Perinatal/Infant Health – Annual Report

For the Perinatal/Infant health domain, the Guam MCH Program selected National Performance Measure (NPM) #4 – A) Percent of Infants who are ever Breastfed and B) Percent of Infants Breastfed Exclusively through 6 Months.

Additionally, included within the domain of Perinatal/Infant health, Guam’s key priority since the 2015 MCH Needs Assessment has been to reduce Guam’s infant mortality rate, along with the related factors of preterm birth and low birth weight.

 Healthy People 2020 established breastfeeding initiation, duration, and degree of exclusivity as nationally recognized benchmarks for measuring success. The first objective for Guam MCH is to increase the percent of infants who have ever breastfed to 82%. The 2018 indicator is from the Guam WIC Program. The estimate for Guam (79%) failed to meet the annual objective and was 2.6% lower than the national estimate. The current indicator for Guam has not changed significantly since 2014 (mean 76.80%).

The second part of the breastfeeding NPM, the Guam MCH 2020 objective is to increase the percent of infants who breastfed exclusively through 6 months to 32%. The 2018 WIC data indicates that 3% of the WIC infants were breastfed exclusively. This was a difference of 120% from the Guam MCH objective.

Breastmilk is provided in a form more easily digested than infant formula. Breast milk contains antibodies that help infants fight off viruses and bacteria. Breastfeeding also strengthens the infant’s immune system, improves immune responses to certain vaccines, offers possible protection from allergies and asthma, and reduces the probability of SIDs/SUID. In addition, babies who are breastfed exclusively for the first six months, have fewer ear infections, respiratory illnesses, and bouts of diarrhea. They also have fewer hospitalizations and trips to the doctor.

Benefits to the mother include reduction of postpartum blood loss, increased postpartum weight loss with no return of weight once weaning occurs, possible delay of fertility, need for reduced insulin in diabetic mothers, psychological benefits of increased self-confidence and enhanced mother/infant bonding, reduced risk of breast, ovarian, and endometrial cancer, and reduced risk of osteoporosis and bone fracture. There is also an economic benefit of breastfeeding for families due to financial savings with breastfeeding compared to the cost of infant formula.

Because women’s social networks are highly influential in their decision making process, they can be either barriers or points of encouragement for breastfeeding. New mothers’ preferred resource for concerns about child rearing is often other mothers. For example, advice from friends is commonly cited as a reason for decisions about infant feeding. Perceived social support has also been found to predict success in breastfeeding.

One of the core services of WIC is to provide breastfeeding education and support to participants. Breastfeeding services include guidance, counseling, and education to pregnant women, providing access to healthy food, provision of breastfeeding aids such as breast pumps, and the availability of trained staff.

WIC provides additional services through Breastfeeding Peer Counseling, which conducts sessions for pregnant and breastfeeding WIC participants to address any breastfeeding concerns and provide one-to-one support to WIC mothers who are interested. The Guam WIC Program uses HANDS (Health and Nutrition Delivery System) to assure success of the program. WIC mothers indicate a high level of satisfaction with the program. Peer Counselors become part of a mother’s circle providing basic breastfeeding information, contact during pregnancy and the postpartum period and referral to resources if necessary.

Despite Guam’s excellent breastfeeding initiation rate, the CDC’s Maternity Practices in Infant Nutrition and Care report shows that birthing facilities on Guam still have opportunities for improvement. The report is based on a survey of hospital practices conducted every two years. Areas for improvement include appropriate use of breastfeeding supplements, inclusion of model breastfeeding policy elements, provision of hospital discharge planning support, and adequate assessment of staff competency.

The Guam Maternal, Infant and Early Childhood Home Visiting Initiative (MIECHV), funded by HRSA/MCHB provides evidence-based home visiting services to help pregnant and parenting families attain and maintain optimal health and well-being for all family members.

As the name suggests, home visiting professionals provide services in a family’s home. They nurture, coach, educate, offer encouragement, and refer families to services to achieve a shared goal: building a safe, healthy, and stimulating environment for their child. During pregnancy, home visitors encourage mothers to receive regular prenatal care, avoid risky behaviors, and adopt healthy habits. Once the baby is born, home visitors coach parents on positive parenting practices, support breastfeeding, help parents prepare for well-child visits, teach parents about child development and nutrition, conduct developmental screenings, support older children when a new baby arrives, and encourage parents to attend to their own health care needs. Home visitors also help families connect with community-based resources and state and federal programs. This could include applying for health insurance, accessing early intervention services, finding childcare, connecting with community resources for stable housing, or finding a job. Home visitors’ roles extend beyond the parent-child relationship—they discuss topics such as continuing family education, managing family finances, understanding domestic violence, and dealing with trauma. Research shows that home visits during the post-natal period were extremely effective for addressing mothers concerns about breastfeeding, providing education, linking the mothers with community resources and involving other family members. In 2017, 83.3% of Project Bisita’s mothers were breastfeeding their infants. In 2018, the percentage was at 100%, an increase of 20% %.

