NATIONAL CENTER FOR HEALTH STATISTICS

Vital and Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

The U.S. National Vital Statistics 

System: Transitioning Into the 21st 

Century, 1990–2017

Programs and Collection Procedures

Series 1, Number 62 March 2018
Copyright information

All material appearing in this report is in the public domain and may be 

reproduced or copied without permission; citation as to source, however, is 

appreciated.

Suggested citation

Ventura SJ. The U.S. National Vital Statistics System: Transitioning into the 21st 

century, 1990–2017. National Center for Health Statistics. Vital Health Stat 1(62). 

2018.

Library of Congress Cataloging-in-Publication Data

Names: National Center for Health Statistics (U.S.), issuing body.

Title: The U.S. National Vital Statistics System : transitioning into the 

 21st century, 1990-2017.

Other titles: Vital and health statistics. Ser. 1, Programs and collection 

 procedures ; no. 62. | DHHS publication ; no. 2018-1338. 0276-4733

Description: Hyattsville, Maryland : U.S. Department of Health and Human 

 Services, Centers for Disease Control and Prevention, National Center for 

 Health Statistics, March 2018. | Series: Vital and health statistics, 

 series 1, program and collection procedures ; number 62 | Series: DHHS pub 

 ; number 2018-1338 | Includes bibliographical references.

Identifiers: LCCN 2018002222| ISBN 9780840606884 (pbk.) | ISBN 0840606885 

 (pbk.)

Subjects: | MESH: National Vital Statistics System (U.S.) | Vital Statistics 

 | Statistics as Topic--trends | Data Collection--methods | United States

Classification: LCC RA407.3 | NLM W2 A N148va no.62 2018

 | DDC 614.4/273--dc23 LC record available at https://lccn.loc.gov/2018002222

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Printed on acid-free paper.
Vital and Health Statistics

Series 1, Number 62

The U.S. National Vital Statistics 

System: Transitioning Into the 

21st Century, 1990–2017

Programs and Collection Procedures

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland 

March 2018 

DHHS Publication No. (PHS) 2018–1338
National Center for Health Statistics

Charles J. Rothwell, M.S., M.B.A., Director

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

Division of Vital Statistics

Delton Atkinson, M.P.H., M.P.H., P.M.P., Director

Hanyu Ni, Ph.D., M.P.H., Associate Director for Science
iii

Contents 

Preface v

Acknowledgments vi

Abstract 1

Introduction 1

1989 Revisions of the U.S. Standard Certificates and Reports and Evaluations of the Forms 2

Evaluation of the 1989 Certificates 2

Revision Recommendations for the 2003 Certificates 3

Evaluating and Testing the Proposed Revised Certificates and Associated Materials 3

Implementation of the 2003 Standard Certificates 4

Background 4

Budgetary and Implementation Challenges 5

Challenges in Implementing the 2003 Revisions 6

Consequences of These Challenges 6

Delay in Approval to Use the New Data Items on Certificates 9

Ongoing Challenges to the Vital Statistics Cooperative Program 9

Reengineering the National Vital Statistics System 10

The Concept of MoVERS 10

Reengineering of Internal Processing Systems 11

Coding Cause of Death for Mortality 11

International Classification of Diseases (ICD) 11

Mortality Coding System 12

Evaluation of Iris Proprietary Software 12

Transmitting Vital Statistics Data From the States to NCHS 12

Improving Timeliness of Birth and Death Statistical Data With “Preliminary” Releases 13

Using Technology to Improve Timeliness of Vital Statistics Data, Especially Mortality 14

Mortality Surveillance Facilitates Continued Improvement in Timeliness 15

Evaluating and Improving Birth Data Quality 15

Evaluation of Worksheets and Comparison With Hospital Birth Records Data 15

Improvements in the Measurement of Gestational Age 16

Birth Data Quality Workgroup 16

Other Initiatives to Enhance Vital Statistics Data Quality 18

Micro-data Files: Data Dissemination Tools and Strategies 18

Content and Availability of Vital Statistics Data 18

Data Sets 19

New Strategies to Enhance Availability and Utility of Vital Statistics Data Sets 22

Vital Statistics Rapid Release Program Showcased in New Online Releases 22

Data Visualization Gallery 22

Other Data Access Tools 22

Publication of Tabulated and Descriptive Analytic Reports 23
iv

Transitioning Vital Statistics From a “Good” to a “Great” System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Implementing a Cooperative Agreement with NAPHSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Implementing a Federal–State Good to Great Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Development of the 2012–2016 Contract for the Vital Statistics Cooperative Program . . . . . . . . . . . . . . . . . . . . . . 24

Workforce Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Other Initiatives Focused on Improving Vital Statistics Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Envisioning the Future of Vital Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Table. Vital statistics history timeline, 1940–2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Appendix I. Initial Decisions in the Mid-1990s to Address Resource Limitations in the National Vital 

Statistics System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Items Dropped From Data Sets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Collection of Abortion, Marriage, and Divorce Data Ended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Appendix II. Mortality Medical Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Appendix III. International Classification of Diseases (ICD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Appendix IV. Collaborative Efforts Based on Real-time Mortality Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Appendix V. Items Deleted From the National Fetal Death Data Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Appendix VI. Followback Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Appendix VII. Effort by National Academies to Generate Attention to Current and Emerging

Uses of Vital Statistics Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Appendix Tables

I. Revision status of each jurisdiction according to when they implemented the revised birth certificate. . . . . . . . . . . . 49

II. Revision status of each jurisdiction according to when they implemented the revised death certificate . . . . . . . . . . . 50

III. Revision status of each jurisdiction according to when they implemented the revised fetal death report . . . . . . . . . . 51

IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised. . . . . . . . . . . . . . . . . . . . . . . . 52

V. Items included on the U.S. Standard Certificate of Death, by year revised.. . . . . . . . . . . . . . . . . . . . . . . . . . 60

VI. Items included on the U.S. Standard Report of Fetal Death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . 64

Appendix Figures 

I. Implementation of the 2003 revised birth certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

II. Implementation of the 2003 revised death certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

III. State and Territorial Exchange of Vital Events (STEVE) certifications, updated March 2018 . . . . . . . . . . . . . . . . 72

IV. Electronic death registration processing status, updated February 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

V. Electronic birth registration status, updated February 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Page v 

Preface

The National Vital Statistics System 

(NVSS) is a decentralized, cooperative 

system comprised of 57 registration 

areas (i.e., the 50 states, the District 

of Columbia, New York City, and five 

territories: Puerto Rico, the Virgin 

Islands, Guam, American Samoa, and 

the Commonwealth of the Northern 

Marianas). Overall coordination and 

guidance for NVSS is provided by the 

National Center for Health Statistics 

(NCHS) and its predecessor agencies. 

The system is an indispensable 

component of the U.S. public health 

system and has been since the beginning 

of the 20th century. Having detailed data 

for every one of the nearly 4 million 

births and 2.5 million deaths annually 

in the United States makes it possible 

to track indicators of health status for 

the population at the national, state, 

and local levels, including disparities 

by age, sex, race and ethnicity, and 

detailed geography. Infant mortality, 

access to prenatal care, maternal risk 

factors and pregnancy history, teen birth 

rates, changes in causes of death and 

rankings of causes, and life expectancy 

patterns are among the key indicators 

available from vital statistics. The data 

are invaluable for identifying populations 

at risk, program planning, and developing 

initiatives to target health disparities, to 

name a few. Identifying rare causes of 

death and the disparate impact of health 

conditions on mothers and decedents is 

also possible with vital statistics data. 

These data are also foundational for 

developing population estimates and 

projections for the country, for states, and 

for local areas. NVSS has been described 

in detail elsewhere (1–4). Uniformity 

and standardization of national statistics 

have been achieved through a number 

of mechanisms, including definitions 

and reporting requirements, and 

recommended laws and regulations (e.g., 

the Model State Vital Statistics Act and 

Regulations). The standard certificates 

have been the principal means of 

achieving uniformity in the information 

to be collected and on which national 

statistics are based.

The Vital Statistics Cooperative 

Program (VSCP) has been the foundation 

for the federal–state partnership in 

producing vital statistics since 1973 (1). 

NCHS has engaged in contracts with the 

jurisdictions to obtain, through funding 

support, individual record data for 

births, deaths (demographic and medical 

information), and fetal deaths. The 

contract for the last half of the 1990s was 

the first to set the stage for automation, 

improved timeliness, and the innovative 

data products described in this report.

Until the mid-1990s, records for 

marriages, divorces, and abortions were 

also included in VSCP. The reporting 

areas for these events, however, never 

included all states and registration areas.

The purpose of this report is to 

update the previous histories, published 

first in 1954 and then in 1997 (1,2). The 

developments and changes over the past 

two decades have been extraordinary 

and far-reaching. While some of the 

broad outlines of these activities were 

envisioned back in the mid-1990s, 

the full scope and breadth were not 

anticipated. The history during this 

recent period encompassed changes 

and challenges in a vast array of areas, 

and many were occurring concurrently 

on different tracks. Thus, this report is 

organized more by general topic area and, 

within topics, chronologically. To aid the 

reader in reviewing and interpreting the 

recent history, this report is accompanied 

by a timeline (Table). The timeline lists 

important activities and milestones 

in all aspects of the history of NVSS 

and related programs chronologically, 

beginning in the mid-20th century to 

provide greater context. Readers can 

refer to significant milestones in the 

timeline and then to the report for more 

details. For the early decades, additional 

information is available elsewhere (1,2). 

Readers can also use the timeline to gain 

a greater understanding of how various 

events and activities intersected and 

overlapped. Additional background and 

context are provided in Appendices I–VII

and in supporting Appendix Tables I–VI

and Appendix Figures I–V.

Although not strictly part of NVSS, 

two programs, the National Survey of 

Family Growth and the natality and 

mortality followback surveys, are also 

discussed briefly in this report. Both 

programs have provided important 

information that has augmented NVSS.

This report is based on extensive 

interviews with colleagues in NCHS’ 

Division of Vital Statistics (DVS) (the 

organizational unit within NCHS where 

NVSS is housed) and retired DVS and 

NCHS staff, whose names are listed 

in the Acknowledgments, as well as 

published and unpublished materials from 

NCHS and other sources. These sources 

are included in the reference section of 

the report. It is expected that the report 

will be useful to a wide audience in the 

public health, public policy, and research 

communities seeking to understand 

how the country’s vital statistics system 

has evolved in the last quarter century 

and how the information collected 

and disseminated in the system can be 

interpreted and analyzed. In addition, it 

is anticipated that the report will provide 

important context and background for 

current NVSS program staff and for staff 

who join the NVSS program in future 

years, as well as for state colleagues.
vi

Acknowledgments

The author is very grateful to Charles 

Rothwell, Director of the National 

Center for Health Statistics (NCHS) 

and Delton Atkinson, Director of the 

Division of Vital Statistics (DVS) in 

NCHS, for sharing their vision for this 

report and encouraging the preparation 

of the report. They wanted to have a 

record of the numerous, far-reaching, 

and extensive changes that have occurred 

in the National Vital Statistics Program 

overall and in DVS over the last 25 or 

more years. The author also gratefully 

acknowledges the helpful and thoughtful 

comments and suggestions on the 

manuscript by Charles Rothwell, Delton 

Atkinson, and NCHS Associate Director 

for Science, Jennifer Madans, and for 

the generous assistance with manuscript 

preparation provided by Hanyu Ni, 

Associate Director for Science, DVS.

NCHS Director Rothwell and DVS 

Director Atkinson enthusiastically 

supported the project and the 

participation of current and former 

NCHS staff to share their expertise. 

Many persons within DVS contributed 

to the preparation of this report and to 

documenting the events and decisions 

made over the years since 1990. The 

manuscript was based in part on 

extensive interviews with current and 

former NCHS staff over several months 

as well as historical materials that they 

provided. Specific acknowledgment 

is made to the following contributors 

who assisted in various ways, including 

generously sharing their time and 

expertise or carefully reviewing the 

manuscript: Farida Ahmad, Robert 

Anderson, Elizabeth Arias, Delton 

Atkinson, Robert Bilgrad, Amy Branum, 

Anjani Chandra, Mary Anne Freedman, 

George Gay, Elizabeth Wilson Gregory, 

Bonita Gross, Brady Hamilton, Donna 

Hoyert, Lillian Ingster, Robert Israel, 

Chrissy Jarman, David Johnson, David 

Justice, Hetty Khan, Karen Knight, 

Kenneth Kochanek, Julia Kowaleski, 

Li (Leo) Lu, Jennifer Madans, Joyce 

Martin, Hanyu Ni, Michelle Osterman, 

Charles Rothwell, Charles Sirc, Steven 

Steimel, Paul Sutton, George Tolson, 

Rajesh Virkar, James Weed, and Michelle 

Williamson. In addition, appreciation is 

extended to Raquel Brown and Andrea 

Price, staff members with the National 

Association for Public Health Statistics 

and Information Systems (NAPHSIS), 

who assisted with jurisdiction-specific 

information. Graphics were prepared 

by Donna Hoyert, Chrissy Jarman, and 

Michelle Osterman. Tables were prepared 

by George Tolson. The manuscript was 

edited by Jen Hurlburt and typesetting 

was done by Ebony Davis.
Page 1 

Introduction

When the last report on the vital 

statistics system was published in 1997 

(1), the National Center for Health 

Statistics (NCHS) and the states were 

on the cusp of revolutionary, though 

not yet fully understood, changes in 

the reporting, collection, analysis, and 

dissemination of vital statistics data. 

Electronic registration was already 

underway for births and in the very 

early stages for deaths. Almost 70% 

of births from more than one-half of 

the states that had or were developing 

and implementing electronic birth 

registration systems (EBRS) were 

registered electronically in 1995 (1). Pilot 

studies were underway for electronic 

death registration systems (EDRS), 

which were slower to develop. Death 

registration is more complicated because 

data are reported from multiple sources 

(i.e., funeral directors, physicians, and 

coroners or medical examiners). The 

main underlying principle for electronic 

systems for vital records is that records 

should be created, edited, coded, 

queried, and corrected at the source. 

These standards turned out to be guiding 

principles for the 2003 revisions of the 

U.S. Standard Certificates and Reports 

that were in the early planning stages in 

the late 1990s.

Concurrent with this transformation 

though was the realization that the 

basic vital registration systems still in 

widespread use were based on outmoded 

registration practices and structures, so 

that even with the transition, at least 

for births to EBRS, the underlying 

systems and processes were antiquated 

and were inconsistent with goals of 

improved data quality and timeliness, 

and efforts to facilitate real-time data 

linkage capabilities. For example, 

early EBRS had limited capability for 

interactive edits. Data transmitted were 

initially submitted from “standalone” 

systems in hospitals and the data 

essentially had to be accepted and used 

“as is.” Hospitals updated their EBRS 

individually. Thus, the data collected 

were not necessarily comparable across 

hospitals. Subsequently, the electronic 

systems transitioned to being web-based. 

Within a jurisdiction, then, hospitals were 

accessing the same version of the EBRS 

software. Thus, software problems had 

widespread consequences. The early 

promise of electronic systems continued 

to be largely unmet. These underlying 

challenges were summarized by NCHS 

Director Charles Rothwell (formerly 

Director of the Division of Vital 

Statistics) in his 2004 essay explaining 

the issues and suggesting strategies to 

address the problems (5). This essay 

makes it clear that although nearly a 

decade had already passed since these 

issues initially received focused attention, 

and some progress had been achieved, 

major challenges in systems, culture, and 

funding persisted. Examples of progress 

include the development of functional 

requirements for reengineered birth 

and death registration and the growth 

of collaborations among a number of 

organizations working on these issues 

(e.g., Model Vital Events Registration 

System [MoVERS]; see section later 

in this report). This situation was the 

impetus for the National Academies’ 

Committee on National Statistics to 

convene a workshop on Vital Data 

for National Needs in 2008 (4). This 

workshop is discussed in Appendix VII.

The U.S. National Vital Statistics 

System: Transitioning Into the 

21st Century, 1990–2017

by Stephanie J. Ventura, M.A.

Objectives

This report describes the history of 

the National Vital Statistics System, 

with a focus on the period 1990–2017. 

The vital statistics system is the 

country’s most enduring program of 

data collection on the health of the 

population. It is based on information 

reported on the certificates of births 

and deaths and reports of fetal 

deaths, collected in each of the states 

and independent registration areas. 

Over the last two decades, the vital 

statistics system has experienced 

far-reaching changes, and has shifted 

in important ways to emphasize data 

quality, timeliness, and analysis. The 

changes underlying these areas are 

described.

Methods

This report is based on extensive 

interviews with current and former 

staff of the National Center for Health 

Statistics’ (NCHS) Division of Vital 

Statistics, the organizational unit that 

houses the National Vital Statistics 

System. The report also includes 

information collected in numerous 

published and unpublished materials 

from NCHS and other sources. 

To aid the reader in reviewing and 

interpreting the recent history, this 

report is accompanied by a timeline. 

The timeline lists, chronologically, 

important activities and milestones 

in all aspects of the history of the 

National Vital Statistics System and 

related programs, beginning mid-20th 

century, to provide greater context.

Conclusions

The National Vital Statistics 

System has experienced 

extraordinary and far-reaching 

changes since the early- to mid1990s. Data content, timeliness, and 

quality have improved significantly 

and these changes have enhanced 

the value of vital records for 

describing and documenting the 

health of the country’s population.

Keywords: birth and death 

certificates • fetal death reports •

reengineering vital statistics •

revisions of standard certificates •

analysis of vital statistics data •

Vital Statistics Cooperative Program

Abstract
Page 2  Series 1, No. 62

As indicated, this period importantly 

coincided with a shift in focus to 

data quality, with the goal that the 

data produced be based on nationally 

comparable collection systems, but 

concerns about timeliness were ongoing 

and persistent. Three inextricably linked 

issues in particular challenged the 

National Vital Statistics System (NVSS) 

during this period: a) ensuring that data 

were nationally comparable, b) focusing 

on data quality, and c) improving data 

timeliness. The data quality concerns, 

initially raised in 1954 (1), were 

especially prominent for the medical and 

health data and reflected a strong belief 

that birth and death registration data 

are crucial components, even building 

blocks, of public health information 

systems and could be used to provide 

essential health statistics for all levels of 

government, institutions, and the public. 

While the system was referred to as a 

national vital statistics system, it was 

widely understood that vital statistics 

were essentially health statistics.

1989 Revisions of 

the U.S. Standard 

Certificates and 

Reports and 

Evaluations of the 

Forms

The 1989 revisions of the birth 

certificate and fetal death report 

represented the first serious foray into 

reporting increased medical and health 

information (6). The use of checkboxes 

was promoted as a way to improve the 

uniformity and comparability, and thus 

the quality, of the data. Prior revisions of 

the certificates included items with openended response options, making it almost 

impossible to compile uniform and 

comparable data. However, soon after the 

1989 revisions were implemented, quality 

concerns abounded: The checkboxes 

were said to be too vague and imprecise, 

not well-defined, and not uniformly 

reported (3,7–14). Further, some items 

were deemed inappropriate for collection 

on the certificates (e.g., alcohol use 

on the birth certificate and fetal death 

report were considered problematic 

because of the stigma associated with this 

substance) (3). To sum up, the mid-1990s 

marked a period when NCHS and the 

registration areas were acknowledging 

and responding to the inadequacies of 

their systems to meet the timeliness and 

quality challenges of these systems; were 

exploring and developing electronic vital 

registration systems; and were identifying 

strategies to meet the demands for 

high-quality, reliable, consistent, 

comparable, and timely vital statistics 

data for important public health and 

public policy needs. The challenges and 

the responses developed to address them 

are detailed in the next sections.

Evaluation of the 1989 

Certificates

Consistent with previous revisions, 

the first steps taken in exploring revisions 

of the standard certificates for the 1990s 

and forward were to evaluate the 1989 

revisions, including their effectiveness, 

and from that launching pad, to examine 

how the certificates and the processes 

could be improved. These evaluations 

were inaugurated with a planning phase 

that began in 1994 and continued through 

the rest of the 1990s. The overarching 

activities were facilitated under the Panel 

to Evaluate the (1989) U.S. Standard 

Certificates (3). NCHS provided resource 

support and coordination, and state vital 

registration executives and medical 

and health experts provided Panel 

leadership. The 1989 revision-based 

evaluations began with surveys of state 

registrars and vital statistics executives 

on their views on items to keep and 

items to discard, and items that their 

jurisdictions recommended adding to the 

U.S. standard certificates. At the early 

stages, in 1998, the decision was made 

to evaluate (i.e., revise) only the birth 

and death certificates and the fetal death 

report; it was decided that the marriage 

and divorce certificates and the induced 

termination of pregnancy report should 

not be revised (see later sections in this 

report, Appendix I, and reference 3). It 

was further agreed that the results of the 

revision process would be implemented 

after International Classification of 

Diseases (ICD–10) coding had begun for 

deaths (in 1999) (15) and any problems 

associated with the millennium transition 

to the year 2000 (known as Y2K) 

that could affect dates and other legal 

elements had been addressed (3). Largely 

because of these factors, although it 

was initially hoped that the evaluation 

activity would result in revisions taking 

effect in the late 1990s, the revision 

activity actually culminated in standard 

certificates that were adopted in 2003 as 

described in this report.

The evaluation objectives and the 

evaluation criteria are reprinted here from 

the Panel Report (3):

Evaluation objectives:

● Review the current certificates, 

prepare a report to assess the 

usefulness of the existing data items, 

and determine how the quality of the 

data can be improved and collected 

for statistical and legal purposes;

● Identify unmet data needs and 

determine if the standard certificates 

are the most appropriate place to 

collect such data. This included 

attempting to identify future data 

needs for the next 15–20 years; and

● Make recommendations for the 

content, format, and standard 

definitions of the proposed standard 

certificates. This task was to be 

accomplished with the understanding 

that a “certificate” is no longer 

represented by the piece of paper on 

which the data are collected, but by 

a standard vital statistics database 

with a strong emphasis on electronic, 

automated data collection.

Evaluation criteria for review of existing 

and new items included:

● Is the item needed for legal, research, 

statistical, or public health programs?

● Is the item collectible with 

reasonable completeness and 

accuracy?

● Is the vital statistics system the best 

source for this information?

The Panel’s work to evaluate the 

1989 certificates continued through 

the 1990s until mid-2000. The Panel’s 
Series 1, No. 62  Page 3 

deliberations are described in detail 

elsewhere (3).

Revision Recommendations 

for the 2003 Certificates

The changes in certificates between 

1989 and 2003 were substantial, far 

exceeding those for previous revisions. 

Major changes included the addition of 

a number of items to the birth certificate 

(16), namely maternal morbidity; 

mother’s height and prepregnancy 

weight; women, infants, and children 

(WIC) food program participation; 

principal source of payment for the 

delivery; infections present; breastfeeding 

status; and whether the infant was living 

at the time of discharge from the birth 

facility. The Panel also recommended 

other substantive changes to the existing 

medical and health information. These 

included enhancements to the smoking 

questions, to capture smoking and 

quitting by trimester, for example, and 

some item deletions. In addition, the 

Panel recommended new and modified 

items along with the addition of specific 

items to facilitate data linkages (e.g., 

infant deaths and multiple births) and 

new sections for “administrative use” to 

fulfill statutory registration mandates. 

Further, the Panel recommended for the 

birth certificate and fetal death report, the 

development of standardized worksheets 

for the mother and hospital staff that 

would include “clear, unambiguous 

questions, definitions, instructions, and 

preferred data sources,” all designed to 

improve data quality and completeness 

and comparability across population 

groups. For the fetal death report (17), the 

focus was on significantly revising the 

cause of fetal death section. Applicable 

changes from the birth certificate were 

also integrated into the fetal death 

report. A new item on place of delivery 

was added. In addition, the Panel 

recommended that the standardized 

worksheets be tested and modified as 

needed.

For the death certificate (18), the 

Panel recommended the addition of some 

items focused on meeting public health 

information needs, facilitating ICD–10 

coding, and improving the quality of 

cause-of-death data. These included 

questions on the relationship between 

tobacco use, pregnancy, and traffic factors 

and the cause of death. The instructions 

for the physician and funeral director 

were improved, with detachable pages 

added to the certificate.

For both certificates and the fetal 

death report, the Panel recommended 

that the items on parents’ or decedent’s 

education and race and Hispanic 

origin be revised to match the new 

data collection method adopted for the 

census for this information (3). These 

specific recommendations significantly 

affected the implementation of the 

revised certificates and report, as will be 

discussed later in this report.

For the birth and death certificates 

and fetal death report, the Panel was 

unequivocal in stating that “States 

and NCHS must advocate the use of 

automated, electronic collection of data, 

which enables detailed instructions, 

help screens, and real-time edit 

checking.” This would be crucial for 

the development of the electronic 

birth and death registration systems. 

Through contracts with experienced 

state and national experts, the NVSS 

program oversaw the production of 

detailed editing specifications, which 

are available on the NCHS website 

(19–21). The conceptual framework and 

informational bases for these guidelines 

were the “Specifications for Collecting 

and Editing the United States Standard 

Certificates of Birth and Death–2003 

Revision” (22), and the “Guide to 

Completing the Facility Worksheet for 

the Certificate of Live Birth and Report 

of Fetal Death” (revised and updated in 

2016) (23). A key motivation of the Panel 

for recommending the development of 

the specifications was the finding of the 

”Working Group to Improve the Quality 

of Birth Data” in 1998, which concluded 

that vital statistics birth data quality had 

declined in the 1990s “associated in 

part with electronic registration of vital 

events” (22,24).

Concomitant with the Panel’s 

recommendations on the content of 

the certificates and on the “automated, 

electronic collection of data,” the Panel 

gave great attention to how to design the 

documents. There was still a focus on 

the documents as paper records, but also 

on how the documents would be used 

for electronic registration. During this 

period, vital statistics advances for births, 

deaths, and fetal deaths intersected with 

a growing vision for the development 

of sophisticated and flexible electronic 

processes. The Panel envisioned the 

revised certificates and report as being 

essential components of the country’s 

public health infrastructure.

Evaluating and Testing 

the Proposed Revised 

Certificates and Associated 

Materials

During the Panel’s deliberations, 

there was broad agreement that the 

Panel’s recommendations should be 

tested and evaluated to validate the 

proposed data collection systems and 

the data themselves. The Panel was 

recommending sweeping changes in 

all aspects of vital statistics registration 

processes, and it was crucial that they 

meet the identified needs for vital 

statistics-based health data. As part of 

the process to ensure the validity of the 

output from the new electronic systems 

using these editing specifications, NCHS 

contracted in 2002 to develop a “test 

deck” to review the electronic output 

from the 2003 revised birth registration 

system and ensure that the systems 

were operating as intended. A number 

of states used the test deck to validate 

their systems. A similar test deck was 

developed to assess the operation of 

the 2003 revised death registration 

system. The instructions for using the 

test decks and the populated test decks 

(subsequently updated during the 

2000s) are available by request from 

NCHS’ Division of Vital Statistics 

(DVS) (25,26). The test decks can be 

a useful tool for registration areas to 

use when they make further changes in 

their systems, in order to ensure that the 

modified systems are still operating as 

envisioned. 

Importantly, the Panel also 

recommended testing the certificates and 

worksheets before they were released to 
Page 4  Series 1, No. 62

the states. NCHS carried out this testing 

for the birth data during April 25, 2000 

through May 5, 2000, under the auspices 

of its Questionnaire Design Research 

Laboratory (QDRL), and the results 

guided some minor modifications in the 

documents (3). The QDRL report is also 

available by request from DVS (27). 

Testing of the revised death certificate 

included two components. For the funeral 

directors, there were three focus groups 

conducted at a national funeral directors 

meeting, with a total of 23 participants. 

Staff from the Center for Health Policy 

Studies (CHPS) led the group meetings; 

NCHS staff also attended. A separate 

focus group was coordinated by the 

Maryland State Funeral Directors’ 

Association. Testing the revised death 

certificate among certifiers (that is, 

physicians, coroners, etc.) was more 

challenging because of difficulties 

in scheduling; a smaller focus group 

participated. Input was also provided by 

the Maryland Medical Society’s Public 

Health Council as well as the Council 

of State and Territorial Epidemiologists 

(28–30).

NCHS obtained feedback on the 

draft revised U.S. Standard Report of 

Fetal Death at the Society for MaternalFetal Medicine Annual Meeting in Miami 

Beach, Fla. in February 2000 (31). A total 

of 20 physicians participated and shared 

their viewpoints on the revised fetal death 

report relative to their experiences in 12 

states. CHPS conducted this focus group, 

and it was also attended by NCHS staff 

members. The facility worksheet was 

also tested (32). NCHS staff members 

also attended a meeting of the Maryland 

Obstetrics and Gynecology Society's 

Executive Committee in May 2000 where 

additional comments were provided 

by seven physicians (both clinicians 

and academics) (33). The initiatives 

described here reflected NCHS’ and the 

jurisdictions’ shared interest in pursuing 

a strong focus on the quality of vital 

records statistical data.

Implementation of 

the 2003 Standard 

Certificates

Background

For the 11 previous revisions of the 

U.S. standard certificate of live birth, 

10 revisions of the death certificate, 

and 7 revisions of the fetal death report, 

the revised forms were implemented 

essentially simultaneously with the 

effective date of the revised forms. 

Thus, for example, nearly every state 

implemented the 1989 revisions in 

1989 following the recommendation 

of NCHS to the state vital statistics 

executives. The 2003 revisions required 

additional steps for full implementation. 

The process involved input, review, and 

concurrence from more federal officials, 

including all the component agencies 

within the Department of Health and 

Human Services (HHS). When all parties 

concurred on the content of the reporting 

forms, the HHS Secretary would be asked 

to recommend that all jurisdictions adopt 

the revisions. 

The Panel’s plans in the final 

stages of its deliberations had been 

for the revisions of the U.S. Standard 

Certificates of Birth and Death and the 

Report of Fetal Death to take effect at 

the beginning of 2002. However, the 

HHS Secretary recommended, after 

an extensive public comment period, 

that the revised certificates, report, and 

the accompanying worksheets; item 

specifications; and other instructions be 

submitted to the states for adoption in 

November 2003 (34). It was clearly too 

late for most states to manage an effective 

date of January 2003, even if they had 

not faced other challenges. Of course, all 

of the jurisdictions were already familiar 

with the revision process that was 

winding up as well as the content of the 

revised forms. Some health departments 

acknowledged the need to fundamentally 

reengineer their registration processes 

and had been seeking resources within 

their jurisdictions, so that both certificate 

implementation and reengineering could 

proceed simultaneously. 

The resource needs, however, were 

much larger than anticipated, more than 

available to most jurisdictions. Only two 

states, Pennsylvania and Washington, 

implemented the birth certificate revision 

in January 2003; five jurisdictions 

implemented the revised death certificate: 

California, Idaho, Montana, New York, 

and New York City; and two (Michigan 

and Washington) implemented the 2003 

revised fetal death report (Tables I–III

and Figures I and II). Subsequent sections 

of this report address the significant and 

unforeseen delays in implementation 

and the multiple activities undertaken 

to facilitate the adoption of the standard 

certificates and report and accompanying 

documentation by all jurisdictions. These 

challenges resulted in an unprecedented 

delay of 13 to 14 years in full 

implementation of the revised certificates 

and report by all jurisdictions.

As noted above, concurrent with the 

initial efforts to implement the revised 

standard birth and death certificates 

and report of fetal death, there was a 

recognition and acceptance that the 

existing systems within the states’ 

vital records agencies were developed 

for paper-based processes that were 

outmoded but that continued to exist 

through legacy processing systems. There 

were two major obstacles to modifying 

these legacy systems. First, system 

changes were difficult, if not impossible, 

to make in the existing environment. 

States and federal partners were not fully 

fluent in technology issues, reflecting 

confusion about systems differences, 

which reflected differences in processing 

activities across states, as opposed to old 

business practices, which largely relied 

on paper-based registration, and some 

states were resistant and reluctant to give 

up these practices. Local registration 

was also a factor; in many jurisdictions, 

the registration of vital events was led 

by local registrars who transmitted 

records to the state authorities. This chain 

of multiple participants exacerbated 

the challenges. Even when there was 

an understanding that changes were 

needed, some states were trying to 

develop their new electronic systems 

to exactly replicate the existing paperbased processes. In other words, the 
Series 1, No. 62  Page 5 

concept that the recommended revisions 

represented extensive and extraordinary 

changes to the essential processes 

as well as to the content of the vital 

event registration forms was not fully 

acknowledged by all of the parties in the 

process. This was an issue especially for 

the mortality reporting systems, where 

EDRS were at the very earliest stages of 

development. Within the relatively few 

states where EDRS had been adopted, 

electronic death registration was not 

universal. Even for birth registration 

where there were models of effective 

electronic birth registration, there was 

resistance to new technology. 

The second equally important major 

obstacle was lack of funding at both the 

federal and state levels for the necessary 

reengineering and implementation of 

the 2003 revisions. The costs of these 

activities were not fully understood, but 

it was widely acknowledged that the 

costs would be substantial and extensive. 

Further, the 9/11 terrorism attack had just 

occurred and in addition to the terrible 

tragedy of the actual events, federal and 

state budgets were significantly strained 

as government authorities struggled 

to implement specific responses to the 

terrorism (described later in this report) 

(35). The next sections of the report deal 

first with the underlying and overarching 

budgetary and implementation challenges 

and their consequences and then with 

the initiatives that NCHS undertook, 

usually with partners such as the National 

Association for Public Health Statistics 

and Information Systems (NAPHSIS) 

and the Social Security Administration 

(SSA), to address the challenges of the 

revision and the need to reengineer state 

and federal data collection and processing 

systems. NAPHSIS is the organization 

that represents the 57 U.S. vital records 

jurisdictions (50 states, 5 territories, New 

York City, and Washington, D.C.).

Budgetary and 

Implementation Challenges

The resource challenges facing 

NCHS and the states through most of the 

2000s had actually begun in the 1990s. 

Over many decades, NCHS and the 

states or jurisdictions were partners in 

collecting, compiling, and disseminating 

vital statistics data. The vital statistics 

system is state (jurisdiction)-based. It 

relies on the collection of vital event 

information at the state level, with states 

having the legal authority to register vital 

events. The production of national vital 

statistics files requires the collaboration 

of NCHS and the state vital statistics 

executives. A complex formula that 

attempted to value the contribution of 

the jurisdictions to the National Vital 

Statistics System and to determine the 

appropriate contribution of NCHS to 

the states for the statistical data was 

developed and revised over the years. 

