2014 FIMR Program
Annual Deliberations Report
Capital Area Healthy Start Coalition
A statistical analysis, brief description, and potential conclusions regarding selected cases of fetal and
infant death in Jefferson, Leon, Madison, Taylor, and Wakulla Counties between January 1, 2014 December 31, 2014. These cases were reviewed between October 2014 - August, 2015.
It has been stated by Florida’s Surgeon General and Secretary of Health, Dr.
John Armstrong, that “Infant mortality and life expectancy are key measures
of population health.” Florida’s 2014 infant mortality rate continued to be
the lowest in state history, however infant mortality among minorities has
increased in our state and in Leon County. Recently released figures show
that death rates increased for Hispanics from 4.4 to 4.9 infant deaths per
1,000 live births and from 10.6 to 11 infant deaths per 1,000 live births for
blacks. These noted racial and ethnic disparities validate the efforts of the
Capital Area Healthy Start Coalition’s etal and nfant ortality eview
Project (FIMR). FIMR plays an integral role in helping to reduce fetal and
infant mortality through a multifaceted process that includes recognition of
issues and problems that often result in poor outcomes. Solutions and ways
to implement changes in the system providing services is key in the process.
FIMR’s community-based efforts examine significant social, economic,
cultural, and environmental barriers to prenatal care which directly affect fetal
and infant outcomes.
Case Review
Team
Fetal or Infant
Death
Data
Gathering
Interventions
Community
Action Team
Improved
Maternal and
Child Health
Outcomes
All available medical, hospital, public health, and case
management records are reviewed. Law enforcement and EMS records and
autopsy reports are also reviewed when pertinent.
A voluntary interview is conducted with mothers
who have suffered a loss.
The CRT is composed of varied healthcare
professionals and representatives who volunteer their time to meet and review
the details of selected fetal or infant death cases. The CRT meets the first
Thursday of each month, except in July. In September, the FIMR Program’s
“Infant
mortality and
life expectancy
are key
measures of
population
health.”
Dr. John Armstrong
Florida’s Surgeon
General and Secretary
of Health
Annual Deliberations Report is presented at a meeting where a summary of the previous year’s CRT case
findings is reviewed for Leon and surrounding counties. Similar statewide statistics are also evaluated
along with contributing factors, recommendations for improvement, and current community initiatives.
At each meeting, three cases are deliberated, focusing on the following:
● What were each mother’s needs, (medical, social, cultural, economic and emotional)?
● Which of their needs were met?
● Which of their needs were not met and why?
● Were clients referred to available community resources and services?
● Were they referred and did not access services?
● Were resources and services needed, but not available?
● What could have been done differently to help these mothers?
Issues and problems that ultimately may have contributed to poor fetal or infant outcomes are identified
through this process. Recognition of barriers influencing access to community resources and services
that influence outcomes is key. Community, provider, and patient education is imperative as well. The
CRT makes suggestions for future initiatives, which are then forwarded to the Community Action Team.
Community initiatives, once implemented, help to ensure improved maternal and child health outcomes.
October 2014 - August 2015
Basinet Data
FIMR by Maternal Race
Cases Reviewed = 30
Other
Black
White
0
1
2
Fetal
3
4
5
6
7
Infant
8
9
10
No Information
As mentioned previously, infant mortality rates among minorities increased this year in our state and in
Leon County. These concerning racial disparities were evident in the cases reviewed by our FIMR Case
Review Team.
FIMR by Maternal Age
Cases Reviewed = 30
< 19 Years
20 - 24 Years
25 - 29 Years
30 - 34 Years
35 - 39 Years
40 + Years
0
1
Fetal
2
3
Infant
4
5
FIMR by Maternal Education
Cases Reviewed = 30
No HS Diploma
HS Diploma / GED
College - No Degree
Fetal
Associate's Degree
Bachelor's Degree
Master's Degree
Infant
Ph.D
No Information
0
1
2
3
4
FIMR by Entry Into Prenatal Care
Cases Reviewed = 30
Unknown
1st Trimester
Fetal
2nd Trimester
Infant
3rd Trimester
0
2
4
6
8
10
12
Interesting to note, the majority of the mothers who experienced a fetal or infant loss began their prenatal
care in the first trimester. It is encouraging that the majority of mothers were able to access care early in
their pregnancies. This is especially important since many of the mothers had preexisting health
problems with the potential to complicate their pregnancies.
