Perinatal/Infant Health

For the Perinatal/Infant Health domain, Guam’s priority needs to “reduce infant mortality and morbidity” did not change. Guam selected National Performance Measure # 4 Breastfeeding based on the Guam 2020 Title V Needs Assessment.

The first component of the Guam five-year cycle is to increase the percentage of breastfed infants to 85% in 2025. As reported by the National Immunization Survey (NIS), the rate of Guam infants who were breastfed peaked in 2014 to 86%, that percentage declined by 2.47% in 2019.

For the second component of the performance measure for breastfeeding, the 2025 objective is to increase the percentage of breastfed infants exclusively through six months to 33.5%. The rate of exclusively breastfed infants in 2019 was 26.4%, a difference of 23.7%.

Healthy People 2030 establishes breastfeeding initiation, duration, and degree of exclusivity as nationally recognized benchmarks for measuring success. Guam reached the Healthy People target of 81.9%.

Breastfeeding is a priority issue for Guam. Community stakeholders continue to recognize breastfeeding as a critical practice to improve birth outcomes, reduce infant mortality, and help the mothers' health and healing following childbirth.

The Guam WIC Program is the lead program for breastfeeding but works collaboratively with other health and community partners. One of WIC’s core services is to provide breastfeeding education and support to participants. Breastfeeding services include providing guidance, counseling, and breastfeeding educational materials to families; direct engagement with mothers and families to ensure more extended participation in the program; facilitating access to healthy foods; and providing breastfeeding aids such as breast pumps.

WIC provides additional services through a Breastfeeding Peer Counseling Program, which conducts group sessions for pregnant and breastfeeding WIC moms to address breastfeeding concerns and provide one-to-one support to those interested. Guam WIC uses the U.S. Department of Agriculture (USDA) “Loving Support” model as an evidence-based curriculum to assure the program's success.

WIC services were significantly impacted by Covid 19. The Guam WIC Program moved to telework with the island-wide “shut down” and stay-at-home orders in March 2020. All WIC clinics were closed for in-person visits, and services for WIC clients were provided remotely via phone or text. Fortunately, the Guam WIC Program is completely “eWIC” (electronic benefits) for food purchases, reducing the number of required in-person clinic visits once the “shut down” is lifted. WIC Breastfeeding Peer Counseling was provided remotely (zoom), phone or text. Group events in person were suspended, and staff considered other methods to encourage WIC mothers to continue networking.

In line with the priority need for the infant/perinatal domain, Guam established a State Performance Measure, “The rate of infant deaths between birth and 1 year of life.”

Infant mortality is widely used as an international measure of overall population health. The U.S. has a higher infant mortality rate than other developed countries. Infant mortality is a multi-factorial societal problem often linked to factors that affect an individual’s physical and mental well-being, including mental health, socioeconomic status, quality and access to medical care, and public health practices. The loss of an infant can adversely affect families and communities, both socially and emotionally, often resulting in several negative symptoms such as depression, grief, and guilt. Families may suffer from long-term psychological distress, which can lead to partner separation or divorce. Grieving parents also face isolation from friends and family.

Between 2010 and 2020, 384 Guam infants died before their first birthday, an average of 38 infants per year. The mean infant mortality rate for the 10 years was 11.5 per 1,000 live births. In all the years examined, Guam’s infant mortality rate

remained higher than Healthy People 2030 objective of 5.0 infant deaths per 1,000 live births.

Preterm birth is the leading cause of infant mortality in Guam. Preterm is defined as a live birth less than 27 weeks gestation. The preterm rate for Guam in 2020 was 11.3; the U.S. rate for 2019 was 10.2. The March of Dimes preterm birth rate goal for 2020 was 8.1. Prematurity is a complex health problem that does not have a single solution. Prematurity and related conditions accounted for nearly half (434%) of all infant deaths in 2020.

The Medicaid program, known as Early Periodic Screening Diagnostic and Treatment (EPSDT), benefits children and adolescents under 21. EPSDT provides a comprehensive array of prevention, diagnostic, and treatment services. The program is designed to assure that children receive early detection and care so that health problems are averted or diagnosed and treated as early as possible.

From 2015 to 2020, Guam EPSDT Participation Report shows that for age group < 1, those eligible for the program decreased 71%, and the number of those <1 that received a screen decreased by 66.2%.

The decrease in screening may be due to private clinics or physicians not being counted on to serve Medicaid patients consistently. This is attributed to the government plans poorly paying (i.e., reimbursement rates are below private insurance plans). Also, it should be noted that few specialists in Guam (i.e., neurologists, surgeons, orthopedics, etc.) continue to care for uninsured and Medicaid patients in need of their specialty care, realizing that these patients have nowhere else to go. Many of these providers offer reduced rates to the uninsured, self-pay patients. Thus, with most private providers unwilling to accept Medicaid, and uninsured patients, particularly those who cannot make payment upfront, thousands of indigent patients have nowhere to turn to their primary health care needs.

Impact on Infant Mortality by Covid 19

Data on the full impact of Covid 19 related infant mortality is currently not available. As more information is available, this section will be updated. However, utilizing a Social Determinants of Health lens can be beneficial for addressing identified and potential problems. In light of the Covid 19 pandemic, many people in Guam face economic instability, lack of adequate health care access, and a reduction of social support, all of which are risk factors for infant mortality. On top of all these factors, CDC recommendations for reducing transmission may have caused hesitancy among some pregnant women in seeking medical care. Some locations in Guam reduced or even canceled in-person prenatal visits and the number of people that could be present during the birth and hospital stay.

The Territorial Epidemiologist, DPHSS Medical Director, MCH Program Manager, and a well-known Obstetrician/Gynecologist have tracked the first-trimester post-Covid 19 vaccination miscarriages. The Ob/Gyn brought this to the attention of the DPHSS Director. The doctor stated that his current post-vaccine first-trimester rate had increased over 33% compared to his clinic average first-trimester miscarriage rate, which is about 8%. He is also corresponding with other clinics to see if there has been a noticed uptick in first trimester miscarriages. He is also reporting to the CDC Vaccine Adverse Event System (VAERS).

During the past decade (2010-2020), Guam has experienced a 16.2% increase in its stillbirth rate. Guam’s rate is currently 16.42 per 1,000 live births plus stillbirths.