Draft for Consultation Not to be quoted

UNFPA - ICOMP REGIONAL CONSULTATION

Family Planning in Asia and the Pacific

Addressing the Challenges
8-10 December 2010, Bangkok, Thailand

Status of Family Planning in Malaysia

Dr Norliza Ahmad, Tey Nai Peng, Pn Kamarul Faridah Kamarul Zaman
Pn Noor Azlin Muhd Sapri, Dr Majdah Abdul Manaf and Ms Yeoh Yeok Kim

Disclaimer: The views and opinions expressed in this article are those of authors and do not necessarily reflect the official
policy or position of UNFPA and ICOMP. The content in this draft article should not be quoted.
 STATUS OF FAMILY PLANNING IN MALAYSIA, 2010.
(Dr Norliza Ahmad, Tey Nai Peng, Pn Kamarul Faridah Kamarul Zaman,
Pn Noor Azlin Muhd Sapri, Dr Majdah Abdul Manaf and Ms Yeoh Yeok Kim)

1. BACKGROUND
1.1 The Beginning of the National Family Planning Program
Prior to 1966, family planning services in Malaysia were provided by the
various state Family Planning Associations, and the services were largely confined to
large urban centres. Findings from the 1966 West Malaysia Family Survey conducted
in Peninsular Malaysia reported a contraceptive prevalence rate (CPR) at merely 8.8
percent.

With the launching of the National Planning Program in conjunction with the
First Malaysia Plan in 1966, family planning became an official policy. The
programme was aimed at improving maternal and child health and decelerating the
rate of population growth from 3% in 1966 to 2% in 1985 by setting targets to
increase the number of family planning acceptors (Noor Laily, et. al, 1982). The
National Family Planning Board was established to plan, execute and coordinate all
family planning activities in the country. The program began with the provision of
clinical contraceptive services mainly in the urban areas. Subsequently, the National
Program was expanded to the rural areas through the integration of family planning
with primary health care services of the Ministry of Health in the early 1970s.

CPR increased substantially from 8 percent in 1966 to 36 percent in 1974 and

further to 52 percent in 1984, but has leveled off since then. Despite the stagnation of
contraceptive prevalence rate, the fertility level has continued to decline towards
replacement level fertility. Rising age at marriage and increased contraceptive use
have been the main contributory factors to fertility decline.

1.2 Evolution of Family Planning Policy

In reviewing the population policy in 1984, the Government called for a major
shift from family planning to family and human resource development, to achieve an
ultimate population of 70 million by 2100. . Under the New Population Policy, the

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Board was renamed the National Population and Family Development Board
NPFDB), and was moved to the Ministry of National Unity and Social Development
in 1989. Following the dissolution of the Ministry of the Ministry of Unity and Social
Development after the 2001 General Election, NPFDB has been placed under the
newly created Ministry of Women, Family and Community Development.

In the early stages of the national program, the Information Education and
Communication (IEC) activities played an important part in increasing family
planning acceptance. However, since the promulgation of the New Population Policy
and the change in the program thrust from family planning to family development in
1984, family planning has been de-emphasized and IEC activities discontinued (Tey.
2007).

As the fertility rate is approaching replacement level, the governments view

on fertility has changed from too high in 1996 to satisfactory in 2007. The policy
on fertility has been revised from one that sought to lower it to one with no
intervention, with emphasis to raise the quality of the population through education
and human resource development. Recognizing the importance of the family as a
social and production units, and its important role in nurturing the future generation
and the care of older people, a National Family Policy is being developed.

2. Trends and Patterns in Contraceptive Use

2.1 Trends in CPR
The CPR in Peninsular Malaysia has leveled off at around 50 percent for the
past three decades (Figure 1). In terms of modern methods, the CPR has increased
slightly from 30.2 percent in 1994 to 34.4 percent in 2004. There had been a decrease
in the use of non modern methods from 24.6 percent in 1994 to 17.5 percent in 2004.

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 Figure 1: Contraceptive Prevalence Rate for Any Method and Modern Method in
Peninsular Malaysia

60.0 52.2 54.8

51.9
50.0
36.0 34.4
40.0 30.3 30.2
30.0 26.3

20.0
10.0
0.0
1974 1984 1994 2004

Any Method Modern

Sources: National Population and Family Development Board (NPFDB);

Malaysian Population and Family Survey 1974, 1984, 1994 & 2004.

The national program was extended to Sabah and Sarawak at the turn of the
century. However, the contraceptive prevalence rate for these two states is
comparable to that of Peninsular Malaysia (Figure 2).

Figure 2: Contraceptive prevalence rate in Sabah and Sarawak

Any Method Modern

57.8
60 53.0
50.1 50.4
50 44.4 42.3
37.4
40
30.1
30
20
Sabah Sarawak
10
0
1989 2004 1989 2004

Sources: National Population and Family Development Board (NPFDB);

Malaysian Population and Family Survey 1992 & 2004.

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2.2 Method Mix
The pill has always been the most popular contraceptive method among
Malaysians. There has been a noticeable increase in the use of IUD and injection
since 1984. The prevalence rate for female sterilization had declined from 7.6 percent
in 1984 to 6.9 percent in 1994 and 6.6 percent in 2004, but the prevalence rate for
condom has been more rather erratic (Table 1).

Of the non modern methods, the rhythm method has been by far the most
popular method, with a prevalence rate of about 9 percent in 1994 and 2004. The
prevalence rate for other non modern methods which include herbal preparations has
declined substantially since 1984. The practice of withdrawal to prevent a pregnancy
had also become less common between 1994 and 2004. Between 1994 and 2004,
while there had been slight increase in male participation in the use of modern
methods (condom), their participation in the use of traditional methods (withdrawal)
had declined.

