Board of Scientific Counselors Program Review

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Vital Statistics What was our past? Where
are we now? What is our future? MCH Epi
Conference
Centers for Disease Control and
Prevention National Center for Health Statistics
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Topics

• Reactions to Dans and Garlands presentations
• A little vital history
• A sprint down Vital Statistics lane
• Budget stuff
• Can regulations be good for you?
• New data items
• Problems in Vital Statistics
• Future

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Reactions

• Dan
• Garland

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A Little Vital History

• 1850-90 - Birth and death data - collected on
  census
• 1850 Collection of national mortality data
  through the Census
• 1900 Death registration areas established (10
  States and D.C.)
• 1915 Birth registration areas established (10
  states and DC)
• 1933 Birth and Death Registration areas are
  complete
• 1973 NCHS begins to pay States for standardized
  vitals data sets

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A Little More Vital History 30/60

• 1912 (my Dads year of birth 17.6 of all deaths
  were to infants
• 1915 (birth registration area established) IMR
  99.9
• 1944 (my year of birth) IMR 39.4
• 1974 (year of birth of my last child) IMR 16.7
• 2004 (last year of final data) IMR 6.8

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Childhood Death Rates by Age at Death

Deaths per 100,000 population
2000
1-4 years
15-19 years
10-14 years
5-9 years
2004
SOURCE CDC/NCHS National Vital Statistics
System, 1900-2004
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History - Life Expectancy Age-Adjusted Death
Rates

Deaths per 100,000 standard population
Age in years

Life expectancy
Age-adjusted death rates
2004
NOTE Prior to 1933, data are for
death-registration States only.
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More History - Leading Causes

• 1900
• Influenza Pneumonia
• Tuberculosis
• Diarrhea
• Heart disease
• Stroke
• Population approx 76 million

• 2004
• Heart disease
• Cancer
• Stroke
• Chronic lower respiratory diseases
• Accidents (unintentional injuries)
• Diabetes
• Alzheimers Disease
• Influenza Pneumonia (60k)
• Population approx 290 million

NOTE Prior to 1933, data are for
death-registration States only.
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A Sprint Down Vital Statistics Lane
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Leading indicators from birth certificate
data Birth Rates by Age Teenage Pregnancy and
Childbearing Timing and Adequacy of Prenatal
Care Cesarean Delivery and VBAC Preterm Birth
and Low Birthweight Multiple Births
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Leading indicators from birth certificate
data Fertility and Maternal/Infant Health
Differences by Race/Hispanic Origin and
Educational Attainment Geographic Differences
(State, county-level data) Neural Tube
Defects Maternal Medical Risk Factors (Diabetes,
Hypertension) Smoking During Pregnancy
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Leading indicators using fetal death
data Pregnancy Health Pregnancy
Rates Perinatal Mortality Rates Tracking Causes
of Pregnancy Loss Differences in Pregnancy
Outcomes by Race/Ethnicity Tracking outcomes for
multiple deliveries
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Leading Indicators Linked Birth/Infant Death
Data Differences in Pregnancy Outcomes by
Race/Ethnicity Marital Status Educational
Attainment Maternal Medical Risk Status Smoking
Status During Pregnancy Gestation and
Birthweight-Specific Infant Mortality
Rates Infant Mortality Rates by
Plurality Geographic Variation in Infant
Mortality Leading Causes of Infant Death
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Fertility rates by race and Hispanic origin
United States, 1920-2006
SOURCE CDC/NCHS National Vital Statistics
System, 1920-2006
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(No Transcript)
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Number of births, birth rate, and percent of
births to unmarried women, U.S.,
1940-2005
2005
SOURCE CDC/NCHS National Vital Statistics
System, 1940-2005
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Number of Births and Birth Rate for Teenagers
15-19 Years U.S., 1940-2005
SOURCE CDC/NCHS National Vital Statistics
System, 1940-2005
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Birth rate for teenagers 15-19 and percent of
teenage births to unmarried teenagers,
U.S.,1950-2006
Percent unmarried
Birth rate
2006
SOURCE CDC/NCHS National Vital Statistics
System, 1950-2006
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Preterm birth

• U.S. preterm birth rates on the rise

Preterm birth rates U.S. 1990-2005
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Percentage low birthweight by race and Hispanic
origin of mother U.S., 1990-2005
Non-Hispanic black
Per 100
Non-Hispanic white
Hispanic
0
Year
Preliminary data
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Percentage of late preterm singleton births by
race and Hispanic origin of mother United
States, 1990, 2000, 2005
Percent
Non-Hispanic
NOTE Late preterm 34-36 completed weeks of
gestation.
Source CDC/NCHS, National Vital Statistics
System
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Infant mortality rates by birthweight U.S.,
2004
Per 1,000 live births
NOTE Birthweight in grams
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Percent change in birthweight by 500 gram
intervals U.S. 1990 and 2004
lt1,000 1,499 1,999 2,499 2,999 3,499 3,999 4,499
4,999 5,000
Birthweight in grams
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Fetal and infant mortality rates United
States, 1990-2004
Infant
Fetal
1995
NOTE Infant mortality rates are the number of
infant deaths per 1,000 live births. Fetal
mortality rates are the number of fetal deaths of
20 weeks of gestation or more per 1,000 live
births and fetal deaths. SOURCE CDC/NCHS
National Vital Statistics System.
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Perinatal mortality rates United States,
1990-2004
0
0
NOTE Perinatal I includes infants deaths less
than 7 days of age and fetal deaths 28 weeks or
more. Perinatal II includes infants less than 28
days of age and fetal deaths 20 weeks or more.
SOURCE CDC/NCHS National Vital Statistics
System.
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Total cesarean delivery rateUnited States,
1989-2005
Percent
0
1996
1989
2005
2000
Year
NOTE The total cesarean delivery rate is the
percentage of all live births by cesarean
delivery.
Source CDC/NCHS, National Vital Statistics
System.
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Total cesarean delivery rates by race and
Hispanic origin of mother United States, 1996
and 2006
Percent
American Indian or Alaska Native
Asian or Pacific Islander
All races
White
Black
Hispanic
Non-Hispanic
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Budget Stuff
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Current Budget Situation - NCHS

