Birth Certificate Methods in Five Hospitals

Birth Certificate Methods in FiveHospitals

Sally Northam, R.N., Ph.D.,

Shea Polancich, R.N., M.S., and

Elizabeth Restrepo, R.N., M.S.

Abstract This study evaluated the methods of data collection of

birth certificate information by five high-delivery hospitals innorthern Texas. Research purposes were to identify sources andmethods of birth certificate data collection and identify the most-

reliable methods. This descriptive study involved interviews ofeach hospital’s data collectors and review of 1999 Texas birthcertificate data. Medical record clerks, whose training varied, but

usually consisted of orientation by another medical record clerk,collected birth certificate data within 24 hours of birth. There wasno standard method for training, nor was there a minimum level

of education required. In four of the five hospitals studied, a birthcertificate clerk collected most of the information with limitedinput from other medical sources. The information obtained onbirth certificates therefore varied according to the collector and

the priority placed upon the accuracy of information. Birthcertificate data contain questionable reliability, which under-mines data use in research, funding, and policy decisions.

Key words: birth certificate, reliability, accuracy, datacollection.

Nearly four million birth certificates were filed in theUnited States in 1999 (National Center for HealthStatistics, 2001), as birth and fertility rates increased byabout 1%, the second such increase since 1990. Theinformation from these national reports reflects anincrease of U.S. births in the last decade. The U.S.standard certificate birth certificates are a primary meansof gathering uniform, population-based information onmaternal and perinatal health. Thus, problems with thedata on these certificates have serious ramifications. Thevalue of the information obtained on the birth certificateis based upon the accuracy of the collected information,making it a necessity to collect the most complete andaccurate information possible.In light of the large number of births in the United

States and the considerable funding allocated for mater-nal and perinatal health, researchers investigated thereliability of the information obtained on the birthcertificates, as well as the collection procedures beingused in Dallas, the third-largest metropolitan area inTexas (Texas Almanac, 2000), with 37,677 births in 1999(Texas Department of Health (TDH), 2000). Earlyinvestigation of the state birth certificate data for thisarea and visits to the top five birth hospitals revealeddiscrepancies in a number of areas. Many mothers withno risk factors had more than 40 prenatal visits, whereasmothers with four or five risk factors received no prenatalcare. Files indicating no maternal alcohol use duringpregnancy had ETOH use recorded in the ‘‘othermaternal risks’’ category. Investigation revealed incon-sistent data collection methods by personnel with limitedtraining and understanding of the complex medicalterminology. The birth certificate data discrepancies andlack of standardized collection procedures led researchersto question the reliability of some birth certificate

Sally Northam is Associate Professor, Texas Women’s University,

Denton, Texas, Shea Polancich is Director of Clinical Outcomes and

Performance Improvement at Texas Health Resources. Elizabeth Restrepo

is Senior Clinical Outcomes Analyst at Texas Health Resources,

Arlington, Texas.

Address correspondence to Sally Northam, Texas Woman’s University,

P.O. Box 425498, Denton, TX 76204. E-mail: [email protected]

Public Health Nursing Vol. 20 No. 4, pp. 318–327

0737-1209/03/$15.00

� Blackwell Publishing, Inc.

318

information. This apparent inconsistent data reliabilitywas the problem under investigation.

STUDY PURPOSES

The purposes of this study were twofold. First, theresearchers sought to describe the methods used to collectbirth certificate informationwithin the five highest-deliveryhospitals in Dallas, Texas. Second, the researchers soughtto identify the most reliable methods of data collection byanalyzing the procedures used in these five hospitals.

BACKGROUND

In the United States, births have been reported nationallysince 1915 (National Center for Health Statistics(NCHS), 1998). In 1850, the national birth-registrationarea was proposed and then formally established in 1915,with 48 states and the District of Columbia participatingin the system by 1933. The current system of live birthregistration in the United States covers the 50 states, theDistrict of Columbia, and the independent registrationareas of New York City, Puerto Rico, the U.S. VirginIslands, Guam, American Samoa, and the Common-wealth of the Northern Mariana Islands, but the statis-tical tables used for U.S. birth data refer only to the 50states and the District of Columbia (NCHS, 2001).Birth certificates are a primary source of population-

based data on maternal and perinatal health. The U.S.Standard Certificate of Live Birth, a document preparedand issued by the Public Health Service, is the principalmeans of obtaining uniformity of content for the collec-tion of information on live births.In the United States, state laws require birth certificates

