Decrease in Infant Mortality (IM) is a top priority for PR MCAH for which it continued to implement strategies in an effort to decrease preterm births, increase the percent of very low birth weight infants delivered at facilities for high-risk deliveries, educate women on how to prevent Zika infection and high risk behaviors during pregnancy, promote and support breastfeeding until infants reach at least 6 months of age, educate parents on unintentional injury prevention and strenghten parenting skills.
Adverse pregnancy outcomes contribute to infant mortality and morbidity. Vital Statistics (VS) data for 2019 report the IM rate of 6.6 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. 2019 VS reported 171.6 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 decreased since 2015, remains high at 11.8% (2019 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 2019, 10.4% of live births had low birth weight or very low birth for gestational age. Infant, neonatal and postneonatal mortality demonstrate a decreasing tendency in preliminary data for 2019, as shown in the following table.
Initiatives continued by the MCAH Program to educate, increase awareness and decrease prevalence of premature birth include;
- The distribution of a magnetic pad featuring warning signs and symptoms of preterm labor and the steps women should take if they suspect they are experiencing preterm labor.
- HVNs routine evaluation of the HVP participants to identify the presence of risks related to premature and LBW deliveries, to provide education and individual orientations 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.
- The 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 MCAH staff continued to provide support to the PR PRAM staff in sharing the results from the 2017-2018 results with stakeholders and promoting collaboration to propose and implement strategies to improve pregnancy outcome and decrease IM by addressing the needs identified in the survey. Promoting oral care in pregnant women and changes in hospitals to improve the support for breastfeeding initiation post partum have been among the needs identified and addressed.
The MCAH Program 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. Prenatal Health Care Services Guidelines (PNHCSG) along with the Preventive Health Services Guidelines for women in reproductive 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 the service of home administration of the 17HP (hydroxyprogesterone) may be offered. During 2018-19 2.1% of pregnant women in PR with medical insurance received 17 HP. (Data provided by the PR HICO)
The MCAH staff also continued to promote the compliance with the Administrative Order 366(2017), which requires hospitals to adopt the Hard Stop Policy to obtain renewal of operational license from the Health Department in collaboration with the Hospital Association. The MCAH director and 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 steakholders. Priorities of this committee continued to be to provide opportunities to collaborate in the to proposal and implementation of strategies to promote the 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 at a 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 educational orientation and promoting pregnant women to adopt preventive measures to avoid mosquito bites and infection by arboviruses (Zika and dengue), 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 all the courses (Prenatal and Parenting) and 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 the 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 hospital institutions that offer services in Puerto Rico. 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 2017-2019 in an innovative approach completing a face to face interview between MCAH staff and a team representing each hospitals administrative and medical staff. During 2018-2019 a report of LOCATe findings specific to each institution was shared in a second interview with a team of representatives of each participating hospital. The hospital team was composed of the OB/GYN Director, NICU or Neonatal Director, Nurse Supervisors and Hospital Administrator. In the 2nd interview, they received results of their classification of maternal and neonate level of care as assessed by the PR LOCATe analysis and further results of data analysis relevant to infant and maternal outcome specific to their institution and aggregate analysis of all the hospital in PR.
This visit provided the opportunity to have a conversation about the findings as well as to clarify any questions regarding the levels of care. It also provided the opportunity to improve data quality. 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 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 for the population. 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 this second interview it was observed that some hospitals changed ownership or improved services, having a change in their classification of level of care as assessed according to PR LOCATe. The following tables summarize the results of the LOCATe assessments.
Many hospitals demonstrated improvement in their level of maternal care classification by the recruitment of a maternal-fetal medicine specialist, and/or obstetrician on site 24/7, and/or anesthesiologist with experience in obstetric anesthesia in charge of the maternal anesthesia services and/or by adding MRI 24/7 services. Hospitals were able to improve their level of neonatal care classification by the recruitment of a neonatologist, or of 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 the hurricane providing the opportunity to identify the challenges faced during and after the storms, and to request hospitals to share their revised protocols for disaster preparedness and management so as to develop general recommendations for hospitals to evaluate their individual plans and modify according to their needs. The face to face interview also provided the opportunity to share 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 continued in the outpatient setting with the first visits to the pediatrician recommended in the first week of life. This message has been shared through the multiple media campaigns along with breastfeeding promotion. The PR PRAMS reported 99.1% of mothers participating in the PR PRAMS survey of 2017 and 2018, responded in 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 behaviour and prenatal care with Prenatal Multimedia Educational Campaign
During 2018-2019 the multimedia campaign El Encuentro de Mi Vida (“The Encounter of My Life”) continued with the purpose 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 main 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 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 wesite also features fact sheets related to various aspects of prenatal care, infant care, safe sleep and breastfeeding among others. 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.
