MDG 4 -Reduce Child Mortality What More Can Be Done?

MDG 4 -Reduce Child Mortality

Target 4A To reduce by two third the mortality rate among children under five from 1990 Indicators:
i. Infant mortality rate (4.4 per 1,000 livebirths by 2015) ii. Under-five mortality rate (5.6 per 1,000 livebirths by 2015) iii. Proportion of 1 year old children immunized against measles

DEFINITION
Term
Under five mortality rate(U5MR)

Definition
The under-five mortality rate (U5MR) is the probability (expressed as a rate per 1,000 live births) of a child born in a specified year dying before reaching the age of five if subject to current age-specific mortality rates. No. of U5 deaths x 1,000 live births Estimated live births

Infant Mortality rate(IMR)

The infant mortality rate is the probability (expressed as a rate per 1,000 live births) of a child born in a specified year dying before reaching the age of one if subject to current age-specific mortality rates. No. of infant deaths Estimated live births x 1,000 live births

Proportion of 1 year-old children immunized against measles

Proportion of 1 year olds children immunized against measles is the percentage of children under one year of age who have received at least one dose of a measles vaccine. No. of children 1-<2 yrs vaccinated x 100 Estimated no. of children aged 1-<2 yrs

INFANT MORTALITY RATE AND UNDER FIVE MORTALITY RATE, MALAYSIA FROM 1970 - 2002

There has not been a significant recent progress in MCH

Maternal Child Health (MCH) progress in Malaysia (2004-2010)
45
40

40 35
30 30 30 30 28 27

30 25 20 15 10 5 0 2004 2005 2006 2007 2008

10 9 10 11 11

Maternal Mortality Rate (MMR, per 100,000 live births)

Low Birth Weight <2500 grams (LBW, % out of total births)

11 11

Infant Mortality Rate (IMR, per 1,000 live births)

2009

2010

Source: Health Facts, various years, Ministry of Health Malaysia UNICEF , MINISTRY OF HEALTH

UNDER-5 MORTALITY RATE, INFANT MORTALITY RATE & NEONATAL MORTALITY RATE (DEATHS PER 1,000 LIVE BIRTHS) FOR MALAYSIA FROM 1990 2010
20 18 16.8

U5MR

IMR

NMR

16
Death per 1,000 live births

14 12

13.1

13.2
10.3

12.5

Stagnation of U5MR & IMR since 2000

10 8
6 4 8.4

9.3
6.8 5.5

8.9
6.5 5.7

8.5
6.6 3.9

8.4 6.7 4.3

2
0
1990 1995 1999 2000 2005 2010

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia

PROJECTION OF REDUCTION INFANT MORTALITY RATE AND ACTUAL UNDER-FIVE MORTALITY RATE FROM 2008 - 2015
18 16

14
12 Rate 10 8 6 4 2 0
IMR (P) U5MR (P) IMR (A) U5MR (A) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 13 16 12 15 12 14 11 14 10 13 10 13 8 11 9.4 12 10 14 9.3 12 6.5 8.9 5.7 8.6 6.5 8.8 6.6 8.7 6.5 8.5 6.6 8.5 6.2 7.9 6.2 7.9 6.2 7.6 6.2 8 6.1 7.4 6.9 8.5 6 7.2 6.7 8.4 5.8 6.8 6.6 8.1 5.4 6.4 6.6 8.1 5 6 4.6 5.8 4.4 5.6

UNDER-5 MORTALITY RATE, INFANT MORTALITY RATE & NEONATAL MORTALITY RATE (DEATHS PER 1,000 LIVE BIRTHS) BY STATE FOR 1990 & 2010
1990
Malaysia :U5MR at 16.8 per 1,000 LB IMR at 13.1 per 1000 LB NMR at 8.4 per 1000 LB

2010

Malaysia: U5MR at 8.4 per 1,000 LB IMR at 6.7 per 1000 LB NMR at 4.3 per 1000 LB

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia 1990 & 2011

NUMBER OF UNDER-5 DEATH, INFANT DEATH & NEONATAL DEATH BY STATE FOR 1990 & 2010
1990 1000
900
800 700
671 521 409 340 295 248 175

