A multivariate method for estimating mortality rates among children under 5 years from health and social indicators in Iraq

Richard Garfielda and Cheng-Shuin Leub

a School of Nursing, Columbia University, NY, USA.
b NYS Psychiatric Institute and Columbia University, USA

Reprint requests to: Richard Garfield, Columbia University, 630 West 168th Street, Box 6, New York, NY 10032, USA. E-mail: rmg3{at}columbia.edu


    Abstract
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
Background Many reports on Iraq suggest that a rise in rates of death and disease have occurred since the Gulf War of January/February 1991 and the economic sanctions that followed it.

Methods Four preliminary models, based on unadjusted projections, were developed. A logistic regression model was then developed on the basis of six social variables in Iraq and comparable information from countries in the State of the World's Children report. Missing data were estimated for this model by a multiple imputation procedure. The final model depends on three socio-medical indicators: adult literacy, nutritional stunting of children under 5 years, and access to piped water.

Results The model successfully predicted both the mortality rate in 1990, under stable conditions, and in 1991, following the Gulf War. For 1996, after 5 years of sanctions and prior to receipt of humanitarian food via the oil for food programme, this model shows mortality among children under 5 to have reached an estimated 87 per 1000, a rate last experienced more than 30 years ago.

Conclusions Accurate and timely estimates of mortality levels in developing countries are costly and require considerable methodological expertise. A rapid estimation technique like the one developed here may be a useful tool for quick and efficient estimation of mortality rates among under 5 year olds in countries where good mortality data are not routinely available. This is especially true for countries with complex humanitarian emergencies where information on mortality changes can guide interventions and the social stability to use standard demographic methods does not exist.

Keywords Mortality, humanitarian crisis, demographic surveys, estimation, multiple imputation

Accepted 12 November 1999


    Introduction
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
Surveys to determine child mortality rates are expensive, require large samples, and are vulnerable to many biases.1 The social stability and resources required to carry out such surveys are often lacking in areas experiencing humanitarian crises where timely and accurate information on changes in mortality rates would be most useful. Many reports on Iraq suggest that a rise in rates of death and disease have occurred since the Gulf War of January/February 1991 and the economic sanctions that followed it. 2–11 There are no verified estimates, however, of the magnitude of this mortality increase through 1998. Reliable data are not available from any demographic surveys in Iraq since 1991. High-quality survey data are available in the Multiple Indicator Cluster Survey (MICS) of 1996 on child nutrition, water quality, adult literacy, and other social and health indicators which may influence child mortality. A model was developed to estimate mortality among under 5 year olds from these social and health indicators. The model was then tested against known mortality rates for Iraq for 1989 and 1991. The model predicted the known rates for those prior years well. If a model like this is robust to the determinants of mortality in other countries, it could have many other applications for estimating mortality.


    Background
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
The first and only large-scale survey to assess mortality levels among children following the Gulf War was carried out by the International Study Team (IST) in 1991.12 This stratified cluster survey included information on births and subsequent deaths among a cohort of 16 076 children under 5 years. For the period of the Gulf War and post-war uprising, 1 January 1991 through 31 August 1991, they estimated an under 5 year old mortality rate of 128.5 per 1000 live births. In Baghdad alone, they found a baseline level of under 5-year-old mortality during 1985–1990 of 34.0 and during the period from January 1991 through August 1991 of 60.7. The relative increase of death was greater for rural or low education mothers. Infants under one month old were relatively less vulnerable, with an estimated rate increase in 1991 compared to that of the period from 1985 through 1990 of 80%, while those aged 2–60 months had nearly fourfold mortality rate increases.

Subsequently, in 1995, a study sponsored by the Food and Agricultural Organization (FAO) in the poor urban neighbourhood of Saddam City in Baghdad calculated a mortality rate among under 5 year olds of 216 per 1000 live births.13 Had mortality risen even higher in 1995 than it was in the post-war period of 1991, when it had already risen nearly threefold? The question was important as no other reliable source was available to estimate current mortality.