Table 1: Contraceptive Prevalence Rate by Method, Peninsular Malaysia

1974 1984 1994 2004
Pill 18.0 11.9 13.3 14.0
IUD 0.8 2.2 3.9 4.5
Injection 0.2 0.5 0.6 1.3
Condom 3.2 7.7 5.4 7.4
Implant 0.0 0.0 0.0 0.4
Other female methods 0.0 0.2 0.2 0.1
Female sterilization 3.8 7.6 6.9 6.6
Vasectomy 0.0 0.2 0.1 0.1
Rhythm 3.8 7.0 8.8 9.3
Withdrawal 2.0 4.0 6.9 4.1
Abstinence 1.5 1.7 1.3 1.3
Other non modern methods 2.2 9.1 7.6 3.0
Total 36.0 52.2 54.8 51.9
Sources: National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey 1974, 1984, 1994 & 2004.

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 Table 2 shows that a much higher proportion of the women in Sabah and
Sarawak were using the pill and injection as compared to their counterparts in
Peninsular Malaysia, but a lower proportion were relying on condom and withdrawal.
There is no significant different in the overall CPR across the three regions.

Table 2: Contraceptive Prevalence Rate by Method for the Three Regions, 2004
Peninsular
Malaysia Sabah Sarawak
Pill 14.0 22.1 23.0
IUD 4.5 4.2 2.6
Injection 1.3 2.4 6.0
Condom 7.4 1.9 2.1
Implant 0.4 0.3 0.3
Foam 0.1 0.0 0.1
Female sterilization 6.6 6.3 8.0
Vasectomy 0.1 0.2 0.2
Rhythm 9.3 7.5 6.0
Withdrawal 4.1 3.3 2.5
Abstinence 1.3 0.4 0.6
Other non modern methods 3.0 0.8 1.6
Total 51.9 50.4 53.0

Sources: National Population and Family Development Board (NPFDB);

Malaysian Population and Family Survey, 2004.

2.3 Socio-economic Differentials in Contraceptive Use

Table 3 shows the differentials in CPR across states and socio-demographic
variables. Contraceptive prevalence rate for Malays has always been lower than the
other main ethnic groups, especially the Chinese. In 2004, the CPR for modern
methods was 28.2 percent for the Malays, 45.6 percent for the Chinese and 32.2
percent for the Indians.

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 Wide variation in CPR can be observed across states. The east coast states
(where Malays make up more than 90 percent of the population have the lowest CPR.
However, it is to be noted that these states had registered a substantial increase in
CPR between 1994 and 2004. On the other hand, the CPR for modern methods had
declined significantly in some northern states during the same period.

Urbanization and education have positive effects on CPR. However, the

differentials in CPR between urban and rural women and across educational
categories are much less pronounced than ethnic differentials.
Table 3: Contraceptive Prevalence Rate by Selected Variables, Peninsular Malaysia
Any method Modern method
1988 1994 2004 1988 1994 2004
P. Malaysia 49.8 54.8 51.9 33.5 30.2 34.3
Ethnicity Malays 39.8 45.9 43.0 24.8 22.4 28.2
Chinese 67.2 72.8 67.0 49.6 47.0 45.6
Indians 57.7 64.1 54.7 39.0 33.2 32.2
State Perlis 61.5 58.6 45.5 53.8 40.0 38.2
Kedah 46.2 56.1 47.2 30.2 30.4 35.8
Penang 62.3 67.3 47.4 44.3 35.6 32.5
Perak 45.4 62.4 53.8 28.9 32.9 38.0
Selangor 59.3 60.6 58.1 40.7 33.9 37.1
WPKL 58.3 54.8 56.9 39.6 31.1 33.2
N. Sembilan 69.7 65.6 67.4 48.3 36.0 43.1
Melaka 57.8 68.2 58.2 24.4 39.4 36.7
Johor 52.7 56.3 49.6 35.2 31.1 32.2
Kelantan 19.5 19.4 26.0 12.6 9.2 17.5
Terengganu 31.8 24.8 32.4 23.5 13.3 20.3
Pahang 43.8 51.3 58.2 31.5 30.9 39.6
Residence Rural 46.7 50.9 46.9 31.6 28.7 31.9
Urban 55.1 58.0 54.3 36.8 31.5 35.5
Education None/primary 50.6 55.0 48.5 34.1 31.5 30.6
Secondary 51.8 55.2 52.6 32.8 29.5 35.0
Post Sec. 50.9 50.9 54.7 33.7 27.5 37.4
Age Below 30 42.3 49.1 49.6 27.3 28.9 34.5
30-39 56.1 58.9 58.2 38.3 33.0 40.7
40+ 50.0 54.2 47.1 34.5 27.5 28.3
CEB 0 to 1 child 26.3 27.8 29.0 15.0 14.2 16.8
2-3 children 57.7 64.1 60.6 39.0 35.1 40.3
4+ children 54.0 59.2 51.9 37.5 33.6 35.0
Source : National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey, 1994 & 2004.
Malaysian Family Life Survey II, 1988

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 Contraceptive prevalence rate for any method had declined for women of all
age groups and parity between 1994 and 2004, but the CPR for modern methods had
increased among women aged 30-39 and those with 2 to 3 children.

2.4 Unmet Need for Contraception

Unmet need for modern contraception for purpose of limiting births had
increased from 25 percent in 1988 to 36 percent in 2004, and all sub-groups and states
had registered very significant increase in unmet need, except those aged 30-39 years.
Paradoxically, while the Chinese and Indians had much higher CPR than the Malays,
they also had higher unmet need for contraception, as shown in Table 4. This can be
attributed to a higher proportion wanting to stop children among the Chinese (80
percent) and Indians (73 percent) as compared to the Malays (48 percent).

The level of unmet need for contraception in Sabah and Sarawak is slightly
lower than that of Peninsular Malaysia. The Chinese in Sabah and Sarawak also have
higher unmet need for contraception as compared to the Bumiputera (Table 5).