to be completed for all births, and federal law mandatesnational collection and publication of births and other vitalstatistics data. The National Vital Statistics System, thefederal compilation of this data, is the result of the coop-eration between the National Center for Health Statistics(NCHS) and the states to provide access to statisticalinformation from birth certificates (DHHS, 1998).The birth certificate has been revised 12 times, based

upon the recommendations of national, state, and countyexperts who rely upon the information for legal, clinical,demographic, and research purposes.Birth certificates have two parts, referred to as the short

form and long form. Figure 1 shows the entire Texascertificate of birth, including all items that constitute theshort and long forms. The short form comes in largerprint, with only the first 37 items that gather demographicinformation, including the infant and parent names, race,ethnicity, parental education, occupation, and address.This is often the only form parents see in the hospital.Information from this short form is reflected in the birth

certificate mailed to parents after receipt and review ofinformation by the state Bureau of Vital Statistics (BVS).The long form involves the remaining seven categories,with 83 items on the certificate. The long form gathersdata useful in surveillance of maternal and infant health,prenatal care, labor and delivery, and birth outcomes.The forms are standardized nationally by NCHS, abureau of the Centers for Disease Control and Preven-tion. Some states elect not to include a few sensitive itemssuch as those pertaining to terminated pregnancies.Hospitals designate individuals, generally medical recordpersonnel, who gather and enter data into standardizedcomputer programs provided by the state. Data are thenelectronically transmitted from the hospital to the localBVS. If all data fields are not completed, the hospital isnotified of omissions and asked to resubmit data. Shortform data generally involve items such as name, address,education, age, and occupation. In Texas, the local BVSenters the data on the legal birth certificate document thatis then mailed to the mother’s address.The long form is used for gathering nationally stan-

dardized information on maternal health, prenatal care,labor and delivery, and birth outcomes. Each categorylists numerous common items to enable quick completionof the form by checking boxes next to applicable items.Categories also include a check box for ‘‘none’’ that canbe used if no items apply such as when a mother has nomaternal health problems. There is also a category for‘‘other’’ that can be checked and space provided fortyping in pertinent data that is not listed in the check boxformat. If no categorical items are checked, the ‘‘none’’box must be checked or the form is returned forcorrection. After receipt of completed form data, thelocal BVS regularly transmits the data to the state BVS,where data for all births are summarized and reportedannually, generally at the end of the subsequent year.Thus, births in 2000 are summarized and reported in late2001. The NCHS purchases the state data from all states.Compiled national data are then analyzed, reported, andused in evaluating trends in births, maternal and infanthealth, and outcomes.Numerous U.S. vital statistics reports are based on the

analysis of birth certificate data, including the NationalVital Statistics Report and the States Vital StatisticsReports (NCHS, 2001). National, state, and local officialsuse the reported statistical information to identify birthtrends and health risks and to support the need forfunding maternal and infant health programs.

REVIEW OF LITERATURE

The accuracy of information obtained on birth certificatesis variable. Some demographic information obtained on

Northam et al.: Birth Certificate Methods 319

Figure 1.

320 Public Health Nursing Volume 20 Number 4 July/August 2003

the short form has been supported as accurate. Baume-ister, Marchi, Pearl, Williams, and Braveman (2000) usedface-to-face interviews with 7,428 Spanish- or English-speaking mothers in 16 California hospitals in 1994–95and concluded that the birth certificate data on ‘‘race’’and ‘‘Hispanic ethnicity’’ were accurate 97% of the time.Unfortunately, information obtained on the long form,

including maternal risks and fetal outcomes, has not beenas accurate, based on studies in a number of states. In aretrospective review of 308,573 birth certificates filed inAlabama between 1988 and 1992, Woolbright andHarshbarger (1995) used birth certificate data to identifypublic health problems, specifically maternal risk factorsin pregnancy. In this study, the researchers used all birthrecords from these years, eliminating the 1% of recordswith missing data. They concluded that the data obtainedon birth certificates are useful in determining prevalenceof population medical risk factors, in identifying subpop-ulation differences, and in predicting the likelihood of lowbirthweight babies among mothers with identified riskfactors, but the identified risk factors were in agreementwith medical records only 58.5% of the time. Thus, theresearchers warned that the maternal risk factor infor-mation should be used cautiously because of inaccurateor unreliable data collection.Prenatal visits were evaluated in another study invol-

