1. THE NEW BIRTH CERTIFICATE Making Vital Statistics More Vital Centers for Disease Control and Prevention National Center for Health Statistics Division of Vital Statistics Reproductive Statistics Branch

2. Development of the Revised Birth Certificate 12 th Revision The U.S. Standard certificate of Live birth had 11 revisions during the 20th century. The last revision, still in use, was in 1989. – The revision process began with a consensus from the States that a revision was needed. – In 1998, the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) assembled an expert panel to evaluate the current certificate and recommend changes.

3. Development of the Revised Birth Certificate The Panel to Evaluate the U.S. Standard Certificates and Report Parent Group was composed of: – State vital registration and statistics executives - Patricia W. Potrzebowski (Chair), PA; Donald Berry, DE; Carol V. Getts, MI; Karen Grady, NH; Dorothy S. Harshbarger, AL; Michael R. Lavoie, GA; A.Torrey McLean, NC; Barry Nangle, UT; Alvin T. Onaka, HI; Lorne A. Phillips, KS; Steven Schwartz, NYC. – Researchers and representatives of data providers and user organizations - (e.g., AAP, ACNM, ACOG, AHA, AHIMA, AMA, and ASTHO).

4. Development of the Revised Birth Certificate -- cont. In a series of meetings over 16 months, the Panel reviewed literature, suggestions, and recommendations and heard outside testimony from other experts and private citizens. – The revision was viewed as a opportunity to improve the data collection process. – Recommendations were made as to: Content Content Format Format Standard definitions Standard definitions Standardized collection of data from the most accurate sources Standardized collection of data from the most accurate sources Standardized worksheets to gather data from medical records (Facility Worksheet) and from the parents (Mother’s Worksheet) Standardized worksheets to gather data from medical records (Facility Worksheet) and from the parents (Mother’s Worksheet) – The Panel made its final recommendations in 1999. – NCHS was mandated to test the new documents.

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

6. Mother’s Worksheet Data are obtained directly from the mother (e.g., race, Hispanic origin, education, cigarette smoking, WIC participation). – Testing of the MWS was done with women who had recently had a live birth. – Slight modifications were made to the worksheet as a result of their comments. – Generally, testing indicated that the MWS worked well.

7. Facility Worksheet Data are obtained directly from medical records of the mother and infant (e.g., date of last menstrual period (LMP), birthweight, risk factors, method of delivery). – Testing of the FWS was done with hospital staff across the country. – Hospital staff were interviewed about current methods of gathering birth certificate data. – Staff (clerical and nursing) were asked to complete the FWS using medical (including prenatal) records and interviewed about their reactions to the FWS. – Results of the testing led to modification or deletion of some items. – Generally, staff reported that the FWS could be completed efficiently and accurately.

8. Guide to Completing Facility Worksheet To assist hospital staff in completing the FWS a comprehensive instruction manual has been developed. It includes: – Definitions – Preferred sources within the medical record (e.g., prenatal care record, labor and delivery record) – Key words and common abbreviations

9. Detailed Specification for Electronic Systems Because almost all births are registered electronically, for the first time, detailed specifications for each data item on the electronic birth certificate have been developed. The specifications include: – Suggested electronic screens – Response categories – Drop-down menus – Edits – Help screens – Ability to edit and query at data entry; resolution of data issues at the source

10. Proposed 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

11. Proposed New Birth Certificate: Modified Items -- cont. – 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

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

13. The U.S. Standard Report of Fetal Death: Modified Items The U.S. Standard Report of Fetal Death was also revised with changes similar to the birth certificate. Modified items include: – Maternal morbidity – Smoking – Method of delivery – Congenital anomalies

14. The U.S. Standard Report of Fetal Death: Cause of Fetal Death Cause of fetal death now captures the single initiating cause as well as other significant causes. Other additions include: – whether autopsy or histological placental examination was performed – if autopsy or histological placental examination results were used in determining cause of death

15. The U.S. Standard Report of Fetal Death: Cause of Fetal Death -- cont. Data are obtained directly from the attendant or medico-legal certifier. – Format changes introduced to prompt attendant to provide specific cause of death – Item testing was done with medical specialists – Slight modifications were made as a result of their comments

16. The Revised U.S. Standard Certificate of Death The Revised U.S. Standard Certificate of Death now includes an item on Maternal Mortality. This will allow us to better identify maternal deaths and improve the quality of maternal mortality data. 36. IF FEMALE:  Not pregnant within past year  Pregnant at time of death  Not pregnant, but pregnant within 42 days of death  Not pregnant, but pregnant 43 days to 1 year before death  Unknown if pregnant within past year 36. IF FEMALE:  Not pregnant within past year  Pregnant at time of death  Not pregnant, but pregnant within 42 days of death  Not pregnant, but pregnant 43 days to 1 year before death  Unknown if pregnant within past year

17. Summary The quality of birth certificate data will be greatly improved as a result of: – Collection of data from the best sources – Standardized worksheets for the facility and the mother – A comprehensive instruction manual – Detailed specifications for the electronic system and the ability to edit and query as data are entered

18. Public Health Implications More accurate and comprehensive reporting on the birth certificate will enhance our ability to analyze and track crucial indicators of maternal and child health, including demographic characteristics, health care utilization, and outcomes. – Teen childbearing – Nonmarital childbearing – Preterm birth – Low birthweight – Cesarean delivery 19401950 1960 1970198019902000 0 20 40 60 80 100 Birth rate per 1,000 women aged 15-19 0 100 200 300 400 500 600 700 Number of births (in thousands) Number of births Birth rate Number of births and birth rates for teenagers aged 15-19 years: United States, 1960-2000

19. 19801985199019951999 Year Per 100,000 live births White Black All races Note: Triplet/+ include births in greater than twin deliveries. Rates are plotted on a log scale. 50 100 Hispanic Non-Hispanic White 275 Triplet/+ birth rates by race and Hispanic origin of mother, 1980-99 Public Health Implications -- cont. – Influence of fertility therapy on twin and triplet/+ births – Maternal medical risk factors – Neural tube defects – Induction of labor – Participation in the WIC program – Prenatal care utilization – Socio-economic differentials – Newborn need for intensive care