Vol.5, No.2, 292-297 (2013) Health
http://dx.doi.org/10.4236/health.2013.52039
Infant mortality rate in Al-Ramadi province from 2000
through 2010, retrospective study
Hammodi F. Aljumaily1*, Muhammed M. Al-Ani2, Muhammed M. Hantush3
1College of Medicine, Anbar University, Fallujah, Iraq; *Corresponding Author:
2Department of Pediatrics, College of Medicine, Anbar University, Fallujah, Iraq
3Al-Ramadi Maternity and Child Teaching Hospital, Al-Ramadi, Iraq
Received 9 October 2012; revised 10 November 2012; accepted 17 November 2012
ABSTRACT
Objectives: To determine the IMR in Al-Ramadi
province, the center of Al-Anbar Governorate,
Western Iraq, from 2000-2010 with rate compa-
rison of the three different stages of that period.
Methods: Data collected from the birth and
death certificate center in Al-Ramadi province,
Western Iraq, included; name, age, sex, resi-
dence, date of birth and death, in three different
stages (the first stage 2000-2002, the second
stage 2003-2007, and the third stage 2008-2010)
in a study period from July to December, 2010.
The IMRs were analyzed and compared with
other studies. Results: The IMR of the last 3
years of sanction was 54.3/1000, 55.7/1000 and
50.6/1000 respectively, this rate had been in-
creased in the war and violence period to reach
its maximum rate 58.6/1000 in 2006, then de-
creased to reach its minimum rate 44.5/1000 in
2008. Approximately two-third of deaths oc-
curred during the neonatal period and one third
in the post neonatal period. Males had higher
IMR than females, and rural residence higher
than urban. Conclusion: Infant mortality rate is
still high in Al-Ramadi province, since the Ame-
rican invasion (2003-2007), when compared w ith
other developing countries. This study found
increase of IMR in Al-Ramadi province during
that period more than other stu died years.
Keywords: Mortality; Rate; Birth; Death Certificate
1. INTRODUCTION
Infant mortality rate is defined as the number of infant
deaths (one year of ag e or younger) per 1000 liv e births;
components of infant mortality rate include neonatal
mortality rate (number of deaths in the first 28 days per
1000 live births) and post neonatal mortality rate (num-
ber of deaths at 29 days and over to the end of first year
of life per 1000 live births) [1]. From all childhood (0 -
14) mortalities, 70% occur within the first year, 46%
within the first month, and 35% within the first week of
life [2]. The IMR varies greatly by country and it is
highest in developing countries [1].
There is an inverse relationship between the improve-
ment of the economic and social situation and the infant
mortality rate. While education is often linked to in come,
it can also be linked to infant mortality, looking at recent
data, parents with no formal education show an infant
mortality rate that is twice the normal rate [3].
The method of calculating IMR often varies widely
between countries, and is based on how they define a live
birth and how many premature infants are born in the
country [4,5].
In 2009, the US Center of Disease Control (CDC) is-
sued a report that stated that the American rates of infant
mortality were affected by the United States high rate of
premature babies compared to European countries [6].
In 1977, and before starting of wars in Iraq, the esti-
mated Iraqi national IMR was 61/1000 [7]. Target pro-
gram were then implemented since 1980s, despite the
Iraq-Iran War (1980-1988), to improve the infant heath
condition through vaccine coverage, promote breast feed-
ing, reduce diarrheal morbidity as well as improve do-
mestic hygiene [8]. These measures were successful and
followed by accelerated decrease in the national IMR
from 63/1000 in 1980, to 48.1/1000 in 1985, and 40/
1000 in 1990 [9].
Since 1990 many reports recorded in Iraq suggesting
significant increase rate in infant morbid ity and mortality
with deterioration of socioeconomic conditions and sur-
vival chance among young children under the effect of
war conflicted and comprehensive UN sanction, then
slightly decrease between 2000-2003, this decrease due
to improvement in economic condition and decrease the
effect of sanction after introduction of oil for food pro-
gram [10].
The United Nation Economic and Social Commission

H. F. Aljumaily et al. / Health 5 (2013) 292-297 293
for Western Asia (ESCWA) reported that almost 3 quar-
ters of the Iraqi p opulation became poor despite th e food
rationing system, which was established in 1991 and that,
the absolute poverty increased from 25% in urban and
33% in rural areas in 1981 to reach 72% in urban areas
and 66% in rural areas in 1993 [11]. The world bank es-
timated (27.2%) of Iraq population liv ing on less than 2$
per day in 2001 [12]. Such a unique situation and ex-
treme poverty causes the infant mortality in Iraq to in-
crease to a n u pwar d tr end nev er r each ed b efo re ( 103/ 100 0
in 1998) [13,14]. The increase prevalence of low birth
weight recorded in Iraq in the past 3 decades added an-
other factor for the increase of the IMRs [15-17].
