INDIAN RIVER COUNTY FETAL INFANT MORTALITY REVIEW 2019-2021 (FIMR) REPORT 2023
Page 2 January 1, 2023 Community Members, Indian River County Healthy Start Coalition’s top priority is to ensure that no family needlessly suffers the loss of a baby. Our continuous journey to stop these tragedies led IRC Healthy Start to take on the challenge of a Fetal and Infant Mortality Review (FIMR) Project. The findings of the FIMR directly inform the development of initiatives and programs to prevent these needless deaths. This project is a huge undertaking made possible by one generous funder: The Indian River County Hospital District and a committee of dedicated community members who met continuously through the perils of a pandemic to help our most vulnerable citizens. At the conclusion of our first FIMR the Community Action Team (CAT) identified three priority areas: preconception health, awareness, and education on issues affecting newborns and new moms, and enhanced care for women with high-risk pregnancies. Healthy Start along with CAT members developed an action plan for each area identified. Together with our community partners, all action plans were completed. This includes community improvements such as the incorporation of no-cost community preconception health classes, completion of the “No One Told Me That“ Campaign, and connecting pregnant and postpartum women who are misusing opioids with Medication Assisted Treatment (MAT), and improved access to specialist Maternal Fetal Medicine (MFM) and neonatology for high-risk cases by bringing a MFM to our area to serve. “ This pregnancy was one of the happiest times of my life I wanted to be pregnant sooner I felt overwhelmed and very sad often. ” Quotes from mothers who have experienced loss ACCOMPLISHED: • “No One Told Me That” Campaign • Medically Assisted Treatment (MAT) for substance misuse in pregnant women • Maternal-Fetal Medicine (MFM) added to local care providers
Page 3 0 20 40 60 80 100 40% 10% 20% 30% Socioeconomic Factors Physical Environment Health Behaviors Health Care Education Job Status Family Social Support Community Safety Income 50% can be traced back to zip code Tobacco Use Diet & Exercise Alcohol Use Sexual Activity Only 20% include those moments in a healthcare environment. Quality of Care Access to Care Source: Institute for Clinical Systems Improvement, Going Beyond Clinical Walls: Solving Complex Problems (October 2014) The current FIMR Team reviewed 19 cases of the 43 fetal and infant deaths reported for the years 2019-2021. Cases were selected that have the most comprehensive records available. The onset of the COVID-19 pandemic brought a disruption of patterns of health care but also of economic and community supports. Healthy Start continued overseeing and delivering our services, constantly closely monitoring outcomes. As the team moved into 2021 a significant rise in infant deaths was identified. The team agreed to begin to review all 2021 cases in order to understand what caused this rise. After review the FIMR Team (CRT) identified these trends in 2021: 1. Changes in Data Definition and Collection 2. Reduced Participation in Women Infant and Children (WIC) 3. COVID- 19 and Related Barriers Other issue highlighted by the 2019-2021 FIMR Case Review Team were: 4. Communication and Care with Medical Teams 5. Disparities within Race and Ethnicity 6. Higher rates of Infant and Fetal mortality within some Geographic Areas I am proud of this work and I hope you will join me to ensure every baby gets a Healthy Start. Andrea Berry, MNM
Page 4 GOAL The goal of the FIMR project is to identify opportunities and promote systemic change that results in the reduction of fetal and infant mortality. OBJECTIVES: • Examine the significant health, safety, cultural, social, and economic system factors associated with fetal and infant mortality through a review of individual cases. • Plan a series of interventions and policies that address these factors to improve the service systems and community resources. • Participate in the implementation of communitybased interventions. • Assess the progress of interventions. • Provide bereavement support information to parents and families who have experienced a pregnancy loss or death of an infant. WHAT IS A FETAL AND INFANT MORTALITY REVIEW (FIMR)? FIMR is a national model that was first introduced in 1990 as a collaborative effort between the American College of Obstetricians and Gynecologists (ACOG) and the Federal Maternal and Child Health Bureau (MCHB). Florida adopted the FIMR model in 1992. Florida FIMR projects are organized under Florida Statutes 766.101. Confidentiality of all information is strictly maintained. All cases brought before the review team are de-identified of the patient, provider, and institutional information. FIMR brings together key members of the community to examine information from individual cases of fetal and infant death to identify the factors that contributed to those deaths, determine if those factors represent system problems that require change, develop recommendations for change, assist in the implementation of change, and determine community effects. The goal of FIMR is to empower the community with information and improve systems. There are currently over 200 FIMR projects in the country. INDIAN RIVER COUNTY FIMR PROCESS Source: FIMR Overview, Publication of the National Fetal and Infant Mortality Review Program, ACOG, 2014. THE FIMR MODEL 2019-2021 COMMUNITY DATA INDIAN RIVER COUNTY BIRTHS 2019-2021 In 2020, Indian River County births dropped below 1200 for the first time since 2003. However, the birth count normalized in 2021, 2022. From 2019 through 2021 there were a total of 3,696 births to Indian River County residents. CYCLE OF IMPROVED HEALTH ACTION COMMUNITY COMMUNITY COMMUNITY SYSTEMS COMMUNITY SYSTEMS CH A N G ES IN CH A N G ES IN RE VIEW RE VIEW C A S E GATHERING DATA
