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Environmental factors in the relationship between breastfeeding and infant mortality: the role of sanitation and water in Malaysia

Butz WP, Habicht JP, DaVanzo J

Am J Epidemiol, 1984 Apr;119(4):516-25.
PMID: 6711541

Mothers' recall data collected in Malaysia in 1976-1977 are analyzed to study correlates of mortality of 5471 infants. Respondent population is 1262 women living in 52 primary sampling units of Peninsular Malaysia. Lengths of unsupplemented and supplemented breastfeeding and presence of piped household water and toilet sanitation are related to infant mortality in regressions that also control other correlates. The analysis is disaggregated into three periods of infancy. Through six months of feeding, unsupplemented breastfeeding is more strongly associated with fewer infant deaths than is supplemented breastfeeding. Type of sanitation is generally more strongly associated with mortality than is type of water supply. The effects of breastfeeding and the environmental variables are shown to be strongly interactive and to change systematically during the course of infancy. Breastfeeding is more strongly associated with infant survival in homes without piped water or toilet sanitation. In homes with both modern facilities, supplemented breastfeeding has no significant effect, and unsupplemented breastfeeding is statistically significant only for mortality in days 8-28. Presence of modern water and sanitation systems appears unimportant for mortality of infants who are breastfed without supplementation for six months.

Matched MeSH terms: Infant Mortality*
Maternal literacy modifies the effect of toilets and piped water on infant survival in Malaysia

Esrey SA, Habicht JP

Am J Epidemiol, 1988 May;127(5):1079-87.
PMID: 3358408 DOI: 10.1093/oxfordjournals.aje.a114884

The effect of toilets, piped water, and maternal literacy on infant mortality was analyzed using data from the Malaysian Family Life Survey collected in 1976-1977. The effect of toilets and piped water on infant mortality was dependent on whether or not mothers were literate. The impact of having toilets was greater among the illiterate than among the literate, but the impact of piped water was greater among the literate than among the illiterate. The effect on the infant mortality rate for toilets decreased from 130.7 +/- 17.2 deaths in the absence of literate mothers to 76.2 +/- 25.9 deaths in the presence of literate mothers. The reduction in the mortality rate for maternal literacy dropped from 44.4 +/- 14.1 deaths without toilets to -10.1 +/- 23.9 deaths with toilets. Reductions in mortality rates for piped water increased from 16.7 +/- 12.7 deaths without literate mothers to 36.8 +/- 21.0 deaths with literate mothers. Similarly, reductions in the mortality rate for maternal literacy rose from 44.4 +/- 14.1 deaths in the absence of piped water to 64.5 +/- 19.5 deaths in the presence of piped water. The results from a logistic model provided inferences similar to those from ordinary least squares. The authors infer that literate mothers protect their infants especially in unsanitary environments lacking toilets, and that when piped water is introduced, they use it more effectively to practice better hygiene for their infants.

Matched MeSH terms: Infant Mortality*
Does breastfeeding really save lives, or are apparent benefits due to biases?

Habicht JP, DaVanzo J, Butz WP

Am J Epidemiol, 1986 Feb;123(2):279-90.
PMID: 3946377

Analysis of mothers' recall data collected in 1976-1977 by a probability survey in Peninsular Malaysia shows an association between breastfeeding up to six months of age and improved survival of infants throughout the first year of life. Inappropriate sample selection and inadequate control of confounding can introduce large biases in these analyses. The magnitude and direction of these biases are presented. Even when these biases are dealt with, unsupplemented breastfeeding appears more beneficial than supplemented breastfeeding. The younger the infant and the longer the breastfeeding, the greater the estimated benefits in terms of deaths averted. The use of powdered infant formula did not appear to offset the detrimental effects of early weaning and supplementation. The positive relationships found in these analyses between breastfeeding and survival are not due to death precluding or terminating breastfeeding. Nor are they likely to be due to a shift away from breastfeeding because of recent illness, which was also controlled in the analyses. Nor are they likely to be due to other factors that both increase mortality risk and shorten breastfeeding; when such factors are taken into account, the beneficial effects of breastfeeding become stronger and imply that, if there had been no breastfeeding in this sample, twice as many babies would have died after the first week of life.

