The number of children under 5 years of age with a birth certificate or whose birth was registered with a civil authority during a specified reference period is expressed as a percentage of children under the age of 5 years old in the same reference period.
There are three data sources for this indicator:
- Civil registration and vital statistics (CRVS) and other routine national surveillance systems
- Routinely collected administrative data other than CRVS
- Population-based household surveys.
A well-functioning and integrated national or subnational CRVS system will universally register and certify vital events, including live births, stillbirths and deaths that occur in the country or administrative area. Birth and death certificates are issued as part of the CRVS system, allowing the compilation, analysis and dissemination of information through vital statistics agencies, including population characteristics (e.g. sex, date of birth or death, birthweight, place of birth or death, place of usual residence) and cause-of-eath information. Some CRVS systems will also register and certify other important vital events within the population, such as adoptions, marriages and divorces (1).
Data from CRVS are the preferred data source for this indicator when the system freely and universally records vital events and data are recorded in a systematic manner that ensures high data quality for both the public and private health sectors and regardless of location of birth (e.g. health facility or community-based births).
Key source of data: The main source of data for this indicator involves several steps and vary based on the policies and procedures of the national or subnational CRVS within health facilities and/or within communities. Declaration of live or stillbirth events are obtained: (a) through forms completed by health personnel at health facilities, or (b) through community-based sources, including registration forms submitted directly by the parents of the live birth or stillbirth to civil registrars. Either paper or electronic forms containing this information are then submitted to the relevant civil authorities and vital statistics agencies, which have the responsibility to officially record the birth event and birth characteristics, such as name, sex, date and place of birth, birthweight, nationality, and the names, ages, education level and occupations of the mother and/or father. At the national or subnational level, the civil authority and vital statistics agency issues birth certificates to formalize the birth registration. A birth certificate is a vital record that documents the birth of a child. The term “birth certificate” can refer to either the original document certifying the birth, or to a certified copy or representation of the registration of that birth, depending on the practices of the country issuing the certificate (2). National or subnational civil authorities and vital statistics agencies are responsible for reporting of this indicator.
Indicator definition and calculation: The indicator is calculated as the percentage of children under 5 years of age whose birth was registered with the relevant national or subnational civil authorities during a specified time period.
(Number of children under 5 years of age whose births are registered with the relevant national or subnational civil authorities in a specified geographical region and time period / Total number of children under the age of 5 in a specified geographical region and time period) x 100
Unless specified, the statistic should include the registration of both live births and stillbirths, as defined by the health facility and/or national or subnational vital statistics offices. To align with the global Sustainable Development Goal (SDG) indicator 16.9 (Proportion of children under 5 years of age whose births have been registered with a civil authority, by age), data from CRVS need to be retrospectively disaggregated by age to obtain the percentage of children under the age of 5 years old with a birth certificate or whose birth was registered by the civil authorities.
Frequency of measurement: Within CRVS, this indicator is monitored at a national or subnational level on an annual basis. These data normally refer to live births that were registered within a year or the legal time frame for registration applicable in the country (2). The data can be compiled and aggregated sub-nationally to provide national-level data.
Disaggregation: By sex, age, vital status (live birth, still birth), location of birth, place of residence (e.g. urban, rural), subnational administrative units (e.g. districts, provinces, regions), socioeconomic status (e.g. education or occupation of mother/father) and type of reporting source (health facility, community).
Missing values: Missing values are usually not known. To ascertain missing data and perform data quality assurance, estimates of the total number of births in a country or administrative area can be compared with the absolute number of registered births in the same period.
ROUTINELY COLLECTED ADMINISTRATIVE DATA:
Data from routinely collected and compiled administrative data sources will provide information as recorded in medical charts/records or registers and are entered into national and/or subnational health management information systems (HMIS).
Data from health information systems may collect information on the number of births officially registered in health facilities. Routinely collected administrative data and health facility statistics are the preferred data source in settings where the CRVS is non-functioning and there is a high utilization of health facility services and data are recorded in a manner that ensures good data quality for both the public and private health sectors. The compiled data in the national HMIS or District Health Information System (DHIS2) should include data from both public and private health sectors, especially when the private sector is a substantial source of service provision to the population. In settings where utilization of health facilities is not high (e.g. settings with a high prevalence of births occurring at home), data may suffer from incompleteness if information about births occurring outside facilities are not captured. In addition, there are often challenges in accurately measuring the numerator and the denominator when routine HMIS data are used to measure this indicator.
