Improving the timeliness of birth registration in Fiji through a financial incentive

Improving the timeliness of birth registration in Fiji through a financial incentive | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Improving the timeliness of birth registration in Fiji through a financial incentive Christine Linhart, Neel Singh, Meli Nadakuca, Varanisese Saumaka, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3968637/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Fiji is a Pacific Island nation of 884,887 (2017 census), with the predominant ethnic groups indigenous Fijians (iTaukei) (62%) and Fijians of Indian descent (31%). In Fiji, birth registration is considered on-time if completed within one year of a child’s birth. From August 2018 to July 2020, the government implemented a financial incentive tied to on-time birth registration called the Parental Assistance Payment Program (PAPP). This study reports on the effect of the PAPP on the timeliness of birth registration in Fiji. Methods: Unit record birth registration data (n=117,842) for children born during 2016-22 were obtained from the Ministry of Justice. Mean birth-to-registration intervals (days between date-of-birth and date-of-registration) and the likelihood of on-time birth registration were analysed before the PAPP (January 2016–July 2018) compared to during the PAPP (August 2018-July 2020), by sex and ethnicity of the child, and by maternal age and marital status. Results: Whilst the PAPP was available, the mean birth-to-registration interval declined sharply by 81%, from 665 days (95%CI: 658-671) to 124 days (121-127). The largest declines were among i-Taukei children (803 to 139 days, 83%) compared to non-iTaukei (283 to 76 days, 73%); mothers aged 10-19 years (880 to 134 days, 85%) compared to ≥20 years (653 to 123 days, 81%); and single mothers (983 to 145 days, 85%) compared to married mothers (570 to 115 days, 80%). On-time birth registration increased from 57% to 93%, and the adjusted odds ratio showed that children born during the PAPP were 5.2 times more likely to have their birth registered on-time compared to children born before the PAPP (p<.0001). When the PAPP was discontinued in August 2020, the birth-to-registration interval increased sharply in all population groups. Conclusions: During the two-year period the PAPP was available, it was highly effective at improving the timeliness of birth registration, particularly among iTaukei children, young mothers, and single mothers. After the PAPP was discontinued, the timeliness of birth registration deteriorated sharply. Longer post-PAPP follow-up time (≠5 years) is required to determine whether the timeliness of birth registration has deteriorated to levels similar to those during the pre-PAPP period. Fiji birth registration timeliness financial incentive ethnicity adolescent marital status BACKGROUND Birth registration gives individuals a legal identity and rights to access benefits and legal protections afforded by the state. These include access to education and medical care, the ability to open a bank account and obtain a passport, and the right to vote. Complete and timely birth registration provides data for a continuous picture of fertility trends and child mortality rates in a country, which are fundamental for monitoring and national planning across multiple sectors. Health planners and policy makers use these data to facilitate the allocation of resources for antenatal and postnatal services. The education sector uses birth registration data to estimate the resources required for schools, and to monitor rates of school enrolment and completion. Government ministries responsible for infrastructure, including transport, housing, water and land resources, depend on accurate population data to plan for current and future populations. At a regional and global level, the importance of birth registration is well recognised in the 2030 Agenda for Sustainable Development, with the aim of providing legal identity for all, including birth registration, a target in and of itself (16.9) [ 1 ]. Disparities often exist in the completeness and timeliness of birth registration among different population groups. The magnitude of the disparity, however, is often unknown due to a lack of birth registration data disaggregated by, for example, the mothers age, ethnicity, education, income level, or marital status. The Ministerial Declaration to “Get Every One in The Picture” in Asia and the Pacific [ 2 ], and the Regional Action Framework (RAF) on Civil Registration and Vital Statistics (CRVS) in Asia and the Pacific [ 3 ], recognise the need to identify and address disparities in the completeness and timeliness of birth registration across different population groups. The Republic of Fiji Islands forms part of Melanesia in the South Pacific. According to the most recent Fiji census of population and housing in 2017, the population was estimated to be 884,887, with the predominant ethnic groups indigenous Fijians (iTaukei) (63%) and Fijians of Indian descent (33%). The most recent patterns in fertility in Fiji, from empirical data on births, show that during 2016-19 the total fertility rate varied between 2.6 and 2.8 births per woman [ 4 ]. Age-specific fertility was highest among women aged 25–29 years (157–171 births per 1,000 women), followed by women 20–24 years (148–156/10 3 ), then 30–34 years (113–123/10 3 ). Fertility declined sharply at 35–39 years (60–67/10 3 ) and further by 40–44 years (20–21/10 3 ). The adolescent fertility rate (15–19 years) showed a consistent gradual increase during 2016-19, from 26 births per 1,000 in 2016 to 34 births per 1,000 in 2019 [ 4 ]. The Ministry of Justice is responsible for overseeing birth registration in Fiji, with the National Births, Deaths and Marriages (BDM) Office located in Suva, and a further 20 BDM offices across Fiji. Birth registration is governed by the Fiji Births, Deaths and Marriages Registration Act of 1975. The Act states that births should be registered within two months of the child’s birth, but birth registration is considered ‘on-time’ if completed within one year of the child’s birth. From August 1, 2018, to July 31, 2020, the Fiji Government introduced a financial incentive tied to on-time birth registration called the Parental Assistance Payment Program (PAPP), which aimed to provide some support to low-income families with the costs of raising a child. Parents could access the program if: their child was born during the two-year period the PAPP was available; birth registration was completed within 12 months of the birth; and the combined annual parental income was ≤ 30,000 Fijian dollars (FJ $ ) (approximately ≤ USD $ 13,000). A PAPP application form needed to be completed at a BDM office at the time of birth registration, which included a combined parental income declaration. The birth certificate and completed PAPP application would then be taken to a bank of the parent’s choice, and the Ministry of Finance deposited FJ $ 500 into the parent’s bank account immediately, with an additional FJ $ 500 deposited into a bank account opened in the child’s name to be made available to parents when the child enrolled in primary school. Audit teams from the Ministry of Finance were responsible for spot checks to verify that PAPP claims and declarations were accurate. Based on the number of PAPP applications completed by BDM offices (n = 29,695), parents of 78% of children born during the two-year PAPP period applied for the PAPP. To date, no national evaluation of the effectiveness of the PAPP on the timeliness of birth registration in Fiji by population disaggregations has been undertaken. The objectives of the present study were to determine the effect of the PAPP on the timeliness of birth registration in Fiji by sex and ethnicity of the child (iTaukei and non-iTaukei), and by maternal age and marital status. METHODS Data sources Birth registrations Birth registration data for children born during 2016-22 were extracted from the Fiji Ministry of Justice database on 5th January 2024 and contained 117,842 individual birth registration unit records. The variables used for analysis in relation to the child were sex (male or female), ethnicity (iTaukei or non-iTaukei), date of birth and date of registration of birth, and the mother’s date of birth and marital status at the time of registration of the child (single, married, divorced/widowed). These variables had a valid entry for ≥ 99% of all unit records. For children born while the PAPP was available, the dataset did not identify the 78% of unit records which had applied for the PAPP, and the 22% which had not. Ethnicity of the child, as reported by the mother, was recorded as either iTaukei or non-iTaukei, and had a valid entry for all unit records during 2016-22. Completeness of the variable for mother’s ethnicity varied greatly by individual year and was deemed unreliable for analysis. For 2019-22, where completeness of the mother’s ethnicity variable exceeded 98%, among the children whose ethnicity was recorded as iTaukei, 95% also had their mother’s ethnicity recorded as iTaukei, 4.2% were recorded as non-iTaukei and 1.3% had no ethnicity recorded. Ethnicity of the child is thus a reasonable surrogate for ethnicity of the mother. Ethnicity of the father is not recorded in the birth registration dataset. Health service data The Ministry of Health and Medical Services (MHMS) has two databases that record the number of births in Fiji: (1) the national unit record electronic database (PATISPlus), which records information contained in notification of birth forms; and (2) the health service utilisation reporting system (known as the Consolidated Monthly Reporting Information System [CMRIS]), which requires all health facilities to report the monthly aggregate birth numbers (both sexes combined) recorded in the hard-copy birth ledger of each health facility. Zone nurses report any community births which occur outside health facilities in their monthly reports, but these are noted to be rare events [ 5 ]. The aggregate number of births reported by individual health facilities through the CMRIS varied minimally each year during 2016-22, indicating that it is a well-functioning system for capturing the aggregate annual number of births in Fiji [ 4 ]. By comparison, a recent estimation of the completeness of the national notification of birth unit record database (PATISPlus) found it to vary widely during 2016–2022 from 28–80% when compared to the health service utilisation reporting system (CMRIS) [ 4 ]. For this reason, the CMRIS birth dataset was selected for use as the denominator for assessing the overall completeness of birth registration in the present study. Analysis The main outcomes of interest for comparing the periods before PAPP and during PAPP were: (1) the mean birth-to-registration interval (days between date of birth and date of birth registration); (2) the percentage of births registered on-time (≤ 365 days); and (3) the odds ratio of on-time birth registration using multiple logistic regression analyses (univariate unadjusted, and multivariable adjusted with and without interaction terms). These analyses were performed by sex and ethnicity of the child, and by maternal age and marital status. Since the mean birth-to-registration interval was not significantly different by 10-year age group among mothers aged 20–49 years, these age groups were combined. Interaction terms in the logistic regression models of the PAPP by the subgroups of interest are useful in quantifying differential effects of the PAPP on these groups, with their 95% confidence intervals and levels of statistical significance. The accuracy of mean birth-to-registration intervals and odds ratios of on-time birth registration calculated in this study are dependent on the completeness of birth registration data. When completeness is high (≥ 95%) they provide an accurate indication of the timeliness of birth registration, but when completeness is lower, they overestimate birth registration timeliness because a large number of late birth registrations are missing from the dataset. Annual birth registration completeness for 2016-22 was estimated by dividing the number of births by year of birth as recorded in the Ministry of Justice birth registration dataset (numerator) by the corresponding number of births in the MHMS CMRIS aggregate birth dataset (denominator). The estimated annual completeness of birth registration data for 2016-19 was ≥ 95%, declining to 80.9% for 2020, 61.7% for 2021 and 52.0% for 2022. For the period following discontinuation of the PAPP (August 2020 onwards), the timeliness of birth registration was not calculated because the decline in birth registration completeness would result in significant underestimation of these measures due to a large number of late birth registrations yet to appear in the dataset. However, the mean birth-to-registration intervals for August to December 2020 are displayed (as broken lines in Fig. 1) to show the initial effect of the discontinuation of the PAPP in August 2020 on the timeliness of birth registration. SAS version 9.4 (SAS Institute Inc., Cary, NC) was used for all analyses. RESULTS The PAPP sharply reduced the overall mean birth-to-registration interval by 81%, from 665 to 124 days, and increased the proportion of births registered on-time from 57–93% (Table 1 , Fig. 1a). The unadjusted odds ratio for on-time registration showed that children born during the PAPP were 9.5 times more likely to have their birth registered on-time compared to children born prior to the PAPP (p < .0001). After adjusting for the sex and ethnicity of the child, the maternal age and marital status, and the differential effects of the PAPP on these subgroups (as shown by the regression model interaction terms), the odds ratio was 5.1 (p < .0001, Table 2 ). Sex of the child Among male children, the PAPP sharply reduced the mean birth-to-registration interval from 660 to 124 days (81% decline), and among female children from 670 to 123 days (82% decline); while on-time birth registration increased from 57–93% in both sexes (Table 1 , Fig. 1a). Adjusted odds ratios showed that prior to the PAPP, there was a small sex-specific disparity in on-time birth registration, with female children 4% less likely to have their birth registered on-time compared to male children (OR = 0.96, p = 0.0167). However, during the PAPP, no significant sex-specific disparity was evident (OR = 1.01, p = 0.7233) (Table 1 ). Ethnicity of the child Among i-Taukei children, the PAPP sharply reduced the mean birth-to-registration interval from 803 to 139 days (83% decline), and among non-iTaukei children from 283 to 76 days (73% decline); while on-time birth registration increased from 48–92% in i-Taukei children, and from 83–96% in non-iTaukei children (Table 1 , Fig. 1b). Adjusted odds ratios showed that prior to the PAPP, on-time birth registration was 78% less likely among iTaukei compared to non-iTaukei children (OR = 0.22, p < .0001), with the disparity reducing to 59% during the PAPP (OR = 0.41, p < .0001) (Table 1 ). Maternal age Among mothers aged 10–19 years, the PAPP sharply reduced the mean birth-to-registration interval from 880 to 134 days (85% decline), and among mothers ≥ 20 years from 653 to 123 days (81% decline); while on-time birth registration increased from 44–93% in mothers aged 10–19 years, and from 58–93% in mothers ≥ 20 years (Table 1 , Fig. 1c). Adjusted odds ratios showed that prior to the PAPP, on-time birth registration was 22% less likely among mothers aged 10–19 years compared to mothers ≥ 20 years (OR = 0.78, p < .0001). However, during the PAPP, no significant age-specific disparity in on-time registration was evident (OR = 1.08, p = 0.3796) (Table 1 ). Maternal marital status The PAPP sharply reduced the mean birth-to-registration interval among single mothers from 983 to 145 days (85% decline); married mothers from 570 to 115 days (80% decline); and divorced/widowed mothers from 276 to 101 days (63% decline). While on-time birth registration increased from 39–92% in single mothers; 63–93% in married mothers; and 80–94% in divorced/widowed mothers (Table 1 , Fig. 1d). Prior to the PAPP, adjusted odds ratios showed that on-time birth registration was 54% less likely among single mothers compared to married mothers (OR: 0.46, p < .0001), with the disparity decreasing to 14% during the PAPP (OR = 0.86, p = 0.0007) (Table 1 ). Table 1 Timeliness of birth registration among children born before and after the introduction of the PAPP Factors/variables n (%) Mean days 95%CI On-time (%) Unadjusted OR (95% CI) p value Adjusted OR ^ (95% CI) p value Children born before the PAPP - January 2016 to July 2018 All 50,152 665 (658–671) 57 Child sex Male 26,098 (52) 660 (651–669) 57 Ref Ref Female 24,054 (48) 670 (661–680) 57 0.98 (0.95–1.01) 0.1415 0.96 (0.93–0.99) 0.0167 Child’s ethnicity Non-iTaukei 13,355 (27) 283 (274–291) 83 Ref Ref iTaukei 36,797 (73) 803 (796–811) 48 0.20 (0.19–0.21) < .0001 0.22 (0.21–0.23) < .0001 Maternal age group ≥ 20 years 47,461 (95) 653 (646–659) 58 Ref Ref 10–19 years 2,691 (5) 880 (850–910) 44 0.58 (0.54–0.62) < .0001 0.78 (0.73–0.84) < .0001 Maternal marital status Married 37,037 (74) 570 (563–577) 63 Ref Ref Single 12,190 (24) 983 (969–997) 39 0.38 (0.36–0.39) < .0001 0.46 (0.44–0.48) < .0001 Divorced/widowed 919 (2) 276 (252–301) 80 1.81 (1.61–2.03) < .0001 1.54 (1.36–1.74) < .0001 Children born during the PAPP - August 2018 to July 2020 All 38,098 124 (121–127) 93 Child sex Male 19,675 (52) 124 (120–129) 93 Ref Ref Female 18,423 (48) 123 (119 − 18) 93 1.03 (0.95–1.11) 0.5375 1.01 (0.94–1.10) 0.7233 Child’s ethnicity Non-iTaukei 8,994 (24) 76 (72–80) 96 Ref Ref iTaukei 29,104 (76) 139 (135–142) 92 0.41 (0.36–0.46) < .0001 0.41 (0.37–0.47) < .0001 Maternal age group ≥ 20 years 35,661 (94) 123 (120–126) 93 Ref Ref 10–19 years 2,437 (6) 134 (122–146) 93 0.98 (0.84–1.15) 0.8336 1.08 (0.92–1.26) 0.3796 Maternal marital status Married 26,507 (70) 115 (111–118) 93 Ref Ref Single 11,443 (30) 145 (139–151) 92 0.79 (0.73–0.86) < .0001 0.86 (0.79–0.94) 0.0007 Divorced/widowed 144 (0) 101 (63–139) 94 1.10 (0.56–2.16) 0.1884 1.10 (0.56–2.16) 0.7907 PAPP = Parental Assistance Payment Program; n = number of birth registrations of children born and registered prior to the PAPP and during the PAPP; OR = odds ratio; Mean days (95%CI) = mean number of days between the recorded date of birth and date of birth registration, with 95% confidence intervals; On-time (%) = the proportion of children registered within 365 days of birth; Ref = reference group (OR 1.00); ^ adjusted for sex and ethnicity of child, and maternal age and marital status; marital status blank for 6 records before the PAPP and 4 records during the PAPP. Figure 1. Mean birth-to-registration interval by month of birth, by sex and ethnicity of the child and by maternal age and marital status, 2016-20 Footnotes: The mean monthly intervals for 2020 may be significantly underestimated because of the lower completeness of the birth registration data in 2020 (81%) compared to 2016-19 (≥ 95%). Given the clear effect of the PAPP for 2018-19, it would be expected that this lower completeness would apply more to children born in the latter (August-December post-PAPP) part of 2020, and the data are displayed as broken lines for this period only to show the initial effect that the discontinuation of the PAPP had on the timeliness of birth registration. The estimates for the 2020 post-PAPP period can be expected to increase somewhat over time, as unregistered children become registered. The divorced/widowed category contains very low numbers and is therefore prone to stochastic variation. Table 2 Univariate unadjusted and multivariable adjusted odds ratios of the overall effect of the PAPP Variables and interactions OR (95% CI) p value Univariate unadjusted analysis Birth period Born before PAPP Ref Born during PAPP 9.45 (9.07–9.85) < .0001 Multivariable adjusted ^ analysis with interaction terms Birth period Born before PAPP Ref Born during PAPP 5.10 (4.50–5.79) < .0001 Child sex Male Ref Female 0.96 (0.93–0.99) 0.0167 Born during PAPP*male Ref Born during PAPP*female 1.05 (0.97–1.15) 0.2160 Child’s ethnicity Non-iTaukei Ref iTaukei 0.22 (0.21–0.23) < .0001 Born during PAPP*non-iTaukei Ref Born during PAPP*iTaukei 1.89 (1.67–2.15) < .0001 Maternal age group ≥ 20 years Ref 10–19 years 0.78 (0.73–0.84) < .0001 Born during PAPP*≥20 years Ref Born during PAPP*10–19 years 1.37 (1.15–1.64) < .0001 Maternal marital status Married Ref Single 0.46 (0.44–0.48) < .0001 Divorced/widowed 1.54 (1.36–1.74) < .0001 Born during PAPP*married Ref Born during PAPP*single 1.88 (1.71–2.06) < .0001 Born during PAPP*divorced/widowed 0.71 (0.36–1.42) 0.3361 PAPP = Parental Assistance Payment Program; OR = odds ratio; 95%CI = 95% statistical confidence intervals; Ref = reference group (OR 1.00); ^ adjusted for sex and ethnicity of child, and maternal age and marital status. DISCUSSION The introduction of a financial incentive scheme tied to on-time birth registration (the PAPP) from August 2018 until July 2020 had immediate and substantial effects on improving the timeliness of birth registration in Fiji throughout the two-year period during which the payment was available. Among children born from January 2016 to July 2018, prior to the introduction of the PAPP, the average time for a child’s birth to be registered was almost two years (665 days) and only 57% of births were registered on-time (≤ 365 days). The most significant delay in birth registration during the pre-PAPP period was among iTaukei children compared to non-iTaukei children, followed by single mothers compared to married mothers, and then younger mothers (10–19 years) compared to older mothers (≥ 20 years). Female children were found to have greater delays in birth registration than male children, however, the difference was very small and of