Table 1 Policy summary

Background

Deaths of parents and grandparent caregivers threaten child well-being owing to losses of financial support, housing, safety, family stability and care globally, but are rarely recognized as a public health crisis. For some important causes, orphanhood is preventable—for example, prescription drug overdose due to depression, as recent reports highlight. For all causes, evidence shows that long-term negative impacts of orphanhood and co-residing caregiver loss are preventable: with strong positive parenting, and economic and educational support for surviving caregivers, children’s outcomes can be equal to those of non-orphaned children. Little is known about the full burden, trends and disparities in all-cause and cause-specific orphanhood and caregiver loss, beyond estimates from select causes.

Main findings and limitations

In the United States, incidence and prevalence trends in orphanhood and co-residing primary and secondary grandparent caregiver loss increased in total by 49.5% and 7.9%, respectively, from 2000 to 2021. In 2021, 2.38 million children (3.4% of children) had in their lifetime experienced prevalent orphanhood, 217,000 (0.3%) primary grandparent caregiver loss (providing most basic needs) and 342,000 (0.5%) secondary grandparent caregiver loss (providing housing but not most other basic needs). Evidence shows that co-residing grandparents also provide salient nurturing and practical care. We found that 66.8% of orphaned children lost their father in their lifetime, and 33.2% lost their mother. Populations disproportionately affected by orphanhood included 5.2% of all adolescents and 6.4% and 4.7%, respectively, of non-Hispanic American Indian or Alaska Native and non-Hispanic Black children. In 2021, prevalent orphanhood of 3% or greater was pervasive across states and highest (approximately 5%) in West Virginia, New Mexico, Mississippi, Louisiana and Kentucky. Since 2021, parental death due to drug overdose increased to historic levels, surpassing COVID-19, as the leading cause of incident and prevalent orphanhood nationally during the COVID-19 pandemic. However, the highest cause of orphanhood in 2021 for every minoritized subgroup was not drug overdose but varied from heart disease to COVID-19 for paternally orphaned non-Hispanic American Indian or Alaska Native, non-Hispanic Black, Hispanic and non-Hispanic Asian children. Variations in leading causes of maternal orphanhood included cirrhosis, COVID-19 and cancer in these minoritized subgroups. Our state-specific analyses showed that orphanhood due to fatal injuries—drug overdose, suicide, homicide and unintentional injuries—exceeded those linked to leading chronic diseases, with fatal injuries and chronic diseases among the top two causes of orphanhood in 48 states. A key limitation is our possible underestimation of the number of children affected by orphanhood and caregiver death associated with erroneous or incomplete reporting; underreporting of caregiver loss is also likely owing to the unavailability of data on the numbers of children in the care of co-resident grandparents.

Policy implications

Policies and programs that provide healing and support for three million children in the United States who have experienced orphanhood and caregiver loss may contribute to reducing acute and long-term negative effects of this adverse childhood experience. Globally, caregiver-loss prevalences are probably above 4% among children in countries where fertility rates and parental death rates are higher than in the United States. Evidence highlights three essential components of orphanhood prevention and response that effectively promote their recovery and resilience and can guide policy investments for both all-cause and cause-specific orphanhood and caregiver loss: (1) prevent death of parents and caregivers through timely prevention and treatment of leading causes of death and ensure access to health and mental health care for all, (2) prepare families to provide safe and nurturing alternative care and (3) protect children affected by orphanhood and vulnerabilities, through grief and mental health counseling, and parenting, economic and educational support. Given the scope of orphanhood and caregiver loss and associated threats to mental and physical health, and lifelong well-being of children, these strategies can be contextualized and prioritized.