The mission of the CNMI’s Title V MCH Program is to promote and improve the health and wellness of women, infants, children - including children with special health care needs (CSHCN) - adolescents, and their families, through the delivery of quality prevention programs and effective partnerships. In the CNMI, Title V supports a spectrum of services, from infrastructure-building services like quality assurance and policy development, to gap-filling of direct health care services for CSHCN.

In the CNMI, the MCH Title V Block Grant award is administered under the Commonwealth Healthcare Corporation, with the Chief Executive Officer as the Authorizing Official and the Public Health Services Director designated as the Project Director. Federal regulations require that at least 30% of the funding must be used for services and programs for children and another 30%, at a minimum, must be used for services and programs for CYSHCN. No more than 10% may be used for administrative costs. Jurisdictions must provide a $3 match for every $4 in federal funds received. Although there are no minimum spending requirements, funding is also to be spent on preventive and primary care services for pregnant women, mothers, and infants up to age one. The CNMI MCH Block Grant funds support state and local program and staff, and are administered by the Maternal, Infant, Child and Adolescent Health (MICAH) unit of the Commonwealth Healthcare Corporation (CHCC).

Every five years, the CHCC conducts a comprehensive, statewide needs assessment to assess the gaps in needs, strengths, and limitations of services available to MCH populations across six domains. The CNMI uses the “Title V Needs Assessment, Planning Implementation, and Monitoring Framework” to guide the needs assessment and program planning process for each five-year cycle, with emphasis placed on engaging stakeholders and community partners. For the 2020 Needs Assessment, the MCH Program contracted with a consultant to conduct needs assessment activities, assist with building the state action plan, and assist with data collection and analysis. The MCH program worked with partners and stakeholders to identify the state’s final priority needs, which included primary and secondary data collection, health themes, and stakeholder input on prioritization of the most significant health needs for the CNMI’s families. An analysis of strengths, weaknesses, opportunities, and threats (SWOT analysis) was conducted. The final selection of priorities was based on programmatic capacity, evidence-base, cost, and ability to make a measurable impact.

Based on the results of the 2020 needs assessment, the CNMI selected eight MCH Priorities across the respective population domains. The information below details the selected priorities for CNMI and the corresponding population domain and performance measure.

CNMI MCH leadership developed a state action plan with specific objectives and strategies to address the eight MCH priorities. The following sections present these objectives and an abbreviated description of notable strategies by each domain area.

WOMEN’S/MATERNAL HEALTH Access to health services was chosen as the priority for the women/maternal domain. It was the primary priority identified by the public input survey conducted in 2020, shows room for improvement based on the 2016 CNMI NCD data of only 43.2% of women reporting completing pap testing within the past 2 years, and was ranked high for feasibility and impact as well as program capacity to affect change. Additionally, an MCH survey conducted in 2021 indicated that just 57% of women ages 18-44 years reported completing an annual preventive visit. Public input data suggested that screening for behavioral health, substance use disorders, trauma, depression and interpersonal violence issues would be integrated into the women/maternal health visits to respond to this identified need. This priority aligns with National Performance Measure (NPM) #1- Well-woman visit.

Priority Need 1: Ability to find and see a doctor when needed (access to health services)

National Performance Measure 1: Percentage of women ages 18-44 years with a past year preventive visit.

Objectives: By 2025, increase the percentage of women who access preventive visits to 65%, an increase from the baseline of 55%.

Strategy: Expand access: Outreach and/ or increased clinic hours.

For FY2024, the CHCC PHS will conduct the following activities to improve women’s health:

• Utilization the CHCC mobile clinic to provide access primary care and preventive screenings for women.
• Conduct community awareness activities to promote primary care and preventive screenings for women.

