The comprehensive FSM-wide needs assessment (NA) is an ongoing collaborative process, that is critical to program planning and development and enables FSM to target services and monitor the effectiveness of interventions that support improvements in the health, safety and well-being of the MCH population. It serves as a vital planning process for determining where best to focus efforts to implement programs, policies and systems building efforts that will measurably demonstrate impact within five years. The NA requires ongoing sources of information about MCH status, risk factors, access, capacity and outcomes. FSM chose a conceptual framework for the NA 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. FSM developed this view collaboratively by discussing the overall framework with the MCH NA Steering Committee (SC) and by subsequently building consensus for this approach with the MCH staff members.

For purposes of assessment and strategic planning, the MCH population was defined as per the standard domains. The overall goal of the process focused on identifying a set of definite priorities that could be acted upon at some depth so that results, even preliminary ones, would be achievable and evident in five years. Strategies employed to achieve results were to be evidence‐based interventions grounded in sound public health theory or research and consistent with the mission and scope of FSM’s MCH program. A clear MCH public health role needed to exist for an issue to be considered as a potential priority. The process focused on meaningfully involving multiple national, state and community stakeholders/partners to enhance collaboration, while looking for opportunities to coordinate and integrate MCH efforts externally and internally across the MCH continuum.

With leadership from the MCH Coordinator, the MCH NA SC established the overall strategic direction and methodology for the NA while providing the ongoing project management and oversight for the process. From September to December 2019, National members of the SC and the NA consultant traveled to each State to conduct individual State NAs. The State meetings were well attended with staff and diverse community members participating. The SC and select State representatives were to meet in Pohnpei at the end of March 2020 to finalize the priority needs. Unfortunately, COVID-19 prevented an in-person meeting and this was conducted virtually and through email. This two part process allowed for individual State input from staff, partners, families, consumers and other key stakeholders into the overall FSM-wide NA.

The SC received support and advice from the State MCH staff. The MCH staff initially provided critical feedback regarding the overall process methodology and later participated in focus groups and/or completed the priority health issues survey. The MCH staff reviewed the priorities prior to submission and will be reconvened after grant funding in order to identify future initiatives.

Stakeholders included representation from national and state MCH programs, family/youth serving agencies, faith-based agencies, and other key MCH community partners such as health care providers and community‐based agency staff, along with representatives from other state agencies and academic institutions. Criteria used for selecting stakeholders included their area of expertise and workplace setting, training and experience, knowledge of public health, and their ability to conceptualize at the strategic level, while not solely advocating for a single issue. Members solicited feedback from their own constituencies/ stakeholders in between meetings which greatly expanded the reach of this effort.

FSM assessed the needs of the MCH population using Title V indicators, performance measures and other data. The SC reviewed major morbidity, mortality, health problems, gaps and disparities for the MCH population in order to identify specific needs by MCH population domain based on analysis of data trends. The cross-cutting and systems building needs were also examined. Specifically, the SC reviewed 2015 NA and interim NA findings and noted trends since the last assessment, recent state, regional and national reports to determine possible issues/problems to be explored in the FSM, and recommendations made by various task forces; identified major data/indicators including trends of health status, access, health needs and health disparities to be included in the assessment for each domain; and determined stakeholder and public input processes. Methods used for assessing needs for each of the population domains included a review of various the data sources including Vital Statistics Data, Census Data, FSM Behavioral Risk Factor Surveillance System (BRFSS) Report, Surveillance Systems and Registries, Mortality Reviews, and other FSM agency data and reports.

Findings were also used to populate the MCH Priority Health Issues Survey. MCH received 139 completed surveys covering the six domains. Survey participants chose their top three issues for each domain, while also identifying any important issues not reflected in the original list. Of the new issues identified, most had been considered by the SC in earlier phases of the NA process.

