Perinatal Epidemiology for Public Health Practice
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Melissa M. Adams Greg R. Alexander Russell S. Kirby Martha S. Wingate l
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Perinatal Epidemiology for Public Health Practice
Authors Melissa M. Adams, RN, MPH, PhD 1696 Council Bluff Drive NE., Atlanta GA 30345-4176 USA
[email protected] Greg R. Alexander, RS, MPH, ScD University of South Florida Lawton & Rhea Chiles Center for Healthy Mothers and Babies 3111 E. Fletcher Ave. Tampa FL 33613 USA
Russell S. Kirby, PhD University of Alabama at Birmingham School of Public Health Department of Maternal & Child Health Ryals 320 1530 3rd Avenue South Birmngham, AL 35294-0022 USA
[email protected] ISBN 978-0-387-09438-0 DOI 10.1007/978-0-387-09439-7
Martha S. Wingate, MPH, DrPH University of Alabama at Birmingham School of Public Health Department of Health Care Organization and Policy Ryals 330 1530 3rd Avenue South Birmingham AL 35294‐0022 USA
[email protected] e-ISBN 978-0-387-09439-7
Library of Congress Control Number: 2008938908 # Springer Science+Business Media, LLC 2009 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper. 987654321 springer.com
In February 2007, our coauthor, friend, colleague, and mentor, Dr. Greg Alexander, passed away unexpectedly and was not able to see this book to completion. Greg was a leading scholar and teacher in perinatal epidemiology and maternal and child health. In his quest for knowledge and insight, Greg constantly pushed himself and his colleagues and students to ask, “Why?” and to think beyond the status quo. His questions were not only to make his colleagues and students better, but also to make a better future for tomorrow’s children and adults. This vision was at the core of Greg’s passion for his work. It was not just about the papers or the publications on fetal growth curves, prenatal care, racial disparities in birth outcomes, and many other topics. It was about the vision of a world where all children are healthy, safe, and loved. Greg leaves his wonderful wife, Donna, and two amazing daughters, Kerry and Morgan, who were his heart. He knew that life was about more than work and this is evident in his beautiful family. The task of completing this book without Greg’s encouragement and prodding has been a long one. We hope that he would be proud of the final product. We are thankful for his ideas and passion that we tried to reflect in this text. Most of all, we are thankful for our friend. We miss you!
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Acknowledgements
The contents were enhanced by the generous review and comments that were contributed by William Callaghan, MD; Wendy Hellerstedt, PhD; Mona LydonRochelle, PhD; Mary Ann Pass, MD, MPH; Melissa Romaire, MPH; and Lowell Sever, PhD. This book benefited from the helpful work of Melissa Romaire and Suzanne Roseman, who identified references and data sources. Sheree Boulet, DrPH supported some of the analyses. Students who attended the course “Perinatal Epidemiology” at the School of Public Health, University of Alabama at Birmingham provided helpful comments on several chapters. This book would not have been possible without the longstanding support, practical guidance and patience of William Tucker, Emma Holgren, and Khristine Queja, all of whom are with the publisher, Springer Publishing Company, New York, NY. Donna Petersen provided guidance and encouragement for the promise of a completed textbook. The authors are grateful for all these contributions. The authors take full responsibility, however, for all errors. MA: Deepest thanks to my loving husband, Philip H. Rhodes, for his on-going multi faceted support throughout the writing of this text. I also extend my appreciation and love to our two children, Jesse and Quinn. To all three of you: please accept my thanks for your many compromises that enabled me to have the time and energy to complete this book. RK: Many thanks to my wife, Elizabeth, for listening and patience during the protracted gestation time for this book. And to my father, Frank E. Kirby who would have been delighted to see his son carry on a family tradition of book publication and to my mother, Emily Baruch Kirby, also a book author, who can, and to my three daughters, Rachel, Amelia, and Jocelyn who know that my love for them encompasses the totality of their health and well-being and that of their future children. MW: Much love and thanks to Bill for his patience and understanding during the book process (and during my pregnancy) and his desire to spend time with our daughter during the final stages! To the sweetest reminder of why we do what we do…Mary Hudson; thank you for being our biggest blessing! 3ws
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Contents
1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
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Reproductive Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.2 Male and Female Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.3 Infertility Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.4 Pregnancy Intention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.5 Legal Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.6 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2.7 Preconception Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Discussion Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Promising Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3
Maternal Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Definitions, Measures, and Measurement Issues . . . . . . . . . . . . . . . . . . . . . 3.2 Overall Maternal Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Antepartum Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Peripartum Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 Postpartum Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 Public Health Interventions: Their Availability and Use . . . . . . . . . . . . . Discussion Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promising Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Definitions, Measures, and Measurement Issues . . . . . . . . . . . . . . . . . . . . 4.2 Overall Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Cause-Specific Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Public Health Interventions, their Availability, and Use . . . . . . . . . . . . Discussion Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49 49 58 59 67 80 85 87 87 87 88
103 103 108 112 113 115 ix
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Promising Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 5
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Infant Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 General Issues of Infant Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Morbidity Associated with Shortened Gestation, Near-Term Intrauterine Growth Restriction, and Sequelae of Prematurity . . . . . . 5.3 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Birth Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Infant Morbidity Due to Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promising Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
121 122 126 131 137 142 146 146 146 147 147
The Continuum of Reproductive Loss from Pregnancy Through Infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Definitions, Measures, Data Sources, and Measurement Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Descriptive Epidemiology: Overall Mortality . . . . . . . . . . . . . . . . . . . . . . . 6.3 Early Pregnancy Loss and Spontaneous Abortion . . . . . . . . . . . . . . . . . . . 6.4 Fetal Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Infant Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6 Public Health Interventions, Their Availability, and Use . . . . . . . . . . . Discussion Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promising Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
155 165 169 171 182 203 206 207 207 208
