1 Introduction

Registering a child at birth guarantees numerous lifelong advantages [1, 2]. A birth certificate is an official legal document that displays the person's full name, sex, parents’ name, date and place of birth [3]. A certified copy of a child’s birth certificate is one of the documents that can be used to apply for legal and social services [4]. A birth certificate has been provided by countries' civil registration and vital statistics (CRVS) bodies. The United Nations Children’s Fund (UNICEF), Division of Data, Analytics, Planning and Monitoring, recommended universal birth registration by 2030 [5]. Birth registration and obtaining a birth certificate also help ensure that children’s other rights are upheld, notably the right to protection from violence and important social services like health care and justice [6]. Individuals’ birth certificates are required when applying for an identity card, passport, family allowances, driver’s license, social security insurance, health insurance, opening a bank account, securing formal employment, and inheriting property [3, 5, 7]. It also enables countries to track trends in fertility, mortality, and disparities between groups at the national level. A fully operational CRVS system is the most reliable source of continuous and up-to-date information on population statistics including birth registration [1]. Universal access to birth certificates will contribute to most SDGs by 2030, including ensuring good health and well-being of all people, decent work and economic growth, reduced inequalities, responsible consumption and production. However, 57% of unregistered births globally were registered in 2019 [2]. Unfortunately, in Africa, in 2016 the majority of vital events (birth, marriage, divorce and death) registrations went undocumented [8]. The problem is worse in sub-Saharan Africa, where 57% of children under five were unregistered (have not received birth certificates), with regional level variations [1, 2, 9]. This has been hindering individuals from utilizing multisectoral advantages [6, 10].

The Ethiopian Federal Vital Events Registration Agency (FVERA) was established in 2014 at the First Conference of African Ministers Responsible for Civil Registration in Addis Ababa, Ethiopia, to oversee the implementation of birth registration and certificate provision [11]. Civil registration (including births) under the new law went into effect nationwide in 2016 [5]. In Ethiopia, Kebele offices (lowest administrative division) are legally mandated to complete the registration [12]. Despite the participation and commitment to implement birth registration and certificates, only 12% of children registered during birth in Ethiopia [10, 13]. This figure significantly lowered Ethiopia’s birth registration status compared to neighboring African countries such as Kenya (62.2% in 2014) [14] and Uganda (70% in 2016) [15].

Moreover, these factors and the status of birth registration were poorly documented and unevenly distributed across the country [16]. However, evidence revealed that regional variations show improvement despite their drawbacks. For instance, in northwestern Ethiopia, only 22.7% of postpartum mothers planned to register their babies [17]. In Ethiopia’s northern and southern regions, 30% and 24.6% of children were registered for birth, respectively [12, 18]. According to a UNICEF report, birth registration was the lowest in the Somali region (0.2%) and highest in the capital, Addis Ababa (24.8%) in 2019 [13].

According to the World Health Organization, World Bank and individual findings, lower performance of birth registration was primarily due to inadequate information delivery to the grassroots-level beneficiaries (child and parents), officers and leaders about its multisectoral importance [11, 17]. Children born from disadvantaged socioeconomic status, rural residence, limited healthcare access, poor utilization of maternal and child health continuum (antenatal care, institutional delivery and postnatal care), a lack of awareness and knowledge, high registration costs, limited exposure to mass media about birth registration, direct and indirect costs related to registration fees, transportation and accommodation, accessibility of CRVS offices, and delayed processing were barriers to birth registration [7, 11, 16,17,18,19]. To our knowledge, there is no single study in the region that can bring the existing facts and lay the groundwork for future research.

This is the first study in the newly established South West Ethiopia Peoples’ Region. The findings will provide basic information about the status and potential factors influencing birth registration. It provides an opportunity to identify contextual factors and address those gaps. Thus, this study is aimed at examining the magnitude and determinants of birth registration in the region.

2 Materials and methods

2.1 Study Area and Period

Bench Sheko zone is one of six in the newly established region, the South West Ethiopia Peoples’ Region. (Fig. 1) The zone comprises six districts, two city administrations, and 139 Kebeles (the smallest administrative units of government in Ethiopia). The zone has 152 private and 159 public healthcare facilities, providing preventive and curative services to residents of the catchment and the surrounding communities. According to the Ethiopian population projection, the zone has a total population of 667,198 (males 329,073 and females 336,125). Among them, 85% lived in rural areas, while the rest lived in urban. Children under 24 months comprise 5.2% of the study area’s population. In 2022, there were 3‚727 children under less than 24 months old residing in the selected Kebeles (Unpublished Bench Sheko Zone Administration Office). The study was conducted from 15 April 2023 to 05 June 2023.