Key source of data: Administrative data sources include health facility and health services data abstracted from medical records, including health services registers. Relevant information about births is recorded by health personnel on paper forms completed by health personnel and/or through an electronic medical record. Data from paper or electronic sources are entered or abstracted into a database or registry and are compiled and analysed within the national and/or subnational HMIS. The Ministry of Health (MoH) and/or National Statistical Offices (NSO) are usually responsible for the reporting of this indicator.
Indicator definition and calculation: The indicator is calculated as the percentage of children under 5 years of age whose births were registered with the relevant national or subnational civil authorities during a specified time period.
(Number of children under the age of 5 whose births are reported as being registered by the health facility with the relevant national civil authorities in a specified time period / Total number of births in a health facility in a specified time period) x 100
(In most countries, the HMIS captures information on births within health facilities. However, in contexts where the HMIS includes both health facility and community birth registration, the denominator should include births registered within the geographic jurisdiction or catchment area of the health facility.)
Unless specified, the statistic should include both registered live and stillbirths, as defined by the health facility and/or national or subnational vital statistics offices. To align with the global indicator for children under 5, data from HMIS would need to be retrospectively disaggregated by age and only include live births to obtain the percentage of children under the age of 5 years old with a birth certificate or whose birth was registered by the civil authorities.
Frequency of measurement: The indicator can be calculated on an annual basis or may be tracked on a more frequent and ongoing basis (e.g. monthly, quarterly), depending on facility, subnational and national processes for data entry, compilation and analysis. As a guide, the recommended frequency of measurement based on reporting level is outlined below:
- Facility level: Monthly, quarterly, or as needed based on the country and/or facility need
- Subnational (first and second administrative) level: Monthly or quarterly
- National level: Annually (data can be aggregated to provide national-level data).
Disaggregation: By sex, age, vital status (live birth, still birth), level of facility, location of facility and place of maternal residence (e.g. urban, rural), subnational administrative units (e.g. districts, provinces, regions).
Missing values: Missing values are usually not known or not reported.
POPULATION-BASED HOUSEHOLD SURVEYS AND CENSUSES:
The main source of data for this indicator has been through population-based household surveys and censuses collected through nationally or subnationally representative and structured questionnaires, such as:
- Demographic Health Surveys (DHS) (5)
- Reproductive Health Surveys (RHS)
- Other household surveys with a similar methodological design
- Multiple Indicator Cluster Surveys (MICS) (6)
The MICS questionnaire asks mothers or primary caregivers of all eligible children under the age of 5 years old about birth registration. In the DHS, the household head or other senior member of the household is asked questions about birth registration for children under the age of 5 in the household questionnaire.
Population-based household survey data or national/subnational census data are the preferred data source in settings where utilization of health facility services is not very high (e.g. settings with a high prevalence of births occurring at home), or where private health sector data are excluded from routinely collected administrative data sources.
Key source of data: Depending on survey methodology, eligible children under the age of 5 years old (0–59 months) are identified in the household survey for inclusion and interviewing using a household or an individual child’s questionnaire. Children under 5 are considered eligible for the survey if they are either usual residents or visitors of the household who stayed there the night before the interview.
Mothers or caregivers of the eligible children under 5 years old at the time of survey interview are asked “Does (NAME) have a birth certificate?” where “name” refers to the name of the child. If the mother/caregiver indicates that the child does not have a birth certificate, or does not know if the child has one, they are asked “Has (NAME)’s birth been registered with the civil authorities?”
The MoH and NSO typically conduct household surveys and compile, analyse and report the results for this indicator in collaboration with the survey programme (e.g. DHS, MICS, RHS) and funding agency.
Indicator definition and calculation: Households with children under 5 or mothers (primary caregivers) of children under 5 are asked if the child has a birth certificate or if the birth was registered at any time between birth and the date of the survey. The definition is as follows: The percentage of children under age 5 with a birth certificate or whose births are reported registered with a civil authority. The indicator consists of the following numerator and denominator:
(Number of children under age of 5 [0–59 months] with a birth certificate or whose birth was reported as registered with civil authorities at the time of the survey / Total number of children under the age of 5 [0–59 months] at the time of the survey) x 100
Frequency of measurement: Household surveys are typically conducted every 3–5 years.
Disaggregation at population level: Place of residence (e.g. urban, rural), subnational administrative units (e.g. districts, provinces, regions), sex of live birth, age, birth order, socioeconomic status (e.g. education level, household wealth quintile).
Missing values: Included in the distribution as “don’t know” or “missing”
Birth registration for children under the age of 5 years old measures the formal recognition of the child’s date of birth, identity and nationality. Birth certificates serve as the first legal identity document that individuals are given and provide the most accurate information on birth dates and proof of age. The lack of formal recognition of birth usually means that a child is unable to obtain a birth certificate and may have implications on their right to health care and education, as well as the safeguarding of their human rights throughout the life-course.
