During the reporting year (2019-20), the Maternal, Child and Adolescent Health Division (MCAHD) continued its work with Women’s Reproductive Health (WRH) and Maternal Health (MH). WRH focuses on health issues during the years between menarche and menopause, including the pre- and interconceptional periods, while MH concentrates on health during pregnancy and immediately after birth. The MCAHD directs its efforts at different levels, including community-wide education and outreach, individual education and support, professional development, and stakeholder/system level interactions.
MCAHD Programs for WRA/MH
The MCAHD has traditionally reached the population of WRA and pregnant women through various strategies. At the individual level, the Home Visiting Program (HVP) focuses on pregnant persons at high risk for adverse birth outcomes. Home Visiting Nurses (HVNs) offer education, support and care coordination to women from pregnancy through two years after the birth of their child. Perinatal Nurses visit birthing hospitals to provide education and referrals to new mothers, regardless of risk level. At the community level, the Health Educators design educational activities and materials on maternal and child health topics and lead the public education efforts. The Community Health Workers (CHWs), in turn, offer health promotion activities in varied community settings. As will be described in this section, beginning in March 2020 the COVID-19 pandemic restrictions have resulted in substantial modifications to the aforementioned intervention strategies. In spite of this, MCAHD has not stopped providing support and education to women in the community.
The MCAHD regional staff that implemented these activities in 2019-20 included 81 Home Visiting Nurses offering services in 70 of the 78 municipalities; 7 regional HVP nurse supervisors; 8 Perinatal Nurses who visit birthing hospitals throughout the Island; 5 Health Educators; and 32 Community Health Workers. At the regional level, they respond to the 7 regional MCAH directors, who in turn report to the MCAHD director.
Home Visiting Program
The Home Visiting Program (HVP), staffed by the Home Visiting Nurses (HVNs), operates throughout the island, including the island municipalities of Vieques and Culebra. The HVP was originally modeled on the Nurse Family Partnership program. It is designed to offer holistic case management, care coordination, support and education services to pregnant and parenting persons, their children up to age 2, and their families. A variety of validated screening instruments and tools are used to identify participants’ strengths and needs. Interventions are based on a biopsychosocial model of care. HVNs educate participants regarding protective behaviors, including appropriate prenatal care, healthy eating, physical activity, breastfeeding, positive parenting, infant and child development, safety, and related topics. Behaviors that can affect mother and baby are also emphasized, including alcohol use, smoking, prescription and over-the-counter medication use, exposure to toxic substances, stress, intrafamily and partner violence, maternal mental health, among others. In addition, social determinants of health including access to health care, employment, housing, social support systems, and others are identified and addressed as needed.
HVNs refer participants to care providers in the community according to the identified needs and offer follow up to ensure services are received. They also monitor whether pregnant women are receiving adequate prenatal care and that infants and children are receiving care according to EPSDT guidelines. Criteria for admission to the program include:
- primigravidas up to 21 or over 35 years of age;
- primigravidas with chronic health conditions (diabetes, hypertension, lupus, epilepsy, among others), morbid obesity, Zika virus infection, or other conditions, regardless of age; in 2020, COVID-19 was added to the list of qualifying conditions;
- pregnant women with a previous pregnancy or infant loss and no living children.
HVP – Intervention with Participants
Puerto Rico has suffered a significant loss of population in the last decade. According to the 2020 Census, there was a decrease of 11.8% of the population between 2010 and 2020, the largest loss of any US jurisdiction[1]. This decrease is attributed to two factors: migration due to the economic collapse that began in 2006, and a steep decline in births[2].
Puerto Rico has faced a series of dramatic natural and political events in the last 4 years. The status of the fragile MCH population had been particularly affected by Hurricanes Irma and María in September 2017 and the earthquake sequence that affected the south and southwest of the Island beginning in December 2019. The appearance of the COVID-19 pandemic early in 2020 further complicated life in Puerto Rico, particularly for the most vulnerable populations. The HVP has striven to adapt and respond to these very different emergency situations in order to continue offering services as effectively as possible.
