1. Medical Information – Page 1 (the hospital/medical worksheet must be used to complete the following items) Filing a Birth Certificate Vital Statistics Services1

2. MOTHER AND FATHER STATISTICAL INFORMATION Filing a Birth Certificate Vital Statistics Services2

3. Education Level  Choose the box that indicates the highest education level completed by the mother.  If she is currently enrolled, check the box that indicates the previous grade or highest degree received. Do not leave this item blank.  Education is highly related to fertility, health practices, and pregnancy outcome. It is also used as an indicator of socioeconomic status. Vital Statistics Services3

4. Hispanic Origin  The Hispanic origin and Race questions should be asked independently.  ‘‘Hispanic’’ is not a race, and a mother/father who is of Hispanic origin may be of any race.  Do not leave this item blank. ‘‘Hispanic’’ is a self-designated classification for people whose origins are from Spain, the Spanish- speaking countries of Central or South America, the Caribbean, or those identifying themselves generally as Spanish or Spanish- American.  Origin can be viewed as ancestry, nationality, or country of birth of the person or person’s parents or ancestors prior to their arrival in the United States.  Although the prompts include the major Hispanic groups, other groups may be specified under ‘‘Yes, other Spanish/Hispanic/Latino(a).’’ Vital Statistics Services4

5. Hispanic Origin Continued Check the box that best describe whether the mother/father is Spanish/Hispanic/ Latino(a). – If the mother/father indicates an ethnic origin not on the list, enter it in the ‘‘Specify’’ space. If the mother/father is not of Hispanic origin, check the box indicating ‘‘No, not Spanish/Hispanic/Latino(a).” Vital Statistics Services5

6. Race  The Race and Hispanic origin questions should be answered independently. Do not leave item blank. If there is no checkbox for the response, check the box ‘‘Other (Specify)’’ and enter the response in the blank, even if it is not a race.  American Indian and Alaska Native refer only to those native to North and South America (including Central America) and do not include Asian Indian. Please specify the name of enrolled or principal tribe (e.g., Navajo or Cheyenne) for the American Indian or Alaska Native.  For Asians and Pacific Islanders, enter the national origin of the mother. For Asians check Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify Other Asian group; for Pacific Islanders check Hawaiian, Guamanian or Chamorro, Samoan, or specify Other Pacific Islander. Vital Statistics Services6

7. Race Continued  In 1997, the Office of Management and Budget mandated the use of specific guidelines in collecting information on race and ethnicity and provided an opportunity for individuals to choose more than one racial category if they wish to reflect multiple racial heritage.  Race is essential in producing data for minority groups and is an important variable in planning for and evaluating the effectiveness of health programs.  It is also used to study racial variations in childbearing, access to health care, and pregnancy outcomes (perinatal mortality and birth weight). Vital Statistics Services7

8. Education Level, Hispanic Origin, and Race Vital Statistics Services8 ‘‘Hispanic’’ is not a race, and a mother/father who is of Hispanic origin may be of any race.

9. PLEASE HAVE THE MEDICAL WORKSHEET READY Medical Information Starts Vital Statistics Services9

10. Place Where Birth Occurred Choose the type of place where the birth occurred. – Hospital – Freestanding birthing center – Home Birth Intended or Not Intended – Clinic/Doctor’s Office – Other Taxi, train, plane, and etc. Vital Statistics Services10

11. Attendant’s Name and Title The attendant at birth is defined as the person physically present at the delivery who is responsible for the delivery. Choose the appropriate title of the attendant: – M.D. – D.O. – CNM – Other Midwife – Other (specify) Vital Statistics Services11

12. Was Mother Transferred? This question really means “Was the mother transferred TO this facility?” Transfers include hospital to hospital, birth facility to hospital, etc. – Does not include home to hospital Choose the appropriate facility from the drop down list. Vital Statistics Services12

13. Place Where Birth Occurred, Attendant, and Transferred 1.REMEMBER: This item is really asking: Was the mother transferred TO your facility”. 2.If the mother was transferred, choose the facility where she was transferred from. Vital Statistics Services13

14. Date of First Prenatal Care Visit The date a physician or other health care professional first examined and/or counseled the pregnant woman for the pregnancy. Enter the month, day, and year of the first visit. If no prenatal care, do not answer this item. Vital Statistics Services14

15. Date of Prenatal Care Visit This item identifies when during the pregnancy the patient entered prenatal care and is needed as the basis for measures of how soon patients initiate prenatal care and for measures of the appropriate utilization of services. This information is also used to study the impact of prenatal care on pregnancy outcome. Vital Statistics Services15

16. Date of Last Prenatal Care Visit The month, day, and year of the last prenatal care visit recorded in the records. Enter the month, day, and year of the last visit given in the most current record available. Do not estimate the date of last visit. Vital Statistics Services16

17. Total Number of Prenatal Care Visits The total number of visits recorded in the record. Count only those visits recorded in the record. Enter the total number of visits listed in the most current record available. – Do not estimate additional visits when the prenatal record is not current. Vital Statistics Services17

18. Total Number of Prenatal Visits This item is needed as the basis for measures of utilization of prenatal care services. It is also used in conjunction with ‘‘Date of First Prenatal Care Visit’’ to assess the adequacy of prenatal care Vital Statistics Services18

19. Prenatal Information 1.When entering a date you must enter it in this format: mm/dd/yyyy. 2.Month pregnancy prenatal care began must be answered, 1 means the first month of pregnancy and 10 is the tenth month of pregnancy (not October). Vital Statistics Services19