A “cost formula” committee comprised 

of NCHS staff and state vital statistics 

executives negotiated this arrangement 

over the years, in a sense independently 

of the NCHS budget. Once agreed 

upon, the NCHS–state cost-sharing was 

integrated into the NCHS budget. The 

challenge here was that NCHS’ budget 

was flat through much of the decade and, 

in some years, it was reduced. In practice, 

this meant that NCHS’ commitment to 

the states, as managed through the Vital 

Statistics Cooperative Program (VSCP), 

was difficult to maintain. Funding was 

typically not available for a full data 

year, meaning that NCHS was only 

able to support the jurisdictional vital 

statistics activities and data collection for 

portions of a data year, with the balance 

of the data year paid for through funds 

from the following fiscal year’s budget. 

This funding issue created significant 

instability both for the jurisdictions and 

NCHS (4).

First steps taken to address 

funding shortfalls

By the mid-1990s, it was necessary 

for NCHS to identify areas to cut in the 

vital statistics contracts to meet urgent 

resource shortfalls. As the funding 

situation worsened, NCHS’ ability to 

produce and disseminate national data 

sets for births, deaths, and fetal deaths 

as well as for marriages, divorces, and 

induced terminations of pregnancy 

(abortions) was severely compromised 

(4,36). The cuts that were made are 

described in detail in Appendix I and 

elsewhere (36) and are summarized here. 

Because the formulation for the VSCP 

contracts was item- and data set-specific, 

cutting items and entire data sets could 

and did lead to specific tangible savings, 

regardless of any judgment on the merit 

or lack of merit of specific cuts.

Initially, NCHS dropped some 

items from the birth and death data 

sets, including for births, the date of the 

mother’s previous live birth (dropped 

in 1994) and the 1-minute Apgar score 

(dropped in 1995). Similarly, NCHS 

discontinued the collection of the 

father’s educational attainment in 1995. 

These items were not reinstated until 

the content of the 2003 revision of the 

birth certificate was fully incorporated 

in NCHS’ birth data sets in 2009 (37). 

Information on autopsy was dropped 

from the death certificate but was later 

restored when the 2003 revision of the 

death certificate went into effect (4). 

Further, occupation and industry of the 

decedent were eliminated as reportable 

items on the death certificate. 

To meet its contractual obligations 

to states, NCHS discontinued altogether 

the collection of individual record data on 

induced terminations of pregnancy (that 

is, abortions) in 1994 (the last data year 

collected was 1992, but data sets were not 

processed for any year after 1988) (4,38). 

NCHS funding constraints also led to 

the discontinuation of the collection 

of individual record data for marriages 

and divorces after 1995 (39), and the 

last reports on these data sets published 

by NCHS were for the 1989 and 1990 

data years (40,41). These decisions were 

made to meet NCHS’ priorities within the 

National Vital Statistics System for birth, 

death, and fetal death data. Additionally, 

at the time of these decisions, the 

reporting areas for marriages, divorces, 

and abortions were not national. The 

decisions and the deliberations behind the 

cuts in these programs, as well as NCHS’ 

current reporting of marriage and divorce 

counts and the availability of other 

information on abortions, are described 

in detail in Appendix I and elsewhere 

(36,38–50).
Page 6  Series 1, No. 62

Challenges in 

Implementing the 2003 

Revisions 

Previous revisions of the U.S. 

Standard Certificates were implemented 

with relatively little difficulty and on a 

timely basis. The state-based systems 

were paper-based. Until the 1989 

revision, the items were relatively 

straightforward and clear. The systems 

for collecting the data and producing 

statistical files were uncomplicated. 

With the 2003 revision, everything 

was more complex. Concurrent with 

the revisions, states were engaged to 

the extent possible in implementing 

EBRS and to a much lesser extent, 

EDRS. The urgency of these efforts 

reflected the fact that in some states, the 

(legacy) registration systems they had 

been using were no longer reliable even 

for the 1989 certificate revisions. In 

other words, completely apart from the 

challenges of adopting the new content 

of the 2003 revisions, the 2003 revision 

was the first that required the updates 

to or a replacement for data collection 

software, or in some cases the initial 

implementation of such software. These 

activities would require substantial 

resources. Further, disentangling these 

two issues (i.e., electronic registration 

systems demands and the enlarged 

content of the standard certificates) was 

essentially not possible. NCHS’ resource 

constraints during this period limited its 

ability to provide tangible support to the 

states to develop modernized electronic 

systems, including developing EDRS or 

completing the EBRS work 

(Figures IV and V). Further, no support 

was available from NCHS to the states to 

implement the 2003 revisions. The states 

were experiencing their own funding 

shortfalls as well, thus exacerbating 

the impact of financial limitations on 

NVSS. With previous revisions of the 

standard certificates and reports, NCHS 

assisted the states in various ways with 

implementing the certificates, and the 

adoption of the certificates was almost 

uniformly carried out in the revision year 

or within a few years thereafter. The 2003 

revision implementation was completely 

different. NCHS lacked the authority and 

was therefore not in a position to direct 

the states to implement immediately or by 

a fixed date. Instead, states were advised 

that they should implement the revised 

certificates as soon as they could. NCHS’ 

Director sent a letter dated December 24, 

2003, to the state registration executives, 

in which he specifically addressed the 

implementation timing, as follows: 

“Rather than expecting that all states 

will implement the revised certificates 

at the same time, as has been the case 

with previous revisions, we believe 

we can be more efficient and effective 

by focusing our limited resources on 

a linked reengineering and certificate 

implementation. Thus, implementation 

will be phased in state-by-state over the 

next several years. We expect that this 

process will be completed within five 

years” (51). This delayed implementation 

differed considerably from the typical 

1- or 2-year implementation for previous

revisions.

Only a handful of states revised in 

the early years, including a number of 

states that had anticipated early on the 

resource requirements and were able to 

secure funding within their state budgets 

for both revising their certificates and 

transitioning to modernized electronic 

systems. As noted, Pennsylvania and 

Washington were the first to implement 

the revised birth certificate in January 

2003. After that, implementation 

proceeded slowly. For example, within 2 

years, by January 1, 2005, an additional 

10 states revised the birth certificate, 

with the revised states accounting for 

31% of U.S. births (52). The situation 

was comparable for the death certificate: 

California and Idaho were the first 

to revise their death certificates as of 

January 1, 2003, and by January 1, 2005, 

an additional 15 states were using the 

revised death certificate, accounting 

altogether for 39% of U.S. deaths in that 

year (53). However, further complicating 

matters for NVSS was that the states 

revising their death certificates were not 

the same as the ones revising their birth 

certificates. Only Washington revised its 

fetal death report by January 1, 2003. By 

January 1, 2005, 11 states were using the 

2003 revision of the fetal death report 

and these states accounted for about 

15% of U.S. fetal deaths (54). A final 

complication in the timing was that for 

some states the official implementation of 

their revised certificate occurred during 

the course of a calendar year (i.e., after 

January 1). Revised items for these states 

could not be included in the NCHS data 

sets until the following calendar year. 

Details of the revision implementation 

dates are shown in Tables I–III and 

are illustrated for births and deaths in 

Figures I and II.

Consequences of These 

Challenges

Processing vital statistics data 

sets since 2003

As just described, the phased 

implementation of the 2003 revisions 

of the birth and death certificate and 

fetal death report had major negative 

consequences for the production of 

NCHS’ annual statistical files. The files 

were submitted to NCHS in a variety of 

formats that were internally inconsistent 

and incompatible across and, in some 

cases, within jurisdictions. The reporting 

of one crucial item changed for births, 

deaths, and fetal deaths and this impacted 

file production and analysis of all the 

data: The race(s) of the mother and 

father and of the decedent were collected 

and processed differently on the 1989 

and 2003 revisions (see next section). 

In addition to the varying file formats, 

there were a number of additional key 

items on the birth certificate that were 

reported in different, noncomparable 

ways on the 1989 and 2003 revisions. 

These items included timing of prenatal 

care, educational attainment of the 

mother (and the father), mother’s 

smoking status during pregnancy, 

and details of the method of delivery 

(e.g., primary cesarean). Because 

the questions on the 1989 and 2003 

revisions were substantively different, 

data from revised and unrevised states 

were presented in separate file locations 

during processing; the data could not be 

combined to produce national estimates 

for these measures or combined on 
Series 1, No. 62  Page 7 

the data files (55). Further, some items 

had different response categories in the 

1989 and 2003 revisions, thus requiring 

separate file locations for the data. 

Finally, the 2003 revision included 

some completely new items, presenting 

data on certain topics for the very first 

time, including payment source for the 

delivery, use of infertility treatment, and 

maternal morbidity.

In the case of fetal death data, 

the processing of the data sets was 

complicated from the earliest years of 

the revision. Files for 2003–2006 were 

produced with revised and unrevised data 

items. As was the case for the birth data, 

questions on prenatal care and mother’s 

educational attainment, among other 

items, were reported in substantively 

different ways on the 1989 and 2003 fetal 

death reports, precluding the production 

of national estimates for these measures.

The fetal death data files began to 

be significantly delayed beginning with 

the 2007 data year because of NCHS’ 

ongoing resource constraints and the 

decision to focus primarily on improving 

the production and timeliness of the 

birth and death statistical files. During 

this period, the NVSS program decided 

that in order to produce and release the 

fetal death data sets, substantial cuts in 

the data elements would be necessary. 

All noncomparable data items were 

removed from the files for 2007–2012, 

resulting in an approximately 50% 

reduction in the file sizes. This made 

it possible to release files for these 6 

data years during the period September 

2013 through April 2014. The files 

were essentially comprised of basic 

demographic elements, including 

parents’ ages, birth order, plurality, sex, 

and mother’s race and Hispanic origin 

and marital status. Some risk factors 

comparable across revisions were 

retained along with method of delivery. 

The revised items have been included 

in the internal database, but are not 

currently reviewed for data quality and 

they are not included in the “in-house” 

or public-use files. In mid-2015, NCHS 

implemented the recommendations of 

the joint NCHS–NAPHSIS Birth Data 

Quality Workgroup, which recommended 

a number of cuts to both the national fetal 

death file and the birth file (56). These 

cuts are described in detail in the section 

on the Birth Data Quality Workgroup 

later in this report and in Appendix V.

In the case of death data, the 

questions on educational attainment 

on the 1989 and 2003 revisions were 

substantively different, as noted 

above, so that data from revised and 

unrevised states could not be combined 

to produce national estimates for this 

measure. Information on new items 

such as pregnancy status, tobacco use 

contributing to death, and decedent’s 

role in transport injury events became 

available in a staggered way. In addition, 

items that were not new but were newly 

requested to be sent to NCHS, such 

as method of disposition, frequently 

were not sent to NCHS until the state 

adopted the standard certificate, so 

that information was not available 

nationwide. Since additional detail was 

not consistently available, for example on 

detailed place of birth, limited values for 

foreign-born decedents were retained in 

some geography fields (57). 

As indicated above, the challenges 

created for file production had significant 

consequences for these data sets, 

especially for the analysis of national 

trends and variations in a wide array of 

crucial public health and reproductive 

health topics. It was not possible to 

describe or interpret, for example, 

current patterns in such traditional items 

as prenatal care use, gestational age, or 

tobacco use by such key demographic 

descriptors as educational attainment or 

race. The available data were not national 

and neither the revised nor the unrevised 

data could be generalized to the United 

States. The statistical files for births were 

most severely impacted, with significant 

consequences on analysis of the data. 

The difficulties were exacerbated because 

of large numbers of data fields and 

records (nearly 4 million annually). Just 

as problematic, the use of key birth data 

for evaluating state-specific progress 

in such areas as reducing preterm 

birth, maternal tobacco use, and racial 

disparities was compromised because 

states were reporting the information in 

noncomparable ways. By the completion 

of this report, all jurisdictions except 

American Samoa were submitting revised 

birth data and all but two territories (U.S. 

Virgin Islands and American Samoa) 

were submitting revised death certificate 

data (Figures I and II). Connecticut, 

American Samoa, and the Virgin Islands 

have not yet submitted revised fetal death 

data.

Race and ethnicity

The reporting of race and Hispanic 

origin on the birth and death certificates 

and fetal death report changed 

significantly between the 1989 and 

2003 revisions. In 1997, the Office of 

Management and Budget (OMB) issued 

the “Revisions to the Standards for the 

Classification of Federal Data on Race 

and Ethnicity,” which replaced the 1977 

standards then in effect (58). The 1997 

standards increased the minimum set 

of race categories to be used by federal 

agencies from four to five and also 

required federal data collection programs 

to allow respondents to select one or 

more race categories in a question that 

provided 15 specific checkboxes and 3 

write-in lines. The U.S. Census Bureau 

implemented these changes effective with 

the 2000 census and continued them, with 

minor modifications, in the 2010 census 

(59). In response to the OMB directive, 

the 2003 standard certificates and report 

include items on race and ethnicity that 

match the Census Bureau items based on 

the 1997 standards.

During the interim period while the 

revised certificates were being phased in, 

it was necessary to “bridge” the responses 

of mothers and fathers who reported 

more than one race and decedents for 

whom more than one race was reported, 

to a single-race category so that data 

from states with revised and unrevised 

race data could be combined. In turn, to 

compute population-based rates, it was 

necessary to develop a set of “bridgedrace” population estimates, which are 

the denominators for the rates. Race 

bridging refers to making data collected 

using one set of race categories consistent 

with data collected using a different set 

of race categories, to permit estimation 

and comparison of race-specific 

statistics at one point in time or over 

time. More specifically, race bridging 
Page 8  Series 1, No. 62

is a method used to make multiple-race 

and single-race data collection systems 

sufficiently comparable to permit 

estimation and analysis of race-specific 

statistics.

To produce the numerators for 

birth and death rates, NCHS developed 

a computer system to code and edit 

reported data so that the multiple-race 

data could be processed uniformly 

across the jurisdictions. Additionally, 

the system “bridges” the multiple-race 

data into the four single-race categories 

of the previous (1977) OMB standards. 

Thus, multiple race is imputed to a 

single race (American Indian or Alaska 

Native, Asian or Pacific Islander, black, 

or white) according to the combination 

of races, Hispanic origin, sex, and age 

of the mother or father indicated on the 

birth certificate or the decedent indicated 

on the death certificate. The imputation 

procedure is described in detail elsewhere 

(60). NCHS staff process and impute 

multiple-race entries, and the NCHS 

codes are returned to the jurisdictions 

so that the state-produced data files are 

compatible with those generated by 

NCHS (60,61). 

As noted, the Census Bureau 

inaugurated the collection of multiplerace population data with the 2000 

census. To produce population-based 

rates during the interim period, the 

Census Bureau, in collaboration with 

NCHS analysts, has provided special 

“bridged-race” population estimates 

with race categories that are consistent 

with the 1977 OMB standards to NCHS. 

Multiple-race population estimates have 

been bridged to single-race categories 

for comparability with birth and death 

data. The population estimates result 

from bridging the 31 race categories 

used in Census 2000 and Census 2010, 

as specified in the 1997 OMB standards 

for the collection of data on race and 

ethnicity, to the four race categories 

specified in the 1977 OMB standards. 

The bridging procedures are described 

in detail in a special report (62) and the 

bridged-race population estimates are 

available (63). In brief, the estimates 

were developed by using data from the 

pooled 1997–2000 National Health 

Interview Surveys (NHIS) conducted 

by NCHS. NHIS has allowed survey 

respondents to enter one or more races 

as applicable for themselves, and if 

more than one race is reported, the 

respondent is asked to indicate his or 

her primary race (62). About 1% of 

the nearly 400,000 respondents in the 

1997–2000 NHIS samples reported 

more than one race and a primary race. 

These data were used to develop models 

to bridge the 2000 census multiplerace data to single-race categories. The 

bridging models included demographic 

and contextual covariates, some at the 

individual level and some at the county 

level. Allocation probabilities were 

obtained from the regression models and 

applied to the Census Bureau’s April 1, 

2000, Modified Race Data Summary File 

population counts to assign multiplerace persons to single-race categories 

(62). NVSS program statisticians have 

analyzed the impact of these changes 

on population-based rates for births 

and deaths as well as the impact of the 

revisions of all population estimates for 

the 1990s, after the 2000 census (64–66). 

It is important to note that the processes 

for imputing multiple-race data for vital 

records (that is, birth and death numerator 

data) and the population denominator 

data needed for computing populationbased rates are very similar. They differ 

mainly due to the nature of the data. The 

same probabilities or percentages and 

algorithms are used for both components.

An additional complication during 

this period for the data on race and 

ethnicity was that some states adopted 

the new guidelines for reporting this 

information before they implemented the 

revised certificates. In other words, the 

“revised” reporting areas for each vital 

record were different for the states using 

the full 2003 revisions and the states that 

incorporated only the revised reporting 

of race and ethnicity. In addition, some 

states implemented the revised reporting 

of race and Hispanic origin after January 

1 of a calendar year, thus delaying 

the availability of their data until the 

following calendar year. 

As of the 2016 data year, all states 

and the District of Columbia reported 

multiple race on birth certificates (67). 

Multiple race was reported on the death 

certificates of 49 states and the District 

of Columbia, representing 99% of U.S. 

deaths (68). Despite the option to report 

multiple races, it is still relatively rare 

for multiple races to be reported on the 

birth and death certificates. In the states 

reporting this information in 2016, 2.4% 

of births were to mothers reporting more 

than one race and 0.4% of deaths were 

of decedents for whom more than one 

race was reported (67–68). For the 2016 

data year, NCHS population-based birth 

and death rates by race will transition to 

the revised standard reporting categories; 

rates using bridged-race categories will 

also be available to enable data users to 

assess the impact of the transition.

Geographic coding of vital 

events

One of the most valued attributes of 

NVSS is that researchers, policy makers, 

public health officials, and others are 

able to analyze geographic patterns in 

health, because individual record data are 

uniquely available at the state and county 

level. This makes it possible to track 

patterns and differences in trends in a 

wide array of important health measures 

for specific geographic entities. This can 

then assist jurisdictions in developing 

strategies to address particular public 

health challenges, including, for 

example, disparities in low birthweight 

and infant mortality, in deaths due to 

cardiac conditions or cancer, and deaths 

associated with environmental issues, 

to name but a few. All states use the 

geographic coding manuals prepared 

by NCHS that are based on information 

provided by the Census Bureau. It should 

be noted that data are available as well 

for cities and towns and comparable 

geographic entities, but the data at 

this level of detail are often affected 

by misreporting and other data quality 

issues. This issue is discussed in the 

concluding section of the report. At the 

time of this writing, the 2014 Geographic 

Coding Manual is in use. New manuals 

are typically issued about 4 years after 

the conclusion of a decennial census. 

While the geographic coding manuals 

are revised periodically, sometimes 

using new geographic coding systems, 

the updates have typically not affected 
Series 1, No. 62  Page 9 

the utility and comparability (across 

states and over time) of the geographic 

information. More information about 

the geographic coding of vital events is 

available elsewhere (69).

Implications of the increase in 

the size of data files on analytic 

uses of vital statistics

The need to incorporate separate 

fields for revised and unrevised data had 

important implications for producing 

data files. These requirements included 

accounting for noncomparable birth, 

death, and fetal death data items and 

differences in reporting race and Hispanic 

ethnicity and educational attainment 

as well as new data items. The record 

lengths for the natality and mortality 

data files increased significantly: The 

size of the birth file expanded by greater 

than 4-fold, from a record length of 

350 fields or positions before the 2003 

revision to a record length of 1,500 fields. 

The mortality data file was affected as 

well, although the file size increase was 

smaller: about 10% for the public-use 

file, with a much larger increase for the 

historical (“in-house”) file that includes 

multiple-race reporting.

The detailed race and ethnicity 

codes for revised states alone added 

significantly to the size of the in-house 

historical files from which the 

public-use files are created (67,68,70). 

The complexity of analyzing the files 

grew exponentially. The resource 

requirements for producing these 

statistical files contributed significantly 

to the deterioration in timeliness of 

data availability during the first decade 

of the 2000s, which has reversed only 

recently. See section below on Microdata Files: Data Dissemination Tools and 

Strategies. At the time of this writing, 

national statistics are available for the 

2016 data year for the birth data items 

mentioned earlier (e.g., prenatal care and 

educational attainment) and for the new 

items on the revised birth certificate. 

Data on cause of death for fetal deaths 

are still not available for all jurisdictions. 

As of this writing, American Samoa 

and the Virgin Islands have not revised 

their death certificates, and Connecticut, 

American Samoa, and the Virgin Islands 

have not revised their fetal death reports 

(Tables I–III and Figures I and II).

To sum up, the implementation of 

the 2003 revisions of the birth and death 

certificates and the fetal death report 

extended more than a dozen years beyond 

the official revision date. Truly national 

data sets were not available during these 

years for researchers, public and health 

policy analysts, and others. The public 

health and public policy utility of these 

data will be greatly enhanced when 

all of the states have adopted the 2003 

revisions.

Delay in Approval to Use 

the New Data Items on 

Certificates

Further compromising the 

availability of new data (especially 

new birth data) during the 2000s when 

implementation of the revised certificates 

was being phased in, was the fact that 

NAPHSIS, the organization of state 

registration executives, had voted in 

2005 to withhold permission from NCHS 

to include the new data items in their 

national data sets (71). The new data 

items are those that are exclusive to 

the 2003 revision of the U.S. Standard 

Certificate of Live Birth. They differ 

from items on the 1989 revision that 

were modified for 2003 to improve data 

quality. The view of the executives was 

that NCHS’ level of support at the time 

did not include support for collecting 

new data items. Thus, the NAPHSIS 

membership voted that NCHS could 

not release the data in statistical files 

and that any NCHS use of the new 

data was restricted to assessing and 

validating the quality of the new data. A 

subsequent NAPHSIS motion stipulated 

that a collaborative research agreement 

be developed “governing analysis, 

dissemination and publication of [the] 

new data items” and that NAPHSIS 

members would “participate fully in 

planning for the analysis of the data;...

have access to data...to conduct analyses 

independently or jointly with NCHS;” 

and “...in conjunction with NCHS 

will develop plans for dissemination 

and fully participate in the preparation 

of all reports and manuscripts” (72). 

While the effect of these motions on 

data availability was most severe for 

the birth data, there were also negative 

consequences for mortality data. 

Examples of new birth data items that 

NCHS could not publish or disseminate 

included smoking in the trimester before 

pregnancy, mother’s height (needed 

with prepregnancy weight and weight 

at delivery to calculate body mass 

index), mother’s receipt of WIC food, 

source of payment for the delivery, and 

maternal morbidity, among other items. 

Death certificate items that NCHS could 

not publish or disseminate included 

pregnancy status for female decedents, 

tobacco use contributing to death, and 

decedent’s role in transport injury events. 

While this was clearly not the intent, the 

decisions incorporated in the resolutions 

had the effect at the time of diminishing 

possible interest in and use of the new 

data items, making it difficult for NCHS 

to “market” the new certificate content. 

Further, the states that had not yet 

revised could see that their delay was 

not affecting the national data sets, since 

NCHS could not publish the new data 

in any case. In 2013, NCHS was given 

permission to disseminate the new data 

items beginning retroactively with the 

2009 data year (37).

Ongoing Challenges to the 

Vital Statistics Cooperative 

Program

During the mid- to late-2000s, 

additional challenges appeared to slow 

and complicate the efforts to include the 

new and revised NCHS data, especially 

for births, in the NCHS public-use 

data sets. Funding issues worsened 

significantly during these years such 

that funds were not adequate to support 

the states in collecting either the basic 

vital statistics data or the new data. The 

existing VSCP contract through which 

states’ data were obtained for NVSS 

included no initiatives to address this 

longstanding problem. The states were 

provided cost-of-living adjustments only 

but no additional funds for the new data 

items. In an effort to reduce the costs of 

VSCP through which the states provided 

data to NCHS, proposals were developed 
Page 10  Series 1, No. 62

to trim the size of the data sets. At the 

time, this appeared to be the only feasible 

option for retaining the basic NVSS 

(4). The idea was to identify “core” and 

“enhanced” data items for births, deaths, 

and fetal deaths. NCHS would commit 

to funding the “core” data items in the 

state VSCP contracts and would seek 

out alternative funding sources to fund 

the “enhanced” data items. This plan, 

which was not implemented, generated 

a great deal of concern among a wide 

range of interested parties. State vital 

statistics offices were concerned about 

whether they could withstand the cut in 

VSCP funding. NCHS staff members 

were concerned that items not included 

in the “core” data sets would lessen in 

quality, and there was even concern that 

these items could be lost indefinitely or 

even permanently. Further, the reliance 

on alternative funding sources would 

jeopardize the availability and stability of 

the “enhanced” data items as components 

of crucial public health data. Public 

policy and research interests were also 

concerned that the promise of the new 

and revised data items would not be 

met, possibly ever. Also in the works 

at the time was a change in contracting 

between NCHS and the states, to a 

system whereby each state would need 

to negotiate individually. For decades 

up to the present, NAPHSIS and its 

predecessor organizations represented 

the states in contract negotiations with 

NCHS, so the prospect of each state 

having to bid and compete for its own 

contract was quite unsettling to all. How 

NCHS and the jurisdictions confronted 

and started to overcome these challenges 

is described in detail in “Transitioning 

Vital Statistics From a ‘Good’ to a ‘Great’ 

System.”

Reengineering 

the National Vital 

Statistics System

The Concept of MoVERS

The Model Vital Events Registration 

System (MoVERS) is the name given to 

the initiative (2001–2003) to reengineer 

the country’s vital statistics system to 

address the acknowledged needs of 

supplying accurate and standardized 

vital event information that is complete, 

continuous, and easily accessible to 

government agencies and individuals. 

The challenges of the vital statistics 

system include, most importantly, that 

the registration of vital events, including 

births, deaths, and fetal deaths, is a state 

function. The decentralized system, 

then, is administered by a varying range 

of jurisdictional laws and rules. While 

being responsive to underlying statespecific issues, this decentralized system 

complicates the process for producing 

national data sets that are timely and of 

high quality (73,74). Reengineering the 

country’s vital statistics systems was 

intended to address these challenges 

and needs as well as to respond to the 

growing demands for improved vital 

statistics data and functions, including 

all phases of birth and death registration. 

A crucial underpinning for the MoVERS 

activity was broad acceptance by all 

partners that the 2003 revisions of the 

vital records were the essential core of 

the data systems being reengineered. The 

MoVERS project was a collaboration of 

NCHS, NAPHSIS, and SSA. Its intended 

products included the development of 

national standards and protocols, webbased technology, automation at the 

source, and implementation of the revised 

Standard Certificates of Live Birth and 

Death and the Report of Fetal Death 

and the NCHS edit specifications for 

electronic systems. 

The overall goals of the MoVERS 

initiative were ambitious. The first 

phase focused on the development 

of system functionality requirements 

for registering vital events. These 

requirements were attained through 

multiple Joint Application Development 

sessions, which showcased how 

“the deployment of MoVERS can 

significantly improve data quality, 

efficiently manage registration methods, 

preserve documents, and distribute 

information through automating vital 

event management, utilizing a web-based 

system” (73). The MoVERS concept as 

envisioned at the outset was to be able 

to define the requirements and use cases 

for a typical state organization that would 

meet about 80% of each state’s needs. 

NCHS believed that the states and federal 

sources could develop a generic system. 

In this scenario, each state’s unique needs 

could be taken care of by the state. 

The underlying concepts for 

MoVERS were more fully articulated 

by state vital statistics executives, 

NCHS, and NAPHSIS in discussions 

in 2002 proposing a model electronic 

vital statistics system (75). The model 

or base system, known as the Model 

Electronic Vital Statistics System, would 

incorporate the business functions and 

requirements that are common to all 

registration areas, as noted, for about 

70%–80% of vital statistics office 

activities. When completed, the base 

system would “consist of modular, 

off-the-shelf components that could 

be used, in part or as a whole, by any 

registration area. However, such a system 

could be modified or customized to meet 

individual registration area needs.” The 

system as envisioned would be flexible 

and easily modified, with no ongoing or 

periodic needs for future major overhauls 

(75). These principles were critical and 

essential for the project to succeed. The 

development of the generic system did 

not happen because of lack of funds, 

but the MoVERS project did develop 

the functional requirements for births, 

and SSA funded the development of 

functional requirements for deaths. 

The high-level discussions that NCHS 

facilitated and largely funded at the time 

helped to inform activities ongoing in 

the states and among software vendors 

to reengineer their registration systems. 

Further, there were some successes in 

efforts to obtain funding to develop 

and implement new systems. Over the 

years, for example, SSA contributed 

substantially to the development of 

reengineered systems in a number of 

jurisdictions for the registration of deaths, 

starting initially with New York City and 

the District of Columbia, and continuing 

to support EDRS now in 48 jurisdictions 

(Figure IV) (76,77). However, these 

activities and efforts were not integrated 

into a unified plan. Unfortunately, the 

development of a generic system for 

registering births, deaths, and fetal deaths 
Series 1, No. 62  Page 11 

did not materialize, and states proceeded 

to invest, on an individual basis and at 

higher cost, in the enhancement of their 

existing systems to meet the requirements 

of electronic registration systems. This 

outcome contributed importantly to the 

ensuing challenges and delays in fully 

implementing the revised certificates 

and integrating them with reengineered 

electronic systems. 

Reengineering of Internal 

Processing Systems

Integrated National Vital 

Statistics System

Much of the narrative thus far 

has focused on the 2003 revisions of 

the U.S. Standard Certificates and 

on the inadequacies of the existing 

legacy infrastructure within the state 

vital registration programs that led to 

challenges implementing modernized 

systems and data collection instruments. 

Concurrent with these ongoing challenges 

was a growing challenge within NCHS 

in the collection, evaluation, processing, 

and production of the national birth, 

death, and fetal death data sets. These 

difficulties were embedded in the 

existing NCHS systems, in particular 

in the mainframe system for managing 

files. As CDC moved to close down its 

mainframe, NCHS needed to reengineer 

its mainframe systems for processing 

and analyzing files. This changing 

computing environment led to substantial 

automation throughout the NVSS 

program. Reengineering the National 

Vital Statistics System, known as the 

reengineered National Vital Statistics 

System (reNVSS), was focused on 

significantly increasing the efficiency 

and timeliness of vital statistics through 

improvements in acquisition, evaluation, 

and analysis of the data. Receipt and 

control processes were automated at the 

initial stages, with reports automatically 

produced for the NVSS staff and 

the jurisdictions, replacing previous 

cumbersome manual processes. 

The new approach has allowed for 

more effective and substantive interaction 

between NCHS and the states as they 

worked together to improve data quality 

and timeliness. Production has been 

automated through the development of 

a relational database and “analytic or 

summary data cubes” that enable analysts 

to produce tables with frequencies for 

year-to-year comparisons. The “cubes” 

are refreshed twice each day, making the 

data readily available for NVSS program 

staff to share findings with the states for 

immediate action. In sum, reengineering 

of the data receipt and evaluation 

processes freed up time for NCHS 

analysts to interact more frequently and 

effectively with jurisdiction colleagues 

on substantive data quality and timeliness 

issues, and to do so on a real-time basis 

so that issues could be readily resolved. 

During this period, NCHS assumed 

responsibility for the coding of cause 

of death for all deaths registered in the 

United States and returning the coded 

information back to the states. This 

change is discussed in the section below 

on Coding Cause of Death for Mortality.

Processing and file production 

also changed substantively within the 

NVSS program units. The idea was 

to modernize the systems with new 

tools and more flexibility, to remove 

existing bottlenecks, and to eliminate 

information and processing “silos” that 

were impeding work at all stages. In 

addition to improving the efficiency 

and effectiveness of the work of the 

NVSS information technology staff, 

the reengineering effort also included 

new options for more responsive 

analytic capability for the subject-matter 

statistical staff members, including, 

for example, “analytic cubes” for the 

birth and death statistical files. This 

represented an all-new effort previously 

not a part of the processes in the NVSS 

program. In developing the new systems, 

a key element to ensure “best practices” 

was that the processing and files be fully 

reproducible and that any differences be 

readily documented and addressed. In 

recounting this period, it is important to 

recall that the reengineering efforts were 

additionally complicated by the phased 

implementation of the 2003 revisions of 

the birth and death certificates and fetal 

death report. File management efforts 

were revised for each of the statistical 

files, including births and fetal deaths 

(both revised and unrevised data), deaths 

(demographic data in both revised and 

unrevised data, and medical), and the 

National Death Index (NDI). During this 

period beginning in 2007 and extending 

through 2014, important gains were made 

in file creation, especially in improving 

the timeliness of the birth and death files, 

which accompanied improvements in the 

analytic capabilities of the files. 

The changes described here in 

internal processing systems were 

accompanied recently by a reorganization 

within NCHS’ NVSS program that 

included: improved business practices 

to take better advantage of technology 

and maximize efficiency, improved 

communications within the NVSS 

program and with state partners, and 

effective initiatives to improve data 

timeliness and availability (78). Later 

sections of this report highlight the 

impressive array of activities, including 

descriptive and analytic reports, birth 

data quality studies, a new automated 

mortality medical coding system, new IT 

and communication initiatives, expansion 

of mortality surveillance activities and 

many others; these activities are ongoing 

concurrently with the push toward faster 

and more efficient file and report releases.

Coding Cause of Death 

for Mortality

International Classification 

of Diseases (ICD) 

ICD is used to classify causes of 

death for statistical purposes. ICD is 

maintained collaboratively by the World 

Health Organization (WHO) and 21 

international collaborating centers, 1 of 

which is the WHO Collaborating Center 

for the Classification of Diseases in North 

America. Currently cause of death is 

being coded using ICD–10, which was 

implemented in the United States in 1999 

(15). Although ICD had previously been 

revised about every 10 years, the last 

two revisions have been in effect much 

longer. ICD provides the basic ground 

rules used to code and classify causes of 

death, to identify the underlying cause 
Page 12 Series 1, No. 62

of death, and to compensate for certifier 

errors in the cause of death statement, all 

of which are crucial functions. The 

revision process, concurrent efforts 

to describe and identify resultant 

discontinuities in data, and plans for 

an upcoming revision are described in 

Appendix III and elsewhere (79,80).

Mortality Coding System

While efforts to fully implement 

EDRS for all deaths across all 

jurisdictions have been underway 

since 1994, the Mortality Medical 

Data System (MMDS) has been in 

development for one-half of a century. 

MMDS includes several components, all 

different, which in combination are 

focused on the development of automated 

entry, classification, and retrieval of 

cause-of-death information reported on 

death certificates (1,81). MMDS was 

launched in 1968 with the Automated 

Classification of Medical Entities 

(ACME), which was designed to select 

the underlying cause of death according to 

ICD rules, replacing manual selection by 

nosologists (mortality medical coders). 

