On September 20, 2017 Maria, a category five hurricane, pounded the entire island of PR and its smaller outlying islands of Vieques and Culebra with rain and wind for 16 hours. The wind and rain caused structural damage to homes and buildings, sudden dangerous flooding, landslides, fallen bridges, and the flooding and debris blocked roads and highways. After the storm the entire island faced an electrical outage, an almost complete failure of the telecommunication system, non-functional water treatment plants and no access to tap water, restricted access to banking or digital commerce, and health care services dependent on the capacity of generators for electrical power. An estimated 18,000 people were in government shelters during the storm.
Although the hurricane caused the electrical grid to fail, most hospital institution thrived and continued to offer maternal-infant services with the use of generators for a source of electricity. One hospital in the south-east coast had to cease operation due to severe structural damage. Despite the damages and the challenges they continued operational by implementing many adaptations such as decreasing ward size, and/or allowing prenatal care to occur in the hospital facilities, because many obstetric offices had severe damage or did not have electricity to operate. In some hospitals the Obstetrics Department faculty and nurses implemented 24 to 48 hours in-house shifts so as to be immediately available in case of a maternal emergency due to lack of communication, poor state of the roads making travel and lack of road lamp post , making traveling difficult and dangerous at night. Few births occurred in unexpected places due to difficulty to reach their hospitals. The following table reports births as they occurred before and after the storm in 2017.
Despite the many challenges there were no significant changes in the percent of women giving birth unplanned at home or in other, out of an institution. Pregnant women had to overcome hardships such as limited access to food and water, therefore long term effects of the stress experienced by this population are at present unknown and will require observation and evaluation.
Home Visiting Nurses (HVNs) assumed a leadership role in their communities evaluating the needs of pregnant women. Because they remained updated of the available services that remained or that emerged in the community after the storm, they were able to refer the population to the resources appropriately. An outstanding example was the HVN in Culebra, an outlying island, who demonstrated her leadership role becoming the main liaison for all the mitigation and recovery efforts directed to families, due to her knowledge and established relationship with the community.
Vital Statistics (VS) data for 2018 report the IM rate of 6.5 per 1,000 Live Births (Preliminary Results). Prematurity (conditions associated) and low birth weight continue to be among the first five causes of infant mortality on the island. 2017 VS reported 270.6 preterm related deaths per 100,000 live births. Respiratory distress syndrome continues to be the main cause of death in early preterm babies. Preterm birth (PTB) in Puerto Rico, although has been decreased since 2015, remains high at 11.9% (preliminary VS 2018). Low birth weight (LBW) is related to preterm birth, an increasing health concern and the first cause of death for early preterm babies. According to preliminary VS data for 2018, 10.3% of live births had low birth weight for gestational age. Infant, neonatal and post-neonatal mortality demonstrate a decreasing tendency in preliminary data for 2018, as shown in the following table.
Multiple factors contribute to IM and morbidity, which remains a priority to address by the PR MCAH. One of them continues to be the risk of fetal infection by Zika virus. Although the epidemic was declared over in 2017, it continues to be a threat for pregnant women due to the year-round presence of Aedes species mosquito which may transmit the Zika virus, due to Puerto Rico’s tropical weather. Therefore, since 2016, the MCAHD has continued providing educational orientation and promoting pregnant women adopt preventive measures to avoid infection. In June 2016 a CDC grant was awarded to the MCAH to develop the Zika Postpartum Emergency Response Survey in Puerto Rico (ZPER) in order to conduct a rapid population-based assessment of maternal behaviors and experiences related to Zika virus exposure among recently pregnant women in PR. The survey was administered during three months in 36 birthing hospitals. Data was analyzed by CDC. MCAH staff collaborated evaluating the Spanish-language questionnaires, requesting IRB approval and assisting in the hiring of the personnel that worked in the study (Coordinator, interviewers, data entry clerk and others). Findings of the first stage of the study were published in the CDC’s Morbidity and Mortality Weekly Report (D’Angelo DV, Salvesen von Essen B, Lamias MJ, et al. Measures Taken to Prevent Zika Virus Infection During Pregnancy — Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep 2017; 66:574–578). Due to the high rate of responses and relevant information obtained a second ZPER was completed in 2017-2018. Puerto Rico received the 2018 National Epidemiology Award at CityMatch for its remarkable achievement in the P.R. Pregnancy Risk Assessment Monitoring System (PRAMS) and Z-PER Survey despite the challenges of the post hurricane disasters.
