Mandana NasiriManesh*, Ladan Ajori**, Mitra Parsapour Moghadam ***, Vida Fallahian **** and Naheed Mostaghel*****

* Mandana Nasirimanesh B.S of Midwifery, Shaheed Beheshti Nursing & Midwifery School, Tehran/ IRAN.
**Ajori Ladan, Assistant Professor of Obstetrics and gynecology Department, Shahid Beheshti University (MC) of Iran.

*** Mitra Parsapour Moghadam, Assistant Professor of Obstetrics and Ggynecology Department, Shahid Beheshti University (MC) of Iran.
****Fallahian Vida, MS, Pasteur Institute of Iran, Tehran

***** Naheed Mostaghel, Assistant Professor, Obstetrics and gynecology Department, Shahid Beheshti University (MC) of Iran

Correspondence:
Ajori Ladan,
Assistant Professor of Obstetrics and gynecology Department,
Shahid Beheshti University (MC) of Iran

INTRODUCTION

The health of the girl child is a concern for health providers. Is the girl child denied her right to life, and are males more highly valued than females?

Are the health needs of the girl child any different to the needs of the boy child?
The answer is that they should not be so different and we do not need to draw a clear distinction between sexes.

In fact sexual differences remain a global issue, nevertheless, there are few, if any countries in the world, especially developing countries where females suffer some disadvantages in relation to males. In an analysis of data from 27 countries, a strong correlation was found between a measure of son preference and males had lower mortality rates during infancy and childhood, to females.⁽²⁾
Nutritional deficiencies in childhood pose health problems for both males and females in future life.

Based on WHO reference, children two or more standard deviations below the median of the reference are considered moderately or severely undernourished⁽³⁾.

Another important area of female disadvantage throughout the world is access to education. It is perhaps the strongest variable affecting the status of women⁽⁴⁾.

From standpoint of health indicators and variables, including neonatal, infant and under 5 years mortality, sex ratio at the time of birth (sex selection before birth), nutrition, education and health indicators, are discussed in relation to child health and especially female children in Iran. It is important to realize that the health network of Iran is an integrated system composed of ministry of health and medical science universities. Three district sectors are currently involved in health care provisions in Iran: Government services (in this system the health house is the most peripheral facility in the network and has the provisions of PHC and family planning), health insurance and the private sector. A male and a female villager known as Behvarz who were selected from among the natives and trained for two years, and have enough knowledge and skills to deliver primary health care staff in a health house in rural areas. In Tehran (capital city of Iran) and other large cities, private sector and referral systems have been more established. Accessibility and facilities are more developed compared to rural areas.

The main objective of this study was to evaluate health status of children in Iran and especially to determine if there are any differences against the health of female children in Iran. This is a review and analysis of current existing data on this issue by descriptive and analytic statistics in SPSS software .P values less or equal to 0.05% were determined significant.
We reviewed health information from national health reports, including:

1.Iran Demographic and Health survey (DHS 2000)⁽⁵⁾.
"The principal objective of that study was to determine population and health statistics, and its practical goal was to use the indicators generated by it for the purposes of urban and rural planning. The specific objectives were: Determine baseline, households' welfare, and fertility and contraceptive usage indicators forneonatal, infant, and under 5 year's mortality. Baseline situation of children, such as child labourers, access to education, prevalence of respiratory infections and diarrhea illnesses.

The sample size for each province (28 provinces and Tehran as the capital city) was set at 2000 urban and 2000 rural households. The actual number of households eventually accessed was 113,957 including 537,108 persons. 173,707 cases were 0- 3 years. The sampling method was single-stage cluster sampling (cluster of equal size). Each cluster consists of 10 ordinary residential households. The basis for weighted adjustments was the ratio of urban to rural residential households in a given province, based on 1996 census data. Ministry of Health and medical education with collaborations of Iran statistics center, civil registration organization, UNFPA and UNICEF, did DHS.

Even though in most of the stages of this survey, other organizations were involved as external monitors and quality controllers, implementing revisions as required, what confirms the scientific accuracy of the data obtained is their internal and external consistency; the latter being achieved with respect to the results of similar studies as well as the 1996 General Population and Household Census" ⁽⁶⁾.

