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About every 10 years, the National Center for Health Statistics (NCHS) revises the U.S. Standard Certificate of Live Birth. The most recent revision process has recently been completed and will be going into effect in the States beginning in 2003. Now is the time to get involved to ensure that midwife-attended births are accurately represented in national birth certificate data. This tip sheet will provide some background information about birth certificates and advice about getting involved in the process on the state level.

Background - The Importance of Birth Certificate Data
Birth certificate data is used for a wide variety of purposes. Researchers have used birth certificate data to compare outcomes among providers (providing dramatic evidence of the benefit of nurse-midwifery care) as well as to study a multitude of questions from the effect of potential environmental hazards to the safety of home birth. Legislators and policy makers use birth certificate data to make decisions about issues from program funding to workforce projections. Each year, the ACNM uses the latest birth certificate data to update a graph depicting the rise in CNM-attended births, and we use birth certificate data in developing our state Fact Sheets. It is therefore essential that birth certificate data is accurate.

NCHS and U.S. Standard Certificate of Live Birth
Since the 1930s, all states have participated in a uniform program of data collection. Although vital registration is a state and local function, the federal government plays an important role. The National Center for Health Statistics (NCHS) is the federal agency charged with collecting and disseminating statistics on the nation's health. The NCHS coordinates the development of U.S. Standard Certificates of Live Birth, Death and Fetal Death, which serve as models for the reporting forms used by the states.

The 1989 revision of the U.S. Standard Certificate of Live Birth was particularly important for nurse-midwives. The "attendant item" was revised to include check boxes for CNMs and also for other midwives, allowing comparisons between physician and CNM-attended births. With regard to the site of birth, there was a check box added to identify a free-standing birth center, as well as a hospital or a home. The 2003 revision process has seen further improvements. The attendant item has been changed to "CNM/CM" and the check box for home birth has been expanded to identify planned versus unplanned home birth.

State Implementation
While the NCHS provides a model in the U.S. Standard Certificates, states are not compelled to adopt this model. Decisions about items included on the state certificate are made by the state registrar in the department of health. Many state certificates do not provide check boxes to clearly identify a CNM-attended birth and differentiate CNMs from other midwives, and many do not provide check boxes to clearly identify births that occurred in free-standing birth centers or planned home births. The lack of these categories clearly affects the quality of birth certificate data.

Birth certificates can provide a wealth of data for use in a wide variety of educational, marketing and policy initiatives at the state level. Most state vital statistics offices publish an annual summary of statistics which typically includes births by site and type of provider and may include more detailed information about births to teens, operative deliveries or some other issue of special interest. Depending on funding, resources and priorities of the vital records staff, they may be willing to provide specific data regarding midwife-attended births.

Action Plan/Future Challenges

• Learn how birth certificate data is collected in your state: is a standard worksheet used? Is filing done electronically?
• Learn what sort of birth certificate data is currently published in your state. Are you confident that midwife-attended births are being accurately identified?
• Set up a meeting with the staff in your state's vital statistics office. Let them know how their data is important to you. Find out what their plans are for revising the state certificate. It is important that midwives are represented on the panels/committees making revisions. If your state has established cumbersome rules that single out nurse-midwives or home births, this meeting may be an opportunity to address these issues.
• If your state's certificate does not allow the identification of CNM-attended births, develop an action plan for adoption of the U.S. Standard Certificate. This is an opportunity for collaboration with representatives from hospitals, health departments and educational institutions that are major employers of nurse-midwives, as well as advocacy groups like the March of Dimes.
• Consider this as a topic for a CE program at a chapter meeting (the Professional Services staff will be happy to provide a suggested outline and material).

Resources/Essential Documents

• Up-to-date information about the revision process can be found on the NCHS web site: www.cdc.gov/nchs/vital_certs_rev.htm. The draft of the new U.S. Standard Certificate of Live Birth is attached.
• Monthly vital statistics report, which includes natality statistics, is published by the National Center for Health Statistics. To receive this publication regularly, contact NCHS by calling 301-436-8500, or e-mail: nchsquery@cdc.gov.
• The ACNM's Nurse-Midwifery Today: A Handbook of State Laws and Regulations, has citations for each state's birth certificate laws; and the list of ACNM State Policy Resources has the address of the state vital statistics office.
• Journal Articles: Taffel SM, Ventura SJ, Gay GA. Revised U.S. Certificate of birth - new opportunities for research on birth outcome. Birth 1989; 16:188-195.
  Paine LL, Greener DL, Strobino DM. Birth registration: nurse-midwifery roles and
  responsibilities. J Nurse Midwifery 1988; 33:107-114.

1. MacDorman MF, Singh GK. Midwifery care, social and medical risk factors, and birth outcomes in the USA. J Epidemiol Community Health 1998; 52:310-317.

For additional ideas or assistance, contact Larry Silver, ACNM Senior Policy Analyst, or Lisa Summers, Senior Technical Advisor, at 202-728-9892.