The HVNs and Community Health Workers (CHWs) continued promoting early prenatal care and testing for Zika in pregnancy as well as referral to the PRDOH surveillance system to follow up babies from Zika positive mothers. The MCAH staff collaborated with all efforts directed by the CDC and the PRDOH for the investigation and management of exposure to the Zika virus.
The MCAH Program has continued collaborating in the PR CoIIN for infant mortality reduction. The main objective of the Collaborative Improvement and Innovation Network (CoIIN), an initiative originated by HRSA and MCHB, is to reduce infant mortality in the US and its jurisdictions. The three strategies that the PR team has continued to promote are: preconception/interconception health, prevention of preterm and early term births, and perinatal regionalization. The MCAH staff also continued to promote the adoption of the Hard Stop Policy by hospitals through collaborative efforts with the Hospital Association. Administrative Order 366, which requires hospitals to adopt the Hard Stop Policy, was developed by MCAH staff and approved by the Secretary of Health on June 8, 2017. Complying with AO 366 is a requirement to obtain renewal of operational license from the Health Department.
MCAH staff members are members of the March of Dimes (MOD) Prematurity Prevention Committee, in which a representative of the Hospital Association also participates, that focuses on prevention of preterm births and the importance of completing at least 39 weeks of pregnancy. The approval of AO 366 was announced in the Prematurity Summit on June 9, 2017, sponsored by MCAH, during which the Sub Secretary of the PRDOH received the Virginia Apgar Prematurity Leadership Award for reducing prematurity by 31.7% during 2015 in Puerto Rico. This activity was attended by 256 participants (pediatricians, obstetricians, nurses, health educators, hospital administrators and other stakeholders).
Maternal and Neonatal Levels of Care Assessment (LOCATe)
The Maternal and Neonatal Levels of Care Assessment Tool (LOCATe) was created with the main objective of producing standardized assessment of level of maternal and neonatal care in hospitals within states, facilitate stakeholder conversations and minimize burden for respondents. The assessment is based on the compliance with the requirements delineated in the Maternal and Neonatal Levels of Care Guidelines by American College of Obstetricians and Gynecologists (ACOG), The Society for Maternal Fetal Medicine (SMFM) and the American Academy of Pediatrics (AAP). Puerto Rico implemented LOCATe during 2017. PR LOCATe, in an innovative approach, was completed in a face to face interview between MCAH staff with a team representing each hospitals administrative and medical staff; composed of the OB/Gyn Director, NICU or Neonatal Director, Nurse Supervisors and Administrator. This was done in an effort to minimize the possibility of having more than one survey by hospital answered by Survey Monkey. About 85% of the birthing hospitals (representing 83.5% of 2016 births) consented to participate in LOCATe. During 2017-2018, 27 out of 28 hospitals completed the initial interview. PR LOCATe interviews started in June 2017, however because of Hurricane María, data collection stopped until March 2018 when the rest of the hospitals were able to complete their initial interviews. After Hurricane María one of the participating hospitals closed the obstetric and nursery ward due to severe damages. Despite challenges after the storm the survey was completed and data was effectively collected. Preliminary data and LOCATe innovative strategy of face to face interviews in PR was presented in the 2018 AMCHP Conference.
Prenatal Multimedia Campaign
During 2017-2018 the multimedia campaign El Encuentro de Mi Vida (“The Encounter of My Life”) was renewed with the purpose to continue to spread the message to pregnant women and the community at large that pregnancy lasts 40 weeks, encouraging adequate care of the pregnant woman and the avoidance of risk behaviors that can affect the fetus, as a strategy to decrease infant prematurity, morbidity and mortality. It consists of a linguistically and culturally appropriate multimedia campaign aimed mainly at Spanish speaking pregnant women and their partners. The idea to appeal to emotions of pregnancy was discussed among MCAHD staff (subject matter and health education experts). Core messages and intended audience were determined by MCAHD staff. An advertising agency was contracted to produce the campaign. Production details, selection of actors, vetting message delivery and ensuring correct breastfeeding position were overseen by the MCAHD team. This project is an innovative campaign aimed at strengthening families by helping parents make informed choices. Videos were aired on TV, movie theaters & online beginning in July 2018. The web page www.encuentrodemivida.com was created providing access to the 5 videos and shorter clips of the couple giving advice regarding optimum prenatal care. The page also features fact sheets related to various aspects of prenatal care, infant care, and breastfeeding. All educational materials available in the website were developed by MCAHD staff, health educators and education specialists in accordance with ACOG and AAP recommendations overseen by the pediatric and obstetric gynecologist consultants. Banner ads for the website were featured on social media & news outlet pages beginning in July 2018.