questionable significance. Following the introduction of the PAPP, the average time for a child’s birth to be registered declined sharply to approximately four months (124 days), and 93% of births were registered on time. The greatest improvements in the timeliness of birth registration were among iTaukei children, mothers aged 10–19 years, and single mothers. However, even during the PAPP, a substantial disparity remained between iTaukei and non-iTaukei children, and, to a lesser extent, between single mothers and married mothers. Whereas disparities between older and younger mothers and male and female children were not present during the PAPP. When the PAPP was discontinued in August 2020, the immediate increase in the birth-to-registration interval rose to approximately half of the pre-PAPP level. While this may indicate a long-term positive effect of the PAPP on social and cultural norms concerning on-time birth registration, it is also partly explained by artefact due to lower completeness of birth registration data during the post-PAPP period. For 2020, where birth registration completeness was estimated at 82%, the mean birth-to-registration intervals can be expected to increase over time, as unregistered children become registered. Given the clear effect of the PAPP for 2018-19, it would be expected that this would apply more to children born in the latter (August-December post-PAPP) part of 2020. Therefore, a longer follow-up time is required for birth registration completeness to reach ≥ 95% for 2020 onwards before it can be determined whether the mean birth-to-registration intervals during the post-PAPP period return to similar levels as those before the PAPP’s introduction, and the extent to which a possible residual effect of the PAPP on timely birth registration exists. For this reason, analysis of mean birth-to-registration intervals and the likelihood of on-time birth for the post-PAPP period were not undertaken in this study due to a lack of sufficient follow-up time (≠ 5 years). We estimated the national completeness of birth registration during 2016-17, prior to the introduction of the PAPP, as ≥ 95%. While high levels of completeness can be achieved in the absence of financial incentives, the mean birth-to-registration interval during 2016-17 was almost two years, whereas during the PAPP (August 2018 to July 2020), the mean birth-to-registration interval was four months. In the absence of the PAPP, the main requirements for birth registration and a birth certificate in Fiji are primarily for school enrolment or for obtaining a child’s passport. These are not linked to timely birth registration, with school enrolment not occurring before the child is at least four years of age, and with many children never obtaining a passport. In the absence of incentives tied to timely birth registration, such as the PAPP, it could be expected to take five or more years for the national completeness of birth registration in Fiji to reach ≥ 95%. For instance, among children born in 2020, birth registration completeness may not reach ≥ 95% until 2025, once those children have reached primary school age and require a birth certificate for enrolment. An increase in birth registration completeness when children are around five years of age has been documented in many countries where birth registration is required for school enrolment, and is often the first incentive for parents to undertake the registration process. This has been observed in Nepal [ 6 ], India [ 7 ], Uganda [ 8 ], and Nigeria [ 9 ]. Delayed birth registration, however, leaves a child without a legal identity and has been shown to increase a child’s risk of statelessness, trafficking, and child labour [ 7 , 10 , 11 ] and exclusion from essential services including health care [ 12 , 13 ]. Delayed birth registration also, importantly, hinders the availability of complete and timely vital statistics on fertility and child mortality that are essential for accurate monitoring and national planning across multiple government sectors, or for reporting progress against global development agenda frameworks such as the Sustainable Development Goals. The largest disparity in the timeliness of birth registration prior to the introduction of the PAPP, and also whilst the PAPP was available, was between iTaukei children and non-iTaukei children. The reasons why iTaukei children had much larger mean birth-to-registration intervals throughout 2016-20 could be various and need to be better understood. Fijians of Indian descent make up the majority of the non-iTaukei population and may have a greater need for a passport, which may partly contribute to the observed higher timeliness of birth registration in the non-iTaukei population. The intersection between wealth quintile and ethnicity is not well known in Fiji, and it is also possible that mothers of iTaukei children are more likely to be in the lower wealth quintile, and thus poverty may have a greater impact on birth registration due to direct and indirect costs, rather than cultural aspects of ethnicity. Furthermore, geography may play a part since the iTaukei population live in more rural and remote areas than the non-iTaukei population, with greater transport barriers in accessing civil registration offices. Standardisation of geographic birth registration data (currently being undertaken by the civil registry) and disaggregation of household income and expenditure data by ethnicity, will facilitate a better understanding of the current ethnic-specific disparities in the timeliness of birth registration in Fiji. Direct and indirect costs associated with birth registration are well documented barriers for parents and caregivers completing the birth registration process [ 14 ]. Many studies have identified that loss of wages and transportation costs are the main barriers to birth registration, particularly among poorer households [ 7 ]. Financial incentives have been shown to be effective in increasing birth registration through a variety of mechanisms in Asia, Africa and Latin America [ 15 ]. The financial incentives have either directly aimed to improve birth registration timeliness and completeness, or have included birth registration as an administrative requirement for access to other financial incentive programs or schemes. In India, the implementation of the Majoni scheme in 2009 provided financial incentives for the registration of female children, and within one-year female birth registration increased from 24–39% in the target population [ 16 ]. In Zimbabwe, the implementation of a cash transfer program in 2010, which mandated birth registration as a condition of enrolment in the scheme, documented an increase in birth registration from 8–25% within one year among children aged 0–4 years in the target population [ 17 ]. South Africa’s Child Support Grant is a nationwide cash transfer to households under the government-determined income threshold, and has been cited as a significant contributor to increasing South Africa’s birth registration from 21% in 1992 to 84% in 2012 [ 18 ]. Limitations The dataset used in this study did not enable individual identification of which birth registrations also accompanied an application for the PAPP (79% overall), and which did not (21%), during the two-year period the PAPP was available. Exceeding the combined parental income threshold likely explains a portion of the latter category. Although the intersection between wealth quintile and ethnicity is not well understood in Fiji, married mothers who had to declare both parents’ income, compared with single mothers, were likely to constitute a larger portion of the group that exceeded the PAPP’s income threshold. This may have resulted in a lower overall effect of the PAPP among married mothers than otherwise if this group had similar access to the PAPP. The maternal marital status used in this study was recorded at the time of birth registration. When birth registration is delayed, particularly by several years, the maternal marital status may be different to what it was at the time of giving birth. In this study, the number of married women was 10% lower during the PAPP compared to before the PAPP, which suggests that before the PAPP up to 10% of women in the married category may have been single at the time of giving birth. The effect of this proportion of potentially misclassified marital status records would not be expected to substantially change the large and statistically significant difference in the timeliness of birth registration identified between single and married mothers. CONCLUSIONS Fiji implemented an effective financial incentive scheme (the PAPP) from August 2018 to July 2020 that improved the timeliness of birth registration. Consequently, the proportion of children spending prolonged periods without a legal identity was reduced, and the availability and timeliness of complete vital statistics data were improved. The economic incentives provided through the PAPP had a particularly large positive impact on the iTaukei population, and on young mothers and single mothers who, prior to the PAPP, had considerably longer birth-to-registration intervals and a significantly lower likelihood of registering within 12 months compared with older, married, and non-iTaukei mothers. The continuation of economic incentives should be considered to improve the completeness and timeliness of birth registration for all subsets of the population, with a particular focus on addressing the large and continued disparity in birth registration between the iTaukei population and the non-iTaukei population. Even small economic incentives, or coupons to exchange for items required to care for a newborn, are likely to have a positive impact on birth registration and these options should be explored. Abbreviations BDM Births, Deaths and Marriages CMRIS Consolidated Monthly Reporting Information System MHMS Ministry of Health and Medical Services PAPP Parental Assistance Payment Program Declarations Ethics approval and consent to participate This study was approved by the Fiji National Health Research and Ethics Review Committee (FNHRERC Number: 01/2024) and by the University of New South Wales Human Research Ethics Committee (iRECS5810). This study involved secondary use of existing data provided to the research team in a non-identifiable format which met the requirements for a waiver of consent as stipulated by the National Health and Medical Research Council of Australia. A waiver of consent for this study was approved by the UNSW HREAP Executive Committee. Consent for publication Not applicable Availability of data and materials The birth registration dataset analysed in this study is not publicly available but may be requested upon submission of a data request to the Civil Registry in the Fiji Ministry of Justice. The nonconfidential information used in this publication was compiled in accordance with the 2018 Information Act of the Republic of Fiji, but which the Civil Registry has no authority to independently verify. The Civil Registry cannot and does not represent that the data was appropriate for this publication, or endorse or support any conclusions that may be drawn from the use of the data. Competing interests The authors declare that they have no competing interests. Funding Not applicable Authors' contributions CL, NS, MN and VS conceived the study and were responsible for acquiring the data. CL, NS, MN and VS performed the data cleaning. CL performed all statistical analysis, with support from SM and RT. CL wrote the first draft to which NS, MN, VS, CC, SS, SM and RT provided feedback during its development, revised the manuscript, and approved the final manuscript for submission. Acknowledgements The authors would like to thank the Fiji Civil Registry for providing the unit record data analysed in this study. References United Nations. Goal 16 Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels. 2023. https://sdgs.un.org/goals/goal16. Accessed 15 Dec 2023. UNESCAP. Ministerial Declaration to “Get every one in the picture” in Asia and the Pacific. 