• All NCHS surveys are in financial trouble not
  just vitals
• FY07 VSCP 17.9million for 12 months
• FY07 VSCP budget - 16.5m 1.5million short
  but could have been worse was 3.1 deficit
  until last moment help
• 1.5 deficit 1 months of data
• FY08 ? but assuming flat will be short 3
  months of data
• FY08 Congress - 8 million above for NCHS -
  but will it happen?

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Regulationsfor Vitals 9/11 Commission
andIntelligence Reform and Terrorism Prevention
Act(IRTPA)
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Specific Issues

• Security of paper
• Security of systems and practices collecting data
• Security of systems and practices issuing
  certificates
• Ability to match birth and death records
• Ability to transmit records within and between
  States

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Philosophy of Reg Development

• Maintain a state-based birth registration and
  certification system - ownership remains with
  the States.
• Make a more secure, timely, responsive birth
  registration and certification system by
  improving security of collection, handling
  issuing of birth certificates
• Make a more connected birth certificate system by
  improving flow of information within and between
  States and between the States and the Federal
  Govt.
• Make no death registration regulations except as
  necessary to make birth certificates more secure.
  
• Make no new Federal data systems

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What needs to happen?

• More secure and responsive registration of vital
  events which will require
• Automation at the source to assure
• The ability to electronically transfer vital
  events within and between States and federal
  partners in real time

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Where are we?

• Federal Agency reps and State Registrar reps have
  provided recommendations for draft standards
• Contractor has developed the draft regs and is
  undertaking the economic and Federalism impact of
  the regs
• Draft regs are at HHS for review
• Hope to publish draft regs in Federal Register in
  the new year.

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Goals

• For the first time - will create regs for
  consistent vital registration processing and
  issuance
• Will require an environment that assures timely
  and secure information on birth records (EBRs
  and EDRs) and
• Which will impact death registration systems
  by requiring immediate matching of birth and
  death records
• And systems to transfer data

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Potential Funding

• The legislation authorizes two grant programs for
  States to
• Help with the cost for secure paper
• Help with the cost for more secure and
  responsive systems and for placing old data into
  those systems
• BUT beware authorization is not appropriation!

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What will this mean for Public Health?

• A more secure, timely, responsive, connected a
  more Vital vital registration system which can
• Once again form the basis of the premier public
  health surveillance as well as provide core
  public health measures

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The Future for Vitals
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New Data
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Rates of gestational diabetes by age of mother
and plurality 12 state reporting area, 2005
Per 1,000 live births

Years
Twins, triplets and other higher order multiple
births.
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Distribution of singleton births admitted to an
NICU by gestational age 12-State Reporting area
2005
37 weeks
47.5
lt32 weeks
17.2
10.4
25.0
34-36 weeks
32-33 weeks
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Neonatal intensive care unit (NICU) admission
for singleton births by gestational age and
race/Hispanic origin of mother 12 state
reporting area, 2004
Weeks of gestation

Non-Hispanic
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Percentage of singleton infants born at 4,500
grams and percentage admitted to an NICU -
whether the mother had prepregnancy (DM) or
gestational diabetes (GDM) 12 state reporting
area, 2005
Percent
DM
GDM
4,500 grams
4,500 grams
NICU admission
NICU admission
NOTE NICU neonatal intensive care unit.
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Some Problems with Vitals

• Need QC follow-up on new items
• VLBW survivorship high in some states
• Quality of fetal reporting
• Data responsiveness by some states
• States need help in implementing EBRs and EDRs.
  

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Some Problems with Vitals

• NCHS authorized to collect vitals but States not
  required to provide
• VSCP pays for data but does not pay for improving
  quality and timeliness
• VSCP pays for data no matter how late
• NCHS internal systems are good for EOY reporting
  but not for YTD reporting - surveillance

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Questions of the Future
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How can we build on our past successes for a new
beginning?To measure what is and not just what
wasAnd with improved quality?
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Future Considerations

• If vitals are VITAL should they not be a
  reportable event?
• Should we develop a reduced (core) data set for
  vitals and pay for that data set by NCHS VSCP
  funds ?
• As with NCHS surveys, should we seek reimbursable
  s from other federal partners to pay for other
  data items beyond the core data set?

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Future Considerations

• With remaining VSCP s and s from other
  federal partners should we provide CA/Grants to
  States for improving quality and responsiveness
  tailored to individual state needs?
• Should we go back to the Birth Registration Area
  idea and only pay those States that can meet new
  timelines and only report for those States?
• How should we integrate with electronic records
  and would that allow us to collect expanded data
  items beyond the core on a sample basis?

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What we do knowThis is not the time to ride
it out !
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Charlie RothwellDirector of Vital
StatisticsCRothwell_at_cdc.gov301-458-4468