Home Visiting Program
The Home Visiting Program (HVP) is an initiative that provides case management and care coordination services, health education and counseling to pregnant women with complex medical and social risk factors associated with LBW and VLBW infants, pregnant teens, and women older than 35 y/o. In the outreach activities delivered by the HEs, CHWs and Perinatal Nurses, they have the opportunity to identify and recruit pregnant women for the HVP. High-risk pregnant women are also referred from WIC and other collaborators in the community. A total 1281 pregnant women were initiated in the HVP during 2017-2018.
The population served by the HVP has a larger percent of adolescents as summarized in the following table. Adolescents are considered at higher risk for complications and poor outcomes but despite these differences in risk, outcomes are comparable to the general PR births outcome.
Although similar birth outcomes are observed in the HVP in comparison to the general birth population, the program serves a high risk population, suggesting its positive impact on birth outcomes. Further evaluations are being implemented in an effort to measure the impact of the HVP.
The Home Visiting Program nurses (HVNs) also delivered orientation and referrals to non-participants of the HVP as reported in the following table.
Educational Strategies implemented by MCAH Staff
The MCAH Program staff also continued offering educational activities to increase awareness of IM to participants, providers and the general population. The MCAH staff, Health Educators (HEs) and Community Health Workers(CHWs), provide education to pregnant women on the signs and symptoms of preterm delivery, the importance of early prenatal care, healthy eating habits and adequate weight gain during pregnancy, physical activity, preconception health, oral health, health complications that may arise, labor and delivery processes, breastfeeding, newborn care, and family planning. During the activities, staff encouraged women to abstain from risk behaviors such as smoking during pregnancy, and offered recommendations to reduce this behavior as well as other factors that contribute to poor outcomes. HVNs ensure that all HVP participants are evaluated in the WIC Program. The WIC Program also contributed toward reducing IM rates by focusing on women with nutritional risk factors.
The MCAHD had 8 perinatal nurses (PNs) during 2017-18, distributed in the 7 regions. The PNs provided educational services to 893 pregnant women; 36% of them were referred to needed services such as GHP, MCAH HVP, WIC, Prenatal course / Parenting course, and Zika prenatal clinics. Among other populations that received orientations from the PNs during 2017-2018 where 5089 post-partum women, 1,119 men and 1,401 accompanying non-pregnant women. Orientations covered by PNs included the following topics: Women's Health, Prenatal Care, Risks during Pregnancy, Delivery Processes, Postpartum Care, Breastfeeding, Neonatal Screening, Premature Baby Care, Newborn Care, Pediatric Preventive Care (EPSDT), Protective Car Seat Placement and Use, and Family Planning. The Perinatal Nurses also completed 8,313 visits to hospital, agencies and organizations.
Population reached by the PNs, CHWs and HEs with topics relevant to WRA and pregnant women are reported in the following table.
MCAH staff offered prenatal courses that discuss important health issues related to the prenatal, postpartum and interconceptional stages. A total of 1323 participants completed the 4 sessions of the prenatal course, “A Baby on its Way”. The main purpose of this course is building knowledge and providing participants with tools to maintain a healthy pregnancy, preventing risk behaviors, increasing the chances for a healthy delivery and appropriate care for the baby. The target population is pregnant women and their companions. This course consists of four educational sessions that include accurate information and educational activities divided into the following topics: healthy lifestyles, prenatal care, risk behaviors, pregnancy stages and changes in pregnancy, conditions affecting pregnancy, delivery planning, delivery process, 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.
