During 2019-20 the MCAHD implemented various strategies and collaborated in promoting evidence-based practices that contribute to decreased infant mortality, such as safe sleep practices, delivery of high risk infants at facilities that fulfill the requirements for the recommended level of care, promoting protective behaviors in pregnant women to avoid Zika and other teratogenic infections, promotion on how to avoid high risk behaviors during pregnancy, promoting early prenatal care, promoting breastfeeding until infants reach at least 6 months of age, educating parents on unintentional injury prevention, and strengthening parenting skills.
Besides decreasing Infant Mortality, identifying and mitigating risk factors that threatened maternal and infant health and well-being during the emerging challenges of 2019-2020 were also considered a top priority for PR MCAHD.
Earthquake
The year 2019 continued to be a time for recovery from the effects of hurricane Maria, but 2020 presented emerging challenges requiring further adaptations for the MCAH Programs and staff. The series of earthquakes in December 2019-january 2020 with the strongest shake causing damage to homes and infrastructure, with major damage in the southwestern region of the Island and consequent displacement of families to shelters. The strongest shake also caused the electrical grid to shut down, causing a blackout in the entire island. It took days for power to be restored, leaving the whole island, including hospitals and community health care services, dependent on emergency generators. One hospital in the south region had to close its facilities due to structural damage and restrict its services to emergency evaluations performed in improvised facilities inside temporary tents. The population relived the difficult days after the recent hurricane disaster of 2017. Despite no major structural damage in the rest of the Island, the aftershocks of the earthquakes presented a continued threat and uncertainty of a major earthquake, increasing the emotional trauma of the whole population.
The MCAHD staff had an immediate response assessing the needs of displaced families and pregnant women and providing support to protect their health in the community and in government-run shelters. The displaced pregnant women in shelters identified by the HVNs and CHW received support and orientation to continue prenatal care. Displaced families with infants received support to promote breastfeeding, safe infant feeding and safe sleep practices.
The MCAH division collaborated with the emergency response initiatives of the PR DOH, visiting communities, identifying emerging needs and alternatives to address them. The Pediatric Consultant, who is also the president of the PR AAP Chapter (2019-2021), organized virtual meetings and a chat group with health care providers to identify priorities affecting the population after the quakes, and to promote the collaboration in initiatives and strategies implemented for mitigation and support efforts. Numerous groups developed initiatives such as promoting safe infant feeding in the communities by members of the BFPCG, services for pregnant women by PROGyn (ACOG), a close collaborator of MCAHD, immunization in mobile units by The Immunization and Health Promotion Coalition (VOCES), and clinical evaluation of families and children by volunteer physicians. Guidelines for the identification and management of common conditions after a disaster and preventive measures to support well-being, including safe sleep, safe infant feeding, oral care, the use of sunblock and mosquito repellent in children, were updated and shared with MCAHD staff, community leaders and groups providing assistance to affected communities.
COVID-19
Not having fully recovered from the earthquake, the COVID-19 pandemic superimposed further challenges. Since the first cases of COVID-19 were announced in the US, the MCAHD was attentive to recommendations and instructions provided by the PR DOH and the CDC, sharing this information with the staff in an effort to protect the workforce and to initiate strategies to help guide the population for an effective public health response. Upon the identification of the presence of COVID-19 cases in the Island on March 16, 2020, the PR Governor ordered a shutdown of all unessential services and business and created an advisory PR COVID-19 Medical Task Force. In response to the threat of COVID-19 and the shutdown, the MCAHD modified the implementation of all its programs, and its staff became collaborators in addressing the needs of the population that emerged in response to this threat. The staff that was able to continue to work from home was assigned tasks. Hand sanitizers and facemasks were obtained and distributed to the staff along with instructions on how to protect themselves during the pandemic. Due to the restrictions imposed to help prevent and control the spread of COVID-19, all personal interventions were stopped and converted to telephone or virtual interventions. The interventions by the HVP, HE and CHW were redesigned to allow the continued support of the MCAH population.
The HVP modified its protocol to phone calls and text messaging. The HVNs continued to communicate with their participants and provide education and support following an amended procedures manual. These efforts are described in the Women/Maternal Health narrative. Although telephone services were continued, many participants had limited access to phones. Recruiting participants was also affected, as collaborating partners that identify and refer candidates, such as WIC and Medicaid, also had to modify their interventions from in-person to telephone services.
