No. 19
June 2012
Revisions to the North Carolina Birth Certificate and
Their Impact on Tracking Maternal and Infant Health Data
by
Kathleen A. Jones-Vessey
Approximately every 10 to 15 years, standards for
collecting statistical information on U.S. birth certificates
are revised. These revised standards specify the data fields
collected on birth certificates and information that should
be reported to the Vital Statistics Cooperative Program
(VSCP). These standards serve as a model to ensure that
birth data are collected and reported in a uniform and
comparable manner across the United States. The latest
revision to the U.S. Standard Birth Certificate, finalized
in 2003, was devised by an advisory panel of experts
which included representatives from the National Center
for Health Statistics (NCHS), the Centers for Disease
Control and Prevention (CDC), state vital registration
and statistics executives, researchers and a variety of
interested data user organizations, such as the American
Medical Association (AMA) and the American Congress
of Obstetricians and Gynecologists (ACOG).1,2
registration system. After years of complex system
development, in August 2010, the North Carolina’s Vital
Records office launched the web-based “Vital Records
Automation System” (VRAS) in delivery hospitals across
the state. VRAS was designed to improve the timeliness
of birth registration and Vital Statistics data dissemination
as well as to implement the 2003 U.S. certificate
standards.
From 1988 to 2010, the statistical information collected
on North Carolina’s birth certificates were based on the
1989 U.S. Standard Birth Certificate and entered into a
DOS-based electronic birth certificate (EBC) registration
system. The magnitude of the changes required to meet
the 2003 revised birth certificate standards necessitated
that North Carolina develop a more sophisticated birth
New Fields Collected on the North
Carolina Birth Certificate
Many of the data fields captured on the 2003 revised
birth certificate are modified or new. The purpose of this
report is to describe the new or modified information
collected on the 2003 revised version of the birth
certificate and highlight any significant differences with
the data fields captured on the previous version of the
birth certificate.
● Facility and Attendant NPI [Items 31 and 32]:
As part of the Health Insurance Portability and
Accountability Act of 1995 (HIPAA), identifying
information on health care providers are collected
by the Centers for Medicare and Medicaid Services
(CMS) and each provider is given a unique 10
digit National Provider Identifier (NPI).3 The
revised birth certificate now includes NPI for the
attendant as well as the facility where the delivery
took place. The inclusion of NPI on the new birth
certificate will facilitate linkage of the birth file
with other healthcare databases.
Items 36 and 37
36.
37. MOTHER'S PREPREGNANCY
WEIGHT --------------- (pounds)
● Women, Infants and Children (WIC) During
Pregnancy [Item 39]: WIC is a federal program
that provides supplemental food, healthcare
referrals and nutrition education for low-income
pregnant, breastfeeding and postpartum women,
and infants and children up to age 5 who are at
nutritional risk.7 Prenatal WIC participation has
been found to be associated with improved birth
outcomes for disadvantaged women.8,9 The revised
birth certificate includes a field for capturing
whether the mother received WIC food for herself
during pregnancy. Since 1988, the State Center
for Health Statistics (SCHS) staff have performed
an annual match of birth certificate data with
state WIC records to gather information on this
population. WIC information collected from the
revised birth certificate will be compared with the
matched data in order to assess the completeness of
this data.
Items 31 and 32
31. FACILITY ID. (NPI)
32. ATTENDANT'S NAME, TITLE, AND NPI
NAME: ---------------------------------------------------------------------------NPI: ----------------------------------------TITLE:
MD
DO
CNM/CM
OTHER MIDWIFE
OTHER (Specify) ------------------------------------------------
● Pre-pregnancy Height and Weight [Items 36
and 37]: Obesity is a growing epidemic in North
Carolina. According to the 2010 North Carolina
Behavioral Risk Factor Surveillance System
survey, over half (55%) of North Carolina women
of childbearing age are classified as overweight
or obese based on their Body Mass Index (BMI).4
Women who are obese during pregnancy may
be at increased risk for a Cesarean section
(C-section) delivery, longer hospital stays after
delivery, gestational hypertension and diabetes,
fetal death and birth defects.5 The previous version
of the certificate recorded information regarding
weight gain during pregnancy. However, without
knowing pre-pregnancy weight and height, it
was impossible to determine if the amount of
weight gained during pregnancy was appropriate.
As a result of increasing rates of obesity among
women of childbearing age, current guidelines
suggest that women who are overweight or obese
going into pregnancy may not need to gain as
much weight as women with normal BMI’s.6 The
revised birth certificate collects information on
the mother’s height, pre-pregnancy weight and
weight at delivery. Using this data, weight gained
during pregnancy can be computed and BMI can be
calculated. This information will be used to report
population-level information regarding obesity and
the percentage of women gaining the appropriate
amount of weight during pregnancy.
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
MOTHER'S HEIGHT
------------------ (feet/inches)
Item 39
39. DID MOTHER GET WIC FOOD FOR
HERSELF DURING THIS PREGNANCY?
Yes
No
● Payment for Delivery [Item 43]: The revised
birth certificate includes a field for capturing
the principal source of payment for the delivery.
Categories include private insurance, Medicaid,
self-pay, and other (specified) insurance. Since
1988, North Carolina SCHS staff have matched all
resident birth records with North Carolina Division
of Medical
Assistance
Item 43
Medicaid claims
and enrollment
43. PRINCIPAL SOURCE OF
PAYMENT FOR THIS
files in order
DELIVERY
to determine
Private Insurance
deliveries paid
Medicaid
Self-Pay
10
by Medicaid.
Other
(Specify) -------------------SCHS will use
this matched
2
Division of Public Health
State Center for Health Statistics
data to compare with this information collected
on the birth certificate in order to assess the
completeness of this data.
the mother at increased risk of complications, as
well as greater risk of preterm, low birthweight
and infant death.13,14 Utilizing data collected from
the revised birth certificate, the State Center for
Health Statistics will be able to assess the impact
of fertility treatments on maternal and infant
outcomes in North Carolina.
● Mother’s Medical Record Number [Item 45]:
The birth certificate is used as a basis for a variety
of surveillance programs, including immunizations,
newborn screening and birth defects. The addition
of mother’s
medical
Item 45
record
number will
45. MOTHER'S MEDICAL RECORD NUMBER
facilitate
data linkage
with other
health
records, as well as ensure that maternal hospital
records can be accessed without difficulty.
● Previous Cesarean Section [Item 46]: Cesarean
sections have risen throughout the United States
over the last decade.15 Women who have had
prior C-sections are more likely to have another
with subsequent deliveries. On the previous
version of the birth certificate, the only method
for determining whether a mother had a previous
C-section was via the method of delivery (vaginal
after C-section or repeat C-section). The revised
birth certificate now includes an indicator for
whether a mother had previous C-section(s) and for
recording the number of previous C-sections.
● Gestational Diabetes [Item 46]: The previous
version of the birth certificate included a checkbox
for maternal diabetes in the medical history section.
