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.

Acting on the feedbacks provided in the 2021 Summary Statement, the National MCH Program requested and scheduled an in-person working meeting with the Pohnpei State MCH and Family Planning Programs’ staff and other public health programs’ staff who may be available and can attend, to review the issues raised in the Summary Statement and using those concerns to develop the FSM MCH Action Plan for 2023. The response to the call for an in-person meeting with the Pohnpei Public Health staff was successful and the workshop was very productive.

The most notable challenges cited in the summary statement included the following; “most strategies in each population domain are based on community education and outreach and are not specific or evidence-based. Additionally, some strategies are similar to the priority”; “Some community education and outreach examples are found in the Women’s Health domain and include, “conduct community-based education focusing on women’s health to promote annual preventive visits,” and “utilize community-based education in partnership with other agencies focused on women’s health to promote annual preventive visits.” Additional examples in the Perinatal/Infant Health domain include “to conduct at least five community awareness sessions (workshops, radio spots) on the importance of early pregnancy booking”. “In the children and Youth with Special Health Care Needs domain it is difficult to distinguish the strategy from the priority. The listed priority is “provide care coordination training for parents/caregivers of children with special health care needs,” while the strategy for this priority is “work collaboratively with specializing trainers to provider training to CSHCN parents/caregivers in the States.” There may be a need for a deeper understanding of existing barriers that prevent women from accessing preventive health services, and the lack of specificity in strategies may not allow the program to decrease such barriers across all domains, effectively”.

The summary statement stated further that, and I quote” the MCH Program has experienced ongoing challenges related to compiling MCH program data. The States collect data and report to the National Government; however, it is evident that there are challenges that inhibit consistent and accurate reporting for MCH indicators, within the current structure of manual reporting. The Program has a desire to collect data in real time, in order to eliminate inconsistencies from year to year”.

“Although there has been significant improvement in alignment of NPMs, SPMs, and ESMs in this year’s FY22 Application/FY20 Annual report from the FY21 Application/FY19 Annual Report, 4 challenges still exist around measuring these indicators. Some relevant examples are listed below:

Within the Women’s Health domain, there are concerns as to how the Program plans to measure ESM 1.1, “percent of women, ages 18 to 44, attending community outreach events on preventive medical visits in the past year,” as the numerator description does not provide a definition for “community outreach event.”

• Within the Infant Health domain, NPM 3, “percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ neonatal intensive care unit (NICU) is not relevant for the FSM, as mentioned by the FSM Title V Program in the FY22 Application/FY20 Annual Report. Furthermore, ESM 3.1, “percent of low birthweight infants born in the hospital,” does not align with the strategy that aims to “conduct community awareness workshops and events on the important of early pregnancy booking.”

• Within the Child Health Domain, ESM 8.1.1, “percent of children ages 6-11 years old who are doing physical activity in schools at least 60 minutes daily before, during, and after the school day,” is similar to the selected NPM 8.1, “percent of children, ages 6 through 11, who are physical active at least 60 minutes per day.” Furthermore, the ESM does not indicate how the Program is implementing the strategy.

•Within the Adolescent domain, the newly added SPM 4, “percent of adolescents aged 12-17 years old who have attended educational awareness sessions on adolescent and behavioral health in schools,” mirrors the ESM. In the CYSHCN domain, SPM 5, “percent of parents/caregivers receiving specialty trainings on CSHCN care coordination by 5%” is similar to ESM 11.1. Additionally, ESM 11.1 could be difficult to measure, as “receiving training” is not well defined”.

The Summary Statement Review and 2023 Action Plan Working Workshop, as we called it, was held from June 21-23, 2022. Workshop topics included: Family Planning (FP) Annual Progress Report (guidance, development and submission); 2023 FP Grant Funds (allotments and work plans); MCH Program 2021 Annual Report; 2021 Summary Statement review and response; MCH Program 2023 Action Plan; MCH Program Unobligated Funds; and Miscellaneous business.

The meeting was attended by the staff of the National and Pohnpei State MCH and Family Planning Programs. Also attended the workshop were the Chief, Division of Primary Health Care, Supervisor, Public Health Nurses, selected Health Assistants who provide services at both the public health main clinic and dispensaries in Pohnpei; MCH Data Clerk; Systems of Care Coordinator for Pohnpei State, and the Administrative Officer (AO) for Pohnpei Public Health who oversees MCH grant funds on a daily basis. Also attended, on the last day of the workshop, were Pohnpei State Budget Officer and another staff from the Budget Office and Chief of Finance and the Federal Programs Fund Certification Officer from Pohnpei State Finance office. They were invited to address FSM MCH Program’s ongoing concerns over the large sums of money that Pohnpei has not been able to spend each year.

Time allocation for the 3 days working meeting was as follow. Day one was allocated for Title X Family Planning Program Services and financial matters. All of day 2 and day 3, up to 3:00 pm, was devoted to the review of the 2021 Summary Statement and revision or development, if you will, of the FSM MCH 2023 Action Plan. The workshop started at 8:30 a.m. and ends at 4:30p.m. each day. The workshop format was in both whole (big) group and small work groups. The Workshop sessions were combination of: 1) slide presentations given by the National MCH Staff on the Block Grant Program Requirements; 2) review of the FSM 2022 Grant Application Action Plan focusing on the State Priorities and National Performance Measures selected, Strategies, Evidenced-Based Informed Strategic Measures, and State Performance Measures developed, Data Sources, and discussion on how to improve the alignment and effectiveness of priorities, NPMs, Strategies, ESMs and SPMs;

As an outcome of the Summary Statement Review & 2023 Action Plan Working Workshop, some Evidenced-Based Informed Strategic Measures and Strategies were either changed or modified and some NPM were replaced with another NPM that is more applicable to FSM or replaced with a 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. The FSM Early Hearing Detection and Intervention Program (EHDI) has developed and conducting tele-audiology services in Pohnpei, Chuuk and Yap States. This enables those children who have failed a follow-up screening and or suspected of hearing loss to have a diagnostic audiological evaluation (DAE) before they are 3 months old as required by EHDI Program Goal #3. Tele-audiology is FSM’s response to scarcity of audiologist in the FSM and is so fitting and ideal with the Covid-19 Pandemic and borders closure in the FSM. FSM MCH Nurses have been trained to operate the equipment on-site working with a contracted Audiologist out of Guam. 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.

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.