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[casi] Iraq letters -- Observer

Just a reminder --

The observer likes you to put 'Letter to the Editor' in the subject field of
emailed letters.

Also, a quote from the Lancet that might be useful (Sweeney implies that the
Lancet rubbished UNICEF's mortality survey).
Lancet Volume 355, Number 9218 27 May 2000
"Assessment of data quality...
The quality of data was undertaken by an independent panel which reviewed
both the procedures used and the quality of various aspects of data. No
problems were detected. "

Full text of EXACTLY what they said about it is pasted below for those who
are interested. (the tables don't come out well in plain text, but there is
plenty of useful information.)




 Articles Volume 355, Number 9218 27 May 2000

  Sanctions and childhood mortality in Iraq

Lancet 2000; 355: 1851 - 1857 Download PDF (120 Kb)
Mohamed M Ali, Iqbal H Shah

Department of Epidemiology and Population Health, London School of Hygiene
and Tropical Medicine, University of London, UK (M M Ali MSc); and World
Bank Special Programme of Research, Development and Research Training in
Human Reproduction, Department of Reproductive Health and Research, World
Health Organization, Geneva, Switzerland (I H Shah PhD)

Correspondence to: Mohamed M Ali, Centre for Population Studies, London
School of Hygiene and Tropical Medicine, 49-51 Bedford Square, London WC1B
3DP, UK (e-mail:

Assessment of data quality


Background In 1999 UNICEF, in cooperation with the government of Iraq and
the local authorities in the "autonomous" (northern Kurdish) region,
conducted two similar surveys to provide regionally representative and
reliable estimates of child mortality (the subject of this paper) and
maternal mortality.
Methods In a cross-sectional household survey in the south/centre of Iraq in
February and March, 1999, 23 105 ever-married women aged 15-49 years living
in sampled households were interviewed by trained interviewers with a
structured questionnaire that was developed using the Demographic and Health
Surveys questionnaire and following a pre-test. In a similar survey in the
autonomous region in April and May 14 035 ever-married women age 15-49 were

Findings In the south/centre, infant and under-5 mortality increased during
the 10 years before the survey, which roughly corresponds to the period
following the Gulf conflict and the start of the United Nations sanctions.
Infant mortality rose from 47 per 1000 live births during 1984-89 to 108 per
1000 in 1994-99, and under-5 mortality rose from 56 to 131 per 1000 live
births. In the autonomous region during the same period, infant mortality
declined from 64 to 59 per 1000 and under-5 mortality fell from 80 to 72 per
1000. Childhood mortality was higher among children born in rural areas,
children born to women with no education, and in boys, and these
differentials were broadly similar in the two regions.
Interpretation Childhood mortality clearly increased after the Gulf conflict
and under UN sanctions in the south/centre of Iraq, but in the autonomous
region since the start of the Oil-for-Food Programme childhood mortality has
begun to decline. Better food and resource allocation to the autonomous
region contributed to the continued gains in lower mortality, whereas the
situation in the south/centre deteriorated despite the high level of
literacy in that region.
Lancet 2000; 355: 1851-57
See Editorial


During the past 20 years Iraq has witnessed spectacular social and economic
development, followed by a dramatic decline. The per capita gross domestic
product (GDP), for example, was estimated at US$3510 in 1989, but only
US$450 in 1996.1 This was primarily due to an 85% reduction in oil
production and the devastation of industrial and service sectors of the
economy.2 Before 1991, much progress has been made in building roads and
infrastructure as well as improving human skills by expansion of education
and advanced training. During the same period, healthcare reached about 97%
of the urban and 79% of rural population.3 The healthcare system was based
on an extensive and expanding network of health facilities linked up by
reliable modes of transport and communications. The country had a
well-developed water and sanitation system and 90% of the population was
estimated to have access to safe drinking water.4 Infant mortality fell from
71 per 1000 live births in 1965 to 29 per 1000 in 1989 while under-5
mortality declined from 111 to 44 per 1000 live births.5,6
These gains were stopped with the start of the Gulf conflict. Trade
sanctions were imposed against Iraq in August, 1990. The war started on Jan
16, 1991, and a ceasefire was declared after 6 weeks. After the Gulf War,
the autonomous region of Iraq, inhabited mainly by Kurds, was placed under
United Nations administration and sanctions were strictly enforced against
Child mortality is a critical measure of the wellbeing of children and a
good proxy indicator of the overall level of development. Immediately after
the Gulf conflict an international study team did an extensive Iraq-wide
mortality and nutrition survey7 and found a three-fold increase in under-5
mortality from 1985 to the first half of 1991.8 However, since 1991 there
has been no countrywide child-mortality survey, and the mortality levels
have been the source of considerable speculation and debate. Recent
malnutrition surveys in Iraq have, however, shown that the prevalence of
underweight under-5 children has increased two-fold since 1991--ie, from 12%
to 23%.9 Since an increase in malnutrition is usually associated with
increased childhood mortality, it is likely that mortality has also