Exclusive breastfeeding of newborn infants is the norm in Micronesia, and in Chuuk, 79% of infants are still breastfed at the age of 6 months (UNICEF Pacific, 2013). However, data derived from recent Guam public health reports indicate that among Chuukese immigrants on Guam only 28.5% exclusively breastfeed at birth, and by the first follow-up appointment, less than 1% are still exclusively or predominantly breastfeeding. This represents an alarming deviation from the usual breastfeeding patterns seen in Micronesia. It is important to understand factors that contribute to this low rate of initiation and subsequent marked drop off in breastfeeding rates among this immigrant group on Guam. In a study entitled Facilitators and Barriers for Successful Breastfeeding among Migrant Chuukese Mothers on Guam [1] it was found that among this population, key catalysts for breastfeeding included high levels of self-confidence, family support, knowledge about breastfeeding, and the existence of strong traditional Chuukese cultural values. Key barriers included experiences of cultural conflict or social change, lack of support from their local community, family and health-care staff, as well as limited self-knowledge about how to manage common breastfeeding problems. 

Guam’s breastfeeding moms, their infants, and breastfeeding advocates gathered at the Governor’s Conference Room in Adelup for the “Global Latch on.” The Latch-on is a worldwide community-building event held every August to celebrate global breastfeeding and aims to provide peer support, and to promote and normalize breastfeeding.

The 2018 Annual Guam Breastfeeding Awareness Health Fair was held at the Micronesia Mall. Breastfeeding information, raffle prizes, health screening, educational tabletop exhibits, and entertainment were featured. The fair aimed to increase public awareness and support of breastfeeding and Guam’s Public Law 32-098, known as the Nana Yan Patgon Act. This law allows working mothers to sustain their breast milk supply while at work. It also serves to protect a woman’s right to breastfeed in private or public establishments and recognizes the act of breastfeeding as normal and natural.

For the comfort of nursing travelers and employees, the airport built 10 nursing/family rooms throughout the airport --- four in the concourse, two on the ground level, one in the arrivals lobby, one near the US Customs and Border Protection Hall, and one on the second level.

The nursing/family rooms are equipped with a counter, lounge chair, and private lock option and are accessible by both male/female parent and guardian. Airport management is also looking at adding artwork in the nursing and family rooms.

The NCD consortium also reported progress with some of the GovGuam entities, such as the Guam Department of Labor, which opened a breastfeeding room for employee and public use through the assistance of their federal counterpart at the USDOL. According to the consortium, the federal DOL also helped ensure that the airport complies with the law. Under the statute, GDOL is responsible for recording data and addressing allegations of discrimination against nursing women in the workplace of both government and nongovernment of Guam entities, and to ensure that women are aware of breastfeeding rights.

The consortium also reported that the University of Guam (UOG) designated a room in the Health Science building for breastfeeding use by students, staff, and faculty. Other departments on campus have also designated areas where mothers can breastfeed or pump in privacy. Additionally, they said UOG has drafted a written statement supporting breastfeeding.

Infant mortality rates are often broken into two components relating to the timing of the death: neonatal and post neonatal. The neonatal mortality rate refers to the number of infant deaths within 28 days after birth. Post neonatal refers to the number of infant deaths from 28 days to the end of the first year of life.

The distinction between neonatal and post neonatal mortality is important because the risk of death is higher immediately after birth/delivery and the causes of death are quite different from those later in infancy. Therefore, effective interventions to reduce infant mortality should take into account the ages at death of infants.

Prematurity is the main cause of infant death on Guam. Prematurity, for the purposes of this report, is a death to an infant who was born before 37 weeks gestation.[2]  In 2018, 9.7% of all live births were preterm which was down from 2017’s 10.7%. Important growth and development occurs throughout pregnancy, but especially in the final months and weeks of gestation; being born preterm carries serious, medical, developmental, and potentially behavioral problems that can last a lifetime. Addressing prematurity is complex and has no one single solution. Infants who survive due to advancements of modern medicine and technology may spend weeks or months hospitalized in a neonatal intensive care unit. In addition to the physical risks to the child, premature birth also results in significant economic impacts to the health care system. Prematurity is the main cause of infant death on Guam.

