Health facilities as a lever for birth registration in low- and middle-income countries: a realist review

The health system has been identified as a key lever for increasing access to birth registration (BR) directly after birth. BR is critical for upholding human rights and accessing essential services, yet many low- and middle-income countries struggle with low BR rates. In this realist synthesis, we reviewed literature on two separate interventions that are designed to increase access to BR services. This included (i) embedding or appointing an official to register births in health facilities and (ii) incorporating education on BR in routine perinatal care programmes. This study aimed to support the knowledge base on how these interventions work, why, and for whom, within health facility contexts. We followed the RAMESES I publication guidelines for realist syntheses. Iterative searches were carried out in PubMed, Scopus, and Web of Science. The search also included grey literature, policy documents, and insights from a key informant in South Africa. We adopted an iterative cycle of searches guided by review team exchanges, stakeholders' insights, and sequential snowballing searches for theory and background information. We developed two initial programme theories, presented as ICAMO configurations, that were then refined against empirical evidence from 17 included studies, with publication dates ranging from 1992 to 2021. Our review findings highlight that the interventions improved BR rates by lowering logistical barriers, raising awareness, and supporting BR staff, (i.e. personnel responsible for conducting BR within health facilities). Literature from low- and middle-income countries suggests that the effectiveness of facility-level BR interventions is often affected by access to care, travel distances, and transportation costs, as well as by the availability of resources, BR infrastructure, and staff motivation within healthcare facilities. These factors may, in turn, affect BR demand, parents' self-efficacy, and the extent to which BR initiatives align with parents' real-life contexts.