2003 Model Practice Application (Public)

Fetal and Infant Mortality Review

Boston Public Health Commission

As part of its recently established framework for understanding and eliminating racial disparities in infant mortality, the Boston Public Health Commission’s (BPHC), has launched a radically new type of Fetal and Infant Mortality Review (FIMR) process. (In 2000, black infants were five times more likely than white infants to die within the first year of life.)

The conceptual model abandons many traditional FIMR elements and seeks instead to identify and devise community-initiated responses to conditions experienced by black women in Boston that compromise optimal preconception and prenatal women’s health. Through collaboration with the Massachusetts Center for Sudden Infant Death Syndrome/ Massachusetts Infant and Child Bereavement Program, women who have experienced a late fetal or infant death are offered bereavement support and referral in a home visit with a public health nurse. As the relationship with the nurse develops, women complete a comprehensive health assessment form (modeled from the BPHC Women’s Health Questionnaire) to help the nurse learn more about her health prior to conception, during the prenatal period, and since the loss of the pregnancy. The goal is to provide information to help the woman, with the nurse, address medical and social risks prior to a subsequent pregnancy.

This model attends almost exclusively to women's own sense of their experience with their health and the health care system. In an effort to explain poor birth outcomes in the women's own terms, it tries to identify points where there are mismatches between women's needs and what they experience. For women who have had a late fetal or infant death, this interview follows a period of bereavement support and grief counseling. The hope is that, through analysis of interview data by a Community Action Team (FIMR CAT) comprising consumers, health care providers, and representatives from other institutions serving this population, the project will be able to propose and lead changes in health care services and develop public health initiatives that will finally eliminate the racial disparity in this critical health measure.

In 1998, the BPHC convened the Health of Women and Infants Working Group to meet monthly and advise BPHC on how best to address a variety of maternal and child health issues. The group comprises clinical providers, public health practitioners, researchers, and community members and advocates, and represents the city's academic research institutions, community health centers, hospitals, community based agencies, and the state department of public health. The FIMR Subcommittee of the Health of Women and Infants Working Group reviews the information collected during home visits, both by the nurses and from the health assessment tool. Subcommittee members prepare data and highlights for discussion at quarterly Community Action Team meetings. The new process offers an opportunity to rapidly mobilize support and mechanisms for change at the individual, clinical, and system levels throughout the city, and to use community expertise to guide that change. Further, it takes advantage of multiple previous collaborations that have established flourishing cross-sector relationships and a shared understanding of the city's situation with respect to this issue.

The FIMR is conducted as part of the surveillance activities and bereavement support program of the Boston Public Health Commission, and thus its costs are contained within the staffing costs of the city. No additional funding has been used for the project, demonstrating its sustainability over the long-term through incorporation into normal public health programming. The costs include three staff people who participate in coordinating and overseeing the FIMR project, including the Director of Research at 10 percent, Senior Manager at 15 percent, and the Director of Clinical Services at 10 percent, totaling about $20,000. To produce the patient education material, $15,000 was provided to the Massachusetts Center for Sudden Infant Death Syndrome/ Massachusetts Center for Infant and Child Bereavement.

The intention of the FIMR to rapidly implement system change affects the project's capacity to measure impact, in that modifications to the health care system are expected to occur at the same time women are being asked their experiences within the system. The hope is that the program will learn more about women's health and access to services and improve both through a systematic approach to the problem. The hope is that by approaching change at the system level, through the FIMR CAT, birth outcomes will ultimately be improved. A process evaluation has not been implemented because of the need to incorporate the work into existing programmatic activities without added costs. However, it is anticipated that modest city funding will be available in the coming fiscal year to conduct a process evaluation.

The most important lesson thus far is that it is possible to conduct an FIMR with minimal new financial investment, and that committed partners can be identified despite the lack of funding. An initial challenge was to engage women from the community to participate in the CAT meetings. It was anticipated that it would be very difficult to include women who had experienced a previous loss, but the staff were hoping to have more consumers attend. Program staff is still working to identify women who could make a commitment to participate in the CAT. Another challenge has been the time involved in developing and implementing a new model for this project. Not only did it take several months to develop the health assessment form, but also the internal review board application approval process took more than six months.

The most critical piece, the catalyst for the project's implementation, has been the consistent backing of an informed and committed executive office at the city’s public health department, which has also creatively incorporated the FIMR's unique contributions into its program and policy development. Another important factor in the project start-up has been having partners at the community, hospital, and state levels. Thanks to their relationships with medical providers and representatives from community-based agencies, who have demonstrated long-term commitment to improving infant mortality rates, program staff has been able to convene a diverse group of experts for the Community Action Team.