A publication of the Northeast Florida Healthy Start Coalition

Fetal & Infant Mortality Review Project

2006-2007 Community Report

Project Impact is a fetal and infant mortality review (FIMR) project for Baker, Clay,Duval, Nassau and St. Johns Counties. Its goal is to reduce infant mortality bygathering and reviewing detailed information to gain a better understanding of fetal andinfant deaths in Northeast Florida. The project examines cases with the worstoutcomes to identify gaps in maternal and infant services and to promote futureimprovements. Project Impact, which started in 1995, is carried out by the Northeast FloridaHealthy Start Coalition with funding from the Florida Department of Health. Each month, fetal/infant death cases are selected for the project based on specificcriteria. Between 2000-2007, more than 200 cases were reviewed through thisprocess. Utilizing an approach developed by the American College of Obstetrics andGynecology (ACOG), information is abstracted from birth, death, medical, hospitaland autopsy records. Efforts are also made to interview the family. No informationwhich identifies the family or medical providers is included on the abstraction form.Case summaries are developed and presented bimonthly to the Case Review Team(CRT). The CRT, a multidisciplinary group of community medical and social service profes-sionals, examines each case to determine medical, social, financial and other issuesthat may have impacted on the poor birth outcome.

8 PROJECT IMPACT

Case Review Team

Project Community Action Recommendations

Healthy Start and Project Impact are funded by the Florida Department of Health

Kathryn Huddleston, MD, Medical Director

Carol Brady, Executive Director, Healthy Start Coalition

Northeast Florida Healthy Start Coalition644 Cesery Boulevard, Suite 210 Jacksonville, FL 32211 (904) 723-5422

www.nefhealthystart.org

Project Impact Staff

1. Address the increase in sleep-related deaths in NE Florida through the implementation of anawareness and information campaign. Information should include: proper sleep positioning,dangers of bed sharing, impact of second hand smoke, importance of breastfeeding andappropriate use of infant beds. Strategies should be developed to target three groups:

a. Expectant and new families - Information should be provided by prenatal care andpediatric providers on safe sleep recommendations. This information should also beprovided through Healthy Start, Healthy Families and other case management andsupport programs.

b. Providers - Information about sleep-related mortality should be provided to all healthcare providers who come into contact with expectant and new families. Thiscommunication should emphasize their roles in providing patient education.Suggested educational resources (pamphlets, brochures, etc.) should also beprovided for their use and distribution.

c. General public - Efforts should be made to identify and distribute appropriate PSAs toarea media. Offer presentation at large public baby showers. Utilize Parish NursePrograms and other faith based community service programs.

2. Implement strategies to address preconception health and planned pregnancies:a. As above, include the general public, women of child bearing age and providers in

educational efforts. Share local FIMR statistics.b. Expand the WIC voucher program to all of the counties in the region. This program,

currently operating in St. Johns County, enables participants to purchase fresh fruitand vegetables from local farmers.

c. Facilitate WIC enrollment and increase program focus on obesity and other nutritionalissues.

d. Educate pregnant women and providers on the importance of contraception and babyspacing. Encourage women to return for their postpartum visit.

Laurie Lee, RN, Coordinator/Abstractor

Graphic design of Project Impact provided bythe Northeast Florida Regional Council Office of Communication and Intergovernmental Relations

Margarita Arruza, MDJoy Burgess, RN

Vicki Chapman-Shaw, ARNPDiana Coyle, RN, MSN

Marsha Davis

Kara Driver, MDDavid Harmon, MD

Kathy Huddleston, MDBeverly LeGree, RNC, MSN

Toni Martin, RDSue Murphy, MSW

Alice Poe, CNMGary Sammet

Carol SynkeweczMary von Mohr, MSW

Steve Williams, Chaplain

Florida Vital Statistics, 2006 Florida Department of Health; Project Impact Summaries of Case Review Team Deliberations, January 2000- June 2007

Infant Mortality By CountyNortheast Florida

2004-2006

5.45.7

10.9

1.4

8.3

9.5

19

6.7

11.6

9.9

5.1

10.4

15.2

4.7

9.5

4.9

2.8

8.2

0

2

4

6

8

10

12

14

16

18

20

Baker Clay Duval Nassau St Johns NEFL

In f

ant

Dea

ths/1

000

Liv

e B

irth

s

2004

2005

2006

The infant mortality rate inNortheast Florida reached itslowest level in ten years, withimprovements posted in each ofthe region’s five counties. Thearea’s infant death rate was 8.2deaths per 1000 live births in 2006compared to 10.4 deaths per 1000in 2005. The region continues toexceed the statewide infantmortality rate of 7.2 deaths per1000 live births. Regional deathrates fell in both the neonatal andpostneonatal periods. Infantmortality rates ranged from 15.2deaths per 1000 in Baker Countyto 2.8 deaths per 1000 in St.Johns County. Duval County’sinfant mortality rate dropped from11.6 to 9.5 deaths per 1000.

