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.

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

The perinatal and infant periods are a time of transition for women and families and an unparalleled period of development for the child. During the child's first three years, 700 new neural connections are created every second. Strong, stable, and nurturing relationships during this period can impact health and development. The foundation for health and well-being starts here.

The American Academy of Pediatrics (AAP) recommends that all infants are exclusively breastfed for six months to support optimal growth and development. Additionally, in 2022, the AAP published updated guidance supporting continued breastfeeding for two years or beyond, as long as mutually desired by mother and child. Breastfeeding has health benefits for infants and mothers, including mental health benefits for both mothers and babies. For infants, breastfeeding can reduce the risk of asthma, obesity, SUID/SIDs, diabetes, ear infections, and some respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and postnatal depression, reduce postpartum hemorrhage, lower the risk of type 2 diabetes, and decrease the likelihood of developing breast, uterine, and ovarian cancers. Human milk remains the optimal source of nutrition for the first months of life.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), administered under the Division of Public Health, provides individualized nutrition counseling, breastfeeding promotion and support, health screening and referral, and specific nutrient-dense foods to income and nutrition-risk-eligible pregnant, postpartum, and breastfeeding individuals, infants, and children under the age of 5. WIC families use a Guam WIC EBT card to purchase their WIC foods at authorized retail grocers.

The average breastfeeding rate six months post-delivery among WIC participants in 2023 was 33%; this exceeded the Health People 2030 goal of 24.9%, a 27.9% difference. The Guam Title V objective was 32%. The breastfeeding duration rate for exclusively breastfed infants among Guam WIC participants was significantly lower than overall breastfeeding rates; WIC participants often need more access to workplace breastfeeding accommodations and return to work earlier in the postpartum period, constraining participants' ability to maintain breastfeeding, especially exclusive breastfeeding.

The WIC Breastfeeding Support Program helps families meet their breastfeeding goals by pairing them with peer counselors and parents with 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.

Data from the 2023 Guam birth certificates indicated that 81.7% of the mothers initiated breastfeeding at hospital discharge. Chamorro women had the highest breastfeeding initiation, at 35.3%, followed by Chuukese mothers at 20.7% and Filipino

women at 19.4%. Carolinian mothers (0.02%), Kosraean mothers (0.8%), and Japanese mothers (0.7%) had the lowest breastfeeding initiation among women who delivered in 2023.

Guam has had an active Breastfeeding Coalition as part of the Non-Communicable Disease Consortium. The Coalition works to promote, protect, and support breastfeeding through the collaboration of community efforts. Some of the efforts included the celebration of National Breastfeeding in Public Day, a day to recognize the importance of breastfeeding for the infant’s health.

Guam La Leche League holds breastfeeding support classes monthly at the public library in the island's capital.

Infant mortality is widely used as an international measure of overall population health. The United States 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 maternal 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 partners also face isolation from friends and family.

From 2018 to 2023, there have been 198 infant deaths. The crude infant mortality rate for this period was 12.06 deaths per 1,000 live births.

In a recently published report by the Center for Disease Control and Prevention's National Center for Vital Statistics, researchers examined birth and infant deaths collected through the National Vital Statistics System (NVSS). Provisional U.S. data showed 5.6 infant deaths per 1,000 live births in 2022, 37% higher than the rate of 5.44 per 1,000 live births in 2021. The Guam infant death rate for 2022 was 10.7 per 1,000, double the U.S. rate. The Guam neonatal mortality rate rose 3% from 3.49 per 1,000 live births in 2021 to 3.58 in 2022, and the postneonatal mortality rate grew 4% from 1.95 per 1,000 to 2.02 over the same period.

Some of the reasons stated were maternity care deserts – where's there a lack or absence of maternity care – which limits the ability to care for infants properly. The second reason is the limited access to abortion, particularly following the Supreme Court decision of Dobbs vs Jackson in June 2022, which overturned Roe vs Wade.

It is important to note that ethnic/racial breakdown in analyses is used to analyze how the experience of living as a person who identifies with an ethnic/racial group affects their health outcomes. This includes cultural practices, prejudice 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 comprised 37% of births in 2018-2023. For every 1,000 births from mothers who identified as Chamorro from 2018 to 2023, 10.7 Chamorro infants would pass away before reaching 12 months of age, making up 35% of all infants.

Following Chamorro births, Chuukese births were 15% of births. 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 2023, 17.7% Chuukese infants would pass away before 12 months of age. Despite only 15% of births, Chuukese infants were 30% of all infant deaths. The odds of infant death for Chuukese infants during 2018-2023 were 83% greater than other infants.

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 live births. Filipino mothers had 21% lesser odds of experiencing an infant death than mothers of other ethnic backgrounds during 2018-2023.

Prematurity is the broad category of neonates born less than 37 weeks gestation. There are sub-categories of preterm birth based on gestational age: 1) extremely preterm (less than 28 weeks); 2) very preterm (28 to less than 32 weeks); 3) moderate to late preterm (32 weeks 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 care are complex, risk factors include maternal smoking and substance abuse, adolescent pregnancy, bleeding in pregnancy, and premature rupture of membranes. Furthermore, social determinants can significantly influence a woman's likelihood of premature delivery.

Preventing deaths and complications from preterm birth starts with a healthy pregnancy. WHO's antenatal care guidelines include critical interventions to help prevent preterm birth, such as counseling on a nutritious diet, optimal nutrition, and tobacco and substance use/abuse; 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 of gestation. This means that if you give birth to an infant before 24 weeks old, their chances of surviving are usually less than 50%. Some infants are born before 24 weeks gestation and do survive.

