January - December 2013
Laurie Lee, RN, BSN, CCM
FIMR Coordinator
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The FIMR Case Review Team meets 9x/year.
Review process developed by the American
College of Obstetrics & Gynecology is used.
Information abstracted from birth, death,
prenatal care, Healthy Start, WIC, hospital and
autopsy records.
Efforts are also made to interview the family.
All information is de-identified.
Purpose is to determine specific medical,
social, financial and other issues that may have
impacted the poor birth outcome.
Recommendations for community action
drafted annually based on findings.
Prepared by Llee
NEFL FIMR
Healthy Start Coalitio
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The purpose of FIMR is to examine cases
with the worst outcomes to identify gaps
in services that might be addressed
through community action.
Cases selected for review based on
specific criteria such as:
 Zip codes with high infant mortality rates
 Fetal losses over 36 weeks gestation or 2500
grams
 Deaths in outlying counties, etc.
Prepared by Llee
NEFL FIMR
Healthy Start Coalitio
Rate per 1,000 Live Births
18.0
16.0
Total
16.7
White
Black
14.0
12.0
10.0
8.0
6.0
4.0
9.6
10.6
7.5
6.1
4.6
2.0
Source:
Florida
Vital
Statistics
20
18
NE FL
FL
US
16
14
12
10
8
6
9.5
7
10.4
8.9
8.2
7.2
7.2
8
7.1
7.2
7.9
6.9
7.3
6.5
7.3
2011
2012
6.5
6.4
7.96
6
6.1
4
2
0
2004
2005
2006
2007
2008
2009
2010
141 infant deaths in 2013
2013
Prepared by L.Lee
Source: Birth and Death
Certificates/Vital Stats
20
NEFL
FL
18
16
14
12
10
8
6
6.6
5.5
4
7.6
5.3
6.2
5.6
5.9
6.3
5.2
5.5
4.9 4.9
5.8 5.6
4.02 4.6
4.6 4.6
5.96
4.6
2
0
2004
2005
2006
2007
2008
2009
2010
2011
68 white infant deaths in 2013
2012
2013
Prepared by L.Lee
Source: Birth and Death
Certificates/Vital Stats
20
FL
18.8
Black
18
16
15.9
12.8
14
12
10
14.2
11.5
12.5
11.8
12.9
12.2
13.2
13.2 11.8 12
12.9
12.5
13.4 13.2
10.7
10.6
8
6
2004
2005
2006
2007
2008
2009
2010
65 black infant deaths in 2013
2011
2012
2013
Prepared by L.Lee
Source: Birth and Death
Certificates/Vital Stats
Infant Deaths
Births
IM Rate
Baker
13
1031
12.6
Clay
31
6258
5.0
Duval
305
37413
8.2
Nassau
10
2254
4.4
St .Johns
23
5695
4.0
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
100%
80%
31%
31%
22%
30%
69%
69%
78%
70%
42%
60%
40%
58%
20%
0%
2009
2010
2011
2012
2013
n=155
n=127
n=108
n=127
n=141
Neonates
Postneonates
50%
58%
Prematurity
Congenital Anomalies
30%
RDS/BPD/Pulmonary
Hypoplasia
Infection
20%
18%
Sleep related
20%
40%
IVH
Cause of Death
5%
2%
4%
0%
7%
9%
10%
NEC
Multiple Organ Failure
*records may have more than one cause of death listed
n=141
< 500 grams (< 1.1 pounds)
500-1499 grams (1.1-3.29 pounds)
1500-2499 grams (3.3 - 5.49 pounds)
2500+ grams (> 5.5 pounds)
20%
30%
13%
37%
Northeast Florida
Sleep related deaths
2009
2010
2011
2012
2013
#
22
16
14
21
25
% of
deaths
15.1%
12.6%
12.9%
16.5%
17.7%
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
Baker
#
deaths
1
(Macclenny)
Clay
2
(Fleming
Island and
Middleburg)
Duval Nassau St
Johns
18
0
4
(3
different
zips in St.
Aug; 1Hastings
Duval county detail:
•In 2013, there were 18 deaths in 14 zips. No zip with > 2. Target
area had 6.
Risk Factor
N=70
Unsafe sleep surface
80%
Not on back to sleep
63%
Not in an infant bed
70%
Never breast fed
63%
Unsafe items in bed
63%
Second/third hand
smoke
47%
Sharing sleep surface
63%
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
•84% single
•60% in their 20’s; 24%-30’s; 16%-teens
•60% black; all others white
•64% inadequate prenatal care
•12 % with no high school diploma
•48% are overweight or obese; only 4 of
these involved co-sleeping
•All singletons except one twin
•88% Medicaid
•84% term
•52% male
25
White
Target Area
Black
Total
12.8
12.6
14.1
14.1
13.8
20
15
15.9
13.6
8.4
11.7
8.8
8.1
5.5
5.8
10
5
7.3
8.3
4.9
8.8
6.1
2.8
0
2009
2010
2011
2012
111 deaths:43-W; 62-B; 20-T
2013
Prepared by L.Lee Source:
Birth and Death
Certificates/Vital stats
Births
7600
7400
7200
7000
6800
6600
6400
2009
2010
2011
2012
2013
Births
4800
4700
4600
4500
4400
4300
4200
2009
2010
2011
2012
2013
Birth Cohort
Death Cohort: n=190
Race
W=56%; B=35%
Age
Teens trended down since
2007, currently about 7%;
20-29 year olds represent
55%; 30’s has steady
increase over last 20 yrs,
currently at 35%; 40+ varies,
but overall, increase in last
20 years, currently at 3%
Slightly higher % of
teens (8.6%) and
20’s (58%); slightly
lower 30’s and 40’s
(32% and <1 %,
respectively).
