Household surveys are an important source of population-level information on completeness of birth registration, and our study involved 13,058 births in four countries with varying contexts for registration. To our knowledge, this is the first study to assess the completeness and quality of data from existing survey questions on birth registration, and importantly to also evaluate new questions regarding registration of stillbirths and neonatal deaths. We also assessed how long the birth registration questions took to answer and explored factors associated with non-registration.
For birth registration, we found that women were able to answer, with no missing data and fewer than 5% don’t know responses across all the questions asked. The time to administer these questions was short, with the full set of birth registration questions taking on average less than 1 min to complete in all sites.
Birth registration reported completeness was low at 30.7% overall for babies surviving the neonatal period (with variation across the four study sites, being lowest in Dabat, Ethiopia), compared to birth registration for just 1.7% of neonatal deaths. Lower completeness of birth and death registration was expected in Dabat because Ethiopia’s first permanent, compulsory and universal registration and certification system for vital events throughout the country is very new, only launched in August 2016 (Table 1). Therefore, national civil registration was still in the early stages during the study period . Higher rates of completeness would be expected in other sites, especially in Kintampo, where an active programme was underway to increase birth registration from 2010 to 2014. For almost all registered children surviving the neonatal period, women were able to report age at registration with a plausible distribution apart from some heaping at 6-month intervals. The majority of children whose births were registered in the first 2 years of life were reported to have been registered during the first 6 months of life. In our study, very few children were registered after 2 years of age. This finding is in contrast to other studies which have found a peak in birth registrations around 5 or 6 years of age, especially where required for school entry [3, 19]. However, as the median age of the children in this study was only 25 months, our study was not designed to detect later registration peaks. Similar to previous studies, lack of birth registration was associated with home birth, lower socio-economic and educational status, but not with the sex of the child [3, 20,21,22,23,24].
Barriers to birth registration are asked in the MICS for 45 countries and in half of these countries, carers reported not knowing how to register the child (Table 2). However in the remaining countries, most caregivers of unregistered children seem aware of the birth registration process . Our study provided more detail by asking new questions to mothers of unregistered children to elucidate if any of seven different potential reasons contributed to non-registration and found complexity of the registration process (36%), cost (28%) and distance to registration facility (16%) as the commonest reported barriers. Our findings regarding knowledge of the registration process and distance are similar to a previous study in Niger ; however, more women in our study reported cost to be a barrier. In a previous study in urban Bandim, 42% of women reported lack of pre-requisite documents and 28% the father’s absence as barriers to birth registration; these were less commonly reported as barriers in our multi-site study .
Whilst many LMICs are now working on strengthening CRVS, there are major variations between even these four countries (Table 1) . In Uganda, Guinea-Bissau and Ethiopia, legislation regarding mandatory registration of births and deaths exists. However, enforcement of these laws is highly variable. Variation in the period within which to report occurrence of births and enforcement of regulation is one of the limiting factors for complete CRVS. In Guinea-Bissau, a birth is by law reported within 30 days, 90 days in Ethiopia and anytime in Uganda. Enforcing penalties on late registration of births is reported as a challenge in some countries such as Ethiopia and Ghana and where no penalties are legislated, like in Uganda, there are still reporting, registration and certification challenges of vital statistics .
Importantly, stillbirth and death registration is not included in either DHS or MICS standard questionnaires. Completeness of stillbirth and death registration has lagged behind birth registration, and whilst completeness has been assumed to be low, no previous estimates of completeness have been made using survey data  and indeed very few population-based studies have assessed completeness of stillbirth or death registration . Our new questions were asked for 2510 stillbirths and neonatal deaths and were found to have high response rates.