Matched MeSH terms: Infant Mortality*
Risks of stillbirth, neonatal mortality, and severe neonatal morbidity by birthweight centiles associated with expectant management at term

Hong J, Crawford K, Odibo AO, Kumar S

Am J Obstet Gynecol, 2023 Oct;229(4):451.e1-451.e15.
PMID: 37150282 DOI: 10.1016/j.ajog.2023.04.044

BACKGROUND: Determining the optimal time of birth at term is challenging given the ongoing risks of stillbirth with increasing gestation vs the risks of significant neonatal morbidity at early-term gestations. These risks are more pronounced in small infants.
OBJECTIVE: This study aimed to evaluate the risks of stillbirth, neonatal mortality, and severe neonatal morbidity by comparing expectant management with delivery from 37+0 weeks of gestation.
STUDY DESIGN: This was a retrospective cohort study evaluating women with singleton, nonanomalous pregnancies at 37+0 to 40+6 weeks' gestation in Queensland, Australia, delivered from 2000 to 2018. Rates of stillbirth, neonatal death, and severe neonatal morbidity were calculated for <3rd, 3rd to <10th, 10th to <25th, 25th to <90th, and ≥90th birthweight centiles. The composite risk of mortality with expectant management for an additional week in utero was compared with rates of neonatal mortality and severe neonatal morbidity.
RESULTS: Of 948,895 singleton, term nonanomalous births, 813,077 occurred at 37+0 to 40+6 weeks' gestation. Rates of stillbirth increased with gestational age, with the highest rate observed in infants with birthweight below the third centile: 10.0 per 10,000 (95% confidence interval, 6.2-15.3) at 37+0 to 37+6 weeks, rising to 106.4 per 10,000 (95% confidence interval, 74.6-146.9) at 40+0 to 40+6 weeks' gestation. The rate of neonatal mortality was highest at 37+0 to 37+6 weeks for all birthweight centiles. The composite risk of expectant management rose sharply after 39+0 to 39+6 weeks, and was highest in infants with birthweight below the third centile (125.2/10,000; 95% confidence interval, 118.4-132.3) at 40+0 to 40+6 weeks' gestation. Balancing the risk of expectant management and delivery (neonatal mortality), the optimal timing of delivery for each birthweight centile was evaluated on the basis of relative risk differences. The rate of severe neonatal morbidity sharply decreased in the period between 37+0 to 37+6 and 38+0 to 38+6 weeks, particularly for infants with birthweight below the third centile.
CONCLUSION: Our data suggest that the optimal time of birth is 37+0 to 37+6 weeks for infants with birthweight <3rd centile and 38+0 to 38+6 weeks' gestation for those with birthweight between the 3rd and 10th centile and >90th centile. For all other birthweight centiles, birth from 39+0 weeks is associated with the best outcomes. However, large numbers of planned births are required to prevent a single excess death. The healthcare costs and acceptability to women of potential universal policies of planned birth need to be carefully considered.

Matched MeSH terms: Infant Mortality
A population-based study of birth defects in Malaysia

Thong MK, Ho JJ, Khatijah NN

Ann Hum Biol, 2005 Mar-Apr;32(2):180-7.
PMID: 16096215 DOI: 10.1080/03014460500075332

Birth defects are one of the leading causes of paediatric disability and mortality in developed and developing countries. Data on birth defects from population-based studies originating from developing countries are lacking. One of the objectives of this study was to determine the epidemiology of major birth defects in births during the perinatal period in Kinta district, Perak, Malaysia over a 14-month period, using a population-based birth defect register. There were 253 babies with major birth defects in 17,720 births, giving an incidence of 14.3/1000 births, a birth prevalence of 1 in 70. There were 80 babies with multiple birth defects and 173 with isolated birth defects. The exact syndromic diagnosis of the babies with multiple birth defects could not be identified in 18 (22.5%) babies. The main organ systems involved in the isolated birth defects were cardiovascular (13.8%), cleft lip and palate (11.9%), clubfeet (9.1%), central nervous system (CNS) (including neural tube defects) (7.9%), musculoskeletal (5.5%) and gastrointestinal systems (4.7%), and hydrops fetalis (4.3%). The babies with major birth defects were associated with lower birth weights, premature deliveries, higher Caesarean section rates, prolonged hospitalization and increased specialist care. Among the cohort of babies with major birth defects, the mortality rate was 25.2% during the perinatal period. Mothers with affected babies were associated with advanced maternal age, birth defects themselves or their relatives but not in their other offspring, and significantly higher rates of previous abortions. The consanguinity rate of 2.4% was twice that of the control population. It is concluded that a birth defects register is needed to monitor these developments and future interventional trials are needed to reduce birth defects in Malaysia.