However, there was no way to determine if the
diabetes was pre-existing or developed during the
pregnancy. In order to address this, the revised
birth certificate now includes two separate fields for
recording diabetes in the “Pregnancy Risk Factors”
section. The first collects information for mothers
who had diabetes prior to pregnancy. The second
field is for mothers that developed high blood
sugar during pregnancy (known as “gestational
diabetes”). Mothers with gestational diabetes are at
increased risk for birth injury, C-section delivery,
high blood pressure during pregnancy and Type II
(adult onset) diabetes in the future. Infants born to
mothers with gestational diabetes are at increased
risk for low blood sugar and infant death.11,12
Item 46
46. RISK FACTORS IN THIS PREGNANCY
(Check all that apply)
Diabetes
Prepregnancy (Diagnosis prior to this pregnancy)
Gestational (Diagnosis in this pregnancy)
Hypertension
Prepregnancy (Chronic)
Gestational (PIH, preeclampsia)
Eclampsia
Previous preterm birth
Other previous poor pregnancy outcome (Includes
perinatal death, small-for-gestational age/
intrauterine growth restricted birth)
Pregnancy resulted from infertility treatment--If yes,
check all that apply:
Fertility-enhancing drugs, Artificial insemination
or Intrauterine insemination
Assisted reproductive technology (e.g., in vitro
fertilization (IVF), gamete intrafallopian transfer
(GIFT)
● Fertility Treatments [Item 46]: The revised birth
certificate now collects information regarding
whether the pregnancy resulted from infertility
treatment(s). This information is recorded through
two separate fields. The first is a field for the use of
fertility enhancing drugs, artificial insemination or
intrauterine insemination. The second field is for
the use of assisted reproductive technology such as
in vitro fertilization (IVF) or gamete intrafallopian
transfer (GIFT). Pregnancies achieved through
infertility treatments may be at increased risk for
multiple pregnancies which in turn, may place
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
Mother had a previous cesarean delivery
If yes, how many ---------------None of the above
● Infections During Pregnancy [Item 47]: The
revised birth certificate includes a new section
focusing on maternal infections present and/or
treated during pregnancy. Specifically, it captures
information on the following communicable
diseases: gonorrhea, syphilis, chlamydia and
hepatitis (B and C). Additionally, North Carolina
3
Division of Public Health
State Center for Health Statistics
chose to add a field for recording testing for the
Hepatitis B surface antigen (HBsAG)—including
the test date and test results. Infants born to
mothers with Hepatitis B infections are more likely
to be born low birth weight and/or premature.16
The U.S. Preventive Task Force has concluded that
HBV screening reduces perinatal transmission of
HBV and recommends that all pregnant women be
tested for HBV infection during their first prenatal
visit.17 North Carolina Division of Public Health
staff will use this information to assess whether
HBV screening is taking place, as well as to
determine the prevalence of prenatal infections.
on the previous version of the certificate. Maternal
labor and delivery complications can increase the
costs associated with labor and delivery and may
also put the mother at increased risk for postpartum
complications and even death.18
● NICU Admission [Item 57]: The “Abnormal
Conditions of the Newborn” section of the revised
birth certificate now includes a field for whether
or not the infant was admitted to the Neonatal
Intensive Care Unit (NICU). This information has
never been available at the state level and will
allow Division of Public Health staff to determine
the percentage of North Carolina newborns that
require higher levels of care after delivery and
might be at risk for morbidity, developmental
delays and infant death.
Item 47
47. INFECTIONS PRESENT AND/OR TREATED DURING
THIS PREGNANCY (Check all that apply)
Gonorrhea
Syphilis
Chlamydia
Hepatitis B
Hepatitis C
None of the above
Was mother tested for HBsAG?
If tested, include test date
Yes
Item 57
57. ABNORMAL CONDITIONS OF THE NEWBORN
(Check all that apply)
Assisted ventilation required immediately following
delivery
Assisted ventilation required for more than six hours
NICU admission
Newborn given surfactant replacement therapy
Antibiotics received by the newborn for suspected
neonatal sepsis
Seizure or serious neurologic dysfunction
Significant birth injury (skeletal fracture(s),
peripheral nerve injury, and/or soft tissue/solid
organ hemorrhage which requires intervention)
None of the above
No
----------/----------/-------------------MM
DD
YYYY
and test results:
Positive
Negative
● Maternal Morbidity [Item 52]: Another new
section included on the revised birth certificate
focuses on maternal complications associated
with labor and delivery. This section includes
fields for recording whether the mother required
a transfusion, had a severe perineal laceration,
ruptured uterus, unplanned hysterectomy,
admission to the intensive care unit or an
unplanned operating room procedure following
delivery. None of this information was collected
● Infant Death [Item 60]: Infant mortality is
considered one of the most important indicators
of population health and well-being.19 In order
to better understand the factors associated with
infant death, the State Center for Health Statistics
routinely
matches
Item 60
all infant
deaths
60. IS INFANT LIVING AT TIME OF REPORT?
Yes
No
with their
Infant transferred, status unknown
matching
birth
certificate.
Most infant deaths occur within the first few hours
or days of life. In order to track infant deaths more
quickly, the revised birth certificate now includes a
field for recording whether the infant was living at
the time the birth certificate was filed.
Item 52
52. MATERNAL MORBIDITY (Check all that apply)
(Complications associated with labor and delivery)
Maternal transfusion
Third or fourth degree perineal laceration
Ruptured uterus
Unplanned hysterectomy
Admission to intensive care unit
Unplanned operating room procedure following
delivery
None of the above
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
4
Division of Public Health
State Center for Health Statistics
● Breastfeeding at Discharge [Item 61]: The
U.S. Preventive Service Task Force concludes
that there are “substantial health benefits for
children and adequate evidence that breastfeeding
provides moderate health benefits for women.”
The Task Force recommends that interventions
be put in place to support the initiation, duration
and exclusivity of breastfeeding.20 Promoting
breastfeeding is also a national public health
priority. Healthy People 2020 includes several
objectives related to increasing the proportion
of infants who are breastfed.21 In an effort to
track the prevalence of breastfeeding initiation,
the revised birth
certificate now
Item 61
records whether
the newborn was
61. IS THE INFANT BEING
being breastfed at
BREASTFED AT DISCHARGE?
Yes
No
hospital discharge.
This data will
allow North
Carolina public health programs to track statewide,
population-level, breastfeeding initiation rates for
the first time.
revised certificate not comparable. Below are a list
of fields which were modified with the revised birth
certificate:
● Birthweight [Item 17]: On the previous version of
the certificate birthweight was collected in pounds
and ounces. On the revised certificate birthweight
can be reported in grams or pounds and ounces.
Item 17
17. BIRTHWEIGHT (grams preferred, specify unit)
-----------------------------------------------------------grams
lb/oz
● Mother’s and Father’s Race* [Items 20 and
21]: Prior to the 2003 revision, the race field on
the birth certificate was open-ended and asked for
the “Color or Race“ of both the mother and the
father. The revised certificate does not mention
color, specifies 15 discrete racial categories plus a
category for “other,” and allows for the selection
of more than one race.22,23 The 2003 revised birth
certificate ethnicity reporting standards meet the
race reporting standards defined by the Office of
Management and Budget (OMB) in 1997.24 One
additional change in race coding has also occurred.