2019. https://getinthepicture.org/resource/ministerial-declaration-get-every-one-picture-asia-and-pacific Accessed 15 Dec 2023. UNESCAP. Regional Action Framework on Civil Registration and Vital Statistics in Asia and the Pacific. 2019. https://getinthepicture.org/resource/regional-action-framework-civil-registration-and-vital-statistics-asia-and-pacific Accessed 15 Dec 2023. Fiji Bureau of Statistics. Republic of Fiji Vital Statistics Report 2016-2021. 2023. https://sdd.spc.int/news/2023/09/26/republic-fiji-vital-statistics-report-2016-2021. Accessed 05 Jan 2024. Fiji Bureau of Statistics. Fiji Multiple Indicator Cluster Survey 2021, Survey Findings Report. Suva: Fiji Bureau of Statistics; 2022. Sharma SK, Ghimire DR, Adhikari D, Thapa S. Birth registration in Nepal: An assessment of progress based on two national surveys. PLOS Glob Public Health. 2023;3(1):e0000759. Kumar K, Saikia N. Determinants of birth registration in India: Evidence from NFHS 2015–16. PLoS ONE. 2021;16(9): e0257014. Candia, DA. Determinants of birth registration of children under 5 years in Uganda. Int J Adv Med Health Res. 2019;6:12-17. Makinde OA, Olapeju B, Ogbuoji O, Babalola S. Trend in the completeness of birth registration in Nigeria: 2002–2010. Demographic Research. 2016;35(12):315-33. UNICEF. United Nations Children’s Fund. Every Child’s Birth Right: Inequities and trends in birth registration. New York: UNICEF; 2013. Larsen JJ, Andrevski H, Lyneham S. Experiences of trafficked persons: an Indonesian sample. Trends and Issues in Crime and Criminal Justice. 2013;449:1–8. UNICEF. From birth to rights: why birth registration matters. 2023. https://www.unicef.org.au/stories/from-birth-to-rights-why-birth-registration-matters Accessed 05 Jan 2024. Harbitz M, Boekie B. Democratic governance, citizenship and legal identity. Washington DC: Inter-American Development Bank. 2009. https://publications.iadb.org/publications/english/document/Democratic-Governance-Citizenship-and-Legal-Identity-Linking-Theoretical-Discussion-and-Operational-Reality.pdf Accessed 15 Dec 2023. Amo-Adjei J, Annim SK. Socioeconomic determinants of birth registration in Ghana. BMC Int Health and Human Rights. 2015;15(1):1-9. World Bank. Incentives for improving birth registration coverage: A review of the literature. Washington DC: World Bank: 2018. Baruah J, Rajkonwar A, Medhi S, Kusre G. Effect of conditional cash transfer schemes on registration of the birth of a female child in India. South East Asia Journal of Public Health. 2012;3(1):30–35. Robertson L, Mushati P, Eaton JW, Dumba L, Mavise G, Makoni J, Schumacher C, Crea T, Monasch R, Sherr L, Garnett GP, Nyamukapa C, Gregson S. Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial. Lancet. 2013 Apr 13;381(9874):1283-92. Garenne M, Collinson MA, Kabudula CW, Gómez-Olivé FX, Kahn K, Tollman S. Completeness of birth and death registration in a rural area of South Africa: the Agincourt health and demographic surveillance, 1992-2014. Glob Health Action. 2016;9:32795. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3968637","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":277247616,"identity":"53166e75-6d70-45b3-8c87-c7e1d2b4af5c","order_by":0,"name":"Christine Linhart","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYFAC5oYDjA1Amr0BKnCAoBZGiBYeHphSYrQwgLVIJBCphb+BsfFw4Q67fHvJN2YPf7YxyPHdSGD8zINHiwTQVYdnnkm27JHOMTfmbWMwlryRwCyNT4sB0FWHeduYDXikc8ykGbcxJG64kcBAjJZ6Ax7JM2aSP7cx1AO1MP8mQsthAx4JHjMJ3m0MCQY3Etjw2iJxGKzluAHPmbQyad5/EoYzzzxss5yDRwt/e/Phz7xt1Qbs7Ye3Sf44YyPPdzz58I03eLQwMKPZygCOqVEwCkbBKBgFlAEAK6BHDlGrziEAAAAASUVORK5CYII=","orcid":"","institution":"UNSW Sydney","correspondingAuthor":true,"prefix":"","firstName":"Christine","middleName":"","lastName":"Linhart","suffix":""},{"id":277247617,"identity":"15185871-9bd1-4d27-9f1a-4fa06089174d","order_by":1,"name":"Neel Singh","email":"","orcid":"","institution":"Ministry of Justice","correspondingAuthor":false,"prefix":"","firstName":"Neel","middleName":"","lastName":"Singh","suffix":""},{"id":277247618,"identity":"bb470f4e-63ee-47ec-8739-2fa69500aeca","order_by":2,"name":"Meli Nadakuca","email":"","orcid":"","institution":"Bureau of Statistics","correspondingAuthor":false,"prefix":"","firstName":"Meli","middleName":"","lastName":"Nadakuca","suffix":""},{"id":277247619,"identity":"8fc0f765-d768-4039-9d7e-313a15330b68","order_by":3,"name":"Varanisese Saumaka","email":"","orcid":"","institution":"Ministry of Health and Medical Services","correspondingAuthor":false,"prefix":"","firstName":"Varanisese","middleName":"","lastName":"Saumaka","suffix":""},{"id":277247620,"identity":"c71c38d4-d5ee-4d0f-8448-f138abdecd0c","order_by":4,"name":"Carlie Congdon","email":"","orcid":"","institution":"Vital Strategies","correspondingAuthor":false,"prefix":"","firstName":"Carlie","middleName":"","lastName":"Congdon","suffix":""},{"id":277247621,"identity":"52520098-0c6d-4029-9415-d7e192f21bde","order_by":5,"name":"Sharita Serrao","email":"","orcid":"","institution":"United Nations Economic and Social Commission for Asia and the Pacific","correspondingAuthor":false,"prefix":"","firstName":"Sharita","middleName":"","lastName":"Serrao","suffix":""},{"id":277247622,"identity":"983f2791-723e-43a8-be83-1d30937aa4ae","order_by":6,"name":"Richard Taylor","email":"","orcid":"","institution":"UNSW Sydney","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Taylor","suffix":""},{"id":277247623,"identity":"467e28be-e469-4705-aec1-c97e83d3e54b","order_by":7,"name":"Stephen Morrell","email":"","orcid":"","institution":"UNSW Sydney","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"","lastName":"Morrell","suffix":""}],"badges":[],"createdAt":"2024-02-19 02:30:07","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3968637/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3968637/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59070163,"identity":"329f6933-c733-4371-8960-623a4bf97aa0","added_by":"auto","created_at":"2024-06-26 04:22:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":737470,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3968637/v1/ce2f47fe-2ca3-4c63-82a0-fe5a92589b49.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Improving the timeliness of birth registration in Fiji through a financial incentive","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eBirth registration gives individuals a legal identity and rights to access benefits and legal protections afforded by the state. These include access to education and medical care, the ability to open a bank account and obtain a passport, and the right to vote. Complete and timely birth registration provides data for a continuous picture of fertility trends and child mortality rates in a country, which are fundamental for monitoring and national planning across multiple sectors. Health planners and policy makers use these data to facilitate the allocation of resources for antenatal and postnatal services. The education sector uses birth registration data to estimate the resources required for schools, and to monitor rates of school enrolment and completion. Government ministries responsible for infrastructure, including transport, housing, water and land resources, depend on accurate population data to plan for current and future populations. At a regional and global level, the importance of birth registration is well recognised in the 2030 Agenda for Sustainable Development, with the aim of providing legal identity for all, including birth registration, a target in and of itself (16.9) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDisparities often exist in the completeness and timeliness of birth registration among different population groups. The magnitude of the disparity, however, is often unknown due to a lack of birth registration data disaggregated by, for example, the mothers age, ethnicity, education, income level, or marital status. The Ministerial Declaration to \u0026ldquo;Get Every One in The Picture\u0026rdquo; in Asia and the Pacific [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and the Regional Action Framework (RAF) on Civil Registration and Vital Statistics (CRVS) in Asia and the Pacific [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], recognise the need to identify and address disparities in the completeness and timeliness of birth registration across different population groups.\u003c/p\u003e \u003cp\u003eThe Republic of Fiji Islands forms part of Melanesia in the South Pacific. According to the most recent Fiji census of population and housing in 2017, the population was estimated to be 884,887, with the predominant ethnic groups indigenous Fijians (iTaukei) (63%) and Fijians of Indian descent (33%). The most recent patterns in fertility in Fiji, from empirical data on births, show that during 2016-19 the total fertility rate varied between 2.6 and 2.8 births per woman [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Age-specific fertility was highest among women aged 25\u0026ndash;29 years (157\u0026ndash;171 births per 1,000 women), followed by women 20\u0026ndash;24 years (148\u0026ndash;156/10\u003csup\u003e3\u003c/sup\u003e), then 30\u0026ndash;34 years (113\u0026ndash;123/10\u003csup\u003e3\u003c/sup\u003e). Fertility declined sharply at 35\u0026ndash;39 years (60\u0026ndash;67/10\u003csup\u003e3\u003c/sup\u003e) and further by 40\u0026ndash;44 years (20\u0026ndash;21/10\u003csup\u003e3\u003c/sup\u003e). The adolescent fertility rate (15\u0026ndash;19 years) showed a consistent gradual increase during 2016-19, from 26 births per 1,000 in 2016 to 34 births per 1,000 in 2019 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Ministry of Justice is responsible for overseeing birth registration in Fiji, with the National Births, Deaths and Marriages (BDM) Office located in Suva, and a further 20 BDM offices across Fiji. Birth registration is governed by the Fiji Births, Deaths and Marriages Registration Act of 1975. The Act states that births should be registered within two months of the child\u0026rsquo;s birth, but birth registration is considered \u0026lsquo;on-time\u0026rsquo; if completed within one year of the child\u0026rsquo;s birth.