20. Mother’s Weight at Delivery The mother’s weight at the time of delivery. Enter the mother’s weight at the time of delivery, use pounds only. – For example, if the mother weighed 140 ½ pounds, enter it as 140 pounds. Do not leave this item blank. Vital Statistics Services20

21. Why is the Mother’s Weight at Delivery Collected? This item is used with the mother’s pre- pregnancy weight to calculate weight gain during pregnancy. Maternal weight gain is associated with pregnancy outcome and maternal morbidity and mortality. Vital Statistics Services21

22. Previous Live Births (Now Living) The total number of previous live-born infants now living. – DO NOT INCLUDE THIS INFANT. Include all previous live-born infants who are still living. For multiple deliveries – Include all live-born infants before this infant in the pregnancy. – If the first born, do NOT include this infant. – If the second born, include the first born, etc. Vital Statistics Services22

23. Previous Live Births (Now Dead) The total number of previous live-born infants now dead. – DO NOT INCLUDE THIS INFANT. Include all previous live-born infants who are now dead. For multiple deliveries – If the first born, do NOT include this infant. – If the second born, include the first born, etc. Vital Statistics Services23

24. Why is This Important Data on the number of previous live births are used to determine live-birth order, which is important in studying trends in childbearing and the spacing of children. They are also useful in studying possible health problems, such as problems associated with first births to older mothers. Vital Statistics Services24

25. Date of Last Live Birth If there were any previous live born (now living or dead) you MUST enter the month and year of the last live born infant. – DO NOT INCLUDE THIS INFANT. If either the month or year of last live birth is UNKNOWN, you must pick “UNKNOWN”. DO NOT ENTER PARTS OF INFORMATION. Vital Statistics Services25

26. Why is the Date of Last Live Birth Needed? The date of last live birth is used with the child’s birth date to compute the interval between births. This information is used to study possible health effects associated with short time periods between births. Vital Statistics Services26

27. Other Pregnancy Outcomes Total number of other pregnancy outcomes that did not result in a live birth. Includes pregnancy losses of ANY gestation age. – Examples: spontaneous or induced losses or ectopic pregnancy. Include all PREVIOUS pregnancy losses that did not result in a live birth Vital Statistics Services27

28. Other Pregnancy Outcomes Include Miscarriage or Spontaneous Abortion: An unintended interruption of pregnancy, the result of which is a fetal death of any gestational age. Induced Termination: An intended termination of pregnancy before the fetus has attained viability. Fetal Death or Stillbirth: Death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not show any other evidence of life. Ectopic Pregnancy: A pregnancy (gestation) that occurs elsewhere than in the uterus; as in a fallopian tube or in the peritoneal cavity. Vital Statistics Services28

29. Why Do We Collect This? Data on the number of other pregnancy outcomes are used to determine total-birth order, which is important in studying trends in childbearing and the spacing of pregnancies. They are also useful in studying possible health problems related to the outcome of previous pregnancies. Vital Statistics Services29

30. Date of Last Other Pregnancy Outcome The date that the last pregnancy did not result in a live birth ended. Enter the month and year. If either the month or year of other pregnancy outcome is UNKNOWN, enter “99” for that field. – If the MM is known but the year isn’t = 01/9999 – If the YYYY is known but the month isn’t= 99/2001 – If MM and YYYY is unknown = 99/9999 Vital Statistics Services30

31. Why Do We Need the Date of Other Pregnancy Outcome? The date of last other pregnancy outcome is used with the child’s birth date to compute the interval between pregnancies. This information is used to study possible health effects associated with short time periods between pregnancies. Vital Statistics Services31

32. More Regarding Other Pregnancy Outcomes Studies have shown that the timing of previous pregnancies and pregnancy outcomes can affect the outcome of the current pregnancy, in terms of maternal health issues as well as infant health. Babies born when the pregnancy is closely spaced with the mother’s previous pregnancy are at elevated risk of poor pregnancy outcome. Vital Statistics Services32

33. Previous Live Birth and Other Outcome If there were any previous live born (now living or dead) you MUST enter the month and year of the last live born infant. DO NOT INCLUDE THIS INFANT. Includes pregnancy losses of ANY gestation age. Examples: spontaneous or induced losses or ectopic pregnancy. Include all PREVIOUS pregnancy losses that did not result in a live birth Vital Statistics Services33

34. Principal Source of Payment The principal source of payment at the time of delivery: – Private Insurance (Blue Cross/Blue Shield, Aetna, etc.) – Medicaid (or a comparable State program) – Self-pay (no third party identified) – Other (Indian Health Service, CHAMPUS/TRICARE, other government [Federal, State, local]) Vital Statistics Services34

35. Is Payment Type Important? Knowledge of medical coverage is helpful in judging the effect of type of insurance on health outcome and assessing the extent to which delivery is not covered. Vital Statistics Services35

36. Date Last Normal Menses Began The date the mother’s last normal menstrual period began. This item provides information on the length of gestation, which can be associated with weight of fetus to determine the maturity of the fetus at delivery. It is also associated with infant morbidity and mortality, and is important in medical research. This item is required and should not be left blank. Vital Statistics Services36

37. Payment and LMP This item provides information on the length of gestation, which can be associated with weight of fetus to determine the maturity of the fetus at delivery. It is also associated with infant morbidity and mortality, and is important in medical research. Vital Statistics Services37

38. Continue to Medical Page 2 Once you have successfully completed all items on Page 1 you will need to complete those items about the risk factors and delivery on page 1. Choose “next” from the bottom of the page: Vital Statistics Services38