1. Vital Statistics: Vital Statistics: What was our past? What was our past? Where are we now? What is our future? MCH – Epi Conference Centers for Disease Control and Prevention National Center for Health Statistics

2. Topics Reactions to Dan’s and Garland’s presentations A little vital history A sprint down Vital Statistics “lane” Budget stuff Can regulations be good for you? New data items Problems in Vital Statistics Future

3. Reactions Dan Garland

4. A Little Vital History 1850-90 - Birth and death data - collected on census 1850 – Collection of national mortality data through the Census 1900 – D eath registration areas established (10 States and D.C.) 1915 – Birth registration areas established (10 states and DC) 1933 – Birth and Death Registration areas are complete 1973 – NCHS begins to pay States for standardized vitals data sets

5. A Little More Vital History “30/60” 1912 (my Dad’s year of birth 17.6% of all deaths were to infants 1915 (birth registration area established) IMR = 99.9 1944 (my year of birth) IMR = 39.4 1974 (year of birth of my last child) IMR = 16.7 2004 (last year of final data) IMR = 6.8

6. Childhood Death Rates by Age at Death SOURCE: CDC/NCHS: National Vital Statistics System, 1900-2004 10-14 years 15-19 years 1-4 years 5-9 years 2000 Deaths per 100,000 population 2004

7. History - Life Expectancy & Age-Adjusted Death Rates NOTE: Prior to 1933, data are for death-registration States only. Deaths per 100,000 standard populationAge in years Life expectancy Age-adjusted death rates 2004

8. More History - Leading Causes 1900 Influenza & Pneumonia Tuberculosis Diarrhea Heart disease Stroke Population approx 76 million 2004 Heart disease Cancer Stroke Chronic lower respiratory diseases Accidents (unintentional injuries) Diabetes Alzheimer’s Disease Influenza & Pneumonia (60k) Population approx 290 million NOTE: Prior to 1933, data are for death-registration States only.

9. A Sprint Down Vital Statistics Lane

10. Leading indicators from birth certificate data: Birth Rates by Age Teenage Pregnancy and Childbearing Timing and Adequacy of Prenatal Care Cesarean Delivery and VBAC Preterm Birth and Low Birthweight Multiple Births

11. Leading indicators from birth certificate data Fertility and Maternal/Infant Health Differences by Race/Hispanic Origin and Educational Attainment Geographic Differences (State, county-level data) Neural Tube Defects Maternal Medical Risk Factors (Diabetes, Hypertension) Smoking During Pregnancy

12. Leading indicators – using fetal death data: Pregnancy Health Pregnancy Rates Perinatal Mortality Rates Tracking Causes of Pregnancy Loss Differences in Pregnancy Outcomes by Race/Ethnicity Tracking outcomes for multiple deliveries

13. Leading Indicators Linked Birth/Infant Death Data: Differences in Pregnancy Outcomes by: Race/Ethnicity Marital Status Educational Attainment Maternal Medical Risk Status Smoking Status During Pregnancy Gestation and Birthweight-Specific Infant Mortality Rates Infant Mortality Rates by Plurality Geographic Variation in Infant Mortality Leading Causes of Infant Death

14. Fertility rates by race and Hispanic origin: United States, 1920-2006 SOURCE: CDC/NCHS: National Vital Statistics System, 1920-2006

16. Number of births, birth rate, and percent of births to unmarried women, U.S., 1940-2005 2005 SOURCE: CDC/NCHS: National Vital Statistics System, 1940-2005

17. Number of Births and Birth Rate for Teenagers 15-19 Years: U.S., 1940-2005 SOURCE: CDC/NCHS: National Vital Statistics System, 1940-2005

18. Birth rate for teenagers 15-19 and percent of teenage births to unmarried teenagers, U.S.,1950-2006 2006 Birth rate Percent unmarried SOURCE: CDC/NCHS: National Vital Statistics System, 1950-2006

19. Preterm birth  U.S. preterm birth rates on the rise Preterm birth rates: U.S. 1990-2005*

20. Percentage low birthweight by race and Hispanic origin of mother: U.S., 1990-2005* Non-Hispanic white Non-Hispanic black Hispanic Year Per 100 0 *Preliminary data

21. Percentage of late preterm singleton births by race and Hispanic origin of mother: United States, 1990, 2000, 2005 Percentage of late preterm singleton births by race and Hispanic origin of mother: United States, 1990, 2000, 2005 Percent NOTE: Late preterm = 34-36 completed weeks of gestation. Source: CDC/NCHS, National Vital Statistics System *Non-Hispanic

22. Infant mortality rates by birthweight: U.S., 2004 Infant mortality rates by birthweight: U.S., 2004 Per 1,000 live births NOTE: Birthweight in grams

23. Percent change in birthweight by 500 gram intervals: U.S.: 1990 and 2004 Birthweight in grams <1,000 1,499 1,999 2,499 2,999 3,499 3,999 4,499 4,999 5,000+

24. Fetal and infant mortality rates: United States, 1990-2004 Fetal and infant mortality rates: United States, 1990-2004 Infant Fetal 1995 NOTE: Infant mortality rates are the number of infant deaths per 1,000 live births. Fetal mortality rates are the number of fetal deaths of 20 weeks of gestation or more per 1,000 live births and fetal deaths. SOURCE: CDC/NCHS; National Vital Statistics System.