Page 5 COMMUNITY DATA: INDIAN RIVER COUNTY INFANT MORTALITY AND FETAL DEMISE DATA 2019-2021 Between 2019 and 2021, there were 43 infant and fetal deaths in Indian River County (26 infant and 17 fetal death). This is an infant death rate of 7 per 1,000 live births, this is above the state rate of 6 per 1000 live births and an increased from 2014-2018. The fetal death rate is 4.57 per 1000 per live births, this is below the state’s rate of 6.94 per 1000 per live births. INDIAN RIVER COUNTY INFANT AND FETAL DEATH 2019-2021 4 4 15 5 8 7 Infant Death Fetal Death 2019 2020 2021 (PROVISIONAL) Indian River County Infant and Fetal Death Rate, 2019-2021 Source: FLHealthCHARTS, Florida Department of Health, Bureau of Vital Statistics, 2019-2021 The top medical causation identified for infant deaths that occurred in 2019-2021 are as follows: • Prematurity Low or Very Low Birth Weight 35% (9 deaths) • Sleep related (Suffocation or SIDS) 24% (6 deaths) Full list of causation of infant death in appendix This is in contrast to 2014-2018 when the top causations were congenital anomalies and premature low or very low birth weight. “Premature rupture of membranes” had a large impact on the rise in prematurity in 2021. In 2019 and 2020 there were 0 notated but in 2021 there were 3. The top medical causation identified for fetal deaths that occurred in 2019-2021 are as follows: • Fetus affected by complications of placenta, cord and membranes 29% (5 deaths) • Fetus affected by maternal complications of pregnancy 18% (3 deaths) Full list of causation of fetal death in appendix
Page 6 History • Indian River County Healthy Start Coalition’s FIMR began in 2019 and assessed 18 cases in which the deaths occurred from 2014-2018. The key findings of the 2019 FIMR report highlighted factors that contributed to the fetal and infant deaths in our county. The report highlighted the Social Determinants of Health (SDOH), the need for preconception health education, and acknowledged clear racial disparities related to infant and fetal death that were key to making meaningful progress on this issue. The FIMR work did not stop after the report was released in January of 2020. On the contrary, the committee continued to meet throughout the pandemic. Additionally, IRC Healthy Start staff continuously monitored and collected data on fetal and infant deaths. • In late 2020, the team noticed a significant rise in fetal deaths from 4 in 2019 (3.2 per 1000 live births) to 8 in 2020 (6.7 per 1000 live births). With the rise of COVID-19 and its impact on the Social Determinants of Health, the team considered what was to come in the following years. Unfortunately, Indian River County saw a large rise in infant deaths in 2021 from 4 in 2020 (3.4 per 1000) to 15 in 2021 (12.07 per 1000). The team immediately started to review these cases to identify causation and create systemic changes. INDIAN RIVER COUNTY FIMR PROCESS When evaluating cases reviewed in the FIMR for substantial changes, a significant rise was noted in 2021 in Fetus affected by maternal complications of pregnancy (0 in 2019, 0 in 2020, and 3 in 2021). As the Case Review Team (CRT) reviewed data of the births, fetal deaths and infant deaths that occurred in 2021, a few items stood out. • Changes in Data Definition and Collection • Reduced Participation Women Infant and Children (WIC) • COVID- 19 and Related Barriers 2021 CHANGES IN DATA DEFINITION AND COLLECTION As the FIMR team began to closely examine the 2021 infant deaths, they noted the inclusion of a number of cases that differed from those previously reviewed. The weight and gestational age of some of the cases differed from cases reviewed in the past. In 8 of the cases of infant death, the “infant” weighed less than 500 grams (1 lb.). Additionally, there were 7 cases whose estimated gestational age was less than 22 weeks. This shows categorizations were inconsistent with historical case classifications. By Florida Statute definition, a Live birth” occurs with the complete expulsion or extraction of a product of human conception from its mother, irrespective of the duration of pregnancy, which, after such expulsion, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, and definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. (see definitions). According to the medical experts on the Community Action Team (CAT) the interpretation of reflex signs of life, and therefore determination of a “live birth” can be subjective and may differ from provider to provider. Variability interpretation of fetal signs of life in the hospital setting was felt by the CAT to have accounted for variability in categorization in these difficult second trimester losses, resulting in unusual reporting. IMPORTANT DEFINITIONS The IRC’s FIMR uses the State of Florida’s definition solidified in statute 382.002 and 382.2162 (17) “Stillbirth” means an unintended, intrauterine fetal death after a gestational age of not less than 20 completed weeks. (8) “Fetal death” means death prior to the complete expulsion or extraction of a product of human conception from its mother if the 20th week of gestation has been reached and the death is indicated by the fact that after such expulsion or extraction the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. (12) “Live birth” means the complete expulsion or extraction of a product of human conception from its mother, irrespective of the duration of pregnancy, which, after such expulsion, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, and definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. (d) “Infant mortality” means the death of a live-born infant within 364 days after the infant’s birth.
