The effect on fertility of the 2003-2011 war in Iraq

This article provides the first detailed account of recent fertility trends in Iraq, with a particular focus on the changes resulting from the 2003–2011 war and the factors underlying them. The study is based on retrospective birth history data from the 2006 and 2011 Iraq Multiple Indicator Cluster Surveys (I-MICS). Estimates from the two surveys indicate that total fertility remained stable from 1997 to 2010, at about 4.5 children per woman. However, examination of the age patterns of fertility reveals an abrupt shift in the timing of births, with adolescent fertility rising by over 30 percent soon after the onset of the war. A decomposition analysis shows that the rise in early childbearing is due to an increased prevalence of early marriage among less-educated women. The prevalence of early marriage and childbearing among women with secondary or higher education is relatively low and has not increased after 2003

Changing views on child mortality and economic sanctions in Iraq: a history of lies, damned lies, and statistics

In August 1990, Saddam Hussein’s army invaded Kuwait and consequently the United Nations imposed economic sanctions on Iraq. In 1991, an international military alliance expelled the Iraqi army from Kuwait during a short war. Nevertheless, the economic sanctions remained in place—their removal required that Iraq should destroy its weapons of mass destruction. Subsequent years saw reports of acute suffering in Iraq. The sanctions undoubtedly greatly reduced the country’s ability to import supplies of food and medicine. Particular concerns arose about the state of young children. These concerns crystalised in 1999 when, with cooperation from the Iraqi government, Unicef conducted a major demographic survey. The results of the survey indicated that the under-5 death rate in Iraq had increased hugely between 1990 and 1991 and had then continued at a very high level. The survey results were used both to challenge and support the case for the invasion of Iraq in 2003. And they were cited by Tony Blair in 2010 in his testimony to the Iraq Inquiry established by the British government. Indeed, the results of the 1999 Unicef/Government of Iraq survey are still cited. Since 2003, however, several more surveys dealing with child mortality have been undertaken. Their results show no sign of a huge and enduring rise in the under-5 death rate starting in 1991. It is therefore clear that Saddam Hussein’s government successfully manipulated the 1999 survey in order to convey a very false impression—something that is surely deserving of greater recognition

The Yazidi genocide: a demographic documentation of ISIL’s attack on Tel Qasab and Tel Banat

On 3 August 2014, the Islamic State of Iraq and the Levant (ISIL) attacked the Yazidis of Sinjar. Within days, reports emerged of men and boys being executed; of women and girls being kidnapped, sold, sexually enslaved, beaten, and forced to work; and of boys forced into ISIL training camps and made to fight. This paper analyses ISIL’s assault on the Yazidis in the villages of Tel Qasab and Tel Banat. It is the second publication of the Yazidi Victims Demographic Documentation Project (YVDDP), the objective of which is to identify every victim of ISIL’s attack. It corroborates YVDDP’s previous findings that the attack targeted the Yazidi community, that those captured were either killed or kidnapped, and that the violations suffered depended on the perceived gender and age of the victims. The data underscores the necessity of using a gender-competent, age-disaggregated analysis in order to understand the full scope of ISIL crimes. The consolidated database resulting from this documentation project will have multiple short, medium, and long-term uses. These include, for example, a data pool that can assist in identification of remains in mass graves, and which provides reliable information for use in planning for and prioritisation of needs – including provision of counselling, increased medical interventions, and gender- and age-specific needs. It also provides reliable information of high probative value for use in criminal prosecutions before national, regional, and international courts, and is capable of informing transitional justice processes, including material and symbolic reparations

Expansion of health facilities in Iraq a decade after the US-led invasion, 2003–2012