Perinatal nurses provide orientation to postpartum women and their families during their hospital stay on different topics relating to newborn care, postpartum care, and safe sleep, among other topics. During the COVID-19 crisis many hospitals adopted stricter protocols for entrance to the facilities, limiting family members and access to the perinatal nurses. Both factors curtailed their interventions with postpartum women.
Another emerging challenge during the COVID-19 pandemic was hospital management of women in labor, postpartum and breastfeeding, due to concerns regarding the prevention and control of infection in suspected or positive cases and the unknown risk of transmission through breastmilk. In the initial phase of the COVID-19 pandemic there was limited knowledge and scientific data related to the way the disease spread, its presenting signs and symptoms, effects on health, and treatment. Throughout the pandemic, the recommendations from the CDC and other professional organizations to prevent and control infection continuously evolved as information and knowledge were accumulated by experience dealing with the disease. The Pediatric Consultant participated in a collaborative multidisciplinary Task Force created to develop recommendations for the management of postpartum women, newborns and breastfeeding in hospitals during the COVID-19 crisis, protecting rooming-in, skin to skin and breastfeeding when maternal and newborn condition made it possible. The recommendations were adopted by the PR COVID-19 Medical Task Force and the PR DOH as public policy during the pandemic. The document can be accessed at Recomendaciones para la prevención de la transmisión del COVID-19 en el entorno obstétrico/neonatal
In collaboration with leaders from all the pediatric medical organizations in PR, short educational videos were developed and published via social media to encourage the population to continue with their pediatric preventive care, scheduled immunizations, newborn well care, breastfeeding, and protective measures to prevent contagion and spread of the disease during the crisis. All educational materials were shared virtually. Multiple webinars related to pediatric health care during the crisis, newborn care and feeding during the pandemic were organized and presented with the collaboration of academic and primary care pediatricians.
Safe Sleep
Promoting safe sleep to decrease infant mortality was identified as a priority in the MCAHD needs assessment for 2020-21. In Puerto Rico, sleep-related Sudden Unexpected Infant Deaths (SUIDs) was the first cause of infant death between the ages of 1 and 11 months from 2017 to 2020. The definition of death due to sleep-related SUIDs includes Sudden Infant Death Syndrome (SIDS), unknown cause, and accidental suffocation and strangulation in bed.
The AAP recommends placing infants to sleep in a safe environment including a back (supine) sleep position, on a separate firm sleep surface (room-sharing with parents until reaching at least 6 months of age without bed sharing), and without soft objects and loose bedding. Further recommendations include breastfeeding and avoiding smoke exposure during pregnancy and after birth as emphasized by the National Institute of Child Health and Development (NICHD) Safe to Sleep Campaign®.
The PR PRAMS 2019 survey revealed that 44% of participants reported placing their babies to sleep on their backs and only 4.1% complied with all three criteria of a safe environment (on their backs, on a separate approved sleep surface, without soft objects or loose bedding). The PR PRAMS results raised concerns regarding the knowledge and practices of safe sleep in PR; therefore, it was necessary to continue to educate on safe sleep recommendations.
The PR MCAH implemented diverse strategies and collaborations to improve safe sleep practices and decrease infant mortality due to SUIDS, promoting the inclusion of infant safe sleep practices in CME and training of hospital staff. Among collaborators in the implementation of these strategies were PROGyn and ACOG, PR Hospital Association, and PRAAP Chapter.
Perinatal Nurses and HVNs also participated in the safe sleep webinar, and the promotion of safe sleep practices continued among PR Title V Home Visiting Program participants.
The HVNs offered prenatal and post-partum orientation and evaluated the families’ safe sleep practices prior to the pandemic.
During the COVID-19 pandemic safe sleep practices continued to be emphasized during the virtual interventions. Families received guidance on how to evaluate and modify the sleeping environment of their babies.
Infant safe sleep practices are also included as a topic in the Prenatal and Parenting courses and in the “Why do babies cry?” workshops that were delivered prior to the shutdown.
Promoting infant safe sleep practices in social media and using “Encuentro de mi Vida” to share recommendations has also provided the opportunity to disseminate messages on safe sleep practices.
It has been very important to emphasize safe sleep practices among displaced families affected by disasters, when many parents may be inclined to sleep with their babies to protect them in case of an earthquake.
Infant mortality
Vital Statistics (VS) data for 2020 reported an IM rate of 7.1 per 1,000 live births (preliminary results) and the preterm-related mortality rate was 284.4 per 100,000 live births. Prematurity-associated conditions and low birth weight continue to be among the first five causes of infant mortality on the island.
