Opinion: The COVID-19 gender mortality gap — is civil registration the answer?

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Vital Strategies calls on governments to invest in ensuring equitable registration of vital events and in improving access to legal documentation for women. Photo by: Hello Lightbulb on Unsplash

In the global struggle against COVID-19, loss of life is the starkest indicator of the pandemic’s human toll. Accurate and timely mortality data — understanding how, where, and when people have died — is invaluable for governments as they coordinate lifesaving public health measures. Most governments already have a system able to capture data on COVID-19’s deadly impact: their civil registration and vital statistics system. Yet systemic underregistration of women’s deaths is likely affecting how completely women are counted under the challenging dynamics of the pandemic.

Data from countries across the globe reveals contradictory observations regarding the intersection of gender, COVID-19, and mortality: While the popular picture indicates that women are succumbing to this deadly virus at much lower rates than men globally, the data itself raises the question of how well we truly understand this gendered dimension of the pandemic. For civil registration systems that for decades have leaned toward an underrepresentation of women, COVID-19 has only exacerbated existing inequities.

Given the strong likelihood that inequalities in registration could be impacting COVID-19 mortality data, we can expect limited registration of female deaths that are directly and indirectly attributed to the virus. This, in turn, further exacerbates the trend of underregistration of female deaths and the existing bias towards men, both in terms of the numbers of confirmed deaths and excess mortality recorded.

To better understand the dimensions of the COVID-19 challenge and advance their response efforts, we call on governments to invest in ensuring equitable registration of vital events and in improving access to legal documentation for women.

A system skewed against women

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CRVS systems serve as the gateway for exercising individual rights and protections and play a critical role in people’s lives, from improving access to health care and education to guaranteeing the right to vote, and ultimately to furnishing data critical for policymaking in health and other sectors.

Lack of access to vital events registration has the opposite effect: Failing to register a child’s birth leaves her invisible in official systems and more vulnerable to labor exploitation or child marriage. Nonregistration of marriage puts women at a great disadvantage should the marriage dissolve. And if a husband’s death is not registered, his widow is unable to assert inheritance rights or transfer any pensions or property titles owned by her late husband.

A number of obstacles contribute to the underregistration of female deaths in particular. In many low- and middle-income countries, most deaths occur at home rather than in a health care facility, with little incentive to undertake the often time-consuming and potentially costly registration of a person’s passing.

The picture is particularly skewed against women, who are less likely than men to leave behind a financial or material inheritance, the transfer of which to surviving heirs may require a death certificate. The result is that in India, for example, male deaths are twice as likely to be registered as female deaths. And even when they are registered, female deaths are less likely to have a medically certified cause of death.

During COVID-19, it can be safely assumed that inequalities such as these have continued, if not worsened, resulting in the observed gender difference in mortality — especially in LMICs.

Male-to-female mortality ratios during the pandemic range from 2:1 in the European Union to 1:1 in Iran and Canada, refuting the generalization that women are not as severely affected as men.

Whereas ongoing research indicates that women face about half the risk of death from COVID-19 than their male counterparts — compared to an estimated global risk ratio of male-to-female mortality of 1.2 to 1.5 during nonpandemic times — women do not have any readily apparent biological advantage for surviving infection. And while behavioral factors represent an important piece of the puzzle, they cannot fully account for gaps as large as those observed in Bangladesh, where less than a quarter of reported deaths are female, and Ecuador, where women make up a third of the death toll.

To better understand the dimensions of the COVID-19 challenge and advance their response efforts, we call on governments to invest in ensuring equitable registration of vital events and in improving access to legal documentation for women.

The challenges faced

To be sure, countries are experiencing a host of challenges related to maintaining essential civil registration services during COVID-19, which could deepen the issue of under-counting female deaths. The burden and mortality related to increased intimate partner violence during lockdowns have been consistently underestimated in CRVS data, for example, and could add up to a significant proportion of missing virus-related deaths.

Restrictions on movement and limitations in nonessential services put in place to slow the spread of the virus have already impeded timely civil registration of events. There is also the real risk that vital events may remain unregistered even after the pandemic, translating into people facing increased difficulties in accessing services to which they are entitled, such as health care, child benefits, or identity documents.

In a period of increased mortality and uncertainty like the present, it is of critical importance that CRVS functions continue at full speed. Now is the time for national governments to take practical steps to bolster their civil registration systems, with the expectation that the investment will continue to yield high returns over the long run.

Strengthening CRVS systems with a gender lens

Women, especially in low-income countries, have faced a number of barriers to registration and obtaining the related legal documentation. Chief among them is the monetary cost of registration and the distance to registration offices, particularly for women who do not have access to transport or have other family obligations they cannot leave unattended. Investments now have the potential to improve women’s lives in important ways.

Bringing CRVS systems closer to women removes one of the top barriers they face in registering vital events; this has been done successfully through the expanded Colombia Rural Vital program, which enlists frontline health workers, trained community leaders, and the country’s extensive cell phone coverage to use text messages for reporting vital events to registration authorities.

Revising legal and regulatory requirements that are restrictive or discriminatory toward women can also have widespread impact; Rwanda and Tanzania have established new birth and death acts that remove barriers to citizen participation, such as registration fees for reporting and registering vital events.

Not only are these improvements sustainable over the long-term, they have an immediate impact on understanding the human toll of COVID-19, across all sectors of a country’s population. Health authorities in Rwanda, Colombia, and other countries are leveraging existing community-based data collection systems to furnish weekly counts of mortality, on top of hospital-based reporting. Disaggregating this information by sex will go a long way toward piecing together the gender-mortality puzzle.

Across Latin America, Africa, and Asia, collaborations between the Bloomberg Philanthropies Data for Health Initiative and our partners in government ministries and agencies have demonstrated a desire to better understand the gender differences in mortality data and, in conjunction with other indicators, use the data to inform a more effective and equitable COVID-19 response.

Countries can make real strides toward closing the gender gap by maintaining strong, unbiased CRVS systems, particularly during a health crisis. As the pandemic continues to evolve, it’s essential that governments coordinate a response that protects all people equally — by ensuring that every death, male and female, is counted and registered.

The views in this opinion piece do not necessarily reflect Devex's editorial views.

About the authors

  • Carla AbouZahr

    Carla AbouZahr is CRVS country adviser at Vital Strategies, as part of the Bloomberg Philanthropies Data for Health Initiative. She worked at the World Health Organization in Geneva for over 20 years on improving estimates of maternal mortality before becoming coordinator for statistics, monitoring, and analysis.
  • Joan Sara Thomas

    Joan Sara Thomas is interim deputy country director for Vital Strategies’ Asia-Pacific regional office in Singapore. With 10 years of experience in the field of global health management and development, Thomas has worked in North and Central America, the Middle East, and Asia. A central component of her current role includes building partnerships with national governments for public health improvement. She also holds expertise in civil registration and vital statistics improvement in the region.