Figure 1: Map of Iraq

The United Nation Children's Fund (UNICEF), in partnership with the
Government of Iraq and the local authorities in Al-Suleimaniyah, Dohouk, and
Erbil (figure 1), did two parallel regionally representative household
surveys in the south/centre and autonomous governorates of Iraq. The main
purpose was to measure the levels, trends, and differentials in childhood
and maternal mortality. Given the controversy surrounding previous
studies,10,11 considerable care was taken in the design and implementation
of these two surveys so that they could yield regionally representative and
reliable estimates. Although data were not collected on the direct causes of
childhood mortality, trends should throw light on the impact of a
deteriorating economic and health situation in Iraq, following the Gulf War.
The maternal mortality survey will be reported elsewhere.


Survey design

The two surveys were designed to provide estimates of overall childhood
mortality rates by key socioeconomic and demographic characteristics of
respondents. Samples of 24000 households for the south/centre and of 16000
households for the Autonomous region were deemed necessary to estimate
reliably the child mortality indices. The 1997 census, which covered only
the south/centre, and the 1997 Directorate of Reconstruction and Development
(DRD)/UNICEF survey, which covered the three autonomous governorates, were
used as the sampling frame.

A three-stage, stratified, self-weighting sampling design was used over all
79 districts in the south/centre and all 23 districts in the autonomous
region. The sampling frame provided a complete listing of enumeration areas
together with estimates of population size needed for the selection of the
first two sampling stages.

The sample design called for the selection of all districts, and then the
use of a three-stage stratified design in each district (Qada'a). In the
first stage, two subdistricts (Nahiya) from each district were selected by
using probability proportion-to-size (PPS). Subdistricts were stratified
into urban and rural parts and divided into clusters (Majal) of households.
At the second stage, clusters were selected systematically with PPS from
each urban and rural stratum separately. The PPS procedure was based on the
numbers of households in each cluster recorded in 1997.

Within each selected cluster, 15 households were selected from the address
list created by the sampling frame by systematic random sampling. All
ever-married women aged 15-49 years, identified during the household
interview, were selected for individual interview, using a structured

Questionnaire design and pre-test

The questionnaire was designed to collect data on child and maternal
mortality, and little additional information was sought from respondents
beyond that needed to derive the mortality estimates. The questionnaire drew
upon the worldwide experience of measuring childhood and maternal mortality
from household surveys, by using relevant parts of the Demographic and
Health Surveys (DHS) core questionnaire12 and was pre-tested. Note that the
DHS programme has been doing household cross-sectional surveys since 1985,
providing information from more than 50 developing countries, on family
planning, maternal and child health, child survival, AIDS and
sexually-transmitted diseases, and reproductive health.

Training and fieldwork

Both supervisors and interviewers were trained, using material from the DHS
and the Gulf Child Health Survey of Iraq, 1989.6 Survey staff were recruited
from the health sector. Supervisors were senior medical officers, and
interviewers were recent graduates from medical schools or junior doctors.
Fieldwork was done between February and March, 1999, in the south/centre and
between April and May, 1999, in the autonomous region.