FIMR by Maternal Weight / BMI
Cases Reviewed = 30
Unknown Weight
Underweight
Fetal
Normal
Overweight
Infant
Obese
0
1
2
3
4
5
6
7
In the U.S., more than one-half of pregnant women are overweight or obese. These women are at
increased risk of several pregnancy problems including gestational diabetes, hypertension, preeclampsia,
and cesarean delivery. In addition, their babies are at increased risk of prematurity, stillbirth, congenital
anomalies, macrosomia with possible birth injury, and child obesity. Obese women are less likely also to
initiate and sustain breastfeeding. (Obesity in Pregnancy, Committee Opinion, ACOG, 2013). In 2014,
the FIMR cases reviewed reflected this concerning and prevalent reality as well.
Florida Charts 2014
2014 Deaths per 1,000 Live Births
Florida
30
Leon County
20
Jefferson County
Madison County
10
Taylor County
0
Fetal Black
Fetal White
Infant Black
Infant White
Wakulla County
Births to Mothers Without High School Education
Florida
30
Leon County
20
Jefferson County
Madison County
10
Taylor County
0
2010
2011
2012
2013
2014
Wakulla County
In 2014, 13.2% of mothers that gave birth in Florida had no high school education. In Leon and
Wakulla counties the percentages were 9.2% and 9.6%, respectively. In rural surrounding counties, the
percentages were higher: 19.7% in Jefferson, 19.4% in Madison and 17.1% in Taylor County.
Births to Mothers With 1st Trimester Prenatal Care
Florida
100
Leon County
90
Jefferson County
80
Madison County
70
60
Taylor County
2010
2011
2012
2013
2014
Wakulla County
An encouraging 79.4% of mothers in Florida received care within the first trimester of pregnancy in
2014. In Leon County, 79.7% of mothers accessed care in the first trimester. In Jefferson and Madison
Counties, the percentages were similar at 74.7% and 71.4%, respectively. 76.2% of mothers received
care in the first trimester in Taylor County and 82.8% in Wakulla County.
Births to Mothers With 3rd Trimester or No Prenatal Care
Florida
10
8
Leon County
6
Jefferson County
4
Madison County
2
Taylor County
0
2010
2011
2012
2013
2014
Wakulla County
In 2014, 5.3% of mothers in the state of Florida initially accessed prenatal care in the 3rd trimester or
received no prenatal care. Leon County’s percentage was similar at 5.5%. In Jefferson and Madison
Counties, the percentages were higher at 9.1% and 10%, respectively. Taylor County had the lowest
percentage at 4.9%, and in Wakulla County 6.6% of mothers initially accessed prenatal care in the 3rd
trimester or received no prenatal care at all.
Births to Overweight Mothers At Time Pregnancy Occurred
Florida
40
Leon County
30
Jefferson County
20
Madison County
10
0
Taylor County
2010
2011
2012
2013
2014
Wakulla County
24.1% of births in Florida in 2014 occurred to overweight mothers. In Leon County 5.1%, 7.1% in
Jefferson County, and 6.3% in Madison County of births were to overweight mothers. Taylor County
had 9.2% and Wakulla County had the lowest percentage of overweight mothers at 3.6%.
Births to Obese Mothers At Time Pregnancy Occurred
Florida
40
Leon County
30
Jefferson County
20
Madison County
10
0
Taylor County
2010
2011
2012
2013
2014
Wakulla County
In 2014, 21.5% of births in Florida occurred to obese mothers. Leon and Wakulla counties saw similar
percentages at 5.2% and 5.1% respectively. Jefferson County had 8.7% and Madison County had 8.4%.
Taylor County saw the highest percentage in our area at 11.1%.
Births Covered By Medicaid
80
Florida
70
Leon County
60
Jefferson County
50
Madison County
40
Taylor County
30
2010
2011
2012
2013
2014
Wakulla County
In 2014, 49.8% of mothers in Florida had births that were covered by Medicaid. Leon County had
48.2% and Wakulla County had 46%. In Jefferson, Madison and Taylor Counties, the percentages were
higher: 66.9% in Jefferson, 75.4% in Madison and 70% in Taylor County.
Sleep Related Deaths
Category
Total
Number
Total Sleeping Infant Deaths
4
Site of Death:
Infant’s Home
Sleeping situation:
With Others
Sleeping Location:
Adult Bed
Mattress on Floor
Sleeping Position When Found:
Abdomen
Back
No Information
Bedding at Time of Death:
Soft
No Information
Items in Bed at Time of Death:
Unsafe Items in Sleeping Area
Bottle in Sleeping Area
Feeding Type:
Breast
Bottle
No Information
4
Symptoms Within Two Weeks of Death:
None
Second Hand Smoke:
None
No Information
4
4
2
2
1
1
2
2
2
4
1
2
1
1
1
3
Number
Primary Cause of Death
Other
7
Prematurity
5
Placental Abruption
3
SUDI (Sudden, Unexpected Death in Infancy)
2
Preeclampsia
2
Cord Accident (Torsion, Compression, Nucal, etc.)
