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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" <firstname.lastname@example.org> To: <email@example.com> Cc: "Campaign Against Sanctions on Iraq" <firstname.lastname@example.org> 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). > body.article1845.htmlbody.article1845.html > body.article1858.htmlbody.article1858.html > > > > > > > > _______________________________________________ Sent via the discussion list of the Campaign Against Sanctions on Iraq. To unsubscribe, visit http://lists.casi.org.uk/mailman/listinfo/casi-discuss To contact the list manager, email email@example.com All postings are archived on CASI's website: http://www.casi.org.uk