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Birth Weight, Gestational Duration, and Fetal Growth . . . . . . . . . . . . . . . 7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Birth Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 Gestational Duration and Fetal Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promising Areas for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
225 225 226 241 266 266 267 267
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Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
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Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Chapter 1
Introduction
At the beginning of the twentieth century, women of childbearing age and infants were at a substantial risk of death. In the United States, nearly 1% of women of childbearing age died of pregnancy-related complications and 10% of their babies never celebrated their first birthdays (1–3). During the past century, reductions in maternal and infant mortality were unparalleled historically. The maternal mortality ratio decreased to 15.1 deaths per 100,000 live births in 2005 (4). The infant mortality rate declined more than 90% from 1915 through 2005, decreasing to 6.9 per 1,000 live births. Improved access to health care, environmental health and sanitation, as well as public health surveillance, increasing levels of education, and other advances contributed to healthier mothers and babies. Improvements in living and environmental conditions in urban areas were a primary focus in efforts to reduce infant mortality. Milk pasteurization contributed to the reduction in milk-borne diseases; improvements in education and economic conditions raised standards of living, thus promoting health; lower fertility rates also contributed to reductions in infant mortality through longer pregnancy spacing, improved nutritional status of mothers, and smaller family size (1, 3). The use of antibiotics further decreased the infant death rate (5). In addition, programs such as Medicaid, Special Supplemental Food Program for Women, Infants, and Children (WIC), and others were implemented to address the underlying issues associated with infant mortality, particularly postneonatal mortality (6). More recently, health promotion campaigns and new medical technologies and therapeutic interventions have been key. One example is the ‘‘Back to Sleep’’ campaign in the 1990s, which encouraged parents to put babies to sleep on their backs and led to a greater than 50% decline in Sudden Infant Death Syndrome (SIDS) (7). The development and use of artificial surfactant to treat and prevent respiratory distress syndrome in premature infants is an example of a clinical therapy that was instrumental in the recent reduction of infant mortality (8). For mothers, a number of factors contributed to the high rate of death due to pregnancy-related complications. The high number of maternal deaths was due largely to poor obstetric education and delivery practices (2). Obstetrical care was typically provided by poorly or untrained medical practitioners and many unnecessary interventions, such as induction of labor and Cesarean deliveries, occurred. Roughly 40% of maternal deaths resulted from sepsis because of unsafe delivery
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1 Introduction
practices; many of the remaining deaths were due to toxemia and hemorrhage (2). Beginning in the 1930s, a number of initiatives were put in place to help lower the number of maternal deaths in the United States. Hospitals and state public health practitioners initiated maternal mortality reviews to identify practices that caused the deaths. Institutional and physician guidelines were implemented to ensure appropriate training and procedures related to delivery. Deliveries were performed in cleaner environments, leading to fewer infections (9). Legalization of induced abortion began in the 1960s and culminated with Roe V. Wade in 1973. Legalization contributed to decline in deaths from sepsis associated with illegal abortions (10). Of the maternal deaths that occur in the United States today, however, more than half are preventable by the use of existing interventions (11). Despite these improvements, challenges in the area of maternal and child health in the United States still require attention. Significant disparities by race and ethnicity persist in infant and maternal health, particularly among Blacks and Whites. Black infants are more than twice as likely to die before their first birthday as White infants (12). American Indian/Alaskan Native infants have higher infant death rates compared with White infants, due largely to higher SIDS rates (13). The disparities of maternal mortality existing between Black and White mothers have increased over time. In the early part of the twentieth century, Black women were twice as likely to die of pregnancy-related complications as White women. Today, Black women are 3 times as likely to die from this cause (3). To address the issues of maternal and infant mortality as well as the other issues facing women and children today, we must understand the factors that contribute to their morbidity and mortality. Strategies to achieve this understanding include researching and intervening on biological, social, economic, psychological, and environmental factors. Epidemiology is one of the effective methods for conducting this research. Epidemiology is defined as ‘‘the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to control health problems’’ (14). In other words, in a defined population, epidemiology addresses these questions: What is the pattern of a specific disease or outcome? What factors influence this pattern? How can we control this disease or modify this outcome? The purpose of this text is to provide a population-based epidemiologic perspective on maternal, perinatal, and infant health issues with a specific focus on public health interventions that address these issues. This text focuses on perinatal health in the United States. To give perspective to rates in the United States of selected perinatal conditions, we present rates from other countries. The intended audience for this book includes public health practitioners, teachers, and students in public health or other health-related areas, clinicians, advocates, and others interested in these topics. The textbook has eight chapters. Except for Chapters 1 (Introduction) and 8 (Conclusion), each chapter addresses a topic related to maternal, perinatal, or infant health. The chapters that address these topics follow a similar outline, with variations as needed. Each chapter begins with an overall introduction and definitions of key terms or concepts associated with the overall topic. Specific measures, data sources related to the topic, and measurement issues are presented. The next section focuses on descriptive epidemiology: temporal trends and geographic and demographic
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variations. Demographic characteristics considered may include age, race, marital status, education, and income. Some chapters discuss attributable risk fractions associated with a specific outcome. The next section describes factors that influence the occurrence of the disease or outcome. This section outlines risk and protective factors as well as the availability, use, and effectiveness of public health interventions. At the end of each chapter, two brief sections list topics for discussion – for those using this text for teaching and a list of important unanswered questions. Additionally, abbreviations and references are included at the end of each chapter. In writing this text, we assumed that readers understand basic epidemiologic terminology and concepts. We define each problem from a population perspective. We did not plan for this text to provide specific clinical information. We assumed that readers have fundamental knowledge related to clinical conditions. We have included a glossary of terms that may be helpful in learning these concepts. We want our readers to gain a clearer understanding of the plethora of maternal and child health issues that need to be addressed in practice and research. Happy reading!
