The Baghdad Child Nutrition and Mortality Survey

The 1995 Baghdad nutrition and mortality survey of children under-five years of age, conducted between August 23 to 28, was a collaborative effort between the FAO Mission and the Nutrition Research Institute (NRI), part of the Ministry of Health. Mission members were responsible for the methodology, including the selection of the sample. In the field, interviews were conducted by NRI staff supervised by FAO Mission members, a UNICEF member and physicians from the NRI. Data were inputed in Epi-Info primarily by NRI staff with assistance from Mission members. Once data entry was completed the data were checked by Mission members and duplicate records were removed. A total of 693 households were visited and 768 mothers interviewed. Information was collected on 2,120 children under 10 years of age. A total of 594 children under-five years of age were measured for anthropometry, with measurements on 184 children from the eight clusters in Saddam City that had been surveyed in 1993 by the previous FAO Mission.

Methods

Selection of clusters for the 1995 Baghdad survey was based upon a random cluster sampling design taken from the nationwide survey of infant and child mortality and nutritional status conducted in 1991. In that survey the number of clusters for each governorate was determined by the population size of the governorate according to the 1987 census. Seventy-three clusters were selected for Baghdad for the 1991 survey. The distribution of clusters within Baghdad was determined by the population size of each district using the 1987 census, representative of the city. Within each district the clusters for the 1995 survey were selected randomly from the 1991 clusters using a random number generator (EPI-INFO, version 6).

The minimum number of clusters required for the 1995 survey was determined to be 25, making the conservative assumption that for 24 contiguous households selected from each cluster between 1–2 children under the age of 10 would be living in each household on average. The assumptions for the sample size for nutritional anthropometry (n = 420) were as follows: a baseline prevalence of wasting of 3.1% (from 1991 estimates from Baghdad); a 2.5-fold increase in wasting observed in 1995; power of 80%; and an alpha level of .05.

The weight of children between ages 1 and 5 years was ascertained using a calibrated hanging scale to the nearest 0.1 kg. Height was measured to the nearest 0.1 cm, using either a length board (for children under age two) or a height board. Infants under the age of one were measured using an infant scale. Children were measured wearing loose clothing and without shoes. Age was determined primarily through registration cards. Surveyors were from the Nutritional Research Institute (NRI).

Percentiles and Z-scores for height-for-age (stunted), weight-for- age (underweight) and weight-for-height (wasted) were calculated using EPI-Info, version 6. Malnutrition was defined as the percentage of children less than -2 standard deviations (SD) below the median values for the NCHS (United States National Centre for Health Statistics) standardized distributions for the indicators: stunted, underweight and wasted. The criteria for exclusion of observations were:

1. Extreme outlier, defined as values of Z-scores:

a. less than -4 SD or greater than 6 SD for weight-for-height;

b. less than -6 SD or greater than 6 SD for weight-for-age and height-for-age;

2. Age equal to or greater than 60 months.

Anthropometric indicators (stunted, underweight and wasted) are presented for Baghdad and for the 8 clusters in Saddam City examined in 1993. In addition, anthropometric indicators were stratified for the overall sample by the following characteristics: child age (1 year intervals), maternal education, point prevalence of diarrhoea (defined as 3 loose stools within 24 hours during the past 2 days) and gender. Infant and child mortality estimates are reported comparing pre and post economic sanctions. Effect modification by maternal education in relation to infant and child mortality is also examined.

Results

The percentage of children below -2 SD in the 8 clusters of Saddam City was 25% for stunting, 22% for underweight and 7% for wasting. In the overall sample (25 clusters) for Baghdad, 28% of children were stunted, 29% were underweight and 12% were wasted (Table 26). Severe malnutrition, defined as the percentage of children below -3 SD, was noted among children: 10% for stunted, 7% for underweight and 3% for wasted. Mild malnutrition, the percentage of children below -1 SD, was: 56% for height-for-age, 65% for weight-for-age, and 39% for weight-for-height for the city of Baghdad.