Background: In the last few decades, Iraq’s health care capacity has been severely undermined by the effects of different wars, international sanctions, sectarian violence and political instability. In the aftermath of the 2003 US-led invasion, the Ministry of Health has set plans to expand health service delivery, by reorienting the public sector towards primary health care and attributing a larger role to the private sector for hospital care. Quantitative assessments of the post-2003 health policy outcomes have remained scant. This paper addresses this gap focusing on a key outcome indicator that is the expansion of health facilities. Methods: The analysis is based on data on health facilities provided by the World Health Organisation and Iraq’s Ministry of Health. For each governorate, we calculated the change in the absolute number of facilities by type from early 2003 to the end of 2012. To account for population growth, we computed the change in the number of facilities per 100,000 population. We compared trends in the autonomous northern Kurdistan region, which has been relatively stable from 2003 onwards, and in the rest of Iraq (centre/south), where fragile institutions and persistent sectarian strife have posed major challenges to health system recovery. Results: The countrywide number of primary health care centres per 100,000 population rose from 5.5 in 2003 to 7.4 in 2012. The extent of improvement varied significantly within the country, with an average increase of 4.3 primary health care centres per 100,000 population in the Kurdistan region versus an average increase of only 1.4 in central/southern Iraq. The average number of public hospitals per 100,000 population rose from 1.3 to 1.5 in Kurdistan, whereas it remained at 0.6 in centre/south. The average number of private hospitals per 100,000 population rose from 0.2 to 0.6 in Kurdistan, whereas it declined from 0.3 to 0.2 in centre/south. Conclusions: The expansion of both public and private health facilities in the Kurdistan region appears encouraging, but still much should be done to reach the standards of neighbouring countries. The slow pace of improvement in the rest of Iraq is largely attributable to the dire security situation and should be a cause for major concern

Prevalence of non-communicable diseases and access to health care and medications among Yazidis and other minority groups displaced by ISIS into the Kurdistan region of Iraq

The increasing caseload of non-communicable diseases (NCDs) in displaced populations poses new challenges for humanitarian agencies and host country governments in the provision of health care, diagnostics and medications. This study aimed to characterise the prevalence of NCDs and better understand issues related to accessing care among Yazidis and other minority groups displaced by ISIS and currently residing in camps in the Kurdistan Region of Iraq

Health needs and care seeking behaviours of Yazidis and other minority groups displaced by ISIS into the Kurdistan Region of Iraq

Background During the summer of 2014, ISIS overran Nineveh governorate in Northern Iraq. Yazidis and other religious minorities were subjected to brutal attacks and forced to seek refuge into the neighbouring Kurdistan Region, where they remain living in local communities or in camps. This survey provides a population-based assessment of the health needs and care seeking behaviours of Yazidis and other groups currently residing in camps. Methods The survey covered 13 camps managed by the Kurdish Board of Relief and Humanitarian Affairs. A systematic random sample of 1,300 households with a total of 8,360 members were interviewed between November and December 2015. Participants were asked if any household members had needed care for a health condition in the two weeks preceding the survey, and whether care was obtained from the camp primary health care centre, an outside public hospital or a private clinic. If care was received, the out-of-pocket payment was recorded; otherwise, the reason for not seeking care was queried. Results In 33.9% (CI: 31.0–37.0) of households one or more members had needed care for a health condition in the two weeks preceding the survey. The most likely to have needed care were older persons (18.5%; CI: 13.6–24.6) and infants (18.0%; CI: 11.6–26.8). The reported health conditions revealed a complex picture of communicable and non-communicable diseases as well as mental health problems and physical injuries. Care was primarily sought from private clinics (41.8%; CI: 36.4–47.4) or public hospitals (27.3%; CI: 22.6–32.7) rather than from the camp primary health care clinics (23.6%; CI: 19.5–28.2). The mean out-ofpocket payment for care received was nearly 3 times higher in public hospitals than in the camp primary health care clinics and nearly 11 times higher in private clinics. Cost was the main perceived barrier to obtaining health services. Conclusion Demand for health services was high among Yazidis and other minorities living in camps. Private services were preferred in spite of the tenuous economic circumstances of displaced households. Declines in public sector funding may further restrict access from camp clinics stressing the need for alternative access strategies

Living in Mosul during the time of ISIS and the military liberation: results from a 40-cluster household survey