FIMR
MCAH staff has headed the Puerto Rico Fetal Infant Mortality Review (PR FIMR) since 2006, complementing local population-based fetal and infant mortality data. The objective of the FIMR is to identify system-related risk factors for fetal and infant mortality and to generate recommendations to address them. To this end, the Review Team examines de-identified comprehensive information regarding infant and fetal deaths. The PR FIMR concentrates on deaths occurring to families participating in the HVP, all of whom are considered at high risk for IM. When a fetal or infant death occurs in the HVP, priority is given to provide the mother bereavement support. If the mother consents to an interview, the HVP nurse supervisor or MCAH perinatal nurse conduct an interview to obtain information which helps identify social determinants of health that have an impact on maternal health and the circumstances surrounding the death. Relevant information from the hospital record is abstracted by the MCAH regional perinatal nurses or MCAH directors. A copy of the HVP participant files is sent to the FIMR coordinator for additional data abstraction. The HVP files contain demographic and social determinant data, besides a chronological description of the participant’s strengths, challenges and interventions during pregnancy obtained by the HVP nurses in their interventions. The MCAH Pediatric Consultant prepares the case summaries that are reviewed and discussed by the Committee. The PR FIMR has identified critical community strengths and weaknesses as well as unique health/social issues associated with poor outcomes. The following table details deaths or losses occurred to participants of the HVP for 2017 to 2018.
In August 2017, the FIMR Committee summarized the following recommendations based on findings of the discussion of cases, to promote:
- Pre-conceptive Health in WRA.
- Providing information to tutors or caregivers of pregnant teens on the symptoms and signs of premature birth and where to go for services if they present them.
- Providing information to women of reproductive age of the risk of contracting sexually transmitted diseases, when using contraceptive methods that do not provide adequate barrier against sexually transmitted diseases.
- The Department of Health establishes a Committee to develop a Protocol to be implemented in hospital and health institutions to manage the loss of an early pregnancy and of a fetal death or Neonatal as indicated in Law No. 184 of 2016.
- Evaluation of hospital practices relating to support of parents during the hospitalization and/or bereavement after protocol is established and implemented.
All the recommendations applicable to HVP were incorporated as priorities to address and take action.
The FIMR coordinator and Pediatric Consultant of PR MCAH, Dr. Cindy Calderon, presented the experience of PR FIMR in evaluating the needs of a pregnant woman with ZIKA, in collaboration with Rosemary Fournier, sponsored by the National Center for Fatality Review & Prevention at the City Match 2017. This activity was from September 17 to 20, 2017 in Nashville Tennessee, coinciding with Hurricane Maria’s hit on the island.
The 2017-2018 period was a challenging year with emerging needs during rescue and recovery after the disasters caused by hurricanes Irma and Maria. FIMR meetings scheduled for October 2017 had to be postponed after the disaster caused by the storms due to other priorities relating to recovery, and lack of appropriate venues to meet. In May 16, 2018, Puerto Rico still was in a recovery phase and the first FIMR meeting was focused on identifying the challenges to birth and neonatal services due to interruptions in basic services caused by the storms and ongoing challenges and gaps to provide neonatal services in hospitals as a result of the damage caused by storms in September 2017. The care of newborns with complications requires life sustaining equipment in specialized units and therefore relies on a constant source of electric power. These patients may also require transfers for sub-specialized services to other institutions. Neonatologist from different regions of the island participated in this FIMR meeting, in a focal group discussion, sharing the challenges they confronted managing the NICU units after the storm due to the prolonged crisis. They provided recommendations based on their experience. From this meeting recommendations to improve preparedness and recovery for future disasters that place infants and pregnant women at risk were developed. The recommendations were shared with the Hospital Association and the Department of Health Emergency Preparedness Team as they develop plans to improve disaster preparedness and response for future catastrophic events for which the population of newborns and pregnant women are a vulnerable population at greater risk.