\u003c/p\u003e \u003cp\u003eFrom August 1, 2018, to July 31, 2020, the Fiji Government introduced a financial incentive tied to on-time birth registration called the Parental Assistance Payment Program (PAPP), which aimed to provide some support to low-income families with the costs of raising a child. Parents could access the program if: their child was born during the two-year period the PAPP was available; birth registration was completed within 12 months of the birth; and the combined annual parental income was \u0026le;\u0026thinsp;30,000 Fijian dollars (FJ\u003cspan\u003e$\u003c/span\u003e) (approximately\u0026thinsp;\u0026le;\u0026thinsp;USD \u003cspan\u003e$\u003c/span\u003e13,000). A PAPP application form needed to be completed at a BDM office at the time of birth registration, which included a combined parental income declaration. The birth certificate and completed PAPP application would then be taken to a bank of the parent\u0026rsquo;s choice, and the Ministry of Finance deposited FJ\u003cspan\u003e$\u003c/span\u003e500 into the parent\u0026rsquo;s bank account immediately, with an additional FJ\u003cspan\u003e$\u003c/span\u003e500 deposited into a bank account opened in the child\u0026rsquo;s name to be made available to parents when the child enrolled in primary school. Audit teams from the Ministry of Finance were responsible for spot checks to verify that PAPP claims and declarations were accurate. Based on the number of PAPP applications completed by BDM offices (n\u0026thinsp;=\u0026thinsp;29,695), parents of 78% of children born during the two-year PAPP period applied for the PAPP.\u003c/p\u003e \u003cp\u003eTo date, no national evaluation of the effectiveness of the PAPP on the timeliness of birth registration in Fiji by population disaggregations has been undertaken. The objectives of the present study were to determine the effect of the PAPP on the timeliness of birth registration in Fiji by sex and ethnicity of the child (iTaukei and non-iTaukei), and by maternal age and marital status.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e \u003cb\u003eData sources\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eBirth registrations\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBirth registration data for children born during 2016-22 were extracted from the Fiji Ministry of Justice database on 5th January 2024 and contained 117,842 individual birth registration unit records. The variables used for analysis in relation to the child were sex (male or female), ethnicity (iTaukei or non-iTaukei), date of birth and date of registration of birth, and the mother\u0026rsquo;s date of birth and marital status at the time of registration of the child (single, married, divorced/widowed). These variables had a valid entry for \u0026ge;\u0026thinsp;99% of all unit records. For children born while the PAPP was available, the dataset did not identify the 78% of unit records which had applied for the PAPP, and the 22% which had not.\u003c/p\u003e \u003cp\u003eEthnicity of the child, as reported by the mother, was recorded as either iTaukei or non-iTaukei, and had a valid entry for all unit records during 2016-22. Completeness of the variable for mother\u0026rsquo;s ethnicity varied greatly by individual year and was deemed unreliable for analysis. For 2019-22, where completeness of the mother\u0026rsquo;s ethnicity variable exceeded 98%, among the children whose ethnicity was recorded as iTaukei, 95% also had their mother\u0026rsquo;s ethnicity recorded as iTaukei, 4.2% were recorded as non-iTaukei and 1.3% had no ethnicity recorded. Ethnicity of the child is thus a reasonable surrogate for ethnicity of the mother. Ethnicity of the father is not recorded in the birth registration dataset.\u003c/p\u003e \u003cp\u003e \u003cem\u003eHealth service data\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe Ministry of Health and Medical Services (MHMS) has two databases that record the number of births in Fiji: (1) the national unit record electronic database (PATISPlus), which records information contained in notification of birth forms; and (2) the health service utilisation reporting system (known as the Consolidated Monthly Reporting Information System [CMRIS]), which requires all health facilities to report the monthly aggregate birth numbers (both sexes combined) recorded in the hard-copy birth ledger of each health facility. Zone nurses report any community births which occur outside health facilities in their monthly reports, but these are noted to be rare events [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The aggregate number of births reported by individual health facilities through the CMRIS varied minimally each year during 2016-22, indicating that it is a well-functioning system for capturing the aggregate annual number of births in Fiji [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. By comparison, a recent estimation of the completeness of the national notification of birth unit record database (PATISPlus) found it to vary widely during 2016\u0026ndash;2022 from 28\u0026ndash;80% when compared to the health service utilisation reporting system (CMRIS) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For this reason, the CMRIS birth dataset was selected for use as the denominator for assessing the overall completeness of birth registration in the present study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAnalysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe main outcomes of interest for comparing the periods before PAPP and during PAPP were: (1) the mean birth-to-registration interval (days between date of birth and date of birth registration); (2) the percentage of births registered on-time (\u0026le;\u0026thinsp;365 days); and (3) the odds ratio of on-time birth registration using multiple logistic regression analyses (univariate unadjusted, and multivariable adjusted with and without interaction terms). These analyses were performed by sex and ethnicity of the child, and by maternal age and marital status. Since the mean birth-to-registration interval was not significantly different by 10-year age group among mothers aged 20\u0026ndash;49 years, these age groups were combined. Interaction terms in the logistic regression models of the PAPP by the subgroups of interest are useful in quantifying differential effects of the PAPP on these groups, with their 95% confidence intervals and levels of statistical significance.\u003c/p\u003e \u003cp\u003eThe accuracy of mean birth-to-registration intervals and odds ratios of on-time birth registration calculated in this study are dependent on the completeness of birth registration data. When completeness is high (\u0026ge;\u0026thinsp;95%) they provide an accurate indication of the timeliness of birth registration, but when completeness is lower, they overestimate birth registration timeliness because a large number of late birth registrations are missing from the dataset. Annual birth registration completeness for 2016-22 was estimated by dividing the number of births by year of birth as recorded in the Ministry of Justice birth registration dataset (numerator) by the corresponding number of births in the MHMS CMRIS aggregate birth dataset (denominator). The estimated annual completeness of birth registration data for 2016-19 was \u0026ge;\u0026thinsp;95%, declining to 80.9% for 2020, 61.7% for 2021 and 52.0% for 2022.\u003c/p\u003e \u003cp\u003eFor the period following discontinuation of the PAPP (August 2020 onwards), the timeliness of birth registration was not calculated because the decline in birth registration completeness would result in significant underestimation of these measures due to a large number of late birth registrations yet to appear in the dataset. However, the mean birth-to-registration intervals for August to December 2020 are displayed (as broken lines in Fig.\u0026nbsp;1) to show the initial effect of the discontinuation of the PAPP in August 2020 on the timeliness of birth registration.\u003c/p\u003e \u003cp\u003eSAS version 9.4 (SAS Institute Inc., Cary, NC) was used for all analyses.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe PAPP sharply reduced the overall mean birth-to-registration interval by 81%, from 665 to 124 days, and increased the proportion of births registered on-time from 57\u0026ndash;93% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;1a). The unadjusted odds ratio for on-time registration showed that children born during the PAPP were 9.5 times more likely to have their birth registered on-time compared to children born prior to the PAPP (p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). After adjusting for the sex and ethnicity of the child, the maternal age and marital status, and the differential effects of the PAPP on these subgroups (as shown by the regression model interaction terms), the odds ratio was 5.1 (p\u0026thinsp;\u0026lt;\u0026thinsp;.0001, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSex of the child\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAmong male children, the PAPP sharply reduced the mean birth-to-registration interval from 660 to 124 days (81% decline), and among female children from 670 to 123 days (82% decline); while on-time birth registration increased from 57\u0026ndash;93% in both sexes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;1a). Adjusted odds ratios showed that prior to the PAPP, there was a small sex-specific disparity in on-time birth registration, with female children 4% less likely to have their birth registered on-time compared to male children (OR\u0026thinsp;=\u0026thinsp;0.96, p\u0026thinsp;=\u0026thinsp;0.0167). However, during the PAPP, no significant sex-specific disparity was evident (OR\u0026thinsp;=\u0026thinsp;1.01, p\u0026thinsp;=\u0026thinsp;0.7233) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthnicity of the child\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAmong i-Taukei children, the PAPP sharply reduced the mean birth-to-registration interval from 803 to 139 days (83% decline), and among non-iTaukei children from 283 to 76 days (73% decline); while on-time birth registration increased from 48\u0026ndash;92% in i-Taukei children, and from 83\u0026ndash;96% in non-iTaukei children (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;1b). Adjusted odds ratios showed that prior to the PAPP, on-time birth registration was 78% less likely among iTaukei compared to non-iTaukei children (OR\u0026thinsp;=\u0026thinsp;0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), with the disparity reducing to 59% during the PAPP (OR\u0026thinsp;=\u0026thinsp;0.41, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMaternal