1. January 2005-December 2009

2. Overview of the Fetal & Infant Mortality Review Process One of the outcome measures included in the Coalition’s contract with the state is that our infant mortality rate not be higher than the state rate when adjusted for mother’s age, race and education level. In order to address our high infant mortality rates, the Coalition started its FIMR project in 1995. We receive funding from the Florida Department of Health and the Coalition itself. The purpose of FIMR is to examine cases with the worst outcomes to identify gaps in services that might be addressed through community action. We select cases for review based on specific criteria such as those from areas where the infant mortality rates are the highest, fetal losses over 36 weeks gestation or 2500 grams, outlying counties, etc.

3. Overview of the Fetal & Infant Mortality Review Process The FIMR Case Review Team meets every other month and uses a process developed by the American College of Obstetrics & Gynecology. Information is abstracted from birth, death, prenatal care, Healthy Start, hospital and autopsy records. Efforts are also made to interview the family. All the information we examine is de-identified. Our purpose is to determine specific medical, social, financial and other issues that may have impacted the poor birth outcome. Every year, we draft recommendations based on our findings for community action.

4. Resident Infant Mortality Rates-All Races Northeast Florida and Florida 2000-2009 Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats

5. Resident White Infant Mortality Rates Northeast Florida and Florida 2000-2009 Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats

6. Resident Nonwhite Infant Mortality Rates Northeast Florida and Florida 2000-2009 Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats

7. NEFL Infant Birth weight 2005-2009 N=811

8. NEFL Causes of Infant Death 2005-2009 * records may have more than one cause of death listed N=811

9. NEFL Infant Age at Death 2005-2009 63% of neonates die w/in 1 st 24 hours 1/3 of those die w/ in 1 st hour Nearly ½ of post neonatal deaths are sleep related N=811

10. Northeast Florida Sleep related deaths 2005-2009

11. Causes of Infant Death January 2005 – December 2009 Prepared by L.Lee Source: Birth and Death Certificates 15.1% for 2009 n for all deaths = 811 n for sleep related deaths=132

12. Total Number of Sleep Related Deaths Northeast Florida 2005 – 2009 20052006200720082009 332327 22 17.5%14.6%17.6%16.4%15.1% Prepared by Llee NEFL FIMR Healthy Start Coalition

13. Rate Comparison 20052006200720082009 # NEFL SIDS cases10 663 NEFL SIDS rate/1,000 live births.55.53.31.32.16 FL SIDS rate.38.39.34 # NEFL Undetermined or other sleep related cases 231321 19 NEFL sleeping infant death rate/1,000 live births 1.831.211.401.45 1.21 Prepared by Llee NEFL FIMR Healthy Start Coalition

14. Risk Factor Comparison Risk Factor 2005 - 2008 n=110 2009 n=22 Unsafe sleep surface (includes any non- infant bed, presence of unsafe items, soft surface, etc.) 79%82% Unsafe items in bed (includes presence of pillows, stuffed animals, bumper pads, comforters, etc.) 56%77% Not on back to sleep67%55% Not in an infant bed68%

15. Risk Factor Comparison (cont) 2005 - 2008 n=110 2009 n=22 Never breast fed70%50% Sharing sleep surface56%68% Second hand smoke53%82%

16. Maternal demographics 2009 sleep related deaths 71% single 67% white/33% black 90% in 20’s (9% teens) Just over 1/2 with no HS diploma (one of these was 8 th grade or less) About 1/4 with HS diploma

17. NEFL Causes of Fetal Death 2005-2009 N=670

18. Resident Fetal and Infant Deaths # of Cases by County All Races 2005-2009 N=1479

19. Resident Infant Mortality Rates by County All Races 2005-2009 State rate = 7.2 Prepared by L.Lee Source: Birth and Death Certificates/Vital Stats

20. Baker County-5 year summary 35 total fetal and infant deaths; 24 infants/11 fetals Maternal Demographics: 75% white; 15% black 65% single moms 35% with no HS diploma Only 5 had any college 14.5% teens ZipCityTotal Fetal and Infant Deaths 32063MacClenny20 32040Glen St. Mary10

21. Baker County (con’t) Maternal behavior: 41.2% w/ unhealthy pregravid bmi-lowest in project; highest % w/ normal pregravid bmi 29% late or no pnc (2 nd worst) 1/5 with poor birth spacing (highest) 21% w/ substance abuse Infants: Even split neonatal and postneonatal deaths Sleep related death make up 42% of all infant deaths 70% unsafe items 60% not on back 60% 2 nd hand smoke 50% bedsharing

22. Clay County-5 year summary Maternal demographics: 51% single 14.5% teens 9% hispanic 72% white 26.6% with no HS diploma and 35% w/ some college ZipCityDeaths 32068Middleburg41 32065Orange Park20 32073Orange Park30 128 fetal and infant deaths; 67 infants/61 fetals

23. Clay county (con’t) Maternal behavior: 23.4% substance abuse 23.4% late or no pnc 51% unhealthy pregravid bmi (highest) Good birth spacing Infant deaths: Nearly 40% are < 29 weeks 61% are neonatal ½ of these occurred in 1 st 24 hrs low sleep related Highest occurrence of congenital anomalies