According to the March of Dimes, the average length of stay for a baby admitted to the NICU is 13.2 days. The average cost of a NICU admission is $76,000 with charges exceeding $280,000 for infants born prior to 32 weeks gestation. The costs of a premature delivery often do not stop after the baby is discharged. Many of these children go on to have long-term health complications, and need services from early intervention and the school system. According to the National Institutes of Health, the average cost to the United States for premature births is $26.2 billion each year.

For the period 2013 through 2018, there were 184 infant deaths on Guam. There were 115 neonatal deaths. Of the neonatal deaths, the population of Chamorro infant deaths equaled 34.7%, Chuukese infant deaths were 32.1% and Filipino infant deaths were 13.9%. For the 69 post-neonatal deaths, the Chamorro population was 47.8%, Chuukese population was 24.6%, and the Filipino population was 14.4%.

For the years 2013-2018, there were 25 mothers (12.8%) aged 15 to 19 that experienced an infant death; within the age group of 20 to 24, 51 mothers (28.8%) had an infant death; within the age group of 25 to 29, 44 mothers (24.5%) experienced an infant death; in the age group of 30 to 34 there were 39 mothers (21.4%) who had an infant that died; within the age group 35 to 39, 19 mothers (9.2%) had an infant that passed away and within the age group 40 to 44, 6 mothers (3.6%) had an infant that passed away.

Of the mothers aged 15 to 19, over half (52.3%) were Chamorro, followed by Filipino mothers at 19% and Chuukese mothers at 14.2%. In the age group 20 to 24 years, 40.4% of the mothers were Chamorro, 36.1% were Chuukese mothers, and 8.5% were Filipino mothers that had an infant that passed away. For the age group 25 to 29 years, 42.5% of the mothers were Chamorro, 27.5% were Chuukese, and 15% were Filipino. The last large group that experienced an infant death was the age group 30 to 34 years of age, in which 60% of the mothers were Chamorro, 22.8% were Chuukese, and 5.7% were Pohnpeian.

Several risk factors unique to teens contribute to higher infant mortality rates. First, teens are more likely to continue smoking throughout a pregnancy, increasing the risk of low birth weight, premature birth, complications during pregnancy and SUID (Sudden Unexplained Infant Death). Second, teens are more likely than older women to have a sexually transmitted disease. Chlamydia, syphilis, and HIV all carry serious risks for the baby during pregnancy and after birth. Third, “regular and early prenatal care” says the March of Dimes, is least likely to occur among teens, who often receive late – or even no prenatal care.

Of the 96 deaths of infants born preterm, 44 (45.8%) were born at 28 weeks or less. Very preterm births are usually born with severe health issues and are more unlikely to survive. Of the 44 infants born at ≤ 28 weeks, 31 (70.4%) died within the first 24 hours of birth. The remainder of the infants died from congenital defects or birth trauma.[3]

When looking at the gestational age group of 35 – 40 weeks, there were 52 infant deaths. Within this gestational age group, 45.4% of the deaths occurred within the Chamorro population, followed by Filipino at 15.9% and lastly, Chuukese infants at 13.6%.

Low Birthweight and Very Low Birthweight

Birthweight is a significant factor directly related to infant mortality. Babies born too soon or too small encounter significant risks of serious, costly, and devastating life-long health conditions. Risk factors for low and very low birthweight include multiple births (more than one fetus carried to term), maternal smoking, low maternal weight gain or low pre-pregnancy weight, maternal or fetal stress, infections, and violence toward the pregnant woman.[4]

Less attention has been paid to the problem of low birthweight and very low birthweight babies. In contrast to infant mortality, the last decade saw no significant drop in the rate of low birthweight. In fact, low birthweight now appears to be on the rise. The medical and social services that are required by low birthweight and very low birthweight infants are significant and the costs are high to society and the American taxpayer. Those babies that survive the first year incur medical bills averaging $93,800. First year expenses for the smallest survivors will average $273,900.

Significant savings can accrue from enabling mothers to add a few ounces to a baby's weight before birth. An increase of 250 grams (about 1/2 pound) in birth weight saves an average of $12,000 to $16,000 in first year medical expenses. Prenatal interventions that result in a normal birth (over 2500 grams or 5.5 pounds) save $59,700 in medical expenses in the infant's first year. The long-term cost of low birthweight infants includes re-hospitalization costs, many other medical, and social service costs and, when the child enters school, often-large special education expenses. These public expenses can go on for a lifetime

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 184 infant deaths for 2013-2018, 109 (53.3%) were born with a low birth weight. There were 58 (54%) Extremely low birth weight (ELBW) infants. Of the 58, there were 27 (46.5%) Chamorro infants, there were 11 (22.4%) Filipino infants and 6 (17.2%) Chuukese infants.  There were 22 Very low birth weight (VLBW) infants that died between 2013 and 2018. There were 10 (52.6%) Chuukese infants, 7 (36.8%) Chamorro infants and 2 (10.5%) Filipino infants.  There were 29 Low birth weight (LBW) infants that passed away between 2013 and 2017. Of the 29, 42.8% were Chamorro infants, 28.5% were Chuukese, and 9.5% were Filipino infants.

