International Journal of Public Health Research Vol 3 No 1 2013, pp (241-248)

PUBLIC HEALTH RESEARCH

Trend of Stillbirths and Neonatal Deaths in University
Kebangsaan Malaysia Medical Centre (UKMMC) From 20042010
Haslina Hassan1, Rosnah Sutan1*, Nursazila Asikin Mohd Azmi1, Shuhaila Ahmad2 and Rohana Jaafar3
1

Department of Community Health, University Kebangsaan Malaysia, Malaysia.

Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia, Malaysia.
3
Departments of Paediatrics, University Kebangsaan Malaysia, Malaysia.
2

*For reprint and all correspondence: Rosnah Sutan, Department of Community Health, Universiti Kebangsaan
Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur.
Email: [email protected] or [email protected]

ABSTRACT
Accepted

22 February 2013

Introduction

The aim of the Fourth Millennium Developmental Goal is to reduce mortality

among children less than 5 years by two thirds between 1990 and 2015.
Efforts are more focus on improving childrens health. The aim of this study
was to describe the trend of stillbirth and neonatal deaths in University
Kebangsaan Malaysia Medical Centre from 2004 to 2010.
A retrospective cross-sectional study was conducted using hospital data on
perinatal mortality and monthly census delivery statistics.
There were 45,277 deliveries with 526 stillbirths and neonatal deaths. More
than half of the stillborn cases were classified as normally formed macerated
stillbirth and prematurity was common in neonatal deaths. The trend of SB
and NND was found fluctuating in this study. However, by using
proportionate test comparing rate, there was a transient significant decline of
stillbirth but not neonatal deaths rates between 2004 and 2006. On the other
hand, the neonatal deaths rate showed significant increment from 2006 to
2008. When both mortality rates were compared using proportionate test,
from the start of the study, year 2004 with end of the study, year 2010, there
was no significant decline noted.
Trends of stillbirth and neonatal death rates in University Kebangsaan
Malaysia Medical Centre within 7 years study period did not show the
expected outcome as in Millennium Developmental Goal of two thirds
reduction.
Stillbirth - Neonatal mortality MDG.

Methods
Results

Conclusions

Keywords

241

Improved Trend of Stillbirth

visits being recommended by World Health

Organization6,7. Institutional deliveries in Malaysia
include care given by government and private
sector which contributed 96.6% of all deliveries in
20046.Universiti Kebangsaan Malaysia Medical
Centre is an example of institutional delivery
facility and was chosen for this study because it
represents one of the specialist hospitals in Klang
Valley area.
The aim of this study was to describe the
trend of stillbirth and neonatal deaths in University
Kebangsaan Malaysia Medical Centre from 2004 to
2010. Institutional data was used to assess trend of
SB and ND and associated factors.

INTRODUCTION
The fourth goal of the Millennium Development is
to reduce mortality among children under 5 years
old by two thirds between 1990 and 20151,2.
Worldwide, child mortality between 1980 and 2000
was reduced by one third while the neonatal
mortality rate was reduced by only a quarter 1,2. To
achieve MDG 4 goals, the neonatal mortality must
at least be halved2,3. Neonatal mortality is divided
into early and late neonatal death. Early neonatal
deaths occur during the perinatal period and have
similar obstetric origins as the stillbirth2,3.Reasons
for early neonatal deaths includes severe congenital
malformation, premature delivery, antepartum or
intrapartum obstetric complications (foetal
malpresentation or obstructed labour) or because of
harmful practices after birth that leads to infections
1-3
. Besides, another common adverse outcomes of
pregnancy is stillbirth3,4. It accounts for over half of
all perinatal deaths3. Perinatal period is measured
as completed 22 weeks of gestation and ends seven
days after birth3,4. Stillbirth can occur before onset
of labour (antepartum death) or during labour
(intrapartum death)3,4. Foetuses may die before
onset of labour due to pregnancy complications or
maternal diseases3. Distinguishing between these
two types is important. Through appropriate
intrapartum care, stillborn can be avoided.
Intrapartum death also known as fresh stillbirth
(FSB) refers to normal appearance of foetus after
delivery4. Antepartum death also known as
macerated stillbirth (MSB) refers to macerated
looking skin of foetus and implies that death is
more than 12 hours before delivery4.
Stillbirth and neonatal mortality data are
important health status indicators. In Malaysia, the
government and private hospitals data were
analysed by the Division of Family Health
Development and annual report are then produced.
In addition, data related to SB and NND in
specialist hospitals maybe published via their own
hospitals annual report or discussed during
departmental meeting. Suggestions for ongoing
improvement are then advised to prevent another
death in cases similar to the index case. Therefore,
in an attempt to lower the stillbirth rate, screening
and treatment strategies should be developed to
best suited local scene5 .
Vital and mortality statistics, community
survey or hospital data gives an overall estimation
of the problem. However, each has its own
limitation and underreporting is common. In
Peninsular Malaysia, the percentage of institutional
deliveries increased from 75.6% in 1990 to 96.6%
in 20046 . The antenatal coverage in 2008 was
94.4% as compared to 73.4% in year 2000 6. The
average number of antenatal visits by the pregnant
mother to public and private health facilities
increased from 8.4 in 2005 to 9.6 in 2008 7. This
was even higher than the minimum four antenatal