Other software was subsequently 

developed to provide automated input to 

ACME and is described in 

Appendix II. Use of the Mortality 

Medical Indexing, Classification, and 

Retrieval System software, known as 

MICAR and Super-MICAR, grew quickly 

in the 1990s, from about 5% of U.S. death

records in 1990 using MICAR to 88% in

1993, and to 70% in 1993 using SuperMICAR (82). As of 2003, all death

records have been processed using SuperMICAR as well as all components of

MMDS. Automated coding has important

advantages over manual coding. ICD

coding and selection rules can be

consistently applied, so data are more

comparable both within the United States

and internationally. Nevertheless, manual

coding remains necessary for about 20%

of death records that cannot be coded

automatically and are rejected by MMDS

because of incomplete information

provided for cause of death or other

factors.

Beginning with the 2011 data year, 

NCHS has been coding cause of death 

for all records. The decision to assume 

this responsibility was announced in 

2010 at the annual joint meeting of the 

VSCP project officers and NAPHSIS 

members (83). This effort was undertaken 

as the number of trained nosologists 

diminished and, in some jurisdictions, 

reached zero. NCHS now receives death 

records in electronic format where they 

are processed through the automated 

coding systems. If records are rejected, 

NCHS nosologists manually code the 

information. NCHS returns the coded 

information to the jurisdictions for their 

own use. Some jurisdictions still code 

cause of death as well, but all of the 

national statistics published by NCHS are 

based on NCHS-coded information.

Evaluation of Iris 

Proprietary Software

Iris is a software system for medical 

coding for death records built on the 

framework of components of MMDS 

and developed as an outgrowth of the 

International Collaborative Effort on 

Automating Mortality Statistics (84). 

It was developed by the Iris Institute, 

which is an international collaboration 

originally involving Germany, France, 

Sweden, Hungary, and Italy. The United 

States, while participating in and advising 

on development activities for many years, 

officially joined this collaboration in 

2014. Since 2014, the United Kingdom 

and the Netherlands have also joined the 

collaboration while Sweden has dropped 

out. Iris is presently used in several 

European countries, Australia, Canada, 

and South Africa. NCHS is currently 

working on the development of a new 

automated coding system to replace 

MMDS. It is expected that Iris (or at least 

some of its components) will be part of 

this new system. Comparability testing 

has shown a 92% match of MMDS- and 

Iris-based data. For the remaining 8%, 

Iris coding has been found to be largely 

correct. Differences are also partly due to 

the fact that Iris reflects current updates 

to ICD–10, whereas MMDS has not been 

updated. An initial review of the software 

with particular focus on security and on 

compatibility with NVSS IT systems 

has shown some deficiencies that will 

need to be addressed. At the time of 

writing this report, a number of technical 

questions remain to be answered before 

any decisions are made on whether 

or not to adopt Iris and how much of 

the system can be used as is. A less 

significant drawback is that Iris cannot 

be used currently to code cause of fetal 

deaths (85).

Transmitting Vital 

Statistics Data From 

the States to NCHS

The transmission of data by states 

to NCHS has evolved significantly as 

a result of NCHS’ and the states’ total 

reengineering effort. Over the last 

two decades, states have transitioned 

from magnetic tape to floppy disks to 

bulletin board (electronic transmission) 

to the CDC Secure Data Network, to 

CDC’s Secure Access Management 

Services (SAMS), and ultimately to the 

State and Territorial Exchange of Vital 

Events (STEVE). STEVE 2.0 is most 

recently underway and is more than 80% 

complete, with 49 jurisdictions fully 

certified; 6 jurisdictions are in various 

stages of implementation or certification 

of STEVE (Figure III) (86,87).

STEVE initially was focused on 

the interstate exchange of records. It 

is a system used by U.S. vital records 

jurisdictions first to exchange data with 

other jurisdictions and then later to 

provide data to NCHS and other public 

health partner programs. STEVE is 

owned by NAPHSIS, which describes 

STEVE as an “innovative messaging 

application for the electronic exchange 

of vital event data across jurisdictions” 

(86). It provides automated support 

for the Inter-jurisdictional Exchange 

of Vital Records (IJE), and replaces 

the less secure practice of exchanging 

paper copies, line lists, and printed 

computer abstracts across jurisdictions. 

The process for transitioning to STEVE 

for transmission of records to NCHS 

involves states’ recreating their extract 

files in the IJE format for distribution. 

Each event (i.e., birth, death, fetal 

death) goes through a detailed extract/

distribution/receipt test to ensure 
Series 1, No. 62  Page 13 

comparability with previous files. NCHS 

certifies the states once they submit three 

consecutive files with no differences 

through STEVE. When the states are 

successfully certified, they can start 

sending files to NCHS via STEVE. 

Initially, using STEVE was facilitated 

by the NCHS/NAPHSIS Cooperative 

Agreement (see later separate section) 

(86,88). STEVE was a tool for improving 

timeliness in the last few years in the 

states where it has been operational, and 

it has been successful in that regard.

STEVE has thus been a crucial piece 

of the new electronic environment and, 

in fact, its adoption was a fundamental 

requirement for states to be in full 

compliance with the 2012–2016 VSCP 

contracts. However, during the most 

recent contract period for 2017–2021, 

NAPHSIS issued a reengineered STEVE 

2.0 (89,90). As a result of changes in 

funding the maintenance of STEVE 2.0, 

the VSCP contracts have been modified 

to indicate that states must transmit the 

data “through STEVE or an alternative 

approved by NCHS.” States have the 

option of transmitting the data through 

the SAMS Network. There is no charge 

to the states for using this system. It 

should be noted that the previous VSCP 

contracts provided a mechanism granting 

states a period of time for their data 

sets to be fully certified for STEVE by 

engaging in a Corrective Action Plan 

with NCHS (discussed in detail later in 

this report). One of the primary benefits 

of using the STEVE system was the 

requirement that states use the IJE format 

that required that mortality records be 

reported in one file. Previously, the 

demographic and medical portions of the 

file were reported separately (88,89).

Improving Timeliness 

of Birth and Death 

Statistical Data With 

“Preliminary” Releases

Until this point, this report has 

focused on the 2003 revisions of 

the standard certificates, budgetary 

challenges for NCHS, efforts to 

improve data quality, and the content 

of the statistical data files. There were 

also significant efforts to address the 

timeliness issues that had persisted for 

decades, as described earlier in this 

report. After all, if the vital statistics 

data cannot be available on a timely 

basis, their value is diminished. During 

the early to mid-1990s, NCHS and the 

jurisdictions explored initiatives to 

improve the timeliness of the birth and 

death data. The discussions occurred 

during negotiations for the VSCP 

contract and the time seemed right for 

this effort. The idea was that the states 

would submit their data as soon as the 

data were available on a “current flow” 

basis, in advance of the completion of 

quality control and other refinements. 

Updates and final processed data would 

follow. In the meantime, NCHS would 

process a “preliminary” file, with reports 

released as quickly as possible. In this 

scenario, preliminary reports could be 

released within 5–6 months of the end 

of a data year. To give context for the 

release timeframes then in existence, 

the 1994 final birth and death data were 

published in June and September 1996, 

respectively, fully 18–21 months after the 

end of the data year. These timeframes 

meant that the vital statistics were much 

less useful than they could be—for public 

health, health research, and public policy 

purposes, to name just a few. NCHS staff 

and state colleagues believed that the 

preliminary reports could be very useful. 

The following standards were set for the 

preliminary files: First, data sets needed 

to be about 90% complete for inclusion 

in the preliminary reports. Data for an 

individual state had to be at least 60% 

complete. Soon after the series started, 

the state-specific standard was raised to 

75%. Second, the preliminary reports 

were not accompanied by a data file, 

because preparing a public-use data file 

would detract from the goal of getting the 

final files and reports published. 

Initially, preliminary reports 

included both birth and death data 

simultaneously. The first report published 

was for 1995 events (91).The content 

of the preliminary reports was limited, 

homing in on the most critical variables 

and measures that would provide the 

most impact for understanding fertility 

and mortality patterns. Estimates were 

provided for population-based rates, 

including birth rates by maternal age and 

race, death rates from various causes, 

life expectancy, and infant mortality, as 

well as estimates for a variety of birth 

statistics, including low birthweight, 

preterm birth, cesarean delivery, and 

nonmarital births. The reports have been 

eagerly awaited and widely referenced; 

media coverage of annual birth and death 

data began to focus almost entirely on 

the preliminary reports because they 

were timely. Because the data are based 

on such large samples, they are reliable, 

and typically, the estimates reported 

in the preliminary reports have been 

validated with the final data. Reports 

were published for calendar years and 

12-month periods ending in June of the 

year for 1996, 1997, and 1998. Beginning 

in 1999, preliminary birth and death data 

were published separately due to the 

transition from ICD–9 to ICD–10 to code 

and classify cause of death (92). This 

shift in coding delayed the availability of 

the 1999 data; thus, the NVSS program 

decided to publish the preliminary birth 

and death data separately thereafter 

(92,93). The quickest report release was 

for 2013 preliminary births, which was 

published in May 2014 (94). Preliminary 

reports for 2012 and 2013 mortality 

were not published because the mortality 

program was concentrating exclusively 

on processing and producing the final 

reports and files; the final file for 2013 

became available late in 2014 (68) along 

with a Data Brief and was followed 

thereafter by the final report. The final 

file and a Data Brief for 2016 deaths were 

published in December 2017 (95,96).

The timeliness of data files was 

improved, initially for the mortality 

data, by releasing the annual public-use 

final data files before the final report. 

Typically, the data files are ready for 

release before formal publications. At one 

time, NCHS’ practice based on informal 

policy within NVSS was to release the 

two concurrently, but this is no longer 

the case. In the case of births, the 2014 

and 2015 final files were released in 

September 2015 and September 2016, 

respectively, 3 to 4 months ahead of the 
Page 14  Series 1, No. 62

availability of the final reports. NVSS 

analysts have prepared NCHS Data 

Briefs with snapshot highlights of the 

final birth data, most recently for the 

2016 data year, and these accompany the 

final data files (95,97,98). 

An indication of the confidence 

shown early on in the preliminary report 

series was the decision made for the 

1998 data year to discontinue the Current 

Mortality Sample (CMS) (99). CMS, a 

10% sample of mortality records, had 

been a product of NVSS since 1943 (1), 

and was inaugurated in response to the 

lengthy delays in data availability at the 

time, which compromised the utility 

of the mortality data for public health 

purposes. With the CMS, mortality 

estimates by cause of death were 

available within one to just a few months 

of the occurrence of the deaths. These 

data were published in the National Vital 

Statistics Reports in the provisional 

data series. As demands increased for 

more detailed data, however, so too 

did the time lag in releasing the CMS 

estimates. CMS was discontinued in 1998 

because it was felt that the preliminary 

estimates were providing more useful 

information, with population-based rates 

and characteristics available by age, race, 

and sex.

Using Technology to 

Improve Timeliness of 

Vital Statistics Data, 

Especially Mortality

Throughout the last two decades, 

NCHS and the states have explored 

a variety of strategies to improve the 

timeliness of birth and death data. The 

timeliness of birth data substantially 

improved during this period, with 

important gains arising from the 

release of the preliminary data reports, 

as described above. From the initial 

publication of preliminary birth reports, 

the gap between the end of a data year 

and the availability of preliminary 

statistics shrank to about 5 to 6 months, 

and, as discussed later in this report, 

this interval has continued to shrink. 

Timeliness has improved for both 

preliminary and final data reports and 

files for births. 

The production of death 

registration and statistical data has 

been fundamentally hampered, as noted 

earlier, by the fact that the process 

involves several distinct data sources. 

Typically, although not exclusively, death 

registration is initiated by the funeral 

director who collects and reports on 

the demographic information about the 

decedent; the funeral director generally 

relies on family members as informants. 

Physicians, or in some cases coroners 

or medical examiners, are the sources 

for the cause-of-death information. 

Bringing these two key sources together 

has long been a challenge, and in some 

cases, has seemed an insurmountable 

one. Because of the impact on the 

timeliness and utility as well as the 

reliability of the mortality data, efforts 

to develop an EDRS have been pursued 

intensively since 1994 when a joint 

NCHS/NAPHSIS workgroup was 

formed to focus exclusively on this goal. 

Representatives from the American 

Medical Association, the American 

Hospital Association, and the American 

Health Information Management 

Association participated in this effort 

(1). There was broad consensus that 

the electronic systems being developed 

needed to be “capable of adapting to 

changing technology, information needs, 

and legal mandates; capable of meeting 

customer needs for prompt registration 

and information; capable of providing 

quality information appropriate for its 

customers while minimizing reporting 

burden on (data) suppliers; acceptable 

to the individuals, organizations, and 

institutions who participate in the system; 

and capable of incorporating methods to 

measure the reliability and validity of the 

data collected” (1). The essence of these 

principles has persevered over the last 

two decades. 

The first EDRS dates back to 1999, 

with the first functional EDRS developed 

in New Hampshire in 2002. The initial 

concept for the EDRS dates back to the 

first automation efforts made in that 

state in 1990 (100,101). As originally 

envisioned by NVSS program staff, a 

functional EDRS is one whereby a state 

registers at least 50% of its death events 

via their EDRS. Anything less meant that 

the state was not deriving the benefits 

of an automated system. By today’s 

standards, a fully functional EDRS is 

one that registers 80% of the deaths in a 

state (101). 

The idea was for the systems to be 

Internet-based to speed up the processes 

for funeral directors and physicians to 

jointly record their data; this coincided 

with the maturing of the Internet in 

about 2000. Funeral directors have 

adopted the electronic systems very 

well and effectively. This has not been 

the case for physicians; at the time of 

this writing, more than 55% of death 

records are completely processed 

electronically (102). Most EDRS in the 

states, while not fully electronic, are 

nevertheless functioning and producing 

data (Figure IV). An EDRS that is not 

fully electronic is one that likely has the 

full (electronic) participation of funeral 

directors but not the participation of the 

physicians and other medical certifiers; 

the latter may continue to certify deaths 

manually. Because of these very different 

stakeholders involved in registering and 

certifying a death, with different training 

requirements and other challenges, fully 

functional EDRS take time to become 

established (89,101). 

As noted above, SSA contributed 

significantly to the development of 

EDRS in a number of jurisdictions for the 

registration of deaths, starting initially 

with New York City and Washington, 

D.C., and continuing to support EDRS 

in 48 jurisdictions (as of October 2017) 

(87). At the time that this report was 

completed, there were still 9 jurisdictions 

that did not have a functioning EDRS, 

though 1 is in the process of building 

or testing a new system (U.S. Virgin 

Islands) (85,102). Currently a number 

of efforts are underway to develop 

functioning EDRS in these states. [See 

subsequent section on efforts to use 

special funding strategies, outlined in 

the current VSCP contract specifications, 

to stimulate EDRS expansion (88,90).] 

In the meantime, a few states have 

been using fax attestation as a way of 

addressing the ongoing timeliness issues 
Series 1, No. 62  Page 15 

with death registration. Fax attestation 

refers to a fax received by an automated 

document imaging system that attaches 

an image of the form to the electronic 

record and is viewable only by authorized 

EDRS users. For example, California and 

Arizona have been collecting about 60% 

of their cause-of-death information in 

their EDRS by fax (85).

Mortality Surveillance 

Facilitates Continued 

Improvements in 

Timeliness

Most recently, the NVSS program 

has been engaged in a transformational 

program to significantly speed up the 

availability of mortality data. Fueling 

the initiatives in real-time mortality 

surveillance are the goals for more timely 

data combined with improved methods, 

associated with reengineering in NCHS. 

Interest in using NCHS mortality data for 

near real-time surveillance purposes has 

been longstanding; however, the delays 

in implementing modernized electronic 

systems for reporting and registering 

deaths have been an impediment to its 

development. With real-time mortality 

surveillance, it is possible to quickly 

identify the emerging trends in crucial 

mortality measures as well as newly 

recognized mortality indicators. The 

timely availability of these data enhances 

their value and utility. 

The vision underlying the new 

initiative is that 80% of deaths will be 

reported to NCHS within 10 days of 

the event. This goal reflects a larger 

effort, supported by others, showcasing 

substantial increases in the value of 

mortality information if the data were 

available on a timely basis. In 2016, 

nationally 44% of deaths were reported 

to NCHS within 10 days, a significant 

increase compared with 17% in 2013. 

However, the percentages of deaths 

reported within 10 days vary significantly 

by state (103). The underlying concept 

is to show that vital statistics can be 

used for rapid mortality surveillance and 

additionally to improve the timeliness 

of releasing final statistical files. In this 

sense, linking NCHS’ priorities to the 

priorities of others can facilitate great 

gains in timeliness (Appendix IV). In 

addition, the benefits are not limited 

to timeliness. By speeding up data 

releases, data quality can be enhanced as 

well: Through more rapid and effective 

communication with jurisdictional 

vital statistics offices, data accuracy is 

improved.

It is important to distinguish 

between real-time surveillance data 

and the annual mortality statistical files 

(104). Surveillance data are available in 

real-time and are updated and revised 

on a “current flow” or ongoing basis as 

new data are reported to NCHS by state 

vital records offices. The full mortality 

statistical files are final, annual data 

files based on all deaths registered in the 

United States. Once final, these annual 

files are not revised or updated. It is not 

currently anticipated that files based on 

surveillance data will be publicly released 

because file content changes may 

introduce discontinuities in the data and 

other challenges to interpreting the data. 

One area where the death certificate 

data have been used for surveillance for 

many years is the publication of weekly 

estimates of “notifiable diseases and 

mortality in 122 cities” that are issued in 

CDC’s Morbidity and Mortality Weekly 

Report (105). The data for the 122 cities 

project are reported by state and local 

registrars directly to the CDC’s Influenza 

Division. Consistent with the recent CDC 

Surveillance Strategy goal to reduce 

the redundancy of CDC surveillance 

systems, NCHS and the CDC’s Influenza 

Division have been piloting the use of 

NCHS real-time surveillance capabilities 

as a replacement for the 122 Cities 

Mortality Reporting System (CMRS) 

(106). Currently, parallel review of 

the 122 CMRS data system and vital 

statistics-based surveillance for influenza 

deaths is ongoing. The vital statisticsbased real-time mortality surveillance 

effort is building off of the culture 

change now underway in vital statistics 

to focus on the production of timely and 

quality data using electronic registration 

systems. The reengineering of internal 

processes within the NVSS program has 

facilitated this effort through extensive 

automation linked with robust tools for 

analysis, visualization, and dissemination 

(103,107). Finally, this activity is a 

strong vehicle for building and enhancing 

surveillance partnerships, some of which 

are well underway, to improve public 

health practice (Appendix IV).

Evaluating and 

Improving Birth Data 

Quality 

Evaluation of Worksheets 

and Comparison of Birth 

Certificate With Hospital 

Birth Records Data

Beginning in about 2005, NCHS 

embarked on a series of efforts to 

evaluate the quality of data from the 

revised birth certificate and registration 

systems, with the objective of improving 

data collection and systems. These 

initiatives were carried out together with 

state partners, with NCHS in some cases 

working in concert with NAPHSIS on 

behalf of the jurisdictions. Both NCHS 

and the states shared the goals of making 

the new and revised data as useful and 

reliable as possible. 

The first initiative was a study 

designed to understand how medical and 

health data items are collected on the 

facility worksheet for the 2003 revision 

of the U.S. Standard Certificate of 

Live Birth and to identify overarching 

issues with specific data items. As noted 

earlier, the development of worksheets 

(for the mother and the birth facility) 

was one of the significant innovations 

recommended by the Panel to Evaluate 

the U.S. Standard Certificates in support 

of the goal of improving data quality. For 

pre-2003 revisions of the birth certificate, 

the source of the birth data reported 

varied widely, but was often believed 

to be the mother herself, even when the 

questions related to very specific medical 

issues. The 2003 revision was intended 

to fundamentally change the process 

of collecting birth data—to collect the 

data from the most appropriate source. 

The mother would be the source for the 

demographic data and would record 
Page 16  Series 1, No. 62

that on the mother’s worksheet, while 

the medical and health data would be 

collected on the hospital or facility 

worksheet. Data for this worksheet would 

come from several different sources, 

including the prenatal care record, the 

admissions record, the labor and delivery 

log, and other medical records. The 

mother’s worksheet process had been 

previously tested, as noted earlier, during 

April 24, 2000–May 5, 2000, through 

cognitive testing in NCHS’ Questionnaire 

Design Research Laboratory with 

recent mothers; the mother’s worksheet, 

available in both English and Spanish, 

was tested in both languages (108,109).

The interviews with hospital staff 

primarily responsible for gathering the 

medical and health data for the birth 

certificate were carried out in 2009–2010 

at 54 hospitals in 4 participating states 

representing geographically diverse areas 

of the country; all had implemented the 

2003 revision of the birth certificate. To 

ensure confidentiality, the states are not 

identified. The study was based on private 

interviews with the hospital personnel 

(birth information specialists) responsible 

for obtaining the facility worksheet 

information and for transferring the 

information to the electronic birth 

certificate. The study found variations 

across states and across hospitals in 

the design of the facility worksheets, 

which contributed to differences in 

the sources used for certain medical 

and health items. In most cases, with 

the exception of the pregnancy history 

information, however, the clinician 

directly reported the medical/health 

items, or the birth information specialist 

obtained the information from medical 

records. The major conclusion of the 

study was that states and hospitals should 

focus on training their staff members 

in the collection of the data, especially 

in the use of the facility guidebook and 

appropriate sources of information, 

and ensure that the data sources are 

separately and clearly identified. The 

results of the study were shared with the 

NAPHSIS membership at their annual 

meeting in 2010, and were used to inform 

the development of e-learning training 

(see below), designed for both the birth 

information specialists and the clinicians 

(physicians and nurses) (110). 

A second important initiative 

undertaken by NCHS was to engage in 

a collaborative study with two states to 

evaluate the quality of selected medical 

and health data from the 2003 revised 

birth certificate (111). Birth certificate 

data were compared with information 

abstracted from hospital medical records. 

The study population included a random 

sample of 600 birth records in 2010–2011 

in one state and a convenience sample of 

495 births in 2009 in another state. Birth 

certificate and hospital medical record 

data were compared for 14 groups of 

items: pregnancy history, prenatal care, 

gestational age, birthweight, pregnancy 

risk factors, obstetric procedures, onset of 

labor, source of payment, characteristics 

of labor and delivery, fetal presentation, 

method of delivery, abnormal conditions 

of the newborn, infant living, and infant 

breastfed. The study found wide variation 

in data quality, by data item and often by 

state and hospital. Importantly, though, 

even some items for which overall 

agreement between sources was “lessthan-optimum,” there was often high 

agreement for one or more hospitals. This 

suggests that quality improvement efforts 

could be successful in expanding the 

number of hospitals with more complete 

reporting and that there is the potential 

for high-quality national data for items 

that currently appear to be incompletely 

reported. A similar but larger validity 

study comparing hospital medical records 

with birth certificate data has recently 

been completed. Results are available 

upon request (112). A smaller study in 

another jurisdiction also helped to inform 

the recent decisions described later in 

this report on the content of the birth 

certificate (112).

Improvements in 

the Measurement of 

Gestational Age 

Although not a part of the 2003 

revision focused efforts to address data 

quality issues, another significant activity 

has been ongoing to determine how best 

to measure gestational age. As a result 

of extensive evaluation and deliberation 

with clinicians and other experts, NVSS 

has recently transitioned, effective with 

the 2014 data year, the measurement 

of gestational age from date of last 

menstrual period-based calculations to 

the obstetric estimate item on the birth 

certificate. The change is expected to 

result in more accurate measurement 

of preterm birth and other aspects of 

gestation, which are key indicators of 

infant health. Discontinuities in the 

series on preterm birth estimates, among 

other measures, were anticipated and 

are the subject of a recent report (113). 

The report focused on this change in 

measurement and the implications for 

tracking preterm birth indicators and 

related measures.

Birth Data Quality 

Workgroup

Later in this report, the development 

and work of the “Getting From Good to 

Great: NAPHSIS/NCHS Partnership” is 

described in some detail. The Partnership, 

formally established in 2010, has been 

focused on creating a truly great national 

vital statistics system by addressing in 

very specific ways the challenges that 

NCHS and the state partners were facing 

in chronic and seemingly intractable 

data quality and timeliness issues. One 

of the specific ways that the partners 

approached the data quality issue 

was to establish a Birth Data Quality 

Workgroup.

The Workgroup is a collaboration 

among NCHS’ NVSS staff, NAPHSIS, 

and individual state vital statistics 

offices and was established in response 

to studies that showed wide variation 

in the quality of birth medical and 

health data across items, states, and 

hospitals. The Workgroup members 

have focused on several priority areas: 

a) identifying approaches to engaging

hospitals on the importance of accurate

and complete vital statistics birth and

fetal death data; b) developing standard

reports for states to use for feedback to

hospitals on data issues; c) assessing and

improving the quality of prenatal care

data; d) identifying items to cut from the

national birth data set because of poor

data quality and lack of potential for

improvement; and e) identifying items to

cut from the national fetal death data set.
Series 1, No. 62  Page 17 

Working with NAPHSIS, the Workgroup 

has fielded several surveys of the vital 

registration reporting areas to better 

understand these issues. Two reports of 

the Workgroup’s activities present survey 

recommendations (114,115).

In its first report, the Workgroup 

recommended improving jurisdictional 

data evaluation efforts and ensuring 

data quality practices that would 

support “greater cooperation between 

birth registration and birth statistics 

staff, better adherence to standardized 

collection instruments, and increased and 

timelier evaluation of vital records for 

data quality.” The Workgroup made eight 

recommendations on the prenatal care 

items, each spelled out in detail in the 

second report (115). Recommendations 

for vital records jurisdictions included 

improving data collection, training, and 

communication with hospital staff and 

prenatal care providers; reviewing data 

quality and taking appropriate action; 

auditing hospital medical records; and 

improving guidelines for collecting data 

and raising awareness. 

Most recently, the Birth Data Quality 

Workgroup (BDQWG) has established a 

new BDQWG “Tweak” subgroup. This 

subgroup’s mission is to review the 2003 

Standard Certificate of Live Birth and 

develop sound, modest recommendations, 

if appropriate, for modifications to items 

collected for the national birth data file 

in the future. This effort will be building 

on the Workgroup’s previous careful 

review of 25 standard birth certificate 

items and a final recommendation to 

cut 12 items from the national birth file; 

the recommendations were accepted 

by NAPHSIS and NCHS leadership 

(described later in this report) (112,116). 

Although not a focus of BDQWG, 

other efforts have been ongoing to 

improve birth data quality. Improvements 

in data elements can potentially be 

achieved with better definitions in NCHS’ 

“Guide to Completing the Facility 

Worksheet for the Certificate of Live 

Birth and Report of Fetal Death” (23) and 

by the work of the ongoing reVITALize 

initiative (117) The reVITALize initiative 

addresses a widely shared goal among 

clinicians, health services researchers, 

electronic health records advocates, state 

vital statistics agencies, NCHS, health 

payer representatives, and a variety of 

other federal agency representatives to 

develop standardized obstetric definitions 

to be used for perinatal and women’s 

health records. More information about 

reVITALize is available elsewhere (117).

Items cut from birth and fetal 

death data sets

In mid-2014 and then again in June 

2015, NCHS announced that several 

items were being cut from the NCHS 

minimum data sets based on the work 

and recommendations of BDQWG 

(56,78,118). The Workgroup developed 

several criteria to use as the basis for 

its recommendations. The Workgroup 

examined data quality, whether the 

item title was unambiguous and could 

be interpreted by the birth information 

specialist (the person who completes 

the birth registration process in the 

birth facility) or clinician without the 

need for specific clinical expertise or 

higher-level training, whether the item 

as reported in the hospital medical 

records was consistent with the birth 

certificate, whether there was potential 

for improvement in data quality, and the 

potential public health usefulness of an 

item, assuming reasonably good data 

quality. Through group consensus, the 

Workgroup then made recommendations 

on whether to improve, watch, or 

eliminate the item. Jurisdictions 

were advised that NCHS would no 

longer review the data on the items 

recommended for deletion for quality or 

provide suggestions for ways to improve. 

The states or jurisdictions are continuing 

to receive full funding for the data sets; 

funding is not being reduced as a result 

of fewer items being included in the data 

sets. The 2014 and 2015 notices followed 

a similar notice in 2011 related to three 

other items. To date, the following items 

have been cut from the NCHS birth data 

set (56,119–120):

● Mother ever married (this was 

a “derived” item based on other 

information on the standard birth 

certificate, and had been part of 

national file)

● Date of last prenatal care visit 

● Premature rupture of the membranes 

≥ 12 hours (Onset of labor)

● Precipitous labor < 3 hours (Onset of 

labor)

● Prolonged labor ≥ 20 hours (Onset of 

labor)

● Tocolysis (Obstetric procedure)

● Cervical cerclage (Obstetric 

procedure)

● Unplanned operating room 

procedures (Maternal morbidity)

● Significant birth injury (Abnormal 

condition of the newborn)

● Other previous poor pregnancy 

outcomes (Risk factors in this 

pregnancy) 

● Moderate/heavy meconium staining 

of the amniotic fluid (Characteristics 

of labor and delivery) 

The above item deletions and those 

described below for fetal death data 

began with the 2014 data year.

Because of longstanding concerns 

with fetal death data quality, including 

concerns with data completeness and 

accuracy of some items, especially the 

medical and health items, a significantly 

larger number of items has been cut 

from the national fetal death data file. 

The criteria that the Workgroup used 

to make their recommendations for 

the fetal death data file were similar 

to those for the birth file listed above, 

but they differed in important respects. 

The Workgroup was to explore the idea 

of substantially reducing the number 

of data items collected to a core set of 

data that could potentially be collected 

accurately, and to use the revised fetal 

death report to test whether an electronic 

data collection system that all states 

could use could be developed as a model 

for the next generation of electronic 

vital records data collection systems. In 

addition to the criteria used for the birth 

data items, the Workgroup considered 

the following in determining whether to 

recommend that a data item be removed 

from the standard report: what is known 

about the completeness and accuracy of 

the item?; is the information available in 

hospital medical records at the time that 

a fetal death occurs, particularly a death 

that occurs unexpectedly long before the 

due date?; is the data item potentially 

useful in understanding why a fetal 
Page 18  Series 1, No. 62

death occurred?; and whether there was 

substantial overlap and redundancy with 

other items on the fetal death report (i.e., 

between the cause of death and non-cause 

of death sections of the report). The 

items that the Workgroup recommended 

for cutting are listed in Appendix V

(56,118,120). 

It is not anticipated that additional 

cuts or deletions will be recommended; 

currently, no further reviews are planned. 

Rather, the focus will be “to improve 

the quality of birth data via improved 

engagements with birthing hospitals and 

the use of effective e-learning for hospital 

staff among their efforts” (78,116).

E-learning for birth clerks

A priority effort of BDQWG has 

been the development of an e-learning 

training for hospital staff responsible for 

collecting and documenting the medical 

and health data for the birth certificate 

and report of fetal death. The Workgroup 

developed standardized electronic 

modules to train hospital staff on a) the 

importance of accurately and thoroughly 

reporting birth certificate data, and b) 

the data collection process for specific 

medical and health items on the birth 

certificate. The audience for this training 

includes birth information specialists, 

physicians, nurses, and hospital 

administrators. The training, which 

includes case studies of potential issues in 

reporting items, is accessible to hospital 

staff in all jurisdictions through the 

web on an ongoing basis and will offer 

continuing medical education (CME), 

continuing nursing education (CNE), and 

continuing education (CE) credits (112). 

The content is specific to medical and 

health items in the Facility Guide (23). 

This training, developed under contract, 

is now available (121).

BDQWG currently has an ongoing 

e-learning subgroup tasked with 

developing ways to promote the new 

e-learning course and to help jurisdictions 

reach as many people involved in the 

documentation and collection of birth 

certificate data as possible (116).

Other Initiatives to 

Enhance Vital Statistics 

Data Quality

Evaluation of the use of 

electronic health records for 

quality

Concurrent with the efforts to 

evaluate, improve, and speed up data 

on vital records, other NCHS staff, 

NAPHSIS and member jurisdictions, and 

individuals and organizations who depend 

on standardized data being reported on 

medical and vital records have been 

exploring potential connections between 

birth certificates and electronic health 

records (EHRs). Many of the medical and 

health data items required on birth and 

death certificates and fetal death reports 

are captured in medical records; in the 

case of birth records, hospital medical 

records are the source for more than onehalf of the data items. Those participating 

in these ongoing efforts have been 

debating the use of EHRs to populate 

data items collected on vital records. 

The hypothesis is that “interoperability 

with EHRs may improve the timeliness, 

accuracy and quality of the information 

collected for vital records purposes.” The 

feasibility of this effort continues to be 

the subject of extensive discussion and 

deliberation (122).

Implementing a Validations and 

Edits Web Service (VIEWS) to 

improve mortality data

As noted, a key objective of the 

electronic systems in development for 

vital registration was the capability of 

editing data at the source. This was an 

objective for VIEWS, initially developed 

as an online web service provided by 

NCHS. VIEWS was intended to provide 

a comprehensive set of mortality-focused 

validations and checks that would enable 

the data provider to correct or clarify the 

data at the source immediately, without 

waiting for after-the-fact follow-up 

efforts, such as queries and cleanup. A 

workgroup comprised of six states and 

NCHS staff was formed to define the 

requirements for an updated version of 

VIEWS to address issues identified in 

the original version. VIEWS II is the 

realization of these requirements, and is 

now operational (123).

Micro-data Files: Data 

Dissemination Tools 

and Strategies

Content and Availability of 

Vital Statistics Data

Overview

Micro-data from the National Vital 

Statistics System are made available in 

an increasing variety of ways, consistent 

with NCHS’ goal and practice to make 

data readily and easily accessible. 

Initially, public-use data sets of vital 

statistics data (including all relevant 

documentation) were available for 

purchase, beginning with the 1968 

data year, in the form of data tapes. 

NCHS has published birth, death, fetal 

death, marriage, divorce, and abortion 

data sets over many decades (1). 

Subsequently, data were made available 

through CD-ROMs that were free and 

available on request. More recently, 

public-use data have been available at 

no charge by downloading the data sets 

from the NCHS website. Natality and 

mortality public-use files are available 

for downloading beginning with the 

1968 data year, and currently include 

annual files through 2016 for natality and 

through 2016 for natality and mortality 

(95). The linked birth/infant death data 

sets are available as well. “Period” 

linked files are currently available from 

1995 through 2015. The “cohort” files 

are available annually for the years 

1983–1991 and 1995–2011 (95). No 

linked files were produced for the years 

1992–1994 because of severe budgetary 

constraints. Data sets for the fetal death 

files are currently available for the years 

1982–2015 (95). More limited data files 

have also been produced for matched 

multiple birth data sets. Before describing 

the individual data sets in the NVSS 

program, it is important to note some 

changes in file content in recent years.
Series 1, No. 62  Page 19 

Changes in file content due to 

confidentiality concerns 

Over the years, confidentiality 

standards for the public release of 

geographic and exact date details on vital 

statistics micro-data files have changed. 

