CENTERS FOR DISEASE CONTROL AND PREVENTION

U.S. Vital

Statistics System

U.S. Vital

Statistics System

Major Activities and Developments, 1950-95

From the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Includes reprint of "History and

Organization of the Vital Statistics

System" to 1950

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics


National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jack R. Anderson, Deputy Director

Jack R. Anderson, Acting Associate Director for

International Statistics

Lester R. Curtin, Ph.D., Acting Associate Director for

Research and Methodology

Jacob J. Feldman, Ph.D., Associate Director for Analysis,

Epidemiology, and Health Promotion

Gail F. Fisher, Ph.D., Associate Director for Data Standards,

Program Development, and Extramural Programs

Edward L. Hunter, Associate Director for Planning, Budget,

and Legislation

Jennifer H. Madans, Ph.D., Acting Associate Director for

Vital and Health Statistics Systems

Stephen E. Nieberding, Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

Division of Vital Statistics

Mary Anne Freedman, Director

James A. Weed, Ph.D., Deputy Director

George A. Gay, Special Assistant for Registration Methods

Harry M. Rosenberg, Ph.D., Chief, Mortality Statistics

Branch

Vacant, Chief, Reproductive Statistics Branch

Nicholas F. Pace, Acting Chief, Systems, Programming, and

Statistical Resources Branch

Ronald F. Chamblee, Chief, Data Acquisition and Evaluation

Branch
Acknowledgments

This report was prepared by Alice M. Hetzel under contract with the National Association for Public

Health Statistics and Information Systems (NAPHSIS), formerly the Association for Vital Records and Health

Statistics (AVRHS).

The author is grateful to NAPHSIS for sponsoring this update of the history of the vital statistics system

in the United States. Special recognition is owed to Mary Anne Freedman and Frederick L. King, who, during

their tenure as officers and executive committee members of AVRHS, actively supported initiation of the

project. The association sought the cooperation of the National Center for Health Statistics (NCHS) and

gained the support of Manning Feinleib, M.D., Dr. P.H., former Director of NCHS, and John E. Patterson,

former Director of the Division of Vital Statistics. Coordination between NAPHSIS and NCHS was expertly

provided under the leadership of George A. Gay, Chief, Registration Methods Branch, Division of Vital

Statistics.

Many persons within NAPHSIS and NCHS contributed to the production of this history with suggestions

for subjects to be included and help in locating pertinent reports and memoranda and in processing the final

manuscript for publication. The author is especially indebted to Judy M. Barnes of the Registration Methods

Branch for her technical assistance with the content of the report and with the activities associated with its

publication. Specific acknowledgment is made to the following reviewers, whose comments helped shape the

report: Robert Bilgrad, Linda Bordonaro, John Brockert, Joe Carney, Ronald Chamblee, Marshall Evans,

Joseph Farrell, Mary Anne Freedman, Donna Glenn, Robert D. Grove, Ph.D., Nancy Hamilton, Susan Hawk,

Robert Heuser, Frederick L. King, A. Joan Klebba, Michael Kogan, Ph.D., Julia Kowaleski, William Mosher,

Stephanie Mounts, Sherry Murphy, William Pratt, Mabel Smith, James Spitler, George Van Amburg, and

James A. Weed, Ph.D.

Manuscript preparation was ably and patiently prepared by Gayle Shannon. This report was edited by

Demarius V. Miller and typeset by Zung T.N. Le, Division of Data Services, Publications Branch.

iii
Contents

Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Preface ............................................................................................... 1

Introduction........................................................................................... 1

Organizational changes ................................................................................ 2

Transfer to the Public Health Service................................................................ 2

National Center for Health Statistics ................................................................ 2

Supporting activities ................................................................................... 2

Public Health Conference on Records and Statistics .................................................. 3

National Association for Public Health Statistics and Information Systems ............................. 3

Developmental activities ............................................................................... 5

Model Vital Statistics Act........................................................................... 5

U.S. standard certificates and reports ............................................................... 6

Registration areas ................................................................................. 9

Improvement of data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Tests of birth registration completeness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Query programs for improving birth and death data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Current Mortality Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Cause-of-death classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Comparability studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Ranking causes of death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Automated mortality data system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Electronic registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Multiple causes-of-death statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Race and ethnicity data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Fetal death and induced termination of pregnancy data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Linked birth/infant death data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Special projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Vital statistics rates in the United States: 1940–60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Vital and health statistics monographs, 1959–61 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Cooperative developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Vital statistics component of the Cooperative Health Statistics System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

State centers for health statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Supplemental data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Follow-back surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

National Survey of Family Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

National Death Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Availability of vital statistics data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Public-use data tapes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

CD-ROM with SETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Vital statistics in the 21st century: A vision for the future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

v
Appendixes

I. Appendix tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

II. History and Organization of the Vital Statistics System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

vi
U.S. Vital Statistics System

Major Activities and Developments: 1950–95

Preface

The early history of the vital statistics system was

presented in detail in Vital Statistics of the United

States, Volume I, 1950. This earlier document is

reprinted in this publication in appendix II. That

report begins with the early collection and preservation of registration records as legal evidence of the

occurrence of the event, primarily for use in protecting

individual rights. It then describes the era in which

death records by cause became recognized as essential

for control of epidemics and for other public health

interests. The report goes on to cover how welfare

legislation of the 1930’s and emergency World War II

legislation of the 1940’s brought about an unprecedented demand by individuals for their birth certificates.

Included in the earlier report is a description of

the long, hard-fought, and often discouraging campaign of individuals, associations, and State and Federal agencies to bring about uniform registration laws

and reporting forms that could not only serve the

increasing needs of individuals for their records but

also provide data for statistical analysis at all levels of

government. The establishment, development, and

completion of the registration areas designed to provide national birth and death statistics and the early

efforts that ultimately led to establishment of similar

registration areas for providing marriage and divorce

data are described. The report traces the Federal

function in vital statistics from its origin in the Bureau

of the Census to its placement in the National Office of

Vital Statistics in the Public Health Service in 1946.

The purpose of this report is to pick up where the

1950 report ended and describe further developments

and major activities and accomplishments that occurred

from 1950 through 1995. Most of the information

included was obtained from or based upon material

contained in government reports. Material from the

1950 report is repeated in certain instances to provide

an informative context for understanding the more

recent developments. Reference is also made to some

pre-1950 activities and achievements that were not

discussed in the earlier report.

All publications that were reviewed by the author

in preparing this report are referred to in the text or

cited as sources. Because the publications reviewed

are in the public domain, much of the material in them

is widely used, appears in numerous publications, and

consequently, is likely to appear in publications not

cited in this report.

Introduction

Vital statistics for the United States are obtained

from the official records of live births, deaths, fetal

deaths, marriages, divorces, and annulments. The official recording of these events is the responsibility of

the individual States and independent registration

areas (District of Columbia, New York City, and territories) in which the event occurs; the Federal Government obtains use of the records for statistical purposes

through a cooperative arrangement with the responsible agency in each State.

Since 1950 attention has been focused on improving the quality of vital statistics and making them

more useful and widely available. Interest in vital

statistics widened when State and Federal agencies,

challenged to define needs for and effects of various

State and Federal health and welfare programs, began

looking for pertinent and reliable statistics on which to

base judgments. The registration certificates assumed

new importance as they were looked to as a source of

credible national vital and health statistics for use by

all levels of government, institutions, and the general

public.

Demand for this information increased, and

research was undertaken to determine the most economical and effective application of the rapidly developing data processing technology. Updating data

collecting, recording, and processing techniques to keep

abreast of rapidly evolving automation capabilities

became an increasingly important part of the vital

statistics program.

As health and social issues became more complex,

the content of the information collected on the vital

records was expanded and measures to improve its

1
quality and usefulness were added. Supplemental data

sources were developed to augment and enrich the

information obtained from the registration system.

The function of producing national vital statistics

was shifted several times from one organizational unit

of the Federal Government to another, the most consequential being its merging with the National Health

Survey to form the National Center for Health Statistics (NCHS). The following is a discussion of the most

prominent milestones in the progress of the national

vital statistics program during the last half of the 20th

century.

Organizational changes

The act of Congress that made the Bureau of the

Census a permanent full-time agency of the Federal

Government in 1902 also gave the Bureau statutory

authority to establish registration areas to produce

nationally comparable vital statistics. This put into

motion the development of a system for the annual

collection of vital statistics data on a national basis.

Transfer to the Public Health Service

These collection activities continued in the Division of Vital Statistics of the Bureau of the Census

until July 1946. At that time the Bureau of the Budget’s recommendations of 1943 were adopted, and the

Federal Security Administration (one of the agencies

that was combined with others to form the Department of Health, Education, and Welfare in April 1953)

was given authority for Federal functions in vital

statistics. The National Office of Vital Statistics was

established in the Public Health Service, with the

head of the office reporting directly to the Surgeon

General.

National Center for Health Statistics

In 1960 the National Office of Vital Statistics was

merged with the National Health Survey to establish

the National Center for Health Statistics (NCHS).

Effective in September 1963, NCHS was reorganized,

with the Division of Vital Statistics becoming one of

five operating divisions. This reorganization separated

support activities, such as data processing and publication activities, from the substantive vital statistics

program operations.

Dr. Forrest E. Linder, the first director of NCHS,

articulated the widely held expectations for the newly

established center in his comments at the Public Health

Conference on Records and Statistics held in 1962. He

envisioned the center as ‘‘not just a factory, but a

scientific organization,’’ the existence of which would

permit greater emphasis on analysis as opposed to

mere collection and dissemination of statistics. Holding it to be essential to protect the integrity of NCHS

statistics by distinguishing analysis from propaganda

or a program for promotion of solutions to problems,

he looked to analysis to identify and clarify problems

that needed solution.

Dr. Linder saw the center as providing emphasis

on methodological research in all areas of concern to

health statistics. This included registration methods

for vital events, extended relations with the States,

more research into operational techniques, and leadership in new areas of data collection, follow-back surveys, and the gathering of institutional data. He

welcomed the enlarged relationships made possible by

the center, including intergovernmental cooperation,

international exchanges, and collaboration with universities, survey centers, and health organizations.

The Health Services Research and Evaluation and

Health Statistics Act of 1974 (Public Law 93–353)

established NCHS in law and codified its mandate and

authorities under section 306 of the Public Health

Service Act. The Act provided for NCHS to collect

statistics on a broad range of health-related subjects,

including births, deaths, marriages, and divorces. It

established the National Committee on Vital and Health

Statistics as an expert advisory committee to the

Secretary of the Department of Health, Education,

and Welfare. It called for the center to undertake and

support research demonstrations and evaluations

regarding survey methods and to provide technical

assistance to State and local jurisdictions. Subsequent

changes in public laws that established, amended, or

extended NCHS authorities did not substantially affect

the national vital statistics system.

Supporting activities

The history of vital statistics is interlaced with

supportive endorsements and activities of numerous

associations and organizations. From the earliest days

of their existence, the American Statistical Association, the American Medical Association, the American

Public Health Association, and the American Bar Association provided strong support for establishing offices

to collect vital statistics. These organizations promoted uniform registration laws for vital events, uniformity in the content of vital records, and an aggressive

public health program with vital statistics as a principal component. Their interest and influence continue, as

they maintain close relationships with State and Federal

activities bearing on the vital statistics program.

In the late 1940’s, a report published by the

National Bureau of Economic Research on ‘‘The Statistical Agencies of the Federal Government’’ validated

the earlier work of these organizations. The study was

produced as part of the work of the Commission on

2 Major Activities and Developments
Organization of the Executive Branch of Government,

which had been appointed by President Hoover. This

commission recommended a new status for the statistical activities of the Federal Government, urging high

priority for them among the basic functions of government and emphasizing the need for budgetary

resources, training and Federal-State coordination to

obtain high-quality, comprehensive, and timely statistics. It reinforced the findings and recommendations of

the various organizations and government agencies

that during the 1930’s and 1940’s had been voicing the

same concerns.

The report presented specific findings and recommendations pertaining to the statistical activities of

the Federal Government. Many were particularly applicable to public health statistics. Foremost among these

was the recommendation that ‘‘appropriate divisions of

the Public Health Service [will] be responsible for the

repetitive collection of natality, mortality, and morbidity statistics (which should be part of a unified collection program) and for specialized research, analysis,

and statistical testing in this field.’’

The report also urged exploration of means of

coordinating and unifying the statistical reporting systems of Federal and State governments; recognition of

the need for recruitment of high-grade statistical personnel; and close liaison between statistical agencies

and respondent and user groups. Bearing on the integrity of health statistics was the recommendation that

the functions of fact finding be ‘‘clearly distinguished

from activities involving the setting of social goals or

the promotion of special aid programs.’’

Public Health Conference on Records

and Statistics

The Public Health Conference on Records and

Statistics (PHCRS) was established to develop and

coordinate registration and statistical practices among

State registration areas with the cooperation of the

National Office of Vital Statistics. This office had its

beginnings in 1935 when the Division of Vital Statistics, then in the Bureau of the Census, was mandated

to promote a cooperative system of vital records and

vital statistics. With Halbert L. Dunn, M.D., as the

principal initiator and organizer, the division began

convening annual meetings of State registration executives and Federal representatives to assess registration problems and to develop and promote solutions.

These annual work conferences, restricted to a geographically representative committee during the war

years, proved fruitful and were continued after the

war.

In May 1949, the PHCRS was formally established

on a permanent year-round basis as a State-Federal

organization sponsored by the National Office of Vital

Statistics, which had by then been established in the

Public Health Service. This brought together the skills

and experience of State registrars, vital statisticians,

and public health statisticians in a joint effort with the

National Office of Vital Statistics to improve registration of vital events and the statistics derived from the

registration records.

The conference carried on much of its work through

two committees, one on registration and one on statistics. All members, according to their choice, served on

one of these two committees. Each committee was

divided into subcommittees as needed to explore and

make recommendations on specific subjects. Over the

years the committee on registration addressed such

issues as confidentiality of records, periodic revision of

the standard certificates, a model law, completeness of

vital registration, marriage and divorce registration,

record linkage, and interchange of nonresident birth

and death certificates. Issues addressed by the committee on statistics included national morbidity reporting,

multiple causes-of-death tabulations, improvement of

medical certification, residence allocation, and fetal

death reporting.

From 1958 until his retirement in 1973, Junior K.

Knee, Assistant to the Director, NCHS, served as

executive secretary of the PHCRS. Under his active

leadership, the PHCRS was a strong influence in

promoting local-State-Federal cooperation. In addition

to working toward increased accuracy and completeness of vital records, he was a strong advocate of

balancing the attention given to the essential legal

purposes of the documents with that given to their

potential to provide information not available elsewhere for analysis of public health problems.

Currently, the PHCRS is a biennial meeting sponsored by NCHS. It focuses on health statistics related

to emerging public health issues. Its sessions address

data needs and issues related to data quality and

integrity, methodological aspects of measuring and

evaluating health care needs and services, appropriateness of various measures, improving data reliability and validity, data collection and analytic issues,

new developments in information and data handling

systems, and other pertinent and timely topics as they

arise.

National Association for Public Health

Statistics and Information Systems

The National Association for Public Health Statistics and Information Systems (NAPHSIS) was organized in 1933 and was first known as the American

Association of State Registration Executives. As

described in its 50th anniversary history (1), the stated

purpose of the association was ‘‘to study and promote

all matters relating to the registration of vital statisMajor Activities and Developments 3
tics.’’ The members were ‘‘all persons in active executive charge of the registration of vital statistics in a

state department and persons holding similar positions in Canada, Mexico, and Cuba. The Chief Statistician for Vital Statistics of the United States Bureau

of the Census shall be a member ex-officio.’’

The association has undergone several name

changes. In 1938 the name was changed to the American Association of State and Provincial Registration

Executives. In 1939 it was changed to the American

Association of Registration Executives (AARE), and in

1958, the name became the American Association for

Vital Records and Public Health Statistics (AAVRPHS). In 1980 it was changed to the Association for

Vital Records and Health Statistics (AVRHS). In 1995

the name became the Association for Public Health

Statistics and Information Systems (APHSIS) and in

1996, the National Association for Public Health Statistics and Information Systems (NAPHSIS). These

later changes reflect the broadening interests of the

association.

Similarly, the stated purpose of the association

also changed over the years. Until 1950, it continued

to be ‘‘to study and promote all matters relating to the

registration of vital statistics.’’ In 1950, it became ‘‘to

work for the development and maintenance of sound

systems of vital records that can provide the information and services needed in the best interest of the

people and their government.’’ In the 1958 revision of

the bylaws, the purpose of the association read ‘‘to

provide opportunity for discussion of and group action

on problems and policies involved in the administration of vital records and public health statistics programs in the United States, its territories and

possessions, and to serve as an advisory group to the

Association of State and Territorial Health Officers for

the programs.’’ The last sentence of the purpose was

amended in 1982 to read ‘‘. . . to serve as an advisory

group to the Association of State and Territorial Health

Officials (ASTHO) and other organizations for these

programs.’’ The 1995 revision of the association bylaws

states: ‘‘This Association will foster discussion and

group action on issues involving public health statistics, public health information systems, and vital

records registration. The Association will provide standards and principles for administering public health

statistics, public health information systems, and vital

records registration. The Association will represent the

States and Territories of the United States regarding

these issues, and will serve as an advisory group to the

Association of State and Territorial Health Officials.’’

The association also widened eligibility for membership as its interests grew. In 1938 it expanded

membership to include ‘‘all persons in active executive

charge of the registration of vital statistics in State

and provincial departments in the United States and

Possessions, Canada, Mexico, Cuba, New York City,

Baltimore, and Washington, DC.’’ In addition to the

Chief Statistician for Vital Statistics of the United

States, it included as ex-officio members the assistant

statistician and officials holding similar positions in

Canada, Mexico, and Cuba. It also provided for life

membership for members who served for 20 years as a

registration executive. The 20-year requirement was

dropped in the 1950 bylaws. In 1946, Boston and New

Orleans were added to the list of included independent

registration areas.

In 1950 the association established a governing

council comprised of the association membership as

defined in 1946. The right to hold office, to serve on

standing committees, and to chair other committees

was limited to members of the governing council.

Concurrently, persons professionally engaged in vital

records work were eligible for election to membership,

and individuals or corporations interested in vital

records were eligible for sustaining membership by

vote of the executive board. In 1958 sustaining memberships were dropped and an associate membership

was established for ‘‘persons professionally engaged in

vital records or public health statistics programs in

State or local health departments.’’

In 1982 the membership categories included governing council members, associate members, and honorary life members. With the 1995 revision of the

association bylaws, different membership categories

were established. Agency-designated members include

State, territorial, and local health departments or

other non-Federal Government agencies; these memberships entitle the designation of up to four salaried

staff persons of the organization. Individual memberships may be purchased for additional agency staff,

including local health department staff who are professionally engaged in public health statistics and information systems, and affiliate (nonvoting) memberships

are open to persons not eligible for voting membership

who are interested in furthering improvements to

public health statistics and information systems. The

right to hold office and to attend special closed sessions

for voting members only is limited to agencydesignated and individual members. Any member may

serve on association committees.

The 1958 revision of the bylaws was preceded by a

request of the Association of State and Territorial

Health Officers (ASTHO) for an evaluation of the

functions and relationships of the American Association of Registration Executives (AARE) and the Public

Health Conference on Records and Statistics (PHCRS).

As a result of that request, the Joint Committee on

Vital Records and Health Statistics was established by

the executive committees of the AARE and the PHCRS.

At its first meeting, the joint committee discussed

and reached tentative agreement on the aims and

objectives of public health records and statistics and

how they might be achieved. At subsequent meetings

4 Major Activities and Developments
the joint committee drafted proposals for reorganizing

the AARE and reconstituting the PHCRS into a study

program; submitted the proposals for review by members of the AARE and the PHCRS; and after considering the comments received, prepared and submitted

final proposals. This added to the existing cooperation

in programs between the PHCRS and the AARE and

moved the AARE toward expanding its objectives and

membership to include both registration and statistics. The 1958 revised bylaws provided the delineation

of objectives and reflected the broadened scope of

activities sought by ASTHO.

The association’s sphere of interest and influence

has continuously expanded. In 1956 at the suggestion

of the statistics section of the American Public Health

Association (APHA), the AARE joined it in a cooperative relationship that led to such joint activities as

co-sponsored sessions at the national APHA annual

meetings.

The association continues to be the link between

the registration areas and the Federal Government in

promoting complete registration of vital records and

producing from them uniform, accurate, and useful

statistics. It has assumed the special function of representing the collective viewpoint of the registration

areas in Federal-State relationships. Its strong influence is felt in all matters pertaining to the collection

and dissemination of vital and health statistics at the

local, State, and Federal levels. The association, as its

current name (National Association for Public Health

Statistics and Information Systems) implies, will also

be a voice with other professional associations, the

Federal Government, and State governments on public

health statistics, vital records, and information systems issues.

The association held biennial meetings until 1969,

when it began annual meetings. Through 1985, in the

years in which the public health conference was held,

the association held its meeting at the same location

immediately preceding or following the conference,

making it possible for its members to attend both.

Although this was discontinued, the association continues to hold annual meetings, inviting representatives of various Federal agencies. Since 1989, in

alternate years the association’s annual meeting has

been held jointly with NCHS as part of the Vital

Statistics Cooperative Program project directors’ meeting. The annual conferences include business meetings

as well as training sessions on current technology,

public health information systems, vital record practices, and leadership development.

Although NCHS has been the prime Federal agency

with which the association interacts, it has expanded

its relationships with numerous other agencies, including other components of the Centers for Disease Control and Prevention, the Health Care Financing

Administration, the Bureau of the Census, the Bureau

of Labor Statistics, the Social Security Administration,

and the National Institutes of Health. The association

is an affiliate of the Association of State and Territorial

Health Officials (ASTHO) and is a member of other

professional associations such as the Council of Professional Associations on Federal Statistics (COPAFS).

Developmental activities

The Federal Government, with no express constitutional authority to enact vital statistics legislation of

a national scope, depends upon the States to enact

laws and regulations that provide methods of registration and data collection comparable from State to

State.

To achieve the uniformity required for combining

data from all States to provide national statistics,

certain standards are recommended by the Federal

agency responsible for national vital statistics as guides

for use by State registration offices. Foremost among

these are a model State vital statistics act, proposed as

a guide for formulating legislation pertaining to registration of vital events, and model forms containing

specified items of information that not only meet the

legal needs of individuals but also provide statistical

data in a standardized form comparable from one

reporting area to another.

Model Vital Statistics Act

The Bureau of the Census submitted the first

model bill to the States in 1907, covering both birth

and death registration. It provided for forms to include

as a minimum the items recommended by the Bureau

of the Census. Numerous revisions of both the model

law and the recommended forms have followed. The

development, periodic review, and revision of the recommended standards became an essential function in

obtaining comparable data from State and local registration offices for producing national vital statistics.

Responsibility for this function was transferred from

the Bureau of the Census to the U.S. Public Health

Service in 1946 and now rests with the Division of

Vital Statistics in NCHS.

In response to the expressed needs of State executives and Federal agencies, a new Model State Vital

Statistics Act was tentatively approved in 1940 and

adopted in 1942 (U.S. Bureau of the Census, 1941).

For the first time, the Model Act gave a statutory

definition of vital statistics, defining them as ‘‘the

registration, preparation, transcription, collection, compilation, and preservation of data pertaining to the

dynamics of the population, in particular, data pertaining to births, deaths, marital status, and the data and

facts incidental thereto.’’ This was the first inclusion of

marriages and divorces in the model legislation perMajor Activities and Developments 5
taining to vital statistics. This revision also included

the first provision for a standard certificate of stillbirth, discarding the making of a birth and a death

certificate to cover a stillbirth. It declared vital statistics records to be public records but restricted the right

of public inspection.

The increasing demand for reliable certified copies

in the 1940’s gave added importance to registration

and uniformity in forms and consequently to the Model

Act and its recommendations.

The Model State Vital Statistics Act was revised in

1959 (U.S. Department of Health, Education, and

Welfare, 1960). This revision was not an abrupt departure from earlier model vital statistics acts but rather

one in a series of revisions carried out periodically to

keep the Model Act current with changing demands

upon State vital records systems.

More substantive changes were made in the Model

Act in 1977 (National Center for Health Statistics,

1978). This revision provided for a centralized system

in each State for the collection, processing, registration, and certification of vital records in which all vital

events are reported directly to the State office of vital

statistics. It placed the local offices under the direct

control of the State registrar and gave the State

registrar the option to direct local offices to perform

any of those functions when it was in the interest of

efficient and effective service. The 1977 revision also

made a significant change in the registration of fetal

deaths, changing the reporting instruments to statistical reports to be used only for medical and health

purposes, as opposed to permanent official records of

the system of vital statistics. Modifications were added

to provide for filing birth certificates for foreign-born

children adopted by citizens in the State where they

are adopted. This revision gave special attention to

privacy concerns, confidentiality, and fraudulent use of

vital records, and strengthened penalty provisions of

the Model Act as a deterrent to illegal use of vital

records.

Model State vital statistics regulations were first

issued in 1973 (National Center for Health Statistics,

1973). It was recommended that both the Act and

regulations be considered when a State modifies its

vital statistics statutes. The purpose of the regulations

was to augment the Model Act and to standardize

many of the administrative practices and procedures

in effect in vital statistics offices. Consistency among

States in day-to-day administrative procedures has

been found to improve the uniformity essential for

national statistics. The model regulations have been

revised in conjunction with all subsequent revisions of

the Model Act.

The 1992 revision of the Model Act and regulations

(National Center for Health Statistics, 1994) was undertaken with the intention of producing a practical rather

than ideal model and one that most States could adopt

with few modifications. The intent was to develop a

model that was flexible enough to accommodate new

technologies that are sure to evolve for the collection,

storage, and retrieval of vital records. The Act specifically allows for the electronic production and transmission of vital records. It also removed the requirements

for signatures except where the requirement relates to

an affidavit.

Provisions of the Model Act concerned with confidentiality and security of vital records were strengthened. Several issues regarding vital records were

addressed for the first time as the result of changes in

societal attitudes and practices. For example, guidance is provided on the naming of the father, and in

some instances the mother, on birth records involving

artificial insemination, in vitro fertilization, and surrogate parenthood.

The Model Act recommends to the States that the

integrity of vital records and reports be protected

through reasonable control of the use of such records,

restricting disclosure of information that can identify

a person or institution named in any vital record or

report. It further recommends that Federal agencies

and researchers who are furnished copies of such

records be required to enter into agreements that

protect the confidentiality of the information provided.

The intent is to encourage legitimate and appropriate

use of the records for statistical and administrative

purposes, while protecting individuals from an unwarranted invasion of privacy.

U.S. standard certificates and reports

The U.S. standard certificates and reports issued

as models for the States and independent registration

areas to use in developing their registration forms are

reviewed periodically to ensure that they meet their

intended uses at the local, State, and national levels.

Persons involved in the registration and statistical

processes at all levels of government are involved in

the review. The opinions of major users of the data are

also sought. Revisions are made to reflect changing

conditions and user needs. The U.S. standard certificates and reports are currently an integral part of the

Vital Statistics Cooperative Program through which

NCHS obtains data to produce national vital statistics.

They contain the minimum basic data set to meet

contract requirements.

There have been 11 issues of the Standard Certificate of Live Birth; 10 of the Standard Certificate of

Death (in 1915 the birth certificate but not the death

certificate was revised); 7 of the Standard Report of

Fetal Death (formerly Stillbirth); 4 of the Standard

Certificate of Marriage and the Standard Certificate of

Divorce, Dissolution, or Annulment; and 2 of the Standard Report of Induced Termination of Pregnancy.

6 Major Activities and Developments
Most of the additions and deletions from one revision

to another resulted from changing perceptions as to

the usefulness of the items in question in meeting the

increasing needs for information.

Before 1937, birth and death statistics published

for States, counties, and cities were by place of occurrence. Beginning with data for 1937, most of the

geographic tabulations were changed to place of residence. The need for complete and accurate residence

information influenced the redesign of the certificates.

The number of items on the birth certificate

increased from 33 in 1900 to 60 in 1989, the most

recent revision. In recent revisions, most new items

relate to information concerning the pregnancy, delivery, and condition of the child.

Similarly the number of items on the death certificate increased from 42 in 1900 to 71 in 1989. Most of

the new items related to the expanded cause-of-death

certification introduced in the 1939 revision and to

items concerning the nature and circumstances surrounding injuries causing death.

Tables showing the changing content of the various standard certificates from the first through the

1989 revision can be found in appendix I. NCHS

published three reports describing in detail the standard certificate revisions of 1968 (2), 1978 (3), and

1989 (4).

U.S. standard certificates of birth, death,

and fetal death

In the early years, few changes were made in the

content of the U.S. standard certificates of birth and

death. For the death certificate, the most noteworthy

were the addition of autopsy information in the 1918

revision, provision for information concerning injuries

from external causes of death in the 1930 version, and

revision of the cause-of-death portion of the certificate

in 1939. Also in 1939, the Social Security number and

more detailed information on place of residence of the

deceased were added.

Early expansion of the birth certificate also was

gradual. Prior to the 1930 revision, the certificate

contained place of birth, identifying information pertaining to the child, and occupation for both the mother

and father. Also included were variations of items

concerning number of children born to this mother,

now living, now dead, and born dead. In the case of

stillbirth (the delivery of a product of conception that

does not show evidence of life after the delivery), both

a birth and death certificate were required to be filed.

In the 1930 revision of the Standard Certificate of Live

Birth, items relating to stillbirth were added (period of

gestation, cause of stillbirth, and whether before labor

or during labor). In 1939 more detailed information

concerning residence of the mother was added.

In the 1949 revision, both the death certificate and

the birth certificate were reformatted. The section

containing the medical certification of cause of death

was placed on the lower half of the death certificate

and a section labeled ‘‘For Medical and Health Use

Only’’ was added to the bottom of the birth certificate.

The latter contained the items on length of pregnancy,

legitimacy, and an added item on weight at birth. The

revised format made possible omission of this personal

information from certified copies of the certificates. An

item on citizenship of the deceased was added to the

death certificate in 1949 but was dropped in 1989. Also

added was an item indicating whether the decedent

was ever in the U.S. Armed Forces. That item was

dropped in 1968 but reinstated in 1978. Although only

minor changes were made in the content of the death

certificate between 1939 and 1989, substantive revisions were made in the birth certificate.

