What is new

• What was known already: Birth registration is a marker of civil rights and is receiving increased investment. Household surveys, including Demographic and Health Surveys (DHS) and UNICEF’s Multiple Indicator Cluster Surveys (MICS), are important sources of population-level information on completeness of birth registration but the data quality is unknown. Stillbirth registration or neonatal/child death registration are not included in DHS or MICS surveys. • What was done: As part of the EN-INDEPTH survey, we evaluated new and modified questions on birth, stillbirth and death registration for 13,058 births (1177 stillbirths, 1333 neonatal deaths, 10,548 live births surviving the neonatal period) in four African Health and Demographic Surveillance Systems sites.

What was found?

• Completeness of responses: Questions were almost universally answered (> 99% responses complete, < 5% do not know responses) in an average of < 1 min in all sites. • Completeness of registration: Birth registration completeness was 30.7% overall for children surviving the neonatal period (with variation across the four study sites, being lowest in Dabat, Ethiopia), compared to just 1.7% for babies who died in the first 28 days. Most infants were reported to be registered in the first 3 months of life. Completeness of neonatal death and stillbirth registration was very low with only 1.2% of babies who died in the neonatal period and 2.5% of stillbirths reported as registered. • Data quality: Women reported age at birth registration for 93.6% of registered children surviving the neonatal period, with a plausible distribution of age at registration, but some heaping at 6-month intervals. • Data utility: Inequities in birth registrations are clear in this study population with children more likely to be unregistered if they were born at home, had younger or less educated mothers and lower socio-economic status. Common reasons for non-registration amongst 7312 unregistered children surviving the neonatal period were complexity of registration process (36%), financial barriers (28%) and distance (16%).

What next in measurement and research?

• Measurement improvement now: Reliable measures in surveys are crucial to track birth registration completeness and identify who is left behind in this marker for child rights, e.g., by sex, maternal education, or socio-economic status. Given that around 80% of the world’s births are now in facilities, facilitating facility-based registration for these babies would increase birth and stillbirth registration completeness and also allow tracking through routine facility and vital statistics data, instead of relying only on 5-yearly surveys. • Research needed: Death registration for stillbirths and neonatal deaths are extremely low. Further research is needed to identify solutions to address barriers to death registration in facility and community systems.