BREASTFEEDING
After the Hurricane
Families with newborns and infants faced many challenges after hurricane Maria. Families were unexpectedly displaced due to emergent life-threatening situations and those who lost their homes were housed by relatives or in government shelters. Most shelters had no guidelines on how to support and help newborns and postpartum mothers, no place to store milk, and limited access to clean and safe water. Breastfeeding in such an emergency becomes a lifesaving strategy, providing nurturing and protection to vulnerable young infants, due to overcrowding in shelters or relatives homes, the lack of electricity to store milk (Breast milk or formula), the initial lack of water from a clean source to ensure clean utensils and bottles for feeding and preparing formula, among others. Therefore promoting BF and safe infant feeding became a priority to which the MCAH staff responded developing and collaborating in multiple strategies. A campaign was developed by the MCAH staff and disseminated by radio (which was the only broadcast medium reliably available to the whole island) and local newspapers, during December 2017 to April 2018, to promote BF as the safest way to feed infants in an emergency. The translation of the logo to English states “Protect your baby, feed him with maternal milk.” This was accompanied by a short message of how Breast Feeding (BF) protects infants in an emergency situation, advices mothers to remain well hydrated and to visit a pediatrician days after discharge to evaluate baby’s health status.
A radio show promoting BF after the disaster with the Secretary of Health as the main spoke person and the Pediatric Consultant was recorded and broadcasted emphasizing these messages.
Two months after the hurricane most of the population remained without electricity or safe water. Another strategy to reinforce BF, Water for Milk, was launched by the PR ACOG Section in collaboration with MCAH, PR AAP and Pan-American Health Organization. The PR ACOG Section distributed water filtration systems to pregnant and post-partum women through their obstetricians to ensure a supply of clean water to sustain hydration and maintain breastfeeding. MCAH staff visited shelters and communities throughout the island identifying pregnant women and mothers with newborns, offering education on the lifesaving benefits of BF during an emergency and providing support to BF mothers. During this recovery process the HVP nurses continued to visit their participating families in the community, and the distribution of the manual breast pumps and the orientation and support on how to use them to stimulate and maintain milk production as an essential aid supporting BF in the recovery from the disaster. In an island with an ongoing threat of repeated storms, promoting BF becomes essential part of every preparedness plan.
The MCAH Coordinator for the Breast Feeding Promotion Collaborative Group(BFPCG) served as a point of contact and facilitator providing orientation for non- profit and federal organizations of available resources and contacts in the BFPCG network, contributing in their recovery efforts to support BF and safe infant feeding. The group Alimentacion Segura Infantil (ASI, English translation Safe Infant Feeding) emerged as a recovery response group with a grant by Save the Children; a group of volunteer women and IBCLC, providing orientation and support to women in shelters and in the community, promoting breastfeeding and safe preparation of formula in disasters. The La Leche League (LLL) of Puerto Rico was another contact reached out by Medic Corps through the BFPCG coordinator. They received a grant to provide orientation and support to women in shelters and in the community, promoting breastfeeding and safe preparation of formula in disasters. Both groups also fostered re-lactation providing the support and supplies necessary for mothers to successfully reestablish breastfeeding after the disaster. The ASI group reached 74 municipalities and the LLL concentrated their efforts in the south and west of the Island. The LLL were able to help 150 women re-establish breastfeeding after the disaster. Both groups established BF support groups in municipalities and hospitals, where previously there were none available.
A conference on Pediatricians Role supporting Breastfeeding in the community was delivered in February 2018 in the PR Chapter of the AAP meeting, in which the Pediatric Consultant emphasized strategies to support BF initiation in the Hospital. After hurricane Maria (September 20, 2017) BF rates were sustained and BF in the first hour post-partum increased slightly. All the efforts in promoting BF contributed to sustaining the Ever-breastfed prevalence at 97% after the storm (see the following table reporting BF prevalence in 2016, 2017, 2018).
The results of the PR PRAMS-ZPER 2 survey (telephone interviews to mothers of babies born between November to December 2017 and when babies age 3 to 4 months old) confirmed that 95% of women reported initiating breastfeeding (ever-breastfed) and 59% were still breastfeeding when they completed the phone follow-up survey.
The PRAMS-ZPER 2 implemented an innovative intervention developed to provide parents a short course on maternal and newborn post-partum care due to feedback from participants in previous PRAMS-ZPER. The course included orientation on the following topics: mood changes in mother, post-partum health care visit, signs and symptoms to watch in the post-partum mother signaling complications, orientation on BF and support, newborn hygiene, infant preventive health care visits, prevention of shaken baby syndrome, and safe sleep. The course was developed by the MCAH staff and delivered by the PRAMS-ZPER personnel. Postpartum stay in the hospital is an opportunity to support families to adapt in the transition process. Families benefit from guidance on issues relevant to the health of the mother and the newborn; an aspect the PNs of the MCAH program contribute to by visiting post- partum women and their family in the hospital.