The aim of this study is to determine IMR in Al-
Ramadi province, the center of Al-Anbar Governorate,
Western Iraq, from 2000-2010 and compare the rate
through 3 different stages (the first stage 2000-2002, the
second stage 2003-2007, and the th ird stage 2008-2010).
2. METHODOLOGY
This is a retrospective descriptive population record
study carried out in Al-Ramadi province, the center of
Al-Anbar gover norate, Western Iraq.
We studied the effect of sanction, war, and violence on
the IMR over 11 years composed of 3 different stages
imposed on the country from 2000-2010, and applied in
a study period from July to December, 2010.
The first stage was the last three years (2000, 2001 and
2002) of comprehensive UN economic sanction (1991-
2003). The second stage from 2003 to 2007, started after
the coalition forces occupation of the country, and de-
spite lifting of the sanction in this period, there were
successive different wars and increased violence inside
most of Iraqi cities leading to loss of security and de-
struction of most of the health services and facilities. The
third stage was from 2008 to 2010 when violence de-
creased, and health facilities and security improved in
most Iraqi cities including Al-Ramadi province.
All information were collected from birth and death
certificate center in Al-Ramadi province and statistic unit
in Al-Ramadi maternity and children teaching hospital
for each year.
Data collected included; name, age, gender, residence
and date of birth and death. Other information like edu-
cation, income and causes of infant deaths were not
available in the record s, thus excluded from this study.
Deliveries occurred in Al-Ramadi maternity and chil-
dren teaching hospital (MCTH), health centers and mid-
wife deliveries, and all deaths registered in births and
deaths certificate center in Al-Ramadi province included
in this study. Deliveries and deaths outside Al-Ramadi
province were excluded.
Frequency distribution tables and Bar Charts were
used to demonstrate the IMR occurring each year and its
association with sex and residence. Chi square was used
for statistical analysis, and P-value < 0.05 was consid-
ered as significant.
3. RESULTS
During the 11 studied years the total number of live
births in Al-Ramadi province was 98307, composed of
49646 females and 48661 males giving a female to male
ratio of 1.02:1.
The total number of inf ant deaths was 5031 composed
of 2867 males, and 2164 females, giving a male to fe-
male ratio of 1.3:1.
The overall IMR of the 11 years was 51.2/1000 live
births, 58.9 for males and 43.5 for females/1000 live
births. Their difference was statistically significant (P-
value < 0.01).
Table 1 shows the number of infant births, deaths, and
IMRs in Al-Ramadi province for each of the 11 studied
years. The highest rate was seen in the American inva-
sion and vi olence period ( second stage 2003- 2007) when
it reached 58.6/1000 in 2006 during the peak of violence.
While the lowest rate was seen in the third stages (2008-
2010); the stage of improvement of security and health
conditions, in which the rate declined to 44.5/1000 in
2008 that was th e lowest recorded rate of all th e 11 stud-
ied years.
Tabl e 2 and Figure 1, show the IMR in the both neo-
natal and post neonatal period during the 11 studied
years. Two thirds (67%) of reported deaths during the
neonatal period (43% in the early neonatal and 24% in
late neonatal periods), and one third (33%) during the
post neonatal periods of infancy.
Distribution of IMR among rural and urban residence
areas was shown in Table 3 and Figure 2, which demon-
strate that 53.5% of the studied dead infants were found
Table 1. Total live birth, total infant death and IMR for each
year, 2000-2010 in Al-Ramadi province.
IMR/1000Total infant death Total live birth Year
54.3 448 8243 2000
55.7 429 7689 2001
50.6 456 9180 2002
45.5 395 8666 2003
49.5 405 8180 2004
55.5 373 6711 2005
58.6 395 6735 2006
54.2 391 7213 2007
44.5 427 9589 2008
48.2 633 13,120 2009
52.3 679 12,981 2010
51.2 5031 98,307 Total

H. F. Aljumaily et al. / Health 5 (2013) 292-297
294
Ta b le 2 . Neonatal (early and late) and post neonatal death for
all included years, 2000-2010.
Post neonatal
deaths
Late neonatal
deaths
Early neonatal
deaths
Infant age
1661 1247 2123 Number
33% 24% 43% %
Table 3. The effect of residence for all years 2000-2010.
IMR Total infant death Total live births Residency
48.6 2340 (46.5%) 55,051 (55%) Urban
62.2 (53.5%) 2691 43,256 (45%) Rural
31.8 31.59 35.12 33.24 32.15 33.24 36.63 33.16 34.21 37.0627. 2 7
68.19 68.4 64.88 66.75 67.84 66.75 63.36 66.8365.78 62.9372.72
0
20
40
60
80
100
120
2000200120022003200420052006 2007 200820092010
PND ND
Figure 1. Rates of neonatal death (ND) and post neonatal death
(PND) for each year 2000 to 2010.