The National Center for Health Statistics (NCHS)
population data sources do not include multiple race
categories, therefore NCHS creates a crosswalk that
“bridges” these multiple race categories back to a
single race through imputation for the purposes of
calculating consistent Vital Statistics rates.25 As part
of this bridging process, race recorded for those of
Modified Fields Collected on the North
Carolina Birth Certificate
In addition to new fields, the 2003 standard birth
certificate also modified many of the existing
demographic and medical information collected on the
birth certificate. In many cases, these changes make
comparisons between data collected under the previous
version of the certificate and data collected under the
Items 20 and 21
20. FATHER'S RACE (Check one or more races to indicate what the father considers himself to be )
White
Asian Indian
Vietnamese
Black or African American
Chinese
Other Asian
American Indian or Alaska Native
(Specify) ----------------------------------------Filipino
(Name of the enrolled or principal tribe)
Japanese
Native Hawaiian
Korean
Guamanian or Chamorro
--------------------------------------------------
Samoan
Other Pacific Islander
(Specify) ----------------------------------------------Other
(Specify) ------------------------------------------------
21. MOTHER'S RACE (Check one or more races to indicate what the mother considers herself to be)
White
Asian Indian
Vietnamese
Black or African American
Chinese
Other Asian
American Indian or Alaska Native
Filipino
(Specify) ----------------------------------------(Name of the enrolled or principal tribe)
Japanese
Native Hawaiian
Korean
Guamanian or Chamorro
--------------------------------------------------
Samoan
Other Pacific Islander
(Specify) ----------------------------------------------Other
(Specify) -----------------------------------------------
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
5
Division of Public Health
State Center for Health Statistics
Hispanic ethnicity has also been modified. Under
race coding specifications for the previous version
of the birth certificate, if a mother or father reported
their race as “Hispanic,” NCHS guidelines typically
stipulated that their race be classified as white. Under
the 2003 revised race coding standards, the majority
of Hispanics are now classified as “other races.”26
Due to this change in race coding for Hispanics, all
reports based on North Carolina birth data will now
be required to combine race/ethnicity (e.g., NonHispanic white, Non-Hispanic black, Hispanic, etc.).
modified. Prior to generating the birth certificate,
the mother is given a worksheet to fill out that
includes demographic questions, such as race and
ethnicity. On the mother’s worksheet, the ethnicity
question is now asked prior to the race question,
in an effort to improve the reporting of race for
Hispanics.27
● Mother’s and Father’s Education* [Items 26 and
29]: The previous version of the birth certificate
captured education levels by asking for the years of
schooling completed. However, this method did not
necessarily reflect degrees or diplomas received.27
To address this problem, the 2003 revision instead
breaks secondary education into separate fields (8th
grade or less, 9–12th grade, high school graduate
or GED) and allows for reporting of specific
degrees received (Associate, Bachelor’s, Master’s
or Doctorate). Since education information is
collected very differently on the two versions of the
certificates, this field is not considered comparable
across the two certificate revisions.
● Mother’s and Father’s Ethnicity* [Items 25 and
28]: Race and ethnicity are recorded in two separate
fields on both versions of the birth certificate. On
the previous version of the birth certificate, ethnicity
was a “yes/no” field that was followed by a separate
question which specified the origin for those
indicating that they were Hispanic. On the revised
birth certificate, ethnicity and origin are recorded
in the same field. The 2003 revised birth certificate
ethnicity reporting standards meet the race and
ethnicity reporting standards defined by the Office
of Management and Budget (OMB) in 1997.24 The
order of the race and ethnicity questions were also
Items 26 and 29
Items 25 and 28
26. FATHER'S EDUCATION (Check the box that
best describes the highest degree or level of
school completed at the time of delivery)
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED completed
Some college credit but no degree
Associate degree (e.g., AA, AS)
Bachelor's degree (e.g., BA, AB, BS)
Master's degree (e.g., MA, MS, MEng, MEd,
MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional
degree (e.g., MD, DDS, DVM, LLB, JD)
25. FATHER OF HISPANIC ORIGIN? (Check the
box that best describes whether the father is
Spanish/Hispanic/Latino. Check the "No" box if
father is not Spanish/Hispanic/Latino)
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
(Specify) ----------------------------------------------
29. MOTHER'S EDUCATION (Check the box that
best describes the highest degree or level of
school completed at the time of delivery)
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED completed
Some college credit but no degree
Associate degree (e.g., AA, AS)
Bachelor's degree (e.g., BA, AB, BS)
Master's degree (e.g., MA, MS, MEng, MEd,
MSW, MBA)
Doctorate (e.g., PhD, EdD) or Professional
degree (e.g., MD, DDS, DVM, LLB, JD)
28. MOTHER OF HISPANIC ORIGIN? (Check the
box that best describes whether the mother is
Spanish/Hispanic/Latina. Check the "No" box if
mother is not Spanish/Hispanic/Latina)
No, not Spanish/Hispanic/Latina
Yes, Mexican, Mexican American, Chicana
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latina
(Specify) ----------------------------------------------
*In North Carolina, in cases where the mother was unmarried at the time of delivery, paternity must be established before the father’s
information can be collected on the birth certificate. In 2010, 42 percent of all North Carolina births were to unwed mothers and 40 percent
of these were missing father’s information on the birth certificate. For this reason, any demographic information collected for the father on
the birth certificate (such as age, race, ethnicity, education and birth place) has a high rate of non-random missing data and is not suitable
for analysis.
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
6
Division of Public Health
State Center for Health Statistics
● Place of Birth [Item 30]: The previous version of
the certificate recorded information on place of birth
which included hospital, freestanding birth center,
clinic/doctors office, residence and other (specified).
When deliveries occurred at a residence, it was
difficult to determine whether the home birth was
planned or unanticipated.27 To remedy this, the revised
birth certificate changes the “residence” checkbox
to “home birth” and includes a field for indicating
whether the home birth was planned or not. Research
indicates that unplanned home births have higher
rates of adverse maternal and infant outcomes.28,29
Information regarding planned and unplanned
home births in conjunction with information on the
attendant at delivery will allow us to examine North
Carolina home births in more detail.
field was the addition of “Certified Midwife” (C.M.)
to the “Certified Nurse Midwife” (C.N.M.) checkbox.
The revised certificate now includes: “C.N.M/C.M.”
in the same checkbox. The American College of
Nurse Midwives recommended this change because
the licensing for both C.N.M.’s and C.M.’s are the
same.27 This field will be used to better assess trends
in delivery attendants over time, particularly the
rise in CNM-attended deliveries. In 1990, C.N.M.’s
attended 1.7 percent of North Carolina resident births,
compared with 11 percent of all births in 2010.30,31
● Maternal Transfer [Item 33]: Both versions of the
standard certificate report whether the mother was
transferred prior to delivery, as well as the hospital
of transfer. However the revised birth certificate
added the stipulation: “for maternal medical or fetal
indications for delivery.”
