We show that a large percentage of children in low and middle-income countries do not have birth certificates, with rural and poor children facing a systematic disadvantage in access to birth certificates in most of the 94 countries included in the analysis. We also show that, at the national level, differences in birth certificate coverage based on the sex of the child were not observed.
The benefits of birth registration are well described in the literature [8, 20, 21], including the role played by registration in poverty reduction by enabling access to cash transfers and social welfare [22, 23]. There is also some research which suggests that improved CRVS performance coincides with improved health [24, 25]. The experience of countries with universal birth certificate coverage demonstrate its benefits for the real time surveillance of births, which - when combined with high quality data on deaths - allows health statistics to be generated and monitored [26]. Our findings show that in most low and middle income countries included in the analysis the realization of both the right to identity for children, and of high quality national data for epidemiologic surveillance, are far from complete. Our findings are consistent with data quality assessments of CRVS systems which suggest that global progress has been slow in the past 30 years, and that most countries with low data quality were in the African or Asian regions [27]. Our findings are also consistent with UNICEF research on birth registration [11], and national and sub-national studies conducted in Nigeria and Ghana which suggest that birth registration is a privilege afforded to a subset of children based on maternal education, income, residential location, and access to primary care [28, 29].
Ethiopia, Rwanda and Somalia had the lowest birth certificate coverage. In Ethiopia, the CRVS system was launched in 2016 which explains the low birth certificate coverage observed in 2005 [30]. In Rwanda, while birth certificate coverage is less than 3 %, birth registration coverage is 56%, and a recent government report highlighted how these records are not being fully utilized by the government for its administrative or social services delivery processes [31]. Reports suggest a functional CRVS system does not exist in Somalia [32]. There is some prior research that explores the reasons behind low registration coverage, which include weak government commitment and poorly funded CRVS systems, which are not comprehensive and are often unable to register births in the hospital/health facility, especially in rural areas [3, 33]. Although registration is free in many countries, the economic cost of registration could include obtaining parental identity documents, official fees, fines for late registration, transportation expenses, and bribes [3]. A registration process which discriminates based on ethnicity, religion, refugee status or single parent status can also affect coverage [3]. Existing studies also suggest that a lack of awareness about registration and its benefits could contribute to varying coverage levels [11]; for example, birth registration in a country can be lower than immunization coverage as caregivers may not see the benefits of registration and child health services may not connected. UNICEF argues that an identity registration system is necessary for social and economic development and is affordable, including for low-income countries [3, 11]. Our findings also show that high coverage is possible in every region and income group.
The results we present begin to answer the question posed in the title of this paper – namely who and where are the uncounted children? We show that the children who are counted and included in a population are not random. Instead, the patterning of who and where the uncounted children are is based on wealth and residential location -- the 74 countries with wealth inequalities in birth certificate coverage and 60 countries with urban/rural inequalities show income, and residential location determine both which children benefit from a birth certificate, and which children are counted in CRVS systems and contribute to the measured birth rate, infant mortality rate and population count.
To understand the unequal distribution of birth certificates - and the unequal access to the right to identity connected to them - Victora and co-authors [34] propose the “inverse-equity” hypothesis. They argue public-health interventions and programs reach those of higher socioeconomic status first, and later affect the poor; they contend that inequities only improve once the rich have achieved access, after which the poor gain greater access. The World Health Organization has also described the bias to serve the better-off first [35]. Our findings show children in the poorest wealth quintile are most likely to be unregistered and - given the focus of social transfers and government schemes on the poor - are also most likely to be eligible for the very services, social protection and government schemes which a lack of registration can prevent them from accessing. Results also suggest that on average, wealth inequalities in birth certificate coverage do not shrink until countries have achieved very high coverage. Notably, even after coverage surpasses 80%, there remains, on average, a 10 percentage point gap between the poorest and wealthiest children. This underscores the importance of policies and programs aimed at raising coverage while preventing an increase in inequality, in the effort to achieve universal birth certificate coverage.
