Sabah’s silent maternal crisis: Why late pregnancy registration costs lives

IN the rural interior of Kampung Inarad, Tongod, pregnancy rarely begins with a clinic card or an appointment date. It begins quietly, with a missed period, morning sickness that comes and goes, and fatigue often explained away as farm work or long days running a household. For many women, the nearest health clinic is hours away along unpaved roads or logging tracks, transport costs money, and the decision to seek care is not always theirs alone.

When national conversations turn to healthcare reform, digital records, or policy targets set for 2026, these words often never reach the communities most affected, or if they do, they feel distant and abstract. The reality on the ground is far more immediate, shaped by a single unspoken question of whether help can be reached in time if something goes wrong.

As Sabah moves deeper into 2026, we must confront a truth that remains deeply uncomfortable. This is still one of the most dangerous places in Malaysia to be a mother or a child. While the country speaks confidently about progress and universal access, Sabah continues to record mortality outcomes that expose long-standing structural gaps which no slogan can hide.

In 2024, Sabah’s under-five mortality rate stood at 12.1 deaths per 1,000 live births, among the highest in Malaysia, while in 2023 the maternal mortality ratio reached 36.6 deaths per 100,000 live births, the highest in the country. These figures are often presented as ratios and trends, but in reality, they translate into something far more tangible: babies who never leave the hospital, mothers who do not survive childbirth, and families left asking how joy turned into grief within hours.

These deaths do not happen because Sabah lacks committed healthcare workers. They occur in a system stretched across vast geography with limited manpower, where Sabah’s doctor-to-population ratio remains close to 1 to 800 compared to the national target of 1 to 400. Ministry of Health Malaysia (MOH) projections indicate that Sabah would need more than 4,600 additional doctors just to reach the minimum level considered safe. The strain is not confined to doctors alone, as Assistant Medical Officers (AMO), nurses, pharmacists, and healthcare workers are similarly stretched thin, frequently covering multiple responsibilities across wide rural areas where staffing gaps disrupt follow-up and early intervention.

Infrastructure and staffing alone do not explain the full picture. Hidden within these mortality statistics is a quieter and less discussed crisis that contributes directly to maternal death, namely late booking of pregnancy. A review of maternal deaths in Sabah between 2015 and 2020 found that more than half of the women who died had never attended a single antenatal visit, meaning no blood tests, no blood pressure measurements, and no opportunity to detect danger early or prepare the body for childbirth.

Another layer of vulnerability involves women who are unregistered or lack formal documentation, including non-residents, who may delay or avoid antenatal care out of fear, uncertainty, or cost. When pregnancies remain invisible to the health system, risks go unassessed, complications go unmanaged, and opportunities for early intervention are lost.

In clinical practice, the first antenatal visit is known as the booking visit, and MOH training materials are explicit that this should occur when the pregnancy is still under 12 weeks. This timing is not about paperwork or policy, but about biology. Pregnancy is not a period of waiting but a metabolic marathon in which blood volume expands rapidly, iron stores are depleted, and the cardiovascular system is forced to adapt quickly. Conditions such as anaemia, hypertension, and gestational diabetes often develop silently during early pregnancy, and without early assessment they remain invisible until they surface as emergencies later in pregnancy or during labour.

Anaemia illustrates this risk clearly, with studies in Malaysia reporting anaemia in pregnancy at levels exceeding 50% in some settings and consistently higher burdens observed in East Malaysia, where many women present with haemoglobin levels below the recommended 11.0 g/dL threshold, often in the 8.0 to 10.0 g/dL range by the time they seek care, reducing oxygen delivery to vital organs and increasing the risk of death during childbirth itself.

Building blood reserves takes weeks, sometimes months, and when a woman presents for care only in her second or third trimester, that window is already closing. If she hemorrhages during childbirth, even timely referral and emergency care may not compensate for blood that was never built. Healthcare workers across Sabah see this pattern repeatedly, as women arrive in labour exhausted, severely anaemic, and frightened, with no antenatal record and no baseline investigations. Care becomes reactive rather than preventive, and when complications arise, the margin for rescue is dangerously narrow.

The reasons women book late, or not at all, are rarely simple. Distance matters, and cost matters, but culture also plays a role that is often acknowledged quietly and avoided publicly. In many Sabahan households, practical realities shape when care is sought. A clinic visit may require someone else to take time off work, arrange transport, or cover fuel costs, and when early pregnancy appears uncomplicated, the urgency to attend is often delayed.

I also spoke to Abdul Hakim bin Mansor, a community health lecturer at Institut Latihan Kementerian Kesihatan Malaysia Kota Kinabalu, who offered a broader perspective on how pregnancy is understood at community level. “Public health works best when prevention is built into everyday life, not treated as a response to illness. In maternal care, early engagement is about shifting mindsets from reacting to danger to anticipating it, which is why policy has long focused on getting women into care early rather than waiting for complications.”

This is why placing the burden of maternal health solely on mothers is both unfair and ineffective. In reality, the true gatekeepers of early booking are often husbands and family elders, and when a husband prioritises the first antenatal visit, everything changes. Transport is arranged, money is found, and the appointment happens. When he does not, booking is delayed, sometimes until complications force an emergency visit.

Research consistently shows that active partner involvement improves clinic attendance, reduces maternal anxiety, and increases adherence to medical advice, not by taking control away from women but by recognising where decision-making power lies and using it to protect life.

Stories from clinics across Sabah reflect this clearly. Some women arrive alone and apologetic, explaining that they came late because no one could bring them earlier, while others present only after symptoms worsen. In contrast, women who attend early, often accompanied by supportive partners, are more likely to complete follow-up visits, take supplements consistently, and seek help promptly when warning signs appear.

None of this removes responsibility from the government. It remains unacceptable that Sabah has far fewer government health clinics than states with comparable geography such as Sarawak, and that specialist services remain concentrated in urban centres while rural districts struggle. Budget 2026 announced that 4,500 contract doctors would be offered permanent posts, but the unresolved question for Sabah is whether underserved districts such as Sandakan, Kalabakan, Pitas, and interior divisions will see a fair share of this workforce.

But while policy decisions take time, pregnancies do not wait. The tragedy is that late booking is one of the few risk factors for maternal death that can be changed quickly, because awareness costs little and understanding saves lives. Knowing that the first 12 weeks matter changes behaviour, and recognising that pregnancy complications begin silently rather than dramatically creates urgency where there was once complacency.

Husbands need to understand that early booking is not excessive or optional but protective, elders must stop advising women to wait until the pregnancy “feels safe,” employers must allow time off without penalty, and community leaders must repeat this message until it becomes normal.

Do not wait for the baby bump to show, do not wait for pain or bleeding, and do not wait until the second trimester. Book before 12 weeks. The maternal and child mortality gap in Sabah will only close if action comes from both sides, with the state strengthening clinics and staffing while communities act early and decisively. In Sabah, motherhood should not be a gamble shaped by distance and delay, and this is a fight for our future that we can start winning now, one early booking at a time.

Melvin Ebin Bondi is a PhD candidate in Public Health at Universiti Malaysia Sabah. He writes a weekly public health column for The Borneo Post.