The FAO study suffered from serious flaws in methods and interpretation which are common to surveys to assess young child mortality: (1) the study sample was small, including only 2108 children; (2) several of the study clusters showed mortality rates far higher than any other; (3) there were no international team members on some of the field data collection teams; and (4) no field verification checks on data collected were performed.

A follow-up study in 1996 by the Center for Social and Economics Rights (CESR)14 selected 44 newly randomized clusters throughout Baghdad and repeated 20 clusters from the 1995 study. Only 80% of the mothers interviewed in repeat clusters were interviewed the year before. Among these 237 mothers, 96% of all births were confirmed on both surveys but 65 of the 74 deaths reported in 1995 were not reported again in 1996. The 1995 study's conclusions were subsequently withdrawn by the authors,14 but not before national projections from these flawed data were published. Notwithdstanding the retraction of the original data, their estimate of more than 500 000 excess child deaths associated with the embargo has often been repeated by critics of sanctions.


    Changes in Health Status
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
Data from the Iraqi Ministry of Health suggest a rapid worsening in the health of children in the 1990s. These data reflect the experiences of only that shrinking portion of the population which uses public medical care services. They can only be used to indicate general trends as they are based on incomplete and changing levels of coverage of the population. Low-weight births, children treated for malnutrition, and the reported number of illnesses which are associated with contaminated water all rose rapidly from 1990 to 1994, and subsequently stabilized at high levels in 1995.


    Univariate Models to Estimate Mortality
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
Given the uncertainties and inconsistencies of the various studies on Iraqi mortality rates, and the incomplete nature of Iraqi mortality reports from hospitals and vital statistics registries, there is an urgent need for independent estimates of mortality changes since 1990. Except for IST data for 1991, the only reliable national data sets for Iraq were from the 1996 MICS study. This report uses these data to develop estimates for changes in mortality rates. Methods for estimating under 5 year old mortality rates are presented below. Four analyses, based on three independent data sources, are detailed. These are followed by a logistic regression based on a data set created with multiple imputation where values were missing.

Model 1: Correlating malnutrition and mortality data
Data from the 1996 MICS survey for each of the three measures of malnutrition were compared to the data for all other countries in the State of the World's Children report16 with levels of malnutrition within a range of 10% higher or lower. Eight countries reported a prevalence of low weight-for-age in the range 20–26%, 12 countries reported low height-for-age in the range 28–34%, and 10 countries reported low weight-for-height among under 5 year olds in the range 9–11%. The average under 5 mortality rates reported for those countries that shared Iraq's weight-for-age values were 126.1 ± 67.0, for those countries that shared Iraq's height-for-age values were 131.2 ± 76.5, and for those countries that shared Iraq's weight-for-height values were 148.6 ± 64.2. The unweighted average of these three rates is 135.3 ± 69.2 (Table 1Go). The major weakness in this approach is the assumption that the relationship between mortality and malnutrition in Iraq is likely to be similar to countries with more stable social conditions. While higher malnutrition usually implies higher mortality, the relationship cannot be assumed to be linear and may be heavily influenced by other cultural or social factors.


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Table 1 Summary of mortality estimates from four models
 
Model 2: Projections from the mortality rate in Baghdad
The mortality rate in the 1996 CESR study in Baghdad cannot be used as a national estimate because, as in most developing countries, mortality is likely to be higher outside the capital city. Data from the IST study provided relative mortality rates for Baghdad and the rest of the country for children under one month old, 1–11 months, and 12–59 months of age.12 Among under one month olds, excess mortality outside Baghdad relative to mortality in Baghdad is 4% and 21% for the periods 1985–1990 and January 1991–August 1991, respectively. Among 1–11 month olds, it is 149% and 250% and among those aged 12–59 months 338% and 505%, for the same two periods of time. The IST found in 1991 that 25% of all deaths in the under 5s occur in the first month, 47% occur during the second to twelfth month of life, and 28% occur at 1–4 years of age. Using these same rates of proportional mortality among under 5 year olds, total mortality among under 5s outside of Baghdad should be between 1.6 and 3.2 times higher than in Baghdad. Assuming that a quarter of all under 5s live in Baghdad, the 1996 CESR mortality estimate would project to a national rate in the range 47–100. The midpoint estimate of this range is 73.5 ± 26.5. Weaknesses in this method include the imprecision of projecting for the nation from one area, the possibility that variables influencing mortality have not changed proportionally in Baghdad and the rest of the country, and the possibility that proportional mortality by age, estimated from IST data for two periods, could have changed in subsequent years.

