Infant mortality rate in Al-Ramadi province from 2000 through 2010, retrospective study

doi:10.4236/health.2013.52039

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Vol.5, No.2, 292-297 (2013) Health

http://dx.doi.org/10.4236/health.2013.52039

Infant mortality rate in Al-Ramadi province from 2000

through 2010, retrospective study

Hammodi F. Aljumaily1*, Muhammed M. Al-Ani2, Muhammed M. Hantush3

1College of Medicine, Anbar University, Fallujah, Iraq; *Corresponding Author: [email protected]

2Department of Pediatrics, College of Medicine, Anbar University, Fallujah, Iraq

3Al-Ramadi Maternity and Child Teaching Hospital, Al-Ramadi, Iraq

Received 9 October 2012; revised 10 November 2012; accepted 17 November 2012

ABSTRACT

Objectives: To determine the IMR in Al-Ramadi

province, the center of Al-Anbar Governorate,

Western Iraq, from 2000-2010 with rate compa-

rison of the three different stages of that period.

Methods: Data collected from the birth and

death certificate center in Al-Ramadi province,

Western Iraq, included; name, age, sex, resi-

dence, date of birth and death, in three different

stages (the first stage 2000-2002, the second

stage 2003-2007, and the third stage 2008-2010)

in a study period from July to December, 2010.

The IMRs were analyzed and compared with

other studies. Results: The IMR of the last 3

years of sanction was 54.3/1000, 55.7/1000 and

50.6/1000 respectively, this rate had been in-

creased in the war and violence period to reach

its maximum rate 58.6/1000 in 2006, then de-

creased to reach its minimum rate 44.5/1000 in

2008. Approximately two-third of deaths oc-

curred during the neonatal period and one third

in the post neonatal period. Males had higher

IMR than females, and rural residence higher

than urban. Conclusion: Infant mortality rate is

still high in Al-Ramadi province, since the Ame-

rican invasion (2003-2007), when compared w ith

other developing countries. This study found

increase of IMR in Al-Ramadi province during

that period more than other stu died years.

Keywords: Mortality; Rate; Birth; Death Certificate

1. INTRODUCTION

Infant mortality rate is defined as the number of infant

deaths (one year of ag e or younger) per 1000 liv e births;

components of infant mortality rate include neonatal

mortality rate (number of deaths in the first 28 days per

1000 live births) and post neonatal mortality rate (num-

ber of deaths at 29 days and over to the end of first year

of life per 1000 live births) [1]. From all childhood (0 -

14) mortalities, 70% occur within the first year, 46%

within the first month, and 35% within the first week of

life [2]. The IMR varies greatly by country and it is

highest in developing countries [1].

There is an inverse relationship between the improve-

ment of the economic and social situation and the infant

mortality rate. While education is often linked to in come,

it can also be linked to infant mortality, looking at recent

data, parents with no formal education show an infant

mortality rate that is twice the normal rate [3].

The method of calculating IMR often varies widely

between countries, and is based on how they define a live

birth and how many premature infants are born in the

country [4,5].

In 2009, the US Center of Disease Control (CDC) is-

sued a report that stated that the American rates of infant

mortality were affected by the United States high rate of

premature babies compared to European countries [6].

In 1977, and before starting of wars in Iraq, the esti-

mated Iraqi national IMR was 61/1000 [7]. Target pro-

gram were then implemented since 1980s, despite the

Iraq-Iran War (1980-1988), to improve the infant heath

condition through vaccine coverage, promote breast feed-

ing, reduce diarrheal morbidity as well as improve do-

mestic hygiene [8]. These measures were successful and

followed by accelerated decrease in the national IMR

from 63/1000 in 1980, to 48.1/1000 in 1985, and 40/

1000 in 1990 [9].

Since 1990 many reports recorded in Iraq suggesting

significant increase rate in infant morbid ity and mortality

with deterioration of socioeconomic conditions and sur-

vival chance among young children under the effect of

war conflicted and comprehensive UN sanction, then

slightly decrease between 2000-2003, this decrease due

to improvement in economic condition and decrease the

effect of sanction after introduction of oil for food pro-

gram [10].

The United Nation Economic and Social Commission

H. F. Aljumaily et al. / Health 5 (2013) 292-297 293

for Western Asia (ESCWA) reported that almost 3 quar-

ters of the Iraqi p opulation became poor despite th e food

rationing system, which was established in 1991 and that,

the absolute poverty increased from 25% in urban and

33% in rural areas in 1981 to reach 72% in urban areas

and 66% in rural areas in 1993 [11]. The world bank es-

timated (27.2%) of Iraq population liv ing on less than 2$

per day in 2001 [12]. Such a unique situation and ex-

treme poverty causes the infant mortality in Iraq to in-

crease to a n u pwar d tr end nev er r each ed b efo re ( 103/ 100 0

in 1998) [13,14]. The increase prevalence of low birth

weight recorded in Iraq in the past 3 decades added an-

other factor for the increase of the IMRs [15-17].

