At the beginning of a new Title V five-year grant cycle, states are required to conduct a comprehensive needs assessment to identify priority needs of the maternal and child health population and to determine the capacity of the public health system to meet those needs. During the years between the comprehensive needs assessment, states are expected to conduct on-going needs assessments in order to identify and significant changes in the needs and capacity.

The needs assessment update for this year focused on continued collection, analysis and reporting on topics central to the Guam MCH population. Guam’s MCH Program reviewed both quantitative and qualitative data to identify areas of significant change, including data related to the ten National Performance Measures selected in 2015. The Guam MCH program uses a wide array for assessment, policy planning, policy development, program implementation, monitoring, and evaluation. Data sources included but are not limited to are the Guam Vital Statistics, Guam Behavioral Risk Factor Surveillance, and the Guam Youth Risk Factor Behavioral Surveillance.

Population based surveys, such as Guam Behavioral Risk Factor Surveillance and the Guam Youth Risk Factor Surveillance provide valuable data for public health surveillance and evaluation. Disparities among sub-populations (race/ethnicity, insurance status, age) in the MCH population were highlighted and discussed.

Guam MCH recognizes that social inequalities and behavioral factors influence the distribution of emerging diseases, both communicable and non-communicable, their course and the population that are most affected. Access to safe water and health nutrition, housing, education, employment, economic status, gender dynamics, unsafe sex, tobacco use, harmful alcohol use, drug abuse, and sociocultural factors that influence health-seeking behaviors all have an impact on health outcomes. The dramatic increases in volume and speed of international travel and commerce also contribute to changing epidemiology of today’s public health challenges. These factors need to be taken into consideration when designing health systems improvements to address public health and MCH issues.

The Planning for the 2020 Title V Needs Assessment began in January 2019. MCH Program Director, along with the MCH and MIECHV Program Coordinators, lead this process. Since the New Year, the following has occurred:

1. We convened a Needs Assessment team who will implement the assessment.
2. Identified a leadership structure for the assessment.
3. Developed a work plan and timeline.
4. Used the Block Grant guidance to develop an overall approach to the assessment.
5. Adopted guiding principles for the assessment. Adopted the MCH Framework to guide data collection.
6. Collected new and existing data sets and reports related to the MCH population that we could leverage for assessment purposes.

Changes in MCH Health Status

Women/Maternal Health

Women comprise 49.4% of Guam’s population with 37.2% identifying as Chamorro, 26.3% Filipino and 6.8% as White.

Preventive Care Utilization – In 2017, the Guam BRFSS revealed that 67.9% of women ages 21-65 has a Pap test within the past 3 years. Among 21-30 years old, that decrease to 64.6%. In 2017, about 70% of women aged 18-44 years had received a preventive health visits in the past year. The percent of infants born to mothers receiving prenatal care beginning in the first trimester has not changed since 2015.

Chronic Disease Burden - Data from the Guam BRFSS also show that current smoking among women on Guam is estimated to be 15.2% among Guam women in 2018. Overall, obesity among Guam women was estimated to be 30.7% in 2018 while overweight was estimated to be 28.6%, for a total of 59.3% overweight or obese. Women of childbearing age on Guam have some of the highest rates of both obesity and overweight. Related to overweight and obesity, Guam’s women have high rates of diabetes at 12.4% overall among women in 2018. Diabetes during pregnancy (gestational diabetes) was estimated to be 3.7% among Guam women in 2018, but highest among women aged 25-34 at 11.3%.

Substance Abuse - The estimated proportion of current smokers, as well as the proportions overweight or obese in Guam’s female population in the 2018 BRFSS both follow an income and educational gradient. Higher proportions of women in lower income households are more likely to report current smoking than higher income households.

Perinatal/Infant Health

Infant Mortality - Guam continues to have a high infant mortality (9.2 per 1,000 live births) and low birthweight births. Almost 10% of infants born on Guam were preterm and of those 53.3% were of low birth weight.

There were 115 neonatal deaths. Of the neonatal deaths, the population of Chamorro infant deaths equaled 34.7%, Chuukese infant deaths were 32.1% and Filipino infant deaths were 13.9%. For the 69 post-neonatal deaths, the Chamorro population was 47.8%, Chuukese population was 24.6%, and the Filipino population was 14.4%.

