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Strengthening the evidence for maternal and child health programs

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ESM 5.1 Percent of SUID cases reviewed by MCDR in prior year with a scene reenactment including photos completed by the investigating agency. (Alaska)

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs ( for this NPM or search for other strategies or promising practices (

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Public health services and systems level of pyramid

Essential Public Health Services: 1. Assess and monitor population health

Service Recipient: Activities related to systems-building

Goal: To improve investigative quality in order to support accurate classification and data related to SUID deaths by ensuring that SUID investigations include a scene reenactment and scene photos.

Numerator: Number of SUID cases reviewed by MCDR in the prior year with scene reenactment and investigative photos completed by the investigating agency.

Denominator: All SUID cases reviewed by the MCDR in the prior year.

Significance: In order to prevent SUID deaths, it is necessary to understand the exact circumstances in which each such death occurs. Knowing these circumstances enables the Maternal Child Death Review (MCDR) program to determine underlying risk factors and craft recommendations that inform prevention measures. In spite of progress with completion of SUIDI forms, the quality of investigations continues to pose challenges towards fully understanding each death, particularly with the respect to the thoroughness of interviews and evidence collection. A scene reenactment with the caregivers, using an appropriate weighted doll as an investigative tool, is a key component of the SUID Investigation. It not only provides information essential to accurate SUID categorization, but also reflects a level of effort and attention to the case that may not occur without a reenactment, even if the form is completed. The MCDR program has undertaken a new project to support investigating agencies with tools and training to help address some of these issues. The MCDR program is significantly funded by Title V.

Data Sources and Data Issues: MCDR Database. Cases reviewed by MCDR in a calendar year are based upon availability of records. Most cases are reviewed within one year, however, there are occasional delays, often related to pending legal cases. For example, the 2019 review year included one death which occurred in 2015. Therefore, we expect to see some delay in improvement for this indicator in response to interventions such as investigator training.

Year: 2020

Unit Type: Percentage, Unit Number: 100


This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.