NUTRITIONAL SURVEYOF CHILDREN UNDER TWO

ATTENDING ROUTINE IMMUNIZATION SESSIONS AT

PRIMARY HEALTH CARE CENTRESIN IRAQ

Conducted by the Ministry of Health (GOI)November 1999

and UNICEF/Iraq

NUTRITIONAL STATUS SURVEY OF CHILDREN BELOW TWO ATTENDING ROUTINE IMMUNIZATION SESSIONS AT PRIMARY HEALTH CARE CENTRES IN IRAQ

November, 1999

Executive Summary

A nutritional status survey was conducted in 127 Primary Health Centers in South and Center of Iraq. The purpose of this survey was to continue the nutritional status follow-up for SCR986, in accordance with the Memorandum of Understanding (MOU) under Food Items (No. 38). To monitor the nutrition status of children surveys are carried out every six months since April 1997. The surveys in April, 1997, March 1998 and April 99 were carried out in under five children attending National Immunization Days for Polio and the surveys in October 1997, October 1998 and the present survey were carried out on children below two years of age attending routine immunization clinics.

The children attending the routine immunization sessions during 24 –30 November 1999 were surveyed. A total of 6,414 children under two years of age were examined for weight and height / length. Results pertain to 125 of the original 127 PHCs sampled in the previous survey of April 1999; two have been excluded because they are not involved in the previous survey for the matter of comparison. The survey showed that 12% of the children under two years of age were malnourished, according to WHO reference criteria of weight-for-age, W/A<-2SD; 13.8% were stunted (i.e. had a low height-for-age, reflecting chronic malnutrition) and 9.2% were wasted (low weight-for-height, reflecting acute malnutrition).

These results show that, in spite of an improved food basket under the OFF programme the nutrition of children continues to be adversely affected and has not shown any improvement. The main factors responsible for that are inadequate intake of foods both in quantity and quality, poor maternal health, high prevalence of infections and inappropriate feeding/weaning practices with an increased use of bottle and formula.

Acknowledgments

The Ministry of Health and UNICEF/Iraq supported this survey. The Director General of Preventive Health at country level and the Director-Generals of the Directorates of Health in the governorates were the key officials responsible for supporting the survey. Nutrition

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Research Institute in collaboration with Programme Managers of the Ministry of Health, with the participation of UNICEF, undertook the preparation, training, analysis and reporting. The survey was carried out through Primary Health Care Center staff, supported by the directors of the governorates.

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CONTENTSSummary

1. Introduction 5

2. Methods 62.1.Sampling2.2.Planning and preparation2.3.Training2.4.Measurement2.5.Field work2.6.Supervision2.7.Data entry, editing and analysis2.8.Limitations of the study

3. Results 83.1. Characteristics of population

3.1.1. Age3.1.2. Sex3.1.3. Urban/rural distribution3.1.4. Literacy/Education of mothers

3.1.5. Feeding pattern3.2. Nutritional status 10

3.2.1.Prevalence of malnutrition; General malnutrition W/A 3.2.2.Chronic malnutrition or stunting, H/A

3.2.3.Acute malnutrition or wasting, W/H3.2.4. Nutritional status by urban/rural residence3.2.5. Nutritional status by feeding pattern3.2.6.Percentage of malnutrition according to Sex3.2.7.Nutritional status by age

4. Consequences of malnutrition 14

5. Recommendations 15

5.1. General recommendation5.2. Targeted nutrition program

5.3. Community education

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1. INTRODUCTION

NUTRITIONAL STATUS SURVEY AT PRIMARY HEALTH CENTRES DURING ROUTINE IMMUNIZATION SESSIONS IN IRAQ- November 1999

A nutritional status survey was conducted in 127 Primary Health Centers throughout the South and Center of Iraq. The children attending the routine immunization sessions during 24 – 30, November 1999 were surveyed. A total of 6,414 children under two years of age were examined for weight and length. The purpose of this survey was to continue the nutritional status follow-up for SCR986, in accordance with the Memorandum of Understanding (MOU) under Food Items (No. 38).

