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RUNNING HEAD: INFANT MORTALITY

Reducing Infant Mortality in Duval County

Barrett Pope

Gina Bongirno

Ashlan Snyder

University of North Florida

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Literature Review

Despite the nations efforts to reduce infant mortality, rates continue to be high. The Centers

for Disease and Control indicates that infant mortality may be divided into two periods. The first

period, neonatal, measures from the birth of the infant until 27 days after birth. The second

period is called the postneonatal period, which lasts from 28 days until the infant has reached

364 days. Two-thirds of the deaths occurring in infants happen in the neonatal stage, caused by

complications from preterm births, birth defects, maternal health conditions, labor and delivery

complications, and lack of access to appropriate care. In the postneonatal period, deaths are from

sudden unexpected infant death (SUIDS), which includes sudden infant death syndrome (SIDS),

injury, and infection. (Centers for Disease Control and Prevention, 2013) One study found that

the risks of premature, stillbirth, early and late neonatal death, and infant death increase linearly

with decreasing care (Partridge, S, Balayla, J., Holcroft, C. A., Abenhaim, H. A., 2012).

According to Healthy People 2020, the target for Infant Mortality is 6.0/1000 births (Baptist

Health, 2016). While the national infant mortality rate is below this: 5.96 deaths per 1000 live

births (Centers for Disease Control and Prevention, 2015), many areas of the country have infant

mortality rates well above the recommendation. According to a study conducted in 2014, The

United States still ranks near the bottom among developed nations in infant mortality and birth

outcomes (Lu, M. C., & Johnson, K. A., p.13). This is especially concerning when the infant

mortality of a community and nation is an indicator of the overall health, social and economic

development (Kieltyka, L., Craig, M., Goodman, D.A., Wise, R., 2012). One contributor to

infant mortality is the racial disparity between white and nonwhite U.S. citizens. According to

Stampfel, Kroelinger, Dudgeon, Goodman, Ramos and Barfield, infant mortality rates for

African American infants in 2009 was more than double the infant mortality rate of white infants
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with rates for African American infants as high as 12.6/1000 compared to that of white infants at

5.3/1000 (Stampfel, C., Kroelinger, C.D., Dudgeon, M., Goodman, D., Ramos, L.R., Barfield,

W.D., 2012, p.2).

The state of Florida has an infant mortality slightly higher than the national at 6.1 per

1000 live birth, and a similar racial disparity for white and nonwhite citizens with the infant

mortality rate for white people at 4.5 and for non-white at 10 (Florida Charts, 2016). In Duval

County, the infant mortality rate is very high, at 8.7 and a disparity of 5.2 for white and 12.9 for

non-white races (Florida Charts, 2016).

The primary statistics for Duval County regarding the contributing factors and causes of

infant mortality are low birthweight, mothers who receive early prenatal care, and preterm births.

The percent of babies born with a low birthweight in Duval County is at 9.4%, though the target

is 7.8% (Baptist Health, 2016). Infant mortality rates have not decreased recently, but according

to the Lau, Ambalavanan, Chakraborty, Wingate and Carlo the increased proportion of low

birthweight and preterm infants contributes to the narrowing of the gap between the infant and

neonatal mortality rates (Lau, C. Ambalavanan, N., Chakraborty, H., Wingate, M. S., Carlo, W.

A., 2013, p.857). In Duval County, mothers who received early prenatal care were low at 70.1%

compared to the target 77.9% (Baptist Health, 2016). In the final category, preterm births in

Duval County are 13.8% and the target is 11.4% (Baptist Health, 2016). According to a study in

2013, a previous national study identified preterm birth as the most frequent cause of infant

death (Lau, C., Ambalavanan, N., Chakraborty, H., Wingate, M.S. & Carlo, W.A., 2013, p.857)

Behavioral factors that contribute to higher rates of infant mortality include insufficient

or nonexistent prenatal care and substance abuse by mothers (Centers for Disease Control and