Respiratory distress syndrome continues to be the main cause of death in early preterm babies. Preterm birth (PTB) in Puerto Rico, although it has decreased since 2015, remains high at 11.6% (preliminary 2020 VS). 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 VS data for 2020, 11.5% of live births had low or very low birth weight for gestational age. Changes in birth weight, infant, neonatal and postneonatal mortality are summarized in the following tables.
The impact of the COVID-19 crisis on the outcome of pregnancies is to be observed in further evaluation of data during 2021. Although strategies to carry out interventions were modified during the pandemic, the MCAHD staff continued to educate, increase awareness, and promote strategies to decrease prevalence of premature birth by;
- HVNs’ routine evaluation of the HVP participants to identify the presence of risks related to premature and LBW deliveries, to provide education about the signs and symptoms associated with premature labor, as well as information concerning the birthing facility levels of care and perinatal services near to their residence.
- Perinatal Nurses’ education to pregnant women on signs and symptoms of premature labor.
- The Prenatal Course providing information on the warning signs and symptoms of preterm labor and the steps women should take if they suspect they are experiencing preterm labor.
- The MCAH Program promotion of the use of the prenatal card by pregnant women in obstetric offices, to record and document pertinent obstetric history and information, and the benefit of carrying it at all times in case of any complication requiring urgent care.
- The “Encuentro de mi Vida” prenatal campaign offered through various media outlets.
The MCAH staff continued to provide support to the PR PRAMS staff in sharing the results from the 2017-2018 survey with stakeholders and encouraging collaboration to propose and implement strategies to improve pregnancy outcome and decrease IM by addressing the identified needs. Promoting oral care in pregnant women and changes in hospitals to improve support for breastfeeding initiation are among the needs that were identified and addressed.
The MCAH Program continued to promote preconceptional/interconceptional health, prevention of preterm and early term births, and perinatal regionalization in an effort to decrease infant mortality. The Perinatal Health Care Services Guidelines (PNHCSG) along with the Preventive Health Services Guidelines for women in reproductive age continued to be developed and updated. The PNHCSG helps in the identification of high-risk pregnancies for adequate referral, such as women with a history of a previous premature birth to whom home administration of 17HP (hydroxyprogesterone) may be offered.
The MCAH staff also continued to promote compliance with Administrative Order 366 (2017) in collaboration with the Hospital Association. This order requires hospitals to adopt the Hard Stop Policy as a condition to renew their operational license from the Health Department. This administrative order has been integrated as part of the recently updated and approved Hospital Regulations Policy #9184 (July 2021).
The MCAH director and the maternal infant epidemiologist are members of the March of Dimes (MOD) Prematurity Prevention Committee, in collaboration with a representative of the Hospital Association, maternal fetal specialists and other stakeholders. Priorities of this committee continued to focus on the proposal and implementation of strategies to promote prevention of preterm births and the importance of completing at least 39 weeks of pregnancy.
Protection from arboviral infection during pregnancy (Zika and Dengue)
During 2015-2016 the threat of the Zika epidemic, due to its teratogenicity and its threat on fetal and infant survival, became an emerging priority for the MCAH program. Transmission of Zika virus occurs via sexual contact and through the mosquito bite of Aedes species, abundant in Puerto Rico all year round due to its tropical climate. This represents an additional threat to pregnant women, who are at higher risk of complications and mortality when they contract dengue. The Zika virus surveillance data demonstrates a decrease in the overall population prevalence from an epidemic to an endemic status in 2017, but remaining as a concern for pregnant women. Therefore MCAHD has continued providing education and encouraging pregnant women to adopt preventive measures to avoid mosquito bites, comply with prenatal screening for the presence of Zika virus, and advocate for support services for pregnant women with positive results.
The HVNs and Community Health Workers (CHWs) continued promoting early prenatal care and compliance with testing for Zika in pregnancy as well as referral to the PRDOH surveillance system to follow up babies from Zika positive mothers.
Education on Zika prevention was included in the Prenatal and Parenting courses and other educational activities provided in the community. The educational intervention focuses on how women can protect themselves and their families from the vector that transmits the Zika virus, from sexual transmission, and how to eliminate mosquitoes in their surroundings.
