Skip Navigation Links
October 2021 - 2nd EditionExpand October 2021 - 2nd Edition
October 2021Expand October 2021
July 2021Expand July 2021
May 2021Expand May 2021
April 2021Expand April 2021
January 2021Expand January 2021
November 2020Expand November 2020
July/August 2020Expand July/August 2020
May/June 2020Expand May/June 2020
March/April 2020Expand March/April 2020
January/February 2020Expand January/February 2020
September/October 2019Expand September/October 2019
July/August 2019Expand July/August 2019
May/June 2019Expand May/June 2019
March/April 2019Expand March/April 2019
January/February 2019Expand January/February 2019
November/December 2018Expand November/December 2018
September/October 2018Expand September/October 2018
July/August 2018Expand July/August 2018
May/June 2018Expand May/June 2018
March/April 2018Expand March/April 2018
January/February 2018Expand January/February 2018
November/December 2017Expand November/December 2017
September/October 2017Expand September/October 2017
July/August 2017Expand July/August 2017
May/June 2017Expand May/June 2017
March/April 2017Expand March/April 2017
January/February 2017Expand January/February 2017
November/December 2016Expand November/December 2016
September/October 2016Expand September/October 2016
July/August 2016Expand July/August 2016
May/June 2016Expand May/June 2016
March/April 2016Expand March/April 2016
January/February 2016Expand January/February 2016
November/December 2015Expand November/December 2015
September/October 2015Expand September/October 2015
July/August 2015Expand July/August 2015
May/June 2015Expand May/June 2015
March/April 2015Expand March/April 2015
January/February 2015Expand January/February 2015
ArchiveExpand Archive
Special Edition - EPRExpand Special Edition - EPR
Special Edition: Title V Technical Assistance MeetingExpand Special Edition: Title V Technical Assistance Meeting
Title V Technical Assistance Meeting

 Using Fatality Reviews to Improve Outcomes through Title V

title v 2.pngSession: Exploring Ways Title V Programs can use Fatality Review Findings to Improve Maternal and Child Outcomes in Communities, Oct. 17


  • Abby Collier, Director, National Center for Fatality Review and Prevention
  • Rosemary Fournier, FIMR Director, National Center for Fatality Review and Prevention
  • Susanna Joy, Program Associate, National Center for Fatality Review and Prevention

"We're seeing communities take the worst thing that can happen to them and change that into a positive so they can move forward." – Abby Collier

Main takeaway

Child Death Reviews (CDRs) and Fetal and Infant Mortality Reviews (FIMRs) help title V programs improve address National Performance Measures to improve outcomes

What they are

CDRs review child deaths, generally from 0 to 18 years of age.   

1,350 local and state teams, covering every state.

FIMRs review live-born infants who die before reaching their first birthday, and stillborn infants;  those born without signs of life, generally after 20 weeks gestation.

175 teams in 29 states

The National Center for Fatality Review and Prevention is a resource and data center that supports CDR and FIMR programs.

How they work

Teams for each are composed of local providers, experts, and leaders from multiple disciplines.

              "We want the table to look like your community and we want the table to fit your needs." – Abby Collier

Continuous quality improvement process identifies system vulnerabilities that contribute to deaths and system change that can prevent deaths.

              "What can we learn from a death that will help us prevent more deaths?" – Rosemary Fournier


  • Involves data gathering, case review, and community action/change
    • The process and team composition differ slightly for CDRs and FIMRs.
  • Covers multiple factors and systems, including medical, social, economic, cultural, family, safety, and health.
  • Family engagement is important but sensitive. FIMR teams interview the mother involved if she wishes.

"We invite her to tell her story. There is so much more we can learn from her experience."  – Rosemary Fournier

National Performance Measures Addressed

Addressed by FIMRs:

1 – Well-woman visit

2 – Low-risk Cesarean delivery

3 – Risk-appropriate perinatal care

Addressed by CDRs:

8 – Physical activity

9 – Bullying

10 – Adolescent well-being

12 – Transition

Addressed by FIMRs and CDRs:

4 – Breastfeeding

5 – Safe sleep

6 – Developmental screening

7 – Injury hospitalization

11 – Medical home

13 – Preventative dental visit

14 – Smoking

15 – Adequate insurance