1. Birth Certificate Data: Essential for Improving the Nation’s Health Marian F. MacDorman, Ph.D. Statistician, Division of Vital Statistics National Center for Health Statistics, CDC Acknowledgements: Fay Menacker and Joyce Martin, NCHS

2. Introduction 1. Importance and uses of birth certificate data. 2. The new, revised birth certificate – new data items, and efforts to improve data quality. 3. Special studies of data quality.

3. Importance and Uses of Birth Certificate Data

4. Importance of Birth Certificate Data Birth certificate data are used to: – Monitor the characteristics and health of women giving birth and their infants. – Determine public policy and funding for local, state, and national maternal and child health programs. – Research to improve maternal and infant health. Thus, accuracy of reported data is essential to making the correct decisions about how to improve maternal and child health.

5. State and Local Health Departments Federal govt. programs: Healthy Start, WIC, SCHIP, etc. National Institutes of Health (NIH) Centers for Disease Control and Prevention (CDC) National Campaign to Prevent Teen Pregnancy March of Dimes (birth defects, preterm birth) Children’s Defense Fund Marketing, Investment, Insurance, Pharmaceutical, Healthcare and Law Firms Independent researchers Major Users of Birth Certificate Data

6. Selected Birth Certificate Data Items used for Health Monitoring Mother’s age (e.g., teen births, older mothers) Mother’s race and Hispanic origin Medical risks (e.g., diabetes, hypertension) Method of delivery (cesarean) Prenatal care Gestational age (preterm birth) Birthweight (low birthweight) And many more!

7. Important Uses of Birth Data 18-19 15-19 15-17 Figure 1. Birth rates for teenagers by age: United States, final 1980-2006 and preliminary 2007-2008

8. Important Uses of Birth Data (continued)

9. Cesarean Delivery Preterm Birth Important Uses of Birth Data (continued) Figure 3. Cesarean Delivery Rate: United States, final 1995-2006 and preliminary 2007-2008 Figure 4. Preterm birth rates by race and Hispanic origin of mother: United States, final 1990-2006 and preliminary 2007-2008

10. Birth Data in Research

16. The New, Revised Birth Certificate: New Data Items, and Efforts to Improve Data Quality

17. The 2003 Revision The 2003 revision of the U.S. Standard Certificate of Live Birth includes improved and new data items Major goal of the revision: improved data quality. Quality improved through standardized: –Data sources and definitions –Worksheets –Guidebook –Electronic systems

18. MT WY ID WA OR NV UT CA AZ ND SD NE CO NM TX OK KS AR LA MO IA MN WI IL IN KY TN MS AL GA FL SC NC VA WV OH MI NY PA MD DE NJ CT RI MA ME VT NH AK HI DC The 2003 U.S. Standard Certificate of Live Birth: Revision Status - 2009 64% of all births by close of 2009

19. MT WY ID WA OR NV UT CA AZ ND SD NE CO NM TX OK KS AR LA MO IA MN WI IL IN KY TN MS AL GA FL SC NC VA WV OH MI NY PA MD DE NJ CT RI MA ME VT NH AK HI DC The 2003 U.S. Standard Certificate of Live Birth: Revision Status - 2010 90% of all births by close of 2010

20. New Birth Certificate: Important New Items –Breast feeding –Did mother get WIC food during this pregnancy? –Principal source of payment for the delivery –Fertility therapy –Infections during pregnancy –Maternal morbidity

21. New Birth Certificate: Modified Items –Mother’s and father’s race, captures multiple race identification –Mother’s and father’s education, captures highest degree attained –Cigarette smoking before and during pregnancy, captures levels of smoking –Method of delivery includes fetal presentation and trial of labor prior to cesarean delivery –Pre-pregnancy weight, weight at delivery and height, used to calculate Body Mass Index –Congenital anomalies

22. New Worksheets To encourage collection from the best sources, two standard worksheets have been developed and tested. –Mother’s Worksheet (MWS) –Facility Worksheet (FWS)

23. Mother’s Worksheet Data are obtained directly from the mother for certain items: -Race -Hispanic origin -Education -Cigarette smoking -WIC participation

24. Facility Worksheet Data are obtained directly from medical records of the mother and infant for certain items, such as: - Date of last menstrual period (LMP) - Obstetric estimate of gestation - Birthweight - Apgar score - Congenital anomalies - Pregnancy risk factors - Method of delivery - Prenatal care items - Obstetric procedures

25. Guide to Completing Facility Worksheet To assist hospital staff in completing the Facility Worksheet, a comprehensive instruction manual has been developed. It includes: –Definitions, key words and common abbreviations. –Preferred sources within the medical record (e.g., prenatal care record, labor and delivery record) The Guide is available at: http://www.cdc.gov/nchs/data/dvs/GuidetoCompleteFacilityWks.pdf http://www.cdc.gov/nchs/data/dvs/GuidetoCompleteFacilityWks.pdf

26. Expanded Health Reports for 2004- 2006 are now available. These highlight new data items, such as: - Neonatal intensive care unit (NICU) admission. - Smoking by trimester of pregnancy - Steroid and surfactant administration (treatment) Reports on Revised Birth Data

27. Distribution of Singleton Births Admitted to a Neonatal Intensive Care Unit (NICU) by Gestational Age: 19-State Reporting Area, 2006 16.6% 24.7% 10.4% 46.9% 37+ weeks 34-36 weeks 32-33 weeks <32 weeks Source: CDC/NCHS National vital statistics system.