Background In June 2014, an estimated 1500 fighters of the Islamic State of Iraq and Syria (ISIS) seized control of Mosul, Iraq’s second city. Although many residents fled, others stayed behind, enduring the restrictive civil and social policies of ISIS. In December 2016, the military activity, known as the liberation campaign, began in east Mosul, concluding in west Mosul in June 2017. Methods To assess life in Mosul under ISIS, and the consequences of the military campaign to retake Mosul we conducted a 40 cluster-30 household survey in Mosul, starting in March 2017. All households included were present in Mosul throughout the entire time of ISIS control and military action. Results In June 2014, 915 of 1139 school-age children (80.3%) had been in school, but only 28 (2.2%) attended at least some school after ISIS seized control. This represented a decision of families. Injuries to women resulting from intimate partner violence were reported in 415 (34.5%) households. In the surveyed households, 819 marriages had occurred; 688 (84.0%) among women. Of these women, 89 (12.9%) were aged 15 years and less, and 253 (49.7%) were aged under 18 at the time of marriage. With Mosul economically damaged by ISIS control and physically during the Iraqi military action, there was little employment at the time of the survey, and few persons were bringing cash into households. The liberation of Mosul in 2017 caused extensive damage to dwellings. Overall only a quarter of dwellings had not sustained some damage. In west Mosul, only 21.7% of houses had little or no damage from the conflict, with 98 (21.7%) households reporting their house had been destroyed, forcing its occupants to move. No houses had regular electricity and there was limited piped water. Inadequate fuel for cooking was reported by 996 (82.9%) households. Conclusion The physical, and social damage occurring during ISIS occupation of Mosul and during the subsequent military action (liberation) was substantial and its impact is unlikely to be erased soon

Demographic and health effects of the 2003–2011 War in Iraq

The increasing international concern about the consequences of warfare for civilian populations has led to a growing body of demographic and health research. This research has been essential in providing estimates of war-induced excess mortality, a primary indicator by which to assess the intensity of wars and the adequacy of humanitarian responses. Far less attention has been paid to war-induced changes in fertility and population health, and the limited existing literature has rarely adopted a longitudinal approach. This is especially evident in the case of the 2003–2011 war in Iraq. Several studies have sought to quantify excess mortality, whereas other demographic and health effects of this war have been largely overlooked. This thesis fills substantive knowledge gaps using longitudinal data from the 2000, 2006 and 2011 Iraq Multiple Indicator Cluster Surveys (I-MICS). The data collected during wartime are found to be of similarly good quality as those collected during peacetime. The analysis shows that, besides causing a heavy death toll, the Iraq war also had profound long-term consequences for women and newborns. It provides the first evidence on the effect of the war on early marriage and adolescent fertility, with implications for women’s empowerment and reproductive health. It is also the first to quantify the effect of the war on neonatal polio immunisation coverage, with relevance for the recent polio outbreak. It finally assesses the main challenges to Iraq’s health sector rehabilitation efforts, namely the ongoing insecurity and persistently high rate of population growth. Overall, the findings have important documentation functions for the international community and serve as inputs for the design of humanitarian relief strategies in Iraq and similar war-torn countries, such as neighbouring Syria

Financial accessibility and user fee reforms for maternal- health care in five sub-Saharan countries: a quasi-experimental analysis

Objectives: Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or receiving a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population. Setting: Women’s experience of user fees in five African countries. Primary and secondary outcome measures: Using quasi experimental regression analysis we tested the impact of user fee reforms on facilities’ births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries' choice. Participants: We analysed data from consecutive surveys in five countries: two case countries that experienced reforms (Ghana and Burkina Faso) in contrast to three that did not experience reforms (Zambia, Cameroon, Nigeria). Results: User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest) and non-educated women and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared to Ghana. Conclusions: Findings show a clear positive impact on access when user fees are removed but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the two case countries. This calls for more research into the impact of reforms on quality of care

Mortality and kidnapping estimates for the Yazidi population in the area of Mount Sinjar, Iraq, in August 2014: a retrospective household survey

In August 2014, the so-called Islamic State of Iraq and Syria (ISIS) attacked the Yazidi religious minority living in the area of Mount Sinjar in Nineveh governorate, Iraq. We conducted a retrospective household survey to estimate the number and demographic profile of Yazidis killed and kidnapped