA PROVIDERS
Pusat Informatik Kesihatan (PIK)

Bahagian Pembangunan Kesihatan Keluarga (BPKK)

Bahagian Perangkaan Penduduk & Demografi

viii
THE CORE TEAM MEMBERS
(MALAYSIAN HEALTHCARE PERFORMANCE UNIT)
Project Manager:
Dr Theyveeka Selvy a/p Rajoo @ Balusamy Radia
Team Members:
Dr Seet Wymen
Dr Ariza binti Zakaria
Dr Joseph Ng Soon Heng
Dr Mohd Kamarulariffin bin Kamarudin
Cik Nur Naim binti Ghazali
Cik Nadiah Hanis binti Hashim
Cik Maisarah binti Mahari
En. Muhammad Afiq bin Mohd Jaffar
ix
ABBREVIATIONS
ABBREVIATION FULL NAME

APH Antepartum Haemorrhage
BPKK Bahagian Pembangunan Kesihatan Keluarga
CDR Crude Death Rate
DSOM Department Of Statistics Malaysia
FHDD Family Health Development Division
HDP Hypertensive Disorders of Pregnancy
IHSR Institute for Health Systems Research
ISSN International Standard Serial Number
MDG Millennium Development Goal
MHPU Malaysian Healthcare Performance Unit
MMR Maternal Mortality Ratio
MNNR Malaysian National Neonatal Registry
MOH Ministry Of Health, Malaysia
NCRC National Clinical Research Centre
NIH National Institutes of Health
NOR National Obstetric Registry
OECD Organization for Economic Co-operation and Development
PIK Pusat Informatik Kesihatan
PPH Postpartum Haemorrhage
UNICEF United Nations Children's Fund
WHO World Health Organization
WP Wilayah Persekutuan
x
TABLE OF CONTENTS
ACKNOWLEDGEMENTS .................................................................................................. iii

SOURCES DATA PROVIDERS ...................................................................................... viii
THE CORE TEAM MEMBERS ..........................................................................................ix
ABBREVIATIONS ............................................................................................................. x
TABLE OF CONTENTS.....................................................................................................xi
LIST OF FIGURES .......................................................................................................... xiii
EXECUTIVE SUMMARY ..................................................................................................xv
INTRODUCTION ............................................................................................................... 1
Chapter 1 : GENERAL HEALTH STATUS OF THE NATION ................................................ 2
1.1. Life Expectancy at Birth .......................................................................................... 2
1.1.1. Definition ............................................................................................................. 2
1.1.2. Rationale for use ................................................................................................. 2
1.1.3. Findings .............................................................................................................. 2
1.1.3.1. Internal benchmarking ..................................................................................... 2
1.1.3.2. External Benchmarking .................................................................................... 8
1.2. Mortality .................................................................................................................. 9
1.2.1. Definition of Crude Death Rate ............................................................................ 9
1.2.2. Rationale for use ................................................................................................. 9
1.2.3. Findings .............................................................................................................. 9
1.2.3.1. Internal Benchmarking ..................................................................................... 9
1.2.3.2. External Benchmarking .................................................................................. 12
Chapter 2 : CHILD HEALTHCARE ..................................................................................... 14
2.1. Crude Birth Rate ................................................................................................... 14
2.1.1. Definition ........................................................................................................... 14
2.1.2. Rationale for use ............................................................................................... 14
2.1.3. Findings ............................................................................................................ 14
2.1.3.1. Internal Benchmarking ................................................................................... 15
2.2. Stillbirth ................................................................................................................. 18
2.2.1. Definition ........................................................................................................... 18
2.2.3. Findings ............................................................................................................ 18
xi
2.3. Perinatal Mortality ................................................................................................. 22

2.3.1. Definition ........................................................................................................... 22
2.3.3. Findings ............................................................................................................ 22
2.4. Neonatal Mortality ................................................................................................. 26
2.4.1. Definition ........................................................................................................... 26
2.4.3. Findings ............................................................................................................ 26
2.4.3.1. Internal benchmarking ................................................................................... 27
2.5. Infant Mortality ...................................................................................................... 31
2.5.1. Definition ........................................................................................................... 31
2.5.3. Findings ............................................................................................................ 31
2.6. Under-five Mortality ............................................................................................... 35
2.6.1. Definition ........................................................................................................... 35
2.6.3. Findings ............................................................................................................ 35
2.7. Additional Information on Childhood Mortality Trending ........................................ 39
Chapter 3 : MATERNAL HEALTHCARE ............................................................................. 41
3.1. Maternal mortality ................................................................................................. 41
3.1.1. Definition ........................................................................................................... 41
3.1.2. Rationale of use ................................................................................................ 41
3.1.3. Findings ............................................................................................................ 41
3.2. Millennium Development Goal 5 ........................................................................... 46
Challenges and Recommendations ................................................................................. 47
References ...................................................................................................................... 48
xii
LIST OF FIGURES
Figure 1.1: Malaysian life expectancy at birth ........................................................................ 3

Figure 1.2: Male life expectancy by states of Malaysia .......................................................... 4
Figure 1.3: Female life expectancy by states of Malaysia ...................................................... 4
Figure 1.4: Life expectancy in Malaysia by ethnicity in 2011.................................................. 5
Figure 1.5 (a),(b),(c),(d),(e): Life expectancy of Malaysian males .......................................... 6
Figure 1.6 (a),(b),(c),(d),(e): Life expectancy of Malaysian Females ...................................... 7
Figure 1.7: Life expectancy at birth, by country and sex, 1970 vs 2010 3............................... 8
Figure 1.8: Number of deaths in Malaysia from 2008 to 2012.............................................. 10
Figure 1.9: Crude death rate according to states ................................................................. 10
Figure 1.10 (a),(b),(c),(d),(e): Crude death rate of Malaysia according to regions ................ 11
Figure 1.11: Adult mortality rate for ages 15 to 60, 2009 ..................................................... 12
Figure 1.12: All causes, estimated mortality rates, 2008...................................................... 13
Figure 2.1: Live birth numbers by states in Malaysia, 2008-2012 ........................................ 15
Figure 2.2: Crude birth rates by states in Malaysia, 2008-2012 ........................................... 15
Figure 2.3 (a),(b),(c),(d),(e): Crude birth rates by regions in Malaysia, 2008-2012 ............... 16
Figure 2.4: Crude birth rates by gender in Malaysia, 2008-2012 ......................................... 17
Figure 2.5: Number of stillbirths by state in Malaysia, 2008-2012 ........................................ 19
Figure 2.6: Stillbirth rates by states in Malaysia, 2008-2012 ................................................ 19
Figure 2.7 (a),(b),(c),(d),(e): Stillbirth rates by regions in Malaysia, 2008-2012 .................... 20
Figure 2.8: Stillbirth rates by gender in Malaysia, 2008-2012 .............................................. 21
Figure 2.9: Number of perinatal mortalities by state in Malaysia, 2008-2012 ....................... 23
Figure 2.10: Perinatal mortality rates by states in Malaysia, 2008-2012 .............................. 23
Figure 2.11 (a),(b),(c),(d),(e): Perinatal mortality rates by regions in Malaysia, 2008-2012 .. 24
Figure 2.12: Perinatal mortality rates by gender in Malaysia, 2008-2012 ............................. 25
Figure 2.13: Number of neonatal mortality by states in Malaysia, 2008-2012 ...................... 27
Figure 2.14: Neonatal mortality rates by states in Malaysia, 2008-2012 .............................. 27
Figure 2.15 (a),(b),(c),(d),(e): Neonatal mortality rates by regions in Malaysia, 2008-2012 . 28
Figure 2.16: Neonatal mortality rates by gender in Malaysia, 2008-2012 ............................. 29
Figure 2.17: Neonatal mortality rates by categories in Malaysia, 2008-2012 ....................... 29
Figure 2.18: Causes of neonatal mortality in Malaysia, 2008-2012 ...................................... 30
Figure 2.19: Number of infant deaths by states in Malaysia, 2008 - 2012 ............................ 32
Figure 2.20: Infant mortality rates by states in Malaysia, 2008 - 2012 ................................. 32
Figure 2.21 (a),(b),(c),(d),(e): Infant mortality rates by regions in Malaysia, 2008-2012 ....... 33
Figure 2.22: Infant mortality rates by gender in Malaysia, 2008-2012 .................................. 34
Figure 2.23: Infant mortality rate, 2010 and decline, 1980 and 2010 3 ................................. 34
xiii
Figure 2.24: Number of under-five mortalities by states in Malaysia, 2008-2012 ................. 36