Results pertain to 125 of the original 127 PHCs sampled in the previous survey of April 1999; two have been excluded because they are not involved in the previous survey for the matter of comparison. The survey showed that 12% of the children under two years of age were malnourished, according to WHO reference criteria of weight-for-age, W/A<-2SD; 13.8% were stunted (i.e. had a low height-for-age, reflecting chronic malnutrition) and 9.2% were wasted (low weight-for-height, reflecting acute malnutrition).

In April 1997, a nutritional status survey in 87 Primary Health Centers throughout South/Center Iraq during the three Polio National Immunization Days (PNID) examined 15,466 children under five years of age. Of those, 24.7% were underweight-for-age, but, at that time the “oil-for-food” programme had not yet been established and it was necessary to repeat the survey during the PNID in March 1998 after one year of implementation of SCR 986.

The March 1998 survey showed little or no changes since 1997 - underweight went from 24.7 to 22.8%, chronic malnutrition (stunting or low height-for-age) from 27.5 to 26.7% and acute malnutrition (wasting or low weight-for-height) from 9.0 to 9.1%.

The April 1999 survey similarly did not show any major changes except a slight reduction in stunting.

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The current survey follows the same methods and provides information on trends in the nutritional status of children below two years of age.

2. METHODS2.1.Sampling

The same 127 PHC’s as in April 1999 from a total of 850 were sampled, (73 urban and 54 rural). The first stage of sampling selected the 15 governorates and the second stage selected PHC’s within each governorate. Seven PHC’s were sampled from most governorates except for Baghdad (16), Basrah and Ninewah (11), Thiqar and Babil (8). The sampling frame consisted of larger PHC’s, so that the required numbers of children would be readily available and so that sufficient staff and facilities could readily cope with both the routine immunization and the nutrition assessment concurrently. In most governorates, the urban sites were randomly selected. In rural areas, the sample was usually taken from PHC’s at District Headquarters. Baghdad was an exception in that the 13 urban PHC’s were sampled so that each district was represented and the PHC’s covered a wide range of social strata.

A total of 50 children were assessed in each center, or 10 per day. This allowed sufficient time to measure them accurately and not delay the immunization session.

Children were selected in a systematic process, using a random start, with each nth child measured upon showing up. The sampling interval was determined from average attendance per day based on the usual immunization sessions. Where more than one registration desk operated, the sample was randomly taken from one of these desks with the required sampling interval. In the current survey, the sampling interval was between 2 and 3.

2.2.Planning and PreparationFor the matter of comparison with the previous surveys 1997-

1998 ,the health facility survey using the same criteria of inclusion of the children had been used in this survey which involved an intensive preparatory process of one to two weeks prior to the field work. Agreements between UNICEF and the Ministry of Health were finalized. Important aspects of the agreement included sharing of the results and combined activities such as training, supervision and data analysis.

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2.3.TrainingThis was mostly retraining, as most of the personnel had received

prior training and had experience in one or several of the previous surveys. Training of PHC governorate directors and MOH programme staff as trainers, was conducted at the NRI (Nutrition Research Institute, Ministry of Health). These directors trained their governorate PHC staff using their own materials provided at NRI.

Training materials were both in Arabic and English - for the questionnaire, field testing, reading and recording tests and diagrams for the Uniscale (an electronic digital readout weighing scale) and the height/length board. The training included demonstrations and practice sessions under supervision followed by evaluation.

2.4.MeasurementsThe questionnaire included the child name, sex, date of birth

(year, month and day), age in months, weight and height, education status of the mother, feeding pattern (exclusive breastfeeding, any bottle feeding, when was milk and any solid or semi-solid food added). Each child was weighed with a Uniscale to the nearest 0.1 kg and measured for length to the nearest 0.1 cm. using a custom made height-length board.

2.5.Field WorkEach Center had a team of four workers - one for weight, two for

height/length and the other one to ensure proper sampling, measuring and recording of age.

