The discussion of findings in each domain starts with a description of the major health issues and the identified critical areas of concerns (needs) in the 5YR HNA 2025, followed by key adjustments to health promotion efforts and services during the past 2020-2025 cycle, staff suggested actions for the 2025-2030 cycle and the current challenges that need to be addressed in the next five years.

Regarding quantitative analysis, when sufficient data were available, a trend analysis spanning three-year or five-year intervals was conducted. This involved calculating the Average Annual Percent Change (AAPC) and performing Chi-square tests for trends to identify statistically significant changes over time, with a significance threshold of p<0.05. In cases where data were limited to two years, a Percent Change (PC) analysis was used to assess the significance of observed changes.

Women and Maternal Health

In 2023, Puerto Rico had 797,112 Women of Reproductive Age (WRA), making up 24.9% of the island's population (ACS, 2023). Most (72.5%) were aged 22 to 49, with smaller percentages in younger age groups. About half (53%) were covered by the Government Health Plan (GHP).

Live births have declined significantly, with 18,645 births in 2023 compared to 34,493 in 2014, a 46% decrease over the decade. Most births (80%) occur among women aged 20 to 34, with 13% from women 35 or older, and 7.2% from adolescents. Approximately 66% of births are from mothers, covered by GHP (Vital Statistics, VS).

The Health Needs Assessment identified the following critical areas of need:

Mental Health has emerged as a significant challenge. Before pregnancy (Figure 1), 14.2% of women reported anxiety and 5.9% reported depression (PR-PRAMS). These conditions correspond with the most common diagnoses in medical and mental health visit claims among WRA, with mood disorders accounting for the highest number of claims during 2021-2023 (Figure 2). The prevalence of depressive disorders (Figure 3) has increased across most age groups (PR-BRFSS), and postpartum depression rose from 10.8% in 2019 to 17.7% in 2023 (PR-PRAMS). Fewer than half of new mothers (46.4%) reported being screened for depression during the postpartum period (PR-PRAMS 2023).

Pregnancy Morbidity remains concerning despite high rates (Figure 5) of prenatal care initiation (85% in first trimester) and overall coverage of prenatal care (98%). Only 18% of women reported comprehensive discussion of all relevant topics during prenatal care (PR-PRAMS). Dental care during pregnancy (PR-PRAMS) decreased by 28% between 2018 and 2022 (Figure 6), with many women (21.8%) not believing dental visits were necessary during pregnancy (Figure 7). The top five pregnancy-related health issues according to PR-PRAMS (Figure 8) were anemia (18%), anxiety (16.7%), high blood pressure (11.4%), depression (9.5%), and gestational diabetes (8.3%).

Preconceptive Care shows gaps in preventive healthcare. According to BRFSS data from 2018 to 2022, a significant decrease in preventive visits over the past 12 months was observed across most age groups, with women aged 25 to 34 years being the only exception (Figure 9). Only 5.4% of women reported comprehensive preconception counseling (PR-PRAMS). Frequently discussed topics included smoking cessation (72.6%) and maintaining healthy weight (55.7%), while important topics like folic acid intake (34.4%) and emotional health (32.5%) were less commonly addressed. Mammography rates among women aged 40 to 49 decreased by 2% between 2014 and 2022 (Figure 10), and young women (21 to 24) had significantly lower rates of cervical cancer screening (Figure 11) compared to older women (PR-BRFSS).

Healthcare Access presents geographical challenges (March of Dimes), with 20% of municipalities classified as "maternity care deserts" lacking hospitals, birthing centers, or obstetric providers (Figure 12). These areas affect over 117,000 women and more than 3,500 births. Additionally, 9.8% of women have no birthing hospital within a 30-minute drive. While prenatal care inadequacy (10.5%) is lower than the U.S. average (14.8%), women with chronic health conditions face a 37% higher risk of preterm birth.

 

Key Adjustments in 2020-2025 Cycle

• The in-person 4-sessions prenatal course was revised and shortened to a single 3-hour session to accommodate the needs and preferences of pregnant women and families.

 

“…as it is only one session pregnant women and the persons who are going to accompany them are more willing to take the course.”

