Christina Litchfield has always been passionate about prevention. As the fetal, infant and child mortality coordinator for the state of Montana for almost 10 years, she saw that passion develop.

Reading every case and reviewing every death report showed her the reality of each case and what led to the death. "I need to be even more prepared now with the information I have gained," she said.

Litchfield became involved with the state's efforts to develop a mortality review program in 1991. She started a pilot project in her hometown of Missoula, then disseminated it statewide. The program achieved the capability of reviewing more than 90 percent of all infant and child deaths in Montana before funding changes eliminated Litchfield's position.

She developed protocols for review, put together a state-level team and created a network for local coordinators that still is going strong.

"A lot of people say we know why children die," Litchfield said. "It's car accidents or suicides or whatever. But mortality review really enlightens communities. We have multidisciplinary teams with a good cross section of people-law enforcement, public health, mental health, child protection, EMS. They get together and review the deaths to see what contributed [to them], with the idea of trying to prevent deaths of a similar nature. What we started to learn were the factors behind these issues. The best part was that individual communities evaluated their risks and looked at things that were true for them that might not be true for others."

Statistics aren't very meaningful in a sparsely populated state like Montana, but communities looking at specific deaths can take action to change things. For example, she said, investigation of a rollover accident revealed that guardrails on that road were far too low, a result of paving projects. The community fixed that rail, and is working with the state to make sure rails in other parts of Montana also are up to standards.

"The preventive nature of mortality review has really compelled people to continue with it at the local level. I'm very impressed with the work people are doing on this," Litchfield said.

Litchfield believes the Montana project showed how much public health nurses are capable of in terms of organization and leadership.

"Public health nursing has such little visibility in the U.S. The project was a good way to show they have a great deal of capability."

Litchfield is back in the public health trenches herself, working with high-risk families and public health issues, particularly those related to poverty. Her experience in the mortality project taught her a lot.

The biggest challenge, she said, was changing people's attitudes. "Some people didn't believe it was necessary. The process was not to expose wrongdoers or breach family confidentiality, but to learn from what happened to that child." The challenge that remains, she believes, is taking what has been learned and working toward more prevention. After all, that is her passion.