2. National health and disease survey 1999⁽⁷⁾.
"The population sample of health survey consisted of one thousandth of the total Iranian population (according to the latest census figures, the population of Iran was 60 million). Cluster sampling randomly selected them. Each cluster consisted of eight families that were visited on a single day by a team of four persons (two physicians, one interviewer and laboratory technician). Data derived from medical history, physical examination and laboratory findings were recorded. The urban and rural population sample comprised 1,097 clusters (8,776 families) and 509 clusters (4,719 families), respectively. A total of 61,137 subjects including 22,271 0-13 years, were interviewed. Laboratory studies were carried out for 84.6% of the total population studied. Para clinical tests were performed in the laboratories of each province. Those included hemoglobin and hematocrit levels, MCV, HBs Ag and Stool examination.

Six different questionnaires were completed. Questionnaire No.1 contained general information about the cluster, No.2 contained information about the standard of hygiene in the household, and No.3 was about the foodstuff ingested by the family within the last 48 hours. Questionnaire 4 was comprised of three parts: Part 1 contained questions about hygienic conditions, medical history and general physical state. Part 2 assessed the level of psychological health and included seven questions about somatization, seven about anxiety state, seven about social dysfunction and seven about depression. Questionnaire No.5 contained information about the clinical findings detected by the examining physicians. Questionnaire No.6 contained information about the results of blood and stool examination."
.
3. National statistical yearbook 2,000 and other health reports⁽⁶⁾.
A comparison study between male and female children from 0-13 years old wasperformed. Variables include: average number of female live births to males, mortality rates of neonatal, infancy and under 5 years period, nutrition, education and health indicators.
Data analysis was done by SPSS software. P value less than 0.05 was significant.

The number of female births registered, relative to male birth is (534,629: 560,536) or sex ratio is 105 males per 100 females^(5,6).

Neonatal mortality rate in 1,000 live births is 14.6±3.5 for female and 21.9±4.6 for male newborns⁽⁵⁾. Infant mortality rate for female and male children are 24.4 ± 4.5 and 32.7 ±5.6 in 1,000 live births⁽⁵⁾.
Under 5 years mortality ratio is 34.6 for females to 37.6 in males⁽⁵⁾.
Last live birth for 15-44 year old mothers is 1.3 for female and 1.4 male⁽⁷⁾.
The overall population by sex female to male is (29,540,329: 30,515,159)⁽⁶⁾.
Medical care and health indicators including immunization and take care against common diseases in 19,175 subjects 13 years or less⁽⁷⁾. have been presented in Tables 1 and 2.

P value equal or less than 0.05% means significant in this study, however there was no significant difference between male and female sexes but there is slightly unmeaning advantage for female children.

Nutrition:
Breast-feeding in Iran up to 12 months is 91% for boys and 90% in girls.
But continuation of breast feeding up to 24 months are 42% and 34% respectively⁽⁷⁾.
11% of under 5 years children are underweight (one in nine children) 11.9% of boys (CI: 10.3-13.8) and 9.7% of girls (CI: 8.1-11.6) are underweight but it has no meaningful difference⁽⁸⁾.
Nevertheless, 15% of Iranian children have stunting. (One out of 7 children at the ages of under 7 years old) but there are no differences between boys and girls.

Education:
Illiteracy rate is 2.7% among female children (6-10 years) compared to 2.1% of male children. 95.5% of boys at the ages of 7 to 14 years old go to school, compared to 91.5% of girls at the same ages⁽⁵⁾.
Numbers of classes in non-profitable organizations for boys are 21,879 compared to 13,094 for girls in primary school (1996).

Although female children go to preliminary schools more than male children (93,162 to 92,729) for secondary school boys go to school more than girls (9,239,889 compared to 8,466,150) in 1996⁽⁹⁾.
The percentage of dropout students due to family problems is 8.5% for girls compared to 7.3% for boys⁽⁵⁾. 11.1% of boys at the ages of (5-14) years work compared to 8.1% of girl children at the same ages in urban areas and in rural areas (24.5% and 18.4%) respectively⁽⁵⁾.

Some observers have suggested that excess female mortality sometimes begins before births , and that sex selective abortion has played an important role in reducing the number of female birth relative to male births⁽¹⁾.

In China, the sex ratio at birth has risen from the normal level of 106 in 1980 (106 male births to 100 female births) to 120 in 1997⁽¹⁰⁾. This pattern is due in part to sex selective abortion, resulting from China's one child policy.