The urban-rural differential in unmet need for contraception is not very

pronounced. However, those with primary or no education had much higher unmet
need for contraception as compared to the higher educated women and this is true for
all the three regions. Unmet need for contraception was much higher among older and
higher parity women (see Tables 4 and 5).

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 Table 4: Unmet need for contraception by selected variables, 1988 and 2004
Any method Modern method
1988 2004 1988 2004
Peninsular Malaysia 16 24.7 25 36.2
Ethnic group
Malays 17 25.9 23 33.6
Chinese 13 22.2 25 39.8
Indians 21 26.6 32 44.7
State
Johor 19.5 25.8 30.2 36.8
Kedah 22.6 29.3 29.2 36.8
Kelantan 31.0 33.3 32.2 37.6
Melaka 13.3 24.8 28.9 39.8
N. Sembilan 10.1 14.9 23.6 31.8
Pahang 20.9 21.9 26.4 33.2
Perak 14.3 27.3 21.6 39.2
Perlis 15.4 23.6 23.1 26.3
Pulau Pinang 18.0 30.3 29.5 41.2
Selangor 10.9 19.4 22.2 32.5
Terengganu 20.0 25.9 23.5 33.1
WP Kuala Lumpur 16.7 25.4 25.0 42.5
Place of residence
Rural 16 25.8 24 35.0
Urban 17 24.1 27 36.9
Womens educational level
Primary or no schooling 22 38.6 32 54.0
Secondary 15 21.1 23 31.6
Tertiary 6.5 15.1 13 24.7
Womens age
Below 30 7 4.0 9 6.4
30-39 15 15.1 27 24.7
40+ 39 44.3 54 62.3
Number of children
0 to 1 child 6 9.7 7 13.2
2 to 3 children 12 21.6 20 34.9
4 and more children 27 36.4 40 50.1
Sources: Tey, 2008

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 Table 5: Unmet need for contraception, Sabah and Sarawak, 2004
Sabah Sarawak
Any Any Modern
method Modern method method method
Total 23.8 31.3 24.0 30.0
Ethnic group
Bumiputera 22.5 29.6 21.6 25.3
Chinese 35.0 47.6 31.6 44.2
Lain-lain 25.2 30.1 6.3 18.9
Education
Primary or no schooling 34.7 42.2 30.1 34.8
Secondary 17.2 24.9 20.4 27.8
Post secondary 13.4 19.5 17.3 20.0
Age
Below 30 6.8 8.9 5.3 7.3
30-39 18.7 26.8 19.5 24.7
40+ 45.3 56.8 41.3 50.6
Total 23.8 31.3
Number of children
0-1 5.8 6.8 11.7 11.8
2-3 18.8 25.7 21.8 29.0
4+ 34.5 44.8 33.1 40.5
Total 23.8 31.3
Sources: Tey, 2008

Tables 6-8 show that in 2004 unmet need for modern contraception for birth
limitation was rather low among women below 30 years of age, and among those with
less than 2 children. However, women 40 and above had very high level of unmet
need for modern contraception for birth limitation, regardless of the number of
children. Close to two thirds of women aged 40 and above and having two or more
children had unmet need for modern contraception.

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 Table 6: Unmet need for modern contraception for birth limitation, Peninsular
Malaysia, by age and parity, 2004.
Age of respondent
Number of children Below 30 30-39 40+ All age groups
0 to 1 child 1.7 9.5 57.3 13.2
2 to 3 children 11.1 23.6 62.2 34.9
4 and more children 15.3 32.3 63.1 50.1
Total 6.4 24.7 62.3 36.2
Source: Tey, 2008

Table 7: Unmet need for modern contraception for birth limitation, by age and parity,
Sabah, 2004.
Age of respondent
Number of children Below 30 30-39 40+ All age groups
0 to 1 child 2.8 7.0 33.3 6.8
2 to 3 children 9.8 23.8 58.2 25.7
4 and more children 23.3 33.5 58.2 44.8
Total 8.9 26.8 56.8 31.3
Source: Tey, 2008

Table 8: Unmet need for modern contraception for birth limitation, by age and parity,
Sarawak, 2004.
Age of respondent
Number of children Below 30 30-39 40+ All age groups
0 to 1 child 3.1 13.6 37.1 11.8
2 to 3 children 10.2 25.2 48.9 29.0
4 and more children 14.0 27.5 54.1 40.5
Total 7.3 24.7 50.6 30.0
Source: Tey, 2008
2.5 Reasons for Not Using/Stopping Contraceptive Method
Table 9 shows that more than half of non-users in Peninsular Malaysia in the
1994 survey mentioned wanting to have children as reason for not using a
contraceptive method, but this had declined 39.3 percent in the 2004 survey. There
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has been a significant increase in the proportion who mentioned fear of side effects
as reason for not using a method, and this had become the second most important
reason in 2004. It is noteworthy that the percentage who mentioned husbands
objection had increased rather substantially from 8 percent in 1994 to 12.6 percent in
2004.

In these sample surveys, no respondent had specifically mentioned religion as

posing a barrier to contraceptive use. However, it is possible that religious
consideration, which may be limited to pockets of the population not included in these
sample surveys, may explain partly the lower contraceptive prevalence rate among the
Malays.

Compared to their counterparts in Peninsular Malaysia, women in Sabah and

Sarawak were more likely to mention wanting more children as the reason for not
using a contraceptive method, but were less likely to mentioned husbands objection.
Fear of side effects is an important reason for not using a contraceptive in all the three
regions.