Matched MeSH terms: Infant Mortality
Combined team management of diabetes mellitus in pregnancy

Ng CS, Lim LS, Chng KP, Lim P, Cheah JS, Yeo PP, et al.

Ann Acad Med Singap, 1985 Apr;14(2):297-302.
PMID: 4037689

225 women with diabetes in pregnancy were managed by a team of obstetricians, physicians (endocrinologists) and paediatricians from the National University of Singapore. A protocol of management was formulated and followed. The incidence of 1.1% or 1 in 90 pregnancies was found, with significantly higher incidence in Indians and lower in Malays. There were 37 established diabetics and 188 diagnosed during pregnancy. Of these (188), 74 were gestational diabetics. All the women were treated with Insulin and Diet or Diet alone. 177 (79%) were treated with Insulin and Diet. Blood sugar profiles were done for monitoring diabetic control. 72.8% of the women were between para 0 and 1 and 85.2% between the ages of 20 and 34. 72.5% of the women delivered at 38 weeks gestation or later. 48.9% went into spontaneous labour, 32.4% were induced and 18.7% had elective caesarean section. 62.2% of the women had labour of less than 12 hours. The overall caesarean section rate was 41.7%. There were 3 stillbirths and 2 neonatal deaths. The perinatal mortality rate was 2.2%. Thirteen babies had congenital malformations (5.8%). 77.8% of the babies had Apgar score of 7 or more at 5 minutes after delivery. 79.1% of the babies weighed between 2.5 kgm and 3.9 kgm. Pre-eclamptic toxaemia was the commonest complication in pregnancy followed by Urinary Tract Infection and Polyhydramnios. Postpartum complications in the mother were confined to 14 women (6.2%), and wound infection or breakdown was the commonest cause.

Matched MeSH terms: Infant Mortality
Perinatal mortality with particular reference to the Singapore situation

Tan KL

Ann Acad Med Singap, 1984 Apr;13(2):252-63.
PMID: 6497323

Perinatal mortality rates have been gradually declining in all countries. The initial decline mainly resulted from improvements in the late foetal mortality rates. Later with improvements in neonatal care, early neonatal mortality rates also improved. The developed countries have consistently shown better results than the developing countries, an indication of the higher standard of living, general health as well as the delivery of health care in these countries. In the Singapore situation, a rapid improvement in perinatal mortality was initially observed due to improvements in the late foetal mortality, followed later by reduction in the early neonatal mortality due to upgrading of neonatal intensive care. The perinatal mortality rate is lowest in the Chinese compared to the Indians and Malays, most likely due to the dietary practices of the three ethnic groups in Singapore; while the Chinese encourage extra nutrition in the pregnant female, the Malays and Indians tend to practise dietary restriction during this period. The improved nutrition of the pregnant mother is a factor in improving the perinatal mortality.

Matched MeSH terms: Infant Mortality*
Neonatal infections in China, Malaysia, Hong Kong and Thailand

Al-Taiar A, Hammoud MS, Cuiqing L, Lee JK, Lui KM, Nakwan N, et al.

Arch. Dis. Child. Fetal Neonatal Ed., 2013 May;98(3):F249-55.
PMID: 22942104 DOI: 10.1136/archdischild-2012-301767

Neonatal sepsis is a major cause of neonatal deaths in Asia but data remain scarce. We aimed to investigate the causative organisms and antibiotic resistance in neonatal care units in China, Malaysia, Hong Kong and Thailand.

