[casi] Re: Iraq letters -- Observer

["Chas Newkey-Burden" <chas@DELETETHISnewkey-burden.com>]

Dear Katy,

I shall write a letter as requested. Why not publicise this link:

http://news.bbc.co.uk/hi/english/audiovideo/programmes/correspondent/newsid_
2053000/2053620.stm

People can send questions to John Sweeney about his show, for a 3pm chat on
the Beeb website. I've sent some myself but they should be bombarded!

Thanks

Chas Newkey-Burden
http://www.newkey-burden.com


----- Original Message -----
From: "Katy Connell" <kcnl@globalnet.co.uk>
To: <kcnl@globalnet.co.uk>
Cc: "Campaign Against Sanctions on Iraq" <casi-discuss@lists.casi.org.uk>
Sent: Sunday, June 23, 2002 1:37 PM
Subject: 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.)
>
> Cheers,
>
> Glenn.
>
>
> ----------------------------------------------------------------------
>
>
>
>
>
>
>  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: Mohamed.Ali@lshtm.ac.uk)
>
> Summary
> Introduction
> Methods
> Assessment of data quality
> Results
> Discussion
> References
>
> Summary
>
> 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
> interviewed.
>
> 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
>
> Introduction
>
> 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
> Iraq.
> 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
> increased.
>
> 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.
>
>
> Methods
>
> 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.
>
> 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.
>
> Analysis
>
> 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
> bias.
>
> 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.
>
>
> Results
>
> 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 (99·8%) 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 (96·6%) households were
> successfully covered of 16499 sampled. 13109 had at least one eligible
> respondent yielding 14 035 completed questionnaires.
>
> Background characteristics of respondents
>
> 14943 (64·7%) of the 23105 women interviewed in the south/centre and 11807
> (84·1%) of the 14035 women in the autonomous region were living in urban
> areas at the time of the survey (table 1). Most (93·0% in the south/centre
> and 94·0% in the autonomous region) of the ever-married women were
currently
> married. As is typical in the middle east region, a high proportion
(61·0%)
> 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 4·3
> children per ever-married women in the south/centre and 4·6 in the
> autonomous region.
>
>   South/centre  Autonomous region
>   n (%) n (%)
> Place of residence
> Urban  14943 (64·7) 11807 (84·1)
> Rural  8162 (35·3) 2228 (15·9)
> Regions of South/centre
> North  3401 (14·7)
> Middle  10947 (47·4)
> Middle Euphrates  4541 (19·7)
> South  4216 (18·2)
> Autonomous governorates
> Erbil   4839 (34·5)
> Dohouk   3500 (24·9)
> Al-Suleimaniyah   5696 (40·6)
> Current age (years)
> 15-19  1379 (6·0) 909 (6·5)
> 20-24  3582 (15·5) 2386 (17·0)
> 25-29  4798 (20·8) 2966 (21·1)
> 30-34  4323 (18·7) 2338 (16·7)
> 35-39  3598 (15·6) 1944 (13·9)
> 40-44  2895 (12·5) 1919 (13·7)
> 45-49  2530 (11·0) 1573 (11·2)
> Relation to last/current husband
>  Cousin 8666 (37·5) 3524 (25·1)
>  Other relative 5351 (23·2) 3083 (22·0)
>  Not related 9088 (39·3) 7428 (52·9)
> Education
>  No education 6811 (29·5) 8026 (57·2)
> Primary*  11140 (48·2) 4353 (31·0)
> Intermediate or higher  5154 (22·3) 1656 (11·8)
> Total  23105 (100·0) 14035 (100·0)
> *Includes respondents with no certificates.
> Table 1: Distribution of respondents by background characteristics and