age\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAmong mothers aged 10\u0026ndash;19 years, the PAPP sharply reduced the mean birth-to-registration interval from 880 to 134 days (85% decline), and among mothers\u0026thinsp;\u0026ge;\u0026thinsp;20 years from 653 to 123 days (81% decline); while on-time birth registration increased from 44\u0026ndash;93% in mothers aged 10\u0026ndash;19 years, and from 58\u0026ndash;93% in mothers\u0026thinsp;\u0026ge;\u0026thinsp;20 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;1c). Adjusted odds ratios showed that prior to the PAPP, on-time birth registration was 22% less likely among mothers aged 10\u0026ndash;19 years compared to mothers\u0026thinsp;\u0026ge;\u0026thinsp;20 years (OR\u0026thinsp;=\u0026thinsp;0.78, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). However, during the PAPP, no significant age-specific disparity in on-time registration was evident (OR\u0026thinsp;=\u0026thinsp;1.08, p\u0026thinsp;=\u0026thinsp;0.3796) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMaternal marital status\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe PAPP sharply reduced the mean birth-to-registration interval among single mothers from 983 to 145 days (85% decline); married mothers from 570 to 115 days (80% decline); and divorced/widowed mothers from 276 to 101 days (63% decline). While on-time birth registration increased from 39\u0026ndash;92% in single mothers; 63\u0026ndash;93% in married mothers; and 80\u0026ndash;94% in divorced/widowed mothers (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;1d). Prior to the PAPP, adjusted odds ratios showed that on-time birth registration was 54% less likely among single mothers compared to married mothers (OR: 0.46, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), with the disparity decreasing to 14% during the PAPP (OR\u0026thinsp;=\u0026thinsp;0.86, p\u0026thinsp;=\u0026thinsp;0.0007) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTimeliness of birth registration among children born before and after the introduction of the PAPP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors/variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean days\u003c/p\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOn-time (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnadjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdjusted OR ^ (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eChildren born before the PAPP - January 2016 to July 2018\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50,152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e665 (658\u0026ndash;671)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26,098 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e660 (651\u0026ndash;669)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24,054 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e670 (661\u0026ndash;680)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.98 (0.95\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.96 (0.93\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild\u0026rsquo;s ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-iTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13,355 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e283 (274\u0026ndash;291)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36,797 (73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e803 (796\u0026ndash;811)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.20 (0.19\u0026ndash;0.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.22 (0.21\u0026ndash;0.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal age group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47,461 (95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e653 (646\u0026ndash;659)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,691 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e880 (850\u0026ndash;910)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58 (0.54\u0026ndash;0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.78 (0.73\u0026ndash;0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal marital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37,037 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e570 (563\u0026ndash;577)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,190 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e983 (969\u0026ndash;997)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.38 (0.36\u0026ndash;0.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.46 (0.44\u0026ndash;0.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e919 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276 (252\u0026ndash;301)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.81 (1.61\u0026ndash;2.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.54 (1.36\u0026ndash;1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren born during the PAPP - August 2018 to July 2020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38,098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124 (121\u0026ndash;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19,675 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124 (120\u0026ndash;129)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18,423 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123 (119\u0026thinsp;\u0026minus;\u0026thinsp;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03 (0.95\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.01 (0.94\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.7233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild\u0026rsquo;s ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-iTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8,994 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (72\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29,104 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (135\u0026ndash;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41 (0.36\u0026ndash;0.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.41 (0.37\u0026ndash;0.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal age group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35,661 (94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123 (120\u0026ndash;126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,437 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134 (122\u0026ndash;146)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.98 (0.84\u0026ndash;1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.08 (0.92\u0026ndash;1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal marital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26,507 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (111\u0026ndash;118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11,443 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e145 (139\u0026ndash;151)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.79 (0.73\u0026ndash;0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.86 (0.79\u0026ndash;0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (63\u0026ndash;139)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.10 (0.56\u0026ndash;2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.10 (0.56\u0026ndash;2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.7907\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePAPP\u0026thinsp;=\u0026thinsp;Parental Assistance Payment Program; n\u0026thinsp;=\u0026thinsp;number of birth registrations of children born and registered prior to the PAPP and during the PAPP; OR\u0026thinsp;=\u0026thinsp;odds ratio; Mean days (95%CI)\u0026thinsp;=\u0026thinsp;mean number of days between the recorded date of birth and date of birth registration, with 95% confidence intervals; On-time (%)\u0026thinsp;=\u0026thinsp;the proportion of children registered within 365 days of birth; Ref\u0026thinsp;=\u0026thinsp;reference group (OR 1.00); ^ adjusted for sex and ethnicity of child, and maternal age and marital status; marital status blank for 6 records before the PAPP and 4 records during the PAPP.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure 1. Mean birth-to-registration interval by month of birth, by sex and ethnicity of the child and by maternal age and marital status, 2016-20\u003c/p\u003e \u003cp\u003eFootnotes: The mean monthly intervals for 2020 may be significantly underestimated because of the lower completeness of the birth registration data in 2020 (81%) compared to 2016-19 (\u0026ge;\u0026thinsp;95%). Given the clear effect of the PAPP for 2018-19, it would be expected that this lower completeness would apply more to children born in the latter (August-December post-PAPP) part of 2020, and the data are displayed as broken lines for this period only to show the initial effect that the discontinuation of the PAPP had on the timeliness of birth registration. The estimates for the 2020 post-PAPP period can be expected to increase somewhat over time, as unregistered children become registered. The divorced/widowed category contains very low numbers and is therefore prone to stochastic variation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate unadjusted and multivariable adjusted odds ratios of the overall effect of the PAPP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables and interactions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eUnivariate unadjusted analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn before PAPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.45 (9.07\u0026ndash;9.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMultivariable adjusted\u003c/b\u003e\u003csup\u003e\u003cb\u003e^\u003c/b\u003e\u003c/sup\u003e \u003cb\u003eanalysis with interaction terms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth period\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn before PAPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.10 (4.50\u0026ndash;5.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.96 (0.93\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05 (0.97\u0026ndash;1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild\u0026rsquo;s ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-iTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.22 (0.21\u0026ndash;0.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*non-iTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*iTaukei\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.89 (1.67\u0026ndash;2.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal age group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.78 (0.73\u0026ndash;0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*\u0026ge;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*10\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.37 (1.15\u0026ndash;1.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal marital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.46 (0.44\u0026ndash;0.