Nutritional Anthropometric and Retrospective Mortality Survey, Children 6 to 59 months: Low Land and Mountainous Ecological Zones, Sa’ada Governorate, Yemen - Final Report

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Dates of the survey: 14th - 24th June, 2014

Executive Summary

1. Introduction:

Sa’ada Governorate is located at the north of the country bordered by Saudi Arabia at the north and Amran, Hajja governorates at the south and west respectively. Al-Jawf governorate bordered Sa’ada at the south- east direction. Sa’ada is divided administratively to 15 districts which subdivided to 122 sub-districts (Ozlas) and 1212 villages. Geographically, Sa’ada composed of two main areas, the mountainous lands at the west and north-west to the capital and the lowlands which are at the other directions to the capital of the governorate. The estimated total population of Sa’ada according to 2004 census and multiply by the growth factor (as per EPI data) reached to 975,400.

The main income source is the agriculture mostly Qat cultivation. The main sources of drinking water is from the wells for the middle and east districts while the mountainous west districts are depend on rain water collection.

The situation of the children in Sa’ada gets deteriorated in the last years due to the repeated rounds of war which destroyed the infrastructure of social services facilities which was originally not enough even before the war. The displacement of around half of the population of Sa’ada from their villages impacted negatively the health and nutrition situations especially children.

Due to the repeated six rounds of war in Sa’ada since 2004, most of the health infrastructures were destroyed in most districts and many health workers were displaced during the war years and also after the war around 130 health workers were displaced to Sana’a in 2011-2012. All these factors make catastrophic consequences on the primary health services being providing for children and mothers.

The misconception of the community regarding some health interventions such as immunizations, family planning and to health education, both qualitative and quantitative indicators for these services were low and this has negative impact on the child and maternal health.

The coverage rates of EPI vaccines, skilled-birth attendants, ANC, PNC and coverage of Vitamin supplementation is low. The main diseases affecting children are diarrheal diseases, acute respiratory infections and measles. In 2012, there was measles outbreak with more than 3000 suspected cases recorded in 2012 in Sa’ada.

WFP Yemen CFSS final version for 2014; there are significant differences in food insecurity between governorates. Sa’ada governorate, which was surveyed for the first time, was found to have the country’s most food insecure regions. Nearly 70 percent of the population there are food insecure, of which more than 40 percent are severely food insecure. Compared to the 2011 CFSS findings, overall food insecurity fell by about 8 percent in 2014. While 44.5 percent of the population was food in secure in 2011, that figure reduced to 41.1 percent in 2014.

1.1 Survey objectives:

The main purpose of the survey was to assess the nutrition situation of the Lowland and Mountainous communities. The final outcome of the survey would be to make recommendations for the purposes of guiding the design and implementation of an appropriate response in Sa’ada governorate.

  • To estimate the global and severe acute malnutrition rates among children aged 6-59 months.

  • To identify groups at higher risk of malnutrition: age group, gender.

  • To estimate the mortality rate and cause of death among children less than 5 years of age over the preceding three months.

  • To estimate the crude mortality rate and cause of death among the population over 5 years of age for the preceding three months - To estimate vaccination coverage Pentavalent3/ Polio3, measles and vitamin A supplementation.

  • To estimate the prevalence of disease in the two week prior to the survey i.e. acute respiratory infections (ARIs) , Diarrhoea , fever and measles - To collect relevant food security , water and sanitation , and care practices information on the surveyed population - To make possible recommendations concerning further programs

Survey date: 14th to 24th of June, 2014.

This nutritional survey was conducted as part of the biyearly nutritional monitoring system of the MOPHP intervention areas. The survey was conducted in collaboration with MOPHP at local and national levels and with technical and financial support from UNICEF. Data collection was completed by seven teams, seven supervisors, seven data enterers and one survey coordinator.

2. Methodology:

Sa’ada governorate, districts are subdivided in to sub-districts; which are further divided into villages. The universe that the samples were drawn was based on the complete list of ‘villages’ in all the districts and the best available population estimates of the selected villages obtained from the central population office.