High Rates Persist in Baker CountyInfant Deaths Drop in Northeast Florida in 2006

2 PROJECT IMPACT

Infant Losses In 2006, there were a total of 282 infantlosses in Northeast Florida. This includes126 fetal deaths or stillbirths (45%) and 156infant deaths (55%). There were 43 fewerfetal and infant deaths in 2006, compared to2005. The five-county area had a fetal-infantmortality rate of 14.7 per 1,000 live birthsand fetal deaths in 2006, comparable to thestate rate of 14.5 per 1,000. Fetal-infantmortality rates for nonwhites were belowstate rates in 2006. Infant mortality includes deaths to liveborn babies during their first year of life. In2006, the five-county area had an infantmortality rate of 8.2 deaths per 1,000 livebirths, the lowest infant death rate in 10years. Despite improvements, the infantmortality rate for nonwhites (12 deaths per1,000) remained twice as high as the ratefor whites (6.2 deaths per 1,000). Northeast Florida continues to exceedstate infant mortality rates, but differencesnarrowed in 2006 for nonwhites. Florida’sinfant mortality rate was 7.2 deaths per1,000 live births in 2006. Statewide, theinfant mortality rate for whites was 5.6 per1,000 live births; for nonwhites it was 11.8per 1,000. Infant mortality includes two components:neonatal mortality (deaths to infants lessthan 28 days old) and postneonatalmortality (deaths to infants between 28 and364 days old).

Components of Infant Mortality,

Northeast Florida 2002-2006

7PROJECT IMPACT

Maternal MedicalHistory General health of the motherwas the most frequently identifiedfactor in the 215 fetal and infantdeath cases reviewed in 2000-2007. Included in this categoryare pre-pregnancy conditionssuch as diabetes, hypertensionand related conditions. This riskwas identified in 66 percent of thecases reviewed. Poor nutritionand obesity were thepredominant problem areas withthis category. In 50 percent of thecases reviewed, the mother hadnutritional issues prior to orduring her pregnancy.

Social Issues Late, inconsistent or no prenatalcare occurred in more than half of theFIMR cases reviewed in 2000-07.Other frequently cited contributingfactors included: poverty and lack ofsocial support (25%) and maternalage <21 or >35 (29%). FIMR reviewsbegan considering life course factorsin 2005; in nearly 40 percent of thecases cited factors that occurred overthe woman’s lifetime as affecting thepoor outcome.

Fetal/Infant Medical Issues Pre-existing medical conditions, including congenitalanomalies, were cited as a contributing factor in 14percent of FIMR cases. In 18 percent of the cases, theinfant experienced an infection.

Contributing Death FactorsMaternal Medical History

66%

18%

39%

0% 10% 20% 30% 40% 50% 60% 70%

General Health ofthe Mother

History of PoorPregnancyOutcome

Incompetent Cervix

Contributing Death FactorsSocial Issues

33%

29%

25%

53%

0% 10% 20% 30% 40% 50% 60%

Family PlanningIssues

Maternal age <21or >35

Poverty or lack ofsupport

Late, inconsistentor no prenatal care

n=215

2006 Fetal-Infant Death RateNortheast Florida & Florida*

7.3

6.6

5.8

5.2

11.6

9.2

4.7

5.2

3.6

3.9

7.7

7.8

2.5

2.9

2.0

2.3

3.9

4.1

0 5 10 15 20 25

FL

NEFL

FL

NEFL

FL

NEFL

Fetal

Neonatal

Postneonatal

NONWHITE

WHITE

TOTAL

* Deaths per 1,000 Live Births + Fetal Deaths.

6.2 6.1 6.1 6.4

5.2

2.63.9 3.4

3.9

2.9

0

2

4

6

8

10

12

2002 2003 2004 2005 2006

Neonatal Postneonatal

Deaths/1000 Live Births

Infant Mortality By Race, 2001-2006Northeast Florida

10.4

8.27.6

6.2

12

9.510

8.8

10

6.6

777.2

16.115.316.3

12.9

16

0

2

4

6

8

10

12

14

16

18

2001 2002 2003 2004 2005 2006

Total White Nonwhite

Deaths/1000 Live Births

Most Frequently Identified Factors FIMR Case Reviews

Contributing Factor % Cases

Source: January 2000 - June 2007 FIMR Case Reviews (n=215). Multiple factors may bepresent in individual cases. *Life course added in 2005 (n=71)

