Women/Maternal Health – Annual Report

Guam selected National Performance Measure (NPM) # 1 – Percent of Women who Had a Preventive Medical Visit within the Past Year, based on the results of Guam’s Maternal and Child Health (MCH) 5-Year Needs Assessment. By July 2020, we sought to increase the percentage of women who had a preventive health visit to 64%; this included preconception and interconception care. In 2017, Guam’s Behavioral Risk Factor Surveillance System (BRFSS) data indicated that 70.3% of women on Guam received a preventive medical visit. The national estimate for 2017 was 70.4%.

In 2017, the prevalence of a women having a routine check-up within the past year increased with household income level. Multi-racial Non-Hispanic women (56.4%) were significantly less likely than Non-Hispanic White women (78.8%) to have received a routine check-up within the past year. Significantly, fewer women with less than a high school education (52.3%) reported having a had a routine check-up within the past year than did women who were high school graduates (63.9%), had some college (71.7%), or were college graduates (72.9%).

Adequate health insurance is an important indicator of a person’s health. People without medical insurance are more likely to lack a source of medical are and skip routine medical care. Without health care coverage, a person increases their risk for serious and disabling health conditions.

On Guam, the percentage of women having health insurance coverage increased from 76.6% in 2013 to 77.8% in 2017. In 2017, disparities between those with a higher income were evident: 93% for those with an income greater than $50,000 had a form of health insurance, but only 63% of those with an income less than $15,000 had a form of health insurance.

Good health care for a woman considers the stages of the women’s life, from adolescence to old age. It means caring for all her needs, throughout her life course. For too many years, women’s health care meant little more than maternal health services, such as pregnancy and birth.

In 2018, there were approximately 35,200 women of reproductive age on Guam. The highest racial composition of this population consisted of Chamorro (37.2%); Filipino (26.3%); White (6.8%) and Other Pacific Islander (11.5%). The ethnic group with the fastest rate of increase is the Chuukese population, from 0.1% in 1990 to currently 7% of the population, a 70-fold increase.

Unhealthy birth outcomes, such as low birth weight and preterm birth, are influenced by many factors both before and during pregnancy. Preconception care allows women to talk to their provider about steps to take to promote a healthy pregnancy before conception or implement strategies to delay pregnancy. It also opens the door for early entry into prenatal care. Prenatal care continues to be a crucial method in identifying health issues throughout pregnancy, allowing for early intervention and healthier birth outcomes. Unintended pregnancy can have significant negative consequences for women, their families, and society. Studies indicate that unintended pregnancies are associated with a plethora of adverse health, social, psychological, and economic outcomes.

For the years 2013-2017, there were 21 mothers aged 15 to 19 that experienced an infant death; within the age group 20 to 24, 57 mothers had an infant death; within the age group 25 to 29, 49 mothers experienced an infant death; in the age group 30 to 34 years, there were 40 mothers who had an infant that died; within the age group 35 to 39, 21 mothers had an infant that passed away; and within the age group 40 to 44 years, 7 mothers had an infant that died.

One of the best ways to promote a healthy birth is by having a healthy pregnancy. Getting early and regular care improves the chances of a healthy pregnancy. Preconception care can help to reduce health risks prior to pregnancy and prenatal care can help prevent complications and informs women about important steps they can take to protect their baby and ensure a healthy pregnancy. Babies of mothers who do not get prenatal care are more likely to have a low birth weight and are more likely to die.

Data in the National Vital Statistics System (NVSS) indicate the percent of pregnant women who receive prenatal care beginning in the 1st trimester on Guam remained relatively unchanged since 2015 at 60.9%. Guam falls 24.4% below the Healthy People 2020 target of 77.9%. The percent of women whose prenatal care initiation was late or received no prenatal care also remained unchanged at 13.4%.

An extremely low birth weight (ELBW) infant is defined as one with a birth weight of less than 1,000 grams (2 pounds, 3 ounces). Most extremely low birth weight infants are also the youngest of premature newborns, usually born at 27 weeks' gestational age or younger. Very low birthweight is defined as weighing less than 1,500 grams (3 pounds 5 ounces). Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of 2,499 grams (5 pounds 8 ounces) or less, regardless of gestational age.

Of the 163 infant deaths for 2013-2017, 87 (53.3%) were born with a low birth weight. There were 47 (54%) Extremely low birth weight (ELBW) infants. Of the 47, there were 23 (48.9%) Chamorro infants, there were 11 (23.4%) Filipino infants, and 6 (12.7%) Chuukese infants. There were 19 Very low birth weight (VLBW) infants that died between 2013 and 2017. There were 10 (52.6%) Chuukese infants, 7 (36.8%) Chamorro infants, and 2 (10.5%) Filipino infants. There were 21 Low birth weight (LBW) infants that passed away between 2013 and 2017. Of the 21, 42.8% were Chamorro infants, 28.5% were Chuukese, and 9.5% were Filipino infants.

