FIMR (Fetal and Infant Mortality Review)

Protect Every Baby Project

Protect Every Baby, which started locally in 1998, is carried out by the Healthy Start Coalition of Sarasota County with funding from the Florida Department of Health. It is one of 12 such projects in Florida. Because of the role of Healthy Start Coalitions throughout the state, Florida undertakes the largest number of FIMR projects of any state in the nation. Cumulatively, the findings are published every year as the Florida FIMR Annual Report.

Each month, fetal/infant death cases are reviewed by a team of medical and other professionals. Utilizing an approach developed by the American College of Obstetrics and Gynecology, information is abstracted from birth, death, medical, hospital, Healthy Start, WIC, and autopsy records. Efforts are made to interview the family. No information which identifies the family or medical provider is included on the abstraction form. Case summaries are developed and presented to the Case Review Team. During the period 2001-2003, 74 such deaths were reviewed.

The Case Review Team, a multidisciplinary group of community medical and social service professionals, examines each case to determine medical, social, financial and other issues that may have contributed to the poor birth outcome.

"The FIMR team analyzes unfortunate outcomes in order to improve knowledge of the needs and resources in Sarasota. I am proud to be a member of the team and hope that our work will assist in the goal of having healthy mothers and babies in this community."

– Kris Emden, Florida Department of Children & Families

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Most Frequently Identified Factors in FIMR Case Reviews

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Twenty-four Babies Saved 2001-2003

During 2000, Sarasota County experienced the loss of 22 babies, giving an infant mortality rate of 8.1 per 1,000 live births. If this rate had continued during each of the next 3 years, the community would have witnessed the loss of 24 additional infant deaths. In fact, the rates of infant mortality in those years fell to 3.6 in 2001, followed by rates of 5 per 1,000 and 6 per 1,000 in the next two years.

The FIMR project was instrumental in this improvement in the infant mortality rate, with new outreach and awareness activities in the African-American community, which in 2000 experienced a number of infant deaths disproportionate to the size of the African-American population.

In 2001, the FIMR project introduced its "Protect Every Baby" theme, initiating a confidential telephone information line providing recorded information about risks to healthy birth outcomes and protective information for expectant mothers. Callers were advised to get early and regular prenatal care, to learn the signs of premature labor, and to understand the importance of fetal "kick counts." Information was provided concerning consumption of alcohol, tobacco, and illegal drugs; poor nutrition, untreated infection, and the relationship of prior infant loss to future birth outcomes.

Since 2000, the FIMR cases reviewed have shown a reduction in the number in which lack of knowledge of kick counts played a role in the poor outcome. The number of women overall in Sarasota County who continue to smoke during pregnancy has declined, although the number of pregnant women who smoke and experience a fetal or infant loss remains high. In the year ahead, with the help of a grant from the March of Dimes, the Healthy Start Coalition will provide a series of training opportunities for medical professionals in "Fresh Start," a patient teaching curriculum developed by the American Cancer Association which promotes smoking cessation among pregnant women and new parents.

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The FIMR Process

In the FIMR process, stillbirths and infant deaths are indicators that spotlight both community system strengths and areas that could benefit from improvement.

Data Gathering:

• Collect information from a variety of sources
• Interview family members
• Remove all identifying information and present case summary
• Case Review Team members come from a broad range of specialties - health, welfare, education, and advocacy - that provide services and resources for women, infants, and families.

• What are the issues that may have contributed to this death?
• Did the family receive the services or community resources needed? If not, why not?
• Are there gaps in the service delivery system?
• Are there barriers to care?
• How can maternal and child health care policies be improved?

• Community Action Group reviews recommendations from Case Review Team
• What actions can we take to address the identified problems?

• Successful community actions lead to better outcomes
• For example, if many mothers who smoked had preterm labor, a successful public education campaign on the dangers of prenatal smoking would result in a smaller number of premature deliveries.

In addition to the local activities of FIMR, the project benefits from linkages to the other 11 FIMR projects throughout Florida. Monthly conference calls, yearly training conferences, and shared best practices among the projects strengthen the local effort and make possible the implement of the local FIMR project on a limited budget of $22,107 per year.