General Health of Mother 66%Maternal Infections & STDs 58%Late/No Prenatal Care 53%Preterm Labor/PROM 52%Previous Poor Outcome 39%Life Course* 39%Pregnancy Conditions/Complications 35%Family Planning Issues 33%Substance Abuse 29%Maternal Age (<21 or >36) 29%No Healthy Start, Other Screening 27%Social Issues (poverty/lack of support) 25%

n = 215

3PROJECT IMPACT

Fetal Mortality Fetal mortality or stillbirths includes deathswhich occur before birth following at least 20weeks gestation. In 2006, the five-county areahad a ratio of 6.6 fetal deaths for every 1,000 livebirths, below the state rate (7.4 deaths per 1,000live births). The fetal mortality ratio for whites in the regionwas 5.2/1,000 live births compared to 5.9/1,000statewide. For nonwhites it was 9.2/1,000,compared to 11.7/1,000 statewide.

Neonatal Mortality Neonatal mortality includes deaths occurring to infants before theyare 28 days old. In 2006, the neonatal mortality rate in NortheastFlorida was 5.2 deaths per 1,000 live births, compared to 6.4 deathsper 1000 in 2005. The neonatal mortality rate for whites was 3.9deaths per 1,000; for nonwhites the rate was 7.8 per 1,000. State-wide, the neonatal mortality rate in 2006 was 4.7/1,000 (3.6/1,000 forwhites and 7.8/1,000 for nonwhites). Most of the infants (60+%) who die in the neonatal period die withinthe first 24 hours of life. Prematurity or low birthweight is the primarycause of neonatal mortality.

Postneonatal Mortality Postneonatal mortality includes deaths of infants from 28 days to 364 days of age. In 2006, the five-county area had apostneonatal death rate of 2.9 per 1,000 live births (2.3/1,000 white and 4.2/1,000 nonwhite). The postneonatal death rate inthe region was 25% lower in 2006 than the previous year and was comparable to the state rate of 2.5 per 1,000 live births. Leading causes of postneonatal death in the region are prematurity, congenital anomalies, and sleep-related deaths,including SIDS.

6 PROJECT IMPACT

FIMR Reviews Highlight Impact of Maternal Health on Outcomes Fetal and infant deaths, reviewed using the FIMR process in 2000-2007, highlight the impact of a mother’s health prior toand during pregnancy on poor birth outcomes. Cases were selected for review during this period based on specific criteria including, type of death (fetal vs. infant),residence (target area vs. other areas) and race (black vs. others). The selection process reflected concern with the dispar-ity in infant health and its contribution to overall fetal and infant mortality in the region.

Maternal Medical Conditions DuringPregnancy Maternal infections and STDs were identified in 58 percent of the cases reviewedby the FIMR case review team. In nearly 30 percent of the cases, the mother wasinvolved in substance use, including tobacco, alcohol or drugs. Pregnancycomplications, including pre-eclampsia, placental abruption, gestational diabetes,gestational diabetes, and hyperemesis, was cited as a contributing factor in morethan a third of the cases reviewed.

Provider Issues Problems were cited in 23 percent of the cases reviews with poor communication by health care providers, lack ofappropriate referrals for high-risk women, poor follow-up of medical conditions and delays in initiating Healthy Start services.Appropriate screening (domestic violence, Healthy Start, substance use) was not evident in 27 percent of the casesexamined in 2000-07. In about 25 percent of cases, fear or dissatisfaction with services was noted as a factor in casereviews.

Parent Education Issues In one third of the cases reviewed, familyplanning issues were identified as acontributing factor in the fetal or infant death.This included short interpregnancy intervalsand inconsistent use of family planningmethods.The mother failed to respond to lackof fetal movement, premature labor andruptured membranes in about 20 percent of theFIMR cases.

Contributing Death FactorsMaternal Medical Conditions-Pregnancy

52%

29%

58%

35%

0% 10% 20% 30% 40% 50% 60% 70%

PretermLabor/PROM/PPROM

Substance Abuse

Maternal Infections, STDS

PregnancyConditions/Complications

n=215

Fetal Death (Stillbirths) Ratio

2002-2006

7.57.7

7.5

6.4

7.2

7.6

6.6

7.57.8 7.4

0

1

2

3

4

5

6

7

8

9

2002 2003 2004 2005 2006

NEFlorida

Florida

Stillbirths/1000 Live Births

Neonatal Mortality (<28 Days) Rates

2002-2006

6.2 6.1 6.16.4

5.25

4.84.5 4.5

4.7

0

1

2

3

4

5

6

7

2002 2003 2004 2005 2006

NEFlorida

Florida

Deaths/1000 Live Births

Postneonatal Mortality (28-364 Days) Rates

2002-2006

2.6

3.9

3.4

3.9

2.9

2.5 2.6 2.52.7

2.5

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

2002 2003 2004 2005 2006

NEFlorida

Florida

Deaths/1000 Live Births