This report highlights 2019 accomplishments and findings of the Delaware CDRC, which conducts three types of fatality review programs with a focus on maternal child health: CDR/SDY, (FIMR), and MMR.

The CFPS reviews all deaths that occur in Colorado among infants, children, and youth under age 18.

In 2018, 843 children under the age of 18 years died in Arizona. Arizona Child Fatality Review Teams reviewed 100% of these deaths and determined 39%could have been prevented (n=327).

The goal of this learning series is to provide local and state review team members with resources on social determinants of health, racial equity, internal bias, and power in order to promote health equity and a better understanding of systemic issues that lead to child deaths.

Consistent FIMR case reviews found that AI/AN women experience higher rates of commercial tobacco use before, during, and after pregnancy.  They recommend that families have improved access to evidence-based and culturally appropriate commercial tobacco cessation services.

The Intertribal Council of Michigan (ITC) developed an online course for new parents called “The Power of Your Newborn” which is culturally grounded and covers safe sleep, breastfeeding, traditional practices, newborn reflexes, and breast/maternal health and healing.

Four lean process improvement workshops took place to improve how recommendations are written, sorted, and elevated to state leadership for analysis and action. Through the workshops, local teams recommended a new FIMR recommendation form and log be developed to assist in writing and tracking actionable, equitable, and specific recommendations.

Delaware’s Child Death Review Commission’s report on childhood firearm fatalities.