DHS COMPARATIVE

REPORTS 46

LEVELS AND TRENDS OF MATERNAL 

AND CHILD HEALTH INDICATORS IN

11 MIDDLE EAST AND NORTH AFRICAN 

COUNTRIES

NOVEMBER 2017

This publication was produced for review by the United States Agency for International Development (USAID). The report was prepared by 

Shireen Assaf, Leah Horton, Marta Bornstein, and Thomas Pullum.

DHS Comparative Report No. 46 

Levels and Trends of Maternal and Child Health Indicators 

in 11 Middle East and North African Countries 

Shireen Assaf 

Leah Horton 

Marta Bornstein 

Thomas Pullum 

ICF 

Rockville, Maryland, USA 

November 2017 

Corresponding author: Shireen Assaf, International Health and Development, ICF, 530 Gaither Road, Suite 

500, Rockville, MD 20850, USA. Phone: +1 301–407–6500; Fax: +1 301–407–6501; E-mail: 

Shireen.Assaf@icf.com 
Acknowledgments: 

The authors are grateful for the comments and guidance provided by USAID Middle East Bureau and 

USAID mission offices. We would also like to thank Steven Gilbert for producing the maps and providing 

direction on the regional distribution of some of the countries in the report. Thanks also to Dr. Ahmed 

Abdel Monem for providing us with the PAPFAM data used in the report. 

Editor: Diane Stoy and Sidney Moore 

Document Production: Chris Gramer 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (AID-OAA-C-13-00095). The views expressed are 

those of the authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about The DHS Program contact: 

DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. 

Phone: +1 301-407-6500; Fax: +1 301-407-6501; E-mail: info@DHSprogram.com; Internet: 

www.DHSprogram.com. 

Recommended citation: 

Assaf, Shireen, Leah Horton, Marta Bornstein, and Thomas Pullum. 2017. Levels and Trends of Maternal 

and Child Health Indicators in 11 Middle East and North African Countries. DHS Comparative Report No. 

46. Rockville, Maryland, USA: ICF. 
iii 

Contents 

TABLES ..................................................................................................................................................... vii 

FIGURES ................................................................................................................................................... xv 

PREFACE ................................................................................................................................................. xxi 

ABSTRACT ............................................................................................................................................ xxiii 

INTRODUCTION ....................................................................................................................................... 1 

DATA AND METHODS ............................................................................................................................ 3 

Data .................................................................................................................................................. 3 

Methods ........................................................................................................................................... 5 

ALGERIA .................................................................................................................................................... 7 

Total Fertility Rate ......................................................................................................................... 10 

Contraceptive Use .......................................................................................................................... 10 

Antenatal Care ............................................................................................................................... 11 

Delivery ......................................................................................................................................... 12 

Child Health Care .......................................................................................................................... 13 

Child Nutrition ............................................................................................................................... 14 

Under-5 Mortality .......................................................................................................................... 16 

Algeria Summary ........................................................................................................................... 17 

EGYPT ....................................................................................................................................................... 19 

Total Fertility Rate ......................................................................................................................... 23 

Contraceptive Use .......................................................................................................................... 24 

Antenatal Care ............................................................................................................................... 28 

Delivery ......................................................................................................................................... 30 

Child Health Care .......................................................................................................................... 36 

Child Nutrition ............................................................................................................................... 40 

Under-5 Mortality .......................................................................................................................... 46 

Egypt Summary ............................................................................................................................. 48 

IRAQ .......................................................................................................................................................... 49 

Total Fertility Rate ......................................................................................................................... 52 

Contraceptive Use .......................................................................................................................... 53 

Antenatal Care ............................................................................................................................... 57 

Delivery ......................................................................................................................................... 58 

Child Health Care .......................................................................................................................... 63 

Child Nutrition ............................................................................................................................... 65 

Under-5 Mortality .......................................................................................................................... 71 

Iraq Summary ................................................................................................................................ 73 

JORDAN .................................................................................................................................................... 75 

Total Fertility Rate ......................................................................................................................... 78 

Contraceptive Use .......................................................................................................................... 79 

Antenatal Care ............................................................................................................................... 83 

Delivery ......................................................................................................................................... 85 

Child Health Care .......................................................................................................................... 91 

Child Nutrition ............................................................................................................................... 95 

Under-5 Mortality ........................................................................................................................ 101 

Jordan Summary .......................................................................................................................... 103 
iv 

LEBANON (PALESTINIAN REFUGEES) ......................................................................................... 105 

Total Fertility Rate ....................................................................................................................... 108 

Contraceptive Use ........................................................................................................................ 108 

Antenatal Care ............................................................................................................................. 112 

Delivery ....................................................................................................................................... 113 

Child Health Care ........................................................................................................................ 118 

Child Nutrition ............................................................................................................................. 120 

Under-5 Mortality ........................................................................................................................ 126 

Lebanon (Palestinian Refugees) Summary .................................................................................. 127 

LIBYA ...................................................................................................................................................... 129 

Contraceptive Use ........................................................................................................................ 132 

Delivery ....................................................................................................................................... 133 

Child Health Care ........................................................................................................................ 133 

Child Nutrition ............................................................................................................................. 134 

Under-5 Mortality ........................................................................................................................ 135 

Libya Summary ............................................................................................................................ 136 

MOROCCO ............................................................................................................................................. 137 

Contraceptive Use ........................................................................................................................ 140 

Antenatal Care ............................................................................................................................. 141 

Delivery ....................................................................................................................................... 141 

Child Health Care ........................................................................................................................ 143 

Child Nutrition ............................................................................................................................. 143 

Morocco Summary....................................................................................................................... 144 

SYRIA ...................................................................................................................................................... 145 

Contraceptive Use ........................................................................................................................ 148 

Delivery ....................................................................................................................................... 148 

Child Health Care ........................................................................................................................ 149 

Child Nutrition ............................................................................................................................. 151 

Syria Summary ............................................................................................................................ 153 

TUNISIA .................................................................................................................................................. 155 

Total Fertility Rate ....................................................................................................................... 158 

Contraceptive Use ........................................................................................................................ 158 

Antenatal Care ............................................................................................................................. 159 

Delivery ....................................................................................................................................... 160 

Child Health Care ........................................................................................................................ 161 

Child Nutrition ............................................................................................................................. 162 

Under-5 Mortality ........................................................................................................................ 164 

Tunisia Summary ......................................................................................................................... 165 

WEST BANK AND GAZA STRIP ........................................................................................................ 167 

Total Fertility Rate ....................................................................................................................... 171 

Contraceptive Use ........................................................................................................................ 172 

Antenatal Care ............................................................................................................................. 176 

Delivery ....................................................................................................................................... 178 

Child Health Care ........................................................................................................................ 184 

Child Nutrition ............................................................................................................................. 186 

Under-5 Mortality ........................................................................................................................ 192 

West Bank and Gaza Strip Summary ........................................................................................... 194 
v 

YEMEN .................................................................................................................................................... 197 

Total Fertility Rate ....................................................................................................................... 201 

Contraceptive Use ........................................................................................................................ 202 

Antenatal Care ............................................................................................................................. 206 

Delivery ....................................................................................................................................... 207 

Child Health Care ........................................................................................................................ 212 

Child Nutrition ............................................................................................................................. 216 

Under-5 Mortality ........................................................................................................................ 218 

Yemen Summary ......................................................................................................................... 220 

OVERALL SUMMARY ........................................................................................................................ 223 

Fertility and Contraception .......................................................................................................... 223 

Antenatal Care and Delivery ........................................................................................................ 224 

Child Health and Nutrition ........................................................................................................... 226 

REFERENCES ........................................................................................................................................ 231 

APPENDIX .............................................................................................................................................. 245 

vii 

Tables 

Table 1: Sources of Data ............................................................................................................................... 3

Table 2: Availability of Indicators ................................................................................................................ 6

Table Algeria.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Algeria 2012-13 MICS4 ................................................................................................................ 10

Table Algeria.02: Percentage of women currently using modern or traditional contraception among 

women age 15-49 in a union, by background characteristics, Algeria 2012-13 MICS4 ............... 11

Table Algeria.03: Percentage of women age 15-49 who had four or more antenatal care visits for 

their most recent pregnancy in the 2 years before the survey, by background characteristics, 

Algeria 2012-13 MICS4 ................................................................................................................ 12

Table Algeria.04: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant (SBA), delivered in a health facility (DHF), or delivered by caesarean 

section (C-section) in the 2 years before the survey, by background characteristics, 

Algeria 2012-13 MICS4 ................................................................................................................ 13

Table Algeria.05: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Algeria 2012-13 MICS4 ............................................... 14

Table Algeria.06: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Algeria 2012-13 MICS4 .................................................................... 15

Table Algeria.07: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Algeria 2012-13 MICS4 ........................................................................................ 16

Table Algeria.08: Under-5 mortality (U5M) rates for the 5 years before the survey, by background 

characteristics, Algeria 2012-13 MICS4 ........................................................................................ 17

Table Egypt.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Egypt 2008 and 2014 DHS ............................................................................................................ 23

Table Egypt.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Egypt 2008 and 2014 DHS .............................. 25

Table Egypt.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Egypt 2008 and 2014 DHS .............................. 27

Table Egypt.04: Percentage of women age 15-49 who had four or more antenatal care visits for their 

most recent pregnancy in the 2 years before the survey, by background characteristics, 

Egypt 2008 and 2014 DHS ............................................................................................................ 29

Table Egypt.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Egypt 2008 

and 2014 DHS ................................................................................................................................ 31

Table Egypt.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Egypt 2008 and 

2014 DHS ...................................................................................................................................... 33

Table Egypt.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 

DHS ............................................................................................................................................... 35
viii 

Table Egypt.08: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Egypt 2008 and 2014 DHS ........................................................... 37

Table Egypt.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Egypt 2008 and 2014 DHS ........................................................... 39

Table Egypt.10: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Egypt 2008 and 2014 DHS ................................................................ 41

Table Egypt.11: Percentage of children under age 5 who are stunted, by background characteristics, 

Egypt 2008 and 2014 DHS ............................................................................................................ 43

Table Egypt.12: Percentage of children under age 5 who are overweight, by background 

characteristics, Egypt 2008 and 2014 DHS ................................................................................... 45

Table Egypt.13: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Egypt 2008 and 2014 DHS ............................................................................................................ 47

Table Iraq.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Iraq 2006 MICS3 and 2011 MICS4 ............................................................................................... 52

Table Iraq.02: Percentage of women currently using modern contraception among women age 15-49 

in a union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 ........................... 54

Table Iraq.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 ................. 56

Table Iraq.04: Percentage of women age 15-49 who had four or more antenatal care visits for their 

most recent pregnancy in the 2 years before the survey, by background characteristics, 

Iraq 2011 MICS4 ........................................................................................................................... 58

Table Iraq.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Iraq 2006 

MICS3 and 2011 MICS4 ............................................................................................................... 59

Table Iraq.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Iraq 2006 MICS3 

and 2011 MICS4 ............................................................................................................................ 61

Table Iraq.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Iraq 2011 MICS4 ......... 63

Table Iraq.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 ............................................. 64

Table Iraq.09: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Iraq 2006 MICS3 and 2011 MICS4 .................................................. 66

Table Iraq.10: Percentage of children under age 5 who are stunted, by background characteristics, 

Iraq 2006 MICS3 and 2011 MICS4 ............................................................................................... 68

Table Iraq.11: Percentage of children under age 5 who are overweight, by background characteristics, 

Iraq 2006 MICS3 and 2011 MICS4 ............................................................................................... 70

Table Iraq.12: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Iraq 2006 MICS3 and 2011 MICS4 ...................................................................... 72
ix 

Table Jordan.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Jordan 2007 and 2012 DHS ........................................................................................................... 78

Table Jordan.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Jordan 2007 and 2012 DHS ............................. 80

Table Jordan.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Jordan 2007 and 2012 DHS ............................. 82

Table Jordan.04: Percentage of women age 15-49 who had four or more antenatal care visits for their 

most recent pregnancy in the 2 years before the survey, by background characteristics, Jordan 

2007 and 2012 DHS ....................................................................................................................... 84

Table Jordan.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Jordan 2007 

and 2012 DHS ................................................................................................................................ 86

Table Jordan.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Jordan 2007 and 

2012 DHS ...................................................................................................................................... 88

Table Jordan.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Jordan 2007 and 

2012 DHS ...................................................................................................................................... 90

Table Jordan.08: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Jordan 2007 and 2012 DHS .......................................................... 92

Table Jordan.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, by 

background characteristics, Jordan 2007 and 2012 DHS .............................................................. 94

Table Jordan.10: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Jordan 2007 and 2012 DHS .............................................................. 96

Table Jordan.11: Percentage of children under age 5 who are stunted, by background characteristics, 

Jordan 2007 and 2012 DHS ........................................................................................................... 98

Table Jordan.12: Percentage of children under age 5 who are overweight, by background 

characteristics, Jordan 2007 and 2012 DHS ................................................................................ 100

Table Jordan.13: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Jordan 2007 and 2012 DHS ......................................................................................................... 102

Table PRL.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Palestinian Refugees of Lebanon 2011 MICS4 ........................................................................... 108

Table PRL.02: Percentage of women currently using modern contraception among women age 15-49 

in a union, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 

and 2011 MICS4 .......................................................................................................................... 109

Table PRL.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Palestinian Refugees of Lebanon 2006 

MICS3 and 2011 MICS4 ............................................................................................................. 111

Table PRL.04: Percentage of women age 15-49 who had four or more antenatal care visits for their 

most recent pregnancy in the 2 years before the survey, by background characteristics, 

Palestinian Refugees of Lebanon 2011 MICS4 ........................................................................... 113
x 

Table PRL.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Palestinian 

Refugees of Lebanon 2006 MICS3 and 2011 MICS4 ................................................................. 114

Table PRL.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Palestinian Refugees 

of Lebanon 2006 MICS3 and 2011 MICS4 ................................................................................. 116

Table PRL.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Palestinian Refugees 

of Lebanon 2011 MICS4 ............................................................................................................. 118

Table PRL.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 

MICS4 .......................................................................................................................................... 119

Table PRL.09: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 .. 121

Table PRL.10: Percentage of children under age 5 who are stunted, by background characteristics, 

Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 ............................................... 123

Table PRL.11: Percentage of children under age 5 who are overweight, by background 

characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 ...................... 125

Table PRL.12: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Palestinian Refugees of Lebanon 2011 MICS4 .................................................. 127

Table Libya.01: Percentage of women currently using modern or traditional contraception among 

women age 15-49 in a union, by background characteristics, Libya 2007 PAPFAM ................. 132

Table Libya.02: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant, delivered in a health facility, or delivered by caesarean section in the 2 years 

before the survey, by background characteristics, Libya 2007 PAPFAM ................................... 133

Table Libya.03: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Libya 2007 PAPFAM ................................................................. 134

Table Libya.04: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Libya 2007 PAPFAM ...................................................................... 135

Table Libya.05: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Libya 2007 PAPFAM .................................................................................................................. 135

Table Morocco.01: Percentage of women currently using modern or traditional contraception among 

women age 15-49 in a union, by background characteristics, Morocco 2011 PAPFAM ............ 140

Table Morocco.02: Percentage of women age 15-49 who had four or more antenatal care visits for 

their most recent pregnancy in the 2 years before the survey, by background characteristics, 

Morocco 2011 PAPFAM ............................................................................................................. 141

Table Morocco.03: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant or delivered in a health facility in the 2 years before the survey, by 

background characteristics, Morocco 2011 PAPFAM ................................................................ 142
xi 

Table Morocco.04: Percentage of children under age five who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Morocco 2011 PAPFAM ............................................ 143

Table Morocco.05: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Morocco 2011 PAPFAM ................................................................ 144

Table Syria.01: Percentage of women currently using modern or traditional contraception among 

women age 15-49 in a union, by background characteristics, Syria 2006 MICS3 ...................... 148

Table Syria.02: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant or delivered in a health facility in the 2 years before the survey, by 

background characteristics, Syria 2006 MICS3 ........................................................................... 149

Table Syria.03: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Syria 2006 MICS3 ...................................................................... 150

Table Syria.04: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Syria 2006 MICS3 ...................................................................... 151

Table Syria.05: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Syria 2006 MICS3 ........................................................................... 152

Table Syria.06: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Syria 2006 MICS3 .............................................................................................. 153

Table Tunisia.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Tunisia 2011-12 MICS4 .............................................................................................................. 158

Table Tunisia.02: Percentage of women currently using modern or traditional contraception among 

women age 15-49 in a union, by background characteristics, Tunisia 2011-12 MICS4 ............. 159

Table Tunisia.03: Percentage of women age 15-49 who had four or more antenatal care visits for 

their most recent pregnancy in the 2 years before the survey, by background characteristics, 

Tunisia 2011-12 MICS4 .............................................................................................................. 160

Table Tunisia.04: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant, delivered in a health facility, or delivered by caesarean section in 

the 2 years before the survey, by background characteristics, Tunisia 2011-12 MICS4 ............. 161

Table Tunisia.05: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Tunisia 2011-12 MICS4 ............................................. 162

Table Tunisia.06: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Tunisia 2011-12 MICS4 .................................................................. 163

Table Tunisia.07: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Tunisia 2011-12 MICS4 ...................................................................................... 164

Table Tunisia.08: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Tunisia 2011-12 MICS4 ...................................................................................... 165

Table WBG.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 171

Table WBG.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, West Bank and Gaza 2010 MICS4 and 

2014 MICS5 ................................................................................................................................. 173
xii 

Table WBG.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, West Bank and Gaza 2010 MICS4 and 

2014 MICS5 ................................................................................................................................. 175

Table WBG.04: Percentage of women age 15-49 who had four or more antenatal care visits for 

their most recent pregnancy in the 2 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 177

Table WBG.05: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant in the 2 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 179

Table WBG.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, West Bank and 

Gaza 2010 MICS4 and 2014 MICS5 ........................................................................................... 181

Table WBG.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, West Bank and 

Gaza 2010 MICS4 and 2014 MICS5 ........................................................................................... 183

Table WBG.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 ................ 185

Table WBG.09: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 ..................... 187

Table WBG.10: Percentage of children under age 5 who are stunted, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 189

Table WBG.11: Percentage of children under age 5 who are overweight, by background 

characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 ......................................... 191

Table WBG.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 193

Table Yemen.01: Total fertility rate for the 4 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS ............................................................................................. 201

Table Yemen.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Yemen 2006 MICS and 2013 DHS ................ 203

Table Yemen.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Yemen 2006 MICS and 2013 DHS ................ 205

Table Yemen.04: Percentage of women age 15-49 who had four or more antenatal care visits for 

their most recent pregnancy in the 2 years before the survey, by background characteristics, 

Yemen 2013 DHS ........................................................................................................................ 207

Table Yemen.05: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant in the 2 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS ............................................................................................. 208

Table Yemen.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Yemen 2006 MICS 

and 2013 DHS .............................................................................................................................. 210
xiii 

Table Yemen.07: Percentage of women age 15-49 who delivered their most recent birth by 

caesarean section in the 2 years before the survey, by background characteristics, Yemen 

2013 DHS .................................................................................................................................... 212

Table Yemen.08: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Yemen 2006 MICS and 2013 DHS ............................................ 213

Table Yemen.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Yemen 2006 MICS and 2013 DHS ............................ 215

Table Yemen.10: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Yemen 2013 DHS ........................................................................... 217

Table Yemen.11: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Yemen 2013 DHS ............................................................................................... 218

Table Yemen.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS ............................................................................................. 219

xv 

Figures 

Figure Map 1: Algeria Map .......................................................................................................................... 9

Figure Map 2: Egypt Map ........................................................................................................................... 22

Figure Egypt.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Egypt 2008 and 2014 DHS ............................................................................................................ 24

Figure Egypt.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Egypt 2008 and 2014 DHS .............................. 26

Figure Egypt.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Egypt 2008 and 2014 DHS .............................. 28

Figure Egypt.04: Percentage of women age 15-49 who had four or more antenatal care visits for their 

most recent pregnancy in the 2 years before the survey, by background characteristics, Egypt 

2008 and 2014 DHS ....................................................................................................................... 30

Figure Egypt.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Egypt 2008 

and 2014 DHS ................................................................................................................................ 32

Figure Egypt.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Egypt 2008 and 

2014 DHS ...................................................................................................................................... 34

Figure Egypt.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 

DHS ............................................................................................................................................... 36

Figure Egypt.08: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Egypt 2008 and 2014 DHS ........................................................... 38

Figure Egypt.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Egypt 2008 and 2014 DHS ........................................... 40

Figure Egypt.10: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Egypt 2008 and 2014 DHS ................................................................ 42

Figure Egypt.11: Percentage of children under age 5 who are stunted, by background characteristics, 

Egypt 2008 and 2014 DHS ............................................................................................................ 44

Figure Egypt.12: Percentage of children under age 5 who are overweight, by background 

characteristics, Egypt 2008 and 2014 DHS ................................................................................... 46

Figure Egypt.13: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Egypt 2008 and 2014 DHS ................................................................................... 48

Figure Map 3: Iraq Map .............................................................................................................................. 51

Figure Iraq.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Iraq 2006 MICS3 and 2011 MICS4 ............................................................................................... 53

Figure Iraq.02: Percentage of women currently using modern contraception among women age 15-49 

in a union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 ........................... 55
xvi 

Figure Iraq.03: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 ................. 57

Figure Iraq.04: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Iraq 2006 

MICS3 and 2011 MICS4 ............................................................................................................... 60

Figure Iraq.05: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Iraq 2006 MICS3 

and 2011 MICS4 ............................................................................................................................ 62

Figure Iraq.06: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 ............................................. 65

Figure Iraq.07: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Iraq 2006 MICS3 and 2011 MICS4 .................................................. 67

Figure Iraq.08: Percentage of children under age 5 who are stunted, by background characteristics, 

Iraq 2006 MICS3 and 2011 MICS4 ............................................................................................... 69

Figure Iraq.09: Percentage of children under age 4 who are overweight, by background characteristics, 

Iraq 2006 MICS3 and 2011 MICS4 ............................................................................................... 71

Figure Iraq.10: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Iraq 2006 MICS3 and 2011 MICS4 ...................................................................... 73

Figure Map 4: Jordan Map .......................................................................................................................... 77

Figure Jordan.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Jordan 2007 and 2012 DHS ........................................................................................................... 79

Figure Jordan.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Jordan 2007 and 2012 DHS ............................. 81

Figure Jordan.03: Percentage of women currently using traditional contraception among women 

age 15-49 in a union, by background characteristics, Jordan 2007 and 2012 DHS ....................... 83

Figure Jordan.04: Percentage of women age 15-49 who had four or more antenatal care visits for their 

most recent pregnancy in the 2 years before the survey, by background characteristics, Jordan 

2007 and 2012 DHS ....................................................................................................................... 85

Figure Jordan.05: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant in the 2 years before the survey, by background characteristics, 

Jordan 2007 and 2012 DHS ........................................................................................................... 87

Figure Jordan.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Jordan 2007 and 

2012 DHS ...................................................................................................................................... 89

Figure Jordan.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 

DHS ............................................................................................................................................... 91

Figure Jordan.08: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Jordan 2007 and 2012 DHS .......................................................... 93

Figure Jordan.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Jordan 2007 and 2012 DHS .......................................... 95
xvii 

Figure Jordan.10: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, Jordan 2007 and 2012 DHS [EDUCATION plot excluded due 

to low counts] ................................................................................................................................. 97

Figure Jordan.11: Percentage of children under age 5 who are stunted, by background characteristics, 

Jordan 2007 and 2012 DHS ........................................................................................................... 99

Figure Jordan.12: Percentage of children under age 5 who are overweight, by background 

characteristics, Jordan 2007 and 2012 DHS ................................................................................ 101

Figure Jordan.13: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Jordan 2007 and 2012 DHS ................................................................................ 103

Figure Map 5: Lebanon Map .................................................................................................................... 107

Figure PRL.01: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Palestinian Refugees of Lebanon 2006 

MICS3 and 2011 MICS4 ............................................................................................................. 110

Figure PRL.02: Percentage of women currently using traditional contraception among women age 

15-49 in a union, by background characteristics, Palestinian Refugees of Lebanon 2006 

MICS3 and 2011 MICS4 ............................................................................................................. 112

Figure PRL.03: Percentage of women age 15-49 who had their most recent birth assisted by a skilled 

birth attendant in the 2 years before the survey, by background characteristics, Palestinian 

Refugees of Lebanon 2006 MICS3 and 2011 MICS4 ................................................................. 115

Figure PRL.04: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Palestinian Refugees 

of Lebanon 2006 MICS3 and 2011 MICS4 ................................................................................. 117

Figure PRL.05: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before 

the survey and for whom advice or treatment was sought from a health facility or provider, 

by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 

MICS4 .......................................................................................................................................... 120

Figure PRL.06: Percentage of children under age 6 months who are exclusively breastfed, by 

|background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 . 122

Figure PRL.07: Percentage of children under age 5 who are stunted, by background characteristics, 

Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 ............................................... 124

Figure PRL.08: Percentage of children under age 5 who are overweight, by background 

characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 ...................... 126

Figure Map 6: Libya Map ......................................................................................................................... 131

Figure Map 7: Morocco Map .................................................................................................................... 139

Figure Map 8: Syria Map .......................................................................................................................... 147

Figure Map 9: Tunisia Map ...................................................................................................................... 157

Figure Map 10: State of Palestine Map—West Bank and Gaza Strip ...................................................... 170

Figure WBG.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 172

Figure WBG.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, West Bank and Gaza 2010 MICS4 and 

2014 MICS5 ................................................................................................................................. 174
xviii 

Figure WBG.03: Percentage of women currently using traditional contraception among women 

age 15-49 in a union, by background characteristics, West Bank and Gaza 2010 MICS4 

and 2014 MICS5 .......................................................................................................................... 176

Figure WBG.04: Percentage of women age 15-49 who had four or more antenatal care visits for 

their most recent pregnancy in the 2 years before the survey, West Bank and Gaza 2010 

MICS4 and 2014 MICS5 ............................................................................................................. 178

Figure WBG.05: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant in the 2 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 .................................................................. 180

Figure WBG.06: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, West Bank and 

Gaza 2010 MICS4 and 2014 MICS5 ........................................................................................... 182

Figure WBG.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, West Bank and Gaza 2010 MICS4 and 2014 MICS5 . 184

Figure WBG.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility 

or provider, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 

MICS5 .......................................................................................................................................... 186

Figure WBG.09: Percentage of children under age 6 months who are exclusively breastfed, by 

background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 ..................... 188

Figure WBG.10: Percentage of children under age 5 who are stunted, West Bank and Gaza 2010 

MICS4 and 2014 MICS5 ............................................................................................................. 190

Figure WBG.11: Percentage of children under age 5 who are overweight, West Bank and Gaza 2010 

MICS4 and 2014 MICS5 ............................................................................................................. 192

Figure WBG.12: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 ......................................... 194

Figure Map 11: Yemen Map ..................................................................................................................... 200

Figure Yemen.01: Total fertility rate for the 3 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS ............................................................................................. 202

Figure Yemen.02: Percentage of women currently using modern contraception among women age 

15-49 in a union, by background characteristics, Yemen 2006 MICS and 2013 DHS ................ 204

Figure Yemen.03: Percentage of women currently using traditional contraception among women 

age 15-49 in a union, by background characteristics, Yemen 2006 MICS and 2013 DHS ......... 206

Figure Yemen.04: Percentage of women age 15-49 who had their most recent birth assisted by a 

skilled birth attendant in the 2 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS ............................................................................................. 209

Figure Yemen.05: Percentage of women age 15-49 who delivered their most recent birth in a health 

facility in the 2 years before the survey, by background characteristics, Yemen 2006 MICS 

and 2013 DHS .............................................................................................................................. 211

Figure Yemen.06: Percentage of children age 12-23 months who have received all basic vaccinations, 

by background characteristics, Yemen 2006 MICS and 2013 DHS ............................................ 214
xix 

Figure Yemen.07: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks 

before the survey and for whom advice or treatment was sought from a health facility or 

provider, by background characteristics, Yemen 2006 MICS and 2013 DHS ............................ 216

Figure Yemen.08: Under-5 mortality rates for the 5 years before the survey, by background 

characteristics, Yemen 2006 MICS and 2013 DHS ..................................................................... 220

Figure 1: Total fertility rate for the 3 years before the survey, all surveys ............................................... 223

Figure 2: Percentage of women currently using modern contraception among women age 15-49 in a 

union, all surveys ......................................................................................................................... 224

Figure 3: Percentage of women currently using traditional contraception among women age 15-49 

in a union, all surveys .................................................................................................................. 224

Figure 4: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, all surveys .................................................... 225

Figure 5: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, all surveys ................................................................. 226

Figure 6: Percentage of women age 15-49 who delivered their most recent birth in a health facility 

in the 2 years before the survey, all surveys ................................................................................ 226

Figure 7: Percentage of women age 15-49 who delivered their most recent birth by caesarean section 

in the 2 years before the survey, all surveys ................................................................................ 226

Figure 8: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, all 

surveys ......................................................................................................................................... 227

Figure 9: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, all surveys ........................................................................................................... 228

Figure 10: Percentage of children under age 5 who are stunted, by background characteristics, all 

surveys ......................................................................................................................................... 228

Figure 11: Percentage of children under age 5 who are overweight, by background characteristics, 

all surveys .................................................................................................................................... 228

Figure 12: Under-5 mortality rates for the 5 years before the survey, all surveys .................................... 229

xxi 

Preface 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to provide policymakers and program managers in low- and 

middle-income countries with easily accessible data on levels and trends for a wide range of health and 

demographic indicators. DHS Comparative Reports provide such information, usually for a large number 

of countries in each report. These reports are largely descriptive, without multivariate methods, but when 

possible they include confidence intervals and/or statistical tests. 

The topics in this series are selected by The DHS Program in consultation with the U.S. Agency for 

International Development. 

It is hoped that the DHS Comparative Reports will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries. 

Sunita Kishor 

Director, The DHS Program 

xxiii 

Abstract 

This report examines 13 maternal and child health indicators in 11 Middle East and North African countries 

using the most recent nationally representative household surveys carried out since 2005. The data used in 

the analysis were obtained from 17 surveys from three sources: the Demographic and Health Surveys 

(DHS), the Multiple Indicator Cluster Surveys (MICS), and the Pan Arab Project for Family Health 

(PAPFAM). Data from two surveys were available for six countries which allowed for trend analysis. 

Indicators covered fertility, contraceptive use, antenatal care, delivery, child health care, child nutrition, 

and under-5 mortality. The report highlights the disparities in these indicators by socio-demographic 

variables, including age, education, wealth quintile, place of residence, and region. A summary is also 

provided that compares the overall levels of these indicators across the countries. 

KEY WORDS: MENA, Middle East, maternal and child health, health disparities, Demographic and Health 

Surveys, Multiple Indicator Cluster Surveys, Pan Arab Project for Family Health. 

1 

Introduction 

The Middle East and North Africa (MENA) region is in a state of constant flux from political, demographic, 

and epidemiologic changes. Reports on health in the region are needed on a frequent basis to monitor these 

changes. This report provides a general overview of maternal and child health in 11 MENA countries with 

the most recent nationally representative household surveys since 2005. The report highlights persistent 

disparities by socio-demographic variables, in order to inform the targeting of intervention programs. 

Results from the report may identify issues that need further study on specific countries or topics. The report 

omits some countries in the MENA region because of lack of available data, but the 11 countries cover a 

large geographic area that extends from Morocco to Yemen. 

Several countries in this report are currently experiencing political turmoil, which has resulted in 

displacement and violence against civilians, and a deteriorating health care system. Thus, several indicators 

in the report may be in a worse condition than at the time of data collection. The report provides the most 

recent national estimates available for several maternal and child health indicators and can serve as a 

baseline for future reports. The literature review for each country provides an update on the health situation, 

especially for Syria and Yemen, which uses reports from international organizations and smaller studies 

conducted in the countries that are more recent than the national surveys. 

The report is organized by country in alphabetical order: Algeria, Egypt, Iraq, Lebanon (Palestinian 

Refugees), Libya, Morocco, Syria, Tunisia, the West Bank and Gaza Strip, and Yemen. For Lebanon, data 

were only available for Palestinian Refugees and not the non-refugee Lebanese population. Thirteen 

maternal and child health indicators are included in the analysis. These indicators cover fertility, 

contraception, antenatal care, delivery, child care, child nutrition, and under-5 child mortality. For each 

country and each indicator, the analysis describes the levels and disparities by socio-economic variables, 

and trends when possible. The report includes a summary for the region by each indicator. 

The report can be used in several ways. Readers may be interested in a specific country, or may refer to the 

summary for an overview of variations across countries in a specific indicator. The summary includes 

subsections on fertility and contraception, antenatal care and delivery, and child health and nutrition. To 

understand the disparities within each country, readers must consult the country-specific sections. The 

report is descriptive in nature, and does not provide policy recommendations. Its purpose is simply to 

highlight aspects of maternal and child health that require further attention because of low coverage levels, 

high disparities, or deteriorating conditions over time. 

3 

Data and Methods 

Data 

The data for this analysis were obtained from DHS, MICS and PAPFAM surveys in Algeria, Egypt, Iraq, 

Jordan, Lebanon (Palestinian refugees), Libya, Morocco, the West Bank and Gaza Strip (State of Palestine), 

Syria, Tunisia, and Yemen, as indicated in Table 1. The table also shows the number of households 

successfully interviewed in each survey. The two most recent surveys after 2005 were selected for these 

countries. Algeria, Libya, Morocco, Syria, and Tunisia only had one survey with data available after 2005. 

Table 1: Sources of Data 

Country Year Source 

Sample Size 

(households 

interviewed) 

Algeria 2012-13 MICS4 27,198 

Egypt 2014 Standard DHS 29,175 

Egypt 2008 Standard DHS 18,968 

Iraq 2011 MICS4 35,701 

Iraq 2006 MICS3 17,873 

Jordan 2012 Standard DHS 15,190 

Jordan 2007 Standard DHS 14,564 

Lebanon (Palestinian refugees) 2011 MICS4 4,747 

Lebanon (Palestinian refugees) 2006 MICS3 6,167 

Libya 2007 PAPFAM 21540 

Morocco 2011 PAPFAM 15,343 

Syria 2006 MICS3 19,019 

Tunisia 2011-12 MICS4 9,171 

West Bank and Gaza Strip (State of Palestine) 2014 MICS5 10,182 

West Bank and Gaza Strip (State of Palestine) 2010 MICS4 13,629 

Yemen 2013 Standard DHS 17,351 

Yemen 2006 MICS3 3,586 

For each survey, 13 indicators were computed according to the definitions given below. For these 

indicators, the selected populations differ slightly between the data sources. For example, in the DHS, the 

child health indicators of vaccination, care-seeking, and exclusive breastfeeding are found for children 

under age 5 of interviewed mothers. In MICS, these indicators are found for all children under age 5 in the 

household, whether or not the mother was interviewed. The differences between these samples are small 

because there are few children whose mother is not in the household. There is another difference with the 

nutrition indicators of stunting and overweight. In the DHS, these indicators are computed for de facto

children, or those who “slept in the household last night,” while in MICS, the indicators are computed for 

de jure children, who are “usual residents.” The difference is small. Also, with the nutritional indicators, 

MICS3 used the NCHS reference population to compute the indicators, while DHS, MICS4, and MICS5 

use the WHO reference population. Finally, in the DHS and PAPFAM, the indicators of delivery by skilled 

birth attendant, delivery in a health facility, and caesarean section deliveries are reported for births in the 5 

years before the survey. In the MICS, these indicators are reported for births in the 2 years before the survey. 

For these indicators, the DHS and PAPFAM samples were reduced to the MICS definition for 

comparability. The indicator of four or more antenatal care visits, which is reported in the DHS and 

PAPFAM for the 5 years before the survey, was reduced to the 2 years before the survey to assure 

comparability with the MICS. 
4 

Total fertility rate (TFR) 

A measure of current fertility, defined as the expected number of children a woman would have by the end 

of her childbearing years if she were to pass through those years bearing children at the age-specific fertility 

rates observed during the 3 years before the survey. 

Contraceptive prevalence rate for modern methods (mCPR) 

The proportion of women age 15-49, currently in a union, who are using a modern contraceptive method. 

Modern contraceptive methods include pills, IUD, injections, implants, diaphragm, female and male 

condoms, female and male sterilization, foam or jelly, and the lactational amenorrhea method (LAM). The 

mCPR may also include other modern contraceptive methods that are country-specific or less common but 

were reported by the respondent and identified in the datasets as modern methods. 

Contraceptive prevalence rate for traditional methods (tCPR) 

The proportion of women age 15-49, currently in a union, who are using a traditional contraceptive method. 

Traditional contraceptive methods include periodic abstinence (rhythm, calendar method), withdrawal 

(coitus interruptus), and country-specific traditional methods of proven effectiveness. 

Four or more visits for antenatal care (ANC) 

Among women age 15-49 who had a birth in the past 2 years, the proportion who had at least four antenatal 

care visits for the most recent birth. The new WHO recommendation indicates that women should have a 

minimum of eight ANC visits (WHO 2016e). However, the previous recommendation of a minimum of 

four visits was used because this was the valid recommendation at the time of the surveys in this report. 

Delivery by a skilled birth attendant (SBA) 

Among women age 15-49 who had a birth in the past 2 years, the proportion whose most recent birth was 

delivered by a skilled birth attendant. If more than one person assisted the delivery, the most qualified 

person is described. The definition of a skilled birth attendant is country-specific but commonly refers to a 

doctor, nurse, midwife, or auxiliary midwife. 

Delivery in a health facility (DHF) 

Among women age 15-49 who had a birth in the past 2 years, the proportion whose most recent birth was 

delivered in a health facility. This indicator distinguishes between home deliveries and facility deliveries. 

Health facilities could be government, private, NGO, or another facility such as a maternity clinic. 

Caesarean section delivery (C-section) 

Among women age 15-49 who had a birth in the past 2 years, the proportion whose most recent birth was 

delivered by caesarean section. The WHO indicates that C-section rates higher than 10% are not associated 

with reductions in maternal and newborn mortality rates (WHO and HRP 2015). 

Full vaccination 

The proportion of children age 12-23 months who received the BCG, measles, three doses of either DPT or 

DPT-HepB-Hib, and three doses of the polio vaccine. 

Care-seeking for symptoms of ARI 

Among children under age 5 with symptoms of ARI (acute respiratory infection, possibly pneumonia) in 

the 2 weeks before the survey, the proportion for whom advice or treatment was sought from a health 

facility or provider. Excludes treatment sought from pharmacies, shops, or traditional healers. 
5 

Exclusive breastfeeding (EBF) 

The proportion of children under age 6 months at the time of the survey who are being breastfed and did 

not have any water, other liquids, or solids in the day or night before the survey. Limited to children who 

are living with the mother. 

Stunting 

The proportion of children under age 5 who have a height-for-age z-score below the median of the WHO 

2007 reference population by more than two standard deviations.

Overweight 

The proportion of children under age 5 who have a weight-for-height z-score that is above the median of 

the WHO 2007 reference population by more than two standard deviations. 

Under-5 child mortality (U5MR) 

Number of deaths before age 5 per 1000 live births, based on observed risk and survival during the 5 years 

before the survey. 

Methods 

Tests of association were performed between the above indicators and several background variables for 

each survey except for the TFR and the under-5 mortality indicators. For the maternal health indicators, the 

background variables include women’s age, education, wealth quintile, place of residence, and region. For 

the child heath indicators, the background variables include the sex of the child, mother’s education, wealth 

quintile, place of residence, and region. These tests identify disparities in the indicator across 

subpopulations. The region categories for each country are described further in the Appendix. 

Tests of differences in proportions determined whether the differences between surveys (both nationally 

and within subgroups) were statistically significant. These results are shown in plots with a solid line that 

indicates a significant change and a dotted line for a non-significant change. The values of the difference 

overall as well as by subgroups are found in the tables. 

All statistical testing was adjusted for the sample design and weights. Stata 14 was used to make all 

calculations. The national estimates, as well as the estimates used to produce the figures, are provided in 

the tables. Significance was determined at the 0.05 significance level and was indicated by an asterisk 

symbol in the tables. The actual p-values are not reported. 

As shown in Table 2, a few surveys had unavailable data for some indicators (indicated by NA in the table). 

The TFR and under-5 child mortality could not be produced for the 2006 Lebanon (Palestinians) survey, 

the 2006 Syria survey, and the Morocco 2011 survey because these surveys did not have a complete birth 

history and used indirect methods to compute these indicators. The TFR could not be produced for the 

Libya 2007 survey because there was missing information on the all-woman factors that were needed to 

compute this indicator. In addition, the vaccine indicator could not be replicated to match the reported 

figures in the final reports from most surveys. This is indicated by NC in the table. 
6 

Table 2: Availability of Indicators 

Country Year Source TFR mCPR tCPR ANC SBA DHF 

CsectionVaccination ARI 

care EBF 

Stunting Overweight U5MR

Algeria 2012-13 MICS4 NC 

Egypt 2014 Standard DHS 

Egypt 2008 Standard DHS 

Iraq 2011 MICS4 NC 

Iraq 2006 MICS3 NA NA NC 

Jordan 2012 Standard DHS 

Jordan 2007 Standard DHS 

Lebanon (Palestinians) 2011 MICS4 NC 

Lebanon (Palestinians) 2006 MICS3 NA NA NA NC NA 

Libya 2007 PAPFAM NA NA NC NA NA 

Morocco 2011 PAPFAM NA NA NC NA NA NA 

Syria 2006 MICS3 NA NA NA NA 

Tunisia 2011-12 MICS4 NC 

West Bank & Gaza Strip 2014 MICS5 NC 

West Bank & Gaza Strip 2010 MICS4 NC 

Yemen 2013 Standard DHS 

Yemen 2006 MICS3 NA NA NA NA NA 

NA = Data not available. NC = Indicator could not be computed. 
7 

Algeria 

In 2016, Algeria was a nation of approximately 41 million people, 71% of whom were living in urban areas 

(Population Reference Bureau 2016). In recent years, Algeria largely escaped the violence and political 

upheaval associated with the Arab Spring uprisings in 2010 and 2011, although political protests did occur 

in the nation. The government remained intact, and several reforms were enacted in response to the protests. 

Over the past decade, Algeria has made substantial progress across a number of health indicators. Life 

expectancy at birth has increased from 72 years in 2005 to 75 years in 2015 (World Bank 2017a). Since the 

early 2000s, the total fertility rate (TFR) has fluctuated from a low of 2.4 in 2002 to a high of 2.9 children 

per woman in 2012 (World Bank 2017a). Although progress has been made in reproductive, maternal, and 

child health, the health system of Algeria faces increasing challenges from shifts in the burden of disease 

toward non-communicable disease. 

The leading maternal health indicators from Algeria demonstrate progress toward safer motherhood and 

pregnancy. Approximately 97% of deliveries occur in facilities and skilled birth attendance is nearly 

universal (UNICEF 2016b). The maternal mortality ratio (MMR) has declined from 170 maternal deaths to 

140 maternal deaths per 100,000 live births between 2000 and 2015 (UNICEF 2016b). Although the MMR 

has declined over time, there are large disparities within the country. Some areas in southern Algeria have 

experienced MMRs as high as 230 maternal deaths per 100,000 live births, while in the capital city of 

Algiers, the MMR is approximately 30 maternal deaths per 100,000 live births (Ouchtati, Mezhoud, and 

Rahmoun 2009). A 2013 study found that nearly half of pregnant women who received care at an Algerian 

health facility were anemic, although the high prevalence of anemia was not significantly associated with 

low birth weight in infants (Demmouche, Lazrag, and Moulessehoul 2011). A second study that examined 

risk factors associated with pre-eclampsia in Tizi Ouzou, Algeria found the overall prevalence of preeclampsia to be 7.8% between 2012 and 2013 among the study population (Kichou et al. 2015). The study 

found that nulliparity and maternal age of 40 or higher were the leading risk factors associated with preeclampsia (Kichou et al. 2015). 

The health status of children in Algeria has been improving over the past decade, and there has been a 

steady decline in the under-5 mortality rate. Under-5 mortality dropped from 30 deaths per 1,000 live births 

in 2007 to 25 deaths per 1,000 live births in 2015 (UN Inter-agency Group for Child Mortality Estimation 

2015). The infant mortality rate declined from 26 infant deaths per 1,000 live births in 2007 to 

approximately 21 infant deaths per 1,000 live births in 2015 (UN Inter-agency Group for Child Mortality 

Estimation 2015). Another important indicator of both child health and health infrastructure is the 

immunization rate. In Algeria, immunization coverage for children has been consistently high. For example, 

the immunization rate for measles among one-year-olds increased slightly after 2007, and has remained 

steady at 95% coverage since 2010 (UNICEF 2016b). The DTP immunization coverage among one-yearolds has also remained steady at 95% since 2009 (UNICEF 2016b). Child nutrition in Algeria has been 

shifting over the last decade. As of 2013, the prevalence of stunting among children under 5 was 

approximately 11% (UNICEF 2016b). However, obesity, especially among children, has been a growing 

concern in Algeria. In a large cross-sectional survey, researchers found that among children age 6-10, the 

prevalence of overweight and obesity had increased from 6.8% in 2001 to 9.8% in 2006 (Oulamara, Agli, 

and Frelut 2009). In another cross-sectional analysis, Taleb and colleagues reported a decrease in obesity 

and overweight among public school children age 4-13 in western Algeria from 1995-2007 (Taleb, 

Oulamara, and Agli 2013). A more recent study in Oran, Algeria among a smaller sample of school children 

age 6-11 found the overall prevalence of overweight and obesity to be 13% (Raiah, Talhi, and Mesli 2012). 

A study of Algerian school children, age 6-8, found that higher household income and higher parental 

education were significantly associated with child obesity (Saker 2011). Although some research on 

childhood obesity trends is inconsistent, there appears to be growing public health concern about 

overweight and obesity in children. 
8 

The strength and scope of the Algerian healthcare system will be increasingly tested as the type of disease 

and disability shift in the country. There is growing concern about the levels of obesity among Algerian 

adults. A 2016 cross-sectional study among adults living in Algiers found an overall prevalence of obesity 

of 25%, although there was a huge disparity between men and women. Two-thirds of women were obese 

compared with just 12% of men (Nadira 2016). Another nationally representative, cross-sectional study 

found that 30% of Algerian women age 35-70 were obese in 2013 (Atek et al. 2013). The authors found a 

borderline significant trend of increasing prevalence of obesity with increasing wealth quintile (Atek et al. 

2013). Chronic, non-communicable diseases such as diabetes and cancer are becoming increasingly 

common. In 2015, the prevalence of diabetes among adults age 20-79 was 6.5% (International Diabetes 

Federation 2015). Cancer incidence has been increasing over the past decade, with the 2014 age 

standardized cancer incidence estimates reaching 118 cases per 100,000 men and 136 cases per 100,000 

women (Hamdi et al. 2015). Country specific studies have estimated the age standardized cervical cancer 

rate in Algeria to be 10.4 cases per 100,000 women (Kim et al. 2013). The leading causes of cancer death 

across both sexes are breast, lung, and stomach cancer (Hamdi et al. 2015). Algeria has a province-based 

cancer registry system that aids in tracking the trends in cancer incidence, survival, and cancer type (Hamdi 

et al. 2015). 

Despite the epidemiologic transition in Algeria, the proportion of total health expenditure for out-of-pocket 

spending has remained steady at 26% since 2006 (World Bank 2017a). In 2014, health expenditures were 

approximately 7.2% of the total Algerian GDP, an increase from 5% in 2010 (United Nations Statistics 

Division 2017). Although indicators such as vaccine coverage are strong, the quality and breadth of health 

services in Algeria varies. As of 2008, it is estimated that 85% of the population has formal health coverage 

(International Labour Organization 2008). Despite the breadth of coverage, some studies have documented 

inconsistent quality of health services. A 2014 study found that blood pressure measurements were not 

taken for more than a quarter of pregnant women in Algeria because the measurement was deemed 

“unnecessary” by their provider (Rayane 2014). This same study found that only 69% of providers reported 

routinely taking blood pressure measurements (Rayane 2014). To improve the documentation of cause of 

death, the National Institute of Public Health in Algeria began collecting and registering causes of death 

using the International Classification of Diseases (ICD) in 1995. As of 2007, cause of death had been 

applied to 36.5% of the deaths registered by the civil registrar (Belamri et al. 2010). 

The results below for Algeria were produced from the 2012-2013 MICS survey. No other survey after 2005 

was available for comparison to observe trends in the indicators. 

 
9 

Figure Map 1: Algeria Map 

Note: See Appendix for a description of regions. 

 
10 

Total Fertility Rate 

As of 2012, the total fertility rate (TFR) in Algeria was 2.7 births per woman. This is one of the lowest 

TFRs among the countries examined in this report; only Tunisia has a lower TFR. As shown in Table 

Algeria.01, the TFR decreases with increasing education level and wealth quintile. The TFR was the highest 

in the South at 3.4 births per woman, followed by the Center Highlands at 3.2 births per woman. There was 

little difference between the TFR in urban areas (TFR 2.8) and in rural areas (TFR 2.6). 

Table Algeria.01: Total fertility rate for the 3 years before the survey, by background characteristics, Algeria 

2012-13 MICS4 

Variable TFR [C.I.] 

Total 2.7 [2.6,2.7] 

Education 

None 3.3 [3.1,3.6] 

Primary 2.9 [2.7,3.0] 

Secondary + 2.4 [2.2,2.5] 

Wealth quintile 

Poorest 3.0 [2.8,3.3] 

Poorer 2.9 [2.8,3.1] 

Middle 2.5 [2.4,2.7] 

Richer 2.5 [2.4,2.7] 

Richest 2.3 [2.1,2.4] 

Place of residence 

Urban 2.6 [2.5,2.7] 

Rural 2.8 [2.7,3.0] 

Region 

North Center 2.6 [2.4,2.8] 

North East 2.1 [1.9,2.2] 

North West 2.5 [2.3,2.7] 

Highlands Center 3.2 [3.0,3.4] 

Highlands East 2.8 [2.7,3.0] 

Highlands West 2.7 [2.6,2.9] 

South 3.4 [3.2,3.6] 

Contraceptive Use 

Almost half of Algerian women age 15-49 in union were currently using a modern contraceptive method 

in 2012-2013. As shown in Table Algeria.02, modern contraceptive use differed significantly by all 

background characteristics except for place of residence, where current modern contraceptive use was 

approximately 49% for both urban and rural women. Modern contraceptive use was lower for the youngest 

and oldest age groups (39% and 34%, respectively), compared with women age 25-44 years. Women with 

primary level education had the highest modern contraceptive use (50.1%) with little difference in modern 

contraceptive use between women with no education and secondary or higher education (47.4% and 47.9%, 

respectively). The expected pattern of increasing modern contraceptive use with increasing wealth quintile 

was not observed in Algeria. The highest modern contraceptive use among the wealth quintiles was found 

for the poorest and richest wealth quintiles at 51.2% and 50.0% respectively and the lowest was the middle 

wealth quintile at 46.6%. The region with the lowest contraceptive use was found in the South at 34.2%; 

the regions with the highest modern contraceptive use were the West Highlands, East Highlands, and the 

North West, all at approximately 55%. 

Approximately 8% of Algerian women age 15-49 in a union were using a traditional contraceptive method 

in 2012-2013. In Table Algeria.02, the results are similar to the results for modern contraceptive use. 

Traditional contraceptive use did not differ significantly by place of residence, although there were 
11 

significant differences in the other background characteristics of women. By age, women age 35-44 had 

the highest traditional contraceptive use (10%), followed by women age 45-49 (8.6%). Traditional 

contraceptive use increased with increasing education level, with 11% of women with secondary or higher 

education level using a traditional method, compared with 4.9% of women with no education. By wealth 

quintile, the greatest use of traditional methods was among women in the middle and richest quintiles (9.6% 

and 9.5%, respectively). The region with the highest traditional contraceptive use was the South (14.9%), 

followed by the North Center (11.6%). The lowest use of traditional contraceptives was in the West and 

Center Highlands, where less than 2% of women were using a traditional contraceptive method. 

Table Algeria.02: Percentage of women currently using modern or traditional contraception among women 

age 15-49 in union, by background characteristics, Algeria 2012-13 MICS4 

Modern CPR Traditional CPR

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 48.8 [47.7,50.0] 8.3 [7.4,9.2] 

Age 

15-24 39.0 [36.3,41.9] * 4.5 [3.4,6.0] * 

25-34 51.6 [49.8,53.4] 7.6 [6.5,8.9] 

35-44 55.3 [53.5,57.1] 10.0 [8.8,11.3] 

45-49 34.0 [31.7,36.3] 8.6 [7.1,10.2] 

Education 

None 47.4 [45.2,49.6] * 4.9 [3.9,6.1] * 

Primary 50.1 [48.6,51.6] 8.0 [6.9,9.2] 

Secondary + 47.9 [46.0,49.7] 11.0 [9.7,12.4] 

Wealth quintile 

Poorest 51.2 [48.8,53.5] * 5.7 [4.3,7.6] * 

Poorer 47.5 [45.1,49.9] 8.4 [7.0,10.1] 

Middle 46.6 [44.3,48.9] 9.6 [8.1,11.3] 

Richer 49.1 [46.8,51.4] 8.2 [6.9,9.6] 

Richest 50.0 [47.6,52.4] 9.5 [8.2,11.0] 

Place of residence 

Urban 48.8 [47.4,50.3] 8.9 [7.8,10.0] 

Rural 48.9 [46.9,50.8] 7.3 [6.0,8.9] 

Region 

North Center 47.2 [44.7,49.8] * 11.5 [9.6,13.8] * 

North East 46.9 [43.9,50.0] 8.7 [6.9,10.8] 

North West 55.1 [52.7,57.5] 3.5 [2.8,4.4] 

Highlands Center 49.8 [47.6,52.0] 1.8 [1.3,2.5] 

Highlands East 54.9 [52.6,57.1] 6.0 [4.9,7.4] 

Highlands West 55.2 [53.2,57.2] 1.2 [0.8,1.9] 

South 34.2 [31.5,37.1] 14.9 [12.5,17.8] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Antenatal Care 

Approximately two-thirds of Algerian women age 15-49 had the recommended four or more antenatal 

(ANC) visits for their most recent birth. However, as shown in Table Algeria.03, there were significant 

differences found by the women’s characteristics. The percentage of women who completed the 

recommended four or more ANC visits decreased with increased age, from 71% among women age 15-24 

to 54.5% for women age 45-49. This indicator increased with increasing education level and increasing 

wealth quintile. The percentage with four or more ANC visits was highest for women in the richest wealth 

quintile (82.3%). The lowest percentages were among women in the South, West Highlands, Center 

Highlands, and North West regions, where slightly over half of the women had four or more ANC visits 
12 

for their most recent birth. The highest percentages were for women in the North Center and North East 

regions. 

Table Algeria.03: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Algeria 2012-13 MICS4 

Variable % [C.I.] Sig.1

Total 67.3 [65.4,69.1] 

Age 

15-24 71.0 [67.3,74.5] * 

25-34 68.2 [65.9,70.4] 

35-44 63.8 [60.5,66.9] 

45-49 54.5 [42.0,66.4] 

Education 

None 47.5 [43.1,51.9] * 

Primary 67.0 [64.4,69.4] 

Secondary + 76.7 [74.2,79.0] 

Wealth quintile 

Poorest 53.9 [49.8,58.0] * 

Poorer 65.7 [62.2,69.0] 

Middle 64.6 [61.1,68.0] 

Richer 74.4 [71.0,77.4] 

Richest 82.3 [79.1,85.0] 

Place of residence 

Urban 72.3 [70.4,74.2] * 

Rural 59.5 [56.0,63.0] 

Region 

North Center 78.6 [74.5,82.3] * 

North East 79.2 [75.0,82.9] 

North West 56.6 [52.0,61.1] 

Highlands Center 54.8 [50.9,58.7] 

Highlands East 64.8 [61.2,68.3] 

Highlands West 52.8 [49.0,56.5] 

South 53.2 [48.9,57.6] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Delivery 

Table Algeria.04 shows that almost all Algerian women age 15-49 had their most recent birth assisted by a 

skilled birth attendant (SBA) or delivered in a health facility. This was approximately 97% for both 

indicators. Significant differences were found between all women characteristics, for both delivery by an 

SBA and delivery in a health facility. The lowest prevalence for these two indicators was among women 

age 45-49, while women in the younger age groups had a similar prevalence. Use of an SBA and delivery 

in a health facility increased with increasing education; however, the proportion of women with primary 

education and secondary or more education was similar for both indicators, at approximately 97%. The 

proportion of SBA use and delivery in a health facility was 94% for women with no education. The 

prevalence of these two indicators was also lowest for women in the poorest wealth quintile, and women 

living in rural areas or in the South. The prevalence of use of an SBA and delivery in a health facility for 

the most recent birth was approximately 91% in the South. It was highest in the North Center and North 

East regions at over 98%. 

