During 2021-2022 the MCAHD implemented various strategies to promote evidence-based practices that contribute to decrease infant and maternal mortality. These efforts were carried out in collaboration with partners in the community and included the adoption of healthful habits during pregnancy, early and continuous prenatal care, delivery of high-risk infants at facilities that fulfill the requirements for the recommended level of care, breastfeeding until infants reach at least 6 months of age, educating parents on unintentional injury prevention and safe sleep practices, and strengthening parenting skills.

COVID-19

As previously reported, in response to the COVID-19 pandemic the MCAHD modified the implementation of its programs. These adaptations changed over the years according to the evolution of the pandemic to allow the MCAHD to continue to provide support and education to the MCH population. In the reporting year, programs and strategies returned to regular operations, with appropriate cautionary measures in place to protect staff and participants.

Safe Sleep

Promoting safe sleep to decrease infant mortality continues to be a priority in the MCAHD needs assessment for 2021-22. In Puerto Rico, sleep-related Sudden Unexpected Infant Deaths (SUIDs) were the third cause of infant deaths between the ages of 1 to 12 months in 2021 and the first cause in 2017 to 2019. The definition of death due to sleep related SUIDs includes Sudden Infant Death Syndrome (SIDS), unknown cause, and accidental suffocation and strangulation in bed.

Causes of Death in Infants from 1 to 12 months old

Puerto Rico, 2021*

  *NVSS 2021, Preliminary Data

    **Codes that define SUIDS; ICD-10: R95 (Sudden Infant Death Syndrome), R99 (Other ill-defined and unspecified causes of mortality), W75 (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 at least 6 months of age without bed sharing), and without soft objects or loose bedding. Other 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®.

In the PR PRAMS 2021 survey, 55.2% of participants reported placing their babies to sleep on their backs, but only 6.9% complied with all three criteria of a safe environment (on their backs, on a separate approved sleep surface, without soft objects or loose bedding). Although there has been a gradual increase in these numbers, the PR PRAMS results raised concerns regarding the knowledge and practices of safe sleep in PR; therefore, providing education on safe sleep continues to be a priority.

 

 

Infant Sleep Practices

PRAMS 2019-2021

 

The MCAHD has 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 hospital staff. Among collaborators in the implementation of these strategies were PROGyn and ACOG, PR Hospital Association, and PRAAP Chapter.

The Home Visiting Nurses (HVNs) offered prenatal and postpartum education regarding safe sleep practices to the 3,045 families that participated in the Home Visiting Program (HVP) in the reporting year. They record the baby’s sleeping environment at each visit and provide guidance if the appropriate conditions are not met. According to 2021-2022 HVP discharge data, HVNs identified 149 participants who were placing their infants in an unsafe sleeping environment. As a result of the HVNs’ intervention, 43 (28.9%) modified their practices and achieved a safe sleep environment. By 4 months of age, the majority of HVP infants complied with at least one of the safe sleep criteria, and nearly half (45.4%) met all three. These numbers are significantly higher than those reported by PRAMS, possibly as a result of the HVNs’ direct education efforts and follow up with their participants.

Infant Sleep Practices

HVP 2021-2022

 

In addition to the HVP efforts, regional MCAHD staff offer education on safe sleep practices through outreach efforts in the community. In the reporting year, the Perinatal Nurses (PNs) reached 3,267 pregnant and postpartum women in their visits to birthing hospitals. The regional Health Educators (HE) and Community Health Workers (CHW) also educate participants on safe sleep practices through individual and group orientations, including the Prenatal and Parenting courses. A total of 533 persons participated in these activities, as detailed in the following table.

Educational activities related to safe sleep practices

offered by HE and CHW

2021-2022

 

Safe sleep practices are also promoted through the PRDOH’s social media and in the “Encounter of my life” educational website (salud.pr.gov/encuentro_mi_vida) to increase the reach of the prevention message. The leaflet illustrating the safe sleep recommendations, which can be downloaded or printed, is available at  www.salud.pr.gov/CMS/562.

Figure 1 – Safe sleep leaflet from the “Encounter of my life” webpage

The video promoting safe sleep practices that was produced in 2020 is currently under revision to include sign language interpretation, as required by the PRDOH. It will be available on the website once updated. In 2021-2022 the video was viewed 235 times.