Earthquake sequence: The earthquake sequence that began in December 2019 and is still active have been described elsewhere in this document. The HVP had developed an emergency data collection form to record participants’ status and needs after Hurricane María, and it was quickly adapted to reflect the situation. HVNs were able to make contact with the majority of their participants by telephone or in person (in their homes, with relatives or in shelters). Some of the HVNs in the area were assigned to offer assistance in the emergency shelters on a temporary basis. Over the following months HVNs worked diligently on identifying available providers in the community and coordinating services needed by the affected families.
At the time of writing this report the seismic sequence is still active, with over 15,000 quakes in the period December 2019 – May 2021[3]. Much of the earthquake damage has been left untouched, since the COVID-19 emergency arrived on the heels of the earthquakes. However, most services have been restored in the area, albeit with limitations imposed by COVID-19 protocols.
COVID-19: In early 2020, the earthquake sequence was still affecting the southwest of the Island with daily tremors, and residents of the stricken areas were struggling to deal with housing, employment, basic services, child care (schools in the region were closed), and daily chores. Information regarding a new viral disease that would come to be called COVID-19 was trickling in, but the impact it would have in PR was not clear.
On March 5 the first guidelines for HVP staff (“Recomendaciones para personal del PVH ante el coronavirus”), which collected the recommendations given at the time by health authorities, were written and distributed. That initial document included the information available at the time regarding the virus and basic infection control measures to minimize the risk of contagion with SARS-CoV-2 during home visits.
However, this protocol was short lived, as it was followed soon after by the PR government’s radical measures to control the spread of SARS-CoV-2. This included a sweeping lockdown, a nightly curfew, closure of nearly all businesses except for essentials like supermarkets, drug stores and gas stations, and shuttering of all government offices. The majority of government employees, including all the HVNs and other MCAHD staff, were ordered to work from home.
One of the most important inputs available to HVNs is the home visit, which allows them to observe living conditions that directly influence the health, safety and wellbeing of the participant mother and child and their family. The stay-at-home order precluded in-person visits to participant families; HVNs thus lost a crucial source of information. This led to the development of a protocol for a modified intervention to be done via telephone and text messaging, which was key to achieving a uniform response to an unstable, rapidly fluctuating situation. Since the governor’s order had been published over a weekend and took effect on the following Monday, most HVNs were not able to retrieve records, forms or materials from their offices. To simplify the interventions that would be carried out by phone, an abbreviated interview form was designed by HVP staff in consultation with regional supervisors and MCAH program directors to ensure appropriateness and usability (see Figure 1). A guide entitled “Protocolo para el seguimiento de las participantes del Programa de Visitas al Hogar durante el período de aislamiento físico por la pandemia de COVID-19” was developed and distributed to the staff on April 3, 2020. Supplemental instructions were issued on June 3, 2020 and July 8, 2020, to adapt the protocol to changes in the official government orders.
The HVP Coordinator, Evaluator and Title V Mental Health Consultant carried out training sessions via Zoom to discuss the emergency protocol with HVNs, regional supervisors and directors. A separate meeting was held for each of the health regions to encourage active participation. In addition to explaining the protocol, we took the time to explore the HVNs’ experiences and feelings regarding the pandemic and their work with our participant families.
The protocol provided five questions to guide the interventions:
- How have you felt since the last time we spoke?
- What concerns or needs do you have at this time?
- Have you had any significant changes or worries in your life? (related to health, employment, relationships, etc.)
- What would you like to know about COVID-19?
- Have you or any friends or family members had symptoms related to COVID-19?
The HVNs were encouraged to allow participants to express their feelings and concerns, especially since the stay-at-home order meant many people were isolated and lonely. The replies to these questions were then used to determine the course of action the HVN would take with the participant. In the initial months of the pandemic, it was deemed more important for the HVN to have frequent contact and offer support than it was to adhere to a protocol that was not applicable due to the difficult circumstances.
A simple electronic form was designed in Google Forms to record all interventions and the information gathered in the telephone interviews. This proved to be a valuable tool that enabled the supervisors and the evaluator to have ready access to the data and monitor HVNs’ productivity.