Beginning with the 1939 revision, the birth certificate became the Standard Certificate of Live Birth,

and in 1955 the Certificate of Fetal Death was required

for stillbirths. In subsequent revisions, the content of

the certificate for fetal deaths followed closely the

content of the birth certificate, except for the addition

of sections containing cause-of-death and burial information. In the 1978 revision, the title was changed to

U.S. Standard Report of Fetal Death to reflect the

nature of the document as a statistical report rather

than a certificate to be filed permanently.

In 1968 items added to the birth certificate and

fetal death report were education of mother and father,

date of last live birth and of last fetal death, date last

normal menses began, prenatal care, complications

related and not related to pregnancy, complications of

labor, congenital malformations or anomalies of child

(or fetus), and birth injuries to child (or fetus). These

items expanded the section containing confidential

information for medical and health use only.

In 1978 the Apgar score was added to the confidential section of the birth certificate. On both the birth

certificate and the fetal death report, a question on

whether the mother was married replaced the item on

legitimacy. Also on both, an item for specifying concurrent illnesses or conditions affecting pregnancy replaced

the item for complications not related to pregnancy.

In the 1989 revision, major changes were made in

the content and format of the live birth certificate and

the fetal death report. Both forms were increased in

size to make room for detailed medical and health

information about the mother and child or fetus. Checkboxes were added for these items to simplify completion of the forms and improve the quality of reporting

of information useful in studies of newborns. Checkboxes were also added to both for clarity, to provide

specific information concerning the attendant, and on

the birth certificate, for information about place of

birth and the certifier. It was anticipated that electronic filing of certificates would negate the need for

large paper documents.

Major Activities and Developments 7
Among the added items providing medical and

health information on both the certificate of live birth

and the report of fetal death were items indicating

specific complications of labor and/or delivery and

specific congenital anomalies of child or fetus. Items

were also provided on both to obtain for the first time

information on obstetric procedures, risk factors for

the pregnancy (medical and other, including maternal

use of tobacco and alcohol, and weight gain), method of

delivery, and for live births, abnormal conditions of the

newborn. Items were added to the fetal death report to

indicate the occupation and business or industry in

which the mother and father worked during the last

year, reflecting interest in the effect on the fetus of

work-related environmental exposure. Although not

added to the birth certificate, States were encouraged

to collect and code these items for births if resources

permit. This body of information facilitates analyses of

interrelationships among specified risk factors, complications of pregnancy, obstetric procedures, and delivery methods, and fetal and infant mortality.

The certificate of death was also enlarged in the

1989 revision. Additional space was provided for the

medical certification section. Space was added for more

complete reporting of conditions that describe the

chain of events leading to death and of other significant conditions contributing to death. Detailed instructions for selected items, including an example for

completing the medical certification, fill the back of the

certificate. The three separate alternative certificates

introduced in 1968 (one for use by physicians, one for

medical examiners or coroners, and one suitable for

use by both physicians and medical examiners or

coroners), were replaced by one for use by all certifiers.

The single certificate is believed adequate to meet the

needs of most States and, if required, is easily modified.

An item was added to the death certificate for

reporting the decedent’s education, useful as an indicator of socioeconomic status and a factor in mortality

differentials. Another item was added to indicate

whether autopsy findings were used in determining

cause of death. The item on manner of death was

reworded to include checkboxes. Two items, country of

citizenship and name of attending physician if other

than certifier, were dropped.

A Hispanic identifier was added for the mother

and father on the certificate of live birth and the report

of fetal death. It was also added for the decedent on

the certificate of death, and for the patient on the

report of induced termination of pregnancy.

U.S. standard report of induced termination

of pregnancy

In January 1973, the U.S. Supreme Court ruled

that the restrictive abortion laws in two States were

unconstitutional and that, within the first two trimesters of pregnancy, whether an abortion was to be

performed or not was a matter between the woman

and her doctor ( Roe v. Wade, 410 U.S. 113 (1973); and

Doe v. Bolton, 410 U.S. 179 (1973)). The net result of

the rulings was that induced abortion under these

criteria became legal in all States. Because of the

impact of abortion on fertility and the need for health

and demographic data about these procedures, the

need for a uniform reporting system was soon recognized. Data needs and reporting requirements for

induced terminations differ from those for spontaneous fetal death. Consequently, separate forms were

recommended.

The 1978 version of the U.S. Standard Report of

Fetal Death was recommended for the collection of

data on spontaneous fetal deaths at 20 weeks of gestation and over. A new form, the U.S. Standard Report of

Induced Termination of Pregnancy, was recommended

for reporting all induced terminations of pregnancy

regardless of length of gestation. Unlike the fetal

death report, this form does not include the name of

the woman having the abortion. Among the items

included on the induced termination of pregnancy

form were facility name and location, age of patient,

whether married or not, date of pregnancy termination, residence, race, education, previous pregnancies,

type of termination procedures, complications of pregnancy termination, date last normal menses began,

physician’s estimate of gestation, name of attending

physician, and name of person completing report. In

the 1989 revision, an item on dilation and evacuation

was added to the list of termination procedures. The

item asking for complications of pregnancy termination was deleted because of underreporting, as most

complications are not evident until after the report has

been filed.

In 1995 the Division of Reproductive Health in

CDC took the lead to revise the list of termination

procedures on the Standard Report of Induced Termination of Pregnancy. The impetus for this action was

the need for one or more categories to identify medical

methods used for terminating a pregnancy.

U.S. standard certificates of marriage and

divorce, dissolution of marriage, or annulment

The first Standard Record of Marriage and Standard Record of Divorce or Annulment were recommended to the States for implementation on January

1, 1955. The recommended Standard Record of Marriage included the following information concerning

both bride and groom: name, place of residence, date

and place of birth, previous marital status (and if

previously married, the number of marriages and how

the last marriage ended), race, usual occupation, kind

of business or industry, signature of applicants, and

date signed. Certification information included date

8 Major Activities and Developments
and place of marriage, date of recording, and signature

and title of officiant.

The recommended Standard Record of Divorce,

Dissolution of Marriage, or Annulment included the

following information concerning both husband and

wife: name, place of residence, date and place of birth,

number of marriage being dissolved, race, occupation,

and kind of business or industry. Decree information

included place and date of marriage being dissolved,

number of children under 18, plaintiff, party to whom

decree was granted, legal grounds for decree, date of

divorce, date of recording, and signature and title of

court official.

In the 1968 revision of the standard certificates,

the titles of the records were changed to U.S. Standard

Certificate of Marriage and U.S. Standard Certificate

of Absolute Divorce or Annulment. A section for confidential information was added to both the marriage

and the divorce certificates. Items added to the marriage certificate were identification of the officiant as

religious or civil, education, and for the previously

married, date last marriage ended. Items added to the

divorce certificate were approximate date couple separated, name of attorney for plaintiff, number of previous marriages ended by death or divorce or annulment,

and the total number of living children as well as the

number under 18 years of age.

In the 1978 revision, the heading of the marriage

certificate was changed to U.S. Standard License and

Certificate of Marriage. The recommendation combined in one form both the license and the certificate

in order to reduce the workload and number of forms

required of the local official responsible for marriage

registration.

Changes made in the content of the 1978 and 1989

revisions of the marriage and divorce certificates were

minor. They consisted mainly of changes in terminology to clarify intent of certain items. In 1989 type of

ceremony was deleted from the marriage certificate

and number of children ever born alive of this marriage was deleted from the divorce certificate. Added to

the divorce certificate was an item to indicate the

number of children under 18 whose physical custody

was awarded to husband, wife, joint husband and wife,

or other.

Registration areas

The first birth and death statistics published by

the Federal Government for the entire United States

were based on information collected during the 1850

decennial census. Similar collections were made during each decennial census up to and including the

census of 1900. These reports were inaccurate and

incomplete, and it became evident that reliable data

could be obtained only from States and large cities

that had efficient systems for the registration of these

events.

In 1880 the Bureau of the Census established a

national ‘‘registration area’’ for deaths. It consisted of

two States, Massachusetts and New Jersey, the District of Columbia, and several large cities in

nonregistration-area States. Those were the areas that

could provide adequate statistics. By 1900 eight additional States had been admitted and the annual collection of mortality statistics for the registration area had

begun. Each area had been requested to adopt the

recommended death certificate and model law and

obtain 90 percent completeness of registration. The

registration area gradually increased as more States

enacted and enforced laws requiring the registration

of deaths. Beginning with 1933, all 48 States and the

District of Columbia were included.

It was more difficult to obtain accurate and complete registration of births than it was for deaths. The

national birth-registration area was not established

until 1915. Admission requirements were similar to

those for deaths. The birth-registration area included

10 States and the District of Columbia. As with the

death-registration area, all 48 States and the District

of Columbia had been admitted by 1933. Alaska was

added to both registration areas in 1959 and Hawaii in

1960, the years in which they gained statehood.

The early collections of national marriage and

divorce statistics began in 1940. These consisted of

numbers or estimated numbers of marriages and

divorces collected from each State. Detailed statistics

were collected and published for both events for States

able to submit transcripts of records or statistical

tables from which data could be consolidated.

The marriage-registration area (MRA) was established in 1957. It included 30 States, Alaska, Hawaii,

Puerto Rico, and the Virgin Islands. New York, counted

as one of the 30 States, excluded New York City. In

1979 the MRA reached its peak and included 42 States,

the District of Columbia, Puerto Rico, and the Virgin

Islands.

The divorce-registration area (DRA) was established in 1958. It was made up of 16 States and the

Virgin Islands. The DRA reached its peak in 1986 and

consisted of 31 States, the District of Columbia, and

the Virgin Islands.

To be admitted to the marriage- and divorceregistration areas, States were required to establish

central State files for collecting copies or abstracts of

the records, to adopt a statistical report conforming

closely in content to the U.S. standard certificates, to

maintain regular and timely reporting to the State

office by all local areas in which marriages or divorces

are recorded, and to agree to tests of completeness and

accuracy in cooperation with NCHS. Registration of

events and reporting of required items were expected

to be at least 90-percent complete. Three States, AriMajor Activities and Developments 9
zona, New Mexico, and Oklahoma, did not have central files of marriage records. The same three States

plus Indiana did not have central files of divorce

records.

The MRA and DRA, patterned after the registration areas used successfully to promote birth and

death registration, were never completed. In 1995 the

MRA included 45 registration areas and the DRA

included only 33. From 1957 and 1958, respectively, to

1995, NCHS obtained detailed marriage and divorce

data from States in the MRA and DRA. However, this

program ended with data year 1995, when Federal

resource constraints forced NCHS to set priorities for

data within the National Vital Statistics System.

Although the importance of marriage and divorce data

was widely recognized, it was also evident that information could be obtained from other sources, including

the Bureau of the Census Current Population Survey.

Consequently, NCHS made the decision to reduce the

scope of the marriage and divorce components of the

National Vital Statistics System, thereby ensuring the

continued viability of the remainder of the system. As

of January 1, 1996, NCHS began to collect and publish

only monthly counts of the marriages and divorces

registered in each State.

Improvement of data

Efforts to improve the quality and usefulness of

vital statistics began with the first collections of data

and are still very much a part of the vital statistics

program. They include testing for completeness and

accuracy of data, querying incomplete or inconsistent

entries on records, updating classifications, improving

timeliness and usefulness of data, and keeping pace

with evolving technology and changing needs for data.

Tests of birth registration completeness

The completeness of the registration of births was

long a subject of concern. Early in the 20th century,

States and local areas began investigations into underregistration of births. Some compared records of infant

deaths or lists of children in school with birth records.

Others sent postal cards to every household (or to a

sample of households) in the State, requesting a report

as to whether a child had been born during a specified

time period. These investigations varied greatly from

State to State both in methodology and quality. As a

result, their findings could not be combined to provide

estimates of underregistration of births for the entire

country.

The first birth registration test to provide national

estimates of underregistration of births, based on uniform data from all States for the same time period,

was carried out in connection with the 1940 decennial

census. It was accomplished through the joint efforts

of the Bureau of the Census (which then had responsibility not only for taking the census but also for the

annual collection of vital statistics data) and the State,

territorial, and independent city registration offices.

This test gave percent estimates of the completeness of

birth registration for the United States, each State,

county, and incorporated city or urban place having a

population of 10,000 or more in 1940 and that part of

each county outside of the cities or urban places of

10,000 or more (5).

A second such test was conducted in connection

with the 1950 decennial census under the same auspices, except by then the responsibility for national

vital statistics data had been transferred to the Public

Health Service and placed in the newly established

National Office of Vital Statistics.

In both of these studies, copies of birth certificates

obtained from State offices of vital statistics were

matched against records obtained from the enumerated population of the respective decennial censuses.

Special records prepared by census enumerators for all

infants alive on April 1 who had been born during

preceding months (4 months for the 1940 test and 3

months for the 1950 test) were matched with copies of

birth records for all infants born during the same

periods. These matches provided information on how

many infants were missed by census enumerators as

well as how many births were not registered. They

also pinpointed problem areas by State and locality

and provided estimates of underregistration by race

and whether the birth occurred in or out of a hospital.

A third nationwide study of birth registration completeness was based on a sample of births occurring

during the 5 years 1964–68 (6). The actual collection of

birth information for this study began in June 1969

and continued through March 1970. The study was

carried out by the Bureau of the Census with the

cooperation of NCHS and the registration offices of the

States and the District of Columbia, and the independent city registration offices. The major objective of

this test was to improve the estimates of births used in

preparing independent estimates of population. For

this purpose the main interest was in national estimates by race, a much less costly undertaking than

developing estimates for States and local areas. Two

continuing household surveys were used in the study—

the Current Population Survey and the Health Interview Survey. The Bureau of the Census is the data

collection agent for these surveys, which use national

probability samples obtained by trained interviewers.

In these surveys, interviewers completed a special

record, referred to as a ‘‘birth card,’’ for each child alive

at the time of the interview who had been born in the

5-year interval 1964–68. The birth cards were reviewed

for completeness of demographic information about

the child and for items essential for matching pur10 Major Activities and Developments
poses. They were then delivered to the State and city

registration offices, where each card was matched with

the birth certificate for that child. Extensive followup

interviews and additional searching procedures were

conducted as required to maximize matches.

Estimates from this test of completeness of birth

registration indicate that birth certificates are on file

for more than 99 percent of children born during the

years 1964–68, an improvement over the estimates for

1950 (98 percent) and 1940 (93 percent).

Query programs for improving birth

and death data

In keeping with its role of promoting improved

accuracy, timeliness, completeness, and uniformity of

data contained in the official records of vital events,

NCHS and its predecessor agencies have provided to

directors of vital statistics offices guidance and assistance in the development and implementation of query

programs.

Over the years querying practices have varied in

intensity from State to State and from time to time.

Variations included differences in procedures employed

to identify problems, proportions of records queried,

reasons for queries, timeliness of queries, and results

achieved by queries.

Currently, the contract between NCHS and individual States provides for the implementation of query

programs. NCHS issues instruction manuals to define

the general duties and responsibilities of individuals

and institutions involved in the registration process.

These manuals provide detailed guidelines for query

programs and set forth the principles and procedures

essential for complete and accurate registration of

vital events.

A separate manual deals exclusively with cause-ofdeath queries. As part of the registration process, vital

statistics offices go back to the certifying physician

when additional information is needed to clarify illegible, incomplete, imprecise, or questionable entries; to

verify causes attributed to diseases that pose serious

threats to the health of others; and to facilitate classification of the causes in a manner that ensures the

quality of cause-of-death statistics. The query programs serve not only to improve the quality of mortality data and to emphasize their importance for health

and research purposes but also to provide guidance to

physicians on proper cause-of-death certification.

The current manuals are Instruction Manual, Part

18, Guidelines for Implementing Field and Query Programs for Registration of Births and Deaths, Vital

Statistics and Instruction Manual, Part 20, Cause-ofDeath Querying, Vital Statistics, Data Preparation.

NCHS has also developed handbooks and made

them available to the States. The handbooks detail

item by item how to complete birth, death, fetal death,

marriage, and divorce records. Handbooks for death

certificates have been prepared for funeral directors,

certifying physicians, and for medical examiners or

coroners. The handbooks were developed with input

from officials in State and local vital records offices,

where the handbooks are widely used.

Current Mortality Sample

During World War II, concern over the threat of

epidemics and the possibility of a general decline in

national health resulting from wartime living conditions produced an urgent need for up-to-date mortality

statistics by cause of death. There were large numbers

of young people suddenly brought together and closely

quartered in training facilities, overcrowded housing

in cities with rapidly growing defense industries and

activities, longer working hours, strained hospital facilities, and shortages of physicians. All these conditions

offered great potential for severe epidemics of virulent

diseases. The wait of a year or more following the

years in which the deaths occurred before the annual

mortality statistics could be made available was no

longer tolerable to public health officials. The Bureau

of the Census responded to the challenge by setting up

a program for taking a monthly 10-percent sample of

all death certificates received in State vital statistics

offices. Thus, the Current Mortality Sample (CMS)

was established. Theodore D. Woolsey was the leading

advocate for the development of the CMS, and W.

Edward Deming, Ph.D., was the principal advisor on

its implementation (7).

The bureau’s sampling program was designed so

that certain statistics on mortality could be compiled

on a month-to-month basis with as little as a 2-month

delay between the month a death occurred and the

month it was included in the published statistics.

Funeral directors or medical examiner/coroners were

required to provide a death certificate to their local

registrar in exchange for a burial permit. In turn, the

local registrars were required to send the death certificates that they had collected each month to the State

central vital statistics office for filing. State offices

were then able to send monthly samples of the death

certificates to the national office. The monthly shipments of death certificates from the local registrars

began to arrive in the State offices about the 10th of

each month, and by the 20th, most of them had been

received. In the sampling program, every 10th certificate of those received between two dates a month

apart was selected, copied, and mailed to the Bureau

of the Census on the 25th of the month, this being the

month following the month in which most of the

deaths occurred. At the time the selection was made,

the certificates were usually in order by registration

Major Activities and Developments 11
districts, thus providing a good geographic distribution of deaths in the sample.

The first data from this sampling program was

published February 5, 1943, in the first CMS report,

which contained statistics for the month of November

1942. Comparative data for August, September, and

October 1942 were also shown, and variation charts

for selected diseases for each month of the preceding

year were included.

Monthly mortality statistics based on the 10-percent

mortality sample are presently published by NCHS in

the Monthly Vital Statistics Report (MVSR). Data based

on the sample are published 1 month after publication

of the monthly provisional national and State counts.

The provisional counts are the number of events registered in a State during a 30-day period. Prior to

1991, no attempt was made to adjust the occurrence

counts to account for differences between occurrence

and resident events. Beginning in 1991, adjustment

ratios were applied to each State to obtain estimates

for births, deaths, and infant deaths by State of residence. The MVSR currently contains much more

detailed statistics and charts than the initial CMS

report, with considerably greater lag time between the

month a death occurs and the month it is included in

the published statistics.

Cause-of-death classification

Causes of death are classified for purposes of

statistical tabulation according to the International

Statistical Classification of Diseases, Injuries, and

Causes of Death, published by the World Health Organization. This classification originated as the ‘‘Bertillon Classification of Causes of Death,’’ prepared in

the late 1800’s by Dr. Jacques Bertillon, chairman of

the committee charged by the International Statistical

Institute with preparation of a classification of causes

of death for international use. In 1898 the American

Public Health Association (APHA) recommended that

the classification be adopted by Canada, Mexico, and

the United States and that it be revised every 10 years

to keep abreast of advances in medicine. The International Statistical Institute accepted the recommendation for decennial revision, and the first revision was

adopted by the United States for use in 1900. To date,

there have been 10 revisions of this classification, now

known as the International Classification of Diseases

(ICD). The years for which causes of death in the

United States have been classified by each revision are

as follows:

Revision Years covered

First 1900–09

Second 1910–20

Third 1921–29

Fourth 1930–38

Fifth 1939–48

Sixth 1949–57

Seventh 1958–67

Eighth 1968–78

Ninth 1979 to date

As of the end of 1995, the 10th revision had not yet

been implemented.

Traditionally, a single cause of death has been

selected for statistical tabulations. When the certifying physician indicated that more than one cause

contributed to the death, a procedure was required for

selecting the cause to be tabulated. In the earliest

editions of the international list, the concept of jointcause classification was evident. Certain principles for

determining the cause to be tabulated when more than

one cause was reported were incorporated as part of

the general classification scheme. Application of these

principles in the interest of continuity and comparability soon resulted in the establishment of definite relationships among various conditions represented by the

rubrics of the international list, indicating which took

precedence for tabulation as the cause of death.

The desirability of uniform treatment in selecting

the cause of death when more than one cause was

reported intensified with the increase in medical knowledge. As diagnostic capabilities improved, multiple

causes were reported more frequently. The result was

a listing of the established relationships in the Manual

of Joint Causes of Death, first published in 1914 and

revised in 1925 and again in 1933 to conform to

successive revisions of the international list. The jointcause relationship expressed in the 1933 manual

remained relatively unchanged until this method of

selection was discontinued under the sixth revision of

the international list, initiated in 1949.

The Sixth Decennial International Revision Conference agreed that the cause to be tabulated should

be the underlying cause of death. It concluded that the

most useful statistic for public health purposes is the

precipitating cause, that is, the disease or injury that

initiated the train of morbid events leading directly to

death or the circumstances of the accident or violence

which produced the fatal injury.

The sixth revision included a revised International

Form of Medical Certificate of Cause of Death. The

revised format elicits information from the certifying

physician as to the sequence of events leading to

death. It provides space for an opinion as to the direct

or immediate cause of death, intervening causes, the

underlying cause starting the train of events leading

to death, and a list of other unrelated but contributing

causes. This method of selecting the cause of death for

statistical purposes was not adopted either in the

United States or internationally until the sixth revision of the ICD was implemented in 1949. The United

12 Major Activities and Developments
States, however, used the revised form during the

1940’s prior to dropping use of the joint-cause manual.

This made it possible to compare the opinions of

physicians and coroners as to cause of death with the

preference indicated in the joint-cause manual.

This revised selection procedure, still in effect,

places responsibility on the physician for reporting

causes of death in such an order that the underlying

cause of death is indicated by its position on the

certification form. It also makes it incumbent upon the

nosologist (a person trained to classify diseases in

accordance with an organized list of diseases and

injuries) to distinguish between properly and improperly reported sequences and requires classification

rules to be applied in such cases.

Comparability studies

Each revision of the international list of causes of

death has produced breaks in the comparability of

mortality statistics. Over the years efforts have been

made to evaluate the effects of the classification changes

between revisions. Early attempts were limited in

both scope and success.

A new approach to the problem was introduced by

Dr. Halbert L. Dunn and William Shackley, in a study

of the effect of classification and associated coding-rule

changes on death rates, as distinguished from the

effects of other factors (Dunn and Shackley, 1944)(8).

Among the other factors mentioned in the study were

decreased fatality due to particular causes as a result

of advances in medical science, increased popularity

among physicians of causes brought to the forefront

through widely published investigations, and the frequently observed excess mortality from all diseases

caused by epidemics of communicable diseases.

In this study of the effects of classification changes,

all deaths reported for 1940 were first classified according to then-current methods. For comparison, the same

certificates were again classified using methods in

effect immediately preceding the introduction of the

1938 revision of the international list.

The study presents percentages that show the

extent to which comparability had been lost by each

international list cause after the adoption of the 1938

revision. These percentages are presented as ‘‘reliable

evaluations which will be found useful in correcting

1940 death rates for incomparability due solely to

classification changes.’’ The authors point out that the

corrections apply strictly to 1940 mortality statistics,

and although they apply in a general way to the

statistics for the decennial period from 1939 to the

time of the next list revision, nonclassification factors

may also introduce discontinuities during that period.

Consequently, the authors state ‘‘it cannot safely be

assumed that the same adjustments can be made

consecutively for each of those years.’’

Dunn and Shackley’s study provided the basis for

the recommendation of the international conference

for the sixth revision, which convened in 1948. The

conference recommended that deaths occurring in the

country in 1949 or in 1950 be coded and tabulated

twice for the Detailed List of Causes of Death, once

using the classification procedures for the fifth revision and again using the sixth revision. These data

were then to be published in such a way as to indicate

changes resulting from the new revision. Effective

with the sixth revision, the United States has since

used this method to measure discontinuities in mortality data resulting from revisions of the ICD.

NCHS has published reports providing estimates

of the discontinuities between the fifth and sixth revisions (9), sixth and seventh revisions (10), seventh and

eighth revisions (11), and eighth and ninth revisions

(12) of the International Classification of Diseases.

Ranking causes of death

Reference to the ‘‘leading’’ causes of death is a

popular way of discussing cause-of-death statistics.

The rank order of any cause depends upon the list of

causes being ranked and the method of ranking. For

comparing rankings among different geographic areas

by characteristics of the population such as age, race,

and sex, and from one time period to another, established, consistently applied procedures are essential. A

procedure for ranking causes of death for official mortality statistics was developed by a working group on

mortality statistics and recommended by the Public

Health Conference on Records and Statistics at its

1951 meeting. The procedure stipulated that the ‘‘List

of 64 Selected Causes of Death’’ (an expansion of the

Abbreviated List of 50 Causes of Death, Sixth Revision, designed for use in the National Office of Vital

Statistics) be used and the following rules applied:

+ Omit the group titles ‘‘Major cardiovascular-renal

diseases’’ and ‘‘Diseases of the cardiovascular system’’ and the single titles ‘‘Symptoms, senility and

ill-defined conditions’’ and ‘‘All other infective and

parasitic diseases’’

+ Rank the remaining group titles and single titles,

omitting any title appearing under a group title

included in the ranking

+ Apply this procedure to deaths by age, race, and

sex, with the exception of deaths under 1 year of

age

+ In published tables of rank order, indicate the list

of causes of death that have been ranked, and the

procedure used

Effective with 1969 data, category titles beginning

with ‘‘other’’ or ‘‘all other’’ were dropped from the

ranking.

Major Activities and Developments 13
This ranking procedure has been used continuously beginning with 1950 data. The list of causes

providing the basis for ranking has changed slightly

over the years and currently has 72 causes. Effective

with data year 1987, the category human immunodeficiency virus infection (HIV infection) was added to

the list of rankable causes. Alzheimer’s disease was

added to the list beginning with data year 1994.

A separate cause-of-death ranking for infants was

formalized in 1979 with the introduction of the ninth

revision of the ICD. The ranking was based on the List

of 61 Selected Causes of Infant Death. The group titles

‘‘Certain conditions originating in the perinatal period’’

and ‘‘Symptoms, signs, and ill-defined conditions’’ are

omitted from the ranking. Effective with data year

1987, HIV infection was added to the list of rankable

causes of infant deaths also.

Automated mortality data system

In the late 1960’s, NCHS gave high priority to the

development of automated entry, classification, and

retrieval of information reported on death certificates.

The system is being developed and implemented by

components and is continuously updated to meet new

requirements and incorporate advanced technology.

The first component of the mortality data system

was the Automated Classification of Medical Entities

(ACME). Beginning with 1968 data, NCHS began

using ACME for selecting the underlying cause of

death, replacing manual selection by a nosologist. This

computer system was designed to apply the same rules

as those applied by a trained nosologist for selecting

the underlying cause of death from the reported medical conditions on the death certificate.

ACME requires the manual coding of each entity

(disease, accident, or injury) reported in the medical

certification section of the death certificate. From those

codes, which retain the location and order as reported

by the certifier, the computer program automatically

assigns the underlying cause of death for each record

according to the selection and modification rules of the

applicable revision of the ICD published by the World

Health Organization. The decision tables by which the

selection is made, developed by experienced nosologists in consultation with medical and classification

specialists, introduced a new consistency into the selection process. The tables are updated periodically to

reflect new information on the relationships among

medical conditions and to convert from one revision to

another of the ICD.

The second component of the mortality data system to be implemented was TRANSAX, which was

developed (1978–80) to facilitate the tabulation and

use of multiple cause-of-death data. TRANSAX translates the axis of classification from an entity to a

record basis by accommodating linkages of entities

provided for by the ICD. For example, diabetes and

acidosis both stated on the record become diabetes

with acidosis. A data retrieval system (RETRIEVE)

was developed in conjunction with TRANSAX to search

the files for a particular disease or injury, making it

possible to count the number of deaths for which that

condition was reported alone or with other conditions

and, if the latter, to identify the conditions and count

the number of deaths for which such combinations

occurred.

Another development for the mortality data system began in 1985 on the Mortality Medical Indexing,

Classification, and Retrieval (MICAR) system. MICAR

was designed to replace the manual coding required by

ACME. With MICAR, data-entry operators enter full

text, abbreviations, or reference numbers for cause-ofdeath terms on personal computer data-entry screens

that are similar to the format of a death certificate.

After certificates are keyed, MICAR matches each

entry (text, abbreviation, or reference number) to the

MICAR dictionary and assigns the entity reference

number that is the unique identifier in the dictionary

for that cause. Any record with an unmatched term is

rejected for manual review.

MICAR makes code assignments to each entity

based on the presence or absence of cause-of-death

terms and their positional relationship to one another,

just as was formerly done manually in preparation for

selection of the underlying cause of death by ACME.

By automating coding rules, MICAR ensures accurate

and consistent application of complex coding rules. It

also reduces personnel and training requirements. It

provides access to every term reported on the death

certificate, even those included with other diseases in

one ICD category. This detail was not previously

available.

A further improvement now underway is Super

MICAR, designed to capture the entire medical certification portion of the death certificate, accepting

entry of all terms in the order in which they appear.

This eliminates reordering the terms into a standard order at time of entry, leaving that to the

computer. Super MICAR not only facilitates the

editing, querying, and coding functions, but also

provides the potential for printing certified death

certificates from the computer.

The various components of the Automated Mortality Data System have been and continue to be implemented on a State-by-State basis as automation

capabilities and resources permit.

Electronic registration

With the emergence of automated data-processing

capabilities, attention has been directed to automating

14 Major Activities and Developments
registration of vital events. In an electronic environment, records should be created, edited, coded, queried, and corrected at the source in an electronic

format. To date, most progress has been made in

automating birth registration. More than one-half of

the States have or are in the process of developing and

implementing that capability. For data year 1995,

almost 70 percent of all births were registered electronically. Pilot studies are being conducted toward development of an electronic death certificate, but are

complicated because demographic information on the

decedent and cause of death are obtained from different sources.

Electronic preparation and transmittal of birth

certificates not only eliminates duplicate (in some

cases triplicate) data entry but also produces more

accurate information with greatly reduced need for

query. This permits flexibility in shifting resources to

use in conducting audits of the quality of data on the

certificates. It also greatly improves timeliness of data.