Table Algeria.04 shows that 16% of Algerian women delivered their most recent birth by C-section in the 

2 years before the survey. This differed significantly by the women’s background characteristics except by 

age. A large difference is apparent by education level, with 8.5% of women with no education delivering 
13 

by C-section versus 21.3% of women with secondary or more education. Delivery by C-section increases 

with increasing wealth quintile, although the poorer, middle, and richer wealth quintiles all had similar 

proportions at 15-16%. Approximately 13% of Algerian women in the poorest quintile delivered their most 

recent birth by C-section compared with 21% of women in the richest wealth quintile. C-section delivery 

was higher for women in urban areas than for those in rural areas, and for women in the North East and 

North West regions. The lowest prevalence of C-section was among women in the South and Center 

Highlands regions. 

Table Algeria.04: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant (SBA), delivered in a health facility (DHF), or delivered by caesarean section (C-section) in the 2 

years before the survey, by background characteristics, Algeria 2012-13 MICS4 

SBA DHF C-section 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 % [C.I.] Sig.1

Total 96.6 [96.0,97.2] 96.8 [96.2,97.3] 16.0 [14.6,17.4] 

Age 

15-24 96.4 [94.8,97.5] * 96.5 [94.9,97.5] * 14.6 [11.8,17.9] 

25-34 96.9 [96.1,97.6] 97.3 [96.6,97.9] 15.6 [13.9,17.4] 

35-44 96.4 [95.4,97.2] 96.4 [95.3,97.2] 17.6 [15.3,20.2] 

45-49 90.8 [82.3,95.4] 88.2 [78.1,94.0] 15.7 [7.7,29.4] 

Education 

None 94.0 [92.1,95.4] * 94.0 [92.2,95.4] * 8.5 [6.4,11.2] * 

Primary 96.7 [95.7,97.5] 97.2 [96.3,97.8] 14.5 [12.8,16.4] 

Secondary + 97.7 [96.8,98.4] 97.7 [96.8,98.3] 21.3 [19.0,23.8] 

Wealth quintile 

Poorest 94.6 [92.9,95.9] * 95.4 [93.8,96.5] * 13.2 [10.7,16.1] *

Poorer 96.6 [95.1,97.6] 96.7 [95.3,97.6] 15.9 [13.2,19.2] 

Middle 96.4 [94.6,97.7] 96.3 [94.5,97.5] 15.6 [13.0,18.7] 

Richer 97.3 [95.9,98.3] 97.6 [96.6,98.4] 15.1 [12.5,18.2] 

Richest 98.7 [97.9,99.2] 98.7 [97.8,99.2] 21.1 [17.8,24.7] 

Place of residence 

Urban 97.8 [97.2,98.3] * 97.8 [97.2,98.2] * 17.8 [16.1,19.6] * 

Rural 94.8 [93.4,96.0] 95.4 [94.1,96.4] 13.2 [11.2,15.5] 

Region 

North Center 98.3 [97.1,99.0] * 98.8 [97.6,99.4] * 17.1 [14.1,20.5] * 

North East 98.4 [97.2,99.1] 98.5 [97.3,99.2] 21.4 [17.6,25.8] 

North West 96.3 [94.6,97.5] 96.7 [95.1,97.8] 19.4 [16.1,23.0] 

Highlands Center 96.0 [93.8,97.5] 95.6 [93.4,97.1] 10.7 [8.7,13.0] 

Highlands East 96.6 [94.4,98.0] 96.8 [94.8,98.1] 14.6 [12.1,17.4] 

Highlands West 95.5 [92.9,97.2] 94.6 [92.1,96.4] 12.0 [9.9,14.4] 

South 91.2 [88.1,93.5] 91.3 [88.4,93.5] 10.1 [8.3,12.3] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Child Health Care 

Table Algeria.05 shows that treatment for acute respiratory infection (ARI) symptoms was sought for twothirds of children under age 5. This differed significantly by the mother’s education level and region. 

Treatment of ARI symptoms was sought for a little over half of children with mothers with no education 

and three-fourths of children with mothers with secondary or higher level of education. While this indicator 

did not differ significantly by wealth quintile, a pattern emerged with higher prevalence of the indicator 

with increasing wealth quintile. There was little difference in treatment sought for ARI by the child’s sex 

or place of residence. The lowest prevalence was found in the Center Highlands and South regions, with a 

little over half of the children under age 5 having had treatment sought for ARI symptoms in the 2 weeks 

before the survey. 
14 

Table Algeria.05: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Algeria 2012-13 MICS4 

Variable % [C.I.] Sig.1

Total 66.4 [61.7,70.9] 

Child’s sex 

Male 67.1 [60.8,72.9] 

Female 65.6 [58.9,71.8] 

Mother’s education 

None 54.2 [41.8,66.2] * 

Primary 63.8 [56.6,70.5] 

Secondary + 76.1 [68.8,82.1] 

Wealth quintile 

Poorest 60.1 [50.6,68.8] 

Poorer 64.6 [54.2,73.8] 

Middle 67.6 [58.2,75.7] 

Richer 73.1 [62.8,81.4] 

Richest 72.9 [57.9,84.0] 

Place of residence 

Urban 69.1 [63.7,74.0] 

Rural 62.6 [53.7,70.8] 

Region 

North Center 68.1 [57.3,77.3] * 

North East 75.9 [61.2,86.3] 

North West 72.7 [58.3,83.6] 

Highlands Center 51.8 [39.6,63.9] 

Highlands East 72.5 [65.4,78.6] 

Highlands West (65.9 [54.1,76.0]) 

South 55.4 [46.6,63.9] 

Note: Figures in parenthesis are based on 25-49 

unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Nutrition 

Overall, only a quarter of Algerian children under age 6 months were exclusively breastfed. This figure was 

similar by background characteristics except for region, where significant differences were seen. Only 

11.1% of children under age 6 months were exclusively breastfed in the Center Highlands, 15.3% in the 

West Highlands, and 18.7% in the East Highlands. The highest proportion of exclusive breastfeeding was 

in the North East at 38.3%. 

 
15 

Table Algeria.06: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Algeria 2012-13 MICS4 

Variable % [C.I.] Sig.1

Total 25.7 [22.9,28.8] 

Child’s sex 

Male 24.8 [21.0,29.0] 

Female 26.7 [22.7,31.1] 

Mother’s education 

None 22.6 [16.4,30.3] 

Primary 27.2 [23.0,31.9] 

Secondary + 25.2 [20.5,30.4] 

Wealth quintile 

Poorest 25.7 [20.6,31.6] 

Poorer 23.1 [17.6,29.7] 

Middle 29.4 [22.5,37.4] 

Richer 21.4 [16.4,27.5] 

Richest 30.3 [22.9,39.0] 

Place of residence 

Urban 25.3 [21.8,29.2] 

Rural 26.4 [21.7,31.7] 

Region 

North Center 28.0 [21.9,35.0] * 

North East 38.3 [29.9,47.5] 

North West 30.7 [24.1,38.3] 

Highlands Center 11.1 [7.4,16.4] 

Highlands East 18.7 [13.3,25.8] 

Highlands West 15.3 [10.6,21.4] 

South 22.1 [17.5,27.4] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Table Algeria.07 shows that 11.7% of Algerian children under the age 5 are stunted. The percentage differs 

significantly by child’s sex, mother’s education level, and region. Male children had a higher proportion of 

stunting compared with female children, although the difference was small, 12.6% for males and 10.7% for 

females. Stunting increases with decreasing level of mother’s education, with 14.2% of stunted children 

with mothers with no education compared with 10.4% stunted children with mothers with secondary or 

higher education. The largest differences in stunting were by region; stunting was highest for children in 

the North West (19.2%) and lowest for those in the North Center (7.2%). 

Table Algeria.07 also shows the prevalence of overweight children under age 5 in Algeria (12.4%). This 

indicator differed significantly by wealth and region. Children in the richer and richest wealth quintiles had 

a higher proportion of overweight children (14.8% and 13.1%, respectively). The remaining wealth 

quintiles had similar prevalence of overweight children at approximately 11.5%. The North West had the 

highest level of overweight children (17.6%). This was also the region with the highest prevalence of 

stunted children. Only 7% of children in the South were overweight. 

 
16 

Table Algeria.07: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Algeria 2012-13 MICS4 

Stunted Overweight 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 11.7 [10.8,12.6] 12.4 [11.5,13.3] 

Child’s sex 

Male 12.6 [11.5,13.8] * 12.8 [11.6,14.0] 

Female 10.7 [9.7,11.8] 11.9 [10.8,13.1] 

Mother’s education 

None 14.2 [12.5,16.0] * 11.2 [9.6,12.9] 

Primary 11.6 [10.4,12.9] 12.5 [11.3,13.7] 

Sec+ 10.4 [9.3,11.6] 12.9 [11.6,14.3] 

Wealth quintile 

Poorest 12.6 [11.0,14.4] 11.5 [9.9,13.2] * 

Poorer 12.1 [10.3,14.2] 11.4 [9.7,13.2] 

Middle 11.0 [9.6,12.7] 11.5 [9.9,13.3] 

Richer 11.7 [10.2,13.4] 14.8 [12.9,16.9] 

Richest 10.6 [8.6,13.0] 13.1 [11.2,15.3] 

Place of residence 

Urban 11.3 [10.2,12.4] 13.0 [11.9,14.1] 

Rural 12.3 [10.8,14.0] 11.4 [9.9,13.0] 

Region 

North Center 7.2 [5.8,9.0] * 12.3 [10.5,14.4] * 

North East 12.6 [10.5,15.2] 13.5 [11.6,15.7] 

North West 19.2 [15.7,23.3] 17.6 [14.9,20.7] 

Highlands Center 15.4 [13.4,17.7] 11.1 [9.5,13.1] 

Highlands East 10.6 [9.1,12.5] 12.3 [10.6,14.3] 

Highlands West 15.6 [13.8,17.6] 10.3 [8.9,12.0] 

South 11.8 [10.0,13.8] 6.9 [5.6,8.6] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Under-5 Mortality 

An estimated 23 Algerian children of 1000 live births did not survive to their fifth birthday in the 5 years 

before the 2012-13 survey. There was little difference in under-5 mortality by the child’s sex; however, 

there were differences by other background characteristics. Under-5 mortality increased with decreasing 

mother’s education level and decreasing wealth quintile. The highest under-5 mortality rate was found 

among children in the poorest households at 31 deaths per 1000 live births. The remaining wealth quintiles 

had very similar mortality rates at approximately 20-21 deaths per 1000 live births. The South and the 

Center Highlands had the highest under-5 mortality rates, both 31 deaths per 1000 live births, followed by 

the North West at 29 deaths per 1000 live births. The lowest number of deaths was found in the North 

Center. 

 
17 

Table Algeria.08: Under-5 mortality (U5M) rates for the 5 years before the survey, by background 

characteristics, Algeria 2012-13 MICS4 

Variable U5M [C.I.] 

Total 23 [20,26] 

Child’s sex 

Male 23 [20,28] 

Female 22 [18,26] 

Mother’s education 

None 27 [21,34] 

Primary 22 [18,26] 

Secondary + 21 [16,28] 

Wealth quintile 

Poorest 31 [24,38] 

Poorer 21 [16,28] 

Middle 20 [15,27] 

Richer 20 [14,27] 

Richest 20 [14,29] 

Place of residence 

Urban 21 [17,25] 

Rural 25 [21,31] 

Region 

North Center 15 [10,22] 

North East 18 [13,26] 

North West 29 [22,38] 

Highlands Center 31 [23,41] 

Highlands East 27 [20,36] 

Highlands West 22 [16,31] 

South 31 [23,41] 

Algeria Summary 

In 2012-13, Algeria had a TFR close to replacement level—an average of 2.7 births per woman—although 

there were large differences by region and wealth quintile. Approximately half of currently married women 

age 15-49 were using a modern contraceptive method and less than 10% used a traditional method. The 

lowest proportion of modern contraceptive use was found in the South, which was also the region with the 

highest use of traditional contraceptive methods. Close to two-thirds of women had the recommended four 

or more ANC visits for their most recent pregnancy. Delivery by an SBA or in a health facility was almost 

universal with proportions close to 97% for both indicators and over 90% for almost all subgroups of 

women. The exception was 88% of women age 45-49 who delivered in a health facility. The proportion of 

C-section deliveries for the most recent birth was 16%, with proportions over 20% for women with 

secondary or more education, women in the richest households, and women in the North East. Child health 

indicators appear to be at reasonable levels with care-seeking for ARI sought for two-thirds of children 

under age 5; approximately 12% of children under age 5 are stunted or overweight. However, only a quarter 

of children under age 6 months were exclusively breastfed, with only 11% exclusively breastfed children 

in the Center Highlands. Finally, the under-5 mortality rate was 23 deaths per 1000 live births, with large 

differences by wealth quintile and region. The under-5 mortality rate was 31 in the poorest households and 

in the South. 

19 

Egypt 

Egypt is among the most populous countries in the Arab world with an estimated total population of 93.5 

million in 2016 (Population Reference Bureau 2016). Approximately 43% of the population lives in urban 

areas and the current life expectancy at birth is 70 years for men and 73 years for women (Population 

Reference Bureau 2016). Between 2011 and 2014, Egypt underwent a period of political and social turmoil 

that began with widespread protests against the political regime. This period was part of a larger movement 

called the Arab Spring that included similar movements in other countries across the region. The results of 

this movement extend beyond the political and include effects on the public health and health infrastructure 

of Egypt. Several national-level surveys were conducted before, during, and after the Arab Spring 

movement, which helped to capture the health effects of the Egyptian revolution at the population level 

(Ministry of Health and Population [Egypt] 2009; Ministry of Health and Population [Egypt], El Zanaty 

and Associates [Egypt], and ICF International 2015b, 2015a). 

In contrast to similarly developed nations, the Egyptian total fertility rate (TFR) has increased over the past 

10 years (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF 

International 2015a). Maternal health in Egypt has improved significantly over the past decade. The 

maternal mortality ratio (MMR) has declined from 63 maternal deaths to 33 maternal deaths per 100,000 

live births between 2000 and 2015 (WHO 2016a). The incidence of “near-miss” events, defined as a woman 

who nearly died but survived a complication associated with pregnancy or child birth, has also been under 

study in Egypt (WHO 2011). The WHO found a near-miss ratio of 12.1 near-miss incidents per 1,000 live 

births at a major hospital in Egypt, which is relatively high when compared to other countries included in 

the study (Bashour et al. 2015). There have been substantial increases in the proportion of women who 

receive antenatal care (ANC) and the proportion of births attended by a skilled health professional (Ministry 

of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015a). Studies 

have found that women with higher education levels and older age at first marriage are more likely to 

deliver in a facility with a skilled birth attendant and receive regular ANC (Chiang et al. 2012). Maternal 

nutritional status is of some concern. A 2013 study evaluated anemia and pregnancy outcomes at a large 

hospital in Cairo (Abdel-Raoufabdel-Aziz Afifi, Ali, and Talkhan 2013). The authors found that 46% of 

the mothers in the study were anemic and that the increasing severity of anemia predicted higher rates of 

preterm labor and lower birth weight (Abdel-Raoufabdel-Aziz Afifi, Ali, and Talkhan 2013). The caesarean 

delivery rate has increased significantly since 2008, with significant differences across geographic location 

and wealth quintile (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF 

International 2015a). 

Reproductive health status in Egypt includes several unique considerations, one of which is the widespread 

practice of female genital mutilation (FGM). In 2015, 87% of women age 15-49 had undergone some form 

of FGM (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF 

International 2015b). There is a substantial disparity in FGM by socioeconomic status: 94% of women in 

the lowest wealth quintile have undergone some form of FGM compared to 70% in the highest wealth 

quintile (UNICEF 2016a). In 2011, a law was passed that banned the practice at a national level and initial 

data indicate that the practice may be declining (UNICEF 2016a). Compared with the 2008 DHS, the 

prevalence of FGM in the 15-19 age group in the 2015 DHS has declined by 11 percentage points (Ministry 

of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015b). A study 

that explored the reasons for the decrease in FGM found that increases in female education and exposure 

to social media are important predictors of FGM across communities (Modrek and Liu 2013). The use of 

contraception is another important reproductive health consideration. The contraceptive prevalence rate 

(CPR) among married women is 58% with a modern contraceptive prevalence rate of 57% (Population 

Reference Bureau 2016). The intrauterine device (IUD) is especially popular in Egypt and is the leading 

form of contraception in nearly every age group (Ministry of Health and Population [Egypt], El Zanaty and 
20 

Associates [Egypt], and ICF International 2015a). The overall CPR has remained steady since 2005, with 

little fluctuation (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF 

International 2015a). A mixed methods study that explored access and use of contraception among young 

married women in Egypt found that while women reported adequate access to contraception, many noted a 

lack of privacy and autonomy in making family planning decisions (Abdel-Tawab et al. 2015). A 

community-based study in Cairo found that women with an unmet need for contraception were significantly 

more likely to believe that contraception was religiously prohibited, have a husband who opposed 

contraception, and a history of unwanted pregnancy (Kotb et al. 2011). Interpersonal violence (IPV) is 

prevalent in Egypt, with a 2015 study finding a prevalence of 44% among pregnant women (Ibrahim et al. 

2015). Women who reported IPV during pregnancy were more likely to have low education levels, higher 

parity, and a younger age (Ibrahim et al. 2015). The 2014 DHS found lower estimates with 30% of evermarried women reporting IPV and 7% reporting IPV during pregnancy (Ministry of Health and Population 

[Egypt], El Zanaty and Associates [Egypt], and ICF International 2015a). 

Indicators for infant and child health have been improving since 2008. Overall, both the infant mortality 

rate (IMR) and under-5 mortality have been declining (Ministry of Health and Population [Egypt], El 

Zanaty and Associates [Egypt], and ICF International 2015a). However, there are substantial disparities in 

the IMR and under-5 mortality based on geography and wealth quintile. Diarrheal diseases remain common 

with 14% of children in the 2014 DHS reported as having been ill with diarrhea in the past 2 weeks (Ministry 

of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015a). In terms 

of nutrition, breastfeeding is nearly universal with 96% of children ever breastfed. However, the proportion 

of infants exclusively breastfed until 6 months of age is significantly lower (Ministry of Health and 

Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015a). One study found that 

among mothers in rural Egypt, only 9.7% of infants were exclusively breastfed for the first 6 months of life 

(Al Ghwass and Ahmed 2011). In children under age 5, the prevalence of stunting has decreased 

substantially since 2008 (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and 

ICF International 2015a). However, overweight and obesity are growing problems among children under 

age 5 and across Egypt (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and 

ICF International 2015a). A 2015 cross-sectional study of school-aged children found that obese children 

were seven times more likely to be iron deficient compared with children of normal weight (Abd-El Wahed 

et al. 2014). The impact of the Egyptian revolution on child health has yet to be fully understood. A 2015 

study examined the potential mental health consequences of witnessing political violence and conflict 

among children who attended school near Tahrir Square, which served as the hub for many of the most 

forceful, violent political protests (Moussa et al. 2015). The authors found high rates of post-traumatic stress 

disorder, depression, and anxiety in the children who were surveyed (Moussa et al. 2015). 

The health infrastructure in Egypt has experienced substantial changes over the past decade, from both a 

demographic and socio-political perspective. Since 2001, the per-capita government expenditure on health 

has more than tripled from $14 (USD) to $47 (USD) in 2011 (Saleh et al. 2014). However, in 2011, it was 

estimated that 57% of the total health expenditure in Egypt was out-of-pocket (Saleh et al. 2014). In 2014, 

only 8% of ever-married women age 15-49 had any form of health insurance (Ministry of Health and 

Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015a). Those who had 

insurance were primarily covered through publicly funded insurance providers (Ministry of Health and 

Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015a). In Egypt, the Health 

Insurance Organization (HIO) is the primary publicly funded healthcare provider. A 2013 study compared 

the responsiveness of the HIO compared to the private healthcare system found that HIO patients were 

twice as likely to report poor responsiveness compared to private healthcare patients (Mosallam, Aly, and 

Moharram 2013). The components of responsiveness included communication, patient dignity, and timely 

attention (Mosallam, Aly, and Moharram 2013). An assessment of primary care practices in Egypt found 

that over half of patient visits were for individuals under age 20 (Aboulghate et al. 2013). Among patients 

older than 20, 73% were female (Aboulghate et al. 2013). Overall, the authors found high levels of care 
21 

seeking, particularly for immunizations, family planning, and ANC (Aboulghate et al. 2013). The Egyptian 

health system is facing increasing pressures from a shifting health profile of the population. Obesity and 

associated conditions such as diabetes, stroke, and cardiovascular events are increasing (Ministry of Health 

and Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015b). According to the 

Institute for Health Metrics and Evaluation, high body-mass index is now the leading risk factor driving 

morbidity and mortality in Egypt (Institute for Health Metrics and Evaluation 2016). Overall, 76% of 

women and 64% of men age 15-59 are considered overweight or obese in Egypt (Ministry of Health and 

Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015b). The prevalence of 

obesity increases by wealth quintile, ranging from 44% in the lowest quintile to 55% in the highest wealth 

quintile (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF 

International 2015b). In 2015, 5% of Egyptian men and women reported a diagnosis of diabetes, although 

this is likely to be an underestimate of the true prevalence. A 2012 survey found that 17% of Egyptians age 

15-65 had an elevated blood glucose level (Ministry of Health and Population [Egypt], El Zanaty and 

Associates [Egypt], and ICF International 2015b). A unique health challenge in Egypt is the extremely high 

prevalence of hepatitis C (HVC). Egypt has the highest prevalence of HVC in the world, with national 

prevalence estimates ranging from 15% to 20% (Mohamoud et al. 2013). In 2015, approximately 4% of the 

Egyptian population ages 1-59 was found to have an active hepatitis C infection, equating to roughly 3.5 

million affected persons (Ministry of Health and Population [Egypt], El Zanaty and Associates [Egypt], 

and ICF International 2015). Liver Cirrhosis associated with hepatitis C infection has been the third leading 

cause of death in Egypt since 2005 (Institute for Health Metrics and Evaluation 2016). Exposure to medical 

procedures such as transfusions and dental procedures are closely associated with HVC infection (Ministry 

of Health and Population [Egypt], El Zanaty and Associates [Egypt], and ICF International 2015b). 

The results discussed below for Egypt utilized data from the 2008 and 2014 Demographic and Health 

Surveys. 

 
22 

Figure Map 2: Egypt Map 

Note: See Appendix for a description of regions. 

 
23 

Total Fertility Rate 

The total fertility rate (TFR) in Egypt increased significantly from 3.0 in 2008 to 3.5 in 2014. As shown in 

Figure 1 of the overall summary section, Egypt was the only country with a significant increase in the TFR 

among all the countries in this report with available data from two surveys. The TFR of Egypt 2014 is 

comparable to the TFR of Jordan; significantly higher than the TFR of Algeria, the Palestinian refugees in 

Lebanon, and Tunisia; and significantly lower than the TFR of Iraq, the West Bank and Gaza Strip, and 

Yemen. 

Table Egypt.01 shows that in both surveys, the highest TFR was found in women with no education, rural 

women, and women who reside in the Upper Egypt and Frontier Governorates regions. As shown in Figure 

Egypt.01, the increase in the TFR between the two surveys was significant across most subgroups. 

However, there was no significant increase in the TFR in the Urban Governorates, and the poorest and 

richest wealth quintiles. In 2008, the TFR increased with decreasing wealth quintile, although in 2014 this 

pattern was not observed. The highest TFR in 2014 was found for women in the middle wealth quintile, 

which also had the largest significant increase between the surveys. Women in the poorest, poorer, and 

richer wealth quintiles had very similar TFRs in 2014. Women in the richest wealth quintile had the lowest 

TFR, which remained unchanged from the 2008 survey. The TFR was higher in the Upper Egypt and 

Frontier Governorates in both surveys compared with the two other regions, and it increased significantly 

between the surveys for all regions except the Urban Governorates. 

Table Egypt.01: Total fertility rate for the 3 years before the survey, by background characteristics, Egypt 

2008 and 2014 DHS 

2008 2014 

Diff1 TFR [C.I.] TFR [C.I.] 

Total 3.0 [2.9,3.1] 3.5 [3.4,3.5] 0.4* 

Education 

None 3.4 [3.3,3.6] 3.8 [3.6,4.0] 0.4* 

Primary 3.2 [2.9,3.4] 3.6 [3.3,3.8] 0.4* 

Secondary + 3.0 [2.9,3.1] 3.5 [3.4,3.5] 0.5* 

Wealth quintile 

Poorest 3.4 [3.3,3.6] 3.6 [3.4,3.8] 0.2 

Poorer 3.1 [2.9,3.3] 3.6 [3.4,3.7] 0.5* 

Middle 3.0 [2.9,3.2] 3.9 [3.7,4.0] 0.8* 

Richer 2.9 [2.7,3.0] 3.5 [3.4,3.7] 0.6* 

Richest 2.7 [2.6,2.9] 2.8 [2.6,2.9] 0.0 

Place of residence 

Urban 2.7 [2.6,2.8] 2.9 [2.8,3.0] 0.2* 

Rural 3.2 [3.1,3.3] 3.8 [3.7,3.9] 0.5* 

Region 

Urban Governorates 2.6 [2.4,2.8] 2.5 [2.4,2.7] -0.1 

Lower Egypt 2.9 [2.0.8,3] 3.4 [3.3,3.5] 0.5* 

Upper Egypt 3.4 [3.3,3.5] 3.8 [3.7,4.0] 0.4* 

Frontier Governorates 3.3 [3.0,3.7] 3.9 [3.6,4.3] 0.6* 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 

 
24 

Figure Egypt.01: Total fertility rate for the 3 years before the survey, by background characteristics, Egypt 

2008 and 2014 DHS 

Contraceptive Use 

More than half of Egyptian women in both the 2008 and the 2014 surveys were using a modern 

contraceptive method at the time of the survey. This did not change significantly between the two surveys, 

with approximately 57% in both surveys. Table Egypt.02 shows that the use of modern contraception 

differed significantly by all women characteristics in 2008, while in 2014 it differed significantly for all 

characteristics except for education. Women in 2008 with no education had the lowest prevalence of 

modern contraceptive use at 55.5%, with very little difference between women in primary and secondary 

or higher education level both near 59%. Table Egypt.02 and Figure Egypt.02 show that modern 

contraceptive use decreased significantly between the surveys for women with secondary or higher 

education. Women in the youngest and oldest age groups had the lowest modern contraceptive use in both 

surveys. Women age 35-44 had the highest proportion of modern contraceptive use at approximately 71-

72% in both surveys. Only women in the age 25-34 group exhibited a significant decrease in modern 

contraceptive use. Modern contraceptive use increased with increasing wealth quintile in both surveys. 

However, in 2014 the gaps between the wealth quintiles were smaller. Only women in the richest 

households had a significant decrease in modern contraceptive use between the surveys. The prevalence of 

modern contraceptive use was lower in rural women and compared to urban women in each survey, and 

there was with a significant decrease in use between the two surveys for urban women. The Upper Egypt 

and Frontier Governorates regions had the lowest modern contraceptive use in both surveys. There was an 

increase in modern contraceptive use between the surveys for women residing in the Frontier Governorates, 

although this increase was not significant. 
25 

Table Egypt.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 57.6 [56.6,58.6] 56.9 [55.8,57.9] -0.7 

Age 

15-24 36.8 [34.8,38.8] * 36.2 [34.1,38.3] * -0.6 

25-34 60.1 [58.6,61.5] 57.8 [56.3,59.2] -2.3* 

35-44 71.6 [70.1,73.0] 70.5 [69.0,71.9] -1.1 

45-49 50.5 [48.0,53.0] 52.3 [49.7,54.9] 1.9 

Education 

None 55.5 [53.9,57.2] * 57.9 [55.6,60.1] 2.3 

Primary 59.3 [56.8,61.8] 57.7 [54.8,60.4] -1.7 

Secondary + 58.4 [57.2,59.5] 56.4 [55.3,57.5] -1.9* 

Wealth quintile 

Poorest 51.9 [49.9,53.9] * 54.2 [51.1,57.4] * 2.4 

Poorer 54.8 [52.6,57.0] 54.3 [52.3,56.3] -0.5 

Middle 58.8 [56.9,60.7] 58.0 [56.0,60.1] -0.8 

Richer 59.3 [57.3,61.2] 58.1 [56.0,60.1] -1.2 

Richest 62.3 [60.2,64.4] 59.3 [57.4,61.1] -3.1* 

Place of residence 

Urban 61.6 [60.1,63.0] * 59.5 [58.2,60.9] * -2.0* 

Rural 54.8 [53.6,56.1] 55.5 [54.0,56.9] 0.6 

Region 

Urban Governorates 62.6 [60.2,64.9] * 60.7 [58.2,63.1] * -1.9 

Lower Egypt 62.4 [61.0,63.8] 62.4 [61.0,63.7] -0.1 

Upper Egypt 48.9 [47.4,50.5] 48.5 [46.6,50.3] -0.5 

Frontier Governorates 48.6 [45.0,52.3] 53.5 [48.1,58.8] 4.8 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
26 

Figure Egypt.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Egypt 2008 and 2014 DHS 

Less than 3% of Egyptian women age 15-49 in a union were using a traditional contraceptive method in 

2008. This significantly decreased to 1.6% in 2014. This decrease was found for all women characteristics 

except for women age 45-49. However, not all reductions were significant. The use of traditional 

contraceptive methods differed significantly by all of the women characteristics except by place of 

residence in 2008, although none differed significantly in 2014. In 2008, traditional contraceptive use 

decreased with increased women’s age but in 2014, the gaps between the age groups decreased. This was 

attributed to a significant decrease in traditional contraceptive use for the age 15-24 and age 25-34 groups 

between surveys (see Figure Egypt.03). The prevalence of traditional contraceptive use was the highest for 

women with secondary or higher level of education in both surveys, and decreased significantly between 

the surveys for all the education groups. In 2008, women in the poorest and richest households had the 

highest proportion of traditional contraceptive use. However, in 2014, it was only women in the richest 

households who had the highest proportion of traditional contraceptive use. This was due to a relatively 

large decrease in use for the women in the poorest households. Women residing in the Upper Egypt and 

Frontier Governorates had the highest traditional contraceptive use in 2008. However, due to the relatively 

large reductions in traditional contraceptive use between the surveys for these two regions, the gaps between 

the regions deceased in 2014. 

 
27 

Table Egypt.03: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 2.7 [2.4,3.0] 1.6 [1.4,1.9] -1.0* 

Age 

15-24 3.7 [3.1,4.5] * 1.7 [1.3,2.3] -2.0* 

25-34 3.2 [2.7,3.7] 1.8 [1.5,2.1] -1.4* 

35-44 1.9 [1.5,2.3] 1.4 [1.1,1.8] -0.5 

45-49 1.4 [0.9,2.2] 1.6 [1.1,2.4] 0.2 

Education 

None 2.2 [1.7,2.6] * 1.3 [1.0,1.8] -0.8* 

Primary 2.4 [1.7,3.3] 1.2 [0.7,1.9] -1.2* 

Secondary + 3.0 [2.7,3.5] 1.8 [1.6,2.1] -1.2* 

Wealth quintile 

Poorest 3.6 [2.9,4.4] * 1.7 [1.2,2.2] -1.9* 

Poorer 2.3 [1.8,3.0] 1.4 [1.0,1.9] -0.9* 

Middle 2.4 [1.9,3.0] 1.4 [1.0,1.9] -1.0* 

Richer 2.1 [1.6,2.8] 1.7 [1.3,2.2] -0.5 

Richest 3.1 [2.4,3.9] 2.1 [1.6,2.7] -1.0* 

Place of residence 

Urban 2.7 [2.3,3.2] 1.8 [1.5,2.2] -0.9* 

Rural 2.7 [2.3,3.0] 1.6 [1.3,1.8] -1.1* 

Region 

Urban Governorates 2.6 [1.9,3.4] * 2.0 [1.4,2.7] -0.6 

Lower Egypt 1.9 [1.6,2.3] 1.4 [1.1,1.7] -0.5* 

Upper Egypt 3.7 [3.2,4.3] 1.9 [1.5,2.2] -1.9* 

Frontier Governorates 3.7 [2.5,5.4] 1.5 [0.9,2.6] -2.1* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the 

two surveys with the significance of the difference. 
28 

Figure Egypt.03: Percentage of women currently using traditional contraception among women age 15-49 in 

a union, by background characteristics, Egypt 2008 and 2014 DHS

Antenatal Care 

Approximately 70% of women age 15-49 had the recommended four or more antenatal care (ANC) visits 

for their most recent pregnancy in 2008. This increased significantly to 84% in 2014. This increase was 

found across almost all the women characteristics. Table Egypt.04 shows that women differed significantly 

in terms of their ANC visit in both surveys except for age in 2008. In both surveys, the proportion of women 

who had four or more ANC visits increased with decreasing age, increasing education level, and increasing 

wealth quintile. As shown in Figure Egypt.04, there were also large increases in ANC visits between the 

surveys, which caused in a large reduction in the gaps between the groups. One of the largest increases was 

for women in households in the poorest wealth quintile, where the proportion of women who had four or 

more ANC visits increased by 28.2 percentage points. This raised the proportion of women who had four 

or more ANC visits for this group from 46.4% in 2008 to 74.6% in 2014. Relatively large increases were 

also observed for women with no education and women who resided in rural areas. 
29 

Table Egypt.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 70.1 [68.5,71.7] 83.8 [82.3,85.2] 13.7* 

Age 

15-24 71.4 [69.0,73.7] 85.6 [83.1,87.8] * 14.2* 

25-34 70.2 [68.1,72.3] 84.0 [82.3,85.5] 13.8* 

35-44 65.7 [61.0,70.0] 77.8 [74.2,81.1] 12.1* 

45-49 50.5 [27.9,72.9] 73.7 [37.0,93.1] 23.2 

Education 

None 50.5 [47.4,53.7] * 70.2 [66.0,74.1] * 19.7* 

Primary 61.0 [56.2,65.6] 75.3 [70.2,79.8] 14.3* 

Secondary + 78.2 [76.5,79.9] 87.6 [86.3,88.7] 9.3* 

Wealth quintile 

Poorest 46.4 [43.1,49.8] * 74.6 [69.7,79.0] * 28.2* 

Poorer 60.8 [57.4,64.2] 77.7 [74.6,80.6] 16.9* 

Middle 68.4 [65.1,71.5] 83.9 [81.4,86.1] 15.5* 

Richer 82.8 [79.8,85.4] 88.4 [86.0,90.4] 5.6* 

Richest 91.7 [89.2,93.6] 93.6 [91.8,95.1] 2.0 

Place of residence 

Urban 82.6 [80.2,84.8] * 88.3 [86.4,90.0] * 5.7* 

Rural 62.4 [60.4,64.4] 81.8 [79.8,83.7] 19.4* 

Region 

Urban Governorates 87.2 [83.2,90.4] * 91.4 [88.0,93.9] * 4.2 

Lower Egypt 70.5 [68.1,72.8] 89.1 [87.2,90.7] 18.6* 

Upper Egypt 62.3 [59.6,65.0] 76.3 [73.6,78.8] 13.9* 

Frontier Governorates 66.9 [60.5,72.7] 77.0 [63.6,86.5] 10.1 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
30 

Figure Egypt.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

Delivery

In Table Egypt.05, more than eight in 10 women age 15-49 had their most recent birth assisted by a skilled 

birth attendant (SBA) in 2008. This proportion increased significantly to over nine in 10 women in 2014. 

The use of an SBA differed significantly by all women characteristics in both surveys except by women’s 

age. The proportion of women who delivered with an SBA increased with increasing education level and 

wealth quintiles for both surveys. As shown in Figure Egypt.05, there were also large increases in the 

indicator, which caused a decrease in the gaps between the groups. The largest significant increase was 

observed for women in the poorest households, which increased from 59.7% in 2008 to 85.2% in 2014. The 

reduction in the gaps between the regions was attributed to the significant increases in assistance by an SBA 

in all regions except the Frontier governorates but most notably in Upper Egypt, which increased from 

70.9% in 2008 to 89.1% in 2014. 

 
31 

Table Egypt.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 81.8 [80.3,83.3] 93.0 [91.9,93.9] 11.1* 

Age 

15-24 81.4 [79.2,83.4] 92.7 [91.2,94.0] 11.4* 

25-34 82.5 [80.5,84.3] 93.3 [91.9,94.4] 10.7* 

35-44 80.6 [76.8,83.9] 92.2 [89.8,94.1] 11.6* 

45-49 71.6 [44.0,89.0] 100.0 28.4 

Education 

None 63.7 [60.0,67.2] * 81.8 [78.1,85.0] * 18.1* 

Primary 77.9 [73.9,81.5] 92.5 [89.6,94.7] 14.6* 

Secondary + 88.7 [87.2,90.0] 95.4 [94.5,96.1] 6.7* 

Wealth quintile 

Poorest 59.7 [55.9,63.4] * 85.2 [81.8,88.0] * 25.5* 

Poorer 74.6 [71.0,77.9] 87.2 [84.7,89.3] 12.6* 

Middle 85.4 [82.7,87.8] 94.9 [93.4,96.0] 9.4* 

Richer 91.3 [89.1,93.1] 97.1 [95.8,98.0] 5.8* 

Richest 97.4 [95.9,98.4] 99.0 [98.0,99.5] 1.6* 

Place of residence 

Urban 91.2 [89.2,92.9] * 97.0 [95.9,97.8] * 5.8* 

Rural 76.1 [73.9,78.1] 91.2 [89.8,92.5] 15.1* 

Region 

Urban Governorates 94.5 [91.6,96.4] * 98.1 [96.0,99.1] * 3.6* 

Lower Egypt 86.7 [84.4,88.6] 96.2 [94.9,97.1] 9.5* 

Upper Egypt 70.9 [67.8,73.8] 88.3 [86.2,90.1] 17.4* 

Frontier Governorates 81.7 [74.6,87.2] 89.1 [81.1,94.0] 7.4 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
32 

Figure Egypt.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

Table Egypt.06 shows that the proportion of women who delivered in a health facility increased 

significantly from 74.6% in 2008 to 88.5% in 2014. Similar patterns were found in this indicator as 

assistance by an SBA. Delivery in a health facility did not differ significantly by age in both surveys and 

there were large significant increases between the surveys observed by almost all the women characteristics. 

This resulted in a reduction in the gaps between the subgroups of women. As with the SBA indicator, the 

largest increase was observed among women in the poorest households, where delivery in a health facility 

for the most recent birth increased from 49.8% in 2008 to 78.2% in 2014. There were also large significant 

increases for women with no education and a primary education level, women residing in rural areas, and 

women residing in the Upper Egypt Region. 

 
33 

Table Egypt.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 74.6 [72.9,76.3] 88.5 [87.1,89.7] 13.8* 

Age 

15-24 74.0 [71.6,76.3] 88.5 [86.5,90.2] 14.5* 

25-34 75.3 [73.1,77.4] 88.8 [87.2,90.2] 13.5* 

35-44 73.7 [69.2,77.7] 86.6 [83.6,89.1] 12.9* 

45-49 71.6 [44.0,89.0] 94.1 [53.2,99.6] 22.5 

Education 

None 54.8 [51.2,58.4] * 73.7 [69.6,77.4] * 18.9* 

Primary 68.3 [63.7,72.5] 86.6 [82.7,89.8] 18.4* 

Secondary + 82.4 [80.7,84.1] 91.7 [90.5,92.8] 9.3* 

Wealth quintile 

Poorest 49.8 [46.0,53.6] * 78.2 [74.4,81.6] * 28.4* 

Poorer 65.9 [62.3,69.4] 81.2 [78.4,83.7] 15.3* 

Middle 75.5 [72.4,78.4] 89.8 [87.8,91.4] 14.3* 

Richer 86.0 [83.3,88.4] 94.1 [92.0,95.7] 8.1* 

Richest 95.4 [93.5,96.7] 97.4 [95.9,98.3] 2.0* 

Place of residence 

Urban 86.5 [84.1,88.7] * 94.2 [92.8,95.3] * 7.7* 

Rural 67.3 [65.0,69.6] 85.9 [84.1,87.6] 18.6* 

Region 

Urban Governorates 91.1 [87.5,93.8] * 95.8 [93.5,97.2] * 4.6* 

Lower Egypt 79.2 [76.6,81.6] 92.8 [91.1,94.2] 13.6* 

Upper Egypt 62.2 [59.0,65.3] 81.9 [79.5,84.2] 19.7* 

Frontier Governorates 76.4 [69.2,82.3] 84.6 [77.1,89.9] 8.2 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
34 

Figure Egypt.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

As shown in Table Egypt.07, almost one-third of women delivered their most recent birth by caesarean 

section (C-section) in 2008. This proportion increased significantly to an alarming figure of more than half 

of women in 2014 who had their most recent birth delivered by C-section. C-section delivery differed 

significantly by all women characteristics in both surveys except by women’s age. The prevalence of Csection delivery increased with increasing education and wealth quintile in both years. There were large 

gaps between women that persisted in 2014 due to uniform increases across the subgroups of women. In 

2008, 16.2% of women in the poorest households delivered by C-section compared with 45.4% in the 

richest households. In 2014, this increased to 43.6% of women from the poorest households compared with 

72.4% from the richest households. Thus, the large gaps remained. The Upper Egypt and Frontier 

Governorates had similar, lower C-section rates in 2014, both approximately 45% compared with the two 

remaining regions with the proportion of C-sections above 60%. 
35 

Table Egypt.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section 

in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 30.6 [29.0,32.4] 57.4 [55.6,59.1] 26.7* 

Age 

15-24 28.6 [26.2,31.2] 56.3 [53.4,59.2] 27.7* 

25-34 31.4 [29.1,33.7] 58.1 [56.0,60.3] 26.8* 

35-44 33.7 [29.2,38.6] 56.5 [52.4,60.6] 22.8* 

45-49 44.8 [23.7,68.0] 58.8 [31.8,81.3] 14.0 

Education 

None 20.7 [18.0,23.7] * 44.8 [40.9,48.8] * 24.1* 

Primary 23.4 [19.2,28.1] 48.9 [43.8,54.0] 25.5* 

Secondary + 35.1 [33.1,37.2] 60.9 [59.1,62.7] 25.7* 

Wealth quintile 

Poorest 16.2 [13.8,19.0] * 43.6 [39.9,47.2] * 27.3* 

Poorer 22.3 [19.2,25.7] 49.2 [45.7,52.7] 26.9* 

Middle 29.9 [26.6,33.4] 57.4 [54.2,60.6] 27.5* 

Richer 39.1 [35.5,42.8] 63.3 [60.1,66.4] 24.2* 

Richest 45.4 [41.6,49.4] 72.4 [69.3,75.4] 27.0* 

Place of residence 

Urban 39.2 [36.3,42.2] * 65.0 [62.3,67.7] * 25.8* 

Rural 25.4 [23.4,27.5] 54.0 [51.7,56.2] 28.6* 

Region 

Urban Governorates 40.4 [35.8,45.2] * 67.3 [62.1,72.1] * 26.8* 

Lower Egypt 32.9 [30.2,35.7] 64.9 [62.1,67.5] 31.9* 

Upper Egypt 24.1 [21.7,26.6] 46.9 [44.4,49.5] 22.8* 

Frontier Governorates 23.2 [18.7,28.4] 44.5 [34.4,55.1] 21.3*

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
36 

Figure Egypt.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section 

in the 2 years before the survey, by background characteristics, Egypt 2008 and 2014 DHS 

Child Health Care

As seen in Table Egypt.08, over nine in ten children age 12-23 months received all basic vaccinations in 

2008, although this decreased to slightly over eight in ten children in 2014. This significant decrease was 

observed by all children’s characteristics except for no change in the Frontier Governorates. In 2008, 

children who received all basic vaccinations differed significantly by their mother’s education level and 

their place of residence and region. However, in 2014, the only difference was by wealth quintile. The 

largest decreases in vaccination by wealth quintile were observed for the poorest and richest households, 

by 10.6 and 13.8 percentage points, respectively. The poorest and richest households had very similar 

proportions of children vaccinated, almost 80%, while the remaining wealth quintiles were near 85%. The 

largest decrease in vaccination by region was found in Lower Egypt followed by the Urban Governorates 

and Upper Egypt. In 2014, the proportion of children vaccinated was the highest in the Frontier 

Governorates at 88.3%, with no significant change from 2008. 

 
37 

Table Egypt.08: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 91.7 [90.3,92.9] 83.6 [81.8,85.3] -8.1* 

Child’s sex 

Male 90.9 [89.0,92.6] 83.8 [81.5,85.9] -7.1* 

Female 92.5 [90.6,94.1] 83.4 [80.9,85.6] -9.1* 

Mother’s education 

None 91.4 [88.6,93.5] * 81.4 [76.5,85.4] -10.0* 

Primary 86.7 [81.2,90.8] 81.1 [73.9,86.6] -5.7 

Secondary + 92.6 [90.9,94.0] 84.4 [82.4,86.1] -8.2* 

Wealth quintile 

Poorest 89.4 [86.1,91.9] 78.8 [73.2,83.4] * -10.6* 

Poorer 89.5 [85.5,92.4] 85.2 [81.8,88.1] -4.3 

Middle 92.8 [89.7,95.0] 85.2 [81.7,88.2] -7.6* 

Richer 92.5 [89.3,94.8] 86.6 [83.1,89.5] -5.9* 

Richest 94.4 [91.0,96.6] 80.6 [76.3,84.3] -13.8* 

Place of residence 

Urban 93.7 [91.6,95.2] * 83.0 [79.6,85.8] -10.7* 

Rural 90.5 [88.5,92.2] 83.9 [81.8,85.9] -6.6* 

Region 

Urban Governorates 94.3 [90.9,96.5] * 86.3 [80.7,90.5] -7.9* 

Lower Egypt 93.7 [91.5,95.4] 84.0 [81.3,86.4] -9.7* 

Upper Egypt 88.4 [85.8,90.6] 82.4 [79.6,84.8] -6.1* 

Frontier Governorates 86.2 [78.2,91.6] 88.3 [82.1,92.6] 2.1 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
38 

Figure Egypt.08: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Egypt 2008 and 2014 DHS 

In 2008, 73.3% of children under age 5 with ARI symptoms were taken to a health facility or provider. This 

decreased significantly to 68.1% in 2014. As shown in Table Egypt.09, care-seeking for ARI symptoms 

differed significantly by all children’s characteristics in 2008, except for mother’s education. In 2014, it 

only differed significantly by wealth quintile. There was no observed pattern for care-seeking with 

increasing wealth quintile in both surveys. However, the richest households had the highest proportion of 

care-seeking for ARI symptoms at 81.5%, although this decreased significantly in 2014 to 67.1% and was 

no longer the highest proportion among the wealth quintiles. In 2008, the proportion of care-seeking for 

ARI symptoms was significantly higher for male children compared with female children. Care-seeking for 

male children decreased significantly in 2014 and this decrease resulted in no significant difference between 

male and female children in 2014. The proportion of care-seeking for ARI symptoms decreased 

significantly for children who reside in urban areas but remained unchanged for children from rural areas. 

The largest decrease appeared to occur in the Frontier Governorates, although this estimate should be 

interpreted with caution because of the small size in this group. The Urban Governorates also exhibited a 

large decrease in care-seeking for ARI symptoms between 2008 and 2014; this decrease was not significant. 

 
39 

Table Egypt.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 73.3 [69.4,76.8] 68.1 [65.1,71.0] -5.2* 

Child’s sex 

Male 77.3 [72.6,81.4] * 69.6 [65.9,73.1] -7.7* 

Female 68.6 [62.8,73.9] 66.1 [62.1,69.8] -2.5 

Mother’s education 

None 70.8 [63.4,77.2] 63.6 [56.9,69.8] -7.2 

Primary 73.1 [60.7,82.7] 64.6 [55.6,72.6] -8.5 

Secondary + 74.5 [69.9,78.6] 69.7 [66.3,73.0] -4.7 

Wealth quintile 

Poorest 69.6 [61.7,76.5] * 63.9 [57.5,69.9] * -5.7 

Poorer 70.8 [62.5,77.8] 62.6 [56.2,68.6] -8.2 

Middle 66.4 [56.3,75.1] 72.8 [66.9,78.0] 6.4 

Richer 79.2 [70.5,85.9] 72.4 [66.9,77.3] -6.8 

Richest 81.5 [73.2,87.7] 67.1 [58.7,74.6] -14.4* 

Place of residence 

Urban 78.4 [72.4,83.3] * 68.9 [63.1,74.2] -9.4* 

Rural 69.5 [64.3,74.2] 67.8 [64.3,71.2] -1.6 

Region 

Urban Governorates 83.9 [73.6,90.7] * 72.5 [61.1,81.5] -11.5 

Lower Egypt 74.0 [66.1,80.6] 69.4 [64.7,73.8] -4.5 

Upper Egypt 68.9 [63.7,73.6] 65.8 [61.8,69.5] -3.1 

Frontier Governorates (84.2 [67.0,93.4]) (60.4 [43.3,75.2]) -23.9* 

Note: Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
40 

Figure Egypt.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Egypt 2008 and 2014 DHS 

Child Nutrition

Over half of children under age 6 months were exclusively breastfed in 2008. This decreased significantly 

to approximately 40% in 2014. As seen in Table Egypt.10, this differed significantly only by place of 

residence and region in 2008, and in 2014 this differed significantly only by place of residence. The largest 

decreases were for children whose mothers had a primary level of education, with a decrease from 54.1% 

in 2008 to 34.0% in 2014. A large decrease was also observed in Lower Egypt from 60.1% in 2008 to 

40.1% in 2014. The estimate for exclusive breastfeeding could not be shown for the Frontier Governorates 

due to small sample size. 

 
41 

Table Egypt.10: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 53.2 [49.9,56.4] 39.7 [36.7,42.7] -13.5* 

Child’s sex 

Male 53.4 [48.8,58.0] 39.1 [35.0,43.5] -14.3* 

Female 52.9 [48.4,57.5] 40.3 [35.9,44.9] -12.6* 

Mother’s education 

None 55.6 [49.7,61.2] 42.7 [35.0,50.7] -12.9* 

Primary 54.1 [42.9,65.0] 34.0 [24.9,44.4] -20.1* 

Secondary + 52.2 [48.2,56.1] 39.6 [36.3,43.1] -12.6* 

Wealth quintile 

Poorest 58.4 [52.2,64.4] 39.4 [33.2,45.9] -19.1* 

Poorer 57.7 [50.4,64.6] 44.6 [38.2,51.3] -13.0* 

Middle 52.4 [45.7,59.0] 37.1 [31.5,43.0] -15.3* 

Richer 50.4 [42.9,57.9] 42.0 [35.3,49.0] -8.4 

Richest 45.9 [37.4,54.6] 35.1 [28.0,42.8] -10.8 

Place of residence 

Urban 45.7 [40.0,51.5] * 34.9 [30.1,40.0] * -10.8* 

Rural 57.6 [53.6,61.4] 41.6 [38.0,45.3] -16.0* 

Region 

Urban Governorates 41.2 [32.2,50.9] * 33.1 [24.3,43.3] -8.2 

Lower Egypt 60.1 [54.9,65.1] 40.1 [35.3,45.1] -20.0* 

Upper Egypt 51.0 [46.3,55.7] 40.5 [36.6,44.5] -10.5* 

Frontier Governorates ND ND 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
42 

Figure Egypt.10: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Egypt 2008 and 2014 DHS 

In 2008, less than one in three children under age 5 were stunted in Egypt. This decreased significantly to 

approximately one in five children in 2014. In 2008, stunting differed only by the child’s sex, place of 

residence and region, while in 2014 stunting differed by all the children’s characteristics except for place 

of residence. There were higher proportions of stunted males then females in both surveys. As shown in 

Figure Egypt.11, the gaps in stunting by mother’s education and wealth quintile increased in 2014. In 2014, 

20.1% of children with mothers with secondary or more education were stunted, compared with 26.8% of 

children with mothers with primary level education. The lowest portion of stunting by wealth quintile in 

2014 was for women in households in the middle wealth quintile (18.1%), while the highest proportion was 

for those in households in the poorest wealth quintile (23.4%), followed closely by the richest wealth 

quintile (24.5%). Significant decreases in stunting were observed across all children’s characteristics. The 

largest reductions were by region and in the Lower Egypt and Frontier Governorates (16.3 and 13.1 

percentage point decrease, respectively). However, the gaps between the regions remained in 2014 with the 

lowest proportion of stunting found in the Frontier Governorates, 15.1% compared with 26.2% in Upper 

Egypt. 

 
43 

Table Egypt.11: Percentage of children under age 5 who are stunted, by background characteristics, Egypt 

2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 28.9 [27.7,30.2] 21.4 [20.1,22.9] -7.5* 

Child’s sex 

Male 30.7 [29.1,32.4] * 22.8 [21.1,24.7] * -7.9* 

Female 27.1 [25.6,28.7] 19.9 [18.5,21.4] -7.2* 

Mother’s education 

None 30.1 [28.0,32.1] 24.5 [22.0,27.2] * -5.5* 

Primary 28.8 [25.3,32.5] 26.8 [23.2,30.8] -2.0 

Secondary + 28.4 [26.9,29.9] 20.1 [18.7,21.6] -8.3* 

Wealth quintile 

Poorest 29.5 [27.4,31.7] 24.1 [21.7,26.7] * -5.4* 

Poorer 30.5 [28.0,33.1] 23.1 [20.6,25.7] -7.4* 

Middle 27.3 [24.9,29.7] 18.1 [16.1,20.2] -9.2* 

Richer 30.3 [27.7,33.0] 20.0 [17.8,22.5] -10.3* 

Richest 26.9 [24.3,29.8] 23.4 [20.3,26.9] -3.5 

Place of residence 

Urban 27.1 [25.1,29.3] * 23.0 [20.5,25.8] -4.1* 

Rural 29.9 [28.4,31.5] 20.7 [19.1,22.4] -9.2* 

Region 

Urban Governorates 22.3 [19.2,25.7] * 19.0 [15.1,23.5] * -3.3 

Lower Egypt 34.2 [32.1,36.3] 17.9 [16.2,19.7] -16.3* 

Upper Egypt 25.7 [24.1,27.4] 26.2 [23.7,28.8] 0.5 

Frontier Governorates 28.2 [23.7,33.3] 15.1 [12.6,18.0] -13.1* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
44 

Figure Egypt.11: Percentage of children under age 5 who are stunted, by background characteristics, Egypt 

2008 and 2014 DHS 

In 2008, approximately one in five Egyptian children under the age 5 was overweight. This decreased 

significantly to approximately 15% in 2014. Table Egypt.12 shows that the proportion of overweight 

children in 2008 differed significantly by the children’s characteristics. However, in 2014, it only differed 

significantly by wealth quintile and region. In 2008, female children had a higher proportion of being 

overweight compared with male children; this decreased significantly for both genders to proportions that 

are similar for male and female children (15.3% and 14.3%, respectively). In 2008, the proportion of 

overweight children generally increased with increasing wealth quintile. This was not the case in 2014, 

which showed more similar proportions between the wealth quintiles. The largest decrease in the proportion 

of overweight children was in the Frontier Governorates, which decreased from 22.8% in 2008 to 8.3% in 

2014. 
45 

Table Egypt.12: Percentage of children under age 5 who are overweight, by background characteristics, 

Egypt 2008 and 2014 DHS 

2008 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 19.1 [18.0,20.2] 14.9 [13.9,15.9] -4.2* 

Child’s sex 

Male 17.6 [16.3,19.0] * 15.3 [14.2,16.6] -2.3* 

Female 20.5 [19.0,22.0] 14.3 [13.2,15.6] -6.1* 

Mother’s education 

None 14.2 [12.6,15.9] * 13.3 [11.5,15.2] -0.9 

Primary 17.9 [15.3,20.8] 15.3 [12.7,18.2] -2.6 

Secondary + 21.3 [20.0,22.8] 15.2 [14.2,16.3] -6.1* 

Wealth quintile 

Poorest 11.9 [10.4,13.6] * 15.6 [13.7,17.8] * 3.7* 

Poorer 17.3 [15.1,19.7] 12.8 [11.3,14.6] -4.4* 

Middle 20.7 [18.6,23.1] 13.9 [12.2,15.7] -6.9* 

Richer 23.6 [21.4,26.0] 15.0 [13.2,17.0] -8.6* 

Richest 22.2 [19.8,24.9] 17.7 [15.6,20.1] -4.5* 

Place of residence 

Urban 20.9 [19.1,22.8] * 16.1 [14.4,18.0] -4.8* 

Rural 18.0 [16.7,19.4] 14.3 [13.2,15.5] -3.7* 

Region 

Urban Governorates 21.1 [18.2,24.4] * 14.7 [11.5,18.6] * -6.4* 

Lower Egypt 24.7 [22.9,26.7] 16.5 [15.1,18.0] -8.3* 

Upper Egypt 12.0 [10.8,13.4] 13.2 [11.9,14.7] 1.2 

Frontier Governorates 22.8 [19.1,26.9] 8.3 [6.0,11.4] -14.5* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
46 

Figure Egypt.12: Percentage of children under age 5 who are overweight, by background characteristics, 

Egypt 2008 and 2014 DHS 

Under-5 Mortality

An estimated 28 Egyptian children of 1000 live births did not survive to their fifth birthday in the 5 years 

before the 2008 survey. This decreased to 27 deaths per 1000 live births in 2014. The decrease was not 

significant. The under-5 mortality rate was higher for males than females in both surveys. This indicator 

increased with decreasing wealth quintile in both surveys and by decreasing mother’s education in 2014. A 

large reduction in deaths was found for children of mothers with primary level education, although the 

decrease was not significant. The largest under-5 mortality rate was found for children in the poorest 

households. This remained unchanged between the two surveys. The largest decrease in under-5 mortality 

was observed for the Frontier Governorates and Urban Governorates—21 and 20 deaths per 1000 live 

births, respectively, in 2014—although this decrease was not statistically significant. 