Promote Improved Access to Adequate Maternal and Neonatal Levels of Care
The first stage of the MCAHD effort to improve access to adequate level of maternal and neonatal care was a collaboration with the CDC to classify the Maternal and Neonatal Levels of Care services available in the hospitals that offer services in Puerto Rico. The Maternal and Neonatal Levels of Care Assessment Tool (LOCATe) was created with the objective of producing a standardized assessment of level of maternal and neonatal care in hospitals within states and jurisdictions, facilitate stakeholder conversations, and minimize burden for respondents. The assessment is based on compliance with the requirements delineated in the Maternal and Neonatal Levels of Care Guidelines by the 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 2017-2019 using an innovative approach. After completing a face-to-face interview, MCAH staff provided a report of LOCATe findings to each hospital’s administrative and medical staff, offering feedback specific to the institution. The report included the classification of maternal and neonate level of care as assessed by the PR LOCATe analysis, results of analysis of infant and maternal outcome data for their institution, and aggregate analysis of all the hospitals in PR. With the information provided during the visits, combined with the Maternal and Neonatal Care Guidelines, hospitals had the necessary tools to re-evaluate their performance, improve their services and obtain a reclassification of the level of care according to the service provided.
The aggregated information obtained will allow the identification of changes required to promote perinatal regionalization to ensure adequate access to the levels of maternal and neonate services. It will also serve to optimize the use of the existing resources and facilitate the creation of inter-hospital agreements for high-risk patient referral. In 2020 48.9% of very low birth weight (VLBW) infants were born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU). The following tables summarize the results of the LOCATe assessments.
Many hospitals demonstrated improvement in their level of maternal care classification by taking one or more of the following actions: recruiting a maternal-fetal medicine specialist and/or an obstetrician on site 24/7; having an anesthesiologist with experience in obstetric anesthesia in charge of the maternal anesthesia services; adding 24/7 MRI services. Hospitals were able to improve their level of neonatal care classification by recruiting a neonatologist or a specific pediatric sub-specialist as recommended in the guidelines. The findings will be disseminated to support decision-making in the public and private health systems.
The visits were completed after Hurricane Maria, providing the opportunity to identify the challenges faced during and after the storms. Hospitals were asked to share their revised protocols for disaster preparedness and management. These would be used to develop general recommendations for hospitals to evaluate their individual plans and modify them according to their needs. Hospitals also received advice and educational materials developed by the MCAHD on safe sleep and breastfeeding support.
Infant preventive medical services begin in the hospital when metabolic, oxygen saturation, hearing and bilirubin level screening are performed and continue in the outpatient setting with the initial visit to the pediatrician recommended in the first week of life. This message, along with breastfeeding promotion, has been shared through multiple media campaigns. The PR PRAMS reported 99.6% of mothers participating in the PR PRAMS surveys of 2019 and 2018 responded in the affirmative when asked if their baby had “any health care visits with a doctor, nurse, or other health care worker since you left the hospital when your baby was born.”
Promote healthier behavior and prenatal care with Prenatal Multimedia Educational Campaign
During 2019-2020 the multimedia campaign “El Encuentro de mi Vida” (“The Encounter of My Life”) continued with the purpose of spreading 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.
The multimedia campaign consists of linguistically and culturally appropriate messages aimed mainly at Spanish-speaking pregnant women and their partners. The key message appeals to the emotions and expectations expressed during pregnancy. Core messages and intended audience were determined by MCAHD staff and 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 innovative campaign is aimed at strengthening families by helping parents make informed choices. Videos were aired on TV, movie theaters & online during 2018-2020. Banner ads for the website were featured on social media and news outlet pages and continue on the PRDOH webpage. The website www.encuentrodemivida.com provides access to the videos and shorter clips of the couple giving advice regarding optimum prenatal care. The website also features fact sheets related to various aspects of prenatal care, infant care, safe sleep, and breastfeeding, among others. All educational materials available on the website were developed by MCAHD staff in accordance with ACOG and AAP recommendations and overseen by the pediatric and OB/GYN consultants.
Title V Home Visiting Program
The Title V Home Visiting Program (HVP) provides case management and care coordination services, health education and counseling to women with complex medical and social risk factors associated with poor pregnancy outcomes. Criteria for admission include pregnancy before age 22 or after 35, certain chronic illnesses, and previous pregnancy loss or death of a child. Women are admitted during pregnancy and followed until the child is 2 years old. In the outreach activities carried out 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 2,785 pregnant women participated in the HVP during 2019-2020. The 81 HVNs active during 2019-2020 visited families in 70 of the 78 municipalities in PR; another 4 municipalities are covered by the MIECHV program, Familias Saludables Puerto Rico. During the pandemic the intervention strategies were modified to offer screening, education and support to the participants via telephone calls and text messages, as discussed in the Women/Maternal Health narrative.