These changes are described on the 

NCHS website (124). During the early 

2000s, NAPHSIS informed NCHS of 

their wish to modify the existing data 

dissemination policy for vital statistics 

data collected through the Vital Statistics 

Cooperative Program. Specifically, some 

NAPHSIS members were concerned 

that more detailed data were available 

in the NCHS data sets than the laws or 

policies in their states would authorize. 

The concerns centered largely around 

two areas: geographic identifiers such as 

state, county, and city; and exact dates 

(e.g., date of birth, date of death). As the 

NCHS data sets have grown considerably 

in complexity and detail, especially since 

the 2003 revisions, it was felt that these 

items could be used inappropriately to 

identify some individuals, especially in 

cases with very unusual characteristics 

(e.g., multiple births, extreme ages of 

parents, and unusual causes of deaths). 

Effective with the 2005 data year, data 

files contain individual-level vital event 

data at the national level only (i.e., no 

state, county, or city identifiers). Most 

other items are included, including the 

year, month, and day of the week. Exact 

dates, however, are not included.

With the changes in level of detail 

available, DVS staff and NAPHSIS 

colleagues have developed procedures 

for researchers to request, and if 

approved, receive data files with all 

counties identified. Such researchers 

must complete a project proposal 

with details of their research plan and 

assurance of their intent to use the 

files only for the purposes stated and 

to refrain from sharing any special 

files with unauthorized individuals and 

organizations. Researchers in federal 

agencies may likewise request and, if 

approved, receive files with exact dates. 

In instances where the requests for 

geographic detail and/or exact dates are 

denied, researchers may apply for access 

to the NCHS Research Data Center 

(RDC). More information on the special 

request files and the RDC is available 

(124–126).

Data Sets

Births

Births (also referred to as live 

births) are reported as one of the three 

components of the VSCP using data 

collected on the U.S. Standard Certificate 

of Live Birth. Virtually all births in the 

United States are registered (67). In 

recent years, nearly 4 million births have 

been registered annually in the United 

States. The 2003 revision of the birth 

certificate included a variety of new 

items that greatly enhanced the value 

and utility of the data as a fundamental 

and crucial resource for reproductive and 

public health. Changes in the content 

of the birth certificate (as well as the 

death certificate and fetal death report) 

are documented in detail in Appendix 

Tables IV–VI. In addition to the core 

demographic items (e.g., age, race and 

Hispanic origin, marital status, birth 

order), the revision includes receipt of 

WIC food, source of payment for the 

delivery, infertility treatment, maternal 

morbidity, date of first prenatal care 

visit (to improve accuracy of prenatal 

care receipt data), enhanced information 

on maternal smoking (by trimester) to 

identify women who quit smoking during 

pregnancy, and mother’s height and 

weight to calculate the woman’s body 

mass index (3,16). Items on the dates of 

the mother’s previous live birth(s) and 

previous other pregnancy outcomes are 

used to calculate birth and pregnancy 

intervals. Items on gestational age and 

method of delivery have been modified to 

improve measurement precision. 

The availability of the new data was 

slowed by a number of factors discussed 

earlier, but significant progress has 

been made in recent years in releasing 

these data, with all new and revised data 

items for 2009–2012 released in 2013. 

The public-use file for 2013 births was 

released in November 2014, and the 

files for 2014, 2015, and 2016 were each 

released in September of the following 

year, the earliest availability of this file 

ever (95). Preliminary birth data for 2015 

were published in June 2016 (127) (See 

previous section for how the preliminary 

data reports for births and deaths were 

launched.). New, more timely methods of 

releasing statistical data and reports for 

births as well as deaths were launched 

effective with the 2016 data year, and are 

also discussed later in this report.

Deaths

Registration of deaths is virtually 

universal in the United States (68). In 

recent years, the data sets for deaths 

have included about 2.5 million records 

annually. The 2003 revision of the death 

certificate includes several items intended 

to improve the precision and utility of 

the cause-of-death data. For example, the 

item asking for the pregnancy status of 

female decedents is intended to improve 

the measurement of maternal mortality. 

The evaluation of this item is underway. 

Similarly, the item on whether tobacco 

use contributed to the decedent’s death 

can help identify smoking-related deaths 

and the item clarifying the decedent’s 

role in transport injury deaths can 

improve the accuracy of cause data 

for these deaths. As noted earlier, the 

registration of deaths typically involves 

at least two parties: the funeral director 

and the certifying physician (or medical 

examiner or coroner). The development 

and implementation of EDRS across 

the states (76) have been importantly 

impacted by this fact, as the registration 

of a given death requires timely and 

complete input from each of these parties. 

Certifier reporting is generally not as 

timely as reporting by funeral directors. 

An important complication during the 

last decade was that the internal systems 

for processing mortality data experienced 

significant challenges beginning in the 

mid-2000s, delaying data availability 

considerably. During 2014, the challenges 

were addressed and files for data years 

2011 through 2013 were released (68). 

The final data files and reports for 2014, 

2015, and 2016 were published in late 

fall of 2015, 2016, and 2017, respectively 

(95). More timely methods of making 

the latest mortality data available more 

rapidly have recently been introduced and 

are described later in this report. 
Page 20  Series 1, No. 62

Fetal deaths

Fetal deaths are reported as a 

component of the VSCP program using 

data collected on the U.S. Standard 

Report of Fetal Death as noted above. 

As of year-end 2017, 49 states, New 

York City, and the District of Columbia, 

as well as three of the five territories 

were using the 2003 revision of the U.S. 

Standard Report to collect and transmit 

this information (Table III). In addition 

to including many of the changes 

incorporated in the 2003 revision of the 

birth certificate, the fetal death report also 

provides for improved data on the cause 

of fetal death. These cause data have 

recently been published for the first time 

from the 2014 data file (128). Staffing 

and resources are being added to the 

NVSS program to facilitate timely coding 

and availability of cause-of-fetal-death 

data (78). NCHS publishes descriptive 

reports on fetal deaths of 20 weeks 

or longer gestation; national data are 

available only for the events at 20 weeks 

or longer. In recent years, these files have 

comprised about 24,000 events annually. 

The issues outlined earlier that resulted 

in major delays in file availability for 

births and deaths also impacted the fetal 

death file. Prior to September 2013, the 

most recent fetal death file was the 2006 

file, published in 2012 (129). As a result 

of an intensively focused effort within 

the NVSS program to bring the fetal 

death data sets up to date, DVS was able 

to release the files for data years 2007 

through 2012 over a period of about 8 

months, beginning in September 2013 

through April 2014. The data files and a 

report for 2006–2012 fetal deaths were 

published in late 2014 (130). As noted 

earlier in this report, it was necessary to 

reduce the number of data elements in the 

file to meet this schedule. The internal 

reengineering within the NVSS program 

was also a major factor in making this 

achievement possible.

Like the linked birth/infant death 

data set described below, the fetal 

mortality file has great potential to 

promote knowledge and understanding 

of perinatal loss and possible maternal 

and infant characteristics that may 

be implicated. Several studies have 

examined the files together, in an effort 

to explore potential reporting issues to 

determine if they are playing a role in 

the trends (129,131,132). For example, 

if infants who die very soon after birth 

are misreported as fetal losses, this could 

affect the trends and variations in both 

infant and fetal mortality.

Linked data sets produced by 

the National Vital Statistics 

System

Linked birth/infant death data set 

The collection of data linking 

infant deaths to their corresponding 

birth certificates has been included as a 

component of VSCP contracts since the 

1987 birth cohort. The linked file has 

tremendous value for maternal and infant 

health research because it combines 

information on the infant’s death, 

including cause-of-death information 

from the final mortality statistical file, 

with the characteristics of the mother and 

infant at the time the child was born, best 

available from the birth certificate. States 

are providing matched birth and infant 

death certificates as a routine product 

for the VSCP. If the birth and death 

occur in different states, NCHS uses 

the matching birth and death certificate 

numbers provided by the states to access 

the final edited data from the NCHS birth 

and death statistical files and to form a 

single statistical record. The result is the 

creation of a national linked record file. 

NCHS and the states work carefully to 

identify the correct linkages for every 

infant death. The most recent published 

linked birth/infant death data set is for 

deaths in 2015 (95,133). A review of 

recent trends in infant mortality has been 

published (134). Typically, more than 

98% of all records are linked. In recent 

years, the data sets have included the 

records of about 24,000–25,000 infant 

deaths annually.

The routine production of the linked 

files was changed in a significant way 

beginning with the 1995 data year. Until 

then, states provided the data as a birth 

cohort; that is, births of a given year were 

linked to infant deaths that occurred in 

the birth year or within 12 months of 

the birth. Beginning in 1995, the data 

are provided on a period basis, based 

on the year of death of the infant. This 

change has had an important impact on 

the timeliness of the linked files, with 

the period files potentially available soon 

after release of the main mortality file 

for a given year. It also means that the 

files can be produced as both period and 

cohort files, making the files even more 

valuable analytically.

Data from the linked birth/infant 

death data set have been invaluable 

in exploring a variety of issues that 

depend on quality data on maternal 

and infant characteristics to understand 

infant mortality patterns. One focus, 

for example, has been changes in 

reporting of infant and fetal deaths and 

changes in the risk profile of births. 

For example, NCHS analysts examined 

the unanticipated increase in infant 

mortality in 2002 and the factors behind 

the persistent international differences in 

infant mortality (131,132,135).

Matched multiple birth file 

In the late 1990s and early 2000s, a 

unique data file, the Matched Multiple 

Birth Data Set, was developed. The 

sets are of all live births, fetal deaths, 

and infant deaths that are part of a 

multiple delivery. Because multiple 

births are relatively rare, accounting 

for about 2%–3% of births each year, 

several data years were combined for 

the sets. The first set was produced 

for 1995–1998, and the second data 

set contains 6 combined years of data 

(1995–2000) and sets of quadruplets 

(quadruplets were not included in the 

original release). The Matched Multiple 

Birth File was developed to allow for 

analysis of characteristics of sets of births 

and fetal deaths in multiple deliveries. 

Such analysis is not possible using the 

traditional NCHS Live Birth and Fetal 

Death Files because these files contain 

records of individual births and deaths in 

multiple deliveries, but do not identify set 

members. Thus, characteristics specific to 

the multiple set (e.g., sex combination of 

the set, outcome of the set, birth weight 

differences among set mates) are not 

available. More than 98% of records 

were matched in 1995–2000 (136). 

Included in the file are 325,516 sets of 

twins, 12,157 sets of triplets, and 760 
Series 1, No. 62  Page 21 

sets of quadruplets. The data set allows 

researchers to investigate such topics as 

the viability of multiples by sex of the 

set and birthweight discordancy among 

set mates.

Other data files produced within 

the National Vital Statistics 

System Program

National Death Index 

NCHS launched the National 

Death Index (NDI) as a tool for medical 

and health research in 1981 to make 

available the fact and location of deaths 

of individuals who had been participating 

in research studies (137). NDI was 

developed in partnership with the states 

(through NAPHSIS) because such an 

endeavor requires the approval of the 

jurisdictions. NDI provides a central 

source of mortality information, enabling 

researchers to determine if individuals 

in their study populations are still alive, 

and if not, in what state the individual 

died and the corresponding state death 

certificate number. The researcher would 

then use that information to contact the 

state of death to request a copy of the 

death certificate (137). Researchers pay 

fees for the matching service. During the 

1980s, researchers expressed growing 

interest in also obtaining the cause 

of death for their study participants. 

NCHS and the states discussed the 

issues extensively. States had concerns 

about the confidentiality of cause of 

death (especially for sensitive causes). 

Eventually in 1996, the states, at their 

annual joint NAPHSIS–VSCP meeting, 

voted to establish NDI Plus, permitting 

the cause codes to be released to NDI 

users provided certain requirements 

were met and provided each state 

approved this. 

In recent years, especially with 

the demise of SSA’s Death Master File 

(DMF) in 2011, there has been a growing 

chorus of researchers advocating for 

more timely release of NCHS’ NDI 

files, which were at the time severely 

delayed because of delays in processing 

the main statistical files. NCHS’ NDI 

staff proposed the development of an 

“early release” NDI file that, while 

incomplete, would include about 90% 

of all deaths from a given year (138). 

The “early release” file would contain 

the demographic information, but 

not the cause of death, and would be 

available within 6 months of the end of 

the data year. Moreover, NCHS would 

deliver a replacement NDI file from 

the final statistical file, including cause 

of death, at no additional charge. The 

“early release” file became a reality in 

July 2014 with the early release of the 

2013 file; the early release file for 2014 

became available in early 2015. These 

efforts were made possible by significant 

support from several federal agencies, 

including the National Institutes of 

Health’s National Institute on Aging, 

National Cancer Institute, and National 

Heart, Lung, and Blood Institute; HHS’ 

Agency for Healthcare Research and 

Quality; and CDC’s National Center 

for Chronic Disease Prevention and 

Health Promotion. 

NDI makes it possible to follow 

large population groups to determine 

their mortality status. Recently, for 

example, NDI searches have been carried 

out for two very large databases of 20 

million records each: One is a joint effort 

of the Department of Veterans Affairs 

and the Department of Defense and 

includes records of all military personnel 

discharged since 1979. The other includes 

all known decedents in the Medicare 

database who died during 1979 through 

2009. 

The NDI program, including its staff, 

is completely self-financed, in the sense 

that the user fees mentioned above are 

assessed for all of the approved searches. 

These revenues completely support 

NCHS’ NDI programs and processing 

and other DVS initiatives and activities 

(described later). Additionally, these 

fees provide revenue to the states, which 

compensates for the revenues lost as a 

result of reduced purchases of certified 

copies of death certificates.

National Survey of Family Growth

The National Survey of Family 

Growth (NSFG) has been housed since 

the late 1960s within the same NCHS 

organizational unit that is responsible 

for natality data and has been conducted 

since 1973. The survey was built on 

several privately conducted national 

fertility surveys, including the Growth 

of American Families in 1955 and 1960 

and the National Fertility Studies in 

1965 and 1970. The purpose of NSFG 

is to collect information that can help to 

explain trends and group differences in 

birth rates and in the birth certificate data 

collected in the National Vital Statistics 

program (139). Thus, the survey provides 

reliable national information on family 

life, marriage, divorce, and cohabitation; 

pregnancy and pregnancy intentions; 

infertility and use of infertility services; 

use of contraception; parenting; use of 

medical and family planning services; 

and men’s and women’s health. These 

data are used by scholars and public 

policy experts; by federal agencies 

to inform program decision-making, 

in research programs, and in social 

service programs; and by private-sector 

research organizations. Data are collected 

through confidential personal interviews 

conducted by trained female interviewers 

in the respondents’ homes. The first 

cycles of the NSFG included female 

participants only, initially married women 

aged 15–44 and women who had children 

of their own living with them. Starting 

in 1982, NSFG included all women aged 

15–44 (139). A major change occurred 

in the 2002 survey, when men aged 

15–44 were included for the first time. 

Beginning in 2006, NSFG has been 

conducted continuously with data sets 

for 2006–2008, 2006–2010, 2011–2013, 

2013–2015, and 2011–2015 released. 

NSFG staff analysts have written a 

wide variety of analytic reports (140). 

Downloadable public-use data files are 

also available (140). The current round 

of data collection covers 2015–2019, and 

beginning in 2015, the age range was 

expanded to 15–49. 

Over the years, NCHS analysts 

have combined birth certificate data and 

NSFG data to produce information on 

topics otherwise not measurable from 

either source alone. An example is the 

development of an ongoing series of 

national pregnancy estimates and rates 

by a variety of maternal characteristics. 

The pregnancy data include estimates of 

fetal loss from the NSFG’s pregnancy 

history data collected from all female 

respondents. These are added to sums 
Page 22  Series 1, No. 62

of births from NCHS’ vital registration 

system and abortion estimates from 

the Guttmacher Institute (based in turn 

on estimates from CDC’s Abortion 

Surveillance System). The national 

pregnancy estimates are available 

annually from 1976 through 2010 

(141–143).

Researchers have used data files 

from NSFG to analyze changes in 

marriage and divorce patterns, including 

the length of marriages and intervals 

between successive marriages, using 

life-table analytic tools. In this area and 

others related to family formation, the 

NSFG has helped to replace for public 

policy and academic researchers, at least 

partially, the loss of the marriage and 

divorce vital statistics data (140). Birth 

registration and NSFG data have also 

been combined to explain the changing 

nature of nonmarital childbearing in the 

United States, highlighting the increase 

in cohabitation as a major type of family 

formation, accounting in recent years for 

58% of nonmarital births (144).

New Strategies to 

Enhance Availability 

and Utility of Vital 

Statistics Data Sets

Vital Statistics Rapid Release

Program Showcased in New 

Online Releases

Most recently, NCHS has developed 

the Vital Statistics Rapid Release (VSRR) 

program. The VSRR program provides 

access to the timeliest vital statistics 

for public health surveillance, through: 

a) releases of Quarterly Provisional

Estimates and b) Special Reports based

on a current flow of vital statistics data

from state vital records offices. Using the

provisional data, the NVSS program is

producing much more timely estimates

of important health indicators for

public health practitioners, researchers,

and health policy-makers than would

be possible using final annual data

(107,145–147). The data in these reports

are referred to as provisional, and are not 

equivalent to the provisional “counts” 

that were published for decades through 

2014 (99).

The new provisional estimates are 

based on vital statistics data received 

and processed by NCHS as of a specified 

cutoff date, and are updated quarterly as 

new data become available. To adjust 

for incompleteness of the provisional 

data, individual records are weighted 

when necessary to independent counts 

of vital records received from the states’ 

vital registration systems through VSCP. 

Some records are imputed if the data 

available for a specific state and month 

are less than 50% complete at the time 

of data closure. Although the adjusted 

estimates based on provisional data were 

found to be close to the final estimates in 

an evaluation conducted by NCHS, they 

are subject to small changes as new data 

and updates are received (see Technical 

Notes in reference 107 for more details). 

NCHS’ VSRR program will continue 

the evaluation of the accuracy of the 

provisional estimates.

In the first pilot release of Quarterly 

Provisional Estimates, issued in the 

summer of 2015, NCHS presented 

estimates of death rates for seven 

selected causes of death for 2013 and 

2014 and the first quarter of 2015 

(106,107,145). The seven selected causes 

of death included in the pilot release, 

influenza/pneumonia, heart disease, 

human immunodeficiency virus (HIV) 

disease, falls (for persons aged 65 and 

over), stroke, Alzheimer’s, and diabetes, 

are all important from a public health 

perspective. Additional causes of death 

based on provisional mortality data, such 

as cancer, suicide, and drug poisoningrelated deaths, were added in subsequent 

quarterly releases; estimates are currently 

being published for 20 mortality 

rates (145).

Selected estimates based on 

provisional birth data have been added 

since the 2016 data year (103,146). These 

include estimates for general fertility 

rates, age-specific birth rates, total and 

low-risk cesarean delivery rates, preterm 

birth rates, and other gestational age 

categories. With the advent of the VSRR 

program for births, the preliminary 

reports for births have been discontinued; 

the last report in that series was for 2015 

births (127). 

VSRR estimates are currently 

presented for: infant mortality (deaths 

of infants under age 1 year per 1,000 

live births), neonatal mortality (deaths 

of infants aged 0–27 days per 1,000 live 

births), postneonatal mortality (deaths of 

infants aged 28 days through 11 months 

per 1,000 live births), and death rates for 

the five leading causes of infant death 

(147). Like the mortality measures, these 

indicators were selected based on their 

importance for public health surveillance 

as well as the feasibility of producing 

reliable estimates using available 

provisional data. A standard schedule 

of releases is a goal and is consistent 

with a “current flow” approach to data 

collection, wherein data are released on a 

regular schedule that is not contingent on 

a statistical file being finalized.

Data Visualization Gallery 

The Data Visualization Gallery, a 

series of interactive maps and charts to 

visualize population-based vital statistics 

rates, has recently been launched 

(148). Data are illustrated in maps and 

charts covering the United States and 

individual states. The latest series of 

data published included teen birth rates, 

natality rates and trends, nonmarital birth 

rates, mortality trends, leading causes of 

death, drug poisoning mortality, injury 

mortality, and potentially excess deaths—

rural versus urban (148).

Other Data Access Tools

Other CDC-hosted data access 

tools include WONDER, which stands 

for Wide-ranging Online Data for 

Epidemiological Research (149), a 

crucial tool for a wide variety of data 

users to not only access mortality data but 

also natality data. These data collections 

are available as online databases, which 

provide public access to ad hoc queries, 

summary statistics, maps, charts, and data 

extracts. Importantly, subnational natality 

and mortality data from DVS files can 

be accessed through WONDER; these 

data are not available in public-use files. 
Series 1, No. 62  Page 23 

NCHS funding has allowed WONDER 

to reengineer the system to use the main 

mortality file (that is, the full statistical 

file) rather than the more limited 

compressed mortality file. Converting 

WONDER to use the main mortality file 

allowed for several new variables to be 

included (e.g., day of the week of death, 

whether an autopsy was performed, and 

place of death) and to provide more 

detailed age information (38). Another 

data access tool is WISQARS, which 

stands for Web-based Injury Statistics 

Query and Reporting System (150). 

WISQARS is an interactive, online 

database that provides fatal and nonfatal 

injury, violent death, and cost of injury 

data from a variety of sources, including 

NCHS’ mortality data. Researchers, 

the media, public health professionals, 

and the public can use WISQARS data 

to learn more about public health and 

the economic burden associated with 

unintentional and violence-related injury 

in the United States.

Publication of 

Tabulated and 

Descriptive Analytic 

Reports

For decades, NCHS and its 

predecessor agencies published Vital 

Statistics of the United States, an annual 

collection of natality and mortality tables 

(151). Reports were also published for 

marriages and divorces. The reports, 

still available in many large public and 

university libraries, were discontinued 

as bound volumes after the 1993 data 

year. Beginning in 1994 and continuing 

through 2003, a collection of tabulated 

birth data was published in an electronic 

version of Vital Statistics of the United 

States, and is available on the Internet 

(152). The printed volumes for 1890 

through 1993 have been scanned and are 

available electronically on the NCHS 

website (151). 

NCHS analysts have written more 

than 300 reports on vital statistics for the 

dedicated report series, the National Vital 

Statistics Reports (and its predecessor 

the Monthly Vital Statistics Report) from 

1995 through Fall 2017. NCHS analysts 

have also authored dozens of descriptive, 

analytic, and methodological reports in a 

number of NCHS report series. The Vital 

and Health Statistics Reports, NCHS’ 

in-depth statistical series, include two 

components from the NVSS program, 

one on natality, marriage, and divorce, 

with 57 reports and one on mortality, 

with 15 reports. NVSS data sets are 

also described in several other Vital and 

Health Statistics series, which cover 

programs and collection procedures, 

data evaluation, and analytic and 

epidemiological studies.

Most recently, NVSS program 

analysts have prepared a large number 

of reports on vital statistics in the NCHS 

report series, NCHS Data Briefs. This 

report series has brought increased public 

attention to a variety of important health 

topics, including drug poisoning and 

overdose deaths, preterm birth trends, 

nonmarital childbearing, infant mortality, 

and teen birth rates, among others. 

Finally, NVSS staff members continue to 

publish widely in peer-reviewed scientific 

journals.

Transitioning Vital 

Statistics From a 

“Good” to a “Great” 

System

Implementing a 

Cooperative Agreement 

With NAPHSIS 

One of the mechanisms recently 

used to promote the overall effectiveness 

of the relationship between NCHS 

and NAPHSIS and to improve the 

jurisdictions’ overall performance is 

the Cooperative Agreement (153). This 

agreement, funded through NDI receipts, 

currently in effect for 2012 through 

mid-2018, has been a way to draw on the 

strengths of the state partners in forging 

stronger and more productive ties. Since 

2004, the Cooperative Agreement has 

been used to improve data quality and 

timeliness in a number of areas, including 

providing training and support for states 

to reengineer and implement the 2003 

revisions of the standard certificates, 

promoting full adoption of electronic 

birth and death registration systems, and 

developing and implementing the 2011 

revision to the Model Law. Cooperative 

Agreement funds have also been used to 

support the development of a new vital 

records security manual and to develop 

and implement web-based training for 

physicians in completing cause-of-death 

information on death records. Further, 

over recent years, NAPHSIS has drawn 

on Cooperative Agreement funds to host 

monthly national webinars with VSCP 

Project Officers to which all jurisdictions 

are invited. The webinars foster enhanced 

communication across jurisdictions 

and facilitate the exchange of ideas and 

methods.

Implementing a 

Federal–State Good to 

Great Partnership 

Background and rationale

The difficulty faced by states in 

modernizing their vital registration and 

statistical systems and in implementing 

the 2003 revisions of the birth and death 

certificates and fetal death report had 

significant, long-term consequences, 

which included major delays in data 

availability, lack of national data for 

key areas of maternal and infant health, 

reduced ability to focus on data quality 

issues, and extended diversion from 

attaining the goal of a reengineered, 

responsive, and nimble vital statistics 

system. These consequences together 

with the prospect that the situation 

would worsen led, in late 2009, to the 

development of a joint NAPHSIS/NCHS 

committee, known as the “Getting From 

Good to Great Partnership,” which 

was formally established in 2010 (83). 

The partners had ambitious goals. The 

jurisdictional representatives and NCHS 

each openly and frankly discussed their 

longstanding concerns and jointly agreed 

to establish a formal partnership to 

address them.

This initiative sparked new hope 

for a truly great national vital statistics 
Page 24  Series 1, No. 62

system. The partners met frequently in 

person and by phone and brought their 

ideas to NCHS’ Board of Scientific 

Counselors. There was a laser-like focus 

on building bridges. Some of the key 

components of the initiative included 

recognition that the jurisdictions and 

NCHS share “ownership” of the data, 

that the partnership should establish 

achievable goals, that the jurisdictions 

should be fairly compensated for their 

efforts, and that the partners would make 

themselves available to help jurisdictions 

that were facing major problems. These 

principles were reaffirmed in a webinar 

for NVSS program staff and VSCP 

Project Officers held October 8, 2014, 

and a recent annual joint meeting of the 

VSCP Project Officers and NAPHSIS 

where continuing the “Getting From 

Good to Great” committee’s activities 

was endorsed (83,154).

Development of the 

2012–2016 Contract for the 

Vital Statistics Cooperative 

Program

The 2012–2016 contract between 

the vital records jurisdictions and NCHS 

represented a dramatic change in the 

thinking and strategy underpinning all 

previous contracts (88). For decades, 

in accordance with the contracts, 

NCHS provided support to the 

states/jurisdictions for their vital statistics 

registration programs and in turn were 

provided state statistical files so that 

NCHS could produce national statistical 

files. The contracts focused on limited 

milestones (dates for deliverables) and 

were tied to the provision of specific 

items in the data sets. The contracts 

provided for limited query (i.e., quality 

control) programs, which were linked to 

NCHS-issued instructional manuals and 

handbooks that defined the general duties 

and responsibilities of those involved 

in the registration process and provided 

detailed item-by-item instructions on 

how to complete the birth and death 

certificates and fetal death report. 

(Handbooks were also produced for 

abortion, marriage, and divorce records, 

but NCHS activity in reporting these 

events in detail ended in the mid-1990s, 

as discussed above and in Appendix I.)

As the electronic registration of 

births and deaths has grown even while 

resources have shrunk, there has been 

increased recognition that the goals and 

purposes of the contracts for VSCP had 

to change as well. A fundamental change 

in the 2012–2016 contract was that it 

provided specific, measurable, and firm 

requirements that jurisdictions were 

expected to meet to be in compliance; 

these requirements were jointly agreed 

upon. Jurisdictions agreed to close their 

files and transmit their data to NCHS 

by specific dates. Over the course of 

the contract period, the dates reflected 

increasingly shorter timeframes after 

the close of a data year: For data year 

2016, for example, the birth files were 

to be complete and final by March 1, 

2017, and death and fetal death files, by 

May 1, 2017. Jurisdictions also agreed 

to have implemented the 2003 revisions 

of the birth and death certificates and 

fetal death report, and to be preparing 

the data in accordance with the coding 

rules, code structures, formats, and 

instructions that are detailed in the NCHS 

specifications for collecting and editing 

the 2003 revisions. The 2012–2016 

contract also called for jurisdictions to 

“...establish and conduct a vital records 

quality assurance program designed to 

strengthen methods and procedures used 

by local registrars, hospital personnel, 

funeral directors, and other source record 

providers...designed to monitor the 

registration system to assure a highly 

acceptable level of registration and 

item completeness as well as timeliness 

and compliance with established 

procedures” (88).

Validating and matching records 

were promoted by provisions in the 

2012–2016 contract. One specified how 

states are to match infant death and birth 

records for those infants on a current 

receipt basis and use information from 

the new item on the 2003 revision of the 

birth certificate asking if the infant is 

alive at the time of the birth registration. 

Quality control in this area was to be 

enhanced by a separate requirement, 

directing the jurisdictions to follow 

up and validate the discharge status of 

infants weighing less than 750 grams 

at birth. To enhance NCHS data on 

multiple births, jurisdictions are required 

to match multiple birth records to assure 

that each member of a multiple birth set 

is registered. In sum, the new contract 

places exceptional emphasis on data 

quality and timeliness.

The current VSCP contract covers 

the years 2017–2021. It essentially 

continues all of the elements of the 

2012–2016 contract. The timeliness 

requirements noted above for data year 

2016 (88), the last year of that contract, 

have been established as the standards for 

the entire current contract (2017–2021) 

(78,88–90,103).

Corrective action plans under 

the 2012–2016 contract

The 2012–2016 contracts included 

a provision for the development of 

corrective action plans (CAPs). As 

noted, previous VSCP contracts included 

limited requirements or enforcement 

mechanisms. Payment for data was 

generally not withheld from the states, 

although payment was sometimes 

delayed when a state’s data were 

incomplete or of questionable quality. 

During the “Getting From Good to 

Great” deliberations, NAPHSIS and 

NCHS agreed that the contract should 

include specific targets and goals and 

deadlines, progressive improvements 

in data timeliness as noted in the 

previous section, and requirements that 

jurisdictions conduct a vital records 

quality assurance program. When 

jurisdictions did not meet contract 

specifications, a CAP was required 

to assist states in meeting contract 

requirements before leveraging 

financial penalties. This notion differs 

fundamentally from the decades-long 

practice of the VSCP and represents a 

major culture shift. Many jurisdictions 

have made significant progress in meeting 

the goals of the ideal vital statistics 

system. Still, a number have not met 

the goals and, in some cases, have had 

extensive work to do to be in compliance. 

The CAP process was modified during 

the 2012–2016 contract period to include 

more frequent updates and more timely 

measurement of compliance. Two major 
Series 1, No. 62  Page 25 

areas of incomplete compliance during 

the 2012–2016 period were the transition 

to the 2003 revisions of the standard 

certificates and report and the transition 

to STEVE or a similar system for 

transmitting data to NCHS (89).

Ultimately, as of early Summer 

2017, revised birth certificate data 

have been available for all jurisdictions 

except American Samoa, while revised 

death certificate data are now available 

for all states (West Virginia revised in 

August 2017), but are not available 

for two territories (U.S. Virgin Islands 

and American Samoa); Connecticut, 

American Samoa, and the Virgin Islands 

have yet to provide revised fetal death 

report data (Tables I–III). As noted, 49 

jurisdictions are now fully compliant 

with STEVE and transmit their data 

in accordance with STEVE or an 

appropriate substitute, meaning that 

9 jurisdictions are not yet fully using 

STEVE (Figure III). Several jurisdictions 

still lack a quality assurance plan and 

struggle with ongoing timeliness issues. 

It is understood that in some cases, the 

jurisdictions lack the requisite resources 

to produce the contract deliverables and 

the state/NCHS partnership is looking for 

ways to address these needs.

At the time of writing this report, 

NCHS and NAPHSIS are engaged in 

efforts to promote measurable action by 

the jurisdictions to meet the goals of the 

2017–2021 contracts. The 2017–2021 

contract retained the use of CAPs for 

jurisdictions that have not revised, but 

CAPs were discontinued for addressing 

other deficiencies. The focus, as noted, 

is on improvements, not punishment 

(88–90). However, financial penalties 

may be imposed in the case of new 

deficiencies identified in the 2017–2021 

contract period (89).

Special projects

The 2012–2016 VSCP contract 

was also unique in the new provision 

for “special projects” (78). These are 

activities that may be funded through 

special funds to enhance the vital 

statistics system. This concept was 

developed as a way to further highlight 

the joint goals of improving data 

quality and utility in areas including 

systems development, data security, 

and innovation to enhance vital 

statistics systems. Projects could also 

include activities that would enhance 

the usefulness of vital statistics for 

emergency response reporting, public 

health program evaluation, accreditation, 

epidemiologic surveillance, measurement 

of health reform outcomes, and use of 

electronic medical records information. 

In a sense, this innovation suggests the 

concept of marketing vital statistics 

in a way that showcases the strengths 

of vital statistics for a wide range of 

activities. Specific examples of potential 

special projects include: developing and 

implementing web-based training and 

Help functions for hospital personnel to 

facilitate reporting of medical/health birth 

certificate items; developing strategies 

to maximize physician enrollment and 

use of EDRS; and providing real-time 

data, including cause of death, to NCHS 

for surveillance purposes. The extent 

and breadth of these potential projects 

make it clear that the overarching goal is 

to transform vital statistics to a “public 

health data” system where vital statistics 

data are continually improved and are 

widely valued as core components 

of public health infrastructure. The 

provision for “special projects” continues 

in the 2017–2021 VSCP contract (89,90). 

Workforce Development 

Training of new registration 

officials

During the last two decades, there 

has been a general reduction in training 

underwritten by NCHS. Training 

initiatives declined in the 1990s and in 

the first decade of the 2000s largely due 

to funding constraints. Training efforts 

are increasingly targeted to web-based 

efforts, a way to significantly reduce 

costs while making the training more 

accessible and available to prospective 

students as well as more responsive to 

changes in technology and health care 

practices. The e-learning enterprise 

described earlier for improving birth 

data quality is a prime example of the 

transition in DVS’ training options from 

in-person classes to web-based offerings 

(121). In the past, NCHS’ NVSS program 

has offered two major in-person courses 

each year, “Vital Records and Their 

Administration” and “Vital Statistics 

Measurement and Statistics.” The Vital 

Records course, a weeklong activity, 

was first offered in the late 1960s as a 

component of NCHS’ Applied Statistics 

Training Institute (ASTI). The ASTI 

program was discontinued in 1982 

because of budget limitations (1), and 

since 1982, the Vital Records course has 

been taught by NCHS staff members 

who are assisted by state colleagues. 