Item 30
Item 33
30. PLACE WHERE BIRTH OCCURRED (Check one)
Hospital
Freestanding birthing center
Home Birth:
Yes
No
Planned to deliver at Home?
Clinic/Doctor's office
Other (Specify) ------------------------------------------
33. MOTHER TRANSFERRED FOR MATERNAL MEDICAL
Yes
No
OR FETAL INDICATIONS FOR DELIVERY?
IF YES, ENTER NAME OF FACILITY MOTHER
TRANSFERRED FROM:
-----------------------------------------------------------------------------------
● Attendant [Item 32]: The delivery attendant was
recorded on both the 1989 and the 2003 standard
certificates. The previous version of the certificate
included the following attendant categories: Medical
Doctor (M.D.), Doctor of Osteopathy (D.O.),
Certified Nurse Midwife (C.N.M.), Other Midwife,
and Other specified. The only change made to this
● Prenatal Care [Items 34a, 34b and 35]: The
previous version of the certificate included a field
for capturing the month that a mother initiated
prenatal care. The revised certificate now asks
for the complete date of the first prenatal care
visit (month/day/year). The advisory group that
made recommendations for the 2003 revised birth
certificate felt that collecting the specific date care
began would yield more accurate prenatal care
data.27 The accuracy of this field is important as
early initiation of prenatal care can help identify
health conditions and risk factors which might
impact the health of both the mother and infant.32,33
Item 32
32. ATTENDANT'S NAME, TITLE, AND NPI
NAME: ---------------------------------------------------------------------------NPI: ----------------------------------------TITLE:
MD
DO
CNM/CM
OTHER MIDWIFE
OTHER (Specify) ------------------------------------------------
Items 34a, 34b and 35
34a. DATE OF FIRST PRENATAL CARE VISIT
No Prenatal Care
----------/----------/-------------------MM DD
YYYY
34b. DATE OF LAST PRENATAL CARE VISIT
----------/----------/-------------------MM
DD
YYY Y
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
7
35. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY
---------------------------------------- (If none, enter "0".)
Division of Public Health
State Center for Health Statistics
● Weight at Delivery [Item 38]: The previous
version of the certificate recorded information
regarding weight gain during pregnancy. The
revised birth certificate now collects information
on the mother’s height and pre-pregnancy weight
which are used in conjunction with the mother’s
weight at delivery to calculate weight gained during
pregnancy to
determine if the
Item 38
mother gained
the appropriate
38. MOTHER'S WEIGHT AT DELIVERY
---------------- (pounds)
amount of weight
during pregnancy.
Research suggests
that excessive weight gain during pregnancy leads
to an increased risk of pregnancy complications,
Cesarean section delivery and longer hospital stays
after delivery.34
smoking at some point during her pregnancy.
Research suggests that smoking cessation during
pregnancy can reduce the incidence of low
birth weight and hospital associated costs.37,38
The revised birth certificate includes fields for
recording smoking status three months before
pregnancy as well as during each trimester of
pregnancy. This method of collecting smoking
information on the revised birth certificate was
selected based on research which determined
that this was the most effective way to gather
accurate maternal smoking behavior.39,40 Given the
substantial changes in how this field is defined,
the National Center for Health Statistics does not
consider this field to be comparable with data
collected through the previous version of the
certificate.41
Item 42
● Other Pregnancy Outcomes [Item 41]: Both
versions of the birth certificate report whether
the mother had prior fetal deaths, abortions or
miscarriages. The previous version of the birth
certificate reported
the number of
Item 41
“other terminations
(spontaneous and
41. NUMBER OF OTHER
PREGNANCY OUTCOMES
induced at any time
(spontaneous or induced
losses or ectopic pregnancies)
after conception).” The
41a. Other Outcomes
revised birth certificate
Number ----------reports the number
None
of “other pregnancy
41b. DATE OF LAST OTHER
PREGNANCY OUTCOME
outcomes (spontaneous
----------/---------or induced losses or
MM
YYYY
ectopic pregnancies).”
42.
● Previous Preterm Birth [Item 46]: On the
previous version of the birth certificate, there
was a checkbox in the “Medical History for this
Pregnancy” section for “previous preterm or smallfor-gestational-age infant.” The revised certificate
reports this in the “Risk Factors for This Pregnancy”
section as: “previous preterm birth” and includes
a separate check box for “other previous poor
pregnancy outcome (includes perinatal death, smallfor-gestational age/intrauterine growth restricted
birth).”
● Cigarette Smoking [Item 42]: Smoking during
pregnancy may put women at increased risk for
vaginal bleeding, placental problems, miscarriage
and stillbirth. Infants born to mothers who smoked
during pregnancy are more likely to have certain
birth defects, be born premature and/or low
birthweight and die from Sudden Infant Death
Syndrome (SIDS).35,36 The previous version of
the birth certificate included a “yes/no” checkbox
regarding tobacco use during pregnancy and a
separate field for recording the average number of
cigarettes smoked per day. However, there was no
means to determine whether the mother smoked
prior to becoming pregnant or whether she ceased
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
CIGARETTE SMOKING BEFORE AND DURING PREGNANCY
For each time period, enter either the number of cigarettes or the
number of packs of cigarettes smoked. IF NONE, ENTER "0"
Average number of cigarettes or packs of cigarettes smoked per day.
# of cigarettes
# of packs
Three months before pregnancy
_____
OR ______
First three months of pregnancy
_____
OR ______
Second three months of pregnancy _____
OR ______
Third trimester of pregnancy
_____
OR ______
● Hypertension [Item 46]: The previous version
of the certificate included check-boxes in the
“Medical History for this Pregnancy” section
for chronic hypertension, pregnancy-related
hypertension and eclampsia. The revised certificate
reports hypertension in the “Risk Factors for This
Pregnancy” section and labels them as prepregnancy
(chronic), gestational (PIH, preeclampsia) and
eclampsia.
8
Division of Public Health
State Center for Health Statistics
Item 50
Item 46
46. RISK FACTORS IN THIS PREGNANCY
(Check all that apply)
50. CHARACTERISTICS OF LABOR AND DELIVERY
(Check all that apply)
Induction of labor
Augmentation of labor
Non-vertex presentation
Steroids (glucocorticoids) for fetal lung maturation
received by the mother prior to delivery
Antibiotics received by the mother during labor
Clinical chorioamnionitis diagnosed during labor
or maternal temperature > 38°C (100.4°F)
Moderate/heavy meconium staining of the amniotic
fluid
Fetal intolerance of labor such that one or more of
the following actions was taken: in-utero
resuscitative measures, further fetal assessment,
or operative delivery
Epidural or spinal anesthesia during labor
None of the above
Diabetes
Prepregnancy (Diagnosis prior to this pregnancy)
Gestational (Diagnosis in this pregnancy)
Hypertension
Prepregnancy (Chronic)
Gestational (PIH, preeclampsia)
Eclampsia
Previous preterm birth
Other previous poor pregnancy outcome (Includes
perinatal death, small-for-gestational age/
intrauterine growth restricted birth)
Pregnancy resulted from infertility treatment--If yes,
check all that apply:
Fertility-enhancing drugs, Artificial insemination
or Intrauterine insemination
Assisted reproductive technology (e.g., in vitro
fertilization (IVF), gamete intrafallopian transfer
(GIFT)
● Method of Delivery [Item 51]: The previous
version of the certificate included a checkbox for
method of delivery which had fields for vaginal,
vaginal birth after C-section, Primary C-section,
Repeat C-section, forceps and vacuum deliveries
(certifiers could check all that applied). The revised
certificate includes additional information regarding
fetal presentation (cephalic, breech, other), whether
forceps delivery was attempted and unsuccessful,
whether vacuum delivery was attempted but
unsuccessful and whether a trial of labor was
attempted prior to Cesarean section delivery.