2.1. Sample size (Anthropometry):

The anthropometry sample size was calculated by using smart software considering the following parameters:

  • The estimated prevalence of global acute malnutrition 21.6% in low land and 9.3% in Mountain and the prevalence used is from Hajja as it is has similar conditions

  • The desired precision was 5 for low land and 3.5 for mountains

  • Design effect 2 for both zones

  • Average household size was 6 in lowland and 7 in mountain

  • Per cent of less than 5 years 17%

  • Per cent of non-response household 5%. The smart software has automatically calculated the number of houses to be visited during the survey and by then number of children appeared during the planning will reached or exceeded but not less

2 .1.1 Sample size (mortality):

The sample size for the Mortality component was calculated using SMART software by considering:  Estimated death rate 0.63 per 10,000l day

  • Desired precision 0.30

  • Percent of non-response households at 5%

  • Design effect 1

  • Recall period in days 90 days The above data entered in to the computer and then the smart software has automatically calculated mortality sample size but the teams used the same number of household calculated for anthropometrics to collect mortality data

2 .2 Sampling procedure selecting (Clusters):

Clusters were selected at the random with the probability of being selected proportional to the size of the population in the districts of the governorate using the ENA software and household were selected when the survey teams visited the selected cluster location and met village leaders. The team leader explained the purpose of the survey and survey procedures.

A total amount of 38 and 36 clusters were selected from Mountains and low land zones respectively using SMART software. As the house hold considered as the primary sampling unit number of children to be included was estimated to provide reasonable estimates of the prevalence of malnutrition with at least 95% confidence. A total of 466 and 571 household were visited from mountains and coastal respectively for data collection. The same method was applied for the retrospective mortality survey. All household including those without children less than 5 years of age were included for mortality survey. The sampling methodology follows the SMART guidelines.

2 .3 Sampling Procedure (selecting house hold and children)

Clusters were selected using SMART software during the planning stage as mentioned above based on the population numbers of each villages or area to be covered by the survey 37 and 33 clusters were selected for the two zones as mentioned above and number of households to be visited daily was decided and agreed by the team.

The first house is picked at random; thereafter houses are picked by proximity using modified EPI method described below.

Anthropometrics result:

Prevalence of acute malnutrition based on weight for height z-score remains poor although it is below the emergency threshold at 15%. Global acute malnutrition (GAM) was 10.4 %( 8.1-13.3 95% C.I.) And 9.0% (6.1-13.3 95% C.I.) and severe acute malnutrition (SAM) was 2.3 %( 1.0 -3.8 95% C.I.) And 2.0% (1.0 – 3.9 95% C.I.) in low land and Mountains respectively.

Statistically there is no difference between low land and mountains in terms of GAM and SAM since the confidence interval is overlapping and the two-survey calculator proves this P= 0.552 which is non-significant statistically.

Weighted prevalence of global acute malnutrition based on weight for-height z-scores for the whole governorate is 9.7% (7.0-13.0 95% C.I.).The weighted analysis is used to correct the bias of a nonrepresentative sample.

In low land zone severe and moderate wasting noticed high in age group of 6-17 months compared to others age group in same zone with 4.6% and 13.8% severe and moderate respectively, this can be attributed to current knowledge for infants as they have the highest micronutrient requirements relative to their energy intake and are more susceptible to increased infection as they begin exploring their environments as well early weaning practices.

Mountains severe wasting reported high in the age group of 18-29 months (3.4%) while moderate wasting reported high among 50-54 months (10%).

Prevalence of stunting, 57.0 % (50.9 – 62.8 95%CI) and 66.9 % (60.8 – 74.4 95%CI) with severe stunting 24.1 % (19.5 – 29.3 95%CI) and 34.4% (29.4 – 39.9 95%CI) in low land and high land respectively. Severe stunting tends to be higher in the age group from 18 to 29 months (33.1% and 42.7%) in low land mountains while moderate stunting noticed higher among mountains children 54 to 59 months (42%).Stunting prevalence in Sa’ada remains critical > 40% according to WHO classification, however in comparison with 2012 Dhamar and Mahaweet the three governorate reported same rate.

Severe stunting noticed high among age group of 18 – 29 months in Low land and Mountains with 33.1% and 42.7% respectively. Moderate stunting a bit higher among low land children aged 30 – 41 months with 37.8% and mountains children aged 54-59 months with 36.2%.