ving birth certificate data review and comparison ofinformation with medical records. In a study of 2,032matched prenatal records and birth certificates, Clark,Fu, & Burnett, 1997) found only 14% agreement betweenGeorgia birth certificates and prenatal clinic recordsregarding total number of prenatal visits. There was 31%agreement between the birth certificate information andclinic records on the month prenatal care began. Of therecords not in agreement, birth certificates were discov-ered to consistently report greater numbers of prenatalvisits and earlier onsets of care, but the reason for thisdiscrepancy was unclear.Gestational age has been used to evaluate pregnancy

outcomes and trends in premature births. Alexander,Tompkins, and Corneley (1990), using 588,781 live birthrecords from South Carolina files from 1974 to 1985,examined trends involving gestational age calculatedfrom data on last menstrual periods collected on thebirth certificate. These data are often used to calculategestational age when making decisions about maternaland perinatal health programs. They concluded that theuse of nonstandardized methods of calculating gesta-tional age resulted in error. Buekens, Notzon, Kotel-chuck, and Wilcox (2000) used the 1994 U.S. singletonbirth certificates of infants alive at birth to examine theincidence of low-birthweight Mexican American infants.Findings from this study further supported the need to

identify a standardized method of identifying gestationalage.Birth defects are another outcome evaluated using birth

certificate data. A number of studies have reported dataerrors that undermine data reliability. Birth certificatesshowed false-positive congenital anomalies reported from1983 to 1986 in New York (Olsen, Polan, and Cross,1996). Of 11,418 congenital malformations on birthcertificates during that period, 1,237 were ascertained asnormal infants when medical records were reviewed. Therecognition of the missed opportunity posed by incorrectrecording of birth anomalies was one reason the birthcertificate long form was changed in 1991 to include thecheck box format. This format was designed to allowclerks to gather data more rapidly. The format removedthe need to write ‘‘birth defects’’ by providing boxes with‘‘Yes’’ and ‘‘No’’ next to the words ‘‘birth defects.’’Unfortunately, Watkins et al. (1996) found, in their studyof birth defects in 76,862 live-born infants born from 1989to 1990 in a five-county metropolitan Atlanta area, thatthe check box format did little to improve the reporting ofbirth defects. One explanation the researchers cited forunderreporting birth defects was the completion of birthcertificates by hospital clerks or medical record techni-cians lacking the knowledge to accurately collect theinformation required on the forms.Many institutions provide inadequate training and have

few educational requirements for the personnel who reportbirth certificate information, with data collected almostexclusively by unlicensed individuals and little or noinvolvement by physicians or nurses. Hospitals were notedto vary greatly in the care and attention given to thecompletion of the birth certificate in the 1995 study byWoolbright and Harshbarger. In a study done by Baume-ister et al. (2000), birth clerks with limited training weregathering birth certificate information in California.

Significance

Thus, existing research indicates that the reliability ofbirth certificate information regarding maternal risks,prenatal care, gestational age, and fetal outcomes is acause for concern. Further, the literature reveals incon-sistent data sources, a lack of standardized terms, andinadequate collector training. Therefore, not only is thestandardization of the form important, the standardiza-tion of collection methods should also be of primaryimportance to the enhancement of data accuracy andcomparability.The purpose of this study was to explore reliability

describing how, when, and by whom birth certificate dataare obtained and recorded in several selected hospitalsand by identifying the sources of data (charts, clinicians,and parents).


Although no formal theory encompasses all aspects ofthe reliability of birth certificate information, it isapparent that birth certificate information is intended toreflect live births. The World Health Organization defineda live birth as the complete expulsion or extraction fromits mother of a product of conception, irrespective of theduration of pregnancy, which after such separation,breathes or shows any other evidence of life, such as thebeating of the heart, pulsation of the umbilical cord, ordefinite movement of voluntary muscles, whether theumbilical cord has been cut or the placenta is attached;each product of such is considered a live birth (DHHS,1998).All information gathered for a live birth certificate

record is based on this definition. The reliability of birthinformation depends upon the collection procedures,including the person collecting the information, thereliability of the source of the information, the recordingof the information on the birth certificate, and thecomputer program designed to transmit informationdirectly to the state data bank.Reliability is the reflection of error or variance. A

variable that is consistently measured is less likely tocontain error. Most measurements incorporate some sortof error, but reducing error in measurement producesmore-reliable results. Although these are the classicaldeterminants of reliability, there are situations in whichreliability is more of a thoughtful process than amathematical determination. When there are multipledimensions or constructs being examined, classical deter-minations of reliability become almost moot. In thissense, the researcher is seeking reliability in other formssuch as making determinations of variance and error, aswas the case for this study.