Prioritization criteria of potential issues included considering them in terms of the MCH/public health role, the existence of strategies for intervention, and the ability to demonstrate outcomes/results within five years using specific indicators to measure progress. A Strengths, Weaknesses, Opportunities and Threats analysis was conducted on each identified priority. To gauge capacity, public health management and staff were asked to assess their organizational capacity to address the potential MCH priority areas. The following four components were utilized to assess capacity for each of the proposed MCH priorities. 1) Structural Resources: Financial, human, and material resources; policies and protocols; and other resources needed for the performance of core functions. 2) Data/Information Systems: Access to timely program and population data; supportive environment for data sharing; adequate technological resources to support the use of data in decision‐making. 3) Competencies/Skills: Knowledge, skills, and abilities of MCH staff. 4) Organizational Relationships: Partnerships, communication channels, and other types of interactions and collaborations with public and private entities. Next, each issue was ranked, using a grid specifying impact and feasibility along an x and y axis. These elements served as key resources for discussion in determining the final set of priorities.

In keeping with the guiding principles of the process, the SC focused on the goal of identifying select areas for MCH investment within its scope of influence, so that a comprehensive set of interventions could be employed at more depth to affect five‐year outcomes. In order to do so, the SC was charged with connecting each potential priority to a national or population‐based outcome measure. To this end, the SC prepared a justification for each priority highlighting the following: public health/MCH role; data to support the need (severity or numbers affected); effective interventions/strategies that exist to address the issue; local capacity score for the issue; and specific indicators that could be used to measure success within the five‐year period.

Realizing the dynamic nature of MCH as well as the depth and breadth of issues specific to these populations, FSM will continue to systematically assess needs during the upcoming five‐year time frame.

One hundred and thirty nine (139) surveys were received. Responses were received from respondents who reside in all four islands of the FSM. The majority, 71%, of respondents were female. Respondents accurately reflected all ages and educational levels in the FSM. Furthermore, 30.9% or 43 Parents/Guardians completed the survey the highest of any identified role. Other roles were Community Service Provider, Health Care Professional, Public Health Employee, Educator, Child Care Provider/Caregiver, Policy Maker/Elected Official and Other Community Member.

Figure 1. Survey Demographics for Age and Highest Level of Education

Women/Maternal Health:

All clinical sites within FSM Public Health perform women’s preventive health exams. However, in 2018 only 15.6% of MCH women had a Pap smear at these clinical sites. It is important to note that in Pohnpei and Yap visual inspection with acetic acid (VIA) is used as an alternative to Pap testing which is not reflected in the data below. According to the 2018 FSM BRFSS three out of ten female respondents (30.6%) reported that they ever had a pap test or VIA. Even so, the FSM has a very large underserved population who are not receiving recommended annual preventive health services. Many women are not receiving adequate preventive health care. As in many underserved communities with a high percentage of families living below the federal poverty level, these women face many barriers to care, including: unaware of health needs; shame or fear in seeking reproductive health services; access to care issues; uninsured status; transportation issues; and childcare issues. The 2018 FSM BRFSS found that 5.9% of women surveyed reported that in general their health is poor.

Table 1 Percent of women receiving services in the MCH Programs who receive a Pap smear

 Source: MCH Program Data

Table 2 Percent of women receiving a preventive medical visit

 Source: MCH Program Data

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 the number of clients that follow the recommended standard of care in preventive health services through increased education and outreach efforts and collaboration with community-based programs. 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. The MCH Program works closely with the Family Planning Program, Tobacco Control Program, STD/HIV Prevention Program, 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.

An assessment of prenatal care conducted at the hospitals in the FSM showed that almost 70% of deliveries receive inadequate prenatal care often due to late entry into care. 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. Prenatal care is only offered on certain clinic days and not by appointment. This means there is limited availability of services that women may have difficulty fitting into their schedules. It also means long wait times in crowded waiting rooms. Besides wait time, the process of being seen is still long as there are many steps to the visit. In some locations, the woman must check in at one location, see the provider at another, then go to a third location for lab draws and a fourth location for the dental check. Streamlining the process may increase prenatal care attendance.