Model 3: Comparison with eight malnutrition and mortality studies
Pelletier et al. identified eight observational studies in six countries where weight-for-age assessments were correlated with subsequent mortality rates among under 5 year olds.17 While the log of mortality rates in these eight studies generated nearly parallel slopes of increase as malnutrition increased, the baseline levels of mortality among those with mild malnutrition carried eightfold. Point estimates and confidence intervals for average mortality among under 5 year olds from these eight studies were 11.4 ± 8.3 per 1000 births for those with normal weight, 19.3 ± 16.1 per 1000 among those mildly underweight, 34.4 ± 23.4 per 1000 among those moderately underweight, and 91.4 ± 63.2 per 1000 for those severely underweight. Each of these rates is multiplied by five to derive the cumulative rate of death among under 5 year olds. Multiplying these rates by the proportion of Iraqi children under 5 years with normal weight (42.8%), and who are mildly underweight (34.3%), moderately underweight (16.6%) and severely underweight (6.3%) as determined in the MICS 1996 survey21,22 (see Endnote) generates a mortality rate estimate of 92.0 ± 68.7 deaths per 1000. Limitations in this approach include the imprecision in using as a model data with widely varying values, the wide confidence band generated, and the possibility that malnutrition-mortality dynamics in Iraq may be different from those in the eight countries used to develop this model.

Model 4: Comparison to countries with similar expected population attributable risk
Pelletier et al.18 observed that although mortality rates varied a great deal, the slopes of the increase in the rate of mortality at various levels of malnutrition were nearly parallel. This permits calculation of an equation for the slope of relative risk of mortality and calculation of the population attributable risk (PAR) associated with low weight-for-age. While the actual mortality rate remains unknown, the proportion of all mortality which is attributable to mild, moderate, and severe malnutrition can be calculated. Rates of the PAR varying from 12% to 66% were presented for 53 countries.17 Data on the proportion of under 5-year-old Iraqis with moderate and severe malnutrition were transformed according to equations provided by Pelletier17 and fitted to his regression equation to estimate the PAR for malnutrition in Iraq in 1996. The Iraqi rate of 64% PAR was within a 10% range of only the highest three countries among the 53 presented: Nepal, Bangladesh, and India. Data on the under 5-year-old mortality rate for these three countries was taken from the 1998 State of the World's Children report.16 They averaged 113.0 ± 2.6. Limitations in this approach are similar to those in the first model and the small number of countries upon which this model's comparisons are based.

These four estimates, depending on three independent data sources, consistently demonstrate a trend toward increased mortality. They generate a range of estimates of mortality among under 5 year olds from 74 to 135.


    Regression Modelling
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
The above models may overestimate mortality by failing to take account of long-term social development investments which have only partly deteriorated. In other words, malnutrition is not the only factor influencing mortality rates among children under 5 years of age. Literacy, measles immunization coverage, and access to piped water and sanitation facilities likely moderate the impact of nutritional and financial declines related to the sanctions. Other factors, including the proportion of children in primary school, and the percentage of children who are breastfed, may have an independent influence on mortality or be markers for independent variables. Several representative surveys provide data on these variables for Iraq (Table 2Go and Endnote).


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Table 2 Variables used for regression models
 
Data from the State of the World's Children report16 for these and the three nutritional indices for all of 195 other reporting countries were used to establish regression equations to predict under 5-year-old mortality rates. Not all data items were complete for each variable in all 195 countries. While several variables were available for all countries, some data were available for as few as half of all countries. A complete set of all variables existed for only 48 countries.