Once electronic entry of the cause-of-death certification is achieved, electronic preparation and transmittal of death certificates will produce advantages similar

to those for birth certificates.

In September of 1994, a working group was formed

by NCHS and NAPHSIS to begin discussions of

re-engineering the death-registration system using

state-of-the-art technology. The group also included

representatives from other components of CDC and

other Federal agencies, and users and providers of the

data, such as the American Health Information Management Association, American Hospital Association,

American Medical Association, International Association of Coroners and Medical Examiners, National

Association of Medical Examiners, and the National

Funeral Directors Association. The work group was

charged with examining the current registration process and practices to determine the best means for

meeting the various uses of the vital statistics data in

the future.

The guiding principles employed by the work

group are that the system that is developed must be

(a) capable of adapting to changing technology, information needs, and legal mandates; (b) capable of

meeting customer needs for prompt registration and

information; (c) capable of providing quality information appropriate for its customers while minimizing

the reporting burden on suppliers; (d) acceptable to

the individuals, organizations, and institutions who

participate in the system; and (e) capable of incorporating methods to measure the reliability and validity of the data collected. The working group will

develop recommendations for the design of an electronic system built around these guiding principles.

It is anticipated that by the year 2000, electronic

death certificate systems will be in place in the

majority of the States.

Multiple causes-of-death statistics

The traditional selection of a single cause of death

for national statistical tabulations resulted in the loss

of valuable medical information. In recognition of this,

national coding of more than one cause was undertaken in a few scattered years, the most ambitious

being in 1955 when up to five additional causes were

coded. In the 1970’s, utilizing this source of medical

data became a major objective of the vital statistics

program. The Automated Mortality Data System was

developed to provide not only underlying cause-ofdeath statistics, but through its TRANSAX and

RETRIEVE components, to include the capability to

tabulate multiple causes. It is now possible to count

the number of deaths for which any given disease or

injury was reported as a cause, alone or in combination with other causes. All of the various combinations

can also be identified and counted. Data for 1978 were

the first national data published from this system. It

appeared in MVSR, Volume 32, Number 10, Supplement 2, February 17, 1984.

Race and ethnicity data

Obtaining valid vital statistics for populations of

specific race or national origin is complicated by the

vast number of possibilities and the uncertainties

inherent in providing and obtaining classifiable

responses. Only the use of broad categories has proven

feasible, but in spite of this, pressure for expanding

detail increases. This coincides with increasing interest in information concerning specific ethnic or racial

groups.

The birth certificate does not provide for reporting

of race of the newborn. Prior to 1989, for statistical

purposes, classification of the child’s race or national

origin was based on the race or national origin of the

parents. When both parents were not of the same race

or national origin, rules had been established for

coding various combinations. If only one parent was

white, the child was assigned the race of the other

parent. If neither parent was white, the child was

assigned the race of the father, with one exception: If

either parent was Hawaiian or part-Hawaiian, the

child’s race was assigned to Hawaiian.

Rules were also established for assigning the child’s

race when race of the parents was not stated. If race

was missing for one parent, the child was assigned the

race of the other parent. When race was missing for

both parents, the race of the child was considered not

stated. Assignment of race for these records has changed

over the years. These changes in classification rules

have produced differences in statistics for racial categories, relatively small for some categories, greater

for others. The size of the differences for racial and

national-origin groups is discussed in the technical

Major Activities and Developments 15
appendices from the volumes of Vital Statistics of the

United States for the respective years.

Beginning with 1989 data, natality tabulations

were modified to show race of the mother, rather than

race of the child. Criteria for reporting race of the

parents did not change. The change in tabulation was

made because the 1989 revision of the standard certificate of live birth included many new items related to

the mother (that is, weight gain during pregnancy,

alcohol and tobacco use, medical-risk factors, obstetric

procedures, and method of delivery). It was determined to be more appropriate to use the race of the

mother in tabulating these items. Many of the other

items on the certificate also related to the mother,

including age, education, month of pregnancy that

prenatal care began, number of prenatal visits, marital status, and date of last live birth.

Growth of the Hispanic population in the United

States stimulated interest in obtaining vital statistics

information pertaining to that group. During the review

process for the 1978 revision of the U.S. standard

certificates and reports, organizations interested in

Hispanic data requested that an item be added for

collecting statistics on the Hispanic-origin population.

The Technical Consultant Panel (TCP), appointed by

the Public Health Conference on Records and Statistics Standing Committee, was given the task of reviewing the 1968 revisions of the standard certificates and

developing drafts of new standard certificates and

reports.

The TCP recommended that the five southwestern

States with substantial Hispanic minorities (California, Colorado, New Mexico, Arizona, and Texas) develop

birth and death statistics for the population of Hispanic origin in their States. It further recommended

that the list of Hispanic surnames used in conjunction

with the 1980 census be used for this purpose. NCHS

and the parent group of the panel agreed with the

recommendation.

However, in June of 1976, a joint resolution of

Congress (Public Law 94–311) required Federal agencies to begin collecting and publishing data on Americans of Spanish origin or decent. Therefore, although

an item on ethnic origin was not added to the certificates in the 1978 revision, NCHS recommended that

the five southwestern States and other States having

significant Hispanic-origin populations, develop a

suitable Hispanic-origin identifier for use on the birth

and death certificates. Work began with those States

toward that objective. During the 1980’s the number of

States including a Hispanic identifier on their birth

and death certificates steadily increased, and NCHS

was able to publish both natality and mortality data

for this population.

The 1989 revisions of the live birth, death, fetal

death, and induced termination of pregnancy forms

include a Hispanic-origin question. In addition, NCHS

developed a general ancestry question as an option for

those States without enough Hispanic population to

justify the specific question or for those that may have

a need for data on other segments of their population.

In the 1989 revision of the standard certificates

and reports, an item requesting yes or no for Hispanic

origin and ‘‘if yes, specify’’ was added for mother and

father on the live birth and fetal death forms, for

decedent on the death certificate, and for patient on

the induced termination of pregnancy form. The Hispanic identifier was not recommended for the marriage and divorce certificates.

Mortality statistics for the Hispanic-origin population were published for the first time for 1984 and

included data for 22 States and the District of Columbia. Natality statistics for the Hispanic-origin population were first published with the 1978 data and

included 17 States. The 1994 data for the Hispanicorigin population included mortality statistics for 49

States and the District of Columbia and natality statistics for 50 States and the District of Columbia.

Fetal death and induced termination of

pregnancy data

NCHS adopted the definition of fetal death recommended in 1950 by the World Health Organization.

Fetal death was defined as ‘‘death prior to the complete expulsion or extraction from its mother of a

product of conception, irrespective of the duration of

pregnancy.’’ The World Health Organization recommended that for statistical purposes, fetal deaths be

classified as early (less than 20 completed weeks of

gestation), intermediate (20 completed weeks of gestation but less than 28), late (28 completed weeks of

gestation and over), and gestation period not classifiable as early, intermediate, or late.

Until 1939, the procedure recommended nationally for registering a fetal death required the filing of

both a live-birth certificate and a death certificate. In

1939 the filing of a newly implemented standard certificate of stillbirth (fetal death) replaced the previous

procedure. This form, undergoing several revisions,

later became the U.S. Standard Certificate of Fetal

Death and, in 1978, the U.S. Standard Report of Fetal

Death.

In 1969 CDC established an abortion surveillance

system to obtain and publish data on induced abortions for each State. They have published data continuously since that time and are the only source of

national data on induced abortions available from the

Federal Government.

The Supreme Court decision of 1973 that made

induced abortion legal prompted more intensive efforts

to obtain national abortion statistics. In the early

1970’s, NCHS began developing a national abortion

16 Major Activities and Developments
reporting system similar to the reporting system used

for other vital events. The intent was for the data

system developed by NCHS to eventually replace the

abortion surveillance system in CDC. The abortionreporting area funded by NCHS gradually expanded,

as additional registration areas met reporting criteria

and as Federal funding became available. However,

less than one-half the States established reporting

systems that met the NCHS criteria and funding for

this program was very limited. As a consequence,

NCHS was able to obtain data from only 15 States.

Because the prospects for expanding the system any

further were unlikely, funding for the system was

discontinued by NCHS after data year 1993.

Linked birth/infant death data

Infant mortality rates are one of the most widely

used measures to gauge the overall health of a community. Researchers and public health officials are constantly looking for data to help them better understand

the causes of infant deaths and to plan strategies and

interventions to reduce the number of deaths. A wealth

of additional data can be obtained by linking the birth

certificates of infants with their death certificates.

The States have a long history of matching birth

and infant death certificates for both statistical and

registration purposes. NCHS undertook its first major

effort to create a national file of linked birth and infant

death records for the birth cohort of 1960. The file was

constructed by collecting actual copies of linked birth

and death certificates from each of the 50 States and

the District of Columbia. Of the nearly 110,000 infant

deaths to the 1960 birth cohort, certificates for 97.4 percent were matched to the corresponding birth

certificates.

The next national linked data set was created for

the birth cohort of 1980 by the Division of Reproductive Health, Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control, in

a project called National Infant Mortality Surveillance

(NIMS). An important side benefit of the NIMS project

was a conference held in May 1986 in Atlanta, Georgia. This conference brought together representatives

from State maternal and child health programs and

State vital statistics offices to exchange information on

data needed to monitor the effectiveness and efficiency

of maternal and child health programs.

In 1985 NCHS initiated a two-stage evaluation

project to determine the feasibility of creating linked

birth and infant death files on a routine, annual basis

as part of the Vital Statistics Cooperative Program

(VSCP). In stage one, a linked file was produced for

the 1982 birth cohort of infant deaths that occurred in

a nine-State area. A match rate of 96.7 percent was

achieved in this pilot, which demonstrated the feasibility of creating the linked file on a routine basis.

In stage two of the evaluation project, State and

national linked files for each of the birth cohorts of

1983–86 were created and evaluated with data from

all States included. Because of the success of the

evaluation project, the provision of the linked birth/

infant death file to NCHS was added to State VSCP

contracts beginning with the 1987 birth cohort.

Beginning with data year 1995, a significant change

was made in the way States provided the linked data

to NCHS. Rather than providing the linked information as a birth cohort, they provided it on a period

basis, based on the year of death of the infant, not the

year of birth. This change will have a major impact on

the timeliness of the release of data from the linked

file. It will also allow for the release of the linked data

set both as a period and birth cohort file, making it

even more useful. The development of the linked file

has proven to be an invaluable tool in the ongoing

struggle to reduce the infant mortality rate.

Training

The Applied Statistics Training Institute (ASTI)

was established in 1967 as part of the Office of State

Services in NCHS. The short-term training courses

were designed to meet the needs of State and local

vital and health statistics personnel for concentrated

training in practical aspects of health statistics. A

workshop on cause-of-death coding was included in the

training curriculum. In the first year, more than 100

experienced coders from 35 States were trained in the

eighth revision of the ICD.

NCHS provided leadership in the training of public health statisticians through the ASTI program

through 1982, when the program was discontinued

because of budget restraints.

The Division of Vital Statistics assumed the responsibility to continue training State vital statistics personnel in vital registration methods and statistics.

Because the division had worked closely with State

and local vital statistics offices in improving timeliness, completeness, and quality of the data, it was

logical for DVS to teach the courses being abolished by

the dissolution of ASTI. Beginning in 1983, DVS offered

two classes: ‘‘Vital Statistics Records and Their Administration,’’ which focuses on matters related to the vital

registration system, and ‘‘Vital Statistics: Measurement and Production,’’ which is a basic vital statistics

course with emphasis on measurement and data quality. DVS has continued to offer these courses to State

and local personnel annually. Equally important was

the continuation of nosology classes that focused on

medical coding. The Division of Data Processing

assumed the responsibility for these courses and has

held them annually since 1983.

A comprehensive disease prevention and health

promotion initiative, Healthy People 2000, produced

Major Activities and Developments 17
an increase in demand for public health statistics and

an increased need for training. As a result, in 1991

steps were taken to reestablish the ASTI program. A

series of short-term courses was developed for working

public health professionals to guide in setting and

evaluating health objectives for the year 2000. Now an

ongoing program, ASTI offers courses that focus on

current public health concerns. The goals set forth are:

to train health professionals in the use of statistical

tools; to apply statistical methods in assessing public

health problems; to provide early training relevant to

statistical requirements of current health legislation

and directives; to provide training in effective decision

making employing statistical models; and to improve

techniques of data collection, analysis, and utilization.

Special projects

Special projects conducted by NCHS have made

important contributions in the realm of vital and

health statistics. These projects include tests of registration completeness; revisions of the U.S. standard

certificates and reports; studies of the effect of the

decennial revisions of the ICD on the comparability of

cause-of-death statistics; and analyses of natality, mortality, and other vital statistics for presentation to

various medical, health, and other associations.

Two unique projects were undertaken by NCHS

during the 1960’s that contributed substantially to the

body of published vital and health statistics and analyses. One was a volume containing vital statistics rates

for a 20-year period (1940–60) on mortality, natality,

marriage, divorce, and life expectancy. The other

involved technical coordinating services and data production for a monograph series focusing on the major

health problems of the Nation.

Vital statistics rates in the United States:

1940–60

The volume Vital Statistics Rates in the United

States, 1940–60 (13), coauthored by Robert D. Grove,

Ph.D., and Alice M. Hetzel, brings forward to 1960 the

basic mortality and natality data included in the previously published volume, authored by Forrest E.

Linder, Ph.D., and Robert D. Grove, Ph.D., covering

the period 1900–40 (14). It also provides statistics on

life expectancy, marriages, and divorces, which were

not covered in the earlier volume. This work shows

some of the basic series back to the earliest year for

which data are available. Population data from the

Bureau of the Census used in the computation of rates

are also included. The text provides a description of

the vital statistics system, definitions and uses of vital

statistics rates and ratios, qualifications of the data,

and charts summarizing trends for selective vital statistics series. In 1996 a new volume was being compiled titled Vital Statistics Rates in the United States:

1969–93.

Vital and health statistics monographs,

1959–61

In the early 1960’s, the American Public Health

Association sponsored a monograph series to present

an indepth study of vital and health statistics. The

study was proposed in October 1958 by the statistics

section of the APHA. As chairman of the Committee on

Vital and Health Statistics Monographs, Mortimer

Spiegelman, associate statistician of the Metropolitan

Life Insurance Company, spearheaded the proposal

and became principal investigator for the project. The

committee selected the topics to be covered by the

series and suggested authors for the monographs.

Conferences were held with authors to establish general guidelines for the preparation of the manuscripts.

Support for this undertaking in its preliminary

stages was received from the Rockefeller Foundation,

the Milbank Memorial Fund, and the Health Information Foundation. Major support for the required tabulations, for writing and editorial work, and for the

related research of the monograph authors was provided

by the Public Health Service (Research Grant HS 00572,

formerly CH 00075, and originally GM 08262).

This study was initiated in response to an increasing awareness both inside and outside of the Government of the need for information defining the major

health problems of the Nation. The study was designed

to present critical analyses not only of current vital

statistics and health data but also of trends as indicated by data collected over the years. The study was

timed to utilize the extensive population data from the

1960 census for computation of rates by various characteristics of the population. The monographs were

expected to provide information useful for program

and research planning and for educational and general

information purposes. First conceptualized as a monograph series based on 3 years of death statistics centered around the 1960 census, the project was soon

broadened to include pertinent findings from special

surveys and studies of social and economic factors not

only in mortality but in morbidity and fertility as well.

Under the leadership of Robert D. Grove, Ph.D.,

National Office of Vital Statistics, NCHS, and a member of the Committee on Vital and Health Statistics

Monographs, NCHS produced special detailed tabulations and computations for the 1959–61 period and

performed technical coordinating services for the

project. NCHS provided data collected through the

vital registration system, obtained population data

from the Bureau of the Census for the rate computations, and provided guidance to keep the results con18 Major Activities and Developments
sistent with official national figures. Other major

sources of statistical data included the National Health

Survey and the University of Chicago study of social

and economic differentials in mortality based on a

matched file of 1960 census records and death

certificates.

To achieve some comparability among monographs, a standard set of mortality tabulations was

produced for each, using the same classifications for

selected characteristics. In general, monograph authors

were able to obtain additional tabulations and rate

computations of their choosing from available data

without need to conform to a uniform pattern.

The Vital and Health Statistics Monographs, 1959–

61, were published by Harvard University Press, Cambridge, Massachusetts. Titles and authors are as follows:

b Infant, Perinatal, Maternal, and Childhood

Mortality in the United States, by Sam Shapiro,

Edward R. Schlesenger, and Robert E.L. Nesbitt, Jr.

b Trends and Variations in Fertility in the United

States, by Clyde V. Kiser, Wilson H. Grabill, and

Arthur A. Campbell

b The Epidemiology of Oral Health, by Walter J.

Pelton, John B. Dunbar, Russell S. McMillan, Palmi

Moller, and Albert E. Wolff

b Cardiovascular Diseases in the United States, by

Iwao Moriyama, Dean E. Krueger, and Jeremiah

Stamler

b Digestive Diseases, by Albert Mendeloff and James

P. Dunn

b The Frequency of Rheumatic Diseases, by Sidney

Cobb, M.D.

b Tuberculosis, by Anthony M. Lowell, Lydia B.

Edwards, and Carroll E. Palmer

b Marriage and Divorce: A Social and Economic

Study, by Hugh Carter and Paul C. Glick

b Infectious Diseases, by Carl Calvin Dauer, Robert F.

Korns, and Leonard M. Schuman

b Mortality and Morbidity in the United States, by

Carl L. Erhardt and Joyce E. Berlin

b Accidents and Homicide, by Albert P. Iskrant and

Paul V. Joliet

b Differential Mortality in the United States: A Study

in Socioeconomic Epidemiology, by Evelyn M.

Kitagawa and Philip M. Hauser

b Epidemiology of Neurologic and Sense Organ

Disorders, by Leonard T. Kurland, John F. Kurtzke,

and Irving D. Goldberg

b Cancer in the United States, by Abraham M.

Lilienfeld, Morton L. Levin, and Irving I. Kessler

b Mental Disorders/Suicide, by Morton Kramer, Earl

S. Pollock, Richard W. Redick, and Ben Z. Locke

b Syphilis and Other Venereal Diseases, by William J.

Brown, James F. Donohue, Norman W. Axnick,

Joseph H. Blount, Neal W. Ewen, and Oscar G.

Jones

Cooperative developments

Vital statistics component of the

Cooperative Health Statistics System

The Cooperative Health Statistics System (CHSS)

was formally established by the Health Services

Research, Health Statistics, and Health Care Technology Act of 1978 (Public Law 95–623). The stated

purpose was the production of ‘‘comparable and uniform health information and statistics.’’ Vital statistics, included as one of seven components, provided the

nucleus of the system. It received high priority for

inclusion in the system because of its importance in

providing population-based information essential in

identifying health and social problems. It also had a

long history of successfully obtaining data through a

Federal-State cooperative arrangement.

Considerable departmental and legislative activity

preceded formalization of the CHSS. Soon after NCHS

was established to coordinate activities in the field of

national health statistics, there was an increased

awareness of the potential for broadening FederalState cooperative activities to include a variety of

health statistics.

During the late 1960’s and early 1970’s, references

to a cooperative health statistics system occurred frequently in departmental memoranda, in testimonies

at hearings before House and Senate Committees, and

in various pieces of legislation. The first steps toward

the development of a cooperative health information

and statistics system were authorized by the Health

Services Improvement Act of 1970. It authorized the

Secretary of the Department of Health, Education,

and Welfare ‘‘to undertake research, development, demonstration, and evaluation relating to the design and

implementation of a cooperative system for producing

comparable and uniform health information and statistics at the Federal, State, and local levels.’’ Funds

for this effort were appropriated to the National Center for Health Services Research and Development.

Under this authorization, collection of vital statistics

data through this arrangement began in 1973. The

ongoing national vital statistics program, already operating through the cooperative efforts of Federal, State

and local governments, was the first component funded

under this act.

The cooperative system was envisioned as a system that would use standard definitions, standard

measurements for quality, and standard methods for

collecting, processing, and analyzing health statistics.

Data originating at the local level would be produced

in content and form for use not only at the local level

but at the State and Federal levels as well. Through

elimination of duplicative efforts, more efficient use of

resources and equitable cost-sharing, data of greater

Major Activities and Developments 19
detail and better quality would be available to all

levels of government.

The vital statistics program already embodied the

basic principles of the proposed CHSS. The records

were being produced by local officials, sent to the State

offices of vital statistics for permanent maintenance in

central State files, and for use in compiling and publishing statistics for State and local areas. The State

offices forwarded copies of the records to NCHS, where

data were edited, coded, tabulated, and published for

the Nation.

These procedures began to change in 1971, as

NCHS began to accept magnetic tapes of State-coded

data, coded according to NCHS specifications. NCHS

was providing leadership not only in promoting uniformity in form and content of vital records and registration laws but also in developing new methods for data

collection, processing, and dissemination. The birth

and death statistics constituted the only series of

annual health statistics that covered all events from

all jurisdictions in a uniform manner according to

specified standards. Although the framework existed,

however, there was a recognized compelling need to

accelerate improvement of the quality and uniformity

of data, to modernize collection and processing methods, to eliminate State-Federal duplication, and to

establish an equitable cost-sharing mechanism.

The vital statistics component of the CHSS involved

six data sets or subcomponents: births; demographic

data for deaths; medical (cause-of-death) data for

deaths; marriages; divorces; and abortions. By 1973

six States had already entered into contracts with the

Division of Vital Statistics of NCHS to provide computer tapes of birth and demographic death data under

the Vital Statistics Cooperative Program (VSCP).

Throughout the early developmental period, available

funds were insufficient to bring into the VSCP all

States technically ready and interested in a contract.

Some States provided tapes to NCHS prior to availability of funding. Contracts were negotiated with additional States subject not only to technical readiness

but to availability of funds. Funding birth and demographic death data in non-VSCP States was given

priority over extending subcomponent coverage in

States already in the program. Several States, however, were technically able to and did include cause-ofdeath data in their first contract.

Beginning in 1971 with the State of Florida

(unfunded), the number of States submitting one or

more subcomponents of data to NCHS on computer

tape steadily expanded as funding became available.

By the 1985 data year, all States, the District of

Columbia, New York City, Puerto Rico, and the Virgin

Islands were submitting birth data and demographic

death data on tape. In 1995, 42 States and the District

of Columbia were submitting medical death data on

tape.

Prior to implementation of the VSCP, the Federal

Government reimbursed the States for use of their

vital records for national statistics at the rate of 4

cents per record. The first VSCP contracts were negotiated individually with the participating States. It

soon became evident that equitable funding among the

States required development of a rationale for cost

sharing that could be applied to all States.

In January 1981, Dorothy P. Rice, then director of

NCHS, established a working group on the completion

of the VSCP. The working group was made up of

NCHS staff members appointed by the NCHS director

and State representatives appointed by the president

of the Association for Vital Records and Health Statistics (AVRHS). The group served as a forum in the joint

effort of NCHS and AVRHS to define the State/local

activities involved in producing vital statistics for use

at all levels of government, the cost of those activities,

and a rationale for determining the Federal share of

that cost. Development of standardized funding criteria to ensure equitable funding among States, and

simplification of the contracting process for the VSCP

contracts were also major concerns.

The working group constructed a model for standardizing funding among States in terms of in-scope

activities and levels of effort. The model provided for a

cost formula limited to the accepted level of effort

necessary to carry out the in-scope functions of the

vital statistics contracts. The working group recommended that implementation of the formula be phased

in over a 3-year period beginning with fiscal year (FY)

1983, and that after sufficient experience, the formula

be reevaluated and revised if necessary.

In May 1986, Dr. Manning Feinleib, then director

of NCHS, established a working group to review the

VSCP cost formula and to develop recommendations

concerning revision. As with the previous working

group, membership was made up of representatives

from NCHS and AVRHS.

The working group recommended updating the

cost formula, eliminating reference to the ‘‘Federal

share’’ in favor of a funding level derived from a base

level with annual cost-of-living adjustments (COLA’s).

For FY 1989, funding was to be established at the FY

1988 level plus a 4.9-percent COLA, with additions for

the cost of collecting and processing new items of data.

In succeeding years funding would be established by

adding a COLA to the previous year’s level. Additional

funds would be provided for implementation of new

components. Reduction in the scope of a program

would be required to offset any reductions in funding.

Full funding to a State would be dependent on the

reporting of all minimum basic data-set items. The fee

for procurement of photocopies or microfilm copies of

records would be increased from 4 cents to 10 cents per

image.

20 Major Activities and Developments
In the fall of 1992, Dr. Feinleib established the

second working group to review the VSCP cost formula. This working group was charged with reviewing

the experience of the last 5 years to evaluate the

adequacy of the current formula to (a) adequately and

fairly distribute funds among States and (b) assure its

relevancy to the current and future operations of the

VSCP. Membership again was made up of representatives from NCHS and AVRHS. The 1992 working

group recommended that no changes be made in the

elements used in the formula to determine the distribution of funds. They also recommended that the 1993

contracts be extended through 1994 and new contracts

be written for 1995–99 data. Data on staffing and

salaries were collected in 1995 for use throughout the

1995–99 contract period, with annual adjustments for

cost of living. In previous contracts, staffing and salary

information had been obtained on an annual basis.

The committee also discussed the need to modify the

formula to reflect automated birth and death systems

under development in the States. However, because

not all States were at the same point in the development of these systems, the working group recommended that no changes related to automation be

made in the formula at this time. NCHS and AVRHS

agreed to develop appropriate cost and staffing models

to reflect an automated vital record system prior to the

next VSCP formula revision.

The working group also discussed ways to encourage

timeliness, at both the State and national levels. The

new cost formula recommended that States provide data

to NCHS as soon as they are received and initially

processed, rather than waiting until all quality control is

completed. Updated records were to be transmitted as

amendments were processed. This would allow NCHS to

process and release the data more rapidly.

The working group agreed that in addition to an

annual release, data should be published and disseminated on a ‘‘flow’’ basis as they become available. The

NCHS current-flow publication plans are discussed in

this report under ‘‘Vital Statistics in the 21st Century:

A Vision for the Future.’’ Thus, the 1995–99 contract

set the stage for moving the vital statistics system

toward automation, improved timeliness, and new datarelease products.

State centers for health statistics

The concept of State centers for health statistics

originated in the 1970’s under the CHSS. They were to

be semi-autonomous organizations housed primarily

in State health agencies that would collect and analyze the major health data bases and be a resource for

statistical analysis and consultation. During the late

1970’s and the 1980’s, efforts were made to obtain

official State designation for these centers, either

through legislation or executive order. In 1980, the

Public Health Service developed proposed guidelines

for the characteristics, authority, statistical mission,

and functions of the State centers. These guidelines

were published in the Federal Register (July 22, 1980).

However, the guidelines were not adopted as regulations by the Public Health Service, although they have

served as a model for some States to follow in setting

up a comprehensive health statistics program.

All 50 States and the District of Columbia have

designated State centers for health statistics, but with

varying results. State centers have diverse capabilities, ranges of authority, and placements within State

government. Although in most States the center is a

part of the health agency, in some the center is located

in a human resources agency, or in one case, in the

budget and control board. In a few States, the State

center plays a major role in the development of information needed for assessment, policy development,

and assurance. There are also a number of State

centers whose function is limited to the tabulation and

analysis of vital statistics.

Supplemental data sources

A number of special data-production activities have

been undertaken as part of the vital statistics program. They include follow-back surveys and the

National Survey of Family Growth (NSFG), conducted

to augment vital records data, and the National Death

Index (NDI) established in 1981 as a central source of

information to aid researchers.

Follow-back surveys

In the mid-1950’s the National Office of Vital

Statistics in collaboration with other agencies began

conducting studies anchored to vital records. The studies were undertaken with the cooperation of the health

departments of the vital registration areas. The health

departments approved the studies, authorized the use

of vital records in the studies, and when appropriate,

cleared the studies with the State medical societies.

The vital record was the basic sampling unit. The total

file of vital records for the given event during the given

period was the sampling frame. Supplementary information about each event was collected from sources of

information identified on the certificate. The sample

figures were inflated to provide unbiased estimates for

the universe from which the sample was selected.

These surveys served as pilot tests for developing

survey methodology for collection of national morbidity, mortality, and medical care data and related socioeconomic differentials. They include the following:

+ The National Lung Cancer Mortality Study

(National Cancer Institute, 1956–57) served as a

Major Activities and Developments 21
pilot test for the National Lung Cancer Study

conducted later

+ The Illness Study of Deceased Persons in the Middle

Atlantic States (National Health Survey Program,

1957–58)

+ The National Lung Cancer Mortality Study

(National Cancer Institute, 1958–60)

+ The Illinois Bone Tumor Mortality Study (Argonne

National Laboratory, 1958–60)

+ The National Study of Socioeconomic Differentials

in Mortality (University of Chicago, 1960)

+ The National Survey of Hospitalization in the Last

Year of Life (National Health Survey Program,

1961)

The National Mortality Surveys were conducted

annually from 1961 through 1968 and in 1986 and

1993. The early surveys of the 1960’s include information on hospitalization, diagnoses, operations performed, income, education, health insurance, charges

for hospital care and surgery, and smoking habits of

the deceased. Both the 1986 and 1993 surveys include

additional information on the access to and use of

health care services during the last year of life, the

amount paid for health care by the decedent, the

source of other health care payments made on behalf

of the deceased, and the household composition, disability, comorbid conditions, cognitive functioning,

drinking habits, and socioeconomic status of the

deceased.

The 1986 survey also includes information on the

deceased’s usual intake of specific food groups, use of

birth control, sterilization, and history of heart attack

among the deceased’s parents and siblings. Hospital

records for the deceased provide information on diagnostic and surgical procedures performed during the

last year of life.

The 1993 survey expands upon the earlier surveys

by including additional information on the deceased’s

use of assistive devices, medical devices implanted or

used while living at home, motor vehicle driving behavior, use of drugs, access to firearms at home, organ

donorship, behavior and lifestyle-related activities, place

of death, and circumstances surrounding injuryrelated deaths. For unintentional and intentional

injury-related deaths, additional information collected

from medical examiner or coroner records includes

events leading to the death, autopsy results, and toxicological findings.

The National Infant Mortality Surveys were conducted annually from 1964 through 1966. They include

information about other children of the mother, household composition, income, employment of mother, education of mother and father, and health insurance.