Figure 2.25: Under-five mortality rates by states in Malaysia, 2008 - 2012 .......................... 36
Figure 2.26 (a),(b),(c),(d),(e): Under-five mortality rates by regions in Malaysia, 2008-2012 37
Figure 2.27: Under-five mortality rates by gender in Malaysia, 2008-2012.......................... 38
Figure 2.28: Benchmarking Malaysia for under-5 mortality 2012 ........................................ 38
Figure 2.29: Trends between childhood mortality indicators from 2000 to 2012 ................... 39
Figure 2.30: Trends of neonatal mortality, infant mortality and under-five mortality rate of
Malaysia, from 1990 to 2010 ............................................................................. 40
Figure 3.1: Number of maternal mortality by states in Malaysia, 2008-2012 ........................ 42
Figure 3.2: Maternal mortality ratios by states in Malaysia, 2008-2011 ................................ 42
Figure 3.3: Maternal mortality ratios by regions in Malaysia, 2008-2011.............................. 43
Figure 3.4: Cause of maternal deaths during postpartum stage .......................................... 44
Figure 3.5: Estimated maternal mortality ratios, selected countries, 1990-2010 .................. 45
Figure 3.6: Trend of maternal mortality ratio in Malaysia from 1933 to 2012 ........................ 46
xiv
EXECUTIVE SUMMARY
This is the first report that focused on healthcare performance benchmarking. It

covers three chapters on health status (life expectancy at birth and all-cause
mortality), child and maternal healthcare performance indicators (standard mortality
indicators such as stillbirth, perinatal, neonatal, under-five and maternal mortalities).
This report mainly used the 5 years secondary data series 2008-2012 from
Department of Statistics Malaysia and standard indicators. In summary as a nation
the health status in terms of life expectancy has improved. However international
benchmarking showed that the rate of improvement is moderate. Ethnic and state
variation existed.
Stillbirth, perinatal, neonatal, under-five rates has also improved since 1990, yet from
year 2000 onwards these rates have plateaued.
Maternal mortality rate has also improved and performance with international was
below Asia 20 but above OECD. Yet Malaysia has not achieved the MDG 5 target in
2015.
In conclusion, this first report serves as a proof that performance benchmarking of

Malaysian health and healthcare is possible. In order to have better quality and more
timely reporting in the coming years, MHPU need to work closer with partners to
develop a National Performance Framework incorporating meaningful National
Indicators for benchmarking. There is a need for better data governance albeit data
sharing policy and guidelines as well as a need to build and capitalize on big data
analytics. Lastly and most important is to get buy-in from data holders for better
teamwork and quality data.
xv
INTRODUCTION
Background
This is the first report that focuses on Malaysian health and healthcare system with
the aim to benchmark the system performance at local and international level.
Apart from feeding information to the health policy makers and planners, the purpose
of the report is also to advocate dissemination of information about our healthcare
performance publicly in a transparent manner.
Methodology
This report leverages on existing indicators used in Ministry of Health (MOH) and
non-MOH agencies that examine trends in health care quality across all the 13
states; Johor, Melaka, Negeri Sembilan, Kedah, Kelantan, Pahang, Perak, Perlis,
Pulau Pinang, Sabah, Sarawak, Selangor, Terengganu, and three federal territories:
WP Labuan, WP Kuala Lumpur and WP Putrajaya.
The indicators were selected on the basis of their relevance to the local health
needs, taking into account their definitions and comparability of existing and
published data.
This report uses routinely collected secondary data. The main sources of data are
the Department of Statistics Malaysia (DOSM) and Family Health Development
Division MOH.
A 5-year data series was constructed from 2008 to 2012. Year 2011 was set as the
index year because data from 2012 was preliminary.
Structure of the report
This report consists of three chapters with each chapter having two subsections;
internal and external benchmarking. Internal benchmarking refers to benchmarking
performance for the 13 states and three federal territories whereas external
benchmarking compares Malaysia with the selected OECD and Asia 20 /22
countries.
Chapter 1 provides an overview of health status of the nation in terms of life

expectancy at birth and all-cause mortality.
Chapter 2 and 3 highlight child and maternal healthcare performance indicators

using standard mortality indicators such as stillbirth, perinatal, neonatal, under-five
and maternal mortalities.
1
Chapter 1 : GENERAL HEALTH STATUS OF THE NATION
This chapter provides an overview of the Malaysian general health status using both
life expectancy at birth and mortality as performance indicator.
1.1. Life Expectancy at Birth
1.1.1. Definition:
Life Expectancy at birth is defined by various institutions and agencies as below;
1. Life Expectancy at birth is the average remaining age (years) for a person
expected to live at birth 1.
2. The average number of years that a new-born could expect to live, if he or she
were to pass through life exposed to the sex- and age-specific death rates
prevailing at the time of his or her birth, for a specific year, in a given country,
territory, or geographic area 2.
3. Life expectancy at birth is the average number of years that a person can be
expected to live, assuming that age-specific mortality levels remain constant 3.
1.1.2. Rationale for use:
Life Expectancy at birth reflects the overall mortality level of a population across all
age groups. Life Expectancy and mortality interact in a reciprocal relationship. If
mortality rate generally decreases, Life Expectancy will generally increase. However,
increase in Life Expectancy does not solely translate into fewer disease incidences
as people can also live longer with diseases through better management.
1.1.3. Findings
1.1.3.1. Internal benchmarking
Figure 1.1 shows gradual increase from 1991 to 2013 in life expectancy at birth for
both genders. The life expectancy at birth in Malaysia from 2002 through 2012 p
increased by 2.1% and 2.5% for male and female respectively.
2
78
76
Male
74
Life expectancy (years)
Female
72
70
68
e=estimate
p = preliminary
66
64
Figure 1.1: Malaysian life expectancy at birth

Source: Department of Statistics Malaysia. Graph was generated by the MHPU.
The estimated life expectancy at birth in 2013e was 72.5 and 77.1 years for male and
female respectively. Sabah and Sarawak population generally lived longer whereas
Kelantan and Terengganu population had the shortest life span (Figure 1.2 and
Figure 1.3). Over the 4-year period (2010-2013), life expectancy at birth improved
steadily across all states. Male from Indian ethnicity had the shortest life expectancy
overall in 2011 (Figure 1.4).
3
76
74
2010
2011p
72
2012e
2013e
70
p – preliminary
e – estimate
68
1 – Includes WP Labuan
2 – Includes WP Putrajaya
66
64
Figure 1.2: Male life expectancy by states of Malaysia