Countries with the most complete data sets are a biased sample of all countries, strongly weighted toward higher social indicators and lower mortality rates. Because of this, and the large amount of missing data, imputing those missing values is important.

The multiple imputation procedure of Rubin24 was used to achieve this goal. In this technique, an imputation model is constructed to estimate missing values as a regression function of known variables. These estimates produce a variety of results, including better and worse case scenarios. The bootstrap procedure selects a random sample with replacement from the data with complete records. The desired imputation model is then fitted to the bootstrap sample to derive coefficients of covariates and a set of error terms, where the error term is the observed value minus model predicted value.

Missing data are imputed by substitution of the predicted values. In our data set, the imputation model estimates a missing value on the basis of known values for under 5-year-old mortality rate, the under one-year-old mortality rate and GNP per capita are independent variables. Imputed values, together with the originally complete records, form one complete data set. The process of iteration is repeated to obtain five completed data sets. Rubin24 provides formulae for combining the results to derive point estimates for imputed values as a simple average of the multiple completed-data point estimates, together with confidence intervals.

The rate of mortality among those aged under 5 is considered as the number of events (deaths) per 1000 trials (births). Because values for this dependent variable fall between 0 and 1, linear and log-linear models are inappropriate. We employ a binomial logistic regression model.

Five completed data sets were generated through multiple imputation. For each data set the binomial logistic regression model with six independent variables was fitted to estimate mortality among under 5-yearolds (Table 3Go). Five estimates, , ..., were obtained. The final estimator of under 5-year-old mortality rate is the mathematical average of the five, i.e.: = i and variance of is:


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Table 3 Logistic regressions using imputed values for missing data
 

Only six of the eight potential independent variables were significantly associated with known under 5-year-old mortality rates among the 195 country cases in our imputed data base. Of these, the variables ‘per cent of infants breastfed at 6 months' and ‘GNP' showed the lowest significance and provided the least contribution to parameter estimates.

Three variables had far larger beta values than any other. These are the per cent of adults who are literate, the prevalence of moderate to severe stunting among under 5-year-olds, and per cent of population with potable water. Very little power was lost by including only these three independent variables rather than the entire variable set. Both are shown. Parameter estimates for the coefficients for the three-variable logistic model were –1.0132 for the intercept, –0.0194 for each unit of adult literacy, 0.0213 for each unit of stunting, and –0.0128 for each unit of population with potable water. The estimated under 5 mortality rate for Iraq in 1996 was 87 per 1000, with a 95% CI of 80–95 per 1000 (Table 3Go).


    Validity Check on Mortality Estimates
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
Good-quality mortality estimates already exist for the end of the period of stability prior to sanctions and the Gulf War (mid-year 1990) and for the first 8 months of 1991, including the period of the Gulf War, sanctions, and the post-war uprisings.12 Estimates for literacy, potable water, and stunting in these two periods of time were applied to the logistic regression model described above. Values generated by these models are shown to provide good estimates for the known under 5-year-old mortality rates (Table 4Go).


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Table 4 Comparison of logistic model and known rates of under 5-year-old mortality
 
The model successfully estimated the 1990 mortality rate within a 95% CI. It underestimated the 1991 rate, a period of rapid mortality increase due to war-related factors. It appears that the model estimates mortality best when the dependent variables are stable.

Data on literacy, population with piped water, and stunting for each governorate from the MICS survey21,22 were grouped by region of the country. Estimates for under 5-year-old mortality rates in the four regions of the country show Baghdad governorate to have the lowest rate. The southern governorates have a 5-year-old mortality rate estimated to be 34% higher than the level in Baghdad. The northern governorates, where United Nations administration and non-governmental organization actions have reduced the impact of the post-Gulf War uprising and displacement of the predominantly Kurdish population, have a rate of mortality higher than Baghdad and lower than the southern governorates (Table 5Go).


