Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood

Abstract

Background: The population effects of armed conflict on non-combatant vulnerable populations are incompletely understood. We aimed to study the effects of conflict on mortality among women of childbearing age (15-49 years) and on orphanhood among children younger than 15 years in Africa.

Methods: We tested the extent to which mortality among women aged 15-49 years, and orphanhood among children younger than 15 years, increased in response to nearby armed conflict in Africa. Data on location, timing, and intensity of armed conflicts were obtained from the Uppsala Conflict Data Program, and data on the location, timing, and outcomes of women and children from Demographic and Health Surveys done in 35 African countries from 1990 to 2016. Mortality among women was obtained from sibling survival data. We used cluster-area fixed-effects regression models to compare survival of women during periods of nearby conflict (within 50 km) to survival of women in the same area during times without conflict. We used similar methods to examine the extent to which children living near armed conflicts are at increased risk of becoming orphans. We examined the effects of varying conflict intensity using number of direct battle deaths and duration of consecutive conflict exposure.

Findings: We analysed data on 1 629 352 women (19 286 387 person-years), of which 103 011 (6·3%) died (534·1 deaths per 100 000 women-years), and 2 354 041 children younger than 15 years, of which 204 276 (8·7%) had lost a parent. On average, conflict within 50 km increased women's mortality by 112 deaths per 100 000 person-years (95% CI 97-128; a 21% increase above baseline), and the probability that a child has lost at least one parent by 6·0% (95% CI 3-8). This effect was driven by high-intensity conflicts: exposure to the highest (tenth) decile conflict in terms of conflict-related deaths increased the probability of female mortality by 202% (187-218) and increased the likelihood of orphanhood by 42% compared with a conflict-free period. Among the conflict-attributed deaths, 10% were due to maternal mortality.

Interpretation: African women of childbearing age are at a substantially increased risk of death from nearby high-intensity armed conflicts. Children exposed to conflict are analogously at increased risk of becoming orphans. This work fills gaps in literature on the harmful effects of armed conflict on non-combatants and highlights the need for humanitarian interventions to protect vulnerable populations.

Funding: Bill & Melinda Gates Foundation to the BRANCH Consortium.

Figure 1

Change in the risk of death for women of childbearing age as a function of proximity to conflict A) Change in average mortality rate due to conflict during year of observation; conflicts are designated as a binary exposure (any death), above median intensity (>35 deaths), or as deciles of exposure intensity by the number of direct combat-related deaths within 50 km. B) Change in average mortality rate due to conflict depending on the number of consecutive years the index woman's cluster of residence has been exposed to nearby conflict (50 km). Error bars indicate 95% CIs.

Figure 2

Spatial distribution and estimated number of maternal deaths in each study country (2000–17) (A) Spatial distribution of maternal deaths. (B) Total deaths by country.

Figure 3

Change in the risk of being an orphan due to conflict The pooled exposure is based on any conflict, and the discretised exposure represents deciles of conflict intensity exposure as the average annual conflict-related deaths experienced by the child. The y-axis represents the increase in percentage points and the labels the average increase above the average prevalence of orphanhood for the entire sample. Error bars represent 95% CIs.

Figure 4

Heterogeneity in effect of conflict on orphanhood (any parent) Error bars indicate 95% CIs.