The National Natality Surveys were conducted

annually from 1963 through 1969 and in 1972 and

1980. They include information on medical and dental

care and radiological treatment of the mother, parental education, type and length of parental employment, family income, pregnancy history, expectations

of having more children, household composition, number and date of marriage(s), health insurance, breast

feeding, previous pregnancies, religious preference of

husband and wife, health status of mother and infant,

whether pregnancy was wanted, and whether mother

had an operation to prevent future pregnancies. The

1980 survey included fetal mortality and items on

alcohol consumption, electronic fetal monitoring, amniocentesis, and ethnicity.

The National Maternal and Infant Health Survey

was a nationally representative follow-back study of

women who had reproductive events in 1988. The

sample was drawn from the 1988 live birth, fetal

death, and infant death vital records from each registration area. It included women who had live births,

women who suffered an infant death, and women who

had a fetal loss. It provided data on the relationship of

such antenatal factors as prenatal care health services, smoking, and use of alcohol and drugs, to adverse

outcomes such as fetal loss, low birthweight, and

infant death. Prior to the 1988 study, many States

excluded out-of-wedlock births from their sample, but

because of favorable pretest results, most States

included them in the 1988 sample.

A longitudinal followup survey was conducted in

1991, in which mothers from the 1988 National Maternal and Infant Health Survey and their children’s

medical providers were recontacted to update health

histories of mother and child and provide information

on such subjects as child injuries, child safety, child

care and development, parental employment patterns,

use of Federal assistance programs, health insurance,

use of pediatric services, and subsequent fertility.

National Survey of Family Growth

The National Survey of Family Growth (NSFG)

was established in response to a well-recognized need

for information that could be used to develop, manage,

and evaluate Federally supported programs related to

family planning, childbearing, and maternal and infant

health, and to aid in refining population projections. In

the late 1960’s, NCHS took the initiative to develop an

interview survey as one of its ongoing systems in the

vital statistics program. It drew upon the expertise of

participants in the successful series of privately conducted national fertility surveys—the Growth of American Families Surveys in 1955 and 1960 and the

National Fertility Studies in 1965 and 1970.

The NSFG supplements information from the regular data collection programs of NCHS and the Bureau

of the Census. In addition to providing deeper explanatory data on birth trends (contraceptions, wanting of

22 Major Activities and Developments
pregnancies, and socioeconomic data), it provides data

to expand various aspects of vital statistics, including

fetal mortality (regardless of gestation), estimates of

total annual pregnancies, and family formation and

stability. It also provides data on infertility, a critical

factor in population replacement as well as an important area of reproductive health.

The need for such data was stated in the ‘‘Report of

the Secretary of Health, Education, and Welfare Submitting Five-Year Plan for Family Planning Services

and Population Research Programs,’’ October 12, 1971,

prepared for the Special Subcommittee on Human

Resources of the Senate Committee on Labor and

Public Welfare. In that document the ongoing efforts of

NCHS were recognized, and plans for developing a

National Survey of Family Growth by NCHS were set

forth.

The Commission on Population Growth and the

American Future, in its March 1977 report, gave a

strong supporting recommendation for ‘‘. . . program

support and continued adequate financial support for

the Family Growth Survey as almost the first condition for evaluating the effectiveness of national population policies and programs.’’

The NSFG is now an integral part of the NCHS

data-collection systems. Differing from the center’s

other population-based surveys, it targets a particular

aspect of the health experience of a particular segment

of the total population, that is, the reproductive histories of women of childbearing ages. It yields data

interrelated with other research studies of health and

health services. As a result, it has been and continues

to be a collaborative undertaking between NCHS and

other Federal agencies.

Data for the NSFG are collected in personal interviews using nationwide cross-sectional probability

samples of women in the childbearing ages. In cycles I

and II of the NSFG, conducted in 1973 and 1976, the

sample included women 15–44 years of age who had

ever been married or, if they had never been married,

had children of their own living with them. Cycle III,

conducted in 1982, was expanded to include all women

15–44 years of age, bringing important new information into the survey. Cycle IV, conducted in 1988,

linked the NSFG to the National Health Interview

Survey (NHIS), a continuing survey conducted every

week of every year. The NSFG was the first survey

successfully linked to the NHIS in the center’s newly

developed integrated survey design.

The beginning and early development of the NSFG

in the vital statistics system are documented in reports

of the U.S. National Committee on Vital and Health

Statistics published by NCHS in Vital and Health

Statistics, Series 4. The survey and sampling designs

of the NSFG cycles appear in Vital and Health Statistics Series 2, and statistics derived from the surveys

are published in Series 23.

National Death Index

Over the years death records have been a fruitful

source of information for researchers in the field of

medicine. Increasing awareness of the many and varied influences on the length and quality of life has

accelerated their use. Death records are utilized in

studies to identify and assess environmental health

hazards, the effects of specific therapies, the influence

of various health programs, and risk factors such as

those inherent in some chemicals, drugs, and consumer products. Without a national source for information on fact of death and location of the death record,

obtaining access to death records for studies can be a

cumbersome process. It can require searches of all of

the individual State vital statistics offices for each

sought-after record, unless the researcher knows the

registration area in which the death occurred. A single

source for determining whether or not an individual

has died and, if so, the location of the death record

greatly facilitates such research in terms of time,

money, and effort.

This need for a central source of mortality information for use in medical and health research led to

implementation of a national death index in 1981.

Leading up to this, in 1964 and again in the early

1970’s, a study group was established under the

auspices of the Public Health Conference on Records

and Statistics to explore the feasibility and means of

establishing such a source. Both study groups recommended a national system for locating death

certificates that would enable medical and health

investigators to ascertain at one central source the

fact of and/or place of death for individuals in their

studies.

Delay in implementing the recommendations of

the study groups was largely the result of concern that

once established, there would be pressure to use the

system for other than its intended statistical purposes

in medical and health research. Until the legality of

the restrictions imposed by the participating States

could be assured, NCHS was reluctant to undertake

responsibility for establishing a national death clearance system. Interest of research groups increased,

however, and early in 1976 more intensive discussions

began between NCHS and the AAVRPHS executive

committee.

In August of 1976, the Office of the General

Counsel of the Department of Health, Education,

and Welfare rendered the opinion that NCHS could

legally limit access to information from a national

death index on the basis of its confidentiality legislation in Section 308 (d) of the Public Health Service

Act, 42 U.S.C. 242 m. In February 1977, in light of

that opinion and after discussions with the executive committee of AAVRPHS, the director of NCHS

established a working group to develop plans and

Major Activities and Developments 23
procedures for the implementation of a national

death index. On August 31, 1978, the working group

submitted its final report to the director. As the

working group recommended, the index was implemented beginning with 1979 deaths. The first year

46 registration areas participated. A computerized

uniform standard data set has since been collected

annually from all registration areas. The system,

which may be used only for statistical purposes in

health and medical research, became available to

researchers in January 1981.

All applications for use of the NDI are reviewed

by drawing on the expertise of individuals from

State vital statistics offices, NCHS staff, and user

groups such as the National Institutes of Health, the

National Institute for Occupational Safety and

Health, medical schools, and private industry. When

approved, applicants are instructed to submit their

records of study subjects on magnetic tape, floppy

disks, or coding sheets. Users of the NDI are required

to provide certain minimum information to access

the index (that is, first and last name and either a

Social Security number or month and year of birth).

The provision of additional data items is useful in

assessing the quality of the resulting NDI record

matches: middle initial, father’s surname, day of

birth, sex, race, marital status, State of residence,

and State of birth.

Once the NDI search is completed, the user is

provided with the State and date of death for each

possible NDI record match and the corresponding

State death certificate number as it appears in the

index. The user must then contact the appropriate

States and purchase copies of the death certificates to

obtain additional information such as cause of death.

Although States submit their death records to the

Federal office for statistical compilation, analysis, and

publication, they reserve the right to respond to all

inquiries concerning individuals and to require additional information and confidentiality assurances from

the NDI users.

To enhance the services provided to researchers,

the NDI program initiated a pilot study in 1995 to

determine the feasibility of also providing the coded

causes of death to NDI users. NCHS and the National

Association for Public Health Statistics and Information Systems (NAPHSIS) are currently evaluating the

pilot results. If the pilot leads to a general implementation, NDI users will have the option of obtaining

coded causes of death for selected potential matches as

part of their NDI output.

As of September 30, 1995, the NDI file contained

more than 35 million death records for the years

1979–94. The NDI had assisted 578 research projects

by performing 1,551 NDI file searches involving 18.2

million records of study subjects.

Availability of vital statistics data

Vital statistics data are made available to the

public in various forms, such as published volumes

and reports, special tabulations, and more recently,

electronic data products. The latter currently include

public use data tapes and CD-ROM disks with the

Statistical Export and Tabulation System (SETS)

designer kit. Made available through these outlets are

counts of events, presentations of rates, ratios, actuarial data, analyses, and discussions of quality, reliability, and methodology. Data obtained by the National

Natality, Mortality, and Maternal and Infant Health

Surveys are made available in similar forms, as are

data from the National Survey of Family Growth.

Publications

Vital Statistics of the United States , bound annual

volumes that are distributed to many libraries for use

by the public, have been published routinely, beginning with 1937 data and continuing to the present

time. They contain numerous tables of detailed vital

statistics and technical appendices explaining the

sources and qualifications of the data.

Monthly Vital Statistics Report, a report of monthly

provisional vital statistics, contains monthly and yearto-date statistics with comparative data for the preceding year. Supplements to the MVSR present annual

summaries of provisional data and of final data when

they become available.

Vital and Health Statistics, intermittent series

reports presenting data, analyses, and information on

a wide variety of topics related to NCHS activities,

include many reports emanating from the vital statistics program.

Public-use data tapes

Beginning with data for 1968, electronic data tapes

are available for purchase containing natality, fetal

death, marriage, and divorce statistics, as well as

demographic, underlying-cause, and multiple-cause

mortality statistics. Also available are data tapes of

the linked files of live births and infant deaths beginning with data for the 1983 birth cohort, and of the

national follow-back surveys and the National Survey

of Family Growth. Measures are taken to protect the

confidentiality of individuals and prevent inadvertent

disclosure of confidential information. Public-use data

tapes accelerate and enhance the availability of data

to researchers and allow them to aggregate findings in

a format appropriate for their analyses. The public-use

data tapes are purchased from the National Technical

Information Service.

24 Major Activities and Developments
CD-ROM with SETS

Linked files of live births and infant deaths for the

birth cohorts of 1985, 1986, 1987, and 1988 have been

produced on CD-ROM using SETS. CD-ROM’s are also

expected to be available in 1996 for the 1989 through

1991 linked files, for the 1991 fetal death and multiple

cause-of-death files, and for the 1992 natality file. In

1995, the 1991 telephone reinterview of respondents in

cycle IV of the National Survey of Family Growth was

made available on CD-ROM using SETS, and in early

1996, the 1991 longitudinal followup to the 1988

National Maternal and Infant Health Survey was also

issued on CD-ROM.

In 1996, a project was initiated to produce a

CD-ROM that would enable users to derive frequencies, percentages, and rates for deaths in the United

States for the data years 1969–93. This CD-ROM, also

formatted and indexed using SETS, would include

aggregate numbers for selected variables (age, race,

sex, county and State of residence, year of event, and

cause of death for decedents), and thus it would be

different from the other CD-ROM’s just described,

which contain individual respondent records. Also being

planned was a similar CD-ROM for aggregate natality

data to cover the same span of years and to include

information on such categories as age, race, birth

order, birthweight, prenatal care, education, marital

status, and State of residence for mothers of births in

the natality file. These aggregates would be retrievable with the appropriate population denominators to

create rates.

Vital statistics in the 21st century:

A vision for the future

As the National Vital Statistics System approaches

its centennial anniversary, it faces a number of challenges. The historical system is based primarily on

paper recording of more than 6 million annual birth

and death events by thousands of physicians, hospitals, funeral directors, and coroners. These records are

typically transmitted through local registration officials, then keyed, queried, and edited as they are

received by State offices. The data are transmitted

periodically to NCHS as files are completed. After

labor-intensive processing in both State offices and

NCHS, the data are released to the public on an

annual basis as reports or electronic products.

Over the last decade, NCHS and NAPHSIS have

taken significant incremental steps to improve the

vital records system within its historical structure.

Examples of these efforts include the electronic birth

certificate and refinements in automated coding. The

pursuit of these improvements has led to the conclusion that it is time to change the very nature of the

system. NCHS and NAPHSIS have a vision for reinventing the vital statistics system for the 21st century.

This vision requires not only automation, but a change

in the basic relationships that exist among NCHS,

State registration officials, and the providers of source

records. The vision was first articulated by John E.

Patterson (1992), then director of the NCHS Division

of Vital Statistics, at the 1992 annual meeting of the

Vital Statistics Cooperative Program State Project

Directors. Since that time, it has been refined and is at

the beginning stages of implementation.

NCHS and NAPHSIS envision for the year 2000

and beyond a vital statistics system in which birth and

death certificates (and possibly other vital events) are

created, edited, coded, queried, and corrected at the

source point in electronic form; transmitted over highspeed lines to a central location in each State for any

State processing and information management; and

finally, electronically transmitted to NCHS on a frequent and regular basis.

This redesign would create an informationmanagement partnership between State vital statistics offices and NCHS. Data entry would be shifted

from the State office to the source data provider, who

completes the original record; the original record would

be electronic rather than paper. Data entry would

employ standardized, automated editing systems to

continually ‘‘clean up’’ the data by the States; changes

and updates to the coded record would be transmitted

to NCHS and entered in the data file on a continual

basis.

These changes would shift the focus of the vital

statistics system from batch processing to dynamic

processing and from an annual data release to a

current-flow release as the data are received from the

States. Users could analyze the data, including any

preliminary or incomplete data that were available

within time-frames of their own choice. For some

surveillance purposes, timeliness may be much more

important than quality and completeness, and it will

be appropriate to use the most current data that are

available. For some demographic and epidemiological

analyses, however, quality and completeness are of

paramount concern, and it may be necessary to wait

until the final annual files are available. All of the

steps that are required to produce a timely surveillance file on a current-flow basis will also contribute to

the timeliness and quality of the final data.

Many of these changes are already underway. In

1995, almost 70 percent of births were registered electronically (although most States were still processing

a paper legal record). Experimentation with electronic

death registration continues. In 1996, NCHS will begin

to release 1995 data on a current-flow basis. Estimates

based on 1995 records processed by March 1996 will be

released for a variety of mortality and natality variables and will provide detailed data never before available this early. In future years, the release schedule

Major Activities and Developments 25
will be adjusted as experience with the system is

gained.

Vital records are the primary source of the most

fundamental public health information. Data on births,

access to prenatal care, maternal risk factors, infant

mortality, causes of death, and life expectancy are

examples of the types of information provided by vital

statistics. Over the past 100 years, the national vital

statistics system has matured into a program that can

provide complete and continuous information on issues

of importance to the Nation’s health. NCHS and its

State partners will continue to nurture and improve

the system as we move into the next century.

References

1. Association for Vital Records and Health Statistics. A

history of the Association for Vital Records and Health

Statistics. 50th anniversary 1933–83. 1983.

2. Grove RD. The 1968 revision of the standard certificates. National Center for Health Statistics. Vital health

stat 4(8). Washington: Public Health Service. 1968.

3. Dundon ML, Gay GA, George JL. The 1978 revision of

the U.S. standard certificates. National Center for Health

Statistics. Vital health stat 4(23). 1983.

4. Tolson GC, Barnes JM, Gay GA, Kowaleski JL. The

1989 revision of the U.S. standard certificates and reports.

National Center for Health Statistics. Vital health stat

4(28). Public Health Service. 1991.

5. Grove RD. Studies in the completeness of birth registration. Bureau of the Census. Vital statistics special reports

17(18). Washington: 1943.

6. Social and Economic Statistics Administration. Test of

birth registration completeness, 1964 to 1968. 1970

Census of population and housing. Bureau of the Census. Washington. 1973.

7. Woolsey TD. Description of methods used in the construction of variation charts for the current mortality analysis. Census Bureau. Vital statistics special reports 17(26).

Washington: 1943.

8. Dunn HL, Shackley W. Comparison of cause of death

assignments by the 1929 and 1938 revisions of the

international list, deaths in the United States, 1940.

Bureau of the Census. Vital statistics special reports

19(14). Washington: Department of Commerce. 1944.

9. Faust MM, Dolman AB. Comparability ratios based on

mortality statistics for the fifth and sixth revisions:

United States, 1950. National Center for Health Statistics. Vital statistics—special reports 51(3). Washington: Department of Health, Education, and Welfare.

February 1964.

10. Faust MM, Dolman AB. Comparability of mortality statistics for the sixth and seventh revisions: United States,

1950. National Center for Health Statistics. Vital

statistics—special reports 51(4). Washington: Department of Health, Education, and Welfare. March 1965.

11. Klebba AJ, Dolman AB. Comparability of mortality statistics for the seventh and eighth revisions of the International Classification of Diseases, United States.

National Center for Health Statistics. Vital health stat

2(66). Washington: Department of Health, Education,

and Welfare. 1975.

12. Klebba AJ, Scott JH. Estimates of selected comparability ratios based on dual coding of 1976 death certificates by the eighth and ninth revisions of the

International Classification of Diseases. National Center for Health Statistics. Monthly vital statistics report

28(11) Supplement. Hyattsville, Maryland. Public

Health Service. 1980.

13. Grove RD, Hetzel AM. Vital statistics rates in the United

States, 1940–1960. Public Health Service. Washington.

National Center for Health Statistics. 1968.

14. Lindner FE, Grove RD. Vital statistics rates in the

United States, 1900–1940. U.S. Department of Commerce. Washington. Bureau of the Census. 1943.

26 Major Activities and Developments
Appendixes

Contents

I. Appendix I tables

Table 1. Content of the U.S. standard certificate of live birth, by year revised . . . . . . . . . . . . . . . . . . . . . . 28

Table 2. Content of the U.S. standard certificate of death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . 32

Table 3. Content of the U.S. standard report of fetal death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . 35

Table 4. Content of the U.S. standard report of induced termination of pregnancy, by year

revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Table 5. Content of the U.S. standard license and certificate of marriage, by year revised . . . . . . . . . . . 39

Table 6. Content of the U.S. standard certificate of divorce, dissolution of marriage, or

annulment, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

II. History and Organization of the Vital Statistics System

Historical development . . . . . . . . . . . . . . . . . . . 43

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Beginnings: First use of records . . . . . . . . . 44

From records to statistics . . . . . . . . . . . . . . 45

Impact of industrialism . . . . . . . . . . . . . . . . 46

Beginnings of modern registration . . . . . . 46

State registration in America . . . . . . . . . . . 47

The Shattuck report . . . . . . . . . . . . . . . . . . . 48

Shattuck and the census of 1850 . . . . . . . . 48

Registration and public health:

1850 to 1872 . . . . . . . . . . . . . . . . . . . . . . . . . 48

Founding of the APHA and the National

Board of Health . . . . . . . . . . . . . . . . . . . . . 49

Leadership by the Census Office: 1880 to

1890 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

The revolution in preventive medicine . . . 50

Advances in disease classification . . . . . . . 51

Census leadership after 1900 . . . . . . . . . . . 51

Division of Vital Statistics: The road to

reorganization . . . . . . . . . . . . . . . . . . . . . . . 53

Changing needs for vital records and

statistics . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Budget Bureau’s recommendations:

1943 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Wartime cooperative arrangements . . . . . . 56

Transfer to the Public Health Service:

1946 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Growth of the birth- and death-registration

areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Marriages, divorces, and notifiable

diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Marriages and divorces . . . . . . . . . . . . . . . . . 59

Notifiable diseases. . . . . . . . . . . . . . . . . . . . . . 61

The vital records and statistics system . . . . . 63

Registration and reporting activities . . . . . . . 63

Registration of births . . . . . . . . . . . . . . . . . . 63

Registration of deaths . . . . . . . . . . . . . . . . . . 63

Registration of fetal deaths (stillbirths) . . . 63

Registration of marriages and divorces. . . 64

Vital statistics organization . . . . . . . . . . . . . . . 64

In local areas . . . . . . . . . . . . . . . . . . . . . . . . . . 64

In the States . . . . . . . . . . . . . . . . . . . . . . . . . . 65

In the United States. . . . . . . . . . . . . . . . . . . . 66

Appendix II tables

Table 1.01. Important dates in the history of birth and death registration: United States . . . . . . . . . . . 58

Table 1.02. Growth of the birth- and death-registration areas: United States . . . . . . . . . . . . . . . . . . . . . . 58

Table 1.03. Year in which each State was admitted to the birth-registration area . . . . . . . . . . . . . . . . . . 59

Table 1.04. Year in which each State was admitted to the death-registration area . . . . . . . . . . . . . . . . . . 59

Table 1.05. Sources of marriage and divorce totals: United States, 1867–1950 . . . . . . . . . . . . . . . . . . . . . 60

Table 1.06. Year in which the central filing of marriage and divorce records began. . . . . . . . . . . . . . . . . . 60

Figure

Flow of vital records and statistics in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

27
Appendix I

Table 1. Content of the U.S. Standard Certificate of Live Birth, by year revised

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Birth information

Name of child ............................................. XXXXXXXXXXX

Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXXXXXXXXX

Date of birth ............................................... XXXXXXXXXXX

Time of birth .............................................. XXXXXX ––XXX

Place of birth:

Name of hospital ........................................ –––– –XXXXX –

Name of facility ......................................... ––––––––––X

Street and number ...................................... X X X ––––––––

If birth occurred in hospital or institution, give its

name instead of street number ......................... – – – X X ––––––

Type of place of birth (checkboxes) ........................ ––––––––––X

Street and number if not in hospital ....................... –––– –XXXXXX

Township of, or ......................................... XXXXX ––––––

Village of, or ............................................ XXXXX ––––––

City ..................................................... XXXXX ––––––

City, town, or location of birth ............................ –––– –XXXXXX

Inside city limits ......................................... –––––––XX ––

If outside city or town limits, write rural .................. –––––XX ––––

County ................................................. XXXXXXXXXXX

Ward. ................................................... XXXXX ––––––

Birth weight ............................................... ––––– –XXXXX

Single, twin, triplet, etc .................................... XXXXXXXXXXX

Birth order if not single birth ............................... XXXXXXXXXXX

Apgar Score:

1 minute ................................................ –––––––––XX

5 minutes ............................................... –––––––––XX

Mother transferred prior to delivery......................... ––––––––––X

Infant transferred prior to delivery .......................... ––––––––––X

Mother information

Maiden name.............................................. –XXXXXXXXX –

Maiden surname .......................................... ––––––––––X

Full name ................................................. X –––––––––X

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXXXXXXXX –

Date of birth .............................................. ––––––––––X

Birthplace ................................................. X X X ––––––––

Birthplace (State or country) ............................... – – –XXXXXXXX

Birthplace (city or place) ................................... – – –XXX –––––

Mother’s stay before delivery:

In hospital or institution ................................. –––––X–––––

In this community ....................................... –––––X–––––

Residence ................................................. XXXXX ––––––

State ................................................... –––– –XXXXXX

County ................................................. –––– –XXXXXX

City, town, or location ................................... –––– –XXXXXX

Street and number ...................................... –––– –XXXXXX

Inside city limits ......................................... –––––– –XXXX

If rural, give location .................................... –––––XX ––––

Is residence on a farm? ................................. –––––––X–––

Mother’s mailing address .................................. –––––X–X–XX

Hispanic origin ............................................ ––––––––––X

Race ...................................................... XXXXXXXXXXX

Education ................................................. ––––––– –XXX

28
Table 1. Content of the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Mother information—Continued

Legitimate ................................................ XXXXX –XXX ––

Mother married? .......................................... –––––X–––XX

Occupation ............................................... XXXXX ––––––

Usual occupation ......................................... –––––X–––––

Nature of industry ......................................... – – –XXX –––––

Date (month and year) last engaged in this work .......... ––––X––––––

Total time spent in this work ............................... ––––X––––––

Father information

Name ..................................................... XXXXXXXXXXX

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXXXXXXXX –

Date of birth .............................................. ––––––––––X

Birthplace ................................................. X X X ––––––––

Birthplace (State or country) ............................... – – –XXXXXXXX

Birthplace (city or place) ................................... – – –XXX –––––

Hispanic origin ............................................ ––––––––––X

Race ...................................................... XXXXXXXXXXX

Education ................................................. ––––––– –XXX

Residence ................................................ XXXXX ––––––

Occupation ............................................... XXXXX ––––––

Usual occupation ......................................... –––– –XXX –––

Nature of industry ......................................... – – –XXXXX –––

Date (month and year) last engaged in this work .......... ––––X––––––

Total time (years) spent in this work ....................... ––––X––––––

Pregnancy information

Pregnancy history:1

Live births, now living ................................... XXXXXXXXXXX

Live births, now dead ................................... – – –XXXXXXXX

Born dead (stillborn, fetal death) ......................... – – –XXX –XX ––

Born dead after 20 weeks pregnancy .................... ––––––X––––

Other terminations (spontaneous and induced):

Under 20 weeks ...................................... –––––––––X–

Over 20 weeks ....................................... –––––––––X–

Other terminations (spontaneous and induced at

any time after conception) ............................. ––––––––––X

Date of last live birth .................................... ––––––– –XXX

Date of last fetal death .................................. ––––––––X––

Date of last other termination ............................ –––––––––XX

Whether born alive or stillborn ............................. –XXXX ––––––

Cause of stillbirth .......................................... ––––X––––––

Stillbirth––before labor or during labor ..................... ––––X––––––

If stillborn, period of gestation .............................. ––––X––––––

Clinical estimate of gestation .............................. ––––––––––X

Date last normal menses began ........................... ––––––– –XXX

Length of pregnancy (completed weeks) .................. ––––––XX –––

Months of pregnancy ...................................... –––––X–––––

Premature or full term ..................................... ––––X––––––

Month of pregnancy prenatal care began .................. ––––––– –XXX

Number of prenatal visits .................................. ––––––– –XXX

Concurrent illnesses or conditions affecting the

pregnancy ............................................... –––––––––X–

Medical risk factors for this pregnancy

(checkboxes) ............................................ ––––––––––X

Other risk factors for this pregnancy (smoking,

alcohol use, weight gain) ................................. ––––––––––X

Complications not related to pregnancy .................... ––––––––X––

Complications of pregnancy ............................... –––––––––X–

Complications related to pregnancy ....................... ––––––––X––

Complications of labor and/or delivery ..................... –––––––––X–

Complications of labor and/or delivery (checkboxes) ....... ––––––––––X

Complications of labor .................................... ––––––––X––

Obstetric procedures (checkboxes) ........................ ––––––––––X

Method of delivery (checkboxes) .......................... ––––––––––X

Abnormal conditions of the newborn (checkboxes) ......... ––––––––––X

Congenital malformations or anomalies of child ............ ––––––––XX –

Congenital anomalies of child (checkboxes) ............... ––––––––––X

Birth injuries to child ....................................... ––––––––X––

Appendix I 29
Table 1. Content of the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Certification information

Signature of certifier ....................................... XXXXXXXXXXX

Type of attendant ......................................... XXXXXXXXX ––

Date signed ............................................... –––– –XXXXXX

Date on which given name was added .................... XXXXXXXX –––

Name of registrar adding given name ...................... XXXXXXXX –––

Name and title of attendant at birth if other than

certifier .................................................. –––––––––X–

Name and title of attendant if other than certifier

(checkboxes) ............................................ ––––––––––X

Mailing address of attendant .............................. ––––––––––X

Name and title of certifier .................................. –––––––––X–

Name and title of certifier (checkboxes) ................... ––––––––––X

Name of certifier .......................................... ––––––––X––

Mailing address of certifier ................................ ––––––––XX –

Address of certifier ........................................ XXXXXXXX –––

Signature of registrar ...................................... –––– –XXXXXX

Registrar. ................................................. XXXXX ––––––

Date received by registrar ................................. –––––––––X–

Date received by local registrar ............................ –––– –XXXX ––

Date filed ................................................. XXXXX –––––X

Signature of parent or other informant ..................... –––––––––XX

Informant. ................................................. –––– –XXXX ––

Relation to child ........................................... –––––X––XX –

Nature of industry ......................................... – – –XXXXX –––

Date (month and year) last engaged in this work .......... ––––X––––––

Total time (years) spent in this work ....................... ––––X––––––

Pregnancy information

Pregnancy history:1

Live births, now living ................................... XXXXXXXXXXX

Live births, now dead ................................... – – –XXXXXXXX

Born dead (stillborn, fetal death) ........................ – – –XXX –XX ––

Born dead after 20 weeks pregnancy ................... ––––––X––––

Other terminations (spontaneous and induced):

Under 20 weeks ...................................... –––––––––X–

Over 20 weeks........................................ –––––––––X–

Other terminations (spontaneous and induced at any

time after conception) .................................. ––––––––––X

Date of last live birth .................................... ––––––– –XXX

Date of last fetal death .................................. ––––––––X––

Date of last other termination ........................... –––––––––XX

Whether born alive or stillborn ............................. – – –XXXX ––––

Cause of stillbirth .......................................... ––––X––––––

Stillbirth––before labor or during labor...................... ––––X––––––

If stillborn, period of gestation .............................. ––––X––––––

Clinical estimate of gestation .............................. ––––––––––X

Date last normal menses began ........................... ––––––– –XXX

Length of pregnancy (completed weeks) .................. ––––––XX –––

Months of pregnancy ...................................... –––––X–––––

Premature or full term ..................................... ––––X––––––

Month of pregnancy prenatal care began .................. ––––––– –XXX

Number of prenatal visits .................................. ––––––– –XXX

Concurrent illnesses or conditions affecting the

pregnancy................................................ –––––––––X–

Medical risk factors for this pregnancy (checkboxes) ....... ––––––––––X

Other risk factors for this pregnancy (smoking, alcohol

use, weight gain) ........................................ ––––––––––X

Complications not related to pregnancy .................... ––––––––X––

Complications of pregnancy ............................... –––––––––X–

Complications related to pregnancy ....................... ––––––––X––

Complications of labor and/or delivery ..................... –––––––––X–

Complications of labor and/or delivery (checkboxes) ....... ––––––––––X

Complications of labor .................................... ––––––––X––

Obstetric procedures (checkboxes) ........................ ––––––––––X

Method of delivery (checkboxes) .......................... ––––––––––X

Abnormal conditions of the newborn (checkboxes) ......... ––––––––––X

Congenital malformations or anomalies of child ............ ––––––––XX –

Congenital anomalies of child (checkboxes) ............... ––––––––––X

Birth injuries to child ....................................... ––––––––X––

30 Appendix I
Table 1. Content of the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Certification information

Signature of certifier ....................................... XXXXXXXXXXX

Type of attendant ......................................... XXXXXXXXX ––

Date signed ............................................... –––– –XXXXXX

Date on which given name was added..................... XXXXXXXX –––

Name of registrar adding given name ...................... XXXXXXXX –––

Name and title of attendant at birth if other than

certifier ................................................... –––––––––X–

Name and title of attendant if other than certifier

(checkboxes)............................................. ––––––––––X

Mailing address of attendant .............................. ––––––––––X

Name and title of certifier. ................................. –––––––––X–

Name and title of certifier (checkboxes). ––––––––––X

Name of certifier .......................................... ––––––––X––

Mailing address of certifier ................................ ––––––––XX –

Address of certifier ........................................ XXXXXXXX –––

Signature of registrar ...................................... –––– –XXXXXX

Registrar. ................................................. XXXXX ––––––

Date received by registrar ................................. –––––––––X–

Date received by local registrar ............................ –––– –XXXX ––

Date filed ................................................. XXXXX –––––X

Signature of parent or other informant...................... –––––––––XX

Informant. ................................................. –––– –XXXX ––

Relation to child ........................................... –––––X––XX –

1Prior to 1939, the pregnancy item included the birth registered. Beginning with 1939 the birth being registered is excluded.

