NUTRITIONAL SURVEY

OF CHILDREN UNDER TWO

ATTENDING ROUTINE
IMMUNIZATION SESSIONS AT
PRIMARY HEALTH CARE CENTRES
IN IRAQ

Conducted by the Ministry of Health (GOI)

November 1999
and
UNICEF/Iraq
NUTRITIONAL STATUS SURVEY OF CHILDREN BELOW TWO
ATTENDING ROUTINE IMMUNIZATION SESSIONS AT
PRIMARY HEALTH CARE CENTRES IN IRAQ

November, 1999

Executive Summary
A nutritional status survey was conducted in 127 Primary
Health Centers in South and Center of Iraq. The purpose of this
survey was to continue the nutritional status follow-up for SCR986, in
accordance with the Memorandum of Understanding (MOU) under
Food Items (No. 38). To monitor the nutrition status of children
surveys are carried out every six months since April 1997. The
surveys in April, 1997, March 1998 and April 99 were carried out in
under five children attending National Immunization Days for Polio
and the surveys in October 1997, October 1998 and the present
survey were carried out on children below two years of age attending
routine immunization clinics.

The children attending the routine immunization sessions

during 24 30 November 1999 were surveyed. A total of 6,414
children under two years of age were examined for weight and
height / length. Results pertain to 125 of the original 127 PHCs
sampled in the previous survey of April 1999; two have been excluded
because they are not involved in the previous survey for the matter of
comparison. The survey showed that 12% of the children under two
years of age were malnourished, according to WHO reference criteria
of weight-for-age, W/A<-2SD; 13.8% were stunted (i.e. had a low
height-for-age, reflecting chronic malnutrition) and 9.2% were wasted
(low weight-for-height, reflecting acute malnutrition).

These results show that, in spite of an improved food basket

under the OFF programme the nutrition of children continues to be
adversely affected and has not shown any improvement. The main
factors responsible for that are inadequate intake of foods both in
quantity and quality, poor maternal health, high prevalence of
infections and inappropriate feeding/weaning practices with an
increased use of bottle and formula.

Acknowledgments

The Ministry of Health and UNICEF/Iraq supported this survey.

The Director General of Preventive Health at country level and the
Director-Generals of the Directorates of Health in the governorates
were the key officials responsible for supporting the survey. Nutrition

2
Research Institute in collaboration with Programme Managers of the
Ministry of Health, with the participation of UNICEF, undertook the
preparation, training, analysis and reporting. The survey was carried
out through Primary Health Care Center staff, supported by the
directors of the governorates.

3
 CONTENTS
Summary
1. Introduction 5

2. Methods 6
2.1.Sampling
2.2.Planning and preparation
2.3.Training
2.4.Measurement
2.5.Field work
2.6.Supervision
2.7.Data entry, editing and analysis
2.8.Limitations of the study
3. Results 8
3.1. Characteristics of population
3.1.1. Age
3.1.2. Sex
3.1.3. Urban/rural distribution
3.1.4. Literacy/Education of mothers
3.1.5. Feeding pattern
3.2. Nutritional status 10
3
3.2.1.Prevalence of malnutrition; General malnutrition W/A
4 3.2.2.Chronic malnutrition or stunting, H/A
5 3.2.3.Acute malnutrition or wasting, W/H
6 3.2.4. Nutritional status by urban/rural residence
7 3.2.5. Nutritional status by feeding pattern
8 3.2.6.Percentage of malnutrition according to Sex
9 3.2.7.Nutritional status by age

4. Consequences of malnutrition 14

5. Recommendations 15

5.1. General recommendation

5.2. Targeted nutrition program
5.3. Community education

4
 1. INTRODUCTION

NUTRITIONAL STATUS SURVEY AT PRIMARY HEALTH

CENTRES
DURING ROUTINE IMMUNIZATION SESSIONS IN IRAQ-
November 1999

A nutritional status survey was conducted in 127 Primary

Health Centers throughout the South and Center of Iraq. The children
attending the routine immunization sessions during 24 30,
November 1999 were surveyed. A total of 6,414 children under two
years of age were examined for weight and length. The purpose of
this survey was to continue the nutritional status follow-up for
SCR986, in accordance with the Memorandum of Understanding
(MOU) under Food Items (No. 38).