In the south/centre 186 staff, including 16 governorate supervisors and 170
interviewers were responsible for data collection. More than 50% of the
supervisors and team leaders, and all interviewers were women. In the
autonomous region there were 37 supervisors and team leaders; of the 168
interviewers, 80% were women. Considerable care was taken to achieve a good
coverage and high quality data. Team leaders were responsible for ensuring
that all sample households were contacted, all eligible women interviewed,
and responses completed for all relevant mortality questions. If
inconsistencies were found the interviewer was asked to resolve them, going
back to the household, if necessary. The supervisor again checked sample
household coverage and also did checks on the internal consistency of
responses. To monitor any changes to the responses in the original
questionnaire, the interviewers had to enter responses in ballpoint pen, so
that any subsequent change would be obvious. Any such change had to be
initialled by the field staff person making the change. Editing and checking
was done at the central level (Baghdad) for completeness and consistency.
Data were available at the UNICEF office where most of the work on data
editing, checking, and analysis was done.


Similar to the approach used in DHS,13 childhood mortality estimates
presented in this paper are based on the information provided in the birth
history section of the questionnaire. Questions on the number of sons and
daughters living with the mother, the number who live elsewhere, and the
number who have died were asked first. These questions were then followed by
a retrospective birth history in which the respondent was asked to list each
of her live births, beginning with the first one. Information was collected
in the birth history on the sex, month, and year of birth, survivorship
status, and current age or age at death for each live birth. Synthetic
cohorts were created from the information in the birth history on the
child's date of birth, survivorship status and the reported age at death or
current age. Life-table method was then used to estimate the mortality
rates. Standard errors were estimated using Greenwood's formula14 and were
adjusted for the design effect using jack-knife repeated replications.15

The following rates were derived: infant mortality rate (IMR)--the
cumulative probability of dying between birth and exact age 1 year per 1000
live births; under-5 mortality rate (U5MR)--the cumulative probability of
dying between birth and exact age 5 years per 1000 live births.

The relative risk of dying by age 1 year and by age 5 years were estimated
by logistic regression models for survey data that take into account the
survey design (stratification and clustering) in the estimation of the
relative risks and their standard errors.

Assessment of data quality

Achieving high quality data was a primary goal and several steps were taken
to ensure that the data collected would yield reliable estimates of
childhood mortality. Age misreporting, selective omission of births and/or
deaths by time period, age or sex and errors in timing of births or deaths
are especially important. The quality of data was undertaken by an
independent panel which reviewed both the procedures used and the quality of
various aspects of data. No problems were detected.

Age reporting

Many surveys show that respondents tend to report ages, which are multiple
of five or sometimes of two. However, in these surveys in Iraq the
distribution of respondent's current age showed no clustering of multiples
of five or two; nor did the distribution of all live births, last birth, and
first birth (aged 0-119 months).
Omission of live births

A commonly observed error in survey data, is the omission of children ever
born or those who died, resulting in decreases in parity or decreases in the
proportion dead in the oldest age-group. Because the births to older women
involve an extended recall period and that their infant or children might
have had excessive mortality making it difficult to remember the number of
all births. However, no such pattern in average parity by age was noted. The
selective omission of births and deaths, by age of women, was evaluated for
omission of live births or by deaths. The distribution of births by calendar
years for living, dead, and all children, by sex ratio at birth, and ratio
of births by calendar year were examined. The result showed no systematic
omission of children of a particular sex or of deaths of boys or girls by
calendar period.

Displacement of live births

More serious errors in timing lie in the systematic displacement of birth
dates by the mother nearer to, or further from, the time of the survey.
Systematic errors in dating births have a characteristics pattern,
concentrating births in the period 5-14 years before the survey, and perhaps
even from the most recent 5-year period. To search for a distortion of this
sort, consistency checks were made, including a simple assessment of births
and deaths by period.