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 2018, Guam MCH saw 270 women for PNI & E. The greatest number of women seen was of Chuukese ethnicity at 41.1%, followed by women who were Chamorro (25.1%) and Filipino (12.9%). The largest age group for the women 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 purpose of the class is to provide participants with the necessary knowledge and tools to have a healthy pregnancy and delivery, prevent risk behaviors, and provide appropriate care for the baby and support for breastfeeding initiation. The target population is pregnant women and their partners. In 2017, 118 women and their partners received education through EPCC; however, in 2018, 70 women and their partners attended EPCC. This represents a decrease of 40.7%. One reason for the decrease was the loss of nursing staff who deliver the EPCC, for this reason classes were decreased from twice a month to once a month.  

On Guam, as stated before, there are 35,200 women of reproductive age and 70.3% of those women are at risk for an unintentional pregnancy. The percent of women at risk for unintentional pregnancy using a “most or moderately” effective method of contraception was 26.1%. The proportion of women using “less effective or no method” of contraception was 74% and 36% respectively.

For the large majority of women of reproductive age, family planning and related reproductive health needs are the driving force for entry into the health care system. The relationship with their family planning provider is essential to addressing the other critical preventive and primary health needs of women in their reproductive years. In 2018, Guam applied for and was awarded a Title X Family Planning grant. One of the features of the grant is the collaboration with the Community Health Centers (CHC) to establish family planning and reproductive health services. In 2017, the CHCs recorded 954 visits for family planning services. In 2017, there were 1,709 family planning visits recorded, an increase of 79.1%.

In relation to the Evidence Strategy Measure (ESM) 1.4, women in the Family Planning/MCH Clinic receive education and counseling on the recommended preventive screenings that optimize health. Information on height, weight, and blood pressure is gathered at each of these visits. After interviewing the client, further education, testing, and/or referrals are provided based on identified needs. Educational topics include sexually transmitted infection screening, pap tests, hemoglobin testing, mammogram referral, and pregnancy testing. The client is also screened for immunization status, smoking, alcohol, illicit drug use, or abuse.

Women in the Family Planning/MCH Clinic who receive a positive pregnancy test are offered a variety of information based on their disposition during the visit. If a client was planning the pregnancy, desires, or seems clear about wanting to continue the pregnancy, she will receive information on Medicaid, SNAP, WIC, and other benefits she may qualify for. If the client seems unsure about the pregnancy, the same information is provided, and other options such as adoption and/or termination are discussed. However, termination may not be option. Presently, Guam has no provider performing such services. The lack of abortion providers on island may force women to go to great lengths or go through great risk to terminate an unwanted pregnancy. In 2017, there were 239 abortions performed, however, in 2018 there were 57 abortions performed, a difference of 76.1%.

The Personal Responsibility Education Program (PREP) replicates evidence-based teen pregnancy prevention model Be Proud/Be Responsible in all Guam public high schools, with the intent to change behavior and delay sexual activity, increase condom or conceptive use for those who are sexually active, and reduce unintended pregnancy. For the school year 2017-18, the program was delivered to approximately 5,000 students, primarily in 9th and 10th grade.

Sexually Transmitted Disease (STD) rates are reported to be higher in populations that do not regularly access healthcare for STD/HIV testing and other sexual health services. These populations include low income and uninsured individuals and adolescents. The high rates of chlamydia and the growing number of gonorrhea and syphilis cases on Guam are a cause of concern because these infections are usually asymptomatic; therefore, many infections are likely undetected.

In 2016, Guam reported 934 cases of chlamydia and in 2017, 1,107 cases were reported among men and women of Guam. This represents an increase of 18.5%. Guam’s rate of chlamydia of 663.3 per 100,000 was higher than the US rate of 528 per 100,000, a difference of 25.6%. As with other inflammatory STDs, a chlamydia infection may facilitate the transmission of HIV infection. In addition, pregnant women infected with chlamydia can pass the infection to their infants during delivery. Because of the large burden of disease and risks associated with infection, CDC recommends that all sexually active women younger than 25 years receive annual chlamydia screening.

Gonorrhea is the second most commonly reported notifiable disease in the United States. Like chlamydia, gonorrhea is often asymptomatic in women. Infection due to gonorrhea, like that resulting from chlamydia, is a major cause of pelvic inflammatory disease (PID) in the US.

While syphilis was nearly eliminated more than a decade ago, today it is on the rise. Diagnoses of primary and secondary syphilis, the most infectious stages of the disease, increased 76% nationally from 2013 to 2017 (17,365 to 30,644). On Guam, the number of primary and secondary syphilis cases doubled from 6 in 2013 to 13 in 2017.

