The physical and mental health and wellbeing of women of reproductive age (WRA) and mothers and birthing persons (MH) is one of the top priorities of the MCAHD. The Title V Home Visiting Program (HVP), Perinatal Nurses, Prenatal Care campaign and courses, and Community Outreach and Education will continue to address the two main concerns of this domain: promoting health and well-being among WRA, and improving birth outcomes.

Maintaining healthy lifestyles lowers the incidence of health risks and chronic diseases that affect women’s health, complicate pregnancy and adversely affect birth outcomes. The adoption of healthful behaviors by women starting long before they think of pregnancy increases the likelihood of positive birth outcomes. Physical and mental health factors are intertwined and require equal attention. Social, cultural and environmental factors that can have a positive or negative effect on the woman’s physical and mental well-being are taken into consideration when designing and delivering interventions.

Home Visiting Program

As discussed in the WRH/MH Annual Report, the COVID-19 pandemic response continued to have an impact on the Home Visiting Program (HVP) protocols. At this writing, home visits have resumed throughout the island. However, a small number of participants, especially those who are pregnant or have newborns, have asked the Home Visiting Nurses (HVNs) to postpone home visits out of fear of contracting COVID-19. In those cases, the modified protocol designed to guide the interventions via telephone and text messaging is used. HVNs continue to use the mobile phones with unlimited data plans that were supplied to them in January 2021 to improve communications capabilities with their participants.

Although most pandemic restrictions have been lifted, there are some residual effects on the availability of services. The HVNs continue to assist participants to navigate the processes needed to access public and private services such as enrolling in WIC, obtaining health care including well-woman preventive visits, prenatal and postpartum care, pediatric care, as well as registering newborns in the Demographic Registry, among others.

In January 2021, while home visits were still curtailed, HVNs delivered educational materials and incentives to their participants following the prevention guidelines set forth in the “Protocolo para entrega de materiales educativos e incentivos a participantes durante la pandemia COVID-19” (“Protocol for delivery of educational materials and incentives to participants during the COVID-19 pandemic”). This marked the first time since March 2020 that they were able to interact face-to-face with their participants, albeit in a limited manner, and the first time they met participants who had been admitted to the HVP during the lockdown. According to the reports of the regional supervisors, both nurses and participants were grateful for the opportunity to meet.

HVNs and MCAHD staff received the COVID-19 vaccines by February 2021 and have received the boosters as required. Home visits resumed in March 2021 following a strict protocol to reduce risk for both HVNs and participants. The protocol for virtual visits remains in effect for participants who are not willing to receive home visits at this time and for those who have COVID-19 or a possible exposure in their home. The supplemental protocol “Retorno a las visitas presenciales a los hogares de participantes” (“Return to in-person home visits”) was distributed on March 9, 2021. The protocol specifies risk mitigation measures and instructions for specific in-home interventions. In August 2021, the Mental Health Consultant and HVP Coordinator facilitated a virtual roundtable discussion regarding home visits in times of COVID-19. In addition to discussing the protocol, the HVNs had the opportunity to express their feelings and share experiences in this regard.

A home visit consent form was developed to ensure that both the HVN and the participant are committed to following protective measures. The PRDOH requires the use of facemasks to receive health services, although it is no longer mandated by the local government; other measures include maintaining social distance, keeping visits to a maximum of 20 minutes, meeting in well-ventilated areas, asking the participant to inform the HVN of any symptoms suggestive of COVID-19 or exposure to someone with the condition, etc. Participants are free to refuse to receive in-person visits for any reason, and they are assured this will not have any consequence in the services they receive.

Figure 1 Consent form for return to in-person home visits

As the pandemic evolves, Central level staff will continue to work with the Regional Directors, Supervisors and HVNs to ensure services are provided in accordance with local and federal public health and emergency response guidelines. The health and safety of our HVNs and participant families is of the utmost importance for the HVP.

Maternal health care remains a main feature of the HVP. The HVNs will continue to receive periodic in-service training on various aspects of women’s physical and mental health, including preconceptional, prenatal and postpartum care, so they can offer updated information to participants. The training sessions will also enhance the HVNs’ knowledge and skills to identify and address any issues identified during their interventions.

The HVP will continue to use validated screening instruments to assess the participants’ needs, including the following:

• Edinburgh Postnatal Depression Scale to screen for perinatal depression

Cambridge Worry Scale to identify sources of worry or stress related to pregnancy and childbirth

• Adverse Childhood Exposure (ACEs) to enable HVNs to take a trauma-informed approach to their interventions
• Women’s Experience with Battering (WEB) scale to identify women facing or at risk for physical or emotional violence.

