This article is part of the supplement: The Lives Saved Tool in 2013: new capabilities and applications

Open Access Review

Control of household air pollution for child survival: estimates for intervention impacts

Nigel G Bruce12*, Mukesh K Dherani1, Jai K Das3, Kalpana Balakrishnan4, Heather Adair-Rohani2, Zulfiqar A Bhutta3 and Dan Pope1

Author Affiliations

1 Department of Public Health and Policy, University of Liverpool, Liverpool L693GB, UK

2 Department of Public Health and Environment, World Health Organization, via Appia, 1211 Geneva 27, Switzerland

3 Aga Khan University, Division of Women and Child Health, Aga Khan University, Stadium Road Karachi- 74800, Pakistan

4 ICMR Centre Department of Environmental Health Engineering, Sri Ramachandra University, No.1, Ramachandra Nagar, Porur, Chennai-600116, India

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BMC Public Health 2013, 13(Suppl 3):S8  doi:10.1186/1471-2458-13-S3-S8

Published: 17 September 2013



Exposure to household air pollution (HAP) from cooking with solid fuels affects 2.8 billion people in developing countries, including children and pregnant women. The aim of this review is to propose intervention estimates for child survival outcomes linked to HAP.


Systematic reviews with meta-analysis were conducted for ages 0-59 months, for child pneumonia, adverse pregnancy outcomes, stunting and all-cause mortality. Evidence for each outcome was assessed against Bradford-Hill viewpoints, and GRADE used for certainty about intervention effect size for which all odds ratios (OR) are presented as protective effects.


Reviews found evidence linking HAP exposure with child ALRI, low birth weight (LBW), stillbirth, preterm birth, stunting and all-cause mortality. Most studies were observational and rated low/very low in GRADE despite strong causal evidence for some outcomes; only one randomised trial was eligible.Intervention effect (OR) estimates of 0.64 (95% CI: 0.55, 0.75) for ALRI, 0.71 (0.65, 0.79) for LBW and 0.66 (0.54, 0.81) for stillbirth are proposed, specific outcomes for which causal evidence was sufficient. Exposure-response evidence suggests this is a conservative estimate for ALRI risk reduction expected with sustained, low exposure. Statistically significant protective ORs were also found for stunting [OR=0.79 (0.70, 0.89)], and in one study of pre-term birth [OR=0.70 (0.54, 0.90)], indicating these outcomes would also likely be reduced. Five studies of all-cause mortality had an OR of 0.79 (0.70, 0.89), but heterogenity precludes a reliable estimate for mortality impact. Although interventions including clean fuels and improved solid fuel stoves are available and can deliver low exposure levels, significant challenges remain in achieving sustained use at scale among low-income households.


Reducing exposure to HAP could substantially reduce the risk of several child survival outcomes, including fatal pneumonia, and the proposed effects could be achieved by interventions delivering low exposures. Larger impacts are anticipated if WHO air quality guidelines are met. To achieve these benefits, clean fuels should be adopted where possible, and for other households the most effective solid fuel stoves promoted. To strengthen evidence, new studies with thorough exposure assessment are required, along with evaluation of the longer-term acceptance and impacts of interventions.