C-section deliveries have risen 37 percent from 22.9
percent of resident births in 1990 to 31.4 percent in
2010.30,31
Mother had a previous cesarean delivery
If yes, how many ---------------None of the above
● Onset of Labor [Item 49]: The information
collected in the “Onset of Labor” section of the
revised birth certificate were previously collected in
the “Events of Labor and Delivery” section of the
previous version of the birth certificate.
Item 49
49. ONSET OF LABOR (Check all that apply)
Premature Rupture of Membranes
(prolonged, >12 hrs.)
Precipitous Labor (<3 hrs.)
Prolonged Labor (> 20 hrs.)
None of the above
Item 51
51. METHOD OF DELIVERY
● Characteristics of Labor and Delivery
[Item 50]: Induction of labor and meconium
were previously collected in the obstetrical
procedures section of the previous version of
the birth certificate. “Non vertex presentation”
was collected as “breech/malpresentation” in
the “events of labor and delivery” section of the
previous version of the birth certificate. “Clinical
chorioamnionitis diagnosed during labor” was
collected as “febrile >100F or 38C” on the
previous version of the birth certificate.
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
A.
Was delivery with forceps attempted but unsuccessful?
Yes
No
B.
Was delivery with vacuum extraction attempted but
unsuccessful?
Yes
No
C. Fetal presentation at birth
Cephalic
Breech
Other
D. Final route and method of delivery (Check one)
Vaginal/Spontaneous
Vaginal/Forceps
Vaginal/Vacuum
Cesarean
If cesarean, was a trial of labor attempted?
Yes
No
9
Division of Public Health
State Center for Health Statistics
● Fetal Presentation at Birth [Item 51]: The
previous version of the birth certificate included
a field for recording breech/malpresentation in
the “events of labor and delivery section.” The
revised certificate provides greater specificity
regarding whether the child was cephalic, breech
or other. Cesarean section delivery is typically
recommended in cases of fetal malpresentation.42,43
This information will be used to assess birth and
method of delivery outcomes for infants born after
fetal malpresentation in North Carolina.
● Abnormal Conditions of the Newborn [Item 57]:
The label for this section changed from “Conditions
of the Newborn” to “Abnormal Conditions of
the Newborn.” The previous version of the birth
certificate included two categories for assisted
ventilation: 1) <30 minutes and 2) >= 30 minutes.
The revised birth certificate has two different
categories: 1) ventilation required immediately
following delivery and 2) ventilation required for
more than six hours. The previous version of the
birth certificate included a checkbox for seizures.
The revised birth certificate changed this to
“seizures or serious neurologic dysfunction.” The
previous version of the birth certificate included
a checkbox for birth injury. The revised birth
certificate modifies this checkbox to: “significant
birth injury” and includes examples of what this
might include.
● Obstetric Estimate of Gestation [Item 54]: The
previous version of the birth certificate labeled this
field as “clinical estimate of gestation.”
Item 54
54. OBSTETRIC ESTIMATE OF GESTATION:
Item 57
------------------------------------ (completed weeks)
57. ABNORMAL CONDITIONS OF THE NEWBORN
(Check all that apply)
Assisted ventilation required immediately following
delivery
Assisted ventilation required for more than six hours
NICU admission
Newborn given surfactant replacement therapy
Antibiotics received by the newborn for suspected
neonatal sepsis
Seizure or serious neurologic dysfunction
Significant birth injury (skeletal fracture(s),
peripheral nerve injury, and/or soft tissue/solid
organ hemorrhage which requires intervention)
None of the above
● Apgar Score [Item 55]: The Apgar score is a
method for quickly assessing the overall health
of a newborn right after delivery. The Apgar
ranks newborn health with regard to skin color/
complexion, reflexes, muscle tone, breathing and
pulse rate. Newborns are typically assessed within
minutes after birth. The previous version of the
certificate recorded both one and five minute Apgar
scores. Research has concluded that one minute
Apgar scores alone are not a valid predictor of an
infant’s future outcome. Five minute Apgar scores
have been determined to be better predictors of
neonatal risk and mortality. Low Apgar scores at
five minutes should be repeated every five minutes
up to 20 minutes.44 As a result of this research, the
revised birth certificate standard now records a
five minute Apgar and only records the Apgar at
10 minutes if the five minute Apgar score was low
(defined as less than six).
● Congenital Anomalies [Item 58]: Research suggests
that congenital anomalies have not been reliably
recorded on past revisions to birth certificates.45,46 In
an effort to improve reporting, the Advisory Panel
that devised the specifications for the 2003 birth
certificate revision carefully examined deficiencies
in how congenital anomalies were captured on prior
certificates. According to the Advisory Panel, the
2003 revised certificate only includes anomalies
that meet the following criteria: “1) the anomaly
is diagnosable within the first 24 hours following
birth using widely available conventional diagnostic
techniques, 2) occurrence will indicate the need
for a specific public health initiative, 3) occurrence
serves as a potential marker for teratogen exposure,
4) occurrence in live borns is affected by prenatal
diagnosis or management and 5) postnatal outcome is
Item 55
55. APGAR SCORE:
Score at 5 minutes: ----------------------------------If 5 minute score is less than 6,
Score at 10 minutes: ---------------------------------
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
10
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State Center for Health Statistics
heavily impacted by access to tertiary or quaternary
care resources.”27 Congenital anomaly information
identified on the revised birth certificate will be
compared to the North Carolina Birth Defects
Monitoring Program registry data to assess if the
accuracy of congenital anomaly data collected
through the revised birth certificate improves
as a result of these reporting changes. Specific
modifications to this section include the following:
Item 58
58. CONGENITAL ANOMALIES OF THE NEWBORN
(Check all that apply)
Anencephaly
Meningomyelocele/Spina bifida
Cyanotic congenital heart disease
Congenital diaphragmatic hernia
Omphalocele
Gastroschisis
Limb reduction defect (excluding congenital
amputation and dwarfing syndromes)
Cleft Lip with or without Cleft Palate
Cleft Palate alone
Down Syndrome
Karyotype confirmed
Karyotype pending
Suspected chromosomal disorder
Karyotype confirmed
Karyotype pending
Hypospadias
None of the anomalies listed above
The previous version of the birth certificate had a
checkbox for “anencephalus” and the revised birth
certificate changes this to “anencephaly.” The previous
version of the birth certificate had a checkbox for
“spina bifida/meningocele” and the revised birth
certificate changes this to “meningomyelocele/spina
bifida.” The previous version of the birth certificate
had a checkbox for “heart malformations” and the
revised birth certificate changes this to “cyanotic
congenital heart disease.” The previous version of the
birth certificate had a checkbox for “diaphragmatic
hernia” and the revised birth certificate changes this
to “congenital diaphragmatic hernia.” The previous
version of the birth certificate had a checkbox for
“omphalocele/gastroscihsis” and the revised birth
certificate separates these into two separate fields
“omphalocele” and “gastroschisis.” The previous
version of the birth certificate had a checkbox for
“polydactyly/syndactyly/adactyly” and the revised
birth certificate modifies this to just “limb reduction
defect (excluding congenital amputation and dwarfing
syndromes).” The previous version of the birth
certificate had a checkbox for “cleft lip/palate” and
the revised birth certificate separates these into two
separate fields “cleft lip with or without cleft palate”
and “cleft palate alone.” The previous version of
the birth certificate had a checkbox for “Down’s
syndrome” and the revised birth certificate includes
this, but further specifies “karyotype confirmed”
and “karyotype pending.” The previous version
of the birth certificate had a checkbox for “other
chromosomal anomalies.” The revised birth certificate
also has “suspected chromosomal disorder,” and
additionally specifies “karyotype confirmed” and
“karyotype pending.” The revised birth certificate
has a checkbox for hypospadias. On the previous
version of the birth certificate this information may
have been collected via two different checkboxes,
one for “malformed genitalia” and another for “other
urogenital anomalies.”
