Clean Cooking Access and Sex Differences in Household Air Pollution Mortality Across Countries

Abstract

Access to clean cooking could coincide with lower household air pollution (HAP) mortality, but cooking roles alone cannot predict sex differences in attributable mortality. This study matched 2021 World Health Organization age-standardized, all-cause HAP-attributable mortality rates by sex to World Bank clean-cooking access estimates. Paired rates, female–male differences and ratios, correlations, and adjusted regressions were examined across countries. In 180 countries, mean female and male rates were 51.39 and 61.36 per 100,000, respectively. The mean female-minus-male difference was −9.97 (95% confidence interval [CI], −12.82 to −7.13). Male rates were higher in 104 countries, female rates in 21, and both were zero in 55. Access correlated inversely with female (Spearman ρ=−0.980) and male mortality (ρ=−0.977). In 175 complete cases, a 10-percentage-point higher access level was associated with 14.94 fewer female deaths per 100,000 (95% CI, 13.66–16.22 fewer) and 17.74 fewer male deaths (95% CI, 15.89–19.59 fewer) after adjustment. The female-by-access interaction was +0.273 per access point (95% CI, 0.181–0.366), indicating a less negative female slope. These ecological associations cannot establish an intervention effect: clean-cooking access and modeled HAP mortality share household-energy inputs, and countries at universal access often have zero modeled mortality.