Women’s/Maternal Health

Annual Report

Improving the domain of women's/maternal health is crucial to the National Outcome Measures (NOMs) related to decreasing infant mortality. The selection of National Performance Measure # 1 – well, women visits recognizes the impact the life course approach will have on increasing healthy births and improving women's health across the lifespan.

The interplay of risk and protective factors, such as socioeconomic status, health behaviors, stress, and nutrition, influence health throughout one's lifetime. Guam has had a long-standing emphasis on improving women's health and has promoted several evidence-based strategies to increase preventive medical visits (NPM # 1), including the Healthy Mothers Healthy Babies Initiative, Jurisdictional Survey, and the Home Visiting Program. 

Data from the Guam BRFSS show that an estimated 75.9% of adult women on Guam received a preventive medical visit in 2018 and 70.3 in 2017. The national estimate for 2017 was 70.4%. In 2018, the prevalence of Guam women having a routine check-up within the past year increased with household income level. Fewer women with less than a high school education (63.7%) reported having had a regular check-up within the past year than did women who were high school graduates (78.5%) had some college (74.7%) or were college graduates (84.6%) in 2018.

Source: Guam BRFSS

On Guam, the percentage of women having health insurance coverage increased by 7.8% from 2013 to 2018. In 2013, economic disparities in health insurance coverage among women with lower household income were evident: 77.3% of women with an income less than $14,999 had a form of health insurance, compared to 78% among women with household incomes of $15,000 to $24,999, 79% among women with household incomes of $25,000 to $34,999, 86.3% of women with a household income of $35,000 to $49,000, 93.5% of women with a household income of $50,000 to $74,999 and 96.5% among women with a household income greater than $50,000.

Source: Guam BRFSS

Data for preventive medical care and access to health care based on the BRFSS show an educational and household income gradient, whereby women with lower education and lower household income were less likely to either have health insurance coverage or have had a routine check-up in the past year.

Included in improving NPM #1 is a focus on preconception care and early prenatal care. Improving access to prenatal care is essential to promoting the health of Guam mothers, infants, and families. Early and adequate prenatal care is a crucial component for a healthy pregnancy and birth outcome because it offers the best opportunity for risk assessment, health education, and the management of pregnancy-related complications and conditions. Prenatal care is also an opportunity to establish contacts with the health care system and provide general preventive visits.

Efforts to improve early prenatal care access must address the factors related to unintended pregnancy and lack of early pregnancy awareness by focusing on women before they become pregnant. Preconception care is a critical component of prenatal care and health care for all women of reproductive age. The main goal of preconception care is to provide health promotion, screening, and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Given the relationship between pregnancy intention and early initiation of prenatal care, assisting women in having a healthy and planned pregnancy can reduce late prenatal care incidence and promote NPM #1 (Well Women Visits).

In efforts to increase the awareness and importance of the well-woman visit, MCH has utilized collaborations between programs. Such as Project Bisita, Guam’s Home Visiting Program, has provided referrals for women’s health services. Through their work with women and families, they provide education about the importance of preventive and reproductive health care, which includes topics such as sexually transmitted infections (STIs), birth spacing, contraception, and preconception counseling. The program also helps women find health services and reduce or eliminate barriers, such as transportation, to ensure that women can get the health care services they need.  

Furthermore, a local newspaper ran a three-part series on the importance of receiving timely prenatal care. The reporter interviewed the administrator of BFHNS, two part-time nurse practitioners, and the MCH coordinator for the series. From the comments left at the end of the series, the series was well-received, and many women commented that the article educated them. 

The Healthy Mothers, Healthy Babies Program, is not a clinical antenatal care service. Instead, it links women to existing services early, provides community-based support beyond what current services offer, and promotes continuity of care. On January 7, The Healthy Mothers and Healthy Babies Task Force held the annual health fair. The fair is for women and their partners thinking about getting pregnant, currently pregnant, or recently post-partum. Community and non-profit organizations had tables at the fair to share information about the resources they provide to moms and babies.

The Prenatal Interview and Examination (PNI & E) is the first antenatal visit for Guam’s MCH clients who suspect a pregnancy. Three areas are addressed during the visit. They are the diagnosis of pregnancy, maternal and fetal health assessment, and the development of a plan for continued care. In 2019, Guam MCH saw 202 women for PNI & E. The highest number of women seen was of Chuukese ethnicity at 41.1%, followed by women who were Chamorro (25.1%) and Filipino (12.9%). The women's largest age group was the age group 20 to 24 at 35.9%, followed by the age group 25 to 29 years at 28.1%, and lastly, the age group 15 to 19 years at 16.2%.

