During 2020-2021 the MCAHD implemented various strategies and collaborated in promoting evidence-based practices that contribute to decrease infant and maternal mortality, such as promoting 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. These efforts were carried out in the context of the COVID-19 pandemic and the effects of the mitigation policies on availability of services.

Earthquake sequence

The earthquake sequence that began in December 2019 is still seismically active, although at a lesser intensity. In the reporting year, it did not have a significant impact on the MCH population.

COVID-19

As was previously reported, the government’s COVID-19 response began in March 2020 with a shutdown of all unessential services and businesses. 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 in-person interventions by the HVP, HE and CHW were converted to telephone or virtual methods to allow for 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 a modified intervention model. These efforts are described in the Women/Maternal Health narrative. 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.

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 third cause of infant death between the ages of 1 and 12 months in 2020 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, 2020

          Data based on 32 total deaths in infants between 1 to 12 months of age in 2020.

         *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 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®.

In the PR PRAMS 2020 survey, 49.6% of participants reported placing their babies to sleep on their backs and only 6.8% 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 continues to be necessary to continue to educate on safe sleep recommendations.

Infant Sleep Practices

PRAMS 2018-2020

 

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. The following educational interventions were offered in September 2020 by the former MCAHD Pediatric Consultant, who was also president of the PRAAP:

• Webinar: Safe Sleep to Decrease Infant Mortality. Audience: Hospital nurses, physicians and administrators; MCAHD Perinatal Nurses and Home Visiting Nurses.
• Facebook Live panel discussion of recommendations for Safe Sleep. Audience: health care professionals and general public

In addition, in October 2020 a short video promoting safe sleep practices was developed by the former Pediatric Consultant and the Maternal Health Education Consultant for dissemination through social media. The following image is a screenshot of the promotion for the video that was published in Facebook.

 

The HVNs offered prenatal and postpartum 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. HVNs have been able to view the baby’s sleeping arrangements via videochat or photos. 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?”.

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.

Infant Mortality

Vital Statistics (VS) data for 2020 reported an IM rate of 7.0 per 1,000 live births and the preterm-related mortality rate was 210.3 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 12.0% (VS 2021). 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 2021, 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.

Percent of Births by Weight and Gestational Age in PR

 

 

Infant Mortality, Puerto Rico 2017-2020

     NVSS 2017-2020

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;

1. 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.
2. Perinatal Nurses’ education to pregnant women on signs and symptoms of premature labor.
3. 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.
4. 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.
5. The “Encuentro de mi Vida” prenatal campaign offered through various media outlets.

The MCAH staff continued to provide support to the PR PRAMS in sharing the results 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 staff also 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 was integrated as part of the 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.

Promoting healthier behavior and prenatal care through a multimedia educational campaign

During 2020-2021 the multimedia campaign “El Encuentro de mi Vida” (“The Encounter of My Life”) continued 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. The multimedia campaign consists of linguistically and culturally appropriate messages aimed mainly at Spanish-speaking pregnant women, their partners and support persons. 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.

“Encuentro de mi Vida” Campaign

2020-2021

 

“Encuentro de mi Vida” Web Page

2020-2021

 

Due to the pandemic, videos were aired only on TV (not in movie theaters) & online during 2020-2021. Banner ads for the website were featured on social media and news outlet pages and continue on the PRDOH webpage. The website www.encuentrodemivida.salud.gov.pr 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, 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 can 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 of 618 pregnant and 2,298 interconceptional women participated in the HVP during 2020-2021. The 76 HVNs active during 2020-2021 visited families in 69 of the 78 municipalities in PR; another 5 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 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 seen 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

 2020-2021

      Source: HVP data and Vital Statistics FY 2020-2021, Demographic Registry, PR Department of Health.

 

   Comparison of Birth Outcomes (Gestational Age at Birth and Birth Weight)

   HPV Participants vs. PR Total Births

   2020-2021

 

 

The HVNs also delivered orientation and referrals to non-participants of the HVP, as reported in the following table.

 

The HVNs educate all families on Safe Sleep practices beginning in the second trimester of pregnancy. Hands-on training on Infant CPR Anytime is temporarily discontinued due to the precautions related to infection control and prevention during the COVID-19 pandemic. However, the HVNs can demonstrate and explain basic techniques as well as choking prevention and management.

Community Education Interventions Implemented by MCAH Staff

The educational efforts of CHWs and HEs continued to be affected by the COVID-19 pandemic measures and restarted gradually as restrictions were relaxed. The MCAH 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 1,386 pregnant women received educational interventions from HEs and CHWs during fiscal year 2020-2021.

Given the restrictions in group activities that prevailed in the reporting year, the HEs also continued to work on updating and developing educational activities and supporting materials regarding the topics.

During 2020-2021 the 6 regional perinatal nurses (PNs) of the MCAHD reached 27 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 309 pregnant women, 139 (44.9%) of whom were referred to services such as GHP, MCAH HVP, WIC, Prenatal or Parenting course, and prenatal care clinic. A total of 3,871 postpartum women also received their services, of whom 515 (13.3%) were referred to GHP, Parenting course, pediatrician, 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 791 men and 409 accompanying non-pregnant women. The Perinatal Nurses also completed 1,078 visits to hospitals, reaching a total of 5,164 persons.

The following table present the educational interventions by the PNs on topics relevant to interconceptional, postpartum, WRA, pregnant women and care of the newborn.

Educational Interventions Delivered by Perinatal Nurses

2020-2021

 

This table summarizes the referrals made by PNs to services needed by the pregnant and postpartum women and their companions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referrals by Perinatal Nurses 2020-2021

 

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 any 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. The following tables show the number of participants in the courses in 2020-2021.