Table 9: Reasons for not using any contraceptive method among never users
2004
Reasons 1994
Peninsular Sabah Sarawak
Malaysia
Want more children 53 39.3 52.5 44.1
Husband's objection 8 12.6 4.8 9.6
Medical and health reason 3.4 5.4 4.8 4.2
Fear of side effects 10.3 26.8 26.4 27.5
Others 25.4 15.9 11.6 14.6
Total 100.0 100.0 100.0 100.0
Source : National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey, 1994 & 2004.

The percentage of women stopping contraceptive use to have children as

reason had decreased from 38.4 percent in 1994 to 27.4 percent in 2004. However,

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side effects, discomfort caused by method use and advice by medical professional and
husbands objection had become important reason for stopping contraceptive use, as
shown in Table 10. Husbands objection constituted a relatively less important reason
for women to stop using a method. A small proportion of women had mentioned
method failure as reason for stopping contraceptive use. The discontinuation rate for
all methods is calculated at 17.2 percent (computed data from MPFS, 2004).

Table 10: Reasons for terminating contraceptive use, 1994, 2004

1994 2004 2004 2004
Peninsular Malaysia Sabah Sarawak
Method failure 4.7 3.1 2.9 2.3
Want to have children 38.4 27.4 39.4 39.5
Side effects 22.4 26.5 22.3 21.5
Advised by medical professional 7.7 10.6 9.6 12.1
Discomfort caused by method 4.0 6.8 8.7 9.0
Husband's objection 2.4 3.9 1.4 4.9
Others 20.5 21.7 15.7 10.8
Total 100.0 100.0 100.0 100.0
Source : National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey, 1994 & 2004

3. Availability of Contraceptive Services/Information and Commodity Security

3.1 Sources of Contraceptive Services and Information
Under the National Program, family planning services and information are
widely available through a wide network of clinics of the Ministry of Health, the
National Population and Family Development Board and Federation of Reproductive
Health Association of Malaysia (FRHAM). Private hospitals/clinics and commercial
outlets also provide family planning services.

NPFDB provides cafeteria type of service to ensure clients receive widest

possible choices of safe, effective, affordable and acceptable method at all its 55
clinics throughout the country. At the same time, NPFDB complements MOH family
planning services by conducting motivation talks in maternity wards. NPFDB also
12
extends its services at the grassroots levels through health camps or special events as
part of their community service. Family planning services at NPFDB headquarters
had been accredited with ISO 9001:2008.

NPFDB has launched an outreach programme called LPPKN@komuniti

middle of 2010. This is a programme under National Key Result Areas targeted
towards families with low household income. This programme which is designed to
increase knowledge and skills to strengthen the family institution has incorporated
family planning services and information in its two-day programme. The targeted
families in all states were identified with the assistance of the Welfare Department.

The marginalized urban poor women are served by six mobile clinics of
NPFDB. Each mobile clinic is a renovated bus and has two consultation rooms, well
equipped with all the necessary clinical equipments. It is envisaged that this
programme will be expanded to all the other states throughout the country.

MOH had introduced guidelines on WHO Medical Eligibility Criteria for

Contraceptive Use and Selected Practice Recommendations for Contraceptive Use as
a mean to maintain quality family planning services. Training workshops were
conducted at all levels of care to train all government health care providers (including
NPFDB) on the use of the guidelines. The guidelines were translated into Malay
language and customized for better understanding and usage by the providers.

Tables 11-13 show that a sizable proportion of contraceptive users had

obtained their supply from private hospitals and clinics as well as the pharmacies. In
Peninsular Malaysia, about three quarters of women who underwent sterilization had
the procedure performed at private hospitals and clinics, and close to 6 out of every 10
pill users obtained their supply from non-Program sources. Even among married
couples, the majority of condom users had obtained their condom supply from these
commercial sources. There is no law and regulation in prohibiting the sales of condom
to unmarried persons.

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 Table 11: Sources of supply/advice of various contraceptive methods, Peninsular
Malaysia 2004
Injectio Condo Implan Female
Pill IUD sterilizatio
n m t
n
NPFDB 3.1 12.9 2.4 2.5 23.1 0.0
FPA 0.9 2.0 0.0 0.4 15.4
MOH 38.5 17.0 28.6 7.4 0.0 25.1
Private
hospitals/clinic 28.0 86.0 69.0 3.7 61.5 72.1
s
Sinseh(Chinese
Traditional 0.7 0.0 0.0 9.9 0.0 0.0
Outlet)
Pharmacy 27.5 0.7 0.0 58.7 0.0 0.0
Others 1.3 1.4 0.0 17.3 0.0 2.8
Total 100.0 100.0 100.0 100.0 10.0 100.0
Source : National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey, 2004.

Table 12: Sources of supply/advice of various contraceptive methods, Sabah, 2004

Female
Pill IUD Injection Condom Rhythm
sterilization
NPFDB 1.0 0.0 0.0 0.0 0.0 0.0
FPA 11.4 8.6 12.5 0.0 1.2 2.2
MOH 59.9 53.4 37.5 22.2 58.1 24.4
Private
16.0 37.9 46.9 18.5 39.5 4.4
hospitals/clinics
Sinseh 0.0 0.0 0.0 0.0 0.0 2.2
Pharmacy 10.7 0.0 0.0 44.4 0.0 0.0
Others 1.0 0.0 3.1 14.8 1.2 .667
Total 100.0 100.0 100.0 100.0 100.0 100.0
Source : National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey, 2004.

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Table 13: Sources of supply/advice of various contraceptive methods, Sarawak, 2004
Female
Pill IUD Injection Condom Rhythm
sterilization
NPFDB 0.5 0.0 0.0 0.0 0.0 0.0
FPA 7.4 4.7 1.0 8.1 0.0 9.6
MOH 57.9 37.2 41.3 13.5 61.8 25.0
Private
hospitals/clinics 11.7 55.8 56.7 0.0 38.2 1.9
Sinseh 0.0 0.0 1.0 0.0 0.0 1.9
Pharmacy 21.7 0.0 0.0 62.2 0.0 0.0
Others 0.8 2.3 0.0 16.2 0.0 61.5
Total 100.0 100.0 100.0 100.0 100.0 100.0
Source : National Population and Family Development Board (NPFDB);
Malaysian Population and Family Survey, 2004.

