Women /Maternal Health

Priority Need – To improve maternal health by optimizing the health and well-being of women of reproductive age.

National Performance Measure #1 – Percent of women, ages 18 through 44, with a preventive medical visit in the past year.

 Source: Behavioral Risk Factor Surveillance System, CDC

There are many factors impacting women's health that can be complex and different, ranging from social-emotional issues, environmental impact, health insurance status, access to health care, birth spacing, and any number of other factors, including the social determinants of health in which individuals are hereditary, grow to, live with, worked with,  and related to age. Improving women's health throughout the lifespan is essential to enhancing Guam's women's health and wellness.

Improving the domain of women's/maternal health is crucial to selecting NPM #1 during the Five-Year Needs Assessment. During the 2020 Needs Assessment, stakeholders were vocal about improving the health of women of childbearing age. Many comments related to obesity, tobacco use, substance use, and morbidity that lead to early deliveries were discussed. The 202 Needs Assessment priority ranking process underscored the importance of improving birth outcomes and health for Guam women.

Guam MCH continues to prioritize increased access and utilization of preventive health care services for women of reproductive age. According to the 2021 Guam Behavioral Risk Factor Surveillance System (BRFSS), 73.1% of women on the island had a routine check-up within the past 12 months. There are clear visit gaps for women who are Medicaid-eligible. Women with an annual income of less than $25,000 (52.6%) were less likely to visit the doctor regularly than those with a yearly income between $25,000 and $49,999 (66.7%) or those above or equal to $50,000 (73.4%). Low-income women experience health inequities that increase their risk of unintended pregnancy. This risk can be influenced by cultural, economic, and social factors and may be linked to unmet reproductive health needs that increase the likelihood of infant and maternal mortality rates in Guam.

Well-women visits are essential to a woman’s overall health and well-being. It provides an opportunity to receive recommended clinical preventive services, discuss their health, and prevent or help identify serious health concerns before they become life-threatening.

Women receive MCH clinical services a Nurse Practitioner (NP) provides during their visits. These services include; risk fact assessment, immunization update, reproductive conselling, and health education, as well as providing breast exams,  assessment of physical, psychosocial function.  As well as providing, breast examinations, and STD/HIV screening and education, and birth control methods. The NP discusses their reproductive health plans with the women and provides a broad range of family planning methods, pregnancy testing, and referral, as necessary.

In 2022, the MCH Women's Clinic (WHC) saw 1,505 women, an increase of 41.6% from the previous year. The largest age group to be seen in the WHC were women within the age group 20-24 years old at 36%, followed by women aged 25-29 at 27%, the age group 30-34 years at 24%, and lastly, the age group 15-19 years at 13%. The most significant proportion of women seen at the WHC were Chuukese women at 46%, Chamorro women at 20%, and Pohnpeian women at 16%.

A pregnancy test detects urine chorionic gonadotropin (UCG) in the urine and confirms or rules out pregnancy. In 2022, The MCH UCG Clinic tested 298 women for pregnancy, with 83.4% testing positive. The age group 20-24 was the largest age group to test positive at 38%, followed by 25-29 at 24% and the age group 15-19 at 14.2%. There were significant differences in ethnicities testing positive for pregnancy, with the largest ethnic group being Chuukese women at 45.3%, Chamorro women at 21%, and Filipino women at 11.4%.

The pregnant woman’s prenatal interview and examination (PNI & E) should be the building block of a healthy pregnancy. The PNI & E includes pregnancy confirmation, maternal and fetal health assessment, and developing a plan for continued prenatal care. In 2022, MCH saw 228 women for a PNI & E appointment, and this was a decrease of 23.3% from 2021. Of the women seen, 46% were Chuukese women, followed by Chamorro women at 20% and Pohnpeian women at 16%.

The effect of early prenatal care is strongest for high-risk groups such as teens and low-income women. The Kessner Index is a standard measure of prenatal care based on information obtained from birth certificates. It combines information on the month prenatal care began, the gestational age at birth, and the number of prenatal visits.

Although Guam women are engaging in some preventive care services, rates of women accessing prenatal care are significantly lower. For 2022, slightly over half (52.2%) of the live births were to women who initiated prenatal care during the first trimester of their pregnancy; 14.8% of the live births received no prenatal care. Twenty percent of Chamorro women, 12.7% of Filipino, 5.5% of White, and 4.6% of Chuukese women initiated prenatal care during their first trimester.

Although Guam women are engaging in some preventive care services, rates of women accessing prenatal care are significantly lower. For 2022, slightly over half (52.2%) of the live births were to women who had initiated prenatal care during the first trimester of pregnancy,

In 2022, the overall percentage of adequate prenatal care based on the Kessner Index was 49.6%. Specific race/ethnicity-related rates for adequate prenatal care for 2022 were 17.8% for Chamorro women, 8.6% for Chuukese, 8.5% for Filipino, and 5.3% for White. These existing disparities align with the need for Guam Title V to improve NPM #1 by focusing on pre-conception and early prenatal care. Improving access to prenatal care is essential to promoting the needs of Guam mothers, infants, and families. Early and adequate prenatal care is crucial to 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.