The aim of this study is to determine IMR in Al-

Ramadi province, the center of Al-Anbar Governorate,

Western Iraq, from 2000-2010 and compare the rate

through 3 different stages (the first stage 2000-2002, the

second stage 2003-2007, and the th ird stage 2008-2010).

2. METHODOLOGY

This is a retrospective descriptive population record

study carried out in Al-Ramadi province, the center of

Al-Anbar gover norate, Western Iraq.

We studied the effect of sanction, war, and violence on

the IMR over 11 years composed of 3 different stages

imposed on the country from 2000-2010, and applied in

a study period from July to December, 2010.

The first stage was the last three years (2000, 2001 and

2002) of comprehensive UN economic sanction (1991-

2003). The second stage from 2003 to 2007, started after

the coalition forces occupation of the country, and de-

spite lifting of the sanction in this period, there were

successive different wars and increased violence inside

most of Iraqi cities leading to loss of security and de-

struction of most of the health services and facilities. The

third stage was from 2008 to 2010 when violence de-

creased, and health facilities and security improved in

most Iraqi cities including Al-Ramadi province.

All information were collected from birth and death

certificate center in Al-Ramadi province and statistic unit

in Al-Ramadi maternity and children teaching hospital

for each year.

Data collected included; name, age, gender, residence

and date of birth and death. Other information like edu-

cation, income and causes of infant deaths were not

available in the record s, thus excluded from this study.

Deliveries occurred in Al-Ramadi maternity and chil-

dren teaching hospital (MCTH), health centers and mid-

wife deliveries, and all deaths registered in births and

deaths certificate center in Al-Ramadi province included

in this study. Deliveries and deaths outside Al-Ramadi

province were excluded.

Frequency distribution tables and Bar Charts were

used to demonstrate the IMR occurring each year and its

association with sex and residence. Chi square was used

for statistical analysis, and P-value < 0.05 was consid-

ered as significant.

3. RESULTS

During the 11 studied years the total number of live

births in Al-Ramadi province was 98307, composed of

49646 females and 48661 males giving a female to male

ratio of 1.02:1.

The total number of inf ant deaths was 5031 composed

of 2867 males, and 2164 females, giving a male to fe-

male ratio of 1.3:1.

The overall IMR of the 11 years was 51.2/1000 live

births, 58.9 for males and 43.5 for females/1000 live

births. Their difference was statistically significant (P-

value < 0.01).

Table 1 shows the number of infant births, deaths, and

IMRs in Al-Ramadi province for each of the 11 studied

years. The highest rate was seen in the American inva-

sion and vi olence period ( second stage 2003- 2007) when

it reached 58.6/1000 in 2006 during the peak of violence.

While the lowest rate was seen in the third stages (2008-

2010); the stage of improvement of security and health

conditions, in which the rate declined to 44.5/1000 in

2008 that was th e lowest recorded rate of all th e 11 stud-

ied years.

Tabl e 2 and Figure 1, show the IMR in the both neo-

natal and post neonatal period during the 11 studied

years. Two thirds (67%) of reported deaths during the

neonatal period (43% in the early neonatal and 24% in

late neonatal periods), and one third (33%) during the

post neonatal periods of infancy.

Distribution of IMR among rural and urban residence

areas was shown in Table 3 and Figure 2, which demon-

strate that 53.5% of the studied dead infants were found

Table 1. Total live birth, total infant death and IMR for each

year, 2000-2010 in Al-Ramadi province.

IMR/1000Total infant death Total live birth Year

54.3 448 8243 2000

55.7 429 7689 2001

50.6 456 9180 2002

45.5 395 8666 2003

49.5 405 8180 2004

55.5 373 6711 2005

58.6 395 6735 2006

54.2 391 7213 2007

44.5 427 9589 2008

48.2 633 13,120 2009

52.3 679 12,981 2010

51.2 5031 98,307 Total

H. F. Aljumaily et al. / Health 5 (2013) 292-297

294

Ta b le 2 . Neonatal (early and late) and post neonatal death for

all included years, 2000-2010.

Post neonatal

deaths

Late neonatal

deaths

Early neonatal

deaths

Infant age

1661 1247 2123 Number

33% 24% 43% %

Table 3. The effect of residence for all years 2000-2010.