Table 3 Percent of pregnant women who receive prenatal care beginning in the first trimester

 Source: MCH Program Data

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. During prenatal care, only Kosrae does routine glucose tolerance testing to screen for gestational diabetes. Pohnpei, Yap and Chuuk do screening based on risk assessment of known history of diabetes or gestational diabetes. In speaking with pediatric providers in the FSM, all report treating many infants with difficulty controlling their blood sugar within the first 48 hours after birth, a telltale sign of missed or poorly control gestational diabetes.

In 2010, the FSM MCH Program noticed an increase in women being diagnosed with anemia during pregnancy. In an effort to increase a woman’s health status prior to pregnancy the program instituted screening of all women for anemia not just pregnant women. In 2018, 21.6% of women of childbearing age screened had anemia. Anemia screening and treatment is still a necessary measure of all women in the FSM.

Perinatal/Infant Health:

The perinatal mortality rate in the FSM in 2018 was 18.2 per 1,000 live births but even that is low comparing the past four years. According to the National Vital Statistics Reports, the most recent national perinatal mortality rate available was 6.00 per 1,000 live births in 2016. When this data is coupled with the 2018 low birth weight percentage of 7.8% of live singleton births a scenario begins to form in which unplanned pregnancy, late access and inadequate prenatal care, and poverty play a significant role in poor birth outcomes, causing additional stressors on the family, community, the health care system and the government. As discussed above, lack of screening for gestational diabetes during prenatal care effects newborn outcomes. The MCH Program is committed to improving prenatal care access and adequacy as stated above through the MCH clinics and dispensaries in remote villages.

Table 4 Perinatal mortality rate per 1,000 live births plus fetal deaths

 Source: Vital Statistics

In 2018, 76.4% of mothers in FSM report exclusively breastfeeding their child at six months of age. Although this is a high percentage, of those that supplement, the supplements are not a healthy alternative but often coconut milk. Education needs to be provided to mothers on breastfeeding and infant nutrition. Currently childcare education is lacking in the FSM. New mothers rely on families to inform them about child care and rearing and this is not always the healthiest or safest information. Anemia is prevalent in the infant population of FSM as well as the childbearing woman population as discussed above. In 2018, 14.4% of infants up to 1 year old screened were anemic. The MCH Program continues to screen infants for anemia due to the high prevalence among the population.

Child Health:

Immunizations are a pillar of child health care. The overall coverage rates of immunization in FSM has improved significantly. Once of the main barriers to immunizations in the FSM is the need for refrigeration of the vaccines, thereby making it difficult to provide to children of the outer and remote islands. This is apparent in the Kosrae specific data. Kosrae is a single island State. In this State without outer and remote islands coverage is consistently greater than 90%. In Pohnpei and Yap, outreach and services to the outer islands is only done once or twice a year and the schedule is often dependent on having fuel for the boat. FSM MCH Program plans to hold gains and improve immunizations through education and outreach.

Table 5 Percent of children through age 2 who have completed routine immunizations

 Source: FSM Immunization Program

FSM children experience a high rate of being overweight 20.5% as compared to the US, 15.6% both in 2017. 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.

Table 6 Percent of children overweight/obese, 2017

 Source: FSM Youth NCD Risk Factors Report

Currently developmental screenings are only completed on the MCH population but not the population at large. In 2018, only 8.2% of all children age 0-9 years old were screened for developmental delays. There are no efforts to screen all children through either a provider or parent tool. Current screening tools are developed up until age 18 months. No standardized tool exists beyond that age group. 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.

Adolescent Health:

The FSM teen birth rate among 15-17 year olds for 2018 was 64.6 births per 1,000 females, which is nine times greater the national average of 7.2 as reported by the CDC National Center for Health Statistics. This population has not followed the US trend towards delaying childbearing. Some progress has been made in delaying age of consent. Just five years ago, Chuuk increased the legal age of consent from 13 to 18 years old. In 2018, Yap increased the legal age of consent from 13 to 16 years old. And just last year, Pohnpei passed its first age of consent law at 18 years old.

