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ACT to foster happiness, peace, prosperity, and tolerance in the Middle East
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Child and Maternal Health in Lebanon
An Overview
This report summarizes findings that are related to child health and mortality in Lebanon from the “Lebanon Maternal & Child Health Survey” that was conducted between February of 1994 and August of 1997. This paper is based on the results of the survey that are posted in the Lebanese Ministry of Public Health website at this URL: http://www.public-health.gov.lb with the survey included in the Arabic language in the Database of the site at this URL: http://www.public-health.gov.lb/p4.html
The
Ministry of Public Health of Lebanon in cooperation with the Ministry of Social
Affairs along with other NGOs and international organizations including the
United Nations, World Health Organization, and The Arab League conducted this
survey that focused on the assessing children health of 5 years of age and
younger and the health status of their mothers.
The goal of the survey was to promote the social and health conditions
for mothers and children in Lebanon by building a database that would enable the
decision makers and researchers in identifying the current status, to better
allocate resources, to draw priorities, and to better design health strategies.
This
paper will provide a brief background given about Lebanon and a brief
description of the survey. Then I
will speak about major findings from the survey about the Lebanese children
mortality figures, children nutritional status, children morbidity, prevention
and vaccination, treatment, breast feeding, handicapped children, maternal care
during pregnancy, Lebanese women fertility rates, and utilization of family
planning methods. I will end up by
presenting the survey’s recommendations as presented by the researchers, and
then I will briefly evaluate this survey.
Lebanon
General Background
Lebanon
is located on the eastern shores of the Mediterranean in the western part of the
Asian continent. It has an area of
10452 Km2 and is bordered by Syria from the north and east, Israel
from the south, and the Mediterranean from the west.
Lebanon is dominated by mountainous terrains and has important water
resources and uniquely moderate climate in the region.
There are 15 rivers and an average of 970 thousands m3 of
water per year for every Km2 of the Lebanese land.
Lebanon
gained its independence from France in 1943.
It has a democratic liberal parliamentary system.
It is also a founding member of the United Nations and the Arab League.
Lebanon is separated to six districts: Beirut, Mount Lebanon, The Bekaa,
The North, The South, and Nabateyh.
Lebanon
was devastated by the civil war of 1975-1990.
However, there has been a consistent, successful, and elaborate effort to
rebuild the country and to make Lebanon again the cultural, financial, and trade
center of the Middle East.
Lebanon’s
agricultural sector that employs 8% of the labor force contributes 10% of the
GDP. The industrial sector
contributes 15% of the GDP with 18 % of the Lebanese labor force employed in it,
and the service sector contributes 75% of the GDP with about 74% of the labor
force working in it.
The
population is estimated to be 3,100,000 in 1996.
About 80% live in urban areas. About
29% are of age that is less than 15 years of age. The child birth rate was 27
/1000 in 1996, and the mortality rate was 7/1000 in the same year. The country’s population was greatly affected by the war
with about 200,000 causalities.
The
health care sector in Lebanon is dominated by the private organizations. Of the 11521 hospital beds, individuals or other private
organizations own 10916. In
1996, there was a doctor for every 560 individuals, and a doctor for every 1.7
nurse.
The
Survey
The
survey was conducted over samples of representative populations from all over
Lebanon drawn at random. There were
23 of the 1422 survey locations that were not accessible for the security
reasons at the time of the survey; most of them were in the south, which was
under the Israeli occupation at that time.
Of the 5431 families in the sample, 4600 were surveyed, with 85% response
rate. Of the 3443 women qualified,
3317 were surveyed, with 96% response rate.
The response rate among the children, which is the main focus of this
paper, was 2156 of 2192 that is 98% response rate.
Of
the children 61% were between the ages of 2 and 5.
Children of less than a year of age were 19% of the children surveyed.
Of the children surveyed, 53% were males, and 37% females.
About 14.2% of the mothers were illiterate, 27.9% had elementary
education, 22.5% completed secondary education, and 23.1% attended or completed
university education.
Child
Mortality Figures
The
survey assessed the child mortality by district and found that the North and the
Bekaa suffers have the highest child mortality in Lebanon with 48.1/1000 and
39.8/1000 respectively. The
district of Nabateyah had the lowest child mortality rate of 17.2/1000. The study also found that the child mortality rates decreases
as the educational level of the mother increases.
The rate was 54.4/1000 for children of illiterate mothers and 14.8% for
children of mothers who completed at least secondary education for example.
The survey also shows that among those surveyed, children of mothers that
are of the age of 20 and younger or those who are 35 of age and older are at
greater risk of death. There was no significant statistical difference between
the males and females children when it comes to death rate.
The first child is more at risk of death in the first month while the
first year marks more risk for the second and third child.