25. Perinatal mortality rates: United States, 1990-2004 Perinatal mortality rates: United States, 1990-2004 NOTE: Perinatal I includes infants deaths less than 7 days of age and fetal deaths 28 weeks or more. Perinatal II includes infants less than 28 days of age and fetal deaths 20 weeks or more. SOURCE: CDC/NCHS; National Vital Statistics System. 0 0

26. Total cesarean delivery rate: United States, 1989-2005 Total cesarean delivery rate: United States, 1989-2005 Percent 1996 2005 Year NOTE: The total cesarean delivery rate is the percentage of all live births by cesarean delivery. 0 Source: CDC/NCHS, National Vital Statistics System. 2000 1989

27. Total cesarean delivery rates by race and Hispanic origin of mother: United States, 1996 and 2006 Percent All races White*Black* Hispanic American Indian or Alaska Native Asian or Pacific Islander *Non-Hispanic

28. Budget Stuff

29. Current Budget Situation - NCHS All NCHS surveys are in financial trouble not just vitals FY07 VSCP – $17.9+million for 12 months FY07 VSCP budget - $16.5m = $1.5+million short but could have been worse – was $3.1 deficit until last moment help $1.5+ deficit = 1 months of data FY08 – ? but assuming flat – will be short 3 months of data FY08 – Congress - $8 million above for NCHS - but will it happen?

30. Regulations for Vitals 9/11 Commission and Intelligence Reform and Terrorism Prevention Act (IRTPA)

31. Specific Issues Security of paper Security of systems and practices collecting data Security of systems and practices issuing certificates Ability to match birth and death records Ability to transmit records within and between States

32. Philosophy of Reg Development Maintain a state-based birth registration and certification system - ownership remains with the States. Maintain a state-based birth registration and certification system - ownership remains with the States. Make a more secure, timely, responsive birth registration and certification system by improving security of collection, handling & issuing of birth certificates Make a more secure, timely, responsive birth registration and certification system by improving security of collection, handling & issuing of birth certificates Make a more connected birth certificate system by improving flow of information within and between States and between the States and the Federal Govt. Make a more connected birth certificate system by improving flow of information within and between States and between the States and the Federal Govt. Make no death registration regulations except as necessary to make birth certificates more secure. Make no death registration regulations except as necessary to make birth certificates more secure. Make no new Federal data systems Make no new Federal data systems

33. What needs to happen? What needs to happen? More secure and responsive registration of vital events which will require Automation at the source to assure The ability to electronically transfer vital events within and between States and federal partners in real time

34. Where are we? Federal Agency reps and State Registrar reps have provided recommendations for draft standards Contractor has developed the draft regs and is undertaking the economic and Federalism impact of the regs Draft regs are at HHS for review Hope to publish draft regs in Federal Register in the new year.

35. Goals For the first time - will create regs for consistent vital registration processing and issuance Will require an environment that assures timely and secure information on birth records (EBR’s and EDR’s) and Which will impact death registration systems … by requiring immediate matching of birth and death records And systems to transfer data

36. Potential Funding The legislation authorizes two grant programs for States to Help with the cost for secure paper Help with the cost for more secure and responsive systems and for placing old data into those systems BUT beware … authorization is not appropriation!

37. What will this mean for Public Health? A more secure, timely, responsive, connected … a more Vital …vital registration system which can Once again form the basis of the premier public health surveillance as well as provide core public health measures

38. The Future for Vitals

39. New Data

40. Rates of gestational diabetes by age of mother and plurality: 12 state reporting area, 2005 Rates of gestational diabetes by age of mother and plurality: 12 state reporting area, 2005 Per 1,000 live births Years * *Twins, triplets and other higher order multiple births.

41. Distribution of singleton births admitted to an NICU by gestational age: 12-State Reporting area: 2005 Distribution of singleton births admitted to an NICU by gestational age: 12-State Reporting area: 2005 17.2% 25.0% 10.4% 47.5% 37+ weeks 34-36 weeks32-33 weeks <32 weeks

42. Neonatal intensive care unit (NICU) admission for singleton births by gestational age and race/Hispanic origin of mother: 12 state reporting area, 2004 Neonatal intensive care unit (NICU) admission for singleton births by gestational age and race/Hispanic origin of mother: 12 state reporting area, 2004 *Non-Hispanic Weeks of gestation

43. Percentage of singleton infants born at 4,500 +grams and percentage admitted to an NICU - whether the mother had prepregnancy (DM) or gestational diabetes (GDM): 12 state reporting area, 2005 Percentage of singleton infants born at 4,500 +grams and percentage admitted to an NICU - whether the mother had prepregnancy (DM) or gestational diabetes (GDM): 12 state reporting area, 2005 Percent NOTE: NICU = neonatal intensive care unit. DMGDM 4,500+ grams NICU admission 4,500+ grams NICU admission

44. Some Problems with Vitals Need QC & follow-up on new items VLBW survivorship high in some states Quality of fetal reporting Data responsiveness by some states States need help in implementing EBR’s and EDR’s.

45. Some Problems with Vitals NCHS authorized to collect vitals but States not required to provide VSCP pays for data but does not pay for improving quality and timeliness VSCP pays for data no matter how late NCHS internal systems are good for EOY reporting but not for YTD reporting - surveillance

46. Questions of the Future

47. How can we build on our past successes for a new beginning? To measure what is and not just what was And with improved quality?

48. Future Considerations If vitals are VITAL should they not be a reportable event? Should we develop a reduced (core) data set for vitals and pay for that data set by NCHS VSCP funds ? As with NCHS surveys, should we seek reimbursable $’s from other federal partners to pay for other data items beyond the core data set?

49. Future Considerations With remaining VSCP $’s and $’s from other federal partners … should we provide CA/Grants to States for improving quality and responsiveness … tailored to individual state needs? Should we go back to the Birth Registration Area idea and only pay those States that can meet new timelines and only report for those States? How should we integrate with electronic records and would that allow us to collect expanded data items beyond the core on a sample basis?

50. What we do know: This is not the time to “ride it out ” !

52. Charlie Rothwell Director of Vital Statistics CRothwell@cdc.gov 301-458-4468 CRothwell@cdc.gov