Prevention, 2015). Examples of poor prenatal care include insufficient sex education in middle
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and high school curricula resulting in women of child bearing age not informed or participating

in birth control contraceptives, such as condoms or birth control pills. Additionally, pregnant

mothers may be unaware or reluctant to expose their pregnancy to their families, delaying

doctors visits and initiation of prenatal supplements such as folic acid. This lack of prenatal

care increases the stress imposed on the pregnant mother and growing fetus, increasing the risk

of infant mortality. Once pregnant, some mothers may continue to engage in unsafe behaviors

such as substance abuse, poor nutrition, and insufficient exercise, increasing their chances of

accidental injury (Centers for Disease Control and Prevention, 2015). Substance abuse can take

many forms, all detrimental to the health outcomes of both the mother and fetus. However, for

the purpose of this analysis, we will focus on the mothers health behaviors regarding smoking

cigarettes and excessive alcohol consumption.

Factors that predispose our target population to higher rates of infant mortality may be

due to low income due to unemployment and stress caused by running a single parent household.

The rates of unemployment in our target population are 7.4% which is more than the state at

7.2% and the nation at 4% (Florida Charts, 2016). The rates of unemployment in Duval County

are nearly double than the average for the rest of the country, and low or minimum income poses

a serious threat to the health of a newborn. Furthermore, the rates of Single Parent Households in

Duval County are currently at 42%, higher than the state and national average of 38% (Florida

Charts, 2016). Having to provide for a child on a single income could become very stressful for

mothers, lowering the health status of both the mother and child. Another important factor to

account for when analyzing the predisposing factors of infant mortality in Health Zone 1 are the

racial and ethnic disparities for the outcomes of births as well as the stagnant state of the United

States infant mortality rates (Lau, Ambalavanan, Chakraborty, Wingate & Carlo, 2013, p. 857).
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Specifically, in Duval County, Health Zone 1 has a minority population of 83.2%. (Florida

Department of Health Duval County, 2013)

Infant mortality is enabled due to the unequal access to medical care and the high costs

associated with newborn care. The proportion of citizens to primary care provider is an

indication of the amount of access to medical care in an area, the higher the number of citizens,

the harder it is to regularly receive medical attention. In Duval County there are fewer primary

care providers (PCPs) in proportion to citizens in the U.S., specifically; there are

1,189 citizens for every PCP in Duval County, and 1,045 citizens for every PCP. In Florida,

there are 1,423 citizens for every PCP (Florida Charts, 2016). Even though Duval Countys rate

of PCPs is better than the State Average for our target population, Health Zone 1 especially has

the highest population density at 2,766.5 people per square mile (Florida Department of Health

Duval County, 2013). High costs of medical care are another factor contributing to higher rates

of infant mortality in Health Zone 1, because in Duval County the rates of citizens who are

uninsured are 19%, higher than the national average of 11%, but lower than the state average of

24% (Florida Charts, 2016). The costs of having a baby can significantly strain the finances of a

family, especially a lower income family. In Health Zone 1 the average household income is

$15,279 - $34,095, compared the average income of Duval County, $49,555, and Health Zone 1

is the only zone that has not had significant increase in average household income in the past ten

years, (Florida Department of Health Duval County, 2013). Health Zone 1 has the highest

proportion of residents living in poverty, as much as 44.6% of citizens are currently living in

poverty, nearly triple of the average of the entire county, only 18%, (Florida Department of

Health Duval County, 2013).

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Two factors that have been shown to reinforce increased rates of infant mortality in our

target population in Duval County, Florida are rates of smoking and excessive drinking in

mothers. The percentage of mothers who smoke cigarettes in our target population was 20%,

higher than both the rates for the State of Florida and the nation, at 18% and 14% respectively

(Florida Charts, 2016). The rates of excessive drinking in both Duval County and Florida are

16% of new mothers, higher than the national rate of 10% (Florida Charts, 2016). Overall, the

data suggests a correlation between elevated rates of excessive drinking and smoking in mothers,

and increased rate of infant mortality.