References 1. Meckel RA. Save the babies: American public health reform and the prevention of infant mortality, 1850–1929. Baltimore, Maryland: The Johns Hopkins University Press, 1990. 2. Loudon I. Death in childbirth: an international study of maternal care and maternal mortality, 1800–1950. New York: Oxford University Press, 1992. 3. Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: Healthier mothers and babies. MMWR, 48:849–858. 4. Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005. National vital statistics reports; Vol. 56 No. 10. Hyattsville, MD: National Center for Health Statistics. 2008. 5. Public Health Service. Vital statistics of the United States, 1950. Vol. 1. Washington, DC: US Department of Health and Human Services, Public Health Service, 1954:258–259. 6. Pharoah POD, Morris JN. Postneonatal mortality. Epidemiologic Review 1979; 1:170–183. 7. Willinger M, Hoffman H, Wu K, et al. Factors associated with the transition to non-prone sleep positions of infants in the United States: The National Infant Sleep Position Study. JAMA 1998; 280:329–339. 8. Schoendorf KC, Kiely JL. Birth weight and age-specific analysis of the 1990 US infant mortality drop: Was it surfactant? Archives of Pediatric and Adolescent Medicine, 1997; 151:129–134. 9. Children’s Bureau. Changes in infant, childhood, and maternal mortality over the decade of 1939–1948: A graphic analysis. Washington, DC: Children’s Bureau, Social Security Administration, 1950. 10. National Center for Health Statistics. Vital statistics of the United States, 1973. Vol. II, mortality, part A. Rockville, Maryland: US Department of Health, Education, and Welfare, 1977. 11. Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987–1990. Obstetrics and Gynecology 1996; 88:161–167. 12. Alexander GR, Wingate MS, Bader D, Kogan MD. The increasing racial disparity in infant mortality rates: Composition and contributors to recent U.S. trends. American Journal of Obstetrics and Gynecology, 2008, 198: 51e1–51e9. 13. Alexander GR, Wingate MS, Boulet S. Pregnancy Outcomes of American-Indians: Contrasts among regions and with other ethnic groups. Maternal and Child Health Journal, 2007, October [Epub ahead of print]. 14. Last JM. A dictionary of epidemiology, 2nd ed. New York: Oxford University Press, 1988.
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Chapter 2
Reproductive Health Issues
This chapter presents factors that set the context for pregnancy and, ultimately, influence maternal and infant health. We begin with fertility and its opposite, infertility. After briefly discussing the epidemiology of clinical treatment for infertility, we focus on the central theme of this chapter: pregnancy intention. We conclude by exploring a way of ending unintended pregnancy (induced abortion), a way to prevent unintended pregnancy (contraception), and a desirable antecedent of an intended pregnancy (preconception care).
2.1 2.1.1
Fertility Definition, Measures, Data Sources, and Measurement Issues
Definition: Fertility is the production of live offspring. Mortality and fertility rates can be used to estimate changes in the future growth of a population. The fertility rate also indicates the average number of deliveries per woman. In the United States, parity is the number of live-born children that a woman has borne. In the United Kingdom, parity is the number of times a woman has delivered a fetus of 24 weeks, regardless of whether that fetus was live or stillborn (1). In countries with higher fertility, average parity also tends to be higher. Fertility describes the experience of a population; parity describes the experience of an individual woman. Parity is related to pregnancy outcome, with risks for a range of maternal and fetal adverse outcomes generally highest for first pregnancies and eighth and subsequent pregnancies. When a population’s fertility rate is high, women tend to begin childbearing in their teens and continue to their late thirties and early forties. Risks for adverse pregnancy outcomes are highest for young teens and women aged 35 and above. Fecundity is distinct from fertility. Fecundity is the ability of a couple to have children, rather than the actual production of children. Couples may have impaired M.M. Adams et al., Perinatal Epidemiology for Public Health Practice. doi: 10.1007/978-0-387-09439-7_2; # Springer Science + Business Media, LLC 2009
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2 Reproductive Health Issues
fecundity if they have difficulty conceiving or carrying a fetus to term. Factors related to the woman, man, or both may impair fecundity (2). Couples may be fecund although they do not bear children. Measures: General measures of fertility include the crude birth rate, general fertility rate, age-specific fertility rate, total fertility rate, gross reproduction rate, net reproduction rate, and fertility ratio. Many of these rates apply to reproductiveaged women, conventionally defined as women aged 15 through 44 years. These measures are defined in Table 2.1. The pregnancy rate differs from the other rates in Table 2.1 in that its numerator consists of all pregnancies – regardless of how they end – that occur in a population of reproductive-aged women in a year. Thus the numerator includes live and stillbirths, induced and spontaneous abortions and ectopic pregnancies. The pregnancy rate is informative in studying the magnitude of potential morbidity related to pregnancy. Because the numerator is pregnancies, women who have more than one pregnancy in a year will be counted twice. The denominator for the crude birth rate is everyone in the population, regardless of their potential to actually bear a child. Because of this inclusiveness, the crude birth rate is influenced by the age distribution in the population. A population with a large portion of persons not in their reproductive years (i.e., children or older adults) relative to the portion of persons aged 15–44 years is likely to have a lower crude birth rate than a population with a large portion of the population aged 15–44 years. This happens because nearly all births occur among women aged 15–44 years. To minimize the confounding effect of these differences in age distributions when comparing populations, researchers often analyze the general fertility rate. The denominator of the general fertility rate includes only women in their reproductive years. However, confounding effects may still remain if, for example, one population contains a greater portion of women at the peak of their reproductive years (ages 20–29 years) than another population. To address this problem, researchers may examine age-specific rates. These rates are often computed for 5-year intervals of maternal age (quinquennia), e.g., 15–19 years, 20–24 years, etc. The total fertility rate estimates the number of children a cohort of 1,000 women would bear if they all went through their childbearing years experiencing the agespecific birth rates in effect for a particular time. Thus, it projects the prevailing age-specific fertility rates for women of one age onto those of another age. It is a synthetic, hypothetical rate, usually standardized to a constant age distribution of women. The total fertility rate may be expressed as births per woman or per 1,000 women. The total fertility rate estimates whether the childbearing population is replacing itself or not. A total fertility rate of about 2,100 per 1,000 women (equal to 2.1 per woman) or above indicates that, on the average, couples are reproducing at a level to replace themselves (replacement fertility). When the total fertility rate exceeds 2,100 for an extended period, the next generation of adults of childbearing age will probably be larger than the present population of that age if all other factors affecting the population, such as death rates and migration, remain constant (3).
