January 2005-December 2011
Laurie Lee, RN, BSN, CCM
FIMR Coordinator
Northeast Florida Healthy Start Coalition
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The FIMR Case Review Team meets bimonthly
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 Coalition
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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.
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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 Coalition
20
18
NE FL
FL
US
16
14
12
10
8
9.8
7.5
6
9.5
7
10.4
7.2
8.2
7.2
8
7.1
8.9
7.2
7.9
6.9
7.3
6.5
6.5
6.4
4
2
0
2003
2004
114 infant deaths in 2011
2005
2006
2007
2008
2009
2010
2011
Prepared by L.Lee
Source: Birth and Death
Certificates/Vital Stats
20
18
NEFL
FL
16
14
12
10
8
6
6.7
6.6
7.6
5.8
5.5
5.3
4
6.2
5.9
6.3
5.6
5.2
5.5
5.8
5.6
4.9
4.9
4.6
4.02
2
0
2003
2004
2005
39 white infant deaths in 2011
2006
2007
2008
2009
2010
2011
Prepared by L.Lee
Source: Birth and Death
Certificates/Vital Stats
20
18.8
NEFL
FL
Black
18
16.2
15.9
15.3
16
14
12
16.1
13.7
12.4
10
11.5
12.5
12.9
12.8 11.9
12
12.2
11.8
13.8
14.1
12.3
12.1
11.8
10.5
10.6
10.8
9.64
12
11.1
10.3
8
6
2003
2004
2005
2006
75 nonwhite infant deaths in 2011- ¾ black
2007
2008
2009
2010
2011
Prepared by L.Lee
Source: Birth and Death
Certificates/Vital Stats
< 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)
No info
26%
14%
2%
25%
33%
58% of the babies that died weighed < 3.3 pounds at birth
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
38.6
35.4
35.7
32.7
31.3
30.7
61.4
64.6
64.3
67.3
68.8
69.3
2005
n=189
2006
n=158
2007
n=154
2008
n=165
2009
n=155
2010
n=127
Neonates
22.2
77.8
2011
n=114
Postneonates
63% of the neonatal deaths occurred in the 1st 24 hours
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
50%
50%
Prematurity
Congenital Anomalies
40%
Sleep related
30%
RDS/BPD/Pulmonary
Hypoplasia
Infection
5%
6%
13%
13%
IVH
4%
0%
16%
10%
13%
20%
Cause of Death
*records may have more than one cause of death listed
NEC
Multiple Organ Failure
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
Northeast Florida
Sleep related deaths
2005-2011
#
2005
2006
2007
2008
2009
2010
2011
33
23
27
27
22
16
14
16.4%
15.1%
12.6%
12.3%
% of 17.5% 14.6% 17.6%
deaths
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NEFL FIMR
Healthy Start Coalition
Baker
#
deaths
2
Clay
Duval
1
11
Nassau St
Johns
0
0
Duval county detail:
•The following zipcodes had one sleep related death: 04, 06, 08, 10,11, 23,
25, 57, 77
•The 06 zip was the only one with > 1 sleep related death and it had only 2
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
2005
2006
2007
2008
2009
2010
2011
# NEFL SIDS
cases
10
10
6
6
3
1
1
NEFL SIDS
rate/1,000 live
births
.55
.53
.31
.32
.16
.06
.06
FL SIDS rate
.38
.39
.34
.35
.32
.30
.20
# NEFL
Undetermine
d or other
sleep related
cases
23
13
21
21
19
15
13
NEFL
sleeping
infant death
rate/1,000 live
births
1.83
1.21
1.40
1.45
1.20
.90
.80
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NEFL FIMR
Healthy Start Coalition
Risk Factor
2005 – 2011
n=162
Unsafe sleep surface
80%
Not on back to sleep
66%
Not in an infant bed
69%
Never breast fed
66%
Unsafe items in bed
60%
Second/third hand
smoke
46%
Sharing sleep surface
55%
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
•79% in their 20’s
•71% single
•63% white
•about ½ had inadequate prenatal care
•42% with no high school diploma
•about 1/3 are overweight or obese
12
10.5
10
8.5
State
rate=6.8
8
5.9
5.2
6
4.1
4
2
0
Baker
Clay
Duval
Nassau St. John's
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29 total fetal and infant deaths; 20 infants/9 fetals
Zip
City
Total Fetal and
Infant Deaths
32063
MacClenny
13
32040
Glen St. Mary
12
61% single moms (highest)
40% infant deaths sleep related (highest)
39% with poor birth spacing (over 3 x higher)
38% all losses w/ congenital anomalies (highest)
32% with no HS diploma (highest)
Second only to Duval for late or no pnc (32%)
Low teen pregnancies and substance abuse
110 fetal and infant deaths; 58
infants/52 fetals
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66% w/ unhealthy BMI (highest)
55% single
25% with late or no pnc
12% teens (second highest)
12% Hispanic (highest)
Zip
City
Deaths
32068
Middleburg
30
32065
Orange Park
22
32073
Orange Park
30
32043
Green Cove
14
32003
Fleming Isl.
7
46 total deaths: 23 infant and
23 fetal
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89% white (highest)
27% w/out HS diploma
(second to Baker)
Highest substance abuse
(33%-all tobacco)
57% w/ unhealthy BMI
(96% of those high)
Lowest congenital
anomalies
Zip
City
Deaths
32011
Callahan
10
32034
Fernandina
16
32097,
32041
Yulee
14
92 total deaths:
•37 infants
•55 fetals (all other
counties had fewer fetals
than infants)
Zip
City
Deaths
32081 & 2
Ponte Vedra
10
32084
Downtown
St Aug
33
32086
St Aug Shores
14
32092
Palmo
19
32145
Hastings
6
Maternal Demographics:
 80% white
 56% married (highest)
 52.3.2% w/ some college (highest)
 Best pnc, birth spacing and healthy
BMI’s
 Highest underweight though-1/3 of
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those w/ unhealthy BMI’s
Highest cocaine use
White
25
Total County
Florida
Target Area
20
20.1
16.8
15
10
5
15.3
16.9
15.5
10.5
7.5
6.9
Black
14.6
15.4
16.4
10.9
7.5
7
11.6
12.9
9.5
7.9
7.2
7.2
7.2
12.9
9
7.1
6.7
15.3
14
15.9
13.1
11.3
13.3
12.8
9.7
8.4
7.2
7.1
6.9
5.5
8.8
8
6.5
7.3
6.4
5.8
2.8
0
1
2003
2004
90 infant deaths in 2011
2005
2006
2007
2008
2009
2010
2011
Prepared by L.Lee Source:
Birth and Death
Certificates/Vital stats
8000
7894
7777
7800
7600
7474
7400
7200
7128
7000
6889
6800
6600
6400
6200
2007
2008
2009
2010
2011
Prepared by Llee
NEFL FIMR
Healthy Start Coalition
6000
5900
5878
5800
5700
5657
5667
5600
5500
5416
5400
5431
5300
5200
5100
2007
2008
2009
2010
2011
Birth Cohort
Death Cohort
Race
W=56%; B=43%
W=30%; B=63%
Age
Teens trended down over last 3
yrs, currently at 8.3%; 20’s –mid
to high 50%
Teens w/ slight trend up
12-13%; 20 year olds
represent 55-60%; slight
upward trend in 40 year
olds
Single Marital
Status
48% last 3 years
Decreased from 65% to
61% last 3 years
Education-HS
or higher
85%
68%
Birth Cohort
Death Cohort
Smoking
8%
Trend 17 – 11% over last
3 yrs
Unhealthy BMI
50%
61%
Inadequate prenatal care
24%
Trending down over last
3 yrs-40 to 36%
Pregnancy Interval < 12 mos
14%
17%
60%
Pre-existing conditions such
as hypertension, diabetes,
asthma, etc.
56%
50%
40%
30%
20%
History of fetal or infant loss
31%
History of previous preterm
or low birth weight baby
20%
15%
11%
10%
History of STD or other GU
infection
History of elective termination
0%
Maternal Medical and OB History
35%
30%
25%
20%
15%
10%
Obesity
Inadequate
Nutrition
(underweight
BMI or anemia
at 1st trimester
pnc visit)
5%
0%
Pre-existing Nutritional Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Life Course Perspective Issues
45%
40%
35%
41%
39%
Maternal Age < 21 or > 35
30%
25%
28%
20%
24%
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
60%
Maternal Infections other than
STD's
50%
40%
52%
48%
STD's
30%
20%
28%
Preterm Labor
23%
10%
PROM/PPROM
0%
Medical Conditions During Pregnancy
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Contributing Factors in FIMR Cases
2009-2011
N=87
60%
Inadequate pnc
67%
50%
53%
40%
Kick counts; signs of
decreased fetal movement
and when to call MD
30%
30%
20%
10%
Family Planning
13%
0%
Substance abuse
-10%
Parental Knowledge/Compliance
Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Contributing Factors in FIMR Cases
2009-2011
N=87
20%
Medical and social
services/community
inadequate to meet needs
18%
16%
14%
11%
12%
Medical and social
services/community resources
available, but not used
10%
8%
6%
4%
5%
3%
Patient fear of/dissatisfaction
with system
2%
0%
Service Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews
Contributing Factors in FIMR Cases
2009-2011
N=87
60%
51%
50%
40%
33%
Prematurity
Infection
30%
Cord Problem
20%
10%
6%
0%
Fetal/Infant Medical Issues
Prepared by L.Lee
Source: FIMR/CRT case
reviews

Continue to focus on preventing sleep related deaths. Of the
114 infant deaths in Northeast Florida in 2011, 14were sleep
related. This represents 12.3 % of all deaths and 58% of deaths
after the first month of life.
 Focus on safe sleep surface and bedsharing.
 Develop additional Cribs 4 Kids programs in region and take advantage
of cash matching program.
 Develop regional Safe Sleep Campaign in collaboration with TPC
Advocacy Center at Wolfson Children’s Hospital.
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Focus on safe sex, STD prevention and family planning.
 Implement jail education program; take advantage of having a captive
audience.
 Within the FIMR cases, STDs during pregnancy increased from 9% in
2009 to 35% in 2011. Duval County ranks 5th in the state based on
2012 data in STD rates.
 Contraception in the immediate postpartum period is a priority for
action. In the FIMR reviewed cases, only one-third of the mothers
received a Depo shot or prescription for contraceptives prior to
hospital discharge.
 More than two-thirds (67%) of the FIMR cases involved
family planning issues including unplanned pregnancies
and inadequate birth spacing.
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Continue to focus on dangers of smoking during pregnancy.
 In 2011, 13% of the mothers in the death cohort self-reported some
type of substance abuse; 83% of these were tobacco users. In 2010,
17% of the death cohort self-reported some type of substance
abuse. Ninety-three percent of these were tobacco users.
 The Community Action Team is implementing an anti-smoking
campaign in the target area (Health Zone 1) based on prior
recommendations.
 Healthy Start program in St. Johns County is also piloting SCRIPT, an
evidence-based smoking cessation program for pregnant women.
Based on pilot results, this program should be considered for
replication throughout the region.