Counting men, missing women: a qualitative exploration of barriers underlying sex disparity in death registration in selected districts of Bangladesh.

Introduction: Accurate and timely reporting of deaths and causes of death is crucial evidence for health policy and planning. However, in practice, there is a low level of completeness of the death registration process in low-income settings such as Bangladesh and more so among females than males. An in-depth exploration of the barriers to low registration among females is needed in Bangladesh, a country bound by unequal gender norms and practices. Methods: The study relied on a qualitative approach and consisted of 33 key informant interviews with field-level implementers, policymakers and 13 focus group discussions among beneficiaries in eight subdistricts with low and high sex disparity. Results: The findings show that poor awareness about the registration process, inheritance-driven need and missing accurate supporting information hinder and delay death registration. Deep-rooted male-dominated inheritance practices contribute to lower registration of female deaths. This is further compounded by complex registration procedures, including the requirement for a pre-existing birth certificate and difficulties in obtaining or verifying supporting documents. In addition, awareness activities often emphasise inheritance-related benefits, unintentionally reinforcing the perception that death registration is more important for men than for women. Conclusions: Policies need to be strengthened and adapted to improve death registration completeness by addressing the barriers. More gender-sensitive, stronger and context-appropriate policy reforms, along with better implementation and oversight, are needed to improve the completeness of female death registration.