Page 7 This finding was immediately addressed with Cleveland Clinic Indian River Hospital, Indian River’s only birthing hospital. The hospital recognized and acknowledge the provider driven change in cationization. State defined definitions were reviewed by all providers. Clerical staff responsible for birth and death certificates have completed formal training and certification. INDIAN RIVER COUNTY INFANT AND FETAL DEATH 2019-2021 4 4 8 5 8 7 Infant Death Fetal Death 2019 2020 2021 (PROVISIONAL) Indian River County Infant and Fetal Death Rate, 2019-2021 if all deaths lower than 22 weeks and 500 grams Source: Indian River County Healthy Start Coalition Leadership and FIMR Team Each of these losses, regardless of weight and gestational age, is a tragic event for the families. The team reviewed each of these deaths to ensure all causations would be addressed. However, it is important to note that the reason for the large rise in infant death in 2021 is primarily due to differences in data collection. Prior to 2021, many of these infant deaths would have been categorized as miscarriages or fetal deaths. REDUCED PARTICIPATION IN WOMEN INFANT AND CHILDREN (WIC) WIC is a federal program that “aims to safeguard the health of lowincome women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. WIC Serves Pregnant women, Breastfeeding women, Non-breastfeeding postpartum women, Infants, Toddlers and Children up to age 5” (https://www.fns.usda.gov/). Due to the COVID-19 pandemic safety protocols, the Indian River WIC offices (along with offices nationwide), closed to nonscheduled public visits. However, the offices remained open for scheduled visits. In doing so, this created a barrier to accessing and obtaining essential WIC services. In 2021, IRC families participating in WIC services decreased from 36.3% in 2020, to 25.7% in 2021. Statewide, WIC participation was 39.6% of all births in 2020, decreasing to 35.3% of all births in 2021. Indian River County utilization of WIC services was a bit lower than seen statewide. The state experienced a 4% reduction of participation. However, Indian River County experienced an 11% reduction. Because WIC participation is known to decrease fetal and infant mortality, barriers to receiving the essential services WIC provides is a potential area of interest as we evaluate the drivers of the 2021 infant mortality in IRC.1 WIC offices are now back to normal operations. Healthy Start continues to collaborate to ensure increased use of these services. COVID- 19 AND RELATED BARRIERS COVID-19 began to greatly alter life in early 2020. The 2019-2021 FIMR Team discussed the impact of the viral infection and our response to the pandemic on pregnant women. The WIC office being closed to the public was not the only limitation pregnant families experienced. There were many barriers created by well-intentioned safety measures. For example, all Healthy Start classes, services and home visitations programs became telephonic or virtual. Many other community services and social supports were limited as family and friends avoided contact for fear of the virus. Lack of access to these services and supports may have impacted Indian River County’s rise in infant deaths. The COVID-19 viral infection has been found to be associated with placental issues. Of the fourteen (14) cases of fetal and infant deaths that occurred after the pandemic took hold three (3) cases reviewed reported a COVID-19 infection during pregnancy. The virus was not determined to be contributory to these deaths. However, in one of those cases barriers to care were notated. The demise of a 35-week-old fetus. The mother was “a 31-year-old asymptomatic, healthy, white, nulliparous woman” who was in week 32 of her pregnancy. Of note, this patient is an essential healthcare worker. The patient was not evaluated during her illness and experienced a 27-day gap in prenatal care due to “ill-advised hospital-specific clinical policies limiting care of pregnant women until complete resolution of symptoms and evidence of negative RT-PCR COVID-19 testing”. The indirect detrimental impact of COVID-19 was substantial, creating large variations in prenatal care, labor, delivery, and breastfeeding protocols. This variability created uncertainty and inconsistent care practices among providers. For pregnant patients in 2020 and 2021, there was a lack of evidence upon which to base many policies. In addition to varied care practices, three other trends emerged that impacted birth outcomes: a decrease in prenatal visits for mothers during this period, strained resources, and insufficient healthcare infrastructure. When reviewing Indian River County birth data, the FIMR team noted that adequate Prenatal Care dropped two years in a row 4% (from 78.7% to 74.4%).