Under-5 death
874

Infant death

Neonatal death

955 906

730 652 499 374 298 208 296 241

770
659 520 505 543 412 312 251

745

Number of death

600 500
400

571

300 200
100 0
Perlis

266

99 81 60

197 159 158 113

Kedah P.Pinang Perak Selangor WPKL N.Semb. Melaka

Johor

Pahang T'gganu Kelantan Sabah Sarawak

2010

Under-5 death

Infant death

Neonatal death

1000 900 800 700 600 500 400 300 200 100 0

Number of death

688

557 483
381 324 274 289 179 145 98 177 350 396

384
251 202 149

121
41 33 24

176 135 78
21 18 11

155 122 123 105 78 68

248 263 197

111

301 193

273 225 142

346 281

176 20 15 12

Perlis KedahP.Pinang Perak Selangor WPKL WP Putrajaya N.Semb. Melaka Johor PahangT'gganu KelantanSabah Sarawak WP Labuan

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia 1990 & 2011

UNDER-5 MORTALITY RATE, INFANT MORTALITY RATE & NEONATAL MORTALITY RATE (DEATHS PER 1,000 LIVE BIRTHS) FOR MALAYSIA FROM 2000 2012
U5MR
10
Death per 1,000 live births

IMR
8.5 6.6

NMR
8.5 6.9 8.4 6.7

8.9

8.6

8.8

8.7

8.5 6.5

8 6.5
6 4 5.7

7.9 6.2

7.9 6.2

8.0 6.2

8.1 6.6

8.1 6.6

6.5

6.6

3.7

3.6

3.8

3.2

3.7

3.9

3.7

3.8

3.9

4.3

4.3

4.2

4.3

2 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia, 2000 -2011 (preliminary) Family Health Development Division - 2012 preliminary data

INFLUENCES OF NEONATAL MORTALITY & POST-NEONATAL MORTALITY IN INFANT MORTALITY RATE, MALAYSIA FROM 1970 - 2000
Neonatal mortality related to maternal health during pregnancy and birth delivery (place of delivery and whether or not the baby is delivered by skilled birth attendant). Post-neonatal mortality are due largely to socio-economic and environmental factors

NUMBER (%) OF UNDER-5 DEATH, INFANT DEATH & NEONATAL DEATH BY STATE FOR 2012
STATE 0 28 days (Neonatal death) 28 days <1 year <1 year 5 years Under 5 death

Perlis Kedah Pulau Pinang Perak Selangor WP Kuala Lumpur WP Putrajaya

14 137 114 In 188 265 75 7

9 78

10 33

33 248

60deaths were among 31 205 2012, 54% of early neonatal 75 were among59 322 and 28.7% post-neonatal. 84 About119 17.9% were among toddlers 468 61 19 24 5 160 31

N.Sembilan
Melaka Johor Pahang Terengganu Kelantan Sabah Sarawak WP Labuan

88
67 164 146 141 148 389 219 11

31
33 117 74 60 91 199 140 5

13
14 72 61 43 57 14 78 4

132
144 353 281 244 296 728 437 20

MALAYSIA

2173 (53.4%)

1171 (28.7%)

728 (17.9%)

4072

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2 Hospital Death & Non-Hospital Deaths report for 28 days - < 5 years; - preliminary

rate per 1,000 live birth

INTERVENTIONS INITIATED
-Maternal and child hcealth services - Development of three 3 tier system - Introduction of immunisation - BCG vaccination - DPT vaccination - Introduction of Modern Contraceptive method

10 1972: Oral Polio Vaccination 1974: Anti Tetanus Toxoid vaccination - Introduction of Child Helath Card - introduction of NCHS Growth Chart 2 tier system replaced 3 tier system - Increase accessibility to rural areas including outreached services

20

30

40

50

60

70

80

Source: Family Health Development Division

1982: Measles vaccination

-G6PD screening - Nutrition Rehabilitation -ARI and CBD Progra - Home death investigationm
1987 : Rubella vaccination 1989: Hepatitis B vaccination

INTERVENTIONS AND TRENDS OF INFANTS AND UNDER 5 YEAR MORTALITY 1980's 1950 - 2007 1990's 2000's 1960's 1970's 1950's

YEAR 1955 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 UNDER 5 YEARS DEATH INFANT DEATH -Neonatal Resucitation Program Brest Feeding Policy Upgrading of Midwife to Community Nurse NIA - Severe Neonatal Jaundice