– Community Outreach Program Staff

 

• Expansion of sites where the prenatal course is offered that now include the homes of pregnant women and families.
• Specific topics contained within the prenatal course are offered as a single educational activity to those women who cannot attend the course.
• Increased responsiveness to mental health in pregnant women and mothers by the Home Visiting Program (HVP) staffed by the Home Visiting Nurses (HVNs) that periodically receive information and training.

 

Staff Suggested Actions for 2025-2030 Cycle

• Offer staff refresher training on topics already covered in health promotion and services (i.e., breastfeeding and birthing) to keep them updated with the latest information. 
• Train staff on emergent issues such as vaping, fentanyl, and the effects of the use of medicinal cannabis on pregnancy and breastfeeding.
• Provide education on mental health issues in women, pregnant women and mothers to the Health Educators (HEs) and Community Health Workers (CHWs) as these staffs often confront emotional issues in individuals receiving group or one-on-one education. 
• Create and use visually appealing educational materials in WRA/maternal health promotion.

Challenges to Address in 2025-2030 Cycle

• Uneasiness and suspicion among women who have been referred to the HVP during the first telephone contact - generated by the HVNs - due to fears that it can be a fraudulent call.  
• Influence of family members on HVP participants whose values and ideas contradict the educational content and information of the program. For example, the HVP promotes and supports breastfeeding, but family members may insist women use formula.  Relatives may also insist on keeping certain sleep practices that are inconsistent with safe sleep.

Perinatal/Infant Health Domain

Puerto Rico's infant population was 17,724 in 2023, less than 1% of the total population (ACS, 2023). All infants were insured, with 40.5% covered by private insurance and 59.5% by GHP (MCH-Jurisdictional Survey, MCH-JS).

Three critical areas of need were identified:

Fetal Death rates have increased significantly (Figure 13), rising from 11.2 per 1,000 live births in 2018 to 16.2 in 2022, an 11% increase (VS). Perinatal mortality also increased, though not significantly, from 6.9 to 7.4 per 1,000 live births. The 2019-2022 Perinatal Periods of Risk analysis showed that the maternal care period (colored in pink) accounted for 26% excess deaths compared to expected levels (Figures 14 to 15). For this period, prevention should focus on preconceptional health, unintended pregnancy, smoking, drug abuse, and specialized perinatal care.

Premature Births increased (Figure 16) from 11.5% in 2020 to 12.2% in 2023 (VS). About 75% of these premature births occur between 34 to 36 weeks gestation and are largely preventable. The infant mortality rate related to premature births rose from 284.4 per 1,000 live births in 2020 to 298.2 in 2022 (Figure 17). Analysis of Attributable Risk (2022) suggests that eliminating late premature births could reduce infant mortality by 60%, potentially lowering the rate to 3 deaths per 1,000 live births.

Infant Mortality increased approximately 4% from 2018 to 2022 (Figure 18), rising from 6.5 to 7.5 deaths per 1,000 live births (VS). Most deaths occur during the neonatal period (5.1 per 1,000) rather than the postneonatal period (2.6 per 1,000). Approximately 84% of infant mortality is attributed to complications occurring during the perinatal period (Figure 19). The Perinatal Periods of Risk analysis confirmed that maternal health and prematurity contributed to 48% excess deaths (Figure 14 and 20), highlighting the critical connection between maternal health and infant survival.

 

Key Adjustments in 2020-2025 Cycle

• Created the Perinatal Mental Health Task Force in response to the need to address mental health in the perinatal population.
• Enhanced the Promotion of Safe Sleep practices among pregnant women, mothers and families through courses, educational activities, individual orientations, and digital videos.
• Enhanced the PR-FMIR data and interviewing processes as all the Perinatal Nurses (PNs) were trained on data extraction while 10 HVNs received training on parental interviews.  

• Developed Emergency Preparedness and Response: A Guide for the MCH Population that considers its characteristics, needs and vulnerabilities.

Staff Suggested Actions for 2025-2030 Cycle

• Offer staff refresher training on topics already covered in health promotion and services (i.e., breastfeeding and birthing) to keep them updated with the latest information. 
• Train staff on emergent issues such as vaping, fentanyl, and the effects of the use of medicinal cannabis on pregnancy and breastfeeding.
• Develop mass campaigns to promote the use of the Postpartum Visit Pocket Guide (currently in progress) that includes importance of attending the postpartum visit as well as other topics that are essential in the first year after a birth or pregnancy.
• Disseminate the Postpartum Visit Pocket Guide through the Demographic Registry Office.
• Offer skills building training to the PNs on approaching and giving support to mothers with losses.
• Create and use visually appealing educational materials to promote perinatal and infant health.