Figure 2 – Screenshot of the safe sleep video

Infant Mortality

Vital Statistics (VS) preliminary data for 2021 reported an IM rate of 7.6 per 1,000 live births and the preterm-related mortality rate was 277.3 per 100,000 live births. Prematurity-associated conditions and low birth weight are 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 11.8% (VS 2022). 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 2022, 11.5% of live births had low or very low birth weight for gestational age.

Changes in birth weight, gestational age, and infant mortality are summarized in the following tables.

Percent of Births by Weight and Gestational Age in PR

 

Infant Mortality, Puerto Rico 2019-2021*

  NVSS 2019-2021*

*Preliminary Data

 

MCAHD staff educate, increase awareness, and promote strategies to decrease prevalence of premature birth by various means, including:  

1. HVNs evaluate HVP participants to identify the presence of risks related to premature and LBW deliveries, 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.
2. Perinatal Nurses offer education to pregnant women on signs and symptoms of premature labor.
3. The Prenatal Courses (in-person and virtual) provide information on the warning signs and symptoms of preterm labor and the steps women should take if they suspect they are experiencing it.
4. The “Encounter of my life” webpage includes information regarding the signs and symptoms associated with premature labor.
5. The MCAHD promotes the use of the prenatal card by pregnant women in obstetric offices to record pertinent obstetric history and information, and the benefit of always carrying it in case of any complication requiring urgent care.

The MCAHD provides support to PR PRAMS in sharing results with stakeholders. It encourages collaboration to propose and implement strategies to improve pregnancy outcomes and decrease IM by addressing identified needs.

The MCAHD promotes preconceptional and interconceptional health, prevention of preterm and early term births, and perinatal regionalization in an effort to decrease infant mortality. To this end, the MCAHD joined the CDC LOCATe initiative, which seeks to evaluate the levels of hospital specialty service for maternal-infant care. In August 2021 MCAHD contacted CDC to begin the process of re-implementing LOCATe in its current 9.2 version. An MOU was signed between the PRDOH and CDC to formalize the data sharing process and develop the required programming in the REDCap electronic platform (now used to complete the survey). This process was completed in April 2022.

CDC shared with MCAHD the new version of the questionnaire so it could be translated to Spanish. MCAHD staff held a virtual meeting with the Perinatal Care Advisory Committee in December 2021 to discuss the survey questions and ensure the wording would be understood by the hospital staff that will answer the questionnaire. A second virtual meeting was held in January 2022 with additional members in the committee with expertise in maternal care to conclude the discussion of questions related to this topic. The draft questionnaire was sent to CDC for review since the Spanish version must present the same content as the English version. In April 2022 MCAHD received CDC approval and programmed the translated questionnaire in the REDCap platform.

The selected sample included 33 hospitals that were eligible to participate (100 or more births during 2021). At the close of the reporting year, arrangements to send a formal invitation letter from the Secretary of Health to the hospitals were under way.

The MCAHD collaborates with the PR Hospital Association to promote compliance with Administrative Order 366 of 2017. 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 was integrated as part of the Hospital Regulations Policy #9184 (June 2020).

The MCAHD director and the maternal infant epidemiologist are members of the March of Dimes (MOD) Prematurity Prevention Committee, which also includes a representative of the Hospital Association, maternal fetal specialists, and other stakeholders. The committee focuses on proposing and implementing strategies to promote prevention of preterm births. Two priorities have been added: the group prenatal care initiative and the use of low dose aspirin among high-risk pregnancies.

Promoting healthier behavior and prenatal care through an educational campaign

During 2021-2022 the educational campaign “Encounter of my life” (“El encuentro de mi vida”) continued to spread the message that pregnancy lasts 40 weeks, encouraging adequate prenatal care and the avoidance of risk behaviors that can affect the fetus as a strategy to decrease infant prematurity, morbidity, and mortality. The campaign features linguistically and culturally appropriate messages aimed at pregnant persons, their partners and support persons, and the general public.

The “Encounter of my life” is housed within the PRDOH website at salud.pr.gov/encuentro_mi_vida. The information is organized in five sections: Prenatal care, Labor and delivery, Postpartum, Breastfeeding, and Infant care, as shown in the figure below. Each section features several fact sheets that can be viewed online, downloaded, or printed. They were developed by MCAHD staff in accordance with ACOG and AAP recommendations and are regularly reviewed for timeliness and accuracy. The Virtual Prenatal Course can also be accessed through this webpage. 