MDG STARTS

1998: Congenital Hypothyroidism Rapid Reporting System of Stillbirths and Neonatal Death 2000: IMCI in Pahang, Sabah and Sarawak 2002: Hib and MMR vaccination 2011 inrtoduce pre-pregnancy care esp for high risk women 2013 Launching of 1000 Hari pertama Kehidupan Kearah Generasi Sihat

Newborn & Child Survival Interventions Coverage Indicators

NUTRITION INTERVENTIONS INCLUDING BREASTFEEDING - Exclusive breastfeeding < 6 months

- Breastfeeding with complementary food at 6 9 months

- Continued breastfeeding at 20 23 months VACCINATION - Measles immunization coverage - Hib immunization coverage OTHER PREVENTION INTERVENTIONS - Vitamin A supplementation coverage - Use of improved sanitation facilities NEWBORN HEALTH - Skilled attendance at delivery - Neonatal tetanus protection - Use of improved drinking waters - Insecticide-treated net coverage - DPT3 immunization coverage

- Timely initiation of breastfeeding

- Prevention of maternal-to-child transmission of HIV

- Postnatal visit within three days of delivery

CASE MANAGEMENT OF ILLNESS - Care seeking of pneumonia - Antibiotic treatment of pneumonia

- Oral rehydration and continued feeding

- Antimalarial treatment

Tracking Progress In Child Survival The 2005 Report

Impact Model for Child Survival Child Survival Indicators

MORTALITY Under-5 mortality rate (MDG4) ; Neonatal mortality rate INFANT FEEDING Exclusive Breast Feeding (<4 and < 6 months) Continued breast feeding (12 15 and 20 23 months) Timely complimentary feeding rate (6 9 months) VITAMIN A List of Child Vitamin A supplementation (under fives) Survival Indicators MALARIA Household availability of ITNs ; ITN use (under fives) (MDG6) Anti-malarial treatment (under fives) (MDG6) WATER AND SANITATION Use of improved drinking water sources (MDG7) Use of adequate sanitary means of excreta disposal (MDG7) NEWBORN CARE Impact on child Timely initiation of breastfeeding survival DIARRHOEA ORT (ORS or appropriate household solution) use IMMUNIZATON Neonatal tetanus protection at birth; Measles immunization coverage (MDG4) DPT3 immunization coverage ACUTE RESPIRATORY INFECTION Antibiotic treatment of pneumonia MALNUTRITION Underweight prevalence (MDG1); birth weight below 2500 grams MATERNAL HEALTH Skilled attendant at delivery Tracking Progress In Child Survival The 2005 Report

CHILD MORTALITY Versus CHILD SURVIVAL

Interventions packages for Child Survival under Western Pacific Region

WHO/UNICEF Regional Child Survival Strategy: Accelerated and Sustained Action towards MDG 4. WHO 2006

Safe delivery and antenatal coverage : Malaysia 1990-2012

110 100

Percentage

90 80 70 60 50 1990 Safe Delivery 92.9 Antenatal coverage 77.9 40 1995 2000 2006 2008 2010 2011 2012 95.5 96.6 98.3 98.6 98.6 98.6 98.7 68.8 74.8 97.2 93.7 82.2 93.6 96.5

Source : Health Informatics Centre, MOH

UNDER FIVE DEATH REPORTED BY PLACE OF DEATH, 1993 - 2006

100% 90% 80% 70% NUMBER OF UNDER 5 DEATH 60% 50% 40% 30% 20% 10% 0% Non Hospital Death Hospital Death

Hospital death at 76.7%

1993
1867 1207

1994
1690 1204

1995
1569 1231

1996
1443 1064

1997
1375 1078

1998
1258 1121

1999
1067 920

2000
1156 1028

2001
954 1029

2002
1028 1475

2003
908 1360

2006
396 1303

Source: Wong Swee Lan et al, 2006

UNDER-5 DEATH IN 2012 BY PLACE OF DEATH

n= 4,072

2500 1955 2000

Number of death

Government Hospital death (with & without specialist) 79.2% (3,226 cases), Private hospital /clinic 3.0% (124 cases) home death 9.9% (405 cases);