Breastfeeding - According to the 2018 Breastfeeding Report Card, 80.6% of babies born on Guam were “ever breasted or fed breast milk” slightly lower than the national estimate of 83.2%. As in the case nationally, rates for breastfeeding are lowest in minority populations, as well as infants in low-income households. These disparities are mirrored in the data for long-term breastfeeding with an overall percentage of 19.4% of infants who are breastfed exclusively for 6 months, lower than the national average of 24.9%.

Child Health

Injury - In 2018, injury was responsible for 15 child/young adult deaths on Guam. Twenty-seven percent (27.2%) of hospitalizations and 86.4% of the emergency room visits for children/young adults aged 0 to 24 years were due to injuries. As in the case nationally, the types of injuries vary by age group and have been broken into groups of injuries to those less than one year, one to nine years old, ten to nineteen years, and twenty to twenty-four years of age.

Immunization - Guam falls well under the US percentage of children aged 19 through 35 months who have completed the combined 7-vaccine series. The 7-vaccine series consists of 4 or more doses of DTaP, 3 or more doses Polio, 1 or more doses of MMR, the Hib full series, 3 or more doses of HepB, 1 or more doses of Varicella, and 4 or more doses PCV.

Adolescent Health

Well Child Screening - From 2015 to 2018, the percent of ten to fourteen year old individuals having an actual screening decreased by 2.4%, whereas in the fifteen to eighteen year old and nineteen to twenty year old groups having an actual screening increased by 13% and 50% respectively.

HPV Vaccination - More than half of Guam adolescents have received at least one dose of HPV vaccine; however less than half have received three doses (or two doses if the first HPV vaccine dose was given after age 15).

Strengths and Challenges that Impact the MCH Population

Many strengths and opportunities are being leveraged to support Guam’s MCH infrastructure and delivery system. Strengths include collaboration and coordination; a commitment to eliminating preventable infant, maternal and child deaths; recognition and expansion of the significant impact of early life experiences on health and wellness across the life course; and strong leadership and expertise within the public health system.

Guam’s Maternal, Infant and Early Childhood Home Visiting Program Project Bisita highlights Guam’s commitment to prevention, early childhood and collaboration between public health, early childhood programs and other sectors that impact health outcomes. By leveraging federal opportunities, Guam is creating a system of home visiting services that can meet the diverse and complex needs of families with young children, particularly in communities facing elevated risk of adverse outcomes. In 2018, Project Bisita serves 68 families improving maternal and child health, development, and family safety, as well as creating pathways for families to access the resources they need.

Despite these strengths and the island’s health care infrastructure, significant challenges still exist. Both nationally and on Guam, health care costs are driven by competing factors such as payment systems, chronic disease incidence, emergency room “super utilizers,” population demographics, and prevalence of adverse health behaviors. Guam has been designated a Health Professional Area and a Medically Underserved Area. Access to all forms of health care is a problem for many of Guam’s residents. It is estimated that roughly 25% of Guam’s population is without any form of health insurance. The island is lacking Primary Care, Dental Health, and Mental Health Professionals. The world ratio of physicians to population is about 14: 10,000, and in the United States, it is about 24:10,000. Guam’s population of about 180,000 to 200,000 should have about 480 physicians to service the population base. As reported in the 2016 Guam Statistical Yearbook from GMH and the Department of Health and Social Services, Guam had 165 physicians including licensed military physicians working part-time at Guam Memorial Hospital.

Particularly in the outlying areas of Guam, transportation is a challenge. This includes not only the method of transportation, but also the time and distance that need to be covered to reach services. A study which examined reasons for the lack of prenatal care among women of reproductive age on Guam showed that lack of medical insurance (24.3%) and lack of transportation (22.6%) were the main reasons given by respondents for not receiving prenatal care during their pregnancies (Haddock, Bell, Naval and Garrido, 2008).

