Dr. Ravichandran Jeganathan, National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia, shares the inspirational story of Malaysia’s efforts to make every death count.
Find out more about some of the specific actions and responses that were introduced as a result of the Malaysia Confidential Enquiry System.
Despite competing demands of this diverse and aspiring population, Malaysia is well known as a country which has made significant strides in maternal health.
Confidential Enquiry into Maternal Deaths (CEMD) was known to be implemented only in the UK and Australia/NZ when Malaysia embarked on it in 1991. Over these last two decades, the maternal mortality ratio has declined from 44 to 27 per 100,000 live births in 2011. Malaysia’s MDG target, however, is 11.
The reports have been followed by various training manuals, case illustrations, guidelines and consensus statements.
Policy changes at the national level, improved facility-based services, as well as enhanced home-based and primary maternal care were a result of these efforts. For example, pharmacological agents e.g. prostaglandin F2a, Novo 7, Tractocile, Duratocin and others, were introduced into managing postpartum haemorrhage, as a result of the CEMD findings.
Certain drugs (e.g. Dexamethsone, MgSO4) were downgraded to allow the midwives to initiate therapy in case of preterm labour and severe preeclampsia/eclampsia from the moment of contact with the patients.
Similarly, patient referral and feedback mechanism were improved, and maternal and foetal surveillance equipment was updated when it was found that targeted CTG as well as Doppler Ultrasound could allow us to better manage and optimise outcomes in high-risk pregnancies.
In order to ensure that some of these changes would be sustainable and the skills were passed on, Malaysia also introduced the Advance Diploma in Midwifery. This was in response to the findings of the CEMD and MDSR that the then midwifery training was lacking.
With the new curriculum in place, there is an increased interaction between the midwifery students and clinicians. Maternal Foetal Medicine as a sub-specialty was also advanced to optimise the care of the mother and foetus at risk.
Malaysia’s success in reducing maternal deaths stems from a range of issues; many of which may not necessarily be unique to the country, but rather generic enough for other countries to draw from. We learnt that:
- It was important to start with achievable targets, maybe at a facility level and thereafter moving forward, rather than aiming for the entire nation to come on board at the very outset.
- The processes had to be non-punitive with no naming, blaming or shaming.
- Engaging all the major stakeholders in the system, including from the public and private health services, academics, NGOs and the politicians, was crucial to make it work.
- A “top down” approach with a strong political will to see the change happen was necessary to push things through.
- Monitoring maternal deaths should receive priority from all quarters. For instance, maternal mortality ratios in Malaysia became a key performance indicator for the Minister of Health and the Director General of Health.
Whilst scarce “resources” is a reality for everyone, being discouraged by it did not help.
Having a dedicated team of people with the passion to see our mothers live longer and willing to persevere for it was enough to start establishing the MDSR/CEMD.
Mapping another country’s success onto our own would not be the best way. Rather, tailoring the learning from other successes to suit our own needs is certainly recommended. Setbacks, brickbats and disappointments are all important ingredients towards achieving success in MDSR/CEMD.
The Malaysian journey has been far from being a bed of roses. We have stumbled, fallen, halted and even rejected along the way. But have picked up the pieces, dusted off the dirt and have moved forward. Success, as you can see, has followed.
By Dr Ravichandran Jeganathan, National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia