If additional years of narrative content are available for this section and state, they will be displayed below. You can view them by selecting a different year.

2022 2023 2024 2025 2026

Annual Needs Assessment Update

Process

MCH continues to collect and analyze data through the various programs under the CNMI MICAH, CHCC hospital, CNMI Health and Vital Statistics Office, and other partners such as the CNMI Public School System and WIC.

Active participation in community events and partner meetings allows the program to interact with stakeholders and gather valuable qualitative information that is used to further guide program activities.

In addition, membership on local groups and committees such as the Disability Network Providers (DNP), Early Intervention Services Program’s Interagency Coordinating Council, and the Head Start Advisory Council (HSAC) provides MCH the opportunity to network with agency partners for obtaining updates on annual plans, objectives, needs, and any emerging issues occurring through partner programs.

MCH conducts a monthly review on Health & Vital Statistics Data, periodic review of hospital admissions data, and conducts chart reviews to help inform ongoing needs assessment processes.

The MCH Jurisdictional survey was implemented in 2020 in the CNMI, providing additional data source for gathering valuable MCH data to inform annual needs assessment activities as well as serving as a data source for National Outcome Measures (NOMs) and National Performance Measures (NPMs) that the CNMI did not have sources for.

MCH Population Needs

Maternal/Women’s Health

The CNMI Family Planning program serves men and women of reproductive age and provides the following services at low to no cost, regardless of an individual’s ability to pay: pregnancy testing, STD/HIV screening and treatment, basic infertility services, contraceptive counseling and access to a wide range of contraceptives, breast and cervical cancer screening, referrals to community programs and other related health services (i.e WIC, prenatal care, etc.).

Source: CNMI Family Planning Annual Report (FPAR)

Annually, the Family Planning program serves an average of 1,200 clients, a large majority women of reproductive age with a large proportion among the 20 to 24 and 25 to 29-year age groups. While there was an overall decrease in the number of unduplicated clients seen in 2020, the program saw increases among the 15 to 17 and 25 to 29-year-old age groups compared to the year prior.

In 2020, a patient satisfaction survey among Family Planning program clients seen at the main service site, CHCC Women’s Clinic, was conducted. A total of 100 surveys were completed. The survey was intended to gather information to identify areas of improvement to be prioritized that would improve overall satisfaction of program services as a means for improving service utilization and improve health outcomes among individuals of reproductive age.

Of the patients surveyed, a large majority rated the medical assistant/health educators and the providers as “Excellent” (96%). The Front Desk Staff, Wait Time, and Convenience of Clinic Hours were identified as areas to focus improvement on, with ratings of “Excellent” at 66%, 63%, and 73%, respectively.

Source: 2020 Family Planning Client Satisfaction Survey

Preventive visit rates among women of reproductive age in the CNMI has remained stable for the past few years. In 2020, 41.9% accessed preventive healthcare, based on electronic health record review of women accessing care at the Commonwealth Healthcare Corporation. This percentage is a slight increase compared to 2019 year which identified 41.3% of women accessing preventive healthcare and a larger increase compared to the 2016 data of 33.9%.

While there have been increases the past 5 years in preventive healthcare utilization among women of reproductive age, the CNMI’s rates still lags behind the US national average. In 2018, for example, 73.6% of women of reproductive age accessed preventive healthcare in the United States.

In the CNMI, gynecological cancers are the most diagnosed forms of cancer. Two (2) screening tests, pap smear and human papillomavirus (HPV) screening, are known to help prevent cervical cancers, a form of gynecological cancer, or detect them early so that they are treatable. According to the 2016 CNMI NCDB Hybrid Survey, only one-third of CNMI adults report having an annual wellness exam and fewer than half (43.2%) of women ages 21- 65 report having a pap test done within the past 2 years. These data clearly illustrate key findings related to preventive healthcare access of the CNMI population and more importantly highlights that there are challenges or barriers women experience in accessing available preventive care, such as pap exams.

Data recently gathered from the CHCC Electronic Health Records (EHR) system from years 2014-2020 showed that 5,623 women between the ages of 21 – 65 years had a cervical cancer screening recorded in the EHR, of which 71.1% (3,998) were up to date of the screening guidelines as of December 31, 2020 and 28.9% (1,625) were out of date. Of the 28.9% out of date, 48.2% (784) women had a visit in 2020 after they were out of date and 52.6% of these 784 women had 6 or more visits (total of 2,260 encounters), representing a missed opportunity to reduce delays in screening, diagnosis, and treatment.

The data shows potential opportunities for strengthening CHCC health system policies and/or protocols to be able to identify and provide pap screenings for women who are already accessing the CHCC health system.

Perinatal/Infant Health

Breastfeeding

While breastfeeding initiation rates in the CNMI of 95.8 percent is higher than US national rate of 83.2 percent [i] , its 6 months breastfeeding rate (44%) trails behind the US average of 57.6 percent. Review of 2020 data on CNMI infants breastfed highlights increases in breastfeeding rates among CNMI infants compared to the year prior. The most recent data shows that 57 percent of infants are breastfed at 3 months, 44 percent at 6 months of age, and 30 percent at 12 months. High breastfeeding initiation rates indicates that a vast majority of mothers in the CNMI want to breastfeed and start out doing so. However, despite the recommendations for exclusive breastfeeding through 6 months, less than 1 percent of CNMI infants are breastfed exclusively at 6 months of age.

Data Source: CNMI WIC Program

Many factors contribute to success in continued breastfeeding and support to breastfeeding moms is critical. Having to return to work is one factor and women typically return to work within one month after childbirth. CNMI government employees are allowed just 15 days of maternity leave; maternity leave policies for private businesses vary. Little is known about the types and level of breastfeeding support provided by local employers.

Donor Breastmilk

Donor breastmilk for infants admitted to NICU in the CNMI was identified as a need by CHCC Pediatrics Department for prevention of complications seen among infants in the NICU, such as necrotizing enterocolitis. The availability of donor breastmilk will provide babies who would otherwise not receive human milk to grow healthier and reduce the risk for morbidity and mortality into their future development.

Through the efforts of the CHCC Pediatrics team, and led by Dr. Julio Pena, a milk bank was identified in San Diego who was willing to enter into an agreement to ship donor breastmilk to the CNMI. A CHCC policy on Donor Breastmilk was identified and Title V funds will be used to support the procurement and transport of this critical resource.

Child Health

Lead Exposure

The CHCC Children’s Clinic saw a significant increase in the number of children ages 5 years and below identified for exposure to lead.

Source: CHCC RPMS, HER

Data from the CHCC Electronic Health Record system for the past 5 years indicates there were more kids identified in 2020 compared to the previous 4 years combined. According to the CHCC Pediatrics department, the increased reporting of lead exposures in children are likely due to multiple factors including but not limited to increased accessibility to testing with point of care screening available in the children’s clinic; increased consistency of lead testing at the 12, 24, and 3 to 5 year well child visits; and possibly more time at home due to quarantine may have resulted in more children having contact with lead based substances.

Obesity

In 2020, the MCH Program worked with an MPH student intern from Emory University, Cindy Rosales, to conduct focus groups and key informant interviews among stakeholders in the CNMI. The project involved conducting a gap analysis by gathering qualitative data to inform strategic action planning for addressing childhood obesity rates in the Northern Mariana Islands. Interviews, listening sessions, and focus groups with an array of public health partners and community members were conducted to learn about opportunities and barriers within the CNMI Commonwealth Healthcare Corporation’s direct sphere of influence for addressing childhood obesity in the territory. The results from the activities were synthesized and will be used to communicate findings and develop recommendation for action to key decision makers and other stakeholders. This work will assist the CHCC in focusing strategic planning efforts (both population based and clinical interventions) and inform the development of the MCH Title V- 5 Year State Action Plan for addressing childhood obesity.

The project resulted in the development of a code book, interview recordings, literature review summary report, research question and interview guide, over 100 pages on interview summaries with coded segments, and a summary of findings.
Interview participants included administrators or directors of the following programs/agencies:

Non-Communicable Disease Bureau (CHCC)

Northern Marianas College- Expanded Food Nutrition and Education Program (PSS)

Diabetes Prevention & Control Program (CHCC)

Nutrition Assistance Program (NAP) (DCCA)

Office of Curriculum & Instruction (Public School System)

Child Nutrition Program (PSS)

Pediatrician- CHCC

Registered Dietitian- CHCC

Special Assistant for Policy- CHCC

WIC- CHCC

Child Care Development Block Grant Program (DCCA)

Early Head Start/Head Start (PSS)

Findings from the project highlighted challenges and opportunities in the areas of nutrition and physical activity. Challenges for nutrition identified include: the lack of variety in fresh produce selection that impacts CNMI residents from choosing healthier options; the time taken to prepare healthy food choices; perception of the high cost of healthier food; access to information that can help or hurt families in making decisions about food and availability of the information. Nutrition facilitators included: CNMI residents and families are farming/gardening for fresh healthy produce making themselves self-sustainable; outreach campaigns or increasing information about healthy choices. Opportunities for improvements and future strategies were also highlighted by the project.