Table 7 Rate of birth (per 1,000) for teenagers aged 15-17 years                              

Source: FSM Birth Certificate and Census Data

Teen births increase health risks to both mother and child including low birth weight, preterm birth, and death in infancy. In addition to health risks teen births set up a cycle of disadvantages. Teen mothers are less likely to finish high school and their children are more likely to have low school achievement, drop out of high school, and give birth themselves as teens. For these reason MCH Program works closely with the FSM Dept of Education to prevent teen pregnancy. Clinic locations are at High Schools and the college. Condoms are available at many community locations. The rate of sexually transmitted diseases (STDs) in the FSM is improving.

Table 8 Rate per 1,000 women aged 15 through 19 years with a reported case of chlamydia                                         

Source: STD Program

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, including, but not limited to: unplanned pregnancy and teen birth; sexually transmitted diseases in the adolescent and young adult population; alcohol use; and drug use. The MCH Program currently works and will continue to work with youth groups in each State to reach the adolescent population.

Risky adolescent behavior such as drug and alcohol use lead to injury such as motor vehicle crashes. Adolescent motor vehicle mortality rate, ages 15 through 19 was 17.3 per 100,000 in 2018. Although not much data exists on current drug and alcohol use, it is believed throughout the community that the use does exist and influences poor outcomes. In 2017, the FSM Youth NCD Risk Factors survey measured alcohol use prevalence. 30.7% of high school students in the FSM reported using alcohol in the past 30 days. Results were highest among males, in the 11th and 12th grade and in Yap State. There is lack of law enforcement surrounding alcohol sales and many businesses in the FSM sell alcohol cheap and to youth. Additionally, in the FSM there is a cultural norm to drink sakau, a sedative agent derived from the roots of a shrub, pounded and mixed with water. This is done both ceremoniously in traditional customs and socially. There is no age limit on drinking sakau and is drank increasingly by the youth.

Table 9 Rate per 100,000 of all non-fatal injuries due to motor vehicle crashes among youth aged 15 through 24 years

 Source: Hospital Discharge Records

Teen suicide is an issue in FSM with a rate as high as 33.6/100,000 adolescents being reported in 2016. More awareness and education around suicide, its causes and prevention is necessary in the FSM.

Table 10 Rate per 100,000 of suicide deaths among youths aged 15 through 19 years

 Source: Vital Statistics

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:

The Program tracks percent of children identified with a special health care need that are part of the CSHCN Program. In 2018, only 8.2% of children were screened for developmental delays. However, of those identified, 91% of children with developmental delays were receiving services according to 2018 data.

Table 11 Percent of CSHCN

 Source: CSHCN Program

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. Transitional services for CSHCN are tracked through the CSHCN Survey using a proxy measure of employment.

Table 12 Percent of youth with special health care needs who are employed as a proxy for receiving the services necessary to make transition to all aspects of adult life, including health care, work and independence.

 Source: Special Education

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 and transitional services.

Cross-cutting/Systems Building:

Behavioral/mental health is recognized as a need across populations. In the 2018 FSM BRFSS one out of ten individual respondents (10.6%) mentioned that they had 14 or more mentally unhealthy days during the previous 30 days. Additionally, the percentage of respondents who have diagnosed depressive disorder was 7.3%. Furthermore, 94% of NA survey respondents reported mental and behavioral health as a concern. Of those three-fourths believe it is a concern for adolescents, half believe it is a concern for women and CSHCN, and about one-third believe it is a concern for children. Unfortunately, behavioral/mental health treatment services are lacking in the FSM.

Figure 2. Survey Responses to “What populations need mental and behavioral health services most in your community? (Select all that apply)”

An identified area of need is for screening and treatment for behavioral health, substance use disorders, trauma, depression and interpersonal violence issues to be incorporated into mental health related activities across all domains. Special emphasis would be placed on behavioral health screening during the well-woman visit, during prenatal care visits and during the adolescent well visit.

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.

A systems building finding is the need for stronger National oversight. Although there is some advantage to the National Program level allowing the State Programs to implement MCH according to their specific needs, this results in a disjointed program. The MCH Program needs to develop guidance through policies and procedures for basic MCH initiatives. In addition, it would be wise for MCH National to develop common educational messages for their communities to be shared by the State Programs. These initiatives can help produce the unity, organization and consistency that is currently lacking while still allowing for some individualization on certain provisions of the program.