INFANT HEALTH Through a stakeholder input survey of infant health priorities conducted in 2020, education and support for breastfeeding and prenatal care were identified as priorities for the CNMI. Early identification of developmental delays and the need for intervention services (ranked first), reducing infant mortality (ranked third), services and treatment for babies born exposed to certain substances such as alcohol or drugs (ranked fourth), and education and services to help prevent and care for premature babies (ranked seventh). These issues were combined into the following priorities for which MCH has program capacity to affect change. This combined priority ranked high for feasibility and impact. In 2021, first trimester prenatal care was at 67% and in 2022 slightly decreased to 62%. Infant mortality was at 12.7 per 1,000 live births in 2022. Because CNMI does not have a level III neonatal intensive care unit, this priority will be a State Performance Measure (SPM) evaluated by early prenatal care.

Priority Need 2: Breastfeeding

National Performance Measure 4 – A) Percent of infants who are ever breastfed and

B) Percent of infants breastfed exclusively through 6 months

Objective: By 2025, increase of the percentage of infants breastfed through 6 months to 54%, an increase from the baseline of 44%.

Strategy: Implement workplace breastfeeding policies/support

For FY2024, the CHCC PHS will conduct the following activities to improve breastfeeding rates:

• Expand workplace breastfeeding support
• Conduct community awareness regarding the importance of breastfeeding for infant health
• Support breastfeeding supplies for families accessing hospital and clinic services

Priority Need 3: Prevention of adverse birth outcomes through Prenatal Care.

State Performance Measure 1: Percent of live births to resident women with first trimester prenatal care.

Objective: By 2025, increase the number of pregnant women with first trimester prenatal care to 75%, an increase from the baseline percentage of 55%.

Strategy: Provide service navigation for pregnant women.
For FY2024, the CHCC PHS will conduct the following activities to improve prenatal care rates:

• Provide service coordination support for prenatal patients (support to address access challenges, i.e. uninsured assistance, transportation vouchers, etc.)
• Expand partnerships with the WIC and Family Planning clinics to increase early prenatal care rates

CHILD HEALTH The top three public input priorities from the 2020 stakeholder survey, information and support to help children reach and stay at a healthy weight [obesity]; information and support about healthy eating options and how to make sure a family has enough food [nutrition/food security]; and safe schools and neighborhood programs, were combined into the priority identified below. The overall economics of the CNMI population makes food security and nutrition for children an explicit issue.

In addition, 31.5% of public input survey respondents in 2020 did not believe children of the CNMI have access to healthy physical activities.

Although nutrition/ food security and obesity was ranked high for feasibility and impact as well as program capacity to affect change, safe schools and neighborhood programs was not.

Though the CHCC has limited capacity to affect change to physical and structural barriers, it was determined that promotion of the safe physical activity options that do exist was a valid priority for this population. This priority aligns with NPM #8- Physical activity.

Priority Need 4: Obesity related issues including nutrition and physical activity

National Performance Measure 8- Percent of children ages 6 through 11 years who are physically active at least 60 minutes per day.

Objective: By 2025, increase the percentage of children ages 6 through 11 years who report being active at least 60 minutes a day to 63%, an increase from the baseline percentage of 53%.

Strategies: Enhance partnerships with CNMI youth serving agencies or organizations to provide more opportunities for physical activity among children 6 through 11 years.

For FY2024, the CHCC PHS will conduct the following activities to improve rates of physical activity among children 6 through 11 years:

• Increase the number of parents/caregivers enrolling in evidence based nutrition and physical activity curriculum/programs to build capacity among families to address nutrition and physical activity needs.
• Conduct community awareness and health promotion activities to promote physical activity for children ages 6 through 11 years.

ADOLESCENT HEALTH It was determined that screening for behavioral health, substance use disorders, trauma, depression and interpersonal violence issues would be integrated into the adolescent health visits to response to this identified need. Both the original and the adolescent specific surveys showed that coping skills, suicide prevention and mental and behavioral health in general are of utmost importance. In addition, 2021CNMI YRBS data shows that 29% of CNMI high school student reported seriously considering attempting suicide, a slight increase from 28.5% reported in 2019.

