BMJ Global Health Bhatia A, et al. BMJ Global Health 2019;4:e001926. doi:10.1136/bmjgh-2019-001926 remain underfunded, underprioritised and underdeveloped in many countries,3–5 have made modest progress,5 21 and continue to exclude marginalised populations.11 The recent galvanisation of resources and commitments made by international agencies, governments and local organisations have led to a multiplicity of efforts to improve the quality, availability and use of vital statistics for public health21 and assess whether ‘every child is counted’ in the context of the SDGs.39 It is in this context that we bring attention to the need for governments and development partners to assess inequities in civil registration and to ensure that equity-­ oriented approaches are central to efforts to improve birth registration. To this end, we also show that the analysis of the birth registration indicator in national surveys provides important insights into exclusions in civil registries: health statistics from civil registries in countries with large inequities in birth registration are likely to systematically mis-­estimate infant mortality rates as children from poor and rural households are less likely to be counted. However, such analyses of survey data are often based on data which are several years old and do not obviate the need for direct assessments of CRVS coverage, quality and functioning, which are current and can guide improvements. For example, the vital statistics performance index indicator, which is solely based on death registration, has been used to measure the performance of CRVS systems,5 67 and has more recently been adapted to assess birth registration data quality and whether data on birth weight, live birth order, maternal age and sex of child are captured.44 Such efforts continue to be important especially since the ultimate goal is to develop inclusive national data systems which make redundant the use of national surveys to measure birth registration and which ensure children and adults have equitable access to birth registration. Conclusion Findings reveal that the wealth and urban/rural inequities in birth registration have persisted in most countries and highlight the importance of monitoring changes in equity to improve birth registration systems and to achieve SDG 16.9. Efforts to improve birth registration should strive to improve averages and actively reduce the unfair and unequal distribution of birth registration. Equity analyses can guide national policy, technical assistance to countries and provide insights into how inclusive CRVS systems are. Acknowledgements We thank Leonardo Zanini Ferreira for his invaluable contributions to data preparation, dataset creation and data checking. Contributors AB conceptualised the paper, conducted analysis and drafted the manuscript. NK contributed to conceptualising the paper and analyses, reviewed results and provided comments on all drafts. JB contributed to conceptualising the paper and analyses, reviewed results and provided comments on all drafts. AJDB contributed to dataset preparation and provided comments on all drafts. CV contributed to conceptualising the paper and analyses, contributed to dataset preparation, reviewed results and provided comments on all drafts. 11 BMJ Global Health: first published as 10.1136/bmjgh-2019-001926 on 16 December 2019. Downloaded from https://gh.bmj.com on 21 July 2025 by guest. Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies. the benefits of birth registration, and that improvements are slower among children in poor and rural households. Critically, our results also show that these inequities can be reduced if not eliminated and are therefore not inevitable. In addition to the 14 countries in our sample that achieved complete birth registration and also eliminated wealth, urban/rural other inequities, 10 countries (Namibia, Mozambique, Vietnam, Indonesia, Nepal, Dominican Republic, Sierra Leone, India, Comoros, Ghana) were able to achieve a concurrent decline in non-­ registration and in wealth inequities. Of note, there were 6 countries (Namibia, Vietnam, Sierra Leone, Indonesia, India, Dominican Rep) where both wealth and urban/ rural inequities declined. However, it is important to note that even among this sample, improvements varied. For example, wealth inequities in Indonesia decreased on average by 1.5 percentage points per year from a 64.0 (2007) to a 56.7 (2012) percentage point difference between children in the poorest and wealthiest households. Although this decline is statistically significant, children from the poorest two wealth quintiles were still almost half as likely to be registered in 2012. In contrast, Sierra Leone achieved a 3.7 percentage point per year decline and wealth inequities fell from 52.5 (2005) to 4.7 (2013) percentage points. Both declines were significant but varied greatly in magnitude. Lessons from these countries could be instructive in understanding approaches to concurrently improve registration and reduce inequities. Further work is needed to untangle the policies and initiatives underpinning these changes, including whether this is the unintended effects of the status quo or a result of policies that were aiming to improve averages or specifically reduce inequities. A brief review of the literature indicates that the following factors can improve birth registration: reducing registration fees; linking registration to the health and education systems; expanding welfare and social protection; strengthening the design of the CRVS system (e.g., through process mapping and digitisation); harmonising parallel identification systems and removing policies and laws which (1) require the marriage certificates of parents to register a child, (2) require a father to be present and (3) discriminate against ethnic minorities especially in the context of providing nationality.11 52–58 Our findings make visible, and quantify, the large wealth and urban/rural inequities which most countries, even those that have improved birth registration, must tackle. These findings contribute to: critical scholarship on who is excluded from definitions and counts of a population59; the growing literature on the importance of studying changes in health inequities over time60–63 and to research arguing for the importance of public health data systems which allow health equity to be monitored to guide the development of equity-­oriented policies, programme and practices.46 64–66 More specifically, our findings support current research and policy calling attention to the need to improve CRVS systems which