2.6.SupervisionDuring the fieldwork, central and local supervision was conducted

by NRI, MOH, UNICEF and PHC departments in Directorates of Health of each governorate. In general, their reports indicated that the measurements were done satisfactorily and the procedures were well organized. Most of the PHC staff and supervisors had also worked during the previous surveys.

2.7.Data entry, editing and analysisData entry was completed at NRI. Analysis using Epi-Info

proceeded concurrently with editing on a case by case and PHC by PHC review with close scrutiny of suspect measures. Methods included lists, tabulations, distributions and graphics to determine acceptable levels. Where possible, feedback was given to governorates for explanations about suspect measures or results and their control. Stricter criteria than usually recommended were developed regarding data acceptance. The range for adverse measures for weight and height-for-age is usually up to – 6 standard

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deviations (SD) of the reference WHO criteria. A level of –3 SD for these W/A and we use a level of – 3 SD for weight-for-height as the cut off measure to indicate those above –3 SD.

2.8.Limitations of the studyIn the present study (similarly in the earlier studies of Oct, 97

and Oct, 98 which were done on children attending immunization clinics) malnutrition is likely to be underestimated since children who do not come to immunization clinic are likely to be worse off regarding proper care and feeding. In addition, sick children who are again more likely to be malnourished excluded from the survey. A community based household survey is more likely to give a representative sample of the population. However in view of the limitation of access to the community, the health institution based study was carried out in this study.

3. RESULTS3.1.Charecterestics of the population:

3.1.1. Age The sample favored younger children. Those in the first year of life

contributed to 82.3% of the sample reflecting the age at immunization. In the 1997 and 1998 surveys, the proportion of infants was slightly lower.

3.1.2. Sex The number of boys was 3,257 (50.8%) and 3,157 (49.2%) were of

girls. This distribution was similar to the previous surveys.

3.1.3. Urban/rural distributionUrban children comprised 54.9% of the sample and the rural

children comprised 45.1% of the sample.

3.1.4. Literacy/Education of mothers: About one-quarter (26.1%) of the mothers were illiterate, 42.5%

had attended primary school, 23% had attended secondary school and 8.3% had higher education. The percentage of illiterate mothers was less than in the 1998 survey, and those with secondary education and with higher education was slightly greater than in 1998 (Table 2).

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Table 1: Mother’s Education - 1999/1998

Education Nov. 99 April 99 *

April 98 *

Oct.98** Oct.97**

% Illiterate 26.7 27.3 33.6 25.4 27.1

% Primary 42.1 39.5 39.4 40.9 42.2

% Secondary

22.9 24.4 20.3 26.3 22.9% Higher 8.3 8.8 6.7 7.4 7.8

TOTAL 6,414 13,572 12,877 3,727 3,257*=U5 children Surveys /Mother’s education not assessed in 1996 .**=U1 children surveys

Illiteracy was higher in rural as compared with urban areas (30% vs. 26%) and higher education less frequent (rural 5% versus urban 11%). Mothers with children under two were younger than all women of child bearing age, hence the illiteracy rate in this sample is probably less (according to the 1987 census, 34.5% women were illiterate).

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3.1.5. Feeding pattern among infants

40.8% infants are exclusively breast fed47% receive breast milk plus infant formula12.2% receive only infant formula

Altogether, 87.8 % infants receive breast milk in the last 24-hour before the survey.Table 2: Feeding pattern in infants

Feeding pattern <6 months >6 monthsExclusive breast feeding

60.4 % 8.6 %

Mixed feeding 32.2 % 71.3 %Bottle feeding 7.4 % 20.1 %

BF rate found to be 92.6% in those below 6 months and 79.9%. in those above 6 months of age. The prevalence of breast-feeding was slightly higher in rural areas.

