PERINATAL/INFANT HEALTH

The CNMI MCH Program’s priorities around perinatal/infant focus on improving breastfeeding rates and rates of early initiation of prenatal care among pregnant women. Prenatal care is most effective when it starts early and continues throughout pregnancy. It can help prevent and address health problems in both mothers and babies. In the CNMI, only 55 percent (n=347) of non-tourist live births are to mothers who initiated prenatal care during the first trimester of pregnancy. This figure is a 10% increase from the 2016 CNMI data, however, still trails behind the US national percentage of 77.6 percent of live births to mother with early prenatal care.

In FY2020, the CNMI was still in the process of recovery from catastrophic damages that resulted from the Super Typhoon Yutu that happened in the year prior. Outreach activities in FY2020 were cancelled due to the COVID-19 pandemic and efforts across the CHCC/CNMI health department were prioritized towards responding to the public health emergency.

 

National Performance Measure 4A: Percent of infants ever breastfed.

Breastfeeding	2016	2017	2018	2019	2020
Percent of Infants	95.5	94.7	95.8	96.5	93.3
Numerator	1,162	1,145	1,209	877	610
Denominator	1,217	1,209	1,262	909	654

Source: CNMI HVSO, Birth Registry

The MCH Program gathers breastfeeding data to inform NPM 4A: Percent of Infants Ever Breastfed from the live birth registry out of the CNMI Health and Vital Statistics Office (HVSO). In 2020, 93.3 percent (n= 610) of infants born were breastfed. There was slight decrease from 96.5 (n= 877) percent from the year prior in the percentage of infants ever breastfed. A collaboration between the CNMI MCH Program, WIC, and the CHCC Hospital, which is the only birthing facility in the CNMI, has been a critical component for
ensuring breastfeeding initiation remains high.

 

National Performance Measure 4B: Percent of infants breastfed exclusively through 6 months.

Exclusive Breastfeeding	2016	2017	2018	2019	2020
Percent of Infants	1.7	2.5	2.5	1.1	.4
Numerator	9	13	12	5	2
Denominator	535	518	486	470	544

Source: CNMI WIC Program

For NPM4B: Percent of infants breastfed exclusively through 6 months, the MCH program utilizes WIC breastfeeding data to report on this measure as a proxy measure for CNMI rates. In 2020, a less than half one percent (n= 2) of infants was breastfed exclusively through 6 months of age. This is a decrease compared to the year prior, which was 1.1 percent (n= 5).

 

 

 

 

 

 

 

 

Breastfeeding Rates among CNMI WIC infants, 2019

                 

                   Source: CNMI WIC Program

 

While breastfeeding initiation rates in the CNMI of 93.3 percent (n= 610) is higher than US national rate of 84.1 percent[i] , its 6 months breastfeeding rate (44 percent) trails behind the US average of 58.3 percent. A review of data on CNMI infants breastfed indicates that 57 percent of infants are breastfed at 3 months, 44 percent at 6 months of age, and 30 percent at 12 months. Data illustrated in the graph above indicates increases in breastfeeding rates at 3, 6, and 12 months compared to the year prior, 2019; an upward trend that the MCH program and WIC program are working collaboratively to maintain.

 

High breastfeeding initiation rates indicates that a vast majority of moms in the CNMI want to breastfeed and start out doing so. However, despite the recommendations for exclusive breastfeeding through 6 months, only a little over 50 percent are being breastfed by 3 months of age and by 6 months, 44 percent are breastfed.

Many factors contribute to success in continued breastfeeding and support to breastfeeding moms is critical. Having to return to work is one factor and women typically return to work before a baby is 3 months of age. In the CNMI, the average maternity leave time is 15 business days for a government employee. Additionally, little is known about the types and level of breastfeeding support provided by local employers, both in the government and private sectors.

Lactation support outside of the typical work week is also lacking in the CNMI. The WIC program is the only program in the CNMI that provides peer counseling services dedicated to supporting moms in breastfeeding. Unfortunately, peer breastfeeding counseling services are not available before 7:30am, after 4:30 pm, and on weekends. Additionally, the COVID-19 pandemic impacted peer counselor support that is made available at the CHCC Obstetrics unit with morning peer counselor rounds temporarily suspended in FY2020.

 

Strategy: Increase access to breastfeeding support and education.