Birth history

A retrospective birth history is susceptible to several possible data
collection errors. First, only surviving ever-married women of ages 15-49
were interviewed; therefore, no data were available for children of women
who died. The resulting mortality estimates will be biased if the fertility
of surviving women and non-surviving women differs substantially. The extent
of this bias is not known but is not considered to be a serious source of

Another problem concerns the fact that the mortality estimates are based
only on those births reported by ever-married women of reproductive age at a
given point in time (ie, the time of the survey) and these are truncated
because women older than 49 years are not interviewed. As this time period
extends, the resulting censoring of information becomes progressively more
severe, and the high rates of childhood mortality are usually associated
with more advanced maternal age. Therefore, results presented for more than
15 years before the survey should be interpreted with caution. However,
child mortality rates more than 15 years before the survey were compared
with published results from surveys done in the 70s and the 80s,5,6,16 and
the two rates were very similar, reassuring the quality of survey data.

The Brass method of indirectly estimating child mortality18 is commonly used
to check the quality of data and for comparison with estimates derived from
life-tables. This approach, which is based on the number of children ever
born and children died by duration of marriage, was also applied. The
indirect estimates of infant, and under-5 mortality rates were identical to
the direct estimates derived from the birth history.


The intensive field supervision, household call-backs, short questionnaire,
and well-organised training and field operations all contributed to a
successful implementation and high coverage of the two surveys. In the
south/centre, of 23 978 sampled households, 23920 (998%) were successfully
covered, 21 048 had at least one ever-married woman age 15-49 years, and all
these eligible respondents were interviewed, resulting in 23 105 completed
questionnaires. In the autonomous region 15942 (966%) households were
successfully covered of 16499 sampled. 13109 had at least one eligible
respondent yielding 14 035 completed questionnaires.

Background characteristics of respondents

14943 (647%) of the 23105 women interviewed in the south/centre and 11807
(841%) of the 14035 women in the autonomous region were living in urban
areas at the time of the survey (table 1). Most (930% in the south/centre
and 940% in the autonomous region) of the ever-married women were currently
married. As is typical in the middle east region, a high proportion (610%)
of women were married to a cousin or other relative in the south/centre, but
less than half in the autonomous region. In the south/centre, about
one-third of the respondents never attended school, less than half (48%) had
some primary education, and 22% had more than primary education. In the
autonomous region, more than half of the respondents never attended school,
around one-third had some primary education, and only 1656 (12%) had more
than primary education. The mean numbers of children ever born was 43
children per ever-married women in the south/centre and 46 in the
autonomous region.

  South/centre  Autonomous region
  n (%) n (%)
Place of residence
Urban  14943 (647) 11807 (841)
Rural  8162 (353) 2228 (159)
Regions of South/centre
North  3401 (147)
Middle  10947 (474)
Middle Euphrates  4541 (197)
South  4216 (182)
Autonomous governorates
Erbil   4839 (345)
Dohouk   3500 (249)
Al-Suleimaniyah   5696 (406)
Current age (years)
15-19  1379 (60) 909 (65)
20-24  3582 (155) 2386 (170)
25-29  4798 (208) 2966 (211)
30-34  4323 (187) 2338 (167)
35-39  3598 (156) 1944 (139)
40-44  2895 (125) 1919 (137)
45-49  2530 (110) 1573 (112)
Relation to last/current husband
 Cousin 8666 (375) 3524 (251)
 Other relative 5351 (232) 3083 (220)
 Not related 9088 (393) 7428 (529)
 No education 6811 (295) 8026 (572)
Primary*  11140 (482) 4353 (310)
Intermediate or higher  5154 (223) 1656 (118)
Total  23105 (1000) 14035 (1000)
*Includes respondents with no certificates.
Table 1: Distribution of respondents by background characteristics and

Childhood mortality rates

Table 2 shows the number of children born and the number who died at age 1
and age 1-5 years for different 5-year periods before the survey, by region.
The table shows that most deaths happen in the first year of life (85% in
south/centre and 80% in autonomous region).