We found a shockingly large gap for stillbirth registration. Currently, of the four countries included in this study, only Ghana has a legal provision for the registration of stillbirths (Table 1). Despite 72.9% of reported stillbirths occurring in facilities, only around 1% were reported to be registered in three sites, with 9.2% reported being registered in IgangaMayuge. In view of the lack of requirement for registration of stillbirths or a formal stillbirth or fetal death register in Guinea-Bissau, Ethiopia or Uganda, it is possible that women may have misunderstood the registration questions and reported ‘registration’ within the HDSS, e.g. when the pregnancy was ‘registered’, or some women may have misreported neonatal deaths (which could have been registered with the civil authority) as stillbirths, as misclassification between these events in surveys is relatively common [28, 29]. Whilst it is possible in Ghana that some of these stillbirths may have been notified directly to the civil registrar by the health providers for inclusion in the stillbirth or fetal death register as recommended by the United Nations Statistical Division , generally completeness of vital statistics for stillbirths in most LMICs is currently very low . A revision of the laws in countries without provision for stillbirth registration is needed to require reporting of late gestation stillbirths, as a minimum, and investment in training and support to implement this legislation in accordance with United Nations guidelines . Enabling registration of all facility stillbirths, with information on timing (antepartum/ intrapartum) and cause of death where feasible using the WHO Medical Certificate for Cause of Death, would greatly increase the availability of data to improve stillbirth estimates and tracking of progress towards ending preventable stillbirths [13, 32]. Once these changes are in place, measuring completeness of stillbirth registration will require design and testing of survey questions that are stillbirth-specific.
The reported completeness of neonatal death registration in this study was even lower than for stillbirths (1.2%), and consistent with the World Health Organization's estimate that fewer than 5% of neonatal deaths globally are registered . A study undertaken in the urban Bandim site found that reported completeness of birth registration for neonatal deaths was much lower than for children surviving the neonatal period . This presents a large gap in vital statistics for these babies which could be partly closed by improving facility-based notification of all births and mandating that both birth and death must be notified and recorded in the case of a neonatal death. Notifying every birth at the time of birth and building strong linkages between civil registration systems and health programmes could enable health programmes to identify live births eligible for services such as postnatal care and immunisation and to follow-up defaulters to identify children who have died and enable provision of care for surviving children. The introduction of local mechanisms for community health staff to serve as notifiers of stillbirths, neonatal and infant deaths could improve capture of these events when they occur outside facilities, as families have little incentive to register them.
Closing the gap for registration of facility births and also deaths around the time of birth, notably stillbirths, could address common reasons for non-registration and lead to large increases in completeness of birth, stillbirth and neonatal death registration in all sites. This is feasible to achieve. UNICEF, WHO and the Global Vaccine Alliance (Gavi) have provided successful examples for integrating CRVS and health systems, in particular immunisation systems, in recent reports including creating awareness of the importance of registration during antenatal and delivery care; ensuring all births and deaths occurring in health facilities are notified to the civil registrar, with death notification including cause of death; increasing the potential co-location of registration facilities within hospitals and other delivery facilities; notifying home births and deaths by community health workers; notifying unregistered children when presented for immunisation and other health services; promoting community outreach for creating demand for birth and death registration; and sensitising health workers on the importance of registration of births and deaths [3, 34,35,36]. However, if these strategies are to be successful, frontline health workers, managers and other stakeholders must be included in the design and roll out of systems to link health management information systems and CRVS . In addition, further investment, training and resources are required to improve the classification and reporting of stillbirths and early neonatal deaths. These are required to reduce misclassification and ensure that comparable information is recorded for all these deaths in the vital statistics system, for example through health providers notifying all these events through a common notification system.
This study has strengths, notably being undertaken across four different settings in sub-Saharan Africa, including information on a large number of children (including 2510 stillbirths and neonatal deaths). However, we note that whilst women were able to provide plausible responses to these questions, we were unable to verify accuracy by comparing responses to actual birth or death registration records. Since this study was undertaken in HDSS sites amongst populations under surveillance, it is possible that this may affect women’s responses, although in none of these sites are women routinely asked about birth or death registration of their children. Potential confusion between ‘registration’ with the HDSS, religious institutions or other groups and registration with the civil authorities, as highlighted in a UNICEF report , may have occurred, particularly with respect to stillbirth and death registration. The completeness of birth and death registration may therefore be even lower than we have estimated.
Reliable measures in surveys are crucial to track progress for birth and death registration. Surveys have the advantage of providing data that can be disaggregated by different categories such as place of residence, sex, maternal education, or socio-economic status to identify which children are being left behind. This study found that questions on both birth and death registration were feasible to ask in a household survey, with minimal additional time implications. Whilst asking birth registration questions for surviving children in the household or the child’s questionnaire has the advantage of capturing information on all children regardless of whether the mother is in the household or eligible to be interviewed, children who are stillborn or who have died are missed. Asking additional questions on birth registration for non-surviving children in the woman’s questionnaire could provide information on deceased children who may be at higher risk of not being registered.