Challenges to Address in 2025-2030 Cycle

• Provide education and support to pregnant women and mothers with special needs as the staff, namely PNs and HVNs, need information and skills to better serve this population.
• Birthing hospitals do not follow placing babies on their back that contradicts the promotion of safe sleep practices.  In this regard, efforts should be made to educate hospital staff.
• Hospital staff do not give breastfeeding support to women during their hospital stay.  To address this challenge, the staff proposed offering education and training to hospital staff.  About this issue, it must be clarified that the PNs fill this gap when they visit mothers in hospitals. All supervisors of the PNs agree that mothers, particularly those whose babies are in NICU, not only receive education but very importantly assurance and tranquility that they can breastfeed.

 

“Having a knowledgeable person, that is, a nurse that takes the time to explain, to answer all questions she [mother] has…that tells her ‘do not worry, I am going to refer you to this place, you have my telephone number, or you can call the region if you have any situation’…gives her [the mother] peace of mind.”

– Perinatal Nurse Supervisor

Child Health Domain

In 2023, Puerto Rico had 203,263 children aged 1-9, representing 6.3% of the population (ACS, 2023). Nearly all (98.8%) were insured, with 74.6% enrolled in GHP and 24.2% covered by private insurance (MCH-JS).

Three main areas of concern emerged:

Death due to unintentional injuries (Figure 21) was a leading cause of child mortality (14.3% of deaths in 2022). Child mortality rates showed variability, peaking at 16.7 deaths per 100,000 in 2021 before slightly decreasing to 16.2 in 2022 (Figure 22). The types of unintentional injuries varied by age: children aged 1-2 were most affected by motor vehicle crashes, drowning, and choking; for those aged 2-5, drowning was the most frequent injury. Other common injuries included falls and being hit by objects (VS).

Mental Health concerns have increased (Figure 23), with psychological developmental disorders (such as autism) and emotional and behavioral disorders (such as separation anxiety and oppositional defiant disorder) being most common (2021-2023 Medicaid MMIS database). The percentage of children diagnosed with behavioral problems rose significantly from 7.1% in 2019 to 10.5% in 2023 (Figure 24). Only 18% of children with behavioral diagnoses received treatment in 2023, decreasing significantly from 55.4% in 2019 to 18% in 2023 (MCH-JS).

Immunization rates declined dramatically (Figure 25), with the percentage of children aged 0 to 24 months completing the 4:3:3:1:1:1:4 vaccine series dropping from 48% in 2021-2022 to 21.9% in 2022-2023 (PR Immunization Registry, PRIR). The most substantial declines were in MMR and Varicella vaccines, attributed to pandemic-related challenges. On a positive note, preventive care screenings (Medicaid, EPSDT) recovered significantly from pandemic lows, reaching 40.2% in 2022-2023 (Figure 26), while preventive visits increased significantly (Figure 27) from 79.9% in 2016 to 92.3% in 2023 (PR-BRFSS).

 

 

 

 

 

 

 

 

 

 

 

Key Adjustments in 2020-2025 Cycle

• Parenting courses (children 0-5 years and 6-11 years) are now being offered to families that were referred to these courses by the PR Department of Family requiring court certification.
• Expansion of sites where the parenting courses are offered that now include families’ homes.
• Specific topics contained in the parenting courses are offered as a single educational activity to those parents and families that cannot attend the courses.

Staff Suggested Actions for 2025-2030 Cycle

• Offer refresher training on topics already covered in health promotion and services for children (i.e., unintentional injuries, immunization) to keep them updated with the latest information.
• Train staff in mental health issues affecting children. Behaviors related to mental health are increasingly being observed by the staff in their interactions with children.

 

“…you are covering a topic [children’s health] and mental health surfaces…And it from fourth graders onward verbalizing emotions…one has to know how to work around this issue. That is a theme that always arises, mental health!

