While a healthy and safe birth for the mother and infant is the goal for all labor and delivery units—regardless of the level of services available—in some instances, what should be a joyous, celebratory event turns to tragedy when the newborn dies. The rate of perinatal mortality in the U.S. has steadily declined to a rate of 6.9 deaths per 1,000 live births in 2001. Nevertheless, since 1996, a total of 47 cases of perinatal death or permanent disability have been reported to the Joint Commission for review under the Sentinel Event Policy. Cases considered reviewable under the Sentinel Event Policy are "any perinatal death or major permanent loss of function unrelated to a congenital condition in an infant having a birth weight greater than 2,500 grams." Forty of the cases resulted in infant death and seven cases involved permanent disability. The mothers ranged in age from 13 to 41, with the average and median age being 27 years, and in just over one-half of the cases, it was the first child. The average gestation was 39 weeks.