Adolescent Health

Sexually Transmitted Infections

During 2020, there were 180 reported cases of chlamydia and 3 reported cases of gonorrhea. A majority (80%) of the cases were reported among women with more than half (52%) among women between the ages of 15 through 24 years. While usually asymptomatic, if left untreated, chlamydia infection in women can lead to pelvic inflammatory disease, a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydia is easily detected and, if identified, treatable with antibiotics. Screening is critical as it is estimated that about 75% of infections among female and 95% among male is asymptomatic [ii].

CNMI Chlamydia & Gonorrhea Cases- 2020

Data Source: CHCC STD/HIV Prevention & Treatment Program

Title V Program Capacity

Organizational Structure & Leadership

The Title V Block Grant is administered within the Population Health Programs (PHP) section under the Commonwealth Healthcare Corporation (CHCC). The CHCC has a Governor-appointed Board of Directors and in that way is part of the central government of the CNMI.

The CHCC is the operator of the Commonwealth's healthcare system and the primary provider of healthcare and related public health services in the CNMI, including management of federal health related grants. The Chief Executive Officer of CHCC is the authorized representative for the MCH Program and the Administrator for the Maternal, Infant, Child and Adolescent Health unit is the Project Director for the award. The Chief Operations Officer (COO) also provides oversight to the programs under MICAH, including the MCH Title V program.

In 2014, CHCC programs serving women and children were combined to form the Maternal and Child Health Bureau (MCHB). Subsequently in the spring of 2021, the MCHB was restructured to include the Immunization and WIC programs and renamed into the Maternal, Infant, Child and Adolescent Health (MICAH) Programs. The Title V Block Grant is administered through the CHCC MICAH Programs. The MCH Program is one of the seven programs under the MICAH, along with Family Planning, Universal Newborn Hearing Screening/Early Hearing Detection and Intervention Programs, H.O.M.E. Visiting, WIC, Immunization and Vaccines for Children (VFC), Family to Family Health Information Center, and State System Development Initiative. The Administrator for the MICAH Programs also serves as the MCH Program Coordinator.

All MCH services are provided at the Tinian and Rota Health Centers either directly or through Resident Directors or rotating physicians.

Agency Capacity

The CHCC through its health system structure, provides primary and preventive health services to the CNMI. Services include medical, dental, mental health, substance abuse counseling, nutrition/dietary services, oncology, preventive screening and testing, among others. Collaboration with other Public Health programs and community partners make it possible to bring health services out into the community via outreach. This work is supplemented by enabling services including outreach, case management, educational materials, and transportation for MCH target populations. The MCH Program has strong collaborative relationships with key physician providers for the MCH populations. The Chief Obstetrician/Gynecologist, Chief Pediatrician, Family Planning Medical Director, Chief Dentist, and Medical Director of Public Health all guide and support the program.

Maternal Child Health Workforce Development and Capacity

Medical Director of Public Health: Dr. Lily Muldoon is an emergency medicine physician at the Commonwealth Healthcare Corporation of Saipan and was appointed to the position of Medical Director of Public Health of the CNMI in June 2021. Dr. Muldoon received a Medical Degree from the University of California San Francisco and a Masters of Public Health from the Harvard School of Public Health. She is a Fulbright Scholar and has extensive past experience in health system strengthening and improving maternal and child health on remote islands of East Africa.

Family Planning Medical Director/OB/GYN: Dr. Maria Hy, graduated from University of Kentucky College of Medicine 2010 and completed her obstetrics and gynecology residency at Christiana Care Hospital in 2014. She is an OB/GYN for the CHCC and also serves as Medical Director for the Title X Family Planning program.

Pediatrics Department Chairwoman- Dr. Sadie LaPonsie is board-certified in general pediatrics and pediatric hospital medicine. She completed medical school at Michigan State University, residency at Northwestern University / Lurie Children's, then worked for five years as a pediatric hospitalist in the Chicago area until relocating to the CNMI in summer 2020. She has held numerous teaching and leadership positions through Northwestern University, the University of Chicago, and the American Academy of Pediatrics. Her clinical interests and expertise include high-value inpatient care, family-centered care, quality improvement, advocacy, and health equity.

Pediatric Nurse Practitioner and IBCLC- Heather Brooke is a Pediatric Nurse Practitioner at the CHCC Children’s Clinic and the only International Board-Certified Lactation consultant in the CNMI. She graduated from University of Minnesota in 2015 with a Doctorate Nursing Practice. She developed an interest in breastfeeding medicine when she felt ill prepared as a primary care provider to help mother-baby dyads with breastfeeding difficulties and realized that the locally poor breastfeeding rates, which started out high and quickly tapered off, were more likely a product of lack of support than disinterest. The interest turned into a passion and now helping moms and babies have successful breastfeeding journeys is the best part of her job.

MICAH Programs Administrator/MCH Title V Project Director: Heather Santos Pangelinan, assumed the role as MCH Program Coordinator and Administrator in August of 2016. As Administrator, she works closely with the several Project Coordinators to manage the programs under MICAH. Mrs. Pangelinan has a MS in Counseling from Grand Canyon University and started her career in Public Health as a Data Specialist for the MIECHV Home Visiting program. She later served as the CNMI Early Childhood Comprehensive Systems program coordinator. Mrs. Pangelinan has been with the CHCC since 2014.

SSDI Project Coordinator: Richard R. Sablan graduated from California State University San Bernardino with a BS in Health Science, with emphasis in Public Health Education. Related coursework completed included: Statistics for the Health Sciences, Research Methodology in Health Science and Health Program Planning, Implementation and Evaluation. The SSDI Project Coordinator is responsible for managing and improving MCH data collection, analysis, and reporting. The incumbent in this position works closely with the Public Health Medical Director/MCH Epidemiologist.

MCH Services Coordinator: Tony Yarobwemal holds a Master’s of Science degree in Education. Prior to his role as MCH Services Coordinator, Mr. Yarobwemal was the Health, Nutrition and Mental Health Manager for the CNMI PSS Head Start Program. As MCH Services Coordinator, Mr. Yarobwemal is responsible to managing referrals to the MCHB, including conducting risk and other needed assessments to be able to assist women, children, and families access health services.

Child Health Coordinator/CSHCN Director: Danielle Youn Jung Su holds a Master’s of Science in Education in Rehabilitation Counseling and a Bachelor of Art’s degree in English Language Arts, both from Hunter College of City University of New York. Ms. Su is a Certified Rehabilitation Counselor (CRC). As the Child Health Coordinator, her work focuses on development, coordination, implementation and evaluation of children, including children and youth with special health care needs programs and related activities.

Partnerships, Collaboration, and Coordination

The CNMI Public School System continues to be a major partner for strategies and activities targeting children ages zero through 17 years. The PSS Early Intervention Services Program and the Early Head Start program serve children from birth through 3 years. PSS serves children ages 3 through 5 years in Head Start programs and children ages 6 through 17 years are enrolled in PSS K through 12th grade programs. The CHCC has formal MOUs with the PSS to collaborate on programs serving children enrolled throughout the system. CHCC population health programs collaborate with PSS to offer training/capacity building, school based screening services (such as STD/HIV and diabetes or hypertension), as well as other sexual and reproductive health services, such as counseling and access to contraceptives to prevent teen pregnancies and STD transmission. Other initiatives that CHCC has partnered with PSS are: Developmental Screenings, Bullying Prevention, Teen Pregnancy Reduction, Improving Immunization rates, Nutrition, and Physical Activity.

The Child Care Development Fund (CCDF), a program serving low income families through child care subsidies, is an additional key partner in the MCH program’s work for serving children and families. MCH continues to partner with CCDF in the CNMI wide implementation of standardized developmental screening and in implementing the Quality Rating Improvement System (QRIS), which is focused on refining and improving the standards of quality for early care and education programs in the CNMI. The MCH provides training to child care providers on developmental screening.

