The MCAHD will continue to address the population's emerging needs and focus its efforts on improving birth outcomes. Strategies will focus on promoting behaviors that can lead to a healthy pregnancy and decrease preterm births, disseminate  information to the MCH population regarding the levels of care of hospitals to increase the percent of very low birth weight infants delivered at facilities with the specialty level required for the care of high-risk neonates, promoting the adoption of safe sleep practices and breastfeeding, especially exclusive breastfeeding until infants reach 6 months of age, and evaluating fetal and infant deaths in the FIMR to identify strategies to decrease infant mortality.  

Pregnant and parenting persons, infants, and children are at increased risk during and after disasters. The MCAHD is developing an Emergency Preparedness and Response Guide that takes into account the characteristics, needs, and vulnerabilities of the MCH population. Topics covered include prenatal care, adequate nutrition, prevention of premature birth, safe infant feeding, safe sleep practices, and special considerations regarding toddlers and older children, among others. This guide responds to Priority Need 3: Decrease Infant Mortality of the PR Title V Action Plan. Please see Section III.E.2.b.iv. MCH Emergency Planning and Preparedness, for a complete discussion of this activity.

COVID-19

After the period of adjustments required by the COVID-19 pandemic, all MCAHD activities have resumed regular operations. The MCAHD remains alert to updated recommendations and guidance provided by the PRDOH and the CDC regarding emerging public health threats, and will continue to take recommended precautions as necessary.

Safe Sleep

Sleep-related Sudden Unexpected Infant Deaths (SUIDs) continue to be among the leading causes of infant deaths between 1 to 12 months of age in Puerto Rico. The MCAHD will continue its efforts to increase knowledge and awareness of safe sleep practices through its programs and educational interventions, including:

• Promoting infant safe sleep practices among Home Visiting Program (HVP) participants beginning in the second trimester of pregnancy and evaluating safe sleep practices once baby is born.
• Educating participants of the Prenatal and Parenting courses on infant safe sleep practices.
• Promoting infant safe sleep practices via social media, the “Encounter of my life” webpage, and the virtual prenatal course. The safe sleep educational video is temporarily off line, pending sign language interpretation required by the PRDOH, and will again be made available through these channels after editing.
• Emphasize safe sleep practices among displaced families affected by disasters.

In 2023-2024, the MCAHD will develop a collaborative effort with birthing hospitals to distribute a short educational video on safe sleep practices to be displayed in hospital information monitors, ensuring the family has watched the video before discharge from the hospital. It will also collaborate with the Puerto Rico Hospital Association to offer continuing education on infant safe sleep practices to hospital staff.

The Title V Epidemiologists, Biostatistician, and the PR PRAMS coordinator are producing a report to be submitted for publication in the MMWR in the coming months. It features the findings of safe sleep practices in PR using the PRAMS database for the years 2017 to 2019. 

Prevention of Premature Births

The implementation of the Hard Stop Policy in all birthing hospitals in order to decrease elective labor induction prior to 39 weeks of gestation in non-medically indicated cases continues to be an area of interest for the MCAHD. Efforts focus on promoting strategies recommended by ACOG for the implementation of the Hard Stop Policy and compliance with the PR Hospital Regulations Policy #9184 (July 2020), in collaboration with the PR Hospital Association (PRHA) and the March of Dimes.

One of the activities planned on this topic is a one-day conference titled Mobilizing Action for Maternal Infant Health, to be held in September 2023. It responds to the White House Blueprint for Addressing the Maternal Health Crisis, which lists among its priorities the need for a strong, well trained perinatal workforce. This conference will provide current information on perinatal heath, prematurity, health equity, quality of healthcare and social determinants of health. In addition, it will be an opportunity to recognize the hospitals that have achieved compliance with the Hard Stop Policy from May 2022 to May 2023. The conference is being planned in conjunction with the PRHA and the March of Dimes. The target audience includes the perinatal staff from the 30 birthing hospitals in PR, including hospital administrators, OB/GYNs, nurses, health educators and social workers, for a total of 200 participants. The speakers are leading experts in their fields.

The preliminary agenda follows.

• State of Premature Birth Rates in PR
• Non-elective Cesarean Sections: Current Statistics and Prevention Strategies
• Health Equity
• Implicit Biases
• Preconceptional Health
• Social Determinants of Health Affecting the Pregnant Population
• Perinatal Mental Health

The MCAHD will continue to increase awareness regarding premature birth using various education and promotion strategies that explain the warning signs and symptoms of preterm labor and the actions to take if preterm labor is suspected. This topic is covered in the prenatal courses offered by the HEs and CHWs at the community level, and in the virtual prenatal course and educational materials available from the “Encounter of my life” website (see next section).