Design and Methodology

This descriptive study examined the research questionshow, when, and by whom birth certificate data areobtained and recorded and how mothers, clinicians, andmedical records are involved as data sources.Data collection involved interview and analysis of 1999

birth certificate data purchased from the State of TexasDepartment of Health, which makes annual birth certif-icate data available to researchers during the latter thirdof the year after collection. The 1999 birth certificate datafrom TDH were obtained in December 2000. Seventeenbirthing hospitals in Dallas delivered 37,677 babies in1999. The top five hospitals in Dallas, in terms of highestraw number of births per year, were identified. Thenumbers of births in each of these five facilities rangedfrom 2,513 to 14,198. Multiple hospitals owned by asingle hospital group were treated as independent sites

when determining the highest birthing hospitals. This wasdone for two reasons: birth certificates are completedwithin each facility even when multiple hospitals are partof a larger hospital system, and coding of facilities in thestate database file is done by individual hospital ratherthan as a facility within a larger hospital system. Tomaintain hospital anonymity, hospitals are identified onlyas A, B, C, D, and E. These designations are unrelated totheir ranking in terms of numbers of deliveries.The researchers contacted each hospital by phone and

spoke with the individual in charge of medical records.Arrangements were made to visit, review forms andworksheets, and speak to the primary individual(s)responsible for collecting and entering birth data intothe computer program for transmission to the state BVS.The goal was to interview at least one individual at eachhospital who had primary responsibility for birth certif-icate data collection. This purpose was clarified whencalling to make an appointment and at the beginning ofthe interview.In two hospitals (A & E), one medical record clerk at

each site had primary responsibility for birth data andwas interviewed. At two hospitals, the birth certificateclerks and their supervisors were present during theinterview and offered input. Both of the supervisorsshared past problems with methods of gathering data andissues that still posed problems. In the remaining hospital,the medical records supervisor introduced the researchersto the birth certificate clerks but was not present for theinterview. All hospitals were visited within a 3-monthperiod, from February to April 2001.The first question posed to all interviewed clerks was:

‘‘Would you please explain to us, step by step, how yougather the birth certificate data?’’ Subsequent questionslisted below were asked only if the information was notaddressed in response to the initial question.

1 Do you use a worksheet to gather data? May we seea copy please?

2 Do you use the chart for gathering data?’’ If yes,Would you tell us how you use the chart? (Clarifywhat variables? Computer chart or paper chart?)

3 Are doctors or nurses involved in gathering orreviewing the data?

4 How do you gather information from mothers?5 How long does it take you to gather the data and

record it?6 What data are the most difficult to obtain?7 What data to you consider to be the most reliable?

Least reliable?8 What happens when you are not here because of

days off, illness, or vacation?


RESULTS

To understand how birth certificate data are gathered, allthree researchers visited each site. During the interviews,the researchers took notes separately and discussed theirobservations afterwards. The visits ranged from 15minutes to 1 hour. The shortest visit occurred in HospitalE, where information was obtained from the labor anddelivery flow sheet or the mother-completed ‘‘shortform.’’ No chart review or data clarification was soughtwhen data was questionable. Other visits were longerbecause individual responses from birth certificate datacollectors included many scenarios when a variety oftechniques to gather and clarify data were used. Theresearchers asked to see worksheets and other forms usedin data collection at each hospital. This process enabledthe team to describe how birth certificate information isgathered in each of the five hospitals. Table 1 summarizesthe methods of data collection used in the five facilities.The primary birth certificate data collector in Hospital

A was a former patient care assistant who had no formaleducation and training in the position. This individualevidenced a limited grasp of medical terminology and saidshe really did not understand the maternal medical riskfactor terms on the birth certificate. For this individual,the collection procedure took roughly 10 minutes fromstart to finish, consisting of limited chart review, briefpatient interaction for clarification of certain demogra-phic information, and entering of data into the state birthcertificate manager program. This individual consideredthe mandatory demographic information required by thestate to be the most important section of the certificate.Although this collector was thorough, the collectionprocedure was limited and involved no clarification bylicensed medical professionals.

