Based on the 2020 comprehensive FSM-wide needs assessment (NA), 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, 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.

 

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. Methods used for assessing needs for each of the population domains included a review of the various data sources including Vital Statistics Data, Census Data, FSM Behavioral Risk Factor Surveillance System (BRFSS) Report, NCD Hybrid Survey Report, Surveillance Systems and Registries, Mortality Reviews, and other FSM agency data and reports.

 

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 next three‐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 three‐year time frame.

 

The reassessment of the MCH population needs was part of the ongoing annual need assessment process as well as FSM’s response to the recommendations made based on the challenges cited in the Application/Annual Report Review Summary highlights the strengths and challenges for FSM Title V program, based on the Fall 2022 review of FSM State Application/Annual Report.

 

“ln response to the FY22 Application/FY2O Annual Report Block Grant review meeting, the Title V Program underwent a review of priority needs and associated measures. Although much

improvement occurred among alignment of priorities, strategies, and measures, there remains

instances in the FY23 Application/FY2l Annual Report and State Action plan in which alignment inconsistencies exist and measures can be further improved. For example, to support the Child Health priority, "improve child health through healthy weight through physical activity and nutrition promotion," the Program adjusted the strategy to, "do a weight contest among school children, 6-11years old, in schools." The corresponding Evidence-Based or -informed Strategy Measure (ESM) 8.1.1 reads, "percent of children ages 6 to 11 years old who participated in the evidence based and could be dangerous for children. The Perinatal/infant Health Domain narrative discusses the change from NPM 3, "percent of very low birth weight (VLBW) infants born in a hospital with a Level lll+ Neonatal intensive Care Unit (NICU)," to NPM 48, "percent of infants breastfed exclusively through six months;" however, the State Action plan table does not reflect this change. Furthermore, ESM 3 in the State Action Plan Table, "percent of low-birth-weight infants born in the hospital," does not support the new breastfeeding strategy and NPM.

 

The summary statement stated further that 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 were challenges that inhibit consistent and accurate reporting for MCH indicators, within the current structure of manual reporting. The Program intends to collect data in real time, in order to eliminate inconsistencies from year to year”.

 

• 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.”

This NPM is not tracked by FSM.  A new NPM 4 will be tracked in 2023 and 2024.

• 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.

The strategy for objective for this ESM is to increase sports activities by providing sporting supplies and equipment to 1-6 graders in the schools.  The Evidenced-Based Strategic Measure (ESM) is Percent of children ages 6 – 11 years old doing school physical activity at least 60 minutes per day and is actually recorded in the physical activity attendance sheet. The numerator is “Number of 6 – 11 years old who are recorded in the school physical activity attendance sheet” and denominator is “total number of children ages 6 – 11 in the schools”.  Activities can be anything from P.E. classes to extracurricular activities that involve the children being active for 60 minutes straight or in interval times that add up to 60 minutes.

 

•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 plan strategy for the SPM is to provide educational awareness in all the schools on the importance of well medical check-ups or health preventive visits.

 

The FSM MCH Program Annual meeting was held from June 29 to July 01, 2023. The agenda included:  2022 Annual Progress Report (guidance, development and submission); MCH Program; MCH Program 2024   Grant application; EHDI program and activities; SSDI program and activities; MCH Program Unobligated Funds; and Miscellaneous business.) This is for 2024 grant application.

 

The meeting was attended by the staff of the National and States MCH program staff including coordinators, Data clerks and CSHCN. Also in attendance were the; Pohnpei State Chief of Personnel 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 be spent this year among other administrative and financial issues within the MCH program.

The meeting started at 8:30 a.m. and ended at 4:30p.m. for the first two days and about 7 hours on the final day (Saturday).  The meeting focused on the State’s 2022 progress report and 2024 Grant application.

 

The group reviewed the progress reports for each of the FSM States and discussed areas of improvement that can be targeted for 2024 continuing application.

 

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 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.

 

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.

 

The priority for this domain is to improve women and maternal health through cervical cancer and anemia screening. The National performance measure (NPM) that was selected during the initial year was “percentage of women with a past preventive medical visit”.

 

Since cervical cancer is one of the leading causes of death for the women population in the FSM, the FSM MCH program prioritized cervical cancer screening by increasing Pap smear and VIA screening during a women's preventive visit so cervical cancer can be detected early and treated. As a result, a State Performance Measure was developed for this purpose. SPM #1 - Percent of women ages 21-65 years old receiving cervical cancer (Pap & VIA) screening for the past year. Stock-out of supplies for cervical cancer screening is often listed as the underlying cause of low screening rates in the FSM states. Therefore, the FSM MCH Program developed a strategy “Assure availability of adequate supplies for continuous cervical cancer screening for all women 21-65 years old” to counter stock-outs of screening supplies. In 2022 all FSM States experienced challenges in addressing cervical cancer screening due to the prioritization and ongoing response of COVID 19. In addition, in the State of Yap health workers protested against the Government and services for cancer screening were interrupted. 

