NPM 4-A) Percent of infants who are ever breastfed. B) Percent of infants breastfed exclusively through 6 months.

PRIORITY NEED: Families are empowered to make educated choices about infant health and well-being.

Adequate Prenatal Care

Prenatal care is the core element in preventive care for expectant mothers. It’s vital to receive adequate prenatal care so that healthcare providers can identify early on any risk factors that can complicate the fetus and the expectant mother’s health during the pregnancy. Pregnant women should be receiving prenatal care beginning in the first four months of pregnancy with the appropriate number of visits for the infant's gestational age. Poor prenatal care could result in the baby being born prematurely and/or at a low/very low birth weight, to name a few.

Before COVID-19, the DOH Prenatal clinic was only seeing women for prenatal care. The prenatal clinic was accepting new patients and walk-in appointments from Monday through Friday. With only one Provider, the prenatal clinic could see up to 20 patients per day. The LBJ OBGYN clinic has 4 providers who alternate at the clinic; the LBJ OBGYN sees up to 40 patients on a daily basis. 

When Covid-19 started spreading in American Samoa, after 18 months since the pandemic started in 2020, all services at all 5 community health centers ceased except for the RHD bicillin and Well Child clinics. In February 2022, American Samoa Government declared Code Red which restricted social gatherings and physical movement unless it was an emergency situation, and all DOH personnel were reassigned from their usual positions to assist with Covid-19 operations. The ability to physically access prenatal care at any DOH community health center and at LBJ hospital was the biggest challenge for pregnant women. With Covid-19 restrictions at the LBJ hospital, pregnant women were only receiving services via telephone calls unless advised by a healthcare provider to seek medical attention at the LBJ emergency room.

Later on in the year, a few Covid-19 restrictions were lifted but receiving prenatal care was not as flexible compared to the past years. The DOH prenatal clinic expanded their services not limiting it for prenatal care only, but for a wide range of women's health services such as menstrual care, breast and cervical cancer screenings, family planning services...etc. At Tafuna Community Health Clinic, the Prenatal clinic could only accept 20 appointments per day, no walk-ins accepted. This was due to COVID-19 restriction of physical distancing to reduce the risk of exposure to COVID-19. Limiting to 20 appointments per day was admissible capacity to avoid overcrowding in the prenatal clinic.  With additional services offered at the DOH prenatal clinic, more women are visiting the prenatal clinic but with limited appointment slots.

Another challenge the DOH Prenatal clinic faces is the shortage of Providers and supporting staff. The DOH prenatal clinic is staffed with 2 providers, 2 nurses and 3 CNAs. Dr. Luzviminda Adriano started at the DOH prenatal clinic in 2022 during COVID-19 to assist Dr. Mirella Chipongian. With additional services offered at the prenatal clinic, Dr. Mirella is now only committing one day of the week for prenatal services, and the remaining 4 days for the Breast and Cervical Cancer clinic. MCH health educators and nurses at the prenatal clinic sometimes get pulled to work at a different clinic to fulfill other DOH needs. With the inconsistency of staffing at the prenatal clinic, this results in the disruption of the daily workflow in the prenatal clinic. The prenatal clinic would close down due to no replacement when the provider is on leave or when provider is required to fulfill other duties within the department, early closure due to in-service training, support staff not performing on par due to constant rotation within the department with minimal training and instruction.

While MCH staff and other DOH programs continue to promote adequate prenatal care in the clinics, pregnant women tend to miss their appointments due to various reasons such as difficulty in accessing public transportation, trouble with transportation, or even no money for public transportation. MIECHV reported that although they do reminder calls for pregnant women to attend their prenatal appointments, many mothers shared that the lack of transportation was always the problem that prevented them from attending to their prenatal visits. MIECHV and ASMCH are determined to seek other avenues that can help resolve this issue.

In 2022, DOH was able to add ultrasounds for expectant mothers as part of the service for prenatal care in the clinics, something that was not possible before. With this service available at DOH CHC prenatal clinic, pregnant women can conveniently have their ultrasound appointments at DOH prenatal clinic instead of having to go to the LBJ hospital.

In 2022, LBJ OBGYN reported concerns of pregnant mothers who were tested positive for drug use giving birth to babies who were affected due to this problem. This concern was again addressed this year at the MCH Stakeholders meeting, prompting MCH, LBJ, and DOH Behavioral Health to collaborate on an effective plan to provide counseling and therapeutic services for these pregnant women. Also involving LBJ Social Services to implement a discharge plan for drug-use mothers after delivery to get appropriate help from existing programs such as MCH, to support mothers and infants during this difficult stage.

Breastfeeding

For the NPM 4, the percentage of infants who are ever breastfed in the WIC program in 2022 is 82%, 2% less than the percentage from 2021. By 6 months, only 48% of infant participants were still breastfed. The decrease in breastfeeding babies is due to various reasons such as breastfeeding mother’s early return to work, mothers unable to pump, babies being adopted…etc. According to WIC, the past year with COVID-19, the WIC staff made monthly courtesy calls to WIC participants to check on their nutritional needs, and to continue to promote breastfeeding to breastfeeding participants. The shortage of Similac during the COVID-19 outbreak influenced many breastfeeding mothers to breastfeed their babies.

For ESM 4.2, WIC has been the main breastfeeding TA trainer in the past year. Unfortunately, in 2022, they were not able to conduct breastfeeding TA training due to unknown reasons; however, they plan to conduct training in 2023 to health educators at WIC, DOH, and LBJ.