To ensure our program is successful, will incorporate components of Healthy Start.

Specific to Duval County, Healthy Start is available to any pregnant women living in Duval

County as well as any children under the age of three living in Duval County. Services include,

but are not limited to, home visits, care coordination, smoking cessation, substance abuse

counseling, and educational material regarding sudden infant death syndrome (SIDS) and safe

sleep. (Florida Department of Health in Duval County, 2016). The emphasis on home visits is

especially noteworthy because, as evidenced by interventions conducted under the Sheppard-

Towner Act from 1924 to 1929, interventions that provided one-on-one contact and

opportunities for follow-up care, such as home visits by nurses and the establishment of health

clinics, reduced infant deaths more than did classes and conferences (Moehling, C.M.,

Thomasson, M.A., 2014, p.367). Another vital component of maternal and infant health is the

practice of birth spacing. According to a study published in 2011, birth-to-pregnancy (BTP)

interval references the interval between the date of the last live birth to the start of the next

pregnancy. The BTP interval of less than six months has an association with increased risks of

maternal mortality, while an interval of 18 to 27 months may increase the risk of maternal,
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perinatal and infant mortality (Salihu, H.M., August, E.M., Mbah, A.K., Alio, A.P., Cuba II, R.,

Jaward, F.M., Berry, E.L., 2011, p.137-138). Interconceptual counseling is another one of the

many free services provided by Healthy Start (Florida Department of Health in Duval County,

2016).

Our program will draw from current interventions that are successful at the state and

national level. The special Supplemental Nutrition Program for Women, Infants, and Children

(WIC) provides breastfeeding education and support for pregnant women, breastfeeding women,

and children under the age of 5. Like Healthy Start, WIC provides home visits in addition to

income-based services such as access to affordable healthy foods, nutrition education,

breastfeeding support groups, and the loan of electric breast pumps (Florida Department of

Health in Duval County, 2016). Project IMPACT, a fetal and infant mortality review project for

Baker, Clay, Duval, Nassau, and St. Johns Counties, gathers information to gain a better

understanding of the fetal and infant deaths that occur in northeast Florida (Florida Department

of Health in Duval County, 2016). In addition to the efforts put forth by the aforementioned

interventions, the Collaborative Improvement & Innovation Network to Reduce Infant Mortality

(CoIIN) strives to increase regionalization and decrease the number of elective deliveries

occurring at less than 39 weeks of pregnancy (Health Resources and Services Administration

Maternal and Child Health, 2013). Lastly, the Fetal and Infant Mortality Review (FIMR) gathers

information from northeast Florida monthly by accessing birth, death, medical, hospital, and

autopsy records. FIMR conducts interviews with families, if possible, and composes case

summaries to aid in determining the factors likely contributing to the death. Recommendations

are issued based on their findings and which are then implemented in communities throughout

the area (Kieltyka, L., Craig, M., Goodman, D.A., Wise, R., 2012). Our program will strive to
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incorporate these undertakings as seamlessly as possible in order to form a cohesive health

portrait for the infant as well as the mother.

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Needs Assessment

The sample we have selected will consist of pregnant women who live in Health Zone 1.

Health Zone 1 has a very dense population due to its urban status. Additionally, Health Zone 1

has the highest low birthweight and infant mortality rates. The low birthweight percent in Health

Zone 1 is 13.7%. Also, the infant mortality rate is a staggering 11.61 per 1000 compared to the

State infant mortality rate at nearly half of this, and the county rate still much lower (Florida

Department of Health Duval County, 2013). The sample from Health Zone 1 will most likely

consist of women who are of an ethnic minority and poor socioeconomic status. The percent of

black peoples in Health Zone 1 is 78 percent, and the individuals living in poverty are also much

higher than the other health zones. People living in Health Zone 1 have a four to nine year

shorter life expectancy as compared to all other health zones in Duval County, with male infants

having the lowest. Black infants have the same life expectancy across the health zones with the

exception of Health Zone 1. (Florida Department of Health Duval County, 2013). Inequities

across the health zone boundaries persist in the 77% difference in infant mortality between

Health Zone 1 having the highest rates and Health Zone 6 with the lowest rates.