Alcohol, tobacco and drug use is assessed using a modified 4P+ Scale[1]. A tobacco use history inventory is administered to participants who state they have ever smoked. Other instruments may be considered for inclusion as the need arises.

The HVNs use the information gleaned from these screening instruments together with the participant’s Biopsychosocial Profile (the core participant record) and their observations as the basis to develop the individualized care plan.

The HVN interventions focus on education, support, case management and care coordination by means of referrals to available services in the community. The HVP protocol specifies the educational and support interventions that are offered to all pregnant and interconceptional women. As always, the HVNs tailor their actions to the participant’s identified strengths and needs, taking into consideration the resources available in the community. Nutrition and physical activity during and after pregnancy, postpartum care, well-woman health care, maternal mental health and well-being are some of the topics that make up the WRA/MH component of the HVP curriculum.

The HVP Central level staff identified the need to incorporate a mental health intervention model. Several potential programs were reviewed to analyze their suitability. However, it was difficult to identify a program that meets all the criteria for adoption, especially availability in Spanish, reasonable cost of the program, and how disruptive the interventions would be to the current service model. Staff requirements were particularly worrisome and difficult to meet, as many are geared to mental health professionals. As a result of the Title V Action Plan PDSA process carried out in early 2022, the team determined to modify this strategy as follows: “Provide continuing education to HVNs to improve their knowledge and skills in identifying, managing, and referring participants who report mental health issues.” These topics will be featured in the training plan for the coming year, as mentioned above.

The first Perinatal Mental Health Awareness Day was observed in Puerto Rico in May 2022. This observance was conceptualized and developed by the Perinatal Mental Health Center, which is affiliated with the Psychiatry Department of the University of Puerto Rico School of Medicine. The Title V Mental Health Consultant is one of the founding members of the Center and author of the measure. It was presented in the Legislature and passed by both the House and Senate as Act 6 of 2022. Its objective is educating and increasing awareness about the issues surrounding emotional and mental health during pregnancy, delivery and the postpartum period. It aims to open the way to education and research activities to identify more effective ways to prevent, diagnose and treat these conditions, which have an adverse effect not only on the health of the pregnant and parenting persons, but also on their children. The MCAHD plans to disseminate information on this important issue through various means in the coming year.

To commemorate the first Perinatal Mental Health Day, the Center sponsored a panel discussion entitled “Perinatal Mental Health: Why is it important for pregnant and postpartum persons?” Health professionals representing academia, PRDOH and NGOs spoke about their service programs and their impact. The HVP Coordinator presented the HVP's protocol and interventions as well as a case study. 

MCAHD staff remains on the alert for emerging health threats or changes to the environment that may require modifications to the programs, protocols, instruments or educational materials. In addition, the HVP is agile in reacting and responding to any required changes. The COVID-19 crisis put this capability to the test. The HVP staff demonstrated their capacity to react effectively and in a timely fashion to emerging threats and needs and to incorporate the response into the protocol.

In March 2022, the Mental Health Consultant, HVP Evaluator and HVP Coordinator presented a poster entitled “Addressing Home Visitors’ Needs in times of Crisis” at the 2022 National Home Visiting Summit sponsored by Start Early. It illustrated the incremental response of the HVP to various crises that have affected Puerto Rico in the past 6 years: the Zika epidemic, Hurricanes Irma and María, the earthquake sequence and COVID-19. The response was framed in administrative, personal and programmatic areas.

It was important to gauge impact of the HPV's response on the HVNs’ work and personal lives. A survey was administered to HVNs in February 2022 exploring their opinions regarding how useful the revised protocols, educational sessions and virtual discussions were on increasing knowledge and self-efficacy, reducing stress, and promoting self-care. The majority of HVNs agreed the interventions had been useful and had helped them to carry out their interventions. Despite the time elapsed since the interventions, the HVNs were able to recall specific self-care techniques and other information that had been shared.

Promoting self-care and attending to HVN's needs is a priority of the HVP, especially in these times of uncertainty and constant changes in service delivery practices. Recognizing and addressing these concerns strengthens the workforce, resulting in improved services to the participant families.