1
Trisomy 13
1
PROM
1
Preterm Labor and Preterm Delivery
1
Incomplete Cervix
1
Neural Tube Defect
1
IUFD (Intrauterine Fetal Demise)
1
PPROM
1
Placental Insufficiency
1
Parvovirus
1
Unknown
1
All Causes of Death
Number
Other
7
SUDI
2
Prematurity
2
Other/Placental Abruption
2
Placental Abruption
1
Cord Accident
1
Trisomy 13
1
Chorioamnionitis /PROM
1
Preterm Labor and Preterm Delivery
1
Incomplete Cervix
1
Other / Preeclampsia
1
Neural Tube Defect
1
IUFD
1
Other (PPROM / Preterm Labor / Preterm Delivery)
1
IVH Other / Placental Abruption / Prematurity / Preterm Labor / Preterm
Delivery)
Other / Prematurity
1
Cardiomyopathy / Maternal Disease (Renal Failure, Diabetes)
1
Preeclampsia
1
Placental Insufficiency
1
Parvovirus
1
Unknown
1
1
:
There were a variety of contributing factors in the cases reviewed. A majority of mothers had
preexisting conditions including hypertension, diabetes and mental health disorders. Obesity was
another prevalent risk factor. Complicating pregnancies also was a history of previous preterm labor and
STDs. A number of mothers experienced complications without a history of previous issues including
gestational diabetes, maternal infection, preeclampsia, preterm labor, premature rupture of membranes,
placental abruption and incompetent cervix.
Several provider issues possibly influencing outcomes included:
● Incomplete documentation of social/economic status in prenatal records, which may have
prevented social service referrals.
● Healthy Start screenings were either not offered or declined by patients, with no explanation as to
why.
● Community services were not accessed which might have been beneficial for some of the mothers
and their families.
Raising awareness about fetal and infant mortality is key in decreasing its prevalence.
Outreach efforts to the community and provider offices to promote Healthy Start services can only help
to ensure better outcomes for all mothers and babies.
A preconception assessment, counseling, and appropriate interventions
were recommended in the majority of FIMR cases reviewed this past year. Preconception health
encourages people to get and stay healthy, to take control of their lives, and to choose healthy habits. It
is a gift to babies, enhancing their best chance for a healthy start in life. Interesting to note, half of all
pregnancies are unplanned in the US, despite the availability of reliable forms of birth control.
Preconception health can make a difference in outcomes if a woman unexpectantly finds herself
pregnant.
In the US, where more than one third of women are obese, preconception assessment and counseling
is imperative and should include information concerning the maternal and fetal risks of obesity in
pregnancy. Women should be encouraged to undertake safe weight reduction programs. Referrals to
the TMH Bariatric Center is an option for women in Leon and surrounding counties.
Nutrition
consultations should be offered and exercise encouraged.
Follow up care (2-6 months after fetal or infant loss) would be ideal to assess
how mothers and their families are coping with their loss. It is encouraging that many mothers had
follow up appointments with their providers 2-6 weeks after delivery. Usually, however, there was no
mention of the mother’s mental/emotional status in postpartum provider office notes. Depression
screens should be done so appropriate referrals can be made for counseling and/or medication therapy.
Some of the mothers declined birth control, wanting to get pregnant again soon after their loss. Also
interesting, the majority of mothers continued to be nonresponsive to requests by Healthy Start’s FIMR
Program for an interview to discuss their experience/perceptions regarding their loss.
Even though 2014’s infant mortality rate indicates a decrease for the State of Florida, the rate increases for Hispanics and Blacks points to a need for continued social and cultural intervention. The aggregate deliberation summary details that 79% of the cases had family support (including
the father of the child), 24% in stable marriages and 34% with supportive friends. Raising awareness of
the importance of social accountability may turn the tide in areas such as access to community services,
compliance with plan of care, child safety education and grief support.
It is estimated that 10 to 15 percent of women experience depression while pregnant. Fear, anxiety, sadness, obsessive, compulsive behavior, and possibly suicidal
thoughts can occur. Mental illness during pregnancy often goes untreated due to social stigmas. This
can be detrimental for both mother and baby. If a mother is depressed prenatally, she is more likely to
have postpartum depression as well. Mothers need to feel that they are not alone, and that help is available. The CAHSC has taken an interest promoting mental health in pregnancy. On June 16, at its annual meeting, a community discussion on perinatal depression was held. Dr. Heather Flynn, a clinical
psychologist and associate professor at FSU, and Sandy Glazer, LCSW, led a conversation on the maternal health needs in our community and how Healthy Start is helping to bridge the gap. Acceptance, referrals, and tools to help mothers struggling with stress and depression are interventions provided by
Healthy Start services.