In light of the above statistics and evaluation, we decided to select our sample through

setting up a booth outside two separate Winn-Dixie Grocery Stores in Health Zone 1. Both

grocery stores are from the Winn-Dixie franchise and offer discounts and savings programs for

pregnant women, infants and young children. The locations of these franchises are on 777

Market Street, and 424 N Pearl Street. For 1 week, a booth will be set up at one of the Winn-

Dixie locations, followed by setting up a booth at the other location for the same amount of time

during the peak sales times for the stores.

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Survey

1. Which of the following behaviors do you find acceptable to engage in during pregnancy? (Check

one or more)

a. Drinking alcohol

b. Smoking Cigarettes

c. Smoking Marijuana

d. Recreational Drug Use

e. Prescription Drug Use

f. Caffeine use

g. Unprotected sex when pregnant

h. None of these are acceptable

2. Which of the behaviors listed above have you engaged in during pregnancy at any time in the past

or present?

3. Have you sought out prenatal care since you found out you were pregnant?

a. Yes

b. No

4. If you answered yes to the above question, what type of care did you receive?(You may check 1

or more of the following options)

a. Vitamins

b. Ultrasound

c. hCG blood test

d. General bloodwork

e. Birth counseling

f. Discussion of options (termination, adoption, etc.)

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5. Have you been to all of your scheduled prenatal care visits so far in your pregnancy?

a. Yes

b. No

c. I am not at this stage in my pregnancy

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Goal and Objectives

GOAL: To reduce infant mortality rates in Duval County, Florida

PROCESS OBJECTIVE: During the program implementation, 75% of participants in prenatal

care information sessions will report very good on their satisfaction with the educational

materials.

IMPACT LEARNER OBJECTIVE: Three months after the program, 75% of participants will

be able to accurately describe three causes of infant mortality.

IMPACT BEHAVIORAL OBJECTIVE: Three months after the program, 80% of program

participants who were, or are planning to become, pregnant will report having sought out

prenatal care.

OUTCOME OBJECTIVE: Five years after the program, infant mortality rates in Duval

County, Florida will have decreased by 10%.

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Theory

Health Belief Model Worksheet

Concept Definition Application Specific activities that will address thes

Ones opinion of Define population(s) During prenatal care information sessio

chances of getting at risk, risk levels. mortality rates and low birth weight sta
condition Personalize risk based populations in Health Zone 1.
on a persons features
or behavior. Make
perceived Duval County IMR is 8.7/1,000 live bir
susceptibility Minorities in Health Zone 1 is 11.61/1,0
consistent w/ actual 2013).
risk.
Perceived
Susceptibility
Low Birth Weight (LBW) in Health Zon
highest of all Health Zones, the next hig
5 at 9.5% (Florida Charts 2013).

Infant Mortality Rates, IMR for whites

5.2/1,000 live births, and non-white IM
births (Florida Charts, 2013)
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Ones opinion of Specify consequences Consequences of not going to prenatal c

how serious a of the risk the receiving any care. One study found tha
condition and its condition. stillbirth, early and late neonatal death a
Perceived Severity consequences are increase linearly with decreasing care (P
L., Holroft, C.A., Abenheem, H.A., 201

Ones opinion of the Define action to take: Receiving sufficient prenatal care would
efficacy of the how, where, when; likelihood of having a healthy baby that
advised action to clarify the positive year of life.
Perceived Benefits reduce risk or effects to be expected.
seriousness of impact

Ones opinion of the Identify & reduce To combat the common barriers of the c
tangible and barriers through for mother and baby, transportation to a
psychological costs reassurance, appointment and cost of prenatal vitami
of the advised action correction of home visits and free prenatal care appoi
misinformation, vouchers for vitamins during our prenat
incentives & sessions. The emphasis for home visits
Perceived Barriers assistance. noteworthy because as evidence by inte
under the Sheppard-Lowner Act from 1
interventions that provided one-on-one
opportunities for follow-up care, such a
nurses and the establishment of health c
deaths more than did classes and confer
C.M., Thomasson, M.A., 2014, p/ 367).

