NEEDS ASSESSMENT UPDATE:

The needs of the MCH population in Guam, as everywhere else, have been impacted by the Covid 19 pandemic and the measures taken for its mitigation and containment. Service sites were closed or operated with reduced hours at reduced capacity. Telework was improvised, and tele visits were instituted with no prior opportunity to coach users on how it all worked. Face-to-face visits became the exception, often used only in situations of high need or urgency, thus preempting much routine, preventive care.

Covid aside, Guam MCH population needs have not significantly changed, as reflected in the list of priority needs retained for this grant cycle 2020-2025. There remains an emphasis on access to services which is addressed by the selection of NPM #1 (preventive medical visits); NPM # 6 (access to developmental screens); NPM #13.2 (access to preventive dental care); and NPM #12 (adolescents transitions to adult health care). The challenge remains in finding new and better ways to reduce barriers and thus improve accessibility.

The Guam Title V program was committed to performing a comprehensive and transparent needs assessment that engaged stakeholders at each phase and identified the most pressing MCH health needs. Areas of need among the MCH health populations became evident following analysis of state and national data and through conversations with families and providers across the island. Among women and birthing people in Guam, access and receipt of timely prenatal care remain challenging, maternal morbidity and mortality rates are rising, and women and birthing people are increasingly in need of services and support for perinatal depression and substance use.

The needs of family planning clients were affected in 2021 with closures due to Covid 19. Some clinics continued with limited hours of operations for those clients who need to see a provider in person. Sexually transmitted infections and efforts were made to address the testing needs of clients, even with the limited hours of operation.

Maternal smoking

Guam MCH collaborates with the Non-Communicable Disease Prevention and Control Program – Tobacco Prevention and Control Program (TPCP). The TPCP continues to bring awareness of tobacco's dangers while providing free resources that have helped individuals quit using tobacco and tobacco products.

With this in mind, Guam MCH, through the 2020 Needs Assessment, created a State Performance Measure (SPM) "Percent of women of reproductive age who are current smokers."

Nearly 6% (5.8%) of women with a live birth in Guam smoked cigarettes three months before becoming pregnant. Over half of those women who smoked during this period continued to smoke into their third trimester (3.6%).

The estimated proportion of current smokers in Guam's female population in the 2020 Guam BRFSS follows an income and educational gradient. Higher proportions of women of lower household income are more likely to report current smoking than higher-income households with less than $15,000 reporting current household smoking at 31.5%, those with incomes of $15,000 - $24,999 at 19.9%, those with incomes at $25,000 - $34,999 at 23.6% compared to those with an annual income of $35,000 to $49,999 at 14% and those at $50,000 and over at 16.2%.

Maternal Mortality

Data from death certificates from 1968-2021 were reviewed to ascertain the number of maternal deaths from the Guam Office of Vital Statistics (OVS). (Note that Guam data are not included in CDC Wonder mortality datasets.) There were 40 maternal deaths On Guam from 1968 to 2021, resulting in very high maternal mortality ratios (MMR) during the years there were maternal deaths. The MMR during the past fifty years of Guam ranged from a low of 22.6 in 1996 to a high of 30.4 in 2021. The three-year average for 2017 – 2019 was 74.0, and the 5-year average for 2017-2021 was 113.1. 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 29.4, is still higher than the U.S. MMR of 23.8 in 2020 (CDC NCHS, 2022). Although the MMR fluctuates for many years with no maternal deaths in 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 ten years, following the national trend. (Mayer, Dingwall, Simon-Thomas et al, 2019).

Regarding the immediate cause of maternal deaths, the majority (55%) were related to cardiovascular conditions or events (e.g., hemorrhage, cerebrovascular events, and pregnancy-related hypertension), another 7.5% infections (sepsis), with 10% other non-cardiovascular conditions and 7.5% pregnancy-related conditions or events (i.e., septic abortion, abruptio placenta, and amniotic fluid thrombosis). Two died from suicide (5%), three from motor-vehicle accidents (7.5%), and three from COVID – 19 (7.5%).

Perinatal/Infant Health

Between 2017-2021, 161 Guam infants died before their first birthday, an average of 32 infants per year. The mean infant mortality rate for the five years was 10.71 per 1,000 live births. Guam's infant mortality rate is higher than the Healthy People 2020 Objective of 5.8 infant deaths per 1,000 live births. During the five years studied, the infant mortality rate among Chamorro infants was 28.5 per 1,000, the rate for Chuukese infants was 16.5 per 1,000 versus the infant mortality rate for Filipino infants was 7.5 per 1,000, and for White infants, 2.25 per 1,000.