Underweight prevalence is 39.0 %( 34.4 – 43.7 95% C.I.), and 43.9 % (38.4 – 49.4 95% C.I) with severe underweight 10.3 %( 7.6 – 14.0 95% C.I.), and 12.3 %( 9.3 – 16.0 95% C.I.), in low land and mountain respectively. Rates remain high and above the WHO cut-off at < 30%, statistically there is no significant difference in the prevalence underweight of the two zones.

Severe underweight noticed higher in Mountains children aged 18-29 months with 20% compared to 13.7% in low land 6-17 months. Moderate underweight found higher as well among Mountains children aged 42-53 months (35.3%) while low land reported 29.4% children 6-17 months. Low land age group of 6-17 months reported the highest prevalence of severe and moderate underweight compared with other age group.

The entire morality rate and under five were remains at the acceptable level with 0.18 (0.07-0.47 95%C.I.) and 0.07 (0.02 – 0.23 95% C.I.) with 0.00 under five mortality in low land and mountain respectively.

Fever is the highest disease prevalence among surveyed children in lowland and Mountains with over 50%. Diarrhoea reported as second disease with 47.4% and 48.9% in low and high land respectively. Mountains areas reported high prevalence of ARIs compared with low land with (40.7%/37.1%). Suspected measles cases were remains high.

Vaccination coverage for Penta3/Polio, Measles and Vitamin A was found low and not meeting the recommended standard. The low coverage might contribute to the high disease prevalence specially Diarrhea and suspected cases of measles. Acceleration campaigns recommended to increase the routine vaccines coverage through the use of out-reach activities or any possible opportunity.

Initiation of breast feeding: almost half of the assessed mothers started breastfeeding with the first hour after delivery, this indicate that still there is 50% of the mothers not started breast feeding as required (one hour) after birth and this practice need to be improved among mothers although the percentage of mothers who were breast fed during the 24 hour after birth is high in both communities.

Proportion of children consumed food from the recommended 7 groups as follow during the last 24 hours, > 90% were consumed grains, roots and tubers in the past 24 hours, this group represent stable food. Dairy product represents about 50%, Flesh food including all types of meat (red and white) remain poor with 30-35% had consumed. Eggs consumption 38 – 39.6%. Vitamin A –rich fruit and vegetable found 19.6- 10% while other types of fruits and vegetables found 17%.Legumes 18.8-16.5% in low land and Mountains.


These recommendations are based on the findings of the survey data, although both zones reported GAM below emergency threshold at 15% but it is remains poor as mentioned above and might deteriorate with the contribution of other factors found at household level and mother practices. Therefore, recommendations are generated as below to address wasting and under nutrition issues.

Specific Recommendation:

  • Scale up of current Community based management of acute malnutrition (CMAM) program through use of mobile team to treat less than five and mothers who were found malnourished. Intervention/scale up can goes beyond the health facility to the second and third level at the community to early identify and detect children with acute malnutrition for early treatment.

  • Promotion of infant and young child feeding (IYCF) practices among the care givers through dissemination of nutrition and health messages through use of the current working community volunteers, community health workers with focus on early initiation of breast feeding, exclusive breast feeding, complementary feeding and continuation of breast feeding to two years and food diversity.  Improvement of routine immunization coverage through the use of out-reach campaign to cover un –reached children as the coverage was low in both zones.

  • Chronic malnutrition remains critical therefore; MoPHP and UNICEF should introduce interventions that prevent young children and mothers from getting malnourished.

General Recommendation:

  • Improve micronutrient supplementation for Vitamin A through the routine and non-routine work as well the use of fortified salt by raising community awareness.

  • Blanket supplementary feeding targeting children below three years to prevent malnutrition using plumpy’doz as the youngest age group has high prevalence of malnutrition compared with other age groups.

  • Strengthen the community out-reach component of CMAM to improve the active and adaptive case finding for early detection and referral as well defaulter tracing and community mobilization.

  • Promote sanitation and hygiene practices especially hand washing practices and latrine use i.e. Community Led Total Sanitation (CLTS) as the percentage of hand washing before feeding children and before food preparation is poor as well people who were use open defecation found to be high in both communities.

  • Enhance the livelihood patterns through introduction of projects that promote the household income such as food voucher and income generation projects that suit their situation.