During 2003-04, the Healthy Start Coalition entered into a cooperative agreement with the Sarasota County Health Department to help staff the FIMR project, ensuring better staff retention and benefiting from years of expertise in the FIMR model. Case abstractions and data support are provided to the FIMR project by SCHD staff with related job responsibilities. The Case Review Team members are all volunteers, and the Community Action Group is drawn from the Healthy Start Coalition membership, who are also volunteers with commitment and expertise in the area of maternal and child health.

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Some findings of the FIMR Project for 2001-2003

Be Healthy Before Pregnancy

• Try to achieve your optimal weight
• Seek treatment for infections

The importance of maternal health prior to conception is becoming better understood. In the 74 cases reviewed, many of the mothers had health problems and untreated symptoms prior to this pregnancy which may have contributed to the poor outcome. Obesity was the single most prevalent factor present in the mother's health before this pregnancy. A history of sexually-transmitted diseases and other infections was also frequently identified.

Higher Levels Of Risk For Minority Populations

Historically, in Sarasota County, African-American infants have suffered a high rate of stillbirth, infant mortality, and low birth weight. The causes are complex. Recently, with the increase in the local Hispanic population, a trend toward higher rates of fetal and infant death among Hispanics has also been observed. Findings such as these help the Healthy Start Coalition and other service providers to allocate limited resources where the need is greatest.

Low Birth Rate at a Glance – Sarasota County Residents

In each year shown, white and Hispanic rates have been lower than the total, and black rates have been higher than the total. Because of the relatively small number of births to minority groups, the percentages can be noticeably affected by a few births. A total of 817 babies were born to black mothers from 2001-2003; and a total of 1,143 babies were born to Hispanic mothers during the same period.

Locally, A Strong System Of Support Leads To Better Outcomes

A look at 15 years of data from the point of view of Sarasota County, the state of Florida, and the United States, provides context for the data reported here. In general, Sarasota County has experienced outcomes more favorable than state or national totals. This is a reflection of the relative wealth of resources that support maternal and child health in our community. Some of the strengths of the local system of care identified through the FIMR case reviews include the range of specialty medical care available; the utilization of available services by women at risk for poor outcomes; the involvement of Healthy Start in many high-risk pregnancies; and the availability of bereavement services for families that do experience a loss.

Multiple Births – Are Twins At Greater Risk?

In 13.5% of the fetal and infant deaths reviewed 2001-03, the demise was that of a twin. This outcome can be compared to 2003 births, when 3.6% of all local live births were twins or other multiples. The importance of preconception education and counseling for couples considering infertility treatments is suggested by these findings.

The question arises whether use of infertility treatments increases the likelihood of multiple gestations, and resulting losses; and research studies attempt to answer this question. A recently completed review of all births in the state of Florida during 2000 and 2001 shows that 2.96% of all live births in 2000 were multiples; and 3.01% of all live births in 2001. The study drew the conclusion that, statewide, a recent slight increase in the infant mortality rate could not be attributed to multiple births (or to increased maternal age).

Pregnancy Is A Time Of Adjustment – Pay Attention To Stress

Not only mental illness, but major stresses, depression, and mental challenges affect women of childbearing age. "Pregnancy changes everything," and it can increase symptoms of mental illness or behavioral problems. Expectant mothers have questions about whether medications used to treat anxiety or depression are safe to use during pregnancy or breastfeeding. Healthy Start clients have access to psychosocial counseling, but many women experience high stress without enough help, because community resources for mental health services are limited.

The Healthy Start Coalition has a new focus on establishing systems of social support for expectant and new mothers within each neighborhood. We have held a successful weekly support group for pregnant women and new mothers in North Port with funding from the Gulf Coast Community Foundation of Venice in 2000-01 and 2003-04. Pregnancy outcomes from this group have been favorable and the members have received informal help from each other, strengthening their system of support.