X Indicates item included on standard certificate.

– Indicates item not included on standard certificate.

Appendix I 31
Table 2. Content of the U.S. Standard Certificate of Death, by year revised

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989

Decedent information

Name ..................................................... XXXXXXXXXX

Name of decedent (in margin) ............................ –––––––––X

Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXXXXXXXX

Race ...................................................... XXXXXXXXXX

Hispanic origin ............................................ –––––––––X

Age:

Years ................................................... XXXXXXXXXX

Months/Days............................................ XXXXXXXXXX

Hours/Minutes .......................................... –XXXXXXXXX

Date of birth............................................... XXXXXXXXX

Birthplace:

State or country ........................................ XXXXXXXXX–

City, town, or county .................................... ––––X–––––

City or town............................................. – – X X––––––

City and State or country ............................... –––––––––X

Citizen of what country.................................... –––– –XXXX–

How long in U.S., if of foreign birth ....................... – –XXX–––––

Marital status.............................................. XXXXXXXXXX

Surviving spouse (if wife, give maiden name) ............ –––––– –XXX

Name of husband or wife ................................. – –XXX–––––

Age of husband or wife, if alive ........................... – – – X–––––

Was decedent ever in U.S. Armed Forces?............... ––––––XX–X

If yes, give war or dates of service ....................... –––––XX–––

If veteran, name war...................................... ––––X–––––

Social Security number ................................... ––––XXXXXX

Occupation................................................ XXXX––––––

Usual occupation ......................................... ––––XXXXXX

Name of employer ........................................ – – X–––––––

Business or industry ...................................... –XXXXXXXXX

Date deceased last worked at this occupation............ – – – X––––––

Total time (years) spent in this occupation ................ – – – X––––––

Residence:

Former or usual residence.............................. X X––––––––

State.................................................... ––––XXXXXX

Length of residence in the State (years, months, and

days) .................................................. – X––––––––

County.................................................. ––––XXXXXX

City, town, or location................................... ––––XXXXXX

If nonresident, give city or town and State ............. – – X X––––––

Ward. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X––––––

Street and number...................................... – –XXXXXXXX

Inside city limits......................................... ––––– –XXX–

Zip code ................................................ –––––––––X

Education ................................................. –––––––––X

Father’s name ............................................ XXXXXXXXXX

Birthplace of father:

State or country ........................................ XXXX X–––––

City or town............................................. – – X X––––––

City, town, or county .................................... ––––X–––––

Mother’s maiden name.................................... XXXXXXXXXX

Birthplace of mother:

State or country ........................................ XXXX X–––––

City or town............................................. – – X X––––––

City, town, or county .................................... ––––X–––––

Place of death information

County .................................................... XXXXXXXXXX

City, town, or location ..................................... ––––XXXXXX

Inside city limits ........................................... ––––––XX––

Township of, or............................................ XXXX––––––

Village of, or .............................................. XXXX––––––

City of..................................................... XXXX––––––

Ward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXX––––––

Street and number ........................................ XXXX––––––

Name of hospital or other institution ...................... ––––XXXXX–

Name of facility ........................................... –––––––––X

If hospital or institution indicate whether dead on arrival,

outpatient/emergency room or inpatient ................ ––––––––X–

If death occurred in a hospital or institution, give its

name instead of street and number ..................... XXXX––––––

If not in hospital or institution, give street address or

location ................................................. ––––XXXXXX

32 Appendix I
Table 2. Content of the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989

Place of death information—Continued

Type of place of death (checkboxes) ..................... –––––––––X

Length of stay in hospital ................................ ––––X–––––

Length of stay in this community ......................... ––––X–––––

Length of stay where death occurred .................... XXXX–X X–––

Length of residence in the State ......................... – X––––––––

Medical certification

Cause of death ........................................... XXXX––––––

Duration ................................................ X X X–––––––

Date of onset .......................................... – – – X––––––

Immediate cause of death ................................ ––––XXXXXX

Interval between onset and death ...................... ––––XXXXXX

Due to, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ––––XXXXXX

Interval between onset and death ...................... ––––XXXXXX

Due to, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ––––XXXXXX

Interval between onset and death ...................... ––––XXXXXX

Due to, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . –––––––––X

Interval between onset and death ...................... –––––––––X

Contributory cause........................................ XXXX––––––

Duration ................................................ X X X–––––––

Date of onset ........................................... – – – X––––––

Other significant conditions ............................... ––––XXXXXX

Duration ................................................ ––––X–––––

Interval between onset and death ...................... –––––X––––

Was autopsy performed? ................................. – – X X –XXXXX

Were autopsy findings considered in determining cause

of death? ................................................ –––––––X––

Were autopsy findings available prior to completion of

cause of death? ......................................... –––––––––X

What test confirmed diagnosis?........................... – – X X––––––

Major findings of autopsy ................................. ––––X–––––

Did an operation precede death? – – X–––––––

Date of operation ....................................... – – X X – X––––

Name of operation...................................... – – – X––––––

Major findings of operations ............................ ––––XX––––

Where was disease contracted if not place of death? .... X X X–––––––

For deaths from external causes:

Accident, suicide, homicide, undetermined, or pending

investigation ........................................... ––––––––X–

Accident, suicide, homicide, or undetermined .......... –––––––X––

Accident, suicide, or homicide .......................... –XXXXX X–––

Manner of death (checkboxes):

Natural, accident, suicide, homicide, pending

investigation, could not be determined.............. –––––––––X

Date of injury.............................................. – – –XXXXXXX

Time of injury ............................................. –––– –XXXXX

How injury occurred....................................... –––– –XXXXX

Injury at work? ............................................ ––––XXXXXX

Place of injury............................................. – – –XXXXXXX

Location of injury.......................................... – –XXXXXXXX

Means of injury ........................................... ––––X–––––

Manner of injury........................................... – – – X––––––

Nature of injury ........................................... – – – X––––––

Was disease or injury related to occupation? ............. – – – X––––––

If so, specify ............................................ – – – X––––––

Certifier:

Signature and title of certifier ........................... XXXXXXXXX–

Title (checkboxes) ...................................... –––––––––X

License number ........................................ –––––––––X

Separate medical examiner or coroner certification....... –––––– –XXX

Date signed ............................................... X X X –XXXXXX

Date of death ............................................. XXXXXXXXXX

Time of death ............................................. XXXXXXXXXX

Date pronounced dead.................................... –––––– –XXX

Hour pronounced dead ................................... –––––––XX–

Name of attending physician, if other than certifier ....... ––––––––X–

Name of certifier .......................................... –––––– –XXX

Address of certifier........................................ XXXXXXXXXX

Dates physician attended decedent....................... XXXXXXXX––

Date last seen alive....................................... XXXXXXXX––

Did physician view body after death? ..................... –––––––X––

Was case referred to medical examiner or coroner?...... ––––––––XX

Appendix I 33
Table 2. Content of the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989

Medical certification—Continued

Pronouncing physician:

Signature and title ...................................... –––––––––X

License number ........................................ –––––––––X

Date signed............................................. –––––––––X

Disposition information

Burial, cremation, or removal ............................. ––––XXXXX–

Method of disposition (checkboxes)....................... –––––––––X

Date of burial ............................................. XXXXXXXX––

Place of burial or removal................................. X X––––––––

Place of burial, cremation, or removal .................... – –XXX–––––

Name of cemetery or crematory .......................... –––– –XXXX–

Location................................................... –––– –XXXXX

Name of cemetery, crematory, or other place............. –––––––––X

Signature of funeral director .............................. ––––X––X––

Signature of funeral service licensee or person acting

as such .................................................. ––––––––XX

License number ........................................ –––––––––X

Name of funeral director (or person acting as such)...... XXXXXX X–––

Address................................................. XXXXXX X–––

Name of facility (funeral home) ........................... –––––– –XXX

Address of facility (funeral home) ......................... –––––– –XXX

Other information

Informant’s signature...................................... ––––X–––––

Informant’s name ......................................... XXXX–XXXXX

Mailing address ........................................... XXXXX–XXXX

Registrar’s signature ...................................... ––––XXXXXX

Registrar .................................................. XXXX––––––

Date received by local registrar........................... ––––XXXX––

Date received by registrar ................................ ––––––––X–

Date filed.................................................. XXXX–––––X

X Indicates item included on standard certificate.

– Indicates item not included on standard certificate.

34 Appendix I
Table 3. Content of the U.S. Standard Report of Fetal Death, by year revised

Item 1930 1939 1949 1956 1968 1978 1989

Fetal death information

Name of fetus................................................................. XXXXX ––

Sex of fetus ................................................................... XXXXXXX

Date of delivery ............................................................... XXXXXXX

Hour of delivery ............................................................... ––––XX –

Place of delivery:

Name of hospital ........................................................... –XXXXX –

Name of facility ............................................................. ––––––X

State........................................................................ X ––––––

If birth occurred in hospital or institution,give its name

instead of street number .................................................. X ––––––

Street and number if not in hospital ........................................ XXXXXXX

Township ................................................................... X ––––––

Village ...................................................................... X ––––––

City ......................................................................... X ––––––

City, town, or location of delivery ........................................... –XXXXXX

Inside city limits............................................................. – – – X X – –

If outside city or town limits, write rural ..................................... – – X X – – –

County of delivery .......................................................... XXXXXX

Ward. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X ––––––

Weight of fetus................................................................ – –XXXXX

Single, twin, triplet, etc........................................................ XXXXXXX

Order if not single delivery .................................................... XXXXXXX

Mother information

Mother’s name (first, middle, last)............................................. ––––––X

Maiden name ................................................................. XXXXX ––

Maiden surname .............................................................. ––––––X

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXXXX –

Date of birth................................................................... ––––––X

Birthplace (State or country) .................................................. XXXXX ––

Birthplace (city or place) ...................................................... X X –––––

Length of stay in hospital or institution before delivery........................ – X –––––

Residence .................................................................... X ––––––

State........................................................................ –XXXXXX

County...................................................................... –XXXXXX

City, town, or location....................................................... –XXXXXX

Street and number.......................................................... –XXXXXX

Inside city limits............................................................. – – –XXXX

If rural, give location ........................................................ – X X ––––

Is residence on a farm? .................................................... – – – X – – –

Zip code .................................................................... ––––––X

Mother’s mailing address ..................................................... – X –––––

Race .......................................................................... XXXXXXX

Hispanic origin ................................................................ ––––––X

Education ..................................................................... ––––XXX

Legitimate..................................................................... X –XXX ––

Mother married? .............................................................. – X – – – X X

Trade, profession, or particular type of work done ............................ X ––––––

Usual occupation ............................................................. – X –––––

Occupation worked during last year .......................................... ––––––X

Kind of business or industry .................................................. X X ––––X

Date (month and year) last engaged in this work X ––––––

Total time (years) spent in this work .......................................... X ––––––

Father information

Name ......................................................................... XXXXXXX

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XXXXXX –

Date of birth................................................................... ––––––X

Birthplace (State or country) .................................................. XXXX –––

Birthplace (city or place) ...................................................... X X –––––

Hispanic origin ................................................................ ––––––X

Race .......................................................................... XXXXXXX

Education ..................................................................... ––––XXX

Residence .................................................................... X ––––––

Trade, profession, or particular type of work done ............................ X ––––––

Usual occupation ............................................................. –XXX –––

Occupation worked during last year .......................................... ––––––X

Kind of business or industry .................................................. XXXX ––X

Date (month and year) last engaged in this work ............................. X ––––––

Total time (years) spent in this work .......................................... X ––––––

Appendix I 35
Table 3. Content of the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989

Pregnancy information

Pregnancy history:1

Live births, now living....................................................... XXXXXXX

Live births, now dead....................................................... XXXXXXX

Born dead (stillborn, fetal death) ........................................... X X – X X – –

Born dead after 20 weeks pregnancy ...................................... – – X ––––

Other terminations (spontaneous and induced):

Under 20 weeks ............................................................ –––––X–

Over 20 weeks ............................................................. –––––X–

Other terminations at any time after conception .............................. ––––––X

Date of last live birth .......................................................... ––––XXX

Date of last fetal death........................................................ ––––X––

Date of last other termination ................................................. –––––XX

Whether born alive or stillborn ................................................ X ––––––

Month of pregnancy prenatal care began ..................................... ––––XXX

Number of prenatal visits ..................................................... ––––XXX

Physician’s estimate of gestation ............................................. –––––X–

Clinical estimate of gestation ................................................. ––––––X

If stillborn, period of gestation................................................. X ––––––

Length of pregnancy (completed weeks)...................................... – – X X – – –

Date last normal menses began .............................................. ––––XXX

Months of pregnancy ......................................................... – X –––––

Premature or full term......................................................... X ––––––

Concurrent illnesses or conditions affecting the pregnancy ................... –––––X–

Complications not related to pregnancy....................................... ––––X––

Complications of pregnancy .................................................. – X – – – X –

Complications related to pregnancy........................................... ––––X––

Complications of pregnancy and labor........................................ – – X ––––

Medical risk factors for this pregnancy (checkboxes) ......................... ––––––X

Other risk factors for this pregnancy (smoking, alcohol use, weight gain) .... ––––––X

Complications of labor and/or delivery ........................................ –––––X–

Complications of labor and/or delivery (checkboxes) ......................... ––––––X

Complications of labor ........................................................ – X – – X – –

Obstetric procedures (checkboxes) ........................................... ––––––X

Method of delivery (checkboxes).............................................. ––––––X

Was labor induced?........................................................... – X –––––

Congenital malformations or anomalies of fetus .............................. ––––XX –

Congenital anomalies of fetus (checkboxes).................................. ––––––X

Was there an operation for delivery? ......................................... – X –––––

State all operations, if any .................................................... – X X ––––

Did the child die before operation? ........................................... – X –––––

During operation?........................................................... – X –––––

Birth injuries to fetus .......................................................... – X – – X – –

Medical certification information

Cause of stillbirth ............................................................. X ––––––

Fetal causes ................................................................ – X X ––––

Maternal causes ............................................................ – X X ––––

Cause of fetal death:

Immediate cause ........................................................... – – –XXXX

Whether fetal or maternal .................................................. ––––XXX

Due to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – –XXXX

Whether fetal or maternal .................................................. ––––XXX

Due to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – –XXXX

Whether fetal or maternal .................................................. ––––XXX

Other significant conditions of fetus or mother................................ – – –XXXX

When fetus died:

Before labor ................................................................ X X –XXXX

During labor or delivery..................................................... – – –XXXX

During labor ................................................................ X X –––––

Unknown ................................................................... – – –XXXX

Was autopsy performed? ..................................................... – – –XXX –

If yes, were autopsy findings considered?.................................. ––––X––

Signature of certifier .......................................................... X X – – X – –

Date signed ................................................................... ––––X––

Title of certifier ................................................................ X X –––––

Address of certifier............................................................ X X – – X – –

Signature of attendant ........................................................ – – X X – – –

Date signed ................................................................... – – X X – – –

Title of attendant .............................................................. – –XXX ––

Address of attendant.......................................................... – – X X – – –

Name of physician or attendant............................................... –––––X–

36 Appendix I
Table 3. Content of the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989

Medical certification information—Continued

Name and title of attendant (checkboxes) .................................... ––––––X

Signature of authorized official if not attended by physician – –XXX ––

Statement of local registrar or coroner if physician not present............... – X –––––

Signature...................................................................... – X –––––

Title ........................................................................... – X –––––

Disposition information

Burial, cremation, or removal ................................................. –XXXX ––

Date of burial ................................................................. –XXXX ––

Place of burial or cremation................................................... – X –––––

Name of cemetery or crematory .............................................. – –XXX ––

Location .................................................................... – –XXX ––

Signature of funeral director .................................................. – X – – X – –

Name of funeral director ...................................................... – – X X – – –

Address..................................................................... –XXX –––

Name of funeral home ........................................................ ––––X––

Address..................................................................... ––––X––

Other information

Name of person completing report............................................ –––––XX

Title ........................................................................... –––––XX

Informant...................................................................... –XXX –––

Address ....................................................................... – X –––––

Signature of registrar ......................................................... XXXXX ––

Date received by local registrar............................................... – –XXX ––

Date filed with local registrar.................................................. X X –––––

Date given name added ...................................................... X ––––––

Signature of registrar ......................................................... X ––––––

1Prior to 1939, the pregnancy history item included the event being registered. Beginning with 1939, the event being registered is excluded.

X Indicates item included on standard report.

– Indicates item not included on standard report.

Appendix I 37
Table 4. Content of the U.S. Standard Report of Induced Termination of Pregnancy, by year revised

Item 1978 1989

Place of induced termination

Name of facility ................................................................................... X X

Address (if not hospital or clinic).................................................................. X X

City, town, or location ............................................................................. X X

County ............................................................................................ X X

Induced termination information

Date of pregnancy termination .................................................................... X X

Previous pregnancies:

Live births––now living ......................................................................... X X

Live births––now dead.......................................................................... X X

Other terminations––spontaneous .............................................................. X X

Other terminations––induced ................................................................... X X

Date last normal menses began .................................................................. X X

Physician’s estimate of gestation ................................................................. X –

Clinical estimate of gestation ..................................................................... – X

Complications of pregnancy termination:

None ........................................................................................... X –

Hemorrhage .................................................................................... X –

Infection ........................................................................................ X –

Uterine perforation.............................................................................. X –

Cervical laceration .............................................................................. X –

Retained products .............................................................................. X –

Other (specify).................................................................................. X –

Type of termination procedures:

Procedure that terminated pregnancy .......................................................... X X

Additional procedures used..................................................................... X X

Suction curettage............................................................................. X X

Sharp curettage .............................................................................. X X

Intra–uterine saline instillation ................................................................ X X

Intra–uterine prostaglandin instillation ........................................................ X X

Hysterotomy.................................................................................. X X

Hysterectomy................................................................................. X X

Dilation and Evacuation (D&E) ............................................................... – X

Other (specify) ............................................................................... X X

Patient information

Patient identification............................................................................... X X

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X

Marital status...................................................................................... X X

Residence:

State............................................................................................ X X

City, town, or location........................................................................... X X

Inside city limits................................................................................. X X

County.......................................................................................... – X

Zip code ........................................................................................ – X

Race (checkboxes) ............................................................................... X X

Education ......................................................................................... X X

Hispanic origin .................................................................................... – X

Other information

Name of attending physician...................................................................... X X

Name of person completing report................................................................ X X

X Item included on standard report.

– Item not included on standard report.

38 Appendix I
Table 5. Content of the U.S. Standard License and Certificate of Marriage, by year revised

Item 1956 1968 1978 1989

Groom information

Name ......................................................................... XXXX

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X

Date of birth................................................................... XXXX

Race .......................................................................... XXXX

Education ..................................................................... –XXX

Usual residence:

State........................................................................ XXXX

County...................................................................... XXXX

City, town, or location....................................................... XXXX

Street and number.......................................................... – X X –

Inside city limits............................................................. – X – –

Birthplace (State or foreign country) .......................................... XXXX

Marital status:

Number of this marriage.................................................... –XXX

Number of previous marriages ............................................. X–––

Previous marital status ..................................................... X–––

How last marriage ended ................................................... XXXX

Date last marriage ended................................................... –XXX

Father’s name ................................................................ –XXX

Birthplace (State or foreign country)........................................ –XXX

Mother’s maiden name........................................................ –XXX

Birthplace (State or foreign country)........................................ –XXX

Occupation.................................................................... X–––

Business or industry .......................................................... X–––

Bride information

Name ......................................................................... XXXX

Maiden name if different ...................................................... XXXX

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X

Date of birth................................................................... XXXX

Race .......................................................................... XXXX

Education ..................................................................... –XXX

Usual residence:

State........................................................................ XXXX

County...................................................................... XXXX

City, town, or location....................................................... XXXX

Street and number.......................................................... – X X –

Inside city limits............................................................. – X – –

Birthplace (State or foreign country) .......................................... XXXX

Marital status:

Number of this marriage.................................................... –XXX

Number of previous marriages ............................................. X–––

Previous marital status ..................................................... X–––

How last marriage ended ................................................... XXXX

Date last marriage ended................................................... –XXX

Father’s name ................................................................ –XXX

Birthplace (State or foreign country)........................................ –XXX

Mother’s maiden name........................................................ –XXX

Birthplace (State or foreign country)........................................ –XXX

Occupation.................................................................... X–––

Business or industry .......................................................... X–––

License information

Signatures of applicants ...................................................... X X – –

Date signed ................................................................... X X – –

Groom’s signature ............................................................ – – X X

Bride’s signature .............................................................. – – X X

Date license was subscribed and sworn to ................................... – – X X

Signature of issuing officer.................................................... – – X X

Title of issuing officer ......................................................... – – X X

Expiration date................................................................ – – – X

Ceremony information

Date of marriage .............................................................. XXXX

Place of marriage:

State........................................................................ X X – –

County...................................................................... XXXX

City ......................................................................... – – X X

Appendix I 39
Table 5. Content of the U.S. Standard License and Certificate of Marriage, by year revised—Con.

Item 1956 1968 1978 1989

Ceremony information—Continued

Person performing ceremony:

Title ......................................................................... – – X X

Signature ................................................................... –XXX

Name ....................................................................... – – – X

Religious or civil ............................................................ – X – –

Address..................................................................... – – – X

Date signed ................................................................... – X – –

Type of ceremony––religious or civil .......................................... – – X –

Witnesses to ceremony––signatures.......................................... –XXX

Other information

Signature of local official making return to State health department .......... XXXX

Date received by local official ................................................. – X X –

Date of recording ............................................................. X–––

Date filed by local official ..................................................... – – – X

X Indicates item included on standard certificate.

– Indicates item not included on standard certificate.

40 Appendix I
Table 6. Content of the U.S. Standard Certificate of Divorce, Dissolution of Marriage, or Annulment, by year revised

Item 1956 1968 1978 1989

Husband information

Name ......................................................................... XXXX

Date of birth................................................................... XXXX

Race .......................................................................... XXXX

Education ..................................................................... –XXX

Usual residence:

State........................................................................ XXXX

County...................................................................... XXXX

City, town, or location....................................................... XXXX

Street and number.......................................................... – X X –

Inside city limits............................................................. – X – –

Birthplace (State or foreign country) .......................................... XXXX

Marital status:

Number of this marriage.................................................... XXXX

If previously married, how many ended by death? divorce?................ – X X –

If previously married, last marriage ended by death, divorce,

dissolution, or annulment.................................................. – – – X

Date last marriage ended................................................... – – – X

Occupation.................................................................... X–––

Business or industry .......................................................... X–––

Wife information

Name ......................................................................... XXXX

Maiden surname .............................................................. – – – X

Date of birth................................................................... XXXX

Race .......................................................................... XXXX

Education ..................................................................... –XXX

Usual residence:

State........................................................................ XXXX

County...................................................................... XXXX

City, town, or location....................................................... XXXX

Street and number.......................................................... – X X –

Inside city limits............................................................. – X – –

Birthplace (State or foreign country) .......................................... XXXX

Marital status:

Number of this marriage.................................................... XXXX

If previously married, how many ended by death? divorce?................ – X X –

If previously married, last marriage ended by death, divorce,

dissolution, or annulment.................................................. – – – X

Date last marriage ended................................................... – – – X

Occupation.................................................................... X–––

Business or industry .......................................................... X–––

Decree information

Date marriage was dissolved ................................................. XXXX

Type of decree––divorce, dissolution, or annulment .......................... –XXX

Date of entry .................................................................. X X X –

Date recorded................................................................. – – – X

County of decree ............................................................. XXXX

Title of court .................................................................. –XXX

Title of court official ........................................................... X X X –

Signature of certifying court official ........................................... XXXX

Title of certifying official ....................................................... XXXX

Date signed ................................................................... – – – X

Party to whom decree granted................................................ X X – –

Legal grounds for decree ..................................................... X X – –

Petitioner...................................................................... – – X –

Petitioner (checkboxes) ....................................................... – – – X

Plaintiff ........................................................................ X X – –

Attorney for petitioner ......................................................... – – X X

Address..................................................................... – – X X

Attorney for plaintiff ........................................................... – X – –

Address..................................................................... – X – –

Number of children whose physical custody was awarded to:

husband, wife, joint (husband/wife), other, or no children ................... – – – X

Appendix I 41
Table 6. Content of the U.S. Standard Certificate of Divorce, Dissolution of Marriage, or Annulment, by year revised—Con.

Item 1956 1968 1978 1989

Other information

Place of this marriage:

State or foreign country..................................................... XXXX

County...................................................................... XXXX

City ......................................................................... – – X –

City, town, or location....................................................... – – – X

Date of this marriage ......................................................... XXXX

Date couple separated........................................................ – X X –

Date couple last resided in same household ................................. – – – X

Number of children ever born alive of this marriage .......................... – – X –

Living children in this family................................................... – X – –

Children under 18 in this family............................................... X X X –

Number of children under 18 in this household as of the date

couple last resided in same household ...................................... – – – X

X Indicates item included on standard certificate.

– Indicates item not included on standard certificate.

42 Appendix I
Appendix II

History and Organization of

the Vital Statistics System

Historical Development

Introduction

More than 7,000,000 birth, death, marriage, and

divorce certificates were recorded in 1950. Many organizations and many millions of citizens used these

records—or certified copies of them—for a variety of

personal, legal, health, and other purposes. Vital statistics derived from the records were part of the factual basis for a great segment of the private and public

business transacted in the United States. They entered

into the planning and operation of health programs,

social welfare, education, economic enterprises (ranging from life insurance to the marketing of babies’

toys), and a broad gamut of other activities essential to

the well-being and prosperity of the country.

Behind the original records, the certified copies,

and the vital statistics is a network of local, State, and

Federal agencies. The purpose of this section is to tell

how the vital records and statistics system of the

United States was begun and developed, how its organization, concepts, and practices were continuously

shaped by the growth and changing needs of the

country. At various stages, new social institutions or

advancing technology, particularly in the field of health,

created new demands for records and statistics, and

sometimes changed the emphasis and motivating drives

of the system itself.

This is a reproduction of a document that first

appeared in the Vital Statistics of the United States,

Volume 1, 1950, pp. 1–19.

Most people take vital statistics for granted, assuming that any statistics they need should be freely

available as part of today’s culture. What distinguishes the men of today from those who lived before

the American Revolution is that ‘‘we have all learned

to talk in size language,’’ as Lancelot Hogben puts it.

‘‘We live in a welter of figures: cookery recipes, railway

time-tables, unemployment aggregates, fines, taxes,

war debts, overtime schedules, speed limits, bowling

averages, betting odds, billiard scores, calories, babies’

weights, clinical temperatures, rainfall, hours of sunshine, motoring records, power indices, gas-meter readings, bank rates, freight rates, death rates....’’1

Death rates are among the typical vital statistics

that most people assume we have always had available

and, without much effort, will continue to have. The real

story is quite different: national statistics of deaths and

births were achieved only within the present generation,

after two centuries of intermittent struggle and building.

Marriage and divorce statistics are still incomplete and

relatively primitive. Progress in registration and vital

statistics has been part of the general advance of science

and medicine, which developed by relying on measurements and other quantitative procedures. Medicine and

the public health movement flourished by adopting the

methods of science, by resorting increasingly to quantitative techniques. Among the most fruitful of these were

the basic measurements of vital statistics. In turn, vital

statistics were developed primarily because medicine

and public health actively promoted and helped build the

registration system that makes vital statistics possible in

this country.

In recent years, as vital statistics became more

precise—more comparable from place to place and

from one period of time to another—they were better

able to serve the general and specialized demographic

needs of business, civil and military branches of government, social research and welfare, and the general

public. In the broad spectrum of needs served by

NOTES: This review of the rise of American registration and vital statistics is

based on a limited survey of original and secondary sources. It is ventured as

a beginning, in the hope that it will at least set forth the main lines of

development so as to give registration and vital statistics personnel a glimpse

of their heritage, provide educational material for the schools and the general

public, and encourage students with a gift for research in history to dig into

the subject matter more deeply.

An effort has been made to tell as a narrative the development of

registration and vital statistics down to about 1900. The more recent

story is presented more briefly, as a series of high lights. 1. Hogben, Lancelot, ‘‘Mathematics for the Million,’’ p. 20, New York, 1940.

43
modern vital statistics, the band occupied by health

and medicine, though still the most important segment, is only a part of the whole.

In some ways the American system is unique; the

reasons for its particular course of development lie in

the historic past. In colonial days, when a handful of

settlements clung precariously to the eastern edge of

the continent, many of our institutions borrowed heavily

on the experience of our forefathers before they emigrated from England and other countries. Hence some

of the roots of our present vital statistics system began

in foreign soil. Some of the major roots lie in the

beginnings of America itself—in the fact that Virginia,

New England, Delaware, the Carolinas, Georgia, Pennsylvania, New Jersey, and other settlements were

sponsored by more or less independent British companies or patrons; that when control of the Colonies

passed to the Crown they were ruled by separate royal

governors; and that when they won independence they

turned, by the nature of their past life and conditioning, to a federal rather than a centralized government,

so that the federated States were self-governing in all

matters not expressly conferred on the national government by the Constitution.