Crude birth rate per 1,000 people
Live births in a population during a year 1;000 Average or mid - year population in that year
General fertility rate per 1,000 aged women 15–44 years
Live births in a population area during a year 1;000 Mid - year female population aged 15 44 in the same population in the same year
Age-specific fertility rate per 1,000 women of a specified age
Live births among women of specified age in a population during a year 1;000 Mid - year female population of the specified age in the same population in the same year
Total fertility rate per 1,000 women aged 15–44 years
A hypothetical rate computed by summing the age-specific fertility rates in a given period for a hypothetical cohort of women
Gross fertility rate per 1,000 reproductive-age women
Live - born girls in an population during a year 1;000 Mid - year female population aged 15 44 years in the same population in the same year
Net reproduction rate per 1,000 reproductive-age women
Gross fertility rate, where the denominator is decreased to take into account maternal deaths
Fertility ratio per 1,000 women aged 15–49 years
Children aged resulting in death)
To Be Completed By: MEDICAL CERTIFIER
Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST
• •Yes • •No
CORONER CONTACTED?
CAUSE OF DEATH (See instructions and examples) 32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
Approximate interval: Onset to death
a._______________________________________________________________________________________________________ Due to (or as a consequence of):
_________________
b.____________________________________________________________________________________ ___________________ Due to (or as a consequence of):
_________________
c._______________________________________________________________________________________________________ Due to (or as a consequence of):
_________________
d.___________________________________________________________________________________________________ ____
_________________
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
33. WAS AN AUTOPSY PERFORMED? • •Yes • •No 34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? • •Yes • •No
35.
DID TOBACCO USE CONTRIBUTE TO DEATH?
• • Yes
• • Probably
• • No
• • Unknown
36. IF FEMALE: • •Not pregnant within past year
37. MANNER OF DEATH
• •Pregnant at time of death • •Not pregnant, but pregnant within 42 days of death • •Not pregnant, but pregnant 43 days to 1 year before death • • Unknown if pregnant within the past year
38. DATE OF INJURY (Mo/Day/Yr) (Spell Month)
39. TIME OF INJURY
• •Natural
• •Homicide
• •Accident • •Pending Investigation • •Suicide
• •Could not be determined
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
41. INJURY AT WORK?
• •Yes • •No 42. LOCATION OF INJURY:
State:
City or Town:
Street & Number:
Apartment No.:
43. DESCRIBE HOW INJURY OCCURRED:
Zip Code: 44. IF TRANSPORTATION INJURY, SPECIFY: • •Driver/Operator • •Passenger • •Pedestrian • •Other (Specify)
45. CERTIFIER (Check only one):
• •Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated. • •Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated. • •Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated. Signature of certifier:_____________________________________________________________________________ 46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32)
To Be Completed By: FUNERAL DIRECTOR
47. TITLE OF CERTIFIER
48. LICENSE NUMBER
55. KIND OF BUSINESS/INDUSTRY
REV. 11/2003
49. DATE CERTIFIED (Mo/Day/Yr)
50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)
51. DECEDENT’S EDUCATION-Check the 52. DECEDENT OF HISPANIC ORIGIN? Check the box that best 53. DECEDENT’S RACE (Check one or more races to indicate what the decedent considered himself or herself to be) box that best describes the highest degree or describes whether the decedent is Spanish/Hispanic/Latino. Check the “No” box if decedent is not Spanish/Hispanic/Latino. level of school completed at the time of death. • • White • • Black or African American • • 8th grade or less • • American Indian or Alaska Native • • No, not Spanish/Hispanic/Latino (Name of the enrolled or principal tribe) ___________________________ • • 9th - 12th grade; no diploma • • Asian Indian • • Chinese • • High school graduate or GED completed • • Yes, Mexican, Mexican American, Chicano • • Filipino • • Some college credit, but no degree • • Yes, Puerto Rican • • Japanese • • Korean • • Associate degree (e.g., AA, AS) • • Vietnamese • • Yes, Cuban • • Bachelor’s degree (e.g., BA, AB, BS) • • Other Asian (Specify)__________________________________________ • • Native Hawaiian • • Master’s degree (e.g., MA, MS, MEng, • • Yes, other Spanish/Hispanic/Latino • • Guamanian or Chamorro MEd, MSW, MBA) • • Samoan (Specify) __________________________________ • • Doctorate (e.g., PhD, EdD) or • • Other Pacific Islander (Specify) ___________________________________ Professional degree (e.g., MD, DDS, • • Other (Specify)________________________________________________ DVM, LLB, JD) 54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).
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MEDICAL CERTIFIER INSTRUCTIONS for selected items on U.S. Standard Certificate of Death (See Physicians’ Handbook or Medical Examiner/Coroner Handbook on Death Registration for instructions on all items)
ITEMS ON WHEN DEATH OCCURRED Items 24-25 and 29-31 should always be completed. If the facility uses a separate pronouncer or other person to indicate that death has taken place with another person more familiar with the case completing the remainder of the medical portion of the death certificate, the pronouncer completes Items 24-28. If a certifier completes Items 24-25 as well as items 29-49, Items 26-28 may be left blank.