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.54 (1.36\u0026ndash;1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*single\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.88 (1.71\u0026ndash;2.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorn during PAPP*divorced/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.71 (0.36\u0026ndash;1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePAPP\u0026thinsp;=\u0026thinsp;Parental Assistance Payment Program; OR\u0026thinsp;=\u0026thinsp;odds ratio; 95%CI\u0026thinsp;=\u0026thinsp;95% statistical confidence intervals; Ref\u0026thinsp;=\u0026thinsp;reference group (OR 1.00); ^ adjusted for sex and ethnicity of child, and maternal age and marital status.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe introduction of a financial incentive scheme tied to on-time birth registration (the PAPP) from August 2018 until July 2020 had immediate and substantial effects on improving the timeliness of birth registration in Fiji throughout the two-year period during which the payment was available. Among children born from January 2016 to July 2018, prior to the introduction of the PAPP, the average time for a child\u0026rsquo;s birth to be registered was almost two years (665 days) and only 57% of births were registered on-time (\u0026le;\u0026thinsp;365 days). The most significant delay in birth registration during the pre-PAPP period was among iTaukei children compared to non-iTaukei children, followed by single mothers compared to married mothers, and then younger mothers (10\u0026ndash;19 years) compared to older mothers (\u0026ge;\u0026thinsp;20 years). Female children were found to have greater delays in birth registration than male children, however, the difference was very small and of questionable significance. Following the introduction of the PAPP, the average time for a child\u0026rsquo;s birth to be registered declined sharply to approximately four months (124 days), and 93% of births were registered on time. The greatest improvements in the timeliness of birth registration were among iTaukei children, mothers aged 10\u0026ndash;19 years, and single mothers. However, even during the PAPP, a substantial disparity remained between iTaukei and non-iTaukei children, and, to a lesser extent, between single mothers and married mothers. Whereas disparities between older and younger mothers and male and female children were not present during the PAPP.\u003c/p\u003e \u003cp\u003eWhen the PAPP was discontinued in August 2020, the immediate increase in the birth-to-registration interval rose to approximately half of the pre-PAPP level. While this may indicate a long-term positive effect of the PAPP on social and cultural norms concerning on-time birth registration, it is also partly explained by artefact due to lower completeness of birth registration data during the post-PAPP period. For 2020, where birth registration completeness was estimated at 82%, the mean birth-to-registration intervals can be expected to increase over time, as unregistered children become registered. Given the clear effect of the PAPP for 2018-19, it would be expected that this would apply more to children born in the latter (August-December post-PAPP) part of 2020. Therefore, a longer follow-up time is required for birth registration completeness to reach\u0026thinsp;\u0026ge;\u0026thinsp;95% for 2020 onwards before it can be determined whether the mean birth-to-registration intervals during the post-PAPP period return to similar levels as those before the PAPP\u0026rsquo;s introduction, and the extent to which a possible residual effect of the PAPP on timely birth registration exists. For this reason, analysis of mean birth-to-registration intervals and the likelihood of on-time birth for the post-PAPP period were not undertaken in this study due to a lack of sufficient follow-up time (\u0026ne;\u0026thinsp;5 years).\u003c/p\u003e \u003cp\u003eWe estimated the national completeness of birth registration during 2016-17, prior to the introduction of the PAPP, as \u0026ge;\u0026thinsp;95%. While high levels of completeness can be achieved in the absence of financial incentives, the mean birth-to-registration interval during 2016-17 was almost two years, whereas during the PAPP (August 2018 to July 2020), the mean birth-to-registration interval was four months. In the absence of the PAPP, the main requirements for birth registration and a birth certificate in Fiji are primarily for school enrolment or for obtaining a child\u0026rsquo;s passport. These are not linked to timely birth registration, with school enrolment not occurring before the child is at least four years of age, and with many children never obtaining a passport. In the absence of incentives tied to timely birth registration, such as the PAPP, it could be expected to take five or more years for the national completeness of birth registration in Fiji to reach\u0026thinsp;\u0026ge;\u0026thinsp;95%. For instance, among children born in 2020, birth registration completeness may not reach\u0026thinsp;\u0026ge;\u0026thinsp;95% until 2025, once those children have reached primary school age and require a birth certificate for enrolment.\u003c/p\u003e \u003cp\u003eAn increase in birth registration completeness when children are around five years of age has been documented in many countries where birth registration is required for school enrolment, and is often the first incentive for parents to undertake the registration process. This has been observed in Nepal [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], India [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Uganda [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and Nigeria [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Delayed birth registration, however, leaves a child without a legal identity and has been shown to increase a child\u0026rsquo;s risk of statelessness, trafficking, and child labour [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and exclusion from essential services including health care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Delayed birth registration also, importantly, hinders the availability of complete and timely vital statistics on fertility and child mortality that are essential for accurate monitoring and national planning across multiple government sectors, or for reporting progress against global development agenda frameworks such as the Sustainable Development Goals.\u003c/p\u003e \u003cp\u003eThe largest disparity in the timeliness of birth registration prior to the introduction of the PAPP, and also whilst the PAPP was available, was between iTaukei children and non-iTaukei children. The reasons why iTaukei children had much larger mean birth-to-registration intervals throughout 2016-20 could be various and need to be better understood. Fijians of Indian descent make up the majority of the non-iTaukei population and may have a greater need for a passport, which may partly contribute to the observed higher timeliness of birth registration in the non-iTaukei population. The intersection between wealth quintile and ethnicity is not well known in Fiji, and it is also possible that mothers of iTaukei children are more likely to be in the lower wealth quintile, and thus poverty may have a greater impact on birth registration due to direct and indirect costs, rather than cultural aspects of ethnicity. Furthermore, geography may play a part since the iTaukei population live in more rural and remote areas than the non-iTaukei population, with greater transport barriers in accessing civil registration offices. Standardisation of geographic birth registration data (currently being undertaken by the civil registry) and disaggregation of household income and expenditure data by ethnicity, will facilitate a better understanding of the current ethnic-specific disparities in the timeliness of birth registration in Fiji.\u003c/p\u003e \u003cp\u003eDirect and indirect costs associated with birth registration are well documented barriers for parents and caregivers completing the birth registration process [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Many studies have identified that loss of wages and transportation costs are the main barriers to birth registration, particularly among poorer households [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Financial incentives have been shown to be effective in increasing birth registration through a variety of mechanisms in Asia, Africa and Latin America [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The financial incentives have either directly aimed to improve birth registration timeliness and completeness, or have included birth registration as an administrative requirement for access to other financial incentive programs or schemes. In India, the implementation of the Majoni scheme in 2009 provided financial incentives for the registration of female children, and within one-year female birth registration increased from 24\u0026ndash;39% in the target population [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In Zimbabwe, the implementation of a cash transfer program in 2010, which mandated birth registration as a condition of enrolment in the scheme, documented an increase in birth registration from 8\u0026ndash;25% within one year among children aged 0\u0026ndash;4 years in the target population [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. South Africa\u0026rsquo;s Child Support Grant is a nationwide cash transfer to households under the government-determined income threshold, and has been cited as a significant contributor to increasing South Africa\u0026rsquo;s birth registration from 21% in 1992 to 84% in 2012 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe dataset used in this study did not enable individual identification of which birth registrations also accompanied an application for the PAPP (79% overall), and which did not (21%), during the two-year period the PAPP was available. Exceeding the combined parental income threshold likely explains a portion of the latter category. Although the intersection between wealth quintile and ethnicity is not well understood in Fiji, married mothers who had to declare both parents\u0026rsquo; income, compared with single mothers, were likely to constitute a larger portion of the group that exceeded the PAPP\u0026rsquo;s income threshold. This may have resulted in a lower overall effect of the PAPP among married mothers than otherwise if this group had similar access to the PAPP.\u003c/p\u003e \u003cp\u003eThe maternal marital status used in this study was recorded at the time of birth registration. When birth registration is delayed, particularly by several years, the maternal marital status may be different to what it was at the time of giving birth. In this study, the number of married women was 10% lower during the PAPP compared to before the PAPP, which suggests that before the PAPP up to 10% of women in the married category may have been single at the time of giving birth. The effect of this proportion of potentially misclassified marital status records would not be expected to substantially change the large and statistically significant difference in the timeliness of birth registration identified between single and married mothers.