OF CHILDREN UNDER TWO ATTENDING
ROUTINE IMMUNIZATION SESSIONS AT
PRIMARY HEALTH CARE CENTRES
Conducted by the Ministry of Health (GOI) November 1999
NUTRITIONAL STATUS SURVEY OF CHILDREN BELOW TWO
ATTENDING ROUTINE IMMUNIZATION SESSIONS AT PRIMARY
HEALTH CARE CENTRES IN IRAQ
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.
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 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.
1. Introduction 5
2. Methods 6
2.2.Planning and preparation
2.7.Data entry, editing and analysis
2.8.Limitations of the study
3. Results 8
3.1. Characteristics of population
3.1.3. Urban/rural distribution
3.1.4. Literacy/Education of mothers
3.1.5. Feeding pattern
3.2. 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/H
3.2.4. Nutritional status by urban/rural residence
3.2.5. Nutritional status by feeding pattern
3.2.6.Percentage of malnutrition according to Sex
3.2.7.Nutritional status by age
4. Consequences of malnutrition 14
5. Recommendations 15
5.1. General recommendation
5.2. Targeted nutrition program
5.3. Community education
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
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.
The current survey follows the same methods and provides information on trends in
the nutritional status of children below two years of age.
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
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 Preparation
For 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.
This 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.
The 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.
Each 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.
During 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
2.7.Data entry, editing and analysis
Data 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 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 study
In 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
3.1.Charecterestics of the population:
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.
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 distribution
Urban 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).
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
40 % Illiterate
30 % Primary
20 % Secondary
10 % Higher
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).
3.1.5. Feeding pattern among infants
40.8% infants are exclusively breast fed
47% receive breast milk plus infant formula
12.2% receive only infant formula
Altogether, 87.8 % infants receive breast milk in the last 24-hour before
Table 2: Feeding pattern in infants
Feeding pattern <6 months >6 months
Exclusive 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 Mixed feeding Bottle feeding
Urban 37.7 % 48.4% 13.9 %
Rural 44.5% 45.2 % 10.2%
3.2. Nutritional Status
3.2.1.Prevalence of malnutrition, General malnutrition (weight/age)
Degree of malnutrition %
-1 SD 19.7
-2 SD 9.7
-3 SD 2.3
3.2.2.Chronic malnutrition or stunting (height/age)
Degree of malnutrition %
-1 SD 20.4
-2 SD 8.7
-3 SD 5.1
3.2.3.Acute malnutrition or wasting (weight/height)
Degree of malnutrition %
-1 SD 13.8
-2 SD 6.6
-3 SD 2.6
3.2.4.Nutritional status by urban/rural residence
Like 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 % %
Urban Rural Urban Rural
General 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 months
Altogether 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
Table 5: Breastfeeding in infants
Feeding pattern % W/A < -2SD W/H < -2SD
Exclusive BF 60.7 7.5 6.8
Mixed feeding 31.9 14.7 10.3
Bottle feeding 7.4 14.4 10.1
NUTRITION STATUS BY FEEDING PATTERN
W/A and W/H in <6 months
40 Exclusive BF
30 Mixed feeding
% W/A < -2SD W/H < -2SD
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
W/A - W/A <- W/A <-
1SD 2SD 3SD
3.2.6.Percentage of malnutrition according to SEX
Malnutrition type Male Female
General malnutrition (Underweight) 51.4 48.6
Chronic malnutrition (Stunting) 51.6 48.4
Acute malnutrition (Wasting) 51.4 48.6
MALNUTRITION BY SEX
49 Chronic malnutrition (Stunting)
Acute malnutrition (Wasting)
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 age
The 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 < 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 13.5
Stunting % 16.1 12 16.5 26.5
Malnutrition by Age
< 1 month 0-6 months 6-12 months 12-24
Table 8: Comparison of the results of the present and the previous surveys (same age
Type of malnutrition 1997 1998 1999
April Oct 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 13.8
Acute (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 height
Malnutrition 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
DEATHS/1000 LIVE BIRTHS YEARS 84-89 89-94 94-99
Neonatal mortality 32 48 66
IMR 47 79 108
<5MR 56 92 131
Source: 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
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.
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
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.