 
47 

Table Egypt.13: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Egypt 2008 and 2014 DHS 

2008 2014 

Variable U5M [C.I.] U5M [C.I.] Diff1

Total 28 [25,32] 27 [24,31] -1 

Child’s sex 

Male 32 [27,38] 30 [25,35] -2 

Female 24 [20,29] 25 [21,30] 1 

Mother’s education 

None 30 [24,37] 35 [27,44] 5 

Primary 38 [27,53] 29 [20,41] -9 

Secondary + 26 [21,31] 25 [22,30] 0 

Wealth quintile 

Poorest 37 [29,46] 36 [29,46] 0 

Poorer 35 [27,45] 30 [23,38] -5 

Middle 27 [19,38] 29 [22,37] 2 

Richer 24 [17,33] 25 [19,34] 2 

Richest 18 [12,28] 16 [11,22] -2 

Place of residence 

Urban 28 [22,36] 21 [17,27] -7 

Rural 28 [24,33] 30 [26,35] 2 

Region 

Urban Governorates 34 [24,47] 20 [13,30] -14 

Lower Egypt 20 [16,26] 23 [19,29] 3 

Upper Egypt 35 [29,41] 34 [29,40] 0 

Frontier Governorates 31 [19,51] 21 [11,39] -10 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
48 

Figure Egypt.13: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Egypt 2008 and 2014 DHS 

Egypt Summary

Several changes in the MCH indicators occurred between the 2008 and 2014 Egypt surveys. The TFR 

increased significantly from 3.0 in 2008 to 3.5 in 2014. This increase was not due to a decrease in modern 

contraceptive use, which remained unchanged between 2008 and 2014 at approximately 57%, (which was 

also the percentage of modern contraceptive use in the 2005 DHS, which was not included in the analysis). 

Traditional contraceptive use was low but decreased further to less than 2% in 2014. Improvements were 

observed in the indicators of women who had four or more ANC visits, assistance by an SBA, and delivery 

in a health facility for their most recent birth. For these indicators, there were significant increases observed 

in the total and across most background characteristics. These increases reduced the gaps between 

subgroups of women. However, the proportion of women who delivered by C-section increased from 30% 

in 2008 to an alarming level of more than half of women in 2014. Over 70% of women in the richest 

households delivered their most recent birth by C-section in 2014. The child health indicators for 

vaccination, care-seeking for ARI symptoms, and exclusive breastfeeding deteriorated significantly 

between 2008 and 2014. However, stunting and overweight decreased significantly. This decrease occurred 

across most subgroups of children except for a slight increase in overweight children in the poorest 

households. The under-5 mortality rates remained unchanged between the surveys, although the gap 

between urban and rural rates increased. 
49 

Iraq 

In mid-2015, the population of Iraq was approximately 37 million, with 70% living in urban areas (WHO 

2016b). Since 2003, Iraq has endured a constant state of conflict that began with U.S. intervention and most 

recently, the conflict with the so-called “Islamic State” (ISIS). The instability and violence wrought by 

these conflicts have had a profound impact on the health of the Iraqi people and the health infrastructure of 

Iraq. Al-Anbar province in western Iraq has been acutely affected by the conflicts because it was the home 

of an Iraqi-led insurgency during the U.S. war. As of 2014, 70% of Al-Anbar province had been captured 

by ISIS fighters. Across Iraq, civilian casualties and injuries have been difficult to measure, although as of 

2013, the toll had surpassed 100,000 casualties (Hagopian et al. 2013; Roberts et al. 2004; WHO, Ministry 

of Health, and Ministry of Planning and Development Cooperation 2008). At the end of 2015, there were 

an estimated 4.4 million internally displaced persons in Iraq and an additional 277,700 Iraqi refugees 

(UNHCR 2016a). The United Nations estimates that in 2017, there are an estimated 11 million Iraqis in 

need of humanitarian assistance (United Nations 2017b). The on-going civil war in neighboring Syria has 

caused hundreds of thousands of Syrians to seek refuge in Iraq. In December 2016, the UN Refugee Agency 

registered 230,000 Syrian refugees in Iraq (UNHCR 2016c). The average life expectancy at birth has 

remained virtually unchanged from 68 years in 2007 to 69 years in 2015 (WHO 2016b; World Bank 2016a). 

The instability precipitated by the on-going military conflicts and pressures from a growing refugee 

population have resulted in variable progress on maternal, child, and infant health indicators over the past 

decade. 

Maternal and reproductive health indicators have been largely stagnant over the past decade in Iraq. The 

maternal mortality ratio (MMR) has remained unchanged at approximately 50 deaths per 100,000 live births 

between 2006 and 2015 (WHO 2016b; World Bank 2016a). Beyond maternal mortality, some studies have 

examined the occurrence of maternal near-miss events in Iraq. The WHO defines a near-miss as a woman 

who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days 

of termination of a pregnancy (WHO 2011). A 2013 study in Baghdad found a maternal near-miss rate of 

5 events per 1,000 live births (Jabir et al. 2013). Among women who experienced a near-miss event, anemia 

and previous cesarean section were the most commonly associated conditions (Jabir et al. 2013). Nearly 

20% of Iraqi women of reproductive age (age 15-49) are considered anemic (WHO 2016b). Other maternal 

health indicators such as the percentage of births attended by a skilled medical professional have remained 

steady over the past decade (WHO 2016b; World Bank 2016a). A relatively low percentage of Iraqi women 

receive one or more antenatal visits and even fewer receive four or more antenatal care visits (WHO 2016b). 

Infant and child health in Iraq has been greatly affected by the on-going conflicts, particularly in terms of 

vaccination coverage and mental health. Although there have only been two confirmed cases of polio in 

Iraq since 2014, a recent study found that children exposed to the Iraq war were 21.5% less likely to receive 

a polio vaccine compared with non-exposed children (Cetorelli 2015; WHO 2017b). Since 1990, 

immunization rates among children for polio, measles, and DPT have decreased, all of which are now 

between 60-70% coverage, which is well below the necessary threshold for herd immunity (WHO 2017a). 

The mental health of children in Iraq is of great concern because of the potential for persistent exposure to 

violence and trauma. A 2006 report estimated that nearly half of the children in Baghdad had been exposed 

to a major traumatic event in the past 2 years (Razokhi et al. 2006). The same report estimated that 10-30% 

of children suffered from post-traumatic stress disorder (Razokhi et al. 2006). A more recent study from 

2013 examined the most common reasons for seeking mental health care among children in Iraq (Lokuge 

et al. 2013). This study found that witnessing violence or death and intentionally-inflicted physical violence 

were the two most common reasons for seeking care (Lokuge et al. 2013). Nearly 40% of children reported 

to care with anxiety-related symptoms, with a further 22% reporting mood or behavior related symptoms 

(Lokuge et al. 2013). The infant mortality rate has decreased since 2007 from 32 to 27 deaths per 1,000 live 

births in 2015 (WHO 2016b; World Bank 2016a). The under-5 mortality rate has also decreased over the 
50 

same time period (WHO 2016b; World Bank 2016a). Among children under age 5, the prevalence of 

stunting has decreased slightly since 2006, although wasting has marginally increased over the same time 

period (WHO 2016b; World Bank 2016a). Over-nutrition is also a growing concern in Iraq. In 2015, 6% of 

children under age 5 were considered obese and 12% were overweight (WHO 2016b). The problem of 

obesity also is found in adults, with 24% considered obese and nearly 60% overweight (WHO 2016b). 

The health system of Iraq has deteriorated over the past decade from a lack of medical professionals and 

resources. As of 2011, it is estimated that nearly 70% of the medical professionals who practiced in Iraq 

before the U.S. intervention in 2003 have left the country (Al-Khalisi 2013). In 2015, there were just 8.4 

physicians per 10,000 population (WHO 2016b). The health expenditure per capita has increased however, 

from $164 USD in 2011 to $292 USD in 2015 (WHO 2016b). The proportion of total health expenditures 

from out-of-pocket expenses is 40% (WHO 2016b). Prior to the first Gulf War, in the 1990s, Iraq was 

considered a middle-income country with a strong healthcare system (Al Hilfi 2014). Since then, the 

healthcare infrastructure has devolved into a system based largely on the provision of care at fragmented 

tertiary care facilities, with little integration of primary care services (Al Hilfi 2014). The need for improved 

primary care access and provision was reinforced by a 2012 qualitative study, which found that supply 

shortages, an inadequate and under-trained workforce, and system management problems contributed to 

the lack of primary care services in Iraq (Shabila et al. 2012). Several assessments of tertiary care facilities 

in Iraq, which have been conducted since 2007, found an overburdened medical workforce. In 2011, 19 

hospitals across Iraq were evaluated for their ability to provide emergency obstetric care (Ameh et al. 2011). 

The authors found that slightly over 25% of the hospitals were able to provide all eight of the signal 

emergency obstetric care functions in the past 3 months (Ameh et al. 2011). These include administering 

antibiotics, uterotonics, and anticonvulsants, and performing assisted vaginal delivery, basic neonatal 

resuscitation, blood transfusions, and surgery (Ameh et al. 2011). In 2014, a similar assessment of a single, 

large referral hospital in Southern Iraq found a perinatal mortality rate of 27.4 deaths per 1,000 live births 

and a neonatal mortality rate of 30.8 deaths per 1,000 live births (Ahamadani et al. 2015). The authors noted 

that the hospital was well-equipped, although the staff was overworked and sometimes lacked appropriate 

training (Ahamadani et al. 2015). 

The results below used data from the 2006 and 2011 MICS surveys. A more recent 2017 MICS survey was 

completed, although the data were not available for inclusion in this analysis. Since the Iraq 2006 MICS 

did not include a wealth index, this variable is not included in the tables for this survey. In addition, figures 

that compare trends could not be produced for the wealth quintile. 

 
51 

Figure Map 3: Iraq Map 

Note: See Appendix for a description of regions. 

 
52 

Total Fertility Rate

As of 2011, the total fertility rate (TFR) in Iraq was 4.5, which was a slight but significant increase from 

4.3 in 2006. In 2011, Iraq had one of the highest TFRs of the countries in this report. However, the Iraqi 

TFR did not differ significantly from the TFR in the West Bank and Gaza Strip in 2010 or Yemen in 2013, 

as shown in Figure 1 of the overall summary. 

The TFR between most sub-groups included in Table Iraq.01 increased between 2006 and 2011, although 

the increase was only significant for a few sub-groups. In both 2006 and 2011, the TFR decreased as 

education increased. As shown in Figure Iraq.01, the TFR increased significantly only for the primary and 

secondary or higher education levels, but not for women without any education. Wealth data, which were 

only available for 2011, showed that the highest TFR was among women in the poorest wealth quintile. 

The TFR decreased incrementally as wealth increased. The TFR for both urban and rural residences 

increased slightly between 2006 and 2011, although the increase was only significant in urban areas. 

As illustrated in Figure Iraq.01, the TFR varied by region of residence as well. The lowest TFR was found 

in the West and Kurdistan Regional Government regions in 2006 and Kurdistan in 2011. There was a 

significant decrease in Kurdistan’s TFR between 2006 and 2011. In contrast, the TFR for both the West 

and Central regions significantly increased between 2006 and 2011. The largest magnitude of change was 

found in the West Region. While the TFR ranking among regions remained relatively consistent between 

2006 and 2011, the West Region shifted substantially from the lowest TFR in 2006 to among the highest 

in 2011. The Central Region had a similar, but less dramatic, shift from the second lowest TFR to the third 

highest between the two surveys. The regions with the highest TFRs in 2011—the West, North Central, and 

South—differed by only a tenth. 

Table Iraq.01: Total fertility rate for the 3 years before the survey, by background characteristics, Iraq 2006 

MICS3 and 2011 MICS4 

2006 2011 

Diff Variable TFR [C.I 1 .] TFR [C.I.] 

Total 4.3 [4.2,4.5] 4.5 [4.4,4.6] 0.2* 

Education 

None 4.8 [4.6,5.1] 5.1 [4.9,5.3] 0.3 

Primary 4.8 [4.7,5.0] 5.1 [5.0,5.3] 0.3* 

Secondary + 3.5 [3.3,3.7] 3.7 [3.6,3.9] 0.2* 

Wealth quintile 

Poorest 5.8 [5.6,6.0] 

Poorer 5.0 [4.8,5.2] 

Middle 4.6 [4.4,4.8] 

Richer 4.0 [3.8,4.2] 

Richest 3.3 [3.1,3.5] 

Place of residence 

Urban 4.0 [3.8,4.1] 4.2 [4.1,4.3] 0.2* 

Rural 5.1 [4.9,5.3] 5.3 [5.2,5.5] 0.2 

Region 

Kurdistan Regional Gov. 3.8 [3.5,4.0] 3.3 [3.1,3.5] -0.5* 

North Central 4.9 [4.5,5.4] 5.0 [4.7,5.4] 0.1 

West 3.7 [3.3,4.1] 4.9 [4.5,5.3] 1.2* 

Central 4.0 [3.8,4.2] 4.4 [4.2,4.6] 0.4* 

South Central 4.6 [4.4,4.8] 4.8 [4.6,5.0] 0.2 

South 5.0 [4.8,5.3] 5.1 [4.9,5.3] 0.1 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
53 

Figure Iraq.01: Total fertility rate for the 3 years before the survey, by background characteristics, Iraq 2006 

MICS3 and 2011 MICS4 

Contraceptive Use

There was a significant decline in overall use of current modern contraceptives between the two surveys, 

from 39% in 2006 to 36% in 2011. This decline was apparent across most sub-groups, as shown in Table 

Iraq. 02. 

In both 2006 and 2011, women in the youngest age group had the lowest current use of modern 

contraceptive compared to older women. Use increased with age, except for the oldest age group, which 

has a smaller percentage using modern contraception but was still higher than the youngest age group. 

Women between age 35-44 had the largest percent using modern contraception at the time of both surveys. 

Patterns of modern contraceptive use by age group remained consistent, although as shown in Figure 

Iraq.02, there was a significant decrease in use by all ages except for the age 45-49 group between the two 

surveys. 

Modern contraceptive use increased significantly with education in both 2006 and 2011. Women with a 

secondary education or more had the highest percent of modern contraceptive use compared to women with 

less education, although this group experienced the largest decline among the education groups between 

the two surveys. 

The prevalence of current modern contraceptive use was lower for women in rural areas compared to 

women in urban areas in 2006. By 2011, use for women in urban areas declined to a percent that was not 
54 

statistically different from women in rural areas. In 2011, use differed significantly by wealth, with the two 

highest wealth quintiles having the highest percentage of women using a modern method. A relatively large 

gap in the percentage of modern contraceptive use was observed between the poorest and poor wealth 

quintiles, although the gaps between the consecutive wealth quintiles were not large. 

Figure Iraq.02 shows that, other than a significant increase in modern contraceptive use in the West Region, 

there was a significant decline between the two surveys in every region except the South Central Region. 

The growth observed in the West Region was of the greatest magnitude with an increase of eight percentage 

points, from 36% in 2006 to 44% in 2011. By 2011, the West Region had a higher rate of modern 

contraceptive use than any other region and one of the highest TFR rates, as shown in Table Iraq.01. The 

largest decline in modern contraceptive use was in the North Central Region, which had the lowest percent 

of current modern contraceptive use in both surveys. By 2011, only a quarter of women were using a modern 

contraceptive method in the North Central Region. 

Table Iraq.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 38.7 [37.7,39.8] 35.5 [34.7,36.4] -3.2* 

Age 

15-24 24.9 [23.2,26.8] * 22.6 [21.2,24.1] * -2.3* 

25-34 41.7 [40.1,43.3] 37.7 [36.3,39.1] -4.0* 

35-44 48.0 [46.1,49.8] 43.6 [42.1,45.1] -4.4* 

45-49 32.2 [29.0,35.6] 32.1 [29.6,34.7] -0.1 

Education 

None 35.2 [33.2,37.2] * 32.7 [31.2,34.3] * -2.5 

Primary 37.7 [36.2,39.3] 35.5 [34.3,36.7] -2.2* 

Secondary + 42.0 [40.2,43.8] 36.8 [35.4,38.3] -5.2* 

Wealth quintile 

Poorest 32.2 [30.8,33.7] * 

Poorer 35.8 [34.1,37.4] 

Middle 35.4 [33.6,37.2] 

Richer 37.6 [35.7,39.5] 

Richest 36.4 [34.3,38.5] 

Place of residence 

Urban 40.5 [39.1,41.8] * 35.9 [34.8,37.0] -4.6* 

Rural 35.4 [33.7,37.1] 34.5 [33.2,35.9] 0.9 

Region 

Kurdistan Regional Gov. 36.4 [34.1,38.7] * 30.9 [29.3,32.6] * -5.5* 

North Central 32.2 [28.9,35.7] 25.6 [22.7,28.8] -6.6* 

West 35.9 [31.9,40.1] 44.1 [41.2,47.1] 8.3* 

Central 40.7 [38.4,42.9] 36.7 [34.9,38.4] -4.0* 

South Central 37.6 [35.8,39.4] 38.5 [36.9,40.2] 0.9 

South 43.7 [41.6,45.9] 39.0 [37.3,40.7] -4.7* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 

. 
55 

Figure Iraq.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

While current use of modern contraception decreased significantly between 2006 and 2011, current use of 

traditional contraceptive methods increased significantly from 11% to 17%. As shown in Table Iraq.03 and 

Figure Iraq.03, use of traditional contraceptive methods increased across all characteristics except for the 

West Region. Table Iraq.03 also shows that traditional use differed significantly by all characteristics in 

both the 2006 and 2011 surveys. 

Traditional contraceptive method use increased with age, education, and wealth. Compared to older women, 

women age 15-24 had the smallest percentage who used traditional contraceptive methods. Women in the 

oldest two age groups, age 35-44 and 44-49, had very similar percentages of current traditional 

contraceptive use. Traditional method use increased for all age groups and education levels, although the 

largest increase was among women with secondary or higher level of education who had a seven percentage 

point increase, from 13% in 2006 to 20% in 2011. 

Current use of a traditional contraceptive method increased with wealth quintile in 2011. Approximately 

12% of women in the poorest wealth quintile used a traditional method compared to 22% of women in the 

richest quintile. 

Table Iraq.03 shows that, in both 2006 and 2011, a higher percentage of women in urban areas used 

traditional methods of contraception than in rural areas. In both places of residence, traditional use increased 

significantly between the two surveys. 
56 

Figure Iraq.03 shows an increase in current use of traditional contraceptive methods for all regions except 

for the West during this time. The West Region had a slight, but statistically insignificant, decrease in 

traditional method use. Kurdistan had the largest increase in traditional contraceptive method use between 

2006 and 2011, and in both years had a higher percentage of women using traditional contraceptive methods 

than any other region. By 2011, one in three women was using a traditional contraceptive method in 

Kurdistan. 

Table Iraq.03: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 11.1 [10.5,11.8] 17.0 [16.2,17.8] 5.8* 

Age 

15-24 5.8 [5.0,6.8] * 11.8 [10.7,13.0] * 6.0* 

25-34 10.9 [9.9,12.0] 17.2 [16.1,18.3] 6.3* 

35-44 14.5 [13.3,15.8] 19.7 [18.4,21.2] 5.3* 

45-49 16.2 [13.8,18.8] 19.6 [17.5,21.9] 3.4* 

Education 

None 9.6 [8.4,11.0] * 13.3 [12.1,14.6] * 3.7* 

Primary 10.4 [9.5,11.3] 15.8 [14.8,16.8] 5.4* 

Secondary + 13.0 [11.9,14.2] 20.1 [18.8,21.5] 7.1* 

Wealth quintile 

Poorest 12.1 [11.0,13.3] * 

Poorer 16.3 [15.0,17.8] 

Middle 17.1 [15.7,18.5] 

Richer 17.6 [16.2,19.1] 

Richest 21.5 [19.5,23.6] 

Place of residence 

Urban 12.8 [11.9,13.7] * 18.8 [17.8,19.8] * 6.0* 

Rural 8.1 [7.2,9.1] 12.5 [11.6,13.5] 4.4* 

Region 

Kurdistan Regional Gov. 21.8 [19.7,24.1] * 33.6 [31.5,35.8] * 11.8* 

North Central 12.5 [10.5,14.8] 18.5 [16.1,21.2] 6.0* 

West 9.4 [7.3,12.1] 7.4 [6.0,9.0] -2.1 

Central 9.7 [8.4,11.2] 14.3 [12.8,15.9] 4.6* 

South Central 8.9 [8.0,9.9] 14.5 [13.3,15.8] 5.6* 

South 8.4 [7.2,9.8] 11.7 [10.4,13.2] 3.3* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
57 

Figure Iraq.03: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

Antenatal Care

Almost half of women surveyed in 2011 had four or more antenatal care (ANC) visits with their most recent 

pregnancy. Information on this indicator was not available in the 2006 survey. As shown in Table Iraq.04, 

ANC differed significantly by all characteristics. The percent of women with at least four ANC visits 

decreased incrementally with age. Over half or 53% of women age 15-24 had four ANC visits, compared 

to 43% of women age 45-49. The percent of women with four or more ANC visits increased with education 

and wealth. Nearly two-thirds (65%) of women in the richest quintile had four or more ANC visits, which 

was ten percentage points higher than women in the wealth quintile directly below them. Women in the 

poorest wealth quintile had the lowest percent of women with four or more ANC visits. Slightly more than 

one-third of women in the poorest wealth quintile had at least four ANC visits. 

A significantly higher percent of women in urban areas had four ANC visits compared to rural areas. Over 

half of urban women had four or more ANC visits, compared to 41% of women in rural areas. Kurdistan 

had the highest percentage of women who attend four or more antenatal care visits (57%), compared to all 

other regions. Women in the West Region had the lowest percentage at 42%. 

 
58 

Table Iraq.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Iraq 2011 MICS4 

Variable % [C.I.] Sig.1

Total 49.6 [48.0,51.2] 

Age 

15-24 53.1 [50.7,55.5] * 

25-34 48.1 [46.0,50.2] 

35-44 47.3 [44.3,50.3] 

45-49 43.2 [29.7,57.7] 

Education 

None 35.5 [33.0,38.0] * 

Primary 48.0 [46.0,50.1] 

Secondary + 59.2 [56.4,61.9] 

Wealth quintile 

Poorest 35.4 [33.0,37.9] * 

Poorer 45.1 [42.4,47.9] 

Middle 53.4 [50.2,56.5] 

Richer 55.0 [51.8,58.2] 

Richest 64.9 [60.8,68.7] 

Place of residence 

Urban 54.0 [51.8,56.1] * 

Rural 40.5 [38.2,42.9] 

Region 

Kurdistan Regional Gov. 57.1 [53.4,60.7] * 

North Central 45.7 [40.4,51.1] 

West 41.7 [35.1,48.7] 

Central 44.6 [41.2,48.1] 

South Central 54.6 [51.5,57.7] 

South 51.1 [47.9,54.3] 

* Significant p-value. 1 Significance of the covariate in each 

survey. 

Delivery

Table Iraq.05 shows the percentage of women who delivered their most recent child with the assistance of 

a skilled birth attendant (SBA). Between 2006 and 2011, this increased significantly from 55% to 91% 

overall. Significant increases occurred over time by age, education, place of residence, and region. Delivery 

by an SBA also differed by all background characteristics in both surveys except by age in 2006. 

Figure Iraq.05 shows the steep increase in SBA use among all age groups between the two surveys of over 

30 percentage points. In both surveys, women age 45-49 had the lowest percentage of births attended by an 

SBA in the 2 years before the survey, although the differences between the age groups was not statistically 

different in 2006. In both 2006 and 2011, SBA delivery increased with higher levels of education. Between 

2006 and 2011, women with no education and a primary education saw the largest gains in this area. 

However, women with secondary or more education had the highest percentage of SBA delivery in 2011 

(96%) and the gaps between the education levels remained. In 2011, SBA delivery increased with increasing 

wealth quintile and reached 96% for the richest group. 

Significant increases in SBA use were found in both urban and rural areas. In 2011, 94% of women in urban 

areas and 85% of women in rural areas gave birth with assistance from an SBA. In addition, all regions saw 

a significant increase in SBA use between the two surveys. The South Central and South regions saw the 

largest increase—more than a 40% increase between the two surveys. 
59 

Table Iraq.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 54.5 [52.8,56.2] 90.9 [89.9,91.7] 36.4* 

Age 

15-24 56.4 [53.6,59.1] 91.7 [90.2,92.9] * 35.3* 

25-34 53.3 [50.9,55.6] 91.0 [89.8,92.1] 37.7* 

35-44 54.5 [50.9,58.0] 89.2 [87.4,90.8] 34.8* 

45-49 49.2 [29.8,68.8] 83.0 [64.9,92.8] 33.8* 

Education 

None 45.2 [41.7,48.7] * 82.4 [80.2,84.3] * 37.2* 

Primary 53.0 [50.7,55.3] 90.1 [88.8,91.3] 37.1* 

Secondary + 62.0 [59.1,64.8] 96.3 [95.4,97.1] 34.3* 

Wealth quintile 

Poorest 82.2 [80.2,84.0] * 

Poorer 89.6 [87.8,91.3] 

Middle 93.7 [92.0,95.0] 

Richer 95.5 [93.8,96.7] 

Richest 96.0 [93.2,97.6] 

Place of residence 

Urban 59.8 [57.6,61.9] * 93.9 [92.8,94.8] * 34.1* 

Rural 46.0 [43.2,48.9] 84.5 [82.7,86.2] 38.5* 

Region 

Kurdistan Regional Gov. 58.7 [54.7,62.7] * 92.4 [90.6,93.9] * 33.7* 

North Central 49.9 [44.8,55.1] 83.9 [80.8,86.6] 34.0* 

West 53.9 [47.3,60.5] 83.3 [77.5,87.9] 29.4* 

Central 59.7 [55.8,63.5] 90.7 [88.4,92.6] 31.0* 

South Central 51.1 [48.0,54.3] 93.9 [92.7,94.9] 42.7* 

South 50.8 [47.4,54.2] 93.4 [91.2,95.0] 42.6* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
60 

Figure Iraq.04: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

Utilization of health facilities for deliveries increased significantly from 63% in 2006 to 77% in 2011. In 

both surveys, women age 15-24 had a higher percent of delivery in a health facility than any other age 

group. There were significant differences between the age groups in both surveys, as well as significant 

increases in health facility delivery for women age 15-24, 25-34, and 35-44, but not for women age 45-49. 

Women with more education had higher rates of giving birth in health facilities compared to women with 

lower levels of education in 2006 and 2011, and health facility birth significantly increased across all 

education levels between 2006 and 2011. The percentage of women giving birth in a health facility also 

increased with wealth. In 2011, 67% of the poorest women gave birth in facilities compared to 84% of 

women in the richest wealth quintile. Facility births increased significantly for both urban and rural women 

between the two surveys, although urban women had a higher percentage of facility births in both years. 

Figure Iraq.06 illustrates the increase in facility births for all regions, with the notable exception of the West 

Region. Although the pattern of health facility births by region was consistent between 2006 and 2011, the 

West Region changed from among the regions with the highest percentage of facility births in 2006 to the 

lowest in 2011. While other regions increased facility birth by 11-17%, the West Region increased by 1%, 

which was not significant. 

 
61 

Table Iraq.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in the 

2 years before the survey, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 62.6 [60.9,64.3] 76.6 [75.3,77.8] 13.9* 

Age 

15-24 65.8 [63.1,68.3] * 79.4 [77.4,81.2] * 13.6* 

25-34 61.5 [59.2,63.8] 74.9 [73.1,76.6] 13.3* 

35-44 59.6 [56.1,63.1] 75.9 [73.3,78.2] 16.2* 

45-49 63.4 [41.1,81.2] 68.3 [50.8,81.8] 4.8 

Education 

None 52.0 [48.3,55.6] * 67.6 [64.9,70.1] * 15.6* 

Primary 60.8 [58.6,63.0] 75.7 [73.9,77.4] 14.8* 

Secondary + 71.3 [68.6,73.9] 82.4 [80.6,84.1] 11.1* 

Wealth quintile 

Poorest 67.4 [65.1,69.6] * 

Poorer 73.8 [71.2,76.3] 

Middle 79.5 [77.0,81.9] 

Richer 81.7 [79.0,84.1] 

Richest 83.5 [80.2,86.3] 

Place of residence 

Urban 67.9 [65.8,70.0] * 79.9 [78.3,81.3] * 12.0* 

Rural 54.1 [51.3,57.0] 69.6 [67.6,71.6] 15.5* 

Region 

Kurdistan Regional Gov. 67.8 [63.8,71.5] * 84.9 [82.6,86.9] * 17.0* 

North Central 53.7 [48.5,58.7] 70.2 [65.9,74.2] 16.5* 

West 62.0 [54.4,69.1] 63.1 [57.5,68.4] 1.1 

Central 61.2 [57.3,64.9] 72.0 [69.1,74.7] 10.8* 

South Central 67.3 [64.5,70.0] 82.0 [79.9,83.9] 14.7* 

South 63.4 [60.1,66.5] 79.4 [76.6,81.9] 16.0* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
62 

Figure Iraq.05: Percentage of women age 15-49 who delivered their most recent birth in a health facility in the 

2 years before the survey, by background characteristics, Iraq 2006 MICS3 and 2011 MICS4 

In 2011, almost a quarter of women delivered their most recent birth by caesarean section (C-section) in 

the 2 years before the survey. There were significant differences in C-section rates by all characteristics, as 

shown in Table Iraq.07. Information on this indicator was not available in the 2006 survey. The C-section 

rates increased with age, education, and wealth. Urban women had significantly a higher percentage of Csection than rural women, with 25% for urban women compared to 16% for rural women. By region, 

Kurdistan had the highest rate of C-section births at 28%, followed by the Central and South Central 

regions. The North Central and West regions had the lowest rates of C-section births. 

 
63 

Table Iraq.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section in 

the 2 years before the survey, by background characteristics, Iraq 2011 MICS4 

Variable % [C.I.] Sig.1

Total 22.2 [21.0,23.3] 

Age 

15-24 18.5 [16.9,20.3] * 

25-34 22.3 [20.7,23.9] 

35-44 28.3 [25.7,31.1] 

45-49 35.7 [21.5,52.9] 

Education 

None 15.4 [13.5,17.5] * 

Primary 20.0 [18.6,21.5] 

Secondary + 28.8 [26.6,31.1] 

Wealth quintile 

Poorest 14.5 [13.0,16.2] * 

Poorer 20.5 [18.4,22.8] 

Middle 21.7 [19.4,24.2] 

Richer 27.3 [24.5,30.4] 

Richest 30.0 [26.8,33.4] 

Place of residence 

Urban 25.1 [23.6,26.7] * 

Rural 16.0 [14.7,17.4] 

Region 

Kurdistan Regional Gov. 28.4 [25.2,31.9] * 

North Central 13.9 [11.3,16.9] 

West 14.0 [10.7,18.0] 

Central 25.0 [22.3,27.9] 

South Central 26.9 [24.9,29.0] 

South 17.4 [15.5,19.4] 

* Significant p-value. 1 Significance of the covariate in each 

survey. 

Child Health Care

Between the 2006 and 2011 surveys, there was a significant reduction in the percent of children under age 

5 who were taken to a health facility or provider for ARI symptoms within the 2 weeks before the survey, 

from 82% in 2006 to 74% in 2011. The decline is evident in several sub-groups as shown in Table Iraq.08. 

There was a significant decline in care-seeking for female children with ARI symptoms between the two 

surveys, but not for males. In 2011, advice or treatment was sought for male children at a significantly 

higher rate than for female children, although in 2006, there had not been a significant difference between 

the sexes. 

Care-seeking for children with ARI symptoms increased with education in both survey years, but the 

differences by education were not significant in 2011. From 2006 to 2011, women with a primary education 

had a significant reduction in care-seeking (83% in 2006 and 73% in 2011). The decreases for no education 

and a secondary or higher level of education were not significant. 

Both urban and rural residences had significant decline in care-seeking for ARI symptoms between the two 

surveys. In both surveys, there was a higher percentage of care-seeking found in urban compared to rural 

areas. All regions saw a decline in this indicator except for Kurdistan, which had a significant increase 

(65% to 77%) in care-seeking for children with ARI symptoms. The declines observed in the North Central 

and West regions were not significant, as shown in Figure Iraq.06. Kurdistan is the only region that had an 

increase in care-seeking between 2006 and 2011. 
64 

Table Iraq.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the survey 

and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Iraq 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 81.6 [79.5,83.5] 74.4 [71.8,76.9] -7.1* 

Child’s sex 

Male 80.3 [77.6,82.9] 76.5 [73.5,79.2] * -3.9 

Female 83.0 [80.2,85.5] 71.8 [67.7,75.5] -11.2* 

Education 

None 74.4 [68.6,79.5] * 72.3 [67.5,76.5] -2.2 

Primary 83.0 [80.1,85.5] 73.3 [69.8,76.5] -9.7* 

Secondary + 83.2 [79.4,86.4] 78.1 [73.1,82.4] -5.2 

Wealth quintile 

Poorest 70.0 [65.8,73.8] 

Poorer 74.4 [69.5,78.8] 

Middle 74.9 [68.7,80.2] 

Richer 79.0 [72.9,83.9] 

Richest 77.7 [68.6,84.7] 

Place of residence 

Urban 83.3 [80.8,85.6] * 76.5 [73.1,79.6] * -6.8* 

Rural 78.9 [75.2,82.2] 70.5 [66.2,74.4] -8.4* 

Region 

Kurdistan Regional Gov. 64.6 [56.4,72.1] * 76.5 [72.8,79.8] * 11.8* 

North Central 86.7 [79.9,91.5] 85.4 [76.7,91.3] -1.3 

West 90.8 [82.3,95.4] 82.9 [72.0,90.2] -7.8 

Central 84.4 [80.0,87.9] 73.2 [65.6,79.6] -11.2* 

South Central 78.0 [74.4,81.2] 68.9 [62.9,74.4] -9.1* 

South 83.0 [77.9,87.1] 69.8 [63.5,75.4] -13.2* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
65 

Figure Iraq.06: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Iraq 2006 MICS3 and 2011 MICS4 

Child Nutrition

Exclusive breastfeeding of children under age 6 months declined significantly from 25% in 2006 to 20% in 

2011. Table Iraq.09 shows that this decline was consistent for all characteristics, except for women in the 

Kurdistan Region. While all regions saw a decline in exclusive breastfeeding, the percentage of children 

under age 6 months exclusively breastfed in Kurdistan increased from 12% in 2006 to 20% in 2011. As 

illustrated in Figure Iraq.09, the West Region had the most dramatic decline during this time, from 38% to 

9%. 

While not significant in 2006, the difference in exclusive breastfeeding rates between urban and rural 

children was significant in 2011. Exclusive breastfeeding decreased significantly between the surveys in 

urban areas, but the decline in rural areas was not significant. 

In 2006 and 2011, exclusive breastfeeding rates did not differ by mother’s education. Between the two 

surveys, exclusive breastfeeding rates decreased significantly for children of women with primary and 

secondary or higher levels of education, but did not decline significantly for children of women with no 

education. There were no significant differences in the percent of children breastfed by wealth quintile. 

However, 23% of children under age 6 months from the poorest wealth quintile were exclusively breastfed 

compared to 17% of children in the richest wealth quintile. 
66 

Table Iraq.09: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Iraq 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 25.1 [22.5,27.8] 19.6 [17.6,21.7] -5.5* 

Child’s sex 

Male 23.5 [20.1,27.2] 20.7 [18.1,23.5] -2.8 

Female 26.7 [23.1,30.6] 18.4 [15.8,21.4] -8.2* 

Mother’s education 

None 25.4 [20.3,31.2] 22.9 [18.9,27.5] -2.4 

Primary 25.2 [21.6,29.2] 20.6 [17.9,23.5] -4.6* 

Secondary + 24.7 [20.4,29.5] 16.3 [13.0,20.3] -8.3* 

Wealth quintile 

Poorest 22.6 [19.3,26.2] 

Poorer 23.7 [19.4,28.7] 

Middle 16.6 [12.6,21.6] 

Richer 16.8 [12.5,22.1] 

Richest 16.6 [11.8,22.9] 

Place of residence 

Urban 23.7 [20.6,27.2] 18.3 [15.8,21.0] * -5.5* 

Rural 27.4 [23.1,32.1] 22.3 [19.4,25.5] -5.1 

Region 

Kurdistan Regional Gov. 11.8 [7.4,18.2] * 19.8 [15.8,24.6] * 8.1* 

North Central 36.3 [27.8,45.7] 24.7 [18.7,31.8] -11.6* 

West 37.6 [25.6,51.2] 8.8 [5.9,13.1] -28.7* 

Central 19.4 [14.4,25.7] 15.7 [12.0,20.3] -3.7 

South Central 33.5 [28.7,38.7] 25.0 [20.8,29.7] -8.6* 

South 20.3 [16.0,25.4] 17.9 [14.5,21.9] -2.4 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
67 

Figure Iraq.07: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Iraq 2006 MICS3 and 2011 MICS4 

Percentages and patterns of stunting remained consistent between the 2006 and 2011 surveys (21-22%) and 

by all characteristics in Table Iraq.10 except for region. In both surveys, stunting was more prevalent among 

children with less educated or uneducated mothers compared to mothers with a secondary or higher level 

of education. Stunting had an inconsistent relationship with wealth in 2011. While children in the poorest 

and poorer quintiles had the highest percent of stunting by wealth quintile, the lowest percent of stunted 

children were in the middle wealth quintile. Stunting was also more common among children who reside 

in rural areas than urban areas in both 2006 and 2011. 

Figure Iraq.08 shows the patterns of stunting between the two surveys, and the significant changes that took 

place in some regions. While the South and South Central regions had significant declines in stunting, the 

West and Central regions had significant increases in stunting rates. The increase in stunting for the West 

Region was relatively large with an approximately 12 percentage point increase. In 2011, almost a third of 

children under age 5 in the West Region were found to be stunted. 
68 

Table Iraq.10: Percentage of children under age 5 who are stunted, by background characteristics, Iraq 2006 

MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 21.4 [20.4,22.3] 21.5 [20.7,22.3] 0.1 

Child’s sex 

Male 22.1 [20.9,23.4] 22.0 [21.0,23.1] -0.1 

Female 20.6 [19.4,21.8] 20.9 [19.9,22.0] 0.3 

Mother’s education 

None 24.0 [22.1,26.0] * 23.6 [22.2,25.0] * -0.4 

Primary 22.3 [21.0,23.7] 22.1 [21.0,23.3] -0.2 

Secondary + 18.3 [16.8,19.8] 19.3 [17.9,20.8] 1.0 

Wealth quintile 

Poorest 23.8 [22.5,25.1] * 

Poorer 22.3 [20.7,24.0] 

Middle 19.4 [17.9,20.9] 

Richer 20.7 [18.8,22.8] 

Richest 20.4 [18.0,23.0] 

Place of residence 

Urban 19.4 [18.2,20.7] * 20.6 [19.6,21.8] * 1.2 

Rural 24.4 [22.9,25.9] 23.2 [22.0,24.4] -1.2 

Region 

Kurdistan Regional Gov. 13.1 [11.4,15.0] * 13.8 [12.5,15.2] * 0.7 

North Central 21.4 [18.8,24.2] 19.2 [17.0,21.7] -2.1 

West 21.1 [17.1,25.7] 32.8 [29.3,36.5] 11.7* 

Central 21.4 [19.3,23.7] 29.2 [27.3,31.2] 7.7* 

South Central 21.6 [20.1,23.3] 18.5 [17.1,20.0] -3.1* 

South 26.2 [24.3,28.1] 18.4 [17.0,19.9] -7.8* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
69 

Figure Iraq.08: Percentage of children under age 5 who are stunted, by background characteristics, Iraq 2006 

MICS3 and 2011 MICS4 

Approximately 9% of children under age 5 who were overweight in 2006. This increased slightly but 

significantly to 11% in 2011. As shown in Table Iraq.11, the proportion of overweight children increased 

between the two surveys by some characteristics. In 2006, significantly more girls than boys were 

overweight, although by 2011, there was no difference in the proportion of overweight children by sex. 

This was due to a significant increase between the surveys in boys and no significant increase for girls, 

which reduced the gap between the sexes. While there were no differences in the proportion of overweight 

children by mother’s education in 2006, in 2011 the proportion of overweight children increased with 

mother’s education. The proportion of children under age 5 who were overweight increased with wealth as 

well. 

In 2006, a larger percentage of rural children were overweight than urban children, although in 2011, there 

was approximately the same percentage of overweight children in urban and rural residences. This is a 

result of a significant increase in overweight children in urban areas between 2006 and 2011. The 

percentage of overweight children in rural areas did not change significantly between the two surveys. 

The percentage of overweight children remained the same or increased between 2006 and 2011 for all 

regions, except for the South Region, which had a significant decline in the number of overweight children 

under age 5 between the two surveys. In 2006, the South Region had the second highest percentage of 

overweight children at 12%. By 2011, the South Region had the lowest percentage among the regions of 

6%, as shown in Figure Iraq.09. 
70 

Table Iraq.11: Percentage of children under age 5 who are overweight, by background characteristics, Iraq 

2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 9.4 [8.7,10.2] 10.8 [10.2,11.5] 1.4* 

Child’s sex 

Male 8.5 [7.7,9.5] * 11.1 [10.3,11.9] 2.5* 

Female 10.3 [9.4,11.3] 10.6 [9.7,11.5] 0.3 

Mother’s education 

None 8.6 [7.3,10.0] 8.2 [7.3,9.1] * -0.4 

Primary 9.7 [8.8,10.8] 10.9 [10.0,11.9] 1.2 

Secondary + 9.4 [8.3,10.6] 12.2 [11.1,13.4] 2.8* 

Wealth quintile 

Poorest 8.2 [7.5,9.0] * 

Poorer 10.6 [9.5,11.9] 

Middle 10.6 [9.4,12.1] 

Richer 12.3 [10.8,13.9] 

Richest 14.1 [12.1,16.2] 

Place of residence 

Urban 8.5 [7.7,9.5] * 11.2 [10.4,12.1] 2.7* 

Rural 10.7 [9.6,12.0] 10.1 [9.2,11.1] -0.7 

Region 

Kurdistan Regional Gov. 3.7 [2.9,4.8] * 10.0 [8.7,11.4] * 6.2* 

North Central 6.9 [5.6,8.6] 9.4 [8.2,10.9] 2.5* 

West 16.3 [12.5,21.0] 21.0 [16.9,25.7] 4.7 

Central 10.8 [9.1,12.7] 16.4 [14.8,18.1] 5.6* 

South Central 9.0 [8.0,10.3] 8.3 [7.4,9.3] -0.7 

South 11.5 [10.0,13.1] 5.8 [4.7,7.0] -5.7* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two surveys 

with the significance of the difference. 
71 

Figure Iraq.09: Percentage of children under age 4 who are overweight, by background characteristics, Iraq 

2006 MICS3 and 2011 MICS4 

Under-5 Mortality

Approximately 40 children under age 5 died for every 1000 live births in both surveys. Under-5 mortality 

rates declined between the 2006 and 2011 surveys and by most characteristics in Table Iraq.12, other than 

two regions with higher under-5 mortality in 2011 than 2006. All changes between the surveys were not 

significant. 

Patterns of under-5 mortality by mother’s education remained consistent between the two surveys. In both 

2006 and 2011, women with a secondary education or more experienced lower rates of under-5 mortality 

than women with a primary or no education. Under-5 mortality declined with increasing wealth. However, 

the middle three wealth quintiles experienced the same under-5 mortality rates. 

In 2006, women in urban and rural residences experienced the same rate of under-5 mortality, although by 

2011, rural women had a higher rate of under-5 mortality due to a decline in urban rate. While the Kurdistan, 

South Central, and Central regions had substantial declines in under-5 mortality, the under-5 mortality rate 

of the North Central and West regions increased between 2006 and 2011. As shown in Figure Iraq.10, the 

West Region had the lowest under-5 mortality rate of all regions in 2006. By 2011, the West’s under-5 

mortality rate exceeded the Kurdistan, Central, and South regions. The North Central Region had a 

comparable under-5 mortality rate to Kurdistan in 2006. By 2011, the North Central Region had the highest 

under-5 mortality rate (47 deaths for every 1000 live births) and Kurdistan had the lowest (31 deaths/1000 

live births). 
72 

Table Iraq.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, Iraq 

2006 MICS3 and 2011 MICS4 

2006 2011 

Variable U5M [C.I.] U5M [C.I.] Diff1

Total 41 [37,45] 37 [34,40] -4 

Child’s sex 

Male 44 [39,49] 41 [36,45] -3 

Female 37 [32,43] 33 [30,37] -4 

Mother’s education 

None 49 [41,58] 40 [34,46] -9 

Primary 40 [35,46] 38 [34,42] -2 

Secondary + 36 [30,44] 35 [29,41] -2 

Wealth quintile 

Poorest 39 [35,45] 

Poorer 37 [31,43] 

Middle 37 [30,44] 

Richer 37 [30,45] 

Richest 34 [26,46] 

Place of residence 

Urban 41 [36,46] 35 [32,40] -5 

Rural 41 [35,47] 40 [36,44] -1 

Region 

Kurdistan Regional Gov. 39 [31,49] 31 [26,37] -9 

North Central 39 [29,53] 47 [39,58] 9 

West 30 [19,46] 38 [28,52] 8 

Central 42 [33,52] 35 [28,43] -7 

South Central 48 [41,56] 40 [34,46] -8 

South 36 [30,44] 34 [29,40] -2 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
73 

Figure Iraq.10: Under-5 mortality rates for the 5 years before the survey, by background characteristics, Iraq 

2006 MICS3 and 2011 MICS4 

Iraq Summary

Maternal health indicators in Iraq changed inconsistently between 2006 and 2011. The TFR increased from 

4.3 to 4.5 births per woman, and there was an overall decrease in modern contraceptive use. However, West 

Region experienced a significant increase in TFR and a significant increase in modern contraceptive use. 

Traditional contraceptive use increased from 11% to 17%, with significant increases by all subgroups 

except for West Region. 

In 2011, half of women had the recommended four or more ANC visits during their most recent pregnancy, 

although there were disparities by all background characteristics. The poorest wealth quintile and the richest 

wealth quintile differed by 30-percentage points (35% vs. 65%), which indicated a large disparity in Iraq’s 

ANC coverage. 

All delivery indicators improved between 2006 and 2011. Delivery with an SBA increased from 55% to 

91% for all regions. Increases were also significant across subgroups, declined with age and increased with 

education and wealth (2011 data only). Health facility delivery also increased, but by a smaller margin than 

SBA delivery. In 2011, 77% of women delivered in a health facility, which showed the same subgroup 

patterns as SBA delivery. In West Region, SBA delivery increased, while health facility delivery did not. 

This suggested that deliveries by an SBA may be occurring outside of a health facility in that region. In 

2011, 22% of women delivered by C-section. 
74 

Child health and nutrition indicators in Iraq remained consistent or worsened between 2006 and 2011. Careseeking for children under age 5 with ARI symptoms declined from 82% to 74%, while exclusive 

breastfeeding of children under age 6 months declined from 25% to 20%. Stunting remained consistent at 

21% and 22%. However, stunting increased significantly in West Region. The Central Region also had a 

significant increase of eight-percentage points, while the South Central and South regions experienced a 

significant decline in the percentage of children who were stunted. The percent of children who were 

overweight increased from 9% to 11% between 2006 and 2011. By region, only the South Region saw a 

significant decline in the percentage of overweight children. Finally, under-5 mortality declined slightly, 

but insignificantly, from 41/1000 to 37/1000 live births overall. The decline, although not significant overall 

or by any subgroup, was largest among mothers with no education, and those residing in Kurdistan. 
75 

Jordan 

In 2015, Jordan had an estimated total population of 8.2 million people, with 84% living in urban areas 

(Population Reference Bureau 2016). Over the past decade, the public health infrastructure in Jordan has 

experienced a number of unique challenges from a surge in refugees and displaced persons in the region. 

The war in Syria and the expansion of the so-called “Islamic State” (ISIS) in Iraq have fueled the growth 

of the refugee population in Jordan. Although the increase in refugees has strained the Jordanian health 

system, the majority of reproductive, maternal, and child health indicators have improved or remained 

constant over the past decade. Life expectancy at birth is 73 years for males and 76 years for females, which 

is an increase from 2007 (Population Reference Bureau 2016). Classified by the World Bank as an upper 

middle income country, Jordan has made significant strides over the past decade toward improving its 

economy, healthcare sector, and infrastructure (World Bank 2016b). 

Over the past decade, some maternal and reproductive health indicators in Jordan have shown improvement 

while others remained unchanged. The maternal mortality ratio (MMR) has decreased slightly from 62 to 

58 maternal deaths per 100,000 live births between 2005 and 2015 (WHO et al. 2016b). A 2012 study of 

maternal mortality in Jordan found that 52.6% of maternal deaths were associated with substandard care 

and the remainder with delays in seeking and obtaining care (Okour et al. 2012). The percentage of births 

attended by a skilled birth attendant (SBA) remained steady at 100% since 2005 (World Bank 2017b). 

Antenatal coverage is nearly universal with 99% of women receiving at least one antenatal care (ANC) visit 

and 95% of women four or more visits (World Bank 2017b). The percentage of births considered “closely 

spaced,” defined as births that occur within 24 months of a preceding birth, has remained steady since 2002 

at approximately 32% (Assaf and Bradley 2014). A 2014 study that used population based survey data 

found that the prevalence of cesarean delivery increased from 18% in 2002 to 30% in 2012 (Al Rifai 2014). 

The authors found that much of the increase in cesarean deliveries was attributed to normal weight, 

singleton births in university teaching hospitals (Al Rifai 2014). This surge in cesarean delivery among 

low-risk pregnancies has been a growing concern. 

Infant and child health have made gains over the past 10 years. The infant mortality rate has declined from 

19.3 in 2007 to 15.4 infant deaths per 1,000 live births in 2015 (World Bank 2016b). A 2016 national study 

of neonatal mortality, defined as death within the first 28 days of life, found an overall neonatal mortality 

rate of 14.9 deaths per 1,000 live births (Batieha et al. 2016). The leading causes of neonatal mortality in 

Jordan were congenital anomalies, multiple births, and unexplained immaturity (Batieha et al. 2016). 

Under-5 mortality among Jordanian children has declined in recent years but despite these gains, there is 

substantial inequality across wealth quintiles (World Bank 2017b). Infant and child nutrition indicators 

have also improved in recent years, with decreases in the proportion of stunted or wasted children 

(Department of Statistics [Jordan] and ICF International 2013). A 2014 study that used a convenience 

sample of 570 mother-infant dyads found that the average duration of exclusive breastfeeding among 

Jordanian mothers was only 1 month (Abuidhail et al. 2014). A 2014 survey also found low levels of 

exclusive breastfeeding among Syrian refugees in Jordan (UNHCR et al. 2016). While the percent of 

children who suffer from undernutrition has decreased, the problem of over-nutrition among children is a 

growing concern. A 2009 survey found that nearly 20% of Jordanian children age 6-12 were overweight 

and 5.6% were obese (Khader et al. 2009). A similar survey conducted in 2016 among 2,700 Jordanian 

children age 6-17 found that 17.3% were overweight and 15.7% were obese (Zayed et al. 2016). 

Over the past decade, the refugee population in Jordan has grown substantially in response to sustained 

instability and conflict in the region. Although refugee population estimates vary, in 2016 Jordan was home 

to 665,000 registered refugees according to the UN Refugee Agency (UNHCR 2017a). The vast majority 

of these refugees are Syrian with a smaller proportion from Iraq. Jordan is among the leading refugee hosts 

in the world, both in terms of the total number of refugees hosted and the per capita ratio (UNHCR 2017a). 
76 

Jordan is home to the Zaatari refugee camp, the fifth largest in the world that is home to over 80,000 

primarily Syrian refugees (UNICEF 2016c). In 2016, 90% of Syrian refugees in Jordan were living below 

the poverty line (UNHCR 2017b). 

The majority of registered refugees in Jordan are women and children, which makes access to primary, 

reproductive, obstetric, and gynecological care paramount in Jordanian refugee camps. Syrian refugees who 

enter Jordan have high fertility rates, with an average of five children per family (Gavlak 2013). A report 

from the Zaatari refugee camp found that 95% of deliveries were vaginal and 5% were emergency cesarean 

sections (Bouchghoul et al. 2015). Over a six-month period, the Zaatari camp maternity unit provided 3,255 

antenatal consultations and 299 deliveries (Bouchghoul et al. 2015). Immunization rates among children 

living in refugee camps is approximately 80%, with significant coverage gains in recent years (Ravishankar 

and Gausman 2016). Although the number of refugees that need care continues to grow, a 2016 survey 

found that Syrian refugees who live outside of camps in Jordan had high access to healthcare with 91% of 

those who sought care receiving it (Doocy et al. 2016). Just under half of those who sought medical care 

reported out-of-pocket expenditures (Doocy et al. 2016). However, as the authors note, access to care for 

refugees has probably deteriorated since this survey was conducted in response reduced healthcare subsidies 

and food vouchers from the Jordanian government (Doocy et al. 2016). Among Syrian refugees, 43% of 

households reported having at least one household member over age 18 with a chronic disease (Ravishankar 

and Gausman 2016). In 2014, the Centers for Disease Control and Prevention, in partnership with several 

other international organizations, conducted a nutritional survey at the Zaatari camp among Syrian refugees 

(Bilukha et al. 2014). The survey found little evidence of malnutrition but did find a high prevalence of 

anemia among children and non-pregnant women of reproductive age, with both exceeding 40% (Bilukha 

et al. 2014). 

The state of healthcare and the health infrastructure in Jordan has evolved over the past decade in response 

to the influx of refugees from the Syria and Iraq. The two largest public health insurance programs cover 

approximately 60% of the Jordanian population (Ravishankar and Gausman 2016). Since the influx of 

refugees began in the mid-2000s, health care spending in Jordan has increased across multiple sectors; this 

includes a 45% increase in primary care and a 15% increase in hospital-based care (Ravishankar and 

Gausman 2016). However, health care expenditure, as a percent of gross domestic product (GDP), has 

decreased from 9.5% in 2009 to 7.4% in 2014 (World Bank 2016b). The number of hospital beds per 1,000 

people has remained steady at 1.8 since 2009 (World Bank 2016b). Among households of Syrian refugees, 

there has been a dramatic increase in out-of-pocket spending on healthcare. The 2014 and 2015 Health 

Access and Utilization Surveys show that the percentage of refugee women who reported incurring no costs 

for delivering a baby since entering Jordan dropped from 75% in 2014 to 49% in 2015 (Ravishankar and 

Gausman 2016; UNICEF 2016c). This may be due to a 2014 policy change that reduced the healthcare 

subsidies provided by the Jordanian government to refugees (Ravishankar and Gausman 2016). Progress is 

being made toward improving the national public health infrastructure. In 2015, scale-up of a national 

public health surveillance system began and now includes 269 healthcare facilities across the country 

(Sheikhali et al. 2016). The surveillance system is completely electronic and is designed to allow for easy 

collection, reporting, and analysis of data (Sheikhali et al. 2016). 

The results discussed below for Jordan used data from the 2007 and 2012 Demographic and Health Surveys. 

A more recent 2017 DHS survey will be completed by December 2017. 

 
77 

Figure Map 4: Jordan Map 

Note: See Appendix for a description of regions. 

 
78 

Total Fertility Rate

Shown in Table Jordan.01, the total fertility rate (TFR) was consistent between the 2007 and 2012 surveys, 

with 3.6 in 2007 and 3.5 in 2012. In both surveys, the TFR declined as wealth increased. Women in the 

poorer wealth quintile had a significant reduction in TFR between 2007 and 2012 (4.4 to 3.9), although 

there were no significant differences or changes by any other background characteristics between the two 

surveys. In both surveys, the North Region had the highest TFR (3.8) and the Central Region has the lowest 

(3.5 in 2007 and 3.4 in 2012). For both surveys, the highest TFR was found for women with primary 

education and the lowest for women with no education. 

