This blog post summarizes the findings of an article that Wendt and co-authors published in SSM – Population Health in September 2021. This blog post is reprinted from the PMNCH website; the original post is here.
By Andrea Wendt and Cesar Victora, University of Pelotas, Brazil; PMNCH ART constituency member
The link between gender and health outcomes is inextricable. Women and girls are disproportionately affected and face greater risks of mortality and morbidity due to pregnancy complications and unsafe abortions, particularly in low- and middle-income settings. The impact of these devastating health outcomes is felt not only by the woman but have long term consequences for the health and well-being of her family and children too. Moreover, gender does not act alone and any analysis of gender on health outcomes must be cognizant of the pervasive role that intersectional determinants play. For example, women are more likely to have access to modern contraception in countries with gender equality and better educational opportunities. As such within the PMNCH 2021-2025 strategy, a focus on advancing Sexual, Reproductive Health and Rights and gender equality has been taken, and additionally prioritized within the PMNCH COVID-19 Call to Action campaign.
Little is known about how the health and nutrition of children living in female-headed households (FHH) differ from that of children in male-headed households. In particular, no global analyses on this topic are available. The literature on FHH proposed two main mechanisms regarding how children living in such households might be affected. First, children could be negatively affected due to socioeconomic disadvantages of FHH due to low wages of women and social or cultural barriers in some countries (e.g., no right to land or inability to register children when the household does not include a man). Second, children might be positively affected because women who are heads of household will likely be more empowered and able to manage family resources in favour of their children, independent of poverty level.
These two situations may vary widely between and within countries. The Countdown to 2030 initiative and the International Center for Equity in Health at the Federal University of Pelotas, Brazil, recently investigated inequalities in child health and nutrition according to sex of the head of household, using data from surveys carried out since 2010 in 95 low- and middle-income countries. The analyses were sponsored by the International Development Research Centre (Canada) and detailed results were made available in a recent publication in the Social Science and Medicine (Population Health) journal.
The results show that about one in four households in low- and middle-income countries are headed by women, but this proportion ranged widely from 1.7% in Afghanistan to more than 45% in Jamaica. In-depth exploration of female-headed households (FHH) showed that this group comprises two main subtypes: those with and those without a resident adult male — the latter being particularly common in Sub-Saharan Africa. In the pooled analyses of all countries, the proportions of all households in these two categories were 9.8% and 15.0%, respectively. FHH without an adult male tended to be poorer than either those with an adult male or than male-headed households (MHH). The respective proportions of families in the poorest national wealth quintiles were 23.8%, 16.7% and 20.0%.
Studied outcomes included full immunization coverage in children aged 12-23 months and stunting prevalence in under-five children. The two FHH groups were compared with MHH using prevalence ratios, that is, dividing the proportions of children who were immunized in each FHH subtype by the corresponding proportion in MHH; the same approach was used for stunting prevalence. A ratio of 1.0 indicates equal proportions of immunized or stunted children in FHH and MHH households. These results were pooled across all 95 countries. Regarding full immunization, the pooled prevalence ratio for FHH (any male) was 0.99 relative to MHH, and also 0.99 for FHH (no male). For stunting prevalence, the pooled prevalence ratios were equal to 1.0 for both FHH groups relative to MHH. None of these differences were statistically significant.
Although no differences were detected in the pooled global analyses, significant inequalities – in both directions – were observed in 28 countries that are listed in the publication. Seven of these 28 countries were included in the World Bank’s list of fragile and conflict-affected situations (FCS) at the time of the surveys included in our analyses (Central African Republic, Congo, DR, Chad, Cote d’Ivoire, Gambia, Mali and State of Palestine/West Bank). Even in these FCS countries, where poverty is intense and women may end up being heads of family due to the death of their husbands, our results on child immunization and stunting go in different directions and children in FHH not always present the worst outcomes.
In Chad, for example, children from FHH (no male) were 34% less likely to be immunized and 16% more likely to be stunted than those in MHH. In Congo, DR, the coverage of full immunization in children living in FHH (any male) also was 49% lower than in MHH and in the State of Palestine stunting prevalence was 92% higher in FHH (no male) than in MHH. On the other hand, children from FHH fared better than those in MHH in some countries. For example, in Cote d’Ivoire and in Mali immunization coverage were 30% and 34% higher, respectively, in FHH than in MHH. Among children from Gambia living in a FHH (no male), stunting prevalence was 29% lower than for those living in MHH. Other fragile countries show mixed results. In 2010, the Central African Republic was receiving donor support as well as peace-keeping missions. Children living in FHH presented a 66% increase in full immunization coverage, but also 11% higher prevalence of stunting that those in MHH.
Additional, yet unpublished analyses are underway. In regard to demand for family planning satisfied by modern contraceptive methods (a women’s health indicator), coverage in FHH was lower than in MHH in some FCS countries (Afghanistan, Haiti, Mali, Congo, DR, Timor-Leste, Zimbabwe and Yemen). The above-described results emphasize the complexity and diversity of FHH and the importance of context and type of outcome under study, even within different FCS.
Overall, these results show that households headed by women, without a resident adult male, tend to be poorer than those headed by men. Although this does not seem to affect child immunization or nutrition in most countries, important gaps do exist in specific settings. There is a need for better and more nuanced indicators to measure child health status at national and sub-national level to effectively guide policy makers. Monitoring inequalities in child health according to sex of the head of households may bring important insights for policymakers.
A critical challenge in child health is ensuring child interventions reach those most vulnerable. Before planning interventions, one needs to use existing data to identify who and where the most vulnerable children are, within each country and if so what gender-related underlying issues are present. These may not necessarily be children from FHH. Based on available data, policies and interventions should address gender inequality in general, and specific short-term (e.g., targeted vertical immunization programs) or long-term strategies (e.g., focus on nutrition and growth throughout the life course). Interventions focused on FHH should be, above all, tailored to the specificities of each country.