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. As per WHO, low birth weight (LBW) is a birth weight of less than 2,500 grams. This definition of LBW has existed for many decades. Low birth weight is further categorized into meager birth weight (VLBW <1,500 grams) and meager birth weight (ELBW <1,000 grams).

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 >2,500 grams. Low birth weight is also associated with long-term neurologic disability, impaired language development, and increased risk of chronic disease, 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-five child mortality worldwide.

The Guam Newborn Metabolic Screening, supported by Title V funding, ensures all newborn infants in Guam receive timely metabolic and genetic screening for core and secondary health disorders that are treatable by diet, vitamins, and/or medication or by anticipatory measures to prevent adverse reactions. Guam Newborn Metabolic screening program collaborates with all of Guam's pediatric providers, the hospital, and facilities to follow up on abnormal screening results based on laboratory recommendations. This includes repeat screenings and referrals for genetic counseling and education, clinical evaluation and management, diagnostic (lab) testing, or other follow-up specialty care services as indicated. Metabolic and genetic disorders are rare but can be serious conditions that can lead to severe health and developmental problems or even result in death if not identified and treated early. The overall goal of the Guam newborn metabolic screening program is to ensure that every infant born in Guam is screened for inherited disorders via a dried blood spot test before discharge. Our newborn metabolic screening program aims to link every infant identified with abnormal screening results to a primary medical home and to ensure they receive timely and appropriate follow-up for medical referrals and connection to early intervention services. The Guam newborn metabolic screening program supports the achievement of Title V measures by decreasing perinatal and infant health disparities by increasing the percentage of infants with newborn screening test results outside normal limits for a newborn screening disorder that receive prompt and appropriate follow-up testing.

A stillbirth (fetal death) is the death or loss of a fetus before or during delivery. Both miscarriage and stillbirth describe pregnancy loss, but they differ according to when the loss occurs. In Guam, a miscarriage is defined as the loss of a fetus before the 20th week of pregnancy, and stillbirth (fetal death) is the loss of a fetus during or after 20 weeks of pregnancy.

The U.S. National Center for Health Statistics defines fetal death as “the delivery of a fetus showing no signs of life as indicated by the absence of heartbeat, breathing, pulsation of the umbilical cord, or defined movements of voluntary muscles.”

Fetal death is a multi-factorial, complex societal and public health problem and an essential indicator of maternal and community health and well-being. The loss of a baby due to stillbirth can be a tragic and traumatic event for families. Unfortunately, stillbirth is often treated as an “invisible death” and not given the same recognition as live-born infants and child deaths.

There have been 440 fetal deaths in Guam between the years 2013 and 2023, an average of 44 deaths per year. The fetal death rate for the ten years combined was 13.33 per 1,000 live births. Guam experienced a 6.7% increase in the stillbirth rate from 2013-2023.

Infection, congenital disabilities, and pregnancy complications such as placental abruption or pre-eclampsia have been associated with stillbirths. Identifying these conditions can be challenging and requires adequate prenatal care. Social determinants of health (low income, housing insecurity, low education, etc.) are also associated with stillbirths. Stillbirths are a significant public health concern – approximately one-fourth of these deaths in the U.S. are preventable.

Stillbirth occurs in families of all races and income levels and women of all ages. However, it disproportionally affects women of Micronesian and Asian ethnicity. The fetal mortality rate for Chuukese women for the years 2013-2023 was 45.36 fetal deaths of 20 weeks or more per 1,000 live births. Chamorro women have a fetal mortality rate of 24.74, and Filipino mothers have a fetal mortality rate of 11.34 per 1,000 live births.

The most prevalent risk factor associated with stillbirth is being Asian/Pacific Islander ethnicity, which relates to the risk of preterm delivery. Other factors contributing to the Asian/Pacific Islander disparity gap are differences in maternal preconception health, infections, income, and access to quality health care. However, much of the disparity in fetal mortality remains unexplained.

Maternal age at either end of the reproductive age spectrum (less than 15 years and greater than 35 years) is an independent risk factor for stillbirth. Maternal age greater than or equal to 35 years of age is associated with an increased risk of stillbirth in multiparous women.

For the years 2013-2022, the fetal death rate for women aged 15 to 19 years of age was 4.64 per 1,000 live births, and for women aged 20 to 24 years, the rate was 18.04 per 1,000, a difference of 118% from the age group 15 to 19 years.

The risk factors for teenagers and young adult women may relate to less favorable socioeconomic and behavioral conditions among those age groups, although biological immaturity may also play a role, particularly for the youngest teenagers (15 years of age or younger).

At the opposite end of the spectrum, fetal mortality rates also increase rapidly for women aged 25 years and over. For the years 2013 and 2022, the fetal death rate for women aged 25 to 29 years was 20% higher than women aged 31-34 years. Moreover, the fetal death rate for women aged 35-40 years was five times the rate for women aged 15-19 years.

From 2013 to 2023, 41.2% of the mothers who experienced a fetal death had between one to five visits, and 13.4% had between six to ten visits. Close to 25% (24.7%) had no prenatal care for their pregnancy, and 10.8% had unknown prenatal care. Cost is a significant barrier for many women despite the health risks of preceding care. Nearly 40% of mothers nationally report that they delayed prenatal care because they lacked the money or insurance to cover their costs.