Too Small And Too Soon – Half Of All Premature Births Can Be Prevented

Low birth weight and prematurity are two risk factors that can be significantly affected by lifestyle choices on the part of the expectant mother. Although all premature births are not preventable, at least half can be prevented. Women can benefit from available knowledge to lower risk before and during pregnancy. Maternal smoking, stress, violence, poor nutrition/general health, and lack of social support can all be changed, even in the presence of poverty. In 2002, only 6.7% of Sarasota County babies had low birth weight, but in 2003 the number rose to 8.2%. Babies born too small or too soon are more likely to have lifelong developmental and health problems.

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Responses to Findings

What have been our responses to these findings?

Higher levels of risk for minority populations

• Outreach with health fair activities and educational events in the African-American community.
• Enlisting partners to help educate women of childbearing age: Second Chance Last Opportunity, HIPPY, Hispanic-Latino Coalition Health Committee.
• Collaboration with SURE [Sarasota United for Responsibility and Equity] in the annual Mother's Day Virtual Prayer Vigil. An appeal is made from the pulpit for congregational prayer and church news bulletin inserts educate the members about issues in prenatal care and healthy birth outcomes.

Depression and mental health issues

• FIMR project findings have shaped local medical provider education: training on perinatal substance abuse interventions, Healthy Steps, post partum depression, and overcoming barriers to breastfeeding. In the year ahead, providers will receive free training on helping pregnant women and new mothers to stop smoking, with a grant from the March of Dimes.
• Counseling and support services for women with post partum mood disorders have been initiated in Sarasota, with a grant from the Community Foundation.
• A new Healthy Start interconception care curriculum may be provided to women who have experienced a stillbirth or infant death.

Risk of infection due to animal handling

• Development of special patient education flyer, "A Pregnant Woman's Guide to Animal-Borne Diseases" that provides information on risks from both microscopic organisms and pet care, as well as job-related animal handling.
• Veterinarians, prenatal care providers, and local employers have been provided with copies of the flyer. FIMR projects throughout the state have also received copies.

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Information on Animal-Borne Diseases

Click here to read our brochure on animal-borne diseases in English and Spanish. You will need Adobe Acrobat Reader to read it. Acrobat Reader is free; download it by clicking the button.

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2007-2008 FIMR Case Review Team

Patricia Blanco, MD, University Pediatrics

Virginia Brockman, RN, Sarasota County Health Department

Claire Burnette, RN, MA

Paul Dezzi, EMS Chief, Sarasota County Fire Department

Carola Fleener, MD, Sarasota Children's Clinic

Dorothy Flynn, Integrated Case Management, Sarasota Memorial Hospital, (Ret.)

Lynne Grief, Ph.D, RN, CEN, Director, Emergency Health Care, Sarasota Memorial Hospital

Debbie Harmon, RN, NICU, Sarasota Memorial Hospital

Rhonda Herdon, RD, LD, Nutrition Program Director, WIC

Jennifer Highland, Executive Director, Healthy Start of Sarasota

Washington Hill, MD, FACOG; Director, Maternal-Fetal Medicine, Sarasota Memorial Hospital

Pauline Hill, RN, BSN Sarasota Memorial Hospital

Barbara Little, RN, MPH, NCSN University of South Florida Sarasota-Manatee College of Nursing

Dr. Sandra MacLeod, Sarasota County Health Department

Diane Musgrave, RN Sarasota County Health Department

Marguerite Rappoport, MPH, Sarasota County Health Department

Shelley Rence, MA, Healthy Start Program Director, Sarasota County Health Department

Tracie Resch, RN, WATCH Nurse

Lisa Rivera, MSW Department of Children and Families

Jean Shoemaker, Safe Kids Coordinator, All Children's Hospital

Douglas Staley, Child Protection Center

Christopher Swain, MD, Sarasota County Health Department

Russell S. Vega, MD, ME, Chief Medical Examiner. District 12 of Florida

Ping Wiseman, RN III/CNS, Mother-Baby Unit, Sarasota Memorial Hospital

Ellen Zottoli, RNC, MS

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