3.2 Commodity Security

A partnership and collaboration system is in place between the NPFDB, MOH
and FRHAM in providing family planning and other reproductive health services. The
Ministry of Health integrates family planning services with the rural health services,
while the National Population and Family Development Board, the FRHAM and
private sectors provide for family planning in urban areas.

The availability of a range of contraceptive methods is central to quality of

services in family planning programme. The three key agencies (MOH, NPFDB and
FRHAM) are involved in family planning efforts in the country and all three have
their own system/supply chain from procuring (including storage),
distributing/disseminating to the usage of family planning
commodities/contraceptives.

For MOH, logistic management of family planning programme is

decentralized to all respective state health departments. The MOH headquarters
allocate specific amount of budget to state health departments for purchasing

15
contraceptives supplies. The amount depends on the requirements by the states which
vary according to forecasted number of female clients in reproductive age. Each state
programme manager is responsible to manage their family planning logistics systems
from purchasing and delivering of supplies from manufacturers to the health clinics
which are the service delivery points. Data are collected on the clients contraceptive
information and stock keeping.

NPFDB forecasts its contraceptive requirement based on previous and current

performances of the contraceptive usage. Procurement is made centrally every three
years with staggered deliveries every six month to maintain continuous fresh supply
to all the states. Additional request is allowable subject to approval. Operational
budget for family planning services are mainly from the Boards annual operational
budget which is based on forecasted needs. NPFDB rarely experiences shortage of
contraceptive supply as purchases are made from reliable and established suppliers.

While MOH and NPFDB may not experience a shortage in terms of supply (as
these are under government allocations), FRHAM may encounter difficulties in
sustaining it as IPPF, the main source of funding for contraceptives for FRHAM, is
imposing a gradual decrease of 30% each year (starting 2010) in its funding for
contraceptives

4. Special Target Groups and Linkages with Other Reproductive Health

Programs
4.1 The Youths
The National Program does not provide contraceptive services to the un-
married. With rising of marriage and out-migration of the young to the cities,
adolescent fertility has become a major concern, due to the rising problems of youth
sexuality, teenage pregnancy and abandoned babies. These problems arise largely due
to the lack of reproductive health knowledge among the young people.

The 2004 MPFS shows that a little less than half of the young people aged 13
to 24 had heard of at least one family planning method, and this varies from 26.9
percent among those aged less than 15 years old to about 60 percent among those

16
 aged 20-24. A higher proportion of young females than of males had heard of family
planning methods. Among the ethnic groups, young Indians had the lowest proportion
who had heard of family planning methods. The proportion of young people who had
knowledge of family planning methods was significantly higher in the urban areas as
compared to rural areas.

The pill is the most commonly cited method, followed by condom. Despite the
availability of condoms in pharmacies and provision shops, only 1 in 4 young people
had heard about the method. The rhythm method was mentioned by a mere two
percent of the young people in the survey (Table 14).

Table 14: Knowledge of Family Planning Methods Among Young (unmarried) People
by Selected Variables

Any
methods Pill IUD Injection Condom Sterilization Rhythm
Total 46.3 35.9 4.3 3.7 25.5 1.5 2.0
Gender
Male 39.1 27.4 3.0 2.3 26.5 0.7 1.4
Female 53.7 44.6 5.7 5.1 24.6 2.4 2.7
Age
< 15 26.9 18.6 1.7 2.1 11.3 0.6 2.1
15-19 52.3 40.7 5.0 3.4 29.3 1.8 1.7
20-24 59.8 49.6 6.3 6.1 37.2 2.3 2.5
Ethnic groups
Malays 47.1 39.6 4.8 3.3 22.0 1.5 0.7
Chinese 47.2 33.3 4.2 2.8 34.5 2.1 2.5
Indians 38.7 21.3 1.2 4.8 25.6 1.2 0.6
Place of residence
Urban 49.0 35.8 4.6 3.5 29.0 1.8 2.9
Rural 42.2 36.0 3.8 3.8 20.3 1.2 0.6

Source : National Population and Family Development Board (NPFDB);

Malaysian Population and Family Survey, 2004.

17
 Between 2005 to 2007, the adolescent fertility rates for Malaysia has not
changed much. The age specific fertility rate for the aged 15-19 years had declined
slightly from 13.8 per thousand women in 2004, 13.5 in 2005, 13.1 in 2006 and 12.8
in 2007.
To address social issues among youths with regard to premarital sexual intercourse,
abandon babies, unwanted pregnancies and HIV/AIDS, the government had
developed various programs for youths such as the kafe@TEEN programme and
PROSTAR (Program for youth living without AIDS). In kafe@TEEN programme,
dissemination of reproductive health information, providing necessary assertive and
protective skills are emphasized. kafe@TEEN centers also provide clinical services,
counseling services and recreational activities. Teen educators who run the centers
also went to schools, higher learning centers and communities for out reach
programme. NPFDB is planning to expand the kafe@TEEN programme throughout
the country by building one kafe@TEEN youth center in each state.

IEC programme are being developed for adolescent where education materials
and modules are used for skill development and preventive measures to overcome
reproductive health issues. Two modules were developed to empower adolescent in
their reproductive health knowledge and soft skills such as assessing risk and handling
negative peer pressure. These modules provide a holistic approach and molded to suit
the Malaysian societal values, cultures and the religious aspect. One of the modules, I
am In Control was developed under the UNFPA project with special focus on
reproductive heath. The other module, Kesejahteraan Hidup (Wellness in Life) has
included other components ie. gender, family and living without violence.