The adaptation process was not without challenges. The most salient was the lack of uniformity in the mobile phones and cell/data plans held by the HVNs. At the time the stay-at-home order was decreed, HVNs did not have a government-issued mobile phone, so their communication capabilities varied widely. Some of the HVNs had antiquated equipment, limited data plans or weak signal strength in their homes. Nevertheless, all were able to find ways to carry out their work; some went to a relative's home or drove to a location that had a stronger signal. This demonstrates the commitment HVNs have to their work and their participants. In addition, many HPV participants had similar technological limitations. Therefore, care was taken to develop interventions that worked with minimal technology requirements.
A second challenge was the limitation of the kinds of interventions HVNs were able to carry out during a phone call or by text messaging (the method preferred by many of the younger participants). It would be difficult to fill out complex forms or to administer sensitive screening tools, such as for substance use, ACEs, and intimate partner violence; in terms of the children, the HVNs could not observe their developmental milestones. Therefore, the telephone intervention protocol focused on offering emotional support, education regarding COVID-19 prevention, covering the most important topics for the prenatal or interconceptional period, identifying pressing needs, and assisting participants in obtaining needed services. Although the instruments were not being administered, the HVNs were alert to signs that could suggest instances of domestic violence, substance use or other threats to the participant's safety and wellbeing. They asked the mothers detailed questions to assess the children’s growth and development and some were able to share photos or videos showing the babies’ movements and demeanor.
The third challenge that presented a barrier to services was that during the initial phase of the lockdown all government and private services were closed or severely limited, except for emergency services, making it difficult to access Demographic Registry, WIC, other aid programs, as well as regular medical attention including prenatal and pediatric care. The HVNs have contacts at the local level to coordinate services, but these channels were not readily available. The MCAH regional directors were able to communicate with peers in various agencies to identify workarounds and alternate means of obtaining the assistance needed. In addition, many medical offices and hospitals developed strict infection control protocols that placed a burden on patients. For instance, many dentists and physicians requested a negative COVID-19 test before seeing patients; limited clinic hours meant appointments were hard to obtain; hospitals restricted the presence of a support person during labor and delivery and limited or prohibited visitors to hospitalized persons.
Before the pandemic, regional HVP supervisors and the central level HVP staff met monthly to discuss programmatic and administrative matters relating to the implementation of the program. In order to deal more effectively with the changing environment after the lockdown, weekly meetings via Zoom (later Microsoft Teams) were held beginning in March and the group was expanded to include the regional directors, the coordinator of the Health Education component, and the Title V director. This enabled the program staff to discuss implementation challenges and opportunities to ensure quality of services offered to participants in the face of challenges presented by the COVID-19 emergency. During the meetings, the regional staff report on barriers to service or cases that present difficulties and share success stories. Once a month an HVN presented a case that had proved to be particularly challenging and the group gave feedback on the handling and results. As a complement to the virtual meetings, a group was formed in an instant messaging application to exchange information quickly and efficiently.
By September 2020 the situation had stabilized enough that the meetings were scaled back to every other week; as of this writing they are scheduled monthly, still via Microsoft Teams. These meetings made an important contribution to the success of the interventions during the pandemic.
After the stay-at-home orders were lifted, the HVNs gradually returned to their offices as allowed by the prevailing government mandates but they continued to carry out virtual interventions with their participants since the risk of transmission was deemed too high to send the HVNs to participants’ homes.
HVP Participant Information
The pace of admissions to the HVP slowed down after March 2020. The usual sources of referrals to the HVP – mainly WIC, Medicaid and OB/GYN offices – were closed or providing limited services. HVNs and CHWs were not able to go out in the community to promote the services or identify candidates for the program. As shown in the following table, the total number of pregnant persons admitted to the HVP in 2019-20 was 979, a decrease of 16.54% over 2018-19. The largest decrease was seen in the number of newly admitted younger participants.
This change might be related to the decrease in the adolescent birth rate for PR over the last decade, which is shown in the following graph:
The HVNs focus their interventions on pregnant and parenting persons, their babies, and their families. During 2019-20, the HVP provided services to 5,130 participants in 2,785 families, distributed as follows:
The women participants ranged in age from 12 to 43 years old, with a mean of 21.23 years. Two thirds (63.7%) were 21 years of age or under. Figure 5 shows their age distribution and Figure 6 their civil status.