This course is intended to provide an 

introductory background to jurisdictional 

vital registration personnel. Topics 

include the history of the vital statistics 

system; registration issues, including 

certification and electronic verification 

procedures; confidentiality; security and 

fraud prevention; disaster recovery and 

business continuity; current legislative 

and regulatory policies, such as the 

Model Law and Intelligence Reform; and 

statistical uses of the data. To encourage 

maximum attendance and diverse 

geographic representation, the course 

has been held in 21 different cities since 

1983.

Training in statistics and 

measurement

The Statistics and Measurement 

course, also a weeklong class, was taught 

annually by NCHS’ NVSS staff members 

from the late 1980s to 2001; the course 

was next offered in 2004, and has not 

been offered since. Budget constraints 

played a role in the suspension of the 

class. 

Training on cause-of-death 

coding 

Training for nosologists played 

a prominent role in NVSS training 

activities for many years when 

nosologists were on the staffs of state 

vital statistics offices (1). It was crucial 

that their skills be maintained and that 

these medical coders were current in all 

the changes ongoing in cause-of-death 

coding, to ensure that jurisdictions could 

continue to provide quality, comparable 

coded data to NCHS. However, with 

the transfer of responsibility for coding 
Page 26  Series 1, No. 62

cause of death from the states to NCHS 

staff members, recent training activities 

have focused on these staff members. 

Staff members from the jurisdictions 

that continue to code cause of death for 

their own data sets may occasionally 

participate in this training. Currently, 

NCHS offers a 1-day refresher on quality 

control and underlying cause issues, an 

example of a targeted training effort that 

is underway to address special issues 

(e.g., issues with the data file) (57). 

Training for statisticians in ICD–10 

issues has been offered periodically. 

This training was formerly a 4-day 

activity during the transition to ICD–10 

and was offered in geographically 

diverse locations to encourage as much 

attendance by state staff members as 

possible. Currently, the training is offered 

on demand as a 1 1⁄2–3-day course, with 

the course design and length reflecting 

the interests and requests of particular 

jurisdictions (57).

As noted above, physicians have 

resisted efforts to record cause of death 

through electronic systems. The paper 

recording and lack of systematic and 

consistent reporting of cause of death 

on death certificates contributed to 

significant data quality problems with the 

statistical file. To begin to address this 

ongoing issue, the New York City Health 

Department developed an e-learning 

tool in March 2008. Subsequently, 

NVSS program senior staff members 

collaborated with New York City and 

NAPHSIS colleagues to develop a 

generic version of the video to train 

physicians in correct certification of 

cause of death. The video, completed 

in April 2011, is comprised of distinct 

modules. Since its adoption by New York 

City, Hawaii and Texas have taken the 

video and tailored it to be compatible 

with their systems. It is anticipated that 

the generic video will be revised soon, 

allowing those who complete the training 

to apply for CME credits (85).

Other Initiatives Focused 

on Improving Vital 

Statistics Data

Intelligence reform on birth 

certificate security

In the aftermath of the devastating 

events of September 11, 2001, Congress 

and the President created The National 

Commission on Terrorist Attacks Upon 

the United States (35). This blue-ribbon 

bipartisan commission was tasked with 

recommending changes to an extensive 

variety of laws and procedures that relate 

to the security of crucial legal records, 

including vital records. Among vital 

records, the birth certificate in particular 

was deemed the “breeder” document 

from which those who perpetrated the 

terrorist attacks were able to obtain 

passports and other documentation 

attesting to their legal status. The 

commission’s final report included this 

specific recommendation: 

“Secure identification should begin 

in the United States. The federal 

government should set standards 

for the issuance of birth certificates 

and sources of identification, 

such as drivers’ licenses. Fraud in 

identification documents is no longer 

just a problem of theft. At many 

entry points to vulnerable facilities, 

including gates for boarding aircraft, 

sources of identification are the last 

opportunity to ensure that people are 

who they say they are and to check 

whether they are terrorists.” (35)

On December 17, 2004, Congress 

passed the Intelligence Reform and 

Terrorism Prevention Act of 2004. The 

Act included many specific provisions, 

including Section 7211, “Minimum 

Standards for Birth Certificates,” which 

includes setting standards for document 

security, requirements for proof and 

verification of identity; and standards 

for the processing of birth certificate 

applications to prevent fraud. Because 

birth registration (like death registration) 

is a decentralized, state-based activity, 

the law’s provisions deal extensively with 

how these requirements are to be met 

in this setting (155). In response to the 

2004 legislation, CDC, working through 

NCHS, developed a Notice of Proposed 

Rule Making (NPRM) for improving the 

security of vital registration practices 

and systems in the states. The draft 

NPRM was first sent to HHS in 2007. 

Discussions and further editing of the 

NPRM have taken place since 2007 

(156). NCHS’ and other colleagues’ 

work on developing the draft NPRM 

was crucial in underpinning subsequent 

activities to revise the Model Vital 

Statistics Act and Regulations (described 

below) to focus on improved security and 

emerging technologies (155,156). The 

draft NPRM has not been implemented.

Model Vital Statistics Act and 

Regulations

The Model State Vital Statistics Act 

and Regulations (known as the Model 

Law) were developed to serve as models, 

with a practical focus, for states to use in 

preparing their own laws and regulations 

for vital event registration. The Model 

Law has been revised five times since it 

was first issued in 1907. The most recent 

law was issued in 1992 (157). Over the 

years, the Model Law has been designed 

to improve the quality and uniformity 

of state data by establishing standard 

reporting requirements, definitions, and 

procedures for registering vital events. 

This impacts how vital statistics data are 

collected, reported, and disseminated at 

the state level, thus affecting national 

vital statistics data sets produced by 

NCHS.

The sixth (2011) revision of the 

Model Law was initiated in 2009 with 

the establishment by the NCHS Director 

of an eight-member working group 

comprised of seven vital statistics experts 

from seven jurisdictions and an attorney 

with extensive experience in public 

health law and the vital statistics system. 

As was the case for previous revisions 

of the Model Law, NCHS provided 

resources for travel and logistics and 

staff support for the working group’s 

activities. The working group had several 

major goals for the 2011 revision, 

including providing guidance for vital 

event registration, issuance, security and 

fraud prevention, data disclosure, and 

protection of confidential information 
Series 1, No. 62  Page 27 

in an electronic environment. As noted 

above, the security and fraud prevention 

concerns were the aftermath of the tragic 

events of September 11, 2001. The 

working group strengthened the wording 

of the Model Law to improve clarity 

and specificity, and in some cases to 

update language, particularly with regard 

to electronic registration and issuance. 

The working group also developed 

approaches to dealing with significant 

changes in medical technology, health 

care, and the law that can impact the 

registration of vital events. These 

include such developments as civil 

unions, same-sex marriages, surrogate 

mothers, and paternity acknowledgments, 

as well as issues around continuity 

of operations in an emergency that 

compromises electronic systems. The 

states or jurisdictions are using the 

2011 Model Law revision to make 

changes to their procedures, especially 

to provide guidance on how state laws 

might be changed to handle security and 

technology issues (158–160).

Envisioning the Future 

of Vital Statistics 

The National Vital Statistics 

System has experienced many amazing 

and remarkable changes and has also 

confronted some major challenges over 

the past two decades. The system has 

evolved in noteworthy ways. Starting out 

in the mid-1990s was the anticipation of 

an evolution to a fully automated system 

incorporating elements of electronic 

registration for births and deaths and 

real-time editing data at the source. 

The existence and even persistence of 

a paper-based registration system was 

acknowledged, but it was also recognized 

that the system had to move forward to 

incorporate strategies that would improve 

data quality and timeliness through 

transforming the legacy registration 

systems then in existence in the states 

and the outmoded processing systems 

ongoing in NCHS. Both state and 

national systems needed to be fully 

reengineered. The very culture under 

which the systems were operating had to 

be fundamentally altered to ensure the 

success of the revolutionary changes that 

were needed.

Looking forward over the next 

several decades, current vital statistics 

leadership and their staff members 

may wish to explore a number of areas 

that will impact the success of these 

efforts. The current revisions of the U.S. 

Standard Certificates of Live Birth and 

Death and the Report of Fetal Death 

were implemented beginning in 2003. 

Following typical past practice, it would 

be time now to be exploring another set 

of revisions. However, an underlying 

concept for the 2003 revisions was 

that the systems would be flexible so 

that items could be added, dropped, or 

modified to meet new needs. Items have 

been dropped from the birth and fetal 

death data sets, as described in the section 

on the Birth Data Quality Workgroup 

(56,118–120) and in Appendix V. 

However, adding and revising items is 

more complex than originally anticipated. 

As it turned out, the new registration 

systems developed in the jurisdictions 

are not readily adaptable and changes 

are costly and time-consuming. Would 

future vital statistics executives want to 

consider tasking a single vendor with 

developing (generic) birth and death 

registration systems that could be easily 

customized by individual jurisdictions 

as needed? Would the requirements for 

such systems include that they be flexible 

and adaptable to new needs? Recall 

that the vision of the MoVERS effort at 

the beginning of the 21st century was 

exactly this: that a single system could be 

developed that would accommodate 80% 

of the needs of all jurisdictions, and that 

the remaining 20% of unique needs could 

be taken care of by each jurisdiction. 

Extensive efforts were expended 

to respond to the targeted language in 

the Intelligence Reform and Terrorism 

Prevention Act of 2004. The draft Notice 

of Proposed Rulemaking focused on 

data security and birth certificate fraud 

prevention. After all, the terrorists of 

September 11, 2001, were able to use 

(fraudulently obtained) birth certificates 

to establish identities and obtain 

passports. The 2011 Model State Vital 

Statistics Act and Regulations expended 

significant effort on focusing states’ 

attention on improving the quality and 

uniformity of state data. These goals 

would be achieved by establishing 

standard reporting requirements, 

definitions, and procedures for registering 

vital events. These activities impact 

how vital statistics data are reported and 

disseminated at the state level, which in 

turn impacts NCHS’ national data sets. 

Neither of these efforts was ultimately 

successful, at least not to date. But, 

can any of the comprehensive work on 

Intelligence Reform and the Model Law 

be revisited and used as the basis for 

changes and improvements in the existing 

systems and in future systems? Should 

the Model Law be revisited and reviewed 

on a regular basis to ensure that it is 

continually responsive to emerging legal, 

medical, and societal changes?

The Cooperative Agreement 

between NCHS and NAPHSIS to 

support a variety of activities intended 

to improve data quality and timeliness 

has been an important ongoing activity. 

Should NCHS and NAPHSIS take 

another look at the agreement and see 

if it should be modified to reflect new 

needs of the jurisdictions, advances 

in their ability to meet the new VSCP 

contract requirements, or new initiatives 

in training, to mention a few areas? 

Alternatively, should the agreement 

be restructured to reflect more of an 

exchange of mutual support in a variety 

of areas, including state outreach and 

technical assistance? Or are there other 

ways the agreement can be strengthened 

to improve its usefulness to the 

jurisdictions and NCHS?

As registration systems and public 

health needs evolve quickly, it may 

be that training opportunities need to 

be expanded accordingly. NCHS has 

assumed responsibility for coding cause 

of death for the national statistical files. 

Yet, some jurisdictions are still interested 

in retaining this skill by having trained 

nosologists on staff. Should consideration 

be given to having NCHS provide this 

training support on a more routine basis? 

Along these lines, could NCHS provide 

useful support to state statisticians in the 

use of ICD–10 (and revisions) to improve 

their analytic capabilities?
Page 28  Series 1, No. 62

As the demands for improving data 

quality and timeliness persist, would 

it be helpful if quality scores were 

developed so that states could see how 

their performance ranks compared with 

their peers? Quality scores could be 

developed for births and deaths. Would 

this be a beneficial effort? One area of 

quality that has continued to be a concern 

is that of the geographic data in the vital 

statistics files. The availability of detailed 

birth and death data for geographic areas 

is one of the unique attributes of the data 

system. The availability of geographic 

detail for every birth and death and fetal 

death opens up the data files to in-depth 

research on factors such as environmental 

influences on births and deaths, on the 

role of socioeconomic considerations in 

exploring disparities, and other areas. 

The state and county of occurrence and 

state and county of residence of births 

and deaths are well reported on vital 

records, but the same cannot be said with 

confidence of the city/town of residence 

information. Data quality varies widely. 

NCHS and state colleagues have long 

explored ways to improve these data. 

One avenue for improvement might be 

address-based geocoding, performed as 

data are received, not after the data year 

has ended, as is often the case now. If 

the quality of the geographic data for 

cities and towns could be significantly 

improved, this would contribute to 

improved value of the data for health 

care program efforts and evaluation 

and surveillance. Concerns about 

data confidentiality would need to be 

addressed, but success in this area would 

expand data value immeasurably.

With the shortened timeframe 

between the end of a data year and the 

availability of preliminary files, an 

important issue has arisen concerning 

the availability of timely population 

estimates for population-based birth and 

death rates. Preliminary and provisional 

(rapid-release) vital statistics files 

are becoming timelier and release of 

these data reports depends on reliably 

available population data. Another issue 

to keep in mind is that as all states fully 

implement the 2003 revisions, NCHS 

may discontinue the use of bridged-race 

population estimates and of bridged-race 

birth and death data. This means that 

discontinuities in the population-based 

rates by race and ethnicity will need to be 

addressed.

Looking further, what is the potential 

role for EHRs in vital statistics? Many 

questions remain and much work is 

needed to fully assess whether the EHR 

is compatible with the vital statistics 

system. Do we see the EHR as a 

“feeding” system into birth registration 

or as a component of an electronic 

birth registration system (161)? In the 

case of death registration, the EHR is 

being used as a gateway to the EDRS 

(i.e., physicians can complete death 

certification using a screen within the 

EHR that mirrors the EDRS, using 

information in the EHR to inform their 

certification). However, cause-of-death 

data fields in the EDRS are not being 

automatically populated using data fields 

in the EHR (162–163). Two projects have 

been funded by NCHS to advance the 

EHR to a vital records system initiative. 

In one project, Minnesota evaluated the 

readiness of the Minnesota Department 

of Health and Minnesota birth hospitals 

to adopt and implement secure, 

standards-based exchange of birth record 

information using the vital recordsrelated electronic standards developed by 

Health Level Seven International (HL7) 

and Integrating the Healthcare Enterprise 

(IHE). HL7 and IHE are standards 

development and standards-related 

organizations. Utah provided support 

for the second project by participating 

in trial implementation activities with 

EHR and vital record systems vendors 

to test the IHE and HL7 birth and death 

standards. The effort for standardized 

birth reporting has been limited to the 

medical and health items collected on the 

national version of the Facility Worksheet 

for the Live Birth Certificate, not the 

demographic items.

If fully exploited, the use of EHRs 

in this way could reduce errors and 

redundancy in data collection and reduce 

costs for hospitals and jurisdictions. 

To fully engage interested parties, 

though, it will be necessary to document 

improvements in these areas, especially, 

for example, in cost reduction. The 

potential benefits are being explored 

through a variety of activities in 

collaboration with the standards 

development and standards-related 

organizations HL7 and IHE. Wider 

testing and evaluation will be needed 

to assess data quality, and revisions to 

the standards may be needed based on 

these activities. National certification of 

systems is being contemplated to ensure 

that systems are standardized as much 

as possible and are working properly. 

Most importantly, additional resources 

and a strong communications effort will 

be needed to fully implement this effort 

(122,161–163).

The NVSS surveillance capacity 

is now being recognized at the federal 

and state levels. The mortality and, most 

recently, natality and infant mortality 

surveillance initiatives have clearly 

demonstrated the value of NVSS in 

meeting some of the surveillance needs 

of federal programs. The results of 

the NVSS surveillance work will no 

doubt greatly expand the utility of vital 

statistics data in ways not yet foreseen. 

And by focusing resources on improved 

timeliness, continued improvements in 

data quality can be expected.

The inauguration of the NVSS Rapid 

Release data program has coincided 

with growing attention to and concern 

about specific causes of death that 

have increased rapidly in recent years, 

including external causes such as drug 

overdoses. These data, now available for 

the 12-month period ending in March 

2017, document the substantial increases 

in drug overdoses across the United 

States and in many states (164). The 

Rapid Release program will continue to 

make it possible to highlight the most 

current data that describe trends and 

patterns in this and other critical public 

health areas.

The content of the revised birth and 

death certificates suggests numerous 

areas where the vital statistics data sets 

can be very useful in understanding a 

variety of aspects of health and health 

care (e.g., to reduce early elective 

deliveries). For the birth data, there 

are items on the source of payment 

(165), receipt of WIC food (166), use of 

infertility services (167), prepregnancy 

weight and weight at delivery (used 
Series 1, No. 62  Page 29 

to compute weight gain) and height to 

measure body mass index (BMI) (166), 

gestational age (113), and smoking 

prevalence and cessation during 

pregnancy (168). In addition, growing 

interest in linking vital records data with 

survey and other health data can enrich 

the value of NVSS. In all these areas, of 

course, it is essential that linked data sets 

be developed with meticulous attention to 

maintaining confidentiality of the highly 

sensitive data.

One thing is clear: NVSS is a 

national treasure, providing the primary 

data on family formation, maternal 

and infant health, infant and perinatal 

mortality, life expectancy, and causes of 

death, as well as serving as the building 

blocks for estimating the growth and 

characteristics of the U.S. population. 

Vital statistics data are unique because 

they are available for every one of the 

approximately 6.5 million vital events 

that are registered annually. Thus, trends 

and variations by a wide variety of 

population characteristics and for detailed 

geographical units can be studied. Basic 

reporting completeness is generally 

high because of strong incentives for 

individuals to have the facts of births 

and deaths in their families accurately 

reported. These data, however, do not 

“fall from trees.” The systems that 

underlie the data and the organizations 

that support the data collection must 

be continually nurtured to ensure the 

continuity and steady improvement of 

this primary source of health information 

for the country.

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Series 1, No. 62  Page 37 

Table. Vital statistics history timeline, 1940–2017

Year(s) Description

1940–1959

1946 Federal functions in vital statistics were located in the Federal Security Administration, which established the National Office 

of Vital Statistics in the Public Health Service. 

1950 Federal and state health agencies began focusing increased attention on data quality and enhanced uses of vital records. 

1953 The Department of Health, Education, and Welfare, newly formed, was given authority for federal functions in vital statistics.

1955 The first standard records of marriage and divorce or annulment were recommended to the states. 

1960–1969

1960 The National Office of Vital Statistics merged with the National Health Survey to establish the National Center for Health 

Statistics (NCHS).

1960 The first linked birth/infant death data set was created for the birth cohort of 1960, with 97.4% of the 110,000 infant deaths in 

that year matched with their birth certificates. 

1961–1968 National Mortality Surveys, known as “followback surveys” and anchored to vital records, were conducted annually, and 

included information on hospitalizations, diagnoses, health insurance, smoking habits, and a variety of demographic 

characteristics.

1963–1969 National Natality Surveys were conducted annually. These surveys are also referred to as “followback” surveys and are 

anchored to vital records. They include information on the mother’s medical care, education, marriage, health insurance, 

household composition, and religion, among other topics. 

1964–1966 National Infant Mortality Surveys were conducted annually.

1964–1968 The third nationwide study of birth registration completeness conducted by the Census Bureau with the cooperation of 

NCHS and state vital registration officials found that birth certificates were on file for more than 99% of children born during 

1964–1968.

1967 The Applied Statistics Training Institute, established in NCHS’ Office of State Services, provided leadership in training public 

health statisticians from 1967 to 1982. 

1968 The Automated Classification of Medical Entities was launched, to select underlying cause of death, replacing manual 

selection by a nosologist.

1968 Revisions of standard certificates of birth and fetal death included items on educational attainment, dates of previous 

pregnancy outcomes, prenatal care information, and several medical items. Standard certificates were first issued in 1900; 

multiple revisions have been issued since, about once each decade.

1968 The second volume of Vital Statistics Rates in the United States was issued for 1940–1960. The first volume, covering 

1900–1940, was issued in 1947.

1968 The earliest year for which electronic data tapes of natality, fetal death, marriage, and divorce statistics, as well as 

demographic, underlying-cause, and multiple-cause mortality statistics, were available for purchase. Tapes were initially 

sold by the National Technical Information Service.

1970–1979

1970 The Health Services Improvement Act of 1970 authorized the Secretary of the Department of Health, Education, and 

Welfare to design and implement a cooperative system for producing health information and statistics at the federal, state, 

and local levels.

1971 NCHS began to accept magnetic tapes of state-coded birth and death certificate data, coded according to NCHS 

specifications. Florida was the first state to provide the electronic data.

1973 The Vital Statistics Cooperative Program (VSCP) was inaugurated as the first component funded under the Improvement 

Act of 1970. Six states had contracts with NCHS’ Division of Vital Statistics to provide computerized birth and death data 

under the VSCP.

1973 The National Survey of Family Growth (NSFG) was launched to provide information explaining trends and variations in birth 

rates and family formation based on confidential interviews with women of childbearing age. 

1978 The Apgar score was added to the birth certificate. The question on infant’s “legitimacy” status was changed to mother’s 

marital status. 

1978 A new form, “U.S. Standard Report of Induced Termination of Pregnancy,” was recommended to states for reporting all 

induced terminations of pregnancy (abortions), regardless of length of gestation.

1980–1989

1981 The National Death Index (NDI) was implemented as a centralized database of death record information, with deaths in 

1979 from 46 participating registration areas. By the end of 2017, the NDI database included approximately 93 million 

records.

1983 The linked birth/infant death data file was created for the 1983 birth cohort, inaugurating a series of crucial research files 

that continues to the present. The file for 1983 included deaths of infants born in 1983 who died before their first birthday in 

either 1983 or 1984. The linked file data set facilitates analysis of the maternal and infant factors that affect infant survival. 

1985 NCHS’ Division of Vital Statistics analysts created and published the first series of estimated pregnancy rates for the United 

States. The rates combine birth data from the National Vital Statistics System (NVSS), fetal loss estimates from NSFG, and 

abortion estimates from CDC and the Alan Guttmacher Institute. The series currently extends from 1976 through 2010.

Table
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Table. Vital statistics history timeline, 1940–2017—Con.

Year(s) Description

1980–1989—Con.

1988 The National Maternal and Infant Health Survey (NMIHS) in 1988 included women with a live birth as well as women with 

a fetal loss or infant death. NMIHS also featured a Longitudinal Followup in 1991 to capture additional information on the 

1988 participants. The 1988 Survey and followup are the last “natality” followback surveys conducted by NCHS.

1989 U.S. Standard Certificates of Live Birth and Death, the Standard Report of Fetal Death, the Standard Reports of Marriage 

and Divorce (or Annulment), and the Report of Induced Termination of Pregnancy were revised, becoming effective in 1989. 

An item asking for Hispanic origin (e.g., parents, decedent) was added to the 1989 certificates. 

1990–1999

Early 1990s The vital statistics system faced major resource challenges. These importantly affected NCHS’ ability to maintain the 

national data sets through the VSCP, the mechanism NCHS used to support the states for collecting, compiling, and 

disseminating vital statistics data. Funding during these years was significantly unstable for the jurisdictions and NCHS. 

1992 The most recent Model State Vital Statistics Act and Regulations, known as the Model Law, was enacted in 1992 and 

adopted by the states in 1995.

1992–1994 NCHS suspended the production of the cohort linked birth/infant death data set due to severe resource challenges. The 

cohort file was resumed in 1995.

1993 NCHS conducted the 1993 National Mortality Followback Survey, the last such survey conducted to date. While there has 

been periodic interest in reviving followback surveys, especially for deaths, the costs are prohibitive. 

1993–1994 NCHS published initial reports from the Mortality Surveillance System (MSS). MSS is based on data from the Current 

Mortality Sample (CMS), a 10% sample of death records. CMS data, initially dating back to 1943, were published monthly 

about 4 months after the main month of occurrence of deaths. The CMS data continued to be the basis for more timely 

mortality data until the preliminary data series was launched in 1996. 

1994 The planning phase for review and evaluation of 1989 Standard Certificates was launched with a Panel to Evaluate the 

Certificates appointed by state registration executives and Division of Vital Statistics leadership. The Panel included 

medical and health experts and was supported by NCHS staff members. The Panel agreed to review and revise only the 

birth and death certificates and fetal death report. The marriage, divorce, and induced termination of pregnancy forms were 

not to be revised.

1994 NCHS discontinued collecting data on induced terminations of pregnancy; the last year of data collection was 1992, but 

these data were not processed after 1988.

1994–1995 NCHS dropped the date of the mother’s previous live birth from the birth certificate in 1994 and the 1-minute Apgar score in 

1995. Education of father was dropped in 1995. Information on autopsy and information on occupation and industry of the 

decedent were dropped from the death certificate.

1994–1995 NCHS joined with state registrars (the National Association of Public Health Statistics and Information Systems) in an 

intense effort to improve the timeliness and quality of death registration data through the development of an electronic 

death registration system (EDRS). 

1994–1999 The concept of electronic death registration continued to be a focus of state and federal health officials during 1994–1999, 

with the first EDRS dating back to 1999.

1995 NCHS discontinued the collection of individual record data for marriages and divorces. NCHS published the last reports for 

these data sets for the 1989 and 1990 data years. These decisions in the first half of the 1990s were made to meet NCHS’ 

priorities for the birth, death, and fetal death data.

1995 The period linked birth/infant death data file was launched and became the basis for NCHS’ official infant mortality statistics. 

The 1995 file includes births and deaths in 1995. The period file can be released more quickly than the cohort-linked file. 

The cohort file has been produced annually, except for 1992–1994.

1996 A new program of preliminary data releases for births and deaths was inaugurated. The first report, including both births and 

deaths, was published in October 1996, covering data for 1995. This series was published semiannually and annually for 

several years. The preliminary reports were not accompanied by a file release. The preliminary series continued for birth 

data through 2015, with annual releases coming within about 5 months of a data year. 

1998 The Current Mortality Sample, launched in 1943, was discontinued in 1998. The preliminary data series is seen as providing 

more useful, detailed, and timely information on emerging mortality patterns.

1998 The Panel to Evaluate the U.S. Standard Certificates and Reports met to establish evaluation objectives: review current 

certificates and assess usefulness of existing items and how data quality can be improved; identify unmet data needs 

to see if standard certificates are the most appropriate place to collect these data; and make recommendations for 

the content, format, and standard definitions of the proposed certificates that would rely on electronic, automated data 

collection.

1998 Widespread concerns about birth data quality led to the creation of a Working Group to Improve the Quality of Birth Data. 

The group concluded that vital statistics birth data quality had declined in the 1990s “associated in part with the electronic 

registration of vital events.” This was an important factor in the deliberations of the Panel to Evaluate the U.S. Certificates 

and Reports. 

1998–1999 The Panel to Evaluate the U.S. Standard Certificates and Reports met seven times to deliberate and make 

recommendations. Race, ethnicity, and educational attainment items were revised to match the new data collection 

methods adopted by the Census Bureau for this information. New items were added to the certificates, reflecting emerging 

public health information needs, and many items were modified to enhance data quality. The Panel recommended 

standardized definitions, editing procedures, and instructions, and other initiatives to respond to concerns detailed in the 

1998 Working Group report. 

1990s to early 2000s The matched multiple birth file, which includes matched sets of twins, triplets, and quadruplets in live births and fetal deaths 

and infant death records for babies who died, was developed. Because of confidentiality concerns with respect to small 

numbers of multiple births, some data fields were suppressed and no geographic identifiers were shown. The currently 

available file includes events for 1995–2000.
Series 1, No. 62  Page 39 

Table. Vital statistics history timeline, 1940–2017—Con.

Year(s) Description

2000–2009

2000 The revised birth certificate and fetal death report forms and their associated worksheets were tested in NCHS’ 

Questionnaire Design Research Laboratory with recent mothers. Testing activities for the death certificate included three 

focus groups with funeral directors and a small focus group with physicians and coroners. The fetal death report was 

evaluated by a group of physician experts on maternal-fetal medicine.

2001 The Panel to Evaluate U.S. Standard Certificates and Reports issued their final report, which included recommendations for 

content and format of revised birth and death certificates and the fetal death report.

2001 The 9/11 terrorism attack led to changes in priorities in vital statistics data collection and renewed attention to the security of 

vital records.

2002 NSFG began including men aged 15–44 in the sample.

2002 The first functional EDRS was developed in New Hampshire in 2002. While funeral directors adopted the electronic systems 

effectively, physicians and other medical officials were slower to certify deaths electronically. 

2002 “Test decks” to review the electronic output from the revised birth and death registration systems were developed. The test 

decks would be useful for the foreseeable future for registration areas to assess whether modified registration systems 

were still operating as envisioned.

2002–2003 The Model Vital Events Registration System (MoVERS) initiative was launched to reengineer the country’s vital statistics 

system. NCHS, the Social Security Administration, and the National Association for Public Health Statistics collaborated 

on the MoVERS project. The intended products were national standards and protocols, web-based technology, automation 

at the source, implementation of the revised certificates, and the adoption of NCHS’ edit specifications for electronic 

systems. MoVERS focused initially on developing system functionality requirements for registering vital events, with a goal 

to define requirements for a generic system for a typical jurisdiction that would meet about 80% of its needs. Ultimately, the 

MoVERS project developed functional requirements for births and deaths. 

2003 Following an extended Department-wide comment period, the Secretary of Health and Human Services formally 

recommended that the registration areas adopt the revised birth and death certificates and fetal death report in November 

2003; the revisions are officially referred to as the 2003 revisions. 

2003 The revised birth and death certificates and revised fetal death report included significant advances in data content, 

enhancing their usefulness in maternal and infant health and public health research. 

2003 Questions on the revised birth certificate on prenatal care, maternal smoking, and method of delivery facilitate more 

understanding of the relationships between these factors and maternal and infant health outcomes. New data are also 

collected on source of payment for the delivery, obstetric procedures, maternal morbidity, pregnancy and birth intervals, 

and maternal infections. 

2003 The revised death certificate asks for more information on injury-related deaths, if tobacco use contributed to the death, 

and for female decedents, whether she was pregnant within the year up to death. Changes in the revised fetal death 

report were similar to those in the birth certificate; additionally, the cause of fetal death item was significantly redesigned to 

improve the quality and specificity of the information collected. 

2003 Adoption of the revised certificates was very limited. Only Pennsylvania and Washington implemented the revised birth 

certificate. Five jurisdictions (California, Idaho, Montana, New York, and New York City) implemented the revised death 

certificate, and Michigan and Washington implemented the revised fetal death report. 

2003 Resource limitations and other challenges precluded universal implementation of the revised certificates by all registration 

areas on a standard schedule. The protracted implementation of the revised certificates was unprecedented in the history 

of the adoption of revised standard certificates.

2003 Population-based rates by race for births and deaths are based on bridged-race data, to allow comparisons among states 

that have and have not revised their certificates to collect multiple races. The intent is to discontinue these rates when all 

states have transitioned to multiple-race reporting on the birth and death certificates. 

2003 Revised trend series for birth and death rates for years beginning with 1990 that incorporate revised bridged-race population 

estimates for these years through the early 2000s were published; this series continues to the 2016 data year. 

2003–2015 Phased implementation of the revised birth and death certificates further complicated file production and data analysis 

because in some cases, states adopted the revised race (multiple-race) and Hispanic origin questions independently of 

implementing the remaining content on the certificates. File sizes increased substantially. 

2003–2016 The protracted implementation phase for the revised certificates resulted in ongoing negative consequences for producing 

these data files. Throughout this period, the files had to incorporate data in varying formats, variable response categories, 

and incompatible data elements. For many key measures, it was not possible to produce national statistics or to interpret 

national trends because the revised reporting areas changed every year during this period. 

2003–2017 Production of complete birth and death data sets was compromised because the 2003 revisions of the birth and death 

certificates had not been adopted by all states. As of the 2006 data year, just 19 states had implemented the revised birth 

certificate, rising to 35 states and the District of Columbia (D.C.) in 2010, 49 states and D.C. in 2015, and 50 states and D.C. 

in 2016. Similarly, implementation of the 2003 revision of the death certificate was significantly delayed, with 21 states and 

D.C. revising as of 2006, 34 states and D.C. in 2010, 48 states and D.C. in 2015, and all 50 states and D.C. in 2017. 

2004 The 9/11 Commission Report included a recommendation that “the federal government set standards for the issuance 

of birth certificates and sources of identification, such as drivers’ licenses.” The NVSS program led an interagency and 

interdepartmental effort to develop a strategy to address this recommendation.

2005 The National Association for Public Health Statistics and Information Systems (NAPHSIS) voted to withhold permission from 

NCHS to include the new data items in the national data sets, especially impacting the birth data file. NAPHSIS leadership 

believed that NCHS should materially support the collection of the new items. This restriction challenged NCHS’ ability to 

“market” the new data items and potentially reduced possible interest in these items. This issue was ultimately resolved in 

2013, and NCHS was able to disseminate the revised and new data for years 2009 and forward. 
Page 40  Series 1, No. 62

Table. Vital statistics history timeline, 1940–2017—Con.

Year(s) Description

2000–2009—Con.

2006 NCHS advised registration areas and data users that state-specific data on several key items on the 2003 and 1989 

revisions could not be combined to produce national estimates. These items included race of parents and decedent and 

educational attainment of the parents and decedent. Items on prenatal smoking, prenatal care, and method of delivery 

on the birth certificate also differed significantly in 2003 compared with 1989. Beginning with the 2004 data year, NCHS 

reported these measures separately for revised (i.e., based on the 2003 revision) and unrevised states. The lack of national 

data for these measures significantly compromised the value of the information. 

2006 NSFG became a continuous survey, with about 5,000 men and women aged 15–44 interviewed each year. The first data set 

from continuous interviewing covered 2006–2008 and was released in May 2010. A 4-year file covering 2006–2010 was the 

largest ever. It included 22,682 men and women and was released in October 2011. 

2006–2012 VSCP funding challenges threatened the security and long-term stability of the vital statistics system. Options that were 

considered to address these challenges included further reductions in the basic or core data sets and reliance on 

alternative funding sources to support other data collections. These resource and funding challenges exacerbated relations 

between NCHS and the states.

