Slide 1

CDC National Survey ofmaternity Care Practices in Infant Nutrition and Care (mPINC):

Using State Reports toInform, Influence, and Monitor Change

Katherine Shealy, MPH, IBCLC, RLCDeborah Dee, PhD, MPHDivision of Nutrition, Physical Activity and ObesityNational Center for Chronic Disease Prevention and

Health PromotionCenters for Disease Control and PreventionAtlanta, GA

DNPAO Teleconference August 13, 2009

ImprovingImprovingHealthy Infant Healthy Infant

Care in Medical Care in Medical SettingsSettings

ImprovingImprovingHealthy Infant Healthy Infant

Care in Medical Care in Medical SettingsSettings

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Outline:I. CDC mPINC Survey background

a. Rationaleb. Survey development and

implementationc. Survey findings

II. Reporting mPINC findingsa. Facility Benchmark Reportsb. www.cdc.gov/mpincc. CDC State Breastfeeding Report

Cardd. State mPINC Reports

III. Utilizing the State mPINC Report

a. Collaboration across facilitiesb. Statewide collaborationsc. Facility Quality Improvement

effortsd. Research opportunities

IV. Future plansa. Preparing for the 2009 mPINC

Surveyb. Reporting future mPINC findings

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Why target the maternity hospital stay?

In the US, >99% of births occur in hospitals:In the US, >99% of births occur in hospitals: Characteristics of care are relatively consistent nationwideCharacteristics of care are relatively consistent nationwide

• Length of stayLength of stay• Delivery of careDelivery of care

The maternity stay is a time when new mothers have abundant The maternity stay is a time when new mothers have abundant access to health professionals.access to health professionals.

The focus is on preventive care:The focus is on preventive care: [in MOST instances] the goal is to maintain existing health of [in MOST instances] the goal is to maintain existing health of

the infant and mother, totally different from other in-patient the infant and mother, totally different from other in-patient hospital populations who are sick hospital populations who are sick

The first days of life are the most ‘sensitive time’ for The first days of life are the most ‘sensitive time’ for establishing breastfeeding.establishing breastfeeding.

Public Health Impact

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Breastfeeding at 8 weeksPercent of mothers (interviewed at 8 wks postpartum about hospital experiences)

(Murray et al., 2007)

Hospital ExperienceNo Yes66 Breastfeeding in the 1st hour 77

65 No supplemented feeding 81

62 Rooming-in 74

69 No pacifiers 78

64Phone number given to

mothers75

Approx mean diff = 12%

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Receiving commercial discharge packs increases likelihood to supplement within 10 weeks by 39%.(Oregon PRAMS)

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30.0%

26.9%

21.5%

13.7%

6.2%

3.2%

15.5%

0 1 2 3 4 5 6

Number of Baby-Friendly steps mothers reported experiencing

Perc

ent of

mot

hers

who

bre

astfed

< 6

wee

ks

The number of supportive strategies that mothers experience predicts risk of breastfeeding cessation.

(DiGirolamo et al., 2008)

Steps measured: Early bf initiation Exclusive breastfeeding

Rooming-in On-demand feedings

No pacifiers Information provided

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Hospital patients expect their medical care to be evidence-based.

Patients expect care decisions to be based Patients expect care decisions to be based on what is necessary and beneficial to their on what is necessary and beneficial to their health.health.

Assumptions: All procedures and practices work towards

improving patient health outcomes Procedures and practices that undermine

patient health outcomes are discouraged and take into account:

• Risk benefit ratio• Extenuating circumstances• Rare exceptions

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However,

Some elements of maternity medical care, including…

…processes, policies, and practices,

…routine practices, traditions, habits,

…design, systems, and expectations…

…can interfere with healthy infant care.

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maternityPractices in Infant Nutrition and Care

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What is the point of assessment and monitoring?

● Monitor progressMonitor progress

● Improve maternity care Improve maternity care practicespractices

● Target problematic Target problematic practicespractices● Provide data for advocacy for Provide data for advocacy for

changechange● Enable performance Enable performance

benchmarkingbenchmarking

● Establish these practices as Establish these practices as standard aspects of perinatal standard aspects of perinatal carecare

● Improve health Improve health outcomes for mothers outcomes for mothers and their babiesand their babies

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What actually happens in maternity care settings?

● How common are positive How common are positive practices?practices?

● How common are negative How common are negative practices?practices?

..

Geographic variations?Geographic variations? Predictors of variations?Predictors of variations?

• Birth censusBirth census• Population servedPopulation served• StaffingStaffing• Others?Others?

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Practices and policies related to the Practices and policies related to the WHO/UNICEF WHO/UNICEF Ten Steps to Successful Ten Steps to Successful BreastfeedingBreastfeeding

Labor and birthing practices such as:Labor and birthing practices such as: Induction & augmentationInduction & augmentation Mode of deliveryMode of delivery

Postpartum care practices such as:Postpartum care practices such as: Infant location for routine proceduresInfant location for routine procedures

mPINC Survey Concepts

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● Biennial national census of facilities Biennial national census of facilities routinely providing maternity servicesroutinely providing maternity services

Private hospitalsPrivate hospitals Public hospitalsPublic hospitals Free-standing birth centersFree-standing birth centers

● Single key informantSingle key informant● Assesses ‘usual practice’ among Assesses ‘usual practice’ among healthy, term newbornshealthy, term newborns

Methodology

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Methodology52 questions52 questions

36 of the questions were categorized into 36 of the questions were categorized into 7 dimensions of care.7 dimensions of care.