Figure 1 - Premature labor printable leaflet available at www.salud.pr.gov/CMS/544

In the HVP, the Home Visiting Nurses (HVNs) evaluate participants to identify the presence of risks related to premature and LBW deliveries and offer education about the signs and symptoms of premature labor. They provide information on the nearest birthing facility with appropriate perinatal services. The Perinatal Nurses offer education to pregnant persons on signs and symptoms of premature labor. The MCAHD promotes the use of a prenatal card that records pertinent obstetric history and information and the value of always having it at hand.

Promotion of healthy lifestyles during pregnancy

The “Encounter of my life” (Encuentro de mi vida) educational campaign delivers the message that pregnancy should last 40 weeks, adequate prenatal care improves outcomes, breastfeeding begins in the hospital, and other topics related to pregnancy, postpartum and infant care organized in five sections: Prenatal care, Labor and delivery, Postpartum, Breastfeeding, and Infant care. A newly designed webpage was created within the Department of Health’s website (salud.pr.gov/encuentro_mi_vida) to house the campaign’s educational materials as well as the virtual prenatal care course. The Prenatal Care section includes leaflets that promote healthy lifestyles, including the benefits of early and continuous prenatal care, physical activity, diet and nutrition, oral health care, emotional wellbeing, abstaining from alcohol, tobacco and drug use during pregnancy, and related topics.

Figure 2 – “Encuentro de mi vida” website image, which reads “Get ready for the encounter of your life. Here you will find all you need to know to have a healthy pregnancy.”

The Home Visiting Program promotes physical and mental well-being of infants, children, and pregnant and parenting participants. The HVNs provide one-on-one education and support to encourage healthy eating habits, physical activity, vaccination and preventive health visits, oral health care of both mother and baby, developmental stimulation, breastfeeding, safe sleep, prevention of unintentional injury, among many other topics. These interventions begin in the prenatal period and extend until the baby reaches their second birthday. The service will continue to be delivered to high risk and vulnerable families, connecting them with the resources in their community.

Births at facilities with the specialty level required for the care of high-risk neonates

As part of the MCAHD efforts of re-implementing the CDC’s Levels of Care Assessment Tool (LOCATe) initiative in order to evaluate the levels of hospital specialty service for maternal-infant care, 33 birthing hospitals that had 100 or more births in 2021 were determined to be eligible to participate in the survey. In September 2022, an invitation letter that explained the purpose of the survey was sent to these hospitals along with a consent form. Three of the invited hospitals reported they did not have an operating delivery room or nursery, due to lack of professionals. Of the 30 birthing hospitals that comprised the final sample, three did not agree to participate in the study; the remaining 27 hospitals completed the survey, for a response rate of 90% (27/30).

The MCAHD is currently in the process of sharing the LOCATe database with CDC to complete the analysis of the evaluation of neonatal and maternal levels of care. The findings and recommendations will be discussed with key staff from the participating hospitals during individual meetings as part of their evaluations. Following that, the MCAHD outreach component and the HVP will collaborate in the dissemination of these findings at the community level. The results will also be used to propose policies and strategies to promote an increase in the percent of very low birth weight and/or premature infants delivered at facilities that provide the specialty level required for the care of high-risk neonates.

Fetal Infant Mortality Review (FIMR)

Over the last decade, Puerto Rico’s infant mortality rates have improved but continue to be above the average national numbers. Between 2018 and 2020, the annual infant death rates in Puerto Rico were between 6.7 to 7.0 deaths per 1,000 live births, higher than those reported during the same period in the United States (5.7 to 5.4).

The Puerto Rico FIMR program (PR-FIMR) was reactivated in the second semester of 2022. The core team is composed of the MCAHD Director, the Pediatric Consultant, the HVP Coordinator, HVP Evaluator, the Reproductive and Pediatric Epidemiologists, and the Title V Mental Health Consultant. The process began with an extensive evaluation and revision of the literature and documentation available on the website of the National Center for Fatality Review and Prevention (NCFRP) and the American Academy of Pediatrics (AAP).

The core team focused on updating the PR-FIMR's Implementation Manual and data collection instruments (parental interview and clinical data collection forms). The Pediatric Consultant and the HVP Coordinator met with the FIMR Director for the NCFRP to discuss the reactivation of the program, clear up some questions on the processes for data abstraction and the parental interview, as well as  to discuss PR’s participation in the National Fatality Review Case Reporting System. Initially, the PR-FIMR will evaluate cases of fetal loss and infant death of participants of the HVP.