Breastfeeding Promotion Strategies
Evidence supports BF’s beneficial effect in decreasing the prevalence of childhood obesity, impacting chronic diseases, and the prevention of Sudden Unexpected Infant Death, therefore decreasing IM. For many years BF practices have been promoted regularly by the PRDOH. The MCAH provided support to the BFPCG by coordinating meetings and fostering collaborative efforts between its members. As a result of the efforts of the MCAH Division, with support from the BFPCG, the PRDOH has established public policies and hospital regulations that support the initiation of breastfeeding. These efforts have also supported laws that protect and support breastfeeding mothers. The BFPCG is composed of representatives of WIC, Women’s Advocate Office, Patients’ Advocate Office, Department of the Family, PR AAP, lactation experts, community based breastfeeding support groups (Proyecto Lacta, La Leche League, Breastfeeding Coalition) and mothers from the community. The inclusion of community-based partners (United Way of PR and Alimentación Segura Infantil - Safe Infant Feeding) in the collaborative work of this group has been instrumental in developing strategies to support breastfeeding in the community.
The BFPCG has focused its work on promoting and delivering education to the general population on the numerous benefits provided by choosing breastfeeding for infants, mothers, their families and the impact on their economy. Other areas of advocacy and orientation focus on the PR laws that protect and support BF. The members of the BFPCG share the goals of Healthy People 2020 to increase the prevalence of successful breastfeeding initiation in the hospital and exclusive BF upon discharge, and breastfeeding beyond 6 months. The group considers data on prevalence and rates of BF provided by WIC, the MCAH Estudio de Salud Materno Infantil de Puerto Rico (ESMIPR, English translation PR Maternal Infant Health Study), Vital Statistics and mPINC (CDC Maternity Practices in Infant Nutrition and Care Survey) scores to propose priorities and strategies. Most strategies are implemented collaboratively so as to have a collective impact on BF rates, promoting the adoption of this practice by mothers on the island. Some strategies are implemented individually by members of the group with support from the other members. Other efforts by the BFPCG focused on working collaboratively to promote the implementation of evidence-based or best practice strategies, such as promoting the adoption of the Baby Friendly steps in hospitals, community support for breastfeeding moms during the postpartum period, and educating BF mothers regarding laws that protect breast milk extraction at work.
The mPINC is an instrument for maternal institutions to self-evaluate their progress in improving maternal care practices that support and promote breastfeeding. Efforts have continued to raise awareness among birthing hospitals in PR of the opportunity to participate in national data collection surveys, such as the mPINC, that pinpoint areas in need of improvement, among them the observance of local existing laws regarding BF rights. There has been a gradual increase in the number of PR birthing hospital that participate in the survey, and an improvement in scores reflecting positive changes in maternal infant practices. The mPINC score in 2011 was 60, in 2013 it was 61, and in 2015 it increased to 69(most recent score reported).
The BFPCG also continued to promote compliance with Administrative Order No. 336, requiring hospitals to implement a policy to establish a breastfeeding support program and rooming-in. This order emphasizes compliance with Law 156 amended in 2016 (assuring women may have a companion through labor and the postpartum period, rooming-in option, and BF rights, among others), and Law 79 of 2004 (banning hospital staff from giving breast milk substitutes to newborns without a doctor's order and the mother's informed consent). In August 2017, the MCAH Pediatric Consultant participated in an educational activity for WIC staff and presented the hospital compliance requirements of AO No. 336, to ensure they have the latest information to share with the pregnant women in their clinics. Knowledge of the hospitals’ responsibilities empowers pregnant women to claim their rights.
Since 2017 Puerto Rico is participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) which serves to evaluate impact of BF support in hospitals and in the community and factors that influence BF practices. Prior to the PR PRAMS, the MCAH staff obtained and analyzed data from the ESMIPR. The 2015-2016 ESMIPR obtained data from mothers at the time they registered their newborns at the Demographic Registry. Participation was voluntary; 38.5% of mothers who registered their babies in 2015 agreed to answer the survey. Follow up telephone interviews were done at 6 and 12 months after birth (response rate at 6 months 61.8%, at 12 months 45.5%). Results of ESMIPR 2015-2016 and 2017 PR PRAMS are compared to demonstrate changes in hospital practices providing data to help develop additional efforts to increase hospital compliance with AO 336.