Concurrently, youth portals had been developed for easy access of

reproductive health knowledge through the internet. Two such portals are portal
kafe@TEEN developed by NPFDB and My Health portal by the Ministry of Health.

FRHAM as the key NGO in the field of RH/FP has developed several training
modules for young people. The Reproductive Health Adolescent Module (RHAM)
has been utilized by Ministry of Education and some schools, while the Perjalanan

18
Kehidupan (Lifes Journey) which has incorporated more elements on HIV is being
used for interventions at juvenile homes throughout the country. There are youth-
friendly centres/clinics in eleven FRHAMs clinics where information, para-
counseling, SRHR education and services are available to young people. Clinical and
referral services will also be provided where appropriate.

4.2 Women at the End of Reproduction

At the moment, no special programme are targeted women aged 40-49, i.e.
those who are at the end of their reproduction. In view of the high unmet need for
contraception among these older women as shown in Tables 4- 5, special attention
needs to be given to them to prevent unwanted births and abortion. The reproductive
health risks among older women are known to be higher. For instance, while women
aged 40-44 and 45-49 contributed only 5.1% and 0.4% of total births, they made up
12.0% and 1.6% of the maternal deaths, as shown in Table 15.

Table 15: Maternal deaths by age groups, 2001-2005

Age 2001 2002 2003 2004 2005

group n % n % n % n % n %
15-19 5 3.0 - - 4 3.3 2 1.6 6 4.8
20-24 17 10.0 15 11.4 10 8.2 18 14.7 11 8.8
25-29 41 24.1 29 22.2 24 19.6 26 21.2 31 24.8
30-34 45 26.5 27 20.6 39 32.0 34 27.6 31 24.8
35-39 36 21.1 37 28.2 26 21.3 31 25.2 29 23.2
40-44 20 11.8 21 16.0 16 13.1 11 8.9 15 12.0
45-49 6 3.5 2 1.5 3 2.5 1 0.8 2 1.6
total 170 100.0 131 100.0 122 100.0 123 100.0 125 100.0
Source : Report on the Confidential Enquiries into Maternal Deaths in Malaysia 2001-
2005

4.3 Linkages of Family Planning with Other Reproductive Health Programs

In MOH, family planning services are already integrated with other services
i.e Maternal and Child care services, outpatient care including HIV & STIs. For
instance, women who are on follow-up for medical reasons in outpatient care are also
counseled on family planning. HIV and STI education and counseling are given
during family planning visits.
19
Since its inception, NPFDB has incorporated STI management in its family planning
services. Only recently, HIV information and counseling were introduced.

FRHAM has also played a substantial role in implementing HIV/AIDS related

programmes since the launching of the first country report on MDG in 2005.
Although SRH/FP has been the core business of FRHAM, there are some
shared/common areas of concern for both SRH/FP and HIV/AIDS; some linkages
between the two have been promoted and integrated wherever necessary/possible.
FRHAM has been promoting SRH and HIV/AIDS education at the state FPAs in
delivering their programmes/services, for the general public as well as for vulnerable
population groups (sex workers, MSM, IDU/spouses, transsexuals and others). Based
on the UNFPA/WHOs Study on strengthening HIV and SRH Linkages in Malaysia
(August 2010), FRHAM is currently trying to network with HIV/AIDS organizations
on promoting further and more meaningful linkages.

4.4 The Role of International Agency and International Cooperation

Foreign assistance played an important role in the early stages of the
Malaysian family planning program. International agencies and foreign foundations,
such as the Ford Foundation, the Population Council, the Swedish International
Development Cooperation Agency, and the United Nations Childrens Fund provided
various types of assistance. With the implementation of the Population Project (1973
78) and the Population and Family Health Project (197982), the United Nations
Population Fund and the World Bank also provided significant financial and technical
assistance for the implementation of population, family planning, and family health
programs (Noor Laily and others 1982). NPFDB has also been collaborating with
other international agencies such as the International Planned Parenthood Federation
(IPPF), International Council on Management of Population Programmes (ICOMP),
Japanese Organization for International Cooperation in Family Planning (JOICFP),
Asian Forum for Parliamentarians on Population and Development (AFPPD), Asian
Institute for Development Communication (AIDCOM), Pan-Pacific and South-East
Asia Womens Association (PPSEAWA), and Asian-Pacific Resource & Research
Centre for Women (ARROW).

20
 Malaysia has been participating actively in international forums on population
issues. Among others, Malaysia had participated actively in the ASEAN Australian
Population Program. UNFPA Malaysia has played a bridging role in some of the
pioneering work on population, reproductive health of the young people and gender
issues. UNFPA support has enabled participating agencies to initiate new programmes
and strategies and strengthen the existing ones, develop expertise and capability
(capacity building) and foster networking and partnership in implementing
programmes to address areas that are of growing concern. The assistance of UNFPA
has made it possible for NGOs to implement projects that are considered sensitive
such as the HIV and sex workers.
UNFPA began providing assistance to Malaysia in 1973 for its national family
planning programme. Besides financial assistance, UNFPA has been providing
technical advisory services and support for strategic development in the areas of
population-related areas, focussing on family/reproductive health and gender issues.
From 1973 through 1996, UNFPA supported programmes/projects for reproductive
health (RH) / family planning (FP), training, research, capacity building activities, as
well as other population and development related projects. In view of Malaysia's
progress towards self reliance and its success with population strategies, UNFPA's
assistance since 1997 has been directed towards selected areas of intervention,
particularly in the area of reproductive health as prescribed in the ICPD-PoA. The
areas covered include family planning, maternal and child health, family and
reproductive health, population and development, population education, population
studies and survey research, training of staff, women and youths, setting up of
specialist and research centres, upgrading of infrastructure and facilities, community
participation and South-South Cooperation.