In Iran male to female ratio at birth is 105 to 100 and it is not far from the natural ratio.
Although there is sex-selective abortion in some countries⁽¹⁾. but reveals 46xx, cells in reports of products of conceptions may be due to maternal cell contamination in 89.7% cases and it does not mean that sex selective abortion has been performed⁽¹¹⁾.

Neonatal, infant and lower than 5 years mortality rates are higher in boys relative to girls implying considerable advantages for girls.

Because of the biological advantage of being female, male mortality rates are generally higher at every age from zero to the highest age attained⁽¹²⁾. Infant and lower 5 years mortality rates are 66, 94 and 86,112 in regional countries: Bangladesh and Pakistan respectively⁽¹³⁾. In Iran even though the proportion of deaths in children under 5 that occurred between the ages of 1 and 59 months has declined in recent years, very little success has been achieved in reducing neonatal mortality rates, and neonatal deaths now account for more than 50% of all deaths in the under 5 age group. Further reduction in U5M rates will require greater focus on the neonatal age group.

Nutrition and medical care fortunately is the same for girl and boy children but unfortunately one out of 9 children under 5 years suffers from malnutrition and they are underweight⁽⁸⁾. and it is a basic challenge for child health and needs more supervision.

Studies in many parts of the world have shown that girls under 5 are given less to eat than their brothers and are more likely to be malnourished⁽⁴⁾. Based on DHS in regional countries^(3,14). Yemen and Armenia, the percentage of malnourished among children younger than five years, are 51.7 and 13.

In Iran more than 95% of children have been immunized but among eight Asian countries surveyed, levels of immunization range from one-third of children in Pakistan to about three-quarters in the Philippines⁽¹³⁾.

Education is another important area of female disadvantage throughout the world, but fortunately in Iran like many other developing countries, females have made progress in the field of education, and families as well as governments almost always invest less in girl's education than boys.
As a result, illiteracy rates for men have fallen faster than those for women; nevertheless, in Iran girls have found their successful ways.

Health and disease indicators, neonatal, infant and mortality ratios show advantages for female children. The health status of children reflects mainly socioeconomic and health services. Although data showed acceptable health standards in this study, and did not reflect significant differences against female children, in order to improve nutritional patterns and health interventions, further studies are required and more information about their social supports and securities in both sexes, male or female children, are still needed. We love both of them and there is no need to draw a clear distinction between sexes.

1. Makinson C., Discrimination against the female child, Int J. Gynecol. Obstet: 46. 1994. 119-125.
   
2. Waldron I, Patterns and causes of excess female mortalities among children in developing countries, World Health stat 40, 1987.
3. Yemen 1997 DHS, Studies in Family Planning; 30,1999:356.
   
4. Sadik N, key issues affecting the status of women, Int. J. Gynecol. Obstet, 46, 1994. 209-214.

5. Demographic and Health Survey in Iran. Undersecretary for health affaires, Family Health and Population Department, Demographic and Health Survey in Iran/DHS -2000.1sted.Tehran (Iran): Family Health and Population Department and UNICEF in Tehran; 2002. p. 30-80.
   

6. Iranian statistical organization, yearbook 2000.
   
7. National Health Survey, Undersecretary for research.1st ed. Tehran (Iran): Ministry of Health and Medical Education in Iran; 2001, p.18-34.
   
8. Nutrition of children in Iranian provinces ; Under secretary for health , Ministry of health and medical education 1998. P.20.16.
   
9. Iranian statistical organization education section 1999.
   

10. Yiz. Ping I, Baochang G etal: causes and implication of the recent increase in the reported sex ratio cet birth in China. Popula. Dev. Rev. 19:2, 1993.
    

11. Kristone I Jarrett Ms and etal, Microsatelite analysis reveals a high incidence of maternal cell contamination in 46xx: products of conception, Am J Obstet Gynecol. Vol 185 No 1. 198-203/ 2001.
    
12. Fathalla M. Women's health: An over view, Int. J. Gynecol. Obstet, 46, 1994.105-118.
    
13. Child survival and Health, Population Reports; (31) no.17, 2003.
    
14. Armenia 2000 DHS. Studies in family planning,(34)2003: 142.