24. Nassau County-5 year summary Maternal Demographics 84% white, 12 % black, 54% single 26% w/out HS diploma 28% w/ some college 16% teen mothers (highest) 54% single ZipCityDeaths 32011Callahan8 32034Fernandina10 32097Yulee19 44 total deaths: 25 infant and 19 fetal

25. Nassau County (con’t) Maternal behavior: 30% w/ self reported substance abuse (highest) 46.5% w/ unhealthy pregravid BMI Lowest birth spacing issues (only 1 case) 16.3% late or no pnc. Infants: 72% neonates 44% < 29 weeks 25% had some type of congenital anomaly Lowest sleep related

26. St. John’s County-5 year summary Maternal Demographics: 81% white (highest) 60% married (highest) 15% teens 43.2% w/ some college (highest) ZipCityDeaths 32082Ponte Vedra9 32084Downtown St Aug 25 32086St Aug Shores15 32092Palmo19 32145Hastings6 100 total deaths: 45 infants 55 fetals (all other counties had fewer fetals than infants)

27. St. Johns county (con’t) Maternal behavior: 30% self reported substance abuse (highest) 21.6% late or no pnc 42% unhealthy pregravid bmi Good birth spacing Infant s 46% < 29 weeks 12% multiples (highest) 57% neonates-3/4 of those died w/in 1 st 24hrs 19% sleep related: 86% 2 nd hand smoke 57% bedsharing, not in infant bed, not on back and had unsafe items

28. Resident Infant Mortality Rates by Race Duval County 2000-2009 Prepared by L.Lee Source: Birth and Death Certificates/Vital stats

29. 70 41 55 33 19 46 93 102 51 60 19 65 97 36 2225 27 35 23 35

30. Maternal Race Duval County 2005-2009 Death Cohort

31. Maternal Age Duval County 2005-2009

32. Single marital status Birth and Death Cohort Comparison Maternal Marital Status Duval County 2005-2009

33. Birth and Death Cohort Comparison Maternal Education Duval County 2005-2009 Death Cohort Births with HS dip. or more Births with NO HS diploma

34. Birth and Death Cohort Comparison Maternal Health Duval County 2005-2009 Smoking *

35. Birth and Death Cohort Comparison Maternal Health Duval County 2005-2009

36. Birth and Death Cohort Comparison Prenatal Care Duval County 2005-2009 Late or no prenatal care

37. Contributing Factors in FIMR Cases July 2005- June 2010 N=143

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

39. Contributing Factors in FIMR Cases July 2005 – June 2010 N=143 Prepared by L.Lee Source: FIMR/CRT case reviews

40. Contributing Factors in FIMR Cases July 2005-June 2010 N=143 Prepared by L.Lee Source: FIMR/CRT case reviews

41. Contributing Factors in FIMR Cases July 2005-June 2010 N=143 Prepared by L.Lee Source: FIMR/CRT case reviews

42. Contributing Factors in FIMR Cases July 2005-June 2010 N=143 Prepared by L.Lee Source: FIMR/CRT case reviews

43. 2010 FIMR Recommendations (based on 2009 data) 1. Continue to address the sleep-related deaths in NE Florida through the implementation of an awareness and information campaign. Information should include: proper sleep positioning, dangers of bed sharing, impact of second and third hand smoke, importance of breastfeeding and appropriate use of infant beds. Continue Safe Sleep Partnership activities to target providers, expectant and new parents/families, and the general public. In 2009, smoke exposure was documented in 82% of our sleep related deaths.

44. 2010 FIMR Recommendations (based on 2009 data) Focus provider and community education on age of vulnerability (2-4 months). Utilize WIC clinics, pediatricians, family practitioners, etc to re-education caregivers on all visits during this time frame. Encourage them to ask specifically about sleep positioning, sleep location, etc. during the baby's visit. Implement education and awareness strategies to address life course perspective, including preconceptional health and planned pregnancies, as well as social determinants that impact birth outcomes

45. 2010 FIMR Recommendations (Based on 2009 data) 2. Since there are so many factors relating to preconceptional health, we will continue to focus our efforts on smoking cessation of all types (tobacco, marijuana, crack, etc.) Include the general public, women of child bearing age and providers in educational efforts. Share local FIMR statistics. Focus on education regarding risks of smoking. 3. Improve Healthy Start Screening and referral rates: Recruit an obstetrician to serve on the FIMR CRT Committee Encourage providers not to “pre-screen” patients. Offer the screening to all patients

46. 2010 FIMR Recommendations (Based on 2009 data) The second area of focus for preconceptional health will be obesity. Twenty seven percent of all moms in the 2008 death cohort and twenty nine percent in the 2009 death cohort had obese pregravid BMI's. Healthy Start services for the baby should also focus on the mom in helping her to lose her weight postpartum. All healthcare students such as nursing and medical should be educated re: the prevalence of obesity and the importance of incorporating this general health focus into all aspects of care. The education re: healthy lifestyle should begin during childhood and continue through all ages.

47. Questions?