– Health Educator

 

• Create and use visually appealing educational materials for parents and children.
• Obtain demonstration models to be used in oral health activities for children.
• Provide toothbrushes and dental paste to children attending oral health activities.
• Offer training to the MCAH Section staff on delivering education and information to parents of children with special needs.

 

“In the workshops [and educational activities] one has to give out information to mothers with children with special needs. This is very important…We must have these skills because mothers of children with special needs will show up.”

– Community Outreach Program Staff

 

• Encourage the HEs to share among themselves the educational materials and activities each one of them develops individually to enable them to replicate those that have been successful in health promotion.

 

Challenges to Address in 2025-2030 Cycle

• Giving out incentives, a common practice among other agencies and/or programs, is lacking in the PR Title V parenting courses (0-5 yrs and 6-11 yrs). Therefore, the staff stressed the need to obtain and distribute incentives to participants not only in the parenting courses but in the prenatal course as well.
• The length of the 0-5 yrs Parenting Course is a challenge as parents found it burdensome to attend all four sessions. Parents are also reluctant to attend the sessions unrelated to their child’s age.  An option, according to the staff, could be to create several courses corresponding to the children’s life cycle: 0-1 yr, 2-3 yrs, 4-5 yrs.  This may encourage more parents to attend parenting courses.

Adolescent Health Domain

Puerto Rico had 443,880 adolescents aged 10 to 21 in 2023, comprising 13.8% of the population (ACS, 2023). The majority (37.7%) were aged 10-14, with smaller percentages in the 15-17 (24.9%), 18-19 (17.9%), and 20-21 (19.6%) age groups. Nearly all (99%) had health insurance (MCH-JS), predominantly through GHP (70.5%).

Three primary needs were identified:

Mental Health issues were prevalent (Figure 28), with emotional and behavioral disorders, including conduct problems and oppositional defiant disorder, being most common (2021-2023 Medicaid MMIS database). Diagnoses of behavioral problems increased by 6.2% in 2023 (Figure 29), while access to treatment decreased significantly by 46.7% (MCH-JS). Feelings of sadness (Figure 30) were more common among females (44.9%) than males (25.8%). Suicide planning decreased overall by 11% (Figure 31), with a larger decrease among females (13%) but a slight increase among males (4%). Across all groups, there was a decrease in suicide attempts, though this reduction was not statistically significant (Figure 32). School bullying (YRBSS) decreased significantly (Figure 33), with appearance, academic achievement, and weight being the main reasons reported for bullying (Figure 34).

Tobacco and Vaping trends showed a significant decline in traditional tobacco use but a marked increase in electronic cigarette use across all groups (Figures 35 to 36). Males (30.7%) reported higher percentages of ever using e-cigarettes (Figure 37) compared to females (27.1%), though by 2021, females (10.7%) were using e-cigarettes (Figure 38) more frequently (YRBSS). The Monitoring the Future survey revealed that e-cigarette use begins early, with 3.3% of 7th graders and 23% of 12th graders report use (Figure 39).

Mortality due to homicides and motor vehicle crashes increased by about 2% between 2018 and 2022 (Figure 40), rising from 42.2 to 49.1 deaths per 100,000. Males had significantly higher mortality rates (78.9 per 100,000) compared to females (18.3 per 100,000). Unintentional injuries and homicides consistently ranked among the top five causes of death across all adolescent age groups (Figure 41), with homicides being among the top three causes for teenagers aged 15 and older (VS).

 

Key Adjustments in 2020-2025 Cycle

• Developed interventions directed at the YHPP to help them manage emotions after a stressful event such as earthquakes.
• Incorporated creative tools and dynamic activities in the Youth Health Promoters Project (YHPP) to facilitate learning and participation.
• Created tools to educate Youth Health Promoters on how to navigate the health care system.
• Created the Childhood and Youth Mental Health Collaborative in response to the need to address youth mental health identified in the HNA 2020.
• Created an adaptation of My Health Planner (“Mi agenda de salud”) for the adolescent population. It retains the structure and basic content, but the messages were tailored to the concerns of youth ages 10-21.
• Offered workshops on My Health Planner to youth groups in schools.
• Incorporated mental health into the works of the Youth Advisory Council (YAC).
• YAC created an environmental committee to raise awareness of the effects of climate change on human health using virtual challenges as a tool to promote environmental health.