To apportion the Congressional representation of

each State according to its population, the States

provided in the Constitution itself for the decennial

census. Hence, throughout the course of its development in this country, the census has been a national

function. The need for vital statistics, on the other

hand, was unrecognized when the Constitution was

framed, and the vital records and statistics system

developed originally not as a national undertaking,

but first as a local, then as a State function. This

historic accident, which makes the course of American

vital statistics so different from that of countries where

the function is national like the census, posed enormous

difficulties, and undoubtedly slowed its development by

many decades. At the same time, because American vital

registration grew in response to local and State needs, it

has support and sources of strength that might be lacking if the system were primarily national.

In practice, for the past century, American vital

statistics and the census have worked hand in hand.

Until recent years, the national functions in vital

statistics were in fact lodged in the Census Bureau.

Between census data and vital statistics, though

they continuously supplement and enrich each other

in practice, there are two essential differences. First,

the census is based on enumeration—a periodic

count of the population and its characteristics made

by canvassers in house-to-house interviews; vital

statistics, on the other hand, are derived from vital

records, which record events that occur to individuals. The second difference is that the census is

decennial; vital records are made continuously, as

the events occur. This second difference was described

in vivid terms by Walter F. Willcox, a former Chief

Statistician in the Washington Census Office:

A census is a sort of social photograph of certain

conditions of a population at a given moment which are

expressible in numbers, while registration is a continuous,

contemporary, movie-camera record of births, marriages,

divorces, or deaths. . . . In theory the two are inseparable; a

census system which does not flower into registration is

almost as fruitless scientifically as capital which does not

fructify in income. As the life of an animal or plant cannot

be studied from a series of photographs alone showing the

stages of its growth, so the life of the American people

cannot be studied from a series of censuses unaided by

registration.2

Beginnings: First use of records

The settlers were predominantly English, and for

the most part followed English customs in the new

country. They were accustomed to the registration of

christenings, marriages, and burials, which in England

dated back to 1538, when the clergy in all parishes

were first required to keep a weekly record of such

events. In 1632, the Grand Assembly of Virginia passed

a law requiring a minister or warden from every

parish to appear annually at court on the 1st of June

and present a register of christenings, marriages, and

burials for the year. These were the traditional events

conducted by the church, but in effect they provided an

account of births, marriages, and deaths.

Apparently little or no statistical use was made

of such records, and there was certainly no thought

of using them for health purposes. In the beginning,

the records were regarded primarily as statements

of fact essential to the protection of individual rights,

especially those relating to the distribution of property. The emphasis on vital records as legal documents to protect both the individual and the

community is clear in the pronouncement of the

General Court or legislative body of the Massachusetts Bay Colony in 1639:

Whereas many judgments have been given in our

Courts, whereof no records are kept of the evidence and

reasons whereupon the verdict and judgment did pass,. . . it

is therefore by this Court ordered and decreed that hence

forward every judgment, with all the evidence, be recorded

in a book, to be kept to posterity. . . that there be records

kept of all wills, administrations, and inventories, as also of

every marriage, birth, and death of every person within this

jurisdiction.

While this law was based on the English precedent, it differed in two important respects: the responsibility was placed on government officers rather than

2. Willcox, Walter F., ‘‘Studies in American Demography,’’ p. 195, New York,

1940.

44 Appendix II
the clergy; and it called for the recording of vital

events—births, deaths, and marriages—rather than

church-related ceremonies. Connecticut and Plymouth, and eventually other colonies, followed a similar pattern.

Thus, at the basis of the vital registration system

was the principle that the records are legal statements

of fact that help assure the rights of individuals as

conferred by organic laws. Machinery was set up to

collect and preserve the records, not at first for statistical reasons, but because authentic evidence was

essential to the just administration of law and the

protection of individual rights.

With this obligation in mind, Massachusetts (and

other colonies) repeatedly strengthened the early registration laws. In 1644, it added a penalty clause for

failure to report vital events, and in 1692, in the most

comprehensive registration act in the period, it empowered town clerks to collect threepence from the next of

kin for each birth or death, to fine individuals for

failure to report, and to charge sixpence for ‘‘a fair

certificate.’’ A century later, in 1795, it required parents to inform the town clerk of births and deaths of

children, householders to give notice of those in their

households, and institutions to report births and deaths

occurring in them.

None of the early registration laws was particularly effective. Although a few cities and towns maintained active registration, for many years not a single

State could be said to have a system covering its entire

area. Permanent legal records, justified largely by

their use as evidence of property rights, seemed unimportant to a footloose population undergoing rapid

change. Eastern seaboard cities were swelled by immigrants, many of whom stayed only long enough to hear

the call of the western frontiers.

Registration needed a new and more impelling

impetus. It was to receive one in the dawning realization by a few gifted statisticians and medical men that

records of births and deaths, particularly records of

deaths by cause, were needed for the control of epidemics and the conservation of human life through sanitary reform.

From records to statistics

Bills of mortality—consisting of parish lists of

interments, usually including cause of death and age

of deceased—had been compiled in England for more

than a century before any effort was made to analyze

them. Towards the end of the 16th century, when an

epidemic of plague gripped the city, bills of mortality

were published in London to restore public confidence.

Vital statistics in the modern sense has been said to

take its origin from the publication, in 1662, of ‘‘Natural and Political Observations Mentioned in a Following Index, and Made Upon the Bills of Mortality,’’ by

John Graunt of London (1620–74). Despite the meagerness of his material, Graunt discerned that vital events

often follow regular patterns, for example, that male

births exceed female births, that deaths at the beginning of life are relatively high, etc. This demonstration

that general truths about the population could be

derived from vital records stimulated further analysis

both in Britain and in the European continent. The

astronomer Edmund Halley (1656–1742), applying mathematical techniques developed in other fields, constructed the first scientific life expectancy table in 1693.

Death records of some sort were apparently kept

by American settlements from the earliest days. At the

outset, disease ranked with starvation as a threat to

the existence of many of the colonies. Malaria, dysentery, and typhoid fever usually decimated settlers on

new clearings. Smallpox, which was brought by the

settlers themselves, and yellow fever which came in

with the Negro slaves, brought repeated devastation.

The toll of the recurrent epidemics is detailed in

sources such as Winthrop’s Journal, various lists of the

parish dead complied by the clergy, and burial returns

made to town officers by cemetery sextons.

One of the earliest uses of such records for statistical purposes was made in 1721 by the clergyman,

Cotton Mather, who noted during a severe smallpox

epidemic in Boston that more than one in six of the

natural cases died but only one in sixty of the inoculated cases. This is a sophisticated use of statistics,

and it is evident that simple records of death by

certain causes were available much earlier.

Parallel to the growth of early registration efforts,

but mostly unconnected at first, was sporadic rise of

local health or sanitary boards, usually in response to

an acute epidemic. During the 17th century and most

of the 18th, there was probably no permanent organization in English America to promote public health.

Outbreaks of disease were met as emergencies, but

eventually the larger cities established boards of

health as the forerunners of the modern local health

departments. Baltimore, in 1793, and Philadelphia,

in 1794 (in response to a yellow fever epidemic that

killed one-eighth of its population), established the

first two local boards. Massachusetts enacted the

first State law authorizing the creation of local

boards in 1797. From various meager indications, it

appears certain that from the very early days the

health officers began scanning the burial returns or

weekly lists of interments and roughly compiling

them in statistical reports. These vital statistics

precursors were used—though the extent is difficult

to determine—as a means of identifying and combating epidemics, and as a means of reporting health

conditions to the community.

In Baltimore, for example, death records have

been collected and compiled by the health department

Appendix II 45
since 1797; annual reports, containing lists of deaths

by causes, have been issued since 1817. The early

reports from time to time called the community’s

attention to an unusually large number of deaths from

a particular disease.3

Impact of industrialism

Meanwhile, one of the great pivotal changes in

human history was gathering force. It would be oversimplication to pick a single date as the beginning of

industrialism and the swift growth of manufacturing

centers. But by 1800, it was obvious that the social

order was changing, and that the change was bringing

with it a train of new problems that the social organization and technology of the time were not equipped to

handle. With rapid urbanization came a dramatic

increase in slums, crime, and poverty. In England,

which was the first country to industrialize, thoughtful men expressed alarm at the overcrowding of cities,

the filth and polluted water, and at the abject misery

that seemed to be overtaking the poorer classes. Epidemics of old and new diseases struck repeatedly. The

reformers of the time groped for whatever vital and

health statistics they could get in order to arouse the

national conscience to a sanitary awakening.

On the European continent, starting first in France,

the industrial revolution brought the same evils and

the same reactions. Pierre Louis (1787–1872), in an

epoch-making series of studies starting in 1825, introduced rational medical statistics to clinics and general

physicians. Louis Villerme ́ (1782–1863) adapted the

statistical approach to public hygiene, and in 1828

showed that the condition of neighborhoods was related

to disease in Paris and the French provinces. Statistical study of disease and its causes, based on the crude

vital statistics of the time and any other data available, began to be used increasingly on the continent

and in England as a weapon of sanitary and social

reform. It was time for a new weapon, since medical

and sanitation practices—such as imperfect quarantine measures—which had seemed adequate for an

earlier day, were proving powerless against catastrophic epidemics of typhus, yellow fever, and cholera. This last disease, which by the 1830’s had spread

from Asia through Russia to Germany to the British

Isles and to Canada and the United States, was obviously related to bad sanitary conditions.

According to Shryock,

After 1831 there was a sudden increase of interest

throughout Europe and America in the whole problem of

public hygiene. Fear now combined with humanitarianism

to demand investigations, cleanups, and general sanitary

reform, as these things had never been demanded before.

Whenever enthusiasm waned, further invasions of cholera,

supplemented by occasional outbreaks of yellow fever,

typhoid, typhus, and smallpox, terrified authorities into

renewed activity. In these circumstances is to be found the

genesis of the modern public-health movement.4

Beginnings of modern registration

The general circumstances that led to action against

disease led inevitably to revived interest in perfecting

vital registration and vital statistics. The crude data of

the time were used with telling effect to characterize

public health problems, to chart the course of epidemics,

and to show the influence of dirt and poverty on disease

and death. But in country after country, the early sanitarians became aware of their need for more precise

statistics, and some of them expressed this need directly

by pressing for effective and comprehensive registration

laws. Here again it was apparently the fear of cholera

that paved the way for legislative action.

Panic was a large factor in securing repentance and

good works when cholera threatened; as it, likewise, was in

an earlier century when plague became epidemic; and in

both instances the desire for complete and accurate information as to the extent of the invasion led in England to the

call for accurate vital statistics. It may truly be said that the

early adoption of accurate registration of births and deaths

was hastened by fears of cholera, and by the intelligent

realisation that one must know the localisation as well as

the number of the enemy to be fought.5

In England, Edwin Chadwick (1800–1890), secretary of the Poor-Law inquiry commission, had been led

into the study of vital statistics, and then into the

general field of public health, by his need for mortality

statistics in connection with voluntary insurance

schemes. Chadwick was apparently influenced by Villerme ́ in a series of investigations that led in the early

1830’s to the reform of the poor laws and of child labor

conditions in the cotton mills. Chadwick also strove to

establish national registration of deaths, since differences in mortality by area or social group were the

kind of vital statistics he could use effectively to

hammer for sanitary reform. 3. But it was not until 1875, when death certificates were first required by

Baltimore law, that any consistent use was made of statistical methods or that

death rates by cause were regularly compiled. Similarly, records of live births

were not kept until 1875, and birth registration was very defective until about

1915. The Baltimore history should be particularly illuminating to students of

registration because of the thorough study made by Dr. William Travis

Howard, Jr., ‘‘Public Health Administration and the Natural History of

Disease in Baltimore, Maryland, 1797–1920,’’ Carnegie Institution of Washington, D.C., 1924.

4. Shryock, Richard Harrison, ‘‘The Development of Modern Medicine,’’ p.

221, New York, 1947.

5. Newsholme, Sir Arthur, ‘‘Evolution of Preventive Medicine,’’ p. 113,

Baltimore, 1927.

46 Appendix II
The English-speaking world lagged in vital registration during this period. According to Willcox, in 1833 the

regions in which deaths and births were routinely registered comprised less than one-tenth of the world’s population. They covered about 80 million people in France,

Belgium, Austria, Prussia, Bavaria, Saxony, the Scandinavian countries with Finland and five cities in the

United States, containing only 6 percent of the country’s

population. The five cities were Boston, New York, Philadelphia, Baltimore, and New Orleans.

The inadequacy of vital statistics in England—and

the spur of a devastating cholera epidemic in 1831–32

which took nearly 42,000 lives in Great Britain and

Ireland—led in 1836 to enactment of a registration

law creating a central register office with responsibility for the records and statistics of births, marriages,

and deaths—by cause—for all of England and Wales.

According to one authority, the act was written by

Chadwick who ‘‘took the details and even the phrasing’’ from Jeremy Bentham’s ‘‘Constitutional Code.’’6

This act was an historic turning point in the

development of registration and public health not only

in England but in the United States and many other

parts of the world. According to Shattuck in 1850 (see

footnote 8), this registration law was the ‘‘most important sanitary (public health) measure ever adopted in

England; and it has been the foundation of nearly all

others. Without it they would have been comparatively

of little value.’’

From this time forward, the course of registration and vital statistics was to be recognized as basic

to the development of public health organization and

practice. Part of the motivation for the act was to

improve vital records as legal documents ‘‘for the

security of property,’’ but its main orientation was to

collect the facts on births, deaths, and disease as a

basis for striking at the appalling sanitary conditions of the time. In 1839, Dr. William Farr (1807–

83), whom Raymond Pearl called ‘‘the greatest

medical statistician who has ever lived,’’ joined the

Register Office as ‘‘compiler of abstracts.’’ Farr compiled vital statistics to present the human cost of

sickness and premature death, in a series of brilliant reports which, in Newsholme’s words, ‘‘have

guided sanitary reform and incited it year by year to

increased activity.’’ Benjamin Ward Richardson said

of Farr’s reports that ‘‘it is no longer true that

pestilence walketh in the dark.’’

State registration in America

The impact of Chadwick, Farr, and the Act of 1836

on vital statistics in the United States was immediate,

specific, and far-reaching. Chadwick inspired Lemuel

Shattuck of Massachusetts (1793–1859), whose influence on American registration and the public health

movement is probably second to none; Farr’s statistical

ingenuity in the use of vital data to point up public

health problems stimulated Shattuck and others in this

country; and the Act of 1836 was the prototype of the

first State registration law in America, which Massachusetts adopted in 1842 and strengthened in 1844.

Shattuck was the prime mover. He used the American Statistical Association, which he largely founded

in 1839, to induce both the American Academy of Arts

and Sciences and the Massachusetts Medical Society

to petition the legislature for an effective registration

law. The act that Shattuck finally steered through the

legislature in 1844 required central State filing; provided for standard forms, fees, and penalties; specified

types of information including causes of death; and

lodged responsibility for each kind of record in designated officials.

The National Medical Convention, which soon organized formally as the American Medical Association

(AMA), channeled medical interest in registration in

1846 by creating a committee to consider methods for

improving birth, marriage, and death registration. A

year later the newly formed AMA addressed memorials

to State legislatures on the need for registration laws.

It was probably about this time that local vital

statistics, which previously had been used mostly by

sanitary and social reformers, gradually came into

routine use by local health officers as a practical guide.

The best described example is that of John Simon

(1816–1904), who was appointed first Medical Officer

of Health in London in 1848, ‘‘the prototype of our

modern health officer, the first health officer in the

modern sense.’’7 According to Round, ‘‘For John Simon,

vital statistics formed the corner-stone of his work.’’

Where did Simon get his information regarding the

conditions prevailing at the moment and upon what information did he base his acts as medical health officer? From

Simon’s book on English Sanitary Institutions we find that

the death returns of the city registrars were made on

Monday mornings and on Monday afternoons they were

placed at his disposal, as he says, ‘‘in a way which enabled

me to complete my use of them during the evening, so that

on Tuesday mornings when the weekly courts of the City

Commission were held, I was ready with all needful

particulars as to the deaths which had befallen the city

population during the previous week, and with my scheme

of such local inquiries as were to be made in consequence.’’

During this period, Great Britain and various

countries on the continent, thanks to small land areas

and a central form of government, carried through

6. Political Science Quarterly, vol. 38, p. 45 ff., 1923.

7. Round, Lester A., ‘‘Consumer Demand for Vital Statistics: The Health

Officer’s Point of View,’’ American Journal of Public Health, vol. 26, p. 489,

May 1936.

Appendix II 47
national investigations of health conditions, and created new health and registration institutions on the

basis of the results. The developing United States,

with its vast and largely unexplored land area and its

Federal-State rather than central form of government,

could not be expected to progress as rapidly on a

national scale. However, the new American Medical

Association made an important contribution by examining conditions of the larger American cities. In 1848,

it reported that disease was as prevalent in Boston,

New York, and Philadelphia as in London, Manchester, and Glasgow, and that the death rates were even

higher in the American cities. These revelations, plus

the example of Massachusetts, prompted six additional States to enact registration laws by 1851, though

for the most part the laws were ineffective and unenforced.

The Shattuck report

In 1850, Shattuck presented to the legislature his

epochal ‘‘Report of the Sanitary Commission of Massachusetts,’’ described by C.-E.A. Winslow as ‘‘one of the

most remarkable documents—perhaps the most significant single document—in the history of public health.’’8

In fifty specific recommendations, including the creation of a State board of health whose program was to

be based solidly on complete registration and vital

statistics, Shattuck anticipated nearly all the public

health measures (except those based on the still unborn

science of bacteriology) which the next two generations

were to introduce. Actually, nearly 20 years were to

elapse before Shattuck’s detailed plans were to be

adopted as the health department organic law of Massachusetts, and then to be widely emulated in other

States. These developments will be treated below in

chronological sequence.

Shattuck and the census of 1850

Meanwhile, in 1849, the Superintendent of the

United States Census, to improve the still-primitive

census practice and to make a start toward collecting

the first national vital statistics, invited Shattuck to

Washington to help draw up plans for the Seventh

Federal Census. In his brilliant ‘‘Census of Boston for

the Year 1845,’’ which Willcox has called ‘‘the pioneer

among modern American censuses,’’ Shattuck had introduced the basic innovation of making the primary

census unit the individual rather than the family.

Instead of describing the whole family on a single line,

he had given a line on the schedule to each person,

which made it easy to record the name, age, birthplace, marital condition, and occupation, and to

assemble the data afterward in new and more revealing types of tables. For the 1850 Federal census,

Shattuck wrote five of the six schedules as well as the

enumerators’ instructions. According to Willcox, ‘‘The

most important improvements during 150 years of

Federal censuses resulted from the adoption in 1850 of

Shattuck’s ideas.’’

Against his better judgment and over his protest,

Shattuck also introduced the practice of using census

enumeration to determine births, marriages, and

deaths. Unalterably convinced that only a registration

system would provide such information, Shattuck

deferred to the census officials to include the items

‘‘Born within the year,’’ ‘‘Married within the year,’’ and

‘‘Disease, if died within the year.’’ It was hoped that

the resulting vital statistics would be better than

none, but the official report later admitted:

The tables of the census which undertake to give the

total number of Births, Marriages, and Deaths, in the year

preceding the first of June, 1850, can be said to have but

very little value. Nothing short of a registration system in

the States can give the required data satisfactorily, and it

has been proved that even where such systems have been

best established, difficulties continually arise which require

a very long time to be removed. Experience has shown that

people will not, or cannot, remember and report to the

census taker the number of the facts, and the particulars of

them which occur in the period of a whole year to eighteen

months prior to the time of his calling.9

(Despite its obvious defects as a method for collecting national vital statistics, census enumeration of

vital events was not entirely abandoned until the

census of 1910, when the developing registration area

was large enough to provide better national statistics.

In defense of the census officials who persisted for 50

years in a discredited method, it must be said that the

registration system was not ready to take over any

earlier, and the choice was vital statistics by enumeration or no national data at all.)

Registration and public health:

1850 to 1872

During the period 1850 to 1860, registration was

working well in a handful of cities and in two States.

In the rest of the country, particularly in rural areas, it

was too sporadic to afford vital statistics in the modern

sense. In an attempt to improve the situation, the

American Medical Association in 1855 adopted the

following resolutions:

8. Shattuck, Lemuel, and others, with a Foreword by Charles-Edward Amory

Winslow, ‘‘Report of the Sanitary Commission of Massachusetts, 1850,’’ p.

VII, reprinted, Cambridge, 1948.

9. DeBow, J. D. B., ‘‘Statistical View of the United States... Being a

Compendium of the Seventh Census,’’ p. 57, Washington, D.C., 1854.

48 Appendix II
RESOLVED, That the members of the medical profession throughout the Union be urgently requested to take

immediate and concerted action for petitioning their several

legislative bodies to establish offices for the collection of

vital statistics.

RESOLVED, That a committee of one from each

State be appointed to report upon a uniform system

of registration of marriages, births, and deaths.

This action was probably spurred by the very high

mortality rates which marked the decade. Since the

beginning of the century, to judge from the imperfect

statistics of the time, city death rates had been climbing to appalling levels. Immigration filled the urban

tenements and overtaxed the rudimentary sanitary

facilities. In Chicago, for example, typhoid deaths in

1854 were recorded at a rate of 175.1 per 100,000

population. In New York City, total deaths rose from

21.5 per 1,000 population in 1810 to 36.8 in 1857.10

Meanwhile, a number of physicians and sanitarians had been considering the idea of a national public

health association. As early as 1851, Wilson Jewell of

the Philadelphia Board of Health began planning such

a group, and in 1857 he and others were able to

organize the National Quarantine and Sanitary Convention. Annual meetings were held until 1861, when

the Convention was disrupted by the Civil War. Meeting ostensibly to consider quarantine regulations, the

group invariably went beyond these to promote broad

plans for sanitation, and paid much attention to vital

statistics and the need for improved registration.

By this time, the health field was divided into two

opposing camps. In the one were the believers in

‘‘contagion,’’ who were convinced that epidemic disease

entered the country mainly through the ports, and was

spread by infected animals or persons. This camp

therefore advocated seaboard quarantine and isolation

of the sick. In the other camp were those who looked

for the causes of disease in their own (and their

neighbors’) backyards—in the filth, miasms, and noxious odors of the crowded cities. This was the sanitary

group, which tried to fight disease with clean streets,

clean water, garbage collections, sewage disposal, and

so on. To locate the sore spots, for example, to find the

typhoid sources to clean up, the sanitary school placed

great stress on vital statistics, and used ‘‘before and

after’’ figures as educational material to promote further reform.11

The Civil War probably delayed public health and

registration by several years, but did both movements

some good—‘‘in spite of itself,’’ as Shryock put it.12 A

number of physicians—notably John Shaw Billings

(1838–1913), Medical Statistician of the Army of the

Potomac—first became interested in public hygiene

when disease proved to be a deadlier enemy than the

opposing army. After the War, Billings and others were

drawn increasingly into the public health movement.

Typhoid fever had scourged both North and South, and

many of the returning soldiers were carriers. The

fantastically high infant mortality rates of the postwar

period were taken as an index of bad health conditions

in general.

Massachusetts led the way to health reform by

enacting, after 19 years’ delay, a comprehensive State

health law modeled on the Shattuck report. By 1872,

the District of Columbia, California, and Virginia followed with similar legislation. Thus began a period of

rapid growth in State health organization, which in

most instances was to include registration and vital

statistics as a regular health department function.

Founding of the APHA and the

National Board of Health

In 1872, a group of physicians and sanitarians,

including many who had learned the value of statistics

in the wartime sanitary commissions, founded the

American Public Health Association (APHA). Taking

up where the earlier Sanitary Conventions had left off,

the APHA worked for an aggressive public health

program, based on sanitary reform with a strong vital

statistics base as a principal component.

Following a disastrous yellow fever epidemic in

the South, Congress, in 1879, created the National

Board of Health, largely on the basis of plans advanced

by the APHA. The leadership of the APHA and a

strong group in the AMA, dissatisfied with the emphasis placed on quarantine measures by the Marine

Hospital Service, had wanted a national agency that

would work on a broader front—to centralize information, engage in sanitary research, and collect vital

statistics.13 Despite some overlapping of functions and

competitive activity between the Board and the Marine

Hospital Service (later the United States Public Health

Service), the Board made important contributions. Not

the least of these was to advance the cause of vital

statistics by placing extraordinary value upon complete and uniform vital registration. In its first year it

established a standing committee, under Stephen Smith

(first president of APHA), and later Billings, to pro10. Proceedings and Debates of the Third National Quarantine and Sanitary mote uniformity in registration. The weekly Bulletin

Convention, p. 523, New York, 1859.

11. In retrospect, depending on the disease and the actual circumstances of its

spread, it is clear that both camps were partly right and partly wrong. But the

controversy flared up repeatedly, often with considerable ill-will, until the

1890’s when the two groups were reconciled by the findings of bacteriology

and medical entomology, as described below.

12. Shryock, Richard H., ‘‘The Early American Public Health Movement,’’

American Journal of Public Health, vol. 27, p. 970, October 1937.

13. Leigh, Robert D., ‘‘Federal Health Administration in the United States,’’ p.

468, New York, 1927.

Appendix II 49
of the Board undertook immediately to publish mortality summaries from cities able to supply the information from vital records.

The difficulties of publishing national vital statistics at this time are apparent in every issue of the

Bulletin. For the year 1879, the Board received annual

mortality reports, or weekly reports for the full year,

from 24 cities. Fourteen separate forms were represented, ‘‘and of these no two are alike. The differences

are such as to render direct comparison in some cases

impossible, and difficult in all. Not only is there no

uniform plan as to nomenclature, classification, or

arrangement, but a most ingenious diversity exists

as to the selection or omission of the several items of

information usually expected in such reports.’’14 But

the rapid effect of the Board’s promotional activity

may be seen in the fact that, by March 1880, it was

receiving weekly mortality reports from an average

of 90 cities, with improvement in the quality of

reporting.

In the second year of its existence, the Board

called a national meeting of State and local registrars

(May 1880) to consider the best methods for collecting

and publishing vital statistics, and took up such questions as standard nomenclature for assigning causes of

death, comparability of vital records, and problems of

obtaining complete registration. As part of the preparation for this meeting, and as a regular function

during its brief existence to 1883, the Board collected

and published information on State and local registration laws, forms, tables, reports, and registration procedures and methodology, and from time to time it

recommended standard models. As a coordinator and

promoter of vital statistics, the Board (mainly through

Billings) had an immediate impact on the perspectives

and methods of the Census Bureau, which for more

than a half-century was to carry on and extend the

work in registration which the Board had begun.

Leadership by the Census Office:

1880 to 1890

Billings, while still chairman of the National Board

of Health’s Committee on Vital Statistics, was placed

in charge of the 1880 census of mortality. The first

three census counts of deaths (1850, 1860, 1870) had

fallen short of actual deaths by 40 percent. Under an

amendment to the census law of 1880, the Superintendent of the Census could withdraw mortality schedules and accept registration records from any areas

having records in satisfactory detail. At Billings’ suggestion, a so-called registration area was established

in 1880, and registration records were obtained from

an increasing number of States and cities in the

succeeding censuses.15 Billings also supplied physicians with books of blank death certificates, and

requested them to fill out a form for each death they

attended. The books were collected by the census

takers and were used to obtain information on additional deaths or to improve the accuracy of death

reports received. Using 1880 data, Billings also produced what were considered accurate life tables for 2

States and 12 cities.

Before the 1890 census, the Census Office wrote to

all States and cities having 5,000 population or more

to obtain an index of probable registration completeness. Experience with the 1880 census had demonstrated that laws governing death registration, degree

of enforcement of such laws, and the manner of obtaining and recording data were so varied that the processing of these records by the Census Office was difficult

and subject to considerable error.

In an effort to obtain better and more uniform

data, the Census Office recommended a form of death

certificate to be used in the 1890 census. In that

census, prompted by the thought that death and disease are not subject to political boundaries, Billings

made the first attempt to produce statistics by geographic and climatic areas.

The Census Bureau, adapting machine techniques

used in the textile industry, used the Hollerith mechanical tabulator for the first time on a large scale operation in the 1890 census. Rapid counting and combining

of characteristics could now be done with a high

degree of accuracy.

The revolution in preventive

medicine

During the 1880’s, medical science was transformed by a series of discoveries which were to change

the course and direction of the public health movement, and multiply its effectiveness against epidemic

disease. Koch isolated the comma bacillus of cholera,

and Gaffky the organism of typhoid fever (1884).

Theobald Smith and F. L. Kilborne opened the way to

the control of the arthropod-borne diseases, such as

malaria and yellow fever, by tracing Texas fever in

cattle to infected ticks (1889). In this period, German

and French bacteriologists found the cause of diphtheria, and the causes of other diseases were soon added.

These discoveries in disease etiology were accompanied by a series of triumphs in immunology, led by the

genius of Pasteur.

The sanitary reformers and the quarantiners found

in the new sciences a common meeting ground, and

together put public health on a more rational basis.

With exact knowledge came discriminating use of tra14. National Board of Health Bulletin, vol. 1, No. 36, March 6, 1880. 15. See separate section on birth- and death-registration areas in this chapter.

50 Appendix II
ditional and new means of disease control. By the

1890’s, the best health departments were beginning to

achieve dramatic results in preventive medicine. To

supplement sanitation and quarantine, they began

setting up laboratories to diagnose disease and later to

provide typhoid vaccine and diphtheria toxinantitoxin. Private medicine found in the new discoveries more effective ways of curing the sick.

In all these developments, vital statistics were

sharpened to keep pace, to point more precisely to

problem areas, and to demonstrate the value of the

new techniques in disease control. It was about this

time, for example, that comparative infant mortality

rates proved the life-saving value of pasteurization of

milk, and induced the American dairy industry to

move toward modern sanitary methods.

Advances in disease classification

The march of bacteriology and other medical sciences helped also to revolutionize diagnosis, and indirectly to transform vital statistics (particularly,

mortality by cause) into a more accurate and useful

health adjunct. From the time of Hippocrates (440–

357 B. C.), physicians had with varying success tried

to diagnose and classify disease by observing its natural history and symptoms. This approach was carried

forward by the brilliant English clinician Thomas

Sydenham (1624–89), whose objective descriptions influenced medical practice and vital statistics until they

were at last overtaken by the precision-methods of the

laboratory. Meanwhile, vital statistics struggled along

with the prevailing nosology or systematic classification of disease—which was not very systematic until

much later. By the second half of the 19th century,

physicians were moving away from vague diagnoses

like ‘‘fever’’ and had identified a large number of

common diseases. The practice of making autopsies

and the advance of surgery after the discovery of

effective anesthetics in the 1840’s led to better diagnosis and classification of disease.