Moreover, preconception care is a critical component of prenatal 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 and 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 the incidence of late prenatal care and promote NPM #1.

The Guam Family Planning Program's (GFP) mission is to ensure that all Guam people have access to high-quality, affordable reproductive health care, comprehensive sexual health education, and the right to control their reproductive lives. The GFP provides affordable, gender-affirming reproductive health care services for all individuals in Guam.

In 2022, the GFP saw 337 MCH clients. Continuing collaboration between the GFP and Title V provides an opportunity to improve care for MCH clients by maximizing reproductive health services by providing information and services to prevent, test, and treat sexually transmitted diseases. Furthermore, out of the 337 women seen by the GFP program, 27% tested positive for pregnancy.

 The GFP provided adolescents with various acceptable and effective medically approved family planning methods and services. Approximately 13% of all clients were among the adolescent population.

In early 2022, the GFP initiated an initiative to integrate family planning into a broader set of services. During this process, the team (including Title V) identified a need to improve and increase male access to family planning services.

The GFP team further recognized that male family planning services are essential for many reasons. These services can:

• Raise males' awareness of how they can protect their health.
• Reduce males’ chances of unintended fatherhood or contracting sexually transmitted infections.
• Support better health outcomes for males, their partners, and potential offspring.
• Lead male clients to potentially build healthier relationships and those with female partners to increase support for contraceptive use.
• Saving money by focusing on prevention instead of treatment.

While progress has been made regarding the teen birth rate, and it has experienced a steady decline in teen births of 15-19-year-olds, in the past five years and prior, Guam continues to struggle with high teen birth rates compared to the national rates. Historically, Guam's teen birth rate ranks higher than the U.S.

Another alarming finding is the number of births to Guam children under age 15, reinforcing the need for earlier intervention with child abuse and education at younger ages regarding sexual intercourse. Guam Youth Risk Behavior Surveillance (YRBS) data shows that at least 8.8% of middle school students reported having sexual intercourse in the past three years.

The adverse effects of parental smoking and now Vaping, that their children have been a clinical and public health concern for decades and were documented in the 1986 U.S. Surgeon General's Report. Unfortunately, millions of children are exposed to secondhand smoke in their homes. These children have an increased frequency of ear infections, acute respiratory illness and related hospital admission during infancy, asthma, and asthma-related problems, and lower respiratory tract infections leading to 7,500 to 15.,000 hospitalizations nationally annually in children under 18.

Guam Title V collaborates with the Non-Communicable Disease Prevention and Control Program – Tobacco Prevention and Control Program (TPCP). The Guam TPCP goals mirror the National Tobacco Control goals: prevent initiation among youth and young adults and eliminate exposure to secondhand smoke.

The estimated proportion of current smokers in the 2021 BRFSS follows an income and educational gradient. Higher proportions of women of lower household income are more likely to report current smoking than higher income households with less than $15,000 reporting current household smoking at 25.5%, those with incomes of $15,000 - $24,999 at 26.4%, those with revenue at $25,000 - $34,999 at 23.9% compared to those with an annual income of $35,000-$49,999 at 19.5% and those at $50,000 and over at 15.2%.

Home visitors promoted smoking cessation for all primary caregivers who reported smoking at enrollment and subsequent 6-month periods during enrollment. Guam's home visiting program "Project Bisita" specifically tracks annual performance data on the percentage of primary caregivers who reported smoking and/or using other tobacco or nicotine products, including e-cigarettes, at enrollment. Caregivers were provided tobacco cessation referrals for counseling services within three months of registration. In addition, home visitors were provided information and resources on tobacco cessation to share with enrolled participants, such as the 1-800 Quit Now. In FY’21, this percentage was 50.2%.

With this in mind, through the 2020 Needs Assessment, a State Performance Measure (SPM) was created, "Percent of Women of Reproductive Age Who are Current Smokers." Overall, 22.5% of women with a live birth smoked cigarettes three months before becoming pregnant.

2022 Live Births with Mothers That Smoked

Source: DPHSS OVS Birth Certificates

Other Women’s Health Activities

Guam’s Maternal, Infant, and Early Childhood Home Visiting Initiative (MIECHV)

Guam's MIECHV Program, Project Bisita I Familia (Chamorro to "visit the family"), provides evidence-based home visiting services to pregnant and parenting families in 8 Guam villages. Project Bisita aims to improve the lives of children and families by supporting parenting, improving maternal and child health, and promoting child development and school readiness. Project Bisita supports emotional wellness and social connectedness among program participants in several ways.