48% last 5 years
Had decreased from
65% to 57% last 5
years; now 70%
13.8%
Was about 30%,
now at 16.2%
Single
Marital
Status
No HS
Diploma
W=37%; B=58%
Birth Cohort
Death Cohort
Smoking
6.9%
Was trending down
17 – 12% over last 4
yrs; now 15%
Overweight/Obese BMI
50.3%
42.8% (plus 8%
underweight)
Inadequate prenatal care
28.2%
Was trending down
over last 5 yrs-40 to
33%; now at 36%
Pregnancy Interval < 12
mos
State tracks <
18 mos; now
39.5%
Was trending down
22-14% last 6
years; now 20%
60%
Pre-existing conditions such
as hypertension, diabetes,
asthma, etc.
56%
50%
40%
History of fetal or infant
loss
33%
History of previous preterm
or low birth weight baby
30%
20%
17%
15%
17%
10%
History of STD or other GU
infection
History of elective
termination
0%
Maternal Medical and OB History
79% all FIMR cases had medical history issues
35%
30%
Obesity
37%
25%
20%
15%
10%
5%
17%
Inadequate
Nutrition
(underweight
BMI or anemia
at 1st trimester
pnc visit)
0%
Pre-existing Nutritional Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Life Course Perspective Issues
35%
30%
25%
35%
32%
Maternal Age < 21 or > 35
27%
20%
25%
Poverty
15%
10%
5%
0%
Socioeconomic
Other emotional stressors
during pregnancy such as loss of
job, loss of loved one,
incarceration, divorce, natural
disaster, etc.)
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Maternal Infections other than
STD's
STD's
50%
48%
45%
40%
44%
Preterm Labor
35%
PROM/PPROM
30%
25%
20%
15%
Anemia
29%
26%
23% 21%
Placental Abruption
10%
5%
0%
Medical Conditions During Pregnancy
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Contributing Factors in FIMR Cases
2011-2013
N=81
60%
50%
Inadequate pnc
70%
75%
40%
30%
32%
20%
10%
Kick counts; signs of
decreased fetal movement
and when to call MD
Family Planning
16%
0%
Substance abuse
-10%
Parental Knowledge/Compliance
Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Contributing Factors in FIMR Cases
2011-2013
N=81
20%
Medical and social
services/community inadequate to
meet needs
18%
16%
12%
14%
12%
Medical and social
services/community resources
available, but not used
10%
8%
5%
6%
4%
2%
Patient fear of/dissatisfaction with
system
2%
0%
Service Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Contributing Factors in FIMR Cases
2011-2013
N=81
50%
45%
46%
40%
40%
35%
Prematurity
30%
25%
Infection
20%
Cord Problem
15%
11%
10%
5%
0%
Fetal/Infant Medical Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
• Continue to focus on preventing sleep
related deaths.
• The number of sleep related deaths has
increased over the last 3 years. The
number of deaths for years 2011, 2012
and 2013 were 14, 21 and 25
respectively. When compared to all
causes of death in infants for years
2011, 2012 and 2013, this represents
13%, 16.5%, and 18%, respectively.
• Education should focus on babies
sleeping alone on a safe sleep surface.
The following are potential partners:
• Healthy Mothers Healthy Babies to revive the Cribs 4 Kids
programs
• Americorp
• Faith based organizations for “Safe Sleep Sundays”
• Make a Noise, Make a Difference
• Curriculum for health advisors
• Baptist Community Health
• Video link
• Safe Kids Coalition
• National SIDS Foundation
• Free educational materials
• WIC
• Include safe sleep in breast feeding courses
• CDC
• Video to use in educational settings
• City Match
• LifeCourse board game
• The Players Center For Child Health at Wolfson Children’s
Hospital- Ready, Set Sleep program
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Continue to focus on dangers of smoking
during pregnancy.
◦ The Community Action Team’s “Don’t Blow Smoke”
campaign is gaining momentum.
 Phase I (target area-Health Zone 1)
 Phase 2 (social media and expansion outside the
target area to include the 32218 and 32244 zip
codes) have been implemented.
◦ The percentage of moms in the death cohort that
self-reported tobacco use was 12% in 2012. It rose
to 15% in 2013. Self-reported tobacco use in the
2013 birth cohort is 6.9%.
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Any questions?