After 1850, steady progress was made in developing an international classification of causes of death

and a standard nomenclature. As recommended by the

AMA, the Census Office in the 1850 and 1860 censuses

employed a classification developed by Farr. In the

1870 census, on the advice of the Surgeon General of

the U.S. Army, the classification and nomenclature of

the Royal College of Physicians of London in 1869

were adopted.

Efforts were continued by the International Statistical Congress, from the 1850’s on, to produce an

acceptable classification of causes of death. The United

States was a member of this body; Billings, for example,

met with the Congress in 1880. Within a few years, as

noted above, bacteriology upset the traditional means

of identifying many of the common diseases, and was

beginning to break down various categorical diseases

into two or more distinct entities. Thus, the advent of

bacteriology set off a parallel revolution in nosology,

and in the resulting vital statistics. In 1898, the APHA

formally adopted a modern classification which Jacques

Bertillon of France had prepared for the International

Statistical Institute. The APHA recommended that

this list be revised periodically to keep abreast of

medical science. Since then, the list has been revised

decennially, on an international basis.

Census leadership after 1900

When the census count of mortality was made in

1900, it seemed likely that a permanent Census Office

was to be established, and plans were made accordingly. Prior to the census, intensive correspondence

was carried on with each State and with cities of 5,000

population or more. The Census Office collected data

and material on law, procedure, estimated rates, probable number of deaths not registered, etc., and released

a circular to acquaint registration personnel with the

findings. It also recommended a death certificate and

requested each area to adopt it by January 1, 1900.

Twelve States adopted the form in full; six States and

the District of Columbia adopted it in part; and seventyone major cities in other States adopted the form in

full or made revision. The census of 1900 included

figures obtained from well-established registration areas

which had adopted model laws and where it was

believed that 90 percent completeness of registration

had been attained.

Marriage and divorce were also matters of public

concern. In 1887, Congress passed an act directing the

Commissioner of Labor to collect statistics on marriages and divorces for the years 1867 through 1886.16

In 1905, President Theodore Roosevelt sent a special

message to Congress in which he recommended that

‘‘the Director of the Census be authorized by appropriate legislation to collect and publish statistics pertaining to that subject (marriage and divorce) covering the

period from 1886 to the present time.’’17

Since 1880, the Census Office had consistently

advocated national uniformity in State supervision, in

basic procedures, and in the forms used for registration of deaths. In the same period, interest in statistics

generally became widespread, and there appeared a

public disposition to consider statistical reporting a

governmental responsibility. The Census Office, which

had previously been disbanded between censuses, was

16. Wright, Carroll D., ‘‘Marriage and Divorce in the United States, 1867 to

1886,’’ Department of Labor, Washington, D. C., 1889.

17. U. S. Bureau of the Census, ‘‘Marriages and Divorces, 1867–1906,’’ p. 4,

U. S. Government Printing Office, Washington, D. C., 1909.

Appendix II 51
made a permanent, full-time agency of the Federal

Government in 1902, and was given its present name,

the Bureau of the Census.

The organic act provided statutory authority for

registration areas for births as well as deaths. From

this time forward, the Bureau completely abandoned

the 50-year effort to obtain mortality information by

census counts, and relied solely upon registration

records. As its principal task, the Bureau undertook to

develop an annual system of collection of vital statistics data, capable of producing comparable statistics

on a national basis. The over-all objective was to

develop and maintain a uniform system of registration

with respect to such matters as law, forms, procedures,

statistical methodology, etc.

It was recognized that these objectives would

require the cooperation of outside organizations and

the public at large. Organizations that formed working

arrangements with the Bureau included the American

Medical Association, American Public Health Association, Conference of Commissioners on Uniform State

Laws, American Statistical Association, American Bar

Association, and the National Tuberculosis Association.

Among the more important steps initiated by the

Bureau were: formulation of principles and wording of

a model law; drafting of standard forms; preparation

of instructions for local registrars, physicians, and

others; preparation of a system of mortality classification satisfactory for statistical purposes; formulation

of rules of statistical practice; and establishment of

working relationships with external groups within and

outside the country. As a working concept, the Bureau

announced that it would become a central office for

mortality statistics, act as a clearing house to harmonize the results of individual efforts in the various

State and city offices, and look forward to the possibility of forming a national association of registrars.

In 1907, the American Public Health Association

established a Vital Statistics Section to develop closer

working relations among registration officials; to promote more effective systems of vital statistics; to aid

the adoption of uniform registration methods and publication of statistical data; etc. For many years the

APHA had been active in promoting uniform State

registration and model laws. At the annual meeting in

1895, various members of the association proposed

that it either draft a model law or set forth principles.

At its annual meeting in 1900, the APHA adopted

principles of a model law for the registration of births

and deaths. Strong support for model State laws came

from Congress, which on February 11, 1903, adopted a

joint resolution requesting State authorities to cooperate with the Census Bureau in securing a uniform

system of birth and death registration. By 1907, a

model bill, which in 1905 had been adopted by Pennsylvania in draft form, was submitted to the States

with the endorsement of a broad list of organizations.

The principles of this and subsequent model laws have

since been adopted in every State of the Union, either

by direct enactment or by regulations.

The Federal Children’s Bureau, created in 1912,

worked actively with the Census Bureau in many of

the State campaigns. Credit should also be given to

the able leadership of William Alexander King, chief

vital statistician of the Census Bureau, 1900–1906,

and Cressy L. Wilbur, who held the position from 1906

to 1914. Through their efforts, uniform State legislation advanced rapidly, and permitted an increasing

number of States to qualify for admission to the deathregistration area.

About 1913, the Census Bureau began appointing

agents in the State health agencies, and authorizing

them to use the mailing privileges of Federal officials,

to promote registration, and to correct the certificates

of birth and death which are the sources of the national

statistics.

In 1914, the Bureau published the first table separating nonresident from resident deaths; the data had

been lumped together up to that time. Although complete reallocation of deaths by place of residence was

not yet possible, the first table was an important step

in this direction.

In 1915, the national birth-registration area was

formed. Before then, the collection and publication of

data were limited to death records because they were

more complete, of greater public interest than birth

records, and because it was believed that the concentration of census efforts in one field of registration

would yield better results than if its efforts were

spread thin.18

After the United States entered the First World

War, the need to provide health authorities with current information on epidemics became apparent.

Largely as a war measure, the Census Bureau obtained

weekly telegraphic reports on the number of deaths

and infant deaths occurring in cities of more than

100,000 population. Beginning October 1917, this information, together with comparative death rates and the

proportion of infant deaths to total deaths, was published in a Weekly Health Index, which was later

expanded to include separate tabulations of influenza

deaths during the pandemic of 1918–19.

The wartime influx of workers into industrial centers, and the growing tendency for serious illnesses of

out-of-town residents to be treated in urban hospitals

aggravated existing distortions in the crude death

rates of many cities and towns. During 1918, the

Bureau therefore sought to obtain complete data on

the ‘‘usual place of abode’’ of nonresidents who died

within the death-registration area. On the basis of this

18. Shapiro, Sam, ‘‘Development of Birth Registration and Birth Statistics in

the United States,’’ Population Studies, vol. IV, No. 1, June 1950.

52 Appendix II
information, the Bureau published the first tables in

which nonresident deaths were reallocated to place of

residence. Deaths of nonresidents living outside the

registration area were shown separately.

Concerned with the slow growth of the registration

areas, the Bureau in 1924 established a committee to

bring all States into the registration areas by 1930.

The advice and assistance of many varied interests

helped advance this program. As a further stimulus, in

1924 the Census Notification of Birth Registration was

developed, to be mailed to parents from State vital

statistics offices when they received certificates of

birth. This offered parents an opportunity to verify or

correct information contained in the birth record and

helped to promote registration generally.

The following excerpt from a report of the National

Resources Committee perhaps best summarized this

period:

The long, hard, often discouraging campaign which

was fought to bring States, one by one, into the fold

constitutes one of the proudest chapters in the history of the

Bureau of the Census . . . . In some States, the boards of

health had to be educated to the need, before the citizens of

that State could approach the legislature. In others, the

legislatures were apathetic, in spite of strong pressures.

After the required legislation was passed, there remained

the problem of bringing a State up to the minimum quota.

Each State had to educate its physicians and undertakers as

to their duties, as well as an army of local registrars. The

Bureau aided the State registrars in preparing promotional

publicity and facilitated the exchange of ideas as to the

most effective ways of presenting public health data to the

general public.19

Division of Vital Statistics: The road

to reorganization

The social and economic forces that had been

generated in the war and postwar periods worked

fundamental changes in the patterns of American life.

In December 1929, President Hoover appointed a group

of social scientists to make a national survey of social

trends—to see what had happened to private economic

organization, government functions, public welfare,

education, family patterns, the role of women in industry and the home, rural and metropolitan patterns,

sports and other recreation, labor organization, and a

wide variety of the other interrelated institutions that

make up American life as a whole and dictate the form

of its social problems. The underlying social data,

including vital statistics, came in for close scrutiny,

particularly by Stuart A. Rice and his associates who

produced several penetrating studies of the current

status and developmental needs of social statistics.20

Both assets and deficiencies were freely discussed, and

important suggestions were made for improving Federal vital statistics.

Much the same concern that had led to these

studies was reflected in the actions of professional

organizations. The Social Science Research Council

and the American Statistical Association, which were

both interested in improving Federal statistics, combined their respective committees on social statistics

in a joint committee, with Professor Robert E. Chaddock as chairman and Dr. Rice as secretary. Though

concerned mainly with social welfare data, this committee had related interests in population and vital

statistics.

Despite growing demands for improved and more

comprehensive statistics to cope with the Depression,

sweeping reductions were made in government statistical services early in 1933, following the Economy Act

of 1932. These cuts were vigorously protested, particularly when the swift expansion of government functions in the economic crisis created urgent

administrative needs for statistics as a factual basis of

decisions and programs. In this situation, the need for

a thorough reappraisal of government statistical services soon became widely recognized.

In the spring of 1933, the Secretaries of Agriculture, Commerce, Labor, and Interior invited the Social

Science Research Council and the American Statistical

Association ‘‘to furnish immediate assistance and advice

in the reorganization and improvement of the statistical and informational services of the Federal Government.’’ In response, the two organizations established

a joint Committee on Government Statistics and Information Services (COGSIS), which began work in June

1933 with financial support from the Rockefeller Foundation. Among many other activities, the COGSIS

made a preliminary survey of the vital statistics of the

Bureau of the Census and the Public Health Service,

which was completed in May 1934.21 This survey,

which was begun during the summer of 1933 while Dr.

Rice was acting chairman of the committee and which

continued in the fall when he joined the Census Bureau

as assistant director, marked the beginnings of a drastic reorganization of the work of the Division of Vital

Statistics.

For approximately a third of a century, the fundamental task of the Bureau of the Census in the field of

vital statistics had been to extend the registration

19. National Resources Planning Board, ‘‘Research—A National Resource,

Part I,’’ p. 210, Washington, D. C., 1938.

20. See, especially, Rice, Stuart A., and collaborators, ‘‘Next Steps in the

Development of Social Statistics,’’ and DePorte, Joseph V., ‘‘Guides to Vital

Statistics in the United States,’’ Volumes I and III in a Report to the

President’s Research Committee on Social Trends on Social Statistics in the

United States, Ann Arbor, 1933.

21. See the final report of COGSIS, ‘‘Government Statistics,’’ Bulletin No. 26,

Social Science Research Council, April 1937.

Appendix II 53
area for births and deaths. With the completion of the

birth area by the admission of Texas in 1933, this

primary responsibility was accomplished. The period

1933 to 1935 was a time of appraisal and preparation

for new types of work for which the Bureau had

become responsible. These fell into two main categories: (1) improvement of all reports for the completed

registration areas; and (2) research in the new fields of

vital statistics which had been opened.

For these tasks, the Division needed considerable

strengthening, both in number of personnel and professional training. After the 1930 census, the Bureau

as a whole had made little progress in recruiting or

holding professional personnel. In the Division of Vital

Statistics only the chief statistician was at the professionally classified level. While studies of means to

strengthen the Division were under way, an opportunity developed in the summer of 1934, with Federal

Emergency Relief Administration Funds, to conduct a

campaign in some 20 States to promote birth registration. The COGSIS staff members helped organize this

program, which improved registration in nearly all the

States and furnished incidental data for checking on

weak registration areas. The Committee also helped

the Bureau to develop the reporting of births and

deaths by place of residence of mother or decedent,

beginning January 1, 1935. This greatly improved the

data, which had previously been published mainly on

the basis of place of occurrence of the birth or death,

and which had become distorted by the growing use of

city hospitals by rural residents.

At the request of the Census Director, the COGSIS

subsequently made a more intensive survey of the

Division and developed, among others, the following

recommendations:

1. The Division should be strengthened by creating office and field positions for several people

with professional degrees.

2. A permanent expert field staff should work

systematically to speed up and improve reliability of reporting in the States.

3. The feasibility of rewarding States for especially meritorious cooperation, perhaps by creating a new registration area, should be

investigated.

4. A monthly reporting system using provisional

figures on births should be established.

5. Systematic plans should be made for publication of special monographic studies.

6. Revisions should be made in annual published

volumes providing for more analytical and interpretive text material, standardization of rates

for age, tabulation by broad socio-economic

groups and certain selected occupational groups,

more extensive tabulations by age groups, and

omission of considerable costly and relatively

unimportant material, such as births by country of birth of mothers.

In 1935, under the new leadership of Halbert L.

Dunn, a physician and biometrician, the Division was

drastically reorganized, and its professional staff greatly

augmented. In the same year, the Secretary of Commerce appointed an Advisory Committee for the Division of Vital Statistics, which at its first meeting

recommended that development of the Division should

be continued along the following broad lines:22

1. Extension of field work in order to secure and

maintain completeness and to improve completeness and accuracy of the data noted upon the

original certificates, and to promote cooperation

between Federal, State, and nonofficial agencies

dealing with and interested in vital statistics.

2. Coordination of State and Federal statistical

office activities with the object of eliminating

overlapping effort insofar as possible.

3. Development of means by which the total data

in the birth and death certificate might be

made available for special public health and

scientific needs.

4. Stimulation of research within the Division by

appropriate cooperation of the Division with

outside scientific and public health agencies,

and by building up within the Division a personnel whose principal duties would be the

analysis and solution of important vital statistical problems.

Changing needs for vital records

and statistics

By the early 1930’s, responsibility for vital records

had been largely transferred from civil offices to health

departments. As more and more departments employed

full-time officers with public health training, they

were able to make more intensive use of the records for

statistical analysis. In addition to using statistics to

locate and deal with disease outbreaks, defective water

and sewage facilities, and related sanitation problems,

many health departments routinely used them as the

basis for maternal, infant, and child care programs,

immunization against childhood diseases, and a variety of other personal health services. During the 1930’s,

the emphasis in public health work shifted even farther away from the sanitation diseases, which by then

were under control in most areas. Greater attention

was paid to communicable diseases in which casefinding was the key to control. The Public Health

22. Dunn, Halbert L., ‘‘Development of Vital Statistics in the Bureau of the

Census,’’ American Journal of Public Health, vol. 25, No. 12, p. 1322,

December 1935.

54 Appendix II
Service developed a national tuberculosis control program to supplement voluntary and State activities,

and greatly expanded national control of venereal

diseases through technical and financial aid to the

States. In both programs, vital statistics were widely

used to map out areas and population groups in which

case-finding efforts would be most fruitful. The need

for this kind of statistics had, in fact, been part of the

impetus for the reorganization of the Vital Statistics

Division.

While these health needs for statistics continued,

the records suddenly became important to large numbers of individuals, who for the first time in their lives

had to prove vital facts about themselves.23 Beginning

about 1935, Federal and State Governments enacted a

variety of welfare legislation, such as old age and other

social security. As a result of new directions in labormanagement relations, the movement toward industrial pension plans became widespread. The common

factor in both the public and private plans was the use

of the birth certificate as a legal document to evidence

the fact of age.

A few years later, the outbreak of World War II

produced an additional shift in emphasis. Congress

wrote into law provisions against the employment of

aliens in certain defense projects, so that for the first

time the birth certificate was widely demanded as

evidence of citizenship. Early in 1940, State offices

were hard pressed to fill requests for birth certificates

of persons seeking employment in defense industries.

Since many of these births had never been registered,

the problem of filing delayed birth certificates became

acute. It was estimated that nearly 55,000,000 native

persons who were living in 1940 had no birth record on

file. Some States did not have express provision in law

or regulation governing delayed certificates. The rules

and standards in operation in other States varied and

were complex, since uniform standards for filing had

not been formulated.

The Division of Vital Statistics was called upon by

State registrars to aid in the development of acceptable standards. Successive meetings of Federal agencies and State representatives resulted in a set of

recommendations which were incorporated in a Manual

of Uniform Procedures for the Delayed Registration of

Births, issued by the Bureau of the Census on July 16,

1941. Procedures for delayed registration were adopted

immediately by a large number of States, but the goal

of uniform principles was not fully achieved.

When the United States entered the War, the

conversion to all-out war production and the drive to

employment in war plants started in earnest. In addition, separate legislation increased the need for certificates, for example, the emergency maternal and infant

care program for dependents of service men. Almost

immediately, State registrar offices were swamped by

the wholesale demand for birth certificates, often by

persons born before the establishment of records systems. Many State and local offices abandoned statistical functions to prepare certified copies and to devise

means of providing delayed birth certificates for persons whose births had not been registered.

To meet these needs the States reacted with various types of emergency legislation, deviating widely

from the model laws which had been providing a fair

degree of national uniformity. Needs for certificates

were met in diverse ways, and standards acceptable in

one State proved either too lenient or too strict in

another. Federal agencies requiring such certificates

were bewildered by the variety of standards, and

pressures began to mount for a return to greater

uniformity. The difficulties encountered by State vital

statistics offices and by applicants for certified copies

led to a series of proposals, numerous bills in Congress, and a general feeling that something drastic

would have to be done.

Budget Bureau’s recommendations:

1943

In July 1942, the President of the United States

urged Congress not to enact any hasty legislation. In

the same letter, he acknowledged ‘‘great confusion in

vital records growing out of the activities of government and industry, particularly in connection with the

security and health laws.’’ In view of the need for

study, the Budget Bureau at his request made its own

survey, and examined the recommendations of an official Commission on Vital Records headed by Dr. Lowell J. Reed, and a report adopted by the Association of

State and Territorial Health Officers.24

The report of health officers, which foreshadowed

the Budget Bureau’s recommendations, had warned

against solutions offering purely financial relief to the

States, solutions that might undermine the work of

existing registration agencies, and solutions that would

dilute the standards and thus weaken the value of

vital records. Instead it proposed the creation of a

cooperative vital records system, comprising the existing State and independent city vital statistics offices

and a national office to ‘‘represent and serve the

system from a Federal standpoint, and, by making

available financial and technical aid, would work to

improve, develop, and integrate the individual units of

the system.’’ It called for a program of continuous

23. An earlier instance of the use of birth certificates for legal purposes—

perhaps the first since colonial days—occurred after World War I when birth

certificates began to be used extensively in the enforcement of regulatory laws

dealing with child labor and compulsory education.

24. Measures Relating to Vital Records and Vital Statistics, House Document

No. 242, Washington, D. C., 1943.

Appendix II 55
allotment of money to the present State, city, and

Territorial offices to be spent for correcting defects in

the registration system and for expansion as required.

The objective of the national office would be ‘‘to

correct the deficiencies now existing on a national,

State, and local basis, in the coordination and standardization of vital records agencies, methods, and

requirements.’’ In addition, the plan provided for the

transfer of Census Bureau functions in vital statistics

to a bureau or division of the United States Public

Health Service. The report noted that ‘‘assurances

have been given by officers of the United States Public

Health Service that, if functions of the Division of

Vital Statistics are transferred to the United States

Public Health Service, the Vital Records Office will

have the responsibility and authority to work out in

cooperation with the other bureaus and divisions of

the United States Public Health Service, and State

and other Federal officers, whatever future programs

may be mutually desirable and beneficial.’’

On the basis of these studies, the Budget Bureau

recommended against legislation to authorize Federal

agencies to issue documents as substitutes for birth

certificates. On the positive side, it recommended:

That a national vital records office should be established as a separate organizational unit in the United States

Public Health Service, the head of the office to report

directly to the Surgeon General.

This office should work with and through the

existing State and local vital statistics agencies

with a view to developing a record system which,

while nationwide in scope, will preserve the wholesome responsibility of the State and local governments. The proposed office should not only assume

the functions of the present Division of Vital Statistics of the Bureau of the Census but should also be

authorized to take appropriate steps (within the

framework of normal Federal-State relationships)

to promote higher standards of performance within

and better coordination among the State and local

vital records agencies.

The recommendations of the Budget Bureau, the

Commission, and the Association of State and Territorial Health Officers were in essential agreement on the

need for a cooperative vital records system with the

coordinating responsibility placed in a single national

agency. Thus, the report was a major turning point in

the position of the Federal Government in vital records

and statistics. While the Census Bureau had been

responsible for publishing vital statistics, and had

worked with vague authority to coordinate practices in

the independent State offices, no Federal agency had

ever been explicitly charged with responsibility for the

vital records system.

At that time the Budget Bureau estimated that

the Federal Government was spending $2 million a

year, and the State and local agencies $6.5 million, for

vital records and vital statistics. In addition, the public was paying a total of perhaps $12 million in fees to

government agencies and others for services in obtaining documentary evidence. Despite these substantial

expenditures, the Budget Bureau found that American

vital records were ‘‘surprisingly inadequate.’’ Visits to

several State vital records offices showed that the

wartime volume of demands for certification was not

being met promptly and adequately, and that in diverting personnel to the certification problem the States

were neglecting the long-run task of seeing that all

current births and deaths were promptly and accurately registered. ‘‘It cannot be assumed,’’ the Bureau

declared, ‘‘that needs for adequate vital records will

disappear after the war emergency is ended; on the

contrary, the course of social evolution points to continually increasing needs for official records of the

existence, identity, and status of individuals, and for

statistics based on such records.’’

Wartime cooperative arrangements

Pending Executive or Congressional action on the

Budget Bureau’s recommendations, the Division of

Vital Statistics continued to work toward a coordinated system, but under special handicaps imposed by

wartime restrictions. Starting in 1934, the Division

had brought the State registrars together in work

conferences, to exchange viewpoints and unify registration practices by cooperative agreements. Successive conferences had been held in 1938, 1940, 1941,

and 1942, when travel restrictions made large meetings impossible. As an interim device, the American

Association of Registration Executives in 1944 urged

the Division to establish a representative Council, to

deal with the many wartime problems. This new organization, created the same year, consisted of seven

regional representatives elected by the registration

executives, the President and Secretary of the Registrars’ Association, and two Federal officials. From time

to time, the regional representatives called regional

meetings. Despite the limitations of these stopgap

mechanisms, they were invaluable in linking State

and national registration and vital statistics interests.

Transfer to the Public Health

Service: 1946

The Budget Bureau’s recommendations of 1943

were adopted in July 1946, when the President’s Reorganization Plan No. 2 gave the Federal Security Administrator25 authority for Federal functions in vital

25. Transferred to the Secretary of the Department of Health, Education, and

Welfare, April 1953.

56 Appendix II
statistics. To administer these functions, and to provide a single locus of authority for vital records at the

Federal level, the National Office of Vital Statistics

(NOVS) was established in the Public Health Service.

The National Office of Vital Statistics continued to

work closely with the Council, which had proved so

useful that it was continued even after the annual

work conference was resumed in 1947. Through this

annual conference and the Council, and in close cooperation with the Registrars’ Association and the Statistics Section of APHA, vital records and statistics

problems of an interstate and national character were

handled with a fair degree of adequacy. But from a

public health viewpoint, there were still serious shortcomings. Of paramount importance was the early development of a public health working conference and

committee mechanism to unite the skills and experience of all those producing public health statistics.

This meant getting registration executives, vital statisticians, and public health statisticians, from all of

the registration areas, into a conference-type organization that would function on a permanent basis.

This last essential was finally achieved on May 17,

1949, when the Public Health Conference on Records

and Statistics was formally launched. It was conceived

as a permanent organization, with working committees assigned to specific problems, and an Executive

Committee (Council) to conduct its affairs in the interim

between national meetings. The Conference was essentially the culmination and fulfillment of organization

and work-methods that had been under development

for some time in the Council and the annual meeting

of State registrars. But its scope was considerably

broadened beyond those of its two predecessors. Of

special importance was the broadening of its base to

include the whole field of public health statistics in

addition to that of vital records and vital statistics.26

A measure of the remarkable progress made by the

registration system was provided by the second nationwide test of birth registration completeness, which

was made in conjuction with the 1950 census. This test

indicated that 97.9 percent of the infants born in the

early part of that year had birth certificates on file in

vital statistics offices. In 24 States and the District of

Columbia, birth registration completeness was 99.0 percent or more and in only 7 States was it lower than

95.0 percent. In the first nationwide test, made in

1940, only 92.5 percent of the births had been registered. Thus, the proportion of infants without birth

certificates was reduced almost three-quarters in the

10-year period. A detailed discussion of the birth registration tests appears in chapter 6.

Growth of the Birth- and Death-Registration Areas

The first birth and death statistics published by

the Federal Government concerned events in 1850 and

were for the entire United States. These statistics

were based on information collected during the decennial census of that year. Similar decennial collections

were made by census enumerators at each census up

to and including the census of 1900, but because of the

time interval between the occurrence of a birth or a

death and the census enumeration, these reports were

inaccurate and incomplete.

In 1880, the Bureau of the Census established a

national ‘‘registration area’’ for deaths. This original

area consisted of only two States—Massachusetts and

New Jersey—the District of Columbia, and several

large cities having efficient systems for the registration of deaths, but by 1900 eight other States had been

admitted. For the years 1880, 1890, and 1900, mortality data were received from the States and cities

included in this expanding area, but birth and death

figures for the entire country were still compiled from

the reports of census enumerators.

The annual collection of mortality statistics for the

registration area began with the calendar year 1900.

In 1902, the Bureau of the Census, which had previously functioned only in census years, was made a

permanent agency by an act of Congress. This act

authorized the Director of the Bureau of the Census to

obtain, annually, copies of records filed in the vital

statistics offices of those States and cities having

adequate death-registration systems. At that time not

all States had enacted laws requiring the registration

of deaths, and in many States the existing laws were

poorly enforced. The important dates in the historical

development of birth and death registration in various

States and the year in which each State was admitted

to the national registration areas, are given in

table 1.01.

The death-registration area for 1900 consisted of

10 States, the District of Columbia, and a number of

cities located in nonregistration States. The registration area in 1900 included 40.5 percent of the population of the continental United States. The original

registration area was predominantly urban and characterized by a high proportion of white persons. If

those reporting cities located in nonregistration States

are excluded, the population coverage of the death

26. The philosophy and working methods of the Public Health Conference,

and the impact of this coordinating mechanism on health records and

statistics, are described in ‘‘The Public Health Conference on Records and

Statistics,’’ by Hazel V. Aune, Canadian Journal of Public Health, December

1951; and in ‘‘Records at Work,’’ published by the Public Health Conference,

March 1952.

Appendix II 57
registration States is much lower, representing 26.2 percent of the total population of the United States.

Inasmuch as it is more difficult to obtain accurate

and complete registration of births as compared with

deaths, the national birth-registration area was not

established until 1915, and no birth statistics were

published by the Bureau of the Census from 1900 to

1914. The original birth-registration area of 1915 consisted of 10 States and the District of Columbia. The

growth of this area is indicated in table 1.02.

Table 1.02 also presents for each year through

1933 the estimated midyear population of the continental United States and the estimated midyear population of those States included in the registration system.

Beginning with 1933, the birth- and death-registration

areas have included all 48 States and the District of

Columbia. The year in which each State was admitted

to the birth-registration area is shown in table 1.03,

and to the death-registration area in table 1.04.

Prior to 1940, most of the national mortality tabulations published by the Bureau of the Census were

based on data collected from the registration areas,

but beginning with 1940 all published material given

in statistical series for the United States prior to the

Table 1.01. Important Dates in the History of Birth

and Death Registration: United States

Area

Records on file

for entire area

Admitted to

registration area

Deaths Births Deaths Births

Alabama ...................... 1908 1908 1925 1927

Arizona........................ 1909 1909 1926 1926

Arkansas...................... 1914 1914 1927 1927

California...................... 1905 1905 1906 1919

Colorado ...................... 1907 1907 1906 1928

Connecticut ................... 1897 1897 1890 1915

Delaware...................... 1881 1881 1890 1921

District of Columbia ........... 1855 1871 1880 1915

Florida ........................ 1899 1899 1919 1924

Georgia ....................... 1919 1919 1922 1928

Idaho. . . . . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1922 1926

Illinois ......................... 1916 1916 1918 1922

Indiana........................ 1900 1907 1900 1917

Iowa........................... 1880 1880 1923 1924

Kansas. . . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1914 1917

Kentucky . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1911 1917

Louisiana...................... 1914 1914 1918 1927

Maine ......................... 1892 1892 1900 1915

Maryland ...................... 1898 1898 1906 1916

Massachusetts ................ 1841 1841 1880 1915

Michigan ...................... 1867 1867 1900 1915

Minnesota..................... 1900 1900 1910 1915

Mississippi .................... 1912 1912 1919 1921

Missouri....................... 1910 1910 1911 1927

Montana ...................... 1907 1907 1910 1922

Nebraska...................... 1905 1905 1920 1920

Nevada . . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1929 1929

New Hampshire............... 1850 1850 1890 1915

New Jersey ................... 1848 1848 1880 1921

New Mexico................... 1919 1919 1929 1929

New York. . . . . . . . . . . . . . . . . . . . . . 1880 1880 1890 1915

North Carolina ................ 1913 1913 1910 1917

North Dakota.................. 1908 1908 1924 1924

Ohio........................... 1909 1909 1909 1917

Oklahoma ..................... 1908 1908 1928 1928

Oregon........................ 1903 1903 1918 1919

Pennsylvania.................. 1906 1906 1906 1915

Rhode Island.................. 1852 1852 1890 1915

South Carolina ................ 1915 1915 1916 1919

South Dakota ................. 1905 1905 1906 1932

Tennessee .................... 1914 1914 1917 1927

Texas ......................... 1903 1903 1933 1933

Utah........................... 1905 1905 1910 1917

Vermont....................... 1857 1857 1890 1915

Virginia........................ 1912 1912 1913 1917

Washington ................... 1907 1907 1908 1917

West Virginia.................. 1917 1917 1925 1925

Wisconsin ..................... 1907 1907 1908 1917

Wyoming...................... 1909 1909 1922 1922

Alaska......................... 1913 1913 1950 1950

Hawaii......................... 1896 1896 1917 1929

Puerto Rico ................... 1931 1931 1932 1943

Virgin Islands ................. 1919 1919 1924 1924

NOTE: See tables 1.03 and 1.04 for footnote references to several States.