Matched MeSH terms: Infant Mortality
Fulltext Use of Wigglesworth pathophysiological classification for perinatal mortality in Malaysia

Amar HSS, Abdul Hamid M, Wong SL

Arch. Dis. Child. Fetal Neonatal Ed., 1996 Jan;74(1):F56-9.
PMID: 8653438

A one year prospective study of perinatal deaths was conducted to test the feasibility of using the Wigglesworth pathophysiological classification in the Malaysian health service. Four regions with high perinatal mortality rates were selected. Deaths were actively identified. Nursing staff were trained to use the classification and every death was reviewed by a clinician. A total of 26,198 births and 482 perinatal deaths were reported. The perinatal mortality rate was 18.4. Only 14 (2.9%) deaths had their Wigglesworth category reclassified. Most deaths were in the normally formed macerated stillbirths (34.4%), asphyxial conditions (26.8%), and immaturity (20.1%) subgroups. The results were compared with data from other countries that used this classification. This study has shown that the Wigglesworth pathophysiological classification can be applied to perinatal deaths in the existing Malaysian health service.

Matched MeSH terms: Infant Mortality*
Socio-economic determinants of fertility in some countries of Asia

Pathak KB, Murty PK

Artha Vijnana, 1982 Jun;24(2):163-78.
PMID: 12339046
Matched MeSH terms: Infant Mortality*
Fulltext Clinical nutrition in East Asia and the Pacific

Darnton-Hill I, Cavalli-Sforza LT, Volmanen PV

Asia Pac J Clin Nutr, 1992 Mar;1(1):27-36.
PMID: 24323002

Identifying the nutrition problems of Asia and the Pacific is made difficult by the enormous geographic, socioeconomic and cultural diversity that exists in these areas. With increasing longevity and reduced infant mortality, the more chronic diseases are becoming increasingly important. For almost 90% of the countries that keep such data in the Western Pacific Region of WHO, at least three of the five leading causes of death are noncommunicable diseases. Nevertheless undernutrition is still the most important nutritional problem in the Region. Even though there have been some encouraging declines in the proportion of malnourished under 5-year-olds, increasing populations have meant the actual numbers have not declined. Vitamin A deficiency, iodine deficiency disorders and iron deficiency anaemia remain major public health problems in many countries. There is evidence that vitamin A deficiency is appearing in countries in which it has not previously been a problem. New challenges are occurring, such as childhood obesity, the susceptibility of undernourished populations to the human immunodeficiency virus and the increase in noncommunicable diseases. The three arms of clinical nutrition: therapeutic, research and public health will need to work closely to meet the considerable and continuing threat posed by the nutrition-related diseases.

Matched MeSH terms: Infant Mortality
Changes of perinatal statistics in a semiurban setup between two time periods in Malaysia

al-Mohdzar SA, Haque E, Abdullah WA

Asia Oceania J Obstet Gynaecol, 1993 Dec;19(4):401-5.
PMID: 8135673

Hospital University Sains Malaysia (HUSM) functions as the state referral centre and the only hospital for the state of Kelantan that can offer neonatal intensive care service. The deliveries in HUSM with grand multiparity, late booking and problems of late referrals resembles a hospital serving a semiurban rather than an urban community. A comparison between the year 1989 and 1991 showed marked improvement of perinatal mortality rate from 41.32 to 24.88, which is significantly better than the improvement achieved from 1987 to 1989 (46.0 to 41.32). This was possible due to a marked fall in the early neonatal mortality rate from 10.02 in 1989 to 5.45 in 1991 and fall in the stillbirth rate from 31.61 to 19.53.

Matched MeSH terms: Infant Mortality/trends*
Grandmultiparity in Malaysian women

Tai C, Urquhart R

Asia Oceania J Obstet Gynaecol, 1991 Dec;17(4):327-34.
PMID: 1801678

Grandmultiparity is an ill defined term, but it is generally believed that increasing parity after the fifth delivery increases the risks of child bearing for both the mother and fetus. Four hundred seventy-seven women aged less than 35 years of parity 5 and above who delivered during one year period at the University Hospital, Kuala Lumpur were studied. There were 406 women of parity 5 and 6 and 71 women of parity 7 and above. The 2 groups as a whole comprised 7.5% of the obstetric population for that year. Obstetric performance in the 2 groups of grandmultipara was compared with 1,135 women, aged 25 to 34 years, having their second baby during the same period. Women of parity 7 and above were significantly more likely to be from lower socioeconomic groups, and suffer from anaemia, hypertension and pre-eclampsia. They were also significantly at risk of preterm delivery and delivering infants weighing less than 2.5 kg. In addition, the perinatal mortality rate was significantly greater in the highly parous group (Para greater than 7) than in women of parity 5 and 6 or the control group. Apart from a significant increase in the incidence of anaemia, women of parity 5 and 6 had a similar obstetric performance and perinatal outcome to that of the control group. We conclude that grandmultiparity per se is not an obstetric risk factor until after the seventh delivery. These findings have implications for those who plan the provision of obstetric services for the community.