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eFiji implemented an effective financial incentive scheme (the PAPP) from August 2018 to July 2020 that improved the timeliness of birth registration. Consequently, the proportion of children spending prolonged periods without a legal identity was reduced, and the availability and timeliness of complete vital statistics data were improved. The economic incentives provided through the PAPP had a particularly large positive impact on the iTaukei population, and on young mothers and single mothers who, prior to the PAPP, had considerably longer birth-to-registration intervals and a significantly lower likelihood of registering within 12 months compared with older, married, and non-iTaukei mothers. The continuation of economic incentives should be considered to improve the completeness and timeliness of birth registration for all subsets of the population, with a particular focus on addressing the large and continued disparity in birth registration between the iTaukei population and the non-iTaukei population. Even small economic incentives, or coupons to exchange for items required to care for a newborn, are likely to have a positive impact on birth registration and these options should be explored.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBDM\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Births, Deaths and Marriages\u003c/p\u003e\n\u003cp\u003eCMRIS\u0026nbsp; \u0026nbsp;Consolidated Monthly Reporting Information System\u003c/p\u003e\n\u003cp\u003eMHMS\u0026nbsp;\u0026nbsp;Ministry of Health and Medical Services\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePAPP \u0026nbsp; \u0026nbsp; Parental Assistance Payment Program\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Fiji National Health Research and Ethics Review Committee (FNHRERC Number: 01/2024) and by the University of New South Wales Human Research Ethics Committee (iRECS5810). This study involved secondary use of existing data provided to the research team in a non-identifiable format which met the requirements for a waiver of consent as stipulated by the National Health and Medical Research Council of Australia. A waiver of consent for this study was approved by the UNSW HREAP Executive Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe birth registration dataset analysed in this study is not publicly available but may be requested upon submission of a data request to the Civil Registry in the Fiji Ministry of Justice. The nonconfidential information used in this publication was compiled in accordance with the 2018 Information Act of the Republic of Fiji, but which the Civil Registry has no authority to independently verify. The Civil Registry cannot and does not represent that the data was appropriate for this publication, or endorse or support any conclusions that may be drawn from the use of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCL, NS, MN and VS conceived the study and were responsible for acquiring the data. CL, NS, MN and VS performed the data cleaning. CL performed all statistical analysis, with support from SM and RT. CL wrote the first draft to which NS, MN, VS, CC, SS, SM and RT provided feedback during its development, revised the manuscript, and approved the final manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Fiji Civil Registry for providing the unit record data analysed in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations. Goal 16 Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels. 2023. https://sdgs.un.org/goals/goal16. Accessed 15 Dec 2023. \u003c/li\u003e\n\u003cli\u003eUNESCAP. Ministerial Declaration to \u0026ldquo;Get every one in the picture\u0026rdquo; in Asia and the Pacific. 2019. https://getinthepicture.org/resource/ministerial-declaration-get-every-one-picture-asia-and-pacific Accessed 15 Dec 2023.\u003c/li\u003e\n\u003cli\u003eUNESCAP. Regional Action Framework on Civil Registration and Vital Statistics in Asia and the Pacific. 2019. https://getinthepicture.org/resource/regional-action-framework-civil-registration-and-vital-statistics-asia-and-pacific Accessed 15 Dec 2023.\u003c/li\u003e\n\u003cli\u003eFiji Bureau of Statistics. Republic of Fiji Vital Statistics Report 2016-2021. 2023. https://sdd.spc.int/news/2023/09/26/republic-fiji-vital-statistics-report-2016-2021. Accessed 05 Jan 2024.\u003c/li\u003e\n\u003cli\u003eFiji Bureau of Statistics. Fiji Multiple Indicator Cluster Survey 2021, Survey Findings Report. Suva: Fiji Bureau of Statistics; 2022.\u003c/li\u003e\n\u003cli\u003eSharma SK, Ghimire DR, Adhikari D, Thapa S. Birth registration in Nepal: An assessment of progress based on two national surveys. PLOS Glob Public Health. 2023;3(1):e0000759. \u003c/li\u003e\n\u003cli\u003eKumar K, Saikia N. Determinants of birth registration in India: Evidence from NFHS 2015\u0026ndash;16. PLoS ONE. 2021;16(9): e0257014.\u003c/li\u003e\n\u003cli\u003eCandia, DA. Determinants of birth registration of children under 5 years in Uganda. Int J Adv Med Health Res. 2019;6:12-17.\u003c/li\u003e\n\u003cli\u003eMakinde OA, Olapeju B, Ogbuoji O, Babalola S. Trend in the completeness of birth registration in Nigeria: 2002\u0026ndash;2010. Demographic Research. 2016;35(12):315-33.\u003c/li\u003e\n\u003cli\u003eUNICEF. United Nations Children\u0026rsquo;s Fund. Every Child\u0026rsquo;s Birth Right: Inequities and trends in birth registration. New York: UNICEF; 2013.\u003c/li\u003e\n\u003cli\u003eLarsen JJ, Andrevski H, Lyneham S. Experiences of trafficked persons: an Indonesian sample. Trends and Issues in Crime and Criminal Justice. 2013;449:1\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eUNICEF. From birth to rights: why birth registration matters. 2023. https://www.unicef.org.au/stories/from-birth-to-rights-why-birth-registration-matters Accessed 05 Jan 2024.\u003c/li\u003e\n\u003cli\u003eHarbitz M, Boekie B. Democratic governance, citizenship and legal identity. Washington DC: Inter-American Development Bank. 2009. https://publications.iadb.org/publications/english/document/Democratic-Governance-Citizenship-and-Legal-Identity-Linking-Theoretical-Discussion-and-Operational-Reality.pdf Accessed 15 Dec 2023.\u003c/li\u003e\n\u003cli\u003eAmo-Adjei J, Annim SK. Socioeconomic determinants of birth registration in Ghana. BMC Int Health and Human Rights. 2015;15(1):1-9.\u003c/li\u003e\n\u003cli\u003eWorld Bank. Incentives for improving birth registration coverage: A review of the literature. Washington DC: World Bank: 2018.\u003c/li\u003e\n\u003cli\u003eBaruah J, Rajkonwar A, Medhi S, Kusre G. Effect of conditional cash transfer schemes on registration of the birth of a female child in India. South East Asia Journal of Public Health. 2012;3(1):30\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eRobertson L, Mushati P, Eaton JW, Dumba L, Mavise G, Makoni J, Schumacher C, Crea T, Monasch R, Sherr L, Garnett GP, Nyamukapa C, Gregson S. Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial. Lancet. 2013 Apr 13;381(9874):1283-92.\u003c/li\u003e\n\u003cli\u003eGarenne M, Collinson MA, Kabudula CW, G\u0026oacute;mez-Oliv\u0026eacute; FX, Kahn K, Tollman S. Completeness of birth and death registration in a rural area of South Africa: the Agincourt health and demographic surveillance, 1992-2014. Glob Health Action. 2016;9:32795.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fiji, birth registration, timeliness, financial incentive, ethnicity, adolescent, marital status","lastPublishedDoi":"10.21203/rs.3.rs-3968637/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3968637/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Fiji is a Pacific Island nation of 884,887 (2017 census), with the predominant ethnic groups indigenous Fijians (iTaukei) (62%) and Fijians of Indian descent (31%). In Fiji, birth registration is considered on-time if completed within one year of a child’s birth. From August 2018 to July 2020, the government implemented a financial incentive tied to on-time birth registration called the Parental Assistance Payment Program (PAPP). This study reports on the effect of the PAPP on the timeliness of birth registration in Fiji.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Unit record birth registration data (n=117,842) for children born during 2016-22 were obtained from the Ministry of Justice. Mean birth-to-registration intervals (days between date-of-birth and date-of-registration) and the likelihood of on-time birth registration were analysed before the PAPP (January 2016–July 2018) compared to during the PAPP (August 2018-July 2020), by sex and ethnicity of the child, and by maternal age and marital status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWhilst the PAPP was available, the mean birth-to-registration interval declined sharply by 81%, from 665 days (95%CI: 658-671) to 124 days (121-127). The largest declines were among i-Taukei children (803 to 139 days, 83%) compared to non-iTaukei (283 to 76 days, 73%); mothers aged 10-19 years (880 to 134 days, 85%) compared to ≥20 years (653 to 123 days, 81%); and single mothers (983 to 145 days, 85%) compared to married mothers (570 to 115 days, 80%). On-time birth registration increased from 57% to 93%, and the adjusted odds ratio showed that children born during the PAPP were 5.2 times more likely to have their birth registered on-time compared to children born before the PAPP (p\u0026lt;.0001). When the PAPP was discontinued in August 2020, the birth-to-registration interval increased sharply in all population groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e During the two-year period the PAPP was available, it was highly effective at improving the timeliness of birth registration, particularly among iTaukei children, young mothers, and single mothers. After the PAPP was discontinued, the timeliness of birth registration deteriorated sharply. Longer post-PAPP follow-up time (≠5 years) is required to determine whether the timeliness of birth registration has deteriorated to levels similar to those during the pre-PAPP period.\u003c/p\u003e","manuscriptTitle":"Improving the timeliness of birth registration in Fiji through a financial incentive","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-11 09:23:03","doi":"10.21203/rs.3.rs-3968637/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e3e7091-d301-4ca1-aca4-50e26762c6fc","owner":[],"postedDate":"March 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-26T04:14:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-11 09:23:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3968637","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3968637","identity":"rs-3968637","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}