Strategies to activate Provide how-to Use WhatsApp free texting application

readiness information, promote information about prenatal care, adverti
awareness, reminders. who are offering discounted or free rate
networks for prospective mothers.
Cues to Action

Self Efficacy Confidence in ones Provide training, Provide opportunities for prospective m
ability to take action guidance in action, on-one with various nurses and OB/GY
progressive goal fears about establishing care and allowi
setting, and first appointments during prenatal care
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reinforcement, sessions.
demonstrate
behaviors, and reduce
anxiety.

Activity

In order to effectively administer this evidence-based Infant Mortality Prevention

Program to Women in Duval County, Health Zone 1 home visits will be conducted in our sample

population. This intervention will target the Behavioral Objectives of our target population

(Barriers to Action and Perceived Susceptibility). According two established programs in Health

Zone 1, Women and Children (WIC) and Healthy Start, home visits were effective methods of

lowering rates of infant mortality. Furthermore, Kothari, Zielinski, James, Charoth & Sweezy

(2014) indicated that home visits reduced disparities in infant mortality in their population. Infant

mortality rates for non-whites in Duval County is 12.9/1,000 live births much higher than the

rate for whites in Duval County, only 5.2/1,000 live births (Florida Charts, 2013). The racial

disparity in infant mortality rates is large in our target population, because home visits have been

shown to reduce the disparity, home visits were chosen as our activity.

Home visits will help our participants overcome two behavioral objectives, barriers to

action and perceived susceptibility. The two barriers that our intervention will overcome are the

cost of prenatal care visits and the time required for transportation to and from a doctors office

because our home visits will be free and be completed in less than one hour. To overcome

perceived susceptibility we will show our participants the risks of not received adequate prenatal

care at an early stage, include risk of low birth weight and birth defects in the baby. We will also

provide advice on creating a safe home environment for mother and baby.

To accomplish our goals with this intervention we will require a staff of qualified
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Registered Nurses (RNs) who are trained in prenatal care, bilingual and minority nurses would

be beneficial in connecting with our sample population. Our Registered Nurses would require a

brief training about the goals of our program and what services they are required to ensure fair,

accurate and professional behavior in the home environment. The Registered Nurses would be

coached to explain the perceived benefits and perceived severity of prenatal care. Additionally,

we require the medical supplies to perform health screenings, pamphlets explaining and

correcting risky behaviors such as alcohol and drug use and common home safety hazards such

as in-ground pools without gates. Each Registered Nurse would require one day of training

before they complete any home visits. We could require six nurses to complete five home health

visits each, for a total of 30 home health visits total. Each visit would be completed in within an

hour and nurses would be compensated for their time spent at the one day training, the five hours

of home health visits and their transportation.

Most prenatal visits will include, checking your blood pressure, measuring your weight

gain, measuring your abdomen to check your baby's growth (once you begin to show), checking

the baby's heart rate (Womens Health, 2012). In order to educate our pregnant mothers about

their susceptibility of infant mortality, we will connect their health status to conditions that

increase chances of infant mortality and instruct them on how to correct their behavior. For

example, continuing smoking and/or drinking alcohol during pregnancy increase the babys

chances of low birth weight, one of the leading causes of infant mortality. Additionally, our

prenatal care visits will include safe proofing the home, according to the Consumer Product

Safety Commission there are twelve products recommended for safe proofing a home, including

smoke alarms and outlet covers. We will provide one free smoke detector and six free outlet

covers at each home visits.