Matched MeSH terms: Infant Mortality
Obstetric performance in the elderly Malaysian primigravida

Urquhart DR, Tai C

Asia Oceania J Obstet Gynaecol, 1991 Dec;17(4):321-5.
PMID: 1801677

The obstetric performance of 240 elderly primigravida delivering at the University Hospital, Kuala Lumpur, Malaysia between January 1987 and February 1990 was compared with a random group of 250 young primigravida delivering during the same time period. The incidence of impaired glucose tolerance, diabetes mellitus, preterm delivery, antepartum haemorrhage and malpresentation was all increased in the elderly primigravida group. The incidence of caesarean section in the older group was 40.4% compared with 6.8% in the younger (p less than 0.001). Recent studies suggest that the perinatal mortality in women who delay having their first baby until after the age of 35 is not significantly different from the rest of the obstetric population. However, in our own population of elderly primigravida, although not quite reaching statistical significance the perinatal mortality rate of 46 per 1,000 is three times that of primigravida aged 20-25. This may reflect our low induction rate (7.5%) and assisted vaginal delivery rate (8.3%) in those women in this high risk group who are allowed to labour. The implications of these findings are discussed.

Matched MeSH terms: Infant Mortality
Low birth weight in Kuala Lumpur

Tahir HM, Ismail NN, Gebbie DA

Asia Oceania J Obstet Gynaecol, 1991 Jun;17(2):135-42.
PMID: 1867582

Low birth weight babies are defined as those weighing under 2,500 g. They make 13.5% of all births at the Maternity Hospital, Kuala Lumpur but contribute to 74.8% of all deaths. They are most likely to be Indian babies and least likely to be Chinese. Among all 3 communities, the primigravidae tend to produce smaller babies than multiparae but this is also true for the Indian of parity more than 3. The Malay teenager is more likely to produce small babies than their older counterparts but not so with the Indian and Chinese. There are definite clinical factors associated with or causing the births of small babies and the lighter the baby, the more influential are these factors. Maternal hypertension, antepartum haemorrhage, multiple pregnancy and unexplained intrauterine death are the 4 outstanding associations with both low birth weight and perinatal death. Although the spontaneous (often premature) onset of labour was the commonest preceding factor, it was much less important in the lowest birth weight groups of babies and was a less important contributor to perinatal death.

Matched MeSH terms: Infant Mortality
Maternal and child health in urban Sabah, Malaysia: a comparison of citizens and migrants

Zulkifli SN, U KM, Yusof K, Lin WY

Asia Pac J Public Health, 1994;7(3):151-8.
PMID: 7794653 DOI: 10.1177/101053959400700302

This paper describes selected maternal and child health indicators based on a cross-sectional study of citizens and migrants in Sabah, Malaysia. A total of 1,515 women were interviewed from a multi-stage random sample of households in eight urban centers. Among the 1,411 women in the sample who had experienced a pregnancy before, 76% were local citizens and 24% were migrants. There were statistically significant differences between citizens and migrants in ethnicity, religion, education, household income, and access to treated water supply and sanitary toilet facilities. Significantly fewer migrants practiced any form of contraception and obtained any antenatal care during any pregnancy. Furthermore, citizens tended to initiate care as early as three months but migrants as late as seven months. Despite these differences, only the infant mortality rate, and not pregnancy wastage, was statistically significantly higher among migrants. Pregnancy interval was also similar between the two groups. The influence of several socioeconomic factors on pregnancy wastage and infant mortality was explored.