The MCH and WIC Programs have worked collaboratively for many years to improve breastfeeding rates, lower childhood obesity rates, and increase access to prenatal care.

The Disability Network Partners (DNP) consists of programs that provide services to individuals with special healthcare needs and their families. The Northern Marianas College’s University Centers of Excellence in Developmental Disabilities, CNMI Office of Vocational Rehabilitation, and Developmental Disabilities Council are the agencies that form that core group of the DNP. Other partners involved in the DNP include the Northern Marianas Protection and Advocacy Systems Inc. (NMPASI), Public School System Special Education Program (SPED), Center for Living Independently (CLI), and the MCH Bureau. The DNP meet on a quarterly basis and work on projects such as the CNMI Disability Resource Directory, and the Annual Transition Conferences.

The CNMI Department of Public Safety and the Division of Fire and Emergency Services are also key partners in promoting the health and safety of the MCH population. MCH partners with the Department of Public Safety on child passenger safety initiatives, which include workforce capacity building that enable child passenger safety technician certification for MCH and CHCC nursing staff.

Internal partnerships across CHCC population health programs helps to strengthen the MCH system in the CNMI. MCH works closely with the Immunization Program in increasing community awareness on the importance of vaccines and in increasing access to immunizations through collaborations on community outreach events. Collaboration with the Breast and Cervical Cancer Screening Program positively contributes in the MCH program’s efforts for increasing preventive screening rates among women in the CNMI. Other collaborative efforts include Diabetes, Cancer, Tobacco Control and other chronic disease prevention and health promotion.

The program coordinates with the Health & Vital Statistics Office, CHCC HIT Dept., and CHCC Medical Records Department on initiatives involving access and improving quality of population-based data.

Emerging Public Health Issues

COVID-19

Reports of a novel coronavirus had made its way to the CNMI and on January 29, 2020, the CNMI governor issued an executive order declaring a state of significant emergency regarding the novel coronavirus that ordered the Commonwealth Healthcare Corporation (CHCC) to implement quarantine and preventive containment measures. On March 16, 2020, Executive Order 2020-04, as amended, was issued declaring a State of Public Health Emergency and a continued Declaration of a State of Significant Emergency establishing response, quarantine, and preventive containment measures concerning COVID-19. This resulted in the CHCC establishing an agency emergency operations center and redirected all health department personnel to aid in the response to the novel coronavirus. In addition, and as result of the first cases of COVID-19 in the CNMI identified on March 28, 2020, subsequent executive orders were issued which implemented stay at home orders, curfews, and other restrictions to ensure the containment of COVID-19. Because of the fragile state of our territory health system, it was critical that preventive measures, including quarantine and other containment strategies, were implemented expeditiously to reduce the risk of potential major adverse impact. These measures resulted in modifications to healthcare services and for a temporary period required that preventive/primary care visits be offered via telehealth; program outreach activities were suspended for the remainder of FY2020.

The CHCC, as the Territorial Health Department, initiated its agency emergency operations center and staff throughout the organization were activated to respond to the public health emergency. Boarder entry screening was implemented with all incoming travelers into the CNMI screened for COVID-19 and on March 23, 2020, the CNMI opened its first quarantine site where incoming travelers were required to quarantine for 14 days. A few weeks later, on April 01, 2020, a second quarantine facility was opened.

May be an image of text

As of August 26, 2021, there are 232 total confirmed COVID-19 cases in the CNMI since March 28, 2020 and 2 deaths. A large majority of the confirmed cases were identified through travel testing with a majority of cases originated from the US mainland.

Impact to MCH Program Services

All MICAH Programs staff took on emergency response roles in various sections including planning, communications, contact tracing, entry screening, and quarantine site operations immediately as the CNMI public health emergency was declared in March.

MCH program services were temporarily suspended beginning in March 2020 as health department personnel took part in response efforts. In May 2020, as quarantine efforts garnered good results in containing COVID-19 in the CNMI, staff returned to MICAH programs to begin the process of assessing priorities and activities that could be reasonably conducted during the pandemic. Home visiting services transitioned to telehealth visits, group prenatal care sessions were suspended, Family Planning implemented a drive thru contraceptive pick up service, parent training events offered virtually via zoom, WIC services offered through telehealth, and vaccination offered through drive thru in addition to pediatrics clinics. All educational and clinical outreach events were cancelled for the duration of 2020.

Impact to Preventive Healthcare and Hospital Services

A couple of weeks prior to the confirmation of the first positive COVID-19 cases in the CNMI, the CHCC began implementation of telehealth services at its outpatient clinics to prevent total disruption in preventive health services. Hospital policies were amended to restrict patient visitors and restrictions on birthing companions at the labor and delivery units were put in place. Additionally, the CHCC outpatient pharmacy began offering drive thru services and the dental clinic temporarily closed to non-emergency visits.

Impact to Births

Perhaps the biggest impact the COVID-19 had was to the CNMI’s live birth rate. While births to tourists had already been declining in 2019 due to changes to the CNMI’s tourist waiver policies, the most significant decrease occurred in 2020 with a drop of approximately 89% in tourist births compared to the year prior. Births to non-tourist women were trending upwards after 2017 and then declined in 2020 during the pandemic.

Live births in the CNMI, 2016 - 2020

Data Source: CNMI HVSO

There were 654 total live births in the CNMI in 2020, a 46% decline compared to 2016. Of the 654 total live births, 631 were to non-tourist mothers and 23 were to tourist mothers.

Impact to Medicaid

As a result of the COVID-19 pandemic, and federal support made through US legislation, several state plan amendments were made that expanded coverage to many individuals in the CNMI including:

May 20, 2020: State Plan Amendment to allow the SMA, hospital and public health centers to make presumptive eligibility (PE) decisions, and allow 12 months’ continuous eligibility for children under age 19.
May 20, 2020: Amendment to cover the new optional group for COVID testing, continue to consider residents who leave the Territory due to the disaster residents of the Territory, extend the reasonable opportunity period, allow 90-day supplies of drugs and early refills, extend all prior authorizations for medications without clinical review, or time/quantity extensions, allow exceptions to the Territory's preferred drug list in case of shortages, and allow use of telehealth methods in lieu of face-to-face reimbursed at 80% of the face-to-face rate.
June 09, 2020: The amendment allows hospital services provided by Commonwealth Healthcare Corporation (CHCC) using telehealth to be cost-reimbursed using the existing state plan cost protocol.
May 28, 2021: Effective January 1, 2021, to extend coverage to individuals who lawfully reside in the Commonwealth of the Northern Mariana Islands in accordance with the Compacts of Free Association (COFA) between the Government of the United States and the Governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

By the end of FY2020, approximately 70% of the CNMI population was enrolled in Medicaid.

[i] Centers for Disease Control and Prevention. (2018). Breastfeeding Report Card.

[ii] Meyers, D.S., H. Halvorson, S. Luckhaupt. 2007. “Screening for Chlamydial Infection: An Evidence Update for the U.S. Preventive Services Task Force.” Ann Intern Med 147(2):135–42

Annual Needs Assessment Update

COVID-19

As of July 07, 2022, the total reported COVID-19 cases in the CNMI were 11,819 with 35 COVID-19 related deaths since the start of the pandemic. Approximately 99 percent of the population aged 5 years and older have completed primary vaccinations against COVID-19, and about 52.2 percent of the population ages 5 years and older have received a booster shot. On June 27, 2022, the CNMI implemented COVID-19 vaccinations for children as young as 6 months old as authorized for emergency use by the FDA and CDC.

The COVID-19 pandemic has posed significant challenges across the various infrastructure systems within the Northern Mariana Islands and has had a tremendous impact on tourism, the major source of revenue for the territory resulting in significant reduction in revenue and unemployment across service industry workers. Tourism from Asian countries had major declines at the beginning of the pandemic in January of 2020 with visitor arrivals declining by 85 percent in March of 2020 compared to the year prior. Visitor arrivals declined from 653,150 in fiscal year 2017 to just 5,365 in fiscal year 2021.

According to the CNMI Prevailing Wage Study (PWS), the reported number of employees earning less than $8 per hour declined by 68 percent from 2019 to 2021 [1]. The decline, as noted by the US Government Accountability Office (GAO) is largely due to the economic hardship during the COVID-19 pandemic and to lower study participation by private businesses.

As the territory’s department of health, the Commonwealth Healthcare Corporation (CHCC) worked swiftly to engage partners from all sectors of government, including private organizations, in response efforts against COVID-19. Effective communication strategies, one stop COVID testing and treatment centers, and coordination across various sectors were implemented to protect public health.