1500 1000 500 66 9 0 0 - < 28 hari

Home During transportation Health clinic/ABC Others

792 479 81 24 16 20 2 227 25 9 28 86 28 hari - < 1 tahun

Government Hospital Unknown Universities Hospital No data

112

14

10 15

95

1 2

1 tahun - < 5 tahun

Private hosp./maternity

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2 Hospital Death & Non-Hospital Deaths report for 28 days - < 5 years; - preliminary

CAUSE OF UNDER-5 DEATH BY ICD CLASSIFICATION FOR 2012

n = 4,072
Unknown, 102 (2.5%) Certain Infections & Parasitic diseases, 361 (8.9%)

Neoplasms, 72 (1.8%)

Disease of Blood Immune System, 22 (0.5%)

Endocrine/Nut. & Met.Diseases, 36 (0.9%) Diseases of Nervous System, 124 (3.0%) Diseases of Circulatory System, 111 (2.7%)

Others, 469 (11.5%) Symptoms,signs and abn.finding NEC , 45 (1.1%) Injuries, poisoning & external causes, 130 (3.2%)

Condition from perinatal period, 1,280 (31.4%) Congenital malformations/ deform. & chrom. abnorm., 923 (22.7%)

Diseases of Respiratory System, 332 (8.2%) Diseases of Digestive System, 59 (1.4%) Diseases of Genitourinary System, 6 (0.1%)

Cause of death by ICD 10 coding is highest in Condition from perinatal period (31.4%) and Congenital malformations/deformities & chromosomal abnormalities (22.7%)
Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2 Hospital Death & Non-Hospital Deaths report for 28 days - < 5 years; - preliminary

TOP FIVE CAUSES OF UNDER FIVE YEARS OLD DEATH IN GOVERNMENT HOSPITALS, 2004-2008

Top Five Causes of Under-5 Death 2012p

Source: Information and Documentation System, MOH, 2009

Source: PNM1/PNM2 FHDD 2012p

NUMBER NEONATAL DEATHS BY STATE 2012

ENND
400

LNND

n= 2,173

350
300
Number of death

327

250 200
150

217 159 113

89 104
Perlis

154

118 113 105 110

29

100
50 24

25

48

63

63

55

12 6 1

25

46

62

65
92

12

33

36

38

Kedah P.Pinang Perak Selangor WPKL WP Putr' N.Semb. Melaka Johor Pahang T'gganu Kelantan Sabah Sarawak WP Lbn

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2

NUMBER OF NEONATAL DEATHS BY DAY OF DEATH in 2012

800 749 n= 2,173 750 700 650 600 550 1712 cases (78.8%) of death occurred in 500 the early neonatal period 450 400 365 350 300 229 250 200 138 150 97 95 72 64 100 42 40 38 27 25 20 21 8 14 15 13 14 7 7 12 13 9 14 15 10 50 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Days
Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2

Number of death

CAUSES OF DEATH BY WIGGLESWORTH CLASSIFICATION 2012

206; 9% 197; 9% 77; 4%

685; 32%

770; 35%

238; 11%

Lethal congenital malformation Immaturity Other specific causes

Asphyxial condition Infection Unknown

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2

NUMBER OF NEONATAL DEATHS BY CAUSE OF DEATH & DAY OF DEATH (ENND) 2012
350
300 286

316
Immaturity is relatively the commonest Cause Of Death for 0 6 days of neonatal death

n= 1,712

250
200 150

114 100 63
50 0

128
82

40 21 23

57

42 15 9

56

35 25 24

33 25 29 28 19 18 17 16 15 15 11 10 10 10 2 8 6 2 17 5 11 9 4 7
Days

49

LCM

Asph.cond.

Immaturity

Infection

Other Spec.causes

Unknown

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2

NUMBER OF NEONATAL DEATH BY CAUSE OF DEATH & DAY OF DEATH (LNND) FOR 2012
40 33 30
n= 461

LCM & Immaturity is relatively the commonest Cause Of Death for 7 27 days of neonatal death
27

20

20 19
15 16 16 16

22 17 14 9 3 442 10 6 3 8 01 11
Days

24

17
13 10 11 4 5

12
10

7 4 2

66 32

8
4

10

8
1 2 0 4 5 4 4 3 22

0 7 8 9

12

13

14-20

21-27

LCM

Asph.cond.