The HVP has a larger proportion of adolescent participants, considered at higher risk for complications and poor outcomes, than the general population of birthing mothers in Puerto Rico.
Despite the HVP serving a high-risk population, similar birth outcomes are observed when compared to the whole island, suggesting its positive impact on birth outcomes. Further evaluations are being carried out 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.
The HVNs educate families on Safe Sleep practices beginning in the second trimester of pregnancy. Between July 2019 and February 2020, HVNs offered CPR Anytime trainings to 521 families. However, trainings to participants were discontinued due to the precautions related to infection control and prevention during the COVID-19 pandemic.
Community Education Interventions Implemented by MCAH Staff
The MCAH Program staff continued offering educational orientation to increase awareness of strategies to decrease IM to participants, providers and the general population in direct person contact previous to the COVID-19 shutdown and via telephone after.
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 encourage women to abstain from risk behaviors such as smoking during pregnancy and offer recommendations to reduce this behavior as well as other factors that contribute to poor outcomes. A total of 2,718 pregnant women received educational interventions from HEs and CHWs during fiscal year 2019-2020.
HVNs ensure that all HVP participants are evaluated in the WIC Program. The WIC Program also contributes toward reducing IM rates by focusing on women with nutritional risk factors.
During 2019-2020 the 8 regional perinatal nurses (PNs) of the MCAHD reached 32 birthing hospitals throughout the island where they provided breastfeeding support and orientation to postpartum women and their families. These services were temporarily interrupted when hospitals implemented stricter protocols to access the hospital in their effort to control and prevent COVID-19 infection. The PNs provided educational services to 341 pregnant women, 36% of whom were referred to services such as GHP, MCAH HVP, WIC, Prenatal or Parenting course, and prenatal care clinic. A total of 3,155 post-partum women also received their services, of whom 10% were referred to GHP, MCAH HVP, Parenting course, pediatrician, pediatric dentist, breastfeeding consultant, and the pediatric center. Besides referring participants to the agencies, PNs follow up via phone calls when needs are identified.
The MCAH targets pregnant women and WRA, but their companions, including partners and relatives, also benefit from the educational initiatives. This has an impact on the health and wellbeing of the family and strengthens the role and responsibilities of the father figure. These contacts were also limited due to hospital protocols during the COVID-19 crisis. Among other populations that received orientation by PNs there were 542 men and 757 accompanying non-pregnant women. The Perinatal Nurses also completed 1,046 visits to hospitals, reaching a total of 5,706 persons. Population reached by the PNs with topics relevant to interconceptional, postpartum, WRA, pregnant women and neonatal care are reported in the following tables.
Before the shutdown, the MCAH HEs and CHWs offered the prenatal course “A Baby on the Way” discussing important health issues related to the prenatal, postpartum and interconceptional stages. 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, safe sleep, oral care of pregnant women and infant, breastfeeding, birth spacing and family planning. Information on the transmission of Zika and preventive measures, its possible effect on the fetus and the need to test during pregnancy for infection were added to this course. A total of 495 participants completed the 4 sessions of the prenatal course. Another 23 participated partially in the prenatal course, but did not complete the 4 sessions. As in other courses offered by MCAH staff, paternal figures (males) also participate.
An achievement of the course is a statistically significant improvement in knowledge in each session as revealed by the evaluation of scores on the pre- and post-tests. During the crisis, a virtual prenatal course was developed and will be offered to pregnant women and their families. The content is presented in short videos with pre- and post-tests to evaluate its impact on knowledge and attitudes.
The CHWs and HEs delivered other community outreach educational activities on newborn and infant care and other important topics relating to prenatal and post-partum care that impact birth outcomes, as reported in the following tables. These orientations were offered to individuals or in groups.
Fetal and Infant Mortality Review (FIMR)
MCAH staff has headed the Puerto Rico Fetal Infant Mortality Review (PR FIMR) since 2006, contributing additional information to 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 increased risk for IM. When a fetal or infant death occurs in the HVP, priority is given to providing the mother bereavement support. If the mother consents, the HVP nurse supervisor or MCAH perinatal nurse conduct the FIMR interview to obtain information that 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 nurse or MCAH director. A copy of the HVP participant record is sent to the FIMR coordinator for additional data abstraction. The HVP record contains demographic and social data, besides a chronological description of the participant’s strengths, challenges and interventions during pregnancy as documented by the HVP nurses. The MCAH Pediatric Consultant prepares the case summaries that are reviewed and discussed by the Committee.