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
100
20002001 20022003 20042005 20062007 200820092010
UD RD
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Figure 2. Numbers of infant deaths according to residence
(urban deaths UD, rural deaths RD), for each year 2000-2010.
in rural (IMR 62.2/1000) and 46.5% of urban residences
(IMR 48.6/1000), the difference was statistically signifi-
cant (P-value < 0.01).
4. DISCUSSION
In most cases, war-affected areas will experience a sig-
nificant increase in infant mortality rates, some studies
provided strong evidence that the Gulf war and trade
sanctions caused a threefold increase in mortality among
Iraqi children [18,19].
During the first stage (the last three years of sanction)
the IMR in Al-Ramadi province was 54.3/1000 in 2000
and 55.7/1000 in 2001, this high rate of infant mortality
coul d b e expl a ined b y d eteriorat i on of he a l t h services and
the socioeconomic conditions of population under the
effect of comprehensive UN Sanction.
The IMRs of Al-Ramadi province in that years were
lower than the national Iraqi IMRs, 62.4/1000 in 2000 and
60/1000 in 2001, most probably because the center and
sout h of Iraq we re se ver ely af fect ed b y th e 19 91 p ost Gul f
War uprising, and the health and social services were
looted or destroyed during these events when compared
with other pa rts of c ountry. Such upri sing did not occ ur in
Al-Ramadi province and other districts of Al-Anbar
Governorate.
In 2002 the rate of infant mortality slightly decrease to
reach 50.6/1000 due to slight improvement of economic
conditions and decrease the effect of sanction after in-
troduction of oil f or food prog ram (und er Security Coun-
cil Resolution 986) [20], which provi ded the huma nitarian
needs of the Iraqi people.
Following the Gulf War and its 13 associated san ction
years, several events, conflicts and incompliance be-
tween the Iraqi government and UN members, especially
USA and UK, ended finally with another disaster, the
invasion and occupation of Iraq in March 2003 by the
Coalition Forces Militaries [21 ].
The invasion despite the lifting of sanction, added a
disastrous second destruction of the remaining weak in-
frastructure and health facilities, causing further loss of
health services, resources, and security conditions. This
was also the cause of increasing violence and terror in
most Iraqi cities including Al-Ramadi city, and the
spreading of this violence from one region to another
which forced people to either migrate or face life trage-
dies [22].
The IMR in Al-Ramadi province during the second
stage was 45.5/1000 in 2003, increased in 2004 (49.5/
1000) and 2005 (55.5 /1000) with maximum rate of 58.6/
1000 in 2006, and slightly decreased in 2007 to reach
54.2/1000 live births. During this period of violence and
war, the health facilities and services became poor in
Al-Ramadi province and many doctors and health em-
ployers left the province migrating to other safer areas
inside or outside the country, where as people stayed in
the province were more prone for explosions, malnutri-
tion and difficulties in reaching health centers and hospi-
tals thus the IMR in Al-Ramadi province reached a high
rate during that period.
With the beginning of improvement of health and se-
curity conditions and decreasin g of violence (third stage)
the recorded IMR decrease to reach 44.5/1000 in 2008,
then increased in 2009 and 2010 to reach 48.2/1000 and
52.3/1000 respectively, this increase of rate during the
improvement of health and security conditions was due

H. F. Aljumaily et al. / Health 5 (2013) 292-297 295
to improvement of registration of births and deaths in the
province and also the recorded high rate of Perinatal
mortality, low birth weight, premature, and births defect
associated deliveries in the province in the last years was
noticed by many studies [23-25], which added another
factors for the increasing of the IMR.
However, the actual IMR may be higher than the re-
ported IMR, because it is possible that deaths were not
reported, because families might wish to conceal the
death or because neonatal deaths might go without men-
tion [26]. In comparing the IMR of Al-Ramadi province
with that of the Iraqi national rate, the national rate
shows decreasing pattern from 2000-2010 [27], while
that of Al-Ramadi province show fluctuating pattern as
illustrating in Figure 3. The World Health Organization
(WHO) reported that the estimated IMR/1000 live births
for both sexes in the year 2000 and the year 2010 in the
developing countries as follow: Saudi Arabia (22/1000,
15/1000), Kuwait (10/1000, 10/1000), Qatar (11/1000,
7/1000), Bahrain (11/1000, 9/1000), Syria (20/1000, 14/
1000), Lebanon (25/1000, 19/1000), Jordan (25/1000,
18/1000), Iraq (34/1000, 31/1000), Iran (35/1000, 25/
1000), Turkey (33/1000, 12/1000), Egypt (37/1000, 19/
1000), Banglade sh (63/1000, 38/1000), Algeria (41/1000,
31/1000) [28].