An additional systems building need is for improved data collection. The reliability and validity of the data collected by the States and reported to the National MCH Program is questionable. This can be seen in much of the data presented above. The data reported from year to year is quite variable without any justification for the severe fluctuations. FSM has engaged a developer for the establishment of an MCH web-based data collection and reporting system to be launched in 2022. The system should improve data collection, reporting, and sharing at State level and between the States and the National level. This should dramatically improve timely data collection and reporting and improve the overall experience of the FSM MCH Program to better understand the current situation as well as monitor change over time and evaluate activities meant to improve MCH population health.

There are two levels of government in the FSM, National and State. The FSM is self-governing with locally elected President, Vice President and Congress at the National level. Each State also elects a Governor, Lieutenant Governor, and Legislature. For the purposes of receiving US Federal Domestic Assistance, the National Government is designated as the "State Agency". However, all funds approved by the US Federal Government to support MCH Title V and allocated to the FSM Government are further allotted to each State MCH Program by way of Allotment Advices issued by the National Budget Office.

At the National level, the Secretary of the Department of Health and Social Affairs (H&SA) manages health affairs for the nation. There are several divisions under H&SA, including the Division of Health Services which houses the Family Health Services Section. The MCH Program is one of the six programs under the Family Health Services Section. The Program Manager of the Family Health Services Section also acts as the National MCH Program Coordinator.

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 MCH populations, each state has an MCH Coordinator.

Health services in the FSM are designed and delivered at the State level. At the State level, the Dept of Health Services is headed by the Director of Health, who is appointed by the Governor of the State and is responsible for all medical and health services in the state. Each state has a central State Hospital with medical, nursing, and support personnel that provide inpatient and outpatient medical services for the residents of the State.

The FSM MCH Programs provides primary care and preventive services to all MCH population domains. The Dept of Health Services provides all of the preventive and primary health care services at no cost to the clients. Teams of physicians and nurses travel to the remote islands to provide screening services.

The staff of the MCH Programs work closely with the staff from other programs to provide the full array of services. The collaboration with other Public Health programs and community partners makes it possible to provide health services. The work is supplemented by enabling services including outreach, case management, educational materials, and transportation to MCH target populations. Below is a description of capacity by domain.

Women/Maternal Health:

Pregnant women are eligible for free of charge direct health care services include the basic and routine high-risk prenatal care. Unfortunately, due to limited clinic space, women/maternal health care is only available at each State clinic on select days.

Prenatal care is provided at each of the State’s Dept of Health Services clinic by general physicians or OB/GYNs. For States with neighboring, outer or remote islands, services are provided by Health Assistants at the dispensaries, although women are encouraged to come to the clinic for the first prenatal visit. There are OB/GYNs at each State Hospital for referrals of high risk cases such as diabetes and hypertension. Increasing the percentage of women receiving adequate prenatal care visits, especially during first trimester, continues to be a focus for the MCH Program. Postpartum clinic provides assessment of maternal and fetal health after delivery as well as family planning counseling and contraceptives.

The HIV/STD Prevention Program provides pre- and post-testing counseling, partner identification and notification, treatment, and case management. One successful campaign of the MCH Program was to treat all pregnant women for Chlamydia during prenatal care to help reduce the rates of Chlamydia.

Women's Health and Gynecological services are provided at the State clinics. Breast cancer and cervical cancer screening exams such as pap smears and clinical breast exams are provided at no cost to women that meet the program's criteria. In addition, program staff conducts outreach presentations on early detection and prevention including risk factors. Women must travel off island to receive mammograms as no facility in FSM offers them.

Perinatal/Infant Health and Child Health:

Perinatal health is described above. Unfortunately, due to limited clinic space, infant and child health care is only available at each State clinic on select days.