80
79
78 2010
2011p
77
2012e
76 2013e
75
p – preliminary
e – estimate
74
1 – Includes WP Labuan
73
2 – Includes WP Putrajaya
72
71
Figure 1.3: Female life expectancy by states of Malaysia

4
82
80
78
76
74
72
70
68
66
64
62
60
Bumiputera Chinese Indian
Male 70.90 74.60 67.60
Female 75.60 79.30 75.80
Figure 1.4: Life expectancy in Malaysia by ethnicity in 2011

5
(a) (b)
(c) (d)
(e)
Figure 1.5 (a),(b),(c),(d),(e): Life expectancy of Malaysian males
by regions in Malaysia
Source: Department of Statistics Malaysia. All graphs were generated by the MHPU.
6
(a) (b)
(c) (d)
(e)
Figure 1.6 (a),(b),(c),(d),(e): Life expectancy of Malaysian Females

according to regions in Malaysia
7
1.1.3.2. External Benchmarking
Malaysian life expectancy was below that of OECD countries but slightly above that
of Asia-22 (22 selected Asian countries) for both genders in 1970 and 2010 (Figure
1.7).
Japan
Hong Kong, China
Australia
Singapore
New Zealand
Korea, Rep.
Macau, China
OECD
Brunei Darussalam
Sri Lanka
Viet Nam
Malaysia
Thailand
China
Asia - 22
Fiji
Indonesia
Korea, DPR
Bangladesh
Philippines
Nepal
Mongolia
Solomon Islands
Lao PDR
Pakistan
India
Myanmar
Cambodia
Papua New Guinea
Figure 1.7: Life expectancy at birth, by country and sex, 1970 vs 2010 3
8
1.2. Mortality
Mortality is one of the most common measures of population health. There can be
different rates of mortality depending on specific groups of which they address. The
rate can also be computed based on overall population death.
1.2.1. Definition of Crude Death Rate
Crude death rate (CDR) is the ratio of the number of deaths in a year to the mid-year
population for that year (per thousand population) 7.
1.2.2. Rationale for use
Crude death rate disregards the age structure of the population. Therefore it should
be interpreted as it is and not to be compared with other population with different
ageing population.
1.2.3. Findings
1.2.3.1. Internal Benchmarking
CDR in Malaysia was 4.7 per 1000 population in 2011. The CDR ranged
approximately 4.6 to 4.8 from 2008 to 2012 (Figure 1.9).
The range spanned from a low 2.4 per 1000 in Sabah and WP Labuan to 6.9 per
1000 population in Perlis respectively (Figure 1.9). The range varied widely from
state to state.
9
(a) Numbers of deaths
20,000
2008
2009
2010
15,000 2011
Number of deaths
2012p
p=Preliminary
10,000
Number of deaths for
WP Putrajaya is
incorporated in Selangor
for 2008 and 2009
5,000 Source : Department of
Statistics Malaysia
Total deaths in Malaysia

0 2008: 134857
2009:130135
2010:130978
2011: 135463
2012p: 136836
Figure 1.8: Number of deaths in Malaysia from 2008 to 2012

according to states
(b) Crude death rate
8.0
7.0
Crude Death rate per 1000 population
2008
2009
6.0
2010
2011
5.0
2012p
4.0
p=Preliminary
3.0 Crude death rate for
WP Putrajaya is
2.0 incorporated in
Selangor during 2008
1.0 and 2009
0.0
Figure 1.9: Crude death rate according to states

10
(a) (b)
(c) (d)
(e)
Figure 1.10 (a),(b),(c),(d),(e): Crude death rate of Malaysia according to regions

11
Age standardization will remove the effect of population age structure on mortality
rate between groups under comparison.
Figure 1.12 shows the age standardized mortality rate in Malaysia; 762 deaths per
100 000 population in comparison with selected countries in the neighboring regions.
Malaysia had a higher mortality than the OECD average (474 per 100,000
populations); but lower than the Asia-20 (902 per 100,000 population).
In Malaysia, mortality rate for males is almost twice that of females. Nevertheless,
this phenomenon is in parallel with generally many other countries where figure for
male gender death is always higher (Figure 1.11) 3.
Benchmarking countries in Asia needs to be done with caution because some of the
developing countries do not have complete vital registration system 3 & 4.
400
Males
Females
300
Per 1 000 population
200
100
Figure 1.11: Adult mortality rate for ages 15 to 60, 2009

Source: WHO(2012f);Statlink http:/dx.doi.org/10.1787/888932722905
12
Myanmar
Cambodia
Lao PDR
Papua New Guinea
Pakistan
India
Bangladesh
Nepal
Indonesia
Fiji
Sri Lanka
Thailand
Asia - 20
Philippines
Mongolia
Korea DRP
Solomon Islands
Viet Nam
Malaysia
China
Brunei Darussalam
OECD
Korea Rep
New Zealand
Singapore
Australia
Japan
Figure 1.12: All causes, estimated mortality rates, 2008

4 3
Source: WHO Global Burden of Disease, 2011 and OECD , Graph reproduced by MHPU
13
Chapter 2 : CHILD HEALTHCARE
This chapter describes healthcare performance in term of Crude Birth Rate, Stillbirth
Rate, Perinatal Mortality, Neonatal Mortality, Infant Mortality and Under-five Mortality.
2.1. Crude Birth Rate
2.1.1. Definition
Crude birth rate is defined as a ratio of the number of live births during a year to the
mid-year population in that year (per 1000 population) 7.
Live birth refers to the complete expulsion or extraction from its mother of a product
of conception, irrespective of the duration of the pregnancy, which, after such
separation, breathes or shows any other evidence of life - e.g. beating of the heart,
pulsation of the umbilical cord or definite movement of voluntary muscles - whether
or not the umbilical cord has been cut or the placenta is attached. Each product of
such a birth is considered live born 5.
Crude birth rate is an important component of growth in the country which

determines the natural growth rate of the population.
2.1.3. Findings
The birth rates recorded across the different states for the specified time period
appear to be consistent with only few exceptions: the relatively high birth rates seen
in the East Coast states of Kelantan and Terengganu and the remarkably high birth
rate in record for WP Putrajaya.
14
(a) Numbers of live births
120,000
2008
100,000 2009
2010
80,000 2011
Number of live births
2012p
60,000 p=Preliminary
Number of live births for

40,000 WP Putrajaya were
incorporated into
Selangor in 2008 and
2009
20,000
Total cases in Malaysia:
2008: 487,346 cases
- 2009: 496,313 cases
2010: 491,239 cases
2011: 511,594 cases
2012p: 508, 774 cases
(b) Crude birth rate

45.0
40.0
2008
35.0
2009
(per 1,000 population)
30.0 2010
Crude birth rate
25.0 2011
2012p
20.0
15.0 p = Preliminary
10.0 Crude birth rates for WP

Putrajaya were
5.0 incorporated into
Selangorin 2008 and 2009
-
15
Crude live birth rates by year for Eastern Peninsular Crude live birth rates by year for Northern Peninsular
states in Malaysia, 2008-2012 states in Malaysia, 2008-2012
45.0 45.0
Malaysia
40.0 40.0
Malaysia Kedah
35.0 35.0
(per 1000 population)