METHODS
This was a retrospective cross sectional study using
Rapid Reporting of Stillbirth and Neonatal Death
form in UKMMC (PNM 1/97) from year 2004 until
2010. National usage of this form was started since
19988. The format is simple, practical and can be
used without autopsy findings because permission
for autopsy is difficult to obtain in Malaysia due to
cultural and religious beliefs9,10. It is only a
reporting system and not a confidential inquiry
system8,10. The classification used was based on a
modified
pathophysiological
Wigglesworth
classification8,9.
UKMMC is located in Cheras, at the
outskirts of Kuala Lumpur but within Klang Valley
area. Klang valley area is the most populated in
Malaysia. It is an institution providing specialist
healthcare and also acted as referral centre for
places across Malaysia as well as from
neighbouring countries11.
All stillbirths and neonatal deaths reported
by UKMMC from 2004 until 2010 were included
in the study. The data of total births by ethnicity,
parity, gestational age, birth weight were collected
from the monthly census data which was kept in
the census files in Obstetrics and Gynaecology
Department. Data were grouped as maternal
related, and foetal related factor. Maternal related
factors are ethnicity, citizenship, age, parity status,
methods for gestational age estimate, antenatal
clinic follow up and maternal medical illnesses.
Foetal related factors includes place of delivery,
who delivered the cases, plurality of pregnancy,
birth weight and sex of the foetus. Exclusion
criteria were incomplete forms which cannot be
verified further. There were 526 forms collected
and 2 (0.4%) forms were rejected because of
incompleteness. Routinely, the form is filled by
the attending doctor on the delivery day of the
stillborn or on the day of death for the neonate.
In this study, stillbirth is defined as a birth
of a dead foetus of at least 22 weeks of gestation or
weighing at least 500grams12. Early neonatal deaths
were deaths of live born babies during the first
seven completed days after birth, and late neonatal

242

International Journal of Public Health Research Vol 3 No 1 2013, pp (241-248)

deaths occurred after 7 completed days and before

28 completed days 3,12. Neonatal mortality includes
early and late neonatal deaths, the rates are given
per 1000 live births3 .Stillbirth rates are reported as
stillbirth beyond a certain gestational age (more
than 22 week or 500g) divided by the number of
total birth12.
Age of a mother is based on the date of
birth stated in the identity card. For those without
identity card, the age is obtained through admission
data. Ethnic group is divided to Malay, Chinese,
Indian or Others (Murut, Bajau, Melanau, Bidayuh,
Kadazan/Dusun, Iban, Orang Asli and noncitizens).
Low birth weight is birth weight less than 2500g3.
Birth weight is determined by duration of gestation
and rate of foetal growth. Infants with birth weight
less than 2500g can be either born prematurely
(preterm birth) or born small for gestational age
(SGA; a proxy for intra uterine growth restriction,
IUGR)13. Preterm birth is delivery before 37
completed weeks of gestation3. Gestational age at
delivery is calculated based on the first day of the
last normal menstrual period till delivery occurs.
Those with revised estimated delivery date were
categorized under ultrasound based estimation.

Gestational age is expressed in completed days or

completed weeks3.
Data was analysed using Statistical
Package for Social Sciences (SPSS Inc. Chicago
USA) version 19.0 for descriptive analyses.
Proportionate tests were conducted to assess rate
significance.