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
● Infant Transfer (Item 59): Both versions of the
birth certificate include fields for reporting if the
infant was transferred to another facility. The
revised birth certificate further specifies whether it
was “within 24 hours of delivery.”
Item 59
59. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY?
IF YES, NAME OF FACILITY INFANT TRANSFERRED TO:
Yes
No
--------------------------------------------------------------------------------------------------------------
Fields that have been Eliminated with
the 2003 Revision
● Alcohol Use During Pregnancy: The previous
version of the birth certificate included an indicator
for whether the mother consumed alcohol during
pregnancy as well as the average number of
alcoholic drinks consumed per week during
pregnancy. Prior research with the 1989 revision to
the North Carolina birth certificate data indicated
that this field was not reliably reported.47 Other
research confirmed substantial underreporting and
inconsistency with prenatal drinking reported on
national health surveys.48 Based on this research,
the Advisory Panel that created the specifications
for the 2003 birth certificate revision concluded
that: “it is not feasible to get quality data on the
birth certificate because of the stigma attached
to alcohol use during pregnancy.” The Advisory
11
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State Center for Health Statistics
panel recommended that this data be obtained from
national health surveys, such as the Pregnancy Risk
Assessment Monitoring System (PRAMS).27
the Advisory panel determined that many of the
congenital anomalies reported on the previous
version of the birth certificate were not reliably
reported.27 As a result, the following congenital
anomaly fields are no longer collected on the
2003 revised birth certificate: hydrocephalus,
microcephalus, other central nervous system
anomalies, other circulatory/respiratory anomalies,
rectal atresia/stenosis, tracheo-esophageal fistula/
esophageal atresia, other gastrointestinal anomalies,
renal agenesis, other urogenital anomalies, club
foot, other musculoskeletal/integumental anomalies
and other chromosomal anomalies.
● Medical History: Based on Advisory Panel
recommendations, several maternal conditions
were eliminated from this section of the certificate
(in the 2003 revision, this section was relabeled
“Risk Factors in this Pregnancy”). Conditions
that did not meet the following criteria were
eliminated: “1) clearly defined clinically, 2)
collectable at least 90 percent of the time, 3)
evidence-based, 4) useful for research (public
health and clinical) purposes, 5) potential to
effect pregnancy outcome, and 6) required by
legal statute.”27 Using this criteria, the following
maternal conditions were eliminated: anemia,
cardiac disease, acute or chronic lung disease,
genital herpes, hydramnios/obligohydramnios,
hemoglobinopathy, incompetent cervix, previous
infant 4000+ grams, renal disease, Rh sensitization
and uterine bleeding.
● Other Specified Diagnoses and Conditions: The
previous version of the birth certificate collected
additional diagnostic information in the “other
specified” fields of the medical history, obstetric
procedures, events of labor and delivery, conditions
of the newborn and congenital anomalies of child
sections. The revised birth certificate has eliminated
these free text fields because they do not result
in uniform data that can be coded and utilized by
states.27
● Events of Labor and Delivery: Based on
Advisory Panel recommendations, this section
of the certificate was also significantly modified
(in the 2003 revision, this section was relabeled
“Characteristics of Labor and Delivery”).
The Advisory Panel recommended that the
following fields be eliminated from the 2003
revised birth certificate: meconium moderate
or heavy, abruption placenta, placentia previa,
other excessive bleeding, seizures during labor,
dysfunctional labor, cord prolapse, anesthetic
complications and fetal distress.
New and Modified Fields Collected for
Legal and Vital Registration Purposes
Some additional fields that are not necessary for medical
or health research, but are helpful for legal and vital
registration purposes have also been added or modified
on the revised birth certificate. Below is a list of these
fields:
● Mother Last Name (Current and Prior to First
Marriage) [Items 9a and 9c];
● Conditions of the Newborn: The Advisory Panel
recommended removal of newborn conditions from
the birth certificate: 1) that are not easily diagnosed
within the first 24 hours following delivery, 2)
which do not have high associations with adverse
neonatal and long-term outcomes and 3) markers for
utilization of costly technological resources.27 Based
on this criteria, the following newborn conditions
were removed from the revised birth certificate:
anemia, fetal alcohol syndrome, hyaline membrane
disease/RDS and meconium aspiration syndrome.
● For Unmarried mothers, whether a paternity
acknowledgement was signed in the hospital [Item
22].
Reporting Data Based on the Revised
Birth Certificate in North Carolina
In 2010, North Carolina’s Vital Records office began
implementing a new birth registration based on the
2003 revised birth certificate standard. Training in the
● Congenital Anomalies: As outlined in the
congenital anomalies modifications section above,
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
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Division of Public Health
State Center for Health Statistics
new web-based birth registration system was rolled
out in August 2010, hospital by hospital. By the end
of 2010, all hospitals in the state were transmitting
birth data to the state Vital Records office through the
new registration system. As a result of this staggered
implementation, North Carolina birth data were
collected under both the 1989 and the 2003 birth
certificate standards in 2010. Therefore, the State Center
for Health Statistics was unable to publish any data
from the new or modified fields for 2010 births. Fields
that were not comparable across the two certificate
revisions, such as maternal smoking, prenatal care and
congenital anomalies were left blank in the 2010 birth
file and were not reported in the 2010 Vital Statistics
reports. Beginning in 2011, birth data were collected
solely under the revised U.S. Standard Certificate,
therefore, 2011 will represent the first full year of
revised birth certificate data that North Carolina’s State
Center for Health Statistics will publish. Researchers
and other data users of North Carolina birth data will
need to be careful not to compare trends in certain key
public health indicators, such as prenatal care, race,
smoking and maternal education levels, across the two
revisions.
for Health Statistics. Tracking Preconception
Health in North Carolina: 2010. Available at:
www.schs.state.nc.us/schs/data/preconception.
html. Accessed April 12, 2012.