Table Jordan.01: Total fertility rate for the 3 years before the survey, by background characteristics, Jordan 

2007 and 2012 DHS 

2007 2012 

TFR [C.I.] TFR [C.I.] Diff1

Total 3.6 [3.5,3.8] 3.5 [3.4,3.7] -0.1 

Education 

None 2.6 [2.1,3.1] 3.0 [2.5,3.7] 0.4 

Primary 3.9 [3.4,4.5] 3.9 [3.4,4.5] 0.0 

Secondary + 3.6 [3.5,3.8] 3.5 [3.3,3.6] -0.1 

Wealth quintile 

Poorest 4.8 [4.5,5.1] 4.4 [4.1,4.7] -0.4 

Poorer 4.4 [4.1,4.7] 3.9 [3.6,4.1] -0.5* 

Middle 3.6 [3.4,3.9] 3.6 [3.4,3.9] 0.0 

Richer 2.8 [2.6,3.1] 3.1 [2.9,3.4] 0.3 

Richest 2.5 [2.2,2.8] 2.6 [2.4,2.9] 0.1 

Place of residence 

Urban 3.6 [3.4,3.7] 3.4 [3.3,3.6] -0.1 

Rural 3.7 [3.6,3.9] 3.9 [3.7,4.1] 0.2 

Region 

Central 3.5 [3.3,3.7] 3.4 [3.2,3.5] -0.1 

North 3.8 [3.6,4.0] 3.8 [3.6,4.0] 0.0 

South 3.6 [3.4,3.8] 3.7 [3.5,3.9] 0.1 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
79 

Figure Jordan.01: Total fertility rate for the 3 years before the survey, by background characteristics, Jordan 

2007 and 2012 DHS 

Contraceptive Use

The percentage of women who use modern contraception in Jordan remained relatively unchanged between 

the 2007 and 2012 surveys (both 42%). However, there were several exceptions by characteristics, as shown 

in Table Jordan.02. Women age 45-49 had a significant and relatively large reduction in current modern 

contraceptive use from 40% to 33%. Modern contraceptive use also differed significantly by age group in 

both 2007 and 2012. The pattern remained the same between the two surveys—increasing use with 

increasing age category, except for the oldest women. 

In both surveys, current modern contraceptive use increased with level of education. Use did not vary 

significantly by age in 2007, although it did in 2012. There was a decline in use between the surveys for 

women with no or primary education, but these declines were not significant. In contrast, there was 

significant variation by wealth category in 2007, but not in 2012. There was a significant increase in use 

among the poorest women between the two surveys. Figure Jordan.02 shows the convergence of 

contraceptive use by wealth quintile between 2007 and 2012. 

Urban and rural women had statistically different percentages of contraceptive use in 2007. There was a 

significant increase in use by rural women, and the differences between the urban and rural women were 

no longer statistically significant in 2012. Regional data showed a similar leveling between 2007 and 2012, 

which was due to a significant increase in modern contraceptive use by women in the North Region. 
80 

Table Jordan.01: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 41.9 [40.4,43.5] 42.3 [40.9,43.8] 0.4 

Age 

15-24 30.0 [26.4,34.0] * 28.5 [24.6,32.7] * -1.6 

25-34 41.6 [39.5,43.7] 42.0 [39.3,44.7] 0.4 

35-44 47.6 [45.1,50.1] 51.0 [48.1,53.9] 3.4 

45-49 40.0 [36.0,44.1] 33.1 [29.0,37.5] -6.9* 

Education 

None 36.1 [30.5,42.1] 31.8 [24.5,40.0] * -4.3 

Primary 39.5 [35.0,44.2] 36.6 [31.6,41.9] -2.9 

Secondary + 42.4 [40.7,44.0] 43.0 [41.4,44.7] 0.7 

Wealth quintile 

Poorest 34.7 [32.3,37.3] * 40.6 [37.3,43.9] 5.8* 

Poorer 38.3 [35.1,41.6] 41.8 [39.0,44.7] 3.5 

Middle 41.0 [38.0,44.2] 41.1 [37.7,44.5] 0.0 

Richer 49.4 [45.8,53.1] 45.0 [41.6,48.4] -4.5 

Richest 46.8 [43.0,50.8] 43.1 [39.0,47.3] -3.8 

Place of residence 

Urban 43.0 [41.2,44.8] * 42.7 [41.1,44.4] -0.2 

Rural 36.0 [33.6,38.4] 40.2 [38.0,42.4] 4.2* 

Region 

Central 44.0 [41.9,46.2] * 42.7 [40.7,44.8] -1.3 

North 37.9 [35.6,40.3] 42.3 [40.3,44.2] 4.3* 

South 38.9 [36.8,41.1] 39.5 [37.1,42.0] 0.6 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
81 

Figure Jordan.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Jordan 2007 and 2012 DHS 

Table Jordan.03 shows that the current use of traditional contraceptive methods increased significantly 

between 2007 and 2012 from 15% to 19%. Traditional contraceptive use increased significantly between 

the two surveys for several subgroups of women. There was also convergence in use within several 

characteristics shown in Figure Jordan.03. Women age 25-34 had significant increases in traditional 

contraceptive use from 15% to 20%. Changes by age were otherwise insignificant. Women age 15-24 had 

the lowest traditional contraceptive use in both years, although there were no statistical differences in use 

by age in 2012. 

Traditional contraceptive use varied by education in 2007, although in 2012 the difference by education 

was not significant. All education levels had increases in use between the two surveys, and this difference 

was statistically significant among women with a secondary or higher level of education. 

As shown in Figure Jordan.03, use by wealth quintile varied significantly in 2007, but converged by 2012. 

This was due primarily to significant increases in use by all wealth categories except for the middle quintile. 

Use in both urban and rural areas increased between the two points in time, but increased more for women 

in rural areas. By 2012, there was a significant difference in traditional contraceptive use in urban and rural 

areas. The Central and South regions had significant increases in traditional contraceptive use, while the 

North Region trended upward, but was relatively consistent between 2007 and 2012. 

 
82 

Table Jordan.03: Percentage of women currently using traditional contraception among women age 15-49 in 

a union, by background characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 15.2 [14.2,16.2] 18.9 [17.8,19.9] 3.7* 

Age 

15-24 11.0 [8.6,14.1] * 14.8 [12.0,18.0] 3.7 

25-34 15.0 [13.4,16.8] 19.6 [17.8,21.6] 4.6* 

35-44 17.6 [15.7,19.6] 20.0 [18.1,22.1] 2.4 

45-49 13.1 [10.3,16.4] 17.6 [14.4,21.4] 4.6 

Education 

None 7.8 [5.2,11.7] * 13.8 [9.0,20.6] 6.0 

Primary 12.5 [9.2,16.6] 16.8 [12.8,21.6] 4.3 

Secondary + 15.7 [14.6,16.8] 19.1 [18.1,20.3] 3.5* 

Wealth quintile 

Poorest 13.4 [11.5,15.5] * 17.4 [15.2,19.8] 4.0* 

Poorer 14.3 [12.5,16.4] 19.1 [16.7,21.7] 4.7* 

Middle 18.9 [16.4,21.7] 18.9 [16.4,21.6] 0.0 

Richer 14.3 [11.9,17.0] 19.1 [16.4,22.0] 4.8* 

Richest 14.9 [12.5,17.6] 19.8 [16.8,23.3] 5.0* 

Place of residence 

Urban 15.1 [14.0,16.2] 18.3 [17.2,19.5] * 3.2* 

Rural 15.6 [13.8,17.7] 21.6 [19.7,23.6] 5.9* 

Region 

Central 14.4 [13.1,15.8] * 18.4 [17.0,19.9] 4.0* 

North 17.3 [15.8,19.0] 19.0 [17.5,20.7] 1.7 

South 14.0 [12.7,15.6] 21.5 [19.8,23.3] 7.5* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
83 

Figure Jordan.03: Percentage of women currently using traditional contraception among women age 15-49 in 

a union, by background characteristics, Jordan 2007 and 2012 DHS 

Antenatal Care

Table Jordan.04 shows that the percentage of women with four or more ANC visits for their most recent 

pregnancy within the 2 years before the survey remained relatively unchanged between the two surveys 

(94%). There were differences within each survey by education in both 2007 and 2012. In both years, the 

percent of ANC visits increased with level of education. There was a similar trend by wealth quintile in 

2007 and 2012. 

In 2007, a significantly higher percent of women in urban areas had four or more ANC visits than women 

in rural areas. However, by 2012 the differences between urban and rural women was not significant. There 

were also significant differences by region in 2007, but not in 2012. 

 
84 

Table Jordan.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 

DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 94.4 [93.2,95.3] 94.2 [92.7,95.4] -0.2 

Age 

15-24 96.0 [93.4,97.6] * 95.1 [92.0,97.1] -0.8 

25-34 93.9 [92.3,95.2] 94.6 [92.6,96.1] 0.7 

35-44 94.2 [91.7,95.9] 92.6 [88.4,95.4] -1.6 

45-49 73.0 [10.3,98.5] 77.1 [27.0,96.8] 4.1 

Education 

None 79.4 [64.2,89.2] * 84.5 [74.1,91.2] * 5.1 

Primary 83.0 [73.8,89.4] 87.0 [78.8,92.3] 4.0 

Secondary + 95.4 [94.3,96.3] 94.8 [93.2,96.1] -0.6 

Wealth quintile 

Poorest 91.0 [88.0,93.4] * 87.2 [82.7,90.7] * -3.8 

Poorer 93.6 [90.7,95.6] 95.0 [92.3,96.8] 1.4 

Middle 96.1 [94.1,97.4] 95.6 [92.6,97.4] -0.5 

Richer 96.3 [93.0,98.1] 97.2 [93.3,98.9] 0.9 

Richest 98.1 [94.4,99.4] 97.6 [90.1,99.4] -0.6 

Place of residence 

Urban 94.9 [93.6,96.0] * 94.5 [92.6,95.9] -0.4 

Rural 91.8 [89.8,93.4] 93.0 [90.7,94.8] 1.2 

Region 

Central 95.1 [93.4,96.3] * 94.0 [91.6,95.8] -1.1 

North 93.9 [91.9,95.5] 95.3 [93.4,96.6] 1.3 

South 91.1 [88.6,93.1] 92.1 [89.6,94.1] 1.0 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
85 

Figure Jordan.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 

DHS 

Delivery

Nearly all women gave birth with assistance from an SBA in the 2 years before the surveys in 2007 and 

2012, as shown in Table Jordan.05. In both surveys, there were slight, but significant differences in SBA 

use by level of education. A lower percent of women with no education gave birth with an SBA than women 

with a primary or secondary or higher level of education. Women with a primary education increased SBA 

use significantly between 2007 and 2012 by 4.3 percentage points. There were also significant but slight 

increases in SBA delivery for women ages 35-44, women residing in rural areas, and in the north region. 

The narrow ranges are shown in Figure Jordan.05. 

 
86 

Table Jordan.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 99.2 [98.7,99.6] 99.4 [98.5,99.8] 0.2 

Age 

15-24 99.6 [98.9,99.9] 99.4 [96.4,99.9] -0.2 

25-34 99.2 [98.3,99.7] 99.3 [97.6,99.8] 0.0 

35-44 98.8 [97.4,99.5] 99.8 [99.2,99.9] 0.9* 

45-49 100.0 100.0 0.0 

Education 

None 96.9 [93.2,98.6] * 96.6 [86.8,99.2] * 0.3 

Primary 95.5 [87.3,98.5] 99.9 [99.0,100.0] 4.3* 

Secondary + 99.5 [99.0,99.8] 99.4 [98.4,99.8] 0.1 

Wealth quintile 

Poorest 98.4 [96.4,99.3] 98.3 [95.7,99.3] 0.0 

Poorer 99.3 [97.8,99.8] 100.0 0.7 

Middle 99.4 [98.6,99.8] 100.0 0.6 

Richer 100.0 98.9 [92.6,99.8] -1.1 

Richest 100.0 100.0 0.0 

Place of residence 

Urban 99.3 [98.6,99.7] 99.3 [98.2,99.7] * 0.0 

Rural 99.0 [98.3,99.4] 99.9 [99.5,100.0] 0.9* 

Region 

Central 99.4 [98.6,99.8] 99.2 [97.6,99.7] 0.2 

North 99.0 [97.5,99.6] 99.9 [99.6,100.0] 0.9* 

South 98.8 [97.8,99.4] 99.2 [97.6,99.8] 0.4 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
87 

Figure Jordan.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 DHS 

Table Jordan.06 shows that nearly all (99%) of women delivered their most recent birth in a health facility 

in 2007 and 2012. There was a slight, but statistically significant increase in health facility delivery for 

women in the poorer wealth quintile. 

The percentage of women who gave birth in a health facility differed by education level in 2007, but no 

longer differed in 2012. This was due to slight, non-significant increases for women with a primary 

education. There were differences in the percent of women who gave birth at a health facility by wealth 

category in both years. The women in the poorest wealth quintile had the lowest percent of women who 

give birth in a health facility in both surveys (98% and 96%). Although high, this was less than women in 

the richest quintile (100% in 2007 and 2012). The only significant increase for health facility delivery was 

found for women in the poorer wealth quintile, although the increase was very small. 

Percentages of health facility delivery did not differ by place of residence or region in either 2007 or 2012. 

 
88 

Table Jordan.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 99.0 [98.4,99.4] 98.7 [97.7,99.2] -0.3 

Age 

15-24 99.3 [98.3,99.7] 97.8 [95.0,99.1] -1.4 

25-34 99.0 [98.1,99.5] 98.7 [97.2,99.4] -0.3 

35-44 98.6 [97.2,99.3] 99.3 [96.5,99.9] 0.7 

45-49 100.0 100.0 0.0 

Education 

None 96.3 [92.7,98.1] * 96.2 [87.1,99.0] -0.1 

Primary 95.0 [87.1,98.1] 97.9 [93.7,99.3] 2.9 

Secondary + 99.3 [98.8,99.6] 98.8 [97.7,99.3] -0.5 

Wealth quintile 

Poorest 97.5 [95.5,98.6] * 95.7 [92.6,97.6] * -1.7 

Poorer 99.2 [97.8,99.7] 99.9 [99.7,100.0] 0.7* 

Middle 99.4 [98.6,99.7] 99.5 [98.0,99.9] 0.1 

Richer 100.0 98.6 [93.3,99.7] -1.4 

Richest 100.0 100.0 0.0 

Place of residence 

Urban 99.0 [98.3,99.4] 98.5 [97.3,99.1] -0.6 

Rural 98.9 [98.1,99.3] 99.5 [98.3,99.8] 0.6 

Region 

Central 99.2 [98.4,99.6] 98.5 [96.9,99.3] -0.7 

North 98.7 [97.1,99.4] 98.8 [97.8,99.4] 0.2 

South 98.4 [97.2,99.0] 99.0 [97.4,99.6] 0.6 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
89 

Figure Jordan.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 DHS 

The percent of women who gave birth by C-section increased from 20% in 2007 to 30% in 2012. There 

were significant changes between surveys by several characteristics shown in Table Jordan.07. The percent 

of C-section births increased significantly between 2007 and 2012 for all age categories except for women 

age 45-49, who also had the highest percent of birth by C-section in both years. In both years, the percent 

of women giving birth by C-section increased with age. 

Women with no education experienced an 11 percentage point decline in C-sections rates between 2007 

and 2012, from 23% to 12%, but this decrease was not statistically significant. In contrast, women with a 

primary and secondary or more education experienced significant increases in the percent of women giving 

birth by C-section between the two surveys. As shown in Figure Jordan.07, the increase was relatively large 

for women with primary education, with an increase of 22 percentage points. By education, C-section was 

highest among women with a primary education and lowest among women with no education in both 

surveys. 

There were significant increases in the percent of women giving birth by C-section between surveys by all 

wealth quintiles except for the richest category. Despite a lack of significant change, women in the richest 

category maintained the highest percent of C-section births compared to the remaining wealth quintiles. 

While C-section delivery differed by wealth quintile in 2007, the increases observed in most of the wealth 

quintiles between the two surveys resulted in no differences between the wealth quintiles in the 2012 survey. 

The percentage of women who gave birth by C-section did not vary by urban/rural residence or region in 

either 2007 or 2012. However, both urban and rural women, as well as women in all regions, saw a 

significant increase in the percent giving birth by C-section between the 2 years. Figure Jordan.07 shows 

the relatively small differences in C-section rates by urban/rural residence and by region.
90 

Table Jordan.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section 

in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 19.5 [17.5,21.5] 29.9 [27.2,32.8] 10.5* 

Age 

15-24 12.2 [9.2,16.2] * 21.3 [16.2,27.5] * 9.1* 

25-34 18.2 [15.8,20.8] 29.3 [25.9,32.9] 11.1* 

35-44 30.7 [25.6,36.2] 39.8 [34.5,45.3] 9.1* 

45-49 31.3 [11.9,60.6] 53.2 [33.7,71.7] 21.9 

Education 

None 22.6 [11.9,38.9] 11.1 [6.2,19.0] * 11.5 

Primary 18.4 [11.8,27.5] 40.0 [29.6,51.4] 21.6* 

Secondary + 19.5 [17.4,21.6] 29.6 [26.8,32.6] 10.2* 

Wealth quintile 

Poorest 16.1 [13.1,19.7] * 28.4 [23.8,33.6] 12.3* 

Poorer 16.0 [12.7,20.0] 23.7 [19.8,28.0] 7.6* 

Middle 20.5 [16.8,24.6] 33.1 [27.7,39.0] 12.6* 

Richer 18.9 [14.0,25.0] 32.9 [26.2,40.4] 14.0* 

Richest 33.4 [25.1,42.9] 33.2 [24.7,43.0] -0.3 

Place of residence 

Urban 19.5 [17.3,21.9] 30.1 [26.8,33.6] 10.5* 

Rural 19.2 [16.1,22.7] 29.4 [26.4,32.7] 10.3* 

Region 

Central 19.6 [17.0,22.4] 30.3 [26.2,34.7] 10.7* 

North 18.4 [15.0,22.4] 28.7 [25.5,32.1] 10.3* 

South 22.1 [19.3,25.1] 31.7 [27.0,36.9] 9.7* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
91 

Figure Jordan.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean 

section in the 2 years before the survey, by background characteristics, Jordan 2007 and 2012 DHS 

Child Health Care

The percentage of children age12-23 months who received all basic vaccinations increased significantly 

from 87% in 2007 to 93% in 2012, and by most characteristics, as shown in Table Jordan.08. Vaccination 

coverage was not significantly different for boys and girls in 2007 or 2012, and both experienced a 

significant increase in the percent vaccinated. In both surveys, the percent of children vaccinated increased 

with mother’s education, while the differences in the percent of children vaccinated differed by education. 

Between 2007 and 2012, the percent of children vaccination increased by all levels of mother’s education, 

although the increase was only significant for children of women with a secondary or higher level of 

education. 

In 2007 and 2012, the percent of children vaccinated did not vary significantly by wealth quintile. However, 

children in the poorest and middle quintiles experienced a significant increase in the percent vaccinated. In 

2007, the percent of children vaccinated varied by urban/rural residence. There was a significant increase 

of sixteen percentage points among children in rural residences and there was no significant difference in 

2012. There were significant differences by region in the percent of children vaccinated in 2007, but not in 

2012. In 2007, the South Region had the lowest percent of children vaccinated at 64%, although this 

increased to 89% in 2012. The steep increases in rural residence and in the South Region are illustrated in 

Figure Jordan.08. 

 
92 

Table Jordan.08: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 87.0 [84.8,88.9] 93.0 [90.1,95.1] 6.0* 

Child’s sex 

Male 85.7 [82.3,88.5] 92.7 [87.8,95.7] 7.0* 

Female 88.2 [85.0,90.7] 93.3 [89.9,95.6] 5.1* 

Mother’s education 

None 57.7 [33.7,78.6] * 69.5 [49.4,84.2] * 11.8 

Primary 71.6 [58.8,81.6] 82.8 [61.1,93.6] 11.2 

Secondary + 88.7 [86.6,90.6] 94.1 [91.3,96.1] 5.4* 

Wealth quintile 

Poorest 82.1 [77.8,85.8] 89.3 [83.8,93.0] 7.1* 

Poorer 87.9 [83.0,91.5] 93.7 [86.6,97.1] 5.8 

Middle 90.0 [85.6,93.2] 97.1 [94.3,98.6] 7.1* 

Richer 87.8 [80.1,92.7] 94.3 [87.0,97.6] 6.5 

Richest 89.4 [79.8,94.8] 91.1 [73.3,97.5] 1.7 

Place of residence 

Urban 89.0 [86.4,91.1] * 93.0 [89.4,95.5] 4.1 

Rural 76.9 [72.9,80.6] 92.8 [89.4,95.2] 15.9* 

Region 

Central 89.2 [86.0,91.8] * 93.0 [88.1,95.9] 3.7 

North 89.5 [86.0,92.3] 94.5 [91.9,96.2] 4.9* 

South 63.5 [58.6,68.3] 88.6 [83.2,92.4] 25.1* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
93 

Figure Jordan.08: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Jordan 2007 and 2012 DHS 

Three-quarters of Jordanian children under age 5 had treatment for their ARI symptoms in the 2 weeks 

before to the survey in both 2007 and 2012. In Table Jordan.09, care-seeking for ARI symptoms did not 

change significantly by any characteristics between the two surveys. Some magnitudes of change appear 

quite large, but were not significant due to the large standard errors caused by the small number of 

observations in some categories. This resulted in some figures not to be displaced in Table Jordan.09 and 

the education trends were also excluded from Figure Jordan.09. In 2007, care-seeking did not differ by any 

characteristic listed in Table Jordan.09. In 2012, it varied only by urban/rural residence with 84% of 

children in rural areas had care sought for their symptoms compared to 76% of children in urban areas. 
94 

Table Jordan.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 75.0 [66.3,82.0] 77.2 [71.7,82.0] 2.3 

Child’s sex 

Male 78.5 [69.4,85.5] 79.1 [71.9,84.8] 0.5 

Female 70.1 [55.1,81.8] 74.0 [65.1,81.3] 3.9 

Mother’s education 

None ND ND 

Primary (55.6 [25.2,82.3]) (85.1 [62.7,95.1]) 29.5 

Secondary + 76.5 [67.1,83.8] 76.9 [71.2,81.8] 0.5 

Wealth quintile 

Poorest 66.0 [49.2,79.5] 79.9 [70.7,86.8] 13.9 

Poorer 80.1 [67.6,88.7] 74.3 [61.4,84.0] 5.9 

Middle 84.9 [69.8,93.2] 83.5 [73.5,90.2] 1.4 

Richer 67.1 [35.0,88.6] 71.9 [51.8,85.9] 4.8 

Richest ND 73.5 [50.3,88.3] 

Place of residence 

Urban 74.0 [64.3,81.7] 75.8 [69.1,81.4] * 1.8 

Rural 83.2 [71.1,90.9] 84.2 [78.1,88.8] 1.0 

Region 

Central 74.3 [61.7,83.9] 78.9 [70.2,85.7] 4.6 

North 74.8 [61.2,84.8] 74.2 [66.2,80.9] 0.6 

South 81.4 [69.5,89.3] 76.4 [66.0,84.4] 5.0 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
95 

Figure Jordan.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Jordan 2007 and 2012 DHS 

Child Nutrition

As shown in Table Jordan10, the percent of children under age 6 months who were exclusively breastfed 

did not change significantly between 2007 (22%) and 2012 (23%). There was one significant change 

between the two surveys. In 2007, 16% of children in rural areas were exclusively breastfed, and in 2012 

26% of children were exclusively breastfed. This was a significant increase of approximately 10 percentage 

points. Although breastfeeding rates differed significantly between urban and rural residences in 2007, the 

difference was no longer significant in 2012 because of the increase in rural areas. 

There were changes by other characteristics shown in Table Jordan.10, although they were not statistically 

significant. There was an increasing trend in the percent of children breastfed as mother’s education 

increased in both 2007 and 2012. However, in 2012 the small number of observations in the no education 

and primary education categories suggest that the results should be interpreted with caution. By region, the 

South Region increased exclusive breastfeeding, which tightened the distribution of the percent of children 

exclusively breastfed by region in 2012. This is shown in Figure Jordan.10. 

The percent of children breastfed differed significantly by wealth in 2007 but not in 2012. This convergence 

is due to slight reductions in breastfeeding among the poorest and poorer quintiles, and increases in the 

middle, richer, and richest quintiles. This leveling is shown in Figure Jordan.10. 
96 

Table Jordan.10: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 21.8 [18.2,25.9] 22.7 [18.2,27.9] 0.9 

Child’s sex 

Male 23.3 [18.1,29.3] 20.1 [15.0,26.5] -3.1 

Female 20.2 [14.7,27.0] 25.8 [19.1,33.8] 5.6 

Mother’s education 

None 8.8 [2.4,27.1] ND 

Primary 17.4 [5.8,41.8] (15.0 [7.4,27.9]) -2.4 

Secondary + 22.4 [18.5,26.7] 22.8 [18.0,28.5] 0.5 

Wealth quintile 

Poorest 23.8 [17.5,31.4] * 19.6 [13.9,26.8] -4.2 

Poorer 31.5 [23.7,40.3] 25.7 [16.4,37.7] -5.8 

Middle 20.1 [13.6,28.7] 23.7 [14.6,36.0] 3.6 

Richer 16.2 [8.8,27.8] 23.4 [14.5,35.6] 7.3 

Richest 8.7 [2.6,25.5] 20.5 [8.7,41.3] 11.8 

Place of residence 

Urban 23.2 [18.9,28.1] * 22.0 [16.7,28.4] -1.2 

Rural 15.5 [12.1,19.7] 25.5 [18.6,33.8] 9.9* 

Region 

Central 22.5 [17.4,28.7] 22.9 [16.6,30.8] 0.4 

North 22.8 [17.7,29.0] 22.9 [16.7,30.7] 0.1 

South 13.8 [10.1,18.4] 20.4 [14.6,27.8] 6.7 

Note: ND indicates figures are not shown because they were based on fewer than 25 

unweighted cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
97 

Figure Jordan.10: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Jordan 2007 and 2012 DHS [EDUCATION plot excluded due to low counts] 

There was a significant reduction in the percent of children under age 5 who were stunted, from 14% in 

2007 to 8% in 2012. There were significant decreases in the percent of children stunted between surveys 

by many characteristics, as shown in Table Jordan.11. 

Both boys and girls saw significant reductions in the percent stunted between the 2 years. For girls, the 

percent stunted was reduced by half from 13% in 2007 to 6% in 2012. However, in 2012, there was a 

significant difference between the sexes in stunting with a higher percentage of boys stunted than girls. 

There were also significant reductions in stunting by the mother’s education and wealth. Children of 

mothers with no education had the largest magnitude of change from 27% to 12%. In both 2007 and 2012, 

the percent of children who were stunted decreased as mother’s education increased, although there was a 

small difference between children of mothers with no education and a primary education by 2012. This is 

shown in Figure Jordan.11. 

In both 2007 and 2012, there were significant differences in stunting by wealth, although all wealth quintiles 

saw significant reductions in the percent of children who were stunted between the two surveys, except for 

the poorest category. The pattern remained consistent by wealth, as shown in Figure Jordan.11, although 

the middle three quintiles (poorer, middle, and richest) had only slight gaps between them in 2012. 
98 

There were no differences in stunting by urban/rural residence, although both decreased significantly and 

similarly between the two surveys. All regions reduced the percent of children stunted, but the South Region 

declined only slightly, and this decline was not statistically significant. The Central and North regions had 

similar percentages of children stunted in 2012, primarily due to a steep reduction in stunting in the Central 

Region. The South Region’s reduction was not large, and the region had substantially higher percentages 

of stunted children in 2012. 

Table Jordan.11: Percentage of children under age 5 who are stunted, by background characteristics, Jordan 

2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 14.5 [12.9,16.2] 7.7 [6.6,8.9] -6.8* 

Child’s sex 

Male 15.7 [13.4,18.4] 9.2 [7.6,11.0] * -6.6* 

Female 13.3 [11.2,15.6] 6.1 [4.7,7.8] -7.2* 

Mother’s education 

None 26.8 [18.2,37.6] * 11.7 [7.5,17.8] * -15.1* 

Primary 16.2 [11.4,22.4] 12.0 [8.3,17.0] -4.2 

Secondary + 14.0 [12.4,15.8] 7.3 [6.1,8.7] -6.7* 

Wealth quintile 

Poorest 18.2 [15.2,21.7] * 13.8 [10.6,17.8] * -4.4 

Poorer 14.1 [11.0,18.0] 7.0 [5.5,9.0] -7.1* 

Middle 12.3 [9.5,15.7] 6.2 [3.8,9.8] -6.1* 

Richer 15.2 [11.3,20.2] 6.8 [4.8,9.6] -8.5* 

Richest 9.2 [6.0,13.9] 1.8 [0.8,3.9] -7.4* 

Place of residence 

Urban 14.0 [12.2,16.1] 7.4 [6.1,8.9] -6.7* 

Rural 16.7 [14.4,19.3] 8.9 [7.6,10.5] -7.7* 

Region 

Central 17.0 [14.6,19.7] * 7.5 [5.8,9.5] * -9.6* 

North 9.8 [7.9,12.2] 6.7 [5.4,8.2] -3.2* 

South 12.9 [10.9,15.3] 12.1 [9.9,14.8] -0.8 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
99 

Figure Jordan.11: Percentage of children under age 5 who are stunted, by background characteristics, 

Jordan 2007 and 2012 DHS 

There were significant reductions in the percent of children under age 5 who were overweight and by most 

characteristics as shown in Table Jordan.12. The overall percent of overweight children decreased from 

11% in 2007 to 4% in 2012. Figure Jordan.12 illustrates the decline in the percentage of overweight children 

by all background characteristics. The percent of overweight boys and girls both declined significantly 

between the two surveys, by half for boys and by three-quarters for girls. 

There were also significant declines for children of mothers with a primary and secondary or higher level 

of education. In 2007 and 2012, the percentage of overweight children did not differ significantly by 

mother’s education. 

The percentage of overweight children declined significantly for all wealth quintiles, while the significant 

difference in overweight children by wealth quintile was no longer present in 2012. This was primarily due 

to a twelve-percentage point reduction in overweight children in the richest wealth quintile. 

The percent of overweight children in both urban and rural residences declined significantly between the 

two surveys. In 2007, 12% of urban children and 10% of rural children were overweight. In 2012, this 

declined to 4% of urban children and 6% of rural children. The percentage of overweight children varied 

by region in 2007 and 2012. In 2007, the Central Region had the highest percentage of overweight children 

(14%) compared to the other regions. In 2012, the Central and the North regions had approximately the 

same percent of overweight children at 4%, compared to 8% in the South Region. Both the Central and 

North regions had significant decreases in the percentage of overweight children between the two surveys 

with a large decline observed for the Central Region. 
100 

Table Jordan.12: Percentage of children under age 5 who are overweight, by background characteristics, 

Jordan 2007 and 2012 DHS 

2007 2012 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 11.3 [9.7,13.1] 4.4 [3.6,5.3] -6.9* 

Child’s sex 

Male 11.7 [9.6,14.3] 5.1 [3.9,6.7] -6.6* 

Female 10.8 [8.9,13.1] 3.6 [2.7,4.8] -7.2* 

Mother’s education 

None 7.5 [4.5,12.2] 3.2 [1.2,7.9] -4.3 

Primary 12.9 [7.2,21.8] 4.8 [2.8,8.2] -8.0* 

Secondary + 11.3 [9.7,13.2] 4.4 [3.6,5.4] -6.9* 

Wealth quintile 

Poorest 10.0 [7.5,13.2] * 4.7 [3.0,7.3] -5.3* 

Poorer 10.8 [8.4,13.8] 3.3 [2.3,4.8] -7.5* 

Middle 10.1 [7.7,13.3] 3.3 [2.3,4.7] -6.8* 

Richer 9.9 [6.4,15.0] 4.8 [3.2,7.1] -5.2* 

Richest 19.4 [13.1,27.7] 6.9 [4.2,11.2] -12.4* 

Place of residence 

Urban 11.6 [9.8,13.8] 4.1 [3.2,5.2] -7.5* 

Rural 9.5 [7.9,11.5] 5.7 [4.5,7.2] -3.8* 

Region 

Central 14.3 [11.8,17.2] * 4.2 [3.1,5.7] * -10.1* 

North 6.2 [4.9,7.7] 3.7 [2.8,4.8] -2.5* 

South 8.0 [6.3,10.3] 7.7 [5.8,10.2] -0.3 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
101 

Figure Jordan.12: Percentage of children under age 5 who are overweight, by background characteristics, 

Jordan 2007 and 2012 DHS 

Under-5 Mortality

Under-5 mortality in Jordan was 21 per 1,000 live births in 2007 and 2012. While there were some changes 

in under-5 mortality by several characteristics in Table Jordan.13, none were statistically significant. 

There were several interesting trends in under-5 mortality between the two surveys. Under-5 mortality 

increased for children of mothers with no education (13 to 22/1,000 live births), but decreased for children 

of mothers with a primary education (40 to 32/1,000) live births. While children in the poorest wealth 

quintile had the highest under-5 mortality in both surveys, the pattern did not remain consistent. In 2007, 

children in the middle quintile had the lowest under-5 mortality (12/1,000 live births), but in 2012, children 

in the richest quintile had the lowest under-5 mortality (14/1,000 live births). Figure Jordan.13 illustrates 

the inconsistent changes in under-5 mortality. 

 
102 

Table Jordan.13: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Jordan 2007 and 2012 DHS 

2007 2012 

Variable U5M [C.I.] U5M [C.I.] Diff1

Total 21 [17,27] 21 [16,27] 0

Child’s sex 

Male 16 [12,22] 19 [15,25] 3

Female 27 [20,35] 23 [16,31] -4

Mother’s education

None 13 [7,27] 22 [8,55] 9

Primary 40 [18,87] 32 [17,58] -8

Secondary + 20 [16,26] 20 [15,26] 0

Wealth quintile 

Poorest 29 [21,42] 30 [19,46] 0

Poorer 19 [11,33] 18 [13,27] -1

Middle 12 [7,21] 24 [14,41] 12

Richer 23 [11,45] 15 [9,24] -8

Richest 24 [11,50] 14 [5,40] -10

Place of residence

Urban 21 [16,28] 21 [15,28] -1

Rural 21 [16,28] 22 [16,32] 1

Region 

Central 21 [15,30] 21 [14,30] -1

North 21 [15,28] 20 [14,28] -1

South 25 [19,32] 27 [20,36] 2

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference.
103 

Figure Jordan.13: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Jordan 2007 and 2012 DHS 

Jordan Summary

Maternal health indicators in Jordan were consistent between the 2007 and 2012 surveys. The TFR in Jordan 

remained steady between the two surveys at 3.5 births per woman in 2012. There was a significant decline 

in the TFR among women in the poorer wealth quintile, from 4.4 to 3.9, but the TFR still decreased 

incrementally as wealth increased. By education level, the lowest TFR was among women with no 

education in both years. Like the TFR, the percentage of women who use modern contraception in Jordan 

remained unchanged overall (2007 and 2012 at 42%). The differences by wealth, urban/rural residence, and 

education in 2007 were not observed in 2012. Current use of traditional contraception increased 

significantly between 2007 and 2012, from 15% to 19%. Traditional use varied by age, education, wealth, 

and region in 2007 but, like modern contraceptive use, the numbers converged by 2012. 

Nearly all (94%) women had the recommended four or more ANC visits during their most recent pregnancy 

in both 2007 and 2012. The number of ANC visits was high across characteristics, except for women age 

45-49 and women with no education. 

Delivery indicators were high in 2007 and remained high in 2012. Nearly all women delivered their most 

recent birth with an SBA and at a health facility in both 2007 and 2012. The number of C-section deliveries 

increased significantly from 20 to 30% between 2007 and 2012, with the highest percentage among women 

ages 45-49 (53% in 2012) and the lowest in women with no education (11% in 2012). The C-section 

deliveries did not vary by region, urban/rural residence, or wealth in 2012. 
104 

Child health indicators improved overall or remained consistent. Basic vaccinations among children age 

12-23 months increased from 87% to 93%. The South Region’s vaccination rate increased from 64% to 

89%. Care-seeking for ARI symptoms in children under age 5 was consistent between 2007 and 2012. 

Exclusive breastfeeding also remained consistent at just over a fifth of children under age 6 months. In 

2012, there was no variation in breastfeeding by background characteristics. Stunting among children under 

age 5 decreased by almost half between 2007 and 2012, from 15% to 8%. The largest change occurred in 

women with no education. There were disparities in stunting by sex, mother’s education, wealth, and region 

in 2012. The percentage of overweight children declined significantly from 11% to 4%. Reductions were 

significant across characteristics. Finally, under-5 mortality did not change between 2007 and 2012, and 

remained at 21/1000 live births in both years. Under-5 mortality was lower among mothers with no 

education than mothers with a primary education (22/1000 and 32/1000 in 2012). 
105 

Lebanon (Palestinian Refugees) 

As of January 2016, the United National Relief and Works Agency for Palestine Refugees in the Near East 

(UNRWA) estimates that there are approximately 500,000 registered Palestinian refugees living in Lebanon 

(UNRWA 2016c). However, the actual number of Palestinian refugees currently residing in Lebanon may 

be closer to 280,000 (Chaaban et al. 2016). An increasing proportion of these refugees are entering Lebanon 

as they flee from the ongoing conflict from Syria. This has resulted in a surge of Syrian and Palestinian 

refugees. Lebanon is now hosting an estimated 1.1 million Syrian refugees and an additional 42,000 

Palestinian refugees from Syria (Chaaban et al. 2016). Palestinian refugees comprise nearly 10% of the 

Lebanese population with 63% of these refugees living in the twelve refugee camps in Lebanon (Chaaban 

et al. 2016). The majority of Palestinian refugees are registered, although it is estimated that there are close 

to 5,000 undocumented Palestinian refugees in Lebanon (UNHCR 2016b). Research and reports on the 

well-being of Palestinian refugees living in Lebanon have found that the Palestinian refugee population is 

marginalized in terms of economic opportunity and legal rights (Chaaban et al. 2016; Chaaban et al. 2010; 

UNHCR 2016b). 

In Lebanon, Palestinian refugees are subject to a number of legal and economic restrictions. Registered 

Palestinian refugees are limited in the type of jobs they can hold and they have only partial access to many 

of the social safety programs open to Lebanese nationals (UNHCR 2016b). As a result, many Palestinians 

are forced to work in low-paying, menial jobs and two-thirds are considered poor or extremely poor 

(Chaaban et al. 2010). The unemployment rate among Palestinian refugees is 23%, which is substantially 

higher than the overall unemployment rate in Lebanon, which was 6.8% in 2016 (Chaaban et al. 2016; 

World Bank 2017f). A 2015 survey found that more than 65% of Palestinian refugees were living below 

the poverty line and up to 65% are food insecure (Chaaban et al. 2016; Ghattas et al. 2015). A second 

survey, which also examined food security among Palestinian refugee households, found that food 

insecurity was associated with low education status and unemployment (Ghattas et al. 2015). Those who 

reported food insecurity were also more likely to self-report bad or very bad health (Ghattas et al. 2015). 

Overall, 27% of children under the age 15 live in household that is considered severely food insecure 

(Chaaban et al. 2016). Research has shown that the abject poverty and marginalized social position of 

Palestinian refugees are associated with poor health outcomes. A 2015 survey, which sought to explore the 

association between socioeconomic status and health outcomes in a Palestinian refugee population, found 

that 14% of respondents reported never attending school and 29% had completed only elementary school 

(Habib et al. 2014). Over half of respondents reported at least one chronic illness and nearly 60% reported 

poor mental health (Habib et al. 2014). The authors found that those who reported low education were twice 

as likely to report two or more health problems and those who reported food insecurity were more than 

three times as likely to report three or more health problems (Habib et al. 2014). 

The legal and social restrictions also influence healthcare access. Palestinian refugees are not granted access 

to Lebanese public health services and must therefore rely on health care provided by the UNRWA and 

other non-profit and NGO providers (Chaaban et al. 2016; UNHCR 2016b). Within the refugee camps, 

UNRWA operates 27 primary healthcare facilities and nine women’s health programs (UNRWA 2016c). 

The UNRWA partners with secondary and tertiary care facilities to subsidize the cost of care for refugees 

who need of higher levels of care (UNHCR 2016b). No one in the refugee population has private health 

insurance, which means that they are reliant on UNRWA for health care services. In 2015, UNRWA 

provided 94% of healthcare services for Palestinian refugees in Lebanon (Chaaban et al. 2016). 

There is limited trend data on maternal and reproductive health outcomes for the Palestinian refugee 

population in Lebanon. A 2011 survey of the Palestinian refugee population in Lebanon, both within and 

outside of refugee camps, examined a wide range of reproductive, maternal and child outcomes (UNICEF 

2014). The survey found very high levels of antenatal care, skilled birth attendance, and delivery within a 
106 

healthcare facility among women who had a live birth in the 2 years prior to the survey (UNICEF 2014). A 

2008 survey estimated the infant mortality rate (IMR) among Palestinian refugees living in UNRWA camps 

to be 19 infant deaths per 1,000 live births. This suggested a dramatic decline in IMR since 1995 (Riccardo, 

Khader, and Sabatinelli 2011). From a nutrition standpoint, a small percentage of children under age 5 were 

underweight and a slightly higher proportion were stunted (UNICEF 2014). Vaccination coverage was 

relatively high. By age 23 months, over 90% of children have been fully vaccinated against BCG and DPT 

(UNICEF 2014), and nearly 90% have been fully immunized against measles and polio (UNICEF 2014). 

In the 14 days before the survey, 14% of children under age 5 had experienced diarrhea (UNICEF 2014). 

Chronic illness poses a substantial health burden in the Palestinian refugee population, with an estimated 

37% of the population reporting one or more chronic conditions (Chaaban et al. 2016). This represents a 

slight increase from 31% in 2010, although this may reflect an increase in detection and not a true increase 

in the prevalence of chronic illness (Chaaban et al. 2016; Chaaban et al. 2010). The prevalence of chronic 

illnesses is highest among older populations, with 83% of those age 55 and above reporting at least one 

chronic illness (Chaaban et al. 2016). Refugee households classified as “extremely poor” suffer more 

chronic illnesses per household than other refugee households (Chaaban et al. 2016). Hypertension, chronic 

pulmonary disease, and diabetes are the leading causes of chronic illness among the refugee population 

(Chaaban et al. 2016). Although not specific to refugee camps in Lebanon, the UNRWA has reported a 

steady increase in the number of patients who receive care at their clinics for diabetes and hypertension 

(Shahin, Kapur, and Seita 2015). In 2013, 11% and 16% of patients over age 40 who attended UNRWA 

clinics had diabetes or hypertension, respectively (Shahin, Kapur, and Seita 2015). Currently, UNRWA has 

system-wide screening guidelines for diabetes and hypertension, as well as clinical guidelines for 

determining a diagnosis (Shahin, Kapur, and Seita 2015). The implementation of an E-health system with 

electronic medical records helps disseminate these system-wide clinical guidelines and policies among the 

UNRWA health facilities (Shahin, Kapur, and Seita 2015). A 2012 audit of clinical care for patients with 

diabetes at UNRWA health facilities found that many of these patients present with serious co-morbidities 

(Shahin et al. 2015). 

Palestinian refugees from Syria (PRS) represent a growing proportion of the Palestinian refugees in 

Lebanon. Within this group, just over half are women and the average age of the population is 24.7 

(Abdulrahim and Harb 2015). A vulnerability assessment of PRS in Lebanon found that 58% of families 

did not have any family member who worked in the month before the assessment (Abdulrahim and Harb 

2015) . Among those that did report working, 90% had temporary jobs (Abdulrahim and Harb 2015). The 

lack of consistent employment opportunities translates into high levels of dependence on the UNRWA for 

basic needs such as food, clothing, and healthcare. Over 90% of those surveyed reported a lack of food or 

lack or money to buy food in the 30 days prior to the assessment (Abdulrahim and Harb 2015). There is 

also a substantial portion of PRS households with at least one vulnerable member, which includes pregnant 

and postpartum women, persons with a chronic illness, and those with physical or cognitive disabilities. 

Among PRS families, 6.5% have a woman who is pregnant or breastfeeding and 47% have someone with 

a chronic illness (Abdulrahim and Harb 2015). 

Two MICS surveys after 2005 were performed for the Palestinian Refugees of Lebanon (PRL); one in 2006 

and the other in 2011. These surveys target the Palestinian refugees who reside in Lebanon and not the 

Lebanese population. The data from these two surveys were used to produce the estimates and results 

discussed below. 

 
107 

Figure Map 5: Lebanon Map 

Note: See Appendix for a description of regions. 

 
108 

Total Fertility Rate

In 2011, the total fertility rate (TFR) among the Palestinian Refugees of Lebanon (PRL) was 2.8. This 

ranged from 2.4 for women in the Beqaa Region, to 3.3 for women with a primary education. This indicator 

was not available for the 2006 survey to observe trends. 

As shown in Table PRL.01, the TFR declined incrementally as wealth increased. The TFR in the richest 

wealth quintile was 2.6, compared to 3.1 in the poorest quintile. The TFR was similar by place of residence, 

but varied by region with Tripoli and Beirut with the highest TFRs, at 3.0 and 2.9, respectively. 

Table PRL.01: Total fertility rate for the 3 years before the survey, by background characteristics, Palestinian 

Refugees of Lebanon 2011 MICS4 

2011 

TFR [C.I.] 

Total 2.8 [2.6,2.9] 

Education 

None 2.9 [1.9,4.2] 

Primary 3.3 [3.0,3.8] 

Secondary + 2.7 [2.5,2.9] 

Wealth quintile 

Poorest 3.1 [2.7,3.5] 

Poorer 2.8 [2.4,3.1] 

Middle 2.8 [2.5,3.1] 

Richer 2.7 [2.4,3.1] 

Richest 2.6 [2.2,2.9] 

Place of residence 

Urban 2.7 [2.6,3.0] 

Rural 2.8 [2.5,3.1] 

Region 

Tripoli 3.0 [2.7,3.3] 

Beirut 2.9 [2.6,3.3] 

Beqaa 2.4 [1.9,3.1] 

Saida 2.6 [2.0.3,3] 

Tyre 2.6 [2.2,3.0] 

Contraceptive Use

Modern contraceptive use among the PRL did not change significantly between the 2006 and 2011 MICS 

surveys. Just over half of the PRL were currently using modern contraception at the time of both surveys. 

The significant changes by several characteristics are shown in Table PRL.02. 

Modern contraceptive use varied significantly by age in both 2006 and 2011. By age, the highest percentage 

of women who were using modern contraception were age 35-44 (62% in 2006 and 64% in 2011), while 

the lowest use was among women age 15-24 (35% in 2006 and 2011). In both years, there was a trend of 

increasing use of modern contraceptives by age, except for the oldest women. Women age 25-34 

experienced a significant decline in modern contraceptive use between 2006 and 2011. In 2006, 61% of 

women age 25-34 were using modern contraception, compared to 55% in 2011. 

In 2006, there were no differences in modern contraceptive use by education level, although significant 

differences emerged in 2011. A higher percentage of women with a primary or secondary or higher level 

of education used modern contraception than women with no education. In addition, women with a primary 

education experienced a significant decline from 56% to 52% in modern contraceptive use between the two 
109 

surveys. In both years, use of modern contraceptives increased as women attained higher levels of 

education. 

There were no differences in modern contraceptive use by wealth quintile in 2006, although differences 

emerged in the 2011 survey. In 2006, there was no clear pattern of modern contraceptive use by wealth 

quintile, while in 2011, modern contraceptive use increased incrementally with wealth quintile. This was 

due to a significant decline in modern contraceptive use by women in the middle wealth quintile, from 59% 

in 2006 to 52% in 2011. 

There were no differences in modern contraceptive use by place of residence, and there were no significant 

changes in modern contraceptive use by place of residence between the two surveys. Modern contraceptive 

use did not vary significantly by region in 2006, but did in 2011. The differences that developed by region 

were due to a significant, 20-percentage point decline in modern contraceptive use in the Beqaa Region, 

from 58% in 2006 to 38% in 2011. In 2006, the Beqaa Region had among the highest percentage of modern 

contraceptive use, while in 2011, Beqaa had the lowest by a margin of 14-percentage points. Beqaa’s 

deviation from the other regions is shown in Figure PRL.01. 

Table PRL.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 56.0 [54.3,57.7] 54.3 [52.3,56.3] -1.7 

Age 

15-24 34.5 [29.7,39.7] * 35.4 [30.4,40.8] * 0.9 

25-34 60.5 [58.0,63.0] 54.5 [50.9,58.1] -6.0* 

35-44 61.5 [58.9,64.0] 63.5 [60.4,66.5] 2.0 

45-49 41.2 [36.3,46.3] 46.5 [41.6,51.5] 5.3 

Education 

None 49.7 [41.3,58.0] 40.0 [30.2,50.7] * -9.7 

Primary 56.4 [54.6,58.2] 52.1 [48.3,55.8] -4.3* 

Secondary + 55.7 [51.4,60.0] 55.5 [53.2,57.8] -0.2 

Wealth quintile 

Poorest 56.3 [52.3,60.1] 50.6 [46.3,54.8] * -5.7 

Poorer 53.7 [49.7,57.6] 50.8 [46.7,54.9] -2.9 

Middle 59.1 [55.6,62.4] 51.5 [47.5,55.4] -7.6* 

Richer 54.7 [50.7,58.5] 56.1 [51.9,60.2] 1.4 

Richest 56.1 [52.8,59.3] 61.2 [56.8,65.5] 5.1 

Place of residence 

Urban 56.2 [54.2,58.2] 54.7 [52.2,57.2] -1.5 

Rural 55.3 [51.8,58.7] 53.5 [50.3,56.7] -1.8 

Region 

Tripoli 56.9 [52.7,60.9] 51.8 [48.5,55.1] * -5.0 

Beirut 52.3 [48.6,56.0] 52.9 [48.1,57.6] 0.6 

Beqaa 58.1 [52.6,63.5] 38.1 [28.8,48.4] -20.0* 

Saida 56.0 [52.7,59.3] 56.9 [52.8,60.8] 0.8 

Tyre 58.4 [54.7,62.0] 58.5 [53.9,62.9] 0.1 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
110 

Figure PRL.01: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

Like modern contraceptive use, traditional contraceptive use did not change significantly between 2006 and 

2011. Although traditional contraceptive use was 12% overall in both years, significant and substantial 

changes were evident by several characteristics shown in Table PRL.03. The magnitude of changes 

observed within these characteristics is displayed in Figure PRL.02. 

In both 2006 and 2011, traditional contraceptive use varied significantly by age. Women age 15-24 had the 

smallest percentage using traditional contraception (9% in 2006 and 10% in 2011), with use increasing with 

age in both years. Traditional contraceptive use remained consistent in all age categories between the two 

surveys. 

There was no significant variation in traditional contraceptive use by education, and use by level of 

education was consistent between 2006 and 2011. There were differences in the percentage of women who 

were using traditional contraception by wealth in 2006 but by 2011, those differences were no longer 

significant. This was due to a significant increase in traditional use among women in the middle wealth 

quintile, from 10% to 14%, and a significant reduction among women in the richest quintile (16% to 11%). 

This pattern is shown in Figure PRL.02. 

Traditional contraceptive use did not differ by place of residence, but did differ by region in both 2006 and 

2011. In addition, several regions experienced significant changes in the percentage of women using 

traditional contraception between the two surveys. In 2006, the lowest percentage of women were using 

traditional contraception was in Tripoli at 6%. This increased significantly to 12% in 2011. Traditional 
111 

contraceptive use increased significantly among women in the Beqaa Region as well, from 10% in 2006 to 

20% in 2011, while the Tyre Region experienced a significant decline in traditional contraceptive use 

between 2006 and 2011, from 13% to 8%. 

Table PRL.03: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 12.4 [11.2,13.9] 12.0 [10.6,13.5] -0.5 

Age 

15-24 8.7 [6.3,11.9] * 9.6 [6.9,13.2] * 0.9 

25-34 9.5 [8.0,11.2] 10.7 [8.7,13.1] 1.2 

35-44 15.2 [13.4,17.2] 12.5 [10.5,14.8] -2.7 

45-49 15.7 [11.3,21.3] 15.5 [12.0,19.8] -0.2 

Education 

None 8.6 [4.8,15.0] 14.0 [7.8,23.8] 5.4 

Primary 12.1 [10.9,13.4] 12.0 [9.5,15.1] -0.1 

Secondary + 14.8 [11.6,18.5] 11.9 [10.4,13.6] -2.9 

Wealth quintile 

Poorest 11.7 [9.1,14.8] * 13.9 [11.0,17.3] 2.2 

Poorer 13.3 [10.5,16.8] 11.2 [8.9,14.0] 2.1 

Middle 10.1 [8.1,12.7] 14.2 [11.6,17.3] 4.1* 

Richer 10.8 [8.4,13.7] 10.4 [7.9,13.7] -0.4 

Richest 15.9 [13.5,18.6] 10.5 [8.0,13.7] -5.4* 

Place of residence 

Urban 12.6 [11.1,14.3] 12.5 [10.8,14.5] -0.1 

Rural 11.7 [9.6,14.3] 10.8 [8.7,13.4] -0.9 

Region 

Tripoli 5.5 [3.9,7.7] * 12.0 [9.7,14.7] * 6.5* 

Beirut 18.2 [15.6,21.2] 15.6 [12.1,19.8] -2.7 

Beqaa 9.8 [5.6,16.5] 19.8 [12.9,29.1] 10.0* 

Saida 13.0 [10.4,16.1] 11.4 [8.7,14.7] -1.6 

Tyre 12.7 [10.4,15.5] 7.8 [5.7,10.7] -4.9* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
112 

Figure PRL.02: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

Antenatal Care

In 2011, 90% of women age 15-49 had the recommended four or more ANC visits during their most recent 

pregnancy. This indicator was not available for the 2006 survey to observe trends. This indicator did not 

differ significantly by any characteristic as shown in Table PRL.04, except for region, while women age 

45-49 had a much lower percentage of ANC visits (45%) compared to the remaining age categories, which 

were near 90%. 

The Tyre Region had the smallest percentage of four or more ANC visits at 79%, compared to 94% of 

women in Tripoli, which had the highest percentage of women with four or more ANC visits during their 

most recent pregnancy. The other regions ranged from 86% to 92%. 

 
113 

Table PRL.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Palestinian Refugees of 

Lebanon 2011 MICS4 

2011 

Variable % [C.I.] Sig.1

Total 89.7 [87.0,91.9] 

Age 

15-24 88.8 [83.2,92.7] 

25-34 90.1 [86.7,92.7] 

35-44 90.5 [84.6,94.3] 

45-49 44.8 [4.8,94.3] 

Education 

None 80.2 [38.9,96.3] 

Primary 89.9 [82.2,94.4] 

Secondary + 89.8 [87.0,92.1] 

Wealth quintile 

Poorest 87.5 [80.7,92.2] 

Poorer 89.7 [83.3,93.9] 

Middle 89.2 [82.9,93.4] 

Richer 90.9 [85.5,94.4] 

Richest 90.7 [84.3,94.7] 

Place of residence 

Urban 90.6 [87.2,93.1] 

Rural 88.1 [83.3,91.7] 

Region 

Tripoli 94.1 [89.8,96.7] * 

Beirut 89.1 [78.7,94.7] 

Beqaa 85.6 [65.7,94.9] 

Saida 92.1 [87.8,95.0] 

Tyre 79.1 [70.5,85.7] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Delivery

Nearly all women age 15-49 delivered their most recent birth with the assistance of an SBA in both 2006 

(99%) and 2011 (97%). However, the small decline in SBA deliveries between 2006 and 2011 was 

significant overall, as well as by several characteristics as shown in Table PRL.05. 

A slightly smaller percentage of women age 35-44 delivered with an SBA in 2011 compared to 2006—this 

was a significant decline from 99% to 96%. There was a downward trend in deliveries with SBAs for the 

remaining age categories, although this was not significant. There was a similar trend downward among 

women with a primary and a secondary or higher level of education, although the decline by education was 

not statistically significant between the two surveys. The sample size was too small to report data for women 

with no education. 

In 2006 and 2011, the percentage of women who delivered with an SBA varied by wealth quintile, although 

there was no clear pattern of SBA deliveries by wealth. Women in the middle wealth quintile experienced 

a significant decline in the percentage who delivered with an SBA between the two surveys, from 99% in 

2006 to 96% in 2011. In 2006, 100% of women in the poorest, poorer, and richest wealth quintiles delivered 

with an SBA. Women in the poorest wealth quintile had a six-percentage point decline in deliveries attended 

by SBAs, although this decline was not statistically significant. 
114 

In 2006, there were no differences in the percentage of deliveries with an SBA by place of residence, but, 

due to a significant decline in deliveries with an SBA among women in rural areas, there was a significant 

difference in by place of residence in the 2011 survey. In 2006, 99% of women in urban and rural areas 

delivered with an SBA, while in 2011 98% of women in urban areas and 95% of women in rural areas did. 

This decline is shown in Figure PRL.03. 