Other results pertaining to BF, obtained from the 2017 PR PRAMS, are as reported in the following tables.
All the data obtained and analyzed is shared with the PR BFPCG, providing awareness of areas for the development of strategies to promote BF. Changes in hospital practices and support interventions are also reflected in BF rates. Puerto Rico Vital Statistics (VS) preliminary data obtained from the birth certificate revealed that in 2018 about 96% of mothers ever breastfed prior to registering their babies (versus 95.5 % in 2017) a sustained increase when compared to 81.5% in 2015. Of the women who reported ever breastfeeding, 49.8 % in 2018 reported exclusive BF prior to registration. In the first hour post-partum, 68.7% of mothers who delivered vaginally and 39.5% of mothers who delivered by cesarean section were able to breastfeed. Exclusive BF rates upon discharge from hospitals reflect the success of implementing support BF strategies. In comparing exclusive breastfeeding rates and 1st hour post-partum BF, hospitals with the highest percent of mothers allowed BF in the first hour tend to have the highest exclusive BF percent of mothers upon discharge as seen in the following graph.
The 2018 CDC Breastfeeding Report Card among infants born in 2015 reported 26.5% exclusive BF at 6 months in Puerto Rico an increase compared to previous 2016 Report of 20.1% among infants born in 2013, surpassing the 2020 Healthy people goal of 25.5%.
Data provided by the WIC program for the year 2017-2018 revealed that 58% of participating infants between the ages of 0 to <12 months of age were breastfed.
On July 31, 2017, the PRDOH began the official celebration of Breastfeeding week with a press conference to present the Governor’s proclamation for BF week and the launch of the campaign Lacta en Familia (“Breastfeed in Family ”) with a poster developed by an interdisciplinary team of MCAH staff. The poster features photos from the Encuentro de mi Vida (English translation Encounter of my Life) campaign with images of family members undertaking housekeeping shores while the mother breastfeeds, an image of a couple breastfeeding in the hospital post-partum, and a close up image demonstrating proper latch. Messages encouraging support for breastfeeding mothers were targeted to fathers and the mom’s family. In the poster and the fifth video of the campaign the paternal and grandparent figures were emphasized. During the press conference the fifth video of the campaign was released, with images of the newborn’s first skin-to-skin contact with mom, paternal presence in the post- partum hospital room while mother breastfeeds, close up of proper latching, and family support at home helping with chores while mother breastfeeds. During the press conference grandparents and fathers from the community shared their experiences providing support for their BF daughters or wives. The press conference had the presence and support of all the members of the BFPCG, among them representatives of WIC. In the press conference breastfeeding moms were invited to share their pictures of family support for breastfeeding using #lactaenfamilia. There was a successful response and the campaign spread nationwide through digital news outlets and social media. The posters were distributed and placed in public places.
Other collaborators of the BFPCG held various activities throughout the island promoting BF and support for BF mothers, for which the regional and central MCAH staff provided support, during the Lactation month of August 2017. The LLL held diverse activities promoting BF throughout the Island. The PR BF Coalition had a week of lectures for the general public, culminating in their annual march through a shopping mall with the purpose of empowering BF mothers and promoting support for BF moms. Other BF promotion activities at the regions had collaboration from the regional MCAH staff in an effort to increase knowledge of the benefits of breastfeeding and the acceptance of this practice by the public.
Another strategy used to promote BF was the Prenatal Course. It is offered by regional HEs and CHWs to pregnant women and their relatives (refer to the table: Participants that completed 4 sessions of the Prenatal Course 2017-2018). The benefits of BF, BF preparation in the prenatal period, BF initiation in the hospital, resources available in the community for postpartum support, and laws and regulations that support BF in Puerto Rico are among the topics included in the course.