In Hospital B, the primary birth certificate datacollector was a bilingual medical records clerk with nopatient care experience. This individual said she hadlimited in-hospital training consisting primarily of paper-work review and had no knowledge of medical termin-ology, did not understand medical risk factors, and couldnot define variables identified on the birth certificate. Hercollection procedure consisted of gathering computerdata from the hospital database, which may be entered bynursing personnel, visitation to the mother for formdistribution and gathering, and entering of data into thestate birth certificate manager program. Her data collec-tion generally took 5 to 10 minutes. According to theinterviewed data collector, some 30% to 40% of mothersbring a completed form with them on admission that theyreceived during hospital preregistration. This formincludes questions about alcohol and smoking, prenatalcare, and pregnancy weight gain. When asked if mothersmight fill the form out early and therefore not accuratelyreport items such as the total number of prenatal visits,the clerk said she did not think that was a problem. Themedical records clerks and supervisors said the greatestdifficulty for them is obtaining paternity information.This difficulty was identified at all five hospitals.The third site was Hospital C. In this facility, the

primary birth certificate data collectors were researchnurses, with limited involvement by the medical recordsclerks who collect only demographic information. Themedical records department was organized and systematicin the collection and transcription of the data. The clerksreportedly collected the demographic information in asfew as 5 minutes per birth and then used the nurse-completed worksheet for information on maternal riskfactors, prenatal care, complications of labor and delivery,and fetal outcomes, including congenital anomalies. This

TABLE 1. Methods of Birth Certificate Collection

Hospital(site visit) Collectors

Time Spent/Collect Form Used Source of Data Comments

Facility A Clerks-2

One primary

10 min Wksheet/Short form Mother, Chart Organized established

but inconsistentOne weekend

Facility B Clerks-3One primary

5 min Wksheet/Short form Mother completedworksheet, Chart,

Organized recent changebut inconsistent

Interview of teen mothersFacility C Clerks-6 Nurses-4 Unknown Wksheet/ long form Mother, Chart Organized recent changeFacility D Clerks-7 Certified

by state

3–5 min Wksheet/ Short form Mother, Chart Organized but inconsistent

recent changeFacility E Clerk-1 5 min Wksheet/ Short form Mother completed

form, L & D logDisorganized newlyestablished inaccurate


institution provided bilingual clerks fluent in Spanish togather information from mothers unable to speak English.In Hospital D, the primary birth certificate data

collectors were medical record clerks who were certifiedbirth certificate data collectors through the state AttorneyGeneral’s office. The collection procedure at this institu-tion was recently changed and was characterized assystematic and thorough by the birth certificate datacollectors. The primary clerk who completed the mostbirth certificates expressed concern about her lack ofunderstanding of birth certificate terms and said sheworried about not getting all the important information.She stated it took about 5 minutes to gather the data. Theother clerks present during the interview concurred withthis time estimate. She verbalized the wish that nurseswould be more involved but expressed a reticence inquestioning the nurses whom she characterized as alwaysbusy and not wanting to be bothered.In Hospital E, the primary data collector had limited

knowledge of the data collection process and limitedunderstanding of the terminology and the importance ofthe data. This individual completed the collection proce-dure based upon a labor and delivery log, compiled bylabor and delivery nurses. The collection procedure andtranscription procedure took approximately 5 minutesand was done by a single clerk.

Discussion of Results

There was considerable variance in how birth certificatedata were obtained in these five high-delivery hospitals.Hospital B, for instance, gave a form to some of themothers during preregistration with instructions to returnthe completed form when they were admitted for delivery.In some of the hospitals, data collectors interviewedmothers, but this method of data collection was incon-sistent. Hospital B, for example, used this method onlywith teenage mothers. The majority of demographic data,including the child’s name and parental information, wasgathered on the hospital-designed worksheet for the shortbirth certificate form. These hospital-designed worksheetswere similar in all five facilities and basically includedmore space to write in information such as the infant’sname, parent’s name, and other identifying informationthan the space available on the short form developed bythe federal government for national use.All data collectors viewed the demographic data as

most important because it contained the information laterprinted on the legal document issued by the state to eachchild’s parents. Only one facility asked mothers to reviewthis information before hospital discharge to prevent laterproblems. Some variance was evident in the time spentcollecting data, ranging from 5 to 10 minutes. The

