1. Fetal and Infant Mortality Review by Thomas M. Miller, MD
Greetings
It is especially nice to participate in Alabama Perinatal Conference, …….
I am delighted to be here and share with you information gained from one of the Department of Public Health’s most exciting new initiatives FIMR.
The returned of the IMR to double digits in 2007 was the impetus to moved ahead with establishing a FIMR program.

2. National Fetal and Infant Mortality Review Program
Collaborative effort
Began in late 1980’s
More than 220 programs
40 states, the District of Columbia, Puerto Rico, and the Virgin Islands
15 statewide programs
I will now review the national FIMR model and then describe the beginning of Alabama’s FIMR program.
First introduced in the late 1980's, Fetal and Infant Mortality Review (FIMR) has been a dynamic, community process
NFIMR is a cooperative agreement between ACOG (American College of Obstetricians and Gynecologists) and the federal Health Resources & Services Administration (HRSA) through HRSA’s Maternal Child Health Bureau, beginning June 1990
FIMR has enjoyed continued growth and refinement as more communities have used it
Today, there are over two hundred twenty FIMR programs nationwide
ACOG serves as the “center of excellence” in developing and refining the model over time

3. FIMR Goals
To describe significant social, economic, cultural, safety, health and systems factors that contribute to mortality
To design and implement community- based action plans built upon information obtained from the reviews
FIMR has two goals
1st goal is to describe significant social, economic, cultural, safety, health and systems factors that contribute to mortality
2nd goal is to design and implement community-based action plans founded on the information obtained from the reviews
This is analogous to the moniker, “from research to practice”

4. FIMR Model - ACOG Guidelines
Infant Death
Infant Death - the “silver lining” from tragedy of death is opportunity to prevent future deaths
Data Gathering - maternal interview is a critical part of data gathering, allowing the process a unique opportunity to further understand aspects such as cultural sensitivity
Information sources include medical records (physician and hospital) as well as records from home visits, WIC and social service providers
All identifying information is removed by the first line data collector (eg, names of families, providers, institutions) and a case summary is presented to a case review team (CRT)
Case Review Team (CRT) - reviews data and makes recommendations for improving the community’s service delivery system
Community Action Team (CAT) - acts on CRT recommendations by planning Interventions
Improved Outcomes - better outcomes over time as the physical, health care and social environment for childbearing families improves
Data Gathering
Case Review Team (CRT)
Community Action Team (CAT)
Interventions
Improved Maternal and Child Health Outcomes

5. Alabama Fetal and Infant Mortality Review Program
Pursuant to section Code of Ala. 1975, §§ 22-9A- 21, (6)
Implemented January 21, 2009
Neonatal deaths
Statewide
The program was implemented January The first cases were assigned February 5, 2009.
The first Case Review Team was held here in Birmingham on May 12, 2009.
We chose to review neonatal deaths (live born infants born alive who die before 28 days of life) occurring in 2009.
Opted for neonatal deaths only (as opposed to all infant deaths), as we were just starting the program and needed experience
Noteworthy are the pioneering efforts of both Jefferson and Mobile Counties in doing FIMR as a component of their federal Healthy Start projects.
Mobile’s FIMR, the Alabama Baby Coalition, was established in 1988, and has been robust..
They review fetal (over 20 weeks gestational age) and infant deaths of Mobile County residents only.
Mobile was using a modified version of the ACOG protocol prior to 2009, and adopted the full ACOG model in 2009, giving us a true statewide FIMR program.

6. Perinatal Regions
FIMR is organized along the same lines as our longstanding Perinatal Program.
The Perinatal Program has been in place since 1980.
The current Perinatal Regions were established geographically in 1996 and are based on predominant “trade patterns” for high risk maternal and infant care and referrals.
Senior level perinatal nurses were already working with the 54 delivery hospitals to improve perinatal health.
Interestingly, the number of Alabama hospitals with delivery service has been decreasing over the years:

7. Factors Contributing to Infant Death
Low birth weight
Prematurity
Maternal pre-existing health
Unplanned pregnancy
Obesity
Substance Abuse
These factors have been identified in the Perinatal Annual Report as issues that need continued effort.
FIMR validates that these are issues but goes a step further…. FIMR, through the Community Action Team develops plans and implement actions to address the contributing factors

8. Key FIMR Concepts Systematic evaluation of individual cases
Identification of a broad range of factors
Inclusion of information not available through routine quantitative methods
Sentinel events
Avoidance of preventable/non-preventable classifications of deaths
Avoidance of blame
Two-tiered process – analytic and action process
Feedback mechanism
Multidisciplinary involvement

9. FIMR Process
Helps communities prepare and deliver culturally appropriate interventions to improve service systems and resources for their multi-ethnic populations.
FIMR in and of itself will not directly lower the IMR but will provide interventions, strategies and programs to address the factors that are associated with fetal and infant deaths.

10. Thank You!
513 infant deaths / 20 kindergarteners per classroom = 26 classrooms - a future lost…..
Questions?