A total of 1,128 infants (less than 12 months of age) participated in the HVP during 2017-2018. Home Visiting Nurses provide breastfeeding support by scheduling a visit in the first week postpartum to the HVP participants. In this and subsequent visits, they evaluate latching and breastfeeding positioning and refer mothers for professional help and support in the community when problems requiring further intervention are identified. The HVP nurses encourage exclusive breastfeeding, at least during the baby’s first 6 months of life. There was an increase in the number of HVP participants reporting ever breastfeeding, to 75.9% in 2018 compared to 67% in 2016, and 28% continued to BF until 6 months (compared to 25% in 2016). Two thirds (63.7%) of HVP participants are adolescents between the ages of 11 to 22, and many continue to attend school after giving birth, requiring additional support to sustain BF beyond the first month.
The WIC program uses an evidence-based BF peer counselor support program which connects experienced BF WIC participants and new mothers. The WIC breastfeeding coordinator is an active member of the PR BFPCG and receives support of other members to present and implement the peer counselor BF program in hospitals and communities.
The MCAH Program Perinatal Nurses continued to distribute posters and brochures to birthing hospitals on current laws about women's and infants' BF rights in these settings, particularly Administrative Order 336, Law 156 amended in 2016, and Law 79 of 2004. The Perinatal Nurses also visit moms postpartum to promote breastfeeding in the hospital and offer orientation on resources that provide breastfeeding support in their community.
OTHER STRATEGIES IMPLEMENTED BY THE MCAHD TO DECREASE IM
Prevention of unintentional injury
The Estudio de Salud Materno Infantil de PR (ESMIPR, Maternal Infant Health Study of Puerto Rico) obtains data regarding safety measures and behaviors that mothers adopt to protect their children from unintentional injuries. The results obtained by telephone follow up survey done from 2016 to 2017, at 6 and 12 months after birth, are reported in the following tables.
The findings guide the selection of topics to emphasize in the Parenting courses and in the HVP interventions. Although sudden unexpected infant death has not been reported in PR, the risk behaviors reflected in this survey place safe sleep as an important topic in educational interventions. The HVNs provided orientation and distributed educational materials directed at reducing unintentional injuries to the participants of the HVP and to the community. The Prenatal and Parenting courses continued to promote injury prevention and providing orientation and recommendations on safety strategies, including: preventing shaken baby syndrome, safe sleep, safe toy selection, the Poison Control phone number and support they provide, and the proper use of car seats among others. The PNs also include orientations on safe sleep and prevention of unintentional injury in their orientation on newborn care to postpartum families.
Prevention of Shaken Baby Syndrome
The HEs and MCAH staff created a culturally appropriate interactive intervention on the management of crying babies, ¿Por qué lloran los bebés? (“Why do babies cry?”). It teaches parents and caregivers strategies to manage crying and irritable babies to prevent Shaken Baby Syndrome (SBS). They incorporated the use of the SBS simulation doll to demonstrate the damaging effects of shaking a baby and to deliver the prevention message more effectively. Updated safe sleep recommendations were included in this course. This intervention was delivered to a total of 1,051 persons during 2017-2018.
Prevention of Forgotten Baby Syndrome
Due to the tropical temperatures in Puerto Rico, a baby forgotten in a car faces rapid dehydration and death. Therefore, education and strategies to prevent forgotten baby syndrome are also included in the HVP and the Prenatal and Parenting courses, including a brochure developed as support and reminder for the families.
Infant CPR and Safe Sleep
During 2017-2018 the HVP continued training of participating families on Infant CPR Anytime, a strategy proven to save lives. The Infant CPR Anytime training is combined with the delivery of Safe Sleep recommendations, complementing strategies aimed at decreasing infant mortality. The HVN used an infant manikin to teach Infant CPR Skills to the participating families, evaluating their performance by using observation guides and providing feedback to ensure competency. Infant CPR Anytime teaches parents and caregivers how to react and rescue an infant in case of choking or cardiorespiratory arrest. During 2017-2018 a total of 2673 persons, HVP participants and family members received the training, with a 98% satisfaction with the training and usefulness upon evaluation by the participants.
Education on Premature Labor Signs and Symptoms
The MCAH Program staff continues to offer educational activities to participants, providers and the general population in an effort to make them aware of preventable causes of infant mortality, such as early recognition of signs and symptoms of premature labor. The HVNs and CHWs continue distributing magnetic pads with information on “Recognizing preterm labor: signs and symptoms” to participants in Ob-Gyn medical offices and through the HVP.
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