Fig. 1
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Map of the study area

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2.2 Study design and participants

A community-based cross-sectional study was conducted with mothers with children less than 24 months living in the Bench Sheko zone. Then, eligible mothers or caregivers with children under 24 months were randomly selected from the Health Post Growth Monitoring logbook, synchronized with a family folder. The study was reported according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines for reporting observational studies [20].

2.3 Inclusion and exclusion criteria

All mothers with children under 24 months who have resided in the study area for at least 6 months were included. Mothers or caregivers of children who were critically ill and unable to talk were excluded from the study.

2.4 Sample size determination and sampling Procedure

The sample size was calculated for both specific objectives. For the first objective, a single population proportion formula was applied with the following assumptions: estimated proportion of birth registration 50% at a 95% confidence interval, the margin of error 0.05, yielding a final sample size of 384. For the second objective, a double population formula was used to calculate considering an educational status of mothers or caregivers as a potential exposure variable from previous study [12] and the final sample size was 626. Adding 10% to the largest sample size makes the final sample size reach 689. A multistage sampling technique was used to select the study participants. First, the zone was classified into urban and rural districts to randomly select urban (one) and rural (two) districts using a lottery method. 30% of kebeles were selected randomly from selected districts. Then, the final sample size was proportionally allocated to each selected kebele based on proportional population contribution. A sampling frame was prepared using the family folder for the selected Kebeles. Finally, a simple random sampling technique was used to select the study participants. Where there were two or more eligible children, we randomly selected one kid. (Fig. 2).

Fig. 2
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Sampling Technique

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2.5 Study variables

2.5.1 Outcome variable

Birth registration was defined as registering and possessing a child's birth certificate. If the child has a birth certificate, ‘yes’ was coded as ‘1’; otherwise ‘, no’ was coded as ‘0’.

2.5.2 Explanatory variables

Sociodemographic factors (mother or caregiver’s age, sex, religion, ethnicity, marital status, caregiver relation to a child, child age, sex, birth order’s monthly income, occupation, educational status), reproductive health factors, knowledge about birth registration, media availability, and accessibility of birth registration, facility-related situations.

2.5.3 Data quality control

Four trained data collectors and two supervisors used a pretested face-to-face interview-based questionnaire to gather the information. Questionnaires containing socio-demographic, reproductive health-related, child-related, knowledge about birth registration, birth registration practice, and birth registration-related characteristics. The questionnaires were prepared in English, then translated into Amharic, and retranslated to the original language to maintain consistency of meaning.

2.6 Data analysis

Data was entered into Epi-data and then exported to SPSS version 26 for further analysis. Descriptive statistics were presented as tables, graphs, and figures. Variables with a p-value < 0.25 were considered for further analysis in multivariable logistic regression. In multivariable logistic regression, variables with a p-value < 0.05 were considered statistically significant determinants of the dependent variable. The adjusted odds ratio was reported along with 95% confidence intervals (CI) to measure the relationship between dependent and independent variables while controlling for other variables included in the analysis.

3 Results

3.1 Sociodemographic characteristics of study participants

The data was collected from a total of 689 caregivers and the mothers of children had a response rate of 100%. The mean age of respondents was 27.7 ± 6.1 years. Most respondents were mothers of 20–29 years 285 (41.4%), rural residents (390/56No at the national level, the recen.6%), and Protestant religion followers 326(47.3%) (Table 1).

Table 1 Socioeconomic and demographic characteristics of the study participant in Bench Sheko Zone, South West Ethiopia Region, Ethiopia, 2023
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3.2 Maternal Health Service Utilization

The result showed that 678 (98.4%) of the mothers had at least one antenatal care visit to the nearby health institution during the last pregnancy. Most of the place of delivery of the last child was health centre 425 (61.7%), followed by a hospital 236 (34.3%). Of the total mothers who delivered in health institutions 270 (39.2%) got birth notifications. The total number of mothers who received at least one postpartum care was 438 (63.6%), with nearly half of them having their first visit 340 (49.3%). The sex distribution of children was 335 (48.6) males and 354(51.4) females. Most of the children, 681 (98.8%), were sons or daughters. In terms of mass media exposure, one-third and less than half of participants had radio and television programs more than once a week, respectively (Table 2).