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Table 5 Estimated under 5-year-old mortality for Iraq in logistic regression model with imputation using three variables
 
In 1999 UNICEF and the Government of Iraq (GOI) carried out demographic surveys in Central/Southern and Northern Iraq. These surveys provide average rates without confidence intervals for 1994–1999. Their estimated under 5 year mortality rate in Central/Southern Iraq is higher (131 compared to 89, 95% CI : 78–98) and in Northern Iraq is lower (69 compared to 81, 95% CI : 75–87) than our estimates for 1996. Differences between our estimates and those of the demographic survey could include the multi-year nature of UNICEF/GOI data, their lack of confidence intervals, inaccuracies in the data for variables used in 1996 for Iraq, or inadequacies in the logistic model to account for rapidly changing rates of mortality. Despite these possible weaknesses the logistic model successfully identified a significant rise in mortality and the relatively greater rise in mortality in Central/Southern Iraq compared to Northern Iraq.


    Implications of Mortality Estimates
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
The logistic regression model developed here provided a rapid estimation procedure which accurately estimated some mortality level changes. Research in other countries with known under 5 mortality rates is needed to further validate and refine the model. The potential utility for such a mortality estimation procedure is great. If this model proves to be valid and sensitive to changes in mortality, and is robust to the varying importance of cultural and economic influences on mortality around the world, it will provide a means of generating current mortality estimates from surveys which are rapid, require a small sample, and are less vulnerable to bias than are standard demographic survey methods. The value of such a method for needs assessments and humanitarian interventions in other crises around the world—from North Korea to Kosovo—would be great. Further testing of this model in other countries, with baseline data sets other than the State of the World's Children report and with target country data sets of varying quality will be needed to determine its utility and generalizability.


    Endnote
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 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
In 1996, UNICEF and the Iraqi government's Central Statistical Organization led a large-scale sample survey in both the 15 governorates controlled by the Iraqi government21 and, separately, in the three governorates in the Kurdish zone in the north.22 The sample frame for the Multiple Indicator Cluster Sample Survey (MICS) was developed by organizations sponsoring the nutritional survey. It used a probability sample—both the sites to be included in the sample and the households were representative. It included 6375 households—425 households in each of the 15 south and central governorates. Survey teams included international investigators and Iraqis trained by the Nutritional Research Institute. The MICS survey was the first national nutrition survey conducted since the IST study in 1991.

In April 1997 the World Food Program, UNICEF, and the Iraqi Ministry of Health carried out a large-scale nutritional survey during a national polio immunization campaign.26,27 The immunization campaign in April included every fifth to tenth child present for immunization. This 1997 Clinic Exit Survey provided a sample of 15 466 children. This over-sampled 1–2-year-old children relative to those aged 4 and 5. A stratified random sample including 87 of the 850 primary health centres in the country was included. The 15 south and central governorates, covering 85% of the population, were included. The results are similar to those found in the 1996 large-scale multistage cluster sample survey carried out by UNICEF

In March 1998 the World Food Program, UNICEF, and the Iraqi Ministry of Health again carried out a clinic exit interview during the spring polio immunization campaign.28 The results of the 1998 Clinic Exit Survey are similar to the clinic exit interview study in April 1997 and the MICS study of August 1996. Malnutrition is highest in rural areas and slightly higher among males. Results from these studies, taken together, suggest that malnutrition rose rapidly from 1991 to 1996 and has been roughly stable among those under 5 years of age from August 1996 to March 1998.

In February and May 1999 the Government of Iraq and UNICEF in the Centre/South, and UNICEF in the North, carried out a three-stage stratified cluster sample survey of households to assess child and maternal mortality. Within each cluster 15 households were included from the address list created by the 1997 population census. All ever-married women in 21 048 households were interviewed.