Table 3 Feeding pattern in urban and rural areas

Area Exclusive breast feeding

Mixed feeding Bottle feeding

Urban 37.7 % 48.4% 13.9 %Rural 44.5% 45.2 % 10.2%

3.2. Nutritional Status3.2.1.Prevalence of malnutrition, General malnutrition (weight/age)

Degree of malnutrition %-1 SD 19.7-2 SD 9.7-3 SD 2.3

normal(>median) 68.3

3.2.2.Chronic malnutrition or stunting (height/age)

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Degree of malnutrition %-1 SD 20.4-2 SD 8.7-3 SD 5.1normal 65.1

3.2.3.Acute malnutrition or wasting (weight/height)Degree of malnutrition %

-1 SD 13.8-2 SD 6.6-3 SD 2.6

normal 77

3.2.4.Nutritional status by urban/rural residenceLike the prior surveys in March 1998 (and in 1997), there was little or no difference in nutritional status by urban/rural location.

Table 4: Malnutrition in urban and rural areas

MALNUTRITION TYPE 1999

% 1998

%Urban Rural Urban

RuralGeneral malnutrition (Underweight)

20.9 21.9 22.1 24.4

Chronic malnutrition (Stunting)

19.6 21.7 25.4 29.5

Acute malnutrition (Wasting)

9.9 8.6 8.8 9.7

Sample (underweight) 13730 13892

3.2.5. Nutritional status by feeding pattern

W/A and W/H in Under 6 monthsAltogether 92.6% babies are breast-fed. More than 7% were not on breast feeding. Among these 92.6 %, only 60.7% are exclusively breast fed when this should be the rule before 6 months.

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Table 5: Breastfeeding in infantsFeeding pattern % W/A < -2SD W/H < -2SDExclusive BF 60.7 7.5 6.8Mixed feeding 31.9 14.7 10.3Bottle feeding 7.4 14.4 10.1

NUTRITION STATUS BY FEEDING PATTERNW/A and W/H in <6 months

One can see that underweight almost doubles in non-breastfed infants and wasting also rises significantly. This result is similar for mixed feeding and bottle-feeding. This most likely shows the impact of increased infections linked to the use of the bottle.

The results in infants under 1-month show that the degree of malnutrition increases if the baby is on mixed feeding or artificial feeding.

Table 6: Prevalence of malnutrition with type of feeding

Type Of Feeding W/A -1SD

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

Exclusive BF 13% 5.7% 0.5%Mixed feeding 16% 6.1% 1.8%Artificial feeding 8.2% 9.5% 2.4%

PREVALANCE OF MALNUTRITION BY TYPE OF FEEDING

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3.2.6.Percentage of malnutrition according to SEX

Malnutrition type Male FemaleGeneral malnutrition (Underweight)

51.4 48.6

Chronic malnutrition (Stunting) 51.6 48.4Acute malnutrition (Wasting) 51.4 48.6

MALNUTRITION BY SEX

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There’s no statistical difference in the percentage of malnutrition according to sex difference. The 1997-1998 nutrition status surveys conducted earlier showed similar findings.

Nutritional status by ageThe sharp rise in underweight after 6 months can be explained

by several factors like the higher prevalence of infectious diseases especially when breast feeding is discontinued, the discontinuation or reduction of maternal milk especially in families who cannot afford adequate amounts of cow milk/formula and do not practice hygienic preparation, the lack of additional foods in most children.

As for stunting, 16.1% of infants <1 month are already stunted. This is in relation with intrauterine growth failure and can improve only with better health and nutrition of women during and before pregnancy.

Table 7: Nutritional status of children by age

Type of Malnutrition

< 1 month 0-6 months

6-12 months

12-24 months

Underweight %

7.7 7.2 19.1 31.2

Wasting % 5.4 7.3 11.2 13.5Stunting % 16.1 12 16.5 26.5

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

Type of malnutrition

1997 1998 1999Apri

lOct March Oct April Nov

General (underweight)

14.7 14.6 13.2 14.7 14.1 12

Chronic (stunting) 15.3 12.2 16.2 11.7 12.8 13.8Acute (wasting) 9 7.5 8.3 8.2 9 9.2

There is a slight reduction in the prevalence of underweight while stunting and wasting have stabilized at unacceptably high rates of 13.8% and 9.2 % respectively. This represent the continuing cumulative deterioration in child growth and development, caused by adverse economic conditions, poor health, inadequate feeding and lack of proper care.