Of the 2,785 women participants, 979 (35.2%) were newly-admitted pregnant participants. One third (37.0%) entered the HVP in the first trimester of pregnancy, a similar proportion to 2018-19. The majority (85.5%) had initiated their prenatal care in the first trimester of pregnancy. Almost all (89.3%) HVP participants were GHP beneficiaries; 9.9% had private insurance and only 0.8% report paying out of pocket for medical care. Accordingly, more than half (57.3%) received prenatal care in an IPA, 39.1% in a private practice and 3.7% elsewhere. No women reported they lacked a prenatal care provider.
Two thirds of pregnant participants (62.5%) reported having a dental care provider. Beginning on admission to the HVP, HVNs offer education on the importance of oral health during pregnancy, given the relationship between oral disease and adverse birth outcomes. Some dentists are reluctant to treat pregnant women, fearing possible complications. The HVNs identify the dentists in the community that accept pregnant patients and refer participants to them. Data regarding completion of referrals of HVP participants will be presented in 2022. PRAMS data for NPM 13.1 reveal that in 2019, 53.3% of respondents had a preventive dental visit during pregnancy.
During 2019-20, HVNs had an average caseload of 23 families (range: 7-40 families), down from 27 families in 2018-19 (range: 13-40). They completed 18,695 home visits, which represents 5,848 (23.8%) fewer visits than in 2018-19. This can be attributed to a decline in new admissions and the limitations imposed by the COVID-19 pandemic measures explained above. However, the drop in in-person visits does not equate to a decrease in services provided to the participants. On the contrary, in the reporting year HVNs carried out 61,696 interventions with participants (see Table 3 for details), an increase of 4,187 (7.3%) over 2018-19. The average number of interventions per participant also increased, as shown in table 4.
The following graph shows the comparison of interventions in 2018-19 and 2019-20 according to the type of contact between the HVN and the participant.
Screening Instruments
A tobacco use history instrument was administered to the 46 pregnant participants who stated in the screening prompt that they had ever smoked. It is important to note that this instrument was temporarily discontinued after March 2020 due to the pandemic, so these numbers reflect only 8 months of interventions.
The next table reflects the responses of the women who were ever-smokers and responded to the tobacco use history instrument.
An alcohol and drug use screening instrument based on the 4P+ screening tool[4] was administered to 646 pregnant participants from July 2019 to March 2020. Two thirds of respondents (388, 60.5%) reported ever having used alcohol. Table 3 shows their responses regarding frequency of alcohol and drug use in the month before pregnancy and in the month before the interview (i.e., during pregnancy). Only one respondent (0.3%) reported using any alcohol and none reported using drugs in the previous month. The information collected in the birth certificate for NOM #10, Alcohol use in the third trimester of pregnancy, reveals a similar low frequency of alcohol use in pregnancy, as shown in Figure 8.
Women are generally aware that alcohol, tobacco and other drug (ATOD) use during pregnancy carries a stigma; therefore, accurate information is commonly withheld from health care providers. With this in mind, the HVNs offer education on the effects of ATOD on the fetus to all women, regardless of their admitted use.
The HVP protocol calls for all participants to be screened for maternal depression/anxiety using the 10-question Edinburgh Postnatal Depression Scale (EPDS) at least once during pregnancy and twice in the first year postpartum. During this reporting year the HVNs discontinued the administration of the EPDS from March 2020, when in-home visits were stopped, to August 2020 when they started administering the instrument by phone. Between July 2019 and February 2020, the EPDS was administered to 1,360 pregnant and interconceptional participants. A total of 1,546 screens were administered, a decrease of 226 (12.7%) from 2018-2019. Figure 10 shows the point distribution of the EPDS for the reporting period.
The responses ranged from 0 to 25 points, with a mean of 3.53 points and a standard deviation of 3.94. No statistically significant differences were found in risk levels over 10 points between participants up to age 21 (8.5%) and those 22 and over (8.0%) (p=.389). Seventeen (1%) screens had a positive response to Item 10 (suicidal ideation).
For participants who obtain >10 points on the scale or a positive answer to Item 10, the HVP protocol requires the HVN to offer education and a referral to mental health services. In addition, they receive frequent follow up by the HVN to ensure completion of the referral and adherence to any treatment that may have been prescribed. Of the 118 participants who obtained >10 points, 16% were already receiving mental health services, 38% were issued a referral for services, and 10% were offered a referral but refused it. Among the 17 women with a positive response to Item 10 (suicidal ideation), 18% were currently receiving services, 59% received a referral for services, and all were given support and information. The number of referrals for service was lower than in 2018-19 because services were severely limited during the pandemic.