ITEMS 24-25, 29-30 – DATE AND TIME OF DEATH Spell out the name of the month. If the exact date of death is unknown, enter the approximate date. If the date cannot be approximated, enter the date the body is found and identify as date found. Date pronounced and actual date may be the same. Enter the exact hour and minutes according to a 24-hour clock; estimates may be provided with “Approx.” placed before the time.
ITEM 32 – CAUSE OF DEATH (See attached examples) Take care to make the entry legible. Use a computer printer with high resolution, typewriter with good black ribbon and clean keys, or print legibly using permanent black ink in completing the CAUSE OF DEATH Section. Do not abbreviate conditions entered in section. Part I (Chain of events leading directly to death) •Only one cause should be entered on each line. Line (a) MUST ALWAYS have an entry. DO NOT leave blank. Additional lines may be added if necessary. •If the condition on Line (a) resulted from an underlying condition, put the underlying condition on Line (b), and so on, until the full sequence is reported. ALWAYS enter the underlying cause of death on the lowest used line in Part I. •For each cause indicate the best estimate of the interval between the presumed onset and the date of death. The terms “unknown” or “approximately” may be used. General terms, such as minutes, hours, or days, are acceptable, if necessary. DO NOT leave blank. •The terminal event (for example, cardiac arrest or respiratory arrest) should not be used. If a mechanism of death seems most appropriate to you for line (a), then you must always list its cause(s) on the line(s) below it (for example, cardiac arrest due to coronary artery atherosclerosis or cardiac arrest due to blunt impact to chest). • If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death, always report its etiology on the line(s) beneath it (for example, renal failure due to Type I diabetes mellitus). •When indicating neoplasms as a cause of death, include the following: 1) primary site or that the primary site is unknown, 2) benign or malignant, 3) cell type or that the cell type is unknown, 4) grade of neoplasm, and 5) part or lobe of organ affected. (For example, a primary welldifferentiated squamous cell carcinoma, lung, left upper lobe.) •Always report the fatal injury (for example, stab wound of chest), the trauma (for example, transection of subclavian vein), and impairment of function (for example, air embolism).
PART II (Other significant conditions) •Enter all diseases or conditions contributing to death that were not reported in the chain of events in Part I and that did not result in the underlying cause of death. See attached examples. •If two or more possible sequences resulted in death, or if two conditions seem to have added together, report in Part I the one that, in your opinion, most directly caused death. Report in Part II the other conditions or diseases.
CHANGES TO CAUSE OF DEATH Should additional medical information or autopsy findings become available that would change the cause of death originally reported, the original death certificate should be amended by the certifying physician by immediately reporting the revised cause of death to the State Vital Records Office.
ITEMS 33-34 - AUTOPSY •33 - Enter “Yes” if either a partial or full autopsy was performed. Otherwise enter “No.” •34 - Enter “Yes” if autopsy findings were available to complete the cause of death; otherwise enter “No”. Leave item blank if no autopsy was performed.
ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH? Check “yes” if, in your opinion, the use of tobacco contributed to death. Tobacco use may contribute to deaths due to a wide variety of diseases; for example, tobacco use contributes to many deaths due to emphysema or lung cancer and some heart disease and cancers of the head and neck. Check “no” if, in your clinical judgment, tobacco use did not contribute to this particular death.
ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN PAST YEAR? This information is important in determining pregnancy-related mortality.
ITEM 37 - MANNER OF DEATH •Always check Manner of Death, which is important: 1) in determining accurate causes of death; 2) in processing insurance claims; and 3) in statistical studies of injuries and death. •Indicate “Pending investigation” if the manner of death cannot be determined whether due to an accident, suicide, or homicide within the statutory time limit for filing the death certificate. This should be changed later to one of the other terms. •Indicate “Could not be Determined” ONLY when it is impossible to determine the manner of death.
ITEMS 38-44 - ACCIDENT OR INJURY – to be filled out in all cases of deaths due to injury or poisoning. •38 - Enter the exact month, day, and year of injury. Spell out the name of the month. DO NOT use a number for the month. (Remember, the date of injury may differ from the date of death.) Estimates may be provided with “Approx.” placed before the date. •39 - Enter the exact hour and minutes of injury or use your best estimate. Use a 24-hour clock. •40 - Enter the general place (such as restaurant, vacant lot, or home) where the injury occurred. DO NOT enter firm or organization names. (For example, enter “factory”, not “Standard Manufacturing, Inc.” ) •41 - Complete if anything other than natural disease is mentioned in Part I or Part II of the medical certification, including homicides, suicides, and accidents. This includes all motor vehicle deaths. The item must be completed for decedents ages 14 years or over and may be completed for those less than 14 years of age if warranted. Enter “Yes” if the injury occurred at work. Otherwise enter “No”. An injury may occur at work regardless of whether the injury occurred in the course of the decedent’s “usual” occupation. Examples of injury at work and injury not at work follow: Injury at work Injury not at work Injury while working or in vocational training on job premises Injury while engaged in personal recreational activity on job premises Injury while on break or at lunch or in parking lot on job premises Injury while a visitor (not on official work business) to job premises Injury while working for pay or compensation, including at home Homemaker working at homemaking activities Injury while working as a volunteer law enforcement official etc. Student in school Injury while traveling on business, including to/from business contacts Working for self for no profit (mowing yard, repairing own roof, hobby) Commuting to or from work •42 - Enter the complete address where the injury occurred including zip code. •43 - Enter a brief but specific and clear description of how the injury occurred. Explain the circumstances or cause of the injury. Specify type of gun or type of vehicle (e.g., car, bulldozer, train, etc.) when relevant to circumstances. Indicate if more than one vehicle involved; specify type of vehicle decedent was in. •44 -Specify role of decedent (e.g. driver, passenger). Driver/operator and passenger should be designated for modes other than motor vehicles such as bicycles. Other applies to watercraft, aircraft, animal, or people attached to outside of vehicles (e.g. surfers). Rationale: Motor vehicle accidents are a major cause of unintentional deaths; details will help determine effectiveness of current safety features and laws. REFERENCES For more information on how to complete the medical certification section of the death certificate, refer to tutorial at http://www.TheNAME.org and resources including instructions and handbooks available by request from NCHS, Room 7318, 3311 Toledo Road, Hyattsville, Maryland 207822003 or at www.cdc.gov/nchs/about/major/dvs/handbk.htm
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283
Cause-of-death – Background, Examples, and Common Problems Accurate cause of death information is important •to the public health community in evaluating and improving the health of all citizens, and •often to the family, now and in the future, and to the person settling the decedent’s estate.