Crude live birth rate

Kelantan Perak
30.0 30.0
Pahang Perlis
25.0 25.0
Terengga Pulau
20.0 nu 20.0 Pinang
18.4 18.5 18.5
15.0 17.2 17.6 17.2 15.0 18.4 17.6 17.2
17.2
10.0 10.0
5.0 5.0
- -
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(a) (b)
Crude live birth rates by year for Central Peninsular Crude live birth rates by year for Southern
states in Malaysia, 2008-2012 Peninsular states in Malaysia, 2008-2012
45.0 Malaysia
45.0
Negeri
40.0 Sembilan
Selangor
40.0 Malaysia
35.0
(per 1000 population)
WP Kuala 35.0
Lumpur Johor
30.0 WP 30.0
Putrajaya
25.0 25.0 Melaka
p=Preliminary
20.0 20.0
18.4 18.5 17.2 Crude birth
17.6 18.5 17.6
15.0 17.2 rates for WP 15.0 18.4 17.2 17.2
Putrajaya
10.0 were 10.0
incorporated
5.0 into Selangor 5.0
in 2008 and
- 2009 -
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(c) (d)
Crude live birth rates by year for East Malaysia
states, 2008-2012
45.0
40.0
Malaysia
35.0
Sabah
30.0
Sarawak
25.0
WP
20.0 Labuan
18.4 18.5 17.6 17.2

15.0 17.2
10.0
5.0
-
2008 2009 2010 2011 2012p
(e)
Figure 2.3 (a),(b),(c),(d),(e): Crude birth rates by regions in Malaysia, 2008-2012
16
19.0
18.5
18.5
18.4
18.0
Total
Crude birth rate
17.5 17.6 Male

Female
17.2 17.2
17.0
16.5
16.0
2008 2009 2010 2011 2012
Figure 2.4: Crude birth rates by gender in Malaysia, 2008-2012

17
2.2. Stillbirth
2.2.1. Definition
Stillbirth is defined as births after 28 completed weeks or more of gestation without

any sign of life during delivery 9.
Unit of Measurement: Deaths per 1,000 total births
Number of stillbirths in year t x 1000

Stillbirth rate = Number of live births + number of stillbirths in year t
Majority of the causes of stillbirths are preventable. This indicator reflects the quality
of the provision of maternal care. Stillbirth reporting is to include statistics for death
only of potentially viable fetus. Therefore different healthcare institution may use
different data definition depending on the capability of the institution to care for the
newborns.
2.2.3. Findings
From 2008 to 2012, stillbirth rate for Malaysia remained fairly constant between four
and five per 1000 total birth respectively. However, Terengganu and Kelantan were
persistently above the average.
18
(a) Numbers of stillbirths
450
2008
400 2009
2010
350
2011
Number of stillbirths
2012p
300
p=preliminary
250
Number of stillbirths for
200 WP Putrajaya were
incorporated into
150 Selangor in 2008 and
2009 .
100
Total cases in
Malaysia:
50
2008: 2,128 cases
2009: 2,216 cases
- 2010: 2,222 cases
2011: 2,305 cases
2012p:2,213 cases
(b) Stillbirth rate
9.0
8.0 2008
Stillbirth rate (per 1000 total births)
2009
7.0 2010
2011
6.0
2012p
5.0
p=preliminary
4.0
Stillbirth rates for
WP Putrajaya
3.0 were incorporated
into Selangor in
2.0 2008 and 2009 .
1.0
Figure 2.6: Stillbirth rates by states in Malaysia, 2008-2012

19
Stillbirth rates by year for Northern Peninsular states Stillbirth rates by year for Eastern Peninsular states
in Malaysia, 2008-2012 in Malaysia, 2008-2012
9.0 9.0
8.0 Malaysia 8.0 Malaysia
(per 1000 total births)

7.0 Kedah 7.0
Stillbirth raterate
Kelantan
6.0 Perak
6.0
Stillbirth rate
Pahang
Perlis
5.0 5.0
4.5 4.5 Pulau Terengg

4.0 4.3 4.4 4.3 Pinang 4.0 4.4 4.5 4.5 anu
4.3 4.3
3.0 3.0
2.0 2.0
1.0 1.0
- -
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(a) (b)
Stillbirth rates by year for Central Peninsular states Stillbirth rates by year for Southern Peninsular states
in Malaysia, 2008-2012 in Malaysia, 2008-2012
9.0 9.0
Malaysia
8.0
Stillbirth rate (per 1000 total births)
Negeri 8.0
Sembilan
Malaysia
7.0 Selangor 7.0
WP Kuala
6.0 Lumpur 6.0 Johor
Stillbirth rate
WP
5.0 Putrajaya
5.0
Melaka
4.0 4.4 4.5 4.5 p=Preliminary 4.4 4.5 4.5
4.3 4.3 4.0 4.3 4.3
3.0 Stillbirth rate for 3.0

WP Putrajaya
2.0 was
incorporated 2.0
into Selangor in
1.0 1.0
2008 and 2009
- -
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(c) (d)
Stillbirth rates by year for East Malaysia states,

2008-2012
9.0
8.0
Malaysia
7.0
Stillbirth rate
6.0 Sabah
5.0
Sarawak
4.0 4.4 4.5 4.5 4.3
4.3
WP
3.0 Labuan
2.0
1.0
-
2008 2009 2010 2011 2012p
(e)
Figure 2.7 (a),(b),(c),(d),(e): Stillbirth rates by regions in Malaysia, 2008-2012
20
5.0
4.8
4.6
4.5 4.5
4.4
4.4 Total
Stillbirth rate
4.3 4.3 Male

4.2 Female
4.0
3.8
3.6
2008 2009 2010 2011 2012
Figure 2.8: Stillbirth rates by gender in Malaysia, 2008-2012

21
2.3. Perinatal Mortality
2.3.1. Definition
Perinatal mortality refers to stillbirths and deaths of infants aged less than 1 week 9.
Unit of Measurement: Deaths per 1,000 total births
Number of deaths under 1 week + number of stillbirths in year t x 1000

Perinatal mortality rate = Number of live births + number of stillbirths in year t
This indicator combines stillbirth and early neonatal death.
2.3.3. Findings
Perinatal mortality rate was relatively constant for overall Malaysia since 2008
(Figure 2.10). Among the states, WP Kuala Lumpur, Selangor and Johor had lower
perinatal mortality whereas Terengganu, WP Labuan and Kelantan harbored
persistently high number of cases per 1000 population.
22
(a) Numbers of perinatal mortalities
800
2008
700 2009
2010
600
Number of Perinatal Mortality
2011
2012p
500
p=Preliminary
400
Perinatal mortality cases for
WP Putrajaya were
300 incorporated into Selangor in
2008 and 2009.
200
Total cases in Malaysia:
2008: 3,560 cases
100 2009: 3,812 cases
2010: 3,791 cases
2011: 3,896 cases
0 2012p: 3,757 cases
Figure 2.9: Number of perinatal mortalities by state in Malaysia, 2008-2012

(b) Perinatal mortality rate
14.0
12.0 2008
2009
10.0
Perinatal Mortality Rate
2010
2011
8.0
2012p
6.0
p=Preliminary
4.0
Perinatal mortality rates
for WP
2.0 Putrajaya were
incorporated into Selangor
in 2008 and 2009
0.0
Figure 2.10: Perinatal mortality rates by states in Malaysia, 2008-2012