2007–2012 A “catch-up” program to process and publish fetal death data sets was implemented. Substantial cuts were made in the data 

elements, including removing all noncomparable data (i.e., not comparable between the 1989 and 2003 revisions). The 

resulting files for data years 2007–2012 were released from September 2013 through April 2014.

2007 to present The reNVSS program (reengineered National Vital Statistics System) was launched in 2007. The immediate impetus was 

CDC’s closing down the legacy “mainframe,” which meant that processing systems for vital statistics data had to be 

reengineered. Staff members are now able to review and analyze the data on a daily basis, using statistical “cubes.” The 

reviews include frequent interactions with state colleagues, facilitating more responsive and effective processing and 

quality assessments.

2009 NAPHSIS began testing the State and Territorial Exchange of Vital Events (STEVE) data transmission system whereby 

states could submit their vital statistics data to NCHS. NAPHSIS owns STEVE, which is described as an “innovative 

messaging application for the electronic exchange of vital event data across jurisdictions.” 

2010 to present

2010 NCHS and NAPHSIS joined forces in establishing a “Getting From Good to Great Partnership.” The goals are to address 

persistent funding and data quality issues as well as the need to acknowledge the distinct and unique roles and 

responsibilities of the partners. 

2011 NVSS staff began to code cause of death for all deaths in the United States. This decision, in large part, reflected the 

decline in the number of trained nosologists. National statistics are now all based on NCHS-coded information, although 

some states still do their own coding for their own purposes.

2011 NAPHSIS adopted the 2011 Revision of the Model State Vital Statistics Act and Model State Vital Statistics Regulations on 

June 8, 2011.

2012 NCHS and the states embarked on a new 5-year contract for VSCP for the years 2012–2016 that included specific, 

measurable requirements for data quality and timeliness. This contract requires states to use the STEVE data transmission 

system or a comparable system when submitting their data to NCHS.

2012 A new program of mortality surveillance was launched with twin goals: (a) identify potential data problems as soon as 

possible and communicate with state and federal colleagues in a position to correct the problem(s), and (b) identify public 

health concerns and communicate these to appropriate public health partners.

2014 The measurement of gestational age transitioned from the first day of the mother’s last normal menstrual period to the 

“obstetric estimate,” a new item on the 2003 revised birth certificate. 

2014 The first NDI Early Release file became available in July 2014. The file covered deaths for 2013 and contains demographic 

information but not cause of death. Cause information was added when the final statistical file was released. 

2015 The Vital Statistics Rapid Release (VSRR) program, representing an effort to release quarterly data on important health 

indicators on an accelerated schedule, was inaugurated. Mortality data are the first to be released in this new system. 

VSRR reports for births were added to the system later in 2016. The launch of this VSRR signals the phasing out of the 

preliminary birth and death data reports, to be replaced by VSRR data releases. 

2015 NCHS’ Division of Vital Statistics and Classifications and Public Health Data Standards staff began working with NAPHSIS, 

state representatives, and other vital records stakeholders to develop vital records standards to enable interoperable 

electronic data exchanges among electronic health record systems, U.S. vital records systems, and potentially other public 

information systems for birth, death, and fetal death events. NCHS supports state pilot testing and trial implementation.

2015 The age range for NSFG was expanded from 15–44 to 15–49 years.

2016 The report of preliminary birth statistics was discontinued, with the last report published on 2015 births (report released in 

June 2016). The reports of preliminary mortality statistics were discontinued after the 2011 data year; the report for 2011 

was published in October 2012. The most timely birth and death data are now published in the VSRR program.

2016 Cause-of-fetal-death data from the revised fetal death report were released for the first time. Data are from the 2014 file, for 

37 jurisdictions, and show that 5 causes account for about 90% of fetal deaths in the reporting area.

2016 The e-learning training, “Applying Best Practices for Reporting Medical and Health Information on Birth Certificates,” was 

developed and disseminated. The training was designed for physicians, nurses, and nonclinical staff at hospitals and other 

facilities who are responsible for completing the medical and health information on the birth certificate and fetal death 

report.

2017 As of early 2017, states were required to use STEVE (version 2.0) or an alternative system approved by NCHS to submit 

their data to NCHS. 
Series 1, No. 62  Page 41 

Table. Vital statistics history timeline, 1940–2017—Con.

Year(s) Description

2010 to present—Con.

2017 Population-based rates by race and Hispanic ethnicity transitioned from bridged race to single race. Vital rates for the years 

2000–2015 were initially published for bridged-race categories that were consistent across jurisdictions and time. Rates 

for single-race groups began with the 2016 data year, published in 2017, and bridged- and single-race rates for 2016 were 

published in 2017 to facilitate trend analysis. 

2017 Quarterly provisional birth and death data from VSRR began to be released within 5 months of the end of a data collection 

period. Quarterly provisional infant mortality estimates were released within 12 months of the end of a data collection 

period. Trends in selected “high-profile” measures are informed by very current VSRR data.

2017 NSFG published the first report from 2011–2015 continuous interviewing. The first release highlights data on teen sexual 

activity and contraceptive use. The trends help explain the ongoing steep decline in U.S. teen birth rates, continuing to 

showcase the role of NSFG in explaining fertility trends and differentials.
Page 42  Series 1, No. 62

Appendix I. Initial Decisions in the Mid-1990s to Address Resource 

Limitations in the National Vital Statistics System

Items Dropped From 

Data Sets

By the mid-1990s, the funding 

situation for the National Center for 

Health Statistics (NCHS) had worsened, 

and the consequences for NCHS’ ability 

to produce and disseminate national data 

sets for births, deaths, and fetal deaths 

as well as for marriages, divorces, and 

induced terminations of pregnancy 

(abortions) were severe (4,36). Initially, 

NCHS dropped some items from the birth 

and death data sets, including for births, 

the date of the mother’s previous live 

birth (dropped in 1994), information that 

was useful in tracking trends between 

successive births, especially for high-risk 

women; and the 1-minute Apgar score 

(dropped in 1995). Similarly, NCHS 

discontinued the collection of the father’s 

educational attainment in 1995. Along 

with mother’s educational attainment, 

these items are considered among the 

best measures of socioeconomic status 

(36,169). These items were not reinstated 

until the content of the 2003 revision of 

the birth certificate was fully incorporated 

in NCHS’ birth data sets in 2009, 

although full adoption of the revisions 

by all jurisdictions is nearly complete 

(Tables I–III) (37,67,68). Information 

on autopsy was dropped from the death 

certificate, but was later restored when 

the 2003 revision of the death certificate 

went into effect (4). Further, information 

on occupation and industry of the 

decedent was eliminated as a reportable 

item on the death certificate.

Collection of Abortion, 

Marriage, and Divorce 

Data Ended 

To meet its contractual obligations 

to states, NCHS discontinued altogether 

the collection of individual record data 

on induced terminations of pregnancy 

(i.e., abortions) in 1994 (the last data 

year collected was 1992 but data sets 

were not processed for any year after 

1988) (4,38). When NCHS decided to 

end its collection of abortion data, 14 

states were providing detailed individual 

record data on abortions to NCHS. The 

data collection had begun with five states 

in 1977 and grew to eight states in 1978, 

and the findings were published (42). 

The last NCHS report on this data set 

was based on abortions in 1988 (43). 

With this decision, the availability of 

abortion information in the United States 

was relegated to two principal sources—

the Guttmacher Institute and the CDC 

Abortion Surveillance System (44–46). 

While the report of induced termination 

of pregnancy (ITOP) was not considered 

for revision when the Panel to Evaluate 

the (1989) U.S. Standard Certificates (3) 

was considering revisions to the birth and 

death certificates and fetal death report, it 

should be noted that the ITOP reporting 

form was modified. CDC’s Division of 

Reproductive Health convened a working 

group of experts who recommended 

that the form be modified to include an 

option to report a medical or nonsurgical 

abortion procedure (170). This change 

was recommended to the states in 

December 1997 (3).

NCHS funding constraints also led 

to the discontinuation of the collection 

of individual record data for marriages 

and divorces after 1995 (39). These 

decisions were made to meet NCHS’ 

priorities within the National Vital 

Statistics System for birth, death, and 

fetal death data. NCHS acknowledged 

the importance of data on marriage 

and divorce (1,36), but felt that other 

data sources could be drawn on for 

this information, including the Current 

Population Survey (1,36). An important 

factor behind NCHS’ decisions to 

discontinue the collection of abortion, 

marriage, and divorce data was that 

none of the data sets was complete 

in the mid-1990s. As noted, detailed 

abortion information was available from 

14 states; marriage data were based 

on 45 registration areas; and divorce 

information was based on 33 areas. 

Thus, the data were not national, and 

the reported marriage and divorce data 

suffered from quality concerns that could 

not be addressed without substantial 

financial infusions (1,4,36,39). These 

resources were not available nor could 

they be anticipated in the foreseeable 

future. NCHS published the last 

descriptive reports of marriage and 

divorce data for 1989 and 1990 (40,41). 

More recently, the U.S. Department 

of Health and Human Services’ 

Administration for Children and Families 

and the Office of the Assistant Secretary 

for Planning and Evaluation engaged 

in a contract to revisit potential interest 

and capacity within the states to restart 

the marriage and divorce data collection 

within the vital statistics system. This 

study found that most states do collect 

some data on these events, with most 

data collection still paper-based. The 

study also found wide variation across 

the states in the extent of detail collected, 

the completeness of the data, and interest 

in compiling statistical data sets (47). 

Because of its resource constraints, 

NCHS elected to implement a “countsbased” system for marriages and divorces 

so that some, albeit limited, marriage and 

divorce information would be available. 

Currently, NCHS is producing annual 

state-specific counts of marriages and 

divorces (48,49). The counts indicate 

the number of marriages and divorces 

occurring in the jurisdictions, and include 

no information on the characteristics 

of the persons marrying or divorcing 

(48–50). It should be noted that some 

states do not report counts of divorces; 

in 2015, for example, six states did not 

provide this information (49).
Series 1, No. 62  Page 43 

Appendix II. Mortality Medical Coding System

The mortality medical coding 

system, known as the the Mortality 

Medical Data System, is comprised of 

a suite of software programs, initially 

inaugurated with the Automated 

Classification of Medical Entities 

(ACME). TRANSAX (translation of 

axes) was developed in the late 1970s 

to complement ACME. The Mortality 

Medical Indexing, Classification, and 

Retrieval System, known as MICAR, 

was implemented in 1990 and allows for 

the input of the literal text as reported by 

the certifier on the death certificate. Data 

entry is in the form of “sanitized” text 

descriptions of entity reference numbers 

[ERN, 6-digit numeric codes assigned 

sequentially by the National Center for 

Health Statistics (without regard to any 

coding scheme)]. MICAR has a number 

of advantages, including eliminating the 

use of the International Classification 

of Diseases index, reducing errors in 

recognizing terms, and eliminating the 

use of multiple-cause coding rules (171). 

MICAR also provides more detailed 

information on the conditions reported 

on the death certificate. Super-MICAR, 

an enhancement of MICAR, was 

implemented in 1993. Whereas the 

original MICAR system required the 

coder to know or be able to look up the 

sanitized text of the ERN, Super-MICAR 

facilitates the total literal entry of the 

multiple cause-of-death text as reported 

by the medical certifier. This information 

serves as input to MICAR, which in turn 

is input into ACME (171).
Page 44  Series 1, No. 62

Appendix III. International Classification of Diseases (ICD)

The International Classification of 

Diseases (ICD) is used to classify causes 

of death for statistical purposes. ICD is 

maintained collaboratively by the World 

Health Organization (WHO) and 21 

international collaborating centers, 1 of 

which is the WHO Collaborating Center 

for the Classification of Diseases in North 

America at the National Center for Health 

Statistics. Currently, cause of death is 

being coded using ICD–10, which was 

implemented in the United States in 1999 

(15). Although ICD has generally been 

revised about every 10 years, the last 

two revisions have been in effect much 

longer. ICD provides the basic ground 

rules used to code and classify causes of 

death, to identify the underlying cause 

of death, and to compensate for certifier 

errors in the cause-of-death statement, all 

crucial functions. The revision process, 

concurrent efforts to describe and identify 

resultant discontinuities in data, and plans 

for an upcoming revision are described in 

this Appendix and elsewhere (84,85). 

ICD functions are crucial. Major 

discontinuities in statistical trends 

typically occur when a new revision 

of ICD is implemented. These 

discontinuities are measured using 

“comparability ratios,” which indicate the 

impact of a change in ICD on the trends 

in given causes of deaths. The most 

recent comparability study was carried 

out after ICD–10 was introduced (79). 

Currently, ICD–11 is in development. 

WHO and colleagues have ambitious 

goals for the ICD–11 revision, including 

the development of a “multi-purpose 

and coherent classification for mortality, 

morbidity, primary care, clinical 

care, research, and public health” 

and a system that is consistent and 

interoperable across different uses. As 

envisioned, ICD–11 should “serve as an 

international and multilingual reference 

standard for scientific comparability 

and communication purposes.” The 

final goal is to ensure that ICD–11 will 

function in an electronic environment, 

“that ICD–11 will be a digital product 

and that it will support electronic health 

records and information systems” (80). 

Implementation of ICD–11 in the United 

States is likely to take several years after 

approval by the World Health Assembly, 

the decision-making body of WHO.
Series 1, No. 62  Page 45 

Appendix IV. Collaborative Efforts Based on Real-time Mortality 

Surveillance

As of the writing of this report, the 

National Center for Health Statistics 

(NCHS) has a number of ongoing 

projects that are based on real-time 

mortality surveillance. One is to track 

deaths from influenza, with support from 

the National Center for Immunization 

and Respiratory Diseases. Other projects 

in the mortality surveillance initiative in 

various stages of development include 

one on suicide, with support from the 

National Institute of Mental Health. 

Another is an effort to create a National 

Disaster-related Mortality Surveillance 

System, with support from the CDC’s 

Office of Public Health Preparedness and 

Response. 

The Food and Drug Administration 

has been collaborating with NCHS 

on a surveillance project to identify 

drugs and drug types involved in drug 

overdoses and poisoning deaths. This 

activity involves “mining” the “literal” 

entries reported in the cause-of-death 

section of the death certificate to 

maximize the utility of this information 

in identifying and reducing these deaths. 

Another activity in the early stages 

of development is the monitoring of 

disaster-related deaths. The National 

Center for Environmental Health is 

funding the National Association for 

Public Health Statistics and Information 

Systems, and NCHS is participating as 

a collaborating agency in a project to try 

to develop standard case definitions of 

disaster-related deaths. Note that in many 

instances, these surveillance activities 

are intended to raise situational and 

public health awareness of the selected 

health indicators. Another example of the 

real-time surveillance is the surveillance 

of Creutzfeld-Jakob disease, a rare 

degenerative neurological disorder that is 

incurable and invariably fatal (106).

One area where the death certificate 

data have been used for surveillance for 

many years is the publication of weekly 

estimates of “notifiable diseases and 

mortality in 122 cities” that are issued in 

CDC’s Morbidity and Mortality Weekly 

Report (105). The data for the 122 cities 

project are reported by state and local 

registrars directly to CDC’s Influenza 

Division. Consistent with the recent CDC 

Surveillance Strategy goal to reduce the 

redundancy of CDC surveillance systems, 

NCHS and the CDC’s Influenza Division 

have been piloting the use of NCHS 

real-time surveillance capabilities as a 

replacement for the 122 Cities Mortality 

Reporting System (CMRS) (106). 

Currently, parallel review of the 122 

CMRS data system and vital statisticsbased surveillance for influenza deaths is 

ongoing.
Page 46  Series 1, No. 62

Appendix V. Items Deleted From the National Fetal Death Data Set

As part of the initiative to review the 

item content of the birth and fetal death 

data sets, the fetal death data quality 

workgroup, comprised of the National 

Center for Health Statistics’ (NCHS) 

National Vital Statistics System staff 

members and members of the National 

Association for Public Health Statistics 

and Information Systems (NAPHSIS), 

met over a 2-year period to assess the 

quality of the data items on the fetal death 

report and to make recommendations 

for item deletions. The workgroup 

presented its recommendations to 

the annual joint meeting of the Vital 

Statistics Cooperative Program (VSCP) 

project officers and NAPHSIS in 

Pittsburgh, Pa. in June 2015 (120). The 

recommendations were affirmed at the 

meeting and NCHS transmitted a formal 

notification of the item deletions in an 

e-mail sent to the VSCP project officers 

on June 16, 2015 (56). The items deleted 

from the national fetal death data set, 

effective with the 2014 data year include 

the following:

● Mother ever married (This was 

a “derived” item based on other 

information on the standard fetal 

death report, and had been part of the 

national file.)

● Mother married? (At delivery, 

conception or anytime between)

● Total number of prenatal visits for 

this pregnancy

○ Edit flag—Total number of 

prenatal visits for this pregnancy 

● Date of last prenatal care visit*

● Mother’s weight at delivery

○ Edit flag—Mother’s weight at 

delivery

● Number of other pregnancy 

outcomes

● Date of last other pregnancy outcome

● Mother/patient transferred for 

maternal medical or fetal indications 

for delivery?

● Previous preterm birth (Risk factors 

for this pregnancy)

● Other previous poor pregnancy 

outcomes (Risk factors for this 

pregnancy)*

● Gonorrhea (Infections present and/or 

treated during this pregnancy**)

● Syphilis (Infections present and/or 

treated during this pregnancy**)

● Chlamydia (Infections present and/or 

treated during this pregnancy**)

● Listeria (Infections present and/or 

treated during this pregnancy**)

● Group B strep (Infections 

present and/or treated during this 

pregnancy**)

● Cytomegalovirus (Infections 

present and/or treated during this 

pregnancy**)

● Parvovirus (Infections present and/or 

treated during this pregnancy**)

● Toxoplasmosis (Infections 

present and/or treated during this 

pregnancy**)

● Other (Specify) (Infections 

present and/or treated during this 

pregnancy**)

● Hysterotomy/hysterectomy (Method 

of delivery)

● Maternal transfusion (Maternal 

morbidity)

● Third or fourth degree perineal 

laceration (Maternal morbidity)

● Unplanned hysterectomy (Maternal 

morbidity)

● Unplanned operating room procedure 

(Maternal morbidity)

● Anencephaly (Congenital anomalies 

of the fetus**)

● Meningomyelocele/Spina bifida 

(Congenital anomalies of the fetus**)

● Cyanotic congenital heart disease 

(Congenital anomalies of the fetus**)

● Congenital diaphragmatic hernia 

(Congenital anomalies of the fetus**)

● Omphalocele (Congenital anomalies 

of the fetus**)

● Gastroschisis (Congenital anomalies 

of the fetus**)

● Limb reduction defect (Congenital 

anomalies of the fetus**)

● Cleft lip with or without cleft palate 

(Congenital anomalies of the fetus**)

● Cleft palate alone (Congenital 

anomalies of the fetus**)

● Down syndrome—karyotype 

confirmed/pending (Congenital 

anomalies of the fetus**)

● Suspected Chromosomal disorder—

karyotype confirmed/pending 

(Congenital anomalies of the fetus**)

● Hypospadias (Congenital anomalies 

of the fetus**)

 *Item previously announced as dropped 

from the national birth file.

**All checkboxes on the national 

standard under this category have been 

dropped.
Series 1, No. 62  Page 47 

Appendix VI. Followback Surveys

Followback surveys were conducted 

periodically by the National Center 

for Health Statistics (NCHS) from 

the early 1960s until the early 1990s 

(172,173). These surveys were housed 

organizationally within NCHS’ National 

Vital Statistics System program. In 

these surveys, the birth or death record 

is the basic sampling unit, with the total 

file of births or deaths representing 

the sampling frame. The purpose 

of followback surveys is to collect 

additional information about each event 

from sources identified on the vital 

record. Because the vital records are the 

sampling frame, followback surveys 

must be conducted with the cooperation 

and support of the vital registration 

jurisdictions. These organizations 

make it possible for researchers to 

gain access to the full vital record in 

order to identify and contact additional 

sources of information that may include 

physicians, hospital personnel, and 

family members, among others. The 1988 

National Maternal and Infant Health 

Survey (NMIHS) included women with 

a live birth as well as women who had 

experienced a fetal loss or infant death. 

A 1991 longitudinal follow-up to the 

1988 NMIHS was conducted to obtain 

additional information about respondents 

from the 1988 survey (172). 

The last mortality followback 

survey conducted by NCHS was the 

1993 National Mortality Followback 

Survey (173). The survey included, for 

the first time, an emphasis on deaths due 

to homicide, suicide, and unintentional 

injury and included information from 

medical examiners and coroners. There 

has been periodic interest in reviving 

the followback surveys in the research 

community, especially for deaths, as 

noted in an Institute of Medicine report 

issued in 2003 (174). However, the costs 

associated with these surveys would be 

prohibitive if conducted under previous 

procedures; it is possible that with the 

expansion of electronic health records, 

such followback surveys may once again 

be feasible.
Page 48  Series 1, No. 62

Appendix VII. Effort by National Academies to Generate Attention to 

Current and Emerging Uses of Vital Statistics Data

Over the last decade, the National 

Center for Health Statistics’ (NCHS) 

ongoing challenges, especially in the 

timeliness of vital statistics data, led 

the Committee on National Statistics 

of the National Academies to convene 

a Workshop on Vital Data for National 

Needs on April 30, 2008. The Workshop 

was organized by the National Academies 

along with the U.S. Census Bureau; 

the Social Security Administration’s 

Office of Research, Evaluation, and 

Statistics; and NCHS, with a focus on 

assessing current and emerging uses of 

vital statistics data, and methodological 

and organizational features of the data. 

A premise of the Workshop organizers 

was that despite their critical importance, 

vital statistics had simply been taken for 

granted for too long, and that it was time 

to consider “the critical importance of 

adequate vital statistics for the statistical, 

research, and policy communities” and to 

identify “improvements that are needed 

at NCHS’ vital statistics programs” (4). 

Workshop presenters described the uses 

of vital statistics data, including, for 

example, to understand social inequalities 

in health, health policy, and research; 

for maternal and child health research; 

to develop population estimates and 

projections; and for potential emerging 

uses in biosurveillance. The federal–state 

cooperative relationship was reviewed, 

focusing on the challenges facing the 

vital statistics system and methodological 

issues, and challenges of the 2003 

revision of the U.S. Standard Certificates 

and Report were discussed. The latter 

included issues around bridged-race 

data, the measurement of perinatal 

mortality, and causes of death. Workshop 

discussions also highlighted the need for 

investment in infrastructure at the federal 

and state levels, geared in particular to 

the development of faster, more efficient, 

and responsive systems. The need for 

periodic review of the content of the 

certificates to ensure that data needs 

are being met and the need to improve 

timeliness and quality for the data to have 

real value were also discussed. 

The Workshop report concluded: 

“The vital statistics system needs to 

be understood as a critical part of the 

nation’s scientific infrastructure, and 

building awareness of the system’s 

strengths and limitations is essential 

to continuing to provide vital data for 

national needs” (4).
Series 1, No. 62  Page 49 

Appendix Tables

Table I. Revision status of each jurisdiction according to when they implemented the revised birth certificate 

State or jurisdiction 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Alabama – – – – – – – – – – – X X X

Alaska – – – – – – – – – – X X X X

American Samoa – – – – – – – – – – – – – –

Arizona – – – – – – – – – – – X X X

Arkansas – – – – – – – – – – – X X X

California – – – X X X X X X X X X X X

Colorado – – – – X X X X X X X X X X

Connecticut – – – – – – – – – – – – – X

Delaware – – – X X X X X X X X X X X

District of Columbia – – – – – – X X X X X X X X

Florida – X X X X X X X X X X X X X

Georgia – – – – X X X X X X X X X X

Guam – – – – – – – – X X X X X X

Hawaii – – – – – – – – – – – X X X

Idaho – X X X X X X X X X X X X X

Illinois – – – – – – – X X X X X X X

Indiana – – – – X X X X X X X X X X

Iowa – – – – X X X X X X X X X X

Kansas – – X X X X X X X X X X X X

Kentucky – X X X X X X X X X X X X X

Louisiana – – – – – – – X X X X X X X

Maine – – – – – – – – – – X X X X

Maryland – – – – – – – X X X X X X X

Massachusetts – – – – – – – – X X X X X X

Michigan – – – – X X X X X X X X X X

Minnesota – – – – – – – – X X X X X X

Mississippi – – – – – – – – – – X X X X

Missouri – – – – – – – X X X X X X X

Montana – – – – – X X X X X X X X X

Nebraska – – X X X X X X X X X X X X

Nevada – – – – – – X X X X X X X X

New Hampshire – X X X X X X X X X X X X X

New Jersey – – – – – – – – – – – X X X

New Mexico – – – – – X X X X X X X X X

New York City – – – – – X X X X X X X X X

New York State – X X X X X X X X X X X X X

North Carolina – – – – – – – X X X X X X X

North Dakota – – – X X X X X X X X X X X

Northern Mariana Islands – – – – – – – X X X X X X X

Ohio – – – X X X X X X X X X X X

Oklahoma – – – – – – X X X X X X X X

Oregon – – – – – X X X X X X X X X

Pennsylvania X X X X X X X X X X X X X X

Puerto Rico – – X X X X X X X X X X X X

Rhode Island – – – – – – – – – – – – X X

South Carolina – X X X X X X X X X X X X X

South Dakota – – – X X X X X X X X X X X

Tennessee – X X X X X X X X X X X X X

Texas – – X X X X X X X X X X X X

Utah – – – – – – X X X X X X X X

Vermont – – X X X X X X X X X X X X

Virginia – – – – – – – – – X X X X X

Virgin Islands – – – – – – – – – – – X X X

Washington X X X X X X X X X X X X X X

West Virginia – – – – – – – – – – – X X X

Wisconsin – – – – – – – – X X X X X X

Wyoming – – – X X X X X X X X X X X

X Indicates state or jurisdiction implemented the revised birth certificate.

– Indicates state or jurisdiction did not implement the revised birth certificate.
Page 50  Series 1, No. 62

Table II. Revision status of each jurisdiction according to when they implemented the revised death certificate

State or jurisdiction 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Alabama – – – – – – – – – – – – – X X

Alaska – – – – – – – – – – – X X X X

American Samoa – – – – – – – – – – – – – – –

Arizona – – – – – – – X X X X X X X X

Arkansas – – – – – X X X X X X X X X X

California X X X X X X X X X X X X X X X

Colorado – – – – – – – – – – – – X X X

Connecticut – – X X X X X X X X X X X X X

Delaware – – – – X X X X X X X X X X X

District of Columbia – – X X X X X X X X X X X X X

Florida – – X X X X X X X X X X X X X

Georgia – – – – – X X X X X X X X X X

Guam – – – – – – – – – X X X X X X

Hawaii – – – – – – – – – – – X X X X

Idaho X X X X X X X X X X X X X X X

Illinois – – – – – X X X X X X X X X X

Indiana – – – – – X X X X X X X X X X

Iowa – – – – – – – – X X X X X X X

Kansas – – X X X X X X X X X X X X X

Kentucky – – – – – – – X X X X X X X X

Louisiana – – – – – – – – – X X X X X X

Maine – – – – – – – X X X X X X X X

Maryland – – – – – – – – – – – – X X X

Massachusetts – – – – – – – – – – – X X X X

Michigan – X X X X X X X X X X X X X X

Minnesota – – – – – – – – X X X X X X X

Mississippi – – – – – – – – – X X X X X X

Missouri – – – – – – – X X X X X X X X

Montana X X X X X X X X X X X X X X X

Nebraska – – X X X X X X X X X X X X X

Nevada – – – – – X X X X X X X X X X

New Hampshire – X X X X X X X X X X X X X X

New Jersey – X X X X X X X X X X X X X X

New Mexico – – – X X X X X X X X X X X X

New York City X X X X X X X X X X X X X X X

New York State X X X X X X X X X X X X X X X

North Carolina – – – – – – – – – – – X X X X

North Dakota – – – – – X X X X X X X X X X

Northern Mariana Islands – – – – – – – – – X X X X X X

Ohio – – – – X X X X X X X X X X X

Oklahoma – X X X X X X X X X X X X X X

Oregon – – – X X X X X X X X X X X X

Pennsylvania – – – – – – – – – X X X X X X

Puerto Rico – – – – – – – – – – – – X X X

Rhode Island – – – X X X X X X X X X X X X

South Carolina – – X X X X X X X X X X X X X

South Dakota – X X X X X X X X X X X X X X

Tennessee – – – – – – – – – X X X X X X

Texas – – – X X X X X X X X X X X X

Utah – – X X X X X X X X X X X X X

Vermont – – – – – X X X X X X X X X X

Virginia – – – – – – – – – – – X X X X

Virgin Islands – – – – – – – – – – – – – – –

Washington – X X X X X X X X X X X X X X

West Virginia – – – – – – – – – – – – – – X

Wisconsin – – – – – – – – – – X X X X X

Wyoming – X X X X X X X X X X X X X X

X Indicates state or jurisdiction implemented the revised death certificate.

– Indicates state or jurisdiction did not implement the revised death certificate.
Series 1, No. 62  Page 51 

Table III. Revision status of each jurisdiction according to when they implemented the revised fetal death report

State or jurisdiction 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Alabama – – – – – – – – – – – X X X X

Alaska – – – – – – – – – – – X X X X

American Samoa – – – – – – – – – – – – – – –

Arizona – – – – – – – – – – X X X X X

Arkansas – – – – – – – – – – – X X X X

California – – – X X X X X X X X X X X X

Colorado – – – – – – – – – – – – X X X

Connecticut – – – – – – – – – – – – – – –

Delaware – – – X X X X X X X X X X X X

District of Columbia – – – – – – – X X X X X X X X

Florida – – – X X X X X X X X X X X X

Georgia – – – – X X X X X X X X X X X

Guam – – – – – – – – X X X X X X X

Hawaii – – – – – – – – – – – X X X X

Idaho – X X X X X X X X X X X X X X

Illinois – – – – – – – – – – – X X X X

Indiana – – – – – X X X X X X X X X X

Iowa – – – – – – – – – X X X X X X

Kansas – – X X X X X X X X X X X X X

Kentucky – X X X X X X X X X X X X X X

Louisiana – – – – – – – – – – X X X X X

Maine – – – – – – – – – – X X X X X

Maryland – – X X X X X X X X X X X X X

Massachusetts – – – – – – – – – – – – X X X

Michigan X X X X X X X X X X X X X X X

Minnesota – – – – – – – – X X X X X X X

Mississippi – – – – – – – – – – X X X X X

Missouri – – – – – – – – X X X X X X X

Montana – – – – – X X X X X X X X X X

Nebraska – – X X X X X X X X X X X X X

Nevada – – – – – – X X X X X X X X X

New Hampshire – – X X X X X X X X X X X X X

New Jersey – – – – – – – – – – – – – X X

New Mexico – – – – – – – – X X X X X X X

New York City – – – – – – – – X X X X X X X

New York State – – – – – – – – – – – – – – X

North Carolina – – – – – – – – – – – X X X X

North Dakota – – – – – X X X X X X X X X X

Northern Mariana Islands – – – – – – – – – X X X X X X

Ohio – – – – – – – – X X X X X X X

Oklahoma – X X X X X X X X X X X X X X

Oregon – – – – – X X X X X X X X X X

Pennsylvania – – – X X X X X X X X X X X X

Puerto Rico – – – – – – – – – – – – – X X

Rhode Island – – – – – – – – – – – – X X X

South Carolina – – – – – X X X X X X X X X X

South Dakota – – X X X X X X X X X X X X X

Tennessee – – – – – – – – – X X X X X X

Texas – – – X X X X X X X X X X X X

Utah – X X X X X X X X X X X X X X

Vermont – – – – – – – – – – – X X X X

Virginia – – – – – – – – – – – X X X X

Virgin Islands – – – – – – – – – – – – – – –

Washington X X X X X X X X X X X X X X X

West Virginia – – – – – – – – – – – – – X X

Wisconsin – – – – – – – – X X X X X X X

Wyoming – – – – – – – X X X X X X X X

X Indicates state or jurisdiction implemented the revised fetal death report.

– Indicates state or jurisdiction did not implement the revised fetal death report.
Page 52  Series 1, No. 62

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Birth information

Name of child X X X X X X X X X X X X

Sex X X X X X X X X X X X X

Date of birth X X X X X X X X X X X X

Time of birth X X X X X X – – – X X X

Place of birth: X X X X X X X X X X X X

Place of delivery – – – – – – X X X X X –

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 – – – – – – –

Place where birth occurred (check one)

Checkbox for “Hospital” – – – – – – – – – – – X

Checkbox for “Freestanding birthing center” – – – – – – – – – – – X

Checkbox for “Clinic/doctor’s office” – – – – – – – – – – – X

Checkbox for “Residence” – – – – – – – – – – – X

Checkbox for “Home birth” – – – – – – – – – – – X

Planned to deliver at home? Checkbox for “yes” or “no” – – – – – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – – – – – X

Street and number if not in hospital – – – – – – X X X X X X

Township of, or X X X X X X – – – – – –

Village of, or X X X X X X – – – – – –

City X X X X X X – – – – – –

City, town, or location of birth – – – – – – X X X X X X

Inside city limits – – – – – – – – X X – –

If outside city or town limits, write rural – – – – – X X – – – – –

County X X X X X X X X X X X X

Ward X X X X X X – – – – – –

Birth weight – – – – – – – X X X X X

Birth weight, checkbox for “grams” and “lb./oz.” – – – – – – – – – – – X

Single, twin, triplet, etc. X X X X X X X X X X X X

Plurality–Single, twin, triplet, etc. (specify) – – – – – – – – – – – X

Birth order if not single birth X X X X X X X X X X X X

If not single birth–Born first, second, third, etc. (specify) – – – – – – – – – – – X

Apgar Score:

1 minute – – – – – – – – – – X –

5 minutes – – – – – – – – – – – X

If 5-minute score is less that 6, score at 10 minutes – – – – – – – – – – – X

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

Mother transferred for maternal medical or fetal indications 

for delivery? Checkbox for “yes” or “no” – – – – – – – – – – – X

If yes, enter name of facility mother transferred from: – – – – – – – – – – – X

Infant transferred – – – – – – – – – – X –

Was infant transferred within 24 hours of delivery? Checkbox 

for “yes” or “no” – – – – – – – – – – – X

If yes, name of facility infant transferred to: – – – – – – – – – – – X

Is infant living at time of report? Checkbox for 

“yes,” “no,” and “infant transferred, status unknown” – – – – – – – – – – – X

Is the infant being breastfed at discharge? Checkbox for “yes” 

or “no” – – – – – – – – – – – X

Newborn medical record number – – – – – – – – – – – X

Mother information

Maiden name – X X X X X X X X X – –

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

Full name X – – – – – – – – – X –

Mother’s name prior to first marriage – – – – – – – – – – – X

Mother’s current legal name – – – – – – – – – – – X

Age X X X X X X X X X X – –

Date of birth – – – – – – – – – – X X

Birthplace X X X – – – – – – – – –

Birthplace (state or country) – – – X X X X X X X X X

Birthplace (city or place) – – – X X X – – – – – –

Mother’s stay before delivery: In hospital or institution – – – X – – – – – – – –

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

Residence X X X X X – – – – – – –

State – – – – – X X X X X X X

County – – – X X X X X X X X X

City, town, or location – – – – – X X X X X X X

See footnotes at end of table.
Series 1, No. 62  Page 53 

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Mother information—Con.