4. CONSEQUENCES OF MALNUTRITION

Acute malnutrition (wasting) puts an immediate threat on survival and sharply increases mortality. Chronic malnutrition has a more insidious and long-standing impact:By depressing the immune function, malnutrition increases the incidence of infectious diseases, the duration of illnesses and the case-fatality rate.Stunting reduces physical growth and adult heightMalnutrition reduces the growth of the brain and its proper functioning, leading to reduced academic performances, professional achievements and psychological resilience.

Trends in child mortality since 1984: The high rate of malnutrition is one of the main contributor to increase the neonatal, infant and child mortality which has been reflected in various surveys in the country.

Table 9: Trends in child mortality In Iraq

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DEATHS/1000 LIVE BIRTHS YEARS 84-89

89-94 94-99

Neonatal mortality 32 48 66IMR 47 79 108<5MR 56 92 131Source: UNICEF/MOH study,1999

Decrease in breastfeeding and increase of formula and bottle-feeding

Although the overall situation calls for promotion of breastfeeding, the inclusion of infant milk substitutes in the ration led many mothers to complement breast feeding or even stop it and use formula instead, most often with a bottle. The belief that formula is superior to human milk seems widespread. Overall, it appears that the inclusion of formula adversely affects breastfeeding and is harmful especially when general hygiene sanitation is poor, water availability is low, time available with the care provider less and fuel/electricity available has gone down.

5. RECOMMENDATIONS

General recommendations on Food Ration

5.1. Increase the quantity and quality of food allocated in the ration.

The food basket target of 2,463 kilocalories and 63.6 grams of protein per person per day was recommended, with a view to meeting the immediate nutritional needs of the Iraqi population in the UN Secretary General’s report (S/2000/208 dated 10/03/2000) to the security council needs to be implemented.

5.2. Appropriate Complementary Foods: The formula should be replaced with an increase in complementary food for children above 6 months of age. It would be advisable to teach mothers how to prepare nutritious weaning mixes from the various ingredients of the ration and add vegetables and/or fruit in whatever amount these are available.

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5.3. Prevention of malnutrition and promotion of proper nutrition practice:

In a situation of high prevalence of malnutrition it is very important to educate mothers to take appropriate measures to prevent malnutrition before it sets in. This will require strengthening the package of preventive eduction in the targeted nutrition programme. The health workers and the community volunteers need to be trained on this and provided with adequate health education material. The areas which need to be stressed are exclusive breastfeeding for six months and appropriate (both in quantity and quality) and timely introduction of complementary feeding. 5.4. Nutrition Rehabilitation of malnourished children:The therapeutic milk under MOU has been ordered and should soon be available. Once it is available and distributed through the PHC /ORT corners and NRCs this will address the moderate/severe cases of malnutrition on an in patient and ambulatory bases. There is an urgent need to operationalize these centers as soon as possible.5.5. Care for pregnant and lactating mothers:The pregnant and lactating women also receive HPB. This also acts as an incentive to attract women to ANC and get the various benefits included, TT shots, iron and folic acid supplements, fetal growth monitoring, screening of pregnancies needing special care etc… This measure has a positive impact on maternal and newborn health. This distribution needs to be coupled with a strong educational component both on pregnancy-related issues and on nutritional care of the baby.5.6. Community Education:This component needs to be strengthened through all available channels like health and nutrition education of mothers and community at all contacts through CCCUs, Primary Healthy Care Centers, Hospitals etc. and use of mass media to educate the community.

Emphasis in community education must be on:1. Exclusive Breastfeeding for 6 months and to avoid early

supplements, bottle, unclean water etc..2. Maintenance of breastfeeding along with complementary

feeding when the child is sick and additional feeding for one week after child recovers.

3. Complementary Feeding: Introduction of nutritious foods i.e. high caloric, protein and micronutrient content for a low volume.

Add a little oil to the weaning food to increase the caloric value. Add new items, one at a time such as mashed pulses, egg yolk,

meat etc…. as often as one can afford. Give vegetable or fruit or both to complementary foods.

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