On-going Needs Assessment Activities

Participation in partner meetings, workgroups, and councils allows the program to interact with stakeholders and gather valuable qualitative information that is used to further guide program activities.

MCH conducts a monthly review on Health & Vital Statistics Data, periodic review of hospital admissions data, and conducts chart reviews to help inform ongoing needs assessment processes.

Update on Health Status/Needs of MCH Population

Women/Maternal Health

Data gathered from the MCH Jurisdictional Survey (MCH-JS) in 2021 indicates that an estimated 57.1 percent of women ages 18 thru 44 years reported completing a preventive health visit in the past year, which is a slight increase from 2019 data of 55.5 percent. Additionally, review of the number of pap smears processed through the Diagnostic Laboratory Services (DLS) in Honolulu show increases in the number of cervical cancer screenings being conducted in the CNMI, with 2,682 pap specimens processed at DLS in 2021 compared 1,895 in 2020. The number of women accessing Family Planning services had increased in 2021 compared to the year prior and the percentage of live births to women accessing early prenatal care increased from 55 percent in 2020 to 67 percent in 2021.

Perinatal/Infant Health

There were 575 live births in the 2021 in the CNMI with approximately 75 percent of the births covered by Medicaid. Approximately 94 percent of infants were breastfed, however less than 1 percent of infants were breastfed exclusively through 6 months. In 2021, 8.2 percent of infants were born with low birthweight, a decrease from 10.4 percent from the year prior and the percent of infant born preterm was 8.9 percent, slightly lower than 10.9 from the year prior. The CNMI informality rate for 2021 was 12.2 per 1,000 which increased from 7.6 in 2020.

Child Health

In 2021, data from the MCH-JS indicates that just 43.5 percent of children ages 6 through 11 years were reported to be physically active at least 60 minutes per day, a decrease from prior survey data of 52.7 percent. The percentage of children who were reported with decayed teeth or cavities on the MCH-JS also increased from 13 percent in 2020 to 17 percent in 2021, however there was an increase in the percentage of children reported to have accessed preventive dental care, with 46.4 percent of children ages 1 through 17 years reporting having a preventive dental visit in the past year. This is an increase from 31.5 percent from the 2019 MCH-JS survey.

The percentage of parents in 2021 that reported their children (ages 0 through 17 years) to be in excellent or very good condition was 72 percent, a decrease from the 2020 percentage of 81.2 percent and significantly lower than the US national percentage of 90.4 percent.

Vaccination coverage among CNMI children ages 19 through 35 months for the combined 7-vaccine series was 70 percent in 2021, similar to the 2020 percentage of 71.5.

Adolescent Health

CNMI 2021 Maternal and Child Health Jurisdictional Survey data on the adolescent well-visits indicate that just 39.3 percent of adolescent ages 12 through 17 years had a preventive visit in the past year, a slight decrease compared to the 2020 percentage of 42.4 percent. Teen births continue to decline with a rate of 13.0 per 1,000 in 2021, a decline from 15.1 per 1,000 in 2020 and 21.0 per 1,000 in 2019. Vaccinations among the CNMI adolescent population are also maintaining high coverage with 95.5 percent of teens ages 13 through 17 years with at least one dose of the HPV vaccine, 98 percent of the same group receiving at least one dose of the meningococcal conjugate vaccine and 97.7 percent receiving at least one dose of the Tdap vaccine.

As of the date of this report, the CNMI was awaiting the results of the Youth Risk Behavioral Survey (YRBS) that was administered in 2021.

Children with Special Health Care Needs (CSHCN)

According to the MCH-JS, the CNMI has an estimated 7.3 percent of children ages 0 through 17 years who met the criteria for having a special health care need based on the CSHCN screener. Data gathered from the CNMI MCH Jurisdictional Survey indicated that only 14.1 percent of CSHCN, ages 0 through 17 in 2021 reported having a medical home, significantly lower than the US percentage of 42.2 percent [2]. Additionally, 32.7 percent of families of CSHCN reported receiving services necessary for transition into adult healthcare.

Title V Program Capacity Updates & Changes

In the spring of 2021, the MCHB was restructured to include the Immunization and WIC programs and renamed into the Maternal, Infant, Child and Adolescent Health (MICAH) Programs. The Title V Block Grant is administered through the CHCC MICAH Programs. The MCH Program is one of the seven programs under the MICAH, along with Family Planning, Universal Newborn Hearing Screening/Early Hearing Detection and Intervention Programs, H.O.M.E. Visiting, WIC, Immunization and Vaccines for Children (VFC), Family to Family Health Information Center, and State System Development Initiative. In December of 2022, the MICAH Programs Administrator, who serves as the Title V Block Grant Project Director, was promoted to the role of Director of Population Health Services. The Fiscal Specialist is currently serving as the MICAH Program Administrator until a permanent staff member is identified for the position.

In April of 2022, the Child Health Coordinator, who also served as the CSHCN Project Director, had resigned from the position. After the departure of the Child Health Coordinator/CSHCN Project Director, the MICAH programs unit began the process to realign the unit structure and restructure staff positions to more effectively address the needs of the community based on the priorities and strategies identified through the needs assessment process. The realignment and restructuring is anticipated to be completed by the end of FY2022.

During the COVID-19 pandemic response in FY2021, the MICAH Administrator/Title V Project Director served as the COVID-19 Vaccinations Operations Lead as part of the CHCC emergency response structure. Other staff members, including the MCH Services Coordinator and Newborn Screening Coordinator were also assigned to COVID-19 vaccination operations.

Partnerships, Collaboration, and Coordination

Perhaps one of the most significant partnerships the MICAH programs works diligently to maintain and strengthen are the partnerships with the clinical providers who serve the CNMI MCH populations. Chairpersons for the Women’s and Children’s Clinics at the CHCC health department and health system are critical collaborators for advocating and championing many of the priorities and strategies that are intended to improve the health and wellness outcomes of CNMI women, children, and their families. The Medical Director for Public Health and the Family Planning Medical Director also play critical roles in the various activities and strategies identified in the CNMI MCH Title V, providing input and guidance on strategies.

The MCH and WIC Programs have worked collaboratively for many years to improve breastfeeding rates, lower childhood obesity rates, and increase access to prenatal care.

The MCH partnership with the Northern Marianas College (NMC) Expanded Food Nutrition and Education Program (EFNEP) is focused nutrition and addressing obesity related activities among the MCH population. Additionally, nursing students through the NMC Nursing Program conduct clinical rotations in the Immunization clinic during the Fall and Spring semesters each year.

The program coordinates with the Health & Vital Statistics Office, CHCC HIT Dept., and CHCC Medical Records Department on initiatives involving access and improving quality of population-based data.

Operationalization of 5-Year Needs Assessment

MICAH Programs staff work to evaluate and revise strategies and activities based on outcomes. Staff work collaboratively across programs and with partners to meet short- and long-term outcomes to support improvements in national and state performance measures that eventually impact the Title V national outcome measures.

5-Year Plan Changes for 2021-2025 (FY 2021)

No changes to Title V priority selections were made in FY2022. However, a change in strategy for the child health domain was made. The strategy of improving well-child visits as a mechanism for improving physical activity and addressing obesity related issues among children 6 through 11 years is replaced with the strategy to increase the number of families enrolling into evidence based nutrition and physical activity programs or curriculum.

Health Equity & Social Determinants of Health

The MICAH programs worked to integrate activities within the Title V MCH work plan for FY 2023 to address social determinants of health in strategies across population health domains as an approach for addressing health equity in the CNMI. Integrating screening for social determinants of health and implementing referral mechanisms were included as part of strategies to address priorities.

Changes in Organizational Structure and Leadership

At the end of FY2021, the Chief Operations Officer, Subroto Banerji, had left the CHCC. The position remained vacant for several months until a replacement was identified in the Spring of 2022.

A major organizational change was the transfer of the CNMI Medical Referral Program to the CHCC. In January of 2022, the CNMI Medical Referral Program was transferred from the Office of the CNMI Governor to the CHCC. The Medical Referral Program is designed to provide residents of the CNMI, inclusive of the MCH populations and CSHCN, access to medical care that is not available in the CNMI. Currently, the CHCC is undergoing a review, revision, and developing policies and procedures to streamline medical referral reviews and processes to more effectively meet the health needs of the CNMI population. With improved program processes, the organization anticipates improvements in financial performance, processes for accessing off-island care, and an opportunity to identify and implement actions to improve sustainability of the program. While there are identified areas of opportunity and potential for improving healthcare access with this transition, it must be noted that the transfer comes with a risk of financially liability. The Medical Referral Program has historically operated underfunded, with an annual appropriation of $2 million a year and annual spending of $15 million to $18 million.