Staff Suggested Actions for 2025-2030 Cycle

PR Title V Staff

• Develop strategies to address increasing mental health problems among youth. Strategies should include tools to enable the CAHP Regional Coordinators to apply them in the YHPP meetings.
• Develop educational campaigns targeted at parents to promote their active participation in youth health.
• Adapt specific topics covered in the Youth Health Promoters Project (YHPP) curriculum to be offered as single educational activities by the HEs and CHWs to expand youth health promotion to youth groups beyond the YHPP.
• Educate and train the HEs and CHWs about adolescent topics including mental health and managing youth groups to enable this staff to better understand and work with the adolescent population.  
• Offer training to the staff of participating YHPP schools on mental health and management of school bullying.

Youth Advisory Council (YAC)

• Reinstitute YAC’s webpage including its logo to better promote youth health.
• Organize health fairs targeted at adolescents and young adults.
• Enable YAC members to provide education and training to parents and families.
• Provide advice to other programs/initiatives within the PRDOH.

Challenges to Address in 2025-2030 Cycle

PR Title V Staff

• The academic calendar of the PR Department of Education along with adverse events like atmospheric phenomena often make it difficult to carry out all the sessions of the YHPP curriculum that have been programmed for the school year.
• In some schools, the school social worker and director fail to manage referrals made by the CAHP regional coordinator resulting in delays in responses to critical situations like bullying and sexual abuse among others.
• Little or no participation of parents in activities of the program.

Youth Advisory Council (YAC)

• Recognition on the part of PRDOH officials of the importance of digital platforms and social networks to promote youth health.
• Offer orientation and support to young adults ages 21-25 about the transition from adolescence to adulthood including health plans and medical visits as they often have little or no correct information.  Some members are nearly 20-21 years of age and are experiencing great need for support during this transition.  Perhaps this challenge can be addressed through the Community Outreach Program.
• YAC members strongly feel they should be regarded as a youth “community impact group” that can develop and implement their own initiatives to reach out to larger numbers of adolescents in PR. In their view, as youth representatives they should be directly involved with other young people. In their own voices:

 

“The main action is to move to the community… My impression when I entered YAC was to impact the community. I saw myself offering workshops, conferences, helping others… To be a liaison, that to my understanding is what been an advisor means.”

– Youth Advisory Council Member

 

“The YAC guide stipulates that the council should be known by youth because we are representing them…What we look for is to be the intermediaries between youth and the DOH.”

– Youth Advisory Council Member

The notion of being a community impact group poses a challenge as it may be inconsistent with YAC’s role as an advisory entity as stipulated by the DOH administrative order 359 that created YAC in 2016. The CAHP may address this challenge by clarifying the roles and limits of YAC to avoid misunderstandings and wrong expectations.   It should also be considered that members of groups go through several stages in knowledge and skills that may result in changes in their views and expectations across time. 

Children with Special Health Care Needs Domain

In 2023, Puerto Rico had 117,607 children aged 0 to 17 with special health care needs (CSHCN), representing 3.7% of the total population (MCH-JS). The largest age groups were 11 to 14 years (29.8%) and 6 to 10 years (29.5%).

Most CSHCN (76.1%) require frequent healthcare services, with 52.7% dependent on medication and 17.3% experiencing functional limitations (MCH-JS). The most common conditions include speech disorders (39.4%), asthma (38.3%), attention deficit disorder (37.1%), learning disabilities (30.8%), and anxiety (24.2%). Nearly all (99%) have insurance coverage, predominantly through GHP (77.8%).

Three key areas of need were identified:

Functional difficulties are common (MCH-JS), with 17.3% of CSHCN experiencing such challenges (Figure 42). Parents reported that their child's condition affects task performance (Figure 43) "always" (7.7%), "generally" (8.8%), or "sometimes" (34.5%), with 23.7% reporting it affects them "a great deal" (Figure 44). The most significant difficulties (Figure 45) included problems with concentration (47.4%), vision (18.8%), performing errands (15.2%), dressing or bathing (9.5%), walking or climbing stairs (5.6%), and hearing (2.1%). The main conditions prompting referrals to Regional Pediatric Centers (Figure 46) were autism (22%), prematurity (20%), and speech and language delays (15%).