The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on line a and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be listed as “probable” even if it has not been definitively diagnosed.
Examples of properly completed medical certifications: CAUSE OF DEATH (See instructions and examples) 32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition ---------> a. Rupture of myocardium resulting in death) Due to (or as a consequence of): Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST
b.
Approximate interval: Onset to death
Minutes 6 days
Acute myocardial infarction Due to (or as a consequence of):
c.
Coronary artery thrombosis
5 years
d.
Atherosclerotic coronary artery disease
7 years
Due to (or as a consequence of):
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
33. WAS AN AUTOPSY PERFORMED? • • Yes
Diabetes, Chronic obstructive pulmonary disease, smoking
• •No
34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? • • Yes • •No 35. DID TOBACCO USE CONTRIBUTE TO DEATH? • • Yes • • Probably • • No
• • Unknown
37. MANNER OF DEATH
36. IF FEMALE: • •Not pregnant within past year • •Pregnant at time of death • •Not pregnant, but pregnant within 42 days of death • •Not pregnant, but pregnant 43 days to 1 year before death • • Unknown if pregnant within the past year
• •Natural • •Accident • •Suicide
• •Homicide • •Pending Investigation • •Could not be determined
CAUSE OF DEATH (See instructions and examples) 32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition ---------> resulting in death) Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST
Approximate interval: Onset to death
a.
Aspiration pneumonia
2 Days
b.
Complications of coma
7 weeks
c.
Blunt force injuries
7 weeks
d.
Motor vehicle accident
Due to (or as a consequence of):
Due to (or as a consequence of): Due to (or as a consequence of):
7 weeks
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
33. WAS AN AUTOPSY PERFORMED? • • Yes
• •No
34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? • • Yes • •No 35. DID TOBACCO USE CONTRIBUTE TO DEATH? • • Yes • • Probably
36. IF FEMALE: • • Not pregnant within past year • •Pregnant at time of death • •Not pregnant, but pregnant within 42 days of death • •Not pregnant, but pregnant 43 days to 1 year before death • • Unknown if pregnant within the past year
• • No • • Unknown
39. TIME OF INJURY
38. DATE OF INJURY (Mo/Day/Yr) (Spell Month)
42. LOCATION OF INJURY:
• • Natural • •Homicide • • Accident • •Pending Investigation • •Suicide • •Could not be determined
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
Approx. 2320
August 15, 2003
37. MANNER OF DEATH
State: Missouri
Street & Number: mile marker 17 on state route 46a
road side near state highway
41. INJURY AT WORK?
• •Yes • • No
City or Town: near Alexandria Apartment No.:
Zip Code: 44. IF TRANSPORTATION INJURY, SPECIFY: • • Driver/Operator • • Passenger • • Pedestrian • • Other (Specify)
43. DESCRIBE HOW INJURY OCCURRED:
Decedent driver of van, ran off road into tree
Common problems in death certification The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about conducting an investigation or providing assistance in completing the cause of death. The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible. “Prematurity” should not be entered wi thout explaining the etiology of prematurity. Maternal conditions may have initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant’s death certificate (e.g., Hyaline membrane disease due to prematurity, 28 weeks due to placental abruption due to blunt trauma to mother’s abdomen). When SIDS is suspected, a complete investigation should be conducted, typically by a medical examiner or coroner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical history is reviewed, and a complete autopsy is perfo rmed, then the death can be reported as Sudden Infant Death Syndrome.
When processes such as the following are reported, additional information about the etiology should be reported: Abscess Abdominal hemorrhage Adhesions Adult respiratory distress syndrome Acute myocardial infarction Altered mental status Anemia Anoxia Anoxic encephalopathy Arrhythmia Ascites Aspiration Atrial fibrillation Bacteremia Bedridden Biliary obstruction Bowel obstruction Brain injury Brain stem herniation Carcinogenesis
Carcinomatosis Cardiac arrest Cardiac dysrhythmia Cardiomyopathy Cardiopulmonary arrest Cellulitis Cerebral edema Cerebrovascular accident Cerebellar tonsillar herniation Chronic bedridden state Cirrhosis Coagulopathy Compression fracture Congestive heart failure Convulsions Decubiti Dehydration Dementia (when not otherwise specified) Diarrhea
Disseminated intra vascular coagulopathy Dysrhythmia End-stage liver disease End-stage renal disease Epidural hematoma Exsanguination Failure to thrive Fracture Gangrene Gastrointestinal hemorrhage Heart failure Hemothorax Hepatic failure Hepatitis Hepatorenal syndrome Hyperglycemia Hyperkalemia Hypovolemic shock
Hyponatremia Hypotension Immunosuppression Increased intra cranial pressure Intra cranial hemorrhage Malnutrition Metabolic encephalopathy Multi-organ failure Multi-system organ failure Myocardial infarction Necrotizing soft-tissue infection Old age Open (or closed) head injury Paralysis Pancytopenia Perforated gallbladder Peritonitis Pleural effusions Pneumonia
Pulmonary arrest Pulmonary edema Pulmonary embolism Pulmonary insufficiency Renal failure Respiratory arrest Seizures Sepsis Septic shock Shock Starvation Subdural hematoma Subarachnoid hemorrhage Sudden death Thrombocytopenia Uncal herniation Urinary tract infection Ventricular fibrillation Ventricular tachycardia Volume depletion
If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear that a distinct etiology was not inadvertently or carelessly omitted. The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago). Such cases should be reported to the medical examiner/coroner. Asphyxia Bolus Choking Drug or alcohol overdose/drug or alcohol abuse
REV. 11/2003
Epidural hematoma Exsanguination Fall Fracture
Hip fracture Hyperthermia Hypothermia Open reduction of fracture
Pulmonary emboli Seizure disorder Sepsis Subarachnoid hemorrhage
Subdural hematoma Surgery Thermal burns/chemical burns
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FUNERAL DIRECTOR INSTRUCTIONS for selected items on U.S. Standard Certificate of Death (For additional information concerning all items on certificate see Funeral Directors’ Handbook on Death Registration) ITEM 1. DECEDENT’S LEGAL NAME Include any other names used by decedent, if substantially different from the legal name, after the abbreviation AKA (also known as) e.g. Samuel Langhorne Clemens AKA Mark Twain, but not Jonathon Doe AKA John Doe
ITEM 5. DATE OF BIRTH Enter the full name of the month (January, February, March etc.) Do not use a number or abbreviation to designate the month.