Also in 2006, the percentage of women delivering with an SBA did not vary by region, although it did in 

2011. This is due to a large, but not statistically significant, reduction in SBA use in the Tyre Region. 

Table PRL.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Palestinian Refugees of Lebanon 

2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 99.2 [98.4,99.6] 97.1 [95.5,98.1] -2.0* 

Age 

15-24 100.0 97.0 [92.7,98.8] -3.0 

25-34 99.0 [97.5,99.6] 97.6 [95.6,98.7] -1.3 

35-44 98.8 [97.6,99.4] 95.9 [91.1,98.1] -2.9* 

45-49 ND ND 

Education 

None ND ND 

Primary 99.0 [98.1,99.5] 96.9 [91.8,98.9] -2.1 

Secondary + 99.5 [96.5,99.9] 97.1 [95.5,98.1] -2.4 

Wealth quintile 

Poorest 100.0 * 93.7 [87.7,96.9] * -6.3 

Poorer 100.0 98.7 [94.9,99.7] -1.3 

Middle 99.1 [96.7,99.8] 95.8 [91.2,98.1] -3.3* 

Richer 97.3 [94.2,98.8] 97.5 [93.6,99.1] 0.2 

Richest 99.5 [96.2,99.9] 99.4 [95.6,99.9] -0.1 

Place of residence 

Urban 99.3 [98.4,99.7] 98.4 [96.4,99.3] * -0.9 

Rural 98.6 [96.4,99.5] 94.7 [91.4,96.8] -3.9* 

Region 

Tripoli 98.3 [95.0,99.4] 97.9 [95.3,99.1] * -0.4 

Beirut 100.0 97.2 [87.9,99.4] -2.8 

Beqaa 100.0 (100.0) 

Saida 98.5 [96.7,99.3] 98.6 [95.9,99.6] 0.2 

Tyre 100.0 92.3 [86.2,95.8] -7.7 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
115 

Figure PRL.03: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Palestinian Refugees of Lebanon 

2006 MICS3 and 2011 MICS4 

The percentage of women age 15-49 who delivered their most recent birth in a health facility did not change 

overall between 2006 and 2011 (98% in 2006, 99% in 2011). The only significant change by characteristics 

shown in Table PRL.06 was an increase in health facility delivery among women with a secondary or higher 

level of education. Health facility deliveries increased from 97% to 99% among these women. Although 

women with no education experienced a 10-percentage point decline in health facility deliveries, this 

change was not statistically significant. There was significant variation in delivery by education in both 

years. Significant variation by wealth quintile was seen in 2011, but not 2006. 

 
116 

Table PRL.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in the 

2 years before the survey, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 

2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 97.7 [96.3,98.5] 98.6 [97.4,99.2] 0.9 

Age 

15-24 98.2 [94.3,99.5] 98.0 [95.0,99.2] -0.2 

25-34 97.5 [95.6,98.6] 99.2 [97.4,99.7] 1.7 

35-44 97.6 [94.6,98.9] 98.0 [93.8,99.3] 0.4 

45-49 ND ND 

Education 

None 90.5 [66.7,97.8] * 80.2 [38.9,96.3] * -10.3 

Primary 98.2 [96.8,99.0] 98.4 [93.5,99.6] 0.2 

Secondary + 96.6 [92.9,98.4] 99.0 [97.8,99.6] 2.4* 

Wealth quintile 

Poorest 98.2 [94.3,99.4] 94.3 [89.2,97.0] * -3.9 

Poorer 97.3 [93.6,98.9] 99.4 [96.0,99.9] 2.2 

Middle 98.3 [94.4,99.5] 98.7 [94.8,99.7] 0.4 

Richer 96.8 [93.0,98.5] 100.0 3.2 

Richest 97.8 [94.1,99.2] 100.0 2.2 

Place of residence 

Urban 97.1 [95.4,98.2] * 98.6 [97.0,99.4] 1.5 

Rural 99.5 [96.5,99.9] 98.6 [96.2,99.5] -1.0 

Region 

Tripoli 98.3 [95.0,99.4] 99.2 [96.7,99.8] 0.9 

Beirut 99.4 [94.7,99.9] 96.2 [90.5,98.5] -3.1 

Beqaa 95.2 [85.6,98.5] (100.0) 4.8 

Saida 96.4 [92.8,98.2] 99.1 [96.3,99.8] 2.7 

Tyre 98.7 [95.8,99.6] 98.6 [94.2,99.7] -0.1 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
117 

Figure PRL.04: Percentage of women age 15-49 who delivered their most recent birth in a health facility in the 

2 years before the survey, by background characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 

2011 MICS4 

In 2011, 30% of women age 15-49 delivered their most recent birth by C-section. This indicator was not 

available for the 2006 survey to observe trends. Delivery by C-section varied significantly by region. As 

reported in Table PRL.07, 26% of women in the Tripoli and Saida regions delivered by C-section, compared 

to 40% of women in Beirut and 47% in Beqaa. The same percentage of women in urban and rural areas 

delivered by C-section as the total population surveyed (30%). This was true for women with a secondary 

or higher level of education as well. Conversely, 40% of women with no education delivered by C-section. 

More than half of women age 45-49 delivered by C-section, compared to 25% of women age 15-24. Csections increased incrementally with age, although due to the wide confidence intervals, this was not 

significant. 

 
118 

Table PRL.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section in 

the 2 years before the survey, by background characteristics, Palestinian Refugees of Lebanon 2011 MICS4 

Variable % [C.I.] Sig.1

Total 30.2 [27.0,33.6] 

Age 

15-24 24.9 [19.6,31.1] 

25-34 31.6 [27.0,36.6] 

35-44 33.8 [26.4,42.1] 

45-49 55.2 [7.0,95.2] 

Education 

None 39.8 [12.7,75.2] 

Primary 28.7 [21.7,36.9] 

Secondary + 30.3 [26.7,34.2] 

Wealth quintile 

Poorest 27.2 [20.0,35.9] 

Poorer 29.5 [22.5,37.7] 

Middle 27.0 [20.1,35.3] 

Richer 31.5 [24.7,39.1] 

Richest 35.2 [27.8,43.4] 

Place of residence 

Urban 30.0 [26.3,34.1] 

Rural 30.4 [24.6,37.0] 

Region 

Tripoli 25.6 [19.9,32.4] * 

Beirut 39.7 [32.3,47.5] 

Beqaa 46.6 [25.1,69.4] 

Saida 25.8 [21.1,31.3] 

Tyre 33.0 [24.7,42.5] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Health Care

Care-seeking for ARI symptoms for children under age 5 increased significantly from 44% in 2006 to 82% 

in 2011. Care-seeking also increased significantly by most background characteristics, as shown in Table 

PRL.08. Data were not reported for several characteristics in Table PRL.08 because of too few cases. 

Among characteristics with data, all increased care-seeking between 2006 and 2011. However, increases 

for the middle wealth quintile and in the Beirut Region were not statistically significant. 

Care-seeking increased significantly for both boys and girls. In 2011, care was sought for 78% of boys and 

85% of girls with ARI symptoms, compared to 48% and 41% in 2006. By mother’s education, sample sizes 

were only sufficient in both surveys for those with a secondary or higher level of education. Among these 

children, care-seeking increased from 48% to 79%. Care-seeking significantly increased for children with 

ARI symptoms in both the poorer and poorest wealth quintiles. However, since data by wealth quintile was 

limited by sample size, results for the poorer and poorest wealth quintiles must be interpreted with caution 

since they are based on 25-49 unweighted cases in 2011. 

There was a significant difference in care-seeking by place of residence in 2006, but this disparity was not 

observed in 2011. Care-seeking increased for children in both urban and rural areas during this period, as 

shown in Figure PRL.05. Care-seeking increased significantly for children with ARI symptoms in Tripoli, 

from 43% in 2006 to 87% in 2011. In 2011, sample sizes were based on 25-49 unweighted cases for Tripoli 

and Beirut. Thus, these results must also be interpreted with caution due to the small number of cases. For 

the remaining regions, there were an insufficient number of cases to produce a reliable estimate. 
119 

Table PRL.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 44.4 [38.8,50.1] 81.5 [72.0,88.3] 37.1* 

Child’s sex 

Male 47.8 [40.3,55.4] 78.2 [64.5,87.6] 30.4* 

Female 40.9 [33.8,48.4] 85.4 [71.6,93.1] 44.5* 

Mother’s education 

None (33.3 [16.9,55.1]) ND 

Primary 44.5 [38.7,50.5] ND 

Secondary + 48.4 [36.1,60.8] 79.3 [67.5,87.6] 30.9* 

Wealth quintile 

Poorest 33.8 [20.2,50.8] (78.8 [53.2,92.4]) 44.9* 

Poorer 44.2 [34.6,54.3] (79.4 [60.2,90.7]) 35.1* 

Middle 44.0 [34.8,53.5] 100.0 56.0 

Richer 47.5 [33.8,61.7] ND 

Richest 54.2 [40.1,67.7] ND 

Place of residence 

Urban 48.4 [41.7,55.1] * 83.9 [72.3,91.2] 35.5* 

Rural 31.6 [21.3,44.2] (76.9 [57.7,89.1]) 45.3* 

Region 

Tripoli 43.0 [32.7,54.0] * (87.3 [74.3,94.3]) 44.3* 

Beirut 64.4 [51.4,75.6] (73.4 [52.1,87.6]) 9.1 

Beqaa ND ND 

Saida 37.7 [29.1,47.1] ND 

Tyre 35.6 [23.8,49.3] ND 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
120 

Figure PRL.05: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

Child Nutrition

The percentage of children under age 6 months who were exclusively breastfed did not change between 

2006 and 2011 overall, or by any characteristic, as shown in Table PRL.09. Despite this, there were notable 

trends by gender and place of residence, shown in Figure PRL.06. In 2006, a significantly higher percentage 

of boys under age 6 months were exclusively breastfed compared to girls (24% vs. 12%). In 2011, this 

trend, which was not significant, was reversed with a higher percentage of girls breastfed in 2011 than boys. 

A similar shift occurred by place of residence. 

 
121 

Table PRL.09: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 18.0 [12.9,24.5] 16.9 [11.8,23.7] -1.1 

Child’s sex 

Male 23.7 [15.9,33.8] * 14.2 [7.5,25.5] -9.5 

Female 12.0 [7.1,19.5] 19.2 [11.7,29.7] 7.2 

Mother’s education 

None ND ND 

Primary 15.9 [10.8,22.7] (12.8 [3.8,35.3]) -3.1 

Secondary + (23.7 [11.9,41.6]) 18.3 [12.4,26.3] -5.4 

Wealth quintile 

Poorest (20.0 [10.2,35.4]) ND 

Poorer (27.3 [15.5,43.4]) (17.3 [7.2,36.1]) -10.0 

Middle (12.8 [6.1,24.8]) (18.7 [8.3,37.1]) 6.0 

Richer (22.9 [12.0,39.2]) (13.9 [5.6,30.6]) -9.0 

Richest (6.1 [1.4,22.9]) (17.9 [5.9,43.4]) 11.9 

Place of residence 

Urban 17.6 [11.8,25.5] 20.0 [13.1,29.3] 2.4 

Rural (19.1 [10.2,33.0]) 12.4 [5.8,24.4] -6.8 

Region 

Tripoli (25.0 [10.7,48.1]) 13.6 [7.3,23.9] -11.4 

Beirut (11.8 [5.1,24.9]) (20.1 [6.2,48.9]) 8.4 

Beqaa ND ND 

Saida 20.6 [11.4,34.4] (18.4 [8.2,36.1]) -2.3 

Tyre 16.0 [8.1,29.2] (13.0 [4.4,32.7]) -3.0 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
122 

Figure PRL.06: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

Stunting among children under age 5 significantly decreased overall, from 20% in 2006 to 12% in 2011, as 

shown in Table PRL.10. In 2011, approximately 12% of both boys and girls were stunted, compared to 

21% of boys and 19% of girls in 2006. 

Significant reductions in the percentage of children who were stunted were evident for children with 

mothers with a primary or a secondary or higher level of education between the two surveys. In 2011, 

stunting declined with increasing education. In addition, the percentage of children who were stunted 

declined significantly in the middle, richer, and richest wealth quintiles. Stunting in the richer and richest 

quintiles reduced by half. 

A smaller percentage of children in both urban and rural areas were stunted in 2011 compared to 2006. In 

2006, 20% of urban and 19% of rural children were stunted, compared to 12% of urban and 13% of rural 

children in 2011. 

Of all characteristics in Table PRL.10, the percentage of children who were stunted only varied significantly 

by region. In 2006, stunting was lowest in the Beqaa region, at 16%, and highest in Beirut, at 27%. In 2011, 

stunting was lowest in Tripoli at 9%, and highest in Tyre at 19%. The Tripoli, Beirut, and Saida regions all 

experienced significant declines in the percentage of children who were stunted between 2006 and 2011, 

as shown in Figure PRL.07. 
123 

Table PRL.10: Percentage of children under age 5 who are stunted, by background characteristics, Palestinian 

Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 19.8 [17.8,22.0] 12.1 [10.5,14.0] -7.7* 

Child’s sex 

Male 20.6 [17.6,23.9] 12.2 [10.0,14.8] -8.4* 

Female 19.1 [16.6,21.8] 12.1 [9.8,14.8] -7.0* 

Mother’s education 

None 16.9 [10.1,26.7] (18.4 [8.4,35.7]) 1.5 

Primary 20.3 [18.2,22.7] 14.7 [11.3,19.1] -5.6* 

Secondary + 18.4 [14.3,23.3] 11.3 [9.5,13.3] -7.1* 

Wealth quintile 

Poorest 20.8 [16.6,25.7] 16.2 [12.5,20.7] -4.6 

Poorer 17.3 [13.4,22.0] 13.6 [10.3,17.7] -3.7 

Middle 17.9 [14.4,22.1] 10.4 [7.5,14.1] -7.5* 

Richer 22.0 [17.8,26.8] 10.4 [7.5,14.3] -11.6* 

Richest 21.3 [16.8,26.5] 10.6 [7.7,14.4] -10.7* 

Place of residence 

Urban 20.1 [17.7,22.7] 11.9 [9.7,14.4] -8.2* 

Rural 19.0 [15.4,23.2] 12.6 [10.3,15.4] -6.3* 

Region 

Tripoli 18.2 [14.6,22.4] * 7.8 [5.8,10.6] * -10.3* 

Beirut 26.5 [21.3,32.4] 14.2 [9.6,20.4] -12.3* 

Beqaa 15.8 [9.5,25.2] 13.0 [5.3,28.5] -2.8 

Saida 18.2 [14.4,22.8] 10.8 [7.9,14.5] -7.4* 

Tyre 19.1 [15.3,23.6] 19.3 [15.5,23.7] 0.1 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
124 

Figure PRL.07: Percentage of children under age 5 who are stunted, by background characteristics, 

Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

The percentage of children under age 5 who were overweight declined significantly between 2006 and 

2011. In 2006, 15% of children were overweight, compared to 10% in 2011. Declines in the percentage of 

children who were overweight were evident by many characteristics, as shown in Table PRL.11. 

In 2006, a similar percentage of boys and girls under age 5 were overweight (16% and 14%). Both 

experienced significant declines in the percentage overweight, and by 2011, 11% of boys and 9% of girls 

were overweight. In 2011, the difference by child’s sex was significant. By mother’s education level, 

children with mothers with a primary education experienced a significant decline in the percentage 

overweight, from 16% to 7% between the two surveys. Children of mothers with no education and a 

secondary or higher education did not experience a significant change. However, because of the large 

reductions, there was no difference in the percent of children who were overweight by mother’s education 

in 2011. By wealth, the poorest and richest wealth quintiles saw a significant change between the two 

surveys. In 2006, the poorest quintile had the highest percentage of overweight children compared to all 

other quintiles. However, in 2011 the poorest had the lowest although overweight did not differ significantly 

by wealth in 2011. The steep decline for the poorest and richest wealth quintile is shown in Figure PRL.08. 

In 2006, 14% of children in urban areas and 21% of children in rural areas were overweight. By 2011, the 

percentage of overweight children in urban and rural areas converged and were no longer significantly 

different. The percentage of overweight children in rural areas declined by more than half, which accounts 

for this convergence. 
125 

A similar shift occurred by region. In 2006, the lowest percentage of overweight children were in the Beqaa 

Region (10%), but by 2011, Beqaa had the highest percentage of overweight children (15%) compared to 

other regions, although these differences by region were not significant in 2011. The Tripoli Region 

changed from 17% children who were overweight in 2006 to 7% in 2011, while the Tyre Region had a 

similar decline, from 21% to 11%. 

Table PRL.11: Percentage of children under age 5 who are overweight, by background characteristics, 

Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

2006 2011 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 15.3 [13.7,17.1] 10.0 [8.6,11.6] -5.3* 

Child’s sex 

Male 16.4 [14.1,19.1] 11.4 [9.4,13.7] * -5.1* 

Female 14.3 [12.0,17.0] 8.6 [7.0,10.6] -5.6* 

Mother’s education 

None 24.1 [17.6,32.1] * (15.4 [7.1,30.2]) -8.7 

Primary 16.3 [14.3,18.6] 7.2 [4.9,10.4] -9.1* 

Secondary + 9.2 [6.5,12.9] 10.6 [9.0,12.4] 1.4 

Wealth quintile 

Poorest 21.1 [16.4,26.7] * 8.6 [5.7,12.7] -12.5* 

Poorer 10.8 [7.9,14.4] 8.8 [6.3,12.1] -2.0 

Middle 13.2 [10.3,16.7] 9.4 [6.9,12.7] -3.7 

Richer 13.0 [10.0,16.6] 13.1 [9.8,17.4] 0.2 

Richest 19.9 [15.8,24.7] 9.9 [6.9,13.8] -10.0* 

Place of residence 

Urban 13.7 [11.9,15.8] * 10.5 [8.7,12.6] -3.2* 

Rural 20.5 [16.9,24.8] 9.1 [6.9,11.9] -11.5* 

Region 

Tripoli 17.4 [14.2,21.3] * 7.0 [5.2,9.5] -10.4* 

Beirut 13.6 [10.5,17.5] 11.5 [8.2,15.9] -2.1 

Beqaa 10.0 [6.0,16.3] 15.3 [5.9,34.0] 5.3 

Saida 11.6 [8.8,15.1] 10.5 [7.9,13.8] -1.1 

Tyre 21.2 [17.1,26.1] 11.4 [8.2,15.7] -9.8* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
126 

Figure PRL.08: Percentage of children under age 5 who are overweight, by background characteristics, 

Palestinian Refugees of Lebanon 2006 MICS3 and 2011 MICS4 

Under-5 Mortality

In 2011, the PRL had an under-5 mortality rate of 17/1000 live births. This indicator was not available for 

the 2006 survey to observe trends. Children with mothers with no education had the highest mortality rate, 

at 57/1000, compared to 10/1000 for children with mothers with a primary education, and 18/1000 for 

children with mothers with a secondary or higher level of education. However, the confidence intervals for 

children with mothers with no education were very wide. Large disparities existed in under-5 mortality by 

region. The lowest under-5 mortality rate was in Beirut, at 8/1000 live births. Beqaa’s under-5 mortality 

was 30/1000, higher than any other region in Table PRL.12. 

 
127 

Table PRL.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Palestinian Refugees of Lebanon 2011 MICS4 

Variable U5M [C.I.] 

Total 17 [13,24] 

Child’s sex 

Male 19 [12,30] 

Female 16 [10,25] 

Mother’s education 

None 57 [14,206] 

Primary 10 [4,23] 

Secondary + 18 [13,26] 

Wealth quintile 

Poorest 26 [14,46] 

Poorer 15 [7,33] 

Middle 12 [5,28] 

Richer 20 [10,38] 

Richest 14 [6,30] 

Place of residence 

Urban 15 [10,23] 

Rural 22 [14,36] 

Region 

Tripoli 23 [14,36] 

Beirut 8 [2,25] 

Beqaa 30 [11,81] 

Saida 15 [8,29] 

Tyre 19 [8,42] 

Lebanon (Palestinian Refugees) Summary

In 2011, the TFR among the PRL was 2.8 births per woman. The Beqaa Region had the lowest TFR, which 

neared replacement at 2.4. Modern contraceptive use among married women age 15-49 remained steady 

overall at just above 50% between 2006 and 2011, but declined by many characteristics. This was most 

notable in the Beqaa Region, which declined from 58% to 38%. By 2011, Beqaa had the lowest percentage 

of modern contraceptive use by region. In contrast, Beqaa experienced a 10% increase in traditional 

contraceptive use between 2006 and 2011, which was unsurpassed by any other region. There was no 

change in modern or traditional contraceptive use for the PRL overall. 

The ANC and delivery indicators varied. In 2011, 90% of women had the recommended four or more ANC 

visits for their most recent pregnancy, although this was 45% for women age 44-49. Nearly all women 

delivered with an SBA in both 2006 and 2011, and nearly all women delivered in a health facility in both 

years as well. The percentage of women who delivered by C-section was 30% in 2011, but as high as 47% 

among women in the Beqaa Region. 

Child health indicators showed improving trends between 2006 and 2011. Care-seeking for children under 

age 5 with ARI symptoms increased from 44% to 82% overall, and improved by most characteristics when 

sufficient data were available. Less than one-fifth of children under age 6 months were exclusively breastfed 

in 2006 and 2011. Stunting among children under age 5 declined overall, from 20% to 12%, and the 

percentage of children who were overweight decreased from 15% to 10%. In 2006, the Beqaa Region had 

a higher percentage of children who were overweight than any other region, while in 2011, Beqaa had the 

lowest percentage of overweight children compared to the other regions. Finally, under-5 mortality in PRL 

was 17/1000 live births in 2011, although this varied widely, particularly by the mother’s education level. 

The under-5 mortality rate among women with no education was 57/1000 live births, although this estimate 

had a wide confidence interval. 

129 

Libya 

Libya, with an estimated total population of 6.3 million as of 2015, has endured a state of near constant 

conflict since 2011 (Population Reference Bureau 2016). In 2011, uprisings associated with the Arab Spring 

resulted in the overthrow of then president Muammar Gaddafi. Subsequently, Libya began a civil war, 

which continues today. Six years of conflict have made the consistent, accurate collection of public health 

data difficult, particularly in areas controlled by militias and the so-called Islamic State. There are an 

estimated 435,000 internally displaced people in Libya and over 30,000 civilians who have suffered severe 

injuries as a result of the on-going civil war (WHO 2016c). Since 2007, life expectancy at birth has remained 

stable at just below 72 years (World Bank 2017c). In 2016, the total fertility rate was estimated to be 2.3, a 

decrease from 3.0 in 2008 (Population Reference Bureau 2016). In some cases, maternal and child health 

outcomes have improved over the last 10 years although current data are unavailable for certain outcomes. 

The effects of the recent conflict on the Libyan health system have been dramatic, although recent data is 

difficult to collect. 

Improvements in maternal and reproductive health outcomes in Libya are difficult to determine given the 

lack of recent, nation-wide data. The maternal mortality ratio (MMR) has remained steady at 9 maternal 

deaths per 100,000 live births since 2010 (Maternal Mortality Estimation Inter-Agency Group 2016). In 

2008, 99.8% of births were attended by a skilled health professional but this is expected to have decreased 

in recent years due to the deterioration of the health system (World Bank 2017c). A 2014 study assessed 

the attitudes toward antenatal care (ANC) of pregnant women who were attending primary health clinics in 

Benghazi. The authors found that 85% of the women had a high level of knowledge of ANC and 96% had 

a positive attitude toward ANC (Ibrahim, El Borgy, and Mohammed 2014). Nationwide data on delivery 

and birth outcomes are unavailable. A 2014 study compared the prevalence of pre-term birth, low birth 

weight, and cesarean deliveries at a large hospital in Benghazi in the months prior to the 2011 civil war and 

during the height of the conflict. The authors found statistically significant increases in all three indicators 

and suggested that the increases may be due, at least in part, to the psychosocial stress associated with living 

in a conflict zone (Bodalal et al. 2014). 

Data on child and infant health outcomes are available, although the data are dated. Since 2002, the infant 

mortality rate has declined from 19.8 to 14 deaths per 1,000 live births in 2008 (UNICEF et al. 2016). The 

under-5 mortality rate has also decreased over the same time period from 25.8 to 20.1 deaths per 1,000 live 

births (UNICEF et al. 2016). The measles immunization coverage among two-year olds has decreased 

slightly over the past decade from 98% coverage in 2007 to 93% coverage in 2015 (World Bank 2017c). 

Overweight and obesity among children and adolescents are growing concerns. Among adolescents, age 

15-18 years, a survey in Tripoli found that 9.9% and 15.3% of the study population were overweight or 

obese, according to the WHO standard (Musaiger et al. 2016). A second study estimated the prevalence of 

overweight in males under age 20 to be 32.5% and 41.7% in females (Ng et al. 2014). While obesity is a 

growing problem, stunting in children remains significant. A 2009 study that used a nationally 

representative sample of children under age 5 found the stunting prevalence to be 20.7% (El Taguri et al. 

2009). Other health concerns include the potential mental health consequences of the protracted conflict on 

the Libyan population. To date, these effects have not been formally assessed in the Libyan population, 

although at least one study has modeled the potential impacts (Charlson et al. 2012). By using mental health 

prevalence models based on other conflict areas, the authors of this study predicted that among Libyan 

populations directly exposed to conflict, the prevalence of post-traumatic stress disorder may be 12.4% and 

severe depression as high as 19.8% (Charlson et al. 2012). 

Since the beginning of the Arab Spring in 2011, the Libyan health system has deteriorated significantly. 

After the 2011 uprisings, a large portion of medical professionals fled the country and have not yet returned. 

This left Libya with a severe shortage of medical professionals (Terzian 2016). According to WHO, an 
130 

estimated 60% of hospitals have closed in conflict areas or become inaccessible (WHO 2016c). In 2012, 

after the 2011 uprisings, the reality that the Libyan health system was close to collapse prompted a 

conference between the Libyan Ministry of Health and the WHO that focused on rebuilding the health 

system (El Oakley et al. 2013). As a result, there were several recommendations that included free basic 

and preventative health care for all Libyans and a suggested target-level of healthcare spending equivalent 

to 5.5-6% of the country’s GDP by 2030 (El Oakley et al. 2013). As of 2014, Libya’s health expenditure as 

a percent of the GDP was approximately 5% (World Bank 2017c). Currently, there is a high dependence 

on foreign health workers and a substantial portion of government health funds dedicated to a program 

which sends Libyans to other countries for healthcare (WHO 2016c). A 2015 case study examined the 

program of sending injured Libyans abroad for treatment and its impact on the Libyan health system in 

conjunction with the presence of international security forces (Bourdeaux et al. 2015). In this case study, 

key informants argued that the program, which costs approximately $3 billion USD, could have been 

avoided if international security forces had provided more direct health care for those wounded in the 

conflict (Bourdeaux et al. 2015). 

The results discussed below for Libya were produced from the 2007 PAPFAM survey. No other survey 

after 2007 was available for comparison to observe trends in the indicators. A PAPFAM survey was 

conducted in Libya in 2014, although the data were not available for analysis. 

 
131 

Figure Map 6: Libya Map 

Note: See Appendix for a description of regions. 

 
132 

Contraceptive Use

As shown in Table Libya.01, similar percentages of women were using modern and traditional 

contraceptive methods at the time of the survey in 2007 (approximately 20% for both indicators). Modern 

contraceptive use in Libya was the lowest of all the countries included in this report (Overall Summary, 

Figure 2). Conversely, traditional contraceptive use was the highest, although not statistically different from 

Jordan (Overall Summary, Figure 3). 

Compared to women in other age groups, women age 35-44 had the highest proportion of current modern 

contraceptive use and women age 25-34 had the highest rates of traditional contraceptive use. Current use 

of both modern and traditional methods increased with education, although more dramatically for 

traditional methods where the gap between women with no education and secondary or more education was 

more than 10 percentage points. Women with a primary and secondary or more education had similar rates 

of modern contraceptive use and the gap between women with no education and secondary or more 

education was approximately 5 percentage points. 

Modern contraceptive use increased with wealth. A similar trend is observed for traditional method use, 

except in the wealthiest quintile. There was a significant difference between the wealth quintiles for modern 

contraceptive use, although wealth quintile did not differ significantly by traditional contraceptive use. 

Both modern and traditional contraceptive method use varied by region. Modern contraceptive use was the 

highest in the Cyrenaica Region, traditional contraceptive use was highest in Tripolitania, and Fezzan had 

the lowest proportion of women using modern and traditional contraceptive methods. 

Table Libya.01: Percentage of women currently using modern or traditional contraception among women age 

15-49 in a union, by background characteristics, Libya 2007 PAPFAM 

 Modern CPR Traditional CPR 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 19.3 [18.3,20.4] 20.2 [19.2,21.3] 

Age 

15-24 10.8 [7.9,14.6] * 13.7 [10.6,17.6] * 

25-34 15.5 [14.1,17.1] 22.0 [20.4,23.6] 

35-44 23.3 [21.8,24.8] 21.7 [20.2,23.3] 

45-49 20.4 [17.9,23.1] 13.9 [11.5,16.5] 

Education 

None 15.4 [12.9,18.2] * 9.9 [8.2,11.8] * 

Primary 19.4 [17.3,21.7] 19.5 [17.2,22.0] 

Secondary + 19.9 [18.7,21.2] 22.1 [20.9,23.3] 

Wealth quintile 

Poorest 13.6 [11.9,15.4] * 18.3 [16.4,20.4] 

Poorer 17.6 [15.6,19.9] 19.0 [17.0,21.2] 

Middle 19.4 [17.4,21.7] 21.3 [19.1,23.6] 

Richer 23.4 [21.2,25.7] 22.1 [19.9,24.5] 

Richest 24.4 [22.0,27.0] 20.7 [18.4,23.2] 

Region 

Tripolitania 19.0 [17.7,20.5] * 22.6 [21.2,24.1] * 

Cyrenaica 22.1 [20.3,24.1] 16.3 [15.0,17.7] 

Fezzan 11.5 [10.0,13.1] 12.3 [10.9,14.0] 

* Significant p-value. 1 Significance of the covariate in each survey. 

 
133 

Delivery

The vast majority of women in Libya gave birth with a skilled birth attendant (SBA) and delivered in a 

health facility. Although significant differences were found by all characteristics included in Table Libya.02 

except for wealth quintile for health facility delivery, percentages of SBA assisted and health facilities 

deliveries were above 95% for almost all subgroups of women. One exception is in the Fezzan Region, 

which had notably lower percentages of SBA and health facility deliveries compared to the other two 

regions although the percentage was above 90% for both indicators. 

The percentage of women who had a C-section delivery for their most recent birth in Libya was 15% 

overall, although this varied by several characteristics shown in Table Libya.02. The highest percentage of 

C-section delivery was among women age 35-44—more than twice as high as women age 15-24. Delivery 

by C-section increased with level of education. Approximately 8% of women with no education delivered 

their most recent birth by C-section compared to 15-16% of women with primary or secondary or more 

education. C-section delivery did not differ significantly by wealth quintile. There were significant 

differences in C-section delivery by region. The highest percentage of C-section delivery was found in the 

Tripolitania Region (16%), while the lowest was in Fezzan (9%).

Table Libya.02: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant, delivered in a health facility, or delivered by caesarean section in the 2 years before the survey, by 

background characteristics, Libya 2007 PAPFAM 

SBA DHF C-section 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 % [C.I.] Sig.1

Total 98.7 [98.5,98.9] 98.4 [98.1,98.6] 14.9 [13.8,15.9] 

Age 

15-24 99.6 [98.6,99.9] * 99.6 [98.6,99.9] * 8.1 [5.6,11.7] *

25-34 99.2 [98.9,99.4] 98.9 [98.5,99.2] 12.9 [11.6,14.4] 

35-44 98.2 [97.7,98.5] 97.8 [97.3,98.2] 18.3 [16.6,20.0] 

45-49 96.6 [95.1,97.7] 96.2 [94.5,97.4] 12.5 [8.5,18.0] 

Education 

None 95.4 [93.9,96.5] * 95.0 [93.3,96.2] * 7.6 [5.4,10.6] *

Primary 98.2 [97.3,98.8] 97.9 [96.9,98.6] 15.2 [12.7,18.0] 

Secondary + 99.1 [98.9,99.3] 98.8 [98.5,99.0] 15.5 [14.3,16.8] 

Wealth quintile 

Poorest 98.0 [97.3,98.6] * 97.8 [97.0,98.3] 13.7 [11.8,15.9] 

Poorer 98.7 [98.2,99.1] 98.4 [97.8,98.8] 14.5 [12.4,16.8] 

Middle 99.0 [98.6,99.3] 98.6 [98.1,99.0] 16.3 [14.3,18.6] 

Richer 99.1 [98.6,99.4] 98.7 [98.2,99.1] 14.0 [11.9,16.3] 

Richest 98.7 [98.2,99.1] 98.4 [97.8,98.9] 16.0 [13.6,18.8] 

Region 

Tripolitania 99.7 [99.4,99.8] * 99.6 [99.3,99.7] * 15.9 [14.5,17.3] *

Cyrenaica 98.1 [97.5,98.6] 97.7 [97.0,98.3] 13.8 [12.0,15.9] 

Fezzan 92.2 [90.7,93.5] 90.1 [88.4,91.6] 9.4 [8.1,10.9] 

* Significant p-value. 1 Significance of the covariate in each survey.

Child Health Care

Treatment or advice for ARI symptoms was sought for approximately two-thirds of children under age 5 

who exhibited symptoms within the 2 weeks before the survey. This did not vary by the characteristics in 

Table Libya.03, other than the mother’s education. Mothers with no education had a lower rate of careseeking for ARI symptoms for their children compared to women with more education. However, this figure 

was based on a limited number of observations and should be interpreted with caution. Large gaps in careseeking behavior were observed between the wealth quintiles and especially between the poorest and poorer 

quintiles compared to the richest wealth quintile, with approximately 70% in the lowest two wealth quintiles 

compared to 57% in the richest quintile. 
134 

Table Libya.03: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Libya 2007 PAPFAM 

Variable % [C.I.] Sig.1

Total 66.4 [60.7,71.7] 

Child’s sex 

Male 69.3 [61.6,76.0] 

Female 62.9 [53.2,71.6] 

Mother’s education 

None (44.7 [27.1,63.7]) * 

Primary 77.8 [63.6,87.6] 

Secondary + 65.8 [59.0,72.0] 

Wealth quintile 

Poorest 70.3 [59.1,79.5] 

Poorer 71.1 [59.1,80.7] 

Middle 61.0 [46.9,73.6] 

Richer 66.2 [50.6,78.9] 

Richest 57.1 [45.3,68.2] 

Region 

Tripolitania 65.0 [57.6,71.9] 

Cyrenaica 68.5 [59.5,76.3] 

Fezzan 74.6 [61.6,84.3] 

Note: Figures in parenthesis are based on 25-49 

unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Nutrition

As shown in Table Libya.04, the percentage of exclusively breastfed children under age 6 months in Libya 

was 10%, which is among the lowest for the countries in this report (along with Tunisia and Yemen as 

shown in the Overall Summary section, Figure 9). Exclusive breastfeeding did not differ by sex of the child, 

mother’s education, or wealth, which were all near 10%. However, exclusive breastfeeding did differ by 

region. The Tripolitania Region had the highest percentage of exclusive breastfeeding at 12%, while 

exclusive breastfeeding in Fezzan was only 2%. 

 
135 

Table Libya.04: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Libya 2007 PAPFAM 

Variable % [C.I.] Sig.1

Total 9.5 [8.2,11.0]

Child’s sex 

Male 9.9 [8.1,12.0]

Female 9.1 [7.5,11.0]

Mother’s education 

None 10.7 [6.6,16.8]

Primary 9.0 [6.3,12.6]

Secondary + 9.5 [8.0,11.2]

Wealth quintile 

Poorest 8.4 [6.2,11.3]

Poorer 9.0 [6.5,12.1]

Middle 9.3 [7.1,12.2]

Richer 9.8 [7.2,13.2]

Richest 12.2 [9.1,16.2]

Region 

Tripolitania 11.6 [9.7,13.8] *

Cyrenaica 6.6 [5.2,8.3]

Fezzan 1.9 [1.1,3.3] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Under-5 Mortality

The under-5 mortality rate in Libya was 20 deaths per 1000 live births. Under-5 mortality for male children 

was 25, compared to 15 for female children. Under-5 mortality was highest for children of mothers with no 

education and lowest for those in the richer wealth quintile at 10 deaths per 1000 live births. For the richest 

wealth quintile, it was 15 deaths. Differences in under-5 mortality were evident by region as well. While 

Tripolitania and Cyrenaica’s under-5 mortality rates were 19 and 16 respectively, Fezzan had an under-5 

mortality rate of 41, which was twice as high as Tripolitania. 

Table Libya.05: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Libya 2007 PAPFAM 

Variable U5M [C.I.] 

Total 20 [17,24]

Child’s sex

Male 25 [20,31]

Female 15 [12,18]

Mother’s education

None 28 [19,40]

Primary 23[16,34]

Secondary + 19 [15,23]

Wealth quintile

Poorest 23 [17,31]

Poorer 22 [16,31]

Middle 26 [18,35]

Richer 10 [7,16]

Richest 15 [11,22]

Region

Tripolitania 19 [15,24]

Cyrenaica 16 [12,23]

Fezzan 41 [33,50] 
136 

Libya Summary

About 20% of married women age 15-49 in Libya used a form of modern or traditional contraception in 

2007. The lowest percentage of modern contraceptive use was among women age 15-24 and women in the 

Fezzan Region. The highest percentage of modern contraceptive use was among women in the richest 

wealth quintile. 

Delivery indicators were high overall. Nearly all women delivered their most recent pregnancy with an 

SBA and at a health facility (99% and 98%). This ranged very little by most background characteristics. 

However, the Fezzan Region had the lowest percentage of women giving birth with assistance from an SBA 

or at a health facility (92% and 90%). C-section delivery was 15% overall, but varied widely from 8% of 

women age 15-24 and women with no education to 18% of women age 35-44. 

Care was sought for two-thirds of children under age 5 with ARI symptoms in the 2 weeks prior to the 

survey. However, only 10% of children under age 6 months were exclusively breastfed. Under-5 mortality 

was 20/1000 live births. The Fezzan Region had the highest under-5 mortality rate at 41/1000. In general, 

the Fezzan Region fared worse than the Tripolitania and Cyrenaica regions across most indicators included 

in the report. 
137 

Morocco 

In 2015, Morocco had an estimated total population of 34.7 million people (Population Reference Bureau 

2016). In 2011, protests throughout Morocco spurred by uprisings across the region during the Arab Spring. 

Despite recent turmoil in the region, Morocco has largely escaped much of the violence and social upheaval 

associated with other Arab Spring uprisings. Over the past decade, health outcomes in Morocco have 

generally improved across maternal, reproductive, and child health indicators. Many of these improvements 

are due to the different programs and health infrastructure improvements spearheaded by the government 

during the last 15 years (Abdesslam 2012; Abouchadi, Belghiti Alaoui, et al. 2013; Boutayeb et al. 2016). 

These include expanding insurance coverage, increasing access to healthcare, and improving data 

collection. Despite the overall improvement in public health, disparities by wealth, geographic location, 

and other sociodemographic characteristics remain. The results of a 2011 national survey demonstrate that 

Morocco has entered the final phase of a demographic transition with falling fertility rates and increasing 

life expectancy at birth (Abdesslam 2012). 

Beginning in the early 2000s, the Moroccan government specifically prioritized maternal health, and 

maternal and reproductive health outcomes have improved (Van Lerberghe et al. 2014). The government 

plan included three broad goals that include reducing geographical and financial barriers to obstetric care, 

improving the quality of obstetric care, and improving or expanding programs dedicated to maternal health 

(Boukhalfa et al. 2016). An audit of maternal deaths in Morocco in 2009 found that 76% of maternal deaths 

were preventable (Abouchadi, Alaoui, et al. 2013). Several major programs emerged from the government’s 

maternal and obstetric care plan such as a formal maternal mortality surveillance program, begun in 2009 

by the Ministry of Health, which has helped expand knowledge and improve maternal health data in 

Morocco (Abouchadi, Belghiti Alaoui, et al. 2013). The maternal mortality ratio (MMR) has declined over 

the past 10 years, and has decreased from 190 in 2005 to 121 maternal deaths per 100,000 live births in 

2015, although there are considerable disparities across urban and rural locations (Maternal Mortality 

Estimation Inter-Agency Group 2016). For example, in 2010 the MMR among rural women was 148 

compared with 73 among urban women (Boutayeb et al. 2016). The Moroccan Ministry of Health recently 

stated that the 2017 National Survey on Population and Family Health, which has yet to be formally 

published, found an MMR of 72.6 that indicated a steep decline (Maroc.ma 2017). A 2014 case study 

suggested that some of this decline may be due to the revitalization and expansion of midwifery and nursemidwives as birth attendants in Morocco (Van Lerberghe et al. 2014). 

A second major program that resulted from the government’s focus on maternal health is the Free Delivery 

and Cesarean Policy, which entitles all Moroccan women to a cost-free delivery in any public hospital 

(Boukhalfa et al. 2016). A 2016 assessment of this policy found that it has largely eliminated costs for 

women who deliver at public hospitals, although almost no delivery was cost-free because of prescriptions 

given to women at the time of hospital discharge (Boukhalfa et al. 2016). The percentage of women who 

delivered in facilities as well as the percentage of births attended by a skilled medical professional have 

increased overall and across wealth quintiles over the past 10 years (Van Lerberghe et al. 2014). Despite 

these gains, large disparities remain. In 2011, women in the richest quintile delivered in facilities nearly 

100% of the time, while women in the lowest wealth quintile delivered in facilities approximately 40% of 

the time (Van Lerberghe et al. 2014). Further highlighting socioeconomic disparities in maternal health in 

Morocco, one recent study examined self-reported maternal morbidity among women in Marrakesh. The 

authors found a maternal morbidity prevalence of 13.1% and that illiterate women had a 24% increase in 

the odds of experiencing maternal morbidity compared with their literate counterparts (Elkhoudri, Amor, 

and Baali 2015). A second study also found an association between illiteracy and severe maternal morbidity, 

with illiterate women more than twice as likely to suffer a “near miss” compared to literate women (Assarag 

et al. 2015). Reproductive health indicators such as contraceptive prevalence have increased but remain 

somewhat low. For example, the contraceptive prevalence rate among women of reproductive age was 67% 
138 

in 2016 (Population Reference Bureau 2016). The knowledge and acceptability of the HPV vaccine was 

also studied in a sample of Moroccan parents. This study was especially important because cervical cancer 

is the second most common form of cancer in women in Morocco. The authors found that no parents had 

vaccinated their daughters against HPV and less than 5% of parents demonstrated awareness of HPV 

infection (Mouallif et al. 2014). 

Child and infant health indicators have improved over the past decade. The infant mortality rate has declined 

from 32 in 2007 to 23.7 infant deaths per 1,000 live births in 2015 (World Bank 2017d). The under-5 

mortality rate has declined from 32 to 27.6 deaths per 1,000 live births over the same time period (World 

Bank 2017d). A 2015 study examined predictors of prematurity in a maternity ward in Rabat. The authors 

found that low levels of maternal education, low utilization of prenatal care, and multiparity were highly 

associated with preterm birth in the study population (Sabiri et al. 2015). Vaccination coverage among 

children is high at over 99% at a national level (Boutayeb et al. 2016). Among rural children, vaccination 

coverage has improved from 87% in 2003 to 100% in 2011 (Boutayeb et al. 2016). Breastfeeding initiation 

is common in Morocco, however, although weaning before age 6 months is an increasing practice 

(Adarmouch et al. 2013). Morocco is similar to other countries in the region and is undergoing a nutritional 

transition, which includes over-nutrition as an increasing public health concern (Musaiger et al. 2016; Ng 

et al. 2014). In 2015 10.7% of children under age 5 were considered overweight or obese, ranking Morocco 

100 of 126 countries worldwide (International Food Policy Research Institute 2016). A second study, which 

examined anemia in school-aged children, found an anemia prevalence of 16.2% (Achouri et al. 2015). The 

study also found that anemia was highly positively associated with the education level of the mother 

(Achouri et al. 2015). 

After the 2011 protests, Morocco adopted a new constitution that included articles which detailed the right 

to universal access to quality healthcare (Tinasti 2015). The healthcare system still faces large challenges 

before these goals can be achieved. It is estimated that 24% of the population has difficulties accessing 

healthcare services, and this is further compounded by an acute shortage of medical professionals (Tinasti 

2015). In 2013, the percentage of out-of-pocket expenditures on health as a proportion of the total 

expenditure on health reached 88% (Tinasti 2015). However, there have been some positive changes. Since 

2000, the percentage of Moroccans with health insurance has increased from 15% to 60% in early 2015 

(Boutayeb et al. 2016). Much of this increase in health insurance coverage occurred as a result of the two 

large health insurance schemes created by the government in 2005 (Tinasti 2015). The first scheme, the 

Mandatory Medical Insurance (AMO), provides coverage for public and private employees. The second, 

the Medical Assistance Scheme (RAMED), provides financial protection from out-of-pocket health 

expenses for the poorest Moroccans (Tinasti 2015). In 2005, Morocco implemented a nation-wide quality 

improvement intervention aimed at hospitals, community health centers, and other institutions that provide 

health care. A 2014 evaluation of the intervention found substantial improvement among participating 

institutions that included improved communication and broader dissemination of best practices (Sahel et 

al. 2015). 

The results discussed below for Morocco were produced from the 2011 PAPFAM survey. No other survey 

after 2011 was available for comparison to observe trends in the indicators. 

 
139 

Figure Map 7: Morocco Map 

Note: See Appendix for a description of regions. 

 
140 

Contraceptive Use

As shown in Table Morocco.01, 54% of women used a modern contraceptive method at the time of the 

2011 survey. In contrast, 8% of women were using a traditional method. Modern contraceptive use only 

differed by age, place of residence, and region while traditional contraceptive use differed by all 

characteristics in Table Morocco.01. 

Modern contraceptive use did not differ significantly by education or wealth. Over 50% of women with all 

levels of education and wealth used modern contraception. However, the proportions differed by age. 

Women age 25-34 and 35-44 had higher rates of current modern contraceptive use than women age 15-24 

or age 45-49. Modern contraceptive use was significantly more common in rural areas compared to urban, 

and also varied by region. The Central/Tensift Region had the largest percentage of women who used 

modern contraception (61%), while the Northwest Region had the lowest (48%). In contrast, the Northwest 

Region had the largest proportion of women who use traditional contraceptive methods, while the 

Central/Tensift Region had the lowest. Traditional contraceptive use differed by all characteristics, as 

shown in Table Morocco.01. In contrast to modern contraceptive use, traditional contraceptive use 

increased with age. The oldest women (age 45-49) had a higher rate of traditional contraceptive use 

compared to women in the younger age groups. In addition, traditional contraceptive method use increased 

with education. Compared to women with no education or a primary education, women with a secondary 

or more education used traditional contraceptive methods at a higher rate. Traditional contraceptive method 

use was significantly higher in urban areas compared to rural, and differed by region. 

Table Morocco.01: Percentage of women currently using modern or traditional contraception among women 

age 15-49 in a union, by background characteristics, Morocco 2011 PAPFAM 

Modern CPR Traditional CPR 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 53.9 [52.6,55.3] 7.8 [7.1,8.7] 

Age 

15-24 47.1 [44.2,49.9] * 3.8 [2.8,5.1] * 

25-34 59.6 [57.7,61.5] 6.7 [5.7,7.9] 

35-44 58.1 [55.9,60.2] 9.8 [8.7,11.0] 

45-49 38.6 [35.7,41.5] 10.0 [8.3,12.0] 

Education 

None 54.2 [52.5,55.9] 7.2 [6.4,8.2] * 

Primary 52.9 [50.6,55.2] 8.6 [7.3,10.1] 

Secondary + 53.9 [49.8,58.0] 12.3 [9.9,15.3] 

Wealth quintile 

Poorest 54.7 [50.8,58.6] 6.2 [4.4,8.5] * 

Poorer 54.0 [51.1,56.8] 5.7 [4.4,7.3] 

Middle 54.6 [52.0,57.2] 6.4 [5.3,7.9] 

Richer 52.3 [49.7,54.9] 9.1 [7.8,10.7] 

Richest 53.9 [51.5,56.4] 12.1 [10.4,14.0] 

Place of residence 

Urban 52.5 [51.1,54.0] * 9.6 [8.7,10.5] * 

Rural 55.6 [53.1,58.1] 5.7 [4.6,7.2] 

Region 

Central/Tensift 60.5 [58.6,62.3] * 4.7 [4.0,5.6] * 

Northwest 47.7 [45.0,50.3] 12.3 [10.6,14.3] 

South Central 51.9 [47.0,56.8] 7.1 [5.2,9.8] 

North Central 49.3 [45.4,53.2] 11.3 [8.5,14.9] 

Eastern 55.8 [51.7,59.7] 5.3 [3.6,7.8] 

Southern 50.8 [45.2,56.4] 7.6 [5.4,10.7] 

* Significant p-value. 1 Significance of the covariate in each survey. 
141 

Antenatal Care

As shown in Table Morocco.02, under half of women in Morocco in 2011 had four or more ANC visits for 

their most recent pregnancy in the 2 years before the survey. This differed by education, wealth, and place 

of residence. 

Although the ANC indicator did not differ significantly by age, 21% of women age 45-49 attended four or 

more ANC visits compared to close to 40% in the remaining age groups. Women with a secondary or more 

education had drastically higher percentages of four or more ANC visits (close to 85%), compared with 

women with no education or primary education at 33% and 58% respectively. In addition, the percentage 

of women who had four or more ANC visits increased with wealth. While 12% of the poorest women had 

four or more ANC visits, 76% of the richest women did. Although ANC differed by place of residence and 

was significantly higher in urban areas, it did not differ significantly by region. However, the North Central 

Region had the lowest percentage of four or more ANC visits at 33%, compared to 60% in the South Central 

Region. 

Table Morocco.02: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Morocco 2011 PAPFAM 

Variable % [C.I.] Sig.1

Total 41.7 [38.4,45.1] 

Age 

15-24 39.9 [35.7,44.2] 

25-34 42.4 [38.2,46.7] 

35-44 43.6 [38.4,48.9] 

45-49 21.0 [10.8,36.8] 

Education 

None 32.8 [29.2,36.6] * 

Primary 58.0 [53.7,62.3] 

Secondary + 84.8 [76.9,90.3] 

Wealth quintile 

Poorest 11.8 [7.8,17.4] * 

Poorer 30.1 [24.6,36.3] 

Middle 47.9 [42.6,53.3] 

Richer 63.3 [58.2,68.0] 

Richest 76.2 [69.9,81.4] 

Place of residence 

Urban 61.9 [58.5,65.3] * 

Rural 24.4 [20.2,29.2] 

Region 

Central/Tensift 41.7 [36.3,47.2] 

Northwest 41.4 [36.6,46.5] 

South Central 60.0 [48.1,70.8] 

North Central 33.3 [25.2,42.6] 

Eastern 40.3 [24.1,58.8] 

Southern 41.6 [32.2,51.6] 

Notes: * Indicates a significant p-value. 1 Significance of 

the covariate in each survey. 

Delivery

Table Morocco.03 shows that approximately three-fourths of Moroccan women gave birth with the 

assistance of a skilled birth attendant (SBA) or delivered in a health facility (DHF). Percentages of women 

delivering with an SBA differed by age category, education level, wealth quintile, and place of residence. 
142 

These differences differed significantly by education, wealth quintile, and place of residence for the health 

facility delivery indicator. 

Compared to women in older age groups, women age 15-24 had higher rates of SBA use (80% of women 

age 15-24 compared to 50% of women age 45-49). This pattern was consistent for giving birth in a health 

facility as well, with three-quarters of women age 15-24 delivering in a health facility compared to 58% of 

women age 45-49. However, the differences of health facility delivery by age were not significant. Nearly 

all women with a secondary or more education gave birth with an SBA or in a health facility (98%). This 

contrasts with the smaller proportions of women with no education giving birth with an SBA or in a health 

facility (71% and 66% respectively). 

Percentages of women with SBA assisted deliveries and health facility deliveries both increased with 

wealth. In the richest wealth quintile, nearly all women delivered their most recent birth with assistance by 

an SBA and the majority (95%) delivered in a health facility. In comparison, half of women in the poorest 

wealth quintile delivered with an SBA, and less than half (41%) delivered in a health facility. 

While 94% of women in urban areas gave birth with an SBA, women in rural areas were significantly less 

likely to do so (64%). This was similar for health facility deliveries with 93% of urban women who 

delivered in a health facility compared to 56% of rural women. Percentages of SBA assisted and health 

facility deliveries did not differ significantly by region, although the highest percentage for both indicators 

was found in the South Central Region. 

Table Morocco.03: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant or delivered in a health facility in the 2 years before the survey, by background characteristics, 

Morocco 2011 PAPFAM 

SBA DHF 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 77.6 [74.3,80.5] 73.2 [68.9,77.0] 

Age 

15-24 80.1 [75.5,84.0] * 75.1 [69.0,80.4] 

25-34 77.0 [72.8,80.7] 73.8 [68.8,78.2] 

35-44 77.4 [73.0,81.2] 70.4 [64.6,75.6] 

45-49 50.3 [36.7,63.8] 57.7 [45.5,68.9] 

Education 

None 70.6 [66.9,74.0] * 65.9 [60.8,70.6] * 

Primary 93.0 [89.4,95.5] 88.9 [84.6,92.1] 

Secondary + 99.7 [97.5,100.0] 98.0 [93.1,99.4] 

Wealth quintile 

Poorest 50.5 [44.5,56.5] * 41.4 [34.2,49.0] * 

Poorer 72.4 [66.7,77.5] 67.5 [60.3,73.9] 

Middle 86.0 [81.3,89.7] 87.0 [83.0,90.1] 

Richer 95.1 [92.6,96.7] 92.1 [89.0,94.4] 

Richest 98.8 [96.9,99.6] 94.5 [88.9,97.4] 

Place of residence 

Urban 93.6 [91.3,95.3] * 92.9 [90.6,94.7] * 

Rural 63.8 [58.9,68.4] 56.3 [49.7,62.6] 

Region 

Central/Tensift 75.3 [69.5,80.2] 76.7 [70.0,82.3] 

Northwest 80.6 [75.9,84.6] 74.0 [68.2,79.2] 

South Central 86.7 [77.6,92.5] 82.2 [74.5,87.9] 

North Central 74.7 [66.7,81.3] 65.7 [52.4,76.9] 

Eastern 77.6 [56.6,90.2] 74.0 [44.7,91.0] 

Southern 77.1 [66.4,85.2] 64.9 [51.2,76.5] 

* Significant p-value. 1 Significance of the covariate in each survey. 
143 

Child Health Care

Almost half of Moroccan children under age 5 had treatment sought for their ARI symptoms. In Table 

Morocco.04, care-seeking for ARI symptoms differed significantly by wealth quintile, place of residence, 

and region but not the child’s sex or mother’s education. The richest quintile had the highest percentage of 

care-seeking for ARI symptoms (68%), while the poorest wealth quintile had the lowest (27%). A higher 

percentage of those in urban residences sought advice or treatment for children with ARI symptoms 

compared to those in rural areas. By region, the Eastern region had the highest percentage of care-seeking 

although this was based on a few observations. The lowest percentage was found in the North Central 

region. 

Table Morocco.04: Percentage of children under age five who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Morocco 2011 PAPFAM 

Variable % [C.I.] Sig.1

Total 45.0 [39.6,50.6] 

Child’s sex 

Male 45.5 [37.8,53.4] 

Female 44.5 [36.6,52.7] 

Mother’s education 

None 42.1 [35.6,48.9] 

Primary 54.1 [43.9,64.0] 

Secondary + ND 

Wealth quintile 

Poorest 27.1 [18.1,38.5] * 

Poorer 46.8 [33.2,61.0] 

Middle 53.2 [43.9,62.3] 

Richer 46.8 [34.3,59.8] 

Richest 67.8 [55.1,78.4] 

Place of residence 

Urban 57.1 [49.7,64.1] * 

Rural 33.3 [25.7,41.8] 

Region 

Central/Tensift 43.7 [34.5,53.5] * 

Northwest 47.1 [34.9,59.5] 

South Central (39.8 [23.0,59.4]) 

North Central 28.8 [20.8,38.4] 

Eastern (60.3 [37.6,79.3]) 

Southern 57.3 [40.0,73.0] 

Note: ND indicates figures are not shown because they 

were based on fewer than 25 unweighted cases. Figures 

in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Nutrition

Table Morocco.05 shows that a quarter of all children (both male and female) under age 6 months in 

Morocco were exclusively breastfed. This differed significantly only by wealth quintile. The richest wealth 

quintile had the lowest proportion of children breastfed with 17% of exclusively breastfed children. The 

highest proportion of exclusive breastfeeding was among those in the poorest wealth quintile with more 

than a third of children under age 6 months exclusively breastfed. While not significant, rural residences 

trended toward higher percentages of exclusive breastfeeding compared to urban residences. 
144 

Table Morocco.05: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Morocco 2011 PAPFAM 

Variable % [C.I.] Sig.1

Total 26.0 [21.8,30.7] 

Child’s sex 

Male 26.6 [21.6,32.3] 

Female 25.2 [19.7,31.8] 

Mother’s education 

None 26.9 [21.9,32.7] 

Primary 24.6 [18.0,32.7] 

Secondary + (19.9 [10.1,35.4]) 

Wealth quintile 

Poorest 35.3 [25.9,46.1] * 

Poorer 26.0 [18.3,35.6] 

Middle 19.5 [12.5,29.1] 

Richer 26.8 [19.0,36.3] 

Richest 17.0 [9.5,28.6] 

Place of residence 

Urban 21.9 [17.5,26.9] 

Rural 29.3 [22.6,37.0] 

Region 

Central/Tensift 27.0 [20.1,35.3] 

Northwest 23.6 [14.9,35.3] 

South Central (23.2 [12.6,38.8]) 

North Central 25.9 [16.4,38.3] 

Eastern 26.5 [19.0,35.7] 

Southern 28.5 [15.7,46.1] 

Note: Figures in parenthesis are based on 25-49 

unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Morocco Summary

Over half of Moroccan women used a method of modern contraception. Modern contraceptive use reached 

61% in Central/Tensift Region. In contrast, only 8% of women used a method of traditional contraception. 