greatest variance existed in the use of charts for infor-mation. Some use of charts for clarification and addi-tional information occurred in four of the five hospitals,but there was no consistent procedure across the fivehospitals and little similarity in procedures. As a result ofthese variations, data on prenatal care, maternal risks,gestational age, labor and delivery variables, and infantoutcomes cannot be expected to be aggregates of the sametypes of data.All facilities gathered most information within 24 hours

of delivery. This was necessary because mothers arequickly discharged after delivery and the local BVS officeexpects regular transmission of completed forms. TheState of Texas standardized computer program is provi-ded to all hospitals and rejects forms with incompletefields. Two hospitals reported receiving complaints fromthe BVS because of incomplete forms or noticeable errorssuch as inaccurate county of maternal residence. Thesecomplaints resulted in improved procedures with moremedical record supervisor oversight in facilities B and D.The use of charts was especially unreliable because

medical records staff, primarily, reviewed the charts, andthey varied in their knowledge of medical terminology.Thus, if a clerk was looking for alcohol use duringpregnancy and did not know the standard use of‘‘ETOH’’ in the records, the available information wouldbe overlooked, and the check box for ‘‘no alcohol’’ usewould be used. The training of personnel in theseinstitutions varied but usually consisted of training withineach hospital. There was no standard method for train-ing, nor was there a minimum level of education requiredby the state and federal governments. Although there isno formal training program for birth certificate clerks, thestate BVS offers a yearly educational/informationalupdate at the capital for those involved with obtainingand filing birth certificate information. Three of the fivehospitals had sent representatives to this educational/informational update, but one of the hospitals sent asenior medical records person who was not involved inbirth certificate data collection. She stated that she sharedinformation with the birth certificate data collector afterattending the meeting.In four of the five hospitals, a birth certificate clerk

collected most of the information, with limited input fromother medical sources. One of the high-delivery hospitals(Hospital C) had recently changed the data collectionprocedures to include research nurses as collectors ofinformation other than demographic information, whichmedical records personnel still collected. This change wasimplemented to enhance data accuracy because theinstitution recognized that annual data from state recordswas not reflective of the population served by thehospital.


The information obtained on birth certificates thereforevaried according to the collector and the priority placedupon the accuracy of information. The state BVS returnsinaccurate birth certificates when required fields aremissing, but the check box format allows the clerk tosimply check ‘‘none’’ if the listed maternal risks, laborand delivery complications, and fetal outcomes are notrecognized terms in the chart.Mothers provided demographic information about

themselves and the infant’s father, except in cases wherethe mother said she was unmarried. If an unmarriedwoman identifies the infant’s father, then he is requiredby Texas state law to provide his demographic infor-mation by completing a standardized state form. Howmothers provided the demographic information varied.Several hospitals distributed forms during preregistra-tion, as stated earlier. Two facilities had designatedindividuals who helped the mother when she did notspeak English or Spanish. The other three facilities leftthe short form with the mother and were unsurewhether she completed it herself or had a familymember or friend complete it. The short form work-sheet, similar in all five facilities, also asked the motherabout her last menstrual period, number of prenatalvisits, and her history of alcohol use and smokingduring pregnancy. The birth certificate clerk at HospitalA stated that, when there was a discrepancy betweeninformation given by the mother and the informationcontained on the chart, she used the chart information.Hospital C had the worksheets typed so the mothercould review the information and sign it. This high-volume facility saved these forms for three months andthen put them on microfilm. When parents discoverederrors later, commonly in the spelling of names, theybecame responsible for handling errors if they signedthe form as it was printed. The varied methods ofgathering information from mothers likely affect theconsistency of the data.Clinicians play unclear roles in supplying information.

In Hospital C, registered nurses recently became involvedin data collection using birth certificate worksheets. Theother four facilities involve clinicians in recording medicalinformation on the chart but still trust the birth certificateclerk to discern medical terminology. Thus, if the medicalpersonnel used the exact word the clerk was looking for,such as induction, anemia, or renal syndrome, the clerkwas likely to mark ‘‘yes’’ for each of those categories onthe birth certificate. If, however, the clinician used thewords Pitocin, hemoglobin 12, or nephritis, the clerk waslikely to mark ‘‘no’’ for each category. Clearly, a birthcertificate clerk’s lack of knowledge regarding medicalterminology yields unreliable results in many areas ofbirth certificate information.