ITEM 7A-G. RESIDENCE OF DECEDENT (information divided into seven categories) Residence of decedent is the place where the decedent actually resided. The place of residence is not necessarily the same as “home state” or “legal residence”. Never enter a temporary residence such as one used during a visit, business trip, or vacation. Place of residence during a tour of military duty or during attendance at college is considered permanent and should be entered as the place of residence. If the decedent had been living in a facility where an individual usually resides for a long period of time, such as a group home, mental institution, nursing home, penitentiary, or hospital for the chronically ill, report the location of that facility in item 7. If the decedent was an infant who never resided at home, the place of residence is that of the parent(s) or legal guardian. Never use an acute care hospital’s location as the place of residence for any infant. If Canadian residence, please specify Province instead of State.
ITEM 10. SURVIVING SPOUSE’S NAME If the decedent was married at the time of death, enter the full name of the surviving spouse. If the surviving spouse is the wife, enter her name prior to first marriage. This item is used in establishing proper insurance settlements and other survivor benefits.
ITEM 12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE Enter the name used prior to first marriage, commonly known as the maiden name. This name is useful because it remains constant throughout life.
ITEM 14. PLACE OF DEATH The place where death is pronounced should be considered the place where death occurred. If the place of death is unknown but the body is found in your State, the certificate of death should be completed and filed in accordance with the laws of your State. Enter the place where the body is found as the place of death.
ITEM 51. DECEDENT’S EDUCATION (Check appropriate box on death certificate) Check the box that corresponds to the highest level of education that the decedent completed. Information in this section will not appear on the certified copy of the death certificate. This information is used to study the relationship between mortality and education (which roughly corresponds with socioeconomic status). This information is valuable in medical studies of causes of death and in programs to prevent illness and death.
ITEM 52. WAS DECEDENT OF HISPANIC ORIGIN? (Check “No” or appropriate “Yes” box) Check “No” or check the “Yes” box that best corresponds with the decedent’s ethnic Spanish identity as given by the informant. Note that “Hispanic” is not a race and item 53 must also be completed. Do not leave this item blank. With respect to this item, “Hispanic” refers to people whose origins are from Spain, Mexico, or the Spanish-speaking Caribbean Islands or countries of Central or South America. Origin includes ancestry, nationality, and lineage. There is no set rule about how many generations are to be taken into account in determining Hispanic origin; it may be based on the country of origin of a parent, grandparent, or some far-removed ancestor. Although the prompts include the major Hispanic groups, other groups may be specified under “other”. “Other” may also be used for decedents of multiple Hispanic origin (e.g. Mexican-Puerto Rican). Information in this section will not appear on the certified copy of the death certificate. This information is needed to identify health problems in a large minority population in the United States. Identifying health problems will make it possible to target public health resources to this important segment of our population.
ITEM 53. RACE (Check appropriate box or boxes on death certificate) Enter the race of the decedent as stated by the informant. Hispanic is not a race; information on Hispanic ethnicity is collected separately in item 52. American Indian and Alaska Native refer only to those native to North and South America (including Central America) and does not include Asian Indian. Please specify the name of enrolled or principal tribe (e.g., Navajo, Cheyenne, etc.) for the American Indian or Alaska Native. For Asians check Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify other Asian group; for Pacific Islanders check Guamanian or Chamorro, Samoan, or specify other Pacific Island group. If the decedent was of mixed race, enter each race (e.g., SamoanChinese-Filipino or White, American Indian). Information in this section will not appear on the certified copy of the death certificate. Race is essential for identifying specific mortality patterns and leading causes of death among different racial groups. It is also used to determine if specific health programs are needed in particular areas and to make population estimates.
ITEMS 54 AND 55. OCCUPATION AND INDUSTRY Questions concerning occupation and industry must be completed for all decedents 14 years of age or older. This information is useful in studying deaths related to jobs and in identifying any new risks. For example, the link between lung disease and lung cancer and asbestos exposure in jobs such as shipbuilding or construction was made possible by this sort of information on death certificates. Information in this section will not appear on the certified copy of the death certificate.
