Priority Need – To reduce infant mortality and morbidity.

National Performance Measure – 4 A) Percent of infants ever breastfed; B) Percent of infants breastfed exclusively through 6 months.

The American Academy of Pediatrics (A.A.P.) recommends that all infants are exclusively breastfed for six months to support optimal growth and development. Breastfeeding has health benefits for infants and mothers, including significant benefits to the mental health of both mothers and babies. For infants, breastfeeding can reduce the risk of asthma, obesity, S.I.D.s, diabetes, ear infections, and respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and post-partum depression, reduce post-partum hemorrhage, and may decrease the likelihood of developing breast, uterine, and ovarian cancer. Human milk remains the optimal source of nutrition for the first months of life.

According to the National Immunization Survey (N.I.S.), in 2018, Guam's initiation rate for breastfeeding was 85.6 (CI 77.4 - 91.2). This meets Guam Title V's objective of 82%. Guam's breastfeeding exclusivity rate through six months was 28.7 (CI 21.1 – 37.7), and the Title V objective was 32%.

Data from the 2022 Guam Birth Certificates indicated that 82.6% of mothers initiated breastfeeding at hospital discharge. Chamorro women had the highest breastfeeding initiation rate at 36.6%, followed by Chuukese (18.7%) and Filipino (18.2%) women. Carolinian (0.02%), Kosraean (0.7%), and Japanese (1.5%) women had the lowest breastfeeding initiation rates among mothers that delivered in 2022.

The Special Supplemental Nutrition Program for Women, Infants, and Children (W.I.C.) is a short-term intervention program designed to influence lifetime nutrition and health behaviors in a targeted high-risk population. W.I.C. mothers are strongly encouraged to breastfeed their infants unless there is a medical reason not to. W.I.C. staff are trained to promote breastfeeding and provide the necessary support to new breastfeeding mothers and infants.

The average breastfeeding rate six months post-delivery among Guam W.I.C. participants in 2022 was 36.4%. That rate exceeded the Healthy People 2030 goal of 24.9% (2019), and the Guam Title V set an objective of 32%. The breastfeeding duration rates for exclusively breastfed infants among Guam W.I.C. participants are significantly lower than overall breastfeeding rates. W.I.C. participants often need more access to workplace breastfeeding accommodations and return to work earlier in the post-partum period, constraining participants' ability to maintain breastfeeding, especially exclusive breastfeeding. W.I.C. data from 2022 shows that 15.8% of participants exclusively breastfed for three months, and 5.6% solely breastfed for six months.

Source: Guam W.I.C. Program

The W.I.C. Breastfeeding Support Program supports families to meet their breastfeeding goals by pairing with peer counselors and parents with "lived" personal experience feeding their children. Peer Counselors are recruited from their communities, often speak the same language, and have similar life circumstances and experiences as their clients. Guam peer counselors improve health by increasing breastfeeding initiation, exclusivity, and duration.

The continuation of the Covid 19 pandemic continued to impact W.I.C. families and their breastfeeding rates. Research is emerging evaluating the negative impact of the pandemic on breastfeeding, particularly among under-resourced populations. Multiple factors are believed to contribute to the disruption in breastfeeding support resulting in decreased breastfeeding rates, including but not limited to the trouble of hospital practices around breastfeeding, decreased in-person appointments, and mixed messaging received by parents across the safety of Covid 19 and breastfeeding.

Improving breastfeeding rates across all races/ethnicities and reducing inequities remain significant public health goals. The poor breastfeeding practices may stem from a range of interrelated historical, cultural, social, economic, and psychosocial factors, as well as suboptimal policies and breastfeeding programs in specific settings. Many sociodemographic factors are associated with an increased likelihood of breastfeeding, such as maternal age, marriage, higher maternal education level, and access to private insurance.     

Priority Need – To reduce infant mortality and morbidity.

State Performance Measure 3 – The rate of infant deaths between birth and one year of life.

The loss of an infant is an inconsolable pain that no parent should ever endure. While tragic, infant mortality rates and patterns are essential metrics to measure the overall health of a community. Measuring and understanding why infant death occurs to the most vulnerable population members is a mission of utmost importance for any society. The U.S. Centers for Disease Control and Prevention defines infant mortality as death that occurs before a child lives for one year.

Source: DPHSS OVS

From 2018 to 2022, there were 160 infant deaths. The crude infant mortality rate for this time period was 11.1 deaths per 1,000 births, which was twice the crude infant mortality rate for the United States.

It is important to note that ethnic/racial breakdowns in analyses are used to analyze how the experience of living as a person that identifies with an ethnic/racial group affects their health outcomes. This includes cultural practices, prejudices they experience that could affect their quality of life, and so on. Thus, race is not a biological metric but a sociological one. Chamorro's made up 37% of births in the time period 2018 to 2022. For every 1,000 births from mothers who identified as Chamorro from 2018 to 2022, 10.7 Chamorro infants would pass away before reaching 12 months of age, making up 35% of all infant deaths.