> region
>
> 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 94·1 (91-96·5) 63·6 (60·9-66·4) 112·0 (109·3-114·7) 78·9
(75·8-81·9)
> Place of residence
> Urban 88·0 (84·9-91·2) 61·5 (58·5-64·6) 103·0 (99·6-106·4) 75·6
(72·2-78·9)
> Rural 103·2 (99·2-197·3) 72·7 (65·9-79·4) 125·8 (121·4-130·3) 92·9
> (85·3-100·4)
> South/centre regions
> North 96·0 (89·7-102·3) ·· 113·0 (103·2-119·8) ··
> Middle 90·9 (87·2-94·5) ·· 106·1 (102·2-110·1) ··
> Middle Euphrates 94·4 (88·8-100·0) ·· 113·0 (106·9-119·0) ··
> South 100·5 (94·7-106·2) ·· 125·1 (118·7-131·5) ··
> Autonomous givernorates
> Erbil ·· 65·9 (61·0-70·7) ·· 79·7 (74·5-85·0)
> Dohouk ·· 68·6 (63·3-73·9) ·· 87·6 (81·7-93·5)
> Al-Suleimaniyah ·· 57·5 (53·1-61·9) ·· 71·0 (66·2-75·9)
> Schooling Never attended 100·5 (96·0-105·0) 69·2 (65·4-72·9) 121·4
> (116·5-126·3) 86·6 (82·5-90·7)
> Primary 97·0 (93·4-100·6) 59·4 (54·6-64·3) 115·3 (111·4-119·2) 72·1
> (66·8-77·5)
> Intermediate or higher 78·1 (69·8-86·3) 37·1 (26·0-48·1) 92·0 (83·0-101·0)
> 49·6 (36·6-62·7)
> Age of mother at birth (years)
> <20 105·9 (97·9-113·8) 78·9 (70·5-87·3) 125·4 (116·9-134·0) 92·9
> (83·9-101·9)
> 20-29 89·7 (86·4-93·0) 59·7 (56·0-63·4) 106·9 (103·3-110·5) 73·8
(69·7-77·9)
> 30+ 85·1 (81·3-89·0) 63·9 (59·2-68·7) 101·0 (96·8-105·3) 81·5 (76·1-86·8)
> Relation to husband
> Cousin 98·4 (94·3-102·4) 74·0 (68·1-79·9) 118·6 (114·1-123·0) 91·1
> (84·6-97·7)
> Other relative 101·8 (96·6-107·0) 62·0 (56·2-67·8) 119·6 (114·0-125·2)
78·7
> (72·2-85·3)
> Not related 85·1 (81·3-89·0) 59·4 (55·7-63·1) 101·0 (96·8-105·3) 73·1
> (69·0-77·2)
> Sex of child
> M 99·0 (95·5-102·5) 68·5 (64·5-72·5) 117·8 (114·0-121·7) 83·5 (79·2-87·9)
> F 88·8 (85·4-92·3) 58·4 (54·6-62·3) 105·9 (102·2-109·6) 73·9 (69·7-78·2)
> 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
>  South/centre
> 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 2·32 (2·15-2·50) 0·87 (0·80-0·96) 2·14 (2·00-2·28) 0·78
(0·71-0·85)
> 1989-94 1·83 (1·69-1·97) 1·14 (1·05-1·25) 1·80 (1·68-1·93) 1·12
(1·04-1·21)
> 1979-84 >1·12 (1·02-1·23) 1·14 (1·04-1·25) 1·11 (1·02-1·22) 1·18
(1·09-1·28)
> /FONT>
> 1974-79 1·15 (1·02-1·28) 1·63 (1·48-1·80) 1·16 (1·05-1·28) 1·81
(1·66-1·97)
> Place of residence (urban)
> Rural 1·10 (1·05-1·16) 1·21 (1·13-1·30) 1·13 (1·08-1·18) 1·26 (1·19-1·35)
> South/centre regions (middle)
> North 1·08 (1·01-1·15) ·· 1·09 (1·03-1·16) ..
> Middle Euphrates 1·01 (0·95-1·08) ·· 1·03 (0·97-1·09) ··
> South 1·08 (1·02-1·15) ·· 1·13 (1·07-1·20) ··
> Autonomous governorates (Al-Suleimaniyah)
> Erbil ·· 1·12 (1·04-1·20) ·· 1·08 (1·02-1·15)
> Dohouk ·· 1·13 (1·05-1·22) ·· 1·12 (1·05-1·20)
> Schooling (intermediate)
> Never attended 1·26 (1·16-1·36) 1·52 (1·30-1·79) 1·30 (1·21-1·40) 1·64
> (1·42-1·90)
> Primary 1·23 (1·14-1·32) 1·30 (1·10-1·53) 1·25 (1·17-1·34) 1·32
(1·13-1·54)
> Age of mother at birth (20-29 years)
> <20 1·15 (1·07-1·23) 1·26 (1·17-1·36) 1·13 (1·06-1·20) 1·20 (1·12-1·28)
> 30+ 1·07 (1·01-1·13) 1·03 (0·95-1·11) 1·06 (1·02-1·12) 1·02 (0·95-1·09)
> Relation to husband (not related)
> Cousin  1·12 (1·06-1·18) 1·19 (1·11-1·28) 1·13 (1·08-1·19) 1·22
(1·14-1·29)
> Other relative 1·13 (1·07-1·20) 1·03 (0·95-1·10) 1·12 (1·06-1·18) 1·05
> (0·99-1·12)
> Sex of the child (female)
> Male 1·17 (1·12-1·23) 1·14 (1·08-1·21) 1·16 (1·11-1·20) 1·09 (1·03-1·14)
> 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.
>
> Discussion
>
> 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
> Iraq.18,19
>
> Acute malnutrition in the south/centre region of Iraq rose from 3% to 11%
> and the percentage of low-birth-weight babies (less than 2·5 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