The birth registration indicator is a measure of a country’s capacity to plan and implement an effective civil registration system and vital statistics agency that are able to accurately and systematically report vital events, such as births and deaths. Statistics based on birth events form the demographic profile of communities, regions and countries. In countries where CRVS is the main source of data and birth registration is universal and complete, the number of births registered can be used to derive population-level indicators of health status, fertility, infant mortality and population growth (1). In turn, these indicators inform health system planning and policy and the allocation of funds and resources for programs and interventions aimed at improving maternal, newborn and child health and survival. The SDG agenda highlights the importance of continued momentum towards improving maternal and newborn health by setting, under SDG goal 17, targets for achieving 100% birth registration and 80% death registration by 2030 (5). However, in many contexts the ability to uniquely identify births within the health system is a challenge. Globally, approximately 75% of children under the age of 5 have been registered and the quality of reporting of this indicator varies greatly between and within countries, particularly in countries without effective civil registration systems in place (6). Comparisons of the prevalence of birth registration at the national or subnational level over time can be used to identify areas where improvements in the capture and reporting of vital events are needed.
Birth registration is part of a national and/or subnational CRVS system. However, CRVS systems are either non-existent and/or the complete coverage, accuracy and timeliness of civil registration systems is a major issue in many countries worldwide. In order to assess the completeness of the CRVS system, evaluations should be conducted to ascertain the quality of the system, as recommended by the United Nation’s revised Principles and Recommendations for a Vital Statistics System (1).
As a result, it is common for births to be unregistered, particularly for stillbirths and live birth registrations for neonatal deaths occurring shortly after birth. This may be due to lack of a legal framework within civil authorities and vital statistics agencies requiring registration for all births, regardless of the outcome. Even in countries with functional CRVS systems and legal frameworks in place, missing or unregistered births still occur due to health professionals and/or parents not knowing the requirement to register stillbirths and in the instance of neonatal death, the need to register both the live birth in addition to the death.
Administrative data may suffer from poor quality such as irregularities
in report generation, data duplication and inconsistencies (7). Reporting challenges exist at the facility level given data quality issues, including incomplete, inaccurate and lack of timely data due to insufficient capacity in the health system or inadequate system design, such as no integration with the private sector.
Many HMIS databases or registries are event-based and only include information on deaths within a health facility. In settings where routine
HMIS data lack information on deaths that occur outside the public sector – for example, in homes or in private sector facilities – the total number of deaths in the HMIS should not serve to estimate the denominator for this indicator.
The systematic recording of births in many countries remains a serious challenge. In the absence of reliable CRVS systems/administrative data, household surveys have become the key source of data to monitor levels and trends of birth registration. In most low- and middle-income countries, such surveys represent the sole source of this information.
Respondents to the survey may not always be clear on who the civil authorities in charge of the birth registrations are and may misinterpret notifying a church or village chief of a birth as formal registration. Household surveys generally customize questionnaires by naming the specific national authority responsible for registration. However, even then, confusion about the birth registration process may result. Similarly, questions regarding the possession of a birth certificate may also be the source of erroneous data, since respondents may confuse a birth certificate with a health card or other
The most commonly reported denominator for the birth registration indicator is the total number of children under 5 at the time of survey, which acts as a proxy for the total number of eligible children. As only respondents with living children at the time of the survey are included, this indicator is prone to survivor bias in that only those children who are alive at the time of the interview would be included and underestimates the total number of births that were registered at birth.
For more information on this indicator, see the MoNITOR indicator reference sheet, developed by the WHO: Who-indicators (srhr.org).
policy, health system strengthening (HSS), management, newborn (NB)
- Principles and recommendations for a vital statistics system. Revision 3. New York: United Nations; 2014 (https://unstats.un.org/unsd/demographic/standmeth/principles/M19Rev3en.
pdf, accessed 21 October 2020).
- Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHOHIS-IER-GPM-2018.1-eng.pdf, accessed 21 October 2020).
- The DHS Program [website]. Rockville: ICF International; 2020 (http://www.dhsprogram.com/, accessed 21 October 2020).
- Multiple Indicator Cluster Surveys (MICS) [website]. New York: UNICEF; 2020 (http://mics.unicef.org, accessed 21 October 2020).
- Sustainable Development Goals [website]. New York: United Nations; 2016 (http://www.un.org/sustainabledevelopment/sustainable-development-goals/, accessed 21 October 2020).
- Birth registration [website]. New York: UNICEF; 2020 (https://data.unicef.org/topic/childprotection/birth-registration/, accessed 21 October 2020).
- Abouzahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005;83(8): 578–83
Program Management in Sexual and Reproductive Health Services