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 redesigned the contents of the “A Baby on the Way” prenatal course and adapted it to a video presentation. It covers all the topics in an abbreviated fashion and refers viewers to “Encuentro de mi vida” (encuentrodemivida.salud.gov.pr) where they can access more complete information. This course was offered in two modalities. The on-demand video went online in February 2021. One session was offered synchronously via Zoom; the participants were together in a classroom; the facilitator presented the video remotely and answered questions live. The following table shows the number and category of participants in both modalities.

Participants of Virtual Prenatal Course by Method

2020-2021

 

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.

Pre- and Post-Test Scoring in Prenatal Course Participants

2020-2021

 

Other Educational Activities

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.

 

 

 

 

 

Participants of Educational Activities Delivered by MCAH Staff, by Topic

2020-2021

 

Number of Activities by Location 2020-2021

 

 

 

 

 

 

 

 

 

 

 

 

 

Referrals made by CHW

2020-2021

 

Agency Contacted by CHW and HE to Coordinate Services or Activities

2020-2021

 

Fetal Infant Mortality Review (FIMR)

MCAH staff has headed the Puerto Rico Fetal Infant Mortality Review (PR FIMR) since2006, 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 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 has focused on deaths occurring among HVP participants. The HVP admission criteria prioritize pregnant persons with risk factors for adverse birth outcomes and IM.

As of this writing, the FIMR is on hiatus. The last review meeting took place on August 15, 2019. The COVID-19 pandemic diverted staff efforts to education and prevention activities. In addition, the Title V Pediatric Consultant, who served as FIMR Coordinator, resigned in September 2021.

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 2019-2020 and compares the results to the general PR population.

    Comparison of Pregnancy Outcomes (Deaths and Losses)

        between HVP and General PR Population 2019-2020

*HVP and PR Vital Statistics from July 2019 to June 2020.

**Statistical information of Women’s Abortion Clinics (4 of 5 clinics), Assistant Secretariat for Planning and Development, PR Department of Health Fiscal Year 2019-2020. 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.

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 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 2013 was 61, in 2015 it was 69, and in the latest mPINC version of 2020 PR achieved the score of 73.

 

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 (2017) is the importance to continue promoting breastfeeding as the 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.

On April 7, 2021 the PRDOH, in collaboration with PRAAP, presented a webinar to 143 pediatric health care professionals on the topic of human milk use and the transition from NICU to home during the COVID-19 crisis. The focus was to provide updated information about the support and promotion of breastfeeding in NICU, the evidence-based practices for optimal transition to home, and the DOH public policies regarding breastfeeding in hospitals. Topics presented were:

1. The importance of human milk use and its therapeutic role during the NICU stay
2. The challenges of human milk donation during the COVID-19 pandemic and the strategies to overcome them
3. Safe infant feeding in home (maintaining the successful breastfeeding)
4. Safe sleep recommendations

A digital poster was developed by an interdisciplinary team of MCAHD staff and published in the “Encuentro de mi Vida” website. The poster features diverse mothers wearing facemasks while breastfeeding.

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

 

The following table reports BF prevalence in Puerto Rico for 2017-2021 using VS data.

 

 

 

 

 

Percent of Mothers Reporting Breastfeeding

2017-2021

 *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

 

Puerto Rico Vital Statistics (VS) data obtained from the birth certificate revealed that 97.2% of mothers ever breastfed prior to registering their babies in 2021, a sustained increase in prevalence above 95% since 2017. Of the women who reported ever breastfeeding, in 2021 46% reported exclusive BF prior to registration. In the first hour post-partum, 69% of mothers who delivered vaginally and 35% 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 2018-2020 PR PRAMS, are reported in the following tables.

 

Exclusive breastfeeding at 3 months of age

PR PRAMS 2018-2020

 

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

PR PRAMS 2018-2020

 

 

 

 

 

Breastfeeding status at the time the survey was answered

PR PRAMS 2018-2020

 

 

Breastfeeding promotion and support in the hospital postpartum

PR PRAMS 2018-2020

 

Breastfeeding support after baby’s birth

PR PRAMS 2018-2020

 

Another strategy used to promote BF was the Prenatal Course, offered by regional HEs and CHWs to pregnant women and their relatives, as reported above. 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 734 infants (birth to 12 months of age) participated in the HVP during 2020-2021. Home Visiting Nurses 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 restrictions of the past 2 years meant that for much of the time those visits were done virtually; however, the nurses were able to assist many participants via video chat. The HVP nurses encourage exclusive breastfeeding during at least the baby’s first 6 months of life. In the HVP, 83.0% of participants reported ever breastfeeding, a decrease from the 87.7% who did in 2019-2020. In contrast, 36.5% continued to BF until 6 months, which is an increase from 34.9% in 2019-2020.

The Perinatal Nurses also reached out to recent mothers in 27 birthing hospitals to promote breastfeeding and offer orientation on resources that provide breastfeeding support in their community, as reported above.  

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.

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 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 during 2018-2020.

 

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

PR PRAMS 2018-2020

 

Other Strategies Implemented by The MCAHD to Decrease IM

Prevention of unintentional injury

The MCAH Program staff continues to offer educational activities to participants, providers, and the general population to make them aware of preventable causes of infant mortality. Various strategies were continued 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 126 persons during 2020-2021. An article recommending safe sleep practices was also written by the MCAH Pediatric Consultant and published in a local parenting magazine in May 2021.

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. 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 Anytime

Infant CPR Anytime is a strategy proven to save lives that has been part of the HVP education protocol. It calls for the HVNs to 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. Hands-on training on Infant CPR Anytime is temporarily discontinued due to the precautions related to infection control and prevention during the COVID-19 pandemic. However, the HVNs can 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 Family Welfare Agency.  During 2021 neonatal abstinence was reported in 0.5/1000 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.