Results pertain to 125 of the original 127 PHCs sampled in the

previous survey of April 1999; two have been excluded because they
are not involved in the previous survey for the matter of comparison.
The survey showed that 12% of the children under two years of age
were malnourished, according to WHO reference criteria of weight-
for-age, W/A<-2SD; 13.8% were stunted (i.e. had a low height-for-
age, reflecting chronic malnutrition) and 9.2% were wasted (low
weight-for-height, reflecting acute malnutrition).

In April 1997, a nutritional status survey in 87 Primary Health

Centers throughout South/Center Iraq during the three Polio National
Immunization Days (PNID) examined 15,466 children under five years
of age. Of those, 24.7% were underweight-for-age, but, at that time
the oil-for-food programme had not yet been established and it was
necessary to repeat the survey during the PNID in March 1998 after
one year of implementation of SCR 986.

The March 1998 survey showed little or no changes since 1997 -

underweight went from 24.7 to 22.8%, chronic malnutrition (stunting
or low height-for-age) from 27.5 to 26.7% and acute malnutrition
(wasting or low weight-for-height) from 9.0 to 9.1%.

The April 1999 survey similarly did not show any major changes
except a slight reduction in stunting.

5
 The current survey follows the same methods and provides
information on trends in the nutritional status of children below two
years of age.

2. METHODS
2.1.Sampling
The same 127 PHCs as in April 1999 from a total of 850 were
sampled, (73 urban and 54 rural). The first stage of sampling selected
the 15 governorates and the second stage selected PHCs within each
governorate. Seven PHCs were sampled from most governorates
except for Baghdad (16), Basrah and Ninewah (11), Thiqar and Babil
(8). The sampling frame consisted of larger PHCs, so that the
required numbers of children would be readily available and so that
sufficient staff and facilities could readily cope with both the routine
immunization and the nutrition assessment concurrently. In most
governorates, the urban sites were randomly selected. In rural areas,
the sample was usually taken from PHCs at District Headquarters.
Baghdad was an exception in that the 13 urban PHCs were sampled
so that each district was represented and the PHCs covered a wide
range of social strata.

A total of 50 children were assessed in each center, or 10 per day.

This allowed sufficient time to measure them accurately and not delay
the immunization session.

Children were selected in a systematic process, using a random

start, with each nth child measured upon showing up. The sampling
interval was determined from average attendance per day based on
the usual immunization sessions. Where more than one registration
desk operated, the sample was randomly taken from one of these
desks with the required sampling interval. In the current survey, the
sampling interval was between 2 and 3.

2.2.Planning and Preparation

For the matter of comparison with the previous surveys 1997-1998
,the health facility survey using the same criteria of inclusion of the
children had been used in this survey which involved an intensive
preparatory process of one to two weeks prior to the field work.
Agreements between UNICEF and the Ministry of Health were
finalized. Important aspects of the agreement included sharing of the
results and combined activities such as training, supervision and data
analysis.

6
2.3.Training
This was mostly retraining, as most of the personnel had received
prior training and had experience in one or several of the previous
surveys. Training of PHC governorate directors and MOH
programme staff as trainers, was conducted at the NRI (Nutrition
Research Institute, Ministry of Health). These directors trained their
governorate PHC staff using their own materials provided at NRI.

Training materials were both in Arabic and English - for the

questionnaire, field testing, reading and recording tests and diagrams
for the Uniscale (an electronic digital readout weighing scale) and the
height/length board. The training included demonstrations and
practice sessions under supervision followed by evaluation.

2.4.Measurements
The questionnaire included the child name, sex, date of birth
(year, month and day), age in months, weight and height, education
status of the mother, feeding pattern (exclusive breastfeeding, any
bottle feeding, when was milk and any solid or semi-solid food added).
Each child was weighed with a Uniscale to the nearest 0.1 kg and
measured for length to the nearest 0.1 cm. using a custom made
height-length board.

2.5.Field Work
Each Center had a team of four workers - one for weight, two for
height/length and the other one to ensure proper sampling,
measuring and recording of age.

2.6.Supervision
During the fieldwork, central and local supervision was conducted
by NRI, MOH, UNICEF and PHC departments in Directorates of
Health of each governorate. In general, their reports indicated that
the measurements were done satisfactorily and the procedures were
well organized. Most of the PHC staff and supervisors had also
worked during the previous surveys.