Medical home availability decreased significantly, with only 29 certified medical homes in 2023, down from 72 in 2019, a 60% reduction. Accordingly, the percentage of parents reporting having a medical home for their child decreased significantly (Figure 47) from 57.1% in 2019 to 53% in 2023 (MCH-JS). The percentage of CSHCN with a personal doctor or nurse decreased from 91.7% to 88.2%, though 91% still had a regular place for care (Figure 48). There was significant improvement in referral access, increasing from 41.5% in 2019 to 60% in 2023, with 89% reporting little to no difficulty obtaining referrals (Figure 49). In terms of family-centered care, there was an improvement in providers responding to guardians' questions and paying attention to their concerns. However, there was a decrease in providers making guardians feel involved in the child's care (Figure 50).

Transition to adult healthcare showed improvement (MCH-JS), with the percentage of young people with special healthcare needs (YSHCN) aged 12 to 17 receiving necessary transition services increasing significantly from 6.4% to 22.2% (Figure 51). More parents reported that healthcare providers worked with youth to understand changes in medical care at age 18 (increasing from 43% to 47.1%) and plan for their future (from 34% to 43.2%). However, fewer parents reported (Figure 52) that the provider helped youth make positive health decisions (decreasing from 73.8% to 63.3%) or acquire self-management skills (from 68% to 61.5%). A health care providers survey administered by CSMNS showed that provider barriers to transition included (Figure 53) lack of time (90%), absence of a coordinator (89%), and insufficient inter-provider collaboration (83%).

 

 

 

 

 

Key Program Adjustments in 2020-2025 Cycle

• Enhanced monitoring of services provided in some Regional Pediatric Centers (RPCs).
• Met the emergent need among families (parents and guardians of CSCHN) to be listened to when facing stressful life situations by receiving empathic support from the Family Engagement and Support Advocates (FESAs). In this regard, the FESAS view themselves as the helping hand that just listens without judgement.  One FESA recounted her experience with a grandfather:

 

“I ask him, do you need to talk to someone. He says, “Do you have time to listen to me?  I, sure.  While sitting next to him, he begins talking, talking, talking….at the end he tells me, this was what I needed, someone who listens…”

– Family Engagement and Support Advocate

Staff Suggested Actions for 2025-2030 Cycle

• Re-establish the functioning of electronic files as they were stopped several years ago.
• Train the RPCs staff in telemedicine and electronic files.
• Evaluate and standardize RPCs procedures, including monitoring of services provided, to improve service delivery.
• Offer refresher training to FESAS to have the latest information about the topics they cover in their interventions with families such as autism, health plans, and confidentiality.
• Re-establish monthly meetings of FESAS as they were stopped some time ago. These meetings are seen as necessary to enable the FESAS to share information and experiences about the work they perform with families.
• Train FESAS on mental health issues and emotional support to CSCHN families including losses to equip them with the necessary tools to continue carrying on this task.
• Review and update the FESAS manual created years ago and clarify functions and roles, if necessary.
• Update information of RPCs services in the PRDOH webpage.

 Challenges to Address in 2025-2030 Cycle

• Activation of functioning of telemedicine as the RPCs have the equipment but cannot use it at the present time due to internet connectivity problems.  

• Little understanding of the importance of the roles FESAS play in the RPCs. To address this challenge, the FESAS proposed offering formal education to other staff in the RPCs about their role in providing orientation and support to families receiving services.
• Importance of making the services provided by the RPCs visible as there is some misinformation and misunderstanding about the RPCs in the community including health professionals. The staff felt that information about the RPCs should be made available through professional associations, workshops, conferences, press, virtual social networks and radio and television programs.
• Unclear FESAs roles as each RPC assigns function to them differently. For example, in some RPCs the FESAs may coordinate services provided by the RPC such as physical therapy and speech therapy while in others they may not. 
• Difficulties in recruiting health professionals to offer services in the RPCs due to higher wages in the private sector.

Conclusion

Puerto Rico's 2025 HNA reveals significant challenges in maternal and child health. Across women, children, and adolescents, key issues include rising mental health disorders, reduced preventive care visits, and increased fetal and infant mortality. The assessment highlights the need for comprehensive, targeted interventions addressing mental health screening, healthcare access, and specialized support for vulnerable populations, with a strategic focus on improving health outcomes through innovative educational and preventive strategies during the 2025-2030 cycle.