In 2016, there were 133 cases of gonorrhea reported on Guam. In 2017, the number of reported cases rose to 202, an increase of 51.8%. Guam’s rate of gonorrhea of 121 per 100,000 was 29.6% lower than the US’s overall rate of 171.9 per 100,000.

The Bureau of Communicable Disease Control (BCDC) was recently awarded the “Accelerating the Prevention and Control of HIV/AIDS, Viral Hepatitis, STDs and TB in the US Affiliated Pacific Islands” grant. The purpose of the grant is to reduce the high incidence rates of tuberculosis and chlamydia on Guam and reduce the incidence of HIV, gonorrhea, syphilis, and viral hepatitis infections.

One of the strategies of the grant is Program Collaboration and Service Integration (PCSI). The PCSI Lead worked with the Title V program to ensure pregnant women received testing for gonorrhea, chlamydia, syphilis, HIV and HBV within the first 20 weeks of pregnancy. Upon pregnancy verification, pregnant women are booked for a Prenatal Initial Interview and Examination (PII & E). The examination includes prenatal blood work and recommended testing for syphilis, gonorrhea, chlamydia, HIV and HBV.

In the first year of the project (2018), there were 148 pregnant women that were within 20 weeks gestation that visited the MCH clinic. Of the 148 women, 58 (39.1%) of the women were tested for HIV, HBV, chlamydia, gonorrhea and syphilis by the PCSI program.

Human papillomavirus (HPV) is the most common viral infection of the reproductive tract. Most sexually active women and men will be infected at some point in their lives and some may be repeatedly infected. The peak time for acquiring infection for both women and men is shortly after becoming sexually active. HPV is sexually transmitted, but penetrative sex is not required for transmission. Skin-to-skin genital contact is a well-recognized mode of transmission.

The Guam Community Health Centers (CHCs) along with partners from MCH; the Department of Education; the University of Guam Cancer Research Center; and the UOG School of Nursing collaborated to implement the HPV vaccination project. The UOG Cancer Research Center provided funding for the project, during which adolescents came to the Northern Region Community Health Center to obtain the HPV vaccination; these patients were followed up by UOG staff to ensure that they completed the HPV vaccination series. Of the 353 clients enrolled in the HPV program, 285 (80.8%) adolescents and adults completed the HPV vaccination series.

The Guam Breast and Cervical Cancer Early Detection Program (GBCCEDP) works to enhance the existing island-wide infrastructure within health systems to provide breast and cervical cancer screening services to uninsured and under-insured women and implement key evidence–based strategies to reduce barriers to screening within health systems. The GBCCEDP works collaboratively with other DPHSS programs, such as MCH, and a network of community-based partnerships that provide services to underserved women, and focuses on health care systems that provide essential primary care services to the most vulnerable populations on Guam. The goal of the GBCCEDP is to decrease breast and cervical cancer incidence, morbidity, and mortality by focusing on the underserved population on Guam who may have increased cancer risk.

Since 2000, 3,588 women have been served through the GBCCEDP. Of those women, 53% had never had a mammogram and 35% had never had a pap smear. There have been 70 cases of Breast Cancer detected and 64 cases of Cervical Cancer detected since the year 2000.

On January 31, 2018, the 34th Guam Legislature presented a Legislative Resolution to the GBCCEDP, recognizing those women who have survived Cancer and those that have lost their lives to Cancer.  

Promoting tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children is the second objective that falls with the Women’s Health Domain. We selected NPM 14.1 Percent of Women who Smoke during Pregnancy and 14.2 Percent of Children, ages 0 through 17, who live in Households where Someone Smokes. Furthermore, Guam MCH created a State Performance Measure (SPM) Percent of Women of Reproductive Age who are Current Smokers.

Tobacco use during pregnancy is associated with increased risk of preterm babies, low birth weight full term babies, stillbirth, and fetal death. It is also a risk factor for a variety of pregnancy related complications, such as placenta previa, placental abruption, and difficulty getting pregnancy.

In spite of the negative consequences of maternal smoking on pregnancy outcomes, women continue to smoke. Maternal smoking rates on Guam are relativity high. While pregnant, 12.8% females smoked in 2017. In 2018, 259 females reported smoking during their pregnancy; this amount was a difference of 44.9%. Furthermore, maternal smoking was reported in 34.4% of infant deaths.

Females who live on Guam, age 18 and over, were asked during the most recent BRFSS survey (2017) if they were current smokers; 22.5% responded that they were. This was an  increase of 32.3% from 2016. Furthermore, women were asked if they smoke every day: in 2017, 14.8% reported that they smoked every day. This was an increase of 19.3% from 2016.