From 2018 to 2021 in Guam, 11.3 infants out of 1,000 born during that time span passed away within the first 12 months of life. When looking at Medicaid and MIP users alone, 13.3 infants out of 1,000 births of users experienced infant mortality. For all of the infant deaths that occurred in Guam during the time period, 46.6% of those who experienced an infant death were paying for their birth with Medicaid or MIP. In this period, people paying for their birth with Medicaid or MIP had a 90% greater odds of experiencing infant mortality than those who paid with any other form of insurance (95% CI: 1.26 to 2.92). With a chi-squared value of 9.34 and a p-value of .002, the infant mortality frequency between those insured with Medicaid and/or MIP is significantly different from those who utilized any other form of insurance. When looking at this interaction by ethnicity, 55.3% of Chamorro mothers and 57.5% of Chuukese mothers who experienced an infant death reported using Medicaid/MIP to pay for their births.

The most notable change noted by our MIECHV Program “Project Bisita” was the impact on families

of a lack of access to technology, which negatively affected the access to schooling for older children, and the ability to engage virtually in home visiting services. From early 2021 to late 2022, the COVID Pandemic made it difficult for families and staff to be trained together with other early childhood programs. The programs had to learn to use ZOOM, Microsoft team, or other media sources to continue training with other agencies.

Youth suicide and suicidal behavior remain top priorities for the Title V program. From 2017 through 2021, 178 competed for suicide among the Guam population (all ages). Adolescent suicides made up 7.3% of the completed suicide and whereas young adults made up 17.9% of the suicides. Data is being analyzed to examine the risk factors for adolescent suicide, including violence victimization, physical activity, and substance use. In addition to risk factors and behaviors, data on adolescent suicide mortality will be analyzed by youth age, sex, and race/ethnicity.

The closing of schools due to the pandemic had many adverse effects on Guam's students. Many reported symptoms of depression, anxiety, and loneliness due to the uncertainty of the pandemic. Students experienced anxiety and stress around managing online learning and navigating the online learning world and personal/family issues. Students worried about their relatives getting sick. Students struggled with not being able to see friends, ending the school year early, and missing end-of-the-year activities, which caused isolation, loneliness, and some suicidal ideation. Students lacked the energy and motivation to engage in schoolwork. They were frustrated, distracted, and developed behavioral issues related to distance learning. For some students, the lack of fluency in English, deficits in technical knowledge, and limited access to good internet connections made the process of distance learning frustrating for many students and parents.

Title V Covid 19 Response Activities

The Covid 19 pandemic affected many people, including the program with the Bureau of Family Health and Nursing Services (BFHNS) DPHSS. The engagement of Title V in initial and ongoing pandemic response efforts has provided a unique view and understanding of the population's needs. Additionally, involvement has provided a foundation for Title V to monitor and assess health outcomes following the pandemic.

In addition to providing support, technical guidance, and flexibility, individual members of the Title V program were integral to specific Covid 19 response activities below:

DPHSS Incident Command and Response – The BFHNS Administrator/Title V Director and Title V Program Manger have been part of the agency response since Incident Command was established, and the Governor declared the island-wide emergency in March 2020. Activities include/ have been included but are not limited to:

• Participated in incident command briefings, webinars, and weekly calls as Nursing Resource Command
• Provided updates to the Governor, Incident Commanders, and response team related to all aspects of the MCH population with special emphasis on pregnant women, infants, young children, individuals with special health care needs
• Help coordinate the drafting and updating approval of Covid 19 guidance for BFHNS and public health priority areas of work and Covid response (e.g., exposure, testing, vaccine) for various audiences, including the public health workforce, providers, families, and the public.
• Monitored the impact on pregnancy and birth outcomes (internally with Territorial Epidemiologist)
• Collaborated and communicated across DPHSS program as it pertains to developing guidance, proposals/plans, response, accommodations, and more
• Served as a member of the School Opening workgroup focusing on developing guidance for schools to operate during the pandemic safely.
• Served as a member of the Vaccine and Antiviral Prioritization Policy Committee (VAPPC)
• Served as DPHSS ESF 8

Guam COVID-19 Vaccination Update

As of August 8, 2022, 139,678 eligible residents (6 months and older) are fully vaccinated. This total includes 14,452 residents 12 – 17 years old. 8,935 residents 5 – 11 years old received their first dose of a two-dose series. 7,286 residents 5 – 11 years old have completed their two-dose series. 102 residents 6 months – 4 years old have received their first dose of a two-dose series. 67,948 eligible residents have received their first booster shots. 11,544 eligible residents have received their second booster shots.