Page 8 INDIAN RIVER COUNTY FIMR PROCESS Data Gathering Information was gathered from multiple available sources, including vital statistics, medical records (e.g., hospital and prenatal records), autopsy reports, social services and law enforcement case notes, and maternal interviews. Eighteen cases were abstracted, de-identified, and reviewed. These cases were selected as they were the most instructive and detailed cases available. Through the data gathering process, inconsistent, unclear, or missing data in records across different organizations and departments was noted in six cases. A Two-Tiered Process for Review and Action: Case Review Team and Community Action Team Two multidisciplinary groups completed the FIMR process, including clinicians and non-clinicians. These professionals represent the local health department, social service agencies, family planning services providers, drug treatment centers, hospitals, and law enforcement agencies. IRCHSC ensured that physicians experienced with OB/GYN, pediatric, and neonatology care participated as members of the CRT. Case Review Team (CRT) The CRT carried a robust 31 members. The information derived from the CRT reviews was then used to identify fetal and infant death trends, as well as key factors in the deaths, and serves as a tool that helps the community implement changes to prevent future losses. HIGHLIGHT ON ISSUES EFFECTING MATERNAL AND CHILD HEALTH IN INDIAN RIVER COUNTY The 2019-2021 FIMR team noted three themes throughout cases reviewed. Healthy Start is already addressing these issues and an action plan will be developed as the Community Action Team begins. COMMUNICATION AND CARE WITH MEDICAL TEAM Within the 2019-2021 FIMR cases reviewed, there were several signs that families are not being heard. “Standard of care was not met” was notated as present on three of the cases and a quote from a mother who endured a loss stated, “I did not feel heard and my concerns were not addressed.” Strong patient-provider relationships have shown to improve pre-natal, labor and delivery, and post-partum health outcomes for the mother and the baby.2 The ideal components of this relationship include effective communication and collaborative decision-making. This decreases stress, uncertainty, and provides women a sense of control and empowerment. Healthy Start, along with Cleveland Clinic Indian River Hospital is working to improve communication. The Centers for Disease Control’s Hear Her campaign will be started in 2023. RACE AND ETHNICITY The racial disparities in health are reflected in the Indian River County infant mortality rate. During the three year FIMR time frame, there were a total of 26 infant deaths. Eleven (11) Black Non-Hispanic, Nine (9) White Non-Hispanic infants, Three (3) Hispanic infants, Two (2) Haitian, one (1) other. Black women represented 14% of our moms who gave birth during 2019- 21, yet accounted for 42% of the infant deaths. Black Non-Hispanic infants and Black Haitian infants had the highest infant mortality rate (21.69 per 1,000 and 27.02 per 1000 live births), which is more than double the rate for White Non-Hispanic infants (4.15 per 1,000 per live births)
Page 9 The data in Indian River County mirrors that seen nationwide. Black mothers and babies suffer a higher rate of morbidity and mortality. Nationally, the Centers for Disease Control and Prevention (2020), state that the risk for Black Non-Hispanic women is more than double that of White Non-Hispanic women. Research shows this may be due, in part, to conventional risk factors for infant mortality such as mother’s socioeconomic status, her consumption of nutritious foods, and access to health care services, but in fact, the disparities are reflective of broader inequities. Research shows that Black mothers are more likely to be susceptible to “weathering” or the premature aging of one’s body due to social stresses. Related, the exposure to discrimination and racialized stress throughout the lifespan can negatively impact birth outcomes. Indian River County Births 2019-2021by Race and Ethnicity Race and Ethnicity 2019 2020 2021 (provisional) White non-Hispanic 2 2 5 Black non-Hispanic 4 1 5 White Hispanic 3 other Haitian 1 2 other 1 unknown Total 7 4 15 Race and Ethnicity Infant Deaths Birth Infant Mortality Rate per 1000 live births % of death % of birth White non-Hispanic 9 2164 4.15896488 35% 59% Black non-Hispanic 11 507 21.69625247 42% 14% White Hispanic 3 795 3.773584906 12% 22% Black Haitian 2 74 27.02702703 8% 2% other 1 152 6.578947368 4% 4% unknown 4 0 0% 0% Combine 26 3696 7.034632035 100% 100% GEOGRAPHIC AREA The neighborhood you live in is one of the most insightful predictors of one’s health outcomes than anything else including health care. Identifying the geographic areas where infant mortality is most prevalent provides opportunities to understand more about residents living in those communities, challenges they face, and even issues they may have with access to services and supports. Comprehensive geographic area data is not available until 2021 data is verified through the Florida Vital Statistics. However, inferences can be made based on past data. “Indian River County has considerable disparities in wealth. These disparities in wealth can mirror the disparities in health. As seen in past data areas that have the lowest income levels tend to have the highest rates of poor birth outcomes. PUBLICLY SUPPORTED PRENATAL CARE AND SERVICES The Indian River Hospital District financially supports the many services to support perinatal families. Two examples of that are Partners in Women’s Health obstetric care clinic now operated by Cleveland Clinic Indian River Hospital. Each year the trustees review outcomes related the practice to monitor birth outcomes and patient satisfaction. As a part of the data collection, the FIMR reports the number of clients who received prenatal care or services through this publicly supported practice that suffered a loss in 2021. IRC Hosptial District Services Funded 2021 (total 15 infant or fetal) Partners in Women’s Health 7 received prenatal care Healthy Start Services 11 of the 15 were connected with Coordinated Intake and Referral. Of those, three accepted services and were enrolled in a home visitation program.
