Household structure, maternal characteristics and childhood mortality in rural sub-Saharan Africa

Introduction: The household dynamics of childhood mortality in rural areas of sub-Saharan Africa is less researched despite the fact that mortality rates are almost two times that of urban settings. This study aimed to investigate the influence of household structure on childhood mortality while controlling for household and maternal characteristics in rural sub-Saharan Africa. Methods: Eight countries with recent demographic and health survey data not earlier than the year 2010 were selected, two from each sub-region of sub-Saharan Africa. The outcome variables were risk of infant and child death while the main independent variables included sex of household head and household structure. Descriptive statistics were generated for all variables. Mortality rates disaggregated by sex of household head and household structure were estimated using the Kaplan-Meier method. Cox proportional hazard regression models were fitted to investigate the relationship between the outcome and explanatory variables in each country. Results: The percentage of children living in female-headed households (FHHs) ranged from 5.2% in Burkina Faso to 49.1% in Namibia while those living in extended family households ranged from 27.4% in Rwanda to 59.9% in Namibia. Multivariate hazard regression showed that, in the majority of the countries, there was no significant relationship between living in FHHs and childhood mortality, but the direction and magnitude of effect varied across countries. A significant negative effect of FHHs on infant mortality was observed in Burkina Faso (HR=1.64, 95% confidence interval (CI): 1.09-2.48) and Zambia (HR=1.49, 95%CI: 1.02-2.17). Likewise, children in extended family households had a higher risk of child mortality in Burkina Faso (HR=1.33, 95%CI: 1.04- 1.69) and Zambia (HR=1.59, 95%CI: 1.02-2.49). There was not much difference in the effect of FHHs between infancy (0- 11 months) and childhood (12-59 months) in the other countries. The pooled adjusted hazard ratio (HR) showed that the risk of death in childhood was 23% higher in extended family households (HR=1.23, 95%CI: 1.09-1.39) than in nuclear family households. Conclusions: In rural sub-Saharan Africa, children in FHHs do not have significantly higher infant and child mortality. Also, there was no difference in infant mortality between nuclear and extended family households but the latter constitute a higher risk for child mortality.