In 2004, UNFPA funded a project: South-South Cooperation in Reproductive

Health in Malaysia aimed at increasing utilization of reproductive health services
through knowledge and experience sharing within ASEAN countries. It was also
aimed at strengthening the capacity of the agencies involved, particularly NPFDB,
MOH, FRHAM to organize, manage and monitor broader, integrated reproductive
health services.

21
 The Regional Technical Meeting and Regional Training Workshop held in
December 2004 had contributed to the sharing of experience and training of
programme managers/service providers from ASEAN countries and Uzbekistan on
the key elements of reproductive health at primary care level. In summary, many of
the participants learnt new strategies towards strengthening their capacity for
planning, management and implementation of RH services at primary care level.

5.0 The Impact of the National Family Planning Program on Fertility Trends

The fertility level in Peninsular Malaysia declined sharply from 5.7 in the mid
1960s to 4.2 by mid 1970s, following the implementation of the national family
planning program.
The fertility level continued to decline from 3.3 in 1995 to 3.0 in 2000 and 2.3
in 2006, despite the stagnation in contraceptive prevalence rate. This can be
explained partly by the rising age at first marriage. Data from population censuses
show that the singulate mean age at marriage (SMAM) for Malaysian women has
been increasing from 22.0 years in 1970 to 24.8 years in 1991 and 25.1 years in 2000.
In 2000, the SMAM for women was highest among Chinese at 27 years and lowest
among Malays at 24.8 years. The proportion of women at ages 30-34 who had never
been married had also gone up from 6 percent in 1970 to 13 percent in 2000, with the
Chinese having the highest proportion at 18 percent.

Table 16 shows that fertility among women aged 40 and above has fallen to a
very low level, and those in the 30s have also registered significant decline. Fertility
decline has occurred in all age groups among all ethnic groups. Low CPR and low
TFR could indicate the possibility of increased abortions, but this remains speculative
as data on abortion are not available.

22
 Table 16: Age Specific Fertility Rates and TFR by Ethnicity and Year, Peninsular
Malaysia
Age specific fertility rate
15-19 20-24 25-29 30-34 35-39 40-44 45-49 TFR
All races 1995 15 123 215 170 103 33 2 3,305
2000 12 92 189 164 98 33 3 2,955
2006 9 68 152 138 78 24 2 2,355
Malays 1995 19 144 234 197 136 57 3 3,950
2000 11 107 222 185 125 49 5 3,520
2006 8 68 178 166 101 35 3 2792
Chinese 1995 10 80 193 149 59 10 0 2,505
2000 10 72 173 156 68 12 1 2,460
2006 8 51 116 123 51 10 1 1800
Indians 1995 22 124 189 127 56 11 0 2,645
2000 16 100 166 127 61 13 1 2,420
2006 10 66 139 108 47 11 1 1914

Source: Computed data from Department of Statistics; Vital Statistics Malaysia, 2008
Note : Each value is the no. of live birth for every 1,000 women during their fertility
period

The impact of contraceptive use on fertility can be assessed by comparing the

CPR and fertility level of different sub-groups. In Malaysia, the fertility rates are
much lower among the sub-groups that have higher CPR (the non-Malays and the
better educated population).

The CPR among the Malays has always been lower than that of the non-
Malays, and this is reflected in the fertility differentials, as shown in Figure 3. Among
the Malays and Chinese, the effects of increased contraceptive use on the fertility
level over the 1974-2004 period is obvious, but the TFR of the Indians had also
declined sharply despite the rather modest increase in CPR over the same period.

23
 A correlation analysis between CPR and TFR at the state level shows a
correlation ratio of -.72. The more developed states generally have higher CPR and
lower TFR. The two east coast states (Kelantan and Terengganu) have the lowest CPR
(Tables 3) and highest TFR of 4.3 and 3.7 respectively.

Figure 3: Scatter plots of total fertility rate with contraceptive prevalence rate by
ethnic
group, 1974 and 2004, Peninsular Malaysia

Contraceptive prevalence rate

24
6.0 Emerging Issues and Recommendation
As part of its efforts to monitor the implementation of the national family
planning/development programs, NPFDB have conducted a series of the Malaysian
Population and Family Surveys in 1974, 1984, 1994 and 2004. Many other smaller
scale surveys on specific topics such as adolescent sexuality, international migration
and infertility have also been conducted. NPFDB had recently conducted an
assessment of the Implementation of ICPD+10 (NPFDB, 2005) and a second
population strategic plan (unpublished). A Mid-term Review of UNFPA Country
Programme for Malaysia (2008-2012) has just been completed (Tey, 2010). These
reviews and assessments have highlighted several emerging issues that warrant
attention.

In view of the stagnation of contraceptive prevalence rate and increased unmet

need, there is a need revitalize family planning to prevent unplanned/unwanted births
and induced abortion, in line with MDGs. The low level of contraceptive use may
have resulted in increased abortion, among the married as well as the unmarried.
Family planning and reproductive health services should also be targeted at the under-
served and the disadvantaged, including foreign migrants and those in the remote
areas in Sabah and Sarawak. Family planning will lead to a reduction in maternal
mortality towards achieving MDG5. In this regard, there is a need to make specialized
services such as treatment of infertility, reproductive tract infection, sexually
transmitted diseases, menopause, andropause and other reproductive health
conditions, as well as cancer screening more accessible and affordable to the public.
The private sector should be encouraged to play an important role, as many are
relying on their services.

To improve reproductive health and to bring the benefits of planned-parenthood

and to a wider segment of the population, program administrators may pay special
attention to the following target groups:
those with unmet need for contraception to space childbearing, to prevent
unwanted or mistimed births;
husbands/males who are apathetic to the benefits of planned-parenthood;

25
 the marginalized groups who may lack knowledge and access to family
planning;
users of traditional methods; and
foreign workers.