5. Centers for Disease Control and Prevention,
Reproductive Health. Pregnancy Complications.
Available at: www.cdc.gov/reproductivehealth/
maternalinfanthealth/PregComplications.htm.
Accessed April 12, 2012.
6. National Academies, Institute of Medicine. Weight
gain during pregnancy: reexamining the guidelines.
Report brief, May 2009. Available at: www.
iom.edu/~/media/Files/Report%20Files/2009/
Weight-Gain-During-Pregnancy-Reexamining-theGuidelines/Report%20Brief%20-%20Weight%20
Gain%20During%20Pregnancy.pdf. Accessed April
12, 2012.
7. U.S. Department of Agriculture, Food and Nutrition
Service. Women, Infants and Children. Available at:
www.fns.usda.gov/wic. Accessed April 12, 2012.
8. Bitler M, Currie J. Does WIC Work? The Effects
of WIC on Pregnancy and Birth Outcomes.
Department of Economics, UCLA, June 2004.
Available at: www.econ.ucla.edu/people/papers/
currie/more/prams.pdf. Accessed April 12, 2012.
9. Buescher P, Horton S. Prenatal WIC participation
in relation to low birth weight and Medicaid
Infant Costs in North Carolina—A 1997 Update.
CHIS Study: No. 122. November 2000. Available
at: www.schs.state.nc.us/schs/pdf/CHIS122.pdf.
Accessed April 12, 2012.
10. Buescher P. Method of linking Medicaid records
to birth certificates may affect infant outcome
statistics. American Journal of Public Health, April
1999;89(4): 564–6. Available at: www.schs.state.
nc.us/SCHS/pdf/medicaid.pdf. Accessed April 12,
2012.
11. American Diabetes Association. Diabetes Basics:
What is Gestational Diabetes? Available at: www.
diabetes.org/diabetes-basics/gestational/what-isgestational-diabetes.html. Accessed April 12, 2012.
12. National Diabetes Information Clearinghouse
(NDIC). What I need to know about Gestational
Diabetes. Available at: http://diabetes.niddk.nih.
gov/dm/pubs/gestational/#3. Accessed April 12,
2012.
13. Welmerink D, Voigt L, Daling J, Mueller B.
Infertility treatment use in relation to selected
adverse birth outcomes. Fertility and Sterility.
December 2010;94(7):2580–6.
References
1. National Center for Health Statistics, Division of
Vital Statistics, Reproductive Statistics Branch.
2003 Revisions of the U.S. Standard Certificates of
Live Birth and Death and the Fetal Death Report.
Hyattsville, MD: Available at: www.cdc.gov/nchs/
nvss/vital_certificate_revisions.htm. Accessed April
12, 2012.
2. National Center for Health Statistics, Division of
Vital Statistics, Reproductive Statistics Branch.
The New Birth Certificate: Making Vital Statistics
More Vital. Hyattsville, MD: Available at: www.
cdc.gov/nchs/ppt/dvs/THE%20NEW%20
BIRTH%20CERTIFICATE.ppt. Accessed April 12,
2012.
3. Centers for Medicare and Medicaid Services
(CMS). National Provider Identifier Standard (NPI).
Available at: www.cms.hhs.gov/Regulations-andGuidance/HIPAA-Administrative-Simplification/
NationalProvIdentStand/index.html?redirect=/
NationalProvIdentStand. Accessed April 12, 2012.
4. North Carolina Department of Health and Human
Services, Division of Public Health, State Center
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
13
Division of Public Health
State Center for Health Statistics
14. March of Dimes. Multiple Pregnancy and Birth:
Considering Fertility Treatments. Available at:
www.marchofdimes.com/Fertility_treatments_and_
multiple_pregnancy_PDF.pdf. Accessed April 12,
2012.
15. Menacker F, Hamilton B. Recent trends in cesarean
delivery in the United States. NCHS Data Brief.
2010, No. 35. Hyattsville, MD: National Center for
Health Statistics. Available at: www.cdc.gov/nchs/
data/databriefs/db35.pdf. Accessed April 12, 2012.
16. American College of Obstetricians and
Gynecologists. Hepatitis B in Pregnancy:
Frequently Asked Questions. Available at: www.
acog.org/~/media/For%20Patients/faq093.pdf?dmc
=1&ts=20120410T1351526804. Accessed April 12,
2012.
17. U.S. Preventive Services Task Force. Screening
for Hepatitis B Virus in Pregnancy: Reaffirmation
Recommendation Statement. Dated June 2009.
Available at: www.uspreventiveservicestaskforce.
org/uspstf09/hepb/hepbpgrs.htm. Accessed April 12,
2012.
18. Danel I, et al. Magnitude of Maternal Morbidity
During Labor and Delivery: United States, 1993–
1997. Am J Public Health. 2003 April;93(4):631–4.
Available at: www.ncbi.nlm.nih.gov/pmc/articles/
PMC1447802. Accessed April 12, 2012.
19. Singh GK, Yu, SM. Infant mortality in the United
States: trends, differentials, and projections,
1950 through 2010. Am J Public Health. 1995
July;85(7):957–64. Available at: www.ncbi.nlm.nih.
gov/pmc/articles/PMC1615523. Accessed April 12,
2012.
20. U.S. Preventive Services Task Force. Primary
Care Interventions to Promote Breastfeeding:
Recommendation Statement. Dated October 2008.
Available at: www.uspreventiveservicestaskforce.
org/uspstf08/breastfeeding/brfeedrs.htm. Accessed
April 12, 2012.
21. Healthy People 2020. Maternal, Infant and Child
Health: Objective: MICH-21.1. Available at: http://
healthypeople.gov/2020/topicsobjectives2020/
objectiveslist.aspx?topicid=26. Accessed April 12,
2012.
22. Buescher P, Gizlice Z, Jones-Vessey K. SelfReported versus Published Data on Racial
Classification in North Carolina Birth Records.
SCHS Study: No 139. February 2004. Available
at: www.schs.state.nc.us/schs/pdf/schs139.pdf.
Accessed April 12, 2012.
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
23. Buescher P, Gizlice Z, Jones-Vessey K.
Discrepancies Between Published Data on Racial
Classification and Self-Reported Race: Evidence
from the 2002 North Carolina Live Birth Records.
Public Health Reports. July–Aug 2005;120:393–8.
Available at: www.ncbi.nlm.nih.gov/pmc/articles/
PMC1497745/pdf/16025719.pdf. Accessed April
12, 2012.
24. U.S. Office of Management and Budget. Revisions
to the Standards for the Classification of Federal
Data on Race and Ethnicity. October 30, 1997.