The PR FIMR helps identify community strengths and weaknesses such as prenatal care access, community support services, barriers for optimal care etc.
The following table details pregnancy outcomes (deaths or losses) of the HVP for 2019-2020 and compares the results to the general PR population.
Due to the staff’s risk for compassion fatigue in the management of families that have perinatal losses, the MCAH Mental Health Consultant is available for consultation and support and participates in the HVP coordination monthly meetings.
The FIMR Committee recommends the continued proposal and implementation of strategies that promote pre-conceptive Health in WRA, providing education and information to tutors or caregivers of pregnant teens of 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. All the recommendations applicable to HVP are incorporated as priorities to address and take action.
After hurricane Maria in 2017, the PR FIMR developed a series of recommendations to improve neonatal care in hospitals after a disaster. Neonatologists from different regions of the island participated in this FIMR meeting, in a focal group discussion, sharing the challenges they confronted managing the NICUs 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 and shared with the Hospital Association and the Department of Health Emergency Preparedness Team to incorporate in the disaster preparedness and response plan.
The PR Department of Health established a committee to develop a protocol to be implemented in hospitals to support families grieving the loss of an early pregnancy or a fetal or neonatal death, as mandated by Law No. 184 of 2016. The MCAH FIMR coordinator was designated coordinator of the committee, with the collaboration of the MCAH Mental Health Consultant. The committee completed a protocol for the evaluation of the needs of families after a loss, support for the bereaved parents during their stay in the hospital, and referral to resources in the community, according to the provisions of the law. This protocol was approved by the Secretary of Health as a public policy of the PR DOH (March 2020) and disseminated to all hospitals for its implementation with the collaboration of the Hospital Association.
Breastfeeding Promotion
Breastfeeding (BF) has proven to have a positive impact on decreasing IM. Evidence supports BF’s beneficial effect in decreasing the prevalence of childhood obesity and in the prevention of Sudden Unexpected Infant Death.
For many years BF practices have been promoted regularly by the PRDOH. The MCAHD provided support to the Breastfeeding Promotion Collaborative Group (BFPCG) by coordinating meetings and fostering collaborative efforts between its members. As a result of the efforts of the MCAH Division with the backing of the BFPCG, the PRDOH has established public policies and hospital regulations that encourage the initiation of breastfeeding. These efforts have also supported laws that protect and assist 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 bolster breastfeeding in the community.
The BFPCG has focused its work on promoting and providing education to the general public on the numerous benefits of breastfeeding for infants, mothers, their families, the impact on their economy, and of supporting breastfeeding mothers. Other areas of advocacy and orientation focus on the PR laws that protect BF.
The members of the BFPCG share the goals of Healthy People 2030 to increase the prevalence of successful breastfeeding initiation in the hospital and exclusive BF upon discharge, and to continue breastfeeding beyond 6 months. The group takes into account data on prevalence and rates of BF provided by WIC, the results of the PR PRAMS, 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 other members.
Other efforts by the BFPCG focused on working collaboratively to promote the implementation of evidence-based or best practice strategies, such as the adoption of the Baby Friendly steps in hospitals, community support for breastfeeding moms in the postpartum period, and educating BF mothers regarding laws that protect breast milk extraction at work.
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. The mPINC is an instrument for maternity institutions to self-evaluate their progress in improving maternal care practices that support and promote breastfeeding. 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, in 2015 it increased to 69, and in the latest mPINC version of 2018 PR achieved the score of 72.
The MCAH staff also continued to encourage hospitals to comply with implementing a policy to establish a breastfeeding support program and rooming-in as required in the Hospital Regulations Policy for licensing and operation #9184 (July 2021). The regulations emphasize 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).
Among lessons learned after hurricane Maria is the importance to continue promoting breastfeeding as the best and safest way to feed infants, even more after a disaster. Puerto Rico is an island and in case of a major disaster, there is the risk that aid to the island may be delayed if seaports and airports are damaged. Therefore, it is important to continue to convey to pregnant women and mothers with newborns the protection provided by breastfeeding and the advantages in case of a major disaster.