Another factor is the complexity of embracing an upstream approach to health and wellness to impact systemic conditions that contribute to poor health outcomes. The knowledge that health begins during preconception – and optimal health and development must occur during the earliest stages of life to improve adult health – is still growing in the broader population.

Addressing social determinants of health holds the same challenge. Participants increasingly understand access to education, adequate and sustainable income, transportation, and social and cultural supports are critical to achieving and maintain health. However, knowing how to impact these factors in communities – and having the resources to do so – is not easy.

Finally, economic disadvantages is dispersed inequitably among racial and ethnic groups on our island, particularly for the children of parents from the Federated States of Micronesia, who are roughly five times more likely to live in poverty than an Chamorro child. Poverty is linked with conditions such as substandard housing, unsafe neighborhoods, homelessness, inadequate nutrition and food insecurity, inadequate childcare, lack of access to health care and unsafe neighborhoods. Poorer children and teens are also at greater risk for poor academic achievement, school dropout, behavioral and social-emotional problems and physical health problem. These effects are compounded by the barriers children and their families encounter when trying to access health care.

Current and Emerging Issues

Maternal Mortality

There were 25 maternal deaths on Guam from 1968 to 2018, and based on Guam’s small population, this results in very high maternal mortality ratios (MMR) (Table 3) during the years when there are maternal deaths. The MMR during the past fifty years ranged from a low of 22.6 in 1996 to a high of 91.2 in 2017. Compiling 10-year averages for MMR reduces the MMR; however, the MMR 10-year average from the most recent ten-year period, 2008-2017 at 27.0 is still higher than the U.S. MMR of 20.7 (CDC Wonder, 2011-2015). Although the MMR fluctuates since there are many years with no maternal deaths on Guam, the MMRs are still very high for Guam compared to the U.S., and the number of maternal deaths and the MMR has been increasing in the past 10 years, following the national trend (Mayer, Dingwall, Simon-Thomas et al, 2019).

Teen Births

Guam’s teen birth rates are high compared to the US teen birth rates (18.8/1,000 )[1]. Guam’s teen birth rate was 39.5 per 1,000 females aged fifteen to nineteen years in 2017; in 2018 the rate of teen birth was 33.9 per 1,000, a decrease of 15.2%. However, in 2017 Guam’s teen birth rate was 71% higher than the US’s teen birth rate.

Adolescent Mental Health, Depression and Suicide

For years 2013-2018, there were 68 suicide deaths among Guam children aged 10 through 24 years. Males comprise the majority (75%) of suicide deaths. Although more females attempt suicide than males, males are approximately four times more likely to die from suicide.[2]

Results from the Guam 2017 Youth Risk Behavior Survey show that more Guam high school students who self-identify as lesbian, gay, or bisexual (LGB) report having been bullied on school property (31%) and cyberbullied (19.8%) in the past year, than their heterosexual peers (16.3% and 13.3%, respectively). The survey also showed that more LGB students (18.5%) than heterosexual students (8.8%) reported not going to school because of safety concerns. Among students who identified as “not sure” of their sexual orientation, they also reported being bullied on school property (25.4%), being cyberbullied (26%), and not going to school because of safety concerns (24.7%).

Sexually Transmitted Diseases

Guam has very high rates of chlamydia, along with increasing numbers of gonorrhea and syphilis cases. Primary and secondary syphilis rates among women increased 473%, from 1.1 to 6.3 per 100,000 during 2009–2013. In 2013, the first congenital syphilis case (after no cases since 2008) was reported (Cha S, Malik T, Abara WE, et al). Little is known about STD screening coverage and factors associated with inadequate screening among pregnant women in Guam. The incidence rate of new chlamydia cases overall was 675.5 per 100,000, which was higher than the U.S. rate of 524.6 per 100,000, in 2017 (CDC, 2017). Gonorrhea rates were slightly lower in Guam compared to the U.S. (170.6 per 100,000 versus 122.0 per 100,000 on Guam); however, gonorrhea cases continue to rise from 99 cases in 2014 to 225 in 2018, a 127 percent increase. Guam’s military population is a major contributor to the high rates of sexually transmitted infections.

[1] CDC 2017

[2] SAMSHA, NSDUH Report, 2011