Figure 3 - “Encounter of my life” main page showing links to each of the five sections.

 

In the reporting year, the “Encounter of my life” page had 41,564 unique visitors, a tenfold increase over the previous year. This increase in traffic was due to a strong marketing campaign that accounted for 33,748 visitors between April 16 and May 12, 2022. The number of page views and sessions had a corresponding increase, as shown in the table.

Visits to “Encounter of my life” Web Page

 

Title V Home Visiting Program

The Title V Home Visiting Program (HVP) provides case management and care coordination services, education, and support to women with 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. Participants are admitted during pregnancy and followed until the child is 2 years old. Referrals come from outreach activities conducted by the HEs, CHWs and Perinatal Nurses, as well as from WIC, Medicaid, OB/GYNs and other collaborators in the community. The 79 HVNs active during 2021-2022 visited families in 70 of the 78 municipalities in PR; another 5 municipalities are covered by the MIECHV program, Familias Saludables Puerto Rico.

In the three years since the appearance of COVID-19, the HVP underwent several adaptations, as described in previous annual reports, starting with a modified protocol to move from in-person visits to virtual interventions (via telephone calls and text messaging). At this writing, the HVP is again offering in-person services as designed, with the option to provide virtual interventions if needed. For a complete discussion of the HVP, please refer to the Women-Maternal Health narrative.

The HVP participants are categorized as pregnant, interconceptional, interconceptional pregnant (those who have a subsequent pregnancy while still in the program), infants (<12 months), and children (12 to 24 months of age). During 2021-2022, the HVP provided services to 5,345 participants in 3,045 families (an increase from 5,181 participants in 2,916 families in 2020-2021). The following table breaks down the distribution of participants by category.

Distribution of HVP participants by category

2021-2022

 

The HVP has historically had 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, as shown in the following tables. This suggests its positive impact on birth outcomes. Further evaluations are being carried out to measure the impact of the HVP.

Comparison of births among HVP participants vs. all PR births

2021-2022

      Source: HVP data and Vital Statistics FY 2021-2022, Demographic Registry, PR Department of Health.

 

Comparison of gestational age at birth of HPV participants vs. PR total births

2020-2021

 

 

 

 

 

Comparison of birth weight of HPV participants vs. PR total births

2020-2021

 

The HVNs also offer limited services to non-participants of the HVP. These can be pregnant and parenting persons who do not qualify for admission to the program, as well as other persons in the community. In 2021-2022 they offered services to 4,109 persons, distributed as shown in the following table.

HVN interventions with non-participants

2021-2022

 

In addition to education and orientation, the HVNs identified needs and referred non-participants to services they required, as reported in the following table.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HVN referrals to non-participants

2021-2022

 

Perinatal Nurses

During 2021-2022 the 6 regional perinatal nurses (PNs) visited 31 birthing hospitals throughout the island where they provided information to pregnant and postpartum women and their partners, relatives, or other companions. Although the focus is on the pregnant or birthing person, including the support persons in the intervention has an impact on the health and wellbeing of the family. The PNs reached a total of 4,329 persons, distributed as shown in the following table.

Persons reached by Perinatal Nurses, by category

2021-2022

 

The PNs carried out a total of 19,011 educational interventions on topics relevant to the health and wellbeing of pregnant and parenting persons, infants, and children, as described in the following table (each person can receive multiple interventions).

 

 

 

 

 

 

 

Educational interventions delivered by Perinatal Nurses

2021-2022

Topic	Pregnant women	Pospartum women	Companions (Male)	Companions (Female)	Total
Women’s health care	11	180	51	302	544
Prenatal care	197	23	13	3	236
Risk behaviors in pregnancy	188	25	2	3	218
Labor and delivery	218	11	5	4	238
Post-partum care	50	1,748	512	141	2,451
Breastfeeding	123	2,765	424	164	3,476
Newborn screening	8	1,144	342	133	1,627
Care of premature baby	5	38	1	1	45
Newborn care	82	2,456	466	154	3,158
Pediatric preventive health care (EPSDT)	60	1,610	484	170	2,324
Correct car seat placement and use	43	2,076	451	192	2,762
Violence and unintentional injury prevention	4	149	51	59	263

 

In addition to the educational interventions, the PNs identify specific needs of the pregnant and postpartum women and their companions and refer them to the needed services. This table offers details on the 557 referrals made by PNs by type of service and population group.