RESULTS
Total deliveries reported in UKMMC from year
2004 to 2010 were 45 277. There were 44,994 live
births, 453 perinatal deaths and 241 neonatal
deaths. Of the perinatal deaths, 283 (54%) were
stillbirths. Out of the stillbirths, 168 (32.1%) were
macerated stillbirths and 115 (21.9%) were fresh
stillbirths. Of the neonatal deaths, 170 (32.3%)
were early deaths and 71 (13.5%) were late
neonatal deaths.
Table 1 shows maternal related factors of
the cases. Majority of the patients were Malay
(88.5 %), with Malaysian citizenship (89.7%), age
more than 35 (79.7%), with multiparity (57.1%)
with 92.7% had antenatal clinic follow-up and
45.9% had specialist clinic follow-up.

Table1 Characteristics of cases according to maternal related factors

Cases
n

SB
N

ND
n

Ethnicity
Malay
Chinese
Indian
Others

336
107
20
7

170
64
14
4

67.5
25.4
5.5
1.6

166
43
6
3

76.1
19.7
2.8
1.4

Citizenship
Yes
No

471
53

252
31

89.0
11.0

219
22

90.9
9.1

Maternal age
< 35
35

403
103

206
62

76.9
23.1

197
41

82.8
17.2

Parity
0
1-4
>5

207
296
15

122
144
12

43.9
51.8
4.3

85
152
3

35.4
63.3
1.3

ANC Follow up
Yes
No

484
37

254
26

90.7
9.3

230
11

95.4
4.6

72

41

14.6

31

11.8

349

180

64.3

169

64.5

1.1

1.2

Place of ANC
follow up
Government Health
Clinic
Hospital
with
specialist
Hospital
without

243

Improved Trend of Stillbirth

specialist
Private
clinic/hospital
Gestational
age
estimated
Last
menstrual
period
Ultrasound
Neonatal assessment
Unknown
Maternal
medical
illness
Hypertension
Diabetes
Vaginal bleeding
Anemia
Prolonged rupture of
membrane
Preterm labour
Other illness

115

56

20

59

22.5

388
109
3
23

210
53
2
17

74.5
18.8
0.7
6.0

178
56
1
6

73.9
23.2
0.4
2.5

68
33
25
17
37

45
21
16
12
16

13.0
6.1
4.6
3.5
4.6

23
12
9
5
21

9.6
5.0
3.8
2.1
8.8

369
35

210
25

60.9
7.3

159
10

66.5
4.2

Abbreviations: n, total cases (of SB and ND)

For those with other illness, there were

four cases of thyrotoxicosis, three cases of
Systemic Lupus Erythematosus (SLE) and three
cases of Thalassemia trait.
Table 2 shows the foetal related factors.
One third of the cases was below 27 week of

gestation (30.2%) and delivered

hospital (93.5%). Majority were
doctors (90.5%), singleton (90.0%),
than 2500 gram (81.3%) and of
(56.6%).

at specialist
delivered by
weighing less
male gender

Table 2 Characteristics of cases according to foetal related factors.

Cases
n

SB
n

ND
n

Gestational age
< 27 W
28- 32 W
33 36 W
> 37 W

147
120
110
109

77
69
64
46

30.0
27.0
25.0
18.0

70
51
46
63

30.4
22.2
20.0
27.4

Place of delivery
Home
Hospital with specialist
Private clinic/hospital

9
487
24

2
265
15

0.7
94.0
5.3

7
222
9

2.9
93.3
3.8

Delivery by
Doctors
Not doctors

475
49

248
35

87.6
12.4

227
14

94.2
5.8

Number of foetus
Singleton
Non singleton

471
50

254
26

90.7
9.3

217
24

90.0
10.0

Birth weight
Less than 2500g
More than 2500g

416
96

229
44

83.9
16.1

187
52

78.2
21.8

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International Journal of Public Health Research Vol 3 No 1 2013, pp (241-248)

Sex of baby
Male
Female
Undetermined/unknown
Abbreviations: n, total cases

268
209
17

154
120
9

Table 3 showed normally formed

macerated stillbirths (NFMSB) accounted for
53.2% of deaths in stillbirth cases. In early and late
neonatal death, prematurity was the common cause
of death. Prematurity comprised 50.3% of the early
neonatal deaths and 53.5% in late neonatal deaths.
The mean birth weight in stillbirths was 1439.6
955 grams, whereas in the neonatal deaths, the
mean was 1699 945grams.
Figure 1 showed trend of SB and ND rates
from 2004-2010. The stillbirth rate declined from

54.4
42.4
3.2

114
89
8

54.0
42.2
3.8

8.1 per 1000 total births in 2004 to 6.2 in 2010. The

neonatal mortality rate has increased from 5.1 per
1000 live births in 2004 to 5.8 in 2010. There is a
transient decline in 2006 for both components of
mortality rates with significant decline seen in SB
rates but not ND. The significant transient
increment of ND was noted from 3.3 in 2006 to 7.7
in 2008. Using proportionate test, there was no
significant changes from year 2004 compared to
year 2010 for both mortality rates.