The ANC and delivery indicators were low in Morocco. Fewer than half of women had the recommended 

four or more ANC visits during their most recent pregnancy (42%), although this varied widely, particularly 

by education level and wealth quintile. A third of women with no education had four ANC visits, compared 

to 85% of women with a secondary or higher level of education. Three quarters of women in the richest 

wealth quintile had four ANC visits, while only 12% of women in the poorest quintile did. Delivery with 

an SBA was 78% overall, and lowest among women in the poorest wealth quintile and women age 45-49, 

while delivery with an SBA reached 100% among women with a secondary or higher level of education. 

Health facility delivery showed a similar trend. While 73% of women delivered at a health facility overall, 

41% of the poorest women did compared to 95% of the richest women. 

Care was sought for fewer than half of children under age 5 with ARI symptoms in the 2 weeks before the 

survey. This varied by wealth, urban/rural residence, and region. While care was sought for 27% of children 

in the poorest quintile, care was sought for 68% of children in the richest quintile. A quarter of children 

under age 6 months were exclusively breastfed, and this varied significantly by wealth. The highest 

percentage of children exclusively breastfed were in the poorest quintile, at 35%, and the lowest percentage 

was in the richest quintile at 17%. 
145 

Syria 

Since 2011, Syria has been embroiled in a violent, complex civil war that has had devastating consequences 

for maternal, reproductive, and child health. The ongoing health and safety impact of the conflict has been 

extreme, precipitating an almost complete collapse of the health system. By late 2016, the Syrian Centre 

for Policy Research estimated that 470,000 Syrians have been killed and nearly 2 million wounded since 

fighting began in 2011 (Nasser et al. 2016). Estimates for 2016 suggest that 10.9 million Syrians are 

internally displaced and 4.8 million Syrians are refugees, who have fled primarily to Lebanon, Jordan, Iraq, 

and Turkey (Nasser et al. 2016). A great deal of evidence has indicated that the health of the Syrian refugees 

has been greatly affected and includes higher risks for gender based violence and child marriage (Klann 

2014; UN Women 2013; UNFPA 2017). By 2016, 45% of the population had been displaced and the 

poverty rate skyrocketed to 85.2% (Nasser et al. 2016; WHO 2016d). An estimated 69.3% of those in 

poverty are categorized as living in “extreme poverty” which means that they are unable to secure the basic 

items required for survival (Nasser et al. 2016; WHO 2016d). In just four years, life expectancy has declined 

from 70.5 years in 2010 to 55.4 in 2015 (Nasser et al. 2016). The intensity of the fighting has made it 

difficult to collect data on common public health indicators such as maternal or infant mortality. The 

information that has been collected indicates a universal decline in the health and safety of the Syrian 

population. 

Although there is limited data, experts estimated that virtually every maternal and reproductive health 

indicator in Syria has regressed since 2011. Prior to the civil war, the overwhelming majority of Syrian 

women delivered with the help of a skilled medical professional (Save the Children 2014). Recent evidence 

indicates that there has been a large shift towards unassisted births in response to the lack of medical 

personnel, difficulties in reaching health facilities, and an overall dearth of access to reproductive healthcare 

(Save the Children 2014). Furthermore, the collapse of the healthcare system has made accessing antenatal 

and postpartum care extremely difficult (Save the Children 2014). One indication of this is the documented 

increase in the prevalence of cesarean sections. Since 2011, the cesarean section prevalence has doubled 

from 19% in 2011 to 45% in 2013 (Save the Children 2014). Experts attribute this increase to women 

wanting to ensure they do not go into labor in an insecure or inaccessible setting, and therefore scheduling 

their deliveries (Save the Children 2014). Prior to the civil war, researchers conducted a maternal mortality 

audit with data from 1989-2008 to better understand the levels and causes of maternal mortality in Syria 

(Almerie, Matar, and Almerie 2011). The authors found that over that 20 year period, 40.7% of maternal 

deaths resulted from hemorrhage, while the second and third leading causes of death were hypertensive 

disorders and embolism, respectively (Almerie, Matar, and Almerie 2011). A study that used data from 

2003 investigated the causes for every maternal death in Syria for that year and determined that 54% of 

maternal deaths were due to poor clinical skill or lack of clinical competency (Bashour et al. 2009). A 

similar study that used data prior to 2011 examined the prevalence and causes of maternal near-miss cases 

in Damascus, which are defined as a woman who nearly died but survived a complication that occurred 

during pregnancy, childbirth or within 42 days of termination of pregnancy (Almerie et al. 2010). The 

authors found a maternal near-miss rate of 32.9 per 1,000 live births, with hypertensive disorders and 

hemorrhage as the leading causes of a near-miss case (Almerie et al. 2010). A second study from 2011 

found a maternal near-miss rate of 4.5. However, the data were collected over a 12-week period in 2011, in 

contrast to the first study that used data over a multi-year period from 2006-2007 (Bashour et al. 2015). 

Current infant and child health indicators are difficult to collect reliably, although there is reason to believe 

that much of the progress made toward reducing child mortality before 2011 has since been erased. By 

2016, nearly 17,000 children had been killed since the beginning of the war (Elsafti et al. 2016). Prior to 

the current conflict, 15% of under-5 mortality was attributable to pneumonia and diarrhea. However, by 

2014, that mortality has doubled to over 30% (Save the Children 2014). Since 2009, vaccination coverage 

among children for measles, polio, and DTP has fallen from 99% to 63%, 57%, and 51% respectively in 
146 

2016 (WHO 2016d). In June 2017, the WHO reported that 17 children had been paralyzed by polio, which 

marked the second large outbreak of polio in Syria since the beginning of the war (Gladstone 2017). The 

first outbreak involved 36 lab-confirmed cases of polio, although one study estimates that the true number 

of cases was more than 80 based on clinical diagnosis (Tajaldin et al. 2015). A 2015 survey of 1,000 children 

from various governorates found that 15% did not have access to safe drinking water or adequate nutrition, 

and over 50% did not have access to education (Elsafti et al. 2016). There is also evidence that the 

prevalence of breastfeeding, both immediately after birth and exclusively until age 6 months, has decreased 

(Devakumar et al. 2015). Overall, it is estimated that two million Syrian children are under-nourished 

(Devakumar et al. 2015). A 2015 cross-sectional survey of children in the northwestern sections of Syria 

found that 32% of surveyed children had clinical symptoms of malnutrition (Elsafti et al. 2016). 

Since the start of the war, healthcare facilities and health workers have been consistent targets, with 

escalation in frequency in recent years and in violation of international humanitarian law set forth in the 

Geneva Convention (Fouad et al.). In 2016, there were 207 reported attacks on healthcare facilities and 

personnel in Syria, which represents an 89% increase in targeted attacks from 2015 (Fouad et al.; WHO 

2016a). Between 2011 and early 2017, 814 medical personnel were killed, with medical doctors as the 

largest percentage of fatalities (Fouad et al.). In response to the targeted attacks, an estimated 50% of Syria’s 

medical doctors have left the country, a reality that compounded the bleak healthcare situation (Fouad et 

al.). The number of doctors on a per-capita basis declined from 1 doctor per 800 residents in 2010 to an 

estimated 1 doctor per 7,000 residents in 2015 (Fouad et al.). Some data suggest that 27% of the Syrian 

population may live in areas completely devoid of trained healthcare personnel (Fouad et al.). Only half of 

the public hospitals and healthcare centers that existed prior to 2011 remain operational, and the rest have 

either closed or are only partially functional (WHO 2016d). According to the WHO, trauma is now the 

leading cause of morbidity and mortality in Syria (WHO 2016d). A 2016 assessment of trauma hospitals in 

Syria found that just 16% of hospitals had a functioning inpatient ward to care for patients after surgery 

(Mowafi et al. 2016). The authors also found that just 23% of trauma hospitals had a fixed x-ray machine 

and that half relied on supply routes that were never or only occasionally open (Mowafi et al. 2016). Prior 

to the civil war, Syria had one of the stronger health infrastructures in the region, with a focus on primary 

and preventative health care (Sen and Al-Faisal 2013). Syria also had a strong pharmaceutical industry that 

produced 90% of the pharmaceutical need within Syria, but since the start of the war, this has declined to 

10% (Ben Taleb et al. 2015). 

This literature review is based on the most recent reports and data. However, the following analysis uses 

MICS survey data collected in 2006, prior to the start of the current conflict. The results discussed below 

for Syria were produced from the 2006 MICS survey. No other survey after 2006 was available for 

comparison to observe trends in the indicators. It is important to note that these results should be viewed as 

a baseline and that indicators are expected to have deteriorated in response to the escalating violence in 

Syria since 2011. 

 
147 

Figure Map 8: Syria Map 

Note: See Appendix for a description of regions. 

 
148 

Contraceptive Use

Almost half (45%) of women in Syria used modern contraception at the time of the MICS3 survey in 2006. 

This varied by all characteristics in Table Syria.01. Modern contraceptive use increased with education, 

wealth, and age, except for women age 45-49. Urban women had a higher percentage of modern 

contraceptive use than rural women by about 10-percentage points. Modern contraceptive use varied by 

region, and was the highest in North and Central regions (47% and 49%), and lowest in East Region (32%). 

Current traditional contraceptive use was 13% in 2006. Traditional contraceptive use increased with age 

and education. Use also increased with wealth, except for the richer quintile, which had lower use than the 

middle quintile by 1%. Traditional contraceptive use did not vary by place of residence, but did vary by 

region. The North and Central regions had the highest percent of traditional use at 14% and 17%, while the 

East and South regions were considerably lower at 7% and 5%. 

Table Syria.01: Percentage of women currently using modern or traditional contraception among women age 

15-49 in a union, by background characteristics, Syria 2006 MICS3 

Modern CPR Traditional CPR 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 45.1 [44.1,46.1] 13.2 [12.5,13.9] 

Age 

15-24 28.6 [26.7,30.6] * 7.5 [6.4,8.7] * 

25-34 48.6 [47.1,50.1] 11.6 [10.7,12.6] 

35-44 52.9 [51.3,54.5] 16.4 [15.3,17.6] 

45-49 33.6 [31.0,36.3] 17.5 [15.6,19.7] 

Education 

None 36.5 [34.4,38.6] * 8.8 [7.6,10.0] * 

Primary 46.3 [44.6,48.0] 11.2 [10.2,12.2] 

Secondary + 47.9 [46.5,49.2] 16.6 [15.6,17.7] 

Wealth quintile 

Poorest 34.1 [31.4,36.8] * 7.8 [6.6,9.0] * 

Poorer 40.8 [38.8,42.8] 12.0 [10.8,13.5] 

Middle 46.2 [44.2,48.2] 15.0 [13.7,16.5] 

Richer 49.6 [47.6,51.6] 14.1 [12.7,15.5] 

Richest 52.4 [50.4,54.5] 15.9 [14.5,17.4] 

Place of residence 

Urban 49.7 [48.3,51.0] * 13.8 [12.9,14.8] 

Rural 39.3 [37.7,41.0] 12.4 [11.5,13.5] 

Region 

North 47.2 [45.5,48.9] * 13.5 [12.5,14.6] * 

East 31.8 [29.3,34.3] 7.3 [6.2,8.7] 

Central 48.9 [47.2,50.5] 16.5 [15.2,17.8] 

South 37.5 [34.4,40.8] 4.9 [3.6,6.6] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Delivery

Ninety-one percent (91%) of women delivered their most recent birth with an SBA in the 2 years before 

the 2006 survey, although this varied by all characteristics shown in Table Syria.02. SBA use declined as 

age increased. Women age 45-49 who delivered with assistance by an SBA were 20-percentage points less 

than women age 15-24 (71% vs. 93%). The use of an SBA increased with education. Most (97%) of women 

with a secondary or higher level of education used an SBA. Except for a slight decline between the middle 

and richer wealth quintiles, SBA use increased with wealth. Nearly all women in the richest quintile gave 

birth with an SBA, compared to 75% of women in the poorest quintile. A significantly higher percent of 
149 

women in urban areas used an SBA compared to women in rural areas. In addition, SBA use varied by 

region. The East Region had the lowest percentage of SBA use at 79%, compared to 97% of women in the 

Central Region. 

More than two-thirds of women delivered their most recent birth in a health facility within the 2 years 

before the survey in 2006. This varied by all characteristics in Table Syria.02. Health facility use increased 

with higher education and wealth, and showed a decreasing trend with age. A significantly higher percent 

of women in urban areas delivered in a health facility compared to women in rural areas. Health facility 

births also varied by region. The North Region had the smallest percent of women who gave birth in a 

health facility, compared to the Central Region which had the largest (65% vs. 83%). 

Table Syria.02: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant or delivered in a health facility in the 2 years before the survey, by background characteristics, 

Syria 2006 MICS3 

SBA DHF 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 91.4 [90.2,92.6] 70.4 [68.6,72.2] 

Age 

15-24 93.3 [91.2,94.9] * 73.3 [70.5,76.0] * 

25-34 91.7 [90.1,93.0] 69.1 [66.7,71.5] 

35-44 88.9 [86.4,91.0] 69.3 [65.8,72.6] 

45-49 71.1 [54.5,83.4] 60.5 [43.9,75.0] 

Education 

None 74.1 [69.7,78.0] * 51.9 [47.3,56.5] * 

Primary 91.6 [89.8,93.1] 66.3 [63.3,69.1] 

Secondary + 97.1 [96.2,97.8] 80.1 [78.1,82.1] 

Wealth quintile 

Poorest 74.9 [70.7,78.6] * 55.3 [50.7,59.8] * 

Poorer 93.0 [91.0,94.6] 71.2 [68.0,74.3] 

Middle 96.7 [95.0,97.8] 71.2 [67.6,74.6] 

Richer 95.8 [94.0,97.1] 75.2 [71.7,78.4] 

Richest 98.6 [97.3,99.2] 82.6 [79.2,85.6] 

Place of residence 

Urban 96.3 [95.2,97.2] * 75.3 [73.1,77.4] * 

Rural 86.5 [84.2,88.5] 65.5 [62.5,68.3] 

Region 

North 91.5 [89.3,93.2] * 65.0 [62.0,67.8] * 

East 79.1 [74.6,83.0] 59.0 [54.2,63.6] 

Central 97.2 [95.8,98.1] 83.1 [80.1,85.7] 

South 94.1 [90.6,96.3] 71.3 [64.5,77.2] 

Notes: * Indicates a significant p-value. 1 Significance of the covariate in each survey. 

Child Health Care

Over two-thirds of children age 12-23 months received all basic vaccinations in 2006. This did not vary by 

sex or place of residence. However, as mother’s education increased the percent of children with all basic 

vaccinations increased. Under half (45%) of children with mothers with no education had all basic 

vaccinations, compared to 77% of children whose mothers had a secondary or higher education. 

Vaccinations increased incrementally with wealth quintile as well, with 52% of those in the poorest quintile 

and 76% of those in the richest quintile receiving all basic vaccinations. There were differences in the 

percent of children vaccinated by region, but not by urban/rural residence. In the Central Region, 78% of 

children had all basic vaccinations, compared to 50% of children in the East Region. 
150 

Table Syria.03: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Syria 2006 MICS3 

Variable % [C.I.] Sig.1

Total 68.1 [65.6,70.5] 

Child’s sex 

Male 67.2 [64.0,70.2] 

Female 69.1 [65.7,72.3] 

Mother’s education 

None 45.4 [39.5,51.4] * 

Primary 66.7 [62.8,70.4] 

Secondary + 76.9 [73.7,79.7] 

Wealth quintile 

Poorest 52.4 [46.5,58.3] * 

Poorer 69.2 [64.7,73.4] 

Middle 72.3 [67.4,76.7] 

Richer 72.7 [67.5,77.3] 

Richest 76.2 [71.0,80.7] 

Place of residence 

Urban 70.1 [66.5,73.4] 

Rural 66.1 [62.4,69.5] 

Region 

North 67.0 [63.0,70.8] * 

East 50.4 [44.3,56.6] 

Central 77.9 [74.0,81.3] 

South 72.8 [60.8,82.2] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Advice or treatment for children under age 5 with ARI symptoms was sought for 77% of children overall 

within 2 weeks before the survey in 2006. In Table Syria.04, care-seeking for ARI symptoms differed 

significantly by mother’s education, wealth quintile, and place of residence, but not by the child’s sex or 

region. Care-seeking increased as mother’s level of education increased. Approximately 82% of children 

of mothers with a secondary or higher level of education had care sought for ARI symptoms, compared to 

69% of children with mothers with no education. The richest wealth quintile had the highest percentage of 

care-seeking for ARI symptoms (86%), while the poorer wealth quintile had the lowest (67%). There was 

no consistent pattern of care-seeking by wealth. A higher percentage of children with ARI symptoms in 

urban residences had advice or treatment sought compared with children in rural areas (81% vs. 72%). 

There was no significant variation in care-seeking by region. 

 
151 

Table Syria.04: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Syria 2006 MICS3 

Variable % [C.I.] Sig.1

Total 76.8 [73.0,80.2] 

Child’s sex 

Male 79.9 [74.9,84.2] 

Female 72.8 [66.4,78.4] 

Mother’s education 

None 68.6 [57.3,78.1] * 

Primary 72.8 [66.0,78.7] 

Secondary + 82.2 [77.0,86.5] 

Wealth quintile 

Poorest 71.6 [60.6,80.5] * 

Poorer 66.7 [58.4,74.0] 

Middle 81.1 [73.9,86.7] 

Richer 79.4 [69.8,86.6] 

Richest 86.2 [77.1,92.1] 

Place of residence 

Urban 80.5 [75.5,84.7] * 

Rural 72.1 [66.0,77.5] 

Region 

North 81.5 [75.6,86.3] 

East 74.4 [62.2,83.7] 

Central 73.4 [67.3,78.8] 

South (73.5 [52.1,87.7]) 

Note: Figures in parenthesis are based on 25-49 

unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Nutrition

Table Syria.05 shows that, overall, 29% of children under age 6 months were exclusively breastfed at the 

time of the survey in 2006. The percent of children breastfed did not differ significantly by the child’s sex, 

mother’s level of education, place of residence, or region, although it did vary by wealth quintile. As wealth 

increased, exclusive breastfeeding decreased, so that 36% of children in the poorest wealth quintile were 

exclusively breastfed, compared to 24% in the richer and richest wealth quintiles. 

 
152 

Table Syria.05: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Syria 2006 MICS3 

Variable % [C.I.] Sig.1

Total 28.7 [25.9,31.7] 

Child’s sex 

Male 27.2 [23.6,31.2] 

Female 30.4 [26.6,34.6] 

Mother’s education 

None 31.4 [24.8,38.8] 

Primary 29.3 [24.9,34.1] 

Secondary + 27.2 [23.3,31.5] 

Wealth quintile 

Poorest 35.5 [29.1,42.4] * 

Poorer 28.6 [23.2,34.8] 

Middle 29.6 [24.5,35.4] 

Richer 23.8 [18.4,30.1] 

Richest 23.8 [18.0,30.8] 

Place of residence 

Urban 27.6 [23.8,31.7] 

Rural 30.0 [25.8,34.5] 

Region 

North 31.8 [27.2,36.8] 

East 26.8 [20.7,34.0] 

Central 25.3 [20.7,30.5] 

South 30.1 [21.3,40.7] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Table Syria.06 reports the percent of children who were stunted and overweight at the time of the survey 

in 2006. Twenty-two percent (22%) of children overall were stunted, and this varied by several 

characteristics. A higher percentage of male children were stunted than female children. Stunting decreased 

as mother’s education increased and as wealth increased. The percentage of children stunted did not differ 

by place of residence, but it did differ by region. The East Region had the highest percentage of children 

stunted at 27%, while South Region had the smallest percentage at 12%. 

The percentage of overweight children in Syria was 12% overall, and did not differ by mother’s education, 

wealth, or place of residence. A significantly higher percentage of girls were overweight than boys. 

Children in East and Central regions had the highest percent of overweight children (13% and 14%), while 

the South Region had that lowest, at 8%. 

 
153 

Table Syria.06: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Syria 2006 MICS3 

Stunted Overweight 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 22.4 [21.3,23.5] 12.4 [11.5,13.3] 

Child’s sex 

Male 23.6 [22.2,25.0] * 11.8 [10.8,12.9] * 

Female 21.1 [19.8,22.5] 13.1 [12.0,14.3] 

Mother’s education 

None 29.1 [26.2,32.2] * 12.9 [11.0,15.1] 

Primary 25.2 [23.5,27.0] 13.0 [11.6,14.4] 

Secondary + 17.6 [16.3,18.9] 11.7 [10.7,12.8] 

Wealth quintile 

Poorest 29.5 [26.6,32.5] * 13.4 [11.4,15.7] 

Poorer 21.1 [19.3,23.0] 11.4 [10.0,13.0] 

Middle 20.9 [19.0,23.0] 11.6 [10.2,13.2] 

Richer 20.2 [18.0,22.5] 13.5 [11.6,15.6] 

Richest 19.9 [17.5,22.4] 12.4 [10.6,14.4] 

Place of residence 

Urban 21.9 [20.4,23.5] 12.9 [11.7,14.2] 

Rural 22.9 [21.4,24.5] 11.9 [10.7,13.2] 

Region 

North 23.9 [22.1,25.8] * 12.1 [10.7,13.6] * 

East 26.5 [23.6,29.6] 13.2 [11.1,15.5] 

Central 21.1 [19.5,22.9] 13.6 [12.2,15.2] 

South 11.9 [9.4,15.0] 8.4 [6.7,10.5] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Syria Summary

In 2006, just under half of married women ages 15-49 in Syria were using a method of modern 

contraception, and 13% were using a traditional method. Modern use ranged from 29% of women age 15-

24 to 53% of women age 35-44. 

Almost all (91%) women delivered with the assistance of an SBA. However, this varied by all background 

characteristics including education and wealth. About three-quarters of women with no education and 

women in the poorest wealth quintile delivered with an SBA, compared to 97% of women with a secondary 

or higher level of education and 99% of women in the richest wealth quintile. In contrast, delivery in a 

health facility was lower, at 70% overall, ranging from 52% of women with no education to 83% of women 

in the richest wealth quintile and women in the Central Region. This suggests that many deliveries assisted 

by an SBA are occurring outside of a health facility. 

Child health indicators also varied by many background characteristics. Although 68% of children age 12-

23 months had all basic vaccinations overall, it was 45% for children with mothers with no education. In 

the East Region, 50% of children age 12-23 months had all basic vaccinations, compared to 78% in the 

Central Region. Care-seeking for ARI symptoms in children under age 5 was slightly less variable, at 77% 

overall. Only care-seeking for children with mothers with no education and children in the poorer wealth 

quintile was below 70%. Exclusive breastfeeding of children under age 6 months was 29% overall and there 

was a decreasing trend as wealth increased. Stunting among children under age 5 was 22% overall. In the 

South Region, 12% of children were stunted, which was the lowest reported. The percentage of overweight 

children was 12% overall and ranged from 8% in the South Region to 14% in the Central Region and in the 

richer wealth quintile. Given the social and political context in Syria since 2006, these data should be used 

as a baseline and not interpreted as the current state of maternal and child health in Syria. 

155 

Tunisia 

In 2015, Tunisia had an estimated total population of 11.3 million (Population Reference Bureau 2016). In 

2011, widespread protests and civil unrest in Tunisia forced the resignation of the country’s long serving 

President. These protests are widely considered as the impetus for similar protests in Egypt, Yemen, and 

other countries in the region, which are collectively called the Arab Spring. After the resignation of the 

Tunisian President, elections were held which were largely declared free and democratic by the 

international community. Since Tunisia’s independence from colonial-rule in the 1950s, the country has 

made great strides toward improving health outcomes among the population. Disparities in health outcomes 

exist across geographic and socioeconomic groups, but overall, maternal, reproductive, and child health 

outcomes in Tunisia have steadily improved over the past decade. 

Indicators across the maternal and reproductive health spectrum have improved or remained steady in 

Tunisia over the past 10 years. Maternal mortality has decreased since 2005 from 74 to 62 maternal deaths 

per 100,000 live births in 2015 (Maternal Mortality Estimation Inter-Agency Group 2016). A review of 

maternal deaths in 2010 found the leading causes of maternal death to be hemorrhage, thrombo-embolic 

disease, and complications from preeclampsia (Tej Dellagi et al. 2014). A second study that examined 

trends in the maternal mortality rate (MMR) over time found that the disparity between urban and rural 

women narrowed over the past 10 years although rural areas still had high levels of maternal death 

compared with the urban areas (Farhat et al. 2012). Over the past decade, both the percentage of women 

who receive antenatal care (ANC) and the proportion of births attended by a skilled medical professional 

remain high (World Bank 2017e). In 2012, 98% of pregnant received one or more ANC visits (World Bank 

2017e), and 98.6% of births were attended by a skilled medical professional (World Bank 2017e). The 

contraceptive prevalence rate among women age 15-44 has increased slightly, from 60.2% in 2006 to 62.5% 

in 2012 (World Bank 2017e). Tunisia has several long-standing policies aimed at protecting contraception 

and prenatal care. Beginning in the 1960s, Tunisia guaranteed free contraception and in the 1990s, the 

country enacted a policy that entitled pregnant women to several free prenatal and postnatal visits 

(Amroussia 2016). 

Child health, particularly in terms of mortality rates, has improved over the last decade in Tunisia. The 

infant mortality rate declined from 18.5 in 2006 to 12.1 infant deaths per 1,000 live births in 2015 (World 

Bank 2017e). Over the same time period, the under-5 mortality rate has declined from 21.7 to 14.0 deaths 

per 1,000 live births (World Bank 2017e). A 2015 study examined the prevalence and risk factors associated 

with pre-term birth in Tunisia (El Mhamdi et al. 2015). Over the study period of 1994-2012, the authors 

found that the prevalence of pre-term birth had increased significantly from 4.8% to 7.2% in 2012 (El 

Mhamdi et al. 2015). An inter-pregnancy interval less than 24 months and maternal age less than 20 or 

greater than 35 were both significantly associated with pre-term birth (El-Jardali et al. 2010). Immunization 

coverage for both DTP and measles remains high at over 95% coverage among children age 23 months 

(World Bank 2017e). A recent survey of Tunisia mothers found that while almost all breastfed their infants 

immediately after delivery, only 1.9% provided exclusive breastfeeding up to 6 months (Bouanene et al. 

2010). From a nutritional standpoint, Tunisia is undergoing a transition with an increasing prevalence of 

overweight and obesity among children and adults. Stunting and wasting among children under-5 have 

remained largely unchanged since 2006. In 2012, the prevalence of stunting was 10.1%, which was a 1 

percentage-point increase from 2006, and the prevalence of wasting was 2.8%, which was virtually 

unchanged since 2006 (World Bank 2017e). 

Since the 1950s, Tunisia has operated a free health care system, in which the government served as the 

single largest healthcare provider (Saleh et al. 2014). As of 2006, 95% of the Tunisia population had access 

to a health care facility within 5 kilometers of their home (WHO 2006). In recent years, a growing network 

of private healthcare providers has opened the healthcare market for those who can afford the private care 
156 

(Saleh et al. 2014). Despite a robust healthcare infrastructure, universal insurance coverage has not yet been 

achieved in Tunisia. It is estimated that 8-10% of the population is not covered and in 2010, the out-ofpocket expenditure was estimated to be 45% of the total health expenditure in Tunisia (Chahed and Arfa 

2014). The total expenditure on healthcare as a proportion of GDP has increased from 5.3% in 2001 to 6.2% 

in 2011 (Saleh et al. 2014). A 2015 analysis of the Tunisian health system assessed the capacity of the 

health system to handle the increasing proportion of morbidity and mortality caused by non-communicable 

diseases (NCDs) such as cancer, heart disease, and diabetes (Ben Romdhane et al. 2015). The authors found 

that the primary health care system in Tunisia was ill-equipped to address NCDs because for many years, 

infectious disease and morbidity associated with poor sanitation have been the priorities (Ben Romdhane 

et al. 2015). These shortcomings extend to staff knowledge and availability, information-sharing systems, 

and adherence to a disease-focused care model rather than a prevention-focused care model (Ben Romdhane 

et al. 2015). 

The results discussed below for Tunisia were produced from the 2011-12 MICS survey. No other survey 

after 2012 was available for comparison to observe trends in the indicators. 

 
157 

Figure Map 9: Tunisia Map 

Note: See Appendix for a description of regions. 

 
158 

Total Fertility Rate

The 2011-12 MICS4 found that the total fertility rate (TFR) in Tunisia was 2.1 children. This was the lowest 

TFR of all the countries included in this report. The TFR in Tunisia did not vary widely by the 

characteristics included in Table Tunisia.01. The TFR was between 1.8 and 2.3 for all subgroups, and was 

lowest in the richest wealth quintile, at the below replacement rate of 1.8, and highest in the richer wealth 

quintile and in rural areas at 2.3. 

Table Tunisia.01: Total fertility rate for the 3 years before the survey, by background characteristics, Tunisia 

2011-12 MICS4 

TFR [C.I.] 

Total 2.1 [2.0,2.2] 

Education 

None 2.1 [1.8,2.6] 

Primary 2.2 [2.0,2.4] 

Secondary + 2.1 [1.9,2.2] 

Wealth quintile 

Poorest 2.2 [1.9,2.5] 

Poorer 2.2 [1.9,2.5] 

Middle 2.0 [1.7,2.2] 

Richer 2.3 [2.0,2.5] 

Richest 1.8 [1.6,2.0] 

Place of residence 

Urban 2.0 [1.8,2.1] 

Rural 2.3 [2.1,2.5] 

Region 

Interior 2.1 [2.0,2.3] 

Coastal 1.9 [1.7,2.2] 

Contraceptive Use

Half of women age 15-49 in Tunisia were using modern contraception at the time of the 2011-12 survey, 

although this varied significantly by all characteristics in Table Tunisia.02, except for region. 

There were significant differences in modern contraceptive use by age. Women age 35-44 had the highest 

percent of modern contraceptive use at 56%, while women age 15-24 had the lowest at 34%. Modern 

contraceptive use differed significantly by education, although the pattern was not linear. Women with a 

primary education had the highest modern contraceptive use at 55%, while women with a secondary or 

higher level of education had the lowest at 47%. Women with no education fell in between at 52%. By 

wealth quintile, modern contraceptive use was highest among the poorest women in Tunisia (56%), with 

use declining incrementally with each increasing wealth quintile. Forty-seven percent (47%) of women in 

the richest wealth quintile used modern contraception. Women in rural areas had a significantly higher 

percentage of modern contraceptive use than women in urban areas (54% vs. 49%). 

A smaller percentage of women in Tunisia were using traditional contraception at the time of the 2011-12 

survey. Twelve percent (12%) of women were using traditional contraception overall, but this varied widely 

by all characteristics in Table Tuniaia.02. 

Similar to modern contraceptive use, women age 35-44 had the highest percentage of traditional 

contraceptive use at 14%, and women age 15-44 had the lowest at 5%. Traditional contraceptive use 

increased incrementally with the level of education and wealth quintile. By education, women with a 

secondary or higher level of education had the highest percentage of traditional contraceptive use (15%), 
159 

compared to 6% among women with no education. By wealth, women in the richest wealth quintile had the 

highest percentage of traditional contraceptive use (18%) and women in the poorest wealth quintile the 

lowest (6%). 

A significantly higher percentage of women in urban areas used traditional contraception (15%) compared 

to women in rural areas (6%), while a significantly higher percentage of women in the Coastal Region used 

traditional methods (17%) compared to the Interior Region (10%). 

Table Tunisia.02: Percentage of women currently using modern or traditional contraception among women 

age 15-49 in a union, by background characteristics, Tunisia 2011-12 MICS4 

Modern CPR Traditional CPR 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 50.7 [48.9,52.5] 11.8 [10.6,13.2] 

Age 

15-24 34.2 [27.5,41.7] * 5.3 [2.9,9.4] * 

25-34 51.4 [48.2,54.6] 9.4 [7.8,11.3] 

35-44 55.8 [53.0,58.6] 13.9 [12.0,16.2] 

45-49 43.5 [39.8,47.2] 13.0 [10.5,16.0] 

Education 

None 51.8 [47.4,56.0] * 5.6 [4.0,7.7] * 

Primary 55.0 [51.9,58.1] 10.5 [8.8,12.6] 

Secondary + 47.0 [44.5,49.5] 15.1 [13.2,17.2] 

Wealth quintile 

Poorest 55.7 [51.9,59.4] * 6.1 [4.5,8.4] * 

Poorer 55.4 [51.6,59.2] 6.9 [5.2,9.0] 

Middle 49.3 [44.9,53.7] 11.1 [9.0,13.8] 

Richer 47.8 [43.6,52.0] 14.9 [12.3,17.9] 

Richest 46.6 [43.1,50.2] 18.3 [15.0,22.2] 

Place of residence 

Urban 49.2 [47.0,51.5] * 14.6 [12.9,16.5] * 

Rural 53.7 [50.4,56.9] 6.1 [4.8,7.8] 

Region 

Interior 50.6 [48.5,52.7] 10.0 [8.8,11.4] * 

Coastal 51.1 [47.4,54.8] 17.2 [14.0,21.0] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Antenatal Care

Table Tunisia.03 reports that 85% of women in Tunisia had the recommended four or more ANC visits 

during their most recent pregnancy, although this varied by several characteristics. The percentage of 

women who had four or more ANC visits increased with level of education, with 89% of women with a 

secondary or higher level of education having four or more visits compared to 71% of women with no 

education. The pattern by wealth was similar. Almost all women in the richest wealth quintile had four or 

more ANC visits, compared to 73% of women in the poorest quintile. However, the poorer and middle 

quintiles did not follow this pattern, and their overlapping confidence intervals indicate that they may not 

have differed. 

Women in urban areas had a significantly higher percentage of four or more ANC visits (88%) than women 

in rural areas (80%). The same held true for women in the Coastal Region (90%) compared to women in 

the Interior Region (84%). 
160 

Table Tunisia.03: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Tunisia 2011-12 MICS4 

Variable % [C.I.] Sig.1

Total 85.1 [82.5,87.4] 

Age 

15-24 83.8 [73.8,90.5] 

25-34 86.2 [83.0,88.8] 

35-44 83.0 [78.2,86.9] 

45-49 ND 

Education 

None 71.2 [63.0,78.3] * 

Primary 81.8 [77.0,85.7] 

Secondary + 89.4 [86.0,92.1] 

Wealth quintile 

Poorest 73.2 [66.6,79.0] * 

Poorer 84.6 [78.1,89.5] 

Middle 82.2 [75.1,87.6] 

Richer 89.3 [83.6,93.2] 

Richest 96.3 [91.3,98.5] 

Place of residence 

Urban 88.2 [84.8,90.8] * 

Rural 79.9 [75.5,83.8] 

Region 

Interior 83.5 [80.5,86.1] * 

Coastal 90.3 [83.8,94.4] 

Note: ND indicates figures are not shown because they 

were based on fewer than 25 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Delivery

Overall, 74% of women in Tunisia gave birth with an SBA in the 2011-12 survey. This differed significantly 

by all characteristics in Table Tunisia.04, except for age. A higher percentage of women with a secondary 

or higher level of education gave birth with an SBA (79%), compared to women with no education or a 

primary education (67% and 66%). The percentage of women delivering with an SBA increased 

incrementally with wealth quintile. Of women in the poorest wealth quintile, 63% delivered with an SBA 

compared to 89% of women in the richest wealth quintile. Women in urban areas had a higher percentage 

of delivery with an SBA compared to rural women, as did women in the Coastal Region compared to the 

Interior Region. The SBA use in the Coastal Region was 16-percentage points higher than in the Interior 

Region. 

Nearly all women delivered their most recent birth in a health facility. While differences were statistically 

significant by characteristics in Table Tunisia.04, the interval between the highest and lowest percentage 

of health facility delivery was small, with 93% (women with no education) to 100% (women with a 

secondary or higher level of education, women in the middle, richer, and richest wealth quintiles, women 

residing in urban areas, and women in the Coastal Region) delivered in a health facility. Health facility 

delivery increased incrementally with level of education. While 100% of women in the poorer, middle, 

richer, and richest wealth quintiles delivered in a health facility, only 94% of women in the poorest wealth 

quintile did. 

Overall, the percentage of women who delivered by C-section in Tunisia was 27% in 2011-12. The 

percentage of women who delivered their most recent birth by C-section varied by age, wealth, place of 
161 

residence, and region. Women age 15-24 had the lowest percentage of C-section deliveries (14%) by age 

and of all characteristics included in Table Tunisia.04. In contrast, 29% of women age 35-44 delivered by 

C-section. The percentage of C-section deliveries by wealth quintile also differed significantly. Although 

the middle and richer wealth quintiles had very similar percentages of C-section deliveries (31%), a smaller 

percentage of women in the poorest wealth quintile gave birth by C-section (15%). Thirty-eight percent 

(38%) of women in the richest wealth quintile delivered by C-section, which was the highest of any 

subgroup in Table Tunisia.04. As with SBA and health facility delivery, the percentage of women 

delivering by C-section was higher for women in urban areas than rural areas, and women in the Coastal 

Region compared to the Interior Region. 

Table Tunisia.04: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant, delivered in a health facility, or delivered by caesarean section in the 2 years before the survey, by 

background characteristics, Tunisia 2011-12 MICS4 

SBA DHF C-section 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 % [C.I.] Sig.1

Total 73.6 [70.3,76.6] 98.5 [97.6,99.1] 26.7 [23.7,29.9] 

Age 

15-24 66.3 [55.1,76.0] 98.6 [93.0,99.7] 13.5 [7.6,22.8] * 

25-34 73.3 [69.1,77.1] 98.3 [97.1,99.0] 27.5 [23.6,31.8] 

35-44 76.9 [71.1,81.8] 98.8 [97.7,99.4] 29.2 [23.6,35.5] 

45-49 ND ND ND 

Education 

None 66.6 [58.3,74.0] * 93.1 [87.9,96.2] * 17.9 [11.8,26.2] 

Primary 66.3 [60.5,71.6] 98.0 [96.2,99.0] 27.3 [22.1,33.1] 

Secondary + 78.6 [74.1,82.5] 99.8 [99.2,99.9] 28.0 [24.0,32.4] 

Wealth quintile 

Poorest 62.8 [55.7,69.4] * 93.8 [89.7,96.4] * 15.3 [11.1,20.7] *

Poorer 68.9 [62.4,74.6] 99.5 [97.8,99.9] 19.7 [14.2,26.7] 

Middle 72.4 [64.4,79.3] 99.7 [97.5,100.0] 31.1 [24.0,39.2] 

Richer 75.8 [68.1,82.1] 99.8 [98.6,100.0] 30.7 [24.4,37.8] 

Richest 89.1 [82.3,93.5] 99.7 [97.5,100.0] 37.7 [29.4,46.8] 

Place of residence 

Urban 77.2 [72.8,81.0] * 99.7 [99.1,99.9] * 30.9 [27.1,35.0] * 

Rural 67.4 [62.0,72.3] 96.5 [94.1,98.0] 19.5 [15.0,24.9] 

Region 

Interior 69.8 [66.2,73.2] * 98.0 [96.8,98.8] * 24.3 [21.1,27.7] * 

Coastal 85.7 [76.7,91.6] 100.0 34.5 [27.2,42.7] 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 

Child Health Care

Treatment or advice was sought for 60% of children with ARI symptoms within the 2 weeks before the 

survey in 2011-12. This did not vary significantly by sex of the child, mother’s education, place of 

residence, or region, but did differ by wealth quintile, as shown in Table Tunisia.05. Care-seeking was 

highest for children in the richest wealth quintile at 74%, and lowest for children in the poorest wealth 

quintile at 46%. 

 
162 

Table Tunisia.05: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Tunisia 2011-12 MICS4 

Variable % [C.I.] Sig.1

Total 59.5 [54.3,64.5] 

Child’s sex 

Male 60.8 [53.9,67.3] 

Female 58.0 [50.4,65.1] 

Mother’s education 

None 46.6 [32.7,61.1] 

Primary 63.4 [54.7,71.3] 

Secondary + 60.2 [52.6,67.4] 

Wealth quintile 

Poorest 46.1 [36.7,55.9] * 

Poorer 62.8 [50.4,73.8] 

Middle 56.3 [42.2,69.5] 

Richer 67.6 [53.7,79.0] 

Richest 74.1 [57.9,85.6] 

Place of residence 

Urban 63.1 [56.8,69.0] 

Rural 52.9 [43.8,61.8] 

Region 

Interior 57.4 [51.6,63.0] 

Coastal 65.6 [53.7,75.9] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Nutrition

At 9%, Tunisia had one of the lowest percentages of children under age 6 months who were exclusively 

breastfed of the countries in this report (Overall Summary, Figure 9). Of the characteristics in Table 

Tunisia.06, exclusive breastfeeding differed significantly only by the mother’s level of education. Although 

5% of children with mothers with a secondary or higher level of education were exclusively breastfed, 14% 

of those with a primary education, and 16% of those with no education were exclusively breastfed. The 

results for mothers with no education should be interpreted with caution because they are based on a small 

number of cases. There was no clear pattern of exclusive breastfeeding by wealth quintile. The highest 

percentage of exclusive breastfeeding was in the poorest quintile (16%), and the lowest in the middle 

quintile (1%). The same percentage of children under age 6 months were breastfed in urban and rural areas. 

While 10% of children in the Interior Region were exclusively breastfed, 3% of children in the Coastal 

Region were. This difference was not statistically significant.

 
163 

Table Tunisia.06: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Tunisia 2011-12 MICS4 

Variable % [C.I.] Sig.1

Total 8.5 [5.5,12.8] 

Child’s sex 

Male 7.1 [3.8,12.6] 

Female 10.2 [5.4,18.4] 

Mother’s education 

None (15.5 [6.0,34.7]) * 

Primary 14.0 [6.6,27.3] 

Secondary + 5.2 [3.0,8.9] 

Wealth quintile 

Poorest 15.7 [8.1,28.0] 

Poorer 9.2 [4.3,18.5] 

Middle 1.4 [0.3,6.0] 

Richer 9.1 [4.0,19.5] 

Richest 7.1 [1.9,22.9] 

Place of residence 

Urban 8.4 [4.7,14.7] 

Rural 8.6 [4.9,14.7] 

Region 

Interior 10.2 [6.6,15.3] 

Coastal 3.0 [0.4,20.8] 

Note: Figures in parenthesis are based on 25-49 

unweighted cases. 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Overall, 10% of children under age 5 were stunted in Tunisia in 2011-12 (Table Tunisia.07). This varied 

based on several characteristics including sex, mother’s education, wealth, and place of residence. A higher 

percentage of boys were stunted compared to girls (11% vs. 9%). By mother’s education, the highest percent 

of stunting (16%) was found in children with mothers with no education. In comparison, 9% of children 

with mothers with a secondary or higher level of education and 10% of children with mothers with a primary 

education were stunted. 

By wealth quintile, the percentage of children who were stunted was highest among the poorest (16%) and 

the poorer quintiles (10%). However, stunting was lowest in the middle (8%) and richest wealth quintiles 

(8%). A significantly higher percentage of children living in rural areas were stunted than those living in 

urban areas (14% vs. 8%), although stunting did not differ by region. 

The presence of overweight children under age 5 in Tunisia was 14% overall and did not differ significantly 

by any characteristics in Table Tunisia.07. The range that compared all characteristics was between 12% 

(children in the richest wealth quintile) and 16% (children in the middle and richer wealth quintiles). 

 
164 

Table Tunisia.07: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Tunisia 2011-12 MICS4 

Stunted Overweight 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 10.1 [8.7,11.7] 14.3 [12.8,16.0] 

Child’s sex 

Male 11.3 [9.5,13.5] * 14.8 [12.8,17.0] 

Female 8.8 [7.2,10.8] 13.7 [11.7,16.0] 

Mother’s education 

None 16.4 [12.7,20.9] * 14.7 [10.8,19.8] 

Primary 9.9 [7.7,12.6] 14.4 [11.9,17.4] 

Secondary + 8.8 [7.1,10.9] 14.1 [12.0,16.5] 

Wealth quintile 

Poorest 15.6 [12.2,19.6] * 14.8 [11.9,18.3] 

Poorer 10.2 [7.6,13.6] 12.5 [9.6,16.1] 

Middle 7.5 [4.9,11.3] 15.7 [12.0,20.3] 

Richer 9.1 [6.5,12.6] 16.0 [12.9,19.7] 

Richest 7.7 [5.1,11.5] 12.3 [8.8,16.9] 

Place of residence 

Urban 8.1 [6.5,10.0] * 14.2 [12.4,16.4] 

Rural 13.6 [11.2,16.5] 14.4 [11.9,17.2] 

Region 

Interior 10.6 [9.0,12.4] 14.3 [12.7,16.1] 

Coastal 8.5 [5.8,12.5] 14.2 [10.6,18.7] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Under-5 Mortality

Under-5 mortality in Tunisia was 19/1000 live births in 2011-12, and ranged from 7/1000 in the richer 

wealth quintile to 42/1000 for children of mothers with no education. Under-5 mortality declined as 

mother’s education and wealth increased (except for the richest wealth quintile, with an under-5 mortality 

rate of 16/1000). In addition, under-5 mortality was higher in rural areas than urban areas and in the Interior 

Region compared to the Coastal Region. 

 
165 

Table Tunisia.08: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Tunisia 2011-12 MICS4 

Variable U5M [C.I.] 

Total 19 [15,25] 

Child’s sex 

Male 21 [15,31] 

Female 17 [11,26] 

Mother’s education 

None 42 [26,67] 

Primary 20 [13,33] 

Secondary + 13 [8,21] 

Wealth quintile 

Poorest 32 [20,50] 

Poorer 20 [12,35] 

Middle 24 [13,45] 

Richer 7 [3,19] 

Richest 16 [7,34] 

Place of residence 

Urban 15 [10,23] 

Rural 26 [18,38] 

Region 

Interior 20 [15,27] 

Coastal 17 [8,33] 

Tunisia Summary 

Tunisia had a replacement level TFR at 2.1 births per woman in 2011-12. There were few differences in 

TFR by background characteristics. Approximately half of married women age 15-49 were using a method 

of modern contraception at the time of the survey, compared to 12% using a traditional method. The lowest 

percentage of modern contraceptive use was among women age 15-24, who also had the lowest traditional 

contraceptive use. Modern contraceptive use did not follow an expected pattern by wealth quintile, with 

percentages of use decreasing as wealth quintile increased. 

Overall, 85% of women received the four or more recommended ANC visits during their most recent 

pregnancy, but this varied by education, wealth, urban/rural residence, and region. There was variance by 

wealth with 73% of women in the poorest wealth quintile and 96% of women in the richest wealth quintile 

having four or more ANC visits. Less than three-quarters of women delivered their most recent birth with 

an SBA, but nearly all gave birth in a health facility. The higher percentage of deliveries in a health facility 

compared to deliveries assisted by an SBA indicates that many deliveries in the health facility were 

performed by non-skilled birth attendants. Health facility delivery was lowest at 93% among women with 

no education. Just over a quarter of women gave birth by C-section; however, among women in the richest 

wealth quintile, 38% gave birth by C-section. 

Child health indicators varied. While care was sought for 60% of children under five with ARI symptoms 

in the two weeks prior to the survey, only 9% of children under six months were exclusively breastfed. 

Exclusive breastfeeding was highest among women in the poorest wealth quintile and among children with 

mothers with no education. A tenth of children were stunted and 14% were overweight. Finally, under-5 

mortality was 19/1000 live births overall, ranging from 7/1000 in the richer wealth quintile to 42/1000 

among mothers with no education.

167 

West Bank and Gaza Strip 

In 2015, there were an estimated 4.7 million people living in the West Bank and Gaza Strip (WHO and 

Ministry of Health [State of Palestine] 2016). The long-standing conflict between Israel and the Palestinian 

Territories has affected not only the economic and social well-being of Palestinians, but also the health 

system and health outcomes. The last major conflict that took place in July 2014 in the Gaza Strip resulted 

in over 2,000 fatalities (Naim et al. 2016). Since 2007, the Gaza Strip has been subjected to a blockade that 

restricts movement and supplies in and out of the territory. This has had severe economic ramifications and 

resulted in one of the highest unemployment rates (over 40%) in the world (UNRWA 2016a). The Gaza 

blockade has resulted in disparate health outcomes between the West Bank and Gaza Strip. Over the past 

decade, maternal and child health outcomes have fluctuated and in some instances, have worsened among 

the Palestinians living in the West Bank and Gaza Strip. 

Maternal health has been greatly affected by the Gaza blockade and has varied across both the West Bank 

and Gaza Strip in recent years. In 2008, the maternal mortality rate (MMR) across the West Bank and Gaza 

Strip was 38 maternal deaths per 100,000 live births (WHO and Ministry of Health [State of Palestine] 

2016). This declined to 24.1 by 2013, with a rate of 26.1 in the West Bank and 21.9 in Gaza (WHO and 

Ministry of Health [State of Palestine] 2016). However, in 2014, the MMR increased slightly overall to 

24.7 with the Gaza strip experiencing a dramatic increase to 30.6 maternal deaths per 1000,000 live births 

(WHO and Ministry of Health [State of Palestine] 2016). A 2015 study by the United National Population 

Fund (UNFPA) sought to understand this increase, with many experts speculating that the July 2014 war 

with Israel may have affected the MMR (Naim et al. 2016). The authors concluded that the July 2014 war 

was linked to several maternal deaths although they also found that severe breakdowns in communication, 

poor record keeping, and a dysfunctional referral system between hospitals contributed to the surge in 

maternal deaths (Naim et al. 2016). Similar to their assessment of maternal deaths in the Gaza Strip after 

the July 2014 war, UNFPA also conducted an evaluation of the war’s impact on reproductive health services 

in the Gaza Strip (Shaar et al. 2014). During the course and immediate aftermath of the seven-week war, 

the authors found an overall increase in stillbirths, miscarriages, preterm birth, and low-birth weight among 

the surveyed maternity wards (Shaar et al. 2014). Beyond the impact on maternity care, just 50% of primary 

care facilities were operational during the war, which precipitated a large decrease in antenatal care (ANC) 

and family planning visits (Shaar et al. 2014). In the West Bank, a 2015 study that examined the patterns 

of maternal morbidity at a hospital in Ramallah found that among 1,558 births, 26.9% of women 

experienced at least one maternal morbidity (Hassan, Wick, and DeJong 2015). A second study also 

examined births at a hospital in Ramallah and found that among the observed births, 12.1% had 

complications that included live-threatening morbidities (Bashour et al. 2015). Although maternal mortality 

has not universally improved across the Palestinian territories, skilled birth attendance and the prevalence 

of facility births both exceed 99% (WHO and Ministry of Health [State of Palestine] 2016). 

Infant and child mortality rates have declined over the past decade, although there are persistently higher 

levels of mortality in the Gaza Strip when compared to the West Bank. According to the Palestinian 

Ministry of Health, as of 2014, the infant mortality rate (IMR) was 12.7 per 1,000 live births, which 

decreased from 25 per 1,000 live births in 1995 (WHO and Ministry of Health [State of Palestine] 2016). 

The IMR was 14.1 in the Gaza Strip and 11.6 in the West Bank (WHO and Ministry of Health [State of 

Palestine] 2016). Other infant outcomes among the Palestinian population have also been assessed. The 

WHO examined the prevalence of small-for-gestational-age (SGA) births across 29 countries and found 

that the West Bank and Gaza Strip had the third highest prevalence (16.1% of births considered SGA) 

among all the countries (Ota et al. 2014). 

Food insecurity is a widespread problem with 27% of the population in the Gaza Strip and the West Bank 

considered food insecure in 2014 (Palestine Food Security Sector and Palestinian Central Bureau of 
168 

Statistics 2016). Children living in the Gaza Strip have been particularly vulnerable to food insecurity since 

the institution of the blockade in 2007. A 2009 study examined the nutritional status of preschoolers in the 

Gaza Strip, after the imposition of the Gaza blockade (Radi et al. 2013). The authors found that 85% of the 

children surveyed in Gaza City lived in household classified as food insecure and that the prevalence of 

wasting, stunting, and underweight was 3.5%, 15%, and 6.1%, respectively (Radi et al. 2013). The authors 

hypothesize that the nutritional deficiencies and material hardships observed in this population are a direct 

result of the continued Gaza blockade (Radi et al. 2013). A 2013 assessment of weaning practices among 

mothers who attended six randomly selected UNRWA health clinics in the Gaza Strip found that 28.4% 

reported exclusively breastfeeding for 4-6 months (Abu Hamad and Sammour 2013). In this sample, the 

principal reason for weaning was pregnancy, which was reported by 42.8% of mothers (Abu Hamad and 

Sammour 2013). However, a similar assessment at three refugee camps in Nablus in the West Bank found 

that nearly 70% of infants were exclusively breastfed for the first six months of life (Musmar and Qanadeelu 

2012). A random sample of school-age children living in the West Bank found the prevalence of parasitic 

infection to be 22.2%, which indicated that these infections are endemic to the area and widespread (Hussein 

2011). Parasitic infection was significantly associated with lower parental education and living in rural or 

refugee camp areas (Hussein 2011). 

There is an extensive body of literature that examines the mental health ramifications for Palestinian 

children of living in a long-term conflict zone. Data from the early 2000s found an increase in the incidence 

rate of several mental health disorders across the Gaza Strip and the West Bank (Giacaman et al. 2011). For 

example, the incidence of affective disorders and neurosis have doubled from approximately 5 cases per 

100,000 people in 2001 to over 10 cases per 100,000 people in 2005 (Giacaman et al. 2011). While some 

of these increases may reflect a true increase in incidence, some of the increase may also be attributable to 

better detection and screening for mental health disorders. An analysis by Doctors Without Borders found 

that 75% of Palestinian children who sought mental health services had mental health problems associated 

with armed conflict (Lokuge et al. 2013). A study in 2012 estimated that 95% of children under age 18 

living in the Gaza Strip suffer some symptoms of post- traumatic stress syndrome (PTSD) (Thirkell 2012). 

An assessment of preschoolers living in the Gaza Strip found that 37% had poor mental health and that 

children with higher exposure to traumatic events has significantly worse health-related quality of life 

scores (Massad et al. 2011). A 2009 survey that examined PTSD in children age 12-16 in the Gaza Strip 

found that, on average, children reported witnessing 8.2 traumatic events (Thabet et al. 2009). Among the 

children surveyed, 30.8% met the DSM-IV diagnostic criteria for PTSD, while more than 80% reported at 

least some PTSD symptoms (Thabet et al. 2009). The Ministry of Health recognizes the urgent need for 

improved mental health services in the West Bank and Gaza Strip and recently released a Mental Health 

Strategy Report for 2015-2019 to help improve quality and access to these services (Ministry of Health 

[Palestine] 2015). As of 2013, there were 13 government-run community mental health centers in the West 

Bank and six in the Gaza Strip, with demand for services increasing on an annual basis (Ministry of Health 

[Palestine] 2015). UNRWA is also an important source of mental health services through their Community 

Mental Health Program, and provided mental health services for an estimated 60,000 Palestinians in 2013 

alone (Ministry of Health [Palestine] 2015). 

Healthcare is provided primarily by four main entities in the West Bank and Gaza Strip: the Ministry of 

Health, UNRWA, various NGOs, and the private sector (Hamidi et al. 2016). Overall, the Ministry of Health 

provides 61.3% of primary healthcare in the Palestinian Territories, although in the Gaza Strip, UNRWA 

is the main provider of healthcare to the majority of Palestinians who reside there (Hamidi et al. 2016; 

UNRWA 2016c). This is due to the high percentage of Palestinians with refugee status in the Gaza Strip 

(UNRWA 2016b). The size of the healthcare work force in the Gaza Strip and the West Bank has increased 

over the past two decades, and has nearly tripled in size since 1995 (WHO and Ministry of Health [State of 

Palestine] 2016). The number of healthcare facilities has also increased from 454 in 1994 to 750 in 2012 

(Hamidi et al. 2016). Costs have also been increasing along with this growth in the healthcare system. 

