Table 2 Effect of paternal death on child outcome

Thurman et al 2006 South Africa [92]

Comparison of orphan and non-orphan youth (age 14-18)

N = 1694, 31% classified as orphan

Significantly more likely to have engaged in sex compared with non-orphans (49% vs. 39%). After adjusting for socio-demographic variables, orphans were nearly one and half times more likely than non-orphans to have had sex. Among sexually active youth, orphans reported younger age of sexual intercourse, with 23% of orphans having had sex by age 13 or younger compared with 15% of non-orphans.

Beegle et al 2009 [93]

Compared groups who lost a parent aged <15 and those who did not

N = 718. Longitudinal study 1990-2004

On average, children who lose their mother before the age of 15 suffer a deficit of around 2 cm in final attained height (mean 1.96; 95% CI 0.06-3.77) and 1 year of final attained schooling (mean 1.01; 95% CI 0.39-1.81). This effect was permanent. Father's death is a predictor of lower height and schooling as well.

Vreeman et al 2008, Kenya [94]

Association between ART adherence and parental death.

1516 0-14 year olds

33% had both parents living when they started ART. 21% father dead, 28% mother dead, and 18% both parents dead. The odds of ART non-adherence increased for children with both parents dead.

Birdthistle et al 2008, Zimbabwe [95]

Comparison between orphans and non-orphans (half experienced parental death).

839 adolescents

Increased sexual risk (HSV2 positive, HIV positive or ever pregnant) among maternal orphans (aOdds Ratio = 3.6; 95% CI 1.7-7.8), double orphans (aOdds Ratio = 2.4; 95% CI 1.2-4.9), and girls who lost their father before age 12 (aOdds Ratio = 2.1; 95% CI 0.9-4.8) but not later (aOdds Ratio = 0.8; 95% CI 0.3-2.2). Maternal and double orphans likely to initiate sex early, have had multiple partners, and least likely to use a condom at first sex and to have a regular sexual partner.

Hosegood et al 2007, Malawi Tanzania South Africa [96]

1988-2004 data from 3 DSS surveys

Incidence of orphanhood doubled over time

Increased orphan prevalence in 3 populations. Paternal death substantially higher than maternal death. Pattern of co-residence in non-orphans predictive of orphan pattern. 77% paternal orphans live with mother and 68% maternal orphans live with father.

Ford & Hosegood 2005 South Africa [97]

Effect of parental death on child mobility

39,163 children 0-17

Survival status and residency of both mother and father affected mobility. Fathers' death from AIDS was not significantly different from other causes of death.

Doring et al 2005 Brazil [98]

1998-2001 AIDS mortality and healthcare registry data, 1131 orphans identi3 ed, 75.4% participated

Survey data

70% had lost their father and 50% their mother, and 21% had lost both parents. At the time of the survey, 41% of the children lived with the mother, 25% lived with grandparents and 5% lived in institutions. In multivariate analysis, HIV positivity multiplied the child's chances of living in an institution by a factor of 4.6, losing a mother by 5.9, losing both parents by 3.7.

Watts et al 2005 Zimbabwe [99]

1998-2000 open cohort follow-up data

Paternal orphan incidence (20.2 per 1000 person years) higher than maternal (9.1 per 1000 person years) and maternal orphans lost fathers at a faster rate than paternal orphans lost their mothers. Paternal and maternal orphan incidence increased with age. Incidence of maternal orphanhood and double orphanhood among paternal orphans rose at 20% per annum. More new paternal and double orphans had left their baseline household. Mortality higher in orphans with the highest death rates observed amongst maternal orphans.

Nyamukapa et al 2005 Zimbabwe [100]

Stratified population survey at 12 sites (1998-2000)

Maternal orphans but not paternal or double orphans have lower primary school completion rates than non-orphans in rural Zimbabwe. Sustained high levels of primary school completion among paternal and double orphans, particularly for girls, result from increased residence in female-headed households and greater access to external resources. Low primary school completion among maternal orphans results from lack of support from fathers and stepmothers and ineligibility for welfare assistance due to residence in higher socio-economic status households.

Crampin et al 2003 Malawi [101]

1106 off spring of HIV-positive diagnosed adults in 1980s

Death of HIV-positive mothers, but not of HIV-negative mothers or of fathers, was associated with increased child mortality. Among survivors who were still resident in the district, neither maternal HIV status nor orphanhood was associated with stunting, being wasted, or reported ill-health.

Lindblade et al 2003 Kenya [102]

Compared non-orphaned children under 6 years with those who lost one or both parents

N = 1190

7.9% lost one or both parents (6.4% father, 0.8% mother and 0.7% both parents). No difference between orphans and non-orphans regarding most of the key health indicators (prevalence of fever and malaria parasitaemia, history of illness, haemoglobin levels, height-for-Age z-scores), Weight-for-height z-scores in orphans were almost 0.3 standard deviations lower. This association was more pronounced among paternal orphans and those who had lost a parent more than 1 year ago.

Thorne et al 1998 European Collaborative Study [103]

Survey study

1123 children born to HIV-infected women, followed prospectively

70% children cared for by their mothers and/or fathers consistently in their first four years of life, by age 8 approximately 60% will have lived away from parents (i.e., with foster or adoptive parents, other relatives or in an institution), irrespective of child HIV status.

Maternal injecting drug use, single parenthood and health status were the major reasons necessitating alternative care.

Kang et al 2008 Zimbabwe [104]

Comparison of orphan versus non-orphan girls

N = 200

Maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had a sexually transmitted infection, to have been pregnant, and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school.

Parikh et al 2007 South Africa [105]

Comparison of orphan and non-orphan children aged 9-16

N = 174; 87 orphans, 87 non-orphans (13 maternal, 30 paternal, 26 double, 19 missing info)

No significant differences in most education, health and labour outcomes. Paternal orphans more likely to be behind in school. Recent mobility positive effect on school outcome.

Timaeus and Boler 2007 South Africa [106]

Household interviews over time waves

5477 reports on children 8-20 years. (approx. 13% maternal orphans, 26% paternal)

Paternal orphanhood and belonging to a different household from one's father resulted in slower progress at school. Absence of father also associated with household poverty (but did not explain falling behind at school).

Bhargava 2005 Ethiopia [107]

Comparison of Maternal AIDS orphan and other orphans

479 maternal AIDS deaths compared with 574 other maternal deaths

The presence of the father in the household did not significantly affect chances of school participation after maternal death. Presence of father in household positive and significant effects on scores on emotional adjustment. If father prepared meals, positive association with mean scores on 60 items of the Minnesota Multiphasic Personality Inventory.

Foster et al 1995 Zimbabwe [108]

570 households comparison of orphan and non-orphan household

81.8% paternal death, 13.6% maternal, 4.5% double

Paternal family caring in only 16% families.