Referrals by Perinatal Nurses

2021-2022

Topic	Pregnant women	Pospartum women	Companions (Male)	Companions (Female)	Total
Government health plan	2	17	1	0	20
Prenatal course	6	2	0	0	8
Parenting course	2	273	0	1	276
Home Visiting Program	47	78	96	0	221
CSHCN Program	1	10	6	0	17
WIC	2	0	0	0	2
Dentist	0	0	5	0	5
Early Intervention Program	0	1	2	0	3
Demographic Registry	0	4	0	0	4
Other	0	1	0	0	1

 

Prenatal course, in-person and virtual

The Prenatal Course includes information and educational activities on the following topics: healthy lifestyles, prenatal care, risk behaviors, stages and changes in pregnancy, conditions affecting pregnancy, delivery planning, delivery process, signs and prevention of premature birth, caesarean birth, postpartum care, baby care, breastfeeding, birth spacing and family planning. The course is kept updated with information regarding current or emerging threats, including COVID-19. As part of the course, the participants complete a socio-demographic profile and a pre- and post-test. It can be offered in four 1-hour sessions or a single 3-hour session, depending on the needs and preferences of the entity coordinating the event. During 2021-2022, both in-person courses were offered to 243 participants (see details in the following tables).

Prenatal course: 1 session, in-person

     *Participants include pregnant persons and companions (partners or other significant support persons)

Prenatal course: 4 sessions, in-person

   *Participants include pregnant persons and companions (partners or other significant support persons)

 

In response to the limitation in group activities due to COVID-19, the health educators created the Virtual Prenatal Course based on the one-session course. The 22-minute video, which includes sign language interpretation, is available on the “Encounter of my life” webpage (salud.pr.gov/encuentro_mi_vida) and presents the information using the same five categories as the educational campaign, namely Prenatal care, Labor and delivery, Postpartum, Infant care and Breastfeeding. After watching the video, visitors can access the educational leaflets included in the campaign for more detailed information.  

Figure 4 – Screen capture of the Virtual Prenatal Course showing the topics included in the video. The sign language interpreter can be seen in the lower right corner.

During 2021-2022, 619 persons completed the Virtual Prenatal Course. Almost all (595, 96.1%) were women; of these, 510 (85.7%) were pregnant.

As presented in the table below, pre- and post-test results reveal a statistically significant increase in participants’ knowledge after completing the courses, regardless of the method.

Pre- and post-test scoring in prenatal course participants

2021-2022

 

Community Education Interventions

The educational efforts of CHWs and HEs are again offered as designed as COVID-19 restrictions were relaxed. The MCAHD 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, family planning and related subjects. 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 1,392 pregnant women received educational interventions from HEs and CHWs during fiscal year 2021-2022.

The CHWs and HEs also offer community outreach educational interventions on newborn and infant care and other topics relating to prenatal and post-partum care that impact birth outcomes. These orientations can be offered to individuals or groups. During 2021-2022, HEs and CHWs offered 1,639 individual interventions on the topics shown in this table. 

Individual orientations on selected topics related to perinatal-infant health

2021-2022

 

The outreach activities are held in diverse settings in the community. In the reporting year, HEs and CHWs reached 12,320 persons in the locations listed below.

Population reached in group activities by outreach staff, by location

2021-2022

Group activities on selected topics related to perinatal-infant health

2021-2022

 

The CHWs refer participants to services available in the community according to the needs and interests of the individual. In 2021-2022 they issued a total of 2,778 referrals, as detailed in the following table.  

Referrals made by CHWs

2021-2022

In addition to offering referrals, CHWs and HEs coordinate with local agencies and service programs (via telephone calls or in person) regarding services needed by people in the community they reach in their interventions. In the reporting period a total of 2,295 contacts were made, as detailed in the next table.

