Iraq - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

�Iraq Multiple Indicator Cluster Survey Final Report, 2006 IRAQ Monitoring the situation of children and women Multiple Indicator Cluster Survey 2006 Volume 1: Final Report Central Organization for Statistics & Information Technology Kurdistan Regional Statistics Office Ministry of Health United Nations Children’s Fund � Iraq Multiple Indicator Cluster Survey Final Report, 2006 �Iraq Multiple Indicator Cluster Survey Final Report, 2006 Monitoring the Situation of Children and Women Findings from the Iraq Multiple Indicator Cluster Survey 2006 VOLUME 1: FINAL REPORT October 2007 Implementing agencies: Central Organization for Statistics & Information Technology Kurdistan Regional Statistics Office Partner: Ministry of Health United Nations Children’s Fund �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 ���Iraq Multiple Indicator Cluster Survey Final Report, 2006 Contributors to the report: Consultant, Manar E. Abdel-Rahman Central Organization for Statistics & Information Technology (COSIT) Kurdistan Regional Statistics Office (KRSO) UNICEF Headquarters, MENA Regional Office and Country Office for Iraq The Iraq Multiple Indicator Cluster Survey (MICS) was carried by Central Organization for Statistics & Information Technology and Kurdistan Regional Statistics Office in collaboration with the Ministry of Health. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) . Technical support was also provided by Government of Iraq Steering Committee (MOH, MOE, MOLSA, MMPW), the United Nations Steering Committee (WHO, UNFPA, WFP), the Pan Arab Project for Family Health (PAPFAM), and MEASURE DHS/ ORC Macro. This survey was also made possible by the Canadian International Development Agency’s (CIDA) financial support. This survey was conducted as part of the third round of MICS surveys (MICS-3), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MICS surveys that were conducted in 1995 and in 2000. Survey tools are based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Central Organization for Statistics & Information Technology and Kurdistan Regional Statistics Office. 2007. Iraq Multiple Indicator Cluster Survey 2006, Final Report. Iraq. �v Iraq Multiple Indicator Cluster Survey Final Report, 2006 Topic Indicator number Indicator National Kurdistan Region Unit MICS MDG FERTILITY Fertility Total fertility rate 4.3 3.8 per woman CHILD MORTALITY Child mortality 1 13 Under-five mortality rate 41 40 per thousand Child mortality 7 7 per thousand 2 14 Infant mortality rate 35 34 per thousand Post neonatal mortality 12 11 per thousand Neonatal mortality 23 23 per thousand NUTRITION Nutritional status 6 4 Underweight prevalence (moderate and severe) 7.6 7.9 percent (severe) 1.4 1.6 percent 7 Stunting prevalence (moderate and severe) 21.4 13.1 percent (severe) 7.5 3.9 8 Wasting prevalence (moderate and severe) 4.8 4.9 percent (severe) 1.2 1.2 Breastfeeding 45 Timely initiation of breastfeeding 30.6 15.2 percent 15 Exclusive breastfeeding rate 25.1 11.8 percent 16 Continued breastfeeding rate percent at 12-15 months 67.6 49.6 percent at 20-23 months 35.7 32.4 percent 17 Timely complementary feeding rate 51 22 percent 18 Frequency of complementary feeding 38 15.2 percent 19 Adequately fed infants 31.8 13.6 percent Salt iodization 41 Iodized salt consumption 28.4 56.8 percent Vitamin A 42 Vitamin A supplementation (under-fives) 2 2.9 percent 43 Vitamin A supplementation (post-partum mothers) 16.1 11.2 percent Low birth weight 9 Low birth weight infants 14.8 14.5 percent 10 Infants weighed at birth 44.9 43.2 percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 91.4 96.6 percent 26 Polio immunization coverage 57 69.2 percent 27 DPT immunization coverage 52.8 62.9 percent 28 15 Measles or MMR immunization coverage 65.3 71.2 percent 29 Hepatitis B immunization coverage 49.4 72.7 percent 31 Fully immunized children 38.5 47 percent Tetanus toxoid 32 Neonatal tetanus protection 61.4 59.4 percent Care of illness 33 Use of oral rehydration therapy (ORT) 30.7 26.5 percent 34 Home management of diarrhoea 15.3 30.4 percent 35 Received ORT or increased fluids, and continued feeding 63.8 63.1 percent 23 Care seeking for suspected pneumonia 81.6 64.6 percent 22 Antibiotic treatment of suspected pneumonia 82 73.8 percent SUMMARY TABLE OF FINDINGS Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Iraq, 2006 vIraq Multiple Indicator Cluster Survey Final Report, 2006 Topic Indicator number Indicator National Kurdistan Region Unit MICS MDG Solid fuel use 24 29 Solid fuels 4.6 5.9 percent ENVIRONMENT Water and Sanitation 11 30 Use of improved drinking water sources 79.1 96.9 percent 13 Water treatment 9.2 3.3 percent 12 31 Use of improved sanitation facilities 92.3 97.7 percent 14 Disposal of child’s faeces 40.7 48.6 percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 49.8 58.2 percent 98 Unmet need for family planning 10.8 13.4 percent 99 Demand satisfied for family planning 82.2 81.3 percent Maternal and newborn health 20 Antenatal care 83.8 80.2 percent 44 Content of antenatal care Blood test taken 65.9 67.4 percent Blood pressure measured 76.2 74.2 percent Urine specimen taken 62.7 61.2 percent Weight measured 59.3 57.1 percent 4 17 Skilled attendant at delivery 88.5 88.1 percent 5 Institutional deliveries 62.6 67.8 percent CHILD DEVELOPMENT 46 Support for learning 46.4 45.4 percent 47 Father’s support for learning 54.9 54.2 percent EDUCATION Education 52 Pre-school attendance 2.5 3.6 percent 53 School readiness 4.2 12.7 percent 54 Net intake rate in primary education (6 years) 63.2 60.2 Net intake rate in primary education (7 years) 82.1 87.5 percent 55 6 Net primary school attendance rate 85.8 94.5 percent 56 Net secondary school attendance rate 40.1 52.5 percent 57 7 Children reaching grade five 95.2 92.5 percent 58 Transition rate to secondary school 78.3 84.4 percent Primary completion rate (gross) 80.9 114.3 percent 59 7b Primary completion rate (net) 43.9 49 percent 61 9 Gender parity index Primary school 0.88 0.95 ratio Secondary school 0.75 0.96 ratio Literacy 60 8 Adult literacy rate 65.6 64.2 percent CHILD PROTECTION Birth registration 62 Birth registration 95 98.5 percent Child labour 71 Child labour 10.7 6.4 percent 72 Labourer students 61.5 79.7 percent 73 Student labourers 9.5 6.4 percent Child discipline 74 Any psychological/physical punishment 83.7 68.1 percent Early marriage 67 Marriage before age 15 5.4 6.8 percent Marriage before age 18 22.6 26.1 percent 68 Young women aged 15-19 currently married 19 10 percent v� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Topic Indicator number Indicator National Kurdistan Region Unit MICS MDG 69 Spousal age difference Women aged 15-19 25.8 26.5 percent Women aged 20-24 21.1 21.4 percent Domestic violence 100 Attitudes towards domestic violence 59.1 36.7 percent Disability 101 Child disability 14.8 18.9 percent HIV/AIDS AND ORPHANED CHILDREN HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young people 2.1 0.7 percent 89 Knowledge of mother- to-child transmission of HIV 18.5 20.7 percent 86 Attitude towards people with HIV/AIDS 8 7.6 percent 87 Women who know where to be tested for HIV 6.1 3.4 percent 88 Women who have been tested for HIV 2.8 0.5 percent Support to orphaned children 75 Prevalence of orphans 5.9 5.5 percent 78 Children’s living arrangements 2.4 1.5 percent 77 20 School attendance of orphans versus non-orphans 0.84 1.10 ratio v��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Summary Table of Findings . iv Table of Contents . vii List of Tables . ix List of Figures . xi List of Maps . xii List of Abbreviations . xiii Preface . xiv Acknowledgements . xv Executive Summary . xvi 1. Introduction . 1 1.1. Background. . 1 1.2. Survey Objectives. 2 2. Sample and Survey Methodology . 3 2.1. Sample Design. 3 2.2. Questionnaires. 3 2.3. Training and fieldwork . 4 2.4. Data Processing . 5 2.5. Data Analysis . 5 3. Sample Coverage and the Characteristics of Households and Respondents . 6 3.1. Sample Coverage . 6 3.2. Characteristics of Households . 6 3.3. Characteristics of Respondents . 7 4. Fertility . 9 4.1. Current fertility. 9 4.2. Abortions and Stillbirths . 10 5. Child Mortality. 11 5.1. Levels and Trends in Infant and Child Mortality . 11 5.2. Differentials in Childhood Mortality by Socioeconomic Characteristics . 12 5.3. Differentials in Childhood Mortality by Biodemographic Characteristics . 13 6. Nutrition. 14 6.1. Nutritional Status . 14 6.2. Breastfeeding . 16 6.3. Salt Iodization . 21 6.4. Vitamin A Supplements . 22 6.5. Low Birth Weight . 23 6.6. Growth Monitoring . 25 7. Child Health . 26 TABLE OF CONTENTS v��� Iraq Multiple Indicator Cluster Survey Final Report, 2006 7.1. Immunization . 26 7.2. Tetanus Toxoid . 28 7.3. Oral Rehydration Therapy . 29 7.4. Care seeking and Antibiotic Therapy of Children with Suspected Pneumonia . 31 7.5. Solid Fuel Use . 32 8. Environment . 33 8.1. Water and Sanitation . 33 9. Reproductive Health . 39 9.1. Contraception . 39 9.2. Unmet Need . 41 9.3. Antenatal Care . 42 9.4. Assistance at Delivery . 45 9.5. Delivery in a Health Facility . 46 9.6. Caesarean Deliveries . 47 10. Child Development . 48 11. Education . 50 11.1. Pre-School Attendance and School Readiness . 50 11.2. Primary School Attendance . 50 11.3. Adult Literacy . 55 12. Child Protection. 56 12.1. Birth Registration . 56 12.2. Child Labour. 56 12.3. Child Discipline . 58 12.4. Early Marriage . 58 12.5. Domestic Violence . 61 12.6. Child Disability . 62 13. HIV/AIDS and Orphaned Children . 64 13.1. Knowledge of HIV Transmission . 64 13.2. Orphaned Children . 68 List of References . 70 Tables . 71 �xIraq Multiple Indicator Cluster Survey Final Report, 2006 Table HH.1: Results of household and individual interviews . 71 Table HH.2: Household age distribution by sex . 72 Table HH.3: Household composition . 73 Table HH.4: Women’s background characteristics . 74 Table HH.5: Children’s background characteristics . 75 Table FR.1: Current fertility . 76 Table FR.2: Current fertility by background characteristics . 77 Table FR.3: Abortions and stillbirths . 78 Table CM.1: Childhood mortality rates . 79 Table CM.2: Child mortality by background characteristic . 80 Table CM.3: Child mortality by biodemographic characteristic . 81 Table NU.1: Child malnourishment . 82 Table NU.2: Initial breastfeeding . 83 Table NU.3: Breastfeeding . 84 Table NU.4: Adequately fed infants . 86 Table NU.5: Iodized salt consumption . 87 Table NU.6: Children’s vitamin A supplementation . 88 Table NU.7: Post-partum mothers’ vitamin A supplementation . 89 Table NU.8: Low birth weight infants . 90 Table NU.9: Growth monitoring . 91 Table CH.1: Vaccinations . 93 Table CH.2: Vaccinations by background characteristics . 94 Table CH.2A: Vaccinations under Polio national campaign . 96 Table CH.2B: Vaccinations under MMR national campaign . 98 Table CH.3: Neonatal tetanus protection . 99 Table CH.4: Oral rehydration treatment . 100 Table CH.5: Home management of diarrhoea . 102 Table CH.6: Antibiotic therapy and care seeking of children with suspected pneumonia . 104 Table CH.7A: Knowledge of the two danger signs of pneumonia . 106 Table CH.8: Solid fuel use . 108 Table EN.1: Use of improved water sources . 110 Table EN.1A: Reliability of the main drinking water sources . 112 Table EN.2: Household water treatment . 113 Table EN.3: Time to source of water . 115 Table EN.4: Person collecting water . 116 Table EN.5: Use of sanitary means of excreta disposal . 117 Table EN.5A: Functionality of the sewage system . 119 Table EN.6: Disposal of child’s faeces . 120 LIST OF TABLES x Iraq Multiple Indicator Cluster Survey Final Report, 2006 Table EN.7: Use of improved water sources and improved sanitation . 121 Table RH.1: Use of contraception . 122 Table RH.1A: Source of contraceptives . 124 Table RH.1B: Reasons for none-use of contraception . 126 Table RH.2: Unmet need for contraception . 128 Table RH.3: Antenatal care provider . 129 Table RH.4: Antenatal care content . 130 Table RH.5: Assistance during delivery . 131 Table RH.6: Caesarean deliveries . 133 Table CD.1: Family support for learning . 134 Table ED.1: Early childhood education . 135 Table ED.2: Primary school entry . 136 Table ED.3: Primary school net attendance rate . 137 Table ED.4: Secondary school net attendance rate . 138 Table ED.4W: Secondary school age children attending primary school . 139 Table ED.5: Children reaching grade 5 . 140 Table ED.6: Primary school completion and transition to secondary education . 141 Table ED.7: Education gender parity . 142 Table ED.8: Adult literacy . 143 Table CP.1: Birth registration . 144 Table CP.2: Child labour . 145 Table CP.2W: Child labour . 146 Table CP.3: Labourer students and student labourers . 148 Table CP.4: Child discipline . 149 Table CP.5: Early marriage . 151 Table CP.6: Spousal age difference . 152 Table CP.9: Attitudes toward domestic violence . 154 Table CP.10: Child disability . 155 Table HA.1: Knowledge of preventing HIV transmission . 157 Table HA.2: Identifying misconceptions about HIV/AIDS . 158 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission for women 15-49 . 159 Table HA.3B: Comprehensive knowledge of HIV/AIDS transmission for women 14-24 . 160 Table HA.4: Knowledge of mother-to-child HIV transmission . 161 Table HA.5: Attitudes toward people living with HIV/AIDS . 162 Table HA.6: Knowledge of a facility for HIV testing . 163 Table HA.10: Children’s living arrangements and orphanhood . 164 Table HA.12: School attendance of orphaned and vulnerable children . 166 x�Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure HH.1: Age and Sex Distribution of Household Population, Iraq, 2006 6 Figure CM.1 Under-five mortality rates for the 5-year period preceding the survey by biodemographic characteristics, Iraq, 2006 12 Figure NU.1: Percentage of children under-five who are undernourished, Iraq, 2006 16 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth, Iraq, 2006 18 Figure NU.3A: Percentage of infants under 6 months of age exclusively breastfed, Iraq, 2006 19 Figure NU.3B: Percent distribution of children aged under 3 years infant by feeding pattern by age group, Iraq, 2006 20 Figure NU.4: Percentage of infants 0-11 months who were adequately fed, Iraq, 2006 20 Figure NU.5: Percentage of households consuming adequately iodized salt, Iraq, 2006 21 Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months for measles or MMR), Iraq, 2006 27 Figure CH.5: Percentage of children aged 0-59 months with diarrhoea in the last two weeks who took increased fluids and continued to feed during the episode, Iraq, 2006 30 Figure CH.7A: Percentage of mothers/caretakers who recognize fast and difficult breathing as signs for seeking care immediately, Iraq, 2006 31 Figure EN.1: Percentage distribution of household members by source of drinking water Iraq, 2006 33 Figure EN.7: Percentage of household population using improved drinking water sources and sanitary means of excreta disposal, Iraq, 2006 38 Figure RH.1A: Current use of contraceptive by method, Iraq, 2006 39 Figure RH.1B: Percentage of currently married women aged 15-49 years using contraceptive methods, Iraq, 2006 40 Figure RH.3A: Percent distribution of women aged 15-49 by number and timing of antenatal care (ANC) visits for the most recent birth, Iraq, 2006 43 Figure RH.3B: Percent distribution of women aged 15-49 who gave birth in the two years preceding the survey by reason for not seeking antenatal care (ANC), Iraq, 2006 43 Figure CD.1: Percentage of children aged 0-59 months for whom household members are engaged in activities that promote learning & school readiness, Iraq, 2006 48 Figure ED.4: Percentage of secondary school NAR, secondary school age children attending primary school and secondary school children out of school, Iraq, 2006 53 Figure ED.6: Gross and net primary school completion rates, Iraq, 2006 53 Figure ED.7: Gender parity index for primary and secondary schools, Iraq, 2006 55 Figure CP.5: Percentage of women aged 15-49 years married before their 15th birthday, percentage of women aged 20-49 years married before their 18th birthday, Iraq, 2006 60 LIST OF FIGURES x�� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure CP.5A: Percentage of women aged 15-49 years married before their 15th birthday, percentage of women aged 20-49 years married before their 18th birthday, Kurdistan Region, 2006 60 Figure CP.9: Percentage of women aged 15-49 years who believe a husband is justified in beating his wife, Iraq, 2006 62 Figure HA.3A: Percent of women aged 15-49 years who have comprehensive knowledge of HIV/AIDS transmission, Iraq, 2006 65 Figure HA.3B: Percentage of women aged 15-24 years who have comprehensive knowledge of HIV/AIDS transmission, Iraq, 2006 66 Figure HA.5: Percentage of women aged 15-49 years who have heard of AIDS who agree with none of the discriminatory statements towards people living with HIV/AIDS, Iraq, 2006 67 Figure HA.12: Double orphans to non-orphans school attendance ratio, Iraq, 2006 68 Map FR.2: Total fertility rate, by governorate, Iraq, 2006 10 Map NU.1: Percentage of children aged 0-59 months who are severely or moderately malnourished, by governorate, Iraq, 2006 15 Map NU.8: Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, by governorate, Iraq, 2006 24 Map EN.1: Percentage of household population using improved drinking water sources, by governorate, Iraq, 2006 34 Map EN.5: Percentage of household population using sanitary means of excreta disposal, by governorate, Iraq, 2006 37 Map RH.3: Percent distribution of women aged 15-49 who were provided antenatal care by skilled personnel, by governorate, Iraq, 2006 44 Map RH.5: Percent distribution of women aged 15-49 who were assisted during delivery by skilled personnel, by governorate, Iraq, 2006 46 Map ED.2: Percentage of children of primary school entry age (7 years) currently attending grade 1, by governorate, Iraq, 2006 51 Map CP.2: Percentage of children aged 5-14 years who are involved in child labour activities, by governorate, Iraq, 2006 57 LIST OF MAPS x���Iraq Multiple Indicator Cluster Survey Final Report, 2006 LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CDC Center for Disease Control CEDAW Convention on the Elimination of All Forms of Discrimination Against Women COSIT Central Organization for Statistics and Information Technology CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DHS Demographic and Health surveys DPT Diptheria, Pertussis, and Tetanus GPI Gender Parity Index Hep B Hepatitis B HIV Human Immunodeficiency Virus ILCS Iraq Living Conditions Survey IUD Intrauterine Device KRSO Kurdistan Regional Statistics Office LAM Lactational Amenorrhea Method LAS League of Arab States MDG Millennium Development Goals MENA Middle East and North Africa MICS Multiple Indicator Cluster Survey MICS-2 The second round of the Multiple Indicator Cluster Survey MICS-3 The third round of the Multiple Indicator Cluster Survey MMR Measles, Mumps, and Rubella MOH Ministry of Health MOI Ministry of Interior NAR Net Attendance Rate NCHS National Center for Health Statistics (USA) ORS Oral Rehydration Solution ORT Oral Rehydration Therapy PAPFAM Pan Arab Project for Family Health PPS Probability Proportional to Size PSU Primary Sampling Unit RHF Recommended Home Fluid SD Standard Deviation SPSS Statistical Package for Social Sciences SSD Suleimaniya Statistical Directorate TFR Total Fertility Rate UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WFFC World Fit For Children WHO World Health Organization x�v Iraq Multiple Indicator Cluster Survey Final Report, 2006 With due acknowledgement of the huge joint effort rendered by all partners, we are pleased to present the final findings of the 2006 Multiple Indicator Cluster Survey (MICS) on key social indicators related to the situation of children and women in Iraq. This survey represents the third round of the Multiple Indicator Cluster Survey (MICS-3) in Iraq. The first MICS was undertaken in 1996, and MICS-2 was completed in 2000. This final report for MICS-3 presents the main findings at the national level for the 18 governorates of Iraq on some of the main topics covered in the overall survey. The primary implementers of MICS-3 are Iraq’s Central Organization for Statistics and Information Technology and Kurdistan Regional Statistics Office, in collaboration with the Ministry of Health. The survey was completed with the much appreciated technical and financial support from UNICEF, and complied with the standard methodologies recommended by UNICEF throughout the various stages of preparation, field work and production of results. MICS is a large-scale and truly representative survey, with a sample size of 18,144 households randomly selected from all governorates of Iraq, including the Kurdistan Region. Iraq is one of the first countries in the Middle East and North African region to release its MICS- 3 survey findings, despite the huge technical, financial and operational difficulties involved in carrying out such a task during this difficult period of time. That Iraq is able to undertake data collection in this way is indeed an outstanding achievement and testifies to the great spirit of resilience and dedication shared by all partners in the MICS-3 process. It is hoped that the MICS-3 findings will positively contribute to monitoring progress towards implementing major international commitments and goals, including the World Fit for Children (WFFC) goals and the