Infants born at a low birthweight are also at increased risk of long-term disability and impaired development. Infants born weighing less than 2,500 grams are more likely than heavier infants to experience delayed motor and social development. Lower birthweight also increases a child’s likelihood of having a school-age learning disability, being enrolled in special education classes, having a lower IQ, and dropping out of high school. [5]Risk for many of these outcomes increases substantially as birthweight decreases, with very low birthweight babies most at risk. Being born with a low birthweight also incurs enormous economic costs, including higher medical expenditures, special education and social service expenses, and decreased productivity in adulthood.

Mothers who receive late prenatal care are more likely to have babies with health problems. Mothers who do not receive any prenatal care are three times as likely to give birth to a low-weight baby, and their baby has an infant mortality rate five times that of infants whose mother has received prenatal care beginning before the third trimester. Adequacy of prenatal care – defined by the timing and frequency of care visits – is an important factor in the success of prenatal care. Adequacy has been correlated with positive birth outcomes and other benefits such as reduced risk of postpartum depression and infant injuries.

Sufficient care is best defined as the amount needed to produce both a healthy baby and a healthy mother. The amount of care received in prenatal programs varies in the number of visits and therapeutic interventions. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have issued guidelines, but professionals disagree about the amount and content of prenatal care for normal pregnancies, about what constitutes a high-risk pregnancy, and about methods for handling high-risk pregnancies.

The ACOG and AAP guidelines call for maternity care visits to begin as early as possible during the first 3 months of pregnancy, continuing every 4 weeks until the 28th week, every 2 to 3 weeks until the 36th week, and then every week until delivery—13 to 15 visits. Such guidelines focus primarily on the number of visits rather than on their content.

Social determinants of health – often defined as the circumstances in which people are born, grow up, live, work, and age – shape individual behavior and the choices that are available to individuals for improving health. Some individuals, and specific groups of people, do not have the same access to health care and have limited choices for improving health. Access to health care and healthy behaviors are important, but social determinants of health can have a greater impact on health and birth outcomes. These factors can adversely influence health when nutritious food, transportation, safe housing, education, livable and/or sustainable wages are not available or are very difficult to obtain.

In looking at health insurance status, 41% of women who experienced an infant death had some form of insurance other than Medicaid. Non-Medicaid mothers who received adequate prenatal care had a lower infant mortality rate than Medicaid women who also received the same level of prenatal care. Onset and adequacy of prenatal care was selected as a comparison factor because it is recorded on the birth certificate.

In looking at the various ethnicities of women that experienced an infant death, within the Medicaid program, 69% of the mothers were Chamorro, 10% were Chuukese mothers, and 9% were Filipino mothers. Within the Medically Indigent Program (MIP), the largest ethnicity under the program were Chuukese women at 65.6%, 15.6% were Chamorro mothers and 3.1% were Filipino. There were 35 women with private insurance that had an infant death; 71.4% were Chamorro, and 11.4% each were Chuukese and Filipino women.

Research supports the importance of a “neighborhood effect” [6]on health outcome including infant mortality and its risk factors, which can vary widely based on where an individual lives. Social scientists and medical geographers have long acknowledged neighborhood/community as an important determinant of health outcome disparities. Nonetheless, scholars across the globe have mainly focused on the importance of individual factors of child health. However, there is increasing support for the hypothesis that infant and child health risks are associated with particular social structure and community ecologies, which can provide useful feedback to policy makers for the development of public health interventions. Studies have generally focused on assessment of community effects on health outcomes by using community-level variables using different data, definitions, and methods.

Newborns on Guam are screened for disorders through two methods: 1) bloodspot screening, where blood is drawn from the infant’s heel, collected on a filter paper and sent to the Oregon Public Health Laboratory for analysis for disorders; and 2) newborn hearing screening, where newborns are tested using physiologic screening methods. The newborn screening program focus on: 1) ensuring newborns are screened and that physicians receive timely notification of screening results; 2) that those newborns with abnormal screening results receive diagnostic testing; and 3) those diagnosed have access to appropriate treatment or intervention.