Also, the children in homes with tiled floor had less child mortality
rate, 26.6/1000, than of children in residences with sandy floor, 68.4/1000.
Also, children of families in which their drinking water source is a
river or a spring are at higher child mortality rate, 63.2/1000, vs. those who
use piped water, 32.3/1000. Of the
infants who died at age of one month or older, 43% of them suffered from fever
and 26% suffered from diarrhea before they died.
Of the infants that are younger than a month when they died, 21% of them
suffered from cough and difficulty breathing.
Child
Nutritional Status
The
assessment of the child’s height and weight were used to indicate the
nutritional status. Of those
surveyed, Bekaa Valley district were found to be the shortest and the in Beirut
and Mount Lebanon districts to suffer less from short height.
Also, the study found that higher percentage of short children for
illiterate mothers than those of mothers who completed secondary education,
19.8% vs. 9.9%. The study found
2.8% of the children surveyed to suffer form low weight in which most of those
suffering are among children who are 12-35 months of age and among the children
of the south.
Child
Morbidity
Of
the children surveyed, 12 % suffered from diarrhea in the two weeks prior to the
survey conducting time. The average
for the duration of the diarrhea was three days.
Children in the Nabateya district suffered most with 15.8% while children
in Beirut and the South districts suffered least with 8.6% and 8.3%
respectively. Of those who had
diarrhea, 37.6% had severe cases as described by their mothers.
The
results also show that 38% of the children had cough in the past two weeks of
the time the survey was conducted. Children
in Mount Lebanon suffered most with 40.3% and those in Nabateya suffered least
with 27 %. Children for mothers
that completed secondary education reported the highest rate of cough for their
children: 41.5% vs. 31.8 % for children of illiterate mothers. This could be could be caused by the educated mothers more
knowledge of disease symptoms.
About
8% of the children below five suffered from measles before, 31% suffered from
fever, and 8 % suffered from ear infection.
The
study also shows that 3 % of the children suffered from injuries after an
accident. Most of the accidents
happened in the residence with wounds and burns forming 2/3 of the injuries,
while the poisoning and broken bones forming the rest along with others.
Prevention
and Vaccination
The
study shows that there was a great percentage of children taking the first
injection of the of the MMR vaccination. About
99.8% of the children surveyed, had the first injection, 96.8% had the second,
and 91.8% had the third as captured by their vaccination cards. The study did not find any significant statistical
relationship between the availability of the vaccines and the proximity of the
vaccination health centers as the reasons people don’t vaccinate or don’t
complete vaccinating their children.
Treatment
The
survey found that in 54% of the cases of diarrhea, mothers seek professional
medical help. Mothers tend to
utilize medical help during the first sixteen months of the child’s age.
In 42% of the doctor visits, doctor prescribed a medicine.
Among those who didn’t seek medical help, 75% said that they thought
that the diarrhea symptoms as minor. Mothers
used hydrating fluids in 27% of the diarrhea when the symptoms were there.
As
for treating the cough during the two weeks preceding the time of conducting the
survey, 79% of the mothers of affected children went to doctors.
About 90% of the children who went to the doctor, were prescribed
medicine.
About
80% of the children who suffered from fever in the two weeks preceding the study
had medical attention. About 62% of
these children were prescribed Aspirin and Parasitamol.
It was noted that boys were more likely to be prescribed as such. 62% and
it was also a common prescription among the South district’s children, 83%.
Breast
Feeding
It
was shown that 88% of the mothers, breast fed their babies.
The tendency to breast-feed was less as age of the mother progressed,
90.2% among mothers of 24 or less, 86.8% among mothers of 30-34, and 85.9% for
mothers of 35-49 for example.
The
breast-feeding average was found to be nine months.
The breast feeding average decreases as the educational status of the
mother improves. For example, it is
six months for mothers of secondary education and more and 13 months for
illiterate mothers.
Mostly
the mothers were feeding their children when they think the baby needed it,
breast-feeding was not provided according to a time schedule mostly. About 58% of the mothers also used bottle-feeding besides
breast-feeding. It was also shown
that using bottle-feeding combined with breast-feeding increases as the
educational level of the mother increases.
The
average age of the child when he or she started getting nutritional supplements
was five months. It was also
observed that 22% of the children who were breast-fed were converted to
bottle-feeding before reaching the age of three months.
Not having enough breast milk was the main reason for early switching.
Handicapped
Children
The
study also addressed the issue of the handicapped children.
Of those surveyed, 1.7% were handicapped.
It was more prevalent among the males than the females.
About 12% of the handicapped had vision disabilities, 59% suffered from
mental retardation, and 32% suffered from disability caused by accidents.
Maternal
Care During Pregnancy
This
Lebanese survey showed that pregnant women went for medical care in 79% of the
cases. In 93% of the cases when
medical care was sought, a doctor was the primary care person.
