Research
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.
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Are inequities decreasing? Birth
registration for children under five in
low-income and middle-income
countries, 1999–2016
Amiya Bhatia ,1,2 Nancy Krieger ,1 Jason Beckfield,3 Aluisio J D Barros ,4
Cesar Victora 4
To cite: Bhatia A, Krieger N,
Beckfield J, et al. Are
inequities decreasing? Birth
registration for children
under five in low-income and
middle-income countries,
1999–2016. BMJ Global Health
2019;4:e001926. doi:10.1136/
bmjgh-2019-001926
Handling editor Seye Abimbola
►► Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
bmjgh-2019-001926).
Received 17 August 2019
Revised 15 October 2019
Accepted 2 November 2019
© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY.
Published by BMJ.
1
Department of Social and
Behavioral Sciences, Harvard
University T H Chan School
of Public Health, Boston,
Massachusetts, USA
2
Department of Global Health
and Development, London
School of Hygiene and Tropical
Medicine, London, UK
3
Department of Sociology,
Harvard University, Cambridge,
Massachusetts, USA
4
International Center for Equity
in Health, Universidade Federal
de Pelotas, Pelotas, RS, Brazil
Correspondence to
Dr Amiya Bhatia;
amb803@mail.harvard.edu
ABSTRACT
Introduction Although global birth registration coverage
has improved from 58% to 71% among children under five
globally, inequities in birth registration coverage by wealth,
urban/rural location, maternal education and access to
a health facility persist. Few studies examine whether
inequities in birth registration in low-income and middle-
income countries have changed over time.
Methods We combined information on caregiver reported
birth registration of 1.6 million children in 173 publicly
available, nationally representative Demographic Health
Surveys and Multiple Indicator Cluster Surveys across
67 low-income and middle-income countries between
1999 and 2016. For each survey, we calculated point
estimates and 95% CIs for the percentage of children
under 5 years without birth registration on average and
stratified by sex, urban/rural location and wealth. For
each sociodemographic variable, we estimated absolute
measures of inequality. We then examined changes in non-
registration and inequities between surveys, and annually.
Results 14 out of 67 countries had achieved complete
birth registration. Among the remaining 53 countries,
39 countries successfully decreased the percentage of
children without birth registration. However, this reduction
occurred alongside statistically significant increases in
wealth inequities in 9 countries and statistically significant
decreases in 10 countries. At the most recent survey,
the percentage of children without birth registration was
greater than 50% in 16 out of 67 countries.
Conclusion Although birth registration improved on
average, progress in reducing wealth inequities has been
limited. Findings highlight the importance of monitoring
changes in inequities to improve birth registration, to
monitor Sustainable Development Goal 16.9 and to
strengthen Civil Registration and Vital Statistics systems.
Introduction
Achieving ‘legal identity for all, including
birth registration, by 2030’ is goal 16.9 of the
Sustainable Development Goals (SDGs).1 The
target responds to a status quo where an estimated 230 million children under age five2
and 1 billion adults are without identification
Key questions
What is already known?
►► Globally, birth registration coverage has improved
from 58% to 71% among children under five; however, an estimated 230 million children do not have
identification documents.
►► Prior studies have established that there are inequities in birth registration coverage by several sociodemographic factors including wealth, urban/rural
location, maternal education and access to a health
facility.
►► Complete birth registration is target 16.9 of the
Sustainable Development Goals (SDGs) and crucial
to ensuring that Civil Registration and Vital Statistics
systems can provide accurate, timely and reliable
information about infant mortality and other health
outcomes, and monitor inequities.
What are the new findings?
►► Out of 67 low-income and middle-income countries,
14 countries had almost complete birth registration.
On average, 39 countries reduced the percentage of
children without birth registration, and in 14 countries the percentage of children without birth registration increased.
►► The reductions in average non-registration were not
met with corresponding reductions in wealth and urban/rural inequities.
►► There were statistically significant reductions in
both non-registration and wealth inequities in 10
countries.
What do the new findings imply?
►► There are large wealth and urban/rural inequities
in birth registration which persisted while average
coverage improved.
►► Children in wealthier households and urban areas
benefitted from on average improvements in birth
registration.
►► Monitoring the reduction of wealth and urban/rural
inequities should be central to monitoring progress
on SDG 16.9 on universal access to birth registration
and legal identity.
Bhatia A, et al. BMJ Global Health 2019;4:e001926. doi:10.1136/bmjgh-2019-001926
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