ESM 4.3 was inactive on the 2022 MCH Block Grant Application for the reason that the virtual chat room for lactation and peer counseling was never established. ASMCH did plan to establish a virtual chat room for breastfeeding women that may need lactation and peer counseling during COVID-19 but was never executed. The WIC Warmline was used in place of the virtual chat room so that women may get help from WIC Lactation Consultants.

For ESM 4.4, 24% of postpartum women received a home-visit from MIECHV personnel. One of MIECHV’s services is to educate and promote breastfeeding. Their educational resources are all in English, but home-visitors are well-versed in breastfeeding in both English and Samoan are able to educate non-English speaking parents about breastfeeding in Samoan. Aside from breastfeeding support, MIECHV was able to conduct postpartum depression screening on 90% of postpartum women served by their program. From the 90% of women who received a postpartum depression screening, no one was required to be referred to the Behavioral Health Clinic.

A collaborative effort between MCH, WIC, MIECHV and Community Health Centers to promote breastfeeding during breastfeeding week in 2022, spearheaded by DOH Nutritionist/Dietitians, was not entirely successful. Dietitians had workshops, training sessions, and different activities planned out for pregnant and breastfeeding mothers, health educators and support staff; unfortunately, they were only able to do a few activities based on the available resources they had. MCH and its breastfeeding support partners ensure that breastfeeding workshops and staff training will be conducted this year during breastfeeding week

The ESM 4.5 was inactive on the 2022 MCH Grant application for the reason that the Breastfeeding Coalition has been inactive for the past few years. With all the planning to aggressively promote breastfeeding in the community this year, some members of the Breastfeeding Coalition wish to revamp the Breastfeeding Coalition to pursue positive changes for breastfeeding women, foster the 2-hour lactation policy for breastfeeding women who work for the government, with hopes that it becomes a legislation that will apply to all working breastfeeding women in American Samoa, whether government or private

2022 Infant Mortality in American Samoa

Infant mortality is defined as the death of an infant before his or her first birthday whereas the infant mortality rate refers to the number of deaths among all live births in a year. In 2021 the infant mortality rate in American Samoa was 6 deaths per 1,000 live births which was 8.5%.  In 2022 the infant mortality rate is also 6 deaths per 1,000 live births. It indicates that there has been no change in the number of infant deaths per 1,000 live births. The lack of change in the infant mortality rate evidently shows no significant improvement in the quality of healthcare services such as prenatal care and infant mortality interventions.

The cause of infant deaths in 2021 and 2022 are not the same. In 2021, 5 infant deaths were caused by respiratory distress, and 1 infant death was from intracerebral bleeding. In 2022, 2 infant deaths were sudden unexpected infant deaths (SUID), 2 infant deaths caused by meconium aspiration, and 2 infant deaths were caused by congenital abnormalities. MCH will use this information to address preventative measures such as public campaigns on safe sleep, respiratory illnesses and what to do, as well as the knowledge of conditions or situations that can be prevented when early and consistent prenatal care is achieved.

MCH continues to work closely with local partners to reduce infant mortality by ensuring expectant mothers have access to quality prenatal care and skilled healthcare professionals. In addition, promoting and increasing immunization for infants, promoting breastfeeding, and empowering families to make educated choices about infant health and well-being are some effective strategies that will help reduce infant mortality in American Samoa.

Low Birth Weight

According to CDC data, the low-birth-weight rate in American Samoa is very low compared to the rest of the United States. In 2022, the low-birth-weight rate in American Samoa was approximately 4%, while the national average in the U.S. was around 8.5%. There is a significant decline in the low-birth-weight rate since 2020 in American Samoa. This may suggest that the survival rate of babies in American Samoa has improved or it may also indicate that babies born in American Samoa are not categorized low birth weight due to the rate of obesity and diabetes of majority of the population, to include pregnant mothers.   Although the data shows low birth weight has reduced, MCH strongly believe that the low birth weight can reduce even more if improvements are made to maternal health services, nutrition, and prenatal care in American Samoa.

Developmental Screening

MCH has been advocating to implement developmental screening of infants at the community health centers. MCH has determined that for most, if not all well-baby clinics, the developmental screening is not being implemented. It is reported that children are being referred to the DOH Nutrition Program by the WIC program for developmental delays due to poor nutrition, which is an issue that should be discovered and addressed during developmental screenings at the well-baby clinics. MCH will continue to promote and encourage DOH clinicians to prioritize developmental screenings in the Well baby clinics and provide educational opportunities for families and parents to request for a developmental screening during their well child visit

PRIORITY NEED: Establish a Newborn Metabolic Screening Program in American Samoa

Newborn Metabolic Screening Program in American Samoa

Implementing a Blood Spot Screening in American Samoa has been an ongoing effort for ASMCH leaders. Fortunately this year, through the work of the MCH Title V office, American Samoa has been awarded a Newborn Blood Spot Screening Grant through HRSA. With the Newborn Screening grant in place, ASMCH plans for the next 12 months to lay the foundation for a well-rounded screening program for all babies born in the territory.  This will require MCH to work closely with the Helping Babies Hear program, the Community Health Centers, CDC, LBJ Hospital, the Family-to-Family Health Information Center, and all other related governmental agencies.  The first year will be mostly spent on planning and initiating contracts to be in place before the GO LIVE date scheduled for July 1st, 2024. This will be such an exciting time and a new beginning for the babies born in our community.