Agencies contacted by CHWs and HEs

to coordinate services or activities

2021-2022

 

Fetal Infant Mortality Review (FIMR)

MCAHD 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 systems-related risk factors for fetal and infant deaths and to generate recommendations to address them. To this end, the Review Team examines de-identified comprehensive information regarding infant and fetal deaths. In recent years, the PR-FIMR focused on deaths occurring among HVP participants.

During the reporting year the PR-FIMR was on hiatus. Please see the Perinatal-Infant Plan for the Application Year narrative for details on the reactivation of the PR-FIMR during 2022-2023. When a fetal or infant death occurs in the HVP, priority is given to providing the mother bereavement support. A Fetal Death Report or Infant Death Report containing general information on the mother, gestational age or age of the infant, and cause of death is filled out by the HVN and submitted with the monthly reports.

The following table details pregnancy outcomes (deaths or losses) of the HVP for 2020-2021 and compares the results to the general PR population. Final mortality data for 2022 were not available at the time of this report. The Demographic Registry Office (DRO) has been transitioning to a digital platform for death registrations since 2021. This change resulted in many data quality setbacks, which had a negative impact on the availability of death data. Therefore, data for 2021 are preliminary until the issue is totally resolved.

 

 

 

 

Comparison of pregnancy outcomes (deaths and losses)

between HVP and general PR population

2020-2021

 *HVP and PR Vital Statistics from July 2020 to June 2021.

 **Statistical information of Women’s Abortion Clinics (4 of 5 clinics), Assistant Secretariat for Planning and Development, PR Department of Health Fiscal Year 2020-2021. Data available for abortions in PR General Population.

 

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. Thus, the PRDOH prioritizes the promotion of BF practices.

The Maternity Practices in Infant Nutrition and Care (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 hospitals that participate in the survey, and an improvement in scores reflecting positive changes in maternal infant practices. The mPINC score in 2013 was 61, in 2015 it was 69, and in 2020 PR achieved the score of 73. In the 2022 mPINC survey, PR achieved the same total score as reported in 2020.

The MCAHD 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 (June 2020). The regulations emphasize compliance with Act 156 as amended in 2016 (assuring women may have a companion through labor and the postpartum period, rooming-in option, and BF rights, among others), and Act 79 of 2004 (forbidding hospital staff from giving breast milk substitutes to newborns without a doctor's order and the mother's informed consent).

The revised 2030 Healthy People objectives include two related to breastfeeding: increase the proportion of infants who are breastfed exclusively through age 6 months and increase the proportion of infants who are breastfed at 1 year.

 

 

 

 

 

 

 

 

 

HP 2030 Breastfeeding Objectives

  *Data Source: NIS, 2015

Puerto Rico Vital Statistics (VS) data obtained from the birth certificate revealed that 96.7% of mothers ever breastfed prior to registering their babies in 2022, a slight decrease compared to 2021 (97.2%). Of the women who reported ever breastfeeding, in 2022 47% reported exclusive BF prior to registration. In the first hour post-partum, 70% of mothers who delivered vaginally and 36% 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. The following table reports BF prevalence in Puerto Rico for 2019-2022 using VS data.

Percent of mothers reporting breastfeeding

2019-2022

 *Data is obtained by the combination of breastfeeding the 1st hour after birth, at the time of discharge and at the     baby registration in the demographic registry office

 **Data reported by hospital

 §Data reported by mother/father at baby registration

 

Most recent data from PRAMS 2021 showed that 25.4% of mothers breastfed exclusively at 3 months. This was an increase of 28% when compared to 2019 (19.8%). The percentage of mothers that were still breastfeeding at the time the survey was answered remained above 50% during the last 3 years of data. Other data pertaining to BF, obtained from the 2019-2021 PR PRAMS, are reported in the following tables.

Exclusive breastfeeding at 3 months of age

PR PRAMS 2019-2021

 

 

 

 

 

Infants who were breastfed at the time the survey was answered, by age

PR PRAMS 2019-2021

 

Breastfeeding status at the time the survey was answered

PR PRAMS 2019-2021

 

Breastfeeding promotion and support in the hospital postpartum

PR PRAMS 2019-2021

 

Breastfeeding support after baby’s birth

PR PRAMS 2019-2021

 

Breastfeeding is actively promoted through various strategies directed at MCAHD participants and the general public. The Prenatal Course, both in-person and virtual, includes information on the benefits of BF, preparation in the prenatal period, 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. As reported above, 248 persons participated in the in-person courses and 619 in the virtual course, for a total of 867 persons.