Millennium Development Goals (MDGs). This critical information will enable the Government of Iraq and all its partners to improve policy development for basic services, and prioritize efforts to protect and promote the wellbeing of Iraqi children and women. Ali Ghaleb Baban Minister of Planning and Development Cooperation PREFACE xvIraq Multiple Indicator Cluster Survey Final Report, 2006 Our children are our flowerbuds of today and our treasure for tomorrow. They are our greatest assets and the Multiple Indicators Cluster Survey (MICS) is an indispensable means of establishing scientific approaches to address the many possible problems facing children and to establish reliable approaches to improve their conditions. We in the Central Organization for Statistics and Information Technology (COSIT) and Kurdistan Regional Statistics Office (KRSO) are both committed to full and active participation in any noble activity on these lines and extend our appreciation to all those who contributed directly or indirectly to the preparation, implementation and the delivery of the findings of the MICS-3. The Iraq Country Office, Headquarters and MENA Regional Office of the United Nations Children’s Fund (UNICEF) and their staff should be acknowledged for their efforts in realising this and spending time and energy for advocating, realising and capacity building in this respect. Our sincere thanks and appreciation go to all the employees in the various departments of the COSIT and KRSO who played a major coordinating role throughout the survey. Their contribution has culminated in the successful completion of this important survey and production of reliable results despite the immense difficulties facing our beloved country. We would also like to acknowledge our fruitful partnership with WHO and UNFPA and the valuable technical support of MEASURE DHS/ ORC Macro and PAPFAM/LAS and their constructive comments and advice provided throughout the various stages of the survey. Dr. Mehdi Alalak and Dr. Jamal Ameen Head of COSIT Head of KRSO ACKNOWLEDGEMENTS The Iraq Multiple Indicator Cluster Survey (Iraq MICS-3) has been conducted as part of the third round of the Multiple Indicator Cluster surveys, carried out around the world in more than 50 countries, in 2005-2006. The total sample size for the survey is 18,144 households. The main purpose of the survey was to provide up-to-date information for assessing and monitoring the situation of children and women in Iraq. The survey collected information from all household members on education, water and sanitation, child labour, child discipline, disability, and salt iodization. The survey also collected information from individual women on marriage, child mortality, birth history, tetanus toxoid, maternal and newborn health, contraception and unmet need, attitude towards domestic violence and HIV/AIDS. Furthermore the Iraq MICS-3 collected information about children under-five on birth registration and early learning, Vitamin A supplementation, breastfeeding, care of illness, immunization, and anthropometry. Current Fertility The Iraq MICS-3 estimated the fertility rate for the three years before the survey as 4.3 children per woman. The total fertility rate is estimated at 5.1 children per woman in rural areas, about 22 percent higher than in urban areas (4.0). Fertility is lower in metropolitan areas (3.8) than in other urban areas (4.2). There are differences in fertility among governorates, ranging from a low of 2.9 in Suleimaniya to a high of 5.4 in Nineveh and Missan. In general, fertility is lower at Kurdistan Region (3.8) than in the South/ Centre governorate (4.4). The level of fertility is inversely related to women’s education, decreasing rapidly from 4.8 children among women with no or primary education to 3.5 children among women who have at least some secondary education. Child Mortality The 2006 Iraq MICS-3 produced mortality estimates compatible with the recent mortality estimates found by the 2004 Iraq Living conditions survey. Both these surveys showed estimates that are considerably lower than previous estimates. The infant mortality rate in the five years preceding the survey is 35 per 1,000 live births and under-five mortality is 41 deaths per 1,000 live births for the same period, indicating that the majority of under- five deaths (85 percent) are infant deaths. At the national level, relatively little, if any improvement has taken place during the last 15 years, with under-five mortality at 49 per 1,000 during the 10-14 year period preceding the survey. Under-five mortality rates are practically the same in the South-Centre governorate as a whole and in Kurdistan Region. The highest mortality rates are observed in the Salahuddin governorate (70 percent higher than the national average), while the lowest rates are observed in Kirkuk (half the national average). Under-five mortality is also relatively higher than the national average in Al- Muthanna, Wasit, Dohuk, Erbil, Kerbala, Nineveh, Al-Najaf, Babil, and Salahuddin governorate. First births, children born to very young mothers, children born after a short interval, and children of high birth orders experience significantly higher risks of mortality. For children of women who give birth above age 40, under-five mortality is elevated to 64 per 1,000 births, while the elevated risk of mortality among first births is also observed. Nutrition Nutritional Status Eight percent of children under-five in Iraq are moderately or severely underweight and one percent is severely underweight. Over one-fifth (21 percent) of children are severely or moderately stunted (or too short for their age) and eight percent are severely stunted. Five percent of children are severely or moderately wasted (or too thin for their height) and one percent is severely wasted. The nutritional status of children under-five has improved from the situation prevailing during the 90’s and the first half of 2000 where 9-25 percent was found to be moderately underweight. Differentials in children’s nutritional status continue to be observed, however, particularly by governorate where the percentage of children who are moderately or severely underweight, stunted, and wasted are highest in Basrah and Wasit governorates. EXECUTIVE SUMMARY Iraq Multiple Indicator Cluster Survey Final Report, 2006xv� Overall, about nine percent of children in Iraq are overweight with more overweight girls than boys and more overweight children in South/Centre Iraq governorates than in Kurdistan Region. Breastfeeding More women start breastfeeding within one day (85 percent) than within one hour (31 percent). Exclusive breastfeeding is low in Iraq where only one in four children aged less than six months are exclusively breastfed. Although this figure is low the current survey revealed a considerable improvement from the 2000 Iraq MICS-2 and 2004 ILCS where exclusive breastfeeding was only half the current level. Less than half of the infants in the Kurdistan Region are exclusively breastfed compared to the South/Centre governorates as a whole. Kerbala governorate stands out as the governorate with the highest percentage of exclusively breastfed infants where around two-thirds of its infants are breastfed as recommended. About one third of Iraqi infants aged 0-11 months are adequately fed. Rural infants are more adequately fed than infants in urban areas. More infants in South/ Centre governorates (34 percent) are adequately fed than in Kurdistan Region (14 percent). The percent of adequately fed infants varies from 8 percent in Erbil to 52 percent in Kerbala governorate. Salt Iodization The recommended amount of iodine was found in 28 percent of households in Iraq. Almost double urban households (34 percent) use iodized salts compared to rural households (16 percent). Dohuk (67 percent) and Suleimaniya (63 percent) governorates have the highest consumption of adequately iodized salt while Missan, Al-Qadisiya and Basrah have the lowest percentage. Overall, more households in Kurdistan Region (57 percent) consume iodized salt than households in South/ Centre Iraq (24 percent). Vitamin A Supplements The majority of children in Iraq did not receive the recommended Vitamin A supplementation. Only two percent of children aged 6-59 months received a high dose of Vitamin A supplement in the six months prior to the MICS. The low percentage of Vitamin A Supplements is attributed to a known shortage of supply in the country. Only about 16 percent of mothers with a birth in the previous two years received a Vitamin A supplement within eight weeks of the birth. Overall coverage is 11 percent in Kurdistan Region compared to 17 percent in the South/Centre Iraq governorates. Low Birth Weight Overall, 45 percent of births were weighed at birth with approximately 15 percent estimated to weigh less than 2,500 grams at birth – a slight improvement from the 12 percent figure from the 2000 Iraq MICS- 2. The highest estimate of low birth weight was found in Al-Muthanna governorate (22 percent) while the lowest was in Al-Anbar governorate (11 percent). Child Health Immunization Thirty nine percent of children aged 18-29 months had all recommended vaccinations by age 12 months (18 months for measles or MMR). Children are considered to have all recommended vaccinations fully immunized if they receive BCG, DPT (1-3 doses), polio (1-3 doses), HepB (1-3 doses) vaccines, by 12 months of age and either a measles or MMR vaccine by 18 months. Forty seven percent of children were fully immunized in Kurdistan Region. For children aged 18-29 months BCG vaccination, DPT3, Polio3, and HepB3 by the age of 12 months was 91, 53, 57, and 50 percent respectively. In addition, the coverage for measles or MMR vaccine by 18 months was at 65 percent. Tetanus Toxoid Tetanus toxoid coverage is relatively widespread in Iraq. Almost two third of mothers in the country are considered protected against tetanus (61 percent). The highest coverage is in Baghdad (80 percent) and lowest is in Wasit (39 percent). Coverage increases from 42 percent among women with no education to 78 percent among women with secondary or higher education. Oral Rehydration Therapy Dehydration caused by diarrhoea is a major cause of mortality and morbidity among Iraqi children. Overall, 13 percent of children under-five years Iraq Multiple Indicator Cluster Survey Final Report, 2006 xv�� xv��� Iraq Multiple Indicator Cluster Survey Final Report, 2006 of age had diarrhoea in the two weeks preceding the survey. The peak prevalence occurred among children aged 6-11 months. Almost one third of the children (31 percent) received ORS while they had diarrhoea. Use of ORS is lowest in Wasit (15 per-- cent), Erbil (19 percent) and Kerbala (19 percent) and highest in Dohuk (47 percent). About two-thirds of children either received ORT or fluid intake was increased, and at the same time, feeding was continued, as is the recommendation. Proper home management of diarrhoea varied by age of the child, with the highest percentage observed for the 24-35 months age group (75 percent) and the lowest percentage observed for the 0-11 months age group (54 percent). Children in Basrah governorate are least properly home managed of diarrhoea (54 percent) while children in Kirkuk receive the best management (82 percent). Care Seeking and Antibiotic Therapy of Children with Suspected Pneumonia Thirteen percent of the children surveyed had suspected pneumonia. A considerably high percentage of these children received an antibiotic during the two weeks prior to the survey (82 percent). Antibiotic therapy of suspected pneumonia is lower among children from rural households and children whose mothers/caretakers have no education than among other children. All governorates had high percentages of over 75 percent, with exception of Diala that had a percentage of 53 and Erbil that had a percentage of 58. A high proportion of children were taken to appropriate providers (82 percent) – 28 percent were taken to private physician, 24 percent to government hospitals, and 19 percent to government health centre. More children were taken to appropriate providers in South/Centre governorates (83 percent) than in Kurdistan Region (65 percent). Mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 22 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility are developing a fever (70 percent) and having diarrhoea (50 percent). Solid Fuel Use Use of solid fuel is not a problem in Iraq with only about five percent of all households in Iraq using it. Use of solid fuels is negligible in urban areas (0.6 percent), but increases in rural areas, with 13 percent of the households using solid fuels. Al- Qadisiya governorate is the governorate that mostly contributes to the solid fuels use in the country. Environment Water Overall, 79 percent of the population has access to improved drinking water sources – 92 percent in urban areas and only 57 percent in rural areas. Basrah governorate is considerably worse than all other governorates with only two percent of the population having access to improved drinking water sources and reliance is on reverse osmosis stored in tankers for water supply. Al-Muthanna and Babil have the next worst access to improved drinking water sources with percentage 53 and 64 percent respectively. Overall, Kurdistan Region governorates have better access to improved drinking water sources than South/Centre Iraq governorates with percentages of 97 and 77 respectively. The above figures may not reflect the condition and reliability of the main drinking water sources where nearly half of those who have access to improved drinking water sources indicated problems with the condition of services. In-house Water Treatment Water treatment is not common in Iraq with about 85 percent of households using none. Those who treat their water mostly either let it stand or boil it. Appropriate water treatment is done in nine percent of households. Kurdistan Region (3.3) has much lower percentage of appropriate water treatment than the South/ Centre governorates as a whole (10.4 percent). Time and Person to Obtain Water A large number of households have drinking water source on the premises (79 percent). It takes less than 30 minutes to get to the water source and bring water for 17 percent of all households. The average time to the source of drinking water was 21 minutes, with this time being almost double in rural areas than in urban areas. More adult women (55 percent) collect water than adult men (37 percent). Only in a small percentage of households do children under age 15 collect water (7 percent). x�xIraq Multiple Indicator Cluster Survey Final Report, 2006 More adult women collect water in rural areas, whereas the opposite is the case in urban areas. The more educated the head of the household is, the more men and fewer women tend to collect drinking water. Use of improved sanitation facilities is relatively high among Iraq population (92 percent), with about six in seven households using flush toilets connected to sewerage systems or septic tanks or pit latrines. As expected, use of improved sanitation facilities is higher in all urban areas (98 percent) than in rural areas (82 percent). Nonetheless, the above figures do not reveal the situation on the ground, as 40 percent of the respondents indicated problems with the functionality of the sewage system around their house. Residents of Al-Qadisiya governorate are the least likely than all other governorates to use improved facilities (64 percent compared with more than 80 percent for all other governorates). Reproductive Health Contraception Half of currently married women or husbands of these women are currently using contraception. Modern methods account for 33 percent of overall use. The most popular methods are the pill (15 percent) and IUD (12 percent). The next most popular methods are the withdrawal method (8 percent) and the lactational amenorrhea method (LAM) (7 percent). Female sterilization, periodic abstinence and injectables and condom are the least popular methods. Unmet Need Eleven percent of married Iraqi women are not us-- ing contraceptives but want to stop having chil-- dren (limit) or postpone the next pregnancy for at least two years (space). More women are in unmet need for spacing for contraception (7 percent) than in unmet need in limiting for contraception (3 per-- cent). Dohuk governorate has the largest number of women in total unmet need (18 percent). Demand for contraception satisfied is high in Iraq (82 percent). Demand for contraception satisfied is lower in rural areas (78 percent) compared to urban areas (84 percent); least in Dohuk governorate and for women in the age group 15-19 years. Antenatal Care Coverage of antenatal care by skilled personnel is relatively high in Iraq with 84 percent of women receiving antenatal care at least once during the pregnancy. Almost all women mostly receive antenatal care from a doctor. More than half the women had the recommended 4 or more antenatal care visits. Antenatal care coverage by skilled personnel is 15 percent more in urban areas compared to rural areas. Governorates of Wasit, Al-Qadisiya, Nineveh, and Erbil are lagging behind in antenatal care coverage. Only 60 percent of women who had antenatal care had their weight measured, 63 percent had a urine sample taken, 66 percent had a blood test taken, and 76 percent had their blood pressure taken. In general, compared to other services, weight measurement was the least to be received by women within the different governorates with a striking low 37 percent for this indicator in Dohuk governorate. Assistance at Delivery Eighty-nine percent of births occurring in the two years prior to the Iraq MICS-3 survey were delivered by skilled personnel (doctor, nurse, or a certified midwife), with more births in urban areas (95 percent) than rural areas (78 percent). More than half of births (55 percent) in the two years prior to the Iraq MICS-3 survey were delivered with assistance of a doctor. Women in Ninevah, Kirkuk, and Wasit governorates were the least likely in the country to have their deliveries assisted by skilled personnel. The more educated a woman is the more likely she is to have delivered with the assistance of a skilled person. Younger women were more assisted by doctors than older women. In contrast, older women were more assisted by midwives than younger women. Delivery in a Health Facility Approximately 2 out of 3 births occurring in the two years prior to the Iraq MICS-3 survey were delivered in a health facility (63 percent). More births are delivered in health facilities in urban areas (68 percent) than in rural areas (54 percent). Women residing in Kurdistan Region governorates were more likely to deliver in a health facility with the highest percentage in the country occurring in Dohuk governorate (76 percent). Kirkuk governorate has the lowest percentage of women delivering in a health facility (43 percent). xx Iraq Multiple Indicator Cluster Survey Final Report, 2006 Caesarean Deliveries One-fifth of the deliveries in the two years prior to the survey were by caesarean section. The likelihood of a caesarean delivery increased by the woman’s age and her educational status. Al- Qadisiya governorate has the highest percentage of caesarean section deliveries (28 percent) and Dohuk has the least (12 percent). Child Development During the three days preceding the survey, an adult is engaged with almost half (47 percent) of the under-five children in more than four activities that promote learning and school readiness. The average number of activities is 3.4. Larger proportions of adults are engaged in learning and school readiness activities with children in urban areas (52 percent) than in rural areas (38 percent). Strong differentials by governorate are also observed: Adult engagement in activities with children was greatest in Al-Anbar (65 percent) and Salahuddin (60 percent) lowest in the Al-Qadisiya (28 percent) and Wasit (30 percent). Education Pre-school Attendance and School Readiness Pre-school attendance is very low in Iraq with only 3 percent of children aged 36-59 months attending pre-school in the country. In general, double the children in Kurdistan Region governorates (4 percent) attend pre-school compared to children in South/Centre governorates overall figure (2 percent). Children in Iraq are more likely to attend early childhood education after they reach four years of age. Only four percent of children who are currently at age 6 and attending the first grade of primary school were attending pre-school the previous year. First graders in Erbil have an outstanding percentage of school readiness (27 percent) compared to all other governorates (<8 percent). Net Intake Rate in Primary Education Of children who are of primary school entry age (age 6) in Iraq, 63 percent (82 percent for age 7) are attending the first grade of primary school. Primary school entry is highest in metropolitan areas (73 percent; 88 percent for age 7), followed by other urban areas (66 percent; 86 percent for age 7), and lowest in rural areas (55 percent; 75 percent for age 7). The least percentage of children of primary school entry age currently attending grade 1 is in Missan governorate (43 percent; 67 percent for age 7) and the highest is in the capital Baghdad (75 percent; 91 percent for age 7). A positive correlation with mother’s education is observed. Net Primary School Attendance Rate Overall, six in