Project Bisita home visitors and supervisors attended a virtual training on common mental health concerns, strategies for supporting parents who experience mental health challenges, and thoughtful self-regulation techniques to help home visitors when working with parents experiencing mental health challenges.

Project Bisita holds group series (Parent Cafés) to facilitate family connections. Project Bisita identifies topics (such as "Being a Strong Parent" and "Building Strong Relationships with Your Children") based on the needs and interests of their participants and the larger community.

Depression Screening

Project Bisita Home visitors screen all prenatal enrolled clients within three months of delivery. Primary caregivers not registered prenatally are screened within three months of enrollment. Home visitors utilize the Edinburgh Postnatal Depression Scale screening tool at these prescribed time points, and anytime they recognize potential symptoms of depression. Individuals who screen positive are provided support by home visitors through their curriculum (Parents as Teachers and Healthy Families America) models. This intervention promotes healthy mood management by teaching pregnant women and new moms how to respond effectively to stress. These needing further assistance are referrd to Guam Behavior Health and Wellness Programs.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

WIC serves pregnant women who recently had a baby or are breastfeeding, infants, and children up to age five years. To qualify for WIC benefits, the applicant must meet income guidelines and have at least one nutritional risk documented. Benefits provided by WIC include quality nutrition education and services, breastfeeding promotion and support, referrals to maternal and child healthcare services and other assistance agencies, and supplemental foods prescribed as monthly food. Supplemental foods include fresh fruits and vegetables, whole grains, dairy, protein sources, juice, infant formula, and specialized formulas ordered by physicians. Guam WIC issues electronic food instruments, with each family member receiving a eWIC card to purchase WIC-approved foods. In response to Covid 19, Guam WIC implemented several federally authorized WIC waivers to ensure participant safety. These included social distancing, remote benefits issuance, and separation of duties, all of which enabled WIC benefits to be issued remotely. For certain participant groups, benefits are automatically given each month without action from the participant. Participants in need of regular nutrition assessments were able to receive benefits via a remote telephone appointment.

Reproductive Rights

On June 24, 2022, the U.S. Supreme Court ruled on Dobbs v Jackson Women's Health Organization, which effectively overturned Roe v Wade and has the potential to impact reproductive rights and the Title V population, with health implications for pregnant women, children, and families. Abortion remains legal in Guam. Several bills have been brought up in legislative sessions to restrict abortion access. However, the Governor of Guam has publicly stated that she would veto any passed bill. According to the Robert Wood Johnson Foundation (RWJF), access to safe and high-quality reproductive medical care, including abortion, is an essential element of comprehensive health care and health equity, and restricting access to abortion compromises the health of pregnant women. RWJF says limiting access to abortion increases maternal mortality by nearly%, and women denied abortions are more likely to experience economic hardships.  According to the World Health Organization (WHO), 23,000 women die from unsafe abortions each year, and a recent University of Colorado study estimated that banning abortion in the U.S. would lead to a 21% increase in the number of pregnancy-related deaths overall. Furthermore, the Association of Maternal and Child Health Programs (AMCHP) poor maternal health outcomes disproportionately impact women with low incomes, women of color, and women in rural communities.

Utilizing the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System Survey (BRFSS), Bensyl, Iuliano, Carter, et al. (2002) examined contraceptive use throughout the US and Territories. For Guam, reliable BRFSS estimates were available for women aged 25-34 and 35-44 and men aged 25-34. The most common birth control methods reported by women in Guam aged 25-34 were birth control pills (41%), followed by tubal ligation (23.9%), condoms (7.5%), shots (4.5%), and vasectomy (4.5%). For women aged 35-44, the most common methods used were tubal ligation (47%), followed by birth control pills (25.4%), vasectomy (9.2%), shots (4.9%), and condoms (4.2%). For men ages 25-34, the most common birth control methods reported were birth control pills (41.1%), condoms (37.4%), tubal ligation (7.7%), and shots (4.9%).

A more recent assessment of contraceptive use in the US Affiliated Pacific Islands (including Guam) was conducted by Green, Ntansah, Frey, et al. [AE1](2020) in the context of possible Zika virus infection. They found that jurisdictional representatives reported that the most common available contraceptive methods used on Guam included (in no particular rank order): injectable, pills, patches, vaginal rings, condoms, and sterilization. This study also found that contraceptive prevalence was estimated to be 53.6% for any methods and 44.5% for modern methods (female and male sterilization, the IUD, the implant, injectable, oral contraceptive pills, male and female condoms, and vaginal barrier methods). Green, Ntansah, Frey, et al. also estimated that Guam's unmet need for family planning [AE2]was 16.8% (CI 9.4%-25.7%) in 2015.