Figure 2 Addressing Home Visitors' Needs in Times of Crisis poster

Community Health Workers, Health Educators And Educational Campaigns

As the pandemic restrictions were eased in 2021, educational activities in the community resumed following prevailing government orders and all necessary precautions to minimize risk of transmission. The plan for the coming year is subject to changes according to the evolution of the pandemic and changes to government guidelines.

The Health Education Component (HE) will provide their traditional group orientations in schools and universities, health care provider offices, human services offices and other locations where the MCH population can be reached, as allowed according to changing regulations. The HEs and Community Health Workers (CHWs) focus on oral health, nutrition and physical activity, COVID-19 and other transmissible diseases, mosquito-borne diseases, alcohol, tobacco and drug use, family planning, well-woman care, signs and symptoms of premature birth, the Hard Stop policy that discourages elective inductions or cesareans before 39 weeks of pregnancy, and related MCH topics in their work at the community level.

In addition to providing education and orientation on health topics, the CHWs will continue to identify pregnant and parenting persons who do not have health insurance coverage and refer them to the Medicaid office for evaluation of eligibility and certification. They also identify pregnant women who are not receiving prenatal care and other persons who are not otherwise connected to the health care system and provide referrals for needed health services.

The Perinatal Nurses (PN) will continue to visit birthing hospitals throughout the island to provide education and referrals to pregnant women and new mothers. They offer these one-on-one educational interventions to all women, regardless of risk level.

The “Encounter of my life” (“Encuentro de mi vida”) prenatal education campaign that started in 2018 acquired even more pertinence during the pandemic, as it allows pregnant and parenting persons to obtain information in a safe manner. The PNs and HVNs refer people to the website for information that complements their verbal communication. The campaign emphasizes the importance of completing 40 weeks of pregnancy, attending prenatal care regularly, adopting healthy behaviors and avoiding risks during pregnancy. It also covers the postpartum period and the importance of breastfeeding and having the father and other relatives support mom and baby.

The success of the campaign led to a new version during 2021-2022. It follows a similar strategy, with increased exposure in social media. An initial meeting between MCAHD, a new advertising agency (AA), the PRDOH Office of Communication (PRFODOC) and the Auxiliary Secretariat of Family Health and Integrated Services (ASFHIS) to present the objective of the new campaign: to promote the benefits of prenatal care, positive health habits during pregnancy, and breastfeeding. It is designed to be distributed through Facebook and Instagram, in order to reach a wide segment of the population of reproductive age. Starting in August 2021, MCAHD staff worked closely with the AA to ensure accuracy and pertinence of the educational messages.

For this new campaign, the AA recommended using social media influencers as spokespersons, to increase interest in the messages among the target population. After evaluating several candidates, the MCAHD selected the Mojica-Ramos family. Vilmarie Mojica has stood out as a pillar of the Puerto Rico women's national volleyball team, including representation in the 2009 Pan American Cup and the 2012 Olympic Qualifying Tournament. Currently, Mojica has more than 241k followers on Facebook and more than 193k on Instagram. Tommy Ramos is a renowned gymnast from Puerto Rico, noted for the 2010 Central American and Caribbean Games and in the 2012 Olympic Games. Ramos has more than 185k followers on Facebook and 41k on Instagram. As social media influencers, they present a positive, healthy lifestyle centered on their family and two young daughters.

The AA produced 13 videos, all under one minute long, on the topics of prenatal care, childbirth, postpartum, breastfeeding and baby care. During production, the MCAHD and the AA held various meetings to review the scenarios, scripts, content, graphic arts and closed captions for the publication of the videos. The videos are embedded in the “Encuentro de mi vida” webpage (encuentrodemivida.salud.gov.pr).

From February to March 2022, the AA completed the production of the campaign videos under the supervision of the MCAHD. The final versions included a call to action to access the website and take the virtual prenatal course. Several meetings were held to review post-production and editing of videos until they gained final approval by the MCAHD.

The AA also presented a proposal for the redesign of the “Encuentro de mi vida” webpage. The MCAHD staff worked with the AA, OITA and PRDOHOC to acquire the new webpage domain following the PR Information and Technology Service guidelines. The AA update of the website features an attractive, modern design to appeal to the target population. It includes the existing written educational content, the new videos of the influencers, and other vaccination and safe sleep videos previously developed by the MCAHD. A button at the top of the new home page directs visitors to the virtual prenatal course. The new webpage domain, encuentrodemivida.salud.gov.pr, and the campaign were launched on April 13, 2022. The new home page (see image below) features a photo of the Mojica-Torres family, the new slogan used in each video, the purple button to access the virtual prenatal course, and icons linking to other videos of the campaign. By May 12, 2022, the website had had 43,223 page views.