 South/centre   Autonomous region
 Number born Number died  Number born Number died
  <1 year 1-5 years  <1 year 1-5 years
1994-99 27194 2852 366 15061 798 90
1989-94 25750 2135 443 14992 1061 240
1984-89 19003 869 193 13559 861 223
1979-84 14416 742 163 10496 771 235
1974-79 8665 469 108 6506 686 271
Table 2: Birth and deaths before age 1 year and between 1 and 5 years

The infant mortality rate (IMR) and the under-5 mortality rate were
estimated for 5-year periods before the survey (figure 2). In the
south-centre, both IMR and under-5 mortality rate consistently show a major
increase in mortality over the 10 years preceding the survey (which roughly
corresponds to the period following the Gulf conflict). The IMR more than
doubled from 47 (95% CI 44-50) for the period roughly equal to 1984-89 to
108 (104-112) deaths per 1000 live births for the period roughly equal to
1994-99. Note that by 1984-89, the IMR in the south/centre had declined from
57 (52-62) deaths per 1000 live births during the period roughly
corresponding to 1974-79. The IMR was, however, never as high in the
previous years as in the 5 years just before the survey. Under-5 mortality
rate also increased during the same time from 56 (52-58) to 131 (127-135)
deaths per 1000 livebirths. In a short span of 10 years following the Gulf
conflict, childhood mortality in the south/centre thus increased more than
two-fold and to levels above those of 20-24 years previously.

FIgure 2: Infant mortality rates (top) and under-5 mortality rates (bottom)
by 5-year period preceding the survey

A different picture, however, emerges for the autonomous region. During the
same period, both the infant and the under-5 mortality rate fell, although a
rise was witnessed for 1989-94 (5-9 years preceding the survey). More
specifically, IMR declined from 64 (60-68) in 1984-89 to 59 (55-63) deaths
per 1000 live births in 1994-99 and the under-5 mortality rate dropped
during the same period from 80 (75-85) deaths to 72 (68-76) deaths per 1000
live births. Unlike the pattern in the south/centre, childhood mortality
rates declined in the autonomous region to rates nearly half those that
existed 20-24 years ago.

Differentials in childhood mortality

Differentials in childhood mortality are commonly used in documenting
socioeconomic, demographic and environmental disparities. Table 3 shows IMR
and under-5 mortality with their 95% CIs, for the most recent 10-year period
(1989-99), by place and region of residence, mother's education, mother's
age at birth, relation to husband, and sex of child. In the last 10 years
before the survey, the overall IMR and under-5 mortality are significantly
higher in the south/centre than in the autonomous region, with 47%
difference in IMR and about 42% in under-5 mortality rate.

 IMR  Under-5 mortality rate
 South/centre rate (95% CI) Autonomous region rate (95% CI) South/centre
rate (95% CI) Autonomous region rate (95% CI)
Overall 941 (91-965) 636 (609-664) 1120 (1093-1147) 789 (758-819)
Place of residence
Urban 880 (849-912) 615 (585-646) 1030 (996-1064) 756 (722-789)
Rural 1032 (992-1973) 727 (659-794) 1258 (1214-1303) 929
South/centre regions
North 960 (897-1023)  1130 (1032-1198) 
Middle 909 (872-945)  1061 (1022-1101) 
Middle Euphrates 944 (888-1000)  1130 (1069-1190) 
South 1005 (947-1062)  1251 (1187-1315) 
Autonomous givernorates
Erbil  659 (610-707)  797 (745-850)
Dohouk  686 (633-739)  876 (817-935)
Al-Suleimaniyah  575 (531-619)  710 (662-759)
Schooling Never attended 1005 (960-1050) 692 (654-729) 1214
(1165-1263) 866 (825-907)
Primary 970 (934-1006) 594 (546-643) 1153 (1114-1192) 721
Intermediate or higher 781 (698-863) 371 (260-481) 920 (830-1010)
496 (366-627)
Age of mother at birth (years)
<20 1059 (979-1138) 789 (705-873) 1254 (1169-1340) 929
20-29 897 (864-930) 597 (560-634) 1069 (1033-1105) 738 (697-779)
30+ 851 (813-890) 639 (592-687) 1010 (968-1053) 815 (761-868)
Relation to husband
Cousin 984 (943-1024) 740 (681-799) 1186 (1141-1230) 911
Other relative 1018 (966-1070) 620 (562-678) 1196 (1140-1252) 787
Not related 851 (813-890) 594 (557-631) 1010 (968-1053) 731
Sex of child
M 990 (955-1025) 685 (645-725) 1178 (1140-1217) 835 (792-879)
F 888 (854-923) 584 (546-623) 1059 (1022-1096) 739 (697-782)
Table 3: Childhood mortality rates and socioeconomic and demographic
characteristics and sex of the child

Children in rural settings had a higher risk of dying before age 5 years.
One in ten children in urban south/centre died compared with one in eight in
the rural south/centre. In the autonomous region 1 in 13 children in urban
areas died and 1 in 11 from rural areas died.

