EXECUTIVE SUMMARY

Beginning in the mid 1990’s the infant mor-tality rate in Delaware was increasing while the national rate was decreasing annually until 2002. This trend in Delaware’s infant mortality rate prompted Governor Minner’s convening an Infant Mortality Task Force (IMTF) in June 2004. The Fetal and Infant Mortality Review (FIMR) pilot study was born out of an interest to help inform the IMTF on the potential benefits of locally applying the national FIMR model, a process of reviewing fetal and infant deaths to address gaps in the systems of care that serve women, children and their families. Infant births that resulted in a death at Christiana Care Health System during 2003 were selected for the pilot study. The study was limited to one hospi