Guam Memorial Hospital Authority (GMHA) in partnership with Guam MCH contracts with Oregon Public Health Laboratory for bloodspot testing. GMHA conducts the bloodspot testing and sends the screen to Oregon Public Health Laboratory. Guam Title V tracks and follows up on abnormal results. Sagua Mañagu (Guam’s only birthing center) also contracts with the Oregon Public Health Laboratory. The Oregon Public Health Laboratory sends the results to the Medical Director at Sagua Mañagu. The Medical Director then sends copies of both normal and abnormal results to the infant’s health care provider. The US Naval Hospital sends its newborn screening samples to Pediatrix, a commercial laboratory in Pennsylvania. After the screening process is complete, staff at the Naval Hospital do all follow up of newborn screening results.

Newborn bloodspot testing screens for genetic conditions using blood spots in order to help identify infants who may have treatable genetic disorders or medical conditions. Early identification can prevent serious complications, such as growth problems, developmental delays, blindness, intellectual disabilities, and seizures.

In 2017, there were 3,293 live births on Guam. All of the newborns received a bloodspot screen. Of the 3,293, 6% had a “presumptive positive” screen; after re-screening was completed 4.2% had a confirmed case of a disorder.

Newborn hearing screening is the standard of care in hospitals nationwide. The primary purpose of newborn screening is to identify newborns who are likely to have hearing loss and who require further evaluation. A secondary objective is to identify newborns with medical conditions that can cause late-onset hearing loss and establish a plan for continued monitoring of their hearing status.

The Guam EHDI Project was established in 2002 through a federal grant awarded to the University of Guam Center for Excellence in Developmental Disabilities Education, Research, & Service (Guam CEDDERS). The Guam EHDI Project receives support through a grant from the U.S. Health and Human Services (HHS), Health Resources and Services Administration (HRSA). The Centers for Disease Control and Prevention (CDC) also provides funding support to complement Universal Newborn Hearing Screening on Guam by implementing Guam ChildLink-EHDI, an integrated data tracking & surveillance system to support the Guam EHDI Project. Through the efforts of this Project, the Universal Newborn Hearing Screening and Intervention Act, Public Law 27-150, became law in December 2004. Guam’s local legislation aligns with national goals and ensures a standard of care for all babies born on Guam.

The Guam EHDI project has maintained a 99% initial hearing screening rate at all civilian birthing sites. Guam Regional Medical City data is included in the 2015 to 2017 screening rate data. The Lost to Follow Up (LFU) rate for outpatient rescreens decreased to 2% in 2015. The LFU rate slightly increased to 3% in 2016 but remained below the benchmark for this level. The LFU rate slightly increased to 8% in 2017, but remained below the benchmark for this level for this four-year period.

The Lost to Follow Up (LFU) rate for High Risk Rescreens was at 17% in 2014, which is below the benchmark for that year. In 2015, the rate decreased to 16%, but was 6% over the established 10% benchmark for the year. In 2016, the rate significantly decreased to 10%, meeting the established Guam EHDI benchmark. In 2017, the rate increased to 15%, exceeding the benchmark for that year.

The Guam EHDI Learning Community, consisting of parents of children who are deaf and/or hard of hearing (D/HH), pediatricians, audiologist, the Guam Early Intervention System Project Coordinator, Department of Education D/HH Coordinator, Nurses, Birthing Assistants and Nursing Supervisors, a Medical Facility Manager, and the Department of Public Health and Social Services Bureau of Family Health & Nursing Services Administrator, was established to increase health professionals’ engagement and knowledge of the EHDI system.

Facilitators and Barriers for Successful Breastfeeding among Migrant Chuukese Mothers on Guam

Kathryn M. Wood PhD, RNC-OB, Kristine Qureshi, PhD, RN, FAAN, CEN, APHN-BC

[2] March of Dimes

[3] Birth trauma (BT) refers to damage of the tissues and organs of a newly delivered child, often as a result of physical pressure or trauma during childbirth. The term also encompasses the long term consequences, often of a cognitive nature, of damage to the brain or cranium

[4]Ricketts, S. A., Murray, E. K., and Schwalberg, R. (2005). Reducing low birthweight by resolving risks: Results from Colorado’s Prenatal Plus Program. American Journal Public Health

[5] Reichman, N. (2005).Low birth weight and school readiness. In School readiness: Closing racial and ethnic gaps.The Future of Children

[6] Northern region includes the villages of Dededo, Tamuning, Tumon and Yigo. Central Region includes the villages of Agana Hts., Asan, Maina, Barrigada, Chalan Pago, Ordot, Hagåñta, Mangilao, Mongmong, Toto, Maite, and Sinajana. Southern Region includes the villages of Agat, Inarajan, Merizo, Santa Rite, Talofofo, Umatac and Yona