Between-country comparisons of birth certificate coverage are useful to track global progress on birth registration. For example, although Gambia and Benin have similar total birth certificate coverage, the absolute difference in coverage by wealth is 43.4 percentage points in Benin and 5.8 percentage points in Gambia. Such examples show that wealth inequalities in registration are not inevitable, and raise questions about how policies that improve a country’s average for a given health indicator without addressing inequality may neither be fair or nor equitable [35].
Efforts to strengthen registration in Brazil, Bangladesh, Nepal and Ghana have shown success and several countries have implemented efforts to link birth registration to health and education services [8, 25, 36], use technology and mobile phones to assist with registration, and have enacted strong legislative support for CRVS systems [8, 22]. However, for these efforts to address inequalities in coverage instead of solely improving average coverage, within country comparisons of birth certificate coverage among sub-groups of wealth, gender, and urban/rural location are needed to monitor inequality and inform efforts to improve access to birth certificates. For example, national birth certificate coverage is 76.8% in Congo Brazzaville, however there is a 22.9 percentage point difference in coverage between urban and rural children, indicating the need to focus on improving access for rural populations. Disaggregating birth certificate coverage data in Tanzania presents a very different picture; national coverage is only 7.7%, being low among all sub-groups and indicating the need for a widespread national intervention to improve access to birth certificates, including efforts to prevent increasing inequality in access.
Some have described unequal registration as the ‘denominator problem’ [36]. We use nationally representative survey data to estimate national birth certificate coverage, which is typically measured through a country’s CRVS system. In the absence of high quality and functioning CRVS systems, such survey data allow both birth registration coverage as well as who is uncounted to be estimated in a way that many registries are currently unable to. Our findings raise important questions about the magnitude of bias in these systems. Krieger [37] examines the definition of a population in the context of research studies to suggest that the ‘restriction of studies to “easy-to-reach” populations can, owing to selection bias, produce biased estimates of risk, lead to invalid causal inferences, and hamper the discovery of needed etiologic and policy-relevant knowledge’. Given the inequalities our findings show, these arguments are relevant for analyses based on data from CRVS systems. Unlike other sources of vital statistics, such as censuses and household surveys, the administrative data provided from CRVS systems permit the production of statistics on population dynamics, health, and inequalities in service delivery on a continuous basis for the country, and for local administrative subdivisions. The weaknesses of these systems have fostered an over reliance on survey data - as we rely on here - to understand counts of births and deaths, arguably detracting from investments in building universal CRVS systems. Boerma and Stansfield [38] underscore the need to address the underlying causes in the deficiencies in health statistics instead of relying solely on national surveys, and although they emphasize the importance of multiple data sources, they suggest the best data source for mortality is through the CRVS system. AbouZahr and co-authors echo this, and suggest that countries and development partners should reject a dependence on suboptimal data sources to monitor mortality and fertility, and investment in CRVS systems will provide a strong evidence base for health and development policies. This will allow household surveys and censuses to focus on the collection of social, behavioral and disease-specific information [21].
Globally, birth registration did not feature prominently in the Millennium Development Goals, however legal identity and birth registration are included in Sustainable Development Goal 16.9 which states “by 2030, provide legal identity for all, including birth registration” [10]. Many have argued that the identity target in the SDGs is foundational to many of the other goals and indicators, especially goal 17.18 which aims to ‘increase significantly the availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts’ and underscores the importance of high quality national data [10]. Given that a birth certificate remains essential proof of registration for the child, inequalities in birth certificate coverage should continue to be monitored to track progress on SDG 16.9, and as efforts to improve national data continue to expand.
This study has several limitations. Selection of the most recent survey may not convey the current picture, however, most of the surveys were conducted after 2010 and selecting the most recent survey does provides the most current survey-based estimate of birth registration available. To address the reliance on survey data for this analysis, CRVS systems - which are currently unable to count vital events - need to be strengthened. Possession of a birth certificate is a self-reported measure and was not verified by the interviewer. The term ‘registered with the civil authorities’ which was part of the questionnaire could have multiple definitions, causing some measurement error, which could be addressed by improvements in survey design. Finally, data are aggregated to the national level for all estimates, and sub-national analyses may present a different picture. Further research is needed to examine within-country differences in birth registration by sociodemographic status and by region.