Matched MeSH terms: Infant Mortality*
Perinatal outcome amongst the Malays in an urban hospital

Arumugam K

Asia Pac J Public Health, 1992;6(1):32-4.
PMID: 1304776 DOI: 10.1177/101053959200600109

National data show that the perinatal mortality amongst the Malays is higher than that of the Chinese but less than that of the Indians. These figures include data from both urban and rural areas. In the University Hospital, Kuala Lumpur, however, the perinatal mortality amongst the Malays was found to be the lowest; an odds-ratio of 0.72 (95% confidence limits; 0.59-0.87; P < 0.0005) when compared to the non-Malays. This occurred despite a significantly higher parity amongst the Malays. The Malays in this group of patients however, had a significantly better social class distribution.
Publication year: 1992-1993

Matched MeSH terms: Infant Mortality*
Fulltext Ethnicity and infant mortality in Malaysia

Dixon G

Asia Pac Popul J, 1993 Jun;8(2):23-54.
PMID: 12287522

PIP: Malaysian infant mortality differentials are a worthwhile subject for study, because socioeconomic development has very clearly had a differential impact by ethnic group. The Chinese rates of infant mortality are significantly lower than the Malay or Indian rates. Instead of examining the obvious access to care issues, this study considered factors related to the culture of infant care. Practices include the Chinese confinement of the mother in the first month after childbirth ("pe'i yue") and Pillsbury's 12 normative rules for Malaysian Chinese care. Malay practices vary widely by region and history. Indian mothers are restricted by diet. Data-recording flaws do not permit analysis of Sarawak or Sabah. The general assumption that Western medicine favors better health for mothers and infants is substantiated among peninsular communities, however, there are also negative impacts which affect infant mortality. The complex interaction of factors impacting on infant mortality reported in seven previous studies is discussed. A review of these studies reveals that immediate causes are infections, injuries, and dehydration. Indirect causes are birth weight or social and behavioral factors such as household income or maternal education. Indirect factors, which are amenable to planned change and influence the biological proximate determinants of infant mortality, are identified as birth weight, maternal age at birth, short pregnancy intervals or prior reproductive loss, sex of the child, birth order, duration of breast feeding and conditions of supplementation, types of household water and sanitation, year of child's birth, maternal education, household income and composition, institution of birth, ethnicity, and rural residence. Nine factors are identified empirically as not significant: maternal hours of work in the child's first year, maternal occupation, distance from home to workplace, presence of other children or servants, incidence of epidemics in the child's first year of life, community types of sanitation, prices and availability of infant foods, and access to various types of medical care. Future empirical study should consider factors such as class differences, place of residence, or extent of illiteracy as underlying or related to ethnicity. Policy-makers should be aware that future decline in infant mortality rates may depend on the blending of traditional with modern practices.

Matched MeSH terms: Infant Mortality*
Fulltext Socio-economic development and mortality patterns and trends in Malaysia

Tan Poo Chang, Kwok Kwan Kit, Tan Boon Ann, Shyamala Nagaraj, Tey Nai Peng, Siti Norazah Zulkifli

Asia Pac Popul J, 1987 Mar;2(1):3-20.
PMID: 12341034

PIP: Morality in Peninsular Malaysia has reached a level that is quite similar to that prevailing in the low mortality countries. This article systematically documents changes in mortality levels and differentials in Malaysia over time and relates these to changes in development indicators and health-related policies. Remedial measures undertaken by the authorities including the expansion of hospital and health services into the estates, together with a comprehensive malaria-eradication program, improvements in sanitation laws, and increased provision of public utilities and education, resulted in beriberi being eliminated and the incidence of malaria, typhus, and smallpox being greatly reduced by the time of World War II. The gain in life expectancy over the period of 1957-1979 was greatest for the Malay, the most significant period being 1957-1967, which saw the introduction of rural health programs. The infant mortality rate and the neonatal and post-neonatal rates declined substantially for all ethnic groups in Peninsular Malaysia for the same time period. Although the lower infant mortality of the Chinese can be explained by their advantageous socioeconomic position the same reason cannot explain the lower decline in infant mortality levels of the Indians. Much still needs to be done to narrow, if not to eliminate, the existing mortality differentials of different groups in the country. Overall, the quality of life of the general population can be further enhanced by reducing the high mortality level of disadvantaged groups.

Matched MeSH terms: Infant Mortality*
Multivariate areal analysis of the impact and efficiency of the family planning programme in peninsular Malaysia

Tan Boon Ann

Asia Pac Popul J, 1987 Jun;2(2):45-66.
PMID: 12341280
Matched MeSH terms: Infant Mortality

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