Within the south/centre, the mortality rates vary between regions. The
middle region (which includes the capital, Baghdad) has lower mortality
rates than the other three regions. The only appreciable difference is
between the middle and the south regions. Within the autonomous region, the
Al-Suleimaniyah governorate had the lowest childhood mortality compared with
the other two governorates, primarily because it is mostly urban, though the
difference was not significant.

The results also show that within each region, children born to mothers with
at most primary education had significantly higher mortality compared with
children born to mothers with at least intermediate education (table 3).
Children born to young or old mothers had higher rates than children born to
mothers aged between 20-29 years. Children born to related parents had
higher risk of dying than children born to unrelated parents. Mortality is
higher for boys than for girls in both regions.

Because of the potential confounding effect of the various background
characteristics on the mortality trend exhibited above, logistic regressions
of the risk of dying by age 1 year and by age 5 years were fitted to
ascertain whether the trends in mortality (in terms or relative risks)
remained unchanged after controlling for the selected background
characteristics. Interactions between time periods and characteristics were
examined and none was significant. Table 4 presents the result of the
regression analysis. The results showed that the adjusted magnitude and the
direction of the association between childhood mortality, time periods, and
women's characteristics are very similar to the unadjusted results presented
in figure 2 and table 3.

 Infant mortality  Under-5 mortality
relative risk (95% CI) Autonomous region
relative risk (95% CI) South/centre
relative risk (95% CI) Autonomous region
relative risk (95% CI)
Period (1984-89)
1994-99 232 (215-250) 087 (080-096) 214 (200-228) 078 (071-085)
1989-94 183 (169-197) 114 (105-125) 180 (168-193) 112 (104-121)
1979-84 >112 (102-123) 114 (104-125) 111 (102-122) 118 (109-128)
1974-79 115 (102-128) 163 (148-180) 116 (105-128) 181 (166-197)
Place of residence (urban)
Rural 110 (105-116) 121 (113-130) 113 (108-118) 126 (119-135)
South/centre regions (middle)
North 108 (101-115)  109 (103-116) ..
Middle Euphrates 101 (095-108)  103 (097-109) 
South 108 (102-115)  113 (107-120) 
Autonomous governorates (Al-Suleimaniyah)
Erbil  112 (104-120)  108 (102-115)
Dohouk  113 (105-122)  112 (105-120)
Schooling (intermediate)
Never attended 126 (116-136) 152 (130-179) 130 (121-140) 164
Primary 123 (114-132) 130 (110-153) 125 (117-134) 132 (113-154)
Age of mother at birth (20-29 years)
<20 115 (107-123) 126 (117-136) 113 (106-120) 120 (112-128)
30+ 107 (101-113) 103 (095-111) 106 (102-112) 102 (095-109)
Relation to husband (not related)
Cousin  112 (106-118) 119 (111-128) 113 (108-119) 122 (114-129)
Other relative 113 (107-120) 103 (095-110) 112 (106-118) 105
Sex of the child (female)
Male 117 (112-123) 114 (108-121) 116 (111-120) 109 (103-114)
Table 4: Adjusted relative risks of dying by age 1 year and age 5 years by
socioeconomic and demographic characteristics

Overall, the results show high mortality among male children born to mothers
with primary or no education and those living in rural areas. South/centre
seemed to have been affected more from the consequences of the UN sanctions
than the autonomous region. Although the differentials in the two regions
are broadly similar, mortality rates in the autonomous region are much lower
than in the south/centre.