IMR Total infant death Total live births Residency

48.6 2340 (46.5%) 55,051 (55%) Urban

62.2 (53.5%) 2691 43,256 (45%) Rural

31.8 31.59 35.12 33.24 32.15 33.24 36.63 33.16 34.21 37.0627. 2 7

68.19 68.4 64.88 66.75 67.84 66.75 63.36 66.8365.78 62.9372.72

100

120

2000200120022003200420052006 2007 200820092010

PND ND

Figure 1. Rates of neonatal death (ND) and post neonatal death

(PND) for each year 2000 to 2010.

100

20002001 20022003 20042005 20062007 200820092010

UD RD

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Figure 2. Numbers of infant deaths according to residence

(urban deaths UD, rural deaths RD), for each year 2000-2010.

in rural (IMR 62.2/1000) and 46.5% of urban residences

(IMR 48.6/1000), the difference was statistically signifi-

cant (P-value < 0.01).

4. DISCUSSION

In most cases, war-affected areas will experience a sig-

nificant increase in infant mortality rates, some studies

provided strong evidence that the Gulf war and trade

sanctions caused a threefold increase in mortality among

Iraqi children [18,19].

During the first stage (the last three years of sanction)

the IMR in Al-Ramadi province was 54.3/1000 in 2000

and 55.7/1000 in 2001, this high rate of infant mortality

coul d b e expl a ined b y d eteriorat i on of he a l t h services and

the socioeconomic conditions of population under the

effect of comprehensive UN Sanction.

The IMRs of Al-Ramadi province in that years were

lower than the national Iraqi IMRs, 62.4/1000 in 2000 and

60/1000 in 2001, most probably because the center and

sout h of Iraq we re se ver ely af fect ed b y th e 19 91 p ost Gul f

War uprising, and the health and social services were

looted or destroyed during these events when compared

with other pa rts of c ountry. Such upri sing did not occ ur in

Al-Ramadi province and other districts of Al-Anbar

Governorate.

In 2002 the rate of infant mortality slightly decrease to

reach 50.6/1000 due to slight improvement of economic

conditions and decrease the effect of sanction after in-

troduction of oil f or food prog ram (und er Security Coun-

cil Resolution 986) [20], which provi ded the huma nitarian

needs of the Iraqi people.

Following the Gulf War and its 13 associated san ction

years, several events, conflicts and incompliance be-

tween the Iraqi government and UN members, especially

USA and UK, ended finally with another disaster, the

invasion and occupation of Iraq in March 2003 by the

Coalition Forces Militaries [21 ].

The invasion despite the lifting of sanction, added a

disastrous second destruction of the remaining weak in-

frastructure and health facilities, causing further loss of

health services, resources, and security conditions. This

was also the cause of increasing violence and terror in

most Iraqi cities including Al-Ramadi city, and the

spreading of this violence from one region to another

which forced people to either migrate or face life trage-

dies [22].

The IMR in Al-Ramadi province during the second

stage was 45.5/1000 in 2003, increased in 2004 (49.5/

1000) and 2005 (55.5 /1000) with maximum rate of 58.6/

1000 in 2006, and slightly decreased in 2007 to reach

54.2/1000 live births. During this period of violence and

war, the health facilities and services became poor in

Al-Ramadi province and many doctors and health em-

ployers left the province migrating to other safer areas

inside or outside the country, where as people stayed in

the province were more prone for explosions, malnutri-

tion and difficulties in reaching health centers and hospi-

tals thus the IMR in Al-Ramadi province reached a high

rate during that period.

With the beginning of improvement of health and se-

curity conditions and decreasin g of violence (third stage)

the recorded IMR decrease to reach 44.5/1000 in 2008,

then increased in 2009 and 2010 to reach 48.2/1000 and

52.3/1000 respectively, this increase of rate during the

improvement of health and security conditions was due

H. F. Aljumaily et al. / Health 5 (2013) 292-297 295

to improvement of registration of births and deaths in the

province and also the recorded high rate of Perinatal

mortality, low birth weight, premature, and births defect

associated deliveries in the province in the last years was

noticed by many studies [23-25], which added another

factors for the increasing of the IMR.

However, the actual IMR may be higher than the re-

ported IMR, because it is possible that deaths were not

reported, because families might wish to conceal the

death or because neonatal deaths might go without men-

tion [26]. In comparing the IMR of Al-Ramadi province

with that of the Iraqi national rate, the national rate

shows decreasing pattern from 2000-2010 [27], while

that of Al-Ramadi province show fluctuating pattern as

illustrating in Figure 3. The World Health Organization

(WHO) reported that the estimated IMR/1000 live births

for both sexes in the year 2000 and the year 2010 in the

developing countries as follow: Saudi Arabia (22/1000,

15/1000), Kuwait (10/1000, 10/1000), Qatar (11/1000,

7/1000), Bahrain (11/1000, 9/1000), Syria (20/1000, 14/

1000), Lebanon (25/1000, 19/1000), Jordan (25/1000,

18/1000), Iraq (34/1000, 31/1000), Iran (35/1000, 25/

1000), Turkey (33/1000, 12/1000), Egypt (37/1000, 19/

1000), Banglade sh (63/1000, 38/1000), Algeria (41/1000,

31/1000) [28].