2.7.Data entry, editing and analysis

Data entry was completed at NRI. Analysis using Epi-Info
proceeded concurrently with editing on a case by case and PHC by
PHC review with close scrutiny of suspect measures. Methods
included lists, tabulations, distributions and graphics to determine
acceptable levels. Where possible, feedback was given to
governorates for explanations about suspect measures or results and
their control. Stricter criteria than usually recommended were
developed regarding data acceptance. The range for adverse
measures for weight and height-for-age is usually up to 6 standard

7
deviations (SD) of the reference WHO criteria. A level of 3 SD for
these W/A and we use a level of 3 SD for weight-for-height as the cut
off measure to indicate those above 3 SD.

2.8.Limitations of the study

In the present study (similarly in the earlier studies of Oct, 97
and Oct, 98 which were done on children attending immunization
clinics) malnutrition is likely to be underestimated since children who
do not come to immunization clinic are likely to be worse off
regarding proper care and feeding. In addition, sick children who are
again more likely to be malnourished excluded from the survey. A
community based household survey is more likely to give a
representative sample of the population. However in view of the
limitation of access to the community, the health institution based
study was carried out in this study.

3. RESULTS
3.1.Charecterestics of the population:
3.1.1. Age
The sample favored younger children. Those in the first year of life
contributed to 82.3% of the sample reflecting the age at
immunization. In the 1997 and 1998 surveys, the proportion of infants
was slightly lower.

3.1.2. Sex
The number of boys was 3,257 (50.8%) and 3,157 (49.2%) were of
girls. This distribution was similar to the previous surveys.

3.1.3. Urban/rural distribution

Urban children comprised 54.9% of the sample and the rural
children comprised 45.1% of the sample.

3.1.4. Literacy/Education of mothers:

About one-quarter (26.1%) of the mothers were illiterate, 42.5%
had attended primary school, 23% had attended secondary school and
8.3% had higher education. The percentage of illiterate mothers was
less than in the 1998 survey, and those with secondary education and
with higher education was slightly greater than in 1998 (Table 2).

8
Table 1: Mothers Education - 1999/1998

Education Nov. 99 April 99 April Oct.98** Oct.97**

* 98 *
% Illiterate 26.7 27.3 33.6 25.4 27.1

% Primary 42.1 39.5 39.4 40.9 42.2

% 22.9 24.4 20.3 26.3 22.9
Secondary
% Higher 8.3 8.8 6.7 7.4 7.8
TOTAL 6,414 13,572 12,877 3,727 3,257
*=U5 children Surveys /Mothers education not assessed in
1996 .
**=U1 children surveys

50
40 % Illiterate
30 % Primary
20 % Secondary
10 % Higher
0
*

*
99

8*

7*
98
99

t.9

t.9
v.
No

ril

ril

Oc

Oc
Ap

Ap

Illiteracy was higher in rural as compared with urban areas (30%

vs. 26%) and higher education less frequent (rural 5% versus urban
11%). Mothers with children under two were younger than all women
of child bearing age, hence the illiteracy rate in this sample is
probably less (according to the 1987 census, 34.5% women were
illiterate).

9
 3.1.5. Feeding pattern among infants

40.8% infants are exclusively breast fed

47% receive breast milk plus infant formula
12.2% receive only infant formula

Altogether, 87.8 % infants receive breast milk in the

last 24-hour before the survey.
Table 2: Feeding pattern in infants
Feeding pattern <6 months >6 months
Exclusive breast 60.4 % 8.6 %
feeding
Mixed feeding 32.2 % 71.3 %
Bottle feeding 7.4 % 20.1 %

BF rate found to be 92.6% in those below 6 months and 79.9%.

in those above 6 months of age. The prevalence of breast-feeding was
slightly higher in rural areas.

Table 3 Feeding pattern in urban and rural areas

Area Exclusive Mixed feeding Bottle feeding

breast feeding
Urban 37.7 % 48.4% 13.9 %
Rural 44.5% 45.2 % 10.2%

3.2. Nutritional Status

3.2.1.Prevalence of malnutrition, General malnutrition
(weight/age)

Degree of malnutrition %
-1 SD 19.7
-2 SD 9.7
-3 SD 2.3
normal(>median) 68.3

3.2.2.Chronic malnutrition or stunting (height/age)

10
Degree of malnutrition %
-1 SD 20.4
-2 SD 8.7
-3 SD 5.1
normal 65.1

3.2.3.Acute malnutrition or wasting (weight/height)

Degree of malnutrition %
-1 SD 13.8
-2 SD 6.6
-3 SD 2.6
normal 77

3.2.4.Nutritional status by urban/rural residence

Like the prior surveys in March 1998 (and in 1997), there was little or
no difference in nutritional status by urban/rural location.