INDIAN RIVER COUNTY FIMR PROCESS The role of the CRT is to: • Review the infant case summaries including demographic, social, medical, and other data collected by the nurse abstractor and summarized by the project coordinator. • Present relevant questions and participate in discussion. • Identify factors present or contributing to each infant death through standardized forms addressing multiple maternal and fetal factors that may have contributed to poor outcomes. • Provide specific recommendations for systems changes. Community Action Team (CAT) The CAT was comprised of 28 professionals, philanthropists, and community members. The CAT used the findings and recommendations of the CRT to develop a strategic approach, including specific actions steps that, once implemented, aims to decrease infant mortality and improve pregnancy outcomes. The CAT met during October 2020. The role of the CAT is to: • Take the recommendations made by the CRT and develop new and creative solutions to improve services and resources for families • Enhance the credibility and visibility of issues related to women, infants, and families by informing the community about critical needs and effective interventions • Work with the community to implement interventions to improve services and resources available to families • Determine if the needs of the community are changing over time by continuous review of infant deaths, and program outcomes • Safeguard successful systems changes initiated by FIMR COMMUNITY ACTION TEAM The information derived from the CRT’s review of cases was aggregated and provided to the Community Action Team (CAT). Using this information, the CAT then identified priorities and opportunities for positively impacting birth outcomes for babies born in Indian River County. In 2020 Indian River County Fetal Infant Mortality Review’s Community Action Team prioritized: 1. Preconception health 2. Awareness and education on issues affecting newborns and new moms 3. Enhanced care for women with high-risk pregnancies The CAT met throughout October 2020, to determine possible strategies and activities for each priority area. The CAT excluded resources that are currently in place; however, the teams discussed enhancements to current programs or enhanced awareness of supports when appropriate. Since that time all items have been completed. COMMUNITY ACTION UPDATES PRECONCEPTION HEALTH In 2020, funds were raised to research and implement a preconception health program. The focus at that time was to partner with the IRC school district to host classes within the schools. Due to COVID-19 and political barriers in 2022 IRCHSC engaged Angela Love, CNM to provide classes to parents and teens within our community. AWARENESS AND EDUCATION ON ISSUES AFFECTING NEWBORNS AND NEW MOMS All Activities accomplished: • Create task force/ focus groups comprised of maternal child health, social services, health and mental health agencies, and community members to identify emergent issues that impact families which children from zero to three (preconception health, prenatal care, resources in the community, postpartum support, breastfeeding, mental health support, safe care and safe sleep). • Use the input to create comprehensive materials and messages culminating in the ‘No One Told Me That’ Campaign, including stories and testimonials from women in the community. Messaging should include information for mothers, fathers, and other caregivers. • Partner with trusted members of the community to distribute this information and advocate for behavioral changes that address the targeted modifiable risk factors possibly using IRCHSC G.R.O.W Doula program. • Distribute revised messaging and materials to all task force members and other organizations (2-1-1, Visiting Nurse Association Mobile Clinic). • Create more awareness for IRC Healthy Start’s Maternity/Coordinated Intake and Referral program as central intake and information point. Page 10