 

All States in the FSM declared NCD as a public health emergency. Parallel thereto, the FSM MCH Program noticed an increase in women being diagnosed with anemia during pregnancy. In 20, 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 an effort to increase a woman’s health status, prior to pregnancy, the program instituted screening for all women for anemia. As a result, a State Performance Measure was developed for this purpose. SPM #2 - Percent of women (15-44 years old) screened for anemia for the past year.  Stock-out of supplies for anemia screening is often listed as the underlying cause of low screening rates in the FSM states. Therefore, the FSM MCH Program developed a strategy to assure availability of adequate supplies for continuous screening of anemia for all women 15-44 years old and to counter stock-outs of screening supplies.

 

The two SPMs that were tracked during the reporting year continue to be tracked in 2023. 

 

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

Percent	2020	2021	2022
FSM:	19.0%	2.3%	1.5%

 Source: MCH Program Data

 

Table 2 Percent of women receiving a preventive medical visit

Percent	2020	2021	2022
FSM:	43.9%	37.9%	21.2%

 Source: MCH Program Data

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

Percent	2021	2022	2022
FSM:	21.9%	21.9%	15.7%

 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.

 

Perinatal/Infant Health:

The perinatal mortality rate in the FSM in 2022 was 23.9 per 1,000 live births; a tremendous drop from previous year. 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

Rate	2020	2021	2022
FSM:	39.7	49.8	23.9

 Source: Vital Statistics

 

Generally, in 2022, 37.7% of mothers in the FSM reported exclusively breastfeeding their child at six months of age. This NPM was not carefully tracked in 2022 due to new NPM selected for the MCH programs.  Although this is very low percentage in comparison to previous years, 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 2022, 18.4% 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 have improved significantly. One 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 boats or irregular shipping schedules.

 

The other challenge of increasing immunization coverages is due to parental or guardian consent. There are many things that contribute to lack of parental or guardian consent including cultural and religious believes as well as misinformation and disinformation. 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

Percent	2020	2021	2022
FSM:	68.4	64	70.6

 Source: FSM Immunization Program

 

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 citizen. 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 early to combat obesity and nutrition to prevent non-communicable diseases.

 

Currently developmental screenings are only completed on the MCH population but not the population at large. In 2022, only 4.7% 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 is decreased to 30.4 births per 1,000 females in 2022. 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 Pohnpei passed its first age of consent law at 18 years old.

Table 6 Rate of birth (per 1,000) for teenagers aged 15-17 years                              

Rate	2020	2021	2022
FSM:	31.4	30.4	22.4

Source: FSM Birth Certificate and Census Data

Teen births 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 Department 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 slowly improving.

 

	2020	2021	2022
Annual Rate:	62.0	7.1	1.3

Table 7 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 continues to work with other public health programs and youth groups in each State to meet these challenges among the adolescent population.

 

Risky adolescent behavior such as drug and alcohol use lead to injury such as motor vehicle accidents. Adolescent motor vehicle mortality rate, ages 15 through 19 was reported at 8.9 per 100,000 in 2020. Although not much data exists on current drug and alcohol use, it is believed throughout the communities 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 to the 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 8 Rate per 100,000 of all non-fatal injuries due to motor vehicle crashes among youth aged 15 through 19 years

Rate	2020	2021	2022
FSM:	8.9	16.7	0

 Source: Hospital Discharge Records

Teen suicide is an issue in FSM with a rate as high as 25.1/100,000 adolescents being reported in 2021. However, the 2022 data shows a great decrease of suicide deaths among adolescents in the FSM.  More awareness and education around suicide, its causes and prevention are necessary in the FSM.

Table 9 Rate per 100,000 of suicide deaths among youths aged 15 through 19 years

Rate	2020	2021	2022
FSM:	17.8	25.1	8.4

 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 especially among hard of hearing clients. In 2022, 5.3% of children were registered as CSHCN clients. However, of those identified, 74% of children were receiving care in a well-function system according to 2022 data.

Table 10 Percent of CSHCN

Percent	2020	2021	2022
FSM:	4.4	2.7	5.3

 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. However, specialty care and specialists in country continues to be a major problem in all FSM States.

 

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.

 

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.