PRAMS data for NOM #24, Postpartum depression, reveal that 11.6% of respondents in 2019 self-reported having postpartum depression. The proportion for HVP participants, is slightly lower at 8.7%. The comparison of the two groups is not direct, since PRAMS does not use a screening instrument to assess for depression. The support and education regarding symptoms of depression that the participants receive from the HVNs beginning in pregnancy may be a contributing factor for a more positive state of mental wellbeing.
Participants are screened for the presence of violence using the Women’s Experience with Battering (WEB) scale. The scale consists of 12 questions that inquire about psychological and physical manifestations of violence in the woman’s relationship. It is answered using a 6-point Likert scale, from “Totally disagree” to “Totally agree.” The possible scores range from 12 (no experiences with violence) to 72 (extreme experience with violence), with a score of 20 or more points representing a high risk for violence. The scale is administered in the second or third trimester of pregnancy and again three months postpartum. A total of 1,046 screens were administered from July 2019 to February 2020. Of these, 1,017 (97.8%) scored low (<20 points) and 23 (2.2%) scored high (≥20 points). The scores ranged from 12 to 50, with a median of 12 points. There were three questions where over 1% of respondents answered, “slightly agree” to “totally agree,” (numbers correspond to the item number in the instrument):
(1) He makes me feel unsafe even in my own home.
(2) I feel ashamed of the things he does to me.
(4) I feel like I am programmed to react a certain way to him.
For all other questions, between 0.2% and 0.8% respondents answered in those categories.
The WEB instrument is answered by the participant, who then hands it to the HVN to score and interpret. As with other instruments that screen for sensitive topics, women may be hesitant to reveal they are living in a violent environment. Therefore, HVNs offer education and support on this topic to all women, regardless of the score. For those women who score high, the HVNs have several options for intervention, including a brief form that the woman can fill out to ask for further help if she is not able to verbalize it due to the presence of the aggressor or other family members. HVNs have a complete directory of services for women who live with violence, ranging from hotlines to shelters and legal assistance if the woman decides to leave home. The HVN can help the woman develop an escape plan, steer her to organizations that can help her press charges, as needed. In the reporting period, HVNs referred 17 participants to services and advised 2 on how to develop an escape plan.
HVP – Activities at the Community Level
The HVNs offer education, support and care coordination on a limited basis to pregnant and parenting persons in the community who do not qualify for the HVP or who are not able to engage in a long-term commitment to the program. Partners, relatives and friends of HVP participants are also offered education to prepare them to support their loved ones. This is a way to increase the scope and reach of the mission of the MCAHD for vulnerable populations. In the reporting year, these interventions took on a more important role for many women who were not able to access their usual sources of care. Normally HVNs can offer a limited number of interventions to assist non-participant women with a specific situation. However, during the lockdown period the rules were relaxed to enable the HVNs to assist women for a longer period if needed. Although the total number of interventions with non-participants decreased from 7,731 in 2018-19 to 6,290 in 2019-20, the number of telephone interventions increased 128%.
A total of 901 referrals were given to non-participants of the HVP, which represents a decrease of 663 (42.4%) from the 1,564 referrals made in 2018-19. Again, this is due to the closing of public and private services beginning in March 2020. Referrals were made to the services detailed below:
Training for HVP Staff
HVNs are offered in-service training on a regular basis to ensure they have the most updated information regarding MCH issues and have the tools and skills needed for effective interventions with their participants. Beginning in March 2020, all training sessions have been done via Zoom or Microsoft Teams. Please see Workforce Development for details of the trainings offered during the reporting year.
As previously discussed, the regional HVP supervisors and MCAHD regional supervisors hold regular meetings with the HVP Coordinator, Evaluator and the Title V Mental Health Consultant. The focus of these meetings is to present new information that pertains to the program, discuss challenges and successes, weigh options to overcome any challenges, and facilitate uniformity and quality of implementation of the program model at the local level. Since March 2020 these meetings have taken place via Zoom/Teams.