Suicide prevention was also ranked high for feasibility and impact as well as program capacity to affect change. This priority aligns with NPM #10- Adolescent well-visit. MCH intends to promote well visits for adolescents at which a holistic approach including promoting coping skills and preventing suicide as part of a behavioral health screening and assessment to be conducted at the well-visit.

In addition, Priority Need 7, Support individuals, families and communities to make changes that will make it more likely for youth to be healthy and successful was determined to be an area of focus for adolescents with and without special healthcare needs that needed to be addressed.

Priority Need 5: Coping Skills and Suicide Prevention

National Performance Measure 10: Percent of adolescents, ages 12 through 17 years, with a preventive medical visit in the past year.

Objective: By 2025, increase the percentage of adolescents who access well visits to 55%, an increase from the baseline of 42%.

Strategy: Work with partners to increase the number of adolescents accessing adolescent health visits.

For FY2024, the CHCC PHS will conduct the following activities to support coping skills and suicide prevention for adolescents:

• Work with pediatric providers to implement evidence based behavioral health screenings during teen wellness visits

Priority Need 7: Support for individuals, families, and communities to make changes that will make it more likely for youth to be healthy and successful.

National Performance Measure 12: Transition- Percent of adolescents with and

without special healthcare needs, ages 12 through 17 years, who received services necessary to make transitions into adult health care.

Objective: By 2025, increase the percentage of adolescents ages 12 through 17 years with and without special healthcare needs who receive transition services to 64% and 61%, respectively, an increase from baseline percentages of 51% and 48%, respectively.

Strategy: Provide education, presentations, and support to high school students and/or their parents in making transition into adult healthcare.

For FY2024, the CHCC PHS will conduct the following activities to improve the percentage of teens accessing transition services:

• Work with youth serving partners to provide education and information to parents/caregivers and teens they serve regarding transition into adult healthcare

CHILDREN WITH SPECIAL HEALTHCARE NEEDS (CSHCN) Coordinated care and assisting parents and caregivers navigate the health care system was chosen as the priority for the children with special health care needs domain.  It was the primary priority identified by the public input survey, shows room for improvement based on the data from the CNMI MCH survey identifying only 14.1% of children with special health care needs reported having a medical home, the vast array of programs and agencies that contribute to services in this domain, and was ranked high for feasibility and impact as well as program capacity to affect change. This priority aligns with NPM #11- Medical home.

Priority Need 6: Helping parents/caregivers navigate the healthcare system

National Performance Measure 11: Percent of CSHCN ages 0 through 17 years who have a medical home.

Objective: By 2025, increase the percentage of CSHCN who report having a medical home to 25%, an increase from a baseline percentage of 14%.

Strategy: Conduct outreach and provide peer support to families of children and youth with special healthcare needs.

For FY2024, the CHCC PHS will conduct the following activities to improve the percentage of CSHCN that report having a medical home:

• Strengthen partnerships with the CNMI Disability Network Partners (DNP) to establish referral mechanisms to connect CSHCN to medical homes

SYSTEMS BUILDING Building workforce capacity to improve the maternal and child health services in the CNMI was chosen as priority need 8. Participants voiced a need for trained, qualified professionals who could deliver services across domains. This incorporates the survey findings related to priority, family engagement and parent education.  The second priority topic chosen by respondents was better and clearer communication about healthy behaviors, health services and supports available in the community. Community outreach was chosen as the preferred method for family engagement with 72.7% of respondents choosing that method. Home visiting was chosen as the preferred method of receiving parent education with 57.6% of respondents choosing that method. 

Priority Need 8: Professionals have the knowledge and information to address the needs of maternal and child health populations

State Performance Measure 2- Percentage of CHCC Public Health Services (PHS) staff who complete training on MCH priorities and related topics.

Objectives: By 2025, at least 50% of CHCC PHS staff will have completed training related to at least 75% of the CNMI MCH Title V population health domains.

Strategy: Provide training to CHCC staff and other MCH serving professionals.

For FY2024, the CHCC PHS will conduct the following activities to increase the number of PHS staff that complete training on MCH topics:

• Implement a learning management system to provide training and capture completion rates