On August 4, 2020, the PRDOH, in collaboration with PRAAP and PR ACOG Chapter, presented a webinar on the topic of Breastfeeding during Crisis in celebration of Breastfeeding week. The focus was to advocate for breastfeeding following the CDC and AAP safety recommendations. The webinar had an introduction by the sub secretary of health on the role of the PR DOH in supporting and promoting BF, the achievements in the ever-breastfed prevalence and positive changes in hospitals. Two mothers presented their testimonies on the challenges they faced to BF during COVID-19 and how they were able to overcome them; PR ACOG District presented the continued efforts to support BF in the hospital; and a pediatrician presented updated recommendations supporting breastfeeding during the COVID-19 pandemic.
A second webinar on the topic of Breastfeeding in the labor room was presented on August 6 to hospital staff in collaboration with the PRAAP Chapter and the PR Hospital Association. A third webinar on the topic of Breastfeeding and wellbeing was delivered on August 27 (pm) in collaboration with PRAAP Chapter and the Perinatal Mental Health Center of the University of Puerto Rico School of Medicine.
A virtual meeting was held on August 27, 2020 (am) with the objective of creating a BF emergency network, a collaboration of several BF-promoting organizations. A group chat was established to share resources and improve communication. All the activities were coordinated by the MCAHD Pediatric Consultant, who is also the PRAAP Chapter President (2019-2021).
A digital poster was developed by an interdisciplinary team of MCAHD staff and published in the “Encuentro de mi Vida” website (www.encuentrodemivida.com). The poster features diverse mothers wearing facemasks while breastfeeding.
During 2018-2019 the MCAH Staff collaborated with the WIC program to update and revise the Safe Infant Feeding Protocols for the PRDOH, in an effort to promote support for breastfeeding as the safest way to feed infants after a disaster and improve safe infant formula handling. The final document was approved in July 2019 by the Secretary of Health as a public policy and incorporated in the PR Public Health Emergency and Disaster Guide (available from:
A pediatrician who collaborates with the BFPCG received a grant from Save the Children to train community leaders and hospital staff in promoting safe infant feeding after a disaster. She incorporated the Safe Infant Feeding Protocols of the PRDOH among the training topics. The training was delivered throughout the island and the MCAH HVP staff participated.
The BFPCG also developed recommendations for hospitals to include BF support strategies as part of their preparedness and disaster plans. This was shared through the Hospital Association with all hospitals in Puerto Rico.
The revised 2030 Healthy People goals include two objectives related to lactation: Increase the number of infants who are exclusively breastfed at 6 months and increase the number of infants who are nursing at 12 months.
The following table reports BF prevalence in 2017, 2018, 2019 and preliminary results for 2020.
Puerto Rico Vital Statistics (VS) preliminary data obtained from the birth certificate revealed that 96.6% of mothers ever breastfed prior to registering their babies in 2020, a sustained increase in prevalence above 95% since 2017. Of the women who reported ever breastfeeding, in 2020 49% reported exclusive BF prior to registration. In the first hour post-partum, 68.7% of mothers who delivered vaginally and 34.9% of mothers who delivered by cesarean section were able to breastfeed. Exclusive BF rates upon discharge from hospitals reflect the success of implementing BF support strategies.
Other data pertaining to BF, obtained from the 2017 and 2018 PR PRAMS, are reported in the following tables.
All the data obtained and analyzed was shared with the PR BFPCG, providing awareness of areas for the development of strategies to promote BF.
Collaborators of the BFPCG held various activities throughout the island promoting BF and support for BF mothers, during Lactation month (August 2019), for which the regional and central MCAH staff provided support.
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 regional level had collaboration from the 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, 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 2019-2020). 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 1,110 infants (less than 12 months of age) participated in the HVP during 2019-2020. 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 during at least the baby’s first 6 months of life.
In the HVP, 87.7% of participants reported ever breastfeeding, a sustained improvement when compared to 67% ever breastfed in 2016, and 34.9% continued to BF until 6 months (compared to 25% in 2016). The HVP targets high-risk pregnant women, therefore it has a high proportion of participants between the ages of 11 and 19 (46.3%). Most of these adolescents 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 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.
As part of the hospital visit for LOCATe during 2018-2019, the MCAHD staff also provided hospitals with their performance statistics on ever breastfed and exclusive breastfeeding upon hospital discharge compared to the overall rates of the other hospitals in the Island. This provided the opportunity to share recommendations to improve their performance and strategies to promote safe sleep, education on the risk associated with the use of informally donated breast milk, the benefits of providing human milk to premature babies, and the use of the educational materials developed by the MCAHD, including the www.encuentrodemivida.com website, with their patients.