Community Health Workers and Health Educators
Community Health Workers (CHW) and Health Educators (HE) direct their educational efforts to group interventions in schools, health service provider sites and communities. HEs also offer training on health topics to various audiences and create educational materials and curricula on diverse MCH topics. The population groups reached by the CHWs and HEs include reproductive age women, pregnant and parenting women and their companions, and the general public.
During 2019-2020, the educational efforts of CHWs and HEs were affected by the COVID-19 pandemic measures. From mid-March to June 2020 the CHWs devoted their time to making phone calls to government agencies and private providers to verify what services were being offered during the lockdown and how they could be accessed. They also assisted in coordinating services for community participants.
Due to the aforementioned circumstances, the data reported in this section pertains to the period of July 2019 to the second week of March 2020. The main interventions directed to WRA and maternal health are the Prenatal Course and group orientations on various aspects of women’s health, pregnancy and reproductive health.
The Prenatal Course consists of four educational sessions that include information and educational activities divided into the following topics: healthy lifestyles, prenatal care, risk behaviors, stages and changes in pregnancy, conditions affecting pregnancy, delivery planning, delivery process, signs and prevention of premature birth, caesarean birth, postpartum care, baby care, breastfeeding, birth spacing and family planning. Information on the transmission of Zika and preventive measures, its effect on the fetus and the need to test during pregnancy for infection has been added to this course. As part of the course, the participants complete a socio-demographic profile and a pre-and post-test.
In the reporting period, the Prenatal Course was offered 121 times by CHWs and 15 times by HEs throughout the Island. A total of 514 pregnant persons and companions (partners or other significant support person) participated in the course; of these, 482 (93.8%) completed all four sessions of the course.
One of the steps taken in response to the prohibition on group activities was to adapt the prenatal course “A Baby on the Way” to an on-demand video presentation. It covers all the topics in an abbreviated fashion and refers viewers to the “Encounter of my Life” website (encuentrodemivida.com) where they can access more complete information. The same strategy will be applied to the parenting courses in the coming months.
Health education topics on WRA/MH include women's preventive physical and mental health care; family planning, reproductive decision-making and contraceptive methods; preconceptional health including control of chronic conditions before pregnancy; interpregnancy spacing; use of folic acid and prevention of birth defects; healthy relationships; intrafamily and intimate partner violence; physical activity and nutrition for a healthy weight; seasonal diseases (influenza, Chikungunya, dengue and others); and community services related to depression, addiction, violence, child care, among others. Topics related to Zika virus transmission include signs and symptoms, effects on the fetus, prevention of mosquito bites and mosquito control inside and outdoors, and the use of condoms for protection from sexual transmission. All educational presentations and materials are revised and updated by the Health Educators as needed.
Community Health Workers reached a total of 16,724 persons aged 10 and up through a variety of activities covering these topics, including individual orientations, prenatal and parenting courses, and group activities in the community, health care provider offices and health fairs. This number included 2,408 pregnant women, 17,719 non-pregnant women, and 3,297 males.
The next two tables refer specifically to individual and group interventions of the CHWs with WRA, both pregnant and non-pregnant, by age group. The first table reports individual orientations and the second refers to group activities according to location of the intervention, age group and pregnancy status.
For their part, in the period of July 2019 to March 2020 the Health Educators reached a total of 4,930 persons aged 10 and over in group and individual orientations. Of these, 2,557 (51.8%) were 21 years of age or under, and 2,373 (48.1%) were 22 or over.
The next two tables reflect the Health Educators’ individual and group interventions with WRA, pregnant and non-pregnant, by age group. The first table reports the individual orientations and the second the group interventions according to location of the intervention, age group and pregnancy status.
Oral Health in Pregnant Women
During 2019-2020, the PR MCAH continued promoting oral health in pregnant women. Prenatal preventive oral health is a determinant that may have impact on the pregnancy outcome. Furthermore, poor maternal preventive oral health also is a risk factor for early childhood caries in their offspring.
Data from the Puerto Rico PRAMS reported 53.1% of pregnant women in 2019 and 48.7% in 2018 had a dental cleaning done by a dentist or dental hygienist in a preventive oral visit. In 2019, 19.6% stated they did not believe a dental visit during pregnancy was safe. These findings support the need to promote the oral health preventive visit and access to oral care for pregnant women.