23
Perinatal mortality rates by year for Northern Perinatal mortality rates by year for Eastern
Peninsular states in Malaysia, 2008-2012 Peninsular states in Malaysia, 2008-2012
14.0 14.0
12.0 Malaysia 12.0

Perinatal mortality rate

Kedah

Malaysia
10.0 10.0
Perak
Kelantan
Perlis
8.0 8.0 Pahang
Pulau
7.6 7.7 7.6 7.6 7.7
Pinang 7.6 Terengganu
7.3 7.4 7.3 7.4
6.0 6.0
4.0 4.0
2.0 2.0
0.0 0.0
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(a) (b)
Perinatal mortality rates by year for Central Perinatal mortality rates by year for Southern
14.0 14.0
Malaysia
12.0 12.0 Malaysia
Negeri
Sembilan
10.0 Selangor 10.0

Johor
WP Kuala
8.0 Lumpur 8.0
7.6 7.7 7.6 WP 7.6 7.7 Melaka
7.3 7.4 Putrajaya 7.6 7.4
6.0 6.0 7.3
p=Preliminary
Perinatal
4.0 4.0
mortality rates
for WP
2.0 Putrajaya 2.0
were
incorporated
0.0 into Selangor in 0.0
2008 2009 2010 2011 2012p 2008 and 2009 2008 2009 2010 2011 2012p
(c) (d)
Perinatal mortality rates by year for East Malaysia
states, 2008-2012
14.0
12.0
Malaysia
10.0
Sabah
8.0
Sarawak
7.6 7.7 7.6 7.4
7.3
6.0
WP
Labuan
4.0
2.0
0.0
2008 2009 2010 2011 2012p
(e)
Figure 2.11 (a),(b),(c),(d),(e): Perinatal mortality rates by regions in Malaysia, 2008-
2012
Source: Department of Statistics Malaysia. The graphs were generated by the MHPU.
24
9.0
8.0
7.6 7.7 7.6
7.3 7.4
7.0
6.0
5.0 Total
Male
4.0
Female
3.0
2.0
1.0
0.0
2008 2009 2010 2011 2012
Figure 2.12: Perinatal mortality rates by gender in Malaysia, 2008-2012

25
2.4. Neonatal Mortality
Neonatal deaths are subdivided into early neonatal deaths, occurring during the first
seven days of life, and late neonatal deaths, occurring after the seventh day but
before the 28 completed days of life.
2.4.1. Definition
Neonatal mortality refers to deaths of infants less than 28 days 9.

Unit of Measurement: Deaths per 1,000 live births
Number of deaths under 28 days of age in year t x 1000

Neonatal Mortality Rate = Number of live births in year t
Neonatal deaths account for a large proportion of child deaths. Mortality during
neonatal period is considered a useful indicator of both maternal and newborn care.
Factors such as health of the mother, antenatal care and birth weight are important
determinants of neonatal mortality.
2.4.3. Findings
Neonatal mortality rate was found to be much lower in the Wilayah Persekutuan
Kuala Lumpur and Selangor than the rest.
26
(a) Number of neonatal deaths
450
400 2008
2009
350 2010
Number of neonatal Mortality
2011
300 2012p
p=Preliminary
250
Neonatal mortality rates
200 for WP Putrajaya were
incorporated into
150 Selangor in 2008 and
2009
100 Total cases in Malaysia

2008: 1,922 cases
50 2009: 2,145 cases
2010: 2,106 cases
2011: 2,133 cases
0 2012p: 2,049 cases
Figure 2.13: Number of neonatal mortality by states in Malaysia, 2008-2012

(b) Neonatal mortality rate
8.0
2008
7.0
2009
2010
6.0
Neonatal mortality rate
2011
(per 1000 live births)
5.0 2012p
4.0
p=Preliminary
3.0 Neonatal mortality

rates for WP
2.0 Putrajaya were
incorporated into
Selangor in 2008
1.0 and 2009
0.0
Figure 2.14: Neonatal mortality rates by states in Malaysia, 2008-2012

Source: Department of Statistics Malaysia. Graph was generated by the MHPU .
27
Neonatal mortality rates by year for Northern Neonatal mortality rates by year for Eastern
8.0 8.0
7.0 Malaysia
7.0
Malaysi a
6.0 6.0

Kedah

Kelanta n
5.0 Perak 5.0
Pahang
4.0 4.3 4.3 Perlis 4.0 4.3 4.3 4.2

4.2 4.0 Terengganu
3.9 4.0 3.9
3.0 Pulau 3.0
Pinang
2.0 2.0
1.0 1.0
0.0 0.0
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(a) (b)
Neonatal mortality rates by year for Central Neonatal mortality rates by year for Southern
8.0 Malaysia 8.0
Negeri
7.0 Sembilan 7.0
Selangor Malaysia
6.0
6.0
WP Kuala
Johor
Lumpur
WP Melaka
5.0 Putrajaya 5.0
4.0 4.3 4.3 p=Preliminary

4.2 4.0 4.3 4.3 4.2
3.9 4.0 3.9 4.0
Neonatal
3.0 mortality rates 3.0
for WP
2.0 Putrajaya 2.0
were
incorporated
1.0 1.0
into Selangor
in 2008 and
0.0 2009 0.0
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(c) (d)
Neonatal mortality rates by year for East Malaysia

states, 2008-2012
8.0
7.0
Malaysia
6.0
Sabah
5.0
Sarawak
4.0 4.3 4.3 4.2
3.9 4.0 WP
Labuan
3.0
2.0
1.0
0.0
2008 2009 2010 2011 2012p
(e)
Figure 2.15 (a),(b),(c),(d),(e): Neonatal mortality rates by regions in Malaysia, 2008-
2012
28
6.0
5.0
4.0 4.3 4.3 4.2

Neonatal death rate
4.0
3.9
Total
3.0
Male
Female
2.0
1.0
0.0
2008 2009 2010 2011 2012
Figure 2.16: Neonatal mortality rates by gender in Malaysia, 2008-2012

100%
90% 414 397 476 456

476
80% Late Neonatal Death
70% Early Neontal Death

Percentage of mortality
60%
50%
40% 1570 1547 1616 1689

1547
p = Preliminary
30%
20%
10%
0%
2008 2009 2010 2011 2012
Figure 2.17: Neonatal mortality rates by categories in Malaysia, 2008-2012

Source: Family Health Development Division, MOH Malaysia.
29
100% 35 28 43 38 98
144 172 160 153
90% 191
249 274 Unknown
279 254
80% 226
Others
236 182 199 189
70% 200 Asphyxia
Infection
Percentage of deaths
60%
Lethal Congenital
556 533 616 Malformation
573 661 Immaturity
50%
40%
30%
20% 803 772 812

732 780
10%
0%
2008 2009 2010 2011 2012
Figure 2.18: Causes of neonatal mortality in Malaysia, 2008-2012

Source: Family Health Development Division, MOH Malaysia.
Between 2008 and 2012, data from the Family Health Development Division (FHDD)
unveiled that the main causes of neonatal death were immaturity and lethal
congenital malformations (Figure 2.18).
30
2.5. Infant Mortality
2.5.1. Definition
Infant mortality refers to deaths of infants aged less than 1 year 9.