    References
 Top
 Abstract
 Introduction
 Background
 Changes in Health Status
 Univariate Models to Estimate...
 Regression Modelling
 Validity Check on Mortality...
 Implications of Mortality...
 Endnote
 References
 
2 Shyrock H, Siegel J et al. The Methods and Materials of Demography. Washington, DC: Bureau of Commerce, 1975.

2 Editorial. Health effects of sanctions on Iraq. Lancet 1995;346:1439.[ISI][Medline]

3 Garfield R, Devin J, Fausey J. The health impact of economic sanctions. Bull NY Acad Medicine 1995;72:454–68.

4 Editorial. Washington Times, 5 December 1997.

5 Garfield R. The impact of economic embargoes on the health of women and children. J Am Med Women's Assoc 1997;52:181–84.[Medline]

6 Garfield R, Zaidi S, Lennock J. Medical care in Iraq after six years of sanctions. Br Med J 1997;315:1474–75.[Free Full Text]

7 Editorial. Health effects of sanctions on Iraq. Lancet 1995;346:1439.[ISI][Medline]

8 UNICEF. Disastrous Situation of Children in Iraq. Press Release, 4 October 1996.

9 World Health Organization. The Health Conditions of the Population in Iraq Since the Gulf Crisis. Baghdad, WHO/EHA/96.1, March 1996.

10 Cordesman AH. Sanctions and the Iraqi People: The WHO Report and Conflicting Views. Washington, DC: Center for Strategic and International Studies, 1997.

11 Reuters New Service, 11 August 1998. Iraq says sanctions have killed 1.4 million. Cnn.com/WORLD/meast/9808/10/RB000433.reut.html

12 Ascherio A, Chase R, Cote T et al. Effect of the Gulf War on infant and child mortality in Iraq. N Engl J Med 1992;327:931–36.[Abstract]

13 Zaidi S, Smith Fawzi M. Health of Baghdad's children. Lancet 1995;346,1485.[ISI][Medline]

14 Zaidi S. Child mortality in Iraq. Lancet 1997;350:1105.

16 UNICEF. State of the World's Children. New York: UNICEF, 1997.

17 Pelletier DL, Frongillo EA, Schroeder DG, Habicht JP. A methodology of estimating the contribution of malnutrition to child mortality in developing countries. J Nutr 1994;214:2106S–22S.

18 Pelletier DL, Fongillo EA, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 1995;73:443–48.[ISI][Medline]

19 UNICEF. Situation Analysis of Children and Women in Iraq. Baghdad: UNICEF, 30 April 1998.

20 Ministry of Health, Government of Iraq, in co-operation with UNICEF and the World Food Program. Nutritional Status Survey at Primary Health Centres during Polio National Immunization Days in Iraq. Iraq, 18 May 1998.

21 Central Statistical Organizations, Iraq. The 1996 Multiple Indicator Cluster Survey: A Survey to Assess the Situation of Children and Women in Iraq. Final Report with Results from South/Centre Governorates. Iraq, UNICEF Ref IRQ/97/288, August 1996.

22 Central Statistical Organizations, Iraq. The 1996 Multiple Indicator Cluster Survey: A Survey to Assess the Situation of Families in Iraq. Final Report with Results from Northern Governorates. Iraq, UNICEF Rep/97/166, May 1997.

23 Government of Iraq. Human Development and Health Conditions in Iraq. Human Development Report 1995. Baghdad: Government of Iraq, 1996.

24 Rubin D. Introduction and summary of repeated-imputation inferences. In: Rubin, D. Multiple Imputations for Non-response in Surveys. New York: Wiley, 1987.

25 Paik MC. The Generalized Estimating Equation approach when data are not missing completely at random. J Am Stat Assoc 1997; 92:1320–29.[ISI]

26 Ministry of Health, Government of Iraq. Nutritional Status Survey at Primary Health Centres during Polio National Immunization Days (PNID) in Iraq. Iraq: UNICEF, World Food Program, Ref IRQ/97/169, 12–14 April 1997.

27 Regional Ministry of Health and Society Welfare, UNICEF. Nutritional Status of Children under Five in the Autonomous Northern Region. Iraq: November 1997.

28 Ministry of Health, Government of Iraq, in cooperation with UNICEF and the World Food Program. Nutritional Status Survey at Primary Health Centres during Polio National Immunization Days in Iraq. Iraq: 18 May 1998.





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