Newborn assessments and breastfeeding support and education for proper technique or identified issues is provided. Well Baby/Child exams are provided at the State clinics free of charge. Services provided include immunization, health education and counseling including nutrition, injury prevention, safety, assessment and monitoring for growth and development and other underlying health problems, and physical examinations. Referrals for dental care, hearing screening, early intervention services, specialty clinics, and home visits are made based on assessment findings.

The Immunization Program ensures availability and accessibility of vaccination services at clinics. Supplemental activities are done to provide immunization out in the villages. One of the difficulties with immunization is the need for refrigeration making transportation and storage of vaccines to and on the outer and remote islands a barrier to receiving proper and timely immunizations.

The Newborn Hearing Screening Program has been successfully screening 90% of our babies before hospital discharge. The MCH Program intends to increase efforts to screen newborns delivered at home at entry into the health care system. The program has been focusing our quality improvement activities to reduce our loss to follow-up numbers. The EHDI surveillance system has been instrumental in identifying babies requiring additional testing.

The Dental Program provides general dentistry services. Oral health for children is focused on prevention through the school sealant and varnish programs.

Adolescent Health:

The adolescent health focus is on the avoidance of risky health behaviors such as drugs, alcohol, and unsafe sex. The MCH Programs works closely with the HIV/STD Program described above. In addition, they collaborate with the Behavioral Health and Wellness (BH&W) Program to promote positive youth behaviors. The BH&W Program leads underage drinking prevention efforts. It also addresses injury and suicide, violence prevention and has strong ties to the federal, state and community agencies and programs that carry out risky behavior reduction activities.

Children with Special Health Care Needs:

CSHCN services are set up to promote an integrated service delivery system for CSHCN from birth to 21 years of age and their families. The CSHCN Program works to ensure that children not only receive specialized health care that they need but that they avail themselves, if qualified, of the different social service programs on island. One priority of the program is to identify these children at the earliest age possible, preferably right after birth. There are care coordinators, special education teachers, and occupational, physical, and speech therapists on staff for all CSHCN. The Program works collaboratively and cooperatively with other agencies and departments to provide appropriate education and support services needed to meet their social, emotional, physical, and medical needs. The CSHCN Program has been developed as an interagency effort among the MCH Program, the State Hospital, the Special Education Program, and the Early Childhood Education Program.

Diagnostics of those children who failed two out of three hearing screenings are conducted through teleaudiology or a contracted audiology visit. Those children who are confirmed as having hearing loss are treated and referred for Early Intervention services with the Special Education Program.

Each year a Pediatric Cardiology team travels from the Orange County Children's Hospital in Los Angeles, CA to provide Pediatric Cardiology Services. This team travels to the four states to follow-up on identified cases and screen for new cases of children with possible heart diseases. Those children who are identified with heart problems and need medical treatment are provided with medicine. For those you need surgery and cannot be done on island are referred to Trippler Army Hospital in Honolulu, HI.  Specialty teams from Canvassback, Trippler Hospital, and Shriner Children Hospital also visit FSM but at a lesser interval, depending on availability of funds by the FSM Dept of Health. These specialized groups provide services in EENT, Orthopedics, and select surgeries. With limited or practically no state-of-the-art medical equipment, compounded with the lack of physicians with specialized skills, FSM is heavily relied on overseas contractors and medical referrals, both of which are very expensive.

In 2020, there are 23 full-time staff in the four FSM States funded by the Title V Program. Out of the total 23 employees, nine are in Chuuk state; three in Kosrae state; four in Pohnpei state; and seven in Yap state. Of the nine MCH staff in Chuuk state, three are staff nurses, two coordinators, two health assistants, one health educator, and one dental assistant. Out of the total three employees in Kosrae state there is one coordinator, one staff nurse, and one dental nurse. Of the total four staff in Pohnpei state, there is one coordinator, one dental nurse, one staff nurse, and one lab technician. Of the total seven staff in Yap state, there are two coordinators, two staff nurses, two dental nurses and one dental technician. In addition, there are four data specialists funded by the SSDI Program that play integral role in the Title V Program, who work in each State’s Vital Statistics and Record Division. These staff constitute the MCH Programs in each of the State Public Health Depts and they directly provide all of the preventive and primary health care services at no cost to clients.

