BACKGROUND: Data from Iowa fetal death certificates (FDCs) suggest that reportable stillbirths (unintended fetal deaths ≥20 weeks gestation and/or weighing ≥350 grams) occur in about 1 in 200 deliveries. In 2005, the Iowa Department of Public Health and the Iowa Registry for Congenital and Inherited Disorders (IRCID) collaborated with other state stakeholders to establish the Iowa Stillbirth Surveillance Project. The goal of this project was to use population-based, active surveillance methodologies to identify reportable stillbirths delivered by Iowa residents since January 1, 2000. METHODS: To conduct stillbirth surveillance, the IRCID expanded its existing public health authority and electronic abstract application for birth defects surveillance. The expanded application was piloted using a random sample (n = 250 of 989) of FDCs reported from January 2000 through December 2004. RESULTS: IRCID procedures for active case finding and medical record abstraction verified 192 (76.8%) as reportable stillbirths. Stillbirths not verified as reportable were due to findings of elective terminations (n = 30), live births (n = 3), induced deliveries (n = 2), and FDC entries for gestational age and/or delivery weight that were either inaccurately recorded (n = 13) or accurately recorded but did not meet Iowa FDC reporting criteria (n = 9); medical records for one FDC were unavailable. Infant malformations were more common among unverified stillbirths, whereas the cause of death due to maternal-related conditions was higher among verified stillbirths. CONCLUSIONS:These results suggest that over-reporting limits the use of FDCs as a primary ascertainment source for stillbirth surveillance in Iowa. Continued expansion of the IRCID active surveillance methodologies to monitor stillbirths in Iowa is recommended. Birth Defects Research (Part A), 2011. © 2011 Wiley Periodicals, Inc.