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

Inside city limits – – – – – – – X X X X X

If rural, give location – – – – – X X – – – – –

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

Apartment No. – – – – – – – – – – – X

Mother’s mailing address – – – – – X – X – X X X

Mother’s mailing address–checkbox for “Same as residence” 

or state, city, town, or location, street and number, apartment, 

zip code – – – – – – – – – – – X

Education–Specify highest grade completed – – – – – – – – X X X –

Elementary (0,1,2,3,4,...or 8) – – – – – – – – X – – –

Elementary/secondary (0–12) – – – – – – – – – X X –

High school (1,2,3, or 4) – – – – – – – – X – – –

College (1,2,3,4, or 5+) – – – – – – – – X – – –

College (1–4 or 5+) – – – – – – – – – X X –

Education (Check the box that best describes the highest 

degree or level of school completed at the time of delivery): – – – – – – – – – – – X

Checkbox for “8th grade or less” – – – – – – – – – – – X

Checkbox for “9th–12th grade, no diploma” – – – – – – – – – – – X

Checkbox for “High school graduate or GED completed” – – – – – – – – – – – X

Checkbox for “Some college credit but no degree” – – – – – – – – – – – X

Checkbox for “Associate degree (e.g., AA, AS)” – – – – – – – – – – – X

Checkbox for “Bachelor’s degree (e.g., BA, AB, BS)” – – – – – – – – – – – X

Checkbox for “Master’s degree (e.g., MA, MS, MEng, MEd, 

MSW, MBA)” – – – – – – – – – – – X

Checkbox for “Doctorate (e.g., PhD, EdD) or 

Professional degree (e.g., MD, DDS, DVM, LLB, JD)” – – – – – – – – – – – X

Of Hispanic origin? (Specify “no” or “yes”–If yes, specify Cuban, 

Mexican, Puerto Rican, etc.) Checkbox for “yes” or “no” 

(specify)__ – – – – – – – – – – X –

Mother of Hispanic origin (Check the box that best describes 

whether the mother is Spanish/Hispanic/Latina. Check the 

“no” box if mother is not Spanish/Hispanic/Latina.) – – – – – – – – – – – X

Checkbox for “No, not Spanish/Hispanic/Latina” – – – – – – – – – – – X

Checkbox for “Yes, Mexican, Mexican American, Chicana” – – – – – – – – – – – X

Checkbox for “Yes, Puerto Rican” – – – – – – – – – – – X

Checkbox for “Yes, Cuban” – – – – – – – – – – – X

Checkbox for “Yes, other Spanish/Hispanic/Latina (specify)” – – – – – – – – – – – X

Race–American Indian, black, white, etc. (specify below) X X X X X X X X X X X –

Race (Check one or more races to indicate what the mother 

considers herself to be)

Checkbox for “White” – – – – – – – – – – – X

Checkbox for “Black or African American” – – – – – – – – – – – X

Checkbox for “American Indian or Alaska Native 

(Name of the enrolled or principal tribe)” – – – – – – – – – – – X

Checkbox for “Asian Indian” – – – – – – – – – – – X

Checkbox for “Chinese” – – – – – – – – – – – X

Checkbox for “Filipino” – – – – – – – – – – – X

Checkbox for “Japanese” – – – – – – – – – – – X

Checkbox for “Korean” – – – – – – – – – – – X

Checkbox for “Vietnamese” – – – – – – – – – – – X

Checkbox for “Other Asian (specify)” – – – – – – – – – – – X

Checkbox for “Native Hawaiian” – – – – – – – – – – – X

Checkbox for “Guamanian or Chamorro” – – – – – – – – – – – X

Checkbox for “Samoan” – – – – – – – – – – – X

Checkbox for “Other Pacific Islander (specify)” – – – – – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – – – – – X

Legitimate X X X X X – X X X – – –

Mother married? – – – – – X – – – X X –

Mother married? (At birth, conception, or any time between) 

Checkbox for “yes” or “no” – – – – – – – – – – – X

 If no, has paternity acknowledgement been signed in the 

hospital? (Checkbox for “yes” or “no”) – – – – – – – – – – – X

Facility ID (National Provider Identifier) – – – – – – – – – – – X

Social security number (mother) – – – – – – – – – – – X

Social security number requested for child? Checkbox for “yes” 

and “no” – – – – – – – – – – – X

Occupation X X X X X – – – – – – –

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

See footnotes at end of table.
Page 54  Series 1, No. 62

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Mother information—Con.

Nature of 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 X X X X X X X X X X X X

Age X X X X X X X X X X – –

Date of birth – – – – – – – – – – X X

Birthplace X X X – – – – – – – – –

Birthplace (state or country) – – – X X X X X X X X X

Birthplace (city or place) – – – X X X X X X X X X

Education–Specify highest grade completed – – – – – – – – X X X –

Elementary (0,1,2,3,4,...or 8) – – – – – – – – X – – –

Elementary/secondary (0–12) – – – – – – – – – X X –

High school (1,2,3, or 4) – – – – – – – – X – – –

College (1,2,3,4, or 5+) – – – – – – – – X – – –

College (1–4 or 5+) – – – – – – – – – X X –

Education (Check the box that best describes the highest 

degree or level of school completed at the time of delivery): – – – – – – – – – – – X

Checkbox for “8th grade or less” – – – – – – – – – – – X

Checkbox for “9th–12th grade, no diploma” – – – – – – – – – – – X

Checkbox for “High school graduate or GED completed” – – – – – – – – – – – X

Checkbox for “Some college credit but no degree” – – – – – – – – – – – X

Checkbox for “Associate degree (e.g., AA, AS)” – – – – – – – – – – – X

Checkbox for “Bachelor’s degree (e.g., BA, AB, BS)” – – – – – – – – – – – X

Checkbox for “Master’s degree (e.g., MA, MS, MEng, MEd, 

MSW, MBA)” – – – – – – – – – – – X

Checkbox for “Doctorate (e.g., PhD, EdD) or 

Professional degree (e.g., MD, DDS, DVM, LLB, JD)” – – – – – – – – – – – X

Of Hispanic origin? (Specify no or yes–If yes, specify Cuban, 

Mexican, Puerto Rican, etc.) Checkbox for “yes” or 

“no” (specify)__ – – – – – – – – – – X –

Father of Hispanic origin (Check the box that best describes 

whether the father is Spanish/Hispanic/Latino. Check the 

“no” box if father is not Spanish/Hispanic/Latino.) – – – – – – – – – – – X

Checkbox for “No, not Spanish/Hispanic/Latino” – – – – – – – – – – – X

Checkbox for “Yes, Mexican, Mexican American, Chicano” – – – – – – – – – – – X

Checkbox for “Yes, Puerto Rican” – – – – – – – – – – – X

Checkbox for “Yes, Cuban” – – – – – – – – – – – X

Checkbox for “Yes, other Spanish/Hispanic/Latino (specify)” – – – – – – – – – – – X

Race X X X X X X X X X X X –

Race (Check one or more races to indicate what the father 

considers himself to be) – – – – – – – – – – X X

Checkbox for “White” – – – – – – – – – – – X

Checkbox for “Black or African American” – – – – – – – – – – – X

Checkbox for “American Indian or Alaska Native (Name of 

the enrolled or principal tribe)” – – – – – – – – – – – X

Checkbox for “Asian Indian” – – – – – – – – – – – X

Checkbox for “Chinese” – – – – – – – – – – – X

Checkbox for “Filipino” – – – – – – – – – – – X

Checkbox for “Japanese” – – – – – – – – – – – X

Checkbox for “Korean” – – – – – – – – – – – X

Checkbox for “Vietnamese” – – – – – – – – – – – X

Checkbox for “Other Asian (specify)” – – – – – – – – – – – X

Checkbox for “Native Hawaiian” – – – – – – – – – – – X

Checkbox for “Guamanian or Chamorro” – – – – – – – – – – – X

Checkbox for “Samoan” – – – – – – – – – – – X

Checkbox for “Other Pacific Islander (specify)” – – – – – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – – – – – X

Residence X X X X X – – – – – – –

Social security number (father) – – – – – – – – – – – X

Occupation X X X X X – – – – – – –

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

Nature of industry – – – X X X X X – – – –

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

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

See footnotes at end of table.
Series 1, No. 62  Page 55 

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical and health information

Did mother get Women, Infants, and Children (WIC) food for 

herself during this pregnancy? Checkbox for “yes” or “no” – – – – – – – – – – – X

Children born to this mother – – – – – X – – – – – –

Children previously born to this mother (Do not include this 

child.) – – – – – – X – – – – –

How many other children of this mother are now living? – – – – – X X X – – – –

How many other children were born alive but are now dead? – – – – – X X X – – – –

How many children were born dead? – – – – – X – – – – – –

Previous deliveries to mother (Do not include this birth.) – – – – – – – X – – – –

Previous deliveries–How many other children... – – – – – – – – X – – –

Are now living – – – – – – X X – – – –

Were born alive–Now dead – – – – – – X X – – – –

Were born dead (fetal death at any time after conception) – – – – – – – – X – – –

How many children were stillborn (born dead after 20 weeks of 

pregnancy)? – – – – – – X – – – – –

How many fetal deaths (fetuses born dead at any time after 

conception)? – – – – – – – X – – – –

Pregnancy history (complete each section) – – – – – – – – – X X –

Live births (Do not include this child.) – – – – – – – – – X X –

Live births, Number___, checkbox for “None” – – – – – – – – – – – X

Live births, now dead – – – X X X X X X X X X

Born dead (stillborn, fetal death) – – – X X X – X X – – –

Born dead after 20 weeks of 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 X

Number of other pregnancy outcomes (spontaneous or induced 

losses or ectopic pregnancies) – – – – – – – – – – – X

Other outcomes–Number____, checkbox for “none” – – – – – – – – – – – X

Date of last other pregnancy outcome – – – – – – – – – – – X

Date of last live birth – – – – – – – – X X X X

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

Date of last other termination – – – – – – – – – X X X

Whether born alive or stillborn X X X X X – – – – – – –

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

Stillbirth–Before labor or during labor – – – – X – – – – – – –

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

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

Obstetric estimate of gestation – – – – – – – – – – – X

Date last normal menses began – – – – – – – – X X X X

Mother’s medical record number – – – – – – – – – – – X

Length of pregnancy (completed weeks) – – – – – – X X – – – –

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

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

Month of pregnancy prenatal care began – – – – – – – – X X X X

Number of prenatal visits – – – – – – – – X X X X

Date of first prenatal care visit – – – – – – – – – – – X

Date of last prenatal care visit – – – – – – – – – – – X

Total number of prenatal visits for this pregnancy – – – – – – – – – – – X

Other risk factors for this pregnancy – – – – – – – – – – X –

Tobacco use during pregnancy–Checkbox for “yes” or “no” – – – – – – – – – – X –

 Average number of cigarettes per day – – – – – – – – – – X –

Alcohol use during pregnancy–Checkbox for “yes” or “no” – – – – – – – – – – X –

 Average number drinks per week – – – – – – – – – – X –

Weight gained during pregnancy: ___lbs. – – – – – – – – – – X –

Mother’s height – – – – – – – – – – – X

Mother’s prepregnancy weight – – – – – – – – – – – X

Mother’s weight at delivery – – – – – – – – – – – X

Cigarette smoking before and during pregnancy. For each time 

period, enter either the number of cigarettes or the number of 

packs of cigarettes smoked. If none, enter “0.” – – – – – – – – – – – X

Average number of cigarettes or packs of cigarettes smoked per 

day – – – – – – – – – – – X

Three months before pregnancy: ____# of cigarettes or ____# of 

packs – – – – – – – – – – – X

First three months of pregnancy: ____# of cigarettes or ____# of 

packs – – – – – – – – – – – X

See footnotes at end of table.
Page 56  Series 1, No. 62

See footnotes at end of table.

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical and health information—Con.

Second three months of pregnancy: ____# of cigarettes or 

____# of packs – – – – – – – – – – – X

Third trimester of pregnancy: ____# of cigarettes or 

____# of packs – – – – – – – – – – – X

Medical risk factors for this pregnancy (check all that apply) – – – – – – – – – – X –

Checkbox for “Anemia (Hct. < 30/Hgb. < 10)” – – – – – – – – – – X –

Checkbox for “Cardiac disease” – – – – – – – – – – X –

Checkbox for “Acute or chronic lung disease” – – – – – – – – – – X –

Checkbox for “Diabetes” – – – – – – – – – – X –

Checkbox for “Genital herpes” – – – – – – – – – – X –

Checkbox for “Hydramnios/oligohydramnios” – – – – – – – – – – X –

Checkbox for “Hemoglobinopathy” – – – – – – – – – – X –

Checkbox for “Hypertension, chronic” – – – – – – – – – – X –

Checkbox for “Hypertension, pregnancy-associated” – – – – – – – – – – X –

Checkbox for “Eclampsia” – – – – – – – – – – X –

Checkbox for “Incompetent cervix” – – – – – – – – – – X –

Checkbox for “Previous infant 4,000+ grams” – – – – – – – – – – X –

Checkbox for “Previous preterm or small-for-gestational age 

infant” – – – – – – – – – – X –

Checkbox for “Renal disease” – – – – – – – – – – X –

Checkbox for “Rh sensitization” – – – – – – – – – – X –

Checkbox for “Uterine bleeding” – – – – – – – – – – X –

Checkbox for “None” – – – – – – – – – – X –

Checkbox for “Other (specify)” – – – – – – – – – – X –

Risk factors in this pregnancy (check all that apply)

Diabetes: – – – – – – – – – – X X

Checkbox for “Prepregnancy (diagnosis prior to this 

pregnancy)” – – – – – – – – – – X X

Checkbox for “Gestational (diagnosis in this pregnancy)” – – – – – – – – – – – X

Hypertension: – – – – – – – – – – – –

Checkbox for “Prepregnancy (chronic)” – – – – – – – – – – X X

Checkbox for “Gestational (Pregnancy-induced 

hypertension, preeclampsia)” – – – – – – – – – – X X

Checkbox for “Eclampsia” – – – – – – – – – – X X

Checkbox for “Previous preterm birth” – – – – – – – – – – X X

Checkbox for “Other previous poor pregnancy outcome 

(includes perinatal death, small-for-gestational age/

intrauterine growth restricted birth)” – – – – – – – – – – – X

Checkbox for “Pregnancy resulted from infertility treatment–

If yes, check all that apply” – – – – – – – – – – – X

Checkbox for “Fertility-enhancing drugs, artificial 

insemination, or intrauterine insemination” – – – – – – – – – – – X

Checkbox for “Assisted reproductive technology [e.g., in 

vitro fertilization (IVF), gamete intrafallopian transfer 

(GIFT)]” – – – – – – – – – – – X

Checkbox for “Mother had a previous cesarean delivery” – – – – – – – – – – – X

If yes, how many? _____ – – – – – – – – – – – X

Checkbox for “None of the above” – – – – – – – – – – – X

Infections present and/or treated during this pregnancy (check all 

that apply) – – – – – – – – – – – X

Checkbox for “Gonorrhea” – – – – – – – – – – – X

Checkbox for “Syphilis” – – – – – – – – – – – X

Checkbox for “Chlamydia” – – – – – – – – – – – X

Checkbox for “Hepatitis B” – – – – – – – – – – – X

Checkbox for “Hepatitis C” – – – – – – – – – – – X

Checkbox for “None of the above” – – – – – – – – – – – X

Principal source of payment for this delivery – – – – – – – – – – – X

Checkbox for “Private Insurance” – – – – – – – – – – – X

Checkbox for “Medicaid” – – – – – – – – – – – X

Checkbox for “Self-pay” – – – – – – – – – – – X

Checkbox for “Other (specify)___” – – – – – – – – – – – X

Concurrent illnesses or conditions affecting the pregnancy – – – – – – – – – X – –

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

Complications of pregnancy – – – – – – – – – X – –

Complications related to pregnancy – – – – – – – – X – – –

Complications of labor – – – – – – – – X – – –

Complications of labor and/or delivery (check all that apply) – – – – – – – – – – X –

Checkbox for “Febrile (>100°F or 38°C)” – – – – – – – – – – X –

Checkbox for “Meconium, moderate/heavy” – – – – – – – – – – X –

Checkbox for “Premature rupture of membranes (>12 hours)” – – – – – – – – – – X –
Series 1, No. 62  Page 57 

See footnotes at end of table.

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical and health information—Con.

Checkbox for “Abruptio placenta” – – – – – – – – – – X –

Checkbox for “Placenta previa” – – – – – – – – – – X –

Checkbox for “Other excessive bleeding” – – – – – – – – – – X –

Checkbox for “Seizures during labor” – – – – – – – – – – X –

Checkbox for “Precipitous labor (<3 hours)” – – – – – – – – – – X –

Checkbox for “Prolonged labor (>20 hours)” – – – – – – – – – – X –

Checkbox for “Dysfunctional labor” – – – – – – – – – – X –

Checkbox for “Breech/malpresentation” – – – – – – – – – – X –

Checkbox for “Cephalopelvic disproportion” – – – – – – – – – – X –

Checkbox for “Cord prolapsed” – – – – – – – – – – X –

Checkbox for “Anesthetic complications” – – – – – – – – – – X –

Checkbox for “Fetal distress” – – – – – – – – – – X –

Checkbox for “None” – – – – – – – – – – X –

Checkbox for “Other, specify” – – – – – – – – – – X –

Onset of labor (check all that apply) – – – – – – – – – – – X

Checkbox for “Premature rupture of the membranes 

(prolonged, ≥12 hrs.)” – – – – – – – – – – X X

Checkbox for “Precipitous labor (<3 hrs.)” – – – – – – – – – – X X

Checkbox for “Prolonged labor (≥20 hrs.)” – – – – – – – – – – X X

Checkbox for “None of the above” – – – – – – – – – – X X

Characteristics of labor and delivery (check all that apply) – – – – – – – – – – – X

Checkbox for “Induction of labor” – – – – – – – – – – – X

Checkbox for “Augmentation of labor” – – – – – – – – – – – X

Checkbox for “Non-vertex presentation” – – – – – – – – – – – X

Checkbox for “Steroids (glucocorticoids) for fetal lung 

maturation received by the mother prior to delivery” – – – – – – – – – – – X

Checkbox for “Antibiotics received by the mother during labor” – – – – – – – – – – – X

Checkbox for “Clinical chorioamnionitis diagnosed during 

labor or maternal temperature > 38°C (100.4°F)” – – – – – – – – – – – X

Checkbox for “Moderate/heavy meconium staining of the 

amniotic fluid” – – – – – – – – – – – X

Checkbox for “Fetal intolerance of labor such that one or more 

of the following actions were taken: In-utero resuscitative 

measures, further fetal assessment, or operative delivery” – – – – – – – – – – – X

Checkbox for “Epidural or spinal anesthesia during labor” – – – – – – – – – – – X

Checkbox for “None of the above” – – – – – – – – – – – X

Obstetric procedures (check all that apply) – – – – – – – – – – X X

Checkbox for “Amniocentesis” – – – – – – – – – – X –

Checkbox for “Electronic fetal monitoring” – – – – – – – – – – X –

Checkbox for “Induction of labor” – – – – – – – – – – X –

Checkbox for “Stimulation of labor” – – – – – – – – – – X –

Checkbox for “Tocolysis” – – – – – – – – – – X X

Checkbox for “Ultrasound” – – – – – – – – – – X –

Checkbox for “None” – – – – – – – – – – X –

Checkbox for “Other” – – – – – – – – – – X X

Checkbox for “Cervical cerclage” – – – – – – – – – – – X

External cephalic version – – – – – – – – – – X –

Checkbox for “Successful” – – – – – – – – – – – X

Checkbox for “Failed” – – – – – – – – – – – X

Checkbox for “None of the above” – – – – – – – – – – – X

Method of delivery (check all that apply) – – – – – – – – – – X –

Checkbox for “Vaginal” – – – – – – – – – – X –

Checkbox for “Vaginal birth after previous C-section” – – – – – – – – – – X –

Checkbox for “Primary C-section” – – – – – – – – – – X –

Checkbox for “Repeat C-section” – – – – – – – – – – X –

Checkbox for “Forceps” – – – – – – – – – – X –

Checkbox for “Vacuum” – – – – – – – – – – X –

Method of delivery – – – – – – – – – – – X

Was delivery with forceps attempted but unsuccessful? 

Checkbox for “yes” or “no” – – – – – – – – – – – X

Was delivery with vacuum extraction attempted but 

unsuccessful? Checkbox for “yes” or “no” – – – – – – – – – – – X

Fetal presentation at birth – – – – – – – – – – – X

Checkbox for “Cephalic” – – – – – – – – – – – X

Checkbox for “Breech” – – – – – – – – – – – X

Checkbox for “Other” – – – – – – – – – – – X

Final route and method of delivery (check one) – – – – – – – – – – – X

Checkbox for “Vaginal/spontaneous” – – – – – – – – – – – X

Checkbox for “Vaginal/forceps” – – – – – – – – – – – X
Page 58  Series 1, No. 62

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical and health information—Con.

Checkbox for “Vaginal/vacuum” – – – – – – – – – – – X

Checkbox for “Cesarean” – – – – – – – – – – – X

Checkbox for “If cesarean, was a trial of labor attempted? 

Checkbox for “yes” or “no” – – – – – – – – – – – X

Maternal morbidity (check all that apply) (complications 

associated with labor and delivery) – – – – – – – – – – – X

Checkbox for “Maternal transfusion” – – – – – – – – – – – X

Checkbox for “Third or fourth degree perineal laceration” – – – – – – – – – – – X

Checkbox for “Ruptured uterus” – – – – – – – – – – – X

Checkbox for “Unplanned hysterectomy” – – – – – – – – – – – X

Checkbox for “Admission to intensive care unit” – – – – – – – – – – – X

Checkbox for “Unplanned operating room procedure 

following delivery” – – – – – – – – – – – X

Checkbox for “None of the above” – – – – – – – – – – X X

Abnormal conditions of the newborn (check all that apply) – – – – – – – – – – X X

Checkbox for “Anemia (Hct. < 38/Hgb. < 13)” – – – – – – – – – – X –

Checkbox for “Birth injury” – – – – – – – – – – X –

Checkbox for “Fetal alcohol syndrome” – – – – – – – – – – X –

Checkbox for “Hyaline membrane dresses/respiratory 

distress syndrome” – – – – – – – – – – X –

Checkbox for “Meconium aspiration syndrome” – – – – – – – – – – X –

Checkbox for “Assisted ventilation < 30 min” – – – – – – – – – – X –

Checkbox for “Assisted ventilation ≥ 30 min” – – – – – – – – – – X –

Checkbox for “Seizures” – – – – – – – – – – X –

Checkbox for “None” – – – – – – – – – – X –

Checkbox for “Other (specify)” – – – – – – – – – – X –

Checkbox for “Assisted ventilation required immediately 

following delivery” – – – – – – – – – – – X

Checkbox for “Assisted ventilation required for more than six 

hours” – – – – – – – – – – – X

Checkbox for “NICU admission” – – – – – – – – – – – X

Checkbox for “Newborn given surfactant replacement therapy” – – – – – – – – – – – X

Checkbox for “Antibiotics received by the newborn for 

suspected neonatal sepsis” – – – – – – – – – – – X

Checkbox for “Seizure or serious neurologic dysfunction” – – – – – – – – – – – X

Checkbox for “Significant birth injury (skeletal fracture(s), 

peripheral nerve injury, and/or soft tissue/solid organ 

hemorrhage which requires intervention)” – – – – – – – – – – – X

Checkbox for “None of the above” – – – – – – – – – – X X

Congenital malformations or anomalies of child – – – – – – – – X X – –

Congenital anomalies of child (check all that apply) – – – – – – – – – – X X

Checkbox for “Hydrocephalus” – – – – – – – – – – X –

Checkbox for “Microcephalus” – – – – – – – – – – X –

Checkbox for “Other central nervous system anomalies 

(specify)” – – – – – – – – – – X –

Checkbox for “Heart malformations” – – – – – – – – – – X –

Checkbox for “Other circulatory/respiratory anomalies (specify)” – – – – – – – – – – X –

Checkbox for “Rectal atresia/stenosis” – – – – – – – – – – X –

Checkbox for “Tracheo-esophageal fistula/esophageal atresia” – – – – – – – – – – X –

Checkbox for “Other gastrointestinal anomalies (specify)” – – – – – – – – – – X –

Checkbox for “Malformed genitalia” – – – – – – – – – – X –

Checkbox for “Renal agenesis” – – – – – – – – – – X –

Checkbox for “Other urogenital anomalies (specify)” – – – – – – – – – – X –

Checkbox for “Cleft lip/palate” – – – – – – – – – – X –

Checkbox for “Polydactyly/syndactyly/adactyly” – – – – – – – – – – X –

Checkbox for “Club foot” – – – – – – – – – – X –

Checkbox for “Other musculoskeletal/integumental anomalies 

(specify)” – – – – – – – – – – X –

Checkbox for “Other chromosomal anomalies (specify)” – – – – – – – – – – X –

Checkbox for “None” – – – – – – – – – – X –

Checkbox for “Other (specify)” – – – – – – – – – – X –

Checkbox for “Anencephaly” – – – – – – – – – – X X

Checkbox for “Meningomyelocele/spina bifida” – – – – – – – – – – X X

Checkbox for “Cyanotic congenital heart disease” – – – – – – – – – – – X

Checkbox for “Congenital diaphragmatic hernia” – – – – – – – – – – X X

Checkbox for “Omphalocele” – – – – – – – – – – X X

Checkbox for “Gastroschisis” – – – – – – – – – – X X

Checkbox for “Limb reduction defect (excluding congenital 

amputation and dwarfing syndromes)” – – – – – – – – – – – X

See footnotes at end of table.
Series 1, No. 62  Page 59 

Table IV. Items included on the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical and health information—Con.

Checkbox for “Cleft lip with or without cleft palate” – – – – – – – – – – X X

Checkbox for “Cleft palate alone” – – – – – – – – – – – X

Checkbox for “Down syndrome” – – – – – – – – – – X X

Checkbox for “Karyotype confirmed” – – – – – – – – – – – X

Checkbox for “Karyotype pending” – – – – – – – – – – – X

Checkbox for “Suspected chromosomal disorder” – – – – – – – – – – – X

Checkbox for “Karyotype confirmed” – – – – – – – – – – – X

Checkbox for “Karyotype pending” – – – – – – – – – – – X

Checkbox for “Hypospadias” – – – – – – – – – – – X

Checkbox for “None of the anomalies listed above” – – – – – – – – – – X X

Birth injuries to child – – – – – – – – X – – –

Certification information

Signature of certifier – – – – – – – – – – X X

Type of attendant – – – – – – – – – – X X

Date signed – – – – – – – – – – X X

Date on which given name was added X X X X X X X X – – – –

Certificate of attending physician or midwife – – – – – – – – – – – –

I hereby certify that I attended the birth of this child, and 

that it occurred on_____, 190_, at ___m. – – – – – – – – – – – –

When there was no attending physician or midwife, then the 

father, householder, etc., should make this return X X – – – – – – – – – –

Signature X X – – – – – – – – – –

Address X X – – – – – – – – – –

Filed___190_, X X – – – – – – – – – –

Registrar X X – – – – – – – – – –

Christian name added from supplemental report, 190_ X – – – – – – – – – – –

Given name added from supplemental report, (date of)_ X X X X X – – – – – – –

Name of registrar adding given name X X X X X X X X – – – –

Name and title of attendant at birth if other than certifier – – – – – – – – – X – –

Name and title of attendant if other than certifier (checkboxes) – – – – – – – – – – X X

Mailing address of attendant – – – – – – – – – – X X

Name and title of certifier – – – – – – – – – X – –

Name and title of certifier (checkboxes) – – – – – – – – – – X X

Name of certifier – – – – – – – – X – – –

Mailing address of certifier – – – – – – – – X X – –

Address of certifier X X X X X X X X – – – –

Signature of registrar X – – – – X X X X X X X

Registrar X X X X X – – – – – – –

Date received by registrar X – – – – – – – – X – –

Date received by local registrar X – – – – X X X X – – –

Date filed X X X X X – – – – – X X

Signature of parent or other informant – – – – – – – – – X X –

Informant – – – – – X X X X – – –

Relation to child – – – – – X – – X X – –

Information for Administrative Use Section – – – – – – – – – – – X

Information for Medical and Health Purposes Only Section – – – – – – – – – – – X

Newborn Information Section – – – – – – – – – – – X

X Indicates item included on standard certificate.

– Indicates item not included on standard certificate.
Page 60  Series 1, No. 62

See footnotes at end of table.

Table V. Items included on the U.S. Standard Certificate of Death, by year revised

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989 2003

Decedent information

Name X X X X X X X X X X X

Name of decedent (in margin) – – – – – – – – – X X

Sex X X X X X X X X X X X

Race X X X X X X X X X X X

Race (Check one or more races to indicate what 

mother considered herself to be)

Checkbox for “White” – – – – – – – – – – X

Checkbox for “Black or African American” – – – – – – – – – – X

Checkbox for “American Indian or Alaska Native (Name 

of the enrolled or principal tribe)” – – – – – – – – – – X

Checkbox for “Asian Indian” – – – – – – – – – – X

Checkbox for “Chinese” – – – – – – – – – – X

Checkbox for “Filipino” – – – – – – – – – – X

Checkbox for “Japanese” – – – – – – – – – – X

Checkbox for “Korean” – – – – – – – – – – X

Checkbox for “Vietnamese” – – – – – – – – – – X

Checkbox for “Other Asian (specify)” – – – – – – – – – – X

Checkbox for “Native Hawaiian” – – – – – – – – – – X

Checkbox for “Guamanian or Chamorro” – – – – – – – – – – X

Checkbox for “Samoan” – – – – – – – – – – X

Checkbox for “Other Pacific Islander (specify)” – – – – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – – – – X

Education (specify highest grade completed) – – – – – – – – X X –

Education (Check the box that best describes the 

highest degree or level of school completed at the 

time of delivery):

Checkbox for “8th grade or less” – – – – – – – – – – X

Checkbox for “9th–12th grade, no diploma” – – – – – – – – – – X

Checkbox for “High school graduate or GED completed” – – – – – – – – – – X

Checkbox for “Some college credit but no degree” – – – – – – – – – – X

Checkbox for “Associate degree (e.g., AA, AS)” – – – – – – – – – – X

Checkbox for “Bachelor’s degree (e.g., BA, AB, BS)” – – – – – – – – – – X

Checkbox for “Master’s degree (e.g., MA, MS, MEng, 

MEd, MSW, MBA)” – – – – – – – – – – X

Checkbox for “Doctorate (e.g., PhD, EdD) or Professional 

degree (e.g., MD, DDS, DVM, LLB, JD)” – – – – – – – – – – X

Was decedent of Hispanic origin? (specify “no” or “yes”–If yes,

specify Cuban, Mexican, Puerto Rican, etc.) Checkbox for “no” 

and “yes” (specify)__ – – – – – – – – – X –

Decedent of Hispanic origin? Check the box that best describes 

whether the decedent is Spanish/Hispanic/Latino. Check the 

“no” box if decedent is not Spanish/Hispanic/Latino.

Checkbox for “No, not Spanish/Hispanic/Latino” – – – – – – – – – – X

Checkbox for “Yes, Mexican, Mexican American, Chicano” – – – – – – – – – – X

Checkbox for “Yes, Puerto Rican” – – – – – – – – – – X

Checkbox for “Yes, Cuban” – – – – – – – – – – X

Checkbox for “Yes, other Spanish/Hispanic/Latino (specify)” – – – – – – – – – – X

Age:

Years X X X X X X X X X X X

Months/days X X X X X X X X X X X

Hours/minutes – X X X X X X X X X X

Date of birth X X X X X X X X X X X

Birthplace:

State or country X X X X X X X X X X –

City, town, or county – – – – – – – – – – –

City or town – – X X – – – – – – –

City and state or country – – – – – – – – – X X

Citizen of what country – – – – – X X X X – –

How long in U.S., if of foreign birth – – X X X – – – – – –

Marital status X X X X X X X X X X –

Marital status at time of death

Checkbox for “Married” – – – – – – – – – – X

Checkbox for “Married, but separated” – – – – – – – – – – X

Checkbox for “Widowed” – – – – – – – – – – X

Checkbox for “Divorced” – – – – – – – – – – X

Checkbox for “Never married” – – – – – – – – – – X

Checkbox for “Unknown” – – – – – – – – – – X

Surviving spouse (if wife, give maiden name) – – – – – – – X X X –
Series 1, No. 62  Page 61 

See footnotes at end of table.

Table V. Items included on the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989 2003

Decedent information—Con.

