III.A.1. Program Overview

The goal of the Federated States of Micronesia (FSM) Maternal Child Health (MCH) Program is to provide comprehensive, coordinated and family-centered preventative services to pregnant women, post-partum women, infants and children, including children with special healthcare needs (CSHCN) from birth to 21 years.

There are two levels of government in the FSM, the National Government level and the State Government level. The National MCH Coordinator works in collaboration with other coordinators at the national level. The administration and management of the Title V Program is under the direct control of the National MCH Coordinator, who provides guidance and works closely with each of the four state MCH Coordinators for the planning, implementation and provision of direct services to the maternal, infant, child, and adolescent populations. Health services in the FSM are designed and delivered at the State level. The MCH Program provides primary care and preventive services to pregnant women; mothers and infants; preventive and primary care for children; and services for CSHCN.

To understand the challenges and context of the FSM, a brief review of the geographical location, political status, population, and the significant ethnic and linguistic diversity of the FSM is necessary. The FSM is an island nation with a total population of approximately 103,000 spread out over some 607 widely dispersed islands in the Western Pacific Ocean. The FSM is a constitutional federation incorporating four main states: Pohnpei, Chuuk, Yap and Kosrae. Kosrae State is the only FSM State composed of a single island. Surrounding each of the other three States are sparsely inhabited outer islands. Each of the FSM States are separated by hundreds of miles of Pacific Ocean accessible only by airplane or boat.

Politically, the FSM is freely associated nation with the United States under a Compact of Free Association entered into with the United States in 1986 with an amended compact entered into on June 30, 2004. Each of the four FSM States has its own constitution, elected legislature and governor. The governments of the FSM and the United States maintain deep ties and a cooperative relationship, with over 25 U.S. federal agencies that maintain programs in the FSM.

The people of the FSM are highly diverse with nine main and different ethnic groups speaking some thirteen (13) different languages. This highly diverse population with different languages or dialect use English to communicate across the four FSM states. English proficiency levels vary, with most of the older population being monolingual in their own native language or bilingual in another language, e.g. Japanese. Most of the younger population has basic English proficiency skills. In the FSM classrooms, children are taught in both their native language and English from first to third grade, after which English is used almost exclusively in middle-elementary to high school. What is truly unique about the linguistic context of the FSM is that each major language is not interrelated with the other language. Each has its own linguistic structure, pronunciation, vocabulary, sentence structures, and semantic, syntactic, and pragmatic rules. With the arrival of many Asian businesses to the FSM, other languages are being introduced, such as Filipino and Chinese. Health literacy across all inhabitants is low as higher education is not common in FSM. The MCH Program respects this cultural and linguistic diversity and seeks appropriately paired demographics within its staff, community leaders and families that participate in the program on each island state.

In 2020 the MCH Program conducted a community and stakeholder driven programmatic Needs Assessment of services provided to mothers and children in the FSM. FSM chose a conceptual framework for the needs assessment process that uses a primary prevention and early intervention –based approach with the goal of optimizing health and well‐being among the MCH population across the life course, taking into account the many factors that contribute to health outcomes. The needs assessment served as an essential tool to direct focus on system changes and examine the health status of FSM’s families. Although there have been improvements in some areas, there continue to be disparities which still present challenges. The effects of the remote location preventing access to basic services as well as the population demographics affecting health literacy was seen in the identified priorities. Based on the assessment, FSM identified seven (7) MCH priorities that will provide guidance for MCH related activities and funding during 2020-2025.

In 2021 FSM MCH Program, acting on feedback provided in the 2020 MCH Block Grant Review Summary Statement, requested for Technical Assistance (TA) Training to address the recommendations made for the weakness cited in the 2021 Grant Application. Some of the weaknesses cited included the following; “many strategies and evidence-based or –informed measures (ESMs) are focused on health promotion, patient education, one-on-one health care provider and patient interactions, and provider training and education, which may not be effective strategies in showing improvements in data trends”. “Denominator values vary across many National Performance Measures (NPMs), ESMs, and State Performance Measures (SPMs), and limited information is included in the field notes to explain the drastic changes in denominators from year to year. Therefore, data trends are difficult to evaluate, which makes it difficult to measure program success”, etc.  A Technical Assistance (TA) Training was authorized for FSM and Dr. Haley Cash conducted a Virtual TA Training on May 18, 20, 25 and 26, 2021. The TA Sessions are two hours long, each, and attended by the National and State MCH Program Coordinators and key staff.

As an outcome of the TA Training some strategies and Evidenced-Based Informed Strategic Measures and Strategies were either changed or modified and some NPM were replaced with SPM in order for us to properly tract program success based on the Priorities selected by the MCH Program in the Federated States of Micronesia (FSM).

Priorities and National Performance Measures

Women/Maternal Health

The FSM maternal health clinics serve as many women’s first entry into medical care or their medical home. MCH recommends and provides preventive health services in accordance with recognized standards of care. The program aims to improve clients’ access to preventive health services through cervical cancer (Pap & VIA) and anemia screening. Because the preventive health clinics of the FSM all exist within the public health facilities, clients can avail themselves of multiple public health screening and preventive services in one visit. In this way, The MCH Program serves as the gateway to care through partnerships with other public health programs and other health and social programs. Once again, clients need not make multiple appointments or visit multiple clinics to participate in these program services, thereby allowing for comprehensive and cohesive preventive health care.