Number of deaths under 1 year of age in year t x 1000

Infant Mortality Rate = Number of live births in year t
Infant mortality reflects the availability, utilization and effectiveness of health care
system, particularly, post-natal care.
2.5.3. Findings
The five years overall trend of infant mortality rates in Malaysia showed a decline.
Notwithstanding that, drilling down to WP Putrajaya, an upward trend of infant
mortality was evident (Figure 2.20).
31
(a) Number of infant mortalities
700
2008
2009
600 2010
2011
2012p
Number of Infant Mortality
500
p=Preliminary
400
Infant mortalities for
WP Putrajaya were
300 incorporated into
2009.
200
Total cases in Malaysia
2008: 3,045 cases
100 2009: 3,404 cases
2010: 3,295 cases
2011: 3,330 cases
0 2012p: 3,204 cases
Figure 2.19: Number of infant deaths by states in Malaysia, 2008 - 2012

(b) Infant mortality rate
12.0
2008
10.0 2009
2010
8.0 2011
2012p
Infant mortality Rate
6.0
p=Preliminary
4.0 Infant mortality rates

for WP Putrajaya
were incorporated
into Selangor in 2008
2.0 and 2009
0.0
Figure 2.20: Infant mortality rates by states in Malaysia, 2008 - 2012

32
Infant mortality rates by year for Northern Peninsular Infant mortality rates by year for Eastern Peninsular
10.0 10.0
Malaysia
8.0 8.0
Infant mortality rate
Malaysia

Kedah
Kelantan
6.9 Perak
6.7 6.5 6.9
6.0 6.2 6.3
6.0 6.7 Pahang
Perlis 6.5 6.3
6.2
Terengganu
Pulau
4.0 Pinang
4.0
2.0 2.0
0.0 0.0
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(a) (b)
Infant mortality rates by year for Central Peninsular Infant mortality rates by year for Southern Peninsular
10.0 10.0
Malaysia
Negeri
Sembilan
8.0 Selangor 8.0

Malaysia
WP Kuala
6.9 6.7 Lumpur Johor
6.0 6.5 WP 6.9
6.3 Putrajaya 6.0 6.7 6.5
6.2 6.2 6.3
Melaka
p=Preliminary
4.0 4.0
Infant mortality
rates for WP
Putrajaya were
2.0 2.0
incorporated into
Selangor in 2008
and 2009
0.0 0.0
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(c) (d)
Infant mortality rates by year for East Malaysia
states, 2008-2012
10.0
8.0 Malaysia
Sabah
6.0 7.1 6.8

6.5 6.5 Sarawak
6.0
WP
4.0 Labuan
2.0
0.0
2008 2009 2010 2011 2012p
(e)
Figure 2.21 (a),(b),(c),(d),(e): Infant mortality rates by regions in Malaysia, 2008-2012
Comparing the infant mortality rates by region from 2008 to 2012, there seems to be
a clustering pattern of certain states in Northern and Eastern Peninsular region that
recorded a much higher still birth rates than the rest (Figure 2.21 (a),(b),(c),(d),(e)).
33
8.0
7.0
6.9
6.7
6.0 6.5
6.2 6.3
5.0
Total
4.0
Male
Female
3.0
2.0
1.0
0.0
2008 2009 2010 2011 2012
Figure 2.22: Infant mortality rates by gender in Malaysia, 2008-2012


Over the last 30 years, there has been marked reduction in infant mortality rate in
Asia/Pacific region. In countries such as Malaysia, Singapore, Republic of Korea,
and Thailand, the decline has been by 75% or more3 (Figure 2.23).
Malaysia was positioned at about the OECD average for infant mortality rate in 2010.
3
Figure 2.23: Infant mortality rate, 2010 and decline, 1980 and 2010
Source: OECD (2012)
34
2.6. Under-five Mortality
2.6.1. Definition
Under-five mortality refers to deaths of children under the age of 5 years old 9.
Number of deaths under 5 years of age in year t x 1000

Under-five mortality rate = Number of live births in year t
The under-five mortality rate reflects the impact of child survival interventions during
the first few years of life. It is a Millennium Development Goal (MDG) 4.
2.6.3. Findings
Under-five mortality rate in Malaysia took a downtrend over the 5 year period (Figure
2.25). However, the pattern was inconsistent at the state level showing peaks at
different point in time. In 2011, Perlis, Pahang and Terengganu ranked atop with
highest mortality rate whereas Selangor, WP Kuala Lumpur and Kedah boasted with
the least (Figure 2.25).
35
(a) Number of under-five mortalities
800
2008
700 2009
2010
600 2011
Number of Under-5 Mortality
2012p
500
p=Preliminary
400 Neonatal mortality

rates for WP
Putrajaya were
300 incorporated into
200 2009
Total cases in
100 Malaysia
2008: 3,887 cases
2009: 4,222 cases
0 2010: 4,108 cases
2011: 4,092 cases
2012p: 3,924 cases
Figure 2.24: Number of under-five mortalities by states in Malaysia, 2008-2012

(b) Under-five mortality rate
14.0
2008
12.0 2009
2010
10.0 2011
Under-five mortality rate
2012p
8.0
p=Preliminary
6.0 Under 5 mortality

rate for WP Putrajaya
were incorporated
4.0 into Selangor in
2008 to 2009
2.0
0.0
Figure 2.25: Under-five mortality rates by states in Malaysia, 2008 - 2012

36
Under-five mortality rates by year for Northern Under-five mortality rates by year for Eastern
14.0 14.0
Malaysia
Malaysia

12.0 Kedah 12.0

Kelantan
10.0 Perak
10.0
Perlis Pahang
8.0 8.5 8.4 8.0 8.5
8.0 8.4 8.0
8.0 7.7 Pulau 8.0 Terengganu
Pinang 7.7
6.0 6.0
4.0 4.0
2.0 2.0
0.0 0.0
2008 2009 2010 2011 2012p 2008 2009 2010 2011 2012p
(a) (b)
Under-five mortality rates by year for Central Under-five mortality rates by year for Southern
14.0 Malaysia 14.0

Negeri
12.0 Sembilan
12.0
Selangor
Malaysia
10.0 10.0
WP Kuala
Lumpur Johor
8.0 8.5 8.4 WP 8.0 8.5
8.0 Putrajaya 8.4
8.0 7.7 8.0 8.0 7.7 Melaka
p=Preliminary
6.0 6.0
Under-five
4.0 mortality rates
4.0
for WP
Putrajaya
2.0 were 2.0
incorporated
into Selangor
0.0 in 2008 and 0.0
2008 2009 2010 2011 2012p 2009 2008 2009 2010 2011 2012p
(c) (d)
Under-five mortality rates by year for East Malaysia

states, 2008-2012
14.0
12.0 Malaysia
10.0 Sabah
8.0 8.5 Sarawak

8.4 8.0
8.0 7.7
6.0 WP
Labuan
4.0
2.0
0.0
2008 2009 2010 2011 2012p
(e)
Figure 2.26 (a),(b),(c),(d),(e): Under-five mortality rates by regions in Malaysia, 2008-

2012
37
10.0
9.0
8.0 8.5
8.4
8.0 8.0
7.7
7.0
6.0
Total
5.0
Male
4.0 Female
3.0
2.0
1.0
0.0
2008 2009 2010 2011 2012
Figure 2.27: Under-five mortality rates by gender in Malaysia, 2008-2012