Page 11 ENHANCE CARE FOR WOMEN WITH HIGH-RISK PREGNANCIES All Activities accomplished: • Sustain and expand effective programs currently being offered such as the G.R.O.W. Doula program, Nurse Family Partnership, Parents as Teachers, Healthy Start, Healthy Families, and others) • Engage community partners such as churches and community-based organizations (2-1-1 and mobile clinic) to disseminate information related to the newly added high risk maternity services (CCIRH Maternal Fetal Medicine). • Create more awareness for Healthy Start and Cleveland Clinic’s Maternity Navigator/ Coordinated Intake and Referral program as central intake and information point. • Continue the work of the MORE (Maternal Opioid Recovery Effort) Initiative group created to address the rise in substance exposed newborns. Tasks may include (identifying a provider for Medication-Assisted Treatment (MAT), conducting 5P screening on all pregnant women, providing naloxone kits to those at risk of overdose). OTHER AND ONGOING INITIATIVES The Community Action Team identified the following opportunities for positively impacting birth outcomes for babies born in Indian River County. These initiatives were not prioritized in the 2020 plan but none the less were accomplished or are ongoing improvements to the Maternal and Child Health system of care. • Improved access to specialist Maternal Fetal Medicine and neonatology for high-risk cases. Cleveland Clinic has recently added a Maternal Fetal Medicine physician. Lack of this level of care was identified as a weakness from 2014- 2018. The action item listed is to ensure there is wide knowledge about the new service. • Promote/normalize home visiting programs* • Innovative postpartum services* • Formal Bereavement/support services* • Diverse prenatal care providers • Training for prenatal providers (Trauma Informed Care, Implicit Bias, Breastfeeding) The list below are a result of issues that immerged in the 2019-2021 FIMR or carried over from the prior FIMR are: • Center for Disease Control and Preventions (CDC) Hear Her Campaign • Promote/normalize home visiting programs* • Innovative postpartum services* • Formal Bereavement/support services* • Diverse prenatal care providers • Training for prenatal providers (Trauma Informed Care, Implicit Bias, Breastfeeding)* • Financial support for families who have a loss; for funeral expenses, mental health support, and medical bills incurred. • Financial support for families who experience a extremely high-risk pregnancy *The initiatives listed above are ongoing work led by Healthy Start CONCLUSION Through the dedication, commitment, and compassion of stakeholders, Indian River County has made great strides toward enhancing the wellbeing of our community. IRCHSC has made steps in accomplishing our goal of FIMR which was to identify opportunities and promote systemic change that result in the reduction of fetal and infant mortality. This journey will continue thanks to funding provided by the Indian River County Hospital District. IRCHSC anticipates developing measurable goals to ensure success in the plan created, and will augment and expand the plan as needed to address opportunities to further reduce fetal and infant mortality. ACKNOWLEDGEMENTS Indian River County Healthy Start Coalition (IRCHSC) would like to thank the Indian River County Hospital District for their assistance, guidance and funding support for the Fetal and Infant Mortality Review (FIMR) in Indian River County. IRCHSC would like to thank Cleveland Clinic Indian River Hospital for their support and partnership. IRCHSC also extends their appreciation and special thanks to the many dedicated individuals, agencies and organizations, who volunteered to become members of the Case Review Team and the Community Action Team for this FIMR. They have participated in and contributed their time and expertise to the activities and accomplishments listed in the Indian River County FIMR 2022 Report.
Page 12 CASE REVIEW TEAM (CRT) • Dr. Audrey Richards, Retired Obstetrics and Gynecology (Team Chair) • Dr. Gregory Rosencrance, Cleveland Clinic Indian River Hospital • Megan McFall, Cleveland Clinic Indian River Hospital • Robert McPartlan, Department of Children and Families • Andrea Berry, Indian River County Healthy Start Coalition • Autumn Schneider, Indian River County Healthy Start Coalition • Sarah Canty, Indian River County Healthy Start Coalition • Sharon Packard Ph.D., Indian River County Healthy Start Coalition • Sheriff Eric Flowers, Indian River County Sheriff ’s Office • Angela Love, Midwife Love • Tony Brown, National Association for the Advancement of Colored Peoples (NAACP) • Donna Hedgecock, School District of Indian River County • Carrie Maynard-Lester, Substance Awareness Center of Indian River County • Jennifer Fredrick, Indian River County Hospital District • Allen Jones, Indian River County Hospital District • Jennifer Moore, Treasure Coast Community Health • Dr. Virginia Hustead, Neonatology • Dr. Felix Bigay, Cleveland Clinic Indian River • Cheryl Martinez, Nurse-Family Partnership • Erin Refsland, Community Member IRSHSC recognize that The FIMR process involves significant time and effort and greatly appreciate all participants’ strong commitment to reducing fetal and infant mortality and improving birth outcomes. REFERENCES Wallace, M., Crear-Perry, J., Richardson, L., Tarver, M., & Theall, K. (2017). Separate and unequal: Structural racism and infant mortality in the US. Health & Place, 45, 140–144. https://doi.org/10.1016/j.healthplace.2017.03.012 [1] Nicoloro-SantaBarbara, J., Rosenthal, L., Auerbach, M. v., Kocis, C., Busso, C., & Lobel, M. (2017). Patient-provider communication, maternal anxiety, and selfcare in pregnancy. Social Science & Medicine, 190, 133–140. https://doi.org/10.1016/J.SOCSCIMED.2017.08.011 [1] Kotlar, B., Gerson, E., Petrillo, S., Langer, A., & Tiemeier, H. (2021). The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review. In Reproductive Health (Vol. 18, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12978-021-01070-6 Swoboda CM, Benedict JA, Hebert C, McAlearney AS, Huerta TR (2019) State Infant Mortality Rate Calculations Vary by Classification of Pre-Viable Infants. J Fam Med Dis Prev 5:111. doi.org/10.23937/2469-5793/1510111 Poisson TM, Pierone G Jr. Placental pathology and fetal demise at 35 weeks of gestation in a woman with SARS-CoV-2 infection: A case report. Case Rep Womens Health. 2021 Apr;30:e00289. doi: 10.1016/j.crwh.2021.e00289. Epub 2021 Jan 28. PMID: 33527073; PMCID: PMC7840395. American College of Obstetricians and Gynecologists and the Maternal and Child Health Bureau. (2008). National fetal and infant mortality review manual: A guide for communities (2nd ed.). Washington, DC: American College of Obstetricians and Gynecologists. Retrieved from http://www.acog.org/departments/n¢mr/CommunityGuide.pdf Benfits.gov, Florida Medicaid. Retrieved November, 2020. From https://www.benefits. gov/benefit/1625. Burgoyne, M. E., Elsamadicy, E. A., Cojocaru, L., & Desai, A. (2020). COVID-19 Barriers to Care for Pregnant Patients in Prolonged Isolation. Case Reports in Obstetrics and Gynecology, 2020. https://doi. org/10.1155/2020/8847859 Centers for Disease Control and Prevention. (2020). Reproductive Health. Maternal and Infant Health. Infant Mortality. Retrieved from https://www.cdc.gov/ reproductivehealth/maternalinfanthealth/infantmortality.htm Centers for Disease Control and Prevention. (2020). Reproductive Health. Maternal and Infant Health. Preterm Birth. Retrieved from https://www.cdc.gov/ reproductivehealth/maternalinfanthealth/pretermbirth.htm Centers for Disease Control and Prevention. (2020). Social Determinants of Health: Know What Affects health. Retrieved from https://www.cdc.gov/ socialdeterminants/
Page 13 Centers for Disease Control and Prevention. (2023) Hear Her Campaign https://www. cdc.gov/hearher/healthcare-providers/index.html?s_cid=DRH_Hear_Her_ SearchOY1_HCPs_Brand_Main Duncan, G. J., Lee, K. T. H., Rosales-Rueda, M., Kalil, A. (2018). Maternal age and child development. Demography, 55(6), 2229–2255. Florida Statutes, MEDICAL MALPRACTICE AND RELATED MATTERS, 766.101 Medical review committee, immunity from liability. Statutes & Constitution :View Statutes : Online Sunshine (state.fl.us), 2020 Florida Perinatal Quality Collaborative. (n.d.). Retrieved December 08, 2020, from https://health.usf.edu/publichealth/chiles/fpqc/provide FIMR Overview, Publication of the National Fetal and Infant Mortality Review Program, ACOG, 2014. Gage TB, Fang F, O’Neill E, DiRienzo G. Maternal education, birth weight, and infant mortality in the United States. Demography. 2013 Apr;50(2):615-35. doi: 10.1007/s13524-012-0148-2. PMID: 23073749; PMCID: PMC3578151. Illinois Department of Health. (2020). Topics & Services. Life Stages & Populations. Infant Mortality. Retrieved from https://dph.illinois.gov/topics-services/life-stages-populations/infant-mortality Khanani, I., Elam, J., Hearn, R., Jones, C., & Maseru, N. (n.d.). The Impact of Prenatal WIC Participation on Infant Mortality and Racial Disparities. https://doi.org/10.2105/AJPH.2009.168922 Kotlar, B., Gerson, E., Petrillo, S., Langer, A., & Tiemeier, H. (2021). The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review. In Reproductive Health (Vol. 18, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12978-021-01070-6 March of Dimes. (2020). Complications & Loss. Loss & Grief. Neonatal Death. Retrieved from https://www.marchofdimes.org/complications/neonatal-death.aspx March of Dimes. (2020). Complications & Loss. Pregnancy Complications. Pregnancy after age 35. Retrieved from https://www.marchofdimes.org/complications/ pregnancy- after-age-35.aspx Michael K. Magill, MD, and Ryan Wilcox, BA, University of Utah School of Medicine Salt Lake City, Utah Am Fam Physician. 