Table 3 Distribution of causes of death according to Wigglesworth Classification of Death

Cause
of
death
Stillbirth
Early neonatal deaths
according to WPC
n
%
n
%
LCM
45
16.2
59
35.0
NFMSB
148
53.2
Birth
84
30.2
17
10.0
asphyxia
Prematurity
85
50.3
Infection
4
2.37
Others
1
0.6
Unknown
1
0.36
3
1.78
Total
278
100
169
100
WPC = Wigglesworth Pathophysiological Classification
LCM = Lethal Congenital Malformation
NFMSB = Normally Formed Macerated Still Birth

Abbreviations: SB, stillbirth; NMR, neonatal mortality rate

Figure 1 Stillbirth and neonatal mortality rates, 2004- 2010 in UKMMC

245

Late neonatal deaths

n
%
19
26.7
5
7.04
38
9
71

53.5
12.7
100

Improved Trend of Stillbirth

Wigglesworths classification was to divide cases into

groups with clear implications for clinical
management. Cases may present in a vague manner.
Classifications are then based on combination of
clinical data and pathological findings18. This figure
could be underestimated due to pathophysiological
approach in reporting deaths in contrast to autopsy or
post-mortem. In addition, investigations on infection
were conducted after loss had occurred. Infection that
presented earlier would be resolved by the time
investigations were done. In other classification, for
example Neonatal and Intrauterine Death Classification
according to Etiology (NICE), it aimed to identify
underlying biological causes of death and not areas of
healthcare provision like Wigglesworths. For example
by using NICE, placenta abruption is identified as
cause of death and not intrauterine death, asphyxia or
immaturity which was the result of the abruption and
lead to death18. Therefore different classifications used
will produce different causes of death for the same set
of data.
This study findings about classification of
neonatal deaths also concurred with the Annual Report
2008 of Ministry of Health, Malaysia. Prematurity,
lethal congenital malformations and asphyxia
conditions were the main causes of neonatal deaths in
Malaysia12. To reduce such causes, the strategy
identified was to strengthen the pre-pregnancy and
antenatal care12. For example in Singapore, prenatal
screening of genetic disorders like Haemophilia has
reduced the average case of -Thalassaemia major of
15 to 20 cases a year to that of one case per year 19. In
Malaysia, history of rubella vaccination during school
years has improved rubella sero-positivity among
antenatal mothers 20.
Women who lacked antenatal care are at risk
for stillbirths4. Antenatal care is one of the pillars for
Safe Motherhood Initiatives21. By attending antenatal
clinic women are exposed to health education and were
taught the essential warning signs and symptoms
during pregnancy which can result in saving her life
and pregnancy. Ministry of Health Malaysia had
produced series of Perinatal Care Manual since 2002
which can be referred as guidance for health care
workers. The Manual consists of five sections: prepregnancy care, antenatal care, intrapartum care,
postpartum care and neonatal care7,22,25. However in
this result, more than 90% of the cases had antenatal
clinic follow up but there is difficult to ascertain the
quantity or earliest booking period of the cases as this
was not captured by the format.
Inadequate antenatal care is one of the
common risk factors for stillbirths in developing
countries4,5. In Malaysia, screening strategies include
foetal kick charts (Cardiff count to ten) which is the
indirect tool to monitor foetal wellbeing26,28 and most
health clinics are equipped with ultra sound for foetal
growth assessment. However, in our data most stillborn
occurred prior to 27 week and the foetal kick chart is