Malaysia is approaching the average of OECD countries in term of under-five
mortality. The principle cause of death was also similar to that of OECD; more death
due to prematurity and congenital anomalies instead of pneumonia.
87 Pakistan
66 Myanmar
63 India
61 Papua New Guinea
54 Lao PDR
51 Cambodia
50 Nepal
48 Bangladesh
35 Indonesia
33 Korea Dem Rep
32 Asia - 20
32 Mongolia
29 Philippines
27 Solomon Islands
23 Viet Nam
18 China
17 Fiji
17 Sri Lanka
13 Thailand
7 Brunei Darussalam
6 Malaysia
6 New Zealand
5 Australia
5 Korea Rep
5 OECD
3 Japan
3
Singapore
100 75 50 25 0 0 25 50 75 100
Pneumonia Prematurity
Deaths per 1 000 live births Birth asphyxia Congenital anomalies
Other
Figure 2.28: Benchmarking Malaysia for under-5 mortality 2012

3 3
Source: UNICEF Childinfo (left); Source: WHO (right)
38
2.7. Additional Information on Childhood Mortality Trending
We have seen a 2-fold improvement in all child death statistics over the past 20
years (1990 to 2010). However, since 2000, the rates have been stagnating (Figure
2.29).
10.0
9.0 Stillbirth rate
8.0
Perinatal
mortality rate
7.0
Neonatal
per 1000 live birth
mortality rate
6.0
Infant mortality
5.0 rate
Under 5 mortality
4.0 rate
3.0
p=Preliminary
2.0
1.0
-
2000 2002 2004 2006 2008 2010 2012p
Figure 2.29: Trends between childhood mortality indicators from 2000 to 2012
Source: Department of statistics Malaysia, Graph was generated by the MHPU.
Caveat:
Cut off point for definition of live birth has been upgraded from 28 weeks to 22 weeks
in year 2000 in MOH Hospitals. Up to 2011, data were collected from 22 weeks
onwards. However from 2012 onwards, data for both cut offs (22 and 28 weeks)
were collected separately.
39
18
16
14
per 1000 live births

12
10
0
1990 2000 2010
Neonatal Mortality rate 8.5 3.7 4.3
Infant Mortality rate 13.1 6.5 6.7
Under 5 Mortality rate 16.8 8.9 8.4
Figure 2.30: Trends of neonatal mortality, infant mortality and under-five mortality
rate of Malaysia, from 1990 to 2010
40
Chapter 3 : MATERNAL HEALTHCARE
This chapter describes indicators pertaining to maternal healthcare.
3.1. Maternal mortality
3.1.1. Definition
Maternal deaths refer to deaths which are caused by complications of pregnancy or

childbirth or the puerperium within the period of 42 days after childbirth 9.
Unit of Measurement: maternal deaths per 100 000 live births
3.1.2. Rationale of use
Complications during pregnancy and childbirth remain the major causes of death and
disability among women of reproductive age in Malaysia. The maternal mortality ratio
represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also a
Millennium Development Goal (MDG) 5 indicator.
3.1.3. Findings
Maternal mortality ratio (MMR) for Malaysia remained fairly unchanged (year 2008
through 2011). However, Negeri Sembilan had a steep rise in MMR from 40.9 in
2008 to 45.3 in 2011 respectively. Kelantan demonstrated a consistently high
maternal mortality ratio across 3 consecutive years (Figure 3.2).
41
(a) Number of maternal mortalities

30
2008
25
2009
2010
No of maternal mortality
20
2011
15 Maternal mortalities
for WP Putrajaya
were incorporated
into Selangor in 2008
10 and 2009
Total cases Malaysia:

2008: 133 cases
5 2009: 134 cases
2010: 128 cases
2011: 134 cases
0 2012p: 130cases
Figure 3.1: Number of maternal mortality by states in Malaysia, 2008-2012

(b) Maternal Mortality Ratio
70.0
2008
60.0
2009
2010
50.0
Maternal Mortality Ratio
(per 100,000 live births)
2011
40.0
Maternal mortality
ratios for WP
30.0 Putrajaya were
incorporated in
Selangor in 2008
and 2009
20.0
10.0
0.0
Figure 3.2: Maternal mortality ratios by states in Malaysia, 2008-2011

42
Maternal mortality ratios by year for Northern Maternal mortality ratios by year for Eastern
70.0 70.0
60.0 Malaysia 60.0 Malaysia

Maternal mortality ratio
(per 100.000 live births)

Kedah Kelantan
50.0 50.0
Perak Pahang
40.0 Perlis 40.0 Terengganu

Pulau
Pinang 30.0
30.0
27.3 27.0 26.1 26.2 27.3 27.0 26.1 26.2
20.0 20.0
10.0 10.0
0.0 0.0
2008 2009 2010 2011 2008 2009 2010 2011
(a) (b)
Maternal mortality ratios by year for Central Maternal mortality ratios by year for Southern
Peninsular States in Malaysia, 2008-2012 Peninsular states in Malaysia, 2008-2011
70.0 70.0
Malaysia
60.0 Negeri 60.0

Sembilan Malaysia
Selangor
50.0 50.0
WP Kuala
Lumpur
Johor
40.0 40.0
WP Putrajaya
30.0 30.0 Melaka

Maternal
27.3 27.0 26.1 26.2 25.6 mortality ratios 27.3 27.0 26.2
20.0 26.1
for WP 20.0
Putrajaya were
10.0 incorporated 10.0
into Selangor in
0.0 2008 and 2009
2008 2009 2010 2011 2012 0.0
2008 2009 2010 2011
(c) (d)
Maternal mortality ratios for East Malaysia states,
2008-2011
70.0
Malaysia
60.0
Sabah
50.0
Sarawak
40.0
WP
Labuan
30.0
27.3 27.0 26.1 26.2

20.0
10.0
0.0
2008 2009 2010 2011
(e)
Figure 3.3: Maternal mortality ratios by regions in Malaysia, 2008-2011
From 2008-2011, wide differentials exist in these rates from state to state and from
year to year within the certain states (Figure 3.3).
43
(c) Cause of Maternal Deaths during Postpartum stage
25
20
15
Number of deaths
10
0
Unspecifie
Associated
d Obstretric Obsteric Puerperal
PPH Ectopic Others HDP Medical APH
complicatio Embolism Trauma Sepsis
Condition
n
2009 19 1 1 6 14 13 24 4 3 6
2010 11 0 0 4 12 17 26 6 2 6
2011 19 0 0 4 19 10 19 9 3 2
Figure 3.4: Cause of maternal deaths during postpartum stage

Source: Family Health Development Division
The main cause of maternal deaths during postpartum stage is concomitant medical
conditions, obstetric embolism and Hypertensive Disorders of Pregnancy (HDP)
(Figure 3.4).
44
Figure 3.5: Estimated maternal mortality ratios, selected countries, 1990-2010

3
Source: WHO (2012), Health at a Glance: Asia/Pacific 2012
Malaysia’s maternal mortality was better in comparison to the Asia-20 but higher
than OECD average (Figure 3.5).
45
3.2. Millennium Development Goal 5
We have seen remarkable progress in maternal care since 1933, however

improvement in maternal mortality has been minimal recently and we are diverting
away from the Millennium Development Goal (MDG) target. The MDG target for
Malaysia is to reduce MMR to 11 deaths per 100,000 live births by 2015 (Figure 3.6).
1200
50
per 100,000 live births

45
Comparison between Malaysia’s
40
Maternal Mortality Ratio with MDG 5
1000 35
30
25
800 20
15
10
5
600
0
2012
1991 1995 2000 2005 2007 2009 2010 2011 2013 2014 2015
p
Target 44 40 35 30 28 26 23.5 21 18.5 16 13.5 11
400
Achievement 44 46.9 28.1 27.9 29 27 26.1 26.2 25.6
200
0
2012
1933 1935 1940 1946 1950 1957 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2009 2010 2011
p
MMR 1080 960 770 670 530 280 240 200 150 80 60 40 20 46.9 28.1 27.9 27 26.1 26.2 25.6
Figure 3.6: Trend of maternal mortality ratio in Malaysia from 1933 to 2012
Source: Department of Statistics Malaysia and Family Health Development Division, Ministry of Health
46
Challenges and Recommendations
1. Assignment of state for death statistics.
Death statistics require the denominator to be assigned to a defined population.