In the coming months the PR-FIMR team will undertake the following steps in the process to begin once again reviewing fetal and infant deaths occurring in the HVP.

• Distribute a letter from the Secretary of Health to inform hospitals about the  PR-FIMR, its purpose and importance. It will also request the assistance of hospital administrators to facilitate access to hospital records for data abstraction by the Perinatal Nurses.
• Train the MCAHD staff who will participate in the program. The HVNs will conduct parental interviews, since they are familiar with the characteristics of the HVP population and have experience and training in interactions with families. The Perinatal Nurses, given their clinical knowledge and background, will carry out the data abstraction with collaboration of the Regional Directors as needed.
• Identify and invite potential members of the case review team (CRT) and the community action team (CAT). The CRT will discuss the deidentified cases and generate a list of recommendations. The CAT will be involved in the implementation of the recommendations received from the CRT. Both teams should include representatives of different fields who can bring diversity, influence, lived experiences and commitment to racial, social and health equity in the FIMR process.

Breastfeeding

The PR MCAH staff supports the initiation of breastfeeding (BF) and continuation of exclusive BF until at least 6 months of age using diverse strategies. The MCAHD will continue to promote BF as a lifesaving measure in a disaster and to disseminate the Safe Infant Feeding Guidelines developed and adopted by the Secretary of Health in 2019 as a public policy.

Data on prevalence and trends of BF in PR reported by WIC, the Demographic Registry, PR PRAMS, Immunization Survey and the Maternity Practices in Infant Nutrition and Care (mPINC) survey inform MCAHD’s strategies to increase initiation and continuation of BF. The MCAHD shares this data with stakeholders to raise awareness among BF advocates, BF support groups and birthing hospitals of gaps in services and support for BF mothers.

The MCAHD provides training to HVNs, HEs, CHWs, and Perinatal Nurses to ensure they have up-to-date information that is geared to the populations they reach and the interventions they carry out. CHWs and HEs offer educational activities in the community; Perinatal Nurses reach pregnant and postpartum persons in hospitals and give one-on-one education; HVNs raise awareness of the benefits of breastfeeding among their participants beginning in pregnancy and support their efforts throughout the postpartum period.

The MCAHD disseminates information of laws that protect the rights of BF mothers in public and in the workplace at the community level through the prenatal courses, the “Encounter of my life” website and other educational activities.

The MCAHD will also continue to promote hospital compliance with PR Hospital Regulations Policy #9184 (July 2020), which includes requirements for hospitals to establish BF support policies. The 2022 mPINC report reflects the positive impact of the strategies implemented by the MCAHD in fostering changes in hospitals to support breastfeeding. The results will guide the proposal and implementation of further strategies.

The MCAHD staff will collaborate with the Puerto Rico Hospital Association to train hospital staff in the promotion of successful breastfeeding initiation and to share information of breastfeeding support groups in community.

To commemorate Breastfeeding Month, in August 2022 a series of five social media posts were published in the PRDOH’s accounts. The messages, shown below, were developed by MCAHD staff and the artwork was designed by the PRDOH’s Communications Office. Left to right, top row: Text post with core message and link for more information; Recommendations for successful breastfeeding; Benefits of BF for baby. Left to right, bottom row: Preparing for BF from pregnancy; BF when mom has COVID-19; BF resources and support groups. 

 Figure 3 - Breastfeeding Month social media posts

The prenatal courses, both in-person and virtual, promote BF by including information relevant to pregnant and parenting persons on the benefits of BF, strategies for successful initiation, the hospitals’ obligation to provide support for BF mothers, and topics relevant to optimum prenatal care and preparation for delivery. The in-person courses are offered by the regional MCAHD Health Educators and Community Health Workers, and the virtual course is found in the “Encounter of my life” webpage on the PRDOH website. The courses are advertised in the PRDOH social media pages using quotes from previous participants that tell of the benefits of participating in the course. The text post that accompanies each photo explains the contents of the courses and how to participate.

Figure 4 - Social media posts advertising the prenatal courses

The “Encounter of my life” section on breastfeeding, shown below, has printable leaflets covering four topics: Benefits of BF,  Preparation for BF, BF positions, and Laws that protect BF.

Figure 5 - Breastfeeding section of "Encounter of my life" webpage

Forgotten Baby Syndrome

Forgotten Baby Syndrome continues to be threat that may occur to any family. A child left in a parked vehicle can die of heatstroke (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. An educational brochure and poster were developed by the interdisciplinary team of consultants of MCAHD giving parents tips on how to develop a strategy to protect their infants.