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 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.

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 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

3
 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.

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

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2.1.Sampling
The same 127 PHC’s 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 PHC’s within each governorate. Seven PHC’s were sampled from
most governorates except for Baghdad (16), Basrah and Ninewah (11), Thiqar and Babil
(8). The sampling frame consisted of larger PHC’s, 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 PHC’s at District Headquarters. Baghdad was an exception in that the
13 urban PHC’s were sampled so that each district was represented and the PHC’s
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 n th
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.

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

5
(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 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

6
 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).

Table 1: Mother’s Education - 1999/1998

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

% Illiterate 26.7 27.3 33.6 25.4 27.1

% Primary 42.1 39.5 39.4 40.9 42.2

% Secondary 22.9 24.4 20.3 26.3 22.9
% 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 /Mother’s education not assessed in 1996 .
**=U1 children surveys

7
50
40 % Illiterate
30 % Primary
20 % Secondary
10 % Higher
0

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).

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 feeding 60.4 % 8.6 %
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.

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 Table 3 Feeding pattern in urban and rural areas

Area Exclusive breast Mixed feeding Bottle feeding

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)

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.

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Table 4: Malnutrition in urban and rural areas

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

3.2.5. Nutritional status by feeding pattern

W/A and W/H in Under 6 months

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

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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 -1SD W/A <-2SD W/A <-3SD

Exclusive BF 13% 5.7% 0.5%

Mixed feeding 16% 6.1% 1.8%
Artificial feeding 8.2% 9.5% 2.4%

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

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3.2.6.Percentage of malnutrition according to SEX

Malnutrition type Male Female

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

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

There’s 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 months 6-12 months 12-24 months

Malnutrition
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

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 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

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

Type of malnutrition 1997 1998 1999

April Oct March Oct April Nov
General (underweight) 14.7 14.6 13.2 14.7 14.1 12
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

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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

DEATHS/1000 LIVE BIRTHS YEARS 84-89 89-94 94-99

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 General’s report (S/2000/208 dated 10/03/2000) to
the security council needs to be implemented.

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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.

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.

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