Another strategy to help promote breastfeeding has been the approval by the Secretary of Health of the recommendations for feeding from 0 to 24 months. These recommendations promote exclusive breastfeeding and the delay in the introduction of solids until 6 months of age and were created by a collaborative work between MCAHD Pediatric Consultant, PR WIC, an infant nutrition specialist from the School of Public Health at Yale University, a representative of the World Health Organization (WHO) and the Pan American Health Organization (PAHO), a nutritionist from PAHO, a neonatologist, and a nutritionist from the Human Development Department of the University of Puerto Rico Graduate School of Public Health. These recommendations have been shared with pediatricians and nutritionists in multiple forums.
The PR PRAMS survey in 2017-19 queried mothers regarding the introduction of solid foods in their babies’ diets. The following table shows the percentage of infants who had not started eating solids at 2, 3, 4 and 5 months of age.
Other Strategies Implemented by the MCAHD to Decrease IM
Prevention of unintentional injury
Various strategies were continued in an effort to promote the prevention of unintentional injury. The HVNs provided orientation and distributed educational materials directed at reducing unintentional injuries at home to the participants of the HVP and to the community.
The Prenatal and Parenting courses continued to promote injury prevention, providing education 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 offered to a total of 485 persons during 2019-2020.
Prevention of Forgotten Baby Syndrome
The Forgotten Baby Syndrome continues to be threat that may occur to any family. A child left in a hot vehicle can die of heat stroke (extreme heat) in a very short time. A child's body heats up to three to five times faster than that of adults, and in a hot car a child can quickly become dehydrated. The major organs begin to collapse when the temperature reaches 104 degrees Fahrenheit (40 degrees Celsius). David Diamond, PhD, professor of psychology at the University of South Florida says, “Forgetting a child is not a problem of neglect but a memory problem. It is a matter of circumstances. It can happen to anyone.”[1] Any parent or caregiver can forget that a child is in the back seat. The risk of this happening increases when parents are very busy, distracted or if there is a change in routine. In the USA, 52 children (between the ages of 7 weeks and 11 years) died from being left in hot cars in 2018. According to Dr. Elizabeth Thomas, “Among the caregivers related to these deaths are dentists, social workers, nurses, military, religious, so this tragedy can affect anyone regardless of their socioeconomic status or educational level.”[2] 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 for families. The most recent death of a forgotten infant in the car occurred in September 2019. This is a recurrent situation in PR despite Law 173, which requires day care centers to call parents if a baby is absent without previous notification to the center.
An informational poster was designed by the interdisciplinary team of consultants of MCAHD to spread the message of how parents need to develop a strategy to protect their infants. During 2019-2020 the MCAHD shared the poster with other agencies and organizations.
Infant CPR
During 2019-2020 the HVP continued training participating families on Infant CPR Anytime, a strategy proven to save lives. However, once the COVID-19 threat was identified, the course was discontinued and will be retaken once it is safe to continue. The Infant CPR Anytime training is combined with the delivery of safe sleep recommendations, complementing strategies aimed at decreasing infant mortality. The HVNs use 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. A grandmother of a participant of the HVP in the south region of the island shared her story on how she was able to dislocate a foreign object causing asphyxia in her grandchild thanks to the training she had received by the HVN.
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 prevention of unintentional injury, and early recognition of signs and symptoms of premature labor.
Opioids
The MCAHD has remained vigilant to the prevalence of withdrawal syndrome in newborns, which requires hospitals to report cases to the PR Family Welfare Agency. During 2019 neonatal abstinence was reported in 1.7/1000 live births among mothers with medical insurance in PR. Although in the lower range when compared to the prevalence in the USA (1.5 to 8/1000 live births in the USA), the MCAHD promotes healthy lifestyles and habits including abstinence form the use of drugs and alcohol during pregnancy. The holistic management of infants with withdrawal syndrome and their families is shared between the primary physicians and PR Family Welfare Agency.
[1] Thomas, E. A. (2021, April 30). Research shows that anyone could forget kids in hot cars. Consumer Reports. www.consumerreports.org/car-safety/anyone-could-forget-kids-in-hot-car-forgotten-baby-syndrome/
[2] Thomas, E. A. (2021, April 30). Research shows that anyone could forget kids in hot cars. Consumer Reports. www.consumerreports.org/car-safety/anyone-could-forget-kids-in-hot-car-forgotten-baby-syndrome/
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