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Home visits will provide the best direct intervention in our target population to improve

rates of infant mortality in our research-based program, according to the current literature. Home

visits will target two barriers to action, cost of care and time required for a visits and perceived

susceptibility.
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Evaluation

This program broke participants into two groups during the information sessions, where

the participants learned about the importance of prenatal care and had the opportunity to meet

with attending OB/GYNs and nurses to sign up for prenatal care appointments. Out of the

session attendees, 50 were chosen randomly to receive home visits for their prenatal care. The

rest of the attendees were encouraged to make appointments while at the session.

Based on the Learner, Behavioral and Outcome objectives listed in the Goals and

Objectives section of this program plan, the decision was made to evaluate the program using a

pre-test and post-test comparison method. Both pre- and post-test surveys will consist of two

questions designed to specifically evaluate the objectives. To evaluate the Learner Objective, the

participants will be asked to list the three causes of infant mortality. For each correct cause

listed, there will be one point added to the survey score, for each incorrect cause listed one point

will be subtracted, and no points will be awarded or subtracted for no answer.

The Behavioral Objective evaluation questions differ for the pre- and post-test surveys.

The pre-test will ask the participant if she plans to make a prenatal care appointment after

learning she is pregnant. Consequently, the post-test survey will ask the participant if she had

attended a prenatal care appointment since a pregnancy was confirmed. Similarly to the

evaluation of the above questions, the yes response to the first question will result in a +1

point, a no will be given a -1 point, and no answer will mean no points are added or subtracted

to the total.

The other questions in the survey concern both data about the attitudes the participants

have towards prenatal care, the programs impact of the participants knowledge about prenatal

care and the likelihood that the participants will use prenatal care in the future. The yes and
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no responses from the participants will be scored in the same way as the objective based

questions, with a yes receiving a +1 point added to the overall score and a no receiving a -1

point taken away from the overall score.

Participants will have been recruited February, having signed up for the program at the

two Winn-Dixie locations in Health Zone 1. The pretest will be administered at the beginning of

the two information sessions held in the beginning of March. The post-test will be given to the

participants during a follow-up meeting in March of the following year, three months after the

program will have been completed, and all of the data from the home visits have been collected.

Additionally, an external evaluator will be hired to evaluate the survey results. Results of this

program evaluation will be shared primarily with the Florida Department of Health-Duval

(FDOH-Duval), the Women Infants and Children organization, and the Healthy Start Coalition.
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Evaluation Survey

Pre-test:

1. List 3 causes of Infant Mortality.

2. Do you know what Prenatal Care is?

a. Yes

b. No

3. Could you describe what prenatal care means to you?

4. Do you plan on making a prenatal care appointment after finding out you are pregnant?

a. Yes

b. No

5. Do you feel that you will pursue prenatal care after confirming that you are pregnant?

a. Yes

b. No
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Post-test

1. List 3 causes of Infant Mortality.

2. Do you feel you have a better understanding of what Prenatal Care is as a result of this

program?

a. Yes

b. No

3. What did this program teach you that you did not already know about prenatal care?

4. Are you more likely to pursue prenatal care as a result of this program during this

pregnancy and future pregnancies?

a. Yes

b. No

5. Have you attended a prenatal care appointment?

a. Yes

b. No
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Budget

Category Item Cost

Wages 2 Part Time Health Educators $30,000

10 Nurses (10 home visits per nurse) $6,000

5 OB/GYN (speakers for information session) $0

Evaluation Consultant $3,000

2 days: Jacksonville Public Library
Venue $2,000
(Main Branch)
Educational Materials Printing (fliers, brochures, forms, etc) $400

Incentives Lunch for Participants $2,000

Gift Card for OB/GYN ($100 each) $500

On-Site Prenatal Care Sign-Up $0

Prenatal Vitamins (12 months, 200
$7,200
participants)
Blood Pressure Monitoring Equipment (cuff,
Equipment $800
logbook, etc.)
General Measurement Equipment (scales, tape
$500
measures, etc)
Office Space $12,000
Smoke/Carbon Monoxide Detector and
$6,000
Installation
Training 1 day of training for Nurses for Home Visits $2,000
Nurses Travel for Home Visits (Gas/repair
Travel Costs $200
costs)
Miscellaneous Staff Meetings $800