Promoting Oral Health In Pregnant Women

The COVID-19 pandemic and response affected access to dental services for the whole population. Even at this date many dental offices are offering limited services, resulting in long waits for appointments. This situation, compounded by fear of contracting COVID-19, has discouraged many people from seeking dental services. Therefore, education of the importance of oral care will continue to be a priority. The “Encuentro de mi vida” campaign and the Prenatal Course will continue to emphasize the importance of preventive dental visits during pregnancy. The HVP will also continue to provide education and referrals to dental care to all pregnant and interconceptional participants.

Promoting Preventive Health Services Among Women

The women’s health pocket guide, entitled “Mi agenda de salud: una guía para mujeres de 10 a 49 años” (“My health planner: A guide for women ages 10 to 49”) is a health promotion tool for women ages 10 to 49. Its aim is to encourage an annual preventive health visit with a primary care physician (PCP), explain what can be expected during the visit, and encourage women to talk to their PCPs regarding any concerns. It offers a list of health protective behaviors, explains the importance of vaccinations and the most common procedures and tests by age group. Please see the Women-Maternal Health Annual Report for a complete description of the guide.

The guide is being disseminated through diverse channels to ensure it reaches as many WRA as possible. The Title V Reproductive Epidemiologist made a presentation to collaborators from around the Island, including health insurance companies and providers; as a result, 40 entities signed on to participate in distributing the guide. A colorful promotional sticker has also been distributed widely. Other channels include the HVNs, PNs, CHWs and HEs; MCAHD Regional Boards; MCAHD Youth Advisory Committee; and PRAMS survey respondents, among others.

A QR code printed on the guide and the sticker leads users to the “Mi agenda de salud” webpage (www.salud.gov.pr/CMS/433). This page offers supplemental information, references, and a short video that explains the importance of the annual health visit and how to use “Mi agenda de salud” to guide the visits. It also has a link to download and print a copy of “Mi agenda” and an instructional video showing the steps to fold the guide.

The Health Education component is developing two educational activities intended to raise awareness of the annual preventive health visit as well as to distribute the guide. One is directed at women ages 10 to 19 and will be implemented in middle and high schools and in organizations that work with young persons. This activity is in the final stages of development and will be piloted in the new school year. The second activity is aimed at adult women (ages 20 to 49) and will be developed in the coming months. Details will be reported next year.

In order to estimate the distribution of the guide and usage by the intended audience, four questions were incorporated in the BRFSS questionnaire in PR in 2022. These questions are asked of women ages 18-44 after the questions regarding the preventive health care visit. At this writing, data regarding the questions is not yet available from CDC but is expected in the coming months.

The updated “Preventive Care Guidelines for Women of Reproductive Age,” directed to health care providers, were thoroughly revised according to current best practices and reviewed by experts in preventive health care and women’s health. The MCAHD plans to disseminate this information through various educational activities for physicians and other health care professionals, MCAHD staff, health insurance companies and other interested parties.

Maternal Mortality Review

After the delays imposed by the COVID-19 pandemic, the Maternal Mortality Review Surveillance System (MMRSS) has resumed work on this important public health initiative. The MMRSS will implement CDC’s Maternal Mortality Review Information Application (MMRIA) data system. MMRIA is a tool that allows the Maternal Mortality Review Committee (MMRC) to collect and organize data in a standardized manner, thus facilitating the identification and study of maternal mortality cases. MMRIA includes clinical and non-clinical data regarding the deceased woman, results of the MMRC analysis, issues associated with the death, and other relevant information.

Following the MMRIA orientation to members of the Maternal Mortality Review Committee (MMRC) in January 2022, the Secretary of the PRDOH signed the Memorandum of Understanding and Data Sharing Agreement in June 2022. These two agreements set forth the workflow expected from the MMRC. Accordingly, the MMRSS Coordinator will participate in bimonthly access with the MMRIA website or program representatives for updates on the system. As part of the preparation process, the MMRC and MMRIA representatives participated in a mock case analysis using the MMRIA formats in April of this year. Identification of maternal deaths and data collection will continue to take place regularly from various sources. Data analysis of the cases selected for further study will be presented in the quarterly MMRC Case Analysis Meetings for review and recommendations. The goal is to have a better understanding of maternal deaths in Puerto Rico.

[1] 4P+©National Training Institute, 1999. Used by permission.