For the Perinatal/Infant Health domain, Guam’s priority needs to “reduce infant mortality and morbidity” did not change. Guam selected National Performance Measure # 4 Breastfeeding based on the Guam 2020 Title V Needs Assessment.

The first component of the Guam five-year cycle is to increase the percentage of breastfed infants to 85% in 2025. As reported by the National Immunization Survey (NIS), the rate of Guam infants who were breastfed peaked in 2014 to 86%, that percentage declined by 2.47% in 2019.

For the second component of the performance measure for breastfeeding, the 2025 objective is to increase the percentage of breastfed infants exclusively through six months to 33.5%. The rate of exclusively breastfed infants in 2019 was 26.4%, a difference of 23.7%.

Most factors that influence infant birth outcomes are linked to maternal health. Therefore, the strategies described in the Maternal/Women’s Health Application impact the Perinatal/Infant domain outcomes. While many of the Title V investments to improve birth outcomes are directed towards the maternal side of the dyad, several Title V strategies focus primarily on improving perinatal/infant health outcomes.

In the application year 2022, the infant and perinatal priority for the Bureau of Family Health and Nursing Services (BFHNS) are to promote equitable and optimal care and protective factors for mothers and infants before, during, and after pregnancy. In meeting this priority, we will continue to remain focused on reducing infant mortality and morbidity.

The American Academy of Pediatrics recommends all infants are exclusively breastfed for six months to support optimal growth and development. Breastfeeding has health benefits for infants and mothers, including significant benefits to the mental health of both mothers and babies. For infants, breastfeeding reduces asthma, obesity, SIDS, diabetes, ear infections, and respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and postnatal depression, reduce post-partum hemorrhage, and be less likely to develop breast, uterine, and ovarian cancers. Human milk remains the optimal source of nutrition for the first months of life. Additionally, the Title V needs assessment revealed that breastfeeding is still a critical MCH issue for Guam’s mothers and infants. Needs assessment themes showed that families want more breastfeeding support and education and have difficulty accessing breastfeeding support professionals and providers that support breastfeeding.

To support NPM 4 (breastfeeding), BFHNS, in partnership with the Bureau of Nutrition and the WIC Program, will continue to support breastfeeding initiatives through training, technical assistance, policy and procedures, and direct support services. In addition, BFHNS, through the Maternal, Infant, and Early Childhood Home Visiting (MIEHCV) grant, will provide training and support for home visitors to become IBCLC certified or receive in-depth breastfeeding education and training.

The Guam MCH Program plans to build on the existing collaboration with the MIECHV and WIC Programs to deliver a training event focused on teaching best practices to home visitors to support breastfeeding moms. The training will be facilitated by WIC staff. It will focus on strategies for encouraging pregnant and new mothers to initiate breastfeeding, addressing hesitancy to breastfeed, supporting mothers to breastfeed for at least six to 12 months, and engaging fathers or male partners to support breastfeeding. Based on MIECHV’s FY 2020 projected caseload, approximately 90 families will benefit from home visitor education and support on breastfeeding.

Newborn Screening (NBS) efforts, through the partnership between Guam Memorial Hospital Authority and BFHNS/ MCH, will continue to emphasize follow-up screens.  This partnership will continue to support efforts to identify infants who have either not returned for the second screen or need a repeat screen due to an abnormal prior screening.  

Guam’s home visiting program Project Bisita will continue to educate families about infant-toddler development, mental health, the critical importance of bonding, injuries in the home, safe sleep, immunizations, and the effects of Adverse Childhood Experiences (ACEs).  

The Title V State Action Planning Sessions gave BFHNS staff a chance to reflect on the work that supports secure parent-child attachment in Guam. Searching for improvement opportunities, participants identified a strength - the practice of reflective supervision within the MIECHV program. Reflective supervision is the regular collaborative reflection between a service provider and their supervisor that builds on the supervisee’s use of their thoughts, feelings, and values within a service encounter. These supervision practice models the desired therapeutic/helping relationship between the service provider and client. It ultimately enables the service provider to serve better and meet the client's needs.

In FFY 2022, Title V will support developing a plan to create a culture of active listening and reflection by implementing reflective supervision internally within BFHNS. Expansion of reflective supervision and movement towards developing a relationship-based organization can improve the quality of family support services and decision-making at multiple levels. Given that MIECHV staff comprise the majority of the BFHNS, the opportunity to scale and spread reflective supervision across the bureau is feasible.  A reflective supervision structure allows for more straightforward communication between the families and communities supported by Title V and within BFHNS.  

Moreover, state action planning participants emphasized that a reflective supervision structure will be critical to future success in the bureau’s workforce development strategy.  By expanding the use of reflective supervision bureau-wide, BFHNS staff would be modeling the very behaviors they seek to encourage in families that support secure attachments.

Infant mortality is a multifaceted societal problem linked to factors that affect an individual’s physical and mental well-being, including maternal health, socioeconomic status, quality and access to medical care, and public health practices. It adversely affects families and communities, both socially and emotionally, resulting in adverse symptoms such as depression, grief, and guilt. Families suffer from long-term psychological distress, leading to partner separation or divorce. Grieving parents also experience isolation from friends and family.

To address disparities among infants born to local Chamorro women and women from the Freely Associated States of Micronesia (FAS), Guam will engage and build better partnerships with internal programs and external community partners working on infant mortality-related topics. As the Needs Assessment Team recommended a shift in priorities for infant health, Guam will continue developing new strategies and refining current ones to meet the needs of communities better.

Guam will improve data collection and evaluation as a strategy to reduce infant mortality. This will ensure data availability for planning, programmatic, and policy decisions to improve maternal and infant health outcomes in communities in Guam. Evaluation will help with determining our progress in achieving our desired maternal and infant health outcomes. In the year ahead, staff will aim to accomplish the following activities:

Establish a Fetal and Infant Mortality Review (FIMR): Without the legislation in place, it will be difficult to access relevant information from important sources such as medical records, birth, and death records, and coroner’s reports to understand fully the circumstances that may have contributed to infant deaths. It is hoped that with the completion of Data Science Team Training (DSST).

The Territorial Epidemiologist, the MCH Program Manager, SSDI data clerk, and a CDC Coordinator are part of the Guam Data Science Team Training (DSTT) conducted by the Council of State and Territorial Epidemiologist (CSTE). Participants in the 12-month program work on a project that addresses a current need. Furthermore, participants will build a set of foundational data science skills to advance existing skill sets.

The Guam Fetal Death Data Analysis Project aims to analyze information on fetal deaths for the decade 2011-2020 using data from the Fetal Demise Reports in the Office of Vital Statistics, DPHSS; medical records of the mothers where possible; and potential interviews with the mothers. The analysis will look at multiple factors affecting fetal demise, utilizing geospatial information, medical, environmental, and vital statistics data to describe these events.