seven children of primary school age in Iraq are attending primary school or secondary school (86 percent). Boys have a higher school attendance (91 percent) than girls (80 percent). More children in urban areas (92 percent) attend school than in rural areas (78 percent). The primary school attendance rate ranged generally between 71 and 96 percent with Missan governorate having the lowest percent in the country. Overall, Kurdistan Region governorates (95 percent) have higher rates than South/Centre governorates (85 percent). The school attendance increases with mother’s education – 95, 87, and 75 percent for mothers with secondary or higher education, primary education, and no education respectively. Net Secondary School Attendance Rate More dramatic than in primary school where 14 percent of the children are not attending school at all, is the fact that only 40 percent of the children of secondary school age are attending secondary school. Of the remaining 60 percent, some of them are either out of school (48 percent) or attending primary school (19 percent). The secondary school net attendance rate is lowest for females (34 percent) than for males (46 percent), low in the rural areas (24 percent) and for children age 17 years (32 percent). These rates are higher in Kurdistan Region governorates (53 percent) than in the South/Centre governorates (38 percent). Net Primary School Attendance Rate of Children of Secondary School Age The primary school net attendance rate of children of secondary school age is 12 percent. Males have a higher rate compared to females. More secondary female children are out school compared to males, and less are attending primary school. Overall, about half the secondary school children in the South/Centre governorates are out of school compared to about one third in the governorates of Kurdistan Region. xx�Iraq Multiple Indicator Cluster Survey Final Report, 2006 Survival Rate to Grade Five Of all children starting grade one, the majority of them (95 percent) will eventually reach grade five. Primary Completion Rate The gross primary completion rate in Iraq is 81 percent. Boys have a higher rate (89 percent) than girls (72 percent); other urban areas have a higher rate (92 percent) than metropolitan areas (86 percent) than rural areas (69 percent). This indicates attendance of more boys of all ages than girls and more children of all ages in urban areas than in rural areas at the 6th grade. The net completion rate is 44 percent, i.e. 44 percent of Iraqi children of primary graduation age (11 years) are attending the 6th grade at age 11 years. Boys have slightly higher rate than girls and the greater difference observed in the primary completion rate is due to the fact that the majority of children over age 11 years at the time of the survey attending the 6th grade of primary school are boys. The net completion rate is greater in urban areas (53 percent) compared to rural areas (32 percent) and the rate increases markedly with mothers’ education. Comparing the gross primary completion rate (81 percent) with the net completion rate (44 percent) indicates the presence of children who are over age 11 years at the time of the survey at the 6th grade. Transition Rate to Secondary School In Iraq, 78 percent of children who were in the 6th grade of primary school last year attended the first grade of secondary school this year. Girls (82 percent) have a higher rate than boys (76 percent). Also, the rate is higher in urban areas (82 percent) than in rural areas (70 percent). The transition rate is lowest in Salahuddin (46 percent). Overall, Kurdistan Region governorates have a higher transition rate (84 percent) than governorates in South/Centre Iraq (77 percent). The rate is associated positively with mothers’ education. Gender Parity Index The gender parity for primary school is 0.88, indicating that more boys attend primary school compared to girls. The indicator drops to 0.75 for secondary education. The disadvantage of girls is particularly pronounced in the rural areas, where the gender parity is 0.79 for primary school and 0.40 for secondary school. Gender parity for primary and secondary school is close to 1.00 in Kurdistan Region governorates as a whole (0.95 and 0.96 respectively) indicating almost no difference in attendance of girls and boys. The disadvantage of girls in primary schools is particularly pronounced in Missan governorate (GPI=0.67), and for secondary school in Nineveh (GPI=0.44) and Salahuddin (GPI=0.46). Adult Literacy Two-thirds of women aged 15-24 are literate. Less than half the women in rural areas are literate compared to 80 percent in metropolitan areas and 72 percent in other urban areas. The highest percentages of literate women were in Baghdad (79 percent) and Al-Anbar (77 percent) and the lowest were in Missan (48 percent), Salahuddin (52 percent), and Dohuk (53 percent). Child Protection Birth Registration The births of 95 percent of children under-five years in Iraq have been registered. Birth registration is least in Al-Muthanna and Nineveh governorates (93 percent). Child Labour About one in nine children aged 5-14 years work (11 percent). Two percent of these children participate in unpaid work for someone other than a household member, an equal percentage of children do household chores for 28 hours or more per week, while a higher percentage of children work for family business (7 percent). A higher percentage of child labour is found in boys, rural areas, and among age group 12-14 years. Children who work are less likely to participate in schools – 10 percent participate in school and 14 percent do not. Involvement of Iraqi children in labour activities decreases as mother’s education increases. Babil (22 percent), Salahuddin (18 percent), and Al- Anbar (17 percent) governorates have the highest percentages of child labour in the country. Child labour is least in Dohuk, Basrah, and Kirkuk with rates less than seven percent. Overall, slightly less than double the children are involved in child labour in South/Centre governorates (11 percent) compared to Kurdistan Region governorates (6 percent). Of the 70 percent of the children 5-14 years of age attending school, 10 percent are also involved xx�� Iraq Multiple Indicator Cluster Survey Final Report, 2006 in child labour activities. Out of the 11 percent of child labourers, almost two-thirds of them are also labourer students (62 percent). A large percentage of rural children (18 percent) are student labourers compared to children residing in urban areas (5 percent). Child Discipline About five in six children in Iraq aged 2-14 years were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members (84 percent) with almost one-third subjected to severe physical punishment (30 percent). Male children and children aged 5-9 years were more subjected to both minor and severe physical discipline. Psychological or physical discipline among 2-14 years children is more in governorates of South/Centre Iraq (86 percent) than in Kurdistan Region governorates (68 percent). It is least in Erbil and Suleimaniya and most in Baghdad (92 percent), Basrah (89 percent), and Nineveh (89 percent). Early Marriage About one in five young women aged 15-19 years is currently married (19 percent). Marriage at a young age is far less observed in Kurdistan Region governorates (10 percent) than in South/Centre governorates (21 percent). It is least in Suleimaniya and Dohuk governorates (both 10 percent) and most in Al-Najaf (32 percent) and Thi-Qar (31 percent) governorates. Five percent of women aged 15-49 years were married before age 15 while 23 percent of women aged 20-49 years were married before age 18. The age pattern for women aged 20-49 years shows that the prevalence of early marriage has declined over time. There exist some important spousal age differences in Iraq. About one in five women aged 20-24 is currently married to a man who is older by ten years or more (21 percent), and about one in four women aged 15-19 is currently married to a man who is older by ten years or more (26 percent). Spousal age difference of 10 years or more for women 20-24 years tend to exist more in Kurdistan Region governorates (21 percent) than in governorates in South/Centre Iraq (14 percent). The highest value for this indicator is in Baghdad (30 percent) and Kirkuk (28 percent) and the lowest value is observed is in Diala (13 percent), Nineveh (13 percent) and Al- Qadisiya (14 percent) governorates. Domestic Violence A high percentage of Iraqi women believe that a husband is justified to beat his wife (59 percent). Going out without telling the husband was the top reason for this justification (47 percent), followed by neglecting the children, arguing with the husband, refusing to have sex with the husband, and lastly burning the food. Women’s belief that a husband is justified to beat his wife is highest among formally married women, and is negatively related the woman’s education. The belief is far less in Kurdistan Region governorates (37 percent) than in South/Centre governorates (63 percent). Child Disability About 15 percent of children in Iraq aged 2-14 years have at least one reported type of disability. Most of these disabilities were inability to speak and delay in sitting, standing, or walking. The highest level of child disability was reported in Erbil governorate, (25 percent) and Al-Najaf governorate (20 percent) and the least was in Diala governorate (7 percent). Prevalence of disability was highest in the 2-4 years age group (20 percent), most of whom had speaking disabilities. HIV/AIDS and Orphaned Children Knowledge of HIV Transmission With known low prevalence rates of HIV/AIDS in Iraq, knowledge of HIV transmission is quite low in the country. A relatively high percentage of women have heard of HIV/AIDS (41 percent) and knowledge of all three main ways of preventing HIV transmission is only 8 percent. Most women know that having one faithful uninfected sex partner is a way of preventing HIV transmission (31 percent), 14 percent know of using a condom every time, and 20 percent know of abstaining from sex as main ways of preventing HIV transmission. While 35 percent of women know at least one way, a high proportion of women (65 percent) do not know any of the three ways. Only one in five women have heard of HIV/AIDS in rural areas compared to one in two in urban areas. Hearing of HIV/AIDS was less common in Missan and Al-Qadisiya governorates than the rest of the xx���Iraq Multiple Indicator Cluster Survey Final Report, 2006 country. Surprisingly, fewer women with secondary education (19 percent) have heard of HIV/AIDS compared to women with primary (73 percent) and no education (26 percent). Only 7 percent of women reject the two most common misconceptions (HIVAIDS can be transmitted by sharing food, and mosquito bites) and know that a healthy-looking person can be infected. Twenty- one percent of women know that HIV cannot be transmitted by sharing food, and 20 percent of women know that HIV cannot be transmitted by mosquito bites, while 19 percent of women know that a healthy-looking person can be infected. Comprehensive knowledge (knowing 2 ways of preventing HIV transmission and rejecting three common misconceptions) of HIV prevention methods and transmission is very low with only three percent of women 15-49 years have comprehensive knowledge. Only two percent of young women aged 15-24 years have comprehensive knowledge of HIV/AIDS. Knowledge of Mother-to-Child Transmission of HIV Nineteen percent of women know all three ways of mother-to-child transmission, while 9 percent of women did not know of any specific way. Knowledge of mother-to-child transmission was better in urban areas (23 percent) than in rural areas (10 percent). Highest knowledge in the country was found in Diala governorate (29 percent), and least knowledge was found in Missan governorate (9 percent). As expected, this indicator significantly increased with women’s education levels. Attitudes Toward People Living With HIV Stigma and discrimination are high in Iraq with 92 of Iraqi women aged 15-49 years who have heard of AIDS agreeing with at least one discriminatory statement and only 8 percent agreeing with none. About four in five women would not buy food from a person with HIV/AIDS (79 percent), about two-thirds of women believe that a teacher with HIV should not be allowed to work (67 percent), and almost half of women would want to keep HIV infection of family member as a secret (46 percent). In spite of all this, a smaller percentage of women would not care for a family member who was sick with AIDS (17 percent). Women in Al-Anbar governorate were most likely in the country to agree with none of the discriminatory statements (20 percent), compared to women residing in Al-Muthanna where only two percent of them agreeing to none of the discriminatory statements. Knowledge of Where to Be Tested for HIV Only six percent of women know where to be tested, with only three percent have actually been tested. Almost three-quarters of these has been told the result (72 percent). Better knowledge of a place to get tested was in urban areas (8 percent), for women with secondary or higher education (12 percent), and women residing in South/Centre governorates (7 percent). The best knowledge in the country is in Kerbala governorate (13 percent) and the least knowledge in Erbil governorate (1 percent). More women were tested in urban areas, in South/Centre governorates, in the age group 25-29, and with secondary or higher level of education. Orphaned Children1 In Iraq, about six percent of children aged 0-17 years are orphans who have lost one or both parent, about two percent are not living with a biological parent and 92 percent of children live with both parents. The highest numbers of orphaned children 0-17 years are in Al-Muthanna (9 percent), Kerbala (9 percent), and Diala (8 percent) governorates. Orphanhood was positively correlated with the child’s age. Most of the orphaned children were in the older age group 15-17 years. One percent of children aged 10-14 have lost both parents. These so-called double orphans have a disadvantage to the non-orphaned children with a ratio of orphans to non-orphans school attendance ratio of 0.84. This disadvantage is greater for girls (0.79) than for boys (0.93). While in some governorates orphans are disadvantaged in school attendance, in other governorates they are advantaged. Orphan children are advantaged in all of Kurdistan Region governorates and also in Al-Muthanna, Wasit, and Kirkuk governorates. On the other hand orphans are severely disadvantaged in school attendance in Missan and Al-Najaf governorates. 1. Orphanhood in this report refers to children orphaned by any cause, not only HIV/AIDS xx�v Iraq Multiple Indicator Cluster Survey Final Report, 2006 �Iraq Multiple Indicator Cluster Survey Final Report, 2006 1.1. Background The Multiple Indicator Cluster Survey (MICS) is a survey program developed by the United Nations Children’s Fund to provide internationally comparable, statistically thorough data on the situation of children and women. Started in 2006, the third round of these surveys covering more than 50 countries is aimed at producing data to measure progress toward the Millennium Development Goals, World Fit for Children, and other major relevant international commitments. This final report is based on the third round of Iraq Multiple Indicator Cluster Survey (MICS-3), conducted in 2006 by the Central Organization for Statistics and Information Technology (COSIT), the Kurdistan Region Statistics Office (KRSO) including Suleimaniya Statistical Directorate (SSD), in partnership with the Ministry of Health (MOH). The survey was based, in large part, on the need to monitor progress towards attainment of goals and targets emanating from the recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of ‘A World Fit For Children’, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. This is in addition to the decisions issued by the League of Arab States and 1. INTRODUCTION Table 1.1 A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “…As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” � Iraq Multiple Indicator Cluster Survey Final Report, 2006 other related institutions and organizations with regard to the Arab framework for Arab child rights, the Cairo declaration towards an “ Arab World Fit for Children”, and the second Arab plan for childhood (2004- 2015) adopted by the Arab summits. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards the same. UNICEF was assigned a supporting role in this task (see Table 1.1). As a follow up to the second round of the Multiple Indicator Cluster Survey (MICS-2) that was conducted in Iraq in year 2000, UNICEF, in close collaboration with its partners, has supported the conduct of the third round of Multiple Indicator Cluster Surveys (MICS-3). MICS is one of the key tools that Governments, UNICEF and its development partners use to monitor ongoing progress towards the realization of children and women’s rights as enunciated in the Convention on the Rights of the Child (CRC) and Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). The data on the indicators covered by MICS are used to measure and report on progress - at the national, regional and global levels - towards the achievement of the goals as enunciated in the ‘World Fit for Children Goals’ (WFFC) and, Millennium Development Goals (MDGs) declarations. Results of Iraq’s MICS-3 will also provide the necessary data and information for the report that the Government of Iraq plans to submit to the UN General Assembly’s Commemorative Session, scheduled in 2007. The national report will cover progress made in Iraq with regards to the implementation of the WFFC goals, whose targets are also milestones to achieving the MDGs. The value of this survey goes beyond the mere generation of data and international reporting purposes. While this preliminary report specifically includes estimates at the national level, the final report will provide disaggregated estimates at subnational levels. The 2006 MICS-3 results should eventually gain special prominence in the development and updating of Iraq’s National Development Strategy and will significantly contribute to the ongoing efforts of the Ministry of Planning and Development Cooperation and the Ministry of Planning in Kurdistan Region, as well as other Iraqi ministries, in formulating effective programmes, plans of actions and policies for children and women that are directed towards expanding inclusion and the reduction of inequalities and poverty. This final report presents the results of the indicators and topics covered in the survey. 1.2. Survey Objectives The 2006 Iraq Multiple Indicator Cluster Survey is primarily to: • Provide up-to-date information for assessing the situation of children and women in Iraq; • Furnish data needed for monitoring progress toward goals established by the Millennium Development Goals and the goals of A World Fit For Children (WFFC) as a basis for future action; • Contribute to the improvement of data and monitoring systems in Iraq and to strengthen technical expertise in the design, implementation and analysis of such systems. �Iraq Multiple Indicator Cluster Survey Final Report, 2006 2.1. Sample Design The sample for the Iraq Multiple Indicator Cluster Survey was designed to provide estimates on a large number of indicators on the situation of children and women at the national level; for areas of residence of Iraq represented by rural and urban (metropolitan and other urban) areas; for the 18 governorates of Iraq; and also for metropolitan, other urban, and rural areas for each governorate. Thus, in total, the sample consists of 56 different sampling domains, including three sampling domains (metropolitan area domain, other urban area domain2 and rural area domain) in each of the 17 governorates outside the capital city Baghdad. and 5 sampling domains in Baghdad (namely, 3 metropolitan areas representing “Sadir City”, “Resafa side”, and “Kurkh side”, and other urban area sampling domain representing the urban area outside the three Baghdad governorate city centres, and a sampling domain comprising the rural area of Baghdad). The sample was selected in two stages. Within each of the 56 sampling domains, 54 PSUs were selected with linear systematic probability proportional to size (PPS) amounting to a total number of 3,024 PSUs. After mapping and listing of households were carried out within the selected PSU or segment of the PSU, linear systematic samples of six households were drawn. Cluster sizes of 6 households were selected to accommodate the current security conditions in the country to allow the surveys team to complete a full cluster in a minimal time. The total sample size for the survey is 18144 households. The sample is not self- weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. 