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 Using a Standardized Approach to Understand Infant Mortality: The State Infant Mortality Toolkit*

By Charlan D. Kroelinger, PhD
Team Lead, Maternal and Child Health Epidemiology Program, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

Caroline Stampfel, MPH
Senior Epidemiologist, AMCHP

David A. Goodman, PhD
Senior Scientist, Maternal and Child Health Epidemiology Program, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

*The findings and conclusions in this article are those of the authors and do not represent the official position of the Centers for Disease Control and Prevention

What is a standardized approach to understanding infant mortality and why is it important?
Infant mortality is considered a measure of population health, and for countries, states, counties, and communities it is indicative of underlying issues such as quality of care, access to services, health inequity, and risk behaviors. The World Health Organization defines a live birth as delivery of an infant, ‘irrespective of duration of pregnancy, which…breathes or shows any evidence of life (e.g., beating of the heart, definite movement of voluntary muscles) whether or not the umbilical cord has been cut or the placenta is attached.’1 An infant death can occur immediately following a live born delivery up to the 364th day of life. The interpretation of the WHO definition of a live birth (e.g., what constitutes a breath or voluntary movement) and subsequent infant death impacts infant death reporting, calculation of the infant mortality rate, and programs and policies identified to impact infant mortality, particularly among those infants who die at delivery. Variations in reporting, along with changes in main causes of death over time,the gestational age or birth weight of the infant (i.e., maturity) at birth or maturity-specific mortality (i.e., excess deaths among sub-groups of infants by weight, for example, very low birth weight births) impact the infant mortality rate (IMR). A standard method that progresses through a series of straightforward analyses is essential to providing critical information for informed decision-making to state, local, urban, and tribal programs. The State Infant Mortality (SIM) Toolkit provides standard and structured guidance for IMR analyses.

Through multiple initiatives like the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality or the Secretary’s Advisory Committee on Infant Mortality (SACIM), states and jurisdictions across the country have already or will soon have the opportunity to work on focused strategies to reduce infant mortality. Additionally, the transformation of the Title V MCH Services Block Grant is on the horizon. As part of these opportunities, states, localities, urban areas, and tribal organizations can use the SIM Toolkit as part of the foundation for infant mortality activities – by increasing understanding of what is driving infant deaths in various settings and moving from data to practice.

What does the SIM Toolkit contain and how can my agency/organization best utilize it?
The SIM Toolkit contains information on developing an IMR analytic strategy, beginning with forming a team of experts and stakeholders, to conducting an overview investigation, to then developing a focused investigation of infant death based on specific analytic results provided during the overview investigation.  The toolkit provides a basic framework for establishing the time period of interest, identifying a study population, and calculating baseline infant mortality rates that can be used by States, localities, urban areas, and tribal organizations.  Next, recommendations are made for review of reporting changes, including changes in the definitions of cause of death, and changes in reporting requirements for birthing facilities.  Changes in the causes of infant death over time are examined, and trends in adverse pregnancy outcomes contributing to the IMR are reviewed to identify areas of further focus.  Examining the age at which infant deaths occur, specifically considering changes in the number of low birth weight or preterm births and survivability of infants within each birth weight grouping is the final stage of the overview investigation.  Examples of approaches in the toolkit include implementing the Perinatal Periods of Risk, including information from a Fetal and Infant Mortality Review, and standardizing causes of infant death by examining multiple classification systems. The focused investigation narrows the analytic plans to examine specific maternal socio-demographic characteristics and behavioral risk factors, the attributes of the social and physical environment, and systems of care specifically for at-risk neonates.  The toolkit provides recommendations on examining the built environment, developing community assessments, and understanding regionalized systems of care.  When used in a systematic way, these analyses culminate in provisional evidence on the causes and contributors to infant death so that programs and policies can be better focused on at-risk or vulnerable populations.

To access the full SIM Toolkit, visit

Has the SIM Toolkit been tested in multiple settings?
The toolkit includes vignettes and clear examples of each type of analysis by state health departments.  The standardized approach for the toolkit was developed by the original five states who participated in the State Infant Mortality Collaborative from 2004-2006: Delaware, Hawaii, Louisiana, Missouri, and North Carolina.  Additionally, the toolkit provides two longer case studies developed by Delaware and Louisiana which provide a step-by-step guide to completing the overview and focused investigations.  The toolkit was additionally tested by the Wyoming Department of Health as a pilot site.  Following use of the toolkit by these six states, CDC and AMCHP, in partnership with state health departments have recruited additional pilot use among two tribes and one community.  Follow-up publications will include the experiences of these two pilot sites.   CDC and AMCHP would like to remain informed of the planned use of the toolkit among states, counties, urban centers, and tribes in order to gather feedback on utility and comprehensiveness.

How can my agency/organization provide feedback on the use of the SIM Toolkit?
Feedback on usage of the SIM Toolkit can be provided directly to AMCHP, (Caroline Stampfel,  Feedback will be used to further enhance the toolkit, revise any errors, and develop new tools that are useful in multiple settings to examine infant mortality.  AMCHP also welcomes feedback from users on programs and policies implemented as a result of Toolkit usage.  This feedback will be used in development of effective practice examples.  AMCHP, CDC, and March of Dimes invite and encourage you to use the SIM Toolkit, and we look forward to learning from your experiences as states, counties, urban areas, and tribes in using this standardized approach to understanding infant mortality.


1.    World Health Organization Statistical Information System (WHOSIS): Indicator definitions and metadata. Accessed on Mar. 28, 2014.