Immaturity

Infection

Other Spec.causes

Unknown

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2

NEONATAL DEATH BY CAUSE OF DEATH & PLACE OF DEATH FOR 2012

250
200 246 258

0 Days

n= 749

150
100 50

608 (81.2%) neonatal death at Day 0 occurred in Government Hospital with Specialist
46
1 0 3 0 2 1
Home

1 1 1 0 0 1

26 16 16 14

33 6

3 6 1

17

5 10 2 5 0

4 1 6 0 0 0
During transport

0 1 3 0 0 1
Others

2 3 2 0 1 2
Unknown

Healthclinic/ABC Govt. hosp. with Spec.

Govt. hosp. without Spec.

Private Hosp.

LCM

Asph.cond.

Immaturity

Infection

Other Spec.causes

Unknown

250 200 150

100

1 Day of life
101 111 48 1 0 2 0 0 1
Home

50 0 1 0 1 0 1 0

38 14 7

4 3 10 1 3 1
Govt. hosp. without Spec.

5 5 4 0 0 0
Private Hosp.

0 0 0 0 0 0
During transport

1 1

0 0 0
Others

1 0 0 0 0 0
Unknown

Healthclinic/ABC Govt. hosp. with Spec.

LCM

Asph.cond.

Immaturity

Infection

Other Spec.causes

Unknown

Column1

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2

LIMITATION IN ANALYSIS OF CONTRIBUTORY FACTORS TO NEONATAL DEATH AT LEVEL OF MANAGEMENT (ANTENATAL CARE) 2012 DATA
n= 2,173
1400

Number of cases

1200 1000 800 600 400 200 0

1159

1162

1084 796 786

1095 830

780

257 149 85 60 155 46

Inadequate management of Hpt/PE/Eclampsia Not filled

227 21
Inadequate maternal monitoring - delay in action

Insufficient antenatal care provided/unbooked

Delay or lack of consultation in high-risk pregnancy Yes No

Not applicable

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2 Hospital Death & Non-Hospital Deaths report for 28 days - < 5 years; - preliminary

LIMITATION IN ANALYSIS OF CONTRIBUTORY FACTORS TO NEONATAL DEATH AT LEVEL OF MANAGEMENT (INTRAPARTUM CARE) - 2012 DATA
1200

n= 2,173

1064 869 928 828

Number of cases

1025 828

1001 837

1000 800 600 400 200

368 264 8 17
Inadequate intrapartum monitoring Yes No

256 64
Inadequate management of preterm delivery Not filled

325

10
Inadequate management of prolonged labor

0 Failure to perform C-section on time - too early

Not applicable

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2 Hospital Death & Non-Hospital Deaths report for 28 days - < 5 years; - preliminary

LIMITATION IN ANALYSIS OF CONTRIBUTORY FACTORS TO NEONATAL DEATH AT LEVEL OF MANAGEMENT (NEONATAL) 2012 DATA
1400 1200

n= 2,173

1206

1143 782

1133 801

1076 794

Number of cases

1000 800 600 400 200 0 Inadequate resuscitation Inadequate management of respiratory distress

732

157 38 31

217 43

196 25

278

Delay/failure to transfer to an appropriate level of care

Delay in recognition/treatment of sepsis

Yes

No

Not applicable

Not filled

Source: Family Health Development Division: Perinatal Mortality Reporting System PNM1/1997 Pind.2000 & PNM 2 Hospital Death & Non-Hospital Deaths report for 28 days - < 5 years; - preliminary

PREVENTABLE DEATH BY PLACE OF DEATH

Hospital Deaths

Preventable (38.1%)
Not Preventable (42.4%)

Patient & Family Factor (54.8%) Department or Treatment Problem (25.4%) Peripheral/Referral Centre (11.5%) Transport problem (5.4%)

Under Five Death

Unsure (16.7%)

Preventable (63.4%)

Patient & Family Factor (64.1%)

Non Hospital Deaths

Transport problem (26.3%)

Department or Treatment problem (8.8%) Peripheral/Referral Centre (5.2%)

Not Preventable (14.9%)

Unsure (14.9%)
Source: Wong Swee Lan et al, 2006

PATIENT & FAMILY FACTOR

HOSPITAL DEATHS Unaware of patients illness (56.3%) Not immunised or missed immunisation (9.9%) Refusal (5.1%) Traditional Medicine (3.7%) Home accident (3.3%)