The four MCH Coordinators, at state level, are responsible for assuring that clinical services are provided to pregnant women, infants, children, and CSHCN. All four MCH Coordinators are Registered Nurses. In addition, each of the States provides in its own budget a medical doctor for the MCH Program. Together they are responsible for assuring that clinical services are provided.

At the National level, one MCH Program Coordinator staff is paid by the MCH program. The National Family Planning Program Coordinator, data manager and financial specialist, although paid for by a different program, also assist the National MCH Program Coordinator in the planning, developing, implementing, and monitoring of MCH program services and activities at the national and state levels on a daily basis. These staff constitutes the core staff at the national level and the National MCH Program Coordinator reports directly to the Secretary of H&SA.

The FSM MCH Program invites parents of CSHCNs to workshops and conferences in the FSM where they present their experiences and expectations as consumers of the MCH Program services. They also attend US conferences depending upon availability of funds.

Training and education of the MCH staff are carried out at three levels: Individual on-site consultation provided twice a year for the Coordinators in the four states on developing policy and procedures, program implementation, data collection, data analysis and interpretation, and improving data capacity; The FSM Annual MCH Workshop held each year bringing together the MCH Coordinators, the MCH Data Clerks, the CSHCN Coordinators, hospital and public health administrators, physicians, nurses, and stakeholders from the National Government and State Health Depts where issues are discussed related to improving services and state data capacity and early intervention services for CSHCN; and Special conferences and other educational opportunities provided to staff who attended in-person or on-line courses from the Fiji School of Medicine, PACRIM Conference in Honolulu, Pacific Basin Medical Association Conferences, and American Pacific Nurses Leadership Conference.

The FSM is composed of four different societies with 13 different major languages. English, however, is the official language of the governments and is taught in the schools. The MCH Program takes serious consideration for the need of a workforce that is competent and culturally sensitive in providing services including awareness, education and counseling and materials development.

FSM’s MCH Program historically has a solid working collaboration with the public and private sectors as well as governmental and non-governmental organizations. MCH programs and other HRSA programs, programs within Public Health, governmental agencies, and local public and private organizations were involved throughout the NA and planning process, as were a wide array of stakeholders and family members. 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 MCH Program and Family Planning Programs are well‐integrated. Efforts to address unintended pregnancy, preconception health and preventing risky teen sexual behavior are both family planning and MCH objectives. MCH funds are not used for direct family planning services, but rather to support population‐based activities around unintended pregnancy prevention.

MCH is also well integrated with Immunization Program, the Substance Abuse and Mental Health Program and the HIV/STD Prevention Program. Again, the efforts and objectives are shared between programs and has allowed for expand staff coverage and program implementation.

Relationships with the Non-Communicable Disease Bureau are strong and support work between MCH projects and programs such as Diabetes, Cancer, Tobacco Control and other chronic disease prevention and health promotion. For example, the NCD Bureau has long worked with MCH to promote healthy weight among children.

The FSM Dept of Education, in particular the Early Intervention Service, is an essential partner of the CSHCN Program. Together the agencies offer services for children served by the FSM Dept of Education and the Public Health CSHCN Program.

In the four states, an interagency agreement for the CSHCN Program has been developed that involves the CSHCN Program, MCH Program, the State Hospital, the Dept of Education, Special Education Program, the Early Childhood Education Program, and the Parent Network. This interagency agreement has been established to assure that children are screened for disabilities, and those who are suspected of having a disability are referred to the CSHCN Program for an assessment. The agreement also assures that an interdisciplinary team of members from each of the agencies is available to conduct an assessment, develop the individualized plan, and provide or coordinate the services.

The MCH Program works with the Kosrae, Chuuk, Pohnpei and Wa’ab (on Yap) Community Health Centers to improve accessibility and expand primary care services for low‐income and vulnerable populations. These efforts include information and data sharing; policy development; and assisting communities with applying for health professional shortage area and medically underserved designations.