2007 May 1;75(9):1310-1311 National Vital Statistics Reports Volume 69, Number 7 July 16, 2020, Infant Mortality in the United States, 2018: Data from the Period Linked Birth/Infant Death File Office of Disease Prevention and Health Promotion. Social Determinants of Health. Retrieved November, 2020. From https://health.gov/healthypeople/ objectives-and-data/social-determinants-health Reproductive and Sexual Health. Reproductive and Sexual Health | Healthy People 2020 June 08, 2020. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhitopics/Reproductive-and-Sexual-Health Smith, I. Z., Bentley-Edwards, K. L., El-Amin, S., & Darity, Jr., W. (March 2018). Fighting at birth: Eradicating the Black-White infant mortality gap. https://socialequity.duke.edu/wp-content/uploads/2019/12/EradicatingBlack-Infant-Mortality-March-2018.pdf US Department of Health and Human Services. (2017). Eunice Kennedy Shriver National Institutes of Child Health and Human Development. What is a high-risk pregnancy? Retrieved from https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/high-risk
Page 14 Resident Infant Deaths by Residence County by Leading Rankable Causes of Infant Death YEAR=2019, 2020, 2021 2019 2020 2021 Total Congenital Anomalies Of Heart (Q20-Q24) 1 1 2 8% Extreme Low Birth Weight Or Extreme Immaturity (P07.0, P07.2) 2 1 2 5 19% Hydrops Fetalis Not Due To Hemolytic Dis (P83.2) 1 1 4% Incompetent Cervix (P01.0) 1 1 4% NOT APPLICABLE 0% Other & Unspecified Respiratory System Diseases (J22, J30-J39, J43-J44, J47-J68, J70-J98) 1 1 4% Other External Causes & Sequelae (X60-X84, Y10-Y36, Y87.0, Y87.2, Y89) 1 1 4% Other Perinatal Conditions (P29, P70.3-P70.9, P71-P76, P78-P81, P83.0-P83.1, P83.3-P83.9, P90-P96) 1 2 3 12% Pneumonia (J12-J18) 1 1 4% Premature Rupture Of Membranes (P01.1) 3 3 12% Pulmonary Hemorrhage (P26) 1 1 4% Respiratory Distress (P22) 1 1 4% Sudden Infant Death Syndrome (R95) 1 1 1 3 12% Unint Inj: Suffocation & Strangulation In Bed (W75) 1 2 3 12% Total 7 4 15 26 100%
Page 15 Resident Fetal Deaths 2019 2020 2021 (provisional) Total Fetus affected by maternal conditions which may be unrelated to present pregnancy (P00) 1 1 Fetus affected by other medical procedures and maternal conditions (P00.7-P00.8) Total 1 1 Fetus affected by maternal complications of pregnancy (P01.0-P01.9) 2 2 Total 2 2 Fetus affected by maternal complications of pregnancy (P01.0-P01.9) 1 1 Fetus affected by maternal death (P01.6) Total 1 1 Fetus affected by complications of placenta, cord and membranes (P02) 1 1 Fetus affected by other forms of placental separation and hemorrhage (P02.1) Total 1 1 Fetus affected by complications of placenta, cord and membranes (P02) 1 1 2 Fetus affected by other and unspecified morphological and functional abnormalities of placenta (P02.2) Total 1 1 2 Fetus affected by complications of placenta, cord and membranes (P02) 1 1 Fetus affected by prolapsed cord (P02.4) Total 1 1 Fetus affected by complications of placenta, cord and membranes (P02) 1 1 Fetus affected by chorioamnionitis (P02.7) Total 1 1 Fetus affected by other complications of labor and delivery (P03) 1 1 Fetus affected by other and unspecified complications of labor and delivery (P03.8-P03.9) Total 1 1 Fetal death of unspecified cause (P95) 1 2 3 Fetal death of unspecified cause (P95) Total 1 2 3 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 1 1 Congenital malformations and deformations of musculoskeletal system, limbs and integument (Q65-Q85 Total 1 1 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 1 1 Multiple congenital malformations, not elsewhere classified (Q89.7) Total 1 1 Unknown 1 1 2 Unknown Total 1 1 2 Fetus affected by maternal conditions which may be unrelated to present pregnancy (P00) 1 1 Fetus affected by maternal complications of pregnancy (P01.0-P01.9) 3 3 Fetus affected by complications of placenta, cord and membranes (P02) 2 2 1 5 Fetus affected by other complications of labor and delivery (P03) 1 1 Fetal death of unspecified cause (P95) 1 2 3 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 2 2 Unknown 1 1 2 Total Total 4 8 5 17 Resident Fetal Deaths by Residence County by 124 Causes of Fetal Death by Leading Rankable Causes of Fetal Death by Year
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