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.

 

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 reducing health problems among mothers and babies. Data collection for sampled birth records will begin in the spring of 2022.

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

Pediatrician- CHCC

Registered Dietitian- 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.

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