Between 2000 and 2011, the per-capita household out-of-pocket healthcare expenditure increased from 
169 

$54USD to $133USD (Hamidi et al. 2016). This is particularly troublesome given the very high levels of 

poverty in the Gaza Strip and the West Bank. The Gaza blockade has severely affected the health system. 

Stock-outs and supply shortages are very common in health facilities in the Gaza Strip, and the problems 

are further compounded by aging and broken medical equipment (Shaar et al. 2014). At the end of the July 

2014 war, it was estimated that only 50% of medical equipment in the Gaza Strip was functioning (Shaar 

et al. 2014). One of the greatest threats to the health system in the Gaza Strip is the recent reduction in 

electricity and power supplies (United Nations 2017a). Beginning in late 2016, the daily electricity 

allowance in the Gaza Strip was reduced to less than 4 hours per day (Al-Mughrabi 2017). This continuing 

electricity shortage has caused hospitals to work at minimal capacity, with electricity available for only the 

most critical functions such as neonatal intensive care units and storage of blood products and vaccines 

(United Nations 2017a). 

The results discussed below for the West Bank and Gaza Strip (WBG) used data from the 2010 and 2014 

MICS surveys. 

 
170 

Figure Map 10: State of Palestine Map—West Bank and Gaza Strip 

Note: See Appendix for a description of regions. 

 
171 

Total Fertility Rate

The total fertility rate (TFR) decreased significantly in WBG between the 2010 and 2014 MICS surveys 

from 4.5 to 4.1, as shown in Table WBG.01. The TFR reductions were significant by most characteristics 

in the table. The TFR declined among women with a primary education and a secondary or higher 

education, although in both years, the TFR was lowest among women with no education. The TFR declined 

significantly in all wealth quintiles except for the poorest and richest. In 2010 and 2014, women in the 

poorest wealth quintile had the highest TFR and women in the richest quintile had the lowest. The TFR 

declined between the two surveys in urban areas, rural areas, and camps. In 2010, the TFR was highest in 

the camps, although in 2014, the TFR was slightly higher in urban areas. 

All significant changes indicated a declining TFR, except for Jerusalem, where there was the only increase 

in TFR by all sub-characteristics, as shown in Table WBG.01. Jerusalem had the lowest TFR of any region 

in 2010, although this was not the case in 2014, as illustrated in Figure WBG.01. 

Table WBG.01: Total fertility rate for the 3 years before the survey, by background characteristics, West Bank 

and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable TFR [C.I.] TFR [C.I.] Diff1

Total 4.5 [4.4,4.6] 4.1 [3.9,4.2] -0.4* 

Education 

None 4.1 [3.7,4.4] 3.2 [2.0,5.1] -0.9 

Primary 4.8 [4.6,4.9] 4.3 [4.1,4.5] -0.5* 

Secondary + 4.4 [4.2,4.5] 4.1 [3.9,4.2] -0.3* 

Wealth quintile 

Poorest 5.2 [5.0,5.5] 4.9 [4.7,5.2] -0.3 

Poorer 5.0 [4.8,5.2] 4.0 [3.7,4.4] -1.0* 

Middle 4.6 [4.4,4.8] 4.2 [3.9,4.4] -0.4* 

Richer 4.2 [4.0,4.4] 3.8 [3.6,4.1] -0.4* 

Richest 3.3 [3.1,3.6] 3.3 [3.1,3.5] 0.0 

Place of residence 

Urban 4.4 [4.3,4.5] 4.1 [4.0,4.3] -0.2* 

Rural 4.6 [4.3,4.9] 3.7 [3.4,4.0] -0.9* 

Camps 5.0 [4.7,5.3] 4.0 [3.6,4.4] -1.0* 

Region 

Gaza City & North Gaza 4.6 [4.3,4.8] 4.6 [4.2,4.9] 0.0 

South Gaza 5.3 [5.0,5.5] 4.5 [4.2,4.8] -0.8* 

North West Bank 4.2 [4.0,4.4] 3.4 [3.2,3.6] -0.8* 

Center West Bank 4.2 [3.8,4.7] 3.8 [3.5,4.2] -0.4 

Jerusalem 3.3 [2.9,3.7] 3.9 [3.5,4.3] 0.6* 

South West Bank 4.7 [4.5,5.0] 4.1 [3.8,4.4] -0.6* 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
172 

Figure WBG.01: Total fertility rate for the 3 years before the survey, by background characteristics, West 

Bank and Gaza 2010 MICS4 and 2014 MICS5 

Contraceptive Use

There was no change overall in the percentage of women (44%) who were using modern contraception at 

the time of the surveys in 2010 and 2014. By the background characteristics in Table WBG.02, only women 

age 45-49 showed a significant change between 2010 and 2014. However, in both years, modern 

contraceptive use varied significantly by age, education, wealth quintile, and region. 

There was a significant increase in the percentage of women age 45-49 who used modern contraception 

between the two surveys. In 2010, 37% of women age 45-49 were using modern contraception, compared 

to 44% in 2014. Women age 35-44 had the highest percentage of modern contraceptive use in both surveys 

(56% and 59%), and women age 15-24 had the lowest (26% and 23%). In both years, modern contraceptive 

use increased with age until the oldest group, which had a lower percentage of modern contraceptive use, 

as illustrated in Figure WBG.02. 

There were no changes between the surveys in modern contraceptive use by education or wealth quintile. 

However, in both 2010 and 2014, a higher percentage of women with a primary education used modern 

contraception than women with no education or with a secondary or higher level of education. Modern 

contraceptive use also increased with wealth, although 43% of women in the poorer and middle quintiles 

were using modern contraception in both years. 
173 

There were no significant changes between the surveys by place of residence or region. Modern 

contraceptive did not vary by place of residence in both surveys although use varied by region in 2010 and 

2014. In 2010, by region, the Center West Bank had the highest percentage of women using modern 

contraception (50%). In 2014, Jerusalem had the highest at 48%, while South Gaza had the lowest 

percentage of modern contraceptive use of all regions (38%) in both 2010 and 2014. 

Table WBG.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 44.2 [43.1,45.3] 43.8 [42.6,45.0] -0.4 

Age 

15-24 26.3 [24.0,28.6] * 23.4 [21.2,25.8] * -2.9 

25-34 45.1 [43.5,46.7] 43.0 [41.1,44.9] -2.1 

35-44 56.0 [54.3,57.8] 58.5 [56.4,60.5] 2.4 

45-49 37.3 [34.6,40.2] 44.3 [41.2,47.5] 7.0* 

Education 

None 42.3 [38.7,45.9] * 42.3 [27.9,58.2] * 0.0 

Primary 46.9 [45.5,48.3] 48.5 [46.6,50.5] 1.6 

Secondary + 41.2 [39.6,42.9] 41.2 [39.8,42.7] 0.0 

Wealth quintile 

Poorest 40.3 [37.9,42.7] * 37.4 [35.0,39.8] * -2.9 

Poorer 42.5 [40.4,44.6] 42.9 [40.3,45.6] 0.5 

Middle 42.7 [40.6,44.9] 42.8 [40.3,45.3] 0.0 

Richer 45.7 [43.3,48.1] 43.9 [41.5,46.3] -1.8 

Richest 49.5 [47.0,52.1] 52.0 [49.3,54.7] 2.5 

Place of residence 

Urban 43.9 [42.6,45.2] 43.2 [41.8,44.6] -0.8 

Rural 44.9 [42.4,47.4] 44.9 [42.0,47.8] 0.0 

Camps 45.4 [42.1,48.9] 47.5 [43.8,51.1] 2.0 

Region 

Gaza City & North Gaza 44.6 [42.3,46.8] * 42.7 [40.1,45.3] * -1.9 

South Gaza 38.1 [36.0,40.3] 37.8 [35.0,40.6] -0.3 

North West Bank 47.0 [45.0,49.0] 46.9 [44.5,49.3] -0.1 

Center West Bank 49.6 [45.2,54.1] 46.5 [42.2,50.8] -3.1 

Jerusalem 47.9 [43.0,52.9] 48.2 [43.6,53.0] -0.3 

South West Bank 41.5 [39.0,44.1] 43.7 [41.2,46.2] 2.2 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
174 

Figure WBG.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

Traditional contraceptive use increased significantly in the WBG from 8% in 2010 to 13% in 2014. Changes 

were significant by many characteristics included in Table WBG.03. 

The percentage of women using traditional contraception increased with age in both 2010 and 2014. All 

age categories experienced an increase in the percentage of women using traditional contraception between 

the two surveys, and the increases were of similar magnitudes, which were between 4% and 5%. The 

differences in traditional contraceptive use by age in 2010 remained in 2014. Traditional contraceptive use 

did not differ significantly by education in either survey, despite the significant increase in the percentage 

of women using traditional contraception among those with a primary and a secondary or higher level of 

education between 2010 and 2014. 

Traditional contraceptive use differed by wealth quintile in 2010, but did not in 2014. This was due to 

significant increases in the percent of women using traditional contraception in all wealth quintiles. The 

increase in traditional use and narrowing of the disparity by wealth quintiles is shown in Figure WBG.03. 

Urban, rural, and camp residences all experienced increases in traditional contraceptive use between 2010 

and 2014 between five and six percentage points. Despite doubling from 5% traditional contraceptive use 

in 2010 to 10% in 2014, camps had the lowest percentage of women using traditional contraception in both 

years. 
175 

All regions experienced significant increases in traditional contraceptive use between 2010 and 2014. South 

Gaza experienced a 10-percentage point increase, which is the largest magnitude of change by any 

characteristic included in Table WBG.03. The percentage of women using traditional contraception in 

South Gaza was among the lowest in 2010, and the highest of any region in 2014. Center West Bank 

experienced a similar magnitude of change, moving from the second lowest to the second highest 

percentage of traditional contraceptive use by region, as illustrated in Figure WBG.03. 

Table WBG.03: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 8.3 [7.7,9.0] 13.3 [12.5,14.2] 5.0* 

Age 

15-24 6.8 [5.6,8.2] * 10.8 [9.3,12.5] * 4.0* 

25-34 8.0 [7.1,8.9] 13.4 [12.1,14.8] 5.4* 

35-44 9.1 [8.1,10.3] 14.4 [13.0,16.0] 5.3* 

45-49 9.6 [8.0,11.4] 15.0 [12.7,17.7] 5.4* 

Education 

None 6.4 [5.0,8.3] 5.7 [1.5,19.1] -0.8 

Primary 8.4 [7.6,9.2] 12.5 [11.2,13.9] 4.1* 

Secondary + 8.6 [7.7,9.5] 13.9 [12.8,15.0] 5.3* 

Wealth quintile 

Poorest 6.8 [5.7,8.1] * 11.6 [9.9,13.6] 4.8* 

Poorer 6.9 [5.9,8.2] 13.2 [11.5,15.2] 6.3* 

Middle 8.7 [7.5,10.1] 13.0 [11.5,14.7] 4.3* 

Richer 8.5 [7.3,9.8] 14.5 [12.7,16.5] 6.0* 

Richest 10.5 [9.0,12.1] 14.3 [12.6,16.3] 3.9* 

Place of residence 

Urban 8.6 [7.9,9.4] * 13.4 [12.4,14.4] * 4.8* 

Rural 8.9 [7.5,10.5] 14.9 [12.7,17.3] 6.0* 

Camps 5.0 [3.9,6.5] 10.0 [7.7,13.0] 5.0* 

Region 

Gaza City & North Gaza 6.6 [5.4,7.9] * 10.3 [8.7,12.2] * 3.7* 

South Gaza 6.6 [5.4,7.9] 16.1 [14.0,18.4] 9.5* 

North West Bank 11.5 [10.3,12.8] 14.4 [12.6,16.3] 2.9* 

Center West Bank 6.0 [4.2,8.4] 15.3 [12.3,18.9] 9.4* 

Jerusalem 5.5 [3.7,8.0] 13.2 [10.5,16.4] 7.7* 

South West Bank 9.8 [8.3,11.6] 12.4 [10.8,14.2] 2.6* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
176 

Figure WBG.03: Percentage of women currently using traditional contraception among women age 15-49 in a 

union, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

Antenatal Care

Overall, the WBG experienced a significant increase in the percentage of women who had the recommended 

four or more ANC visits during their most recent pregnancy. At 96% in 2014, WBG had among the highest 

percentage of women who received four or more ANC visits during their most recent pregnancy of all 

countries in this report (Overall Summary, Figure 4). Significant differences by age, education, wealth, 

place of residence, and region present in 2010 were no longer significant in 2014. This was due to the 

relatively large increases in sub-groups who had among the lowest percentages of ANC visits in 2010. 

By wealth, the poorest quintile had the lowest percentage of women with four or more ANC visits in 2010 

(91%), although this increased to 96% in 2014. Due to this increase, and small and insignificant changes in 

other wealth quintiles, ANC visits did not differ by wealth in 2014. This convergence is illustrated in Figure 

WBG.04. 

There were also significant differences in the percentage of women who had four or more ANC visits by 

place of residence in 2010. Rural areas had the smallest percent of women with four or more ANC visits in 

2010, but this increased by five percentage points in 2014. In 2014, there were no significant differences in 

ANC by place of residence. 
177 

This pattern of convergence occurred by region as well. The smallest percentage of women with four or 

more ANC visits in 2010 was found in Jerusalem and the South West Bank, although both increased by 

six-percentage points in 2014. None of the other regions saw significant changes, so that in 2014, there 

were no significant differences in ANC visits by region. 

Table WBG.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, West Bank and Gaza 2010 

MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 94.0 [93.2,94.7] 95.5 [94.6,96.3] 1.5* 

Age 

15-24 95.9 [94.6,96.9] * 95.8 [94.1,96.9] -0.2 

25-34 93.5 [92.3,94.5] 95.8 [94.5,96.8] 2.3* 

35-44 92.5 [90.5,94.1] 93.9 [91.0,96.0] 1.4 

45-49 90.6 [61.9,98.3] ND 

Education 

None 83.4 [77.6,87.9] * ND 

Primary 93.4 [92.2,94.4] 93.8 [91.5,95.5] 0.4 

Secondary + 95.8 [94.9,96.6] 96.1 [95.2,96.9] 0.3 

Wealth quintile 

Poorest 90.7 [88.7,92.4] * 95.9 [94.0,97.2] 5.1* 

Poorer 94.1 [92.3,95.5] 93.8 [91.0,95.8] -0.3 

Middle 94.5 [92.7,95.9] 96.1 [94.0,97.4] 1.5 

Richer 96.4 [94.9,97.4] 95.5 [92.9,97.2] -0.9 

Richest 94.8 [92.8,96.3] 96.3 [93.0,98.0] 1.4 

Place of residence 

Urban 94.6 [93.7,95.3] * 95.8 [94.7,96.7] 1.2 

Rural 90.0 [87.5,92.0] 94.7 [91.9,96.5] 4.7* 

Camps 96.5 [94.6,97.7] 94.4 [91.5,96.3] 2.1 

Region 

Gaza City & North Gaza 94.7 [92.9,96.0] * 95.4 [93.2,96.9] 0.7

South Gaza 97.0 [95.7,97.8] 95.2 [93.2,96.7] -1.7 

North West Bank 95.5 [94.0,96.7] 96.0 [93.8,97.4] 0.4 

Center West Bank 94.5 [91.5,96.6] 93.8 [88.7,96.7] -0.7 

Jerusalem 91.2 [86.2,94.6] 97.4 [92.0,99.2] 6.1* 

South West Bank 89.4 [87.3,91.3] 95.4 [92.9,97.1] 6.0* 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
178 

Figure WBG.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

Delivery

There was a slight, but statistically significant increase in the percentage of women who delivered with an 

SBA between 2010 and 2014, from 99% to 100% overall. In 2010, SBA deliveries ranged among 

characteristics from 97% to 100%, while in 2014, they ranged from 99% to 100%. 

Changes were significant for two subgroups in Table WBG.05—women age 25-34 increased SBA 

deliveries from 99% in 2010 to 100% in 2014, and women in the South West Bank increased SBA deliveries 

from 98% in 2010 to 100% in 2014. In addition, significant differences in SBA deliveries by education, 

place of residence, and region in 2010 were no longer significant in 2014 because nearly all women in all 

categories were delivering their babies with assistance by an SBA in 2014. 

 
179 

Table WBG.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, West Bank and Gaza 2010 MICS4 

and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 99.0 [98.7,99.3] 99.6 [99.2,99.8] 0.5* 

Age 

15-24 99.5 [99.0,99.8] 99.3 [98.5,99.7] 0.2 

25-34 98.8 [98.3,99.2] 99.6 [99.2,99.8] 0.8* 

35-44 98.9 [98.0,99.4] 100.0 1.1 

45-49 ND ND 

Education 

None 96.8 [92.9,98.6] * ND 

Primary 99.2 [98.7,99.5] 99.7 [99.0,99.9] 0.5 

Secondary + 99.1 [98.6,99.5] 99.5 [99.0,99.7] 0.4 

Wealth quintile 

Poorest 98.8 [97.8,99.3] 99.7 [98.8,99.9] 0.9 

Poorer 99.2 [98.4,99.6] 99.3 [98.1,99.7] 0.1 

Middle 99.0 [98.2,99.5] 99.5 [98.5,99.8] 0.5 

Richer 99.4 [98.6,99.8] 99.9 [99.0,100.0] 0.4 

Richest 98.8 [97.5,99.4] 99.4 [97.1,99.9] 0.6 

Place of residence 

Urban 99.2 [98.8,99.4] * 99.6 [99.2,99.8] 0.4 

Rural 98.3 [96.8,99.0] 99.6 [98.4,99.9] 1.3 

Camps 99.6 [98.4,99.9] 99.3 [96.7,99.8] 0.4 

Region 

Gaza City & North Gaza 99.6 [99.0,99.9] * 99.6 [98.8,99.9] 0.0

South Gaza 99.7 [99.0,99.9] 99.5 [98.4,99.8] 0.2 

North West Bank 98.7 [97.8,99.2] 100.0 1.3 

Center West Bank 98.7 [95.9,99.6] 99.2 [97.0,99.8] 0.5 

Jerusalem 99.0 [96.7,99.7] 98.9 [94.5,99.8] 0.1 

South West Bank 98.4 [97.2,99.1] 99.7 [98.6,99.9] 1.3* 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two surveys 

with the significance of the difference. 
180 

Figure WBG.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, West Bank and Gaza 2010 MICS4 

and 2014 MICS5 

The percentage of women who delivered in a health facility increased significantly overall, from 98% to 

99%, between the 2010 and 2014 surveys. Changes were small but statistically significant for several 

characteristics in Table WBG.06. In addition, while there were significant differences in health center 

delivery by education and region in 2010, these differences were no longer significant in 2014. 

Increases in facility delivery were experienced by women age 25-34, women with a primary and secondary 

or higher level of education, women in the poorest and poorer wealth quintiles, women in urban and rural 

areas, and women in Gaza City, North Gaza, and the North West Bank. The magnitude of significant 

increases ranged from 1-2 percentage points. 

In 2010, the percentage of women who delivered in a health facility by all characteristics in Table WBG.06 

ranged from 96% to 99%, while in 2014, the range was 99% to 100%. The narrowing of the ranges is 

illustrated in Figure WBG.06. 

 
181 

Table WBG.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in the 

2 years before the survey, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 98.0 [97.5,98.5] 99.3 [98.9,99.6] 1.3* 

Age 

15-24 98.9 [97.9,99.5] 99.0 [98.2,99.5] 0.1 

25-34 97.6 [96.9,98.2] 99.3 [98.7,99.6] 1.7* 

35-44 97.8 [96.2,98.7] 100.0 2.2 

45-49 ND ND 

Education 

None 95.6 [92.2,97.6] * ND 

Primary 98.2 [97.4,98.7] 99.4 [98.5,99.8] 1.3* 

Secondary + 98.2 [97.4,98.7] 99.3 [98.7,99.6] 1.1* 

Wealth quintile 

Poorest 97.9 [96.5,98.7] 99.5 [98.5,99.8] 1.6* 

Poorer 97.5 [96.2,98.4] 99.1 [97.8,99.6] 1.6* 

Middle 98.6 [97.6,99.2] 99.3 [98.0,99.7] 0.7 

Richer 98.3 [97.1,98.9] 99.3 [98.2,99.7] 1.1 

Richest 98.0 [96.6,98.9] 99.3 [97.0,99.8] 1.3 

Place of residence 

Urban 98.2 [97.6,98.7] 99.3 [98.8,99.6] 1.1* 

Rural 97.0 [94.7,98.3] 99.3 [97.9,99.8] 2.3* 

Camps 98.6 [97.0,99.4] 99.5 [96.3,99.9] 0.9 

Region 

Gaza City & North Gaza 97.6 [96.1,98.5] * 99.4 [98.4,99.8] 1.8* 

South Gaza 99.1 [98.2,99.6] 99.3 [98.0,99.7] 0.1 

North West Bank 96.7 [95.0,97.9] 98.8 [97.4,99.5] 2.1* 

Center West Bank 97.9 [95.9,99.0] 99.6 [97.3,99.9] 1.7 

Jerusalem 98.7 [95.7,99.6] 99.1 [93.8,99.9] 0.4 

South West Bank 98.7 [97.6,99.3] 99.7 [98.6,99.9] 1.0 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
182 

Figure WBG.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 

MICS5 

Overall, the percentage of women who delivered their most recent birth by C-section between 2010 and 

2014 increased from 17% to 20%. There were significant changes by many characteristics in Table 

WBG.07. 

In both 2010 and 2014, women age 15-24 had the lowest percentage of women who delivered by C-section 

compared to all other age categories. While the other age categories had significant increases in C-section 

delivery between the two surveys, women age 15-24 did not. Women age 45-49 had a drastic increase in 

the percentage of women who delivered by C-section. While 13% of these women delivered by C-section 

in 2010, 68% did in 2014. This shift is illustrated in Figure WBG.07. 

The percentage of C-section delivery increased for women with a primary and secondary or higher level of 

education between 2010 and 2014. However, the percentage of women who had C-sections did not vary by 

level of education in either year. By wealth quintile, the percentage of women delivering by C-section did 

not differ significantly in 2010, but did in 2014. This was due to a significant increase in the percent of 

women in the richer and richest wealth quintiles delivering by C-section between the two surveys. In 2010, 

19% of women in the richest wealth quintile had a C-section, and this increased to 27% in 2014. 
183 

A higher percentage of women who reside in urban and rural areas delivered by C-section in 2014 than in 

2010. However, in both years, there were no significant differences in C-section delivery by residence. In 

contrast, there were significant differences by region in both 2010 and 2014. Despite a significant increase 

between surveys, the South West Bank was the region with the lowest percentage of women delivering by 

C-section in 2010 and 2014, at 12% and 16% respectively. In 2010, 16% of women in Jerusalem delivered 

by C-section. This increased to 25% in 2014, which was the largest increase by region. 

Table WBG.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section in 

the 2 years before the survey, by background characteristics, West Bank and Gaza 2010 MICS4 and 2014 

MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 16.7 [15.5,17.9] 20.4 [18.9,21.9] 3.7* 

Age 

15-24 12.2 [10.3,14.5] * 13.6 [11.6,16.0] * 1.4 

25-34 16.3 [14.8,18.0] 20.5 [18.4,22.7] 4.2* 

35-44 25.2 [22.3,28.3] 35.0 [30.6,39.6] 9.8* 

45-49 12.8 [3.3,39.0] 68.3 [35.4,89.5] 55.5* 

Education 

None 19.2 [14.3,25.3] 19.5 [4.2,57.0] 0.3 

Primary 17.1 [15.4,18.9] 22.4 [19.6,25.5] 5.3* 

Secondary + 16.0 [14.3,17.7] 19.6 [17.9,21.4] 3.6* 

Wealth quintile 

Poorest 13.6 [11.4,16.1] 17.7 [14.8,20.9] * 4.1* 

Poorer 16.9 [14.8,19.2] 17.1 [14.2,20.4] 0.2 

Middle 17.4 [14.9,20.2] 20.3 [17.2,23.8] 2.9 

Richer 17.2 [14.6,20.2] 21.9 [18.8,25.3] 4.6* 

Richest 19.4 [16.2,23.1] 26.5 [22.5,31.0] 7.1* 

Place of residence 

Urban 16.1 [14.7,17.6] 19.4 [17.7,21.3] 3.3* 

Rural 18.5 [15.7,21.7] 24.1 [20.3,28.2] 5.6* 

Camps 18.0 [14.7,21.8] 22.4 [17.7,28.0] 4.4 

Region 

Gaza City & North Gaza 14.6 [12.5,17.1] * 18.0 [14.9,21.7] * 3.4 

South Gaza 13.3 [11.3,15.7] 16.7 [14.0,19.8] 3.4 

North West Bank 25.4 [22.5,28.5] 27.9 [24.1,32.1] 2.5 

Center West Bank 19.5 [14.2,26.2] 25.3 [20.4,31.0] 5.8 

Jerusalem 15.8 [11.4,21.3] 24.8 [19.8,30.6] 9.1* 

South West Bank 11.8 [9.6,14.3] 15.7 [13.0,18.9] 4.0* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
184 

Figure WBG.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section 

in the 2 years before the survey, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

Child Health Care

Advice and treatment seeking for children under age 5 with ARI symptoms in the 2 weeks before the survey 

increased significantly overall, and by many characteristics included in Table WBG.08. Overall, careseeking for children with ARI increased from 65% in 2010 to 77% in 2014. 

There were no differences between the percentage of care-seeking for boys and girls in either survey. In 

addition, care-seeking increased for both boys and girls between 2010 and 2014, and by a similar magnitude 

of 11 and 12-percentage points. Care-seeking also increased significantly for children with mothers with a 

secondary or higher education, from 59% in 2010 to 80% in 2014. Care-seeking for ARI symptoms was 

significantly higher for children with mothers with a secondary or higher level of education than those with 

a primary education in 2014. 

Care-seeking for ARI symptoms did not vary significantly by wealth quintile in 2010 or 2014. Care-seeking 

for children in the poorest wealth quintile increased from 58% in 2010 to 78% in 2014. This shift is shown 

in Figure WBG.08. 

By place of residence, the lowest percentage of care-seeking was for children in camps, at 51% in 2010. In 

2014, care was sought for 77% children with ARI symptoms in camps, which was statistically the same as 

children residing in urban and rural areas. This was due to a 26-percentage point increase in care-seeking 

for children who reside in camps. 
185 

In 2010, South Gaza had the lowest percentage of care-seeking for children with ARI symptoms at 47%. 

This increased by 29-percentage points between the two surveys, which is the largest magnitude of change 

reported in Table WBG.08. In 2010, South Gaza had the lowest percentage of care-seeking. By 2014, careseeking in South Gaza was not statistically different from care-seeking in other regions. 

Table WBG.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 64.8 [60.1,69.3] 76.5 [73.1,79.7] 11.7* 

Child’s sex 

Male 66.5 [60.4,72.1] 78.7 [74.6,82.3] 12.2* 

Female 62.4 [55.8,68.6] 73.7 [68.0,78.7] 11.2* 

Mother’s education 

None 68.1 [47.3,83.6] ND * 

Primary 67.6 [61.5,73.1] 70.8 [64.8,76.2] 3.2 

Secondary + 59.4 [51.8,66.6] 79.5 [75.5,82.9] 20.0* 

Wealth quintile 

Poorest 57.6 [47.6,67.1] 77.6 [70.7,83.3] 20.0* 

Poorer 64.7 [55.9,72.7] 66.5 [57.9,74.1] 1.7 

Middle 64.1 [51.8,74.9] 76.6 [68.8,83.0] 12.5 

Richer 70.2 [59.8,78.8] 80.3 [73.7,85.6] 10.1 

Richest 74.6 [60.0,85.2] 81.9 [70.5,89.5] 7.3 

Place of residence 

Urban 67.4 [61.5,72.9] * 77.3 [73.4,80.8] 9.9* 

Rural 65.3 [55.3,74.2] 73.2 [63.2,81.3] 7.9 

Camps 50.9 [37.4,64.2] 76.5 [62.7,86.3] 25.6* 

Region 

Gaza City & North Gaza 63.9 [53.5,73.2] * 71.9 [62.5,79.7] 7.9

South Gaza 46.9 [35.6,58.6] 75.8 [69.5,81.2] 28.9* 

North West Bank 79.2 [71.9,85.0] 80.5 [73.5,86.0] 1.3 

Center West Bank (71.5 [51.1,85.7]) 81.7 [67.5,90.5] 10.2 

Jerusalem ND 86.7 [68.4,95.2] 

South West Bank 65.1 [54.2,74.7] 73.7 [65.3,80.6] 8.6 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
186 

Figure WBG.08: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

Child Nutrition

Table WBG.09 reports that the percentage of children under age 6 months who were exclusively breastfed 

increased significantly from 29% in 2010 to 39% in 2014. By 2014, the WBG had among the highest 

percent of children exclusively breastfed of all countries included in this report (Overall Summary, Figure 

9). There were no significant differences in the percentage of children who were exclusive breastfed by any 

sub-group in 2010 or 2014. However, several subgroups included in Table WBG.09 experienced a 

significant increase in exclusive breastfeeding between the two surveys. 

The percentage of children exclusively breastfed increased for both boys and girls between the two surveys. 

The change was significant for boys. By 2014, 39% of boys and 38% of girls were exclusively breastfed. 

In 2010, 28% of children of mothers with a primary education were exclusively breastfed. In 2014, this 

increased to 44%, which surpassed the percentage of children exclusively breastfed among mothers with a 

secondary or higher level of education. The sample size for children with mothers with no education was 

under 25 unweighted cases in 2014 and was therefore not reported. 

Exclusive breastfeeding increased significantly in the poorest, middle, and richer wealth quintiles between 

the two surveys. By wealth quintile, between 37% and 42% of children were exclusively breastfed in 2014, 

compared to 23% and 38% in 2010. The pattern of exclusive breastfeeding by wealth category was not 

linear, as illustrated in Figure WBG.09. 
187 

Exclusive breastfeeding increased significantly for children residing in urban and rural areas between the 

two surveys. In 2010, the lowest percentage of children who were exclusively breastfed were in rural areas, 

but in 2014 children in rural areas had the highest percentage of exclusive breastfeeding. The differences 

between place of residence were not statistically significant, as illustrated in Figure. WBG.09. By region, 

exclusive breastfeeding became more disparate between 2010 and 2014.Only the South West Bank Region 

had a statistically significant increase in the percentage of children exclusively breastfed. 

Table WBG.09: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 28.8 [25.9,31.9] 38.6 [34.7,42.7] 9.8* 

Child’s sex 

Male 26.1 [22.2,30.4] 38.9 [33.6,44.5] 12.8* 

Female 31.7 [27.4,36.2] 38.3 [32.6,44.4] 6.7 

Mother’s education 

None (13.4 [6.2,26.6]) ND 

Primary 28.1 [24.2,32.4] 43.7 [35.8,51.8] 15.5* 

Secondary + 30.7 [26.5,35.4] 36.8 [32.2,41.7] 6.1 

Wealth quintile 

Poorest 23.1 [17.7,29.7] 37.2 [29.9,45.1] 14.1* 

Poorer 30.7 [24.7,37.4] 37.2 [27.0,48.7] 6.6 

Middle 29.1 [23.3,35.6] 41.9 [32.3,52.2] 12.9* 

Richer 25.2 [19.5,32.0] 36.8 [28.6,45.8] 11.5* 

Richest 37.6 [29.6,46.5] 41.8 [32.1,52.1] 4.1 

Place of residence 

Urban 29.0 [25.6,32.7] 38.2 [33.5,43.1] 9.2* 

Rural 26.4 [20.0,33.9] 40.7 [32.0,50.0] 14.3* 

Camps 31.5 [22.7,41.7] 39.1 [26.8,52.9] 7.6 

Region 

Gaza City & North Gaza 30.4 [24.3,37.4] 38.3 [31.1,45.9] 7.8 

South Gaza 24.5 [18.3,32.0] 34.1 [23.3,46.9] 9.6 

North West Bank 31.0 [25.4,37.2] 40.0 [31.9,48.6] 8.9 

Center West Bank 30.0 [18.9,44.1] 24.6 [15.1,37.5] -5.4 

Jerusalem 26.1 [15.4,40.5] (38.6 [22.0,58.2]) 12.5 

South West Bank 29.0 [22.9,35.9] 49.0 [41.4,56.6] 20.0* 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
188 

Figure WBG.09: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, West Bank and Gaza 2010 MICS4 and 2014 MICS5 

In the WBG, stunting in children under age 5 declined from 11% to 7% between 2010 and 2014. There 

were significant declines by all characteristics included in Table WBG.10. 

The percentage of boys and girls who were stunted significantly declined between the two surveys. 

However, in both surveys, significantly more boys were stunted than girls. The gap between boys and girls 

narrowed slightly in 2014. In both 2010 and 2014, a lower percentage of children with mothers with a 

secondary or higher level of education were stunted compared to children with mothers with a primary or 

no education. The pattern of stunting by mother’s education level remained consistent between the two 

surveys, although stunting declined significantly for children with mothers with a primary or secondary or 

higher level of education. Despite this, the disparity in stunting by mother’s level of education remained in 

2014. 

There were significant reductions in the percentage of children who were stunted in the poorest, middle, 

and richest wealth quintiles. The reductions of the greatest magnitude were in the poorest quintile, so that 

in 2014, there were no longer significant differences in stunting by wealth quintile. The convergence and 

overall reduction in stunting by wealth is shown in Figure WBG.10. 

The percentage of children who reside in urban areas, rural areas, and camps who were stunted declined 

between the two surveys. There were no significant differences in the percentage of children stunted by 

place of residence in either 2010 or 2014. However, there were significant differences in the percentage of 

children who were stunted by region. While Jerusalem saw the sharpest decline in stunting by eight-
189 

percentage points, stunting declined significantly in all regions. In 2010, stunting by region ranged from 

8% in the North West Bank to 16% in Jerusalem. In 2014, stunting ranged from 5% in North West Bank to 

10% in South West Bank. 

Table WBG.10: Percentage of children under age 5 who are stunted, by background characteristics, West 

Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 10.9 [10.2,11.8] 7.4 [6.7,8.2] -3.5* 

Child’s sex 

Male 11.9 [10.9,13.0] * 8.1 [7.2,9.2] * -3.8* 

Female 10.0 [9.0,11.0] 6.6 [5.7,7.6] -3.3* 

Mother’s education 

None 16.0 [13.0,19.7] * (21.5 [8.6,44.1]) * 5.4 

Primary 11.5 [10.5,12.6] 9.3 [8.0,10.7] -2.2* 

Secondary + 9.6 [8.6,10.7] 6.5 [5.7,7.4] -3.1* 

Wealth quintile 

Poorest 14.5 [12.9,16.2] * 7.3 [6.0,8.7] -7.2* 

Poorer 10.7 [9.3,12.3] 8.4 [6.9,10.3] -2.3 

Middle 10.0 [8.6,11.8] 7.6 [6.2,9.4] -2.4* 

Richer 9.5 [8.0,11.3] 7.3 [5.9,9.1] -2.2 

Richest 8.4 [6.6,10.5] 5.8 [4.4,7.6] -2.6* 

Place of residence 

Urban 11.0 [10.1,12.0] 7.5 [6.7,8.4] -3.5* 

Rural 10.9 [9.2,13.0] 7.6 [5.9,9.7] -3.4* 

Camps 10.5 [8.3,13.1] 6.4 [4.8,8.6] -4.1* 

Region 

Gaza City & North Gaza 10.6 [9.2,12.2] * 7.5 [6.2,9.0] * -3.1* 

South Gaza 10.2 [8.7,11.9] 6.5 [5.1,8.3] -3.7* 

North West Bank 7.5 [6.2,8.9] 5.2 [4.1,6.7] -2.2* 

Center West Bank 15.2 [12.1,19.0] 9.4 [7.0,12.5] -5.8* 

Jerusalem 15.7 [11.3,21.5] 7.7 [5.6,10.5] -8.1* 

South West Bank 14.7 [12.4,17.3] 9.9 [7.9,12.3] -4.8* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference 
190 

Figure WBG.10: Percentage of children under age 5 who are stunted, West Bank and Gaza 2010 MICS4 and 

2014 MICS5 

There was a significant increase in the percentage of children under age 5 who were overweight in the WBG 

between 2010 and 2014. In 2010, 5% of children were overweight. This rose to 8% in 2014. The percentage 

of overweight children increased by most characteristics included in Table WBG.11, with the exception of 

children residing in Jerusalem, where there was a significant decline in the percentage of overweight 

children between the two surveys. 

In both 2010 and 2014, significantly more boys were overweight than girls, and the percentage of both boys 

and girls who were overweight increased significantly between the two surveys. In 2014, 9% of boys and 

7% of girls were overweight. 

The percentage of children who were overweight did not vary significantly by mother’s education level in 

2010 or 2014. A higher percentage of children with mothers with a primary or a secondary or higher level 

of education were overweight in 2014 compared to 2010 (both increased from 5% to 8%). 

In 2010, the poorest, poorer, middle, and richer wealth quintiles all had approximately 5% children who 

were overweight. By 2014, there were significant differences in the percentage of children who were 

overweight by wealth quintile. The middle, richer, and richest quintiles all experienced significant increases 

in the percent of children who were overweight between 2010 and 2014. In 2014, the poorest wealth quintile 

had the lowest percentage of children who were overweight (6%) and the highest percentages were in the 

middle and richest quintiles (10%). 
191 

In 2010, there were no differences in the percent of children who were overweight by place of residence. 

However, there were differences by place of residence in 2014, which were primarily due to a significant 

increase in the percent of children who were overweight in urban and rural areas. In 2014, 11% of children 

in rural areas were overweight, compared to 5% in 2010. The percentage of children who were overweight 

increased in urban areas and camps, but to a lesser degree and not significantly in camps. This increase and 

dispersion by place of residence are illustrated in Figure WBG.11. 

There were significant differences in the percentage of children who were overweight by region in both 

2010 and 2014. The South West Bank had the greatest increase between the two surveys, although all 

regions except for Central West Bank and Jerusalem experienced an increase in the percent of children who 

were overweight between the two surveys. 

Table WBG.11: Percentage of children under age 5 who are overweight, by background characteristics, West 

Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 5.3 [4.8,5.9] 8.2 [7.4,8.9] 2.8* 

Child’s sex 

Male 6.0 [5.3,6.8] * 9.1 [8.1,10.2] * 3.1* 

Female 4.6 [4.0,5.3] 7.1 [6.3,8.1] 2.5* 

Mother’s education 

None 6.2 [4.4,8.7] (8.5 [2.1,29.4]) 2.4 

Primary 5.4 [4.7,6.1] 7.9 [6.7,9.2] 2.5* 

Secondary + 5.1 [4.4,6.0] 8.3 [7.5,9.2] 3.1* 

Wealth quintile 

Poorest 4.6 [3.6,5.8] 6.3 [5.1,7.8] * 1.7 

Poorer 5.3 [4.4,6.4] 6.7 [5.4,8.4] 1.4 

Middle 5.2 [4.2,6.4] 10.0 [8.4,11.8] 4.8* 

Richer 5.4 [4.3,6.6] 9.4 [7.7,11.5] 4.0* 

Richest 6.7 [5.2,8.5] 9.6 [7.7,11.9] 2.9* 

Place of residence 

Urban 5.5 [4.8,6.2] 7.9 [7.0,8.8] * 2.4* 

Rural 5.3 [4.1,6.8] 10.9 [9.1,13.1] 5.6* 

Camps 4.4 [3.2,6.0] 6.1 [4.5,8.3] 1.7 

Region 

Gaza City & North Gaza 3.8 [2.9,4.9] * 6.6 [5.3,8.2] * 2.8* 

South Gaza 4.2 [3.3,5.3] 6.4 [5.2,7.8] 2.2* 

North West Bank 4.7 [3.8,5.8] 8.5 [7.1,10.2] 3.8* 

Center West Bank 11.1 [7.7,15.7] 11.1 [7.7,15.8] 0.0 

Jerusalem 10.8 [7.2,15.9] 6.8 [4.8,9.4] -4.0 

South West Bank 6.9 [5.7,8.4] 11.9 [9.8,14.5] 5.0* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference 
192 

Figure WBG.11: Percentage of children under age 5 who are overweight, West Bank and Gaza 2010 MICS4 

and 2014 MICS5 

Under-5 Mortality

Under-5 mortality declined from 23/1000 to 21/000 live births between 2010 and 2014. The decrease was 

only significant for children in the poorest wealth quintile, where there was a reduction from a mortality 

rate of 32/1000 in 2010 to 20/1000 2014. In 2014, the lowest under-5 mortality was among children in the 

richest wealth quintile at 14/1000, while the highest was among children with mothers with no education 

at 30/1000. 

Despite a lack of statistical significance, declines in under-5 mortality by region were notable, and in 

particular in South Gaza and the North West Bank. 

 
193 

Table WBG.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 

2010 2014 

Variable U5M [C.I.] U5M [C.I.] Diff1

Total 23 [20,26] 21 [18,25] -2 

Child’s sex 

Male 26 [22,31] 22 [18,28] -4 

Female 20 [16,24] 20 [16,25] 1 

Mother’s education 

None 37 [25,55] 30 [8,114] -7 

Primary 24 [20,29] 27 [20,35] 3 

Secondary + 20 [16,25] 19 [15,23] -1 

Wealth quintile 

Poorest 32 [25,40] 20 [14,29] -12* 

Poorer 22 [17,29] 28 [19,39] 5 

Middle 23 [17,30] 27 [19,36] 4 

Richer 22 [16,31] 18 [12,26] -4 

Richest 13 [8,21] 14 [8,24] 1 

Place of residence 

Urban 22 [19,26] 22 [18,26] -1 

Rural 25 [19,33] 22 [15,32] -3 

Camps 24 [17,33] 19 [12,30] -5 

Region 

Gaza City & North Gaza 22 [17,30] 25 [18,35] 3 

South Gaza 31 [23,42] 21 [15,29] -10 

North West Bank 26 [21,32] 19 [13,28] -6 

Center West Bank 18 [10,33] 16 [8,32] -2 

Jerusalem 10 [5,21] 17 [8,35] 7 

South West Bank 20 [14,28] 24 [17,33] 4 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
194 

Figure WBG.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

West Bank and Gaza 2010 MICS4 and 2014 MICS5 

West Bank and Gaza Strip Summary

The WBG had a TFR of 4.5 in 2010, which declined to 4.1 in 2014. Jerusalem was a notable exception, 

with the only statistically significant increase in TFR from 3.3 to 3.9 during this time. In general, the TFR 

declined with increasing wealth. Fewer than half of women were using a method of modern contraception 

in 2010, and this did not change significantly in 2014. The smallest percentage of women using modern 

contraception in both years was in the age 15-24 group. Traditional contraceptive use increased from 8% 

in 2010 to 13% in 2014, and increased significantly by nearly all background characteristics. 

The ANC and delivery indicators were high in 2010 and 2014. By 2014, most women (96%) had the 

recommended four or more ANC visits. While there was some variance by background characteristics in 

2010, particularly by region, there were no differences in 2014. Delivering with an SBA was nearly 

universal with 99% of women delivered with an SBA in 2010, and 100% in 2014. The percentage delivering 

at a health facility was similar at 98% in 2010 and 99% in 2014. C-sections became more prevalent in 2014, 

and increased from 17% to 20%. C-sections increased with age and wealth, and varied by region. In 2010 

and 2014, the South West Bank had the lowest and the North West Bank had the highest percentage of Csection deliveries by region. 

Several child health indicators showed improvements between 2010 and 2014. Exclusive breastfeeding of 

children under age 6 months increased from 29% to 39%. Women in the poorest wealth quintile increased 

exclusive breastfeeding from 23% to 37%. Stunting in children under age 5 decreased from 11% to 7%. 
195 

However, the percentage of overweight children increased from 5% to 8%. Finally, under-5 mortality was 

reduced from 23/1000 to 21/1000 live births between 2010 and 2014. This reduction was not significant 

overall or by background characteristics, except for the poorest wealth quintile, among whom under-5 

mortality declined from 32 to 20/1000 live births. 

197 

Yemen 

As of 2016, Yemen has a total population of 27.5 million people, with 35% of the population living in urban 

areas (Population Reference Bureau 2016). Yemen is among the poorest country in the Arab region 

(Population Reference Bureau 2016). Since the Arab Spring in 2011, Yemen has experienced a state of near 

constant unrest and conflict. Since 2015, a civil war has consumed the country. The United Nations 

estimates that in the first 18 months of fighting, 10,000 people were killed and three million Yemenis have 

been displaced (Ghobari 2016). Due to the continuing conflict, it has been difficult to collect health indicator 

estimates. For most estimates, the most recent estimates are from the 2013 Yemen Demographic and Health 

Survey (Ministry of Public Health and Population (MOPHP) et al. 2015). Many estimates from 2013 

indicate progress in terms of maternal, child, and nutritional outcomes in Yemen. However, due to the 

deteriorating health system, early data from 2015 reveals that for some health indicators, progress has 

stalled or even reversed (Qirbi and Ismail 2017). 

Maternal and reproductive health indicators have made progress in the last 10 years but are marked by 

consistent disparities across wealth and education groups. The maternal mortality ratio (MMR) has decline 

markedly since 2003 from 365 maternal deaths per 100,000 births to 148 in 2013 (Ministry of Public Health 

and Population (MOPHP) et al. 2015). Nearly 60% of the maternal deaths identified in the 2013 DHS 

occurred at home or on the way to a health facility, which is an indication of difficulties recognizing a 

medical emergency and accessing care (Ministry of Public Health and Population (MOPHP) et al. 2015). 

Both the percentage of births that occur in health facilities and the percentage of births attended by a skilled 

medical professional have increased, although the overall prevalence of both indicators is low (Ministry of 

Public Health and Population (MOPHP) et al. 2015). As with other maternal health indicators, striking 

disparities exist by wealth quintile (Ministry of Public Health and Population (MOPHP) et al. 2015). Some 

research has found that disparities by socioeconomic status extend to the prevalence of clinical outcomes 

such as eclampsia. A case control study in Hajjah, Yemen that compared women with eclampsia and 

preeclampsia to women with normal deliveries, and found low education and low level of prenatal care 

were significantly associated with preeclampsia (Al-Rukeimi, Al-Haddad, and Adam 2014). Nearly 40% 

of women report receiving no antenatal care, however, this represents some improvement from 2006 when 

50% of women reported receiving no antenatal care (Ministry of Public Health and Population (MOPHP) 

et al. 2015). Just 28% of births in Yemen were protected against tetanus in 2013, a decrease from 31% of 

births in 2006 (Ministry of Public Health and Population (MOPHP) et al. 2015). A 2009 survey of 20 health 

facilities, including 4 district hospitals, found that none of the facilities were able to perform all eight of the 

signal functions for safe labor and delivery as designated by the WHO (Al Serouri et al. 2009). Among the 

district hospitals, none of them provided cesarean delivery services and overall, the authors found that due 

to lack of resources, poor management, and inadequately trained staff, none of the facilities were fully 

functioning (Al Serouri et al. 2009). A similar assessment of obstetric services conducted in 2010 found a 

sharp distinction between the health resources available to Yemeni women by location (Al Serouri et al. 

2012). Across three rural governorates, Amran, Marib, and Shabwa, with a combined population of 1.9 

million, there were just three obstetricians and three anesthesiologists (Al Serouri et al. 2012). In a single 

urban governorate, with a total population of 666,000, there were 54 obstetricians and 10 anesthesiologists 

(Al Serouri et al. 2012). An issue unique to Yemen is the chewing al-qat, a plant which serves as a natural 

amphetamine. A large survey from 2008 found that 40% of women reported chewing al-qat during 

pregnancy and those who reported chewing al-qat were more likely to be poor, live in a rural area, and have 

low education levels (Khawaja, Al-Nsour, and Saad 2008). A 2011 study found a significant dose-response 

relationship between the frequency of al-qat chewing and the number of child deaths experienced by a 

woman (Ibrahim Ali Omer et al. 2011). A case-control study in 2015 found that women who regularly 

chewed al-qat during pregnancy were significantly more likely to experience pre-term labor and 

preeclampsia. Their infants were more likely to be low birth weight, and had significantly increased odds 

of admission into the neonatal intensive care unit (Abdel-Aleem et al. 2015).
198 

Women in Yemen face numerous obstacles in health care. In the 2013 DHS survey, women were asked 

about barriers to accessing healthcare in Yemen. The most commonly cited issues included not wanting to 

go alone, not having a female healthcare provider, distance to the facility, and ability to pay for care 

(Ministry of Public Health and Population (MOPHP) et al. 2015). A further barrier to health care is the 

nearly complete lack of health insurance among women in Yemen. In 2013, just over 2% of women 

surveyed reported having some form of health insurance (Ministry of Public Health and Population 

(MOPHP) et al. 2015). Beyond issues of access to healthcare, Yemeni women face other health challenges 

such as female circumcision. Overall, 19% of women age 15-49 have undergone some form of female 

circumcision (Ministry of Public Health and Population (MOPHP) et al. 2015). The largest differentials in 

prevalence of female circumcision are by geographic location with some Yemenis governorates, such as 

Al-Mhrah and Hadramout, reporting the prevalence of female circumcision as over 80%, while several 

other governorates report 0% prevalence (Ministry of Public Health and Population (MOPHP) et al. 2015). 

The contraceptive prevalence rate (CPR) among married women has increased since 2003, although there 

are large disparities in contraceptive use by wealth and place of residence. Women who live in urban areas 

and women in the highest wealth quintile have substantially higher levels of contraceptive use compared to 

poor, rural women (Ministry of Public Health and Population (MOPHP) et al. 2015). Nutritional deficits 

are also of concern. Among women age 15-49, 70% are anemic (Ministry of Public Health and Population 

(MOPHP) et al. 2015). Approximately 50% of women have a BMI (kg/m2

) within the normal range (BMI 

18.5-24.9), 24% are overweight or obese (BMI ≥ 25), and the remaining quarter are considered underweight 

(Ministry of Public Health and Population (MOPHP) et al. 2015).

Similar to the maternal health indicators, infant and child health has improved over the last decade although 

disparities persist along socio-economic lines. Both infant mortality and under-5 mortality have declined 

since 2003. Despite this progress, there are significant differences in mortality by wealth and other 

socioeconomic indicators (Ministry of Public Health and Population (MOPHP) et al. 2015). A 2016 study 

found that Yemeni women in the highest wealth and education terciles had the lowest rates of stillbirth, 

neonatal, and infant mortality (Alosaimi et al. 2016). Vaccination coverage has declined since 2006. 

Overall, 16% of children have received no vaccinations by the age of 2, which is a slight increase from 

2006 when 12% of children reported no vaccinations (Ministry of Public Health and Population (MOPHP) 

et al. 2015). Coverage rates for measles, polio, and DPT have all declined since 2006 (Ministry of Public 

Health and Population (MOPHP) et al. 2015). Diarrheal disease is quite prevalent with 31% of children 

under age 5 experiencing a diarrheal episode in the 2 weeks before the DHS administration (Ministry of 

Public Health and Population (MOPHP) et al. 2015). In 2017, Yemen was subject to an explosive cholera 

outbreak, with over 700,000 cases reported by mid-September and over associated 2,000 deaths, with 

thousands of new cases being reported each week (Miles 2017). The nutritional status of children in Yemen 

is poor (Rikimaru 2015). Among children under age 5, stunting and underweight are pervasive, with a 

smaller proportion of children considered wasted (Ministry of Public Health and Population (MOPHP) et 

al. 2015). All nutrition measures are higher among children living in poor and rural households compared 

with those living in wealthier households and urban areas (Ministry of Public Health and Population 

(MOPHP) et al. 2015). A survey among rural Yemeni children under age 5 found the prevalence of 

underweight and stunting to be 46% and 63%, respectively (Al-Sobaihi, Nakamura, and Kizuki 2016). 

Since 2003, the percentage of children considered underweight has decreased slightly, while the percent of 

children considered stunted or wasted has increased (Ministry of Public Health and Population (MOPHP) 

et al. 2015). Breastfeeding is nearly universal in Yemen, although the proportion of infants exclusively 

breastfed at age 6 months has decreased significantly (Ministry of Public Health and Population (MOPHP) 

et al. 2015). A recent report from 2017 indicates that the on-going conflict has resulted in sky-rocketing 

levels of undernutrition and food insecurity, with an estimated 2 million children acutely malnourished 

(World Food Programme 2017). Since 2014, the percentage of households reporting limited access to 

sufficient food has increased from 41% to 63% in 2017 (World Food Programme 2017). 
199 

Prior to the current conflict, Yemen’s health system was dysfunctional with numerous barriers to access to 

care including high out-of-pocket expenditures, physical access to health facilities among rural populations, 

and inadequate training among providers (Qirbi and Ismail 2017). A 2010 study assessed the health 

infrastructure in Yemen by examining the relationship between distance to a health facility and child 

vaccination (Al-Taiar et al. 2010). The authors found a strong relationship between driving distance and 

vaccination, which indicated that in Yemen, physical distance to a health facility may be a strong predictor 

of access and use of medical services (Al-Taiar et al. 2010). This is an especially acute problem among 

households in rural areas. Prior to 2011, out-of-pocket spending by Yemeni families accounted for twothirds of the total health expenditure in the country and by 2014, this increased to over 75% (Holst and 

Gericke 2012; Qirbi and Ismail 2017). Over the same time period, the percentage of total health expenditure 

from the government dropped from 33% to 22% (Qirbi and Ismail 2017). The remaining portion of total 

health expenditure was supported by international donors and public funding (Holst and Gericke 2012). 

Although the government was taking strides towards expanding public financing for the health care system, 

the 2011 political upheaval and the subsequent civil war have largely derailed these efforts (Qirbi and Ismail 

2017). The healthcare cost burden was exacerbated in the time period right before the civil war in response 

to a steep decrease in outside donor funding (Qirbi and Ismail 2017). In 2011, as the political upheaval 

began, researchers conducted an evaluation of hospital disaster preparedness in Yemen’s capital city, 

Sana’a (Aladhrai et al. 2015). In a follow-up assessment completed in 2013, the authors found that among 

the 11 hospitals surveyed, there was little to no progress made in hospital emergency preparedness despite 

the social and political turmoil (Aladhrai et al. 2015). Since the start of the civil war in 2015, the healthcare 

infrastructure in Yemen has collapsed. In June 2016, the WHO classified 17% of the health facilities in 

Yemen non-functional and another 38% were deemed partially functional (Qirbi and Ismail 2017). Among 

these health facilities, 8% have been completely or partially destroyed in the war (Qirbi and Ismail 2017). 

It is estimated that approximately half the population does not have access to basic healthcare (Qirbi and 

Ismail 2017). The effects of the rapidly deteriorating healthcare system are beginning to be seen in the latest 

health indicators from Yemen. Data from 2015 have shown a decrease in life expectancy and increases in 

the maternal mortality ratio (MMR), infant mortality rate, and the under-5 mortality rate (Qirbi and Ismail 

2017). 

The results discussed below for Yemen used data from the 2006 MICS survey and 2013 DHS survey. This 

is the only country in the report that compares data from two different sources. 

 
200 

Figure Map 11: Yemen Map 

Note: See Appendix for a description of regions. 

 
201 

Total Fertility Rate

The total fertility rate (TFR) in Yemen decreased significantly between 2006 and 2013 from 5.2 to 4.4. The 

decrease in the TFR was apparent by most characteristics included in Table Yemen.01, and there were no 

significant increases in TFR by any characteristic. There were, however, several significant declines in the 

TFR. 

Women with no education and women with a secondary or higher level of education both reduced their 

TFR between 2006 and 2013. In 2013, the TFR declined with increasing levels of education, so that the 

TFR among women with no education was 5.3, while among women with a secondary or higher level of 

education, the TFR was 2.8. The TFR declined for every wealth quintile except the poorest between 2006 

and 2013. In both years, the TFR declined with increasing wealth. In 2013, the TFR ranged from 6.1 in the 

poorest wealth quintile to 2.9 in the richest wealth quintile. 

The TFR declined in both urban and rural areas and in several regions including Hadramawt, Al-Janad, and 

Saba. Of all regions, the Saba Region had the largest decline in the TFR from 6.4 in 2006 to 4.3 in 2013. 