NON HOSPITAL DEATHS Unaware of patients illness (49.1%) Home accident (11.8%) Refusal (5.6%) Traditional medicine (3.1%) Poor compliance or defaulted treatment (1.9%)

Source: Wong Swee Lan, et al, 2006

33

DEPARTMENT OR TREATMENT PROBLEM

HOSPITAL DEATHS Treatment problem
Inadequate resuscitation (18.4%) Delayed or wrong diagnosis (16.1%) Delayed treatment (13.8%) Inadequate treatment (12.6%) Poor antenatal or perinatal care (12.6%)

NON HOSPITAL DEATHS Treatment problem

Inadequate treatment (25.0%) Delayed or wrong diagnosis (25.0%) Underassessment (18.8%) Delayed treatment (12.5%) Poor antenatal or perinatal (6.3%) Poor monitoring (6.3%) Inadequate resuscitation (6.3%)

No ICU bed or ventilator (11.9%) Nosocomial infection (6.3%)

Source: Wong Swee Lan, et al, 2006

Inadequate counselling (22.7%)

34

Taraf Pemakanan Kanak-kanak Bawah 5 Tahun Di Malaysia, 2000 2012

120
100

80

Peratus (%)

60

40

20

0 KBB Teruk KBB Sederhana

Berat Normal

2000 1 13 81.6 4.5

2001 0.9 11.5 84.5 3.2

2002 0.9 11.2 85.1 2.9

2003 0.7 9.9 86.7 2.7

2004 0.7 8.5 88.7 2.1

2005 0.6 7.5 90.3 1.6

2006 0.6 7.1 90.7 1.6

2007 0.5 6.1 92.2 1.2

2008 0.5 5.8 92.7 1.1

2009 0.5 5.2 93.2 1.2

2010 0.4 4.3 94.6 0.8

2011 0.3 3.8 95 0.9

2012 0.3 3.2 95.9 0.6

Berlebihan Berat Badan

Sumber: PIK 2012

Bahagian Pemakanan, KKM

37

Peratus Kanak-kanak Bawah Lima Tahun Mengalami Masalah Kurang Berat Badan Mengikut Negeri Di Malaysia, 2012
10 8
Peratus (%)

9.5

6.3 6 4 2 0

5.7 3.8 3.5 3.3 2.5 2.4 2.4 2.3 2

2 1.7 1.6

1 0.8

0.4

Sumber: PIK 2012

Negeri
Bahagian Pemakanan, KKM 38

ETHNIC DIFFERENTIAL IN CHILD MORTALITY RATE, MALAYSIA 1970 - 2000

These differentials reflected the fact the Chinese were much more concentrated in urban areas which offered better medical services

By 2000 , ethnic inequities in child had narrowed appreciably

INFANT MORTALITY RATE (DEATHS PER 1,000 LIVE BIRTHS) BY ETHNICITY FOR MALAYSIA FROM 2008 2011
10
Death per 1,000 live births

8.1 8 6 4 2 7.2 6.2

6.9
6.9

7.0
6.7

7.7

7.5
6.6

6.1
5.7
4.1

6.4
4.1

6.4 5.9
4.2

5.5
3.9

3.5

3.9
2.7

4.2

Malaysia
0
Malaysia Malay Chinese
India Other Bumi's

Malay

Chinese
2009 6.9 8.1 3.9 5.5
6.9

India
2010 6.7 7.7 4.1 6.4
7.0

Other Bumi's
2011 6.6 7.5 4.2 5.9
6.4

Others

2008 6.2 7.2 4.1 5.7

6.1

Others

3.5

3.9

2.7

4.2

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia, 2000 -2011 (preliminary) Family Health Development Division - 2011 preliminary data

Analysis is based on 82 developing countries with data un under-five mortality rate by residence, accounting for 75 percent of total births in developing countries in 2010
Source:

RURAL URBAN DIFFERENTIAL IN CHILD MORTALITY RATE, MALAYSIA 1970 - 2000

The spread of health improvements and broad development to both urban & rural areas. Absolute differentials have narrowed appreciably over the period 1970 - 2000