Perinatal/Infant Health

The perinatal mortality rate in the FSM is at least three times that of the national average. An assessment of prenatal care in the FSM showed that only about 31% of women come in for care during the first trimester. In addition, some FSM states report up to 10% of deliveries received no prenatal care at all. MCH Program continues to strive to improve prenatal care adequacy. The process of prenatal care at the clinic may be a deterrent to some women. Streamlining the process may increase prenatal care attendance. Even amongst those seeking prenatal care, that care is not always adequate. There is limited pregnancy expectation education so the community is unaware of what to anticipate during pregnancy and prenatal care. Unplanned pregnancy, late access and inadequate prenatal care, limited preventive health screening services, and poverty play a significant role in poor birth outcomes, causing additional stressors on the family, community, the health care system and the government. The MCH Program is committed to improving prenatal care access and adequacy through the MCH clinics and dispensaries in remote villages.

Child Health

Physical activity is not tracked well in the FSM. In addition, it is uncertain if all children’s health care providers are aware of the recommendations for physical activity for children and if this is promoted during well children visits. FSM children experience a higher rate of being overweight as compared to the US. Unfortunately, post WWII with the introduction of western culture, locals began eating processed foods such as canned meats and rice. This diet has been integrated into the culture of the locals and is considered “traditional food”. Processed foods are affordable and plentiful in this remote area where fresh ingredients are often hard to come by, perishable, and expensive for the average FSM resident. This highly processed diet in a population with a strong genetic propensity to diabetes and hypertension leads to devastating rates of diabetes, heart disease, stroke, renal failure and dialysis in patients much younger than the average age in the US mainland. FSM MCH Program intends to start young to combat obesity and nutrition to prevent non-communicable diseases.

Adolescent Health

FSM teens have a high rate of pregnancy, sexually transmitted diseases, alcohol use, non-fatal motor vehicle crashes and suicide. The MCH goal is to encourage positive health behavior activity in adolescents, through comprehensive interventions at age-appropriate levels in a culturally-sensitive manner that will impact the frightening possibilities of adolescent risk behavior activity. Currently the FSM MCH program provides school physicals until age 12 but not again unless required for college entry. As such, well adolescent visits do not occur with regularity. The Program plans to expand these school physicals into the high school grades. During these well adolescent visits, youth will receive assessment on violence and safety and information and education on risky behavior and its possible negative outcomes.

Children with Special Health Care Needs

Most children in the program are identified through Child Find a program of Special Education, when diagnosed as deaf or hard of hearing, or seen and referred by Shriners during Shriners annual visit. Diagnosis often depends on specialist visits from off island so MCH provides gap care until the next specialist is on island. Interventions for those with delays do not begin until age 3 with Special Education, therefore the MCH program provides gap care for these children as well. The CSHCN Program in FSM relies heavily upon its partnership with the Special Education. Although the strong relationship is an asset, the CSHCN Program needs to do more distinct work with their population, including providing care coordination services.

Cross Cutting

Although FSM MCH sees behavioral/mental health as a need across populations. However, given the reality of the situation in the FSM (limited infrastructure and resources to do screening) FSM MCH will continue to track behavioral health screening of our mothers for our policy and decision-making use BUT this will not be a reportable indicator to MCHB per this application.

Systems Building

Impeding priorities in families’ life creates challenges and barriers in seeking preventative health screenings. Poor health literacy contributes to not seeking preventive health services as individuals may not understand the connection of prevention in relation to their general health. The MCH Program has to be in the forefront of providing guidance to communicate the importance and availability of health services throughout the lifespan including healthy behaviors and resources. The MCH Program is committed to developing guidance through policies and procedures for basic MCH initiatives. In addition, MCH National will develop common educational messages for their communities to be shared by the State Programs to provide unity, organization and consistency while still allowing for some State individualization on certain provisions of the program.

FSM’s MCH Program historically has a solid working collaboration with the public and private sectors as well as governmental and non-governmental organizations. The MCH Program has been instrumental in forging strong partnerships to enhance disease prevention and public awareness activities. Much of the work accomplished by MCH staff is done in collaboration with other state agency staff, particularly Public Health and Education. MCH personnel work with other state agency staff on a nearly daily basis through coalitions, task forces, advisory groups, committees, and through cooperative agreements. The FSM MCH Program is well‐integrated with Family Planning Program, Immunization Program, Substance Abuse and Mental Health Program, HIV/STD Prevention Program, Non-Communicable Disease Unit including Diabetes, Cancer, Tobacco Control, and the FSM Department of Education, in particular the Early Intervention Service. The MCH Program works with each FSM State’s Community Health Centers to improve accessibility and expand primary care services for low‐income and vulnerable populations. The MCH Program has an established working partnership with the College of Micronesia for training needs of both clinical and programmatic staff, conducting awareness activities in nutrition and physical activity, and to prevent and control non-communicable disease. The MCH Program staff at the state level work closely with parents’ support groups, church leaders, women's groups, and community and traditional leaders.

The FSM does not have the following programs or services: Title V- H.O.M.E. Visiting, Title XIX - Medicaid, Title XXI - Child Health Insurance Program, Social Services, Child Welfare Programs, Social Security Administration, WIC Program, or Rehabilitation Services.

The MCH Program leverages funds and resources from and works with international agencies such as Red Cross, World Health Organization and United Nations Children’s Fund and Population Fund.