Following Chamorro births, Chuukese births were 15% of births in 2018-2022. The Chuukese population in Guam has been quickly growing since the Compact of Free Association, which has allowed individuals from the Federated States of Micronesia to work in the U.S. However, infant mortality outcomes have been exceptionally high for minority Micronesians in Guam. For every 1,000 births from mothers who identified as Chuukese from 2018 to 2022, 17.7 Chuukese infants would pass away before 12 months. Despite only 19% of births, Chuukese infants were 30% of all infant deaths. The odds of infant deaths for Chuukese infants during 2018-2022 were 83% greater than for other infants. Mothers who identified as Pohnpeian also experienced very high rates of infant mortality. Pohnpeian births were only 3.3% of births during 2018-2022 but experienced 7.5% of infant losses. Pohnpeian mothers giving birth during 2018-2022 had 140% greater odds of experiencing an infant loss than all other ethnicities.

After Chamorro and Chuukese births, 17% of the births were from Filipino mothers. They experienced a crude infant mortality rate of 9.2 deaths per 1,000 births. Filipino mothers had 21% lesser odds of experiencing an infant death than mothers of other ethnic backgrounds during 2018-2022 (p-value = .40 95% CI .47 – 1.26). This association is insignificant because the p-value is much more significant than 0.05, and the 95% confidence interval contains the null value of 1. Regardless, after 2018, Filipino mothers experienced yearly infant mortality rates below the overall infant mortality rate.

Prematurity is the broad category of neonates born less than 37 weeks gestation.

There are sub-categories of preterm birth based on gestational age:

• extremely preterm (less than 28 weeks)
• very preterm (28 to less than 32 weeks)
• moderate to late preterm (32 to 37 weeks).

Preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization. Although the causes of preterm birth are complex, risk factors include maternal smoking and substance abuse, adolescent pregnancy, bleeding in pregnancy, and premature rupture of membranes. High-quality preconception and prenatal care are key factors in preventing preterm delivery. Furthermore, social determinants can significantly influence a woman's likelihood of premature delivery.

Source: DPHSS OVS

Preventing deaths and complications from preterm birth starts with a healthy pregnancy. WHO's antenatal care guidelines include key interventions to help prevent preterm birth, such as counseling on a healthy diet, optimal nutrition, and tobacco and substance use; fetal measurements, including the use of early ultrasound to help determine gestational age and detect multiple pregnancies; and a minimum of 8 contacts with health professionals throughout pregnancy – starting before 12 weeks – to identify and manage risk factors such as infections.

Infants born very early are generally not considered viable until after 24 weeks gestation. This means that if you give birth to an infant before they are 24 weeks old, their chance of surviving is usually less than 50 percent. Some infants are born before 24 weeks gestation and do survive.

Source: DPHSS OVS

An infant’s birth weight is the first weight recorded after birth, ideally measured within the first hours after birth, before significant postnatal weight loss has occurred. Low birth weight (L.B.W.) is defined as a birth weight of less than 2500 g (up to and including 2499 g), as per the World Health Organization (WHO)[1]. This definition of L.B.W. has been in existence for many decades. In 1976 the 29th World Health Assembly agreed on the currently used definition. Before this, the definition of L.B.W. was '2500 g or less. Low birth weight is further categorized into very low birth weight (V.L.B.W., <1500 g) and extremely low birth weight (E.L.B.W., <1000 g)[2]

Low birth weight is a valuable public health indicator of maternal health, nutrition, healthcare delivery, and poverty. Neonates with low birth weight have a >20 times greater risk of dying than neonates with a birth weight of >2500 gm.[3],[4]. Low birth weight is also associated with long-term neurologic disability, impaired language development, impaired academic achievement, and increased risk of chronic diseases, including cardiovascular disease and diabetes. Preterm infants carry additional risk due to the immaturity of multiple organ systems, including intracranial hemorrhage, respiratory distress, sepsis, blindness, and gastrointestinal disorders. Preterm birth is the leading cause of all under-5 child mortality worldwide. [5].

In addition, economic studies in low-income settings have demonstrated that reducing the burden of low birth weight would have important cost savings for the health system and households.

[1] Organization W.HW.H. International statistical classification of diseases and related health problems, tenth revision, 2nd ed. World Health Organization; 2004.

[2] Organization W.HW.H. International statistical classification of diseases and related health problems, tenth revision, 2nd ed. World Health Organization; 2004.

[3] Kramer M.S. Determinants of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ. 1987;65(5):663–737.

[4]  Badshah S., Mason L., McKelvie K., Payne R., Lisboa P.J.P.J. Risk factors for low birth weight in the public hospitals at Peshawar, NWFP-Pakistan. B.M.C. Pub Health. 2008;8:197.

[5] You D., Hug L., Ejdemyr S., Idele P., Hogan D., Mathers C. Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the U.N.U.N. Inter-agency Group for Child Mortality Estimation. Lancet. 2015;386(10010):2275–2286