2.2. Questionnaires Three questionnaires were used in the survey. In addition to the household questionnaire which was used to collect information on all household members, an individual woman questionnaire was administered in each household to all women aged 15-49. Mothers or caretakers of under-five children were identified in each household, and these persons were interviewed using the questionnaire for children under-five. The questionnaires included the following modules: Household Questionnaire • Household Listing • Education • Water and Sanitation • Household Characteristics • Child Labour • Child Discipline • Disability • Salt Iodization Questionnaire for Individual Women • Marriage • Child Mortality • Birth History • Tetanus Toxoid • Maternal and Newborn Health • Contraception and Unmet Need • Attitude Towards Domestic Violence • HIV/AIDS 2. SAMPLE AND SURVEY METHODOLOGY 2. “Metropolitan area domain” represents the governorate city centre and “other urban area domain” represents the urban area outside the governorate city centre. � Iraq Multiple Indicator Cluster Survey Final Report, 2006 Questionnaire for Children Under Five • Birth Registration and Early Learning • Vitamin A • Breastfeeding • Care of Illness • Immunization • Anthropometry The questionnaires were based on the third round of the Multiple Indicator Cluster survey model questionnaires. From the MICS-3 model English version, the questionnaires were revised and customized to suit local conditions and translated into Arabic and Kurdish languages. The Arabic language version of the questionnaire was pre-tested during January 2006 while the Kurdish language version was pre-tested during March 2006. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Iraq MICS questionnaires is provided in Appendix G. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of children age under-five years. Details and findings of these measurements are provided in the respective sections of the report. 2.3. Training and Fieldwork Fieldwork and training were conducted at consecutive dates for the 15 South/Centre governorates of Iraq and for the Kurdistan Region. Nevertheless, frequent coordination efforts took place between South/Centre (COSIT and steering committee members from MOH) and Kurdistan Region in ensuring consistency and uniformity of methodology adopted across the whole country. Training was given special prominence in the conduct of the survey. For the South/Centre governorates, training activities were organized by COSIT, and training activities in Kurdistan Region were organized by KRSO including SSD. The following main training activities were undertaken in 2006 in preparation for the conduct of the survey: • Training of mappers and household listers • Training of field interviewers and local supervisors • Training of Editors • Data Entry Training • Training on Data cleaning (for South/Center governorates) All supervisors (from COSIT, KRSO, SSD and MOH) were trained for 14 days in a training of trainers’ workshop in December 2005 in Amman by PAPFAM and consultants from MEASURE DHS/ ORC Macro. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. These supervisors in turn, trained the interviewers for 10 days in January and February 2006 for Iraq South/Centre governorates and Kurdistan Region respectively. Refresher trainings were carried out prior to start of fieldwork in Kurdistan Region. The data were collected by 167 teams; each was comprised of two interviewers (one female from MOH and one male from COSIT, KRSO including SSD) except for Baghdad and Al-Anbar governorates which had larger teams. Details of the survey teams compositions is found in Table TC.1 in Appendix D. In general, in the South/Centre governorates, groups of three teams were supervised by a local supervisor from the statistical office of each governorate. A central supervisor from the steering committee members and MOH was assigned to each governorate. In Kurdistan Region, groups of three teams were supervised by two local supervisors (one from KRSO including SSD and one from MOH). Two central supervisors from KRSO including SSD and MOH were also assigned to each governorate. A high committee, consisting of members from KRSO including SSD and MOH was also assigned for overall supervision of the survey in Kurdistan. Vehicles were rented by all fieldwork teams (including local, central supervisors and steering committee members) to transport them to the selected clusters. �Iraq Multiple Indicator Cluster Survey Final Report, 2006 Fieldwork began in the South/Centre governorates of Iraq in February 2006 and concluded in March 2006. In the Kurdistan Region, fieldwork began in Suleimaniya governorate in April 2006 and was completed in April 2006 while fieldwork was initiated in May 2006 in Erbil/Dohuk governorates and concluded in June 2006. 2.4. Data Processing Questionnaires were edited simultaneously with fieldwork and data were entered on 88 microcomputers (70 in South/Centre governorates and 18 in Kurdistan Region) using the CSPro software. In order to ensure quality control, all questionnaires were entered twice and internal consistency checks were performed. Procedures and standard programs developed under the global MICS-3 project and adapted to Iraq questionnaires were used. Data processing in the South/Centre parts of Iraq began simultaneously with data collection in March 2006 and finished in April 2006. Similarly, in Kurdistan Region, data processing began on April 2006 and finished in June 2006. 2.5. Data Analysis Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 14, customizing the model syntax and tabulation plans developed by UNICEF for this purpose. Table numbers used in this report refer to the same numbers used in the global tabulation plan. Each table number is prefixed by two letters denoting the section to which the table belong. Generally figure and map numbers reflect the table numbers from which the data used is obtained. � Iraq Multiple Indicator Cluster Survey Final Report, 2006 3.1. Sample Coverage One cluster of the 3,024 clusters selected was not completed. Of the 18,144 households selected for the sample, 18,123 were found to be occupied. Of these, 17,873 were successfully interviewed for a household response rate of 98.6 percent. In the interviewed households, 27,564 women (age 15-49 years) were identified. Of these, 27,186 were successfully interviewed, yielding a response rate of 98.6 percent. In addition, 16,570 children under age five were listed in the household questionnaire. Of these, questionnaires were completed for 16,469 children which correspond to a response rate of 99.4 percent. Overall response rates of 97.3 and 98.0 are calculated for the women’s and under-five’s interviews respectively (Table HH.1). Overall, almost all areas of residence, regions and governorates have more or less similar and high response rates. However, it is noted that Kurdistan Region has lower response rates than the rest of the country. This may be attributed to the end of year school exams and holidays in Erbil and Dohuk, where mothers in particular, do not accept visitors if their children are involved in exams. In Sulimaniya governorate most of the none respondents were working women. 3.2. Characteristics of Households The age and sex distribution of survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 17873 households successfully interviewed in the survey, 112,856 household members were listed. Of these, 56,941 were males, and 55,915 were females. These figures also indicate that the survey estimated the average household size at 6.3. The 2004 Iraq Living Conditions Survey that was conducted by COSIT with the support of UNDP and FAFO has also shown the average household size as 6.3. Figure HH.1: Age and sex distribution of household population, Iraq, 2006 3. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS �Iraq Multiple Indicator Cluster Survey Final Report, 2006 The age structure of Iraq is experiencing rapid growth with larger proportion of its population in the younger age groups than in the older age groups. Forty one percent of the population is under the age of 15 years. There exist irregular bulges of individuals at ages 50-54 years - mostly pronounced for women. This may partly be due to the effect of the Iraq war that has led to the loss of lives of men. Also there may be possible heaping3 on age 50, in addition to the possibility that women may have been pushed from age 45-49 to 50-54 perhaps to reduce the interviewers’ workload. In fact, by examining the single year age distribution in Table DQ.1 in Appendix C, a clear leap from age 49 to age 50 is observed for women. The broad age structure of the Iraq MICS-3 compares well with the 2005 projected population from the UN population division with the latter having 41.5, 55.7, and 2.8 percent for the age groups <15, 15-64, and 65+ respectively. Almost half the population comprise children 0-17 years (48 percent). There was a very small percentage of missing ages (0.2 percent). Table HH.3 provides basic background information on the households. Within households, the sex of the household head, metropolitan/other urban/rural status, governorate, and number of household members are shown in the table. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted total numbers of households are equal, since sample weights were normalized (See Appendix A). The table also shows the proportions of households where at least one child under 18, at least one child under-five, and at least one eligible woman age 15-49 were found. A small minority of households in Iraq are headed by females (11 percent). Forty one percent of households reside in metropolitan areas whereas 27 percent reside in other urban areas. About two thirds of individuals live in households in rural areas. Almost a quarter of the population lives in households in the capital city Baghdad. This is followed by Nineveh and Suleimaniya governorates. The second most populated governorates are Kerbala followed by Missan and Al-Muthanna. Eighty six percent of households constitute the South/Center governorates while the remaining 14 percent form the Kurdistan Region governorates. More than half of the households had 4-7 members (52 percent) reflecting the large family sizes in Iraq. Fifty-five percent of the households contained at least one child under-five years of age and 93 percent contained at least one woman aged 15-49 years. 3.3. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to governorates, metropolitan/other urban/ rural areas, age, marital status, motherhood status, and education4. 3. Heaping refers to concentration of numbers in certain values 4. Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. � Iraq Multiple Indicator Cluster Survey Final Report, 2006 About 40 percent of female respondents 15-49 years of age live in metropolitan areas and 27 percent live in other urban areas, while about one third of all women live in rural areas (34 percent). The Iraq MICS-3 sampled all women of reproductive age. The majority (59 percent) of all women are aged 15-29 years compared to only 15 percent in the oldest age groups, 40-49 years. Of the 27,186 successfully interviewed women, 15,875 women (58 percent) were currently married, 958 women (4 percent) were formerly married, and 10,353 women (38 percent) were never married. Eighty- seven percent of those women who where ever married gave birth while 13 percent never did. To assess their education, women were asked about highest level of school they reached. About 18 percent of all women never attended any form of education. The majority (42 percent) of all women have primary education and 39 percent have secondary education. Less than one percent of women have non-standard curriculum education which includes religious schools, such as Quranic schools, which do not teach a full standard school curriculum. Some background characteristics of children under-five are presented in Table HH.5. These include distribution of children by several attributes: sex, area of residence, governorate, age in months, mother’s or caretaker’s education. The percentage of male children under-five is similar to the female (51 percent vs 49 percent respectively). The majority (40 percent) of these children reside in rural areas whereas 34 and 26 percent reside in metropolitan and other urban areas respectively. Most of the children under-five were one year of age or over (79 percent) while the remaining 21 percent aged less than 12 months. �Iraq Multiple Indicator Cluster Survey Final Report, 2006 4.1. Current Fertility Fertility refers to the number of live births women have. The measurement of fertility levels and differentials was an important objective of Iraq MICS-3. Previous surveys had indicated that the level of fertility was declining. Information on fertility obtained from the Iraq MICS-3 provides recent indicators of fertility rates, at the national level and also at sub-national levels. The fertility indicators in this report are based on information provided by ever-married women age 15-49 years regarding their reproductive histories. Each woman was asked to provide information on the total number of sons and daughters to whom she had given birth and were living with her, the number living elsewhere, and the number who has died. Information on all live births is collected using the birth history module of the questionnaire administered to individual women. For all live births of the respondent the module collected information on sex, month and year of birth, survivorship status and current age, or, if the child had died, age at death. Fertility rates can be calculated for specific age groups to see differences in fertility behaviours at different ages or for comparison over time. The age-specific fertility rate gives the number of live births per 1,000 women at a specific age group. The total fertility rate (TFR) calculated as the sum of the age-specific fertility rates is a useful means to summarize what fertility is now, without waiting for the end of the childbearing years. The TFR is the average number of children that would be born to a woman by the time she ended childbearing if she were to pass through all her childbearing years (15-49) conforming to the age-specific fertility rates of a given year. Table FR.1 gives the reported age-specific fertility rates and total fertility rate for the three-year period preceding the survey per 1,000 women. The total fertility rate for the three years before the survey (approximately 2003 through 2006) is 4.3 children per woman. The age pattern of fertility indicates that Iraqi women give birth to most of the children they will ever have (about 70 percent) between 20 and 34 years of age. Young women in the age group 15-19 give birth to only a small percentage of the children they will ever have (8 percent). Fertility is low among this age group and increases to a peak of 221 per 1,000 among women age 25-29 and declines thereafter. Table FR.2 show differentials in fertility by area of residence, governorate (Map FR.2), and education. Considering the variation by area of residence, the fertility is higher in rural areas than in urban areas. The total fertility rate is estimated at 5.1 children per woman in rural areas, about 22 percent higher than in urban areas (4.0). Fertility is lowest in metropolitan areas (3.8) than in other urban areas (4.2). There are differences in fertility among governorates, ranging from a low of 2.9 in Suleimaniya to a high of 5.4 in Nineveh and Missan. Fertility levels in Kirkuk, Diala, Al-Anbar, Baghdad, Babil, Suleimaniya and Erbil governorates are less than the national average. The level of fertility is inversely related to women’s education, decreasing rapidly from 4.8 children among women with no or primary education to 3.5 children among women who have at least some secondary education. 4. FERTILITY �0 Iraq Multiple Indicator Cluster Survey Final Report, 2006 Map FR.2: Total fertility rate, by governorate, Iraq, 2006 4.2. Abortions and Stillbirths For women who did not have a live birth, the survey collected information on the total number of abortions and stillbirths. Overall, 29 percent of these women had more than one abortion and 7 percent reported more than one stillbirth (Table FR.3). Seventeen and 5 percent of the women reported having only one abortion and stillbirth respectively. Abortion and stillbirth percentages did not vary by area of residence but increased by age. The percentages were higher in Kurdistan Region (31% for abortions, 10% for stillbirths) than in the rest of the country (29% for abortions, 6% for stillbirths). ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 One of the overarching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction of under- five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Women’s Questionnaire. Women in the age-group 15-49 were asked whether they had ever given birth, and if they had, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of their children in chronological order starting with the first child. Women were asked whether a birth was single or multiple; the sex of the child; the date of birth (month and year); survival status; age of the child on the date of the interview if alive; and if not alive; the age at death of each live birth. Since the primary causes of childhood mortality change as children age, mostly biological factors to environmental factors, childhood mortality rates are expressed by age categories and are customarily defined as follows; • Neonatal mortality (NN): the probability of dying within the first month of life • Postneonatal mortality (PNN): the difference between infant and neonatal mortality • Infant mortality (1q0): the probability of dying between birth and the first birthday • Child mortality (4q0): the probability of dying between exact ages one and five • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday The rates of childhood mortality are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one. 5.1. Levels and Trends in Infant and Child Mortality Table CM.1 presents neonatal, post neonatal, infant, child and under-five mortality rates for the three recent five year periods before the survey. Neonatal mortality in the most recent 5-year period is estimated at 23 per 1,000 live births, while the postneonatal mortality rate is estimated as 12 per 1,000 live births. This indicates that of all infant deaths, more than two-thirds (66 percent) occur during the first month of life. The infant mortality rate in the five years preceding the survey is 35 per 1,000 live births and under-five mortality is 41 deaths per 1,000 live births for the same period, indicating that the majority of under-five deaths (85 percent) are infant deaths. Table CM.1 also provides estimates of mortality rates during the last three 5-year periods preceding the survey, thus providing information on recent trends. The table shows that at the national level, relatively little, if any improvement has taken place during the last 15 years, with under-five mortality at 49 per 1,000 during the 10-14 year period preceding the survey, and 41 per 1,000 live births during the most recent 5-year period, roughly referring to the years 2001-2006. Similar patterns are observed in all other indicators. 5. CHILD MORTALITY �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure CM.1: Under-5 Mortality Rates for the 5-year period preceding the survey by biodemographic characteristics, Iraq, 2006 5.2. Differentials in Childhood Mortality by Socioeconomic Characteristics Table CM.2 provides estimates of child mortality by sex, urban rural residence, governorates and mother’s education for the five years preceding the survey. The table shows that male children experience somewhat higher mortality than female children. There appears to be little difference in regard to the risk of mortality between urban and rural residence. With respect to mother’s education, differentials exist, where mortality risks of children born to mothers with no education are higher than those with primary education or secondary education and higher. Differences between the three education groups mainly emanate from mortality risks during the postneonatal period, and between the first and fifth ages (child mortality). Mortality rates have also been calculated for the 18 governorates. Under-five mortality rates are practically the same in the South-Centre governorates as a whole and Kurdistan Region. Although sample sizes are smaller and the governorate-based estimates have wider confidence intervals, the inspection of unweighted numbers of cases forming the denominators in each of the governorates are sufficiently large to warrant these calculations. Nevertheless, calculation for the sampling errors for these estimates as part of further analyses will be useful. Table CM.2 shows wide differences between governorates in regard to levels of child mortality. The ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 highest mortality rates are observed in the Salahuddin governorate, while the lowest rates are observed in Kirkuk. In the latter, the under-five mortality rate is about half of the national average, whereas children in the Salahuddin governorate appear to be experiencing 70 percent higher mortality during the first five years of life compared to the rest of the country. Under-five mortality is also relatively higher than the national average in Al-Muthanna, Wasit, Dohuk, Erbil, Kerbala, Ninevah, Al-Najaf, Babil and Salahuddin governorates. 5.3. Differentials in Childhood Mortality by Biodemographic Characteristics Several biodemographic characteristics of the mother and the child are known to play an important role in the mortality risks children are exposed to. These include, but are not limited to, mother’s age at birth, birth order and birth intervals. Mortality rates by these biodemographic characteristics are shown in Table CM.3. The table shows that first births, children born to very young mothers, children born after a short interval, and children of high birth orders experience significantly higher risks of mortality. For children of women who give birth above age 40, under-five mortality is elevated to 64 per 1,000 births, while the elevated risk of mortality among first births is also observed in the table. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 6.1. Nutritional Status Malnutrition is associated with more than half of all children’s deaths worldwide. Undernourished children are more likely to die from common childhood illnesses. And those who survive have recurring sicknesses like diarrhoeal diseases and respiratory infections and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. Recent surveys and nutritional assessments revealed deterioration in the nutritional status of Iraqi children. The implementation of the food ration system in Iraq is intended to be an effective system to reach the poor and supply them with monthly food baskets. The instability in the country is affecting the appropriateness of the calorie supply of these baskets, which would influence the nutritional status of Iraqi children. Humanitarian agencies like UNICEF have ongoing programs to supply high protein biscuits and therapeutic milk to boost the nutritional status of the children in the country. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under two years of age. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height for age is a measure of linear growth. Children whose height for age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height for age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Children whose weight for height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Finally, children whose weight for height is more than two standard deviations above the median of the reference population are classified as overweight. Overweight or obesity is a chronic condition that increases the risk of many diseases and health conditions. Individual behaviours, environmental factors and genetics all contribute to the complexity of being overweight. In MICS, weights and heights of all children under-five years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. 6. NUTRITION ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. In Table NU.1, children who were not weighed and measured and those whose measurements are outside a plausible range are excluded and these amounted to 7 percent. Eight percent of children under age five in Iraq are moderately or severely underweight and one percent are classified as severely underweight (Table NU.1). This result indicates that the underweight status of children improved during the recent period. This is in comparison to figures for moderately or severely underweight of 11.7 from Iraq Living Conditions Survey in 2004, 11.5 percent from Baseline Food Security Analysis in Iraq in 2004, and 15.9 from Iraq Multiple Indicator Cluster Survey in 2000. Over one-fifth (21 percent) of children are severely or moderately stunted (or too short for their age) and eight percent are severely stunted. Five percent of children are severely or moderately wasted (or too thin for their height) and one percent is severely wasted. Gender differentials are very small. Children in rural areas are more likely to be stunted than other children. Children who live in metropolitan areas are better nourished than those who live in other areas. Map NU.1: Percentage of children aged 0-59 months who are severely or moderately malnourished, by governorate, Iraq, 2006 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 The percentage of children who are moderately or severely underweight, stunted, and wasted are highest is Basrah and Wasit (Map NU.1). Underweight and wasting have similar patterns in South/Centre Iraq governorates as a whole compared to Kurdistan Region governorates, whereas children in the South/Centre Iraq governorates appear to be more stunted compared to children in Kurdistan Region governorates. The age pattern shows that a higher percentage of children aged 12-23 months are stunted in comparison to children who are younger and older (Figure NU.1). Figure NU.1: Percentage of children under-five who are undernourished, Iraq, 2006 Looking at educational differentials, as expected those children whose mothers have secondary or higher education are the least likely to be underweight and stunted. Overall, about nine percent of children in Iraq are overweight with more overweight girls than boys. Children in the South/Centre Iraq governorates appear to be more overweight (10 percent) than children in Kurdistan Region governorates (4 percent). Also the results show slightly more overweight children in rural areas (11 percent) than in urban areas (9 percent). Overweight rates are highest in younger children. For example, 17 percent of overweight infants are less than 6 months old. This percentage decreases to 7 percent for children aged 48-59 months. Overweight rates do not seem to vary much by mother’s education. 6.2. Breastfeeding Exclusive breastfeeding for the first six months of life and appropriate and adequate complementary breastfeeding for the first two years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. This is also a World Fit for Children goal, however, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 WHO/UNICEF have the following feeding recommendations: Exclusive breastfeeding for first six months; Continued breastfeeding for two years or more; Safe, appropriate and adequate complementary foods beginning at 6 months; Frequency of complementary feeding: 2 times per day for 6-8 month olds, 3 times per day for 9-11 month olds. It is also recommended that breastfeeding be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate (0-5 months and 0-3 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 and 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). Only 31 percent of women started breastfeeding within one hour of birth, with this percentage increasing to 85 percent when considering breastfeeding within one day of birth. Women differed in the timing of initial breastfeeding according to governorates, particularly when considering initiation of breastfeeding within one hour. Women in Nineveh, Erbil, and Suleimaniya were the least likely to start breastfeeding within one hour (Figure NU.2). Initial breastfeeding also varied with area of residence, increasing slightly from metropolitan to other urban to rural areas. Slightly more women with lower education tend to start breastfeeding earlier than women with higher education. In Table NU.2, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk and vitamins, mineral supplements, or medicine. The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding (receiving breast milk and solid/ mushy food) of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Only one in four children aged less than six months are exclusively breastfed (25 percent). At age 6-9 months, half of the children are breastfed together with receiving solid or semi-solid foods (51 percent). By age 12-15 months, 68 percent of children are still being breastfed and by age 20-23 months, 36 percent continue breastfeeding. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth, Iraq, 2006 Girls are slightly more likely to be exclusively breastfed and have timely complementary feeding than boys, while boys breastfed slightly longer than girls. Slightly more children living in rural areas (27 percent) are exclusively breastfed compared to urban areas (24 percent). There exist wide variations between governorates in the percentage of children who are exclusively breastfed, with the least percentages in Erbil, Al-Muthanna, and Al-Najaf (Figure NU.3A). Kerbala governorate is standing out as the governorate with the highest percentage of exclusively breastfed infants where around two-thirds of its infants are breastfed as recommended. Overall, less than half the infants are exclusively breast fed in the governorates of Kurdistan Region compared to the governorates in the South/Center Iraq. Figure NU.3B shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is below 2 percent. Only about 30 percent of children are receiving breast milk after 2 years, with almost all of these children receiving breast milk together with complementary food. Complementary feeding is introduced at early ages with the percentage of children who are breastfed and given complementary food reaching 57 percent by nine months of age. ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure NU.3A: Percentage of infants under 6 months of age exclusively breastfed, Iraq, 2006 Adequately fed infants aged 0-11 months are those who are appropriately fed i.e. infants aged 0-5 months that are exclusively breastfed and infants aged 6-11 months that are breastfed and ate solid or semi-solid foods the appropriate number of times the day before the survey. Table NU.4 shows that about one third of Iraqi infants are adequately fed (32 percent). Interestingly, rural infants are more adequately fed than infants in urban areas. This indicator does not vary much by sex and area of residence but varies greatly by governorate, where much less infants in Kurdistan Region (14 percent) are adequately fed than in South/ Centre governorates (34 percent). The percent of adequately fed infants varies from 8 percent in Erbil to 52 percent in Kerbala governorate. �0 Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure NU.3B: Infant feeding patterns by age: percent distribution of children aged under 3 years by feeding pattern by age group, Iraq, 2006 Figure NU.4: Percentage of infants 0-11 months who were adequately fed, iraq 2006 ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 6.3. Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal was to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). UNICEF provides all required materials to ensure the sustainability of salt iodization program in the country. However after the war in 2003, due to the break-down of the centrally controlled system as a result of the ongoing insecurity situation in Baghdad and many parts of Iraq, MOH/MOI’s ability to enforce the implementation of existing legislation on salt iodisation is restricted. In Kurdistan Region, where the security situation is much better, health inspection teams continue to monitor the local market for non iodized salt. In 99 percent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodide. Table NU.5 shows that in a very small proportion of households (0.2 percent), there was no salt available. In 28 percent of households in Iraq, salt was found to contain 15 parts per million (ppm) or more of iodine. Figure NU.5: Percentage of households consuming adequately iodized salt, Iraq, 2006 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Almost double urban households (34 percent) had iodized salts that contained 15 parts per million (ppm) or more of iodine compared to rural households (16 percent). Metropolitan areas (38 percent) had more households with iodized salt than other urban areas (30 percent). There are wide governorate differences with Dohuk (67 percent) and Suleimaniya (63 percent) governorates with the highest consumption of adequately iodized salt (Figure NU.5). The figure also shows that Missan, Al-Qadisiya and Basrah have the lowest percentage of households with adequately iodised salt with percentages less than or equal to 12 percent. In Kurdistan Region governorates 57 percent of the households consumed salt that contained 15 parts per million (ppm) or more of iodine compared to 24 percent in the South/Centre Iraq governorates. 6.4. Vitamin A Supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly’s Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high- dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother>s stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programs, the definition of the indicator is the percentage of children 6-59 months of age receiving at least one high dose of vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Iraq Ministry of Health recommends that children aged 6-11 months be given 50,000 IU dose Vitamin A capsules and children aged 12-59 months given a 100,000 IU vitamin A capsule every 6 months. Vitamin A capsules supplementation is linked to immunization services and are given when the child has contact with these services after six months of age, usually with Measles vaccination at age 9 months and booster dose of DPT at age 15 months. Furthermore, the policy recommends supplementation at school entry with two doses of IU 200,000 to all 1st grade pupils (in the 1st and the 2nd semester). It is also recommended that mothers take a 200,000 IU dose Vitamin A supplement within eight weeks of giving birth due to increased Vitamin A requirements during pregnancy and lactation. The survey results show that almost all children in Iraq do not receive the recommended Vitamin A supplementation. Within the six months prior to the MICS, only 2 percent of children aged 6-59 months received a high dose of Vitamin A supplement (Table NU.6). Approximately 4 percent did not receive the supplement in the last 6 months but did receive one prior to that time. Five percent of children received a Vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when. Vitamin A supplementation coverage does not vary much by sex and areas of residence, and variation in the ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 governorates might be due to small numbers. The coverage is generally low in the governorates ranging between less than one percent and six percent. The age pattern of Vitamin A supplementation shows that supplementation in the last six months decreased from 5 percent among children aged 6-11 months to 4 percent among children aged 12-23 months and then declined to less than one percent among children over 23 months of age. The percentages of children receiving a supplement in the last six months are two and three percent among children whose mothers have no education or primary education and mothers with secondary or higher education respectively. Only about 16 percent of mothers with a birth in the previous two years before the MICS received a Vitamin A supplement within eight weeks of the birth (Table NU.7). This percentage is highest in Baghdad, Babil, and Thi-Qar at a range of 21 to 31 percent and lowest in Erbil, Missan, and Salahuddin at a range of 5 to 6 percent. In Kurdistan Region governorates 11 percent of the mothers received vitamin A supplementation compared to 17 percent in the South/Centre Iraq governorates. Post-partum mothers’ vitamin A supplementation did not vary by area of residence. It increases sharply with the education of the mother but it is still only about 22 percent among women with secondary or higher education. The low percentages seen for both children and mother’s receiving of Vitamin A Supplements is attributed to shortage of supply of Vitamin A supplements in the country for more than one year. This shortage is due to ongoing insecurity inside Iraq where UNICEF’s entire consignment of vitamin A stolen by insurgents in Anbar province. The consignment was insured and the stock was replenished in March 2006. 6.5. Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth5 . Overall, 45 percent of births were weighed at birth with approximately 15 percent of infants estimated to weigh less than 2500 grams at birth (Table NU.8). There are some variations by governorate (Map NU.8). The highest estimated percentage of infants weighing less than 2500 grams at birth was in Al-Muthanna governorate (22 percent) while the lowest estimated percentage was in Al-Anbar governorate (11 percent). The estimated percentage of low birth weight does not vary much by urban and rural areas or by mother’s education. Map NU.8: Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, by governorate, Iraq, 2006 5. For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 6.6. Growth Monitoring Data on growth monitoring were collected for children aged three years. The results in Table NU.9 show that growth was seen by the interviewers monitored in a chart in only 11 percent of children aged three years, while for an additional 12 percent of children their mothers/ caretakers reported that growth was monitored but no card was seen. Only about one fifth of children aged three were regularly weighed. Growth monitoring and regular weighing was far less in rural than in urban areas and less among children with less educated women. There were also large differences among governorates with a striking large percentage of growth monitoring seen on a card for Sulimaniya governorate (47 percent) compared to no monitoring at all in the other two neighbouring governorates of Kurdistan Region. Children aged three years were also not weighed in the governorates of Dohuk and Erbil. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 7.1. Immunization The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to the national immunization schedule, by a first birthday each child in Iraq should receive through routine immunization - a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, four doses of polio vaccine, three doses of Hepatitis B vaccine and a measles vaccination at the age of 9 months. In addition, an MMR vaccination is given to children at 15 months of age as part of the second opportunity for measles vaccination to protect against measles, as well as against mumps and rubella. In the estimation of fully immunized children, we do not consider children 12-23 months so as to avoid censoring of some children who are not eligible for the MMR vaccine by 12 months. Alternatively, to estimate the percentage of fully immunized children, children age 18-29 months are considered in this report. Children are considered fully immunized if they receive BCG, DPT (1-3 doses), polio (1-3 doses), HepB (1-3 doses) vaccines, by 12 months of age and either a measles or MMR vaccine by 18 months. Mothers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS-3 questionnaire. If the child did not have a card, the mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and Polio, how many times. Overall, 55 percent of children aged 18-29 months had health cards that were seen by interviewers (Table CH.2). The percentages of children aged 18 to 29 months who received a BCG and each of three DPT, polio vaccinations, HepB vaccination, measles or MMR vaccinations, and were fully immunized are shown in (Table CH.1). The denominator for the percentages in the table consists of children aged 18-29 months so that only children who were old enough to be fully vaccinated were counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the bottom panels, only those who were vaccinated before their first birthday were included. For children without vaccination cards, the proportion of vaccinations given before 12 or 18 months was assumed to be the same as for children with vaccination cards. Approximately 91 percent of children aged 18-29 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 82 percent. The percentage declines for subsequent doses of DPT to 71 percent for the second dose, and 53 percent for the third dose (Figure CH.1). Similarly, 88 percent of children received Polio 1 by age 12 months and this percentage declines to 57 percent by the third dose. Eighty-seven percent of children received the first dose of HepB, while only 50 percent of children received the third dose of HepB by 12 months. The coverage for measles or MMR vaccine by 18 months is at 65 percent. The percentage of children who had all recommended vaccinations (full vaccination) by age 12 months (18 months for measles or MMR) is 39 percent. 7. Child Health ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months for measles or MMR), Iraq, 2006 Tables CH.2 shows vaccination coverage rates among children 18-29 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. Metropolitan areas had the highest immunization coverage for all vaccines followed by other urban areas and rural areas. The percentage for full vaccination in metropolitan areas is 66 percent compared to 56 percent in other urban areas and only 41 percent in rural areas. Compared to all other governorates in Iraq, the survey results show that Diala governorate has the highest coverage for all vaccinations as well as the highest full vaccination coverage of 74 percent. Al- Najaf, Salahuddin, Missan, Al-Qadisiya, Wasit, Al-Muthanna, Thi-Qar, and Nineveh governorates all have vaccination coverage below the national coverage of 54 percent with the least being in Al-Najaf and Salahuddin with coverage less than 30 percent. Often given to infants at the time of birth, BCG vaccine has the highest coverage with not very large variations among governorates. In general, percentages of currently vaccinated children aged 18-29 months by the different vaccines fluctuated across governorates. But it is worth noting that DPT 3 and HepB3 lagged much behind in Missan governorate, Polio 3 lagged behind in Missan and Wasit, and Measles or MMR lagged behind in Thi-Qar. Children in Kurdistan Region are more likely to be fully vaccinated any time before the survey than those in South/Centre governorates. The full vaccination percent is about 10 percent higher in Kurdistan Region than in South/Centre governorates. Mother’s education is highly positively associated with vaccination coverage – Children of mothers with secondary or higher level of education are about 40 percent more likely to be vaccinated than those to mothers with no education. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 The Ministry of Health launched two rounds of national polio campaigns in Iraq during June and July of 2005. The campaigns targeted children 0-59 months of age. Therefore, only children in the MICS-3 sample who were 7 months or more in South/Centre Iraq and children 11 months or more in Kurdistan Region were exposed to this campaign. Table CH.2A presents results for children vaccinated in each round and in both rounds of the campaign in South/Centre Iraq and in Kurdistan Region. Overall, 84 percent of children in South/Centre Iraq exposed to the campaign received polio vaccinations at both rounds of campaigns. This percentage is the same for Kurdistan Region. Vaccination coverage varied slightly among governorates with Al-Anbar (64 percent) and Erbil (71 percent) having the minimum percentages while Dohuk has the maximum percentage (94 percent). The coverage was more or less similar in urban and rural areas and increased by mother’s educational level. An MMR campaign was also launched in April/May 2005 in Iraq South/Centre governorates and in May of the same year in Kurdistan Region. The MMR campaign targeted children aged 12-60 months born from May 2000 to May 2004 for South/Centre of Iraq and children born from June 2000 to June 2004 for Kurdistan. Thus, only children in the MICS-3 sample currently 20 months or more for South/Centre governorates of Iraq and 23 months or more for Kurdistan were exposed to this MMR campaign. Results of the MMR campaign are presented separately for these two groups of children in Table CH.2B. In South/ Centre governorates of Iraq, 68 percent of the children exposed to MMR campaign received an MMR vaccination. Al-Anbar and Al-Qadisiya governorates had the least coverage with percentage 42 and 55 percent respectively. The highest coverage of 80 percent or higher was in Baghdad and Kirkuk. The MMR campaign mostly covered children born between 2001 and 2003. Similar to the polio campaigns above, the coverage did not vary by urban and rural areas and increased by mother’s education. A generally similar picture is seen for Kurdistan Region with an overall coverage percentage of 67, although the coverage varied by area of residence with a higher percentage in urban areas (70 percent) compared to rural areas (59 percent). The coverage did not vary much by governorate. The large proportions of immunized children at these campaigns clearly contribute to the overall protection of these children against these diseases. 7.2. Tetanus Toxoid One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district. A World Fit for Children goal was to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: • Received at least two doses of tetanus toxoid vaccine, the last within the prior three years; • Received at least three doses, the last within the prior five years; • Received at least four doses, the last within 10 years; • Received at least five doses during lifetime. Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 12 months. The results of the survey indicate that tetanus toxoid coverage is relatively widespread in Iraq. Almost two third of mothers in the country are considered protected against tetanus (61 percent). Tetanus toxoid protection is higher among metropolitan and other urban areas, and younger women. Differentials in protection by governorate show that protection is highest in Baghdad (80 percent) and lowest in Wasit (39 percent). There is a strong positive relationship between the mother’s education and tetanus toxoid ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 protection. The percentage of mothers who are protected increases from 42 percent among women with no education to 78 percent among women with secondary or higher education. 7.3. Oral Rehydration Therapy Dehydration caused by diarrhoea is a major cause of mortality and morbidity among Iraqi children. Dehydration is caused by loss of large quantities of water and electrolytes from the body in liquid stools. Oral rehydration therapy (ORT) – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. RHF are fluids which have electrolytes usually made from sugar, salt and water. The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • (ORT or increased fluids) AND continued feeding Mothers or caretakers were asked to report whether their child had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child drank and ate during the episode. In this survey questions were asked about the following oral homemade treatments: drinking water, rice water, vegetable soup, yogurt drink and fruit juice. None of these homemade treatments is considered as RHF and thus the ORT indicator is based on the use of ORS only. Overall, 13 percent of children under-five years of age had diarrhoea in the two weeks preceding the survey (Table CH.4). The peak diarrhoea prevalence occurred among children aged 6-11 months. Table CH.4 also shows the percentage of children receiving various types of liquids during episodes of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add up to 100. Drinking water (84 percent) was the most commonly cited fluid, followed by yoghurt drinks (47 percent) and fruit juice (42 percent). Almost one third of the children (31 percent) received ORS (i.e. ORT) while they had diarrhoea. This percentage did not vary much by sex or area of residence. There were some governorate variations with minimum percentages occurring in Wasit (15 percent), Erbil (19 percent) and Kerbala (19 percent) and maximum percentage in Dohuk (47 percent). Use of ORS did not vary steadily with age of child. The age group 6-11 months had the highest percentage of ORS use. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are important strategies for managing diarrhoea. About one quarter (23 percent) of under-five children with diarrhoea drank more than usual while 76 percent drank the same or less (Table CH.5). Sixty seven percent ate somewhat less, same or more (continued feeding), but 32 percent ate much less or ate almost none. Given these figures, only 15 percent children received increased fluids and at the same time continued feeding. Combining the information in Table CH.5 with those in Table CH.4 on oral rehydration therapy, it is observed that 64 percent of children either received ORT or fluid intake was increased, and at the same time, feeding was continued, as is the recommendation. The home management of diarrhoea varies slightly by sex, where males were more likely to receive ORT or increased fluids and continued feeding (66 percent) than females (61 percent). In rural areas 67 percent of children received ORT or increased fluids and continued feeding compared with 57 percent in metropolitan areas and 69 percent in other urban areas. �0 Iraq Multiple Indicator Cluster Survey Final Report, 2006 There were also governorate variations with Basrah governorate having the lowest percentage of children who either received ORT or fluid intake was increased, and at the same time, feeding was continued (54 percent) and Kirkuk having the highest percentage (82 percent). The home management of diarrhoea varied by age of the child, with the highest percentage observed for the 24-35 months age group (75 percent) and the lowest percentage observed for the 0-11 months age group (54 percent) (Figure CH.5). Differentials by mother’s educational level varied, with children of mothers with secondary or higher edu-- cation receiving the least percentage of receiving ORT or increased fluids and continued feeding. Figure CH.5: Percentage of children aged 0-59 months with diarrhoea in the last two weeks who took increased fluids and continued to feed during the episode, Iraq, 2006 ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 7.4. Care seeking and Antibiotic Therapy of Children with Suspected Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-fives with suspected pneumonia is a key intervention. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were due to a problem in the chest and not solely a blocked nose. Information was collected for children who had suspected pneumonia as to whether or not they had received an antibiotic within the previous two weeks. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia Table CH.6 presents the percentage of children aged 0-59 months with suspected pneumonia in the last two weeks before the survey, care seeking behaviour, and the use of antibiotics for the therapy of this pneumonia by sex, age, area of residence, governorates, and mother’s education. In Iraq, 13 percent of the children surveyed had suspected pneumonia. Although this percentage did not vary in urban and rural areas, metropolitan areas had a slightly higher percentage of suspected pneumonia (15 percent) compared to other urban areas (12 percent). The prevalence of suspected pneumonia varied by age of the child, with the highest percentage observed for the 12-23 months age group (16 percent). Figure CH.7A: Percentage of mothers/caretakers who recognize fast and difficult breathing as signs for seeking care immediately, Iraq, 2006 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Overall, a high percentage of under-five children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey (82 percent). The table also shows that antibiotic therapy of sus-- pected pneumonia is lower among children from rural households and children whose mothers/caretakers have no education than among other children. All governorates had high percentages of over 75 percent of use of antibiotics for treatment of suspected pneumonia, with the exception of Diala that had a percent-- age of 53 and Erbil that had a percentage of 58. The use of antibiotics is more or less similar for different age groups of the child, with the least use of antibiotics observed for older children aged 48-59 months (79 percent). A high proportion of children were taken to appropriate providers (82 percent) – 28 percent were taken to private physicians, 24 percent to government hospitals, and 19 percent to government health centres. The percentage of children taken to appropriate providers did not vary much with area of residence, but was higher in South/Centre governorates (83 percent) than in Kurdistan Region governorates (65 percent) with the least percentages in Erbil (53 percent) and Suleimaniya (60%) governorates. Mother’s education is positively related to the indicator and infants 0-11 months were taken to appropriate providers more than other children. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 22 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility are developing a fever (70 percent) and having diarrhoea (50 percent). Thirty-five percent of mothers identified fast breathing and 41 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Governorates varied markedly in knowledge of two danger signs of pneumonia, with Thi- Qar, Wasit, and Nineveh showing the least knowledge with percentages less than five percent. Missan, Salahuddin, and Basrah gave the highest percentages (more than 40 percent) (Figure CH.7A). As expected, knowledge increases with mother’s education. 7.5. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Table CH.8 shows that overall, only about five percent of all households in Iraq are using solid fuels for cooking. Use of solid fuels is negligible in urban areas (0.6 percent), but increases in rural areas, with 13 percent of the households using solid fuels. The findings show that use of solid fuels is very uncommon among households in Basrah, Kirkuk, and Baghdad. Al-Qadisiya governorate is the governorate that mostly contributes to the solid fuels use in the country. Differentials with respect to educational level of the household head are significant – nine percent for no education, five percent for primary education, and two percent for secondary education or higher. The table also shows that about half of households use of solid fuel comes from the use of wood for cooking purposes. ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 8.1. Water and Sanitation Safe drinking water is a basic necessity for good health and also a human right. Unsafe drinking water can be a significant carrier of diseases such as cholera, typhoid, and diarrhoeal diseases such as amoebic and bacillary dysentery. Drinking water can also be contaminated with chemical, physical and radiological contaminants with potentially harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, particularly in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS is as follows: Water: • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation: • Use of improved sanitation facilities • Sanitary disposal of child’s faeces Figure EN.1: Percent distribution of household members by source of drinking water, Iraq, 2006 8. Environment Other 0.4% With-drawal 7.5% Periodic abstinence 2.1% LAM 7.0% Male sterilization/Implants/ Female condom/ Diaphragm/ foam/ jelly 0.3% Condom 1.1% Injections 2.0% IUD 12.2% Pill 14.6% Female sterilization 2.6% Not using any method 50.2% Tubewell/borehole 1% Public tap/standpipe 9% Protected well or spring 2% Unprotected well or spring 5% Surface water 7% Other unimproved 11% Piped into dwelling, yard or plot 65% �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 0.0 - 1.5 1.6 - 60.0 60.1 - 75.0 75.1 - 90.0 90.1 - 100.0 Nineveh 83.7 Al Anbar 94.2 Al Najaf 88.1 Al Muthanna 53.1 Basrah 1.5 Missan 75.1 Thi-Qar 69.9 Wasit 7.1 Al-Qadisiya 74.5 Babil 63.9 Kerbala 90.3 Baghdad 95.6 Diala 72.5 Suleimaniya 95.5 Kirkuk 97.7 Erbil 97.2 Dohuk 98.6 Salahuddin 72.5 8.1.1. Water The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tube well/borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. Overall, 79 percent of the population has access to improved drinking water sources – 92 percent in urban areas and only 57 percent in rural areas. The situation varies markedly among governorates (Map EN.1). Basrah governorate is considerably worse than all other governorates with only two percent of the population having access to improved drinking water sources. Al-Muthanna and Babil have the next worst access to improved drinking water sources with percentage 53 and 64 percent respectively. Overall, Kurdistan Region governorates have better access to improved drinking water sources than South/Centre Iraq governorates with percentages of 97 and 77 respectively. Map EN.1: Percentage of household population using improved drinking water sources by governorate, Iraq, 2006 The above figures may not reflect the condition and reliability of the main drinking water sources. Based on a question in the survey about the reliability of the drinking water source, results show that nearly half (48 percent) of those who have access to improved drinking water sources indicated problems with the condition of services. Twenty one percent of the respondents reported problems on a daily basis, while 19 and nine percent indicated less than weekly and weekly problems respectively (Table EN.1A). Problems ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 with condition of services were more present in South/Centre governorates (51 percent) than in Kurdistan region (29 percent), and in Baghdad and Al-Muthanna governorate where more than three quarters of the population who have access to improved drinking water indicate problems with the condition of services. Two-thirds of the households have water piped into their dwellings (66 percent). Water supply sources from surface water and tanker truck are the main unimproved sources of drinking water, mostly occurring in rural areas. The source of drinking water for the population varies strongly by area of residence and governorates (Table EN.1). In the rural areas, only 47 percent of the population uses drinking water that is piped into their dwelling or into their yard or plot. In the metropolitan areas and other urban areas, 90 and 89 percent, respectively, use piped water. With the exception of Basrah, the population in all governorates mostly uses drinking water that is piped into their dwelling (percentages ranging between 43 and 90 percent). In Nineveh, Kirkuk, Al-Anbar, Baghdad, Kerbala, and Kurdistan Region governorates the second important source of drinking water is water piped into yard/ plot. In Diala, Babil, Wasit, Salahuddin, Al-Najaf, Al-Qadisiya, Thi- Qar, and Missan between 11 and 33 percent of the population use surface water (an unimproved source) as a second important source of drinking water. A similar percentage of the population in Al-Muthanna who use water piped into dwelling, use water from tanker truck (about 43 percent). Ninety-two percent of the population in Basrah reported using water from “Other/missing” category of the unimproved sources. The households rely on reverse osmosis for water supply. The water is then stored in tankers for a long time which classifies it as an unimproved drinking water source. The interviewers coded such cases in the “Other” category. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all households, for households using improved and unimproved drinking water sources. About 85 percent of households in Iraq do not use any method for water treatment. Letting water stand and settle (9 percent) and boiling (5 percent) are the most common methods for those who use some treatment method. Nine percent of households use appropriate water treatment method for all drinking water sources, both for improved and unimproved. Use of appropriate water treatment method varied by area of residence with the highest percentage occurring at other urban areas (12 percent) followed by rural (10 percent) and metropolitan areas (7 percent). Households in Thi-Qar and Missan were most to use any method of water treatment and Basrah was the least to use any method of water treatment. Thi-Qar has the highest percentage of use of appropriate method for all drinking water sources. Almost all use of the solar disinfection method in the country is implemented in this governorate, together with Babil governorate. The next highest percentage of appropriate water treatment method for all drinking water sources was in Diala and Salahuddin governorates. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. Table EN.3 shows a high percentage of households have drinking water source on the premises (79 percent). For 17 percent of all households, it takes less than 30 minutes to get to the water source and bring water, while only two percent of households spend more than 1 hour for this purpose. Excluding those households with water on the premises, the average time to the source of drinking water is 21 minutes. The time spent in rural areas in collecting water is almost double the time in urban areas. As expected from previous results in Table EN.1, only two percent of households in Basrah governorate have water on the premises. In spite of this, the governorate has the minimum meantime to source of drinking water in the country, due to reliance on tankers that deliver water nearby the houses. Dohuk governorate has the highest average time spent in collecting water (92 minutes), noting that this is referring to only two percent of the population who do not have water on the premises. With 20 percent of the population in Salahuddin seeking water outside the premises, the mean time to collect water is the second highest (73 minutes) in the country. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 In more than half of the households in the country where water is not on premises, water is collected by adult women (55 percent) (Table EN.4). This is followed by adult men (37 percent). Only in a small percentage of households children under age 15 collect water (7 percent), with slightly more male children (4 percent) collecting water than females (3 percent). Gender differentials exist when considering the background characteristics. More adult women collect water in rural areas, whereas the opposite is the case in urban areas. Some striking findings are the high percentage of female children collecting water in Salahuddin and the high percentage of male children in Basrah collecting water. The more educated the head of the household is, the more men and fewer women tend to collect drinking water. 8.1.2. Sanitation Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities include: flush toilets connected to sewerage systems or septic tanks or pit latrines, ventilated improved pit latrines and pit latrines with slabs, and composting toilets. Respondents in Iraq MICS-3 using flush toilets connected to sewerage systems or septic tanks or pit latrines were asked about the functionality of the sewerage systems around their house by indicating whether they have no problems, occasional, weekly, or daily problems. Overall, 92 percent of the population of Iraq is living in households using improved sanitation facilities (Table EN.5) with 87 percent of the population using flush toilets connected to sewerage systems or septic tanks or pit latrines. The percentage of households using improved sanitation facilities is 98 percent in all urban areas and 82 percent in rural areas. The use of improved sanitation is similar at metropolitan areas and other urban areas. The above figures do not reveal the situation on the ground, as 26 percent of the respondents indicated problems with the functionality of the sewage system around their house (Table EN.5A). The most common improved sanitation facility in metropolitan areas is flush toilet piped to sewer system (48 percent), in other urban areas is flush toilet connected to septic tank (57 percent), while toilets flushed to pit (latrine) are most common in rural areas (36 percent). Residents of Al-Qadisiya governorate are the least likely than all other governorates to use improved facilities (64 percent compared with more than 80 percent for all other governorates) (Map EN.5). Thirty- seven percent of residents in this governorate use an unimproved sanitation facility – 26 percent use toilets that flush or pour to some-where else or unknown/unsure place or use pit latrine without slab or open pit, 11 percent are with no facilities or use bush or field. Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet or by rinsing the stool into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table EN.6. ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Map EN.5: Percentage of household population using sanitary means of excreta disposal, by governorate, Iraq, 2006 Stools of only two in five children are disposed of safely. The most regularly used unsafe place of disposal of children’s faeces is in the garbage (37 percent). The proportion of children whose stools are disposed of safely varies by area of residence and by governorate. In rural areas, only one third of children have their stools safely disposed compared to 42 percent in metropolitan areas and 50 percent in other urban areas. Missan and Salahuddin governorates have the least percentage of children having their stools safely disposed – 25 and 32 percent respectively while the highest percentage occurs in Dohuk (60 percent). 8.1.3. Water and Sanitation The differences in use of water and sanitation become clear when examining the percentage of the population who have access to both improved water and sanitation sources. An overview of the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. About 3 out of 4 households use both improved drinking sources and sanitary means of excreta disposal in Iraq with only one in two households in rural areas, and about 9 in 10 households in both metropolitan and other urban areas (Figure EN.7). Kurdistan Region governorates have high percentages for this indicator (over 93 percent). The governorates in South/Centre Iraq with percentages of households using both improved sources of drinking water and sanitary means of excreta disposal that are below the national average may be ranked in the following order - Basrah (1 percent), Al-Muthanna (50 percent), Al-Qadisiya (57 percent), and Thi-Qar (61 percent), Babil (62 percent), Missan (70 percent), Wasit (70 percent), Diala (70 percent) and Salahuddin (71 percent). As expected, this indicator is positively related to education of the household head. 0.0 - 63.5 63.6 - 83.4 83.5 - 87.6 87.7 - 94.1 94.2 - 97.1 97.2 - 99.5 Nineveh 93.3 Al-Anbar 99.4 Al-Muthanna 81 Basrah 87.6 Missan 83.1 Thi-Qar 80.8 Wasit 94.1 Al-Qadisiya 63.5 Babil 83.4 Kerbala 91.8 Baghdad 99.5 Diala 95.8 Suleimaniya 97.1Kirkuk 93.6 Erbil 98.2 Dohuk 98.1 Salahuddin 92.8 Al-Najaf 93.2 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure EN.7: Percentage of household population using improved drinking water sources and sanitary means of excreta disposal, Iraq, 2006 ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 9.1. Contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception is defined as the proportion of women who reported they were using a family planning method at the time of the interview. In Iraq MICS-3, only women who were married at the time of survey were asked questions about current use of contraception. Current use of contraception of currently married women or husbands of these women was reported by half the women (Table RH.1). Many more women are using modern methods (33 percent) than traditional methods (17 percent). Thus modern methods account for 66 percent of overall use. The most popular method is the pill which is used by 15 percent of married women in Iraq (Figure RH.1A). The next most popular method is IUD, which accounts for 12 percent of married women. Eight and seven percent of women reported use of the withdrawal method and the lactational amenorrhea method (LAM) respectively. Between two and three percent of women reported use of female sterilization, periodic abstinence and injectables. Condom use is very rare; only one percent of married women reported using it as a method of contraception. Figure RH.1A: Current use of contraceptive by method, Iraq, 2006 Younger women are less likely to use contraception than older women. Only about 21 percent of married women aged 15-19 currently use a method of contraception compared to 36 percent of 20-24 years old and 64 percent of 40-44 years old women. This is probably due to the fact that younger women want more children. Figure RH.1B displays modern and traditional use of contraceptives by woman’s age. Use of modern contraceptive methods is more common than traditional methods across all age groups. Use of traditional methods is nearly constant for women older than 25 years. 9. Reproductive Health Other 0.4% With-drawal 7.5% Periodic abstinence 2.1% LAM 7.0% Male sterilization/Implants/ Female condom/ Diaphragm/ foam/ jelly 0.3% Condom 1.1% Injections 2.0% IUD 12.2% Pill 14.6% Female sterilization 2.6% Not using any method 50.2% Tubewell/borehole 1% Public tap/standpipe 9% Protected well or spring 2% Unprotected well or spring 5% Surface water 7% Other unimproved 11% Piped into dwelling, yard or plot 65% �0 Iraq Multiple Indicator Cluster Survey Final Report, 2006 The use of any contraceptive method is negligible when the woman has no living children (one percent). The greater the number of living children a woman has the more likely she is to use contraceptives - the contraceptive use rate rises from 34 percent for women with one living child to 65 percent for women with four or more living children. Iraq MICS-3 data indicate that some women are much more likely to be using contraception than other women. The level of current contraceptive use is higher is urban (53 percent) than in rural areas (44 percent). The pill is the most popular method among both urban and rural women. In spite of the low condom use, there is a sharp difference in its use between urban (1.5 percent) and rural women (0.4 percent). Iraq MICS-3 data indicate that there are some significant differences in contraceptive use between women in different socio-economic categories. The level of current contraceptive use is higher is urban (53 percent) than in rural areas (44 percent). The pill is the most popular method among both urban and rural women. Figure RH.1B: Percentage of currently married women aged 15-49 years using contraceptive methods, Iraq, 2006 There are some differentials in the current use of family planning across the 18 governorates of the country. Married women in Kurdistan Region governorates tend to use contraceptive methods more than married women in the rest of the governorates. There are differences within Kurdistan Region governorates with Suleimaniya (66 percent) and Erbil (62 percent) having the highest contraceptive prevalence rates in the country, while Erbil has one of the lowest prevalence rates (41 percent). The lowest contraceptive prevalence rates in the country occur in Al-Qadisiya and Babil with a 40 percent current contraceptive use for both governorates. All married women in Kurdistan Region are more likely to use IUDs than the pill. The method mix varies between the South/Centre governorates interchanging between the pill and IUDs. Women’s education levels are associated with contraceptive prevalence. The percentage of women using any method of contraception rises from 45 percent among those with no education to 48 percent among women with primary education, and to 55 percent among women with secondary or higher education. Contraceptive users with secondary or higher education are more likely to use the pill and IUDs (32 percent) compared with those with no or primary education users (23 and 25 percent, respectively). ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Users of contraceptives mostly get or seek their contraceptive methods from private physicians or pharmacies or relatives (Table RH.1A) With almost half of women not using contraceptives, Table RH.1B presents the results of the reasons for this non-use of contraception. Percentages do not add up to the total number of women currently married & not using contraception as women may have indicated more than one reason for non-use. The most reported reason for non use was the desire to have children followed by health reasons. Desire to have children was the most reported reason in Diala governorate where half of the women reported this reason. This reason was also mostly reported by younger women and by women who have fewer living children. 9.2. Unmet Need Unmet need6 for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth or who wish to stop childbearing altogether. Unmet need is identified in MICS by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity, and fertility preferences. Women in unmet need for spacing includes women who are currently married, fecund (are currently pregnant or think that they are physically able to become pregnant), currently not using contraception, and want to space their births. Pregnant women are considered to want to space their births when they did not want the child at the time they got pregnant. Women who are not pregnant are classified in this category if they want to have a child (or another child), but want to have the child at least two years later. Women in unmet need for limiting are those women who are currently married, fecund, currently not using contraception, and want to limit their births. The latter group includes women who are currently pregnant but had not wanted the pregnancy at all, and women who are not currently pregnant but do not want to have a child (or another child). Total unmet need for contraception is simply the sum of unmet need for spacing and unmet need for limiting. Using information on contraception and unmet need, the percentage of demand for contraception satisfied is also estimated from the MICS data. Percentage of demand for contraception satisfied is defined as the proportion of women currently married who are currently using contraception, of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. Table RH.2 shows the results of the survey on contraception, unmet need, and the demand for contraception satisfied. Total unmet need for contraception in Iraq is 11 percent, i.e. 11 percent of married Iraqi women are not using contraceptives but want to stop having children (limit) or postpone the next pregnancy for at least two years (space). More women are in unmet need for spacing for contraception (7 percent) than in unmet need in limiting for contraception (3 percent). Total unmet need for contraception is slightly greater for rural (12 percent) women than for urban women (10 percent). Married women in the 18 governorates differ in their total unmet need for contraception - Dohuk governorate has the largest number of women in total unmet need (18 percent) and Basrah governorate has the least number of such women (6 percent). In all governorates, except Al-Anbar, the unmet need for spacing is greater than the unmet need for limiting. With the exception of women in the age group 15-19 years, the total unmet need for contraception decreases as age increases reaching the peak at the age group 20-24 years. 6. Unmet need measurement in MICS is somewhat different than that used in other household surveys, such as the Demographic and Health Surveys (DHS). In DHS, more detailed information is collected on additional variables, such as postpartum amenorrhoea, and sexual activity. Results from the two types of surveys are strictly not comparable. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Table RH.2 also shows that a high percentage of currently married women (82 percent) of the total number of women demanding contraception are currently using contraception. This percentage of demand for contraception satisfied is lower in rural areas (78 percent) compared to urban areas (84 percent); least in Dohuk governorate (70 percent) and for women in the age group 15-19 years. 9.3. Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother’s health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women’s nutritional status and prevent infections (e.g. STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anemia • Weight/height measurement (optional) ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure RH.3A: Percent distribution of women aged 15-49 by number and timing of antenatal care (ANC) visits for the most recent birth, Iraq, 2006 Coverage of antenatal care (by a doctor, nurse, or certified midwife) is relatively high in Iraq with 84 percent of women receiving antenatal care at least once during the pregnancy (Table RH.3). Almost all women aged 15-49 years who gave birth in the two years preceding the survey received antenatal care from a doctor (84 percent). Antenatal care coverage by skilled personnel is 15 percent more in urban areas compared to rural areas. More than half the women had 4 or more visits and about 80 percent of them sought antenatal care for the first time during first and second trimester (Figure RH.3a). Furthermore, three in four women sought antenatal care for the last time in the last trimester. Figure RH.3B: Percent distribution of women aged 15-49 who gave birth in the two years preceding the survey by reason for not seeking antenatal care (ANC), Iraq, 2006 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Map RH.3: Percent distribution of women aged 15-49 who were provided antenatal care by skilled personnel, by governorate, Iraq, 2006 The number of women receiving antenatal care varied by governorate, with the highest in Al-Anbar (93 percent) and Baghdad (91 percent) (Map RH.3). Governorates of Wasit, Al-Qadisiya, Nineveh, and Erbil are lagging behind for this indicator, having percentages of women receiving antenatal care between 76 and 78 percent. As expected, the percent of women receiving antenatal care increased markedly by women’s education. This percent also decreased steadily by women’s age, except for the women in the older age group 45-49 years who tend to have a higher percentage of receiving antenatal care. Sixteen percent of women did not receive any antenatal care during pregnancy (Table RH.3). For births of these women, mothers were asked why they did not seek antenatal care. Almost two-thirds of the women reported that they did not feel the need to see anyone (Figure RH.3b). Every one in five women mentioned that it was difficult to reach the ANC center. The types of services pregnant women in Iraq received are shown in Table RH.4. The results in the table may provide insight into the content of the care women get during pregnancy. Respondents to the questionnaire answered yes if they received any of the specific cares at least once during her pregnancy. About five in six women received antenatal care one or more times during their pregnancies (84 percent – 90 percent in urban areas, and 75 percent in rural areas). Only 60 percent of these women had their weight measured, 63 percent had a urine sample taken, 66 percent had a blood test taken, and 76 percent had their blood pressure taken. Only about two thirds of rural women had their blood measured and about half or less had their weight measured, urine specimen taken, or blood test taken. In general, compared to other services, weight measurement was the least to be received by women within the different governorates with a strikingly low 37 percent for this indicator in Dohuk governorate. 76.1 - 80.0 80.1 - 85.0 85.1 - 90.0 90.1 - 95.0 Nineveh 76.5 Al-Anbar 92.9 Al Muthanna 80.5 Basrah 86.5 Missan 80.4 Thi-Qar 80.3 Wasit 76.1 Al-Qadisiya 76.3 Babil 85.2 Kerbala 83.7 Baghdad 91.4 Diala 79.5 Suleimaniya 80Kirkuk 85.1 Erbil 77.9 Dohuk 82.9 Salahuddin 82 Al-Najaf 88.6 ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 9.4. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, or a certified midwife. Eighty-nine percent of births occurring in the two years prior to the Iraq MICS-3 survey were delivered by skilled personnel (Table RH.5). This percentage is more in urban areas (95 percent) than rural areas (78 percent). More than half of births (55 percent) in the two years prior to the Iraq MICS-3 survey were delivered with assistance of a doctor. Certified midwives assisted with the delivery of a quarter of births (25 percent), uncertified midwives assisted with five percent of the births, nurses assisted with nine percent of the births, and traditional birth attendants referred to as “Gida” in Iraq assisted with six percent of births. Almost all women in Al-Najaf governorate were assisted during delivery by skilled personnel (98 percent). Women in Ninevah, Kirkuk, and Wasit governorates were the least likely in the country to have their deliveries assisted by skilled personnel (74-78 percent). It is worth noting that more than one in five women is assisted by either traditional birth attendants (Gidas) or uncertified midewifes in Nineveh and Wasit governorates. Moreover, Kirkuk governorate has the highest percentage in the country where delivery is assisted by a relative or a friend (8 percent) (Map RH.5). �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Map RH.5: Percent distribution of women aged 15-49 who were assisted during delivery by skilled personnel, by governorate, Iraq, 2006 The more educated a woman is the more likely she is to have delivered with the assistance of a skilled person. Younger women were more assisted by doctors than older women. In contrast, older women were more assisted by midwives than younger women. 9.5. Delivery in a Health Facility Overall, approximately two out of three births occurring in the two years prior to the Iraq MICS-3 survey were delivered in a health facility (63 percent) (Table RH.5). More births are delivered in health facilities in urban areas (68 percent) than in rural areas (54 percent). Women residing in Kurdistan Region governorates were more likely to deliver in a health facility with the highest percentage in the country occurring in Dohuk governorate (76 percent). Kirkuk has the lowest percentage of women delivering in a health facility (43 percent). Very young and older women were more likely to deliver their births in a health facility compared to women in the middle age group 30-39 years. Delivery in a health facility increases with a woman’s educational level – only about half of the uneducated women delivered in a health facility (52 percent), compared with 61 percent for women with primary education and 72 percent for women with secondary or higher education. 