(1) Effective January 1, 2003, the department shall use the 2003 revisions of the United States standard forms of live birth and fetal death as the basis for the state certificates of live birth and fetal death. These forms are developed by the United States Department of Health and Human Services, National Center for Health Statistics.

(2) Copies of these forms may be obtained by contacting the department's center for vital statistics.

(3) Tables 1 and 2 list the statistical information contained in the confidential sections of the birth and fetal death certificates that the board requires the department to collect, and the differences between the state and U.S. standard.

u.s. standard certificate of live birth
TABLE 1: Confidential Birth Certificate Items
Item Number	Item Name	Difference from U.S. Standard, if any
15	Is mother married to the father?
	If no, was mother married to anyone during the pregnancy?	Added
	Has the paternity affidavit been signed?
20	Mother's education	Add "Specify": next to box for "8th Grade or less"
21	Mother of Hispanic origin?
22	Mother's race
23	Mother's occupation	Added
24	Mother's kind of business/industry	Added
29	Father's education	Add "Specify": next to box for "8th Grade or less"
30	Father of Hispanic origin?
31	Father's race
32	Father's occupation	Added
33	Father's kind of business/industry	Added
34	Mother's medical record number
35	Mother's prepregnancy weight
36	Mother's weight at delivery
37	Mother's height
38	Did mother get WIC food for herself during pregnancy?
39	Cigarette smoking before and during pregnancy
40a	Number of previous live births
40b	Date of last live birth
41a	Number of other pregnancy outcomes
41b	Date of last other pregnancy outcome
42a	Date of first prenatal care visit
42b	Date of last prenatal care visit
43	Total number of prenatal visits for this pregnancy
44	Date last normal menses began
45	Was mother transferred to higher-level care for maternal medical or fetal indications for delivery?
46	Principal source of payment for this delivery	Add "Indian Health" and "CHAMPUS"
47	Newborn medical record number
48	Birth weight
49	Infant head circumference	Added
50	Obstetric estimate of gestation
51	Apgar score at 5 min; if score is less than 6, score at 10 minutes
52	Plurality
53	If not single birth - born 1st, 2nd, 3rd etc.
54	Was infant transferred within 24 hours of delivery?
55	Is infant living at time of the report?
56	Is infant being breastfed?
57	Risk factors in this pregnancy	Add "Group B streptococcus culture positive"
58	Method of delivery
59	Infections present and/or treated during this pregnancy	Add "HIV infection" and "Other: Specify"
60	Obstetric procedures
61	Abnormal conditions of the newborn
62	Characteristics of labor and delivery
63	Congenital anomalies of the newborn
64	Maternal morbidity
65	Onset of labor

u.s. standard report of fetal death
TABLE 2: Confidential Fetal Death Certificate Items
Item Number	Item Name	Difference from U.S. Standard, if any
38	Weight of fetus
39	Obstetric estimate of gestation
40	Plurality
41	If not single birth - Born 1st, 2nd, 3rd etc.
42	Mother's education	Add "Specify": next to box for "8th Grade or less"
43	Mother of Hispanic origin?
44	Mother's race
45	Mother's occupation	Added
46	Mother's kind of business/industry	Added
47	Mother married?
48	Mother's height
49	Did mother get WIC food for herself during pregnancy?
50	Mother's prepregnancy weight
51	Mother's weight at delivery
52	Date last normal menses began
53	Date of first prenatal care visit
54	Date of last prenatal care visit
55	Total number of prenatal visits for this pregnancy
56a	Number of previous live births
56b	Date of last live birth
57a	Number of other pregnancy outcomes
57b	Date of last other pregnancy outcome
58	Cigarette smoking before and during pregnancy
59	Was mother transferred to higher-level care for maternal medical or fetal indications for delivery?
60	Father's education	Added
61	Father of Hispanic origin?	Added
62	Father's race	Added
63	Father's occupation	Added
64	Father's kind of business/industry	Added
65	Risk factors in this pregnancy
66	Method of delivery
67	Congenital anomalies of the fetus
68	Maternal morbidity
69	Infections present and/or treated during this pregnancy	Add "HIV infection" and "Other: Specify"

PDFWAC 246-491-029

Information collected on the confidential section of live birth and fetal death certificates; modifications to the United States standard certificates and report forms.