Emerging Public Health Issues

The COVID-19 pandemic continues to be a public health priority in the CNMI. The first wave or surge of COVID-19 cases in the CNMI occurred in November 2021, almost 2 years since the pandemic began. Thus, the surge occurred at a time when a vast majority of the CNMI population had been fully vaccinated and therapeutics available for treatment. However, the CNMI maintains vigilant in monitoring the pandemic as the situation evolves and new variants identified. Additionally, other threats in infectious diseases that may threaten the MCH population continued to be monitored, such as the Monkeypox outbreak, which was just determined by the World Health Organization as a Public Health Emergency of International Concern in July 2022.

[1] United State Government Accountability Office. (2022). Commonwealth of the Northern Mariana Islands Recent Workforce Trends and Wage Distribution. Retrieved on July 07, 2022 from https://www.gao.gov/assets/gao-22-105271.pdf

[2] Maternal and Child Health Bureau. (2020). 2019-2020 National Survey of Children's Health. Retrieved on July 29, 2022 from https://www.childhealthdata.org/browse/survey/results?q=8569&r=1

COVID-19

The first COVID-19 community cases in the CNMI were identified on March 26, 2020 with limited further transmission. After eliminating local transmission in 2020, CNMI experienced its next community outbreak, again comprising only a small cluster of cases, in March 2021. A larger, more prolonged outbreak occurred at the end of 2021, extending into 2022. Before this large outbreak, the CNMI had time to obtain adequate resources, train personnel and deliver a community-based vaccination campaign and access to treatments. Thus, by the time of the first significant community spread, CNMI was uniquely protected; the case fatality rate was low and there was sufficient capacity within the health-care system to cope with increased case numbers as a result of the importation of both the Delta and Omicron variants of concern (VOCs).

Between March 2020 and October 2021, the period between the first case notification and the start of the larger community outbreak in October 2021, the CNMI recorded just 291 cases, with a vaccination coverage rate at 73.4% in the overall population and 90.4% of the vaccine-eligible population (individuals aged 12 years and older)[1]. By December 2021, just 2 months after the start of the CNMI’s first surge, the COVID-19 cases reported totaled 3,281 (see Figure 1).

Figure 1. Daily number of laboratory-confirmed COVID-19 cases, Commonwealth of the Northern Mariana Islands, 26 March 2020–31 December 2021 (N = 3281)

The COVID-19 outbreak that occurred at the start of FY2022 resulted in schools transitioning to virtual learning, increased community-based testing, and increased vaccination activity to vaccinate those in the community who have not been vaccinated and young children and infants, when vaccines were made available to those populations. The CHCC worked closely with the CNMI Public School System to provide school-based vaccination services, coordinate communications to increase vaccine confidence, and monitor vaccination data to inform targeted vaccination activities and to assist with decisions on when schools will resume in person learning. Division of Public Health staff members, including MICAH team members were engaged in the overall territory response efforts, including aggressive testing, treatment, and vaccination campaigns, guided by recommendations by the US Centers for Disease Control and Prevention. A second wave, or surge, of COVID-19 infections occurred in the early part of 2022 and then a third smaller surge in the summer months (see Figure 2).

Figure 2. COVID-19 Cases Reported in the CNMI in 2022.

Source: Commonwealth Healthcare Corporation Weekly Syndromic Surveillance Report

In addition to schools, many community partner agencies transitioned to remote work suspending face to face activities and community events, which significantly impacted the CNMI MCH Title V workplan activities including the implementation of evidence based strategies and the collection of Evidence Based or Informed Strategy Measures (ESMs).

As of July 08, 2023, there were a total of 13,981 reported cases of COVID-19 in the CNMI, 311 hospitalizations and 46 deaths related to COVID-19. The COVID-19 fatality ratio in the CNMI is .33%, lower than the nation’s rate of 1.1%.[2]

In 2020, the COVID-19 pandemic severely impacted the CNMI workforce, especially those in the tourist and service industries, which are major sources of revenue in the Northern Mariana Islands. However, in 2022, with the easing of travel restrictions and the downgrade of covid-19 pandemic, the tourist industry began showing signs of recovery with 95,956 or 656% increase in tourist arrivals from the previous year. Majority of the tourist populations that are traveling to the CNMI are from Korea, representing 78% of visitors, followed by Guam and U.S. at 10% and 7% respectively. Table 1 illustrates the tourist arrivals by quarter in the year 2022 [3].

Figure 3. Number of arrivals to the CNMI in 2022

On-going Needs Assessment Activities

MCH continues to collaborate with the CHCC hospital, Health and Vital Statistics Office, and key partners such as the CNMI Public School System and WIC for improved data collection, analysis and reporting activities. Participation is highly encouraged in partnership meetings with associates and stakeholders for gathering quality data in promoting programmatic activities. In addition, establishing membership with local groups and committees such as the Disability Network Providers (DNP), Early Intervention Services Program’s Interagency Coordinating Council, and the Head Start Advisory Council (HSAC) provides MCH opportunities to network with agency partners for obtaining updates on annual plans, objectives, needs, and any emerging issues occurring through partner programs.

MCH continues to receive data from the health system primary care clinics, Health & Vital Statistics Office (HVSO), hospital admissions and Carevue Electronic Health Records for chart reviews and to help inform ongoing needs assessment processes.

The MCH Jurisdictional survey is a Federally available data (FAD) source used to gather valuable MCH data to inform annual needs assessment activities as well as serving as a data source for National Outcome Measures (NOMs) and National Performance Measures (NPMs). A third round of MCH Jurisdictional survey is critical for attaining data to inform the Title V Maternal and Child Health (MCH) Block Grant annual reports. The 2021 MCH Jurisdictional survey provided data for 19 National Performance Measures and 14 National Outcome Measures for the Title V MCH Block Grant Programs.

In May 2021, the CHCC was awarded funding through the Centers for Disease Control and Prevention (CDC) to implement the Pregnancy Risk Assessment Monitoring System (PRAMS). The PRAMS collects jurisdiction-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS surveillance currently covers about 81% of all U.S. births. The CNMI MCH will utilize the PRAMS data to investigate emerging issues and to plan and review programs and policies aimed at improving health outcomes for CNMI mothers and babies. The State Systems Development Initiative (SSDI) supports the PRAMS Integrated Data Collection System (PIDS) by using SAS software to generate monthly samples and summarize information in the dataset. Data collection from the sample birth records began in July 2022 through June 2023. For the Calendar Year 2022, the PRAMS project sampled 373 birth records of the total 473 live births recorded in the CNMI. At the end of the Phase 8 data collection, the CNMI PRAMS project accomplished a 57.91% response rate. Currently, the CDC PRAMS is working with the CNMI to submit all requirements for data weighting. When weighted data becomes available, the CNMI MCH will be able to analyze and use data to support informed decision-making pertaining to public health interventions specific to the MCH population.

Update on Health Status/Needs of MCH Population

Women/Maternal Health

Data gathered from the MCH Jurisdictional Survey (MCH-JS) in 2021 indicates that an estimated 57.1 percent of women ages 18 thru 44 years reported completing a preventive health visit in the past year, which is a slight increase from 2019 data of 55.5 percent. However, review of other indicators of preventive services among women of reproductive age in 2022 illustrate slight decreases in the number of Pap Smears conducted (803 less pap smears conducted), number of family planning visits (17% decrease), and the percentage of early prenatal care among women with live births (5 percentage point decrease).

Perinatal/Infant Health

In 2022, Health and Vital Statistics reported 473 live births in the CNMI, of which 73.57 percent of the births covered by Medicaid. Approximately 94 percent of infants were breastfed, however less than 1 percent of infants were breastfed exclusively through 6 months. Additionally, 10.8 percent of infants were born with low birthweight, an increase of 2.6 percentage points from the previous year; and the percentage of infants born preterm was 12.3 percent, an increase of 3.4 percentage points from 2021. The CNMI infant mortality rate for 2022 was 12.7 per 1,000, a slight increase from 12.2 in 2021.

