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Lessons Learned From Highest Malaysia Covid Pregnancy-Related Deaths In Decades – Dr John Teo

Malaysia’s 2021 maternal mortality ratio (MMR) of 68.2 per 100,000 live births is a 170% increase from 2020 figures, and a 220% increase from 2019. The last time Malaysia recorded MMR over 60 was in the 1980s.

A pregnant woman. Picture by StockSnap from Pixabay.

Maternal Mortality Rate

On October 27, 2022, the Department of Statistics Malaysia released official data for maternal deaths in 2021. 

There were 300 pregnancy-related mortalities, which represents a maternal mortality ratio (MMR) of 68.2 per 100,000 live births.

These figures comprised Malaysian and legal immigrants, and may not possibly include all undocumented mothers, due to the nature of their status.

57.3 per cent or more than half of the maternal deaths in 2021 were due to Covid infection and its complications.

Covid infections in pregnant women are known to be associated with substantial risk of adverse outcomes including deaths, pre-eclampsia, and preterm labour.

The 2021 MMR of 68.2 (100,000 live births) represents a 170 per cent increase from 2020 figures of 24.9 (100,000 live births), and a 220 per cent increase from 2019 figures of 21.1 (100,000 live births).

The last time we saw MMR over 60 per 100,000 live births was in the 1980s, about 40 years ago.

Covid Pandemic and Vulnerable Groups

Malaysia entered into the first lockdown during the pandemic in March 2020, and thereafter multiple movement control orders were implemented with subsequent Covid waves.

Access to health care for many became a constant challenge as hospitals, doctors , nurses, and medical services struggled to cope with the demand. At times, the health care system was on the verge of breakdown as Covid cases increase relentlessly and exponentially. 

The Families on the Edge research project was carried out from May 2020 to early 2021, and was commissioned by UNICEF and UNFPA.

It sets out to document how 500 families with children in Kuala Lumpur urban low cost flats were affected by the devastating effects of the Covid pandemic either directly or otherwise.

The findings showed that low-income groups, persons with disabilities, women, children, and other marginalised groups suffered more and were disproportionately affected by the pandemic.

Urban low-income families were much more likely to be unemployed, have shorter working hours, and experienced greater challenges in accessing health care.

Pregnant Women

Pregnant women, especially from low-income, marginalised, or undocumented groups represent an extremely important and vulnerable segment and were even more likely to have very minimal access to health care, or none at all.

The overwhelmed health care system, movement restrictions, fear of contracting the virus at health care facilities, and unemployment were all factors in decreasing health care access by many pregnant women.

In addition, critical care, including high dependency and ICU care, may be inaccessible to these groups. Significant barriers may also exist as many vulnerable and severely sick patients vie for limited number of beds.

The statistics showed that the consequences were deadly for many pregnant women, and in fact many more may had suffered permanent or long-term health disabilities.

Preventing Maternal Deaths

We have known for a long time that the majority of maternal deaths are preventable, when the three critical life-saving strategies of quality antenatal care, safe delivery at hospitals, and contraceptives to prevent unplanned pregnancies are implemented. 

Quality antenatal care includes vital Covid vaccinations for pregnant women. Malaysia started vaccinating all pregnant women around August 2021, albeit this was somewhat late, and amidst some initial confusion over the eligible category of pregnant women who can take the vaccine. 

Accessing regular antenatal check-ups were challenging for some mothers throughout the pandemic, especially those from undocumented and immigrant communities, who were heavily reliant on daily wages. Their fear of being nabbed by enforcement officials also played a part with regard to this. 

On the same note, these vulnerable groups tend to deliver at homes, unsupervised by trained health care personnel, and will lack access to life-saving drugs.

Unintended Pregnancies And Contraceptive Coverage

40 per cent of all pregnancies globally are unintended, and Malaysia is no exception. Significant barriers exist during the movement control order, whereby condom manufcaturers and family planning clinics were ordered to shut as contraceptive services were not classified as essential services.

These challenges in accessing contraceptive services were made more difficult by movement restrictions, shorter operating hours at pharmacies and clinics, as well as disruptions to the supply chain. 

Contraceptive usage, uptake, and continuation by many women seemed to have decreased, based on multiple studies globally.

In reality, contraceptive services and provisions were put on the back burner as the Covid pandemic raged on, and health care priorities were directed to other more pressing areas. 

The unseen pandemic of unintended pregnancies, unsafe abortions, unsafe home deliveries, sexually transmitted diseases, and women dying or suffering irreversible health damage, can be significantly reduced by removing barriers towards contraceptive provisions, facilitating continuous supply, and reclassifying contraceptive services as essential services.

It was estimated that with full contraceptive coverage, up to 30 per cent of maternal deaths could have been prevented. 

No woman should die from a pregnancy-related complication if she was not pregnant in the first place, and did not want to get pregnant. 

Lessons Learned

The lessons learned are critical, if Malaysia wants to avoid such an astronomical maternal death rate in the future.

It is vital to ensure the following:

We must start protecting vulnerable groups with vaccination as soon as possible, in particular, pregnant women, and classify them as a priority group in all research studies, development of vaccination guidelines and programme implementation.

We need to remove barriers towards antenatal care and make available safe delivery services for all pregnant mothers, regardless of legal status or nationality. This means decoupling enforcement activities or economic status with health care accessibility, and protecting health care access as a human right for all pregnant women.

We need to be colour, documentation, and nationality-blind as far as health care access is concerned, more so during a viral pandemic.

Above all, making contraceptive access should be a paramount response strategy during the Covid pandemic or any other crisis. This should be as vital as ensuring and increasing the availability of ICU units and bed strength.

No women should die when giving life, and we must never let maternal deaths be in vain, lest we fail every mother in this nation.

Dr John Teo is a consultant obstetrician and gynaecologist.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of Ova.

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