The government-imposed shutdown (beginning in March 2020) and the practices implemented to prevent, and control COVID-19 infection affected access to dental services for the whole population during 2020-2021. Fear of contagion was added to the fear of receiving services during pregnancy, further influencing patient delays of preventive dental services.
During 2019 and 2020, despite the pandemic, the PR MCAH continued its efforts on strengthening collaborations with MCH stakeholders that provide services to pregnant women and implemented strategies to promote preventive oral health care visits. The Pediatric Consultant collaborated with the PR Territorial Dental Officer from the Health Promotion Division and other oral care stakeholders on improving oral health outcomes. PR MCAH contributed in promoting improvement in access to preventive oral health services for all pregnant women. Strategies implemented to attain the goals included:
October 2019 – The Oral Health Program, with collaboration of the MCAHD staff, developed a fact sheet entitled “Oral Health in Pregnant Women in PR, 2018” using 2018 PR-PRAMS data. The fact sheet is available from www.salud.gov.pr/Sobre-tu-Salud/Documents/Salud%20Oral%20Embarazo.pdf.
To increase awareness on the topic, key points on the data were also developed and projected during breaks in the February 2020 CME Dental Convention.
December 2019 – The MCAH Pediatric Consultant and President of the PR AAP Chapter coordinated and led a meeting with the presidents of the PR Pediatric Society (PPS) and the PR Pediatric Dental Society (PRPDS), a representative of the PR Dental Surgeons College (PRDC) and a member of the executive committee of the PR AAP Chapter to present data relevant to early childhood caries and oral health during pregnancy in PR. The data were also shared with the PR ACOG district president. The purpose was to promote collaboration in proposing and implementing strategies to improve oral health in pregnancy and early childhood. As a result, these partners developed a strategic plan led by the MCAH Pediatric Consultant.
Among the strategies focused on pregnant women’s oral care are:
- December 2019 – A promotional campaign via social media and email blast was directed to all OB/GYN members of the PR ACOG district and pediatricians who are members of the PR AAP Chapter. The campaign included a holiday card which proposed promoting oral health care visits in pregnancy and prevention of early childhood caries (ECC) in the population they serve as a resolution for 2020. This strategy was initiated in a Title V needs assessment meeting.
- January 15, 2020 – A workshop on oral health of pregnant women and infants and on how to adopt the infant ECC risk screening was offered by the MCAH Pediatric Consultant to 78 nurses, health technicians and staff of Head Start (HS) and Early Head Start (EHS) of 11 municipalities. The MCAH regional offices continue to provide educational activities in the community to promote the prevention of ECC and the establishment of a dental home for all the pediatric population.
- February 12, 2020 – Newspaper article entitled “Take care of baby teeth” was published to promote the benefits of preventive oral health care visits in pregnant women and family members, early establishment of dental home for infants at higher risk for caries, and recommendations for families to adopt habits that prevent ECC. The article was written by the MCAH Pediatric Consultant and the President of PPS and was published in a special supplement on pediatric health care topics in “El Nuevo Día” newspaper, which has the largest circulation in PR. It emphasized the importance of caring for deciduous teeth and of having a dental visit during pregnancy.
- February 15, 2020 – Press conference Prevención de caries en infantes y salud oral de la mujer embarazada promoting the benefits of preventive oral health care visits in pregnant women, infants, and family members, with the participation of all oral health stakeholders.
- February 2020 – Two continuing medical education (CME) lectures on the topics of preventive oral care of pregnant women and the identification of risks and prevention of ECC were offered during the PR Dental Annual CME Congress, which was attended by more than 300 oral health professionals.
- March 5-11, 2020 – Newspaper article titled “United for Oral Health” featuring the pediatric consultant, AAP-PR Chapter, ACOG-PR, PPS, and PRPDS was published in El Expresso newspaper, promoting best practices for early cavity prevention and oral health for pregnant women.
- July 13, 2020 – A webinar on oral health entitled “Oral Health of Pregnant Women and Children” was provided to 170 MCAH Home Visiting Nurses (HVN) and HS personnel to increase their skill in delivering information and evaluating cases by the pediatric consultant.