The MCH program continues its partnership with the hospital nursery, NICU, and pediatrics units in supporting the breastfeeding needs of babies and their families who access hospital services. Breast pumps and breast pump kits available in these units are supported by Title V funds. Additionally, the MCH program partnered with CHCC Children’s Clinic Provider, Dr. Heather Brooke to enhance lactation support services offered through the CHCC outpatient clinics. Dr. Heather Brooke is a certified IBCLC and began providing lactation consultation visits for women who needed additional support or experiencing challenges with breastfeeding. Additionally, Dr. Brooke facilitated capacity building training events focused on lactation and breastfeeding support, including: 4 hour CEU nurse training for CHCC NICU, L&D, Obstetrics, and Pediatrics hospital unit staff, 1 hour CEU for Children’s Clinic nursing staff, and 2 grand rounds presentations for CHCC medical providers. Through Title V funds, lactation supports such as nipple creams, nipple shields, loaner breast pumps, and breast pump kits are made available to women who are seen at the Children’s Clinic for lactation visits.

 

Strategy: Increase partnerships and collaboration in support of breastfeeding.

In 2020, the MCH program had plans to conduct training on employer support for breastfeeding and to partner with businesses to implement a pilot workplace breastfeeding project. However, due to the COVID-19 pandemic, plans were suspended and reprioritized for the next fiscal year.

The MCH program continued to work with the Home Visiting program to ensure breastfeeding support is provided to enrolled women. The MCH program facilitates referral of prenatal women to the Home Visiting program. Home Visitors (Family Partner Advocate) have completed training on lactation and breastfeeding support and the program offers breastfeeding supplies and breast pumps, for those who may need them or women returning to work.

 

Evidence Based Strategy Measure 4.2 Percent of infants enrolled in Home Visiting that are breastfed through 6 months. 

Home Visiting	2016	2017	2018	2019	2020
Percent of Infants	51.6	56.5	45.1	49.1	70.0
Numerator	33	13	23	27	28
Denominator	64	23	51	55	40

 

In 2020, 70 percent (n= 28) of 6-month-old infants enrolled in the Home Visiting program were breastfed through 6 months of age. This is a 21 percent increase from the year prior.

 

State Performance Measure 2: Percent of deliveries to resident women receiving prenatal care beginning in the first trimester of pregnancy. 

Prenatal Care	2016	2017	2018	2019	2020
Percent of Pregnant Women	43.4	45.8	47.5	47.9	55
Numerator	319	297	323	334	347
Denominator	735	648	680	697	631

 

In 2020, 55 percent (n= 347) of non-tourist live births were to women who accessed early prenatal care. Data for this measure is obtained through the Birth Registry from the CNMI Health and Vital Statistics Office. There was a 7 percent increase in the percentage of early prenatal care compared to the prior year.

Strategy: Increase community awareness regarding the importance of early and adequate prenatal care.

As part of efforts to increase community awareness regarding the importance of early and adequate prenatal care, the MCH program developed posters and an updated prenatal care awareness video for distribution within the CNMI community. Posters were displayed at the Food Stamp Office, Medicaid Office, and the Tinian Health Center and Rota Health Centers.

The MCH program had updated its prenatal care awareness video and had plans to air the videos at the local movie theater on the island of Saipan. However, due to the COVID-19 pandemic, the movie theater was shut down and the contract for airing the MCH videos was cancelled.

Strategy: Increase access to prenatal care

In 2020, the MICAH unit began offering transportation vouchers for free transportation to healthcare services for pregnant women. Informational advertisements and flyers were disseminated throughout partner programs and placed in the local newspapers. 

In 2019, the MCH program worked with the Family Planning Program to develop and begin utilizing a referral protocol for prenatal patients. Through Title V funds, free pregnancy testing is made available at the CHCC Women’s Clinic for patients seen through Family Planning. Patients who are identified pregnant are referred to the MCH program for prenatal service coordination where an assessment for risk status is completed and assistance in accessing supports and services, including Medicaid application processing, prenatal transportation assistance, and referrals to other programs such as tobacco cessation is provided. A standard operating procedure (SOP) outlining prenatal service coordination was developed.

 

                         Prenatal Referral to MCH Program by insurance status, 2019-2020

 

A total of 86 pregnant women were referred to the MCH program for prenatal service coordination. This total number was a decrease from the 257 prenatal referrals received the year prior in 2020. Of the Total referrals in 2020, almost half (46%) were women enrolled in Medicaid and more than one-third (36%) were uninsured. The decreases in referral and prenatal service coordination activity in 2020 was a result of the CHCC’s efforts to respond to the COVID-19 pandemic. The MCH program staff were activated as part of the CHCC emergency operations center and stationed in areas to support response to COVID-19. The MCH services coordinator, who is the lead in providing prenatal service coordination, was assigned to support the COVID-19 response communications section.

 

                            Graph 6. Prenatal referrals to MCH Program by trimester, 2019-2020

 

A review of the past two years of prenatal referrals illustrates that program received higher percentage of early (first trimester) referrals in 2020 compared to 2019. Although the overall referral number in 2020 decreased, larger percentage of the 2020 referrals (78%) were of women in their early stages of pregnancy compared to 60% in 2019.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[i] Centers for Disease Control and Prevention. (2020). Breastfeeding Report Card.