This program assists pregnant women who have been approved for Medicaid in selecting a prenatal health care provider. Information about enrolling in WIC, Healthy Start, and other needed services is also provided.
(Sisters who Trust, Respect and take every Opportunity to be Nice,
Graceful, Encouraging, and Responsible): This program was offered to elementary and middle school
girls in 2014, encouraging girls to take a more active interest in their health. The girls learned about
nutrition, personal hygiene, exercise, health, and wellness through a variety of interesting hands-on
activities, discussions, and field trips. Increasing self-esteem and promoting positive character are also
goals of this program.
Preconception health programs are key in reducing the fetal and
infant mortality rate in Leon and surrounding counties. Classes were held throughout Leon County, to
different age groups, discussing the importance of preconception health, with a focus on women of
childbearing age. Preconception health is important for all women and their families, and not just those
planning pregnancy. It encourages women to take control of their lives and encourages healthy habits.
Maintaining a healthy weight by eating a well balanced diet, exercising, promoting dental health,
practicing safe sex and abstinence, and mental health issues are included topics discussed at classes.
Participants are also given reproductive life plans to complete during the Preconception Health classes
Thank you to CRT Members
Amelia Morse
Angela Gifford
Ashlee Morgan
Barbara Cottrell
Brenda Yosikawa
Cedrika Prewitt
Chelsea Pender
Chris Rivers
Christy Baldwon
Connie Styons
Courtney Atkins
Cumi Allen
Cynthia Schwartz
Debbie Pedersen
Denee Glen
Donna Florence
Donna Hagan
Dr. Clarence Jackson
Dr. Edward Holifield
Dr. Esais Lee
Emily Fritz
Erin Ryals
Faith Walker
Fran Close
Heather Barrow
Heather Jordan
Jane McPherson
Jeanna Olsen
Jeff Ahsinger
Jennifer Brown
Jennifer Johnson
Jennifer Tuten
Joedrecka Brown, MD
Judy St. Petery, MD
Kelsi Williams
Kim Johnson
Kristen Nelson Sella
Kristie Lutz
Kristy Lee Goldwire
Kyra Adams
Laura McGorty
Layla M. Swisher
Lee Brannon
Libbie Stroud
Linda Frimmel
Lisa Flannagan, MD
Louise Hudson
Lynn Forrester Smith
Marcia Thomas-Simmons
Marion Rollins
Mary Brock
Mary Shannahan
Mary Westbrook
Melissa Nelms
Meardith Pooler
Miriam Gurniak
Monica McDonald
Pam Banks
Pam Mezzina
Phyllis Conlin
Quartil Robinson
Rhonda Brown
Robin Glady
RoseAnn Scheck
Sandra Glazer
Shanetha (Nita) Mitchell
Susan Hayes
Susie Gilson
Tangela Knight
Tanya Price
Terry Stevens
Tiffany Jones
Tom Truman, MD
Tonya Bell
Tracy Coomer
Vivienne Treharne
Thank you to Our Community Action Team
Adkins, Courtney
Deeb, Jo
Glazer, Sandy
Goldwire, Kristy
McCall, Carmita
Monroe, Anya
Annette Phelps
Scheck, RoseAnn
Schwartz, Cynthia
Smith, Nancy
Styons, Connie
Treharne, Vivienne
Notes
Notes
Capital Area Healthy Start Coalition
1311 N. Paul Russell Rd., Ste. A-101
Tallahassee, FL 32301
850.488.0288
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Board of Directors and Officers
Ex Officio Board Members
Jerri L. Hanna, President
Claudia Blackburn, Health Dept. at Leon County
Steve Slepin, President Elect
Padraic Juarez, Health Dept. at Wakulla County
Patty Kitchen, Secretary
Lane Williams, Treasurer
Staff
Mildred Brickler
Kristy Lee Goldwire, Executive Director
Robin Glady, RN
Sandy Glazer, QA/QI Director
Dr. Samantha Goldfarb
Bill Cutchin, Director of Operations
Dr. Torhonda Lee
Monica McDonald, Community Liaison
Glenn Robertson
Tracy Coomer, MomCare Coordinator
Shacafrica Simmons
Kerry-Ann Rapheal, FIMR Program Coordinator
Vivienne Treharne
Debbie Pedersen, FIMR volunteer
Denee Glenn, Community Health Educator