Women/Maternal Health Domain

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

Priority Need: Women have access to and receive coordinated, comprehensive services before, during and after pregnancy. 

Five Year Objectives: By 2025, American Samoa will increase the percentage of women ages 18 to 44 with a preventive medical visit in the past year to 59%, an increase from the baseline of 47% in 2019.

In the 2020 Needs Assessment ASMCH leadership and stakeholders prioritized improving access to coordinated, comprehensive services for women before, during, and after pregnancy. Efforts to improve pregnancy outcomes and maternal and infant health should begin prior to conception. Establishing healthy behaviors and achieving optimal health before pregnancy is crucial, as many women may not initially be aware they are pregnant.

In 2018, only 54.8% of American Samoa’s adult population prioritized annual wellness visits, compared to the national rate of 70.4%. Chronic conditions remain prevalent among the adult population. Various strategies have been identified to align ASMCH Title V priorities towards improving this perspective, starting with promoting wellness visits for women in the 2021-2025 Action Plan. Collaboration with service providers, technical assistance to improve competencies, updating standard operating procedures, and community outreach activities have shown promising outcomes in the fourth year of this five-year cycle.

Wellness Visit: In FY2023, all ASDOH programs who address the health needs of women/maternal population domain continued to work together to promote women wellness through systems building efforts and collaboration. Because of these collaborative efforts, a more holistic approach is being promoted at the Community Health Centers in order to support this concept. Whenever a woman shows up in any of the ASDOH clinics, they are further referred to all other healthcare clinics if any of the preventive screenings are due including dental, medical gynae, behavioral, family planning and STI screening. Continuous quality improvement projects are set in place to improve patient care and increase encounters which is gradually improving the rate of women accessing preventive wellness visits.

According to the MCH Jurisdictional surveys conducted in American Samoa in 2019, 2021 and 2024 by the National Opinion Research Center of the University of Chicago, there is a steady improvement in women accessing wellness visits annually. In 2019, the MCHJS showed a very low 47% rate, which then improved by 8.6% (55.6%) in 2021 and an additional increase by 2% (58.4) in 2024. This is shown in the graph above. This is a huge success considering the shutdown of clinics during COVID-19 between 2021-2022 for mass vaccination and community outbreaks; and the tremendous efforts across health agencies and community partners in promoting access and utilization of preventive health care services in the aftermath.

Data Source: CHC UDS Report

These promising results are also supported by the reports from the American Samoa Community Health Centers’ (CHC) 2023 annual report. CHC reported a total number of 4,911 women had accessed their clinics for a medical check-up. This is 56.4% of the total female population ages 18 – 44 years of 8714, in American Samoa. Chronic diseases (NCD) continue to be common among women seeking care. Majority of NCD concerns obesity, Diabetes Mellites, hypertension, heart disease and cancer. Contributing risk factors remain high in terms of inadequate nutrition, poor accessibility to nutritious food, high rate of physical inactivity, and evidently low rates of annual preventive health care visits despite the gradual rise in women’s annual visits. There is a need to continue to promote wellness visits through policy, collaborations and accessibility to affordable diagnostic and specialty care.

Breast and Cervical Cancer Screening: Moving to expand services by providing screening during Saturdays at villages and church halls as well as opening after-hour clinics on Tuesdays and Thursdays are showing promising results for the Breast and Cervical Cancer Prevention (BCCP) program. BCCP reported a total of 265 women between the ages of 18 through 44 accessed their clinic for preventive care. A total of 245 women (92.5%) received a clinical breast exam, 167 women (63%) received a mammogram, and 114 received a pap smear. This is a huge increase from the 19 pap smears in 2022. However, there is a drop in the number of mammograms from the 404 women in 2022. BCCP continues to refer all women who are suspected to be pregnant to the Prenatal clinics. In 2023, they expanded their services to the Manua Islands.

Data Source: BCCP 2023

STI Screening: The AS HIV/STD/TB/Viral Hepatitis Program prepares, prevents, responds and controls the spread of diseases of public health concern in American Samoa through surveillance, disease reporting and investigation in collaboration with health care providers and key responders for a healthier and safer community.  The HIV/STD/TB/Viral Hepatitis Program offers free testing and treatment, contact tracing, HIV testing and linkage to care, contraceptives, risk-reduction counseling, health education, and community outreaches in American Samoa. As the nation’s rates of STI are on the rise, so does American Samoa’s numbers. In 2023 the HIV/STD Program reported a total of 268 women who were tested positive for Chlamydia and 31 tested positive for Gonorrhea. Numbers of both STIs increased from 2022 to 2023 by 120 positive Chlamydia cases and 23 positive gonorrhea cases. Majority of these women were pregnant women because it mandatory to be screened for STI once they registered for prenatal care. Sexual partners are also tested and treated if positive.

Behavioral Health Services: A 0.8% of women ages 18 - 44 years who accessed the Primary Care Clinic were screened positive for depression and were referred to the Behavioral Health Services (BHS) for care management. This is a 0.4% increase from 2022.

Dental Visit: A total of 688 women or 7.9% of women ages 18 through 44 visited a CHC dental clinic at least once a year. This indicator remains very low confirming the lack of reinforcements and care coordination between clinics ‘referral systems. Women/Prenatal and Primary care clinics make the effort to refer women to the dental clinics but there is evidently lack of follow through to ensure these referrals receive the desired results.

AS MCH Objective: Increase the percentage of pregnant women beginning prenatal care in the first trimester by 2% every year.

Pregnant Women and Early Prenatal Care: A total of 732 women ages 14 through 46 delivered 737 live births in 2023. Majority of these maternal women are Samoans and other Pacific Islanders with 94.0%. Asians at 2.8% and multiple races at 2.6%. Maternal race matters as language barriers support the need for translation of health education resources and making them available through the community. Number of births has been decreasing in the past 10 years.