Child Health

The 2021, MCH-JS indicated 43.5 percent of children ages 6 through 11 years were reported to be physically active at least 60 minutes per day, a decrease from 2019 survey data of 52.7 percent. The percentage of children who were reported with decayed teeth or cavities on the MCH-JS also increased from 13 percent in 2019 to 17 percent in 2021, however there was an increase in the percentage of children reported to have accessed preventive dental care, with 46.4 percent of children ages 1 through 17 years reporting that they had a preventive dental visit in the 2021. This is an increase of 14.9 percentage points from the initial 2019 MCH-JS survey.

The percentage of parents in 2021 that reported their children (ages 0 through 17 years) to be in excellent or very good condition was 72 percent, a decrease from the 2019 percentage of 81.2 percent and significantly lower than the US national percentage of 90.4 percent.

There was a decrease in the vaccination coverage among CNMI children ages 19 through 35 months for the combined 7-vaccine series between 2021 (70%) and 2022 (66.3%).

Adolescent Health

CNMI 2021 Maternal and Child Health Jurisdictional Survey data on the adolescent well-visits indicate that just 39.3 percent of adolescent ages 12 through 17 years had a preventive visit in the past year, a slight decrease compared to the 2020 percentage of 42.4 percent. The State value for teen births among 15 to 19 years olds decreased to 9.9 per 1000 in 2022 compared to a rate of 13.0 per 1,000 in 2021, a decline from 15.1 per 1,000 in 2020 and 21.0 per 1,000 in 2019. Vaccinations among the CNMI adolescent population are also maintaining high coverage with 96.6 percent of teens ages 13 through 17 years with at least one dose of the HPV vaccine, 98.3 percent of the same group receiving at least one dose of the meningococcal conjugate vaccine and 99.5 percent receiving at least one dose of the Tdap vaccine.

Data for the 2021 CNMI Youth Risk Behavior Survey (YRBS) was released in the spring of 2023 providing updates on a variety of youth risk behavior for middle and high school students in the CNMI. Table 1, below, provides trend data for select indicators for the years 2015 thru 2021.

Table 1. CNMI YRBS Trend Data for select indicators, percent among High School Students, 2015 – 2021

Survey Question	2015	2017	2019	2021
Unintentional Injuries and Violence
Were electronically bullied	15.4	17.3	14.2	15.4
Were bullied on school property	22.1	23.2	18.4	9.9
Felt sad or hopeless	36.2	40.7	47.7	54.6
Seriously considered attempting suicide	22.8	25.0	28.5	29.6
Made a plan about how they would attempt suicide	23.3	22.8	27.1	27.6
Actually attempted suicide	13.5	13.6	18.0	17.6
Suicide attempt resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse	2.9	4.3	4.9	5.3
Tobacco Use
Ever tried cigarette smoking	54.9	45.2	44.8	35.6
Currently smoked cigarettes	17.9	12.4	10.8	6.9
Currently smoked cigarettes daily	2.8	2.5	1.9	1.4
Ever used electronic vapor products	53.3	53.6	64.5	56.1
Currently used electronic vapor products	26.3	13.7	24.4	26.4
Currently used electronic vapor products daily	2.0	1.9	4.1	7.8
Sexual Behavior
Were currently sexually active	29.0	24.3	23.6	17.5
Did not use a condom during last sexual intercourse	54.2	47.4	61.0	61.9
Did not use both a condom during last sexual intercourse and birth control pills; an IUD (e.g., Mirena or ParaGard) or implant (e.g., Implanon or Nexplanon); or a shot (e.g., Depo-Provera), patch (e.g., OrthoEvra), or birth control ring (e.g., NuvaRing) before last sexual intercourse	--	--	--	94.7
Physical Activity
Were not physically active at least 60 minutes per day on 5 or more days	56.6	62.8	63.5	71.8
Spent 3 or more hours per day on screen time	--	--	--	77.6
Did not attend physical education (PE) classes on all 5 days	70.2	71.5	73.8	72.8
Obesity, Overweight, and Weight Control
Had obesity	16.0	16.4	21.6	23.4
Were overweight	17.4	18.2	15.9	19.2
Described themselves as slightly or very overweight	32.3	33.8	36.0	41.0
Other Health Topics
Never saw a dentist	7.9	6.2	--	5.2
Reported that their mental health was most of the time or always not good	--	--	--	31.9
Did not get 8 or more hours of sleep	71.9	77.2	76.4	81.7

-- indicates No Data

Data Source: Centers for Disease Control and Prevention, High School YRBS, Northern Mariana Islands

According to the 2021 results of Youth Risk Behavioral Survey (YRBS), adolescents in grades 9 through 12 who are obese increased from 21.6 to 23.4 percent in 2019 to 2021 respectively; similarly, adolescents who were not physically active at least 60 minutes per day on 5 or more days increased from 63.5 percent in 2019 to 71.8 percent in 2021. Additionally, an increase is noted in the percentage of high school teens reporting suicidal ideation, with almost 30 percent of high school student in the CNMI reporting seriously considered attempting suicide in 2021. While the CNMI is reporting a decrease in cigarette use among high school students, the number of teens currently using and daily use of electronic vapor products, or e-cigarettes, is on the rise. According to the 2021 CNMI YRBS, more than half (56.1 percent) of high school students have tried electronic vapor products, more than a quarter (26.4 percent) reported current use, and 7.8 percent reported daily use.

Children with Special Health Care Needs (CSHCN)

According to the MCH-JS, the CNMI has an estimated 7.3 percent of children ages 0 through 17 years who met the criteria for having a special health care need based on the CSHCN screener. Data gathered from the CNMI MCH Jurisdictional Survey indicated that only 14.1 percent of CSHCN, ages 0 through 17 in 2021 reported having a medical home, significantly lower than the US percentage of 42.0 percent [4]. Additionally, only 32.7 percent of families of CSHCN reported receiving services necessary for transition into adult healthcare.

Title V Program Capacity Updates & Changes

In the spring of 2021, the MCHB was restructured to include the Immunization and WIC programs and renamed into the Maternal, Infant, Child and Adolescent Health (MICAH) Programs. The Title V Block Grant is administered through the CHCC MICAH Programs. The MCH Program is one of the seven programs under the MICAH, along with Family Planning, Universal Newborn Hearing Screening/Early Hearing Detection and Intervention Programs, H.O.M.E. Visiting, WIC, Immunization and Vaccines for Children (VFC), Family to Family Health Information Center, PRAMS and State System Development Initiative. In December of 2022, the MICAH Programs Administrator, who serves as the Title V Block Grant Project Director, was promoted to the role of Director of Population Health Services. In January of 2023, the former Fiscal Specialist is now serving as the MICAH Programs Administrator.

In April of 2022, the Child Health Coordinator, who also served as the CSHCN Project Director, resigned from the position. After the departure of the Child Health Coordinator/CSHCN Project Director, the MICAH programs unit began the process to realign the unit structure and restructure staff positions to more effectively address the needs of the community based on the priorities and strategies identified through the needs assessment process. The realignment and restructuring was completed on April 2023. Mrs. Shiella Deray has is now serving as the CSHCN Project Director.

During the COVID-19 pandemic response in FY2021 and into FY2022, the MCH Title V Project Director served as the COVID-19 Vaccinations Operations Lead as part of the CHCC emergency response structure. Other staff members, including the MCH Services Manager and CYSHCN Program Manager were also assigned to COVID-19 vaccination operations.

Partnerships, Collaboration, and Coordination

The Child Care Development Fund (CCDF), a program serving low-income families through childcare subsidies, is an additional key partner in the MCH program’s work for serving children and families. MCH continues to partner with CCDF in the CNMI wide implementation of standardized developmental screening and in implementing the Quality Rating Improvement System (QRIS), which is focused on refining and improving the standards of quality for early care and education programs in the CNMI.

The MCH and WIC Programs have worked collaboratively for many years to improve breastfeeding rates, lower childhood obesity rates, and increase access to prenatal care.

The Disability Network Partners (DNP) consists of programs that provide services to individuals with special healthcare needs and their families. The Northern Marianas College’s University Centers of Excellence in Developmental Disabilities (UCEDD), CNMI Office of Vocational Rehabilitation, and Developmental Disabilities Council comprise the CNMI Tri-Agency partners who lead the overall DNP. Other partners involved in the DNP include the Northern Marianas Protection and Advocacy Systems Inc. (NMPASI), Public School System Special Education Program (SPED), Center for Living Independently (CLI), and the MICAH Programs. The DNP meets on a quarterly basis and works on projects such as the CNMI Disability Resource Directory, and the Annual Transition Conferences. Additionally, the CNMI MCH Title V Project Director serves as a council member on the Governor appointed CNMI Developmental Disabilities Council.