Since 1991, most of the hospitals and health centres in the south/centre of
Iraq have had little or no repair or maintenance work carried out. The
functional capacity of the healthcare system has been further degraded by
shortages of water and power supply. Communicable diseases, such as
water-borne diseases and malaria, which had previously been under control,
returned as epidemics in 1993 and have now become part of the endemic
pattern of the precarious health situations in the south/centre of

Acute malnutrition in the south/centre region of Iraq rose from 3% to 11%
and the percentage of low-birth-weight babies (less than 25 kg) rose from
4% in 1994 to about 25% of registered births in 1997, mainly due to maternal
malnutrition which was estimated to be up to 70% in 1997.20 The most
vulnerable groups have been the hardest hit, especially children under 5
years of age who are being exposed to unhygienic conditions.18 Drinking
water is currently accessible only to 50% of urban and 33% of rural
populations in south/centre, which is far below the proportion before
sanctions (90% in urban and 70% in rural areas21)
In April, 1995, the UN Security Council adopted a resolution (SCR 986),
which was intended to provide for the humanitarian needs of the Iraqi
people. This initiative came to be known as the "Oil-for-Food" programme.
The adoption of the "Oil-for-Food" programme has played an important part in
averting major food shortages in Iraq and has helped to alleviate the health
situation, especially in the autonomous region. Since the beginning of the
programme, the extent of malnutrition seems to have stabilised in the more
populous south/centre of Iraq, albeit at an insufficient caloric level,
whereas in the autonomous governorates the situation has improved somewhat.
In the autonomous governorates the availability of equipment and trained
staff, as well as drugs and supplies, have contributed to substantially
increased patient attendance and better care. There is a decline in some
infectious diseases such as measles, and better control of poliomyelitis.
Water and sanitation have also improved in the autonomous region, because of
the "Oil-for-Food" programme.21

Results from the two surveys on childhood and maternal mortality in Iraq
clearly show that childhood mortality in the south/centre increased during
the period of the UN sanctions that followed the Gulf conflict. Information
from several other studies and surveys shows an increase in the rates of
malnutrition and in babies born with low birthweight. In the 10 years since
the Gulf conflict, infant and under-5 mortality has more than doubled in the
south/centre. Childhood mortality rates in the south/centre are now much
higher than those 20-24 years ago.

Childhood mortality in the autonomous region, however, presents a different
picture. Historically, the three autonomous governorates were less developed
than the 15 governorates of the south/centre. Since 1991, however, relief
has been coupled with development activities. The region also has a less
severe embargo as it contains most of the country's rain-fed agriculture and
has borders with neighbouring countries that are more open than those in
south/centre. The "Oil-for-Food" goods have been distributed more rapidly,
the per capita allocations from the programme were set 22% higher than in
south/centre and the cash component of the programme assistance in the
autonomous region equivalent in value to 10% of all goods. In addition, many
more non-governmental organisations (34, compared with 11 in south/centre)
are present.23 All these advantages in the autonomous region compared with
the south/centre have contributed to a decline in infant and under-5

Although rates of mortality in the two regions differ, the differentials by
place and region of residence, education and age of the mother, blood
relation and sex of the child are similar. The patterns are plausible and
reinforce the credibility of the survey findings. As found in other
countries, children born to women with no education, or in rural areas, have
higher mortality than those born to women with education, and in urban
areas. Despite a high amount of literacy in the south/centre compared with
the autonomous region, childhood mortality rates are higher in the
south/centre. Clearly, education of mother, suggested to be a determinant of
infant-child mortality, has a limited effect in deteriorating socioeconomic
and health conditions, as seen in the south/centre of Iraq.

Mohamed Ali designed the study, did the data management, and analysis, and
wrote the paper. Iqbal Shah did the analysis and wrote the paper.

We thank UNICEF for permission to use the data from the two surveys on
infant, child, and maternal mortality; the Government of Iraq; the local
authorities in the autonomous region for their support and major
contributions; the staff and consultants who implemented the surveys in
difficult circumstances; the respondents who graciously gave their time for
the interviews; and Gareth Jones, Paul Van Look, John Blacker, John Cleland,
Carine Ronsmans and Evelyn Dodd. UNICEF provided the financial and technical
support for the surveys.

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