Prior to 1982, the calculation for death statistics took the place of occurrence (the
state where the death occurred) as the denominator. However, after 1982, the
place of residence of the person as documented in his or her death registry form
by the National Registration Department is used instead.
Recommendations: Statistical computation using either place of residence or

place of occurrence (of death) has its own respective implication. Death rate as
according to places of residence may reflect long term performance of healthcare
delivery to the population in the respective region whereas assorting death data
by the place of occurrence gives an opportunity to assess performance at the
facility level. Therefore, we recommend the recording and analysis using both
variables.
2. Differences in practice of documenting place of residence
There is inconsistency in recording the person’s address in the death registry

form. The home address recorded can be either the address on the
identification card or the address given by next of kin. Each may be different
from the usual place of residence of the person who died. This is especially so
when the address on the identification card was not updated. To date, the
magnitude of discrepancy is unknown.
Recommendations: To conduct a study measuring the discrepancy between the

recorded address in the death registry form and the usual place of residence.
3. Gaps in the methodology of performance and outcome reporting
Whilst completing this 2014 report, we have identified gaps in the methodology of
performance and outcome reporting that may lead to misinterpretation in
performance benchmarking both internally as well as internationally.
Recommendation: In order to produce a purposeful 2015 publication, we plan to

build summary tables of data availability for each service or specialty that we
intend to report. In doing so, we hope that we could identify and optimize all data
resources and build a clearer picture so as to bridge the limitations that we may
face.
Our report uses available published data with the assumption that these are the
most up-to-date. This report may impose the need for both new and improved
data collection as unavailability or inadequacy of quality data will significantly limit
meaningful comparison.
47
References
1. Department of Statistics, Malaysia. Abridged Life Tables, Malaysia 2010-

2013. Putrajaya: Department of Statistics, Malaysia; 2013. 108 p.
2. World Health Organization [Internet]. Life expectancy at birth (years). Indicator

and Measurement Registry version 1.7.0 WHO 2011. Available from:
http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=65
3. Oecd-ilibrary.org [Internet]. OECD/World Health Organization (2012), Health

at a Glance: Asia/Pacific 2012, OECD Publishing. Available from:
http://dx.doi.org./10.1787/9789264183902-en
4. Who.int [Internet]. WHO Civil registration: why counting births and deaths is
important [updated May 2014]. Available from:
http://www.who.int/mediacentre/factsheets/fs324/en
5. Who.int [Internet]. WHO Health statistics and information systems. Available

from: http://www.who.int/healthinfo/statistics/indmaternalmortality/en
6. Oecd.org [Internet]. OECD Health Data 2007: Statistics and Indicators for 30
Countries, OECD, Paris, 2007, Data sources, definitions and methods.
Glossary of Statistical Terms [cited on 24th March 2015]. Available from:
http://stats.oecd.org/glossary/detail.asp?ID=1530
7. Department of Statistics, Malaysia. Yearbook of Statistics, Malaysia 2007.

Putrajaya: Department of Statistics, Malaysia; 2008. 397 p.
8. Oecd.org [Internet]. OECD Underlying Cause of Death. Handbook of Vital

Statistics Systems and Methods, Volume 1: Legal, Organisational and
Technical Aspects, United Nations Studies in Methods, Glossary, Series F,
No. 35, United Nations, New York 1991. Glossary of Statistical Terms [cited
on: 15 February 2015]. Available from:
http://stats.oecd.org/glossary/detail.asp?ID=2790
9. Department of Statistics, Malaysia. Vital Statistics Time Series, Malaysia,

1963-1998: Department of Statistics, Malaysia; 2001. 285 p.
48

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Malaysian Health and Healthcare

Maternal and Child Mortality

MALAYSIAN HEALTHCARE PERFORMANCE UNIT

Ariza binti Zakaria

Joseph Ng Soon Heng

Mohd Kamarulariffin bin Kamarudin

Jamaiyah binti Haniff

Theyveeka Selvy a/p Rajoo @ Balusamy Radia

This report is supported by National Institutes of Health (NIH), Ministry of Health

Malaysian Healthcare Performance Unit

Tel : (603) 8000 8000

Y.Bhg. Datuk Dr Lokman Hakim bin Sulaiman

Y.Bhg. Dato' Dr Hj Azman bin Abu Bakar

YBhg. Datuk Dr Haji Abdul Rahman bin Hasan

Dato’ Dr Ahmad Razin bin Dato’ Haji Ahmad Mahir

Y.Bhg. To’ Puan Dr Safurah binti Hj Jaafar

Datuk Dr Zulkifli bin Jantan

Dato’ Dr Norhizan bin Ismail

Dr Haji Mohammad bin Omar

Dr Zaini bin Hussin

Dr Md. Khadzir bin Sheikh Hj. Ahmad

SPECIAL THANKS FOR FINAL REVIEW

Professor Niek Klazinga

THE EDITORIAL BOARD

Dr Jamaiyah binti Haniff

Dr Theyveeka Selvy a/p Rajoo @ Balusamy Radia

Y.Bhg. Dato' Dr Hussain Imam bin Haji Mohammad Ismail

Dr Ravichandran a/l Jeganathan

Dr Roslinah binti Ali

Dr Kamariah binti Hussain

Dr Hayati binti Mohd Radzi

Dr Jamilah binti Hashim

En. Ahmad Jessree bin Kamaruddin

Dr Sharmala Devi Karalasingam

Datin Dr Siti Hajar binti Daud

Dr Mahani binti Abdul Hamidy

Dr Siti Sara binti Yaacob

Dr Arpah binti Ali

Dr Jafanita binti Jamaludin

Dr Zul Azuin binti Zulkifli

Dr Yeong May Luu

Dr Junaideen bin Mohamad Zain

En. Mohd Sofi bin Ali

SOURCES DATA PROVIDERS

Pusat Informatik Kesihatan (PIK)

Bahagian Pembangunan Kesihatan Keluarga (BPKK)

Bahagian Perangkaan Penduduk & Demografi

THE CORE TEAM MEMBERS

(MALAYSIAN HEALTHCARE PERFORMANCE UNIT)

Dr Theyveeka Selvy a/p Rajoo @ Balusamy Radia

Dr Ariza binti Zakaria

Dr Joseph Ng Soon Heng

Dr Mohd Kamarulariffin bin Kamarudin

Cik Nur Naim binti Ghazali

Cik Nadiah Hanis binti Hashim

Cik Maisarah binti Mahari

En. Muhammad Afiq bin Mohd Jaffar

ABBREVIATION FULL NAME

ACKNOWLEDGEMENTS .................................................................................................. iii

2.3. Perinatal Mortality ................................................................................................. 22

Figure 1.1: Malaysian life expectancy at birth ........................................................................ 3

Figure 2.24: Number of under-five mortalities by states in Malaysia, 2008-2012 ................. 36

This is the first report that focused on healthcare performance benchmarking. It

In conclusion, this first report serves as a proof that performance benchmarking of