DISCUSSION
This study shows that stillbirths were the commonest
cause for perinatal deaths in UKMMC. This is
consistent with most studies done in analyzing
perinatal deaths 12,14,15. The stillbirths and neonatal
mortality rates in this study were higher compared to
the figures reported in Annual Report of Stillbirth and
Neonatal Deaths in Malaysia 2003-2006 or from
Department of Statistics, Malaysia 1998-20067. This
discrepancy could be due to deaths from complicated
cases managed in such tertiary referral center. In
addition, different definition of death was used. For
example, the Department of Statistics used 28 week
gestational age as the definition of death12. Another
reason is the differences in method of how notification
form was analyzed in Ministry of Health compared to
specialist hospitals. In public hospitals, the
notifications will eventually be submitted to the
national level whereby the findings will be tabulated
based on the patients residential address categorized
by states. This is because the patient may receive
antenatal care from one state in Malaysia but delivered
eventfully at another state. This differs to this study as
data collected were based on place of death i.e.
UKMMC. Nevertheless, the overall trend of SB rates
was not declining significantly.
Since there was a significant transient decline
in SB rate in 2004-2006, some intervention could have
been taken place prior to the study. Underreporting is
unlikely since notification was done by the respective
ward where death has taken place and it has been
counter check with monthly census.
There was non-significant transient declined
of neonatal mortality from 5.1 in 2004 to 3.3 in 2006.
In UKMMC, the neonatal resuscitation program (NRP)
was implemented in1998. The outcome of the program
was reviewed from 1996 to 2004 and concluded that
NRP was associated with improvement of neonatal
mortality rates16. However, the Malaysian NRP success
has yet to be reviewed since the last study which was
done in 2004. Given the circumstances of transient
significant increment of ND rate from 3.3 in 2006 to
7.7 in 2008, other factors besides the NRP could also
be at fault and further study is warranted. Factors such
as staffing, facilities, intrapartum interventions,
paediatric factors and parental data have been found to
have significant associations 17. However, no published
data available related to any intervention done in
UKMMC to explain this increment.
In developing countries, infection is estimated
to contribute to 25-50% of the stillbirths4,5. This is in
contrast to this study result. As mentioned previously,
NFMSB are the predominant classification (53.2%) of
deaths among stillbirth. This result is similar as
produced by the Report of Stillbirths and Neonatal
Deaths by Ministry of Health Malaysia. Infection as
the classification of death was none in the analysis of
stillbirth category as opposed to 15.1% as the cause of
death in live births. This is because the aim of the

246

International Journal of Public Health Research Vol 3 No 1 2013, pp (241-248)

only given from 28 weeks gestation onwards. Perhaps

other screening strategies can be employed earlier in
second trimester rather than at the end of trimester.
Perinatal Care Manual mentioned that antenatal
booking should start as early as 12 weeks gestation26.
Ultrasound is used during booking visit depending on
the facilities at the clinics. Symphysio-fundal height
(SFH) tape measurement is performed routinely from
22 weeks of gestation. If there is a discrepancy
between the SFH and gestational age, patient will also
be referred for ultrasound24. Antenatal coverage in
Malaysia in 2008 was 94.4% with increase in average
number of antenatal visits as well7. Malaysians
antenatal coverage has been extensive as also
evidenced by increasing number of health clinics and
hospitals by the Malaysian Plans7. The health clinic has
its own specialist known as the Family Medicine
Specialist (FMS). The FMS is responsible for receiving
and handling cases referred to him or her and will
ensure the cases seen are in accordance with clinical
practice guidelines established by the Ministry of
Health Malaysia. The FMS can refer complicated cases
to tertiary hospitals. Therefore infrastructure,
manpower and equipment seem to be adequate.
Perhaps, public need to be educated on importance of
early antenatal booking, especially those with high risk
factors for adverse outcomes in pregnancy.
Further analysis of the trend by gestational
age per year showed that stillbirth rates were highest
among those with gestational age less than 27 week
and of low birth weight (i.e. less than 2500 grams). The
mean birth weight for stillbirth cases was 1439.6
grams. This strongly puts across the message that
stillbirth is a result of low birth weight because of early
gestation of delivery. Risk factor for low birth weight
babies are poor maternal nutritional status27-29,
advanced maternal age4, low economic status27-,29.
Indian race27, unbooked28 and pre eclampsia 4,28,29. In
this study it is impossible to measure the maternal
nutritional status as the parameter was not considered
in the format. The mean maternal age for stillbirths (30
years old 5.8) and neonatal deaths (30 years old 4.8)
did not differ much and the possible explanation is that
the majority of the population that utilize the health
care facilities is from the age of 35 years and less
which made up 80% of the total cases.

2.

ACKNOWLEDGEMENT

15.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.
14.

We would like to express appreciation to staff of

Obstetrics & Gynecology UKMMC for their help and
support. Besides a note of thanks to the Ethical
Committee of University Kebangsaan Malaysia for
approving this study (UKM-CGPM-TKP-070-2010).

16.

17.

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