Of
those who sought care, 11% went to government medical care centers while 87%
utilized the services offered by the private health care sector.
The utilization of private health care was prevalent among all kind of
pregnant women.
The
main reason for not seeking medical care was the pregnant woman feeling that
“there is no need”, 32% of the cases, while the second main reason was the
cost of the service.
About
88% of the deliveries were made in care centers with the rest at home. It was noticed also that in 17% of the deliveries at the
health centers were by cesarean surgery.
Mothers’
Fertility Rates
The
survey showed that overall fertility rate for the women declined by third. From an average of 3.8 pregnancies in the period of 10-14
years preceding the survey to 2.5 pregnancies in the 0-4 years period preceding
the study.
The
number of babies was an average of 3.4 per married woman; it was an average of
5.0 babies for the woman that are currently 45-49 of age.
It was also found that one of every ten women has nine children or more.
The
fertility rate among women decreased with increasing educational level, it was
an average of 5.7 babies for illiterate women, 3.5 for those of elementary
education, and an average of 2.2 babies for women of secondary education or
more. The fertility rates also differ by region, where it was
highest in the North district with an average of 3.4 babies per woman, and
lowest in Beirut district with an average of 1.7 babies per woman in the three
years preceding the survey.
Family
Planning
The
survey shows that 99.4% of the women surveyed to know about a method of family
planning. There was no significant
statistical difference among the ages, the place of residence, or the
educational level in this. At the
time of the survey, 61% of the women were using anti pregnancy methods, with the
tube insertion being used most, 17% of the cases, and pills were used second,
10% of the cases.
It
was also noted that the number of live children affected the use of anti
pregnancies with the use increasing as the number of children increases among
all groups of women. It was also
noted that the methods were used more when the number of boys exceeded two or
when the number of boys exceeded the number of girls.
Of
those using family planning methods, 66% of them obtained the kits through
medical professionals in hospitals, clinics, pharmacies, and family planning
centers.
As
for the main reasons for not using anti pregnancy methods was the desire to have
another child in 60% of the cases. About
57% of the husbands of wives that are not using anti pregnancy methods are
conceding to the use of such methods.
Survey’s
Recommendations
The
researchers recommended that focus should be in improving the family planning
policies, the environmental surroundings, and the health education programs that
would target the following areas.
Children’s nutritional status.
Breast feeding and its timing.
The dangers of childhood diseases and how to prevent them.
The importance of hydrating fluids.
The importance of timely vaccination.
The importance of health care during pregnancy.
The importance of health care after delivery for woman and babies alike.
Evaluation
This
is definitely a good survey that contributed greatly to the amount of knowledge
we know about the status of Lebanon’s child and maternal health, an essential
task in the efforts in promoting Lebanon status after the war of 1975-1990.
The researchers carefully identified the findings that could be affected
by recall bias or weaknesses of analysis in small sample sizes as that of the
handicapped children. The format of
the report was done excellently with extensive use of graphs and tables. The sample size was big enough and comprehensive, but for
security reasons didn’t include parts of the South that was occupied at the
time. The study also was in Arabic;
an important survey like this should be reported in English and French for
international audience interested in the subject. Moreover, the names of the researchers were all included;
however, the contact information was not.
The researchers didn’t identify what was the most important
problem affecting child health and mortality health in Lebanon among
those addressed.
The
was a detailed description about the procedure of designing the survey, media
coverage, its conduction, its validation, and the methods of analysis.
I found no reference to the aspect of consent among those surveyed.
The
researchers didn’t indicate how would the excluded sample from the South
affect the findings. The
researchers didn’t include suggestions on why the child mortality rates are
higher in certain regions although they suggested possible reasons for other
interesting patterns like the increased number of children suffering from coughs
among educated women. Also, this
was not addressed in the recommendation were no mention or recommendation to
address the factors causing differences in child and maternal health across the
regions of Lebanon. The survey
didn’t address to a great extent the level of child and maternal health to the
socio economic status of the families surveyed.
Also, it was oblivious from the survey that the level of women’s
education affects the health of the child and the mother.
Why they didn’t include a recommendation for improving women’s
overall education. The study also
didn’t address directions for future research to evaluate more the child and
maternal care in Lebanon. One could
suggest evaluating the hygiene in schools and its effect as Lebanese children
start attending school at the age of three, evaluating the risk of second hand
smoking on child health and the risk of increased levels of smokers among women
for example as a great percentage of Lebanese adults are smokers, and evaluating
better the socioeconomic status and its effect on child health and maternal
health.
After
all, plenty of information has been added to our understanding of child and
maternal health in Lebanon by this survey; nonetheless, there are enough aspects
to be studied and researched with better surveys.
Andre Doreid Berro
University of Michigan Ann Arbor