While the national IMR continued decreasing in its rate,
as these are hospital based studies, their registration may
be less affected during the loss security conditions than
population based studies, a nd also the l ow birth deliveri es,
neural tube defect, and perinatal mortalities are related
directly to the health of mother during pregnancy, and
different than the IMR which is more related and affected
by post neonatal environment and security conditions.
However , a marked decline in infant mortality rates was
reported in all Arab countries from 1990 to 2009. The
decline in infant mortality rates ranged from 10.2% to
66.7%. A sharp decline in rates was especially seen in the
member countries of the Gulf Cooperat ion Council (GCC),
Tunisia, Egypt and Jordan [3]…
For all included years (2000-2010), IMR of Al-
Ramadi province (51.2/1000 live births) was higher than
IMR of Haditha province (38.9/1000 live births) for the
same period [29] most probably because of registration
in the births and deaths in Al-Ramadi province still
0
10
20
30
40
50
60
70
200 02001200 2200 3200 4200 5200 6200 7200 8200 9201 0
IMRRamad i
IMRIraq
Figure 3. The IMR of Al-Ramadi province and the IMR of Iraq.
working during the period of war and violence, and
could be the registration of data in center of governorate
more than other cities. In addition to improvement of
registrations, many reasons may be behind the elevation
of IMR in 2009, 2010 in Al-Ra madi, these may be du e to
the low availability of equipments and efficacy medi-
cations for the sake of early diagnosis and detection,
mismanagement due to lack of facilities necessary for
fetal management, and trained personnel’s leading to
medical malpractice Organic Maternal causes with stress-
ful life that may lead to restricted fetal growth and other
morbidities which determined by low pregnancy body
mass index, low gestational weight gain, the same find-
ings noticed by other studies [24]. The appearance of
incidences of congenital anomalies was recorded mostly
at that period as a complication of war. Moreover, Al-
Ramadi at that time, still safety unsecured compared with
other areas of Iraq a little bite safer, because of terrorism
groups (hot region) may lead the global health care pro-
fessionals not to visit Al-Ramadi and provide their es-
sential health services. All these events may lead to in-
crease of IMR at that period.
In this study the mortality in neonatal period show in-
crease rate when compared with post neonatal period
which was consistent with Iraqi [27] and Brazilian stud-
ies [30]. It was seen that the first month of life was asso-
ciated with problems related to infant and pregnancy
such as preterm delivery, low birth weight and birth de-
fect, while after the first month of life was greatly asso-
ciated with social and environmental factors such as in-
fection and access to health care facilities [31].
This study showed that IMR is significantly higher in
males than females which was consistent with other
studies [18,19]. In the present study ,there were a male
infants had higher mortality than female infants, this ob-
servation was consistent with observation of other stud-
ies in developing countries, particularly Asia of an im-
balance in the sex ratio in infant mortality favoring males
led researchers to hypo thesize that environmental factors
have encountered. It was also reported that male infant
fatality rate higher than female infant, and this may at-
tributed to many etiological factors like sepsis, G6PD
deficiency, and x-linked disorders which were more pre-
valent in male gender. In a study was done in Al-Ramadi
from 2010-2011, which showed that the number of Con-
genital Anomalies (CAs) was found significantly more in
males than females in total birth and live birth deliv-
eries [32]. Surprisingly, the rise of IMR may be related to
the social trend of this tribal populated area to pay more
attention and care for boys rather than girls, this may
lead to over estimation of male gender. Moreover, boys
were found to be 60% to be born prematurely and suffer
from pre-term birth condition such as neonatal respira-
tory distress syndrome [33].

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We record higher IMR among infants from rural areas
than urban areas, this was in agreement with other stud-
ies [18,19,30]. This is expected since poverty, poor healt h
services and facilities are more common in rural than
urban areas [34].
In conclusion: the study limited by the fact that it did
not record the causes of infant deaths which will clarify
whether deaths were due to malnutrition and medical
diseases of sanction, or the trauma or injuries of wars or
both.
Whereas, Iraq still has a high IMR comparing with
other developing countries, due to deterioration of so-
cioeconomic circumstances and survival chance among
young children under the effect of war conflicts and
American invasion.
However, there is an increase in neonatal mortality
rate more than post neonatal mortality rate and increase
in early mortality rate more than late mortality rate,
probably due to poor antenatal care, increase rate of pre-
mature deliveries, and absenc e of modern facilities in the
neonatal care unit.
In addition to a significant association between IMR
and Rural residence, and an association between IMR
and Male gender.
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