The method mix shows that male participation in family planning is still very low.
More concerted efforts are needed to encourage and facilitate their active
participation, and to reduce their objection to family planning practice. Male
participation in sharing the responsibility to practice family planning is identified as a
vital strategy in increasing the contraceptive prevalence rate. It is important to
neutralize the stereotyping or feminization of the service as a whole. Therefore,
activities must involve both the healthcare provider and the clients (AM Rosliza and
M Majdah 2010)

A rather high proportion of couples were still using traditional methods. Users of
traditional methods represent a potential target group for modern methods of
contraception. However, the religious issues and fear of side effects of some of the
modern methods will have to be properly addressed. With regard to high non-use and
discontinuation rate, a wider range of contraceptives methods eg: low dose estrogen
and long acting formulation need to be made widely available with increase coverage
to effectively reduce side effects.

Much has been said about social and health problems brought about by foreign
workers, with the increasing number of foreign workers, their reproductive health
needs must be addressed. More concerted efforts are required to prevent the spread of
STIs and HIV/AIDs.

The IEC programs that had previously played a very important role in promoting
planned- parenthood should be integrated in the reproductive health programs. There
is also a need to introduce reproductive and sex education in schools to prepare the
young for healthy and responsible living. With the advent of ICT, the IEC programs
can now be implemented more effectively in educating and motivating the public on
the benefits of planned-parenthood, and informing them of the availability of

26
reproductive health services. Appropriate programs should be implemented for
specific target groups to allow them to decide on the number and timing of birth, to
upgrade their socio-economic and health conditions. On a broader scale, IEC
programmes should encompass promotion by the private sectors in the provision of
family planning services in areas where the CPR is low.

Adolescent sexuality has emerged as one of the most pressing social problems.
The rising problems of youth sexuality, teenage pregnancy and abandoned babies
have been highlighted in the media. Strategies are being developed and implemented
to overcome such problems. The introduction of reproductive health and social
education must therefore be given high priority, especially now that the government
has approved the policy on RH and social education. There is a need to strengthen the
alliance of partners in advocating to desensitize SRH education for its
implementation. The Ministry of Education has also decided to introduce sex
education in schools, based on the modules I am in control developed by the
National Population and Family Development Board under the Kafe@Teen project.
The Kaf@Teen concept and strategies have proven to be acceptable to the
community, and hence efforts will be made to strengthen and up-scale. The RHAM
module developed by FRHAM should also be updated for wider dissemination.

The pandemic of HIV/AIDs has been a major concern since the

1990s.Measures implemented to combat HIV/AIDS include blood screening,
information/education campaigns, antiretroviral treatment, non- discriminatory
policies and distribution of condoms. FRHAM has successfully implemented many
projects, some with UNFPA assistance, to reach the youth and women, especially on
areas considered sensitive. FRHAM has also been an important partner in the fight
against HIV/AIDS. The various pilot projects should be expanded and up-scaled with
assistance from UNFPA and other agencies.

Studies have shown the close linkage between reproductive health and
HIV/AIDS, and provided evidence of important synergies between reproductive
health and HIV prevention, care and treatment interventions. Forging closer linkages
between these programme areas should result in significant public health benefits.

27
WHO and UNFPA are currently conducting a joint study towards strengthening
linkages between HIV and SRH in Malaysia. UNFPA should continue to work with
WHO, MOH and other relevant agencies in implementing programmes to reduce HIV
through SRH programmes.

To be effective, NPFDB must continue to work closely with the relevant

government agencies, such as the Economic Planning Unit, the Ministry of Health,
the Ministry of Education, the Ministry of Information, the Treasury, the Ministry of
Youth and Sport (all of which are represented in the Board). NPFDB must also
engage in smart partnership with the private sector and the NGO as well as
institutions of higher learning in implementing programs. At the same time, it is
necessary to work closely with UN agencies, in particular, UNFPA and engage in
international collaboration.

28
REFERENCES
1. Ang Eng Suan. 2007. Study on Safe Haven for Babies. National Population
and Family Development Board.

2. AM Rosliza & M.Majdah. Male Participation and Sharing of Responsibility in

Strengthening Family Planning Activities in Malaysia. Malaysia Journal of
Public Health Medicine 2010, Vol.10(1):23-27

3. Department of Statistics; Vital Statistics Malaysia, 2008.

4. Division of Family Health Development, Ministry of Health Malaysia. 2008.

Report on the Confidential Enquiries into Maternal Deaths in Malaysia 2001-
2005.

5. Lee LK, Chen PCY, Lee KK, Kaur J. Premarital sexual intercourse among
adolescents in Malaysia: a cross-sectional Malaysian school survey.
Singapore Med J 2006; 47: 476-481

6. National Population and Family Development Board (NPFDB); Malaysian

Population and Family Survey 1974, 1984, 1994 & 2004.

7. National Population and Family Development Board, Malaysia (2005).

Assessing the Implementation of the ICPD-PoA in Malaysia.

8. Norlaily et all. 1982. Facts and Figures. Malaysian National Population and
Family Development Programme.

9. Report Malaysian Family Life Survey II.1988.

10. Tey Nai Peng. 2008. Contraceptive Use and Unmet for Contraception in
Peninsular Malaysia. Paper presented at FFPAM RRAAM Consultation
Increasing Access to The Reproductive Right to contraceptive Information and
Services; Monitoring Progress since 1994 ICPD Agreements, 21 October,
2008, Subang Jaya, Selangor, Malaysia.

11. Tey Nai Peng. 2007. The Family Planning Program in Malaysia in Warren
Robinson and John Ross (eds). The Emergence of Family Planning Programs
in the Developing World. World Bank.

12. Tey Nai Peng. 2010. Mid-term Review Report of UNFPA Country
Programme for Malaysia (2008-2010).

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