Table 4: Malnutrition in urban and rural areas

1999 1998
MALNUTRITION TYPE % %
Urban Rural Urban
Rural
General malnutrition 20.9 21.9 22.1 24.4
(Underweight)
Chronic malnutrition 19.6 21.7 25.4 29.5
(Stunting)
Acute malnutrition 9.9 8.6 8.8 9.7
(Wasting)
Sample (underweight) 13730 13892

3.2.5. Nutritional status by feeding pattern

W/A and W/H in Under 6 months

11
Altogether 92.6% babies are breast-fed. More than 7% were not on
breast feeding. Among these 92.6 %, only 60.7% are exclusively
breast fed when this should be the rule before 6 months.
Table 5: Breastfeeding in infants
Feeding pattern % W/A < -2SD W/H < -2SD
Exclusive BF 60.7 7.5 6.8
Mixed feeding 31.9 14.7 10.3
Bottle feeding 7.4 14.4 10.1

NUTRITION STATUS BY FEEDING PATTERN

W/A and W/H in <6 months

70
60
50
40 Exclusive BF
30 Mixed feeding
20 Bottle feeding

10
0
% W/A < -2SD W/H < -2SD

One can see that underweight almost doubles in non-breastfed

infants and wasting also rises significantly. This result is similar for
mixed feeding and bottle-feeding. This most likely shows the impact of
increased infections linked to the use of the bottle.

The results in infants under 1-month show that the degree of

malnutrition increases if the baby is on mixed feeding or artificial
feeding.

Table 6: Prevalence of malnutrition with type of feeding

Type Of Feeding W/A W/A <-2SD W/A <-3SD

-1SD
Exclusive BF 13% 5.7% 0.5%
Mixed feeding 16% 6.1% 1.8%
Artificial feeding 8.2% 9.5% 2.4%

12
 PREVALANCE OF MALNUTRITION BY TYPE OF FEEDING

16%
14%
12%
10% Exclusive BF
8%
Mixed feeding
6%
4% Artificial
2% feeding
0%
W/A - W/A <- W/A <-
1SD 2SD 3SD

3.2.6.Percentage of malnutrition according to SEX

Malnutrition type Male Female

General malnutrition 51.4 48.6
(Underweight)
Chronic malnutrition (Stunting) 51.6 48.4
Acute malnutrition (Wasting) 51.4 48.6
MALNUTRITION BY SEX

52
51
General m alnutrition
50 (Underw eight)
49 Chronic m alnutrition (Stunting)
48
Acute m alnutrition (Wasting)
47
46
Male Fem ale

13
 Theres no statistical difference in the percentage of
malnutrition according to sex difference. The 1997-1998 nutrition
status surveys conducted earlier showed similar findings.

Nutritional status by age

The sharp rise in underweight after 6 months can be explained
by several factors like the higher prevalence of infectious diseases
especially when breast feeding is discontinued, the discontinuation or
reduction of maternal milk especially in families who cannot afford
adequate amounts of cow milk/formula and do not practice hygienic
preparation, the lack of additional foods in most children.

As for stunting, 16.1% of infants <1 month are already stunted. This
is in relation with intrauterine growth failure and can improve only
with better health and nutrition of women during and before
pregnancy.

Table 7: Nutritional status of children by age

Type of < 1 month 0-6 6-12 12-24

Malnutrition months months months
Underweight 7.7 7.2 19.1 31.2
%
Wasting % 5.4 7.3 11.2 13.5
Stunting % 16.1 12 16.5 26.5

Malnutrition by Age

35
30
25
Underweight %
20
Wasting %
15
Stunting %
10
5
0
< 1 month 0-6 months 6-12 months 12-24
months

14
Table 8: Comparison of the results of the present and the
previous surveys (same age group):

Type of 1997 1998 1999

malnutrition Apri Oct March Oct April Nov
l
General 14.7 14.6 13.2 14.7 14.1 12
(underweight)
Chronic (stunting) 15.3 12.2 16.2 11.7 12.8 13.8
Acute (wasting) 9 7.5 8.3 8.2 9 9.2

There is a slight reduction in the prevalence of underweight

while stunting and wasting have stabilized at unacceptably high rates
of 13.8% and 9.2 % respectively. This represent the continuing
cumulative deterioration in child growth and development, caused by
adverse economic conditions, poor health, inadequate feeding and
lack of proper care.