The MCH Clinic staff delivers the Early Prenatal Counseling Class (EPCC). The class aims to provide participants with the necessary knowledge and tools to have a healthy pregnancy and delivery, prevent risk behaviors, provide appropriate care for the baby, and support breastfeeding initiation. The target population is pregnant women and their partners. In 2018, 70 women and their partners received education through EPCC; however, in 2019, 52 women and their partners attended EPCC. This represents a decrease of 25.7%. One reason for the decline was the loss of nursing staff who deliver the EPCC; for this reason, classes were decreased from twice a month to once a month.

Preconception health refers to the health of men and women during their reproductive years, typically 15-44 years of age, and focuses on protecting and promoting optimal health. Preconception health for women is especially important as it can impact any future children, and these healthcare services target health conditions and behaviors that have been shown to increase the chance of having a healthy baby. Preconception health services reinforce critical aspects of preventive health such as reproductive cancer screenings (Pap tests), tobacco cessation, reducing alcohol use, maintaining a healthy body weight (BMI), eliminating illicit drug use, obtaining and staying up-to-date with important vaccinations, and screening for STIs, depression, diabetes, and domestic violence (NOM10- 11). For women, preconception health services and counseling directly affect both mother and baby (NOM2-6; 8-9.4). Having optimal health and health habits before pregnancy and between pregnancies reduces preterm births and low birth weight babies, giving the newborn a healthy start.

Data from the National Vital Statistics System (NVSS) indicate that the percentage of pregnant women who received prenatal care beginning in the 1st trimester remained relatively unchanged since 215 at 60.9%. The percent of women whose prenatal care initiation was late or received no prenatal care also remained unchanged at 13.4%

Source: National Vital Statistics System

Preterm delivery is delivery prior to 37 weeks gestation. Infants who are delivered early in the gestational period with low birth weight have an increased potential for acute as well as chronic health issues. Other pregnancy complications that occur at a higher rate among pregnant women who smoke are placental issues such as placenta previa and placental abruption. Placenta previa is a condition wherein a placenta attaches to the lower segment of the uterus and partially or even fully covers the cervix. Placental abruption is the separation of the placenta from the uterine wall. Abruption is a severe condition that requires immediate medical attention.

By its very nature, childbirth carries potential risks for women and their babies, regardless of the delivery route. Although cesarean sections are medically required in some instances, these births pose a greater risk of maternal morbidity and mortality, as well as neonatal morbidity and mortality than vaginal births. According to the American College of Obstetrics and Gynecologists (ACOG), potential risks of cesarean delivery for moms and babies include a more extended hospital stay, an increased risk of respiratory problems for the infant, and more significant complications in subsequent pregnancies, including uterine rupture, placental implantation problems, and the need for a hysterectomy. 

For Guam, the total cesarean rate has remained relatively stable, with a 9% increase from 2014 and 2018. However, the low-risk cesarean section deliveries have risen substantially (92.4%) during the same time frame.

Research suggests a correlation between early elective deliveries and poor birth outcomes, such as lower brain mass, low birth weight, feeding problems, and respiratory issues. Additionally, cesarean deliveries financed by Medicaid an average cost of nearly $5,000 more than vaginal births, and the average payment for maternal and newborn care, including neonatal intensive care unit stay, is about $6,100 higher for cesarean deliveries than vaginal births.

Medicaid Covered Vaginal and Cesarean Births

2014-2018

Source: DPHSS Division of Public Welfare Medicaid Program

There are many potential adverse outcomes associated with smoking during pregnancy, including short- and long-term health complications for mother and infant. The immediate consequences of continuing to smoke during pregnancy can be seen in the timing of deliveries (preterm births) and the placenta's health.

Guam Title V Action included the following strategies:  1)Collaborate with the Guam Breast and Cervical Cancer Program to help educate women on the importance of cervical cancer screening and the importance of cervical cancer treatment; and 2) Collaborate with the Guam Breast and Cervical Cancer Program to help recruit women whom the Guam Breast and Cervical Cancer Program criteria as well as non-program women and educate them on the importance of cervical cancer screening.

According to the Guam Cancer Registry, the leading cause of breast cancer on Guam is the influence of genes, lifestyles, and the environment on cancer development and progression. Some factors include the use of tobacco and obesity. Among the adults on Guam with cancer, 57% were tobacco-related, while 30% were obesity-related. Guam's cancer incidence is high compared to the rest of the United States. According to the 2008 2012 Guam Cancer Facts and Figures report, cancer in the U.S. has been declining while new cancer cases and deaths on Guam continue to rise. On average, one person is diagnosed with cancer on Guam each day. One person dies of cancer every 2.5 days. Breast cancer is one of Guam's top five cancers, and this disease has touched many families.