A poster presentation on the development and implementation of this campaign was presented and shared in the March 2019 AMCHP conference and has been included in AMCHP's Implementation Toolkit for National Performance Measure 4: Breastfeeding, as a recommended practice for education (June 2019). The BFPCG has also been included in AMCHP's Implementation Toolkit for National Performance Measure 4 as a recommended practice in Policy and Systems Approaches.
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 1061 pregnant women participated in the HVP during 2018-2019.
The population served by the HVP has a larger percent of adolescents, considered at higher risk for complications and poor outcomes.
Despite the HVP serves 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 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.
The HVNs continued to train participant families on how to perform Infant CPR Anytime during the third trimester and a refresher in the first month of the infants life. They also educate families on Safe Sleep practices beginning in the second trimester of pregnancy.
The PR PRAM 2018 study revealed that 43.6% of participants reported placing their babies to sleep on their backs and only 4.1 % complied with all three criteria of placing them in a safe environment (on their backs, on a separate approved sleep surface, without soft objects or loose bedding). Therefore, it is has been necessary to continue to educate on safe sleep recommendations that are included in the Parenting and Prenatal courses, “Why do babies cry?” workshop, and other community education interventions.
Communitty Educational Interventions 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.
During 2018-2019 the 8 regional perinatal nurses (PNs) of the MCAHD reached 31 birthing hospitals throuhout the island providing breastfeeding support and orientation to post partum women and their families. The PNs provided educational services to 426 pregnant women of which 44% were referred to services such as GHP, MCAH HVP, WIC, Prenatal course / Parenting course, and the public housing agency. A total of 5,448 post-partum women also received their services of which 10 % were reffered to GHP, MCAH HVP, Parenting course , pediatrician,pediatric dentist, breasfeeding consultant, and the pediatric center. Besides referring participants to the agencies, follow up phone calls are performed when needs are identified.
In the work of the MCAH staff the main targets are pregnant women and WRA, but accompanying males and grandparents also benefit of the educational initiatives which also have impact on the health and wellbeing of the family and strenghten the role and responsabilities of the father figure. Among other populations that received services there were 1,104 men and 1,746 accompanying non-pregnant women. The Perinatal Nurses also completed 1,467 visits to hospital, reaching a total of 8,781 persons. Population reached by the PNs with topics relevant to interconceptual, post partum, WRA, pregnant women and neonatal care are reported in the following tables.
MCAH HEs and CHWs offered the prenatal course “A Baby on its 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 effect on the fetus and the need to test during pregnancy for infection were added to this course. A total of 1,342 participants completed the 4 sessions of the prenatal course.
An achievement of the course is a statistical significant improvement in knowledge in each session as revealed upon evaluation of scores on the pre and post test.
Participants reached by the CHWs and HEs in other communitty outreach educational activities on relevant topics to WRA and pregnant women are reported in the following tables.
Fetal and Infant Mortality Review (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 2018-2019 and 2017-2018.
Due to the staff’s risk for compassion fatigue in the management of families that have perinatal losses, a workshop was offered to all the HVP staff in december 2018 by the MCAH Clincal psychologist Consultant. Topics covered were definition of compassion fatigue, its causes, how to identify it, tools to help auto evaluate and strategies to manage and overcome it.
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 were incorporated as priorities to address and take action.
After hurricane Maria in 2017, the PR FIMR developed a series of recommendations to improve o neonatalcare in hospitals after a disaster. Neonatologist 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 FIMR coordinator and Pediatric Consultant of PR MCAH, Dr. Cindy Calderon, shared the experience of the PR FIMR in helping identify needs to improve preparedness to manage neonates at high risk after a disaster, in a collaboration with Rosemary Fournier, FIMR Director of the National Center for Fatality Review & Prevention at the City Match 2018 Conference in Providence, Rhode Island.
The PR Department of Health established a Committee to develop a Protocol to be implemented in hospital to support families to overcome the grief with the loss of an early pregnancy, or a fetal or Neonatal death as indicated in Law No. 184 of 2016. The MCAH FIMR coordinator was assigned coordinator of the committee, with collaboration of the MCAH Clinical Psychologist Consultant . The committee will establish protocols for the evaluation of the needs of families after a loss and the support for the bereavement during their stay in the hospital and referral to resources in the communiity, according to the stipulations in the law.
Breastfeeding Promotion
Breastfeeding has proven to have a positive impact on decreasinge IM. Evidence supports BF’s beneficial effect in decreasing the prevalence of childhood obesity, therefore chronic diseases, and in the prevention of Sudden Unexpected Infant Death.
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 communitybased 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,the impact on their economy and the benefit of breastfeeding support for mothers. 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 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 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).
Among lessons learned after huricane Maria, is the importance to continue to promote 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 newborn the protection provided by breastfeeding and the advantages in case of a major disaster.
