The beginnings of Fetal and Infant Mortality Review (FIMR) date back to the mid-1980s, when concern over high infant mortality rates intensified nationwide. The Maternal and Child Health Bureau (MCHB) conceptualized Infant Mortality Review (IMR), the forerunner of FIMR, as a promising method to improve understanding of local factors contributing to infant mortality and to motivate community response. In 1988, MCHB began funding IMR demonstration projects, and over the next several years they supported the implementation and testing of the IMR processes in 10 states and communities, including Hartford, CT; Mott Haven, New York City; South Carolina; Utah; Alaska; Pulaski County, AR; Marion County, IN; Wyandotte County, KS; and Boston, MA. From the very beginning, the IMR model strongly emphasized the importance of a community-based two tiered process that promoted the use of separate groups to carry out an analytic function and a subsequent action function. The Community Review Team has the role of reviewing cases and drafting recommendations, while the Community Action Team helps to disseminate findings, and facilitates implementation of recommended policies and interventions.
In 1990, the MCHB entered into a cooperative agreement with the American College of Obstetricians and Gynecologists (ACOG) to create the National Infant Mortality Review Program. Within the first year, the name was changed to the National Fetal and Infant Mortality Review (NFIMR) Program. NFIMR was designed to serve as the national resource center for information on perinatal and infant mortality review. This public health collaboration served to develop a community based process to help communities improve the services and resources available to women and families to improve birth outcomes. Many prominent MCH leaders began to advocate for FIMR, seeding community projects in geographically dispersed states and localities, and routinely reporting best practices information to the field.
In addition to MCHB and ACOG, the March of Dimes Birth Defects Foundation, the Centers for Disease Control and Prevention, and Carnation Nutritional Products of California were important supporters of FIMR development and provided substantial financial support for two cycles of demonstration projects. In 1991 the federal Healthy Start Program incorporated FIMR into the Healthy Start model. The Robert Wood Johnson Foundation and ACOG District IV funded five new projects in 1993. These early projects and related efforts moved the methodology from theory to practice and placed FIMR on solid footing for sustainability.
Interest in the method grew around the country throughout the 1990s, and the number of FIMR programs increased steadily, from approximately 60 in 1995 to about 200 by 2001. Today, there are 168 FIMR programs in 29 states, all working to improve the lives and health of vulnerable women, infants, and families.
From 1997–2004, MCHB also sponsored 12 state FIMR Support Programs to encourage states to institutionalize FIMR as an integral component of the core public health functions, utilize local FIMR findings for state-level capacity building, and coordinate multiple MCH-related review programs.
From the beginning, MCHB and NFIMR explored how best to evaluate FIMR programs. A consensus evolved that the value of FIMR as a community strategy should not be measured by changes in the infant mortality rate alone, particularly given the complexity of infant mortality and the difficulty of disentangling the effects of multiple community perinatal interventions. The challenge was to develop an evaluation methodology to analyze overall program effects, incorporating valuable outcomes other than infant mortality rates.
In 1996, MCHB awarded funds to the Johns Hopkins University Women’s and Children’s Health Policy Center to conduct a nationwide evaluation of FIMR, focusing on the utility of FIMR at the community level. The approach taken by the Policy Center focused on identifying the “value added” of FIMR compared to other types of perinatal initiatives. The results of the evaluation demonstrated that FIMR is an effective perinatal systems intervention and that FIMR significantly enhances the performance of core public health functions. In particular, evaluation findings revealed that communities with FIMRs, compared with those without, are significantly more likely to be engaged in activities related to these core public health functions:
• Data assessment and analysis
• Client services and access
• Quality Assurance and improvement
• Community partnerships and mobilization
• Policy development
• Enhancing workforce capacity
As part of the evaluation, FIMR teams identified case review issues that they had found were more likely than others to lead to community action: prenatal care (82.5% of recommendations), substance abuse (81.5%), sudden unexpected infant death risk reduction (86%), smoking cessation (72%), and domestic violence (75.5%).
In 2015, the Health Resources and Services Administration made the decision to integrate the FIMR and Child Death Review (CDR) resource centers into one Center, now named the National Center for Fatality Review and Prevention (NCFRP). NCFRP is a resource and data center that supports CDR and FIMR programs around the country. The three key focus areas of the National Center are to provide technical assistance, training and resources to state and local review teams; maintain the CDR Case Reporting Systems and expand it to include FIMR; and to work with states and national partners to move review data to action.
For more information and greater detail on the history of FIMR, readers can go to the Maternal and Child Health Journal, Vol. 8, No. 4, December 2004