Maternal Mortality

Maternal mortality is the death of a woman during pregnancy, childbirth, or the postpartum period, and it serves as a sensitive indicator of the quality of a community's health and health care. Many different definitions of maternal mortality are used to track and analyze deaths in other contexts, but Guam uses the following standard definitions from the Centers for Disease Control and Prevention (CDC):

Pregnancy-Associated Death - the death of a woman during pregnancy or within one year of the end of pregnancy from any cause.

Pregnancy-Related Death - The death of a woman during pregnancy or within one year of the end of a pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.

Upon review of death certificates, there were 40 maternal deaths in the US Territory of Guam from 1968 to 2021, resulting in very high maternal mortality ratios (MMR) during the years when there were maternal deaths. The MMR during the past 50 years in Guam ranged from a low of 22.6 in 1994 to a high of 304.2 in 2021. The three-year average for 2017-2019 was 74.0, and the 5-year average for 2017-2021 was 113.1. Compiling 10-year averages for MMR reduces the MMR; however, the MMR 10-year average from the most recent ten-year period, 2008-2017, at 29.4, is still higher than the US MMR of 23.8 in 2020. Although the MMR fluctuates since there are many years with no maternal deaths in Guam, the MMRs are still very high for Guam compared to the US, and the number of maternal deaths and the MMR has been increasing in the past ten years, following the national trend.

Guam's Maternal and Child Health Program is continuing initiatives to address infant, fetal, and maternal mortality in Guam. In 2022, the Territory of Guam was 1 of 8 states (and the only Territory) to receive a grant award from the Centers for Disease Control and Prevention (CDC) to create a Maternal Mortality Review Committee (MMRC) to assess why there is such high maternal mortality on Guam. 

A Maternal Mortality Review Committee (MMRC) is a group of professionals and partners who serve pregnant and postpartum women and who collectively review these deaths and examine factors that led to the death. The MMRC aims to determine if the death is related to the pregnancy and if it could have been prevented. The committee then provides recommendations that could prevent future deaths and protect the health and well-being of women during and after pregnancy.

On a typical week for our FNP who sees our MCH Women’s Health Clinic are:  Teen pregnancies,  Advanced age pregnancies, primigravids over 40s, Anemia patients, Gestational Diabetes,  a patient that is  needing a Non- Stress Test,  a preeclampsia,  a positive client with Chlamydia, a with Twins pregnancies, patient that smokes, vapes, and chews betel nut, a mother who just loss her baby, an Obese patients,  a patient that needs rhogam  or a patient with MODY 2 is maturity-onset diabetes of the young adult. 

The MCH High-risk prenatal patients are referred to NRCHC Women’s Clinic for prenatal services.  Accessing and referrals to this clinic is done in an efficient and timely manner.  The FNP has good communication/rapport with both OB/GYN providers from Northern Community Health Centers; Dr Meadows and Carlo Losinio CMW-PhD.  They are also available for consultation as needed. The patients are charged based on a sliding fee, and even the patients who have difficulty affording care are able to be seen.

A new challenge is addressing OB care of obese patients.  This group of patients are at risk of not only Gestational diabetes, high blood pressure, large babies, blood clots-but also fetal, miscarriage, stillbirths. Weekly NST are recommended later in pregnancy to ensure a good outcome.

These high rates in the MCH population, the program staff needed to help find some solutions to this Health Care Crisis. The director of the Department of Public Health and Social Services (DPHSS)was discussing this issue with the Governor of Guam. Then invited Title V MCH program staff, to submit data to assist in providing more evidence to recruit potential OBY/GYN physicians or NPs, they also researched on the Public Health Service Corporation identify funding source, and to research on other avenues of recruiting Health Care providers, to our Public Health system. Also there was retirement of another OB/GYN doctor. A Guam OB/GYN Task force was formed to work on solutions on recruiting providers to assist the DPHSS clinics.

The following programs were added to the taskforce: the DPHSS Medical Advisor, the Medicaid State Office to look at increasing their Medicaid provider visits fees so providers can increase their interest to seeing more prenatal Medicaid clients, Guam Memorial Hospital Authority (GMHA), to discuss other ways to recruit local medical physicians on island, and draft their scope of work of a OB/GYN, the United States Naval Hospital of the Pacific Commander to explore ideas how the off-duty physician can contribute to the crisis. With the Leadership from the Governor’s Office Chief of Staff on Health, to assist in bringing in the leaders in the different clinics on Guam together and accomplish the goal of recruiting more OB/GYN providers to the DPHSS clinics. So, in November 2022, the DPHSS had hired a part-time OB/GYN doctor from the US Naval Hospital staff to assist in providing High-Risk OB/prenatal care clients at least once a week in the OB/GYN clinics. Page 1 of 1 pages Created on 7/31/2023

[AE1]provide brief explanation on how they obtained their data

[AE2]what is the definition of this "unmet need for family planning?"