Table 1.02. Growth of the Birth- and Death-Registration

Areas: United States

(Beginning with 1933 and each succeeding year, areas include entire

continental United States)

Year

Estimated

midyear

population

of continental

United

States

Birth-registration

States

Death-registration

States

Estimated

midyear

population

Percent

of total

Estimated

midyear

population

Percent

of total

1933 ...... 125,578,763 125,578,763 100.0 125,578,763 100.0

1932 ...... 124,840,471 118,903,899 95.2 118,903,899 95.2

1931 ...... 124,039,648 117,455,229 94.7 118,148,987 95.3

1930 ...... 123,076,741 116,544,946 94.7 117,238,278 95.3

1929 ...... 121,769,939 115,317,450 94.7 115,317,450 94.7

1928 ...... 120,501,115 113,636,160 94.3 113,636,160 94.3

1927 ...... 119,038,062 104,320,830 87.6 107,084,532 90.0

1926 ...... 117,399,225 90,400,590 77.0 103,822,683 88.4

1925 ...... 115,831,963 88,294,564 76.2 102,031,555 88.1

1924 ...... 114,113,463 87,000,295 76.2 99,318,098 87.0

1923 . . . . . . 111,949,945 81,072,123 72.4 96,788,197 86.5

1922 ...... 110,054,778 79,560,746 72.3 92,702,901 84.2

1921 ...... 108,541,489 70,807,090 65.2 87,814,447 80.9

1920 ...... 106,466,420 63,597,307 59.7 86,079,263 80.9

1919 ...... 104,512,110 61,212,076 58.6 83,157,982 79.6

1918 ...... 103,202,801 55,153,782 53.4 79,008,412 76.6

1917 ...... 103,265,913 55,197,952 53.5 70,234,775 68.0

1916 ...... 101,965,984 32,944,013 32.3 66,971,177 65.7

1915 ...... 100,549,013 31,096,697 30.9 61,894,847 61.6

1914 ...... 99,117,567 - - - - - - 60,963,309 61.5

1913 ...... 97,226,814 - - - - - - 58,156,740 59.8

1912 ...... 95,331,300 - - - - - - 54,847,700 57.5

1911 . . . . . . 93,867,814 - - - - - - 53,929,644 57.5

1910 ...... 92,406,536 - - - - - - 47,470,437 51.4

1909 ...... 90,491,525 - - - - - - 44,223,513 48.9

1908 ...... 88,708,976 - - - - - - 38,634,759 43.6

1907 ...... 87,000,271 - - - - - - 34,552,837 39.7

1906 ...... 85,436,556 - - - - - - 33,782,288 39.5

1905 ...... 83,819,666 - - - - - - 21,767,980 26.0

1904 ...... 82,164,974 - - - - - - 21,332,076 26.0

1903 ...... 80,632,152 - - - - - - 20,943,222 26.0

1902 ...... 79,160,196 - - - - - - 20,582,907 26.0

1901 ...... 77,585,128 - - - - - - 20,237,453 26.1

1900 ...... 76,094,134 - - - - - - 19,965,446 26.2

1890 ...... 1

62,947,714 - - - - - - 19,659,440 31.2

1880 ...... 1

50,155,783 - - - - - - 8,538,366 17.0

- - - Birth registration area was not established until 1915.

1Population enumerated in the Federal census of May 31.

58 Appendix II
completion of the death-registration area in 1933 omits

data for registration cities located in nonregistration

States, and includes only findings for the registration

States. This change decreases the mortality statistics

coverage of the United States by the exclusion of cities

in nonregistration States, but it has its advantages in

that more reliable population estimates are available

for the registration States than for the registration

areas. No change in coverage has been made for

natality statistics since the birth-registration area at

no time included cities in nonregistration States.

Because of the growth of the areas for which data

have been collected and tabulated, a national series of

geographically comparable data prior to 1933 can be

obtained only by estimation. Annual estimates of births

have been prepared by P. K. Whelpton for the period

1915 to 1934. (See table 6.02 in chapter 6.) These

estimates include an adjustment for States not in the

birth-registration area prior to 1933 and for underregistration. In conjunction with annual estimates prepared by the National Office of Vital Statistics for the

period 1935 through 1949, they constitute a series of

data consistent with respect to geographic coverage

and registration completeness. Corresponding estimates for deaths are not yet available. However, rates

for the expanding groups of death-registration States

are approximations to complete national rates, and

general comparisons over a long period of years are

made. More exact trends for parts of the United

States can be secured through the use of some

constant area, such as the original registration States,

or the registration States of 1920. The crude marriage and divorce rates; birth rates; fetal death

ratios; and death, infant mortality, and maternal

mortality rates for the registration States, geographic divisions, and individual States for a series

of years are given in chapters 5, 6, 7, and 8. Rates or

ratios by place of occurrence and place of residence

are given in separate tables.

Marriages, Divorces, and Notifiable Diseases

Marriages and divorces

The earliest Federal statistics on marriages and

divorces in the United States were collected in a field

survey by the Commissioner of Labor, covering the 20-year

period 1867 to 1886. A survey covering the next 20 years,

and the single-year collections for 1916 and for each year

from 1922 to 1932 were made by the Bureau of the

Census. In all these studies, marriage statistics were

confined to numbers of occurrences, by county, with

considerable incompleteness for the first 20 years. Divorce

data were considered practically complete, and included

detailed statistics on such items as legal grounds

(‘‘causes’’), duration of marriage prior to divorce, etc.

Table 1.03. Year in Which Each State was Admitted to the

Birth-Registration Area

Year State Year State

1915 .......... Connecticut 1921 .......... Delaware

Maine Mississippi

Massachusetts New Jersey

Michigan 1922 .......... Illinois

Minnesota Montana

New Hampshire Wyoming

New York 1924 .......... Florida

Pennsylvania Iowa

Rhode Island1 North Dakota

Vermont 1925 . . . . . . . . . . West Virginia

District of Columbia2 1926 .......... Arizona

1916 .......... Maryland Idaho

1917 .......... Indiana 1927 .......... Alabama

Kansas Arkansas

Kentucky Louisiana

North Carolina Missouri

Ohio Tennessee

Utah 1928 .......... Colorado

Virginia Georgia

Washington Oklahoma

Wisconsin 1929 .......... Nevada

1919 .......... California New Mexico

Oregon 1932 South Dakota

South Carolina3 1933 .......... Texas

1920 .......... Nebraska

1Dropped from the birth-registration area in 1919; readmitted in 1921.

2Included in States.

3Dropped from the birth-registration area in 1925; readmitted in 1928.

Table 1.04. Year in Which Each State was Admitted to

the Death-Registration Area

Year State Year State

1880 .......... Massachusetts 1911 .......... Missouri

New Jersey 1913 .......... Virginia

District of Columbia1 1914 .......... Kansas

1890 .......... Connecticut 1916 .......... South Carolina

Delaware2 1917 .......... Tennessee

New Hampshire 1918 .......... Illinois

New York Louisiana

Rhode Island Oregon

Vermont 1919 .......... Florida

1900 .......... Maine Mississippi

Michigan 1920 .......... Nebraska

Indiana 1922 .......... Georgia5

1906 .......... California Idaho

Colorado Wyoming

Maryland 1923 .......... Iowa

Pennsylvania 1924 .......... North Dakota

South Dakota3 1925 .......... Alabama

1908 .......... Washington West Virginia

Wisconsin 1926 .......... Arizona

1909 .......... Ohio 1927 .......... Arkansas

1910 .......... Minnesota 1928 .......... Oklahoma

Montana 1929 .......... Nevada

North Carolina4 New Mexico

Utah 1933 .......... Texas

1911 . . . . . . . . . . Kentucky

1Included in States.

2Dropped from the registration area in 1900; readmitted in 1919.

3Dropped from the registration area in 1910; readmitted in 1930.

4Included only municipalities with populations of 1,000 or more in 1900 (about 16 percent of the total population); the remainder of the State was added to the area in 1916. 5Dropped from the registration area in 1925; readmitted in 1928.

Appendix II 59
In 1940, the Bureau of Census, through its Vital

Statistics Division, undertook a new program of marriage and divorce statistics, following the pattern used

for birth and death statistics. Transcripts of marriage

and divorce records were collected, chiefly from those

States which could provide them through their State

offices of vital statistics. For the first time, the Federal

program provided some detailed statistics on marriages, more than mere numbers of occurrences. However, the data were for fewer than 30 States. Some

detailed statistics on divorces were obtained for 6 to 12

States. Marriage data for 1939 and 1940 were published, as well as divorce data for 1939. This program

was discontinued, owing to war conditions. Meanwhile, numbers or estimated numbers of occurrences

by State were obtained and published for the years

1937 to 1940.

Beginning in 1944, the Bureau of the Census, at

first through its Population Division and later through

its Vital Statistics Division, resumed efforts to provide

numbers of occurrences. This program has been continued by the former Vital Statistics Division, designated the National Office of Vital Statistics since its

transfer to the Public Health Service in 1946.27 In

addition, a program of detailed statistics of marriages

and divorces, based on State tabulations, was inaugurated by the National Office of Vital Statistics in 1949.

Data for 1950 are presented in tables 1 through 12 in

Volume II, as well as in several text tables in chapter 5.

Table 1.05 summarizes some of the preceding discussion, and shows the sources of national marriage

and divorce totals from 1867 to 1950.

27. For specific references to published reports of earlier surveys, see

‘‘Historical note on earlier studies’’ and footnotes in ‘‘Marriage and Divorce

Statistics: United States, 1946,’’ National Office of Vital Statistics, Vital

Statistics—Special Reports, vol. 27, No. 10, pp. 171, 172, 1947.

Table 1.05. Sources of Marriage and Divorce Totals:

United States, 1867–1950

Year Sources of marriage totals Sources of divorce totals1

1867–86 ...... Estimates published in 1947

by National Office of Vital

Statistics, from incomplete

data of survey by Comissioner

of Labor, published in 1889.

Figures collected (with

detailed data) by

Commissioner of Labor,

published in 1889.

1887–1906 .... Estimates published in 1947

by National Office of Vital

Statistics, from data of nearly

complete survey by Bureau of

the Census, published in

1908–1909.

Figures collected (with

detailed data) by Bureau of

the Census, published in

1908–1909.

1907–15 ...... Estimates published in 1928

by Bureau of the Census,

from records of selected

States.

(Same as marriage.)

1916 .......... Figures collected by Bureau

of the Census, published in

1919.

Figures collected (with

detailed data) by Bureau of

the Census, published in

1919.

1917–21 ...... Estimates published in 1928

by Bureau of the Census,

from the records of selected

States.

(Same as marriage.)

1922–32 ...... Figures collected each year

and published in annual

reports by Bureau of the

Census.

Figures collected (with

detailed data) each year and

published in annual reports by

Bureau of the Census.

1933–36 ...... Estimates by S. A. Stouffer

and L. M. Spencer (American

Journal of Sociology, January

1939).

(Same as marriage.)

1937–40 ...... Estimates published in 1942

by Bureau of the Census,

from nearly complete survey.

(Same as marriage.)

1941–43 ...... Estimates published in 1946

by National Office of Vital

Statistics, from records of

selected States.

(Same as marriage.)

1944–50 ...... Figures include estimates and

marriage licenses; published

annually by National Office of

Vital Statistics, from surveys

of States and of selected

counties.

Estimates published annually

by National Office of Vital

Statistics, from records of

selected States.

1Includes reported annulments.

Table 1.06. Year in Which the Central Filing of Marriage

and Divorce Records Began

Area

Marriage Divorce AreaMarriage Divorce

Alabama ............ 1908 1908 New Hampshire..... 1858 1881

Arizona. . . . . . . . . . . . . . – – New Jersey ......... 1848 1795

Arkansas............ 1917 1923 New Mexico......... – –

California............ 1905 – New York............ 1880 –

Colorado ............ – – North Carolina ...... – –

Connecticut ......... 1897 1947 North Dakota........ 1925 1949

Delaware............ 1913 1935 Ohio................. 1949 1949

Dist. of Columbia . . . 1811 1802 Oklahoma ........... – –

Florida .............. 1927 1927 Oregon.............. 1907 1925

Georgia ............. – – Pennsylvania........ 1906 1943

Idaho................ 1947 1947 Rhode Island........ 1852 –

Illinois ............... – – South Carolina ...... 1950 –

Indiana.............. – – South Dakota ....... 1905 1905

Iowa................. 1880 1914 Tennessee .......... 1945 1945

Kansas.............. 1913 – Texas ............... – –

Kentucky ............ – – Utah................. 1919 –

Louisiana1

........... 1937 1942 Vermont............. 1857 1896

Maine ............... 1892 1892 Virginia.............. 1853 1918

Maryland ............ 1914 1914 Washington ......... – –

Massachusetts ...... 1841 – West Virginia........ 1921 –

Michigan ............ 1867 1897 Wisconsin ........... 1907 1907

Minnesota........... – – Wyoming............ 1941 1941

Mississippi .......... 1926 1926

Missouri............. 1948 1948 Alaska............... 1913 1949

Hawaii............... 1896 –

Montana ............ 1943 1943 Puerto Rico ......... 1931 1931

Nebraska............ 1909 1909 Virgin Islands ....... – –

Nevada ............. – –

– Not in registration area.

1Not all parishes report.

60 Appendix II
Table 1.06 shows for each State the year in which

central filing of marriage and divorce records was

started.

Notifiable diseases

The collection of data on notifiable diseases by the

Public Health Service had its beginning nearly 75

years ago when, by an act of Congress in 1878, such

collection was authorized for use in connection with

quarantine measures against such pestilential diseases as cholera, smallpox, plague, and yellow fever.

One year later, a specific appropriation was made for

the collection and publication of reports of notifiable

diseases, principally from foreign ports. In 1893, an

act provided for the collection of information each

week from State and municipal authorities throughout

the United States. In order to secure uniformity in the

registration of morbidity statistics, Congress enacted a

law in 1902, which directed the Surgeon General of the

Public Health Service to provide forms for the collection, compilation, and publication of such data.

Reports on notifiable diseases were received from a

very few States and cities prior to 1900, but gradually

more and more States submitted monthly and annual

summaries. It was not until after 1925 that all States

reported regularly.

Until 1942, the collection, compilation, and publication of morbidity statistics was under the direction

of the Division of Sanitary Reports and Statistics of

the Public Health Service. These functions were transferred to the Division of Public Health Methods in

1942, and to the National Office of Vital Statistics in

1949.

Appendix II 61

The Vital Records and Statistics System

Records and statistics of vital events in the United

States flow from a coordinated system of separate

local, State, and Federal agencies, as shown in the

accompanying chart. Legal responsibilities for the registration and preservation of vital records are laid

upon private citizens and upon officials at all levels of

government. Responsibility for statistical services also

is laid by law upon agencies of government at all three

levels.

Nevertheless, the strength of the system lies in the

recognition by all its participants of their common

interests, and the ready cooperation that flows from

this understanding. Without it, the system would not

have attained its present degree of effectiveness. The

success of the record programs and the value of the

statistics depend upon the precision and consistency

with which the many operations are performed. While

the law provides essential authorization for the system, only clear comprehension and the will to strive

for the common ends can give it success.

The remainder of this chapter describes briefly the

organization and functions of the vital records and

statistics system.

Registration and Reporting Activities

Vital records and reports originate with private

citizens—members of the families affected by the events,

their physicians, funeral directors, clergymen, and

others. The responsibilities of these individuals are

defined in State laws, and penalties for noncompliance

are also provided by statute. The public’s understanding of the values of vital records is best evidenced by

the fact that State and local officials who administer

the State laws very seldom find it necessary to hale

offenders into the courts. The system draws millions of

reports from the population each year, while the enforcement cases are reckoned only in the dozens.

The following paragraphs describe the usual assignments of responsibility for furnishing facts on birth,

death, fetal death, marriage, and divorce registrations.

Registration of births

By law, the registration of births is the direct

responsibility of the professional attendant at birth,

generally a physician or midwife. In their absence, the

parents of the child are responsible for the report.

Each birth must be reported promptly—the reporting

requirements vary from State to State, ranging from

24 hours after the birth to as much as 10 days.

Certificates must be filed with the local registrar of the

district in which the birth occurs.

Registration of deaths

By law, the registration of deaths is the direct

responsibility of the funeral director, or person acting

as such. The funeral director obtains the data required

other than the cause of death. The person who supplies the information to the funeral director is usually

required to sign the certificate as informant to attest

to the truth of the facts entered. The physician in

attendance at the death is required to indicate the

cause of death. If no physician was in attendance, the

coroner, or person acting as such, is required to enter

the cause of death. Where death is from other than

natural causes, the coroner may be required to examine the body and report the cause of death, even

though a physician was in attendance.

In most States, a burial-transit permit must be

obtained from the local registrar of the district in

which the death occurred, before the body may be

removed from the district, buried, or otherwise disposed of.

Registration of fetal deaths

(stillbirths)

By law, the registration of fetal deaths (infants

born dead) is the direct responsibility of the funeral

director, or person acting as such. The funeral director

obtains the personal data required other than the

cause of fetal death. The person who supplies the data

to the funeral director is usually required to sign the

certificate as informant to attest to the truth of the

facts entered. Where a funeral director is not engaged,

the physician is urged, in behalf of improved fetal

death registration, to report the event to the local

registrar. The physician in attendance at the death is

required to certify the cause of fetal death. If no

physician was in attendance, the coroner, or person

acting as such, may be required to enter the cause of

fetal death. The coroner may be required to examine

the body and make the report where fetal death was

caused by other than natural cause.

A burial-transit permit must usually be obtained

from the local registrar of the district where the fetal

death occurred, before the body may be removed from

the district, cremated, or otherwise disposed of.

Appendix II 63
Registration of marriages and

divorces

In most States, marriage licenses are issued by

town or county clerks who obtain the personal particulars from the applicants and verify information from

the serological tests. After the marriage is performed,

the officiant (cleric or lay person) certifies to the facts

of the marriage, and sends the record to the official

who issued the license. In approximately three-fourths

of the States, there is now also some provision for the

local licensing official to send the original, a copy, or an

abstract of the completed marriage record to the State

registrar of vital statistics. In most States, original

divorce and annulment records are filed with the clerk

or other official of the court where the decree is

granted. Personal particulars are obtained by the clerks

from attorneys or petitioners. In approximately half of

the States, there is now also some provision for filing a

certificate or transcript abstracted from the record

with the State registrar.

Vital Statistics Organization

In local areas

Each State is divided into local registration districts for the purpose of collecting vital records. In

most cases, the extent of these districts is determined

by law. Originally, registration districts were very

small, frequently consisting of each city, village, town,

township, or road district. With increasing urbanization and improved transportation and communication

facilities, districts have been consolidated in some

States so that now the entire county comprises the

local registration district, while in others each city,

incorporated town, or other primary political unit (such

as township or civil district) still constitutes the local

registration district. The number of registration districts was reduced from close to 30,000 in 1940 to less

than 18,000 in 1950, and this trend still is in evidence.

A local registrar is appointed for each district and,

where necessary, he is assisted by a deputy local

registrar. Local registrars may be appointed or may

acquire the duties of registrar in conjunction with

legal appointment to civil positions. In some States,

the health officer of the county or large city is designated as the local registrar, and the registration of

births, deaths, and fetal deaths becomes a regular

function of the health department.

The local and county registrars are responsible for

the complete, accurate, and timely collection of vital

records. The Nation and the States rely on them for

the success of the system which can be no more

reliable than are the basic data collected. These registrars are the officials who develop and maintain working relationships with the physicians, midwives, funeral

directors, coroners, and other persons required by law

to prepare and file vital records.

The duties of the local registrar generally include

receiving and collecting records of all births, deaths,

and fetal deaths in his district; inspecting these certificates for completeness and accuracy; querying, correcting, and completing the inconsistent or missing items;

dating, signing, and numbering each record; issuing

burial-transit permits; maintaining a local copy, register, or index of the records; reporting infractions of the

registration law to county or State officials; promoting

registration reporting; and transmitting on a regular

schedule, to the local health unit or to the State

division of vital statistics, all original certificates

received, except where duplicate copies are transmitted and the original records are retained in permanent

files by the local offices. In some States, the local

registrar issues requested certified copies, for which a

fee is usually charged.

In some States, the office of the local registrar sends

notifications of birth registration to new parents, to be

retained if accurate or to be returned requesting correction if inaccurate; the office may also be responsible for

carrying out the preliminary review and abstracting of

delayed certificates of birth. In other States, both the

notification and delayed registration programs are

handled entirely by the State office.

For performance of the prescribed duties, the local

registrar usually is paid a fee by the county or State

for each certificate filed.

The more recent development of transmitting the

certificates first to the county health unit and then on

to the State office makes possible their use in current

planning, development, and appraisal of the local health

program in the many States where this procedure is in

practice. For example, death certificates may be examined to determine the causes of death and conditions

relating thereto. They may be compared with case records

to test the completeness of communicable disease reporting. The birth certificates, and certificates for infant and

maternal deaths, indicate the need for and initiate various phases of the local infant and maternal hygiene

program. Prompt and accurate information regarding

births and deaths becomes in this way a daily tool in the

work of an efficient local health organization.

Local registrars of vital statistics generally collect

marriage records only where, as in New England the

town clerks, or as in Illinois the county clerks, are

responsible for all nonjudicial records. Divorces and

annulments, of course, are recorded in the courts that

hear the suits.

64 Appendix II
In the States

The primary duties of the State vital records and

statistics office are the development and maintenance

of State and local procedures for the collection of vital

records, the enforcement of the law requiring that the

events be registered, and the production of State vital

statistics.

Vital records are permanently filed in vital statistics divisions of the State governments. In New

England, with the exception of Rhode Island, original

records are maintained in the local offices; but in these

States duplicate copies are maintained in State offices.

In addition, a few large cities have been constituted by

State law as independent registration areas which

maintain files of their own original records.

Certificates from all parts of the State are received

by the State office from the local registrars or county

health officers each month, on or before a date specified by law. As a part of the process of receiving,

completing, and filing them, the certificates are counted

and verified against the number reported to have been

sent. They are next examined for completeness, accuracy, and timeliness, and are credited to the account of

the appropriate local registrar. Monthly, quarterly,

semiannually, or annually, depending upon State practices, vouchers are prepared and transmitted either to

the State treasury or to the county commissioners or

supervisors who are obligated by law to pay the local

registrar. Special query forms or letters are sent to the

local registrar or attendant asking for additional or

clarifying information, if a certificate is deficient.

In nearly all States, some type of notification of

birth form is sent to new parents by either the State or

local registrar offices. About half of the State offices

issue birth notification forms furnished by the National

Office of Vital Statistics. Others have developed their

own State forms, and in a number of areas the local

office provides its own notification forms. Regardless of

the form used or the office issuing it, the practice has

been found to be useful both in improving the accuracy

of the information contained on the certificate and in

improving the completeness of birth registration. Experience has demonstrated that many parents read the

notification carefully, and if names are misspelled, or if

the date or the place of birth or other information is

incorrect, the parents correct the notification form and

return it for correction of the certificate.

Correction of vital records is one of the more

intricate tasks undertaken by State offices. Two distinct points of view regarding the alteration and correction of original certificates are reflected in differences

in the State procedures governing corrections. According to one view, the principal value of the certificate

lies in the fact that it is the original and that it has

remained unchanged throughout many years. According to the other view, held by the majority, a certificate

should be accurate; and if through no fault of the

individual concerned there are errors in it, it should be

amended upon the presentation of adequate evidence.

In those States where the former point of view dominates, the registrar is forbidden, by statute or regulation, to make any alteration on the face of the certificate

but he is authorized to file and certify affidavits and

other documents attesting to the inaccuracy of the

facts appearing on the face of the certificate. In States

where the primary emphasis is on accuracy, the registrar may correct the face of the original certificate

upon presentation of adequate documentary proof.

In all States, special consideration is given to

adoption, legitimation, and foundling cases. The

recent tendency among the States has been to make

legislative provision for new birth certificates in

these instances. The law specifies that the original

certificate in adoption cases shall be sealed with the

certified court order of adoption, while a new birth

certificate is prepared showing the adopting persons

as the parents.

Central vital statistics offices issue certified copies

of birth and death certificates to qualified persons on

request. In recent years, many States have developed

forms by which official agencies may obtain confidential verification of birth facts. Many States also use the

birth registration card or other type of short form

certification of birth facts which does not disclose

information concerning birth out of wedlock, adoption,

or medical data irrelevant to most certification purposes. A fee is usually charged for certifications and

birth cards and the vital statistics offices usually

maintain fee accounting systems, although most States

require that the revenues be paid into the State treasury. The number of certified copies issued by State

offices, although very large, is by no means a measure

of the total volume of documents sought and obtained

by individuals and agencies as evidence of the facts

concerning births and deaths. Many county and municipal officers also issue copies of vital records which

were filed with them prior to the establishment of

central registration or passed through their hands

before reaching State offices.

The task of registering births which were not

properly registered within the time prescribed by law,

has always been a part of the work of the State vital

statistics office. (The development of uniform procedures and standards for filing delayed registrations of

birth is referred to in the historical portion of the text

in this chapter.) Applicants are required to submit

documentary evidence sufficient to warrant the acceptance for filing of a delayed certificate. As indicated

elsewhere, some of the local registrars are authorized

to conduct preliminary review activities for delayed

registration of births, for submittal to the State office.

The State registrar is responsible for reviewing and

determining whether the evidence presented to the

Appendix II 65
State or local offices is acceptable. In addition, in a

number of States delayed registrations may be filed

through the local courts, Nebraska being the only

State in which the courts are required by law to

adhere to prescribed minimum standards of documentary evidence in accepting delayed registrations.

It is essential that certificates be located easily

and quickly, hence the value of an indexing system is

apparent. In past years, typical State indexes consisted of handwritten or typed entries of the necessary

identifying items for each certificate in ledgers or card

files. The present trend is to mechanical preparation of

indexes, although the States without tabulating equipment or those with a relatively small volume still

maintain card indexes. Regardless of the type, the

indexes are either alphabetic or phonetic and, in some

States, both systems are used. In the permanent files,

the certificates usually are arranged by county and

month of event, by surname, and in chronological

order. In most States they are bound, usually in books

of 500, either in sewed bindings or in some form of post

or staple binder.

State offices furnish forms and supplies to local

offices as prescribed by law, sponsor training meetings,

and provide instruction and advice for local registration officials.

Table 1.06 indicates the year in which the various

State offices first provided for centralized registration

of marriages and divorces. Where such centralized

files are maintained, the State registrar receives the

original, a copy, or a partial transcript of the marriage

record for marriages performed and some type of

transcript for each divorce granted. Offices having

central files of marriage and divorce records usually

maintain indexes for both types of records and tabulate and publish statistics in some degree of detail.

The procedures employed in processing statistics

vary in the different States, as do the resultant statistical services rendered. However, all States prepare

monthly, quarterly, annually, or biennially, reports based

on data drawn from the various types of certificates

filed. Thus, the information on the certificates is used

directly in planning, evaluating, and administering

health activities.

The State vital statistics offices send copies (transcripts, microfilm, or punched tabulating cards) of

each birth, death, and fetal death certificate to the

National Office of Vital Statistics of the U. S. Public

Health Service.

In the United States

The Department of Health, Education, and Welfare is the Federal agency responsible for publishing

national vital statistics, and for giving expression to

the national interest in vital records. The Department

has entrusted the management of its program to the

Public Health Service, because that constituent agency

has direct relations with the health agencies that

administer vital records and vital statistics operations

in the States. The National Office of Vital Statistics is

the arm of the Public Health Service that conducts the

Federal vital statistics program.

Publications of the National Office provide national

statistics of births, deaths, fetal deaths, marriages,

divorces, and notifiable diseases. All of these are derived

from the routine registrations and reports collected by

State and local governments. The data reach the Federal agency through cooperative arrangements with

the States. The most detailed of the national reports

are those relating to deaths, while the simplest are the

statistics of notifiable diseases, which consist mainly

of counts of reported cases. At present, the NOVS

obtains and publishes annual figures or estimates on

numbers of marriages and divorces occurring, together

with current monthly figures on numbers of marriage

licenses for the United States and divorces for a group

of States. In addition, beginning with data for 1948,

some tables of detailed marriage and divorce statistics

are published, not for the entire United States, but

only for those States in which the State vital statistics

office is able to furnish such tables. The number of

States able to supply these statistics and the amount

of obtainable information have increased gradually

from year to year.

The National Office provides services needed to

foster more complete and uniform registration throughout the Nation. Among these services are: assistance

in coordinating vital statistics activities of the various

State, city, and county health offices; promotion of

more complete registration; the conduct of educational

campaigns and tests for completeness of registration;

assistance to State officials in developing standard

forms, recommended legislation, standard definitions,

and statistical tables; assistance to State agencies of a

clearing-house nature; and development and promotion of methods for the collection and use of statistical

data.

The National Office of Vital Statistics is the focal

point of the vital records and statistics system. It

provides the nerve center through which conflicting

demands upon the system are compromised by interstate action of the responsible technicians. It provides

a channel for clarification and resolution of problems

in Federal-State relations. It also is the country’s

representative in the advancement of international

comparability in vital statistics, and the source to

which international agencies turn for United States

data.

66 Appendix II
For a list of reports published by the National Center for Health

Statistics contact:

Data Dissemination Branch

National Center for Health Statistics

Centers for Disease Control and Prevention

6525 Belcrest Road, Room 1064

Hyattsville, MD 20782

(301) 436–8500

Internet: http://www.cdc.gov/nchswww/nchshome.htm
DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

6525 Belcrest Road

Hyattsville, Maryland 20782

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