ITEM 54. DECEDENT’S USUAL OCCUPATION Enter the usual occupation of the decedent. This is not necessarily the last occupation of the decedent. Never enter “retired”. Give kind of work decedent did during most of his or her working life, such as claim adjuster, farmhand, coal miner, janitor, store manager, college professor, or civil engineer. If the decedent was a homemaker at the time of death but had worked outside the household during his or her working life, enter that occupation. If the decedent was a homemaker during most of his or her working life, and never worked outside the household, enter “homemaker”. Enter “student” if the decedent was a student at the time of death and was never regularly employed or employed full time during his or her working life. Information in this section will not appear on the certified copy of the death certificate.
ITEM 55. KIND OF BUSINESS/INDUSTRY Kind of business to which occupation in item 54 is related, such as insurance, farming, coal mining, hardware store, retail clothing, university, or government. DO NOT enter firm or organization names. If decedent was a homemaker as indicated in item 54, then enter either “own home” or “someone else’s home” as appropriate. If decedent was a student as indicated in item 54, then enter type of school, such as high school or college, in item 55. Information in this section will not appear on the certified copy of the death certificate. NOTE: This recommended standard death certificate is the result of an extensive evaluation process. Information on the process and resulting recommendations as well as plans for future activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm. REV. 11/2003
Glossary
Adverse event (outcome) Any disease, injury, or death. Age-specific fertility rate The rate of fertility among women of a specific age. Antepartum fetal death Fetal death occurring before the initiation of labor. ART Assisted reproductive technology refers to interventions to assist couples to conceive. Association A term signifying a relationship between two or more events or variables. Events are said to be associated when they occur more frequently together than one would expect by chance. Association does not imply a causal relationship. Statistical significance testing enables a researcher to determine the likelihood of observing the sample relationship by chance if in fact no association exists in the population that was sampled. The terms association and relationship are often used interchangeably. Birth certificate Official, legal document recording details of a live birth, usually comprising name, date, place, identity of parents, and sometimes additional information such as birth weight. It provides the basis for the vital statistics of birth and birthrates in a political or administrative jurisdiction and the denominator for infant mortality and certain other vital statistics. Birth cohort prevalence rate In developmental disabilities surveillance, the prevalence of a specific disorder in a geographic area, among children of a specific age who were born in that geographic area, within a specified time interval. Birth defect A structural abnormality present at birth. Birth interval The length of time between termination of one pregnancy and the termination of a second.
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Birth order The ordinal number of a given live birth in relation to all previous live births of the same woman. Birth rate A summary rate based on the number of live births in a population over a given time period, usually one year. Birth weight Infant’s weight recorded at birth, and in some countries, entered on the birth certificate. Birth weight-specific mortality rate The number of infant deaths that occurred among live births in a specific birth weight category in a calendar year divided by the total number of live births that occurred in that category in that year. To express the rate per 1,000 live births, multiply the result by 1,000. Case ascertainment Identification of cases of an exposure or health outcome in public health surveillance, usually according to a specific case definition. Causality Relating causes to the effects they produce. Most of epidemiology concerns causality, and several types of causes can be distinguished. A cause is termed necessary when a particular variable must always precede an effect. This effect need not be the sole result of the one variable. A cause is termed “sufficient” when a particular variable inevitably initiates or produces an effect. Any given cause may be necessary, sufficient, neither, or both. Cause-of-death Defined by the World Health Organization as the underlying cause of death, which is recorded on the death certificate. The cause of death is (a) the disease or injury that initiated the train of morbid events leading directly to death or (b) the circumstances of the accident or violence that produced the fatal injury. Cohort fertility The fertility of cohort of women who were born during a specified interval and followed through their reproductive years. Cohort infant mortality rate The number of infant deaths that occurred among live births in a calendar year, divided by the total number of live births that year. To express the rate per 1,000 infants per year, multiply the result by 1,000. Confidence interval A range of values for a variable of interest, constructed statistically so that this range has a specified probability of including the true value of the variable (1). Contraceptive failure rate The average probability of having an unintended pregnancy during a year of using a specific contraceptive method.
Glossary
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Crude birth rate The rate of live births in a defined population during 1 year. The denominator is the average or mid-year population during that year. Crude fertility rate Rate of live births during 1 year in a defined population of women aged 15–44 years. The denominator is the mid-year female population aged 15–44 years. Cumulative birth rate The total number of births to women who were born during a specified interval until they reach a specified age. Death certificate A vital record signed by a licensed physician or by another designated health worker that includes cause of death, decedent’s name, sex, birth data, places of residence and of death, and whether the deceased had been medically attended before death. Occupation, birthplace, and other information may be included. Immediate cause of death is recorded on the first line, followed by conditions giving rise to the immediate cause; the underlying cause is entered last. Death rate An estimate of the proportion of a population that dies during a specified period. The numerator is the number of persons dying during the period; the denominator is the number in the population. For the death rate per year, the denominator often is estimated as mid-year population. Disease May be defined as a failure of the adaptive mechanisms of an organism to counteract adequately, normally, or appropriately noxious stimuli or infectious pathogen, to which it is subjected, resulting in a disturbance in the function or structure of some part of the organism. This definition emphasizes that disease is multifactorial and may be prevented or treated by changing any factor or a combination of the factors. Disease is a very elusive and difficult concept to define, being largely socially defined. Thus, criminality and drug dependence are presently seen by some as diseases, when they were previously considered to be moral or legal problems. Epidemiology The study of the patterns of determinants and antecedents of disease in human populations. Epidemiology utilizes biology, clinical medicine, and statistics in an effort to understand the etiology (causes) of illness and/or disease. The ultimate goal of the epidemiologist is not merely to identify underlying causes of a disease but to apply findings to disease prevention and health promotion. Exposure A general term used to describe contact with a risk factor. An exposure can be a physical agent (e.g., radiation) or a behavior (e.g., excessive drinking). Fertility The actual production of live offspring. Stillbirths, fetal deaths, and abortions are not included in the measurement of fertility. Fertility rate The rate of live births per 1,000 women aged 15–44 years.
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Glossary
Fertility ratio The rate of children aged