74.1 - 80.0 80.1 - 85.0 85.1 - 90.0 90.1 - 95.0 95.1 - 100.0 Nineveh 74.1 Al-Anbar 94 Al Muthanna 84.7 Basrah 96.9 Missan 84.6 Thi-Qar 86.9 Wasit 77.5 Al-Qadisiya 95.4 Babil 90.6 Kerbala 97.1 Baghdad 93.9 Diala 90.5 Suleimaniya 91.9Kirkuk 75.5 Erbil 87.5 Dohuk 84 Salahuddin 82.5 Al-Najaf 97.9 ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 9.6. Caesarean Deliveries Iraq MIC3 collected information on whether a child was delivered by caesarean section. Table RH.6 shows that one-fifth of the deliveries in the two years prior to the survey were by caesarean section. Women residing in metropolitan areas are more likely to have caesarean delivery than those residing in urban other and rural areas. The likelihood of a caesarean delivery increased by both age of mother and her educational status. Al-Qadisiya governorate has the highest percentage of caesarean section deliveries (28 percent) and Dohuk has the lowest percentage (12 percent). �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this early period. In this context, adult activities with children, presence of books in the home, for the child, and the conditions of care are important indicators of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, drawing things, or memorising religious versus. During the three days preceding the survey, an adult was engaged in more than four activities that promote learning and school readiness with almost half (47 percent) of the under-five children in Iraq (Table CD.1 and Figure CD.1). The average number of activities that adults are engaged with children was 3.4. The table also indicates that only 3 percent of children were living in a household without their fathers. In cases where fathers lived in the household, they were involved in such activities with more that half (55 percent) of children under-five. Figure CD.1: Percentage of children aged 0-59 months for whom household members are engaged in activities that promote learning & school readiness, Iraq, 2006 10. Child Development ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 There are no gender differentials in terms of adult activities with children; however, a slightly larger proportion of fathers engaged in activities with male children (57 percent) than with female children (52 percent). Larger proportions of adults are engaged in learning and school readiness activities with children in urban areas (52 percent) than in rural areas (38 percent). Strong differentials by governorate were also observed: adult engagement in activities with children was greatest in Al-Anbar (65 percent) and Salahuddin (60 percent) lowest in the Al-Qadisiya (28 percent) and Wasit (30 percent). Father’s involvement was most in Salahuddin and Missan, and least in Al-Qadisiya and Basrah. Household members were more engaged with children two years or more than younger ones. The more educated mothers and fathers are the more engaged they become in such activities with children than those with less education. �0 Iraq Multiple Indicator Cluster Survey Final Report, 2006 11.1. Pre-School Attendance and School Readiness Attendance to pre-school education in an organized learning or child education program is important for the readiness of children to school. One of the World Fit for Children goals is the promotion of early childhood education. Only 3 percent of children aged 36-59 months are attending pre-school (Table ED.1). Urban-rural and governorate differentials are significant – the figures are four percent in metropolitan areas and three percent in other urban areas, compared to less than one percent in rural areas. Among children aged 36- 59 months, attendance to pre-school is more prevalent in Suleimaniya (6 percent), Najaf, Al-Muthanna and Baghdad (both 4 percent), and lowest in Missan, Kirkuk, and Nineveh (less than 1 percent). In general, double the children in Kurdistan Region governorates (4 percent) attend pre-school compared to children in South/Centre governorates (2 percent). There are slightly fewer male children (3 percent) attending early childhood education than females (2 percent). The proportion of children attending pre-school at ages 48-59 months (3.4 percent) is more than double the proportion at ages 36-47 months (1.5 percent), indicating that children in Iraq are more likely to attend early childhood education after they reach four years of age. Mother’s education has a positive correlation with school readiness. Table ED.1 also shows the proportion of children in the first grade of primary school who attended pre- school the previous year, an important indicator of school readiness. Overall, only four percent of children who are currently at age 6 and attending the first grade of primary school were attending pre-school the previous year. No gender differential has been observed. Similar to results of the previous indicator, area of residence and governorate differentials are significant. Children attending first grade in metropolitan or other urban areas (6 percent) are about three times more likely to have attended pre-school the previous year than children in rural areas (2 percent). First graders in Erbil have an outstanding percentage of school readiness (27 percent) compared to all other governorates (<8 percent), but most of these figures are based on small sample size and should be interpreted with caution. 11.2. Primary School Attendance Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. The indicators for primary and secondary school attendance include: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of children of secondary school age • Female to male education ratio (or gender parity index - GPI) The indicators of school progression include: • Survival rate to grade five • Transition rate to secondary school • Net primary completion rate 11. Education ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 A more accurate method of calculation of the primary school entry indicator is to consider the cohort born between 1 January 1999 and 31 December 2000. According to the education system in Iraq these represent the children expected to be attending grade 1. In this survey data collected related to education included age of the child in completed years on his/her last birthday. Since the data collected do not allow the exact calculations above we will consider both children 6 years of age and 7 years of age as primary school entry ages. This will allow us to provide a range for the estimate for the actual value of the primary school entry indicator. Of children who are of primary school entry age (age 6) in Iraq, 63 percent (82 percent for age 7) are attending the first grade of primary school (Table ED.2), with slightly more male children (64 percent; 85 percent for age 7) than female (62 percent; 79 percent for age 7). Significant differentials are present by urban-rural areas and governorates. Primary school entry is highest in metropolitan areas (73 percent; 88 percent for age 7), followed by other urban areas (66 percent; 86 percent for age 7), and lowest in rural areas (55 percent; 75 percent for age 7). The least percentage of children of primary school entry age currently attending grade 1 is in Missan governorate (43 percent; 67 percent for age 7) and the highest is in the capital Baghdad (75 percent; 91 percent for age 7) (Map ED.2). A positive correlation with mother’s education was observed: for children age six and age seven whose mothers have at least secondary school education, 77 percent and 91 percent respectively were attending the first grade. Map ED.2: Percentage of children of primary school entry age (7 years) currently attending grade 1, by governorate, Iraq, 2006 70.1 - 75.0 65.1 - 70.0 75.1 - 80.0 80.1 - 85.0 85.1 - 90.9 Nineveh 76.8 Al-Anbar 88 Al Muthanna 68.7 Basrah 86.5 Missan 67.2 Thi-Qar 75.7 Wasit 76.4 Al-Qadisiya 67.6 Babil 83.4 Kerbala 88.6 Baghdad 90.9 Diala 83.5 Suleimaniya 90.8Kirkuk 86 Erbil 83.6 Dohuk 87.3 Salahuddin 68.5 Al-Najaf 81 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Overall, six in seven children of primary school age in Iraq are attending primary school or secondary school (86 percent) (Table ED.3) i.e., 14 percent are not attending primary or secondary school. Males have a higher school attendance (91 percent) when compared to females (80 percent). In urban areas, 92 percent of children attend school while in rural areas 78 percent attend. This disparity is more pronounced for females (89, urban vs 68 percent, rural) than for males (94, urban vs 87 percent, rural). The primary school attendance rate varied by governorate ranging generally between 71 and 96 percent with Missan governorate having the lowest percent in the country. This is more pronounced when considering female children where the primary net attendance rate in Missan is only 56 percent. Overall, Kurdistan Region governorates (95 percent) have higher rates than South/Centre governorates (85 percent). Again this is more pronounced for female children compared to male children. Attendance rates are least for children 11 years of age compared to other children of primary school age. The school attendance increases with mother’s education – 95 percent for mothers with secondary or higher education, 87 percent for mothers with primary education, and 75 percent for mothers with no education. The secondary school net attendance rate (NAR) is presented in Table ED.4. More dramatic than in primary school where 14 percent of the children are not attending school at all, is the fact that only 40 percent of the children of secondary school age are attending secondary school. Of the remaining 60 percent, some of them are either out of school or attending primary school (see below). The secondary school net attendance rate is lowest for females (34 percent) than for males (46 percent). The secondary school net attendance rate differentials are especially low in the rural areas (24 percent) and for children age 17 years (32 percent). These rates vary by governorate. They are higher in Kurdistan Region governorates (53 percent) than in the South/Centre governorates (38 percent). The indicator is positively related to mother’s education, overall and for both male and female children The primary school net attendance rate of children of secondary school age is presented in Table ED.4W. Almost 12 percent of secondary school age are attending primary school when they should be attending secondary school. Out of the 60 percent children of secondary school age who are not attending secondary school, the remaining 48 percent are not attending school at all - they are children out of school. Disparity exists for this rate between male and female children (Figure ED.4). The secondary NAR is greater for males compared to females. More secondary female children are out of school compared to males, and less are attending primary school. Disparities also exist among governorates. Overall, about half the secondary school children in the South/Centre governorates are out of school compared to about one third in the governorates of Kurdistan Region. The percentage of children entering first grade who eventually reach grade 5 is presented in Table ED.5. Of all children starting grade one, the majority of them (95 percent) will eventually reach grade five. Notice that this number includes children that repeat grades and that eventually move up to reach grade five. Slightly more males (96 percent) than females (94 percent) eventually reach grade five. There are no urban/ rural disparities in children reaching grade five. In general, among the various governorates, most of the children reach grade five with the lowest percentage in Suleimaniya governorate (90 percent) and the highest percentage in Diala governorate (99 percent). ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure ED.4: Percentage of secondary school NAR, secondary school age children attending primary school and secondary school children ouf of school, Iraq, 2006 Table ED.6 presents the gross primary completion rate and the net primary completion rate. The gross primary completion rate considers the number of children of all ages who are completing the final year of primary education, as a percentage of the population of the official primary school graduation age. The net rate is calculated as the number of children of primary school completion age who are completing the final year of primary education as a percentage of the population of the official primary school graduation age. In Iraq the primary school cycle spans 6 years with children officially entering primary school at 6 years and officially graduating at 11 years. Figure ED.6: Gross and net primary school completion rate, Iraq, 2006 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 Results show that the gross primary completion rate in Iraq is 81 percent. The rate varies within sex, area of residence, governorates, and mother’s education. Boys have a higher rate (89 percent) than girls (72 percent); other urban areas have a higher rate (92 percent) than metropolitan areas (86 percent) and rural areas (69 percent). This indicates attendance of more boys of all ages than girls and more children of all ages in urban areas than in rural areas at the 6th grade. The gross primary completion rates vary markedly by governorate, the lowest being in Nineveh and reaching over 100 in the Kurdistan Region (Figure ED.6). Governorates with gross primary completion rates over 100 indicate the presence of more students of all ages in the final year than students who are 11 years of age. These rates increase with mothers’ education. The net completion rate is 44 percent, i.e. 44 percent of Iraqi children of primary graduation age (11 years) are attending the 6th grade at age 11 years. The rate for boys is slightly greater than that for girls (Figure ED.6) and the greater difference observed in the primary completion rate is due to the fact that the majority of children over age 11 years at the time of the survey attending the 6th grade of primary school are boys. The net completion rate is greater in urban areas (53 percent) compared to rural areas (32 percent) and the rate increases markedly with mothers’ education. The net completion rate also varies by governorate, the highest being in Diala and Baghdad (about 60 percent) and the lowest being in Missan governorate (25 percent). Comparing the gross primary completion rate (81 percent) with the net completion rate (44 percent) indicates the presence of children who are over age 11 years at the time of the survey at the 6th grade (Figure ED.6). A similar interpretation of the large values of the gross primary completion rate compared to the net rate is reached when comparing these rates across all the background characteristics. The transition rate to secondary education is also shown in Table ED.6. In Iraq, 78 percent of children who were in the 6th grade of primary school last year attended the first grade of secondary school this year. The percentage is higher for girls (82 percent) than boys (76 percent) and for urban areas (82 percent) than rural areas (70 percent). The transition rate to secondary education was highest in Diala (90 percent) and Erbil (89 percent) and lowest in Salahuddin (46 percent). Overall, Kurdistan Region governorates have a higher transition rate (84 percent) than governorates in South/Centre Iraq (77 percent). The rate is associated positively with mothers’ education. The rate of girls to boys attending primary and secondary education is provided in Table ED.7. These rates are better known as the Gender Parity Index (GPI). Notice that the rates included here are obtained from net attendance rates rather than gross attendance rates. The gross attendance rates provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary education tend to be boys. The table shows that gender parity for primary school is 0.88, indicating that more boys attend primary school compared to girls. The indicator drops to 0.75 for secondary education indicating that for every 100 boys attending secondary school 75 girls attend. The disadvantage of girls is particularly pronounced in the rural areas where the gender parity for primary school is 0.79 and gender parity for secondary school is 0.40. Gender parity in metropolitan areas was slightly higher than that of other urban areas. Also gender parity increased with mother’s education. ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 Figure ED.7: Gender parity index for primary and secondary schools , Iraq, 2006 Table ED.7 and Figure ED.7 also show that gender parity for primary and secondary school is close to 1.00 in Kurdistan Region governorates as a whole (0.95 and 0.96 respectively) indicating no difference in attendance of girls and boys. One interesting result is that for Suleimaniya governorate for every 100 boys attending secondary school 108 girls attend. The disadvantage of girls in primary schools is particularly pronounced in Missan governorate (GPI=0.67), and for secondary school in Nineveh (GPI=0.44) and Salahuddin (GPI=0.46). 11.3. Adult Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy is also an MDG indicator used to monitor progress towards achieving universal primary education, relating to both men and women. In MICS-3, since only a women’s questionnaire was administered, the results are based only on females age 15-24. . Literacy was assessed on school attendance for women with secondary or higher education and on the ability of women to read a short simple statement for women with primary education. The percent literate is presented in Table ED.8. No response was reported for a negligible number of women (0.1 percent). Two-thirds of women aged 15-24 are literate. Literacy varies considerably between urban and rural areas of residence, with less than half the women in rural areas literate compared to 80 percent in metropolitan areas and 72 percent in other urban areas. The highest percentages of literate women were in Baghdad (79 percent) and Al-Anbar (77 percent) and the lowest were in Missan (48 percent), Salahuddin (52 percent), and Dohuk (53 percent). It is interesting to note that only 55 percent of those women who reported attaining primary education were literate. �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 12.1 Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under-five years of age whose birth is registered where birth certificates were either seen by the interviewer or whose mothers or caretakers say the birth has been registered. The births of 95 percent of children under-five years in Iraq have been registered (Table CP.1). There are no significant variations in birth registration across sex or mother’s education categories. Birth registration is lowest in Al-Muthanna and Nineveh governorates (93 percent). Older children are more likely to have been registered than younger children. 12.2 Child Labour Article 32 of the Convention on the Rights of the Child states: «States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child>s health or physical, mental, spiritual, moral or social development.» The World Fit for Children mentions nine strategies to combat child labour and the MDGs call for the protection of children against exploitation The child labour module asks a series of questions to the mother/caretaker of each child in the household 5-14 years of age about the kind of work a child does and for how many hours. Data is also collected on economic activities and domestic work. Economic activities include paid or unpaid work for someone who is not a member of the household and work for a family farm or business. Domestic work includes household chores like collecting firewood, fetching water, cooking, cleaning, looking after animals/livestock, or caring for children. In the MICS questionnaire, a number of questions addressed the issue of child labour, that is, children 5-14 years of age involved in labour activities. A child is considered to be involved in child labour activities at the moment of the survey if during the week preceding the survey: • Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. • Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows differentiation between child labour and child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained above. Table CP.2 presents the results of child labour by the type of work. Percentages do not add up to the total child labour as children may be involved in more than one type of work. The Iraq MICS-3 survey estimates that about one in nine children aged 5-14 years work (11 percent). Two percent of these children participate in unpaid work for someone other than a household member, an equal percentage of children do household chores for 28 hours or more per week, while a higher percentage of children work for family business (7 percent). Boys (12 percent) work more than girls (9 percent). A higher percentage of children work in the rural areas (18 percent) compared to the urban areas (6 percent). Child labour rates are slightly higher among the age group 12-14 years (12 percent) when compared to the younger age group 5-11 years (10 percent). 12. Child Protection ��Iraq Multiple Indicator Cluster Survey Final Report, 2006 The results also show that children who work are less likely to participate in school – 10 percent participate in school and 14 percent do not. Involvement of Iraqi children in labour activities decreases as mother’s education increases – this involvement is highest for children of mothers with no education (14 percent) with most of these children working for family business (11 percent). Map CP.2: Percentage of children aged 5-14 years who are involved in child labour activities, by governorate, Iraq, 2006 Child labour profoundly varies among governorates (Map CP.2). In Babil governorate, more than one in five children aged 5-14 years is involved in child labour activities (22 percent). A relatively high percentage is also observed in Salahuddin (18 percent) and Al-Anbar (17 percent). Most of these children work for family business. Child labour rates are least in Dohuk, Basrah, and Kirkuk with rates less than seven percent. Overall, slightly less than double the children are involved in child labour in South/Centre governorates (11 percent) compared to Kurdistan Region governorates (6 percent). Table CP.3 presents the percentage of children classified as student labourers or as labourer students. Student labourers are the children attending school that were involved in child labour activities at the moment of the survey. More specifically, of the 70 percent of the children 5-14 years of age attending school, 10 percent are also involved in child labour activities. On the other hand, out of the 11 percent of the children classified as child labourers, almost two- thirds of them are also attending school (62 percent) i.e. labourer students. More boys (11 percent) are student labourers than girls (7 percent), and a large percentage of rural children (18 percent) are student labourers compared to children residing in urban areas (5 percent). Student labourers are also more in 4.1 - 7.0 7.1 - 12.0 12.1 - 17.0 17.1 - 25.0 Nineveh 7.4 Al-Anbar 16.7 Al Muthanna 8.4 Basrah 5.1 Missan 11.6 Thi-Qar 9.7 Wasit 10 Al-Qadisiya 13.5 Babil 21.7 Kerbala 8.1 Baghdad 10.4 Diala 10.8 Suleimaniya 7Kirkuk 6.3 Erbil 7.4 Dohuk 4.3 Salahuddin 18.1 Al-Najaf 13.4 �� Iraq Multiple Indicator Cluster Survey Final Report, 2006 the age group 5-11 years (10 percent) than in the age group 12-14 years (7 percent), and their numbers decrease with mother’s education. Student labourers are most prevalent in Babil and Al-Anbar governorates. A similar gender differential for labourer students exist as for student labourers, although the opposite is observed when considering areas of residence where labourer students are slightly more in urban areas (66 percent) than in rural areas (60 percent). Labourer students are more prevalent in the age group 5-11 years (71 percent) than in the age group 12-14 years (40 percent), increasing w

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