SOCIAL DETERMINANTS FOR HEALTH AND EQUITY

Source:

Infant mortality and household poverty follow similar trends

Under 5 mortality rates vs incidence of income poverty (2003-2011)
%

Source: World Bank, Department of Statistics Malaysia, Economic Planning Unit Malaysia UNICEF , MINISTRY OF HEALTH

SPATIAL PATTERN OF DIFFERENTIAL IN CHILD MORTALITY RATE, BY STATE IN MALAYSIA 1970 - 2000

The spatial pattern of differentials in child mortality in Malaysia closely to differentials in level of development by state

SPATIAL PATTERN OF DIFFERENTIAL IN CHILD MORTALITY RATE, BY STATE IN MALAYSIA 2000 - 2010

Under-5 Mortality Rate per 1000 LB Source: Population And Demographic Statistics Division, Department of Statistics Malaysia

THE WAY FORWARD WHAT MORE CAN BE DONE?

Equitable distribution of coverage across socioeconomic quintiles/underserved population Different number of U5D within states/ districts; household wealth and geographic location; by targeting health resources to them Increase Equity to access to health care services particularly for the URBAN poor and that are remote in rural area Health risks among sub national socioeconomic groups & geographic areas eg. Iodine deficiency areas.

Equity in intervention coverage

Geographical differences

Prioritizing budgets and resources committing to action plans to end PREVENTABLE child death

Effective interventions to address the main causes of child death

Health Promotion and

Education

Investing in neonatal and maternal care and nutrition Promotion of First 1,000 Days Life towards Healthy Generation - National Launching January 2013 (Nut.Div.MOH)

Source:

Victora C, Barros A, et al, How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 2012, 21 September 2012.

NEW GOAL BY 2025 FOR THE REDUCTION OF DEATHS DUE TO COMPLICATIONS OF PRETERM BIRTH

For countries with a current neonatal mortality rate level of 5 per 1,000 live births
To reduce the mortality due to preterm birth by NMR 2012p at 4.3 per 1000 LB 50% between 2010 and 2025 Cause of neonatal death: Immaturity
(35.4%) in 2012p

For countries with a current neonatal mortality rate level of < 5 per 1,000 live births
To eliminate remaining preventable preterm deaths, focusing on equitable care for all and quality of care to minimize long-term impairment
Source:

Moderate increase in coverage of selected interventions results in mortality reduction even in the absence of neonatal intensive care.

Source:

WHERE AND WHEN PRETERM BIRTHS OCCURS?

Source:

NEONATAL DEATHS DUE TO IMMATURITY BY POA FOR MALAYSIA 2008 - 2012

n=803 n=732 n=772 n=812 n=770

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

51 108 206

38 92 193

22 100 189

32 95 199

19 83 177

>50% (63.7%) among immaturity under sub-categories Extremely preterm < 28 weeks POG range from 54.5% - 63.7% from 2008 - 2012

438

409

461

486

491

2008 <28 weeks

2009 2010 2011 28 to <32 weeks 32 to<37 weeks

2012 No data

Source: FHDD Family Health Development Division 2008 - 2012 - preliminary data PNM 1/1997 Pind.2000

NEONATAL DEATHS DUE TO IMMATURITY BY BIRTH WEIGHT(GM) FOR MALAYSIA 2008 - 2012
n=803 n=732 n=772 n=790 n=770

100% 90% 80% 70% 60% 50% 40% 30% 20% 10%
0%

7 12 33 79 186

8 2 36 68 161

8 6 20 65 187

7 6 22 72 186

3 10 7 22 49 174

Neonatal mortality rate (NMR) was 4.3 per 1000 LB for 2012p. Assuming premature birth >1000 gm is salvageable, NMR will be 3.8 per 1000 LB & U5MR at 7.5 per 1000 LB. (The target is < 5 per 1000 LB for NMR)

486

457

486

497

505

2008
500-999 1000-1499

2009
1500-1999

2010
2000-2499

22 immaturity case, Birth weight <499 gm

2011

2012
No data

2500-2999

3000 and >

Source: FHDD Family Health Development Division 2008 - 2012 - preliminary data PNM 1/1997 Pind.2000