The program coordinates with the Health & Vital Statistics Office, CHCC HIT Dept., and CHCC Medical Records Department on initiatives involving access and improving quality of population-based data.

Operationalization of 5-Year Needs Assessment

5-Year Plan Changes for 2021-2025 (FY 2022)

No changes to Title V priority selections were made in FY2022. However, a change in strategy for the child health domain was made. The strategy of improving well-child visits as a mechanism for improving physical activity and addressing obesity related issues among children 6 through 11 years is replaced with the strategy to increase the number of families enrolling into evidence-based nutrition and physical activity programs or curriculum.

Health Equity & Social Determinants of Health

Changes in Organizational Structure and Leadership

A major organizational change was the transfer of the CNMI Medical Referral Program to the CHCC. In January of 2022, the CNMI Medical Referral Program was transferred from the Office of the CNMI Governor to the CHCC. The Medical Referral Program is designed to provide residents of the CNMI, inclusive of the MCH populations and CSHCN, access to medical care that is not available in the CNMI. Currently, the CHCC is undergoing a review, revision, and developing policies and procedures to streamline medical referral reviews and processes to more effectively meet the health needs of the CNMI population. With improved program processes, the organization anticipates improvements in financial performance, processes for accessing off-island care, and an opportunity to identify and implement actions to improve sustainability of the program. While there are identified areas of opportunity and potential for improving healthcare access with this transition, it must be noted that the transfer comes with a risk of financial liability. The Medical Referral Program has historically operated underfunded, with an annual appropriation of $2 million a year and annual spending of $15 million to $18 million.

Emerging Public Health Issues

The end of the US federal COVID-19 Public Health Emergency (PHE) was on May 11, 2023 in addition to the World Health Organization (WHO) declaring the end of the Global Pandemic in the same month. Multiple factors contributed to the end of both the PHE and the Global Pandemic, including population immunity, access to therapeutics and treatment, and a downward trend in infections and deaths. For very many in the CNMI, the end of the PHE also means and end to Medicaid coverage. In FY2022, the CNMI had approximately 24,000 (51%)[5] community members enrolled under the Medicaid Presumptive Eligibility coverage, which ended with the PHE. The loss of Medicaid coverage for thousands in the CNMI is an emerging public health issue with the potential to negatively impact access to primary and preventive care for the CNMI population, including the MCH populations.

[1] World Health Organization. (2023). How the Commonwealth of the Northern Mariana Islands stalled COVID-19 for 22 months and managed its first significant community transmission.

[2] John Hopkins Coronavirus Resource Center. (2023). Mortality Analysis. Retrieved on July 19, 2023 from https://coronavirus.jhu.edu/data/mortality

[3] CNMI Department of Commerce (2022) Economic Indicator: Visitor Arrivals. Retrieved on July 5, 2023, from: https://ver1.cnmicommerce.com/ei-visitor-arrivals/

[4] The Child & Adolescent Health Measurement Initiative. (ND). 2020-2021 National Survey of Children's Health. Retrieved on July 14, 2023 from https://www.childhealthdata.org/browse/survey/results?q=8569&r=1

[5] Commonwealth Medicaid Agency. (2022). 2022 Citizen-Centric Report Commonwealth Medicaid Agency (CMA) Office of the Governor. Accessed on July 14, 2023 from https://cnmileg.net/resources/files/2022%20CENTRIC%20REPORT/Medicaid%20CCR22.pdf

On-going Needs Assessment Activities

MCH continues to collaborate with the CHCC hospital, Health and Vital Statistics Office, and key partners such as the CNMI Public School System and WIC for improved data collection, analysis and reporting on the health and wellness outcomes of the CNMI MCH population. Participation is highly encouraged in partnership meetings with associates and stakeholders for gathering quality data in promoting programmatic activities. In addition, establishing membership with local groups and committees such as the Disability Network Providers (DNP), Early Intervention Services Program’s Interagency Coordinating Council, and the Head Start Advisory Council (HSAC) provides MCH opportunities to network with agency partners for obtaining updates on annual plans, objectives, needs, and any emerging issues occurring through partner programs.

The MCH Jurisdictional survey is a Federally available data (FAD) source used to gather valuable MCH data to inform annual needs assessment activities as well as serving as a data source for National Outcome Measures (NOMs) and National Performance Measures (NPMs). The MCH-JS was conducted in the CNMI three times, in 2019, 2021, and 2023. The MCH Jurisdictional survey provides data for 19 National Performance Measures and 14 National Outcome Measures for the Title V MCH Block Grant Programs.

In May 2021, the CHCC was awarded funding through the Centers for Disease Control and Prevention (CDC) to implement the Pregnancy Risk Assessment Monitoring System (PRAMS). The PRAMS collects jurisdiction-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS surveillance currently covers about 81% of all U.S. births. The CNMI MCH will utilize the PRAMS data to investigate emerging issues and to plan and review programs and policies aimed at improving health outcomes for CNMI mothers and babies. The State Systems Development Initiative (SSDI) supports the PRAMS Integrated Data Collection System (PIDS) by using SAS software to generate monthly samples and summarize information in the dataset. In 2022, the PRAMS project sampled 373 birth records of the total 473 live births recorded in the CNMI. At the end of the Phase 8 data collection, the CNMI PRAMS project accomplished a 57.91% response rate. The CNMI received its first PRAMS weighted data set from the CDC on June 2024. The CNMI will work to develop a report on CNMI maternal health using the PRAMS data to share with organizational leaderships, community stakeholders, and policymakers.

Update on Health & Well-being Status/Needs of MCH Population

Women/Maternal Health

Data gathered from the MCH Jurisdictional Survey (MCH-JS) in 2023 indicates that an estimated 55 percent of women ages 18 thru 44 years reported completing a preventive health visit in the past year, a slight decrease from 57 percent in 2021 and 56 percent in 2019. Additionally, the total number of cervical cancer screenings conducted via pap smears in 2023 was 1,518, a decrease of 361 screenings conducted compared to the year prior. The percentage of women of reproductive age accessing preventive health service via the CNMI Family Planning Program increased to 15.4 percent in 2023 from a percentage of 13.1 in 2022. Among non-tourist pregnant women with live births in the CNMI, 61 percent in 2023 reported early prenatal utilization, which is a rate maintained from 2022 (62%). It is estimated that 3.3 percent of live births were to women who reported smoking in pregnancy, while 3.6 of the same population reported drinking alcohol in the last 3 months of pregnancy, an increase from 1.1 in 2022.

Perinatal/Infant Health

In 2023, the Health and Vital Statistics Office reported 581 live births in the CNMI, of which 66 percent of the births covered by Medicaid and 79 percent enrolled in WIC. Approximately 93 percent of infants were breastfed and 11 percent of infants were breastfed exclusively through 6 months, a significant increase from .5 percent in 2022. Additionally, 10.5 percent of infants were born with low birthweight, an increase of 1.8 percentage points from the previous year; and the percentage of infants born preterm is 10.5 percent, a decrease from 12.3 percent in 2022. The CNMI infant mortality rate for 2023 is 13.8 per 1,000 live births, a slight increase from the rate pf 12.7 per 1,000 in 2022.

Child Health

The 2023, MCH-JS indicated 60.7 percent of children ages 6 through 11 years were reported to be physically active at least 60 minutes per day, an increase from 43.5 percent in 2021. The percentage of children who were reported with decayed teeth or cavities on the MCH-JS in 2023 was 25.2 percent, an increase from 17.0 in 2021. Additionally, just 36.9 percent of CNMI children ages 1 through 17 years were reported to have completed a preventive dental visit in the past year, slightly higher than the pre-pandemic percentage of 31.5. but a decrease from 46.4 percent in 2021.

The percentage of parents in 2023 that reported their children (ages 0 through 17 years) to be in excellent or very good condition was 76 percent, a increase from 72 percent reported in 2021.

There was a decrease in the vaccination coverage among CNMI children ages 19 through 35 months for the combined 7-vaccine series between 2022 (69%) and 2023 (62%). High annual influenza vaccination coverage rates among CNMI children 6 months through 17 years is maintained 81 precent in 2023.

Adolescent Health

CNMI 2023 Maternal and Child Health Jurisdictional Survey data on the adolescent well-visits indicate that just 27.3 percent of adolescent ages 12 through 17 years had a preventive visit in the past year, a decrease from 39.3 percent in 2021. The teen birth rate among 15 to 19 years olds increased from 9.9 per 1000 in 2022 compared to 16.9 per 1000 in 2023. Vaccinations among the CNMI adolescent population are also maintaining high coverage with 96 percent of teens ages 13 through 17 years with at least one dose of the HPV vaccine, 98 percent of the same group receiving at least one dose of the meningococcal conjugate vaccine and 98 percent receiving at least one dose of the Tdap vaccine.

