BMJ Global Health 2 registration can face a range of exclusions and vulnerabilities. Without proof of legal identity, children are often invisible in the eyes of the state,2 25 and depending on a country’s citizenship regime, may also be stateless.25–27 The absence of birth registration also makes proof of age and family relationships challenging.28 Proof of age is often relied on for vaccination, the measurement of malnutrition,29 school enrolment, making adjudications about child marriage and a child’s rights in the context of juvenile justice and child migration.30 31 Proof of family relationship is particularly important in the context of orphaning and family separation. Without the proof of identity linked to birth registration, accessing government social transfers, the banking system and voter registration is challenging or impossible.11 Research also indicates that birth registration can help protect children from abuse and exploitation32 33 and is associated with improved health outcomes, including early childhood growth and development.34–36 Accordingly, given the lack of data on trends in inequities in birth registration and the importance of birth registration, this study examines the direction and magnitude of changes in on-­average birth registration and wealth, urban/rural and gender-­based inequalities between 1999 and 2016 in all LMICs with Demographic Health Surveys (DHS)/Multiple Indicator Cluster Surveys (MICS) data to ask whether national-­level improvements in birth registration were concurrent with reductions in inequities. Methods Data sources and design We combined publicly available, nationally representative DHS and MICS from 67 countries between 1999 and 2016. Both DHS and MICS use multistage cluster sampling, are designed to produce nationally representative estimates of health outcomes at the national, urban– rural and regional levels37 38 and are often used to establish national targets and monitor progress on the SDGs. In many LMICs, the absence of comprehensive and functioning civil registries means that questions about birth registration DHS and MICS represent the only source of information about birth registration. The number of countries with household survey data on birth registration increased from approximately 70 in 2000 to over 120 in 2017.39 Using data from DHS and MICS allowed us to construct a dataset with the most data points for each country over time where the outcome measure, covariates and sampling design were comparable within and across countries. Birth registration questions were included in the DHS from 1999 and in the MICS from 2000. For birth registration, all children under 5 years of age residing in fixed households were sampled—irrespective of whether their biological mother is also resident in the household—and interviews were conducted with the caregiver. Children who had died, were living on the street or in state institutions are not included in these surveys and we therefore Bhatia A, et al. BMJ Global Health 2019;4:e001926. doi:10.1136/bmjgh-2019-001926 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. documents, and Civil Registration and Vital Statistics (CRVS) systems in many low-­income and middle-­income countries (LMICs) are unable to generate accurate and timely information about birth, death, marriage and other vital events.3–6 Compounding this problem of under-­registration is a status quo where, although UNICEF estimates of birth registration in the past decade indicate a global increase from 58% to 65%,2 3 and most recently to 71%,7 little is known about global changes in inequities. Both comparative and country-­specific cross-­sectional studies point to large inequalities in birth registration by socioeconomic status, maternal education, residential location and access to primary care, indicating that birth registration is often unevenly and unfairly distributed among children and communities.2 8–11 Such inequalities are unfair, unjust and avoidable and are therefore inequities.12–14 In line with this, a cross sectional analysis of over 4 million children in 94 countries reported significant wealth inequities in birth registration in 74 countries and urban/ rural inequities in 60 countries.10 However, few studies examine whether these inequities have persisted or been addressed over time. The importance of birth registration—and eliminating inequities in birth registration—is profound. The United Nations defines civil registration as ‘the continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events’.15 Civil registration and the generation of vital statistics have long been the foundation of public health systems and central to the exercise of government responsibilities, with implications for how individuals are counted or seen by the state and how they in turn are able to—or are excluded from—making claims on the state.16 17 CRVS systems are implicated in good governance and enable governments to benefit from an accurate and timely understanding of who is being born, who is marrying and who is dying and from inclusive population denominators all of which underpin policy development, resource allocation and efforts to monitor and address inequities in health outcomes.6 18 In the context of improving child health, women’s health and preventing mortality, vital statistics from civil registration allow reliable and timely estimates of infant and under-­five mortality rates, the maternal mortality ratio, life expectancy at birth, the crude death rate and indicators of total fertility rate.4 6 19 20 However, when CRVS systems are weak, decision makers have to rely on other statistical estimates that vary according to the methods used to develop them. For example, in many LMICs, there is a reliance on modelled estimates based on survey and census data to measure and monitor infant and child mortality.21–23 For the 192 states that have ratified the 1989 Convention on the Rights of the Child, birth registration has also become central to the obligation these states have to fulfilling the rights of children.24 In addition to the ways in which population-­level inequities in birth registration can hinder efforts to measure and monitor population health, children without birth