Table 2 Caregivers Health Service Utilization in Bench Sheko Zone, South West Ethiopia, 2023
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3.3 Information, knowledge, and access to birth registration services

More than two-thirds of participants, 468(67.9%), have heard about birth registration. In this regard, nearly one-third of 200(29%) of the participants indicated that health institutions were the main source of such information. In comparison, 101(14.7%) got it from the media, 93(13.5%) families, and 63(9.1%) training or meeting. Only 389(56.5%) of the respondents have good knowledge about birth registration and certification. The fee for all birth registrations was free. Those who were certified were paid 30 birrs for birth certificates. Extra indirect costs (transportation, lodging or any other) were covered by the caregivers/mothers or accompanying family members. Most participants (169, 92.9%) were accompanied by their fathers or partners when they registered and received birth registration services. Almost two-thirds, 118 (64.8%) of participants, said they had to return multiple times to obtain birth certificates. 165 (90.7%) of respondents obtained birth registration services during the regular working day, while 17 (9.3%) did so on weekends (Table 3).

Table 3 Service accessibility-related characteristics of the caregivers in Bench Sheko zone, South West Ethiopia Region, Ethiopia, 2023
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3.4 Status of birth registration and certification in South West Ethiopia

This study registered 182 (26.4%) 95% CI (23.2–29.6%) births. All 182 births recorded in the Kebele Center registration logbook had birth certificates. However, 46 (25.3%) of the total registered births received the certificate within three months of their birth date.

The main reasons for nonregistration were lack of information about birth registration 329 (65%), not knowing its benefits (29%), living a long distance from the registration site 22 (4%), and not knowing the registration site 11 (2%). (Fig. 3).

Fig. 3
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Reasons for not registering Birth in South West Ethiopia

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3.5 Factors associated with birth registration in South West Ethiopia

In the bivariable logistic regression, variables with p-value < 0.25 were entered into multivariable logistic regressions to control confounders. Under the multivariable logistic regression model, birth notification, information about the advantages of birth registration, lower monthly income, and poor knowledge were significantly associated with birth registration. Accordingly, the odds of birth registration practice among mothers who had birth notification were twenty-two times more likely to register their children than their counterparts. The odds of birth registration among mothers who had information about the advantages of birth registration were four times more likely to register at birth (AOR = 3.9, 95%CI 1.4, 11.3) than mothers who had no information about the advantages of birth registration. About 71% of mothers with less than 2000 Ethiopian birr per month were less likely to get birth registration compared to higher income counterparts (AOR = 0.29, 95% CI 0.13–0.62). Similarly, 82% of mothers earning from 2000 to 5000 Ethiopian Birr per month were less likely to get birth registration (Table 4).

Table 4 Multivariable logistic regressions of selected variables about birth registration in Bench Sheko zone, South West Ethiopia Region, Ethiopia, 2023
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4 Discussion

Only 26.4% of births were registered in the study area, despite its widespread importance. Regarding the determinants of birth registration, birth notification, information and knowledge about the advantages of birth registration and household income level were significant determinants of birth registration.

In our study, nearly three-fourths of children were not registered. This is in line with previous findings in Ethiopia regions with higher birth registration, mainly Amhara (24.1%), Addis Ababa (24.8%) [13] and Tigray (30%) [12] regions. However, it is twice as high as the national birth registration coverage (12%). This disparity may be due to the gradual improvement in information delivery for mothers, infrastructure accessibility, and capacity building provided for CRVS administration from federal to local levels. On the other hand, birth registration coverage in other Horn of Africa countries is three times greater than the current findings [14, 15]. Better coverage in those countries might be related to socio-demographic and cultural differences. Thus, our findings suggest that more consideration should be given to reaching intercultural, economically marginalised society segments to achieve SGDs by 23,030. This, in turn, contributes to a better understanding of the challenges and disparities in birth registration coverage across locations, allowing for more targeted interventions to improve birth registration and ensure accurate population data collection. Furthermore, our study participants could give birth retrospectively from April 2021, after the COVID-19 pandemic period, and they might hesitate to visit health facilities to get birth registration and certificates [21].