28. Percent Low Birth Weight by Smoking Status: 17-state Reporting Area, 2006 Source: CDC/NCHS National vital statistics system.

29. Special Studies of Data Quality

30. NCHS is fielding two different types of studies to evaluate the health/medical items on the birth certificate 1)In-depth interviews with birth record specialists in Florida, Kansas, Vermont, and Washington. 2)Validity studies that compare data from the birth certificate with data from hospital medical records. Special Studies of Data Quality

31. Data Quality Study: Results Important to collect information from the best data sources! From the mother: Demographic and behavioral risk factors -Smoking during pregnancy -WIC use From the medical record: Medical and health information - Date of last menstrual period -Obstetric estimate of gestation -Prenatal care information - Previous cesarean delivery

32. Data Quality Study Results: Gestational Age Date of LMP: Enter the first day of the mother’s LMP from the prenatal care record Do not ask the mother! Do not use a pregnancy wheel to estimate gestational age. Obstetric estimate of gestation Enter the best obstetric estimate of the infant’s gestational age (in completed weeks). Gestation should be determined by all perinatal factors and assessments, but not from the neonatal exam. Ultrasound taken early in pregnancy is a preferred source. Information most often found in labor and delivery record. Do not complete this item based solely on the infant’s date of birth and mother’s date of last menstrual period.

33. Data Quality Study Results: Number of Prenatal Care Visits Problem: -Prenatal care records often sent to the hospital a few weeks before delivery. -This can lead to underreporting of number of prenatal visits. Solution: - Contact prenatal care provider to get the updated number of prenatal visits. -If not possible, use the latest information available. -Do not attempt to estimate additional visits.

34. Data Quality Study Results: Breastfeeding Item: Is infant being breastfed at discharge? - Mark “yes” if infant is breastfed at any time between birth and hospital discharge

35. Data Quality Study Results: Trial of Labor New item: If cesarean, was a trial of labor attempted? Problem: Item does not exactly correspond to an item in the medical records. Solution: Review labor and delivery record for indications of labor, such as augmentation, induction, precipitous labor, prolonged labor, etc. If the woman had labor prior to the cesarean, this item should be marked “yes.”

36. Data Quality Study Results: Mother Had a Previous Cesarean Delivery? An item under Risk Factors in the Pregnancy asks if the mother had a previous cesarean delivery, and if yes, how many? This item, when combined with the Method of Delivery item will tell us for a cesarean delivery, whether it is primary or repeat cesarean delivery. And for a vaginal delivery, whether is a vaginal birth after cesarean, or VBAC delivery. Information available from the prenatal care, or labor and delivery records.

37. NCHS Developing Improved Reference Materials Guide to Completing the Facility Worksheet being revised. Other approaches under consideration: – Detailed definitions and instructions available online – Webinars with periodic updates – On-going training – Setting up HELP lines for immediate access to state and national experts.

38. As you gain experience with the revised birth certificate, we would love to hear your ideas and questions. - What are the hardest items to fill out on the birth certificate? - What do you struggle with? - What questions do you have? Your feedback will help us to improve data quality and also to ask the right questions in future studies. Your Feedback is Important!

39. Conclusions Birth certificates are the most important national data source for assessing and improving the health of mothers and infants. Virtually every data item collected on the birth certificate is used for research to improve mother’s and infant’s health. Examples of the most important data items include: - Maternal age - Race/ethnicity - Gestational age - Birthweight - Method of delivery By the end of 2010 almost all states will be using the Revised Birth Certificate. New and modified data items provide important infor- mation to improve the health of mothers and infants. Studies are currently underway to assess the quality of birth certificate data and to develop strategies for improvement. First results will be presented at the NAPHSIS meeting in June.

40. By the end of 2010 most states will be using the Revised Birth Certificate. New birth certificate provides essential information to improve the health of mothers and infants. Data quality has improved, but more work is needed. NCHS collaborating with state colleagues to further improve quality Your feedback is important to data improvement efforts! Conclusions

41. Thank you for all that you do to improve the health of mothers and babies!

42. Questions? Marian MacDorman: mfm1@cdc.gov