Table Yemen.01: Total fertility rate for the 4 years before the survey, by background characteristics, Yemen 

2006 MICS and 2013 DHS 

2006 2013 

TFR [C.I.] TFR [C.I.] Diff1

Total 5.2 [4.9,5.4] 4.4 [4.3,4.6] -0.7* 

Education 

None 6.0 [5.7,6.3] 5.3 [5.1,5.5] -0.8* 

Primary 4.0 [3.6,4.4] 4.1 [3.8,4.3] 0.1 

Secondary + 4.3 [3.6,5.1] 2.8 [2.5,3.1] -1.5* 

Wealth quintile 

Poorest 6.5 [5.9,7.2] 6.1 [5.7,6.5] -0.4 

Poorer 6.2 [5.6,6.9] 5.3 [5.0,5.7] -0.9* 

Middle 5.2 [4.7,5.7] 4.5 [4.2,4.9] -0.7* 

Richer 4.9 [4.5,5.4] 3.8 [3.0.6,4] -1.1* 

Richest 3.4 [3.0,3.9] 2.9 [2.7,3.1] -0.5* 

Place of residence 

Urban 4.0 [3.7,4.4] 3.2 [3.0,3.4] -0.8* 

Rural 5.8 [5.5,6.1] 5.1 [4.9,5.3] -0.7* 

Region 

Hadramawt 4.7 [3.9,5.8] 3.6 [3.3,3.9] -1.1* 

Aden 4.5 [3.9,5.3] 3.9 [3.6,4.1] -0.6 

Al-Janad 5.2 [4.7,5.8] 4.3 [4.0,4.8] -0.8* 

Saba 6.4 [5.1,8.0] 4.3 [3.8,4.7] -2.1* 

Tihama 5.4 [5.0,5.9] 5.0 [4.6,5.3] -0.5 

Azal 5.1 [4.6,5.6] 4.6 [4.3,4.9] -0.5 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference. 
202 

Figure Yemen.01: Total fertility rate for the 3 years before the survey, by background characteristics, Yemen 

2006 MICS and 2013 DHS 

Contraceptive Use

The percentage of women who were using a method of modern contraception at the time of the survey 

increased significantly in Yemen from 25% in 2006 to 29% in 2013. Modern contraceptive use also 

increased significantly by several characteristics in Table Yemen.02. Despite this increase, Yemen had 

among the lowest modern contraceptive use of all countries in this report (Overall Summary, Figure 2). 

Modern contraceptive use remained consistent among women age 15-24 and 45-49 between the two surveys 

and increased significantly among women age 25-34 and 35-44. In both years, modern contraceptive use 

varied significantly by age group. The pattern of lowest use among women age 15-24 and 45-49 remained 

consistent between 2006 and 2013 (Table Yemen.02). 

There was a significant increase from 21% to 25% in the percentage of women with no education using 

modern contraception between the two surveys. The increases for higher levels of education were not 

significant. In both years, modern contraceptive use varied significantly by level of education, and use 

increased as level of education increased. This is illustrated in Figure Yemen.02. 

Modern contraceptive use increased significantly among women in the poorer and middle wealth quintiles, 

but not for women in the other wealth categories. There were significant differences in contraceptive use 

by wealth quintile in both 2006 and 2013. The pattern of increased modern contraceptive use with 

increasing wealth quintile remained consistent between the 2 years. 
203 

Urban areas had a significantly higher percentage of modern contraceptive use than rural areas in 2006 and 

2013. Although modern contraceptive use increased significantly in rural areas between the two surveys, 

the gap between the two areas remained. In 2013, 40% of women in urban areas were using modern 

contraception compared to 24% of women in rural areas. 

Modern contraceptive use changed significantly in the Azal Region, and increased from 29% in 2006 to 

40% in 2013. In 2006, the Azal Region had approximately the same percent of modern contraceptive use 

as the Aden, Al-Janad, and Saba regions. However, in 2013, the Azal Region had the highest percent of 

modern contraceptive use compared to all other regions, with the next highest being the Aden Region at 

33%. This difference in modern contraceptive use by region is illustrated in Figure Yemen.02. 

Table Yemen.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 24.9 [22.7,27.2] 29.2 [27.9,30.4] 4.3* 

Age 

15-24 19.3 [16.4,22.5] * 20.0 [18.3,21.9] * 0.8 

25-34 27.9 [25.0,31.0] 34.0 [32.3,35.7] 6.1* 

35-44 28.8 [25.6,32.3] 32.9 [31.0,34.9] 4.1* 

45-49 19.6 [15.6,24.3] 22.9 [20.0,25.9] 3.3 

Education 

None 21.1 [18.9,23.4] * 24.8 [23.2,26.4] * 3.7* 

Primary 31.2 [27.9,34.6] 32.5 [30.7,34.2] 1.3 

Secondary + 35.0 [29.2,41.3] 38.4 [35.6,41.2] 3.4 

Wealth quintile 

Poorest 14.0 [10.8,18.0] * 13.6 [11.7,15.9] * -0.4 

Poorer 14.9 [11.8,18.7] 21.0 [19.0,23.2] 6.1* 

Middle 24.1 [20.4,28.1] 30.5 [28.2,33.0] 6.5* 

Richer 33.1 [29.0,37.5] 35.8 [33.4,38.3] 2.8 

Richest 37.5 [33.0,42.3] 42.2 [40.0,44.5] 4.7 

Place of residence 

Urban 37.7 [33.4,42.1] * 40.2 [38.1,42.3] * 2.5 

Rural 19.2 [16.9,21.6] 24.0 [22.5,25.6] 4.9* 

Region 

Hadramawt 18.7 [11.9,28.1] * 25.2 [22.1,28.6] * 6.5 

Aden 29.8 [23.9,36.5] 32.9 [30.5,35.4] 3.1 

Al-Janad 26.2 [21.3,31.7] 29.0 [26.1,32.1] 2.9 

Saba 27.9 [15.0,46.0] 28.6 [25.1,32.4] 0.7 

Tihama 15.8 [12.6,19.7] 15.0 [12.7,17.6] -0.8 

Azal 29.0 [25.0,33.4] 40.1 [37.6,42.6] 11.0* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
204 

Figure Yemen.02: Percentage of women currently using modern contraception among women age 15-49 in a 

union, by background characteristics, Yemen 2006 MICS and 2013 DHS 

Traditional contraceptive use in Yemen was also among the lowest of the countries in this report (Overall 

Summary, Figure 3), although it increased significantly between 2006 and 2013 (3% to 4%). Traditional 

contraceptive use increased in several subgroups between surveys, including among older women, women 

with no education or a primary education, and women in the poorer and richer wealth quintiles. 

Traditional contraceptive use varied by age category in 2006 and in 2013. In both surveys, the oldest two 

age groups (age 35-44 and 45-49) had the highest percentage of traditional use by age. These were also the 

only two age groups that had a significant increase in traditional contraceptive use between the two surveys, 

reaching 6% by 2013. 

In both 2006 and 2013, traditional contraceptive use increased with higher levels of education. Between the 

2 years, women with no education and women with a primary education saw significant increases in 

traditional contraceptive use. This was most notable for women with a primary education, who increased 

traditional contraceptive use from 3% to 5%. 

While traditional contraceptive use differed by wealth quintile in both 2006 and 2013, the substantial and 

significant increase among women in the richer wealth quintile—illustrated in Figure Yemen.03—partially 

closed the gap in traditional use between the richer and richest quintiles. Women in the poorer quintile also 

experienced a significant increase (1.5%) in traditional contraceptive use. 
205 

More urban women than rural women used traditional contraception in both surveys, although both had a 

significant increase in use between 2006 and 2013. In 2013, 7% of urban women and 3% of rural women 

used traditional contraception. There were also significant changes by region. Although the Hadramawt and 

Azal regions had significant increases in traditional contraceptive use, the Aden Region was the only region 

and the only characteristic with a significant decline in traditional contraceptive use between 2006 and 

2013, as shown in Figure Yemen.03. 

Table Yemen.03: Percentage of women currently using traditional contraception among women age 15-49 in 

a union, by background characteristics, Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 2.8 [2.2,3.5] 4.3 [3.9,4.8] 1.6* 

Age 

15-24 1.2 [0.7,2.2] * 2.1 [1.7,2.7] * 0.9 

25-34 3.3 [2.3,4.6] 4.1 [3.5,4.7] 0.8 

35-44 3.6 [2.4,5.4] 6.3 [5.4,7.3] 2.7* 

45-49 3.2 [1.8,5.5] 6.4 [4.6,8.8] 3.2* 

Education 

None 2.0 [1.4,2.9] * 3.2 [2.7,3.7] * 1.1* 

Primary 3.1 [2.2,4.3] 5.3 [4.6,6.0] 2.2* 

Secondary + 7.1 [4.5,11.1] 6.5 [5.4,7.9] -0.6 

Wealth quintile 

Poorest 0.7 [0.2,1.9] * 0.9 [0.5,1.4] * 0.2 

Poorer 1.5 [0.8,2.7] 3.0 [2.3,4.0] 1.5* 

Middle 3.0 [1.5,5.7] 3.3 [2.6,4.1] 0.3 

Richer 2.3 [1.5,3.5] 6.4 [5.5,7.5] 4.1* 

Richest 6.2 [4.5,8.4] 7.5 [6.4,8.8] 1.3 

Place of residence 

Urban 4.7 [3.4,6.4] * 7.3 [6.4,8.3] * 2.6* 

Rural 1.9 [1.4,2.7] 2.9 [2.5,3.4] 1.0* 

Region 

Hadramawt 3.7 [2.2,6.2] * 8.1 [6.7,9.7] * 4.4* 

Aden 8.2 [6.0,11.1] 4.5 [3.5,5.8] -3.7* 

Al-Janad 1.6 [0.8,3.0] 3.0 [2.1,4.1] 1.4 

Saba 0.6 [0.0,6.7] 3.3 [2.2,5.1] 2.8 

Tihama 1.2 [0.6,2.2] 2.2 [1.6,3.1] 1.0 

Azal 3.0 [1.8,4.9] 6.2 [5.3,7.2] 3.2* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the 

two surveys with the significance of the difference. 
206 

Figure Yemen.03: Percentage of women currently using traditional contraception among women age 15-49 in 

a union, by background characteristics, Yemen 2006 MICS and 2013 DHS 

Antenatal Care

In 2013, 25% of women in Yemen had the recommended four or more ANC visits during their most recent 

pregnancy within the 2 years before the survey. As shown in Table Yemen.04, this varied significantly by 

age, education, wealth quintile, place of residence, and region. This indicator was not available for the 2006 

survey to observe trends. 

The percentage of women who had four or more ANC visits declined with age with 28% of women age 15-

24 having four or more visits and 7% of women age 45-49. The decline was incremental. Conversely, ANC 

increased with level of education. Women with a primary education had more than double the percentage 

of four or more ANC visits than women with no education (32% vs. 13%). Nearly half of women with a 

secondary or higher level of education had four or more ANC visits. 

The percentage of women who had four or more ANC visits also increased with wealth quintile with 8% 

of women in the poorest quintile having four or more ANC visits and 62% of women in the richest quintile. 

There were incremental increases in the percentage of women with four or more ANC visits with each 

wealth quintile. The largest disparity in ANC visits was by wealth quintile. 

Approximately half of women in urban areas had four or more ANC visits, compared to 16% of women in 

rural areas. This varied by region as well. Women in the Hadramawt Region had the highest percentage of 

four or more ANC visits at 43%, compared to women in Tihama with the lowest at 15%. The other regions 

were similar with between 25% and 33% of women having four or more ANC visits in the Aden, Al-Janad, 

Saba, and Azal regions. 
207 

Table Yemen.04: Percentage of women age 15-49 who had four or more antenatal care visits for their most 

recent pregnancy in the 2 years before the survey, by background characteristics, Yemen 2013 DHS 

Variable % [C.I.] Sig.1

Total 24.8 [23.2,26.4] 

Age 

15-24 28.4 [25.8,31.1] * 

25-34 25.1 [23.1,27.3] 

35-44 18.7 [16.0,21.7] 

45-49 6.5 [2.8,14.5] 

Education 

None 13.4 [11.7,15.2] * 

Primary 32.1 [29.5,34.7] 

Secondary + 50.7 [46.3,55.0] 

Wealth quintile 

Poorest 7.9 [6.0,10.3] * 

Poorer 11.8 [9.7,14.3] 

Middle 19.5 [16.8,22.6] 

Richer 34.2 [31.0,37.6] 

Richest 61.6 [56.7,66.3] 

Place of residence 

Urban 50.5 [47.0,54.0] * 

Rural 15.7 [14.1,17.4] 

Region 

Hadramawt 43.1 [36.2,50.2] * 

Aden 33.5 [29.3,38.0] 

Al-Janad 25.7 [21.9,29.9] 

Saba 29.0 [22.4,36.6] 

Tihama 14.5 [12.1,17.2] 

Azal 25.0 [22.3,27.9] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Delivery

Between the 2006 MICS and 2013 DHS surveys, the percentage of women who gave birth with a skilled 

birth attendant (SBA) for their most recent birth increased from 27% to 47% overall. This increase was 

evident and statistically significant by every characteristic included in Table Yemen.05. The percentage 

increase in SBA deliveries by all characteristics are illustrated in Figure Yemen.04. 

Delivery with the assistance of an SBA increased significantly for all age categories. Women age 45-49 

had the lowest percentage of SBA deliveries in both years, but still increased from 13% to 29% between 

surveys. Women age 15-24 experienced the largest percent increase by age, from 27% in 2006 to 53% in 

2013. Because of this, the differences in SBA deliveries by age were significant in 2013. 

The SBA deliveries increased among women with all levels of education. The greatest magnitude of change 

between 2006 and 2013 was among women with a secondary or higher level of education who experienced 

a 31-percentage point increase from 47% to 78%. The SBA deliveries among women with a primary 

education increased from 36% in 2006 to 57% in 2013, while women with no education increased from 

20% to 33%. 

Women in the richer wealth quintile had a 28-percentage point increase in SBA deliveries from 37% to 

65%, while the percentage of women delivering with an SBA increased for all wealth quintiles. The smallest 

increase by wealth quintile was in women in the poorest wealth quintile (increased 11-percentage points 
208 

from 10% to 21%). In both years, SBA deliveries differed by wealth quintile and the pattern of increased 

SBA use with increased with wealth remained consistent. 

Women in urban areas also saw one of the largest percent increases in SBA deliveries from 50% in 2006 

to 77% in 2013. A smaller percentage of women in rural areas delivered with an SBA in both years, although 

they increased from 19% to 37% between surveys. There was an increase in the percentage of SBA 

deliveries in all regions. Women in the Azal region had the smallest increase at 13-percentage points from 

31% in 2006 to 44% in 2013, and women in the Saba region had the greatest increase of 34-percentage 

points from 29% to 62%. In both years, the Tihama Region had the lowest percentage of women who 

delivered with an SBA (39% in 2013), while the Hadramawt and Aden Regions had the highest 

(approximately 65% in 2013). 

Table Yemen.05: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 26.9 [24.0,30.0] 47.4 [45.0,49.9] 20.5* 

Age 

15-24 27.2 [23.1,31.7] 53.2 [49.6,56.8] * 26.0* 

25-34 26.5 [22.6,30.8] 47.0 [44.3,49.8] 20.5* 

35-44 28.9 [23.5,35.0] 39.3 [35.5,43.1] 10.4* 

45-49 12.5 [5.4,26.4] 29.0 [20.1,40.1] 16.5* 

Education 

None 20.2 [17.1,23.7] * 33.2 [30.7,35.8] * 13.0* 

Primary 36.1 [31.1,41.4] 57.2 [53.9,60.5] 21.1* 

Secondary + 46.7 [37.8,55.8] 77.8 [73.6,81.6] 31.1* 

Wealth quintile 

Poorest 9.8 [6.5,14.3] * 21.2 [18.2,24.5] * 11.4* 

Poorer 15.1 [11.3,20.0] 32.5 [28.7,36.5] 17.3* 

Middle 21.4 [16.5,27.3] 47.0 [42.1,51.9] 25.6* 

Richer 36.9 [31.1,43.1] 64.9 [60.8,68.8] 28.0* 

Richest 64.2 [57.0,70.8] 84.6 [80.7,87.8] 20.4* 

Place of residence 

Urban 49.9 [44.3,55.5] * 77.1 [73.0,80.7] * 27.1* 

Rural 18.6 [15.3,22.3] 37.0 [34.1,40.0] 18.4* 

Region 

Hadramawt 46.4 [35.5,57.6] * 64.8 [55.0,73.4] * 18.4* 

Aden 38.2 [28.8,48.5] 65.5 [60.5,70.1] 27.3* 

Al-Janad 22.9 [17.6,29.4] 45.3 [40.0,50.8] 22.4* 

Saba 28.5 [19.4,39.7] 62.2 [53.0,70.6] 33.7* 

Tihama 12.4 [8.9,17.1] 39.0 [32.9,45.6] 26.6* 

Azal 31.1 [24.9,38.0] 43.7 [40.2,47.2] 12.6* 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
209 

Figure Yemen.04: Percentage of women age 15-49 who had their most recent birth assisted by a skilled birth 

attendant in the 2 years before the survey, by background characteristics, Yemen 2006 MICS and 2013 DHS 

The percentage of women ages 15-49 who delivered their most recent birth at a health facility also increased 

significantly between 2006 and 2013, although by a smaller magnitude than deliveries with an SBA. Table 

Yemen.06 shows that there was a 8 percentage point increase in health facility deliveries overall, as well as 

statistically significant increases in health facility deliveries by many characteristics included in the table. 

Health facility deliveries increased for younger women, but not for older women between the two surveys. 

In 2006, the percentage of health facility deliveries did not differ significantly by age, but in 2013 it did. 

Women in the youngest age group, age 15-24, had the highest percentage of facility deliveries by age 

category at 35%. In 2013, health facility delivery declined as age increased. In both 2006 and 2013, the 

percentage of women who delivered at a health facility differed by level of education. Women with higher 

levels of education had higher percentages of health facility delivery in both years. In 2013, over half of 

women with a secondary or higher level of education delivered in a health facility, compared to 23% of 

women with no education. 

There was a similar pattern of the percentage of women who delivered at a health facility increasing with 

wealth quintile in both 2006 and 2013. Although facility delivery increased significantly between the two 

surveys for all wealth quintiles, except the poorest, the pattern remained consistent. This is illustrated in 

Figure Yemen.05. In 2013, health facility delivery by wealth quintile ranges from 14% among women in 

the poorest quintile, to 61% among women in the richest quintile. In both 2006 and 2013, there was a 

significant difference in the percentage of women who gave birth in a health facility by place of residence. 

In 2006, 40% of women in urban areas and 17% of women in rural areas delivered at a health facility. In 

2013, this was 52% in urban areas and 25% in rural areas. While women in urban and rural areas both 

experienced statistically significant increases in health facility deliveries between the two surveys, the 
210 

difference between them did not diminish. The highest magnitude of change in health facility delivery was 

seen by region. Specifically, the Al-Janad, Aden, and Saba regions increased health facility delivery by 16-

18 percentage points. However, despite this gain, the Al-Janad Region had the second lowest percentage of 

health facility deliveries by region in 2013. Despite no significant changes in the Hadramawt and Azal 

regions, the pattern of health facility deliveries remained consistent by region in 2006 and 2013. The highest 

percentage of health facility delivery was in the Hadramawt Region, and the lowest was in Tihama in both 

surveys. 

Table Yemen.06: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 23.5 [20.7,26.7] 31.9 [30.0,34.0] 8.4* 

Age 

15-24 22.5 [18.4,27.1] 35.3 [32.1,38.7] * 12.8* 

25-34 23.2 [19.6,27.3] 32.1 [29.7,34.5] 8.8* 

35-44 26.6 [21.1,32.9] 26.5 [23.3,29.9] 0.2 

45-49 21.4 [10.6,38.3] 19.4 [12.0,30.0] 1.9 

Education 

None 19.3 [16.1,22.9] * 22.6 [20.5,24.9] * 3.3 

Primary 28.1 [23.6,33.1] 37.9 [34.8,41.0] 9.8* 

Secondary + 39.2 [30.4,48.7] 53.3 [48.8,57.8] 14.1* 

Wealth quintile 

Poorest 8.7 [5.6,13.4] * 13.6 [11.3,16.3] * 4.9 

Poorer 14.4 [11.0,18.8] 19.6 [17.0,22.5] 5.1* 

Middle 18.9 [14.9,23.8] 31.5 [27.7,35.5] 12.5* 

Richer 34.6 [28.4,41.4] 44.3 [40.1,48.6] 9.7* 

Richest 51.0 [44.5,57.4] 60.7 [56.1,65.0] 9.7* 

Place of residence 

Urban 40.3 [34.5,46.3] * 52.1 [47.8,56.4] * 11.8* 

Rural 17.4 [14.2,21.2] 24.9 [22.7,27.1] 7.4* 

Region 

Hadramawt 55.1 [43.0,66.6] * 53.0 [43.5,62.4] * 2.0 

Aden 35.3 [24.7,47.4] 51.2 [46.6,55.8] 15.9* 

Al-Janad 12.9 [8.7,18.6] 29.8 [25.2,34.7] 16.9* 

Saba 29.3 [19.9,40.8] 47.0 [41.0,53.1] 17.7* 

Tihama 9.9 [6.7,14.3] 16.8 [13.6,20.5] 6.9* 

Azal 28.0 [22.3,34.4] 32.6 [29.2,36.2] 4.7 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
211 

Figure Yemen.05: Percentage of women age 15-49 who delivered their most recent birth in a health facility in 

the 2 years before the survey, by background characteristics, Yemen 2006 MICS and 2013 DHS 

In 2013, 6% of women in Yemen gave birth by C-section. The percentage of women who gave birth by Csection did not differ significantly by age, although it did differ significantly by all other characteristics 

included in Table Yemen.07. This indicator was not available for the 2006 survey to observe trends. 

Women with higher levels of education had higher percentages of C-section deliveries. Three-percent (3%) 

of women with no education had a C-section, compared to 7% with a primary, and 13% with a secondary 

or higher level of education. A similar pattern was observed for wealth quintile. One-percent (1%) of 

women in the poorest wealth quintile gave birth by C-section compared to 15% of women in the richest 

quintile. 

Women in urban areas had a significantly higher percentage of delivering by C-section than rural women 

(12% vs. 4%), and, by region, women in the Hadramawt Region had the highest percentage of C-section 

births at 10%, and the Tihama Region had the lowest at 3%. Between 6% and 9% of women in the other 

four regions gave birth by C-section. 
212 

Table Yemen.07: Percentage of women age 15-49 who delivered their most recent birth by caesarean section 

in the 2 years before the survey, by background characteristics, Yemen 2013 DHS 

Variable % [C.I.] Sig.1

Total 5.7 [5.0,6.5] 

Age 

15-24 5.6 [4.3,7.4] 

25-34 5.7 [4.7,6.8] 

35-44 6.4 [4.9,8.4] 

45-49 0.1 [0.0,0.9] 

Education 

None 2.8 [2.3,3.6] * 

Primary 7.3 [5.9,8.9] 

Secondary + 13.0 [10.1,16.5] 

Wealth quintile 

Poorest 1.4 [0.8,2.3] * 

Poorer 2.6 [1.8,3.7] 

Middle 4.4 [3.3,5.9] 

Richer 8.3 [6.4,10.6] 

Richest 14.6 [11.9,17.8] 

Place of residence 

Urban 11.9 [9.9,14.2] * 

Rural 3.5 [2.9,4.3] 

Region 

Hadramawt 9.8 [7.0,13.6] * 

Aden 7.5 [5.7,10.0] 

Al-Janad 5.8 [4.2,8.0] 

Saba 9.0 [5.8,13.9] 

Tihama 2.8 [1.9,4.0] 

Azal 5.9 [4.6,7.6] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Child Health Care

Between 2006 and 2013, the percentage of children age 12-23 months who received all basic vaccinations 

increased significantly overall, although the increase was only significant for a few characteristics included 

in Table Yemen.08. In 2006, 37% of children were vaccinated, compared to 43% in 2013. This did not vary 

by sex of the child in either 2006 or 2013, and there were slight, but not statistically significant, increases 

in the percentage of both girls and boys vaccinated between the two surveys. 

The percentage of children vaccinated did not change significantly by the mother’s level of education 

between 2006 and 2013. In both survey years, the percent of children vaccinated varied significantly by the 

mother’s level of education and increased with increasing level of education. A similar pattern was observed 

by wealth. In both survey years, the percentage of children vaccinated increased as wealth increased. There 

was a significant increase in the percent of children vaccinated in the richer wealth quintile (40% in 2006 

to 52% in 2013), although the changes were not significant among children in any other wealth quintile. 

The percent of children vaccinated was higher in urban areas than rural areas in both surveys. However, 

children in rural areas experienced a significant increase in the percent vaccinated between 2006 and 2013. 

By 2013, while the difference in percent vaccinated between urban and rural children was still significant, 

the gap reduced slightly, as illustrated in Figure Yemen.06. 
213 

In 2006, the percent of children vaccinated did not differ significantly by region, and there were no 

significant changes in the percent of children vaccinated between 2006 and 2013. However, the 2013 data 

show statistically significant differences in the percent of children vaccinated by region, ranging from 25% 

in the Saba Region to 50% in Aden. 

Table Yemen.08: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 37.0 [32.3,41.9] 42.6 [39.8,45.4] 5.6* 

Child’s sex 

Male 35.9 [30.2,42.0] 41.3 [38.0,44.8] 5.4 

Female 38.0 [31.9,44.6] 43.9 [40.3,47.6] 5.9 

Mother’s education 

None 28.3 [23.0,34.2] * 34.2 [30.7,37.7] * 5.9 

Primary 47.4 [38.4,56.6] 49.2 [44.6,53.7] 1.7 

Secondary + 59.8 [48.2,70.4] 60.5 [54.3,66.3] 0.7 

Wealth quintile 

Poorest 17.4 [10.3,27.9] * 23.8 [19.3,29.0] * 6.3 

Poorer 26.5 [18.9,35.8] 36.3 [31.6,41.3] 9.9 

Middle 37.9 [28.3,48.5] 44.9 [39.1,50.8] 7.0 

Richer 39.9 [30.7,49.9] 52.0 [46.2,57.8] 12.1* 

Richest 69.7 [58.8,78.8] 62.4 [56.9,67.5] -7.4 

Place of residence 

Urban 56.4 [48.1,64.3] * 58.8 [53.8,63.7] * 2.4 

Rural 29.0 [23.6,35.1] 36.7 [33.5,40.1] 7.7* 

Region 

Hadramawt 40.4 [20.6,64.0] 48.0 [39.8,56.3] * 7.6 

Aden 43.0 [29.3,58.0] 49.5 [43.2,55.9] 6.5 

Al-Janad 39.6 [31.9,47.8] 46.7 [39.4,54.1] 7.1 

Saba (16.7 [6.3,37.3]) 25.1 [17.3,35.0] 8.4 

Tihama 27.9 [19.9,37.6] 37.7 [31.9,43.9] 9.8 

Azal 42.4 [32.8,52.6] 43.1 [38.8,47.6] 0.7 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
214 

Figure Yemen.06: Percentage of children age 12-23 months who have received all basic vaccinations, by 

background characteristics, Yemen 2006 MICS and 2013 DHS 

The percentage of children under age 5 for whom medical advice or treatment was sought for ARI 

symptoms in the 2 weeks before the surveys declined overall between 2006 and 2013. In 2006, care was 

sought for 44% of children with ARI symptoms, compared to 34% in 2013. Care-seeking for ARI symptoms 

showed a declining trend by all characteristics in Table Yemen.09. Decreases were significant within 

several subgroups. 

In 2006, care-seeking was similar for boys and girls, but declined steeply for girls between the two surveys. 

In 2013, there was a significant difference in care-seeking for boys and girls. Care for ARI symptoms was 

sought for 41% of boys compared to 27% of girls in 2013. 

Significant declines in care-seeking were observed for children with mothers with no education and a 

primary level of education. However, in both 2006 and 2013, care-seeking for ARI did not differ 

significantly by mother’s education level. Similarly, care-seeking showed a declining trend for all wealth 

quintiles, although the only significant decline was for children in the richer wealth quintile. The differences 

in care-seeking by wealth quintile were not significant in 2006 or 2013. 

In 2006, there was a significantly higher percentage of care-seeking for children with ARI symptoms in 

urban areas compared to rural areas. Care-seeking decreased for children in both urban and rural areas 

between 2006 and 2013. However, care-seeking for children in urban areas declined more sharply, so that 

by 2013, there was no difference between urban and rural areas in the percent of children with ARI 

symptoms who had care sought for them. 
215 

There was not enough data to report on care-seeking for two regions in 2006 (Hadramawt and Saba). In 

2013, all regions with data for both surveys had significant declines in care-seeking for ARI symptoms. 

There were also differences in care-seeking by region in 2013. In 2013, care-seeking ranged from 33% in 

the Tihama Region to 52% in Hadramawt. The declining trends in care-seeking for children with ARI 

symptoms across characteristics can be seen in Figure Yemen.07.

Table Yemen.09: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1 Diff2

Total 43.7 [38.4,49.2] 34.0 [31.0,37.0] -9.7* 

Child’s sex 

Male 45.0 [37.6,52.7] 40.8 [36.8,44.9] * -4.2 

Female 42.2 [35.0,49.8] 26.5 [23.1,30.2] -15.8* 

Mother’s education 

None 41.5 [35.5,47.9] 33.2 [29.7,37.0] -8.3* 

Primary 46.4 [36.7,56.4] 33.8 [28.6,39.4] -12.7* 

Secondary + (58.7 [37.1,77.4]) 37.7 [28.1,48.5] -21.0 

Wealth quintile 

Poorest 40.4 [30.2,51.4] 30.7 [25.5,36.3] -9.7 

Poorer 39.4 [29.7,50.0] 32.0 [26.7,37.8] -7.4 

Middle 43.1 [31.4,55.6] 34.5 [28.3,41.2] -8.6 

Richer 53.0 [38.0,67.5] 34.7 [28.3,41.6] -18.4* 

Richest 49.4 [34.1,64.9] 42.4 [33.5,51.8] -7.0 

Place of residence 

Urban 55.8 [43.6,67.4] * 37.8 [31.2,45.0] -18.0* 

Rural 39.8 [33.9,46.1] 32.8 [29.6,36.2] -7.0* 

Region 

Hadramawt ND 51.5 [39.3,63.6] * 

Aden (53.2 [36.6,69.1]) 42.1 [34.1,50.7] -11.0 

Al-Janad 38.7 [26.7,52.2] 29.8 [24.1,36.1] -8.9 

Saba ND 37.8 [31.6,44.3] 

Tihama 47.3 [38.0,56.9] 33.0 [26.4,40.4] -14.4* 

Azal 43.2 [33.4,53.6] 34.8 [29.9,40.0] -8.5 

Note: ND indicates figures are not shown because they were based on fewer than 25 unweighted 

cases. Figures in parenthesis are based on 25-49 unweighted cases. 

* Significant p-value. 1 Significance of the covariate in each survey. 2 Difference between the two 

surveys with the significance of the difference. 
216 

Figure Yemen.07: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the 

survey and for whom advice or treatment was sought from a health facility or provider, by background 

characteristics, Yemen 2006 MICS and 2013 DHS 

Child Nutrition

In 2013, 10% of children under age 6 months were exclusively breastfed in Yemen. Although there was 

some variation by the characteristics included in Table Yemen.10, the variation was not statistically 

significant. This indicator was not available for the 2006 survey. 

There was a trend toward a lower percentage of children being exclusive breastfed with increasing levels 

of mother’s education. The percent of children exclusively breastfed was consistent across wealth 

categories (10% to 12%), except for the richest wealth quintile with 7% of children exclusively breastfed. 

In urban areas, 9% of children were exclusively breastfed, compared to 11% in rural areas. By region, the 

percentage of children exclusively breastfed ranged from 5% of children in the Aden Region to 19% of 

children in Hadramawt. 

 
217 

Table Yemen.10: Percentage of children under age 6 months who are exclusively breastfed, by background 

characteristics, Yemen 2013 DHS 

Variable % [C.I.] Sig.1

Total 10.3 [8.3,12.7] 

Child’s sex 

Male 9.5 [7.3,12.3] 

Female 11.0 [8.4,14.4] 

Mother’s education 

None 10.8 [8.4,13.9] 

Primary 10.7 [7.8,14.7] 

Secondary + 7.1 [4.3,11.4] 

Wealth quintile 

Poorest 10.4 [6.7,15.7] 

Poorer 11.7 [8.1,16.8] 

Middle 10.6 [7.1,15.6] 

Richer 10.3 [5.9,17.2] 

Richest 7.4 [3.9,13.6] 

Place of residence 

Urban 8.8 [5.3,14.3] 

Rural 10.8 [8.5,13.6] 

Region 

Hadramawt 18.6 [6.6,42.6] 

Aden 5.3 [2.8,9.9] 

Al-Janad 8.7 [5.1,14.5] 

Saba 7.9 [4.4,13.7] 

Tihama 9.1 [5.5,14.6] 

Azal 13.1 [9.9,17.2] 

* Significant p-value. 1 Significance of the covariate in 

each survey. 

Yemen had the highest percentage of children who were stunted and the lowest percentage of children who 

were overweight of all the countries in this report (Overall Summary, Figure 10 and 11). These indicators 

were not available for the 2006 survey to observe trends. 

Table Yemen.11 shows that 47% of children in Yemen were stunted in 2013. Stunting differed significantly 

by all characteristics. Slightly more boys were stunted than girls (48% vs. 45%), and this difference was 

statistically significant. The percentage of children who were stunted decreased incrementally as mother’s 

education level increased. The pattern was similar for wealth. There were incremental declines in stunting 

as wealth quintile increased. About a quarter of children in the richest quintile were stunted, compared to 

59% in the poorest quintile. A high percentage of children residing in rural areas were stunted compared to 

children in urban areas. Regional differences were also observed. Over half of children in the Tihama 

Region were stunted, compared to 29% in Hadramawt. 

The same table shows the percent of children who were overweight in Yemen in 2013. Two percent (2%) 

of children were overweight in the country overall, and this varied significantly only by wealth quintile and 

region. By wealth, the lowest percentage of children were overweight in the poorest wealth quintile. The 

highest percentage of children was overweight in the richer wealth quintile, followed by the richest. 

Regionally, there was variation in the percent of children who were overweight. The Hadramawt Region 

had the highest percent of overweight children at 4%, and the Saba and Tihama regions had the lowest at 

1%. In all other regions, 2% of children were overweight. 

 
218 

Table Yemen.11: Percentage of children under age 5 who are stunted or overweight, by background 

characteristics, Yemen 2013 DHS 

Stunted Overweight 

Variable % [C.I.] Sig.1 % [C.I.] Sig.1

Total 46.5 [45.1,48.0] 2.0 [1.8,2.4] 

Child’s sex 

Male 47.6 [45.9,49.4] * 2.0 [1.7,2.5] 

Female 45.4 [43.7,47.1] 2.1 [1.7,2.5] 

Mother’s education 

None 53.7 [52.0,55.3] * 1.9 [1.6,2.3] 

Primary 40.1 [37.6,42.7] 2.4 [1.9,3.0] 

Secondary + 31.5 [28.7,34.5] 1.8 [1.2,2.7] 

Wealth quintile 

Poorest 59.2 [56.5,61.8] * 1.3 [0.8,2.1] * 

Poorer 55.5 [52.9,58.1] 2.0 [1.4,2.7] 

Middle 48.1 [45.4,50.7] 1.9 [1.3,2.8] 

Richer 38.3 [36.0,40.8] 2.8 [2.1,3.6] 

Richest 25.9 [23.2,28.7] 2.4 [1.8,3.3] 

Place of residence 

Urban 33.7 [31.2,36.2] * 2.4 [1.9,3.1] 

Rural 51.4 [49.8,53.0] 1.9 [1.6,2.3] 

Region 

Hadramawt 29.2 [25.9,32.8] * 4.0 [2.9,5.7] * 

Aden 34.5 [31.6,37.5] 1.9 [1.3,2.8] 

Al-Janad 47.0 [43.8,50.3] 2.3 [1.6,3.2] 

Saba 40.0 [33.9,46.4] 1.3 [0.8,2.3] 

Tihama 53.6 [50.6,56.6] 1.3 [0.9,1.9] 

Azal 48.3 [46.0,50.7] 2.3 [1.8,2.9] 

* Significant p-value. 1 Significance of the covariate in each survey. 

Under-5 Mortality

The under-5 mortality rate in Yemen decreased from 77/1000 live births in 2006 to 53/1000 in 2013. This 

25-point reduction was statistically significant. Significant declines in under-5 mortality were apparent by 

many characteristics included in Table Yemen.12. 

Boys and girls both experienced significant declines in under-5 mortality between 2006 and 2013, with the 

declines in boys from 80/1000 to 57/1000, and girls from 74/1000 to 48/1000. Children with mothers with 

no education had a significant decline in mortality as well from 84/1000 to 56/1000, which is similar to 

rates of under-5 mortality in children of mothers with a primary education. 

Under-5 mortality in the poorest quintile had the largest decline by wealth quintile, from 117/1000 in 2006 

to 56/1000 in 2013. In 2013, the poorest wealth quintile no longer had the highest under-5 mortality rate, 

and was surpassed by the poorer quintile. This pattern of change is illustrated in Figure Yemen.08. There 

was also a significant decline in under-5 mortality for the middle wealth quintile from 74/1000 in 2006 to 

49/1000 in 2013. 

Under-5 mortality decreased significantly in rural areas between the two surveys from 85/1000 to 56/1000, 

although rural areas still had a higher mortality rate than urban areas in 2013, despite the 29-percentage 

point reduction. The Saba Region had the highest under-5 mortality rate of all the regions in both 2006 and 

2013, but reduced mortality from 163/1000 to 61/1000 between the two surveys. Saba went from being an 

extreme outlier in 2006, to being similar to several other regions in Yemen in 2013. This is illustrated in 

Figure Yemen.08. 
219 

Table Yemen.12: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS 

2006 2013 

Variable U5M [C.I.] U5M [C.I.] Diff1

Total 77 [66,90] 53 [48,58] -25* 

Child’s sex 

Male 80 [67,95] 57 [50,65] -23* 

Female 74 [61,90] 48 [42,55] -26* 

Mother’s education 

None 84 [69,101] 56 [49,64] -27* 

Primary 65 [49,86] 54 [47,62] -11 

Secondary + 52 [29,91] 32 [23,45] -19 

Wealth quintile 

Poorest 117 [95,144] 56 [47,67] -61* 

Poorer 81 [57,113] 71 [58,86] -10 

Middle 74 [56,97] 49 [40,60] -25* 

Richer 59 [40,87] 44 [36,55] -15 

Richest 37 [24,58] 38 [29,50] 1 

Place of residence 

Urban 55 [39,78] 43 [36,52] -12 

Rural 85 [72,100] 56 [50,63] -29* 

Region 

Hadramawt 36 [18,73] 30 [21,42] -7 

Aden 49 [25,92] 36 [29,45] -13 

Al-Janad 55 [41,71] 56 [43,73] 2 

Saba 163 [126,207] 61 [50,75] -101* 

Tihama 81 [63,104] 56 [45,68] -26* 

Azal 89 [67,116] 57 [49,65] -32* 

* Significant p-value. 1 Difference between the two surveys with the 

significance of the difference 
220 

Figure Yemen.08: Under-5 mortality rates for the 5 years before the survey, by background characteristics, 

Yemen 2006 MICS and 2013 DHS 

Yemen Summary

The TFR in Yemen declined significantly from 5.2 in 2006 to 4.4 in 2013 but still remained as the country 

with one of the highest TFRs in this report. The largest decline in the TFR occurred in the Saba Region 

although this region did not show a significant increase in contraceptive use. Just under a third of married 

women age 15-49 were using modern contraception in Yemen in 2013, which was an increase from 2006. 

Fourteen percent (14%) of women in the poorest wealth quintile used a method of modern contraception in 

2013, the lowest of any other subgroup. In the richest quintile, 42% of women were using modern 

contraception. Traditional contraceptive use also increased from 2006 to 2013, particularly in the 

Hadramawt region. In contrast, the Aden Region had a significant decrease in traditional contraceptive use. 

There was variance by age, education, wealth, urban/rural residence, and region within the ANC and 

delivery related indicators. In 2013, a quarter of women in Yemen had the recommended four or more ANC 

visits during their most recent pregnancy. As women aged, the percentage who had ANC visits declined. 

Differences were present by education, wealth, urban/rural residence, and region. While 8% of women in 

the poorest wealth quintile had four or more ANC visits, 62% of women in the richest quintile did. 

Delivering with an SBA increased in Yemen between 2006 and 2013, from 27% to 47%. Increases were 

apparent throughout, although disparities by age, education, wealth, urban/rural residence, and region 

remained. SBA delivery increased with education and wealth, and decreased with age. Health facility 

delivery was similar with 24% in 2006 and 32% in 2013, with increases within education and wealth 

categories and decreases with age. Just 17% of women in the Tihama Region delivered at a health facility, 
221 

compared to 53% of women in Hadramawt. The higher percentage of deliveries by an SBA in 2013 

compared to deliveries in a health facility implies that many deliveries by an SBA are occurring outside a 

health facility. In 2013, 6% of women in Yemen delivered by C-section, ranging from 1% of women in the 

poorest wealth quintile to 15% in the richest. Women age 45-49 had one of the lowest C-section rates at 

0.1%. 

Child health indicators showed some improvements and some declines between 2006 and 2013. While the 

percentage of children age 12-23 months who had all basic vaccinations increased from 37% in 2006 to 

43% in 2013, care-seeking for ARI symptoms for children under age 5 declined from 44% to 34%. Careseeking for boys and girls was nearly equal in 2006, although in 2013 care-seeking was 41% for boys and 

27% for girls. Large declines in care-seeking were apparent across characteristics. A tenth of children under 

age 6 months were exclusively breastfed in 2013, and this decreased as mother’s education increased. The 

Aden Region had the lowest rate of exclusive breastfeeding at 5%, compared with 19% in Hadramawt. 

Stunting among children under age 5 was common with 47% of children stunted in 2013. Stunting declined 

as mother’s education and wealth increased. Conversely, 2% of children were overweight. Under-5 

mortality in Yemen reduced significantly from 77/1000 to 53/1000 live births between 2006 and 2013. 

Declines were large. The Saba Region experienced a decline under-5 mortality from 163/1000 to 61/1000 

live births. However, by region, Saba continued had the highest under-5 mortality rate in both years. 

223 

Overall Summary 

Fertility and Contraception

As shown in Figure 1, the TFR for all surveys was above replacement level except for the TFR in the 

Tunisia 2012 survey. In the West Bank, Gaza Strip, and Yemen, the TFR decreased significantly between 

the two surveys available for these countries. In Egypt, the TFR increased significantly between 2008 and 

2014, while in Iraq and Jordan, the TFR remained unchanged. For the most recent surveys, the highest TFR 

was in Iraq in 2011 and this did not differ significantly from the TFR in Yemen in 2013. The TFR was 

above four in Iraq 2011, Yemen in 2013, and the West Bank and Gaza Strip in 2014. The lowest TFRs were 

found in Tunisia in 2012 (2.1), followed by Algeria in 2012 (2.7) and the Palestinian refugees of Lebanon 

(2.8). The TFR could not be computed for the Syria 2006 survey, the Palestinian Refugees of Lebanon 2006 

survey, the Libya 2007 survey, and the Morocco 2011 survey. 

Figure 1: Total fertility rate for the 3 years before the survey, all surveys 

Figures 2 and 3 summarize the use of modern and traditional methods of contraception for all surveys. Over 

half of women in a union in Egypt, the Palestinian refugee camps in Lebanon, Morocco, and Tunisia were 

using a modern contraceptive method. The percentage in Algeria was slightly below 50%, while it was near 

40% in Jordan, the West Bank and the Gaza Strip, and Syria. Among the countries with two surveys 

available, none showed a change in modern contraceptive use except for Iraq, where there was a significant 

decrease and Yemen, where there was a significant increase in use. Libya had the lowest percentage of 

modern contraceptive use with only 19% of women in a union using a modern method in 2007. The most 

recent survey in Yemen showed 29% for modern contraceptive use.

While Egypt had one of the highest percentages of modern contraceptive use, it had the lowest percentage 

of traditional contraceptive use, with only 2% of women using a traditional method in 2014. This was a 

significant decrease from 3% in 2008. By contrast, Libya had the lowest percentage of women using a 

modern contraceptive method and the highest percentage of traditional contraceptive use, with 20% of 

women in a union using a traditional method in 2007. Yemen had one of the lowest percentages for both 

modern and traditional contraceptive use. Use of a traditional method significantly increased in Yemen 

from 3% in 2006 to 4% in 2013, which was one of the lowest percentages among the countries in the 

analysis. The percentage of traditional contraceptive use in Jordan in 2012 did not differ significantly from 

that of Libya, with both having the highest percentages of traditional contraceptive use. Use of a traditional 
224 

method significantly increased in Jordan, Iraq, the West Bank and Gaza Strip, and Yemen but did not 

change for the Palestinian refugees of Lebanon. The largest increase was in Iraq and the West Bank and 

Gaza Strip with an increase of 5-6 percentage points between consecutive surveys for these countries. 

Figure 2: Percentage of women currently using modern 

contraception among women age 15-49 in a union, all 

surveys 

Figure 3: Percentage of women currently using traditional 

contraception among women age 15-49 in a union, all 

surveys 

Antenatal Care and Delivery

Among the countries with available data on the number of antenatal care (ANC) visits, almost all women 

in the West Bank and Gaza Strip and Jordan had attended at least four ANC visits for their most recent 

birth. Approximately 96% of women had the recommended four or more ANC visits in the West Bank and 

Gaza Strip in the most recent survey in 2014, while it was 94% for Jordan in 2012. The percentage of ANC 

visits was just under 90% for the Palestinian refugees in Lebanon in 2011. There was a large and significant 

increase in the percentage of ANC visits in Egypt from 70% in 2008 to 84% in 2014. The lowest percentage 

was in Yemen in 2013 with only a quarter of women who had completed the minimum of four ANC visits. 

The indicator was not available in the Yemen 2006 survey, and was also unavailable for the 2006 Iraq, 2007 

Libya, 2006 Palestinian refugees of Lebanon, and the 2006 Syria surveys. Thus, trends could not be 

observed for Iraq, the Palestinian Refugees of Lebanon, and Yemen. 
225 

Figure 4: Percentage of women age 15-49 who had four or more antenatal care visits for their most recent 

pregnancy in the 2 years before the survey, all surveys 

Almost 100% of women in the West Bank and Gaza Strip, Libya, and the Palestinian refugees of Lebanon 

have delivered their most recent birth with an SBA. The percentage was also over 90% in Egypt in 2014, 

Jordan in both surveys, Algeria in 2012, Iraq in 2011, and Syria in 2006. The lowest percentage was in 

Yemen despite a large increase from 27% in 2006 to 47% in 2013. There was also a large increase in SBA 

delivery in Iraq from 55% in 2006 to 91% in 2011, which was an increase of 36 percentage points. There 

was an 11 percentage point increase in Egypt from 82% in 2008 to 93% in 2014. 

Delivery in a health facility was also almost universal in Algeria in 2012, Libya in 2007, Palestinian 

refugees of Lebanon in both surveys, the West Bank and Gaza Strip in both surveys, and Tunisia in 2012. 

It was also very high in Jordan for both surveys (94%). The percentage of delivery by an SBA and delivery 

in a health facility were very similar for Jordan, Algeria, Libya, the Palestinian refugees of Lebanon, and 

the West Bank and Gaza Strip, which indicating that most SBAs were performing the delivery in a health 

facility. However, the percentages were very different for the recent surveys of Yemen, Iraq, and Tunisia. 

In the recent surveys of Yemen and Iraq, the percentage of delivery in a health facility was approximately 

15 percentage points less than delivery by an SBA, indicating that many deliveries performed by an SBA 

occurred outside of a health facility. For Tunisia, 74% of women had their most recent birth delivered by 

an SBA although 99% of these births were performed in a health facility. These percentages suggest that 

many deliveries performed in a health facility were performed by an unskilled birth attendant. As with 

delivery by an SBA, there were significant increases in delivery in a health facility in Egypt, Iraq, and 

Yemen, with the largest increase—14 percentage points—observed in Egypt and Iraq. 

Related to the large increase in health facility delivery in Egypt is the large increase in delivery by Csection, from 30% in 2008 to 57% in 2014. This was the largest percentage of C-section delivery among 

the countries with available information on this indicator. Almost a third of women in Jordan in 2012 and 

Palestinian refugees of Lebanon in 2011 had a C-section delivery for their most recent birth. In the West 

Bank and Gaza Strip, the percentage of C-section delivery increased from 17% in 2010 to 20% in 2014. 

The lowest percentage was in Yemen in 2013, with only 6% of women having a C-section delivery. Since 

this indicator was not available in the Iraq, Palestinian refugees of Lebanon, and Yemen 2006 surveys, 

trends could not be described for these countries. The indicator was also not available for the Morocco 2011 

and the Syria 2006 surveys. 
226 

Figure 5: Percentage of women age 15-49 who had their 

most recent birth assisted by a skilled birth attendant in the 

2 years before the survey, all surveys 

Figure 6: Percentage of women age 15-49 who delivered 

their most recent birth in a health facility in the 2 years 

before the survey, all surveys 

Figure 7: Percentage of women age 15-49 who delivered 

their most recent birth by caesarean section in the 2 years 

before the survey, all surveys 

Child Health and Nutrition

The vaccination indicator was produced for four countries (Egypt, Jordan, Syria, and Yemen), in which the 

coverage of basic vaccinations was very different. Egypt and Jordan had the highest percentage of children 

age 12-23 months that had completed all basic vaccinations. However, this significantly decreased for 

Egypt from 92% in 2008 to 84% in 2014, and significantly increased for Jordan from 87% in 2007 to 93% 

in 2012. There was also a significant increase in Yemen, which had the lowest percentage of the four 

countries, from 37% in 2006 to 43% in 2013. In Syria, basic vaccination coverage for children age 12-23 

months was 68% in 2006, although coverage is expected to have drastically declined since 2011. 

Figure 8 shows that care-seeking for ARI symptoms ranged from two-thirds to three-fourths of children for 

Algeria, Egypt, Jordan, Iraq, Libya, the WBG, and Syria. There was a drastic increase in care-seeking for 

the PRL, which almost doubled from 44% in 2006 to 82% in 2011. There was a smaller but significant 

increase in the WBG from 65% in 2010 to 77% in 2014. The lowest percentage of care-seeking for ARI 
227 

symptoms, only 34%, was in Yemen in 2013. The indicator was also relatively low in Morocco, with care 

being sought for only 45% of children under age 5 with ARI symptoms. 

Figure 8: Percentage of children under age 5 who had symptoms of ARI in the 2 weeks before the survey and 

for whom advice or treatment was sought from a health facility or provider, all surveys 

Exclusive breastfeeding of children under age 6 months is generally not highly practiced in the countries in 

this report. The highest percentages from the most recent surveys were found in Egypt and the WBG in 

2014, with approximately 40% of children under age 6 months being exclusively breastfed. Egypt had a 

higher percentage in 2008 (53%), although this significantly decreased to 40% in 2014. The indicator 

significantly increased in the WBG from 29% in 2008 to 39% in 2014. Exclusive breastfeeding ranged from 

approximately 20% to-25% in Algeria, Jordan, Iraq, Morocco, and Syria. Exclusive breastfeeding was the 

lowest in Libya, Tunisia, and Yemen at approximately 10%. This was followed closely by the PRL at 17% 

in 2011. 

The percentage of stunted children was by far the highest in Yemen in 2013, with almost half of children 

under age 5 being stunted. Yemen also had the lowest percentage of overweight children under age 5. 

Stunting significantly decreased in Egypt, Jordan, the PRL, and the WBG. Approximately one-fifth of 

children under age 6 were stunted for the most recent surveys available in Egypt, Iraq, and Syria. For the 

most recent surveys of the remaining countries, stunting was approximately 10% or below. It was lowest 

in the WBG in 2014 and Jordan in 2012, below 10%. Egypt had one of the highest levels of stunting in 

2014, and one of the highest levels of overweight children under age 6 in the same year. Approximately 

15% of Egyptian children under age 6 were overweight in 2014. This was similar to the level in Tunisia in 

2012. The most recent surveys of the remaining countries were below this level, with most having 

approximately 10% overweight children. Significant decreases in overweight children were observed in 

Egypt and Jordan. The PRL showed small but significant increases in Iraq and the WBG. 
228 

Figure 9: Percentage of children under age 6 months who 

are exclusively breastfed, by background characteristics, all 

surveys 

Figure 10: Percentage of children under age 5 who are 

stunted, by background characteristics, all 

surveys 

Figure 11: Percentage of children under age 5 who are 

overweight, by background characteristics, all surveys 

The under-5 mortality rate significantly decreased in Yemen from 77/1000 births in 2006 to 53/1000 in 

2013. Yemen remained the country with the highest under-5 mortality rate, among all the countries with 

available data on this indicator. The second highest rate was found in Iraq, approximately 40/1000 in both 

surveys. Under-5 mortality was approximately 20/1000 for Algeria, Tunisia, Jordan and the WBG in both 

surveys, and was the lowest for the PRL in 2011 at 17 deaths per 1000 live births. Under-5 mortality could 

not be assessed for Syria, the PRL 2006 survey, and Morocco. 
229 

Figure 12: Under-5 mortality rates for the 5 years before the survey, all surveys 

231 

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Appendix 

Table 1: Region categories 

Country Regions 

Algeria 

North Center: Alger, Blida, Boumerdès, Tipaza, Bouira, Médéa, Tizi-Ouzou, Béjaïa, Chlef et Ain Defla 

North East: Annaba, Constantine, Skikda, Jijel, Mila, Souk Ahras, El Tarf et Guelma 

North West: Oran, Tlemcen, Mostaganem, Ain Témouchent, Relizane, Sidi Bel Abbés et Mascara 

Highlands Center: Djelfa, Laghouat et M’Sila 

Highlands East: Sétif, Batna, Khenchela, Bordj Bou Arréridj, Oum El Bouaghi et Tébessa 

Highlands West: Tiaret, Saïda, Tissemsilt, Naâma et El Bayadh 

South: Béchar, Tindouf et Adrar, Ghardaïa, Biskra, El Oued et Ouargla, Tamanrasset et Illizi 

Egypt 

Urban Governorates: Cairo, Alexandria, Port Said, Suez 

Lower Egypt: Damietta, Dakahlia, Sharkia, Kalyubia, Kafr El-Sheikh, Gharbia, Menoufia, Behera, Ismailia 

Upper Egypt: Giza, Beni Suef, Fayoum, Menya, Assuit, Souhag, Qena, Aswan, Luxor 

Frontier Governorates1: Red Sea, New Valley, Matroh, North Sinai, South Sinai 

Iraq 

Kurdistan Regional Government: Dohuk, Sulemaniya, Erbil 

North Central: Ninewa, Kirkuk 

West: Al-Anbar 

Central: Baghdad, Salahaddin, Diyala 

South Central: Babil, Karbala, Al-Najaf, Al-Qadisiya, Wasit 

South: Al-Muthanna, Thi-Qar, Missan, Basrah 

Jordan 

Central: Amman, Zarqa, Balqa, Madaba 

North: Irbid, Jarash, Ajloun, Mafraq 

South: Karak, Tafielah, Ma’an, Aqaba 

Lebanon 

(Palestinian 

refugees) 

Tripoli: Akkar, Tripoli, and North 

Beirut: Beirut and Mount Lebanon 

Beqaa: Baalbek, Beqaa, and Hermel 

Saida: Chouf and Saida 

Tyre: Nabatieh, South, and Tyre 

Libya 

Tripolitania: Sirt, Misurata, Al-Merqeb, Tripoli, El-Jafara, Zawia, El-Nikat El-Khams, El-Gabal El-Gharbi, Naloot

Cyrenaica: El-Batan, Derna, Gebel Akhdar, El-Marj, Benghazi, El-Wahat, El-Kufra 

Fezzan: El-Joufra, Sebha, Wadi El-Shati, Wadi El-Haya, Murzuk, Ghat 

Morocco 

Central/Tensift: Chaouia Ourdigha, Grand Casablanca,Tadla,Azilal, Marrakech,Tensift,El-Haouz, 

Doukkala,Abda 

Northwest: El-Gharb,Chrarda Bni Hassen, Rabat-Sale,Zemmour,Zair, Tanger,Tetouan 

South Central: Meknes,Tafilalet 

North Central: Taza- Al Hoceima,Taounate, Fes, Boulemane 

Eastern: Region Oriental 

Southern: Sahara, Souss, Massa, Draa 

Syria 

North: Hama, Tartous, Lattakia, Idleb, Aleppo 

East: Lattakia, Deir Ezzor, Raqqa 

Central: Damascus, Rural-Damascus, Sweida, Homs 

South: Daraa, Quneitra 

Tunisia Coastal: District Tunis 

Interior: North East, North West, Center East, Kasserine, Kairouan, Sidi Bouzid, South East, South West 

West Bank 

& Gaza 

Strip 

North Gaza and Gaza City 

South Gaza: Deir El-Balah, Khan Younis, Rafah 

North West Bank: Jenin, Nablus, Tubas, Tulkarm, Qalqiliya, Salfit 

Center West Bank: Ramallah & Al-Bireh, Jericho 

Jerusalem 

South West Bank: Bethlehem, Hebron 

Yemen 

Hadramawt: Hadramout, Al-Maharah, Shabwah 

Aden: Aden, Abyan, Lahej, Al-Dala’a 

Al-Janad: Ibb, Taiz 

Saba: Mareb, Al-Jawf, A-Baidhah 

Tihama: Al-Hodeidah, Raimah, Al-Mahweet, Hajjah 

Azal: Sana’a City, Sana’a,Dhamar, Amran, Sa’adaj 

1 North and South Sinai were excluded from the 2014 DHS sample. This does not affect comparison with the 2008 DHS sample 

because sample size in these governorates is small.