Data Source: SILAS

Data Source: SILAS

Early Prenatal Care (EPC) is essential for identification of maternal disease and risks for complications of pregnancy or birth. This can help ensure that women with complex problems, chronic illness, or other risks are seen by specialists.  Early prenatal care can also provide important education and counseling on modifiable risks in pregnancy, including smoking, drinking, and inadequate or excessive weight gain. Although early high-quality prenatal care is essential, particularly for women with chronic conditions or other risk factors, it may not be sufficient to assure optimal pregnancy outcomes. CHC prenatal care providers are now seeing some high-risk women affected by obesity, gestational diabetes and those who are expecting multiple births. These conditions used to be an automatic referral to LBJ Hospital OBGYN clinic however CHC providers are competent and confident to continue serving moms until they are 37 weeks in which they are then transitioned over to the hospital.

2023 ESM: Percent of prenatal care women receiving early prenatal care.

Early Prenatal Care continues to improve in the past 5 years. This is a testament to the ongoing promotional mass media campaign, dedicated clinic days for Amouli and Leone clinics, ultrasound scans made available, appointment call reminders improving, as well as 3 dedicated service providers who are efficient, dependable and competent. Lab tests are now being picked up by lab staff at Amouli and Leone Prenatal clinics and hence women do not have to travel farther from their villages to the hospital or Tafuna laboratory to get their lab tests done.

Data Source: SILAS

2023 ESM: Percent of postpartum women who received a depression screening and were referred to a behavior health counselor/psychologist.

In 2023, 65 postpartum women were enrolled in the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, and 63 of them received postnatal depression screening. This group represented 8.6% of all women who gave birth in 2023. None of these women required a referral to Behavioral Health Services. This indicator improved by 2% in 2023, up from 6.6% in 2022 and 4% in 2021. This measure is significant and encourages service providers to enhance service delivery and referrals.

Data Source: CHC UDS Report

Dr. Adriano, one of the prenatal physicians at the Tafuna Community Health Center, shared her weekly schedule. Mondays are typically reserved for prenatal registration, while Tuesdays, Thursdays, and Fridays are dedicated to prenatal physical examinations (first visits). Wednesdays are typically for scheduled ultrasound scans at LBJ Hospital. Due to the breakdown of the DOH ultrasound scanner in July 2023, all CHC clients have their scans at the LBJ Hospital OBGYN clinic, performed by Dr. Adriano. Postpartum visits can be scheduled on any day as needed, and walk-ins are always welcome. Dr. Adriano also alternates with Dr. Mirella to serve the women at the Amouli and Leone Women's Clinics on Tuesdays and Thursdays. In July 2023, CHC added a third physician, Dr. Virisila Vema, to serve women's clinics.

A total number of 72 pregnant women received depression screening and 50% (n=36) were referred to BHS for further screening and counseling. Dr. Adriano has indicated that even though more postpartum women showed up for postnatal care, none received depression screening. Women's health clinics started conducting depression screening for postpartum women in January 2024 and this data will be available in 2026 Title V application.

The table below summarizes the types of services DOH Women’s clinics provided in 2023.

2023 ESM: Percent of Providers receiving Technical Assistance Training in Prenatal Care Standards of Care and Provider Competencies.

Postpartum Check-up: The CHC Prenatal Clinics reported in 2023, a total of 72 maternal moms attended their postpartum check-ins within 12 weeks of giving birth. It is evident that there is a need for more accessibility and better care coordination (reminder calls and tracking) in the clinics to ensure postpartum women return for their check-up. Another way to capture these women can be recommended to the Tafuna Well Baby Clinic team to refer women bringing in their babies for their 4-6 weeks shot to the prenatal clinic. For mental health services, postpartum women can also get the postnatal depression screening at the WBC by the physician or nurse while waiting for their infants’ check-ups and vaccinations. In October 2023, three physicians from the CHC Women’s Health clinic attended an in-service training by BHS physician and nurse on maternal depression screening. Physicians in the Primary care setting for CHC have always been providing prenatal depression screenings and made about 62 referrals but none were done for the postpartum moms in the women’s health clinic. They just started carrying out postnatal depression screening in January of 2024, with a push from Title V.

Other Accomplishments:

• Annual Stakeholders Meeting: Conducted virtually on July 11, bringing together stakeholders from various programs to share reports, success stories, challenges, and update target objectives.
• Hear Her Campaign: Materials ordered from CDC and disseminated to prenatal and well-baby clinics.

Challenges:

• Standardized Health Education Materials: Need for more appropriate, translated materials across clinics and programs.
• Postpartum Reminder Calls: Ensuring assigned staff conduct reminder calls is a challenge. Refresher training for providers and updated policies and standard operating procedures are recommended.
• Lack of Maternal Mortality Review Committee (MRC). With two maternal deaths in 2022 significantly spiked the MMR to 283.3 per 100,000 live births. In 2023, one maternal death was reported, resulting in an MMR of 135.7 per 100,000 live births. Plans are underway to establish the American Samoa Maternal Mortality Review Committee (MMRC) to identify and reduce preventable causes of maternal deaths. Improving the quality of medical care for women before, during, and after pregnancy will help reduce maternal deaths, as highlighted by the Healthy People 2030 initiative.
• Manual collection of postpartum cards and newborn cards: Picking up of these cards from the hospital and taking them to CHC to be manually entered in a spreadsheet for tracking postpartum and newborns are no longer needed. MCH Epi Tech will work with Family Trac who administers SILAS database to ensure all information needed for this surveillance is captured and can be downloaded from SILAS. Prioritizing a time to work with the women’s clinic staff to access all these information is crucial for monitoring and providing reminder calls for postpartum moms.