Surviving spouse (if wife, give name prior to first marriage) – – – – – – – – – – X

Name of husband or wife – – X X X – – – – – –

Age of husband or wife, if alive – – – – X – – – – – –

Was decedent ever in U.S. armed forces? – – – – – X X – X X X

If yes, give war or dates of service – – – – – X X – – – –

If veteran, name war – – – X – – – – – – –

Social security number – – – – X X X X X X X

Occupation X X X X – – – – – – –

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

Name of employer – – X – – – – – – – –

Business or industry – X X X X X X X X X X

Date deceased last worked at this occupation – – – X – – – – – – –

Total time (years) spent in this occupation – – – X – – – – – – –

Residence: Former or usual residence X X – – – – – – – – –

State – – – – X X X X X X X

Length of residence in the state (years, months, and days) – X – – – – – – – – –

County – – – – X X X X X X X

City, town, or location – – – – X X X X X X X

If nonresident, give city or town and state – – X X – – – – – – –

Ward – – X X – – – – – – –

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

Inside city limits – – – – – – X X X – –

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

Apt. No. – – – – – – – – – – X

Zip code – – – – – – – – – X X

Father’s name X X X X X X X X X X X

Birthplace of father:

State or country X X X X X – – – – – –

City or town – – X X – – – – – – –

City, town, or county – – – – X – – – – – –

Mother’s maiden name X X X X X X X X X X –

Mother’s name prior to first marriage (first, middle, last) – – – – – – – – – – X

Birthplace of mother:

State or country X X X X X – – – – – –

City or town – – X X – – – – – – –

City, town, or county – – – – X – – – – – –

Place of death information

County X X X X X X X X X X X

City, town, or location – – – – X X X X X X X

Inside city limits – – – – – – X X – – –

Township of, or X X X X – – – – – – –

Village of, or X X X X – – – – – – –

City of X X X X – – – – – – –

Ward X X X X – – – – – – –

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

Name of hospital or other institution – – – – X X X X X – –

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

If not in hospital or institution, give street address or location – – – – X X X X X X X

Type of place of death (if hospital)

Checkbox for “Inpatient” – – – – – – – – – – X

Checkbox for “Emergency room/outpatient” – – – – – – – – – – X

Checkbox for “Dead on arrival” – – – – – – – – – – X

Type of place of death (if other)

Checkbox for “Hospice facility” – – – – – – – – – – X

Checkbox for “Nursing home” – – – – – – – – – X –

Checkbox for “Nursing home/long-term care facility” – – – – – – – – – – X

Checkbox for “Residence” – – – – – – – – – X –

Checkbox for “Decedent’s home” – – – – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – – – – X

Length of stay in hospital – – – – X – – – – – –

Length of stay in this community – – – – X – – – – – –

Length of stay where death occurred X X X X – X X – – – –

Length of residence in the state – X – – – – – – – – –
Page 62  Series 1, No. 62

See footnotes at end of table.

Table V. Items included on the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical certification

Cause of death X X X X – – – – – – X

Duration X X X – – – – – – – –

Date of onset – – – X – – – – – – –

Immediate cause of death – – – – X X X X X X X

Interval between onset and death – – – – X X X X X X X

Due to – – – – X X X X X X X

Interval between onset and death – – – – X X X X X X X

Due to – – – – – – X X X X X

Interval between onset and death – – – – X X X X X X X

Due to – – – – – – – – – X X

Interval between onset and death – – – – – – – – – X X

Contributory cause X X X X – – – – – – –

Duration X X X – – – – – – – –

Date of onset – – – X – – – – – – –

Other significant conditions – – – – X X X X X X X

Duration – – – – X – – – – – –

Interval between onset and death – – – – – X – – – – –

Was autopsy performed? – – X X – X X X X X –

Was an autopsy performed? Checkbox for “yes” or “no” – – – – – – – – – – X

Were autopsy findings considered in determining cause 

of death? – – – – – – – – – – –

Were autopsy findings available prior to completion of 

cause of death? – – – – – – – – X X –

Were autopsy findings available to complete the cause of death? 

Checkbox for “yes” or “no” – – – – – – – – – – X

What test confirmed diagnosis? – – X X – – – – – – –

Major findings of autopsy – – – – X – – – – – –

Did tobacco use contribute to death? – – – – – – – – – – X

Checkbox for “Yes” – – – – – – – – – – X

Checkbox for “No” – – – – – – – – – – X

Checkbox for “Probably” – – – – – – – – – – X

Checkbox for “Unknown” – – – – – – – – – – X

If female:

Checkbox for “Not pregnant within past year” – – – – – – – – – – X

Checkbox for “Pregnant at time of death” – – – – – – – – – – X

Checkbox for “Not pregnant, but pregnant within 42 days of death” – – – – – – – – – – X

Checkbox for “Not pregnant, pregnant 43 days to 1 year before death” – – – – – – – – – – X

Checkbox for “Unknown if pregnant within the past year” – – – – – – – – – – X

Did an operation precede death? – X – – – – – – – – –

Dates of operation – – X X – X – – – – –

Name of operation – – – X – – – – – – –

Major findings of operation – – – – X X – – – – –

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 – X X X X X X – – – –

Manner of death:

Checkbox for “Natural” – – – – – – – – – X X

Checkbox for “Accident” – – – – – – – – – X X

Checkbox for “Suicide” – – – – – – – – – X X

Checkbox for “Homicide” – – – – – – – – – X X

Checkbox for “Pending investigation” – – – – – – – – – X X

Checkbox for “Could not be determined” – – – – – – – – – X X

Date of injury – – – X X X X X X X X

Time of injury – – – – – X X X X X X

How injury occurred – – – – – X X X X X X

If transportation injury, specify:

Checkbox for “Driver/operator” – – – – – – – – – – X

Checkbox for “Passenger” – – – – – – – – – – X

Checkbox for “Pedestrian” – – – – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – – – – X

Injury at work? – – – – X X X X X X X

Place of injury – – – X X X X X X X X

Location of injury – – – X X X X X X X X

Means of injury – – – – X – – – – – –

Manner of injury – – – X – – – – – – –

Nature of injury – – – X – – – – – – –
Series 1, No. 62  Page 63 

Table V. Items included on the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989 2003

Medical certification—Con.

Was disease or injury related to occupation? – – – X – – – – – – –

If so, specify – – – X – – – – – – –

Certifier:

Signature and title of certifier X X X X X X X X X – –

Checkbox for “Certifying physician” – – – – – – – – – X X

Checkbox for “Pronouncing & certifying physician” – – – – – – – – – X X

Checkbox for “Medical examiner/coroner” – – – – – – – – – X X

License number – – – – – – – – – X X

Separate medical examiner or coroner certification – – – – – – – X X X X

Date signed X X X – X X X X X X X

Date of death X X X X X X X X X X –

Actual or presumed date of death – – – – – – – – – – X

Time of death X X X X X X X X X X –

Actual or presumed time of death – – – – – – – – – – X

Time pronounced dead – – – – – – – – – – X

Date pronounced dead – – – – – – – X X X X

Hour pronounced dead – – – – – – – X X – –

Name of attending physician, if other than certifier – – – – – – – – X – –

Name of certifier – – – – – – – X X X X

Address of certifier X X X X X X X X X X X

Dates physician attended decedent X X X X X X X X – – –

Date last seen alive X X X X X X X X – – –

Did physician view body after death? – – – – – – – – X – –

Was case referred to medical examiner or coroner? – – – – – – – X X X –

Was medical examiner or coroner contacted? 

Checkbox for “yes” or “no” – – – – – – – – – – X

Pronouncing physician:

Signature and title – – – – – – – – – X X

License number – – – – – – – – – X X

Date signed – – – – – – – – – X X

Disposition information

Burial, cremation, or removal – – – – X X X X X – –

Method of disposition:

Checkbox for “Burial” – – – – – – – – – X X

Checkbox for “Cremation” – – – – – – – – – X X

Checkbox for “Donation” – – – – – – – – – X X

Checkbox for “Entombment” – – – – – – – – – X X

Checkbox for “Removal from state” – – – – – – – – – X X

Checkbox for “Other (specify)” – – – – – – – – – X X

Date of burial X X X X X X X X – – –

Place of burial or removal X X – – – – – – – – –

Place of burial, cremation, or removal – – X X X – – – – – –

Name of cemetery or crematory – – – – – X X X X – –

Location (city, town, or county) – – – – – X X X X X X

Place of disposition (name of cemetery, crematory, or 

other place) – – – – – – – – X X X

Signature of funeral director – – – – X – – X – – –

Signature of funeral service licensee or person acting as such – – – – – – – – X X X

License number – – – – – – – – – X X

Name of funeral director (or person acting as such) X X X X – X X – – – –

Address X X X X X X X – – – –

Name of facility (funeral home) – – – – – – – X X X X

Address of facility (funeral home) – – – – – – – X X X X

Other information

Informant’s signature – – – – X – – – – – –

Informant’s name X X X X – X X X X X X

Mailing address X X X X X – X X X X X

Registrar’s signature – – – – X X X X X X –

Registrar X X X X – – – – – – –

Date received by local registrar – – – – X X X X – – –

Date received by registrar – – – – – X X X X – –

Date filed X X X X – – – – X X X

X Indicates item included on standard certificate.

– Indicates item not included on standard certificate.
Page 64  Series 1, No. 62

Table VI. Items included on the U.S. Standard Report of Fetal Death, by year revised

Item 1930 1939 1949 1956 1968 1978 1989 2003

Fetal death information

Name of fetus X X X X X – – –

Name of fetus (optional–at the discretion of the parents) – – – – – – – X

Sex of fetus X X X X X X X X

Sex of fetus (m/f/unk) – – – – – – – X

Date of delivery X X X X X X X X

Hour of delivery – – – – X X – –

Place of delivery:

Name of hospital – X X X X X – –

Name of facility – – – – – X – –

Facility ID (National Provider Identifier) – – – – – – – 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 X X X X X X X X

Township X – – – – – – –

Village X – – – – – – –

City X – – – – – – –

City, town, or location of delivery – X X X X X X X

Inside city limits – – – X X – – –

If outside city or town limits, write rural – – X X – – – –

County of delivery X X X X X X X X

Ward X – – – – – – –

Place where birth occurred (check one)

Checkbox for “Hospital” – – – – – – X X

Checkbox for “Freestanding birthing center” – – – – – – X X

Checkbox for “Clinic/doctor’s office” – – – – – – X X

Checkbox for “Residence” – – – – – – X X

Checkbox for “Home delivery” Planned to deliver at home? Checkbox for “yes” or “no” – – – – – – – X

Checkbox for “Other (specify)” – – – – – – X X

Weight of fetus – – X X X X X X

Weight of fetus (grams preferred, specify unit) Checkbox for “grams” or “lb./oz.” – – – – – – – X

Single, twin, triplet, etc. X X X X X X X –

Plurality–Single, twin, triplet, etc. (specify)... – – – – – – X X

Order if not single delivery X X X X X X X –

If not single birth–Born first, second, third, etc. (specify) – – – – – – – X

Mother information

Mother’s name (first, middle, last) – – – – – – X –

Mother’s current legal name (first, middle, last, suffix) – – – – – – – X

Maiden name X X X X X – – –

Maiden surname – – – – – – X X

Mother’s name prior to first marriage – – – – – – – X

Age X X X X X X – –

Date of birth – – – – – – – X

Birthplace (state or country) X X X X X – – –

Birthplace (city or place) X X – – – – – –

Birthplace (state, territory, or foreign country) – – – – – – X X

Length of stay in hospital or institution before delivery – X – – – – – –

Residence X – – – – – – –

State – X X X X X X X

County – X X X X X X X

City, town, or location – X X X X X X X

Street and number – X X X X X X X

Apt. no. – – – – – – – X

Inside city limits – – – X X X X –

Inside city limits? Checkbox for “yes” or “no” – – – – – – – X

If rural, give location – X X – – – – –

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

Zip code – – – – – – X X

Mother’s mailing address – X – – – – – –

Education (Specify only highest grade completed) – – – – – – X –

Elementary/secondary (0–12) – – – – – – X –

College (1–4 or 5+) – – – – – – X –

Education (Check the box that best describes the highest degree or level of school completed 

at the time of delivery): – – – – – – – X

Checkbox for “8th grade or less” – – – – – – – X

Checkbox for “9th–12th grade, no diploma” – – – – – – – X

Checkbox for “High school graduate or GED completed” – – – – – – – X

Checkbox for “Some college credit but no degree” – – – – – – – X

See footnotes at end of table.
Series 1, No. 62  Page 65 

Table VI. Items included on the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989 2003

Mother information—Con.

Checkbox for “Associate degree (e.g., AA, AS)” – – – – – – – X

Checkbox for “Bachelor’s degree (e.g., BA, AB, BS)” – – – – – – – X

Checkbox for “Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)” – – – – – – – X

Checkbox for “Doctorate (e.g., PhD, EdD) or Professional degree 

(e.g., MD, DDS, DVM, LLB, JD)” – – – – – – – X

Of Hispanic origin (Specify “no” or “yes”–If yes, specify Cuban, Mexican, 

Puerto Rican, etc.) – – – – – – – X

Checkbox for “yes” or “no” (specify) – – – – – – X –

Mother of Hispanic origin (Check the box that best describes whether 

the mother is Spanish/Hispanic/Latina. Check the “no” box if mother 

is not Spanish/Hispanic/Latina) – – – – – – – X

Checkbox for “No, not Spanish/Hispanic/Latina” – – – – – – – X

Checkbox for “Yes, Mexican, Mexican American, Chicana” – – – – – – – X

Checkbox for “Yes, Puerto Rican” – – – – – – – X

Checkbox for “Yes, Cuban” – – – – – – – X

Checkbox for “Yes, other Spanish/Hispanic/Latina (specify)” – – – – – – – X

Race–American Indian, black, white, etc. (specify below) X X X X X X X –

Race (Check one or more races to indicate what the mother considers 

herself to be) – – – – – – – X

Checkbox for “White” – – – – – – – X

Checkbox for “Black or African American” – – – – – – – X

Checkbox for “American Indian or Alaska Native (Name of the enrolled 

or principal tribe)” – – – – – – – X

Checkbox for “Asian Indian” – – – – – – – X

Checkbox for “Chinese” – – – – – – – X

Checkbox for “Filipino” – – – – – – – X

Checkbox for ”Japanese“ – – – – – – – X

Checkbox for ”Korean“ – – – – – – – X

Checkbox for “Vietnamese” – – – – – – – X

Did mother get Women, Infants, and Children (WIC) food for herself 

during this pregnancy? – – – – – – – X

Legitimate X – X X X – – –

Mother married? – X – – – X X –

Mother married? (At delivery, conception, or any time between) 

Checkbox for “yes” or “no” – – – – – – – X

If no, has paternity acknowledgement been signed in the hospital? 

Checkbox for “yes” or “no” – – – – – – – X

Trade, profession, or particular type of work done X – – – – – – –

Usual occupation – X – – X X – –

Occupation worked during last year – – – – – – X X

Kind of business or industry X X – – – – X X

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

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

Residence X – – – – – – –

Trade, profession, or particular type of work done X – – – – – – –

Usual occupation – X X X – – – –

Occupation worked during last year – – – – – X X X

Kind of business or industry X X X X – – X X

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

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

Pregnancy information

Pregnancy history:

Live births, now living X X X X X X X X

Live births, now dead X X X X X X X X

Born dead (stillborn, fetal death) X X – X – – – –

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

Under 20 weeks – – – – – X – –

Over 20 weeks – – – – – X – –

Other terminations at any time after conception – – – – – – X X

Number of other pregnancy outcomes (spontaneous or induced losses or 

ectopic pregnancies) – – – – – – – X

Whether born alive or stillborn – X X X X – – –

Date of last live birth – – – – X X X X

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

Date of last other termination – – – – – X X –

Date of last other pregnancy outcome – – – – – – – X

Month of pregnancy prenatal care began – – – – X X X –

Date of first prenatal care visit – – – – – – – X

See footnotes at end of table.
Page 66  Series 1, No. 62

Table VI. Items included on the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989 2003

Pregnancy information—Con.

Date of last prenatal care visit – – – – – – – X

Number of prenatal visits – – – – X X X X

Physician’s estimate of gestation – – – – – X – –

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

Obstetric estimate of gestation at delivery – – – – – – – X

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

Length of pregnancy (completed weeks) – – X X – – – –

Date last normal menses began – – – – X X X X

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 – – – – –

Tobacco use during pregnancy–Checkbox for “yes” or “no” – – – – – – X –

Average number cigarettes per day – – – – – – X –

Alcohol use during pregnancy–Checkbox for “yes” or “no” – – – – – – X –

Average number of drinks per week – – – – – – X –

Weight gained during pregnancy ___lbs. – – – – – – X –

Mother’s height – – – – – – – X

Mother’s prepregnancy weight – – – – – – – X

Cigarette smoking before and during pregnancy. For each time period, 

enter either the number of cigarettes or the number of packs of 

cigarettes smoked. If none, enter “0.” – – – – – – – X

Average number of cigarettes or packs of cigarettes smoked per day – – – – – – – X

Three months before pregnancy____# of cigarettes or ____# of packs – – – – – – – X

First three months of pregnancy____# of cigarettes or ____# of packs – – – – – – – X

Second three months of pregnancy____# of cigarettes or ____# of packs – – – – – – – X

Third trimester of pregnancy____# of cigarettes or ____# of packs – – – – – – – X

Medical risk factors for this pregnancy (check all that apply)

Checkbox for “Anemia (Hct.<30/Hgb.<10)” – – – – – – X –

Checkbox for “Cardiac disease” – – – – – – X –

Checkbox for “Acute or chronic lung disease” – – – – – – X –

Checkbox for “Diabetes” – – – – – – X –

Checkbox for “Genital herpes” – – – – – – X –

Checkbox for “Hydramnios/oligohydramnios” – – – – – – X –

Checkbox for “Hemoglobinopathy” – – – – – – X –

Checkbox for “Hypertension, chronic” – – – – – – X –

Checkbox for “Hypertension, pregnancy-associated” – – – – – – X –

Checkbox for “Eclampsia” – – – – – – X –

Checkbox for “Incompetent cervix” – – – – – – X –

Checkbox for “Previous infant 4,000+ grams” – – – – – – X –

Checkbox for “Previous preterm or small-for-gestational age infant” – – – – – – X –

Checkbox for “Renal disease” – – – – – – X –

Checkbox for “Rh sensitization” – – – – – – X –

Checkbox for “Uterine bleeding” – – – – – – X –

Checkbox for “None” – – – – – – X –

Checkbox for “Other (specify)” – – – – – – X –

Risk factors in this pregnancy (check all that apply)

Diabetes

Checkbox for “Prepregnancy (diagnosis prior to this pregnancy)” – – – – – – – X

Checkbox for “Gestational (diagnosis in this pregnancy)” – – – – – – – X

Hypertension – – – – – – – X

Checkbox for “Prepregnancy (chronic)” – – – – – – – X

Checkbox for “Gestational (pregnancy-induced hypertension, preeclampsia)” – – – – – – – X

Checkbox for “Eclampsia” – – – – – – – X

Checkbox for “Previous preterm birth” – – – – – – – X

Checkbox for “Other previous poor pregnancy outcome (includes 

perinatal death, small-for-gestational age/intrauterine growth restricted birth)” – – – – – – – X

Checkbox for “Pregnancy resulted from infertility treatment–If yes, 

check all that apply” – – – – – – – X

Checkbox for “Fertility-enhancing drugs, artificial insemination, or intrauterine insemination” – – – – – – – X

Checkbox for “Assisted reproductive technology [e.g., in vitro fertilization (IVF), gamete 

intrafallopian transfer (GIFT)]” – – – – – – – X

Checkbox for “Mother had a previous cesarean delivery” – – – – – – – X

If yes, how many _____ – – – – – – – X

Checkbox for “None of the above” – – – – – – – X

See footnotes at end of table.
Series 1, No. 62  Page 67 

Table VI. Items included on the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989 2003

Pregnancy information—Con.

Infections present and/or treated during this pregnancy (check all that apply) – – – – – – – X

Checkbox for “Gonorrhea” – – – – – – – X

Checkbox for “Syphilis” – – – – – – – X

Checkbox for “Chlamydia” – – – – – – – X

Checkbox for “Hepatitis B” – – – – – – – X

Checkbox for “Hepatitis C” – – – – – – – X

Checkbox for “None of the above” – – – – – – – X

Method of delivery (check all that apply) – – – – – – X –

Checkbox for “Vaginal” – – – – – – X –

Checkbox for “Vaginal birth after previous C-section” – – – – – – X –

Checkbox for “Primary C-section” – – – – – – X –

Checkbox for “Repeat C-section” – – – – – – X –

Checkbox for “Forceps” – – – – – – X –

Checkbox for “Vacuum” – – – – – – X –

Checkbox for “Hysterotomy/hysterectomy” – – – – – – X –

Method of delivery – – – – – – – X

Was delivery with forceps attempted but unsuccessful? 

Checkbox for “yes” or “no” – – – – – – – X

Was delivery with vacuum extraction attempted but unsuccessful? 

Checkbox for “yes” or “no” – – – – – – – X

Fetal presentation at birth – – – – – – – X

Checkbox for “Cephalic” – – – – – – – X

Checkbox for “Breech” – – – – – – – X

Checkbox for “Other” – – – – – – – X

Final route and method of delivery (check one) – – – – – – – X

Checkbox for “Vaginal/spontaneous” – – – – – – – X

Checkbox for “Vaginal/forceps” – – – – – – – X

Checkbox for “Vaginal/vacuum” – – – – – – – X

Checkbox for “Cesarean” – – – – – – – X

Checkbox for “If cesarean, was a trial of labor attempted? 

Checkbox for “yes” or “no” – – – – – – – X

Hysterotomy/hysterectomy–Checkbox for “yes” or “no” – – – – – – X X

Maternal morbidity (check all that apply) (complications associated with 

labor and delivery) – – – – – – – X

Checkbox for “Maternal transfusion” – – – – – – – X

Checkbox for “Third or fourth degree perineal laceration” – – – – – – – X

Checkbox for “Ruptured uterus” – – – – – – – X

Checkbox for “Unplanned hysterectomy” – – – – – – – X

Checkbox for “Admission to intensive care unit” – – – – – – – X

Checkbox for “Unplanned operating room procedure following delivery” – – – – – – – X

Checkbox for “None of the above” – – – – – – – X

Complications of labor – X – – – – – –

Complications of labor and/or delivery (check all that apply) – – – – – – X –

Checkbox for “Febrile (> 100°F or 38°C)” – – – – – – X –

Checkbox for “Meconium, moderate/heavy” – – – – – – X –

Checkbox for “Premature rupture of membranes (> 12 hours)” – – – – – – X –

Checkbox for “Abruptio placenta” – – – – – – X –

Checkbox for “Placenta Previa” – – – – – – X –

Checkbox for “Other excessive bleeding” – – – – – – X –

Checkbox for “Seizures during labor” – – – – – – X –

Checkbox for “Precipitous labor (< 3 hours)” – – – – – – X –

Checkbox for “Prolonged labor (> 20 hours)” – – – – – – X –

Checkbox for “Dysfunctional labor” – – – – – – X –

Checkbox for “Breech/malpresentation” – – – – – – X –

Checkbox for “Cephalopelvic disproportion” – – – – – – X –

Checkbox for “Cord prolapsed” – – – – – – X –

Checkbox for “Anesthetic complications” – – – – – – X –

Checkbox for “Fetal distress” – – – – – – X –

Checkbox for “None” – – – – – – X –

Checkbox for “Other, specify” – – – – – – X –

Was labor induced? – X – – – – – –

Congenital malformations or anomalies of fetus – – – – X X X –

Congenital anomalies of fetus (checkboxes) – – – – – – X X

Checkbox for “Anencephaly” – – – – – – – X

Checkbox for “Meningomyelocele/spina bifida” – – – – – – – X

Checkbox for “Cyanotic congenital heart disease” – – – – – – – X

Checkbox for “Congenital diaphragmatic hernia” – – – – – – – X

Checkbox for “Omphalocele” – – – – – – – X

Checkbox for “Gastroschisis” – – – – – – – X

See footnotes at end of table.
Page 68  Series 1, No. 62

Table VI. Items included on the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989 2003

Pregnancy information—Con.

Checkbox for “Limb reduction defect (excluding congenital amputation 

and dwarfing syndromes)” – – – – – – – X

Checkbox for “Cleft lip with or without cleft palate” – – – – – – – X

Checkbox for “Cleft palate alone” – – – – – – – X

Checkbox for “Down syndrome” – – – – – – – X

Checkbox for “Karyotype confirmed” – – – – – – – X

Checkbox for “Karyotype pending” – – – – – – – X

Checkbox for “Suspected chromosomal disorder” – – – – – – – X

Checkbox for “Karyotype confirmed” – – – – – – – X

Checkbox for “Karyotype pending” – – – – – – – X

Checkbox for “Hypospadias” – – – – – – – X

Checkbox for “None of the anomalies listed above” – – – – – – – X

Cause of fetal death information

Cause of stillbirth X X X – – – – –

Before labor X – – – – – – –

During labor X – – – – – – –

Fetal causes – X X – – – – –

Maternal causes – X X – – – – –

Cause of fetal death: – – – X X X X X

Immediate cause – – – X X X X –

Whether fetal or maternal – – – – X X X –

Due to – – – X X X X –

Whether fetal or maternal – – – – X X X –

Due to – – – X X X X –

Whether fetal or maternal – – – – X X X –

Other significant conditions of fetus or mother contributing to fetal death 

but not resulting in the underlying cause given in Part 1 – – – X X X X –

Cause/conditions contributing to fetal death initiating cause/condition 

(Among the choices below, please select the one which most likely 

began the sequence of events resulting in the death of the fetus) – – – – – – – X

Maternal conditions/diseases (specify) – – – – – – – X

Complications of placenta, cord, or membranes:

Checkbox for “Rupture of membranes prior to onset of labor” – – – – – – – X

Checkbox for “Abruptio placenta” – – – – – – – X

Checkbox for “Placenta insufficiency” – – – – – – – X

Checkbox for “Prolapsed cord ” – – – – – – – X

Checkbox for “True knot in cord” – – – – – – – X

Checkbox for “Chorioamnionitis” – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – X

Other obstetrical or pregnancy complications (specify) – – – – – – – X

Fetal anomaly (specify) – – – – – – – X

Fetal injury (specify) – – – – – – – X

Fetal infection (specify) – – – – – – – X

Other fetal conditions/disorders (specify) – – – – – – – X

Checkbox for “Unknown” – – – – – – – X

Other significant causes or conditions (select or specify all other 

conditions contributing to death) – – – – – – – X

Maternal conditions/diseases (specify) – – – – – – – X

Complications of placenta, cord, or membranes:

Checkbox for “Rupture of membranes prior to onset of labor” – – – – – – – X

Checkbox for “Abruptio placenta” – – – – – – – X

Checkbox for “Placenta insufficiency” – – – – – – – X

Checkbox for “Prolapsed cord” – – – – – – – X

Checkbox for “True knot in cord” – – – – – – – X

Checkbox for “Chorioamnionitis” – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – X

Other obstetrical or pregnancy complications (specify) – – – – – – – X

Fetal anomaly (specify) – – – – – – – X

Fetal injury (specify) – – – – – – – X

Fetal infection (specify) – – – – – – – X

Other fetal conditions/disorders (specify) – – – – – – – X

Checkbox for “Unknown” – – – – – – – X

When did fetus die? – – – X – – – –

Checkbox for “Before labor” – – – X – – – –

Checkbox for “During labor or delivery” – – – X – – – –

Checkbox for “Unknown” – – – X – – – –

Fetus died before labor, during labor or delivery, unknown (specify) – – – – X X X –

Did child die before labor? _____ During labor?_____ X – – – – – – –

See footnotes at end of table.
Series 1, No. 62  Page 69 

Table VI. Items included on the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989 2003

Cause of fetal death information—Con.

Estimated time of fetal death

Checkbox for “Dead at time of assessment, no labor ongoing” – – X X X X – –

Checkbox for “Dead at time of assessment, labor ongoing” – – – – – – – X

Checkbox for “Died during labor, after first assessment” – – – – – – – X

Checkbox for “Unknown time of fetal death” – – – – – – – X

Was autopsy performed? – – – X X X – –

If yes, were autopsy findings considered? – – – – X – – –

Was an autopsy performed? Checkbox for “yes,” “no,” or “planned” – – – – – – – X

Was histological placental examination performed? Checkbox for “yes,” “no,” or “planned” – – – – – – – X

Were autopsy or histological placental examination results used in determining cause of 

fetal death? Checkbox for “yes” or “no” – – – – – – – 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 – – – – – –

Medical certification information

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 – – X X X – – X

Address of attendant – – X X – – – –

Name and title of attendant (checkboxes) – – – – – – X –

Attendant’s name, title, and National Provider Identifier – – – – – – – X

Checkbox for “MD, DO, CNM/CM, other midwife, and other (specify)” – – – – – – – X

Name of physician or attendant – – – – – X – –

Name of person completing report – – – – – X X –

Title – – – – – – X X

Name and title of person completing report – – – – – – X X

Date report completed – – – – – – – X

Title – X – – – – – –

Date received by registrar – – – – – – – X

Signature of authorized official, if not attended by physician – – X X X – – –

Statement of local registrar or coroner if physician not present – X – – – – – X

Signature – X – – – – – –

Signature of registrar X X X X X – – –

Date received by local registrar – – X X X – – –

Date filed with local registrar X X – – – – – –

Date given name added X – – – – – – –

Signature of registrar X – – – – – – –

Disposition information

Burial, cremation, or removal – X X X X – – –

Method of disposition

Checkbox for “Burial” – – – – – – – X

Checkbox for “Cremation” – – – – – – – X

Checkbox for “Hospital disposition” – – – – – – – X

Checkbox for “Donation” – – – – – – – X

Checkbox for “Removal from state” – – – – – – – X

Checkbox for “Other (specify)” – – – – – – – X

Date of burial – X X X X – – –

Place of burial or cremation – X – – – – – –

Name of cemetery or crematory – – X X X – – –

Location – – X X X – – –

Signature of funeral director – X – – X – – –

Name of funeral director – – X X – – – –

Address – X X X – – – –

Name of funeral home – – – – X – – –

Address – – – – X – – –

Informant information

Informant – X X X – – – –

Address – X – – – – – –

X Indicates item included on standard report.

– Indicates item not included on standard report.
Page 70  Series 1, No. 62

Appendix Figures

 

Figure I. Implementation of the 2003 revised birth certificate
Series 1, No. 62  Page 71 

 

Figure II. Implementation of the 2003 revised death certificate
Page 72  Series 1, No. 62

 

SOURCE: National Association for Public Health Statistics and Information Systems (NAPHSIS) website: https://www.naphsis.org/systems.

 

Figure III. State and Territorial Exchange of Vital Events (STEVE) certifications, updated March 2018
Series 1, No. 62  Page 73 

 

SOURCE: National Association for Public Health Statistics and Information Systems (NAPHSIS) website: https://www.naphsis.org/systems.

 

Figure IV. Electronic death registration processing status, updated February 2018
Page 74  Series 1, No. 62

 

SOURCE: National Association for Public Health Statistics and Information Systems (NAPHSIS) website: https://www.naphsis.org/systems.

 

Figure V. Electronic birth registration status, updated February 2018
Vital and Health Statistics 

Series Descriptions

Active Series

Series 1. Programs and Collection Procedures

Reports describe the programs and data systems of the 

National Center for Health Statistics, and the data collection 

and survey methods used. Series 1 reports also include 

definitions, survey design, estimation, and other material 

necessary for understanding and analyzing the data.

Series 2. Data Evaluation and Methods Research

Reports present new statistical methodology including 

experimental tests of new survey methods, studies of vital and 

health statistics collection methods, new analytical techniques, 

objective evaluations of reliability of collected data, and 

contributions to statistical theory. Reports also include 

comparison of U.S. methodology with those of other countries.

Series 3. Analytical and Epidemiological Studies

Reports present data analyses, epidemiological studies, and 

descriptive statistics based on national surveys and data 

systems. As of 2015, Series 3 includes reports that would 

have previously been published in Series 5, 10–15, and 20–23.

Discontinued Series

Series 4. Documents and Committee Reports

Reports contain findings of major committees concerned with 

vital and health statistics and documents. The last Series 4 

report was published in 2002; these are now included in 

Series 2 or another appropriate series.

Series 5. International Vital and Health Statistics Reports

Reports present analytical and descriptive comparisons of 

U.S. vital and health statistics with those of other countries. 

The last Series 5 report was published in 2003; these are now 

included in Series 3 or another appropriate series.

Series 6. Cognition and Survey Measurement

Reports use methods of cognitive science to design, evaluate, 

and test survey instruments. The last Series 6 report was 

published in 1999; these are now included in Series 2.

Series 10. Data From the National Health Interview Survey

Reports present statistics on illness; accidental injuries; 

disability; use of hospital, medical, dental, and other services; 

and other health-related topics. As of 2015, these are included 

in Series 3.

Series 11. Data From the National Health Examination Survey, the 

National Health and Nutrition Examination Surveys, and 

the Hispanic Health and Nutrition Examination Survey

Reports present 1) estimates of the medically defined 

prevalence of specific diseases in the United States and the 

distribution of the population with respect to physical, 

physiological, and psychological characteristics and 2) 

analysis of relationships among the various measurements. 

As of 2015, these are included in Series 3.

Series 12. Data From the Institutionalized Population Surveys

The last Series 12 report was published in 1974; these reports 

were included in Series 13, and as of 2015 are in Series 3.

Series 13. Data From the National Health Care Survey

Reports present statistics on health resources and use of 

health care resources based on data collected from health 

care providers and provider records. As of 2015, these reports 

are included in Series 3.

Series 14. Data on Health Resources: Manpower and Facilities

The last Series 14 report was published in 1989; these reports 

were included in Series 13, and are now included in Series 3.

Series 15. Data From Special Surveys

Reports contain statistics on health and health-related topics 

from surveys that are not a part of the continuing data systems 

of the National Center for Health Statistics. The last Series 15 

report was published in 2002; these reports are now included 

in Series 3.

Series 16. Compilations of Advance Data From Vital and Health 

Statistics

The last Series 16 report was published in 1996. All reports 

are available online; compilations are no longer needed.

Series 20. Data on Mortality

Reports include analyses by cause of death and demographic 

variables, and geographic and trend analyses. The last Series 

20 report was published in 2007; these reports are now 

included in Series 3.

Series 21. Data on Natality, Marriage, and Divorce

Reports include analyses by health and demographic 

variables, and geographic and trend analyses. The last Series 

21 report was published in 2006; these reports are now 

included in Series 3.

Series 22. Data From the National Mortality and Natality Surveys

The last Series 22 report was published in 1973. Reports from 

sample surveys of vital records were included in Series 20 or 

21, and are now included in Series 3.

Series 23. Data From the National Survey of Family Growth

Reports contain statistics on factors that affect birth rates, 

factors affecting the formation and dissolution of families, and 

behavior related to the risk of HIV and other sexually 

transmitted diseases. The last Series 23 report was published 

in 2011; these reports are now included in Series 3.

Series 24. Compilations of Data on Natality, Mortality, Marriage, and 

Divorce

The last Series 24 report was published in 1996. All reports 

are available online; compilations are no longer needed.

For answers to questions about this report or for a list of reports published 

in these series, contact:

Information Dissemination Staff

National Center for Health Statistics

Centers for Disease Control and Prevention

3311 Toledo Road, Room 4551, MS P08

Hyattsville, MD 20782

Tel: 1–800–CDC–INFO (1–800–232–4636)

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Online request form: https://www.cdc.gov/info

For e-mail updates on NCHS publication releases, subscribe 

online at: https://www.cdc.gov/nchs/govdelivery.htm.
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National Center for Health Statistics 

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