> mortality.
>
> 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.
>
>
> Contributors
> Mohamed Ali designed the study, did the data management, and analysis, and
> wrote the paper. Iqbal Shah did the analysis and wrote the paper.
>
>
> Acknowledgments
> 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.
>
>
>
> References
> 1 UNICEF. The state of the world's children 1997. New York: UNICEF, 1997.
> 2 The Economist. Iraq country profile. London: The Economist Intelligence
> Unit, 1998.
> 3 UNICEF. Situation analysis of children and women in Iraq 1998. Baghdad:
> UNICEF, 1998.
> 4 Hoskins E. Public health and the Persian Gulf War. In: Levy B, Sidel V,
> eds. War and public health. New York: Oxford University Press, 1997.
> 5 UNICEF. Iraq immunization, diarrhoeal disease, maternal and childhood
> mortality survey: evaluation series No 9. Amman: UNICEF Regional Office
for
> the Middle East and North Africa, 1990.
> 6 Ministry of Health. National child health survey: preliminary report
1989.
> Gulf Council of Ministers, 1990.
> 7 The Harvard Study team. The effect of the Gulf crisis on the children of
> Iraq. N Engl J Med 1991; 325: 977-80 [PubMed].
> 8 Ascherio A, Chase R, Cote T, et al. Effect of the Gulf War on infant and
> child mortality in Iraq. N Engl J Med 1992; 327: 931-36 [PubMed].
> 9 Central Statistical Organisations. The 1996 multiple indicators cluster
> survey: a survey to assess the situation of children and women in Iraq.
> Final report with result from south-centre governorates. Baghdad: UNICEF,
> 1997 (UNICEF IRQ/97/288).
> 10 Zaidi S. Child mortality in Iraq. Lancet 1997; 350: 1150.
> 11 Ronsmans C, Campbell O. Sanctions against Iraq. Lancet 1996; 347: 198
> [PubMed].
> 12 Institute for Resource Development. Model "B" questionnaire with
> additional health questions and commentary for low contraceptive
prevalence
> countries(basic documentation Number 4) Colombia: Institute for Resource
> Development 1987.
> 13 Bicego G, Ahmad O. Infant and child mortality: DHS comparative studies.
> Number 20. Calverton: Marco International, 1996.
> 14 Greenwood M. Report on public health and medical subjects. Number 33,
> Appendix 1. London: H M Stationery Office, 1926.
> 15 Le Thana N, Verma VK. An analysis of sample designs and sampling errors
> of the demographic and health surveys. DHS Analytical Report Number 3.
> Calverton: MACRO International, 1997.
> 16 Central Statistical Office. Iraq fertility survey. Baghdad: Central
> Statistical Office, 1974.
> 17 United Nations Manual X. Indirect techniques for demographic estimation
> (ST/ESA/Series A/81). New York: UN 1983; 81-85.
> 18 United Nations. Report on the second panel established pursuant to the
> note by the President of the Security Council of 30/12/99 concerning the
> current humanitarian situation in Iraq (S/1999/356). New York: UN 1999.
> 19 United Nations. Review and assessment of the implementation of the
> humanitarian programme, established pursuant to security council
resolution
> 986. S/19. New York: UN 1999.
> 20 Food and Agricultural Organization and the World Food Programme
> (FAO/WFP). Food supply and nutrition assessment mission to Iraq
> (TCP/IRQ/6713). Rome: FAO, 1997.
> 21 UN working group on repairing water delivery and treatment facilities.
> Assessment and review of the humanitarian programme (SCR 986). Baghdad:
> UNICEF, 1999.
> 22 Garfield R. Health and well-being in Iraq: sanctions and the impact of
> oil for food program (unpublished, New York: Columbia University).
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