HEADLINE MESSAGES
More than 1:10 babies are born preterm Over 1 million children die due to complications of preterm birth Preterm birth rates are increasing in almost all countries with reliable data Prematurity is the leading cause of newborn deaths in under 5 Accelerating progress towards the goal of halving deaths due to preterm birth by 2025 Coordinate action and ensure accountability Every Women Every Child Family planning and increased empowerment of women & improved quality of care Strategic investments in innovation and research

Historical data and new analyses deaths from preterm complications can be reduced over even without the availability of neonatal intensive care Inequalities in survival rate in high-income countries vs low-income settings Ensuring frontline workers are skilled in the premature babies and improving supplies of live-saving commodities and equipment

Source:

The links between coverage and its determinants that affect maternal, newborn & child survival

INTERVENTION IN PRETERM BIRTH & PREMATURE BABY

Reducing risks during the preconception period and before birth in the pregnancy period advances preterm birth prevention, while actions taken during labor, delivery and after birth are necessary to reduce prematurity-associated mortality and disability
Source:

CONCEPTUAL FRAMEWORK FOR PRECONCEPTION CARE

Source:

PRIORITY EVIDENCE-BASED PACKAGES AND INTERVENTIONS FOR Closing the gaps in PREMATURE BABIES coverage, equity &

quality for each indicators e.g in our context at primary, secondary & tertiary level of care

- insufficient

- insufficient

Saving live and preventing disability from preterm birth can be achieved with a range of evidencedbased care increasing in complexity and ranging from simple care such as warmth and breastfeeding up to full intensive care
Source:

INTEGRATED SERVICE DELIVERY PACKAGES FOR MATERNAL, NEWBORN & CHILD HEALTH

A schematic matrix of the basic health packages spanning the continuum of care and through various service delivery modes within the health system highlighting the interventions
Source:

THE WAY FORWARD WHAT MORE CAN BE DONE?

Strengthening of pre-pregnancy care (detect high risk cases and advice family planning/spacing while optimizing maternal health) Strengthening of prepregnancy care Higher mortality with congenital anomalies Maximizing and Optimising Personalised Care Approach During intrapartum care and post partum Care Maternal and Child Health Surveillance optimising HBCH Record and Antenatal Health Record. Quality Supervision
Printed by UN Malaysia 2011

Higher perinatal deaths

QUALITY of Service DELIVERY

Up Scaling of Quality of Service Delivery

Source: Malaysia The Millennium Development Goals at 2010

ACTION TO BE TAKEN WHAT MORE CAN BE DONE?

Strengthening of pre-pregnancy care (detect high risk cases and advice family planning/spacing while optimizing maternal health)

Higher mortality among neonatal

- Major investment in pre-pregnancy care - Phasing reduction of Neonatal Mortality Rate (NMR) Improve individual patient management e.g enhanced maternal health care, obstetric care, shift to facility births; Wide uptake of antimicrobials; Basic thermal care, further focus on neonatal and infant nutrition Kangaroo Mother Care for small babies (BW < 2000 grams) Upscale of Neonatal Intensive Care
Printed by UN Malaysia 2011

Source: Malaysia The Millennium Development Goals at 2010

ACTION TO BE TAKEN WHAT MORE CAN BE DONE?

Surveillance of Under-5 reporting system Under-5 Death Report at Clinic/ Hospital , District and State level Audit all U-5 death, identify and implement remediable measures locally (Hospital, clinic & district) Improve quality of data - e.g to reduce the unfilled and unsatisfactory information at management level Strengthening data collection from public and private sector Disaggregate data by state, urban/ occupation, rural, income, sex and ethnic group to identify the disparities in health care >70% deaths occurs in hospital Hospital death the cause of death must be according to ICD 10 coding All home death should be certified by medical personnel (primary care level) Verbal autopsies for non-hospital deaths
Printed by UN Malaysia 2011

Strengthening quality of data

Comprehensive picture of total care provided by the health-care system

Improving death certification

Inaccuracy in diagnosis and is not systemic grouped under signs and symptoms Certification by non-medical personnel

Source: Malaysia The Millennium Development Goals at 2010

Conclusion
What More to be done : To reduce inequity to Health Care Accessibility Analyse situation at LOCAL Level to identify gaps for improvement Its about providing QUALITY Service Its looking at CHILD SURVIVAL rather than CHILD MORTALITY indirectly MATERNAL HEALTH.