While the national IMR continued decreasing in its rate,

as these are hospital based studies, their registration may

be less affected during the loss security conditions than

population based studies, a nd also the l ow birth deliveri es,

neural tube defect, and perinatal mortalities are related

directly to the health of mother during pregnancy, and

different than the IMR which is more related and affected

by post neonatal environment and security conditions.

However , a marked decline in infant mortality rates was

reported in all Arab countries from 1990 to 2009. The

decline in infant mortality rates ranged from 10.2% to

66.7%. A sharp decline in rates was especially seen in the

member countries of the Gulf Cooperat ion Council (GCC),

Tunisia, Egypt and Jordan [3]…

For all included years (2000-2010), IMR of Al-

Ramadi province (51.2/1000 live births) was higher than

IMR of Haditha province (38.9/1000 live births) for the

same period [29] most probably because of registration

in the births and deaths in Al-Ramadi province still

200 02001200 2200 3200 4200 5200 6200 7200 8200 9201 0

IMRRamad i

IMRIraq

Figure 3. The IMR of Al-Ramadi province and the IMR of Iraq.

working during the period of war and violence, and

could be the registration of data in center of governorate

more than other cities. In addition to improvement of

registrations, many reasons may be behind the elevation

of IMR in 2009, 2010 in Al-Ra madi, these may be du e to

the low availability of equipments and efficacy medi-

cations for the sake of early diagnosis and detection,

mismanagement due to lack of facilities necessary for

fetal management, and trained personnel’s leading to

medical malpractice Organic Maternal causes with stress-

ful life that may lead to restricted fetal growth and other

morbidities which determined by low pregnancy body

mass index, low gestational weight gain, the same find-

ings noticed by other studies [24]. The appearance of

incidences of congenital anomalies was recorded mostly

at that period as a complication of war. Moreover, Al-

Ramadi at that time, still safety unsecured compared with

other areas of Iraq a little bite safer, because of terrorism

groups (hot region) may lead the global health care pro-

fessionals not to visit Al-Ramadi and provide their es-

sential health services. All these events may lead to in-

crease of IMR at that period.

In this study the mortality in neonatal period show in-

crease rate when compared with post neonatal period

which was consistent with Iraqi [27] and Brazilian stud-

ies [30]. It was seen that the first month of life was asso-

ciated with problems related to infant and pregnancy

such as preterm delivery, low birth weight and birth de-

fect, while after the first month of life was greatly asso-

ciated with social and environmental factors such as in-

fection and access to health care facilities [31].

This study showed that IMR is significantly higher in

males than females which was consistent with other

studies [18,19]. In the present study ,there were a male

infants had higher mortality than female infants, this ob-

servation was consistent with observation of other stud-

ies in developing countries, particularly Asia of an im-

balance in the sex ratio in infant mortality favoring males

led researchers to hypo thesize that environmental factors

have encountered. It was also reported that male infant

fatality rate higher than female infant, and this may at-

tributed to many etiological factors like sepsis, G6PD

deficiency, and x-linked disorders which were more pre-

valent in male gender. In a study was done in Al-Ramadi

from 2010-2011, which showed that the number of Con-

genital Anomalies (CAs) was found significantly more in

males than females in total birth and live birth deliv-

eries [32]. Surprisingly, the rise of IMR may be related to

the social trend of this tribal populated area to pay more

attention and care for boys rather than girls, this may

lead to over estimation of male gender. Moreover, boys

were found to be 60% to be born prematurely and suffer

from pre-term birth condition such as neonatal respira-

tory distress syndrome [33].

H. F. Aljumaily et al. / Health 5 (2013) 292-297

296

We record higher IMR among infants from rural areas

than urban areas, this was in agreement with other stud-

ies [18,19,30]. This is expected since poverty, poor healt h

services and facilities are more common in rural than

urban areas [34].

In conclusion: the study limited by the fact that it did

not record the causes of infant deaths which will clarify

whether deaths were due to malnutrition and medical

diseases of sanction, or the trauma or injuries of wars or

both.

Whereas, Iraq still has a high IMR comparing with

other developing countries, due to deterioration of so-

cioeconomic circumstances and survival chance among

young children under the effect of war conflicts and

American invasion.

However, there is an increase in neonatal mortality

rate more than post neonatal mortality rate and increase

in early mortality rate more than late mortality rate,

probably due to poor antenatal care, increase rate of pre-

mature deliveries, and absenc e of modern facilities in the

neonatal care unit.

In addition to a significant association between IMR

and Rural residence, and an association between IMR

and Male gender.

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