Available at: www.whitehouse.gov/omb/
fedreg_1997standards. Accessed April 12, 2012.
25. National Center for Health Statistics, National Vital
Statistics System. U.S. Census Populations With
Bridged Race Categories. Available at: www.cdc.
gov/nchs/nvss/bridged_race.htm. Accessed April 12,
2012.
26. National Center for Health Statistics, Division
of Vital Statistics. NCHS Procedures for MultipleRace and Hispanic Origin Data: Collection, Coding,
Editing, and Transmitting. May 7, 2004. Available
at: www.cdc.gov/nchs/data/dvs/multiple_race_
documentation_5-10-04.pdf. Accessed April 12,
2012.
27. National Center for Health Statistics, Division of
Vital Statistics. Report of the Panel to Evaluate the
U.S. Standard Certificates. April 2000, Addenda
Nov 2001. Available at: www.cdc.gov/nchs/data/
dvs/panelreport_acc.pdf. Accessed April 12,
2012.
28. Declercq E, MacDorman MF, Menacker F, Stotland
N. Characteristics of planned and unplanned
home births in 19 states. Obstet Gynecol.
2010;116(1):93–9.
29. MacDorman MF, Mathews TJ, Declercq E. Home
births in the United States, 1990–2009. NCHS
data brief, no 84. Hyattsville, MD: National Center
for Health Statistics. 2012. Available at: www.cdc.
gov/nchs/data/databriefs/db84.htm. Accessed
April 12, 2012.
30. North Carolina Department of Health and Human
Services, Division of Public Health, State Center
for Health Statistics. North Carolina Selected
Vital Statistics: Volume 1—1990. Available at:
www.schs.state.nc.us/schs/pdf/1990_NORTH_
CAROLINA_VITAL_STATISTICS_VOLUME_1.pdf.
Accessed April 12, 2012.
31. North Carolina Department of Health and Human
Services, Division of Public Health, State Center
14
Division of Public Health
State Center for Health Statistics
for Health Statistics. North Carolina Selected Vital
Statistics: Volume 1—2010. Available at: www.
schs.state.nc.us/schs/vitalstats/volume1/2010.
Accessed April 12, 2012.
32. McCormick MC, Siegel E. Recent Evidence on
the Effectiveness of Prenatal Care. Ambulatory
Pediatrics. 2001;1(6):321,5.
33. Alexander, GR, Kotelchuck M. Assessing the
Role and Effectiveness of Prenatal Care: History,
Challenges, and Directions for Future Research.
Public Health Reports. 2001;116(4):306–16.
Available at: www.ncbi.nlm.nih.gov/pmc/
articles/PMC1497343/pdf/12037259.pdf.
Accessed April 12, 2012.
34. Abdullah et al. Associations of maternal prepregnancy obesity and excess pregnancy weight
gains with adverse pregnancy outcomes and
length of hospital stay. BMC Pregnancy Childbirth.
2011;11:62. Available at: www.ncbi.nlm.nih.gov/
pmc/articles/PMC3178538/?tool=pmcentrez.
Accessed April 12, 2012.
35. Centers for Disease Control and Prevention,
Reproductive Health. Tobacco Use and Pregnancy.
Available at: www.cdc.gov/reproductivehealth/
tobaccousepregnancy. Accessed April 12, 2012.
36. Salihu HM, Wilson RE. Epidemiology of prenatal
smoking and perinatal outcomes. Early Human
Development. November 2007;83(11):713–20.
37. Marks JS, Koplan JP, Hogue CJ, Dalmat ME. Costbenefit/cost effectiveness analysis of smoking
cessation for pregnant women. American Journal
of Preventive Medicine. 1990;6:282–9.
38. Lightwood JM, Phibbs C, Glantz SA. Shortterm health and economic benefits of smoking
cessation: low birth weight. Pediatrics.
1999;104:1312–20.
39. Ventura S. Using the Birth Certificate to Monitor
Smoking During Pregnancy. Public Health
Reports. January/February 1999;114:71–3.
Available at: www.ncbi.nlm.nih.gov/pmc/
articles/PMC1308346. Accessed April 12, 2012.
40. Kharrazi et al. Evaluation of four maternal
smoking questions. Public Health Report.
January-February 1999;114(1):60–70. Available
at: www.ncbi.nlm.nih.gov/pmc/articles/
PMC1308345. Accessed April 12, 2012.
41. Osterman MJK, Martin JA, Mathews TJ, Hamilton
BE. Expanded data from the new birth certificate,
2008. National Vital Statistics Reports. 2011;59:7.
Hyattsville, MD: National Center for Health
Statistical Primer No. 19 ♦ June 2012
N.C. Department of Health and Human Services
Statistics. Available at: www.cdc.gov/nchs/data/
nvsr/nvsr59/nvsr59_07.pdf. Accessed April 12,
2012.
42. ACOG Committee Opinion No. 340. Mode of
term singleton breech delivery. Obstet Gynecol.
2006;108(1):235–7. Available at: www.acog.
org/Resources_And_Publications/Committee_
Opinions/Committee_on_Obstetric_Practice/
Mode_of_Term_Singleton_Breech_Delivery.
Accessed April 12, 2012.
43. Lee et al. Population Trends in Cesarean Delivery
for Breech Presentation in the United States
1997–2003. American Journal of Obstetrics and
Gynecology. July 2008;199(1):59.e1–8. Available
at: www.ncbi.nlm.nih.gov/pmc/articles/
PMC2533265/?tool=pmcentrez. Accessed April
12, 2012.
44. American Academy of Pediatrics, Committee
on Fetus and Newborn, American College of
Obstetricians and Gynecologists and Committee
on Obstetric Practice. The Apgar Score. Pediatrics.
2006;117:1444–7. Available at: http://pediatrics.
aappublications.org/content/117/4/1444.full.
pdf+html. Accessed April 12, 2012.
45. Snell et al. Reliability of birth certificate
reporting of congenital anomalies. American
Journal of Perinatology. May 1992;9(3):219–22.
46. Watkins et al. The surveillance of birth defects:
The usefulness of the revised US standard birth
certificate. American Journal of Public Health.
1996;86:731–4. Available at: www.ncbi.nlm.nih.
gov/pmc/articles/PMC1380486/?tool=pubmed.
Accessed April 12, 2012.
47. Buescher P, Taylor K, Davis M, Bowling J.
The quality of the new birth certificate
data: a validation study in North Carolina.
American Journal of Public Health. August
1993;83(8):1163–5. Available at: www.ncbi.nlm.
nih.gov/pmc/articles/PMC1695166. Accessed
April 12, 2012.
48. Weisskopf, MG. Quality of birth certificate data
on tobacco and alcohol use during pregnancyGreat Lakes Region, United States: 1989–1995.
Presented at the CDC Epidemic Intelligence
Service Conference. 2001.
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Division of Public Health
State Center for Health Statistics
State of North Carolina
Beverly Eaves Perdue, Governor
Department of Health and Human Services
Albert A. Delia, Acting Secretary
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