Table 27 presents the prevalence of anthropometric indicators for malnutrition by child age, maternal education and diarrhoeal disease. No significant gender differences were noted in this population. However, certain districts within Baghdad demonstrated higher prevalence estimates of underweight in central part of the city, in neighbourhoods of Rasafah, Karrada and New Baghdad. For wasting higher prevalences were noted in Karkh and New Baghdad.

Table 28 reports results from the mortality analysis. Infant and child mortality prior to the institution of economic sanctions (August 1990) was compared to the mortality rates for the year prior to the interview (September 1994 to August 1995). Infant mortality had increased approximately two fold compared with the year prior to the intitiation of econonic sanctions. Further analysis indicates a two fold increase in infant mortality during the first year of economic sanctions which included the Gulf War (August 1990 to September 1991). This two fold increase in infant mortality has been sustained since 1990 until the present. Child mortality had increased nearly five fold, comparing the rate prior to the economic sanctions with the rate observed during the past five years. Table 29 stratifies infant and child mortality rates by maternal education. The effect of the sanctions on infant and child mortality is most pronounced among children of illiterate mothers. Infant mortality increased about 3.6 times and child mortality increased 8.5 times compared with pre-sanction estimates for this sub group.

Discussion

Nutritional status of Iraqi children before the Gulf war and sanctions was similar to children in Kuwait. Since 1991, shortly after the inception of the sanctions, the nutritional status of children in Baghdad has significantly deteriorated. Compared with 1991 estimates, the current survey demonstrates a 4-fold increase in wasting for the city of Baghdad. Prevalence estimates for stunting and underweight have also risen dramatically .

For the Saddam City district of Baghdad, there appears to be a modest reduction in the prevalence of wasting compared with the FAO mission report from 1993 that reported a wasting prevalence of 16 per cent. There are several reasons for observed changes in level of wasting which is acutely sensitive to external factors. Since the 1993 survey was conducted in November and the current study was conducted in August, seasonal variation may in part explain the observed reduction in prevalence. Differential child mortality may also explain the lower prevalence of wasting observed in Saddam City in 1995 if severely wasted children were more likely to die in 1995 than in 1993 due to deteriorating conditions. In addition, this population may be better able to cope with adversity since there are more economic options such as begging or peddling goods which were not available in 1993. The Mission noticed that fewer male members were at home during the current survey as compared to the 1993 survey.

For Baghdad overall, the prevalence of underweight children (29%) has increased to a level comparable with children from Ghana (27%) and Mali (31%). For stunting, prevalence rates are similar to estimates from Sri Lanka (28%) and the Congo (27%). The prevalence of wasting in Baghdad is comparable with estimates from Madagascar (12%) and Burma (11%). The prevalence of severe wasting is comparable to data from northern Sudan (2.3%). In contrast, 1991 estimates of malnutrition from Baghdad are comparable with estimates from Kuwait (12% for stunting, 6% for underweight, and 3% for wasting).

The current nutritional situation among children in Baghdad is more similar to lesser developed countries with a larger percentage of the population residing in rural settings which may be a reflection of the inability to maintain systems for sanitation and clean water under sanctions. The observed increase in under five mortality may also be related to the sanitation/water problem in Baghdad, where the occurrence of diarrhoea-related deaths has increased nearly threefold compared to the time period prior to the sanctions. Due to the increasing problem of food insecurity and the inability to repair the infrastructure for provision of sanitation and potable water, the nutritional status of children in Baghdad will continue to deteriorate unless appropriate measures are taken to secure food and to provide a safe environment. The Mission recommends that a nation-wide nutritional surveillance system be put into place immediately in light of the poor nutritional status of children in Baghdad in order prevent the further deterioration of the nutritional status and mortality of children under five years of age in Iraq. Moreover, it should be noted that the nutritional status of children in southern Iraq and North is likely to be even worse than reported in Baghdad.

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