On July31, 2019, 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 Confianza (“Breastfeed with Confidence ”) with a poster developed by an interdisciplinary team of MCAH staff. The poster features a breastfeeding mom in semidarkness, compelling a tender image of a breastfeeding mother in the shadows, a situation that may occur in absence of electricity after a mayor disaster. This actvity was covered by local press and among the speakers there were families of the HVP who presented their testimonials on how breastfeeding their baby after the hurricane disaster, with support from the HVP nurses, helped them overcome the challenge of safely feeding their infant. All collaborators form the Breastfeeding Promotion Collaborative Group that provided support and promoted breastfeeding after the disaster were recognized and received a certifcate recognizing their contribution.
Subsecretary of PR DOH, Collaborators of the BFPCG, MCAHD Staff, Family from HPV program during the Breastfeeding Week Press Conference
During 2018-2019 the MCAH Staff collaborated with the WIC program to update and revise the Safe Infant Feeding Protocols for the PR DOH, in an effort to promote support for breastfeeding as the safetest 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.
A collaborator from the BFPCG, Dra Yvette Piovanetti received a grant from Save the Children to train communitty leaders and hospital staff in promoting Safe inFant feeding after a disaster, for what she incorporated the Safe Infant Feeding Protocols of the PR DOH among her topics. The training was delivered through out the island and the MCAHD staff of the HVP particpated.
The BFPCG also developed recommendations for hospitals to include BF support strategies as part of their preparedness and disaster plan. This was shared through the Hospital Association with all hospital institutions in Puerto Rico.
Puerto Rico has sustained an increase in the prevalence of everbreastfed due to the many strategies promoted and implemented in the last 5 years such as; education of hospital staff, public policies of the PR DOH for hospitals to support BF initiation, educational initiatives in the communitties, media campaigns, and collaboration with groups that promote BF. The following table reports BF prevalence in 2017, 2018 and preliminary results for 2019.
The everbreastfed percents obtained by the Jurisdictional Survey of 2019 was 87.4% versus 96.5% reported by VS. A possible explanation for thiese diferrences may be due to the small sample size used for the JS versus the VS which is based on the total newborns registered on the island.
Puerto Rico Vital Statistics (VS) preliminary data obtained from the birth certificate revealed that 96.5% of mothers ever breastfed prior to registering their babies in 2019 a sustained increase in prevalence above 95% since 2017. Of the women who reported ever breastfeeding, 47.5% in 2019 reported exclusive BF prior to registration. In the first hour post-partum, 66.4% of mothers who delivered vaginally and 33.5% 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 results pertaining to BF, obtained from the 2017 and 2018 PR PRAMS, are as 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 the Lactation month of August 2018, 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 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, 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 2018-2019). 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 1,198 infants (less than 12 months of age) participated in the HVP during 2018-2019. 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 90.7% and 69.5% exclusively breastfeeding on 2018-2019, compared to 67% everbreastfed in 2016. Thirty-one percent (31%) continued to BF until 6 months (compared to 25% in 2016), 16.4% exclusively. Forty-five percent (45%) of HVP participants are adolescents between the ages of 11 to 20, 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.
As part of the hospital visit for LOCATe during 2018-2019 the MCAH staff also provided hospital 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 website www.encuentrodemivida.com with their prenatal patients.
During 2019 the regional MCAH Health Educators delivered multiple presentations of the laws that support and protect breastfeeding mothers to the staff of the PR Family Welfare Agency, from all over the island.
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 Dr. Calderon, PR WIC,, infant nutrition specialist Dr. Rafael Escamilla from the School of Public Health at Yale University, representative of the World Health Organization (WHO) and the Pan American Health Organization (PAHO) in Puerto Rico Dr. Raul Castellano, nutritionist Sofia Pérez from PAHO, neonatologist Dr. Maribel Campos, and nutritionist Dr. Cristina Palacios from the Human Development Department of the University of Puerto Rico Graduate School of Public Health. These recommendations have been shared in multiple forums to pediatricians and nutritionist. PR PRAMS 2018 reports infant feeding practices by mothers.
OTHER STRATEGIES IMPLEMENTED BY THE MCAHD TO DECREASE IM
Prevention of unintentional injury
Multiple 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 delivered to a total of 677persons during 2018-2019.
Prevention of Forgotten Baby Syndrome
Although a forgotten baby also occurs in other states and territories, due to the tropical temperatures in Puerto Rico, a baby forgotten in a car faces a high risk of 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 2018-2019 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. 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 foreing object causing axphixia in her grandchild due 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.
During 2019 neonatal abstinence was reported in 1.7/1000 live births among mothers with medical insurance in PR, lower than the incidence of 8/1000 live births in the USA. The holistic management of these infants and their families is shared between the primary physicians and PR Family Welfare Agency.
To Top
Narrative Search