In this study, mothers with low income had a 71% lower likelihood of obtaining birth registration than mothers with higher income. This can be due to poor communities being underserved in accessing national services due to the lack of costs associated with transportation and registration to visit CRVS offices and obtain birth certificate fees. Other studies and higher global institutions like UNICEF, WHO and World Bank reported that birth certificate processing fees and poverty were potential obstacles to securing a child’s birth certificate in lower and middle-income countries [5, 6, 9, 11, 19]. Also, this finding suggests that conducting qualitative or further quantitative studies can help uncover the underlying factors and provide insights for developing targeted interventions to promote birth registration among mothers with low incomes.

Our study revealed a strong association between receiving a birth notification from a health facility and higher odds of birth registration. Specifically, the odds of birth registration were exponentially higher among mothers who received a birth notification compared to those who did not receive a birth notification. This confirms the importance of raising CRVS awareness among caregivers and mothers to increase birth registration coverage. It facilitates the necessary steps for registering the birth. This is a notable input that the community, healthcare institutions, and vital statistics offices can use to improve the registration system [7, 17, 18]. Thus, our study suggests that health facilities should be crucial in advocacy and social mobilisation on birth registration. This can include implementing standardised procedures, improving communication channels, and ensuring timely and accurate notifications.

Moreover, children whose caregivers are aware of the benefits of birth registration have a higher chance of becoming registered than children whose caregivers are unaware of the benefits. Because having important information raises their awareness about the practice and benefits of birth registration. A study from northwestern Ethiopia found that nearly 42% of women had better knowledge about birth registration [17]. The core reason behind the discrepancy could be the timeline of the study interview compared to our study. Recent advocacy and social mobilization regarding the benefits of birth registration might be important in delivering better information for mothers [8]. Focusing on providing awareness and accurate information about birth registration for mothers/caregivers, officers and stakeholders can work towards improving birth registration rates and ensuring accurate population statistics [22, 23]. These efforts to increase birth registration rates have numerous benefits, including protecting children's rights, improving access to critical services, and producing reliable demographic data for effective planning and policymaking. Overall, these efforts contribute to a more inclusive and equitable society in which every child's rights are recognised and fulfilled by 2030.

In practice, birth registration is vital for enrolling children in school and providing adequate social assistance. It also includes data for vital statistics, research, citizenship and nationality, health planning, policy formulation, and resource allocation. It helps to further demographic studies, population health research, epidemiology, and social science research. Birth registration data is also useful in tracking progress toward national and international development goals as part of the SDGs. However, the current findings suggest that just one-quarter of children in the research area may benefit from birth registration.

Having face-to-face interviews strengthens this study by getting real information from the study participants. However, the study has some limitations. Being a cross-sectional design of the study makes it challenging to establish a clear temporal relationship between the variables of interest. Secondly, the deficiency of a substantial body of literature in a similar context can limit the ability to make detailed comparisons and draw robust conclusions. Comparing findings across studies helps to validate and contextualise the results. However, when there is limited existing research, it becomes challenging to establish a comprehensive understanding of the topic or to fully explore potential variations and factors specific to the study context. Also, social desirability bias can affect the validity of self-reported data; sensitive issues like income and birth order could hamper the robust estimate of the findings. As a result, participants may underreport certain information or respond in accordance with social norms, resulting in biased estimates of the associations under study. Furthermore, due to the retrospective nature of some questions, mothers may forget them, resulting in recall bias.

5 Conclusion

This study found that birth registration coverage is low and steadily increasing in the study area despite gradual improvements. To improve birth registration, it is critical to ensure low-cost infrastructure while improving information, education, and communication systems in the study area. Additionally, increasing institutional delivery uptake can help to improve birth registration rates. Higher institutional delivery makes it easier to record and register births quickly. Efforts should be made to improve access to quality healthcare services, encourage institutional deliveries, and strengthen healthcare providers' ability to facilitate birth registration. Addressing birth registration barriers and challenges requires a comprehensive approach focusing on improving information dissemination, promoting institutional deliveries, empowering income generation, and enhancing the community. By implementing these strategies, the region can increase the coverage of birth registration and the achievability of SDGs by 2030.