Table 1. CNMI YRBS Trend Data for select indicators, percent among High School Students, 2015 – 2021

Survey Question	2015	2017	2019	2021
Unintentional Injuries and Violence
Were electronically bullied	15.4	17.3	14.2	15.4
Were bullied on school property	22.1	23.2	18.4	9.9
Felt sad or hopeless	36.2	40.7	47.7	54.6
Seriously considered attempting suicide	22.8	25.0	28.5	29.6
Made a plan about how they would attempt suicide	23.3	22.8	27.1	27.6
Actually attempted suicide	13.5	13.6	18.0	17.6
Suicide attempt resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse	2.9	4.3	4.9	5.3
Tobacco Use
Ever tried cigarette smoking	54.9	45.2	44.8	35.6
Currently smoked cigarettes	17.9	12.4	10.8	6.9
Currently smoked cigarettes daily	2.8	2.5	1.9	1.4
Ever used electronic vapor products	53.3	53.6	64.5	56.1
Currently used electronic vapor products	26.3	13.7	24.4	26.4
Currently used electronic vapor products daily	2.0	1.9	4.1	7.8
Sexual Behavior
Were currently sexually active	29.0	24.3	23.6	17.5
Did not use a condom during last sexual intercourse	54.2	47.4	61.0	61.9
Did not use both a condom during last sexual intercourse and birth control pills; an IUD (e.g., Mirena or ParaGard) or implant (e.g., Implanon or Nexplanon); or a shot (e.g., Depo-Provera), patch (e.g., OrthoEvra), or birth control ring (e.g., NuvaRing) before last sexual intercourse	--	--	--	94.7
Physical Activity
Were not physically active at least 60 minutes per day on 5 or more days	56.6	62.8	63.5	71.8
Spent 3 or more hours per day on screen time	--	--	--	77.6
Did not attend physical education (PE) classes on all 5 days	70.2	71.5	73.8	72.8
Obesity, Overweight, and Weight Control
Had obesity	16.0	16.4	21.6	23.4
Were overweight	17.4	18.2	15.9	19.2
Described themselves as slightly or very overweight	32.3	33.8	36.0	41.0
Other Health Topics
Never saw a dentist	7.9	6.2	--	5.2
Reported that their mental health was most of the time or always not good	--	--	--	31.9
Did not get 8 or more hours of sleep	71.9	77.2	76.4	81.7

-- indicates No Data

Data Source: Centers for Disease Control and Prevention, High School YRBS, Northern Mariana Islands

Children with Special Health Care Needs (CSHCN)

According to the MCH-JS, the CNMI has an estimated 8 percent of children ages 0 through 17 years who met the criteria for having a special health care need based on the CSHCN screener. Data gathered from the MCH Jurisdictional Survey indicated that only 13 percent of CNMI CSHCN, ages 0 through 17 reported having a medical home, significantly lower than the US percentage of 42.0 percent [1]. Additionally, only a little half (51%) of CNMI CSHCN reported receiving services necessary for transition into adult healthcare.

Title V Program Capacity Updates & Changes

In the spring of 2021, the MCHB was restructured to include the Immunization and WIC programs and renamed into the Maternal, Infant, Child and Adolescent Health (MICAH) Programs. The Title V Block Grant is administered through the CHCC MICAH Programs. The MCH Program is one of the seven programs under the MICAH, along with Family Planning, Universal Newborn Hearing Screening/Early Hearing Detection and Intervention Programs, H.O.M.E. Visiting, WIC, Immunization and Vaccines for Children (VFC), Family to Family Health Information Center, PRAMS and State System Development Initiative. In December of 2022, the MICAH Programs Administrator, who serves as the Title V Block Grant Project Director, was promoted to the role of Director of Population Health Services. In January of 2023, the former Fiscal Specialist is now serving as the MICAH Programs Administrator.

In FY 2023, the Division of Public Health underwent a subsequent restructuring as part of efforts to strengthen the CNMI’s Public Health foundational capabilities in alignment with the Foundational Public Health Services (FPHS) framework. The Immunization program was re-organized into the Communicable Disease Programs section and two new Public Health sections were established: 1) Data, Surveillance, and Performance Management; and 2) Health Promotions & Partnerships. The State Systems Development Initiative (SSDI) and the Pregnancy Risk Assessment Monitoring System (PRAMS) were restructured into the Data, Surveillance, and Performance Management section under Public Health.

As part of the re-organization, the Division will work to update its vision and mission statements, and strategic plan to align with the re-organization. This work is being conducted in FY2024 through support from the Association of State & Territorial Health Officials (ASTHO).

Partnerships, Collaboration, and Coordination

Perhaps one of the most significant partnerships the MICAH programs works diligently to maintain and strengthen are the partnerships with the clinical providers who serve the CNMI MCH populations. Chairpersons for the Women’s and Children’s Clinics at the CHCC health system are critical collaborators for advocating and championing many of the priorities and strategies that are intended to improve the health and wellness outcomes of CNMI women, children, and their families. The Medical Director for Public Health and the Family Planning Medical Director also play critical roles in the various activities and strategies identified in the CNMI MCH Title V, providing input and guidance on strategies.

The MCH and WIC Programs have worked collaboratively for many years to improve breastfeeding rates, lower childhood obesity rates, and increase access to prenatal care.

The Disability Network Partners (DNP) consists of programs that provide services to individuals with special healthcare needs and their families. The Northern Marianas College’s University Centers of Excellence in Developmental Disabilities (UCEDD), CNMI Office of Vocational Rehabilitation, and Developmental Disabilities Council comprise the CNMI Tri-Agency partners who lead the overall DNP. Other partners involved in the DNP include the Northern Marianas Protection and Advocacy Systems Inc. (NMPASI), Public School System Special Education Program (SPED), Center for Living Independently (CLI), and the MICAH Programs. The DNP meets on a quarterly basis and works on projects such as the CNMI Disability Resource Directory, and the Annual Transition Conferences. Additionally, the CNMI MCH Title V Project Director serves as a council member on the Governor appointed CNMI Developmental Disabilities Council.

The program coordinates with the Health & Vital Statistics Office, CHCC HIT Dept., and CHCC Medical Records Department on initiatives involving access and improving quality of population-based data.

Operationalization of 5-Year Needs Assessment

5-Year Plan Changes for 2021-2025 (FY 2023)

No changes to Title V priority selections or strategies were made in FY2023.

Health Equity & Social Determinants of Health

Changes in Organizational Structure and Leadership

In FY2023, Ms. Halina Palacios was appointed as Chief Operations Officer for Population for the CHCC. The Division of Public Health, which administers the MCH Title V Block grant, is unit within CHCC Population Health, co-located with the Community Guidance Center, which functions as the CNMI state mental health agency, and the CHCC Outpatient clinics.

Emerging Public Health Issues

The end of the US federal COVID-19 Public Health Emergency (PHE) was on May 11, 2023 in addition to the World Health Organization (WHO) declaring the end of the Global Pandemic in the same month. Multiple factors contributed to the end of both the PHE and the Global Pandemic, including population immunity, access to therapeutics and treatment, and a downward trend in infections and deaths. For very many in the CNMI, the end of the PHE also means and end to Medicaid coverage. In FY2022, the CNMI had approximately 24,000 (51%)[2] community members enrolled under the Medicaid Presumptive Eligibility coverage, which ended with the PHE. The loss of Medicaid coverage for thousands in the CNMI is continued to be an emerging public health issue with the potential to negatively impact access to primary and preventive care for the CNMI population, including the MCH populations.

[1] The Child & Adolescent Health Measurement Initiative. (ND). 2020-2021 National Survey of Children's Health. Retrieved on July 14, 2023 from https://www.childhealthdata.org/browse/survey/results?q=8569&r=1

[2] Commonwealth Medicaid Agency. (2022). 2022 Citizen-Centric Report Commonwealth Medicaid Agency (CMA) Office of the Governor. Accessed on July 14, 2023 from https://cnmileg.net/resources/files/2022%20CENTRIC%20REPORT/Medicaid%20CCR22.pdf

The state did not provide any content for this Narrative Section.

Back
To Top

Quick Links

Narrative Search

Search Tips

Narrative Text Search

Contact Us