Prior to the pandemic, the MCAH staff provided individual and group in-person education on good oral hygiene, regular preventive dental check-ups, dental decay and oral disease to pregnant women, families, children, and adolescents, in an effort to increase awareness of the risks to overall health and wellbeing and how preventive oral hygiene, healthy oral habits, and preventive dental visits contribute to better health. The Prenatal Courses also provided education and promotion of oral care during pregnancy and encouraged a dental visit during pregnancy as part of every woman’s prenatal care plan. The HVNs provided education to participants about the importance of dental care and referred them to visit the dentist as part of their prenatal care.
The shutdown in March 2020 caused the postponement of in-person educational promotional efforts, but adjustments were adopted, and the efforts continued through telephone interactions, as in the HVP, or by delivering education and promoting oral care of pregnant persons through webinars.
Promoting Preventing Health Services Among Women
The MCAH Preventive Care Guidelines for women in reproductive age, which were developed beginning in 2016-17, were updated according to the latest developments and recommendations of local and national public agencies and professional organizations, including ACOG. The current update to the Women's Preventive Services Initiative (WPSI) Well-Woman Chart provided valuable guidance for the content and recommendations.
According to 2019 BRFSS data, around three-quarters of respondents had a preventive medical visit (NPM #1) in the year before the survey (see Figure 9), with very little change over the last 5 years. A question related to the annual preventive medical visit was recently added to the new HVP data collection forms and included in the first home visit. Preliminary data reveal that during 2019-20, 57.2% of HVP participants had a preventive medical visit in the past 12 months, which is considerably lower than the BRFSS results. HVNs educate participants on the importance of this visit and make the necessary referrals in the interconceptional period.
A pocket guide to women’s health, “Mi agenda de salud” (“My Health Planner”) is one component of the strategy designed to increase this indicator. It was not possible to develop the proposed pocket guide during the reporting year due to the efforts devoted to responding to the COVID-19 pandemic. “Mi agenda de salud” was developed in the first half of 2021 and will be distributed in the second half of 2021. Please see the Women/Maternal Health Application Year narrative for full details.
Maternal Mortality
The review of maternal mortality continues to be a priority for the MCAHD. The Maternal Mortality Epidemiological Surveillance System (MMESS) Act (Act #186-2016) was enacted in 2016 and the implementation protocol was registered in 2017. This legislation protects the information collected, the members of the Maternal Mortality Review Committee (MMRC) and the review process in general.
A letter from the Secretary of Health requesting access to the medical records was sent to 8 hospitals where possible maternal deaths were identified. The Title V OB/GYN Consultant and the TV evaluator who works with the MM review system started visiting hospitals and gathering available information regarding the deaths with the intention of preparing the cases to be presented to the MMRC. However, the COVID-19 pandemic restrictions put a temporary stop to those efforts.
The TV Evaluator has continued to link and evaluate the Vital Statistics birth and death data to identify maternal deaths. To date, 202 cases dating from 2009 to 2019 have been identified. The initial review of cases identified pregnancy-related hypertension (22%) as the major cause of pregnancy-related death between 2015 and 2019 in Puerto Rico. During this time period a maternal death was 12.1 times more likely to occur to women age 35 or older as compared with younger women (Confidence Interval: 7.1 to 20.7).
[1] Cortés Chico, R. (April 26, 2021). “Censo 2020: Puerto Rico pierde el 11.8% de su población en la última década.” https://www.elnuevodia.com/noticias/locales/notas/censo-2020-puerto-rico-pierde-el-118-de-su-poblacion-en-la-ultima-decada/
[2] Martin, J. A., Hamilton, B. E., Osterman, M. J. K., & Driscoll, A. K. (2021). Births: Final Data for 2019. National Vital Statistics Reports, 70(2). DOI: https://dx.doi.org/10.15620/cdc:100472.
[3] Alvarado León, G. E. (May 14, 2021). “Sigue ‘activa y vigente’ la secuencia sísmica que inició el 28 de diciembre de 2019.” https://www.elnuevodia.com/noticias/locales/notas/sigue-activa-y-vigente-la-secuencia-sismica-que-inicio-el-28-de-diciembre-de-2019/
[4] 4P+©National Training Institute, 1999. Used by permission.
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