January 2005-December 2011 Laurie Lee, RN, BSN, CCM FIMR Coordinator Northeast Florida Healthy Start Coalition

 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

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 Coalition

Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats 114 infant deaths in 2011

Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats 39 white infant deaths in 2011

Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats 75 nonwhite infant deaths in ¾ black

58% of the babies that died weighed < 3.3 pounds at birth Prepared by Llee NEFL FIMR Healthy Start Coalition

63% of the neonatal deaths occurred in the 1 st 24 hours Prepared by Llee NEFL FIMR Healthy Start Coalition

* records may have more than one cause of death listed Prepared by Llee NEFL FIMR Healthy Start Coalition

Northeast Florida Sleep related deaths

Total Number of Sleep Related Deaths Northeast Florida 2005 – # % of deaths 17.5%14.6%17.6%16.4%15.1%12.6%12.3% Prepared by Llee NEFL FIMR Healthy Start Coalition

BakerClayDuvalNassauSt Johns # deaths 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

# NEFL SIDS cases NEFL SIDS rate/1,000 live births FL SIDS rate # NEFL Undetermine d or other sleep related cases NEFL sleeping infant death rate/1,000 live births Prepared by Llee NEFL FIMR Healthy Start Coalition

Risk Factor Comparison Risk Factor2005 – 2011 n=162 Unsafe sleep surface80% Not on back to sleep66% Not in an infant bed69% Never breast fed66% Unsafe items in bed60% Second/third hand smoke 46% Sharing sleep surface55% Prepared by Llee NEFL FIMR Healthy Start Coalition

Maternal Demographics Sleep Related Deaths 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

State rate=6.8

 29 total fetal and infant deaths; 20 infants/9 fetals  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 ZipCityTotal Fetal and Infant Deaths 32063MacClenny Glen St. Mary12

 66% w/ unhealthy BMI (highest)  55% single  25% with late or no pnc  12% teens (second highest)  12% Hispanic (highest) ZipCityDeaths 32068Middleburg Orange Park Orange Park Green Cove Fleming Isl fetal and infant deaths; 58 infants/52 fetals

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 ZipCityDeaths 32011Callahan Fernandina , Yulee14 46 total deaths: 23 infant and 23 fetal

Maternal Demographics:  80% white  56% married (highest)  % w/ some college (highest)  Best pnc, birth spacing and healthy BMI’s  Highest underweight though-1/3 of those w/ unhealthy BMI’s  Highest cocaine use ZipCityDeaths & 2Ponte Vedra Downtown St Aug St Aug Shores Palmo Hastings6 92 total deaths: 37 infants 55 fetals (all other counties had fewer fetals than infants)

Prepared by L.Lee Source: Birth and Death Certificates/Vital stats 90 infant deaths in 2011

Prepared by Llee NEFL FIMR Healthy Start Coalition

Birth CohortDeath Cohort RaceW=56%; B=43%W=30%; B=63% AgeTeens 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 yearsDecreased from 65% to 61% last 3 years Education-HS or higher 85%68%

Birth CohortDeath Cohort Smoking8%Trend 17 – 11% over last 3 yrs Unhealthy BMI50%61% Inadequate prenatal care24%Trending down over last 3 yrs-40 to 36% Pregnancy Interval < 12 mos14%17%

Prepared by L.Lee Source: FIMR/CRT case reviews

Contributing Factors in FIMR Cases N=87 Prepared by L.Lee Source: FIMR/CRT case reviews

Contributing Factors in FIMR Cases N=87 Prepared by L.Lee Source: FIMR/CRT case reviews

Contributing Factors in FIMR Cases N=87 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.

 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 Duval County ranks 5 th 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.

 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.