Insurance (general liability) $1,000

WhatsApp sign-up $0

Total $74,400
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Timeline

Year 1
Tasks: Jan Feb Mar Apr May June July Aug Sept
Reserve Office Space X
Reserve Space for Information Sessions X
Hire Nurses and Health Educators X
Enlist Doctors to Speak at Info. Sessions X
Acquire the Equipment and Supplies X
Recruit Participants (200) X
Train Nurses X
Two Information Sessions X
Gather Pre-test Data/Survey X
Home Visits X X X X X X X
Staff Meetings X X X

Year 2

Tasks: Jan Feb Mar Apr May June July Aug Sept
Home Visits X X
Follow-Up Meeting (with Participants) X
Collect Data With Post-Test Survey X
Send Post-Test to Evaluator for Data X
Analyze Data X
Prepare Results and Conclusions from
X
Program Data
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Bibliography

Baptist Health (2016) Healthy People 2020 Tracker. Retrieved from

http://www.baptistjax.com/about-us/social-responsibility/assessing-community-health-

needs

Centers for Disease Control and Prevention (2015, November 6). National Vital Statistics

System: Mortality Data. Retrieved from http://www.cdc.gov/nchs/deaths.htm.

Centers for Disease Control and Prevention (2013). CDC Grand Rounds: Public Health

Approaches to Reducing U.S. Infant Mortality. Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6231a3.htm

Florida Charts (2016). Duval County, Florida County-State Profile. Retrieved from

http://www.floridacharts.com/charts/DisplayHTML.aspx?

ReportType=7200&County=16&year=2014&tn=25

Florida Department of Health Duval County (2013) Health: Place Matters 2013. Public Health

Statistics, Assessment and Research 11(1), 2-8. Retrieved from

http://duval.floridahealth.gov/programs-and-services/community-health-planning-and-

statistics/place-matters/_documents/place-matters-final-dec2014.pdf

Florida Department of Health in Duval County (2016) Healthy Start. Retrieved from

http://duval.floridahealth.gov/programs-and-services/clinical-and-nutrition-

services/maternal-child-health/healthy-start/index.html

Florida Department of Health in Duval County (2016) WIC Program. Retrieved from

http://duval.floridahealth.gov/programs-and-services/clinical-and-nutrition-services/wic-

and-nutrition/index.html

Health Resources and Services Administration Maternal and Child Health (2013).
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Collaborative Improvement & Innovation Network to Reduce Infant

Mortality.

Retrieved from http://mchb.hrsa.gov/infantmortality/coiin/

Kieltyka, L., Craig, M., Goodman, D.A., Wise, R. (2012). Louisiana

Implementation of the National Fetal and Infant Mortality Review

(NFIMR) Program Model: Successes and Opportunities. Maternal and

Child Health Journal, 16, 353-359.

Kothari, C.L., Zielinski, R., James, A., Charoth, R.M., Sweezy, L.C. (2014) Improved Birth

Weight for Black Infants: Outcomes of a Healthy Start Program. American Journal of

Public Health, 104(1), 96-104. doi: 10.2105/AJPH.2013.301359

Lau, C. Ambalavanan, N., Chakraborty, H., Wingate, M. S., Carlo, W. A. (2013).

Extremely Low Birth Weight and Infant Mortality Rates in the United States.

American Academy of Pediatrics. 131(5), (855-860).

Lu, M. C., & Johnson, K. A. (2014). Toward a National Strategy on Infant Mortality.

American Journal of Public Health, 104(S1), S13-S16.

Moehling, C.M., Thomasson, M.A. (2014). Saving Babies: The Impact of Public Education

Programs on Infant Mortality. Population Association of America, 51, 367-386. doi:

10.1007/s13524-013-0274-5

Northeast Florida Healthy Start Coalition, Inc. (2016). Fetal and Infant Mortality Review.

Retrieved from http://nefhealthystart.org/for-babies/fimr/

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