4. CONSEQUENCES OF MALNUTRITION
Acute malnutrition (wasting) puts an immediate threat on survival and
sharply increases mortality. Chronic malnutrition has a more insidious
and long-standing impact:
By depressing the immune function, malnutrition increases the incidence
of infectious diseases, the duration of illnesses and the case-fatality rate.
Stunting reduces physical growth and adult height
Malnutrition reduces the growth of the brain and its proper functioning,
leading to reduced academic performances, professional achievements
and psychological resilience.

Trends in child mortality since 1984: The high rate of malnutrition

is one of the main contributor to increase the neonatal, infant and
child mortality which has been reflected in various surveys in the
country.

Table 9: Trends in child mortality In Iraq

15
DEATHS/1000 LIVE BIRTHS YEARS 84- 89-94 94-99
89
Neonatal mortality 32 48 66
IMR 47 79 108
<5MR 56 92 131
Source: UNICEF/MOH study,1999

Decrease in breastfeeding and increase of formula and bottle-

feeding
Although the overall situation calls for promotion of
breastfeeding, the inclusion of infant milk substitutes in the ration led
many mothers to complement breast feeding or even stop it and use
formula instead, most often with a bottle. The belief that formula is
superior to human milk seems widespread. Overall, it appears that
the inclusion of formula adversely affects breastfeeding and is
harmful especially when general hygiene sanitation is poor, water
availability is low, time available with the care provider less and
fuel/electricity available has gone down.

5. RECOMMENDATIONS

General recommendations on Food Ration

5.1. Increase the quantity and quality of food allocated in the

ration.
The food basket target of 2,463 kilocalories and 63.6 grams of
protein per person per day was recommended, with a view to meeting
the immediate nutritional needs of the Iraqi population in the UN
Secretary Generals report (S/2000/208 dated 10/03/2000) to the
security council needs to be implemented.

5.2. Appropriate Complementary Foods: The formula should be

replaced with an increase in complementary food for children above 6
months of age. It would be advisable to teach mothers how to prepare
nutritious weaning mixes from the various ingredients of the ration
and add vegetables and/or fruit in whatever amount these are
available.

16
5.3. Prevention of malnutrition and promotion of proper
nutrition practice:
In a situation of high prevalence of malnutrition it is very
important to educate mothers to take appropriate measures to
prevent malnutrition before it sets in. This will require strengthening
the package of preventive eduction in the targeted nutrition
programme. The health workers and the community volunteers need
to be trained on this and provided with adequate health education
material. The areas which need to be stressed are exclusive
breastfeeding for six months and appropriate (both in quantity and
quality) and timely introduction of complementary feeding.
5.4. Nutrition Rehabilitation of malnourished children:
The therapeutic milk under MOU has been ordered and should soon
be available. Once it is available and distributed through the PHC
/ORT corners and NRCs this will address the moderate/severe cases
of malnutrition on an in patient and ambulatory bases. There is an
urgent need to operationalize these centers as soon as possible.
5.5. Care for pregnant and lactating mothers:
The pregnant and lactating women also receive HPB. This also acts as
an incentive to attract women to ANC and get the various benefits
included, TT shots, iron and folic acid supplements, fetal growth
monitoring, screening of pregnancies needing special care etc This
measure has a positive impact on maternal and newborn health. This
distribution needs to be coupled with a strong educational component
both on pregnancy-related issues and on nutritional care of the baby.
5.6. Community Education:
This component needs to be strengthened through all available
channels like health and nutrition education of mothers and
community at all contacts through CCCUs, Primary Healthy Care
Centers, Hospitals etc. and use of mass media to educate the
community.

Emphasis in community education must be on:

1. Exclusive Breastfeeding for 6 months and to avoid early
supplements, bottle, unclean water etc..
2. Maintenance of breastfeeding along with complementary
feeding when the child is sick and additional feeding for one week
after child recovers.
3. Complementary Feeding: Introduction of nutritious foods i.e.
high caloric, protein and micronutrient content for a low volume.
Add a little oil to the weaning food to increase the caloric value.
Add new items, one at a time such as mashed pulses, egg yolk,
meat etc. as often as one can afford.
Give vegetable or fruit or both to complementary foods.

17
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