The State of Texas birth certificate guidelines call for aphysician or physician designee to be responsible for birthcertificate data. In four of the five hospitals, there was noinvolvement of physicians in data collection or review.Interviewed clerks and supervisors verbalized no physi-cian involvement and assumed that the hospital wasresponsible for the data collection. In one of the fivehospitals, a physician recently increased his involvementand hired registered nurses as birth certificate datacollectors to improve data accuracy.Hospital C used the most reliable methods, having

registered nurses gather data. This enabled individualsfamiliar with medical records and medical terminology tofind and report available information. When informationwas missing, they could easily request input from nursesworking on the obstetrical unit. A birth certificate clerk,on the other hand, is less familiar with medical recordsand medical terminology, with several reporting discom-fort in asking a nurse for additional information. Onebirth certificate clerk in Hospital D said she rarely askednurses for information, even when she needed it, becauseshe was hesitant to disturb them when they were busy.She also verbalized the opinion that the nurses usuallyacted as though they did not want to be bothered.The use of mothers for information is reasonable for

demographic maternal variables. All five hospitals invol-ved mothers, but not all provided mothers the oppor-tunity to review typed information to discern errorsbefore transmission to the BVS. Language barriersinvolving non-English speaking mothers play an unclearrole in data reliability, but are likely to have a negativeeffect, particularly on variables that require some explan-ation, such as last menstrual period. The practice inHospital A of using chart information rather thanmother-provided information, in cases of discrepancies,was unique among the hospitals and also has an uncleareffect on data. This practice implies that medical recordinformation is more reliable than similar information thatcould be provided by the mother. Neither the literaturenor the findings of this study support this notion.Although provision of a form for the mother to

complete before hospitalization may facilitate accuratedata collection by allowing more time for the mother tocomplete the information, recording prenatal visits andweight gain too early may introduce error that reduces thereliability of the gathered data. The true effect of earlyform completion remains unclear, as does demographicinformation for the mothers who elect to use this option.The method used in Hospital E, where a brief labor and

delivery form is used as the primary source of informa-tion, seemed to be the least reliable among the hospitals.This was the only facility visited that did not use the chartat all. The labor and delivery form used by the clerk had


no place for listing maternal risks or complications.Therefore, only a specific notation by labor and deliverypersonnel about one or more of the 18 maternal riskterms or the 13 labor and delivery complication termswould result in the clerk recording the variable. Thisreliance on write-in information without listing promptsundermines consistency.

CONCLUSIONS

The variance in data collection across hospitals makes itdifficult to determine how accurately the data representtrue maternal and infant information. Although the fivehospitals had similar worksheets, all data collectorsconsidered the demographic information section to bethe most important. Researchers, epidemiologists, andpolicy makers are often more interested in the variables ofmaternal risk, prenatal care, labor and delivery compli-cations, and infant outcomes. The lack of understandingby data collectors of the terminology and importance ofthese maternal and fetal variables is troubling. The datacollection variance and devaluing by data collectors aresources of error that reduce the reliability of the data.The lack of involvement of clinicians in data collection

and review is also troubling. State guidelines relate anexpectation that physicians will oversee data collection.The reasons for their lack of involvement are unclear.Clinicians, including nurses, nurse-practitioners, andphysicians, understand the medical terms on the birthcertificate and could facilitate accurate data collectionand reporting. One wonders if they even realize that aproblem exists.The inconsistent use of the mother as an information

source undermines the opportunity for her to discern andcorrect errors. The inconsistent use of charts and thechallenge posed by complex medical terminology alsoincrease the probability of error in the clerk’s reporting ofmaternal and infant variables. These inconsistenciesoperated differently within the hospitals and are sourcesof error that undermine data integrity.The multiple sources of error in gathering and report-

ing birth certificate information undermine insight intothe latent variables of interest. Those variables ofmaternal risk, prenatal care, labor and delivery care andcomplications, and infant outcomes are currently used inhealth research and decision-making. Caution is thereforeneeded when using birth certificate data because thosereported may not be an accurate reflection of maternaland fetal health.