A total of 1,090 infants (birth to 12 months of age) participated in the HVP during 2021-2022. HVNs provide breastfeeding education and support to the participants. The HVP protocol calls for weekly visits in the first 4 weeks postpartum where, among other topics, 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, 88% of participants reported ever breastfeeding, an increase from the 83% who did in 2020-2021. Likewise, 38% continued to BF until 6 months, which is an increase from 37% in 2020-2021.

The Perinatal Nurses reached out to 2,962 new mothers in 31 birthing hospitals to promote breastfeeding and offer orientation on resources that provide breastfeeding support in their community.

The WIC program uses an evidence-based BF peer counselor support program which connects experienced BF WIC participants and new mothers. According to the information provided by WIC, the BF rate for their participants was 59.9% for 2021-2022. The data for the peer counselor program reports the number of contacts between the counselor and the participants; it does not reflect the actual number of persons served. The contacts include individual in-person orientation, telephone consultations, home visits and group orientations. In the reporting year WIC reports 62,895 contacts with pregnant and parenting persons. Of these contacts, 1,142 persons received support while still in the hospital after the birth of their infant.  

WIC BF Peer Counselor Interventions by Participant Category

2021-2022

 

The recommendations for feeding infants and children from 0 to 24 months of age were approved and adopted as public policy by the Secretary of Health in 2018. They promote exclusive breastfeeding and the delay in the introduction of solids until 6 months of age. These recommendations continue to be shared with pediatricians and nutritionists in multiple forums.

The PR PRAMS survey queried mothers regarding the introduction of solid foods in their babies’ diets. Data for 2021 showed that there was an increase in the percent of infants who had not received solids foods at 5 months, from 63.1% in 2020 to 66.3% in 2021. The following table shows the percentage of infants who had not started eating solids at 2, 3, 4 and 5 months of age during 2019-2021.

 

 

 

 

 

 

 

 

Infants who had not received solid foods at the time of the survey, by age

PR PRAMS 2019-2021

 

Other Strategies Implemented by the MCAHD to Decrease IM

Prevention of unintentional injury

The MCAH Program staff offers educational activities to participants, providers, and the general population to increase awareness of preventable causes of infant mortality and 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 PNs also include orientations on safe sleep and prevention of unintentional injury in their orientation on newborn care to postpartum families.

The Prenatal and Parenting courses include content on injury prevention, safety strategies, 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. CHWs and HEs also offer individual and group orientations to promote the prevention of unintentional injury. During 2021-2022, MCHAD staff offered 382 individual orientations and reached 1,984 persons through group activities on this topic.

Prevention of Shaken Baby Syndrome

The HEs and MCAHD 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 intervention, which was offered by HEs to 150 persons during 2021-2022.

Prevention of Forgotten Baby Syndrome

Forgotten Baby Syndrome may happen to any family. A child left in a parked vehicle can die of heat stroke (extreme heat) in a very short time. 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. Act 173 of 2016 requires day care centers to call parents if a child 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. MCAHD staff continues to share the poster with other agencies and organizations.

 

Infant CPR Anytime

Infant CPR Anytime is a strategy proven to save lives that is included in the HVP education protocol. HVNs use an infant mannequin 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. Hands-on training on Infant CPR Anytime is temporarily discontinued due to the precautions related to infection control and prevention. However, the HVNs use the Baby Anne® infant CPR trainer to demonstrate and explain basic techniques as well as choking prevention and management. The Infant CPR Anytime training is combined with the delivery of safe sleep recommendations, complementing strategies aimed at decreasing infant mortality.

Opioids

The MCAHD has remained vigilant to the prevalence of withdrawal syndrome in newborns, which requires hospitals to report cases to the PR Department of the Family. During 2022 neonatal abstinence was reported in 0.5/1000 live births among mothers with medical insurance in PR. Although this is in the lower range when compared to the prevalence in the USA (1.8 to 40.8/1000 live births in the USA in 2021), the MCAHD promotes healthy lifestyles and habits including avoidance of drugs, tobacco, and alcohol during pregnancy. The holistic management of infants with withdrawal syndrome and their families is shared between the primary physicians and PR Department of the Family.