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.

Each state has established coordinated relationships and linkages among the local Depts of Education - Special Education, Population Education Projects, and Early Childhood Education Program; Depts of Agriculture- Family Food Production and Nutrition Program; Nutrition Council, in the case of Pohnpei; and social services. With the establishment of these inter agency linkages, gaps in communication have narrowed and duplication of efforts has been minimized.

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

The MCH Program staff at the state level work closely with parents support groups, church leaders, women's groups, and community and traditional leaders. However, the current use of the parent/consumer partnership is limited. Outside the CSHCN population, the parent/consumer partnership is non-existent at this time. The MCH program intends to expand its parent/consumer partnership in the coming years to improve public input into the program and its policies and objectives.

The FSM does not have the following programs or services: Title V- Maternal, Infant, and Early Childhood Home Visiting Grants, Title XIX - Medicaid, Title XXI - Child Health Insurance Program, Social Services, Child Welfare Programs, Social Security Administration, WIC Program, or Rehabilitation Services.

Feedback received in response to the needs assessment was helpful in identifying issues impacting MCH populations in the FSM that stakeholders consider a priority. In keeping with the guiding principles of the process, the focus was on the goal of identifying select areas for MCH investment, so that a comprehensive set of interventions could be employed at more depth to affect five‐year outcomes. In addition, the chosen priorities needed to be tied to the MCH scope of influence in order to assure ultimate impact. In order to do so, each potential priority was connected to a national or population‐based outcome measure. To this end, a justification was prepared for each priority highlighting the following: public health/MCH role; data to support the need (severity or numbers affected); effective interventions/strategies that exist to address the issue; local capacity score for the issue and specific indicators that could be used to measure success within the five‐year period. Survey findings were grouped by each of the six domains. Presented below is a summary of the highest priority issues identified by the respondents by FSM State and overall for each domain.

Table 13 Top Priorities by Domain for Each State and FSM Overall

Presented below is a summary of the three highest priority issues identified by the respondents by FSM overall for each domain. Respondents were allowed to choose three answers and therefore response percent and response count will not add up to 100% or total respondents, respectively.

Table 14 Top Three Priorities by Domain

Several themes arose from the findings, including access to direct health services, prevention, access to social and support services and improved communication. Access to direct health services is seen in the well-woman, prenatal care and well-adolescent visits. Prevention is apparent in prevention of obesity through physical activity and nutrition, prevention of infant mortality through adequate prenatal care, and prevention of poor outcomes through behavioral health screening and support. Social and support services are important to support transition to healthy adulthood, physical activity, and navigation of coordinated care systems. Another key finding was stakeholders identified the community as critical in impacting the health status of MCH populations and viewed better and clearer communication about healthy behaviors, health services and community resources as a priority.

The FSM selected the final seven priorities based on the needs assessment finding.

Access to health services- Improve women’s health through cervical cancer and anemia screening

Improve perinatal/infant outcomes through early and adequate prenatal care services including Gestational Diabetes and anemia screening

Improve child health through healthy weight through physical activity and nutrition promotion

Improve adolescent health by providing well medical visits, assessing violence and safety and promoting healthy adolescent behaviors and reducing risk behavior (i.e. drug and alcohol use) and poor outcomes (i.e. teen pregnancy, injury, suicide)

Provide care coordination training for parents/caregivers of Children with Special Health Care Needs

Improve health promotion communication

Improve screening and treatment for behavioral health, substance use disorders, trauma, depression and interpersonal violence issues during well women, well adolescent and prenatal care visits

The comparison to prior priorities identified in 2015 is slightly different given the broader view FSM MCH program took of the priorities to improve overall health through specific actions. Three domain priorities (women, perinatal, adolescent) were continued, three domain priorities (child, CSHCN, cross-cutting) were replaced given past performance and needs assessment findings, a systems building domain priority was added.

Table 15 Comparison of Previous and Current Priorities

The FSM selected the following five National Performance Measures and two State Performance Measures in relation to the identified priority areas.

Table 16 Priority Linkage to Performance Measure