RECOMMENDATIONS

The use of registered nurses to gather and record birthcertificate data is the most important recommendation of

these authors. Training of the nurses involved in collec-tion of birth certificate data would be important also, butnurses understand medical terminology and are familiarwith the various parts of the medical record in which birthcertificate data can be obtained. The use of registerednurses would eliminate the errors evident when individ-uals unfamiliar with medical terminology and chart data,such as lab values, record vital birth certificate data. Themove by Hospital C to involve research nurses demon-strates that institution’s commitment to improve dataquality. Although the expense of such a strategy mayseem prohibitive, the benefits to institutions in accuratelyrecording and reporting their served populations areinestimable because these data are used to support policyand funding decisions for the institutions.All birth certificate data collectors need a standardized,

effective method for data collection and recording.Despite similar worksheets across the five hospitals,more-standardized methods of using medical records,mothers, and clinicians are clearly needed.The inclusion of some brief, clear, standardized defini-

tions on the collection form is recommended to reduceerror. Not all variables require clarification, but lastnormal menses and what constitutes a prenatal visit aretwo examples of variables in which interpretation cancause variance. Provision of such definitions wouldundoubtedly increase the form’s length but would alsostandardize interpretation. National use of the same formand worksheets would also increase comparability ofdata.Training of data collectors should be mandatory and

should include testing to be certain each data collectorunderstands medical terminology on the birth certificate.Further, trained individuals must be able to recognizestandard abbreviations and medical terms, which wouldenable them to more accurately complete the birthcertificate form.Data collectors should be taught to use the most direct

sources of information to the fullest. This would includegathering timely reports from the mother. Medicalrecords should also be used in an organized, consistentmanner. Instructing data collectors to avoid short cuts,such as the use of labor and delivery reports, is alsorecommended. Random site visits by state BVS employ-ees to encourage and foster consistency and to discussissues would provide ongoing training across hospitals.Relying on individual hospital-based training is likely toperpetuate flawed methods.Nurse and physician involvement would likely improve

data quality. Exposing them to summary hospital datawould enable them to evaluate the congruence betweensummary data and their knowledge of the served popu-lation. Further, involving clinicians in discussions of data


collection and data uses could facilitate their playing akey role in quality improvement. Their increased aware-ness of the importance of data could lead clinicians toconsistently use recognizable terms listed on the birthcertificate long form and consistently place information inthe same location within the medical record to help birthcertificate data collectors locate pertinent information.Hospital administrators need to be informed about the

great advantage of accurate recording of data. Currently,users of local, state, and national birth statistics canidentify a hospital by its code number and can rundescriptive statistics on its served population. Such datasummaries are likely to underreport the complexities ofthe hospital’s high-risk maternal population, labor anddelivery complications, and fetal outcomes. At a time ofnational focus on health outcomes, it seems apparent thataccurate documentation of those outcomes can helpagencies seek funding to address areas of concern.Another important recommendation is to inform and

coach data collectors on the tremendous value of accurateinformation regarding the numerous birth certificatevariables. No data collector visited described an under-standing of the current use of this information in researchor policy formulation. When individuals lack insight intothe importance of what they do, it seems logical to believethat they would place little value on doing it well.Future research is needed in comparing trained clerks

with clinicians when birth certificate data are collectedand reported. A study such as this could then compareaccuracy by reviewing various sources of data for actualconsistencies and discrepancies.

SUMMARY

Accuracy and reliability of information obtained on anyrecord depends upon the collection procedure, includingthe person collecting the information, the reliability ofthe source of the information, and the form itself. Thegoal of data collection is to produce information that isusable and represents the nature of the situation forwhich the information is obtained. Numerous citedstudies have reported reliability problems in birthcertificate data, and this study confirms the need forimproved data collection methods, particularly theinvolvement of individuals fluent in medical termin-ology. Through improved data quality, usefulness of thedata will be enhanced, underreporting and overreportingwill be controlled, and maternal and infant healthsurveillance will be maximized. Currently, national andstate resource allocations are based on this inconsistentlycollected data. Hospitals unwilling to expend additionalfunds to involve more-skilled personnel may find thatmore accurate reporting of their served population

enables them to compete for funds to better servemothers and newborns. Nurses are in an excellentposition to serve as birth certificate data collectors.Because they understand medical terminology and rou-tinely gather the same data for the medical record,nurses could readily become involved in completing thebirth certificate form. This is an exceptional opportunityfor nurses to document the population they serve withininstitutions and facilitate improved regional, state, andnational reporting of vital statistics.

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Documents

Birth Certificate Methods in Five Hospitals