Points were assigned to responses to Points were assigned to responses to every question.every question. Higher points were given for practices Higher points were given for practices

that are supportive of breastfeeding.that are supportive of breastfeeding.

SubscoresSubscores = average of points for each question = average of points for each question in the dimension.in the dimension.

Composite quality practice scoresComposite quality practice scores = average = average of care dimension subscores.of care dimension subscores.

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DC

PR

DC

PR

State Mean Composite Quality Scores State Mean Composite Quality Scores (Quartiles), 2007(Quartiles), 2007

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Composite Mean, 63

59

76 79

70

40

51

66

Labor and

Delivery

Care

Feeding of

Breastfed

Infants

Breastfeeding

Assistance

Mother-

Infant

Contact

Discharge

Care

Staff Training Structural &

Org Aspects

of Care

Typical maternity care in the US includes many types of problematic practices.

Most practices are beyond the control of individual patients.

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Inappropriate practices are common, especially among surgical(cesarean) births.

Percent of facilities agreeing

Vaginal births

Surgical births

Routine care for most mothers does not include skin-to-skin contact with the infant.

33.7% 51.2%

Less than half of breastfeeding patients begin breastfeeding within…

…1 hour

19.7%…2 hours

32%

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87.4%

65.5%

86.6%

66.4%

60.4%

60.3%

18.1%

3.4%

85.8%

Mother out of room

Mother bathing

Heel stick

Hearing test

Infant's bath

Infant photos

Pediatric rounds

Change of shift

Visiting hours

Mothers and babies are separated for many reasons, the cumulative effect may be problematic.

Percent of facilities reporting each practice

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Yes,

88.1%

No, 11.9%

Receiving infant formula free of charge Receiving infant formula free of charge contradicts AMA policy recommendations contradicts AMA policy recommendations and makes it more difficult to adhere to and makes it more difficult to adhere to HACCP plans.HACCP plans.

Yet 88% of facilitiesYet 88% of facilitiesdo it anyway.do it anyway.

Does your facility receive infant formula free of charge?

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Yes,

72.6%

No, 27.4%

Almost three quarters of facilities provide infant

formula samples to breastfeeding mothers.

Are discharge packs containing infant formula provided to breastfeeding mothers?

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Benchmark Reports were mailed individually to specific people at each respondent facility.

This multipurpose document is anThis multipurpose document is anintervention strategyintervention strategy developed to developed to

raise awarenessraise awareness, , provide motivators for changeprovide motivators for change, and , and identify barriers to changeidentify barriers to change that are specific to that are specific to

the facility.the facility.

The report is The report is customized to each respondentcustomized to each respondent and provides detailed survey information.and provides detailed survey information.

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Hospital audience:Hospital audience: CEO/AdministratorCEO/Administrator Director of Quality Director of Quality

ImprovementImprovement Director of ObstetricsDirector of Obstetrics Director of PediatricsDirector of Pediatrics Mother Baby Nurse ManagerMother Baby Nurse Manager Survey RecipientSurvey Recipient

Birth Center Birth Center audience:audience:

Birth Center OwnerBirth Center Owner Medical DirectorMedical Director Head MidwifeHead Midwife Key InformantKey Informant

The target audiences for the Benchmark Reports were very narrowly defined, and content was specifically tailored to meet audience needs.

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Additional Reports of mPINC Findings:CDC State Breastfeeding Report Card

www.cdc.gov/breastfeeding/data/report_card.htm

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● Breastfeeding Coalitions● Perinatal Associations● CDC Funded Obesity

Programs● Health Departments● WIC Agencies● Medicaid Programs● Insurance Commissions

● AAP Chapters● ACOG Chapters● ANA Chapters● AWHONN Chapters● ILCA Affiliates● Hospital Associations

Planned audience for each state includes:

State mPINC reports provide each state with a targeted, concise, prioritized, action-oriented summary of their data

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What is this & who did it?

Why change maternity care?

What’s going well?

What’s not?

Who cares about breastfeeding?

1.

2.

3.

4.

5.

STATE

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What is this?

Why change maternity care?

Who cares about breastfeeding?

1.

2.

3.

STATE OUTLINESTATE

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What’s going well?4.

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What’s not?5.

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92.5% of facilities include breastfeeding education as a routine element of their prenatal classes.

98.5% of facilities consistently ask about and record mothers’ infant feeding decisions.

Some positive policy elements are already widespread in most facilities.

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No

62%

Yes

38%

Are mother and baby usually skin-to-skin while staff are completing routine newborn procedures?

NB: Routine newborn procedures include Apgar, foot printing, ID banding, etc.

Almost 2/3 of facilities unnecessarily separate mothers and infants within the first 30 minutes of life.

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31.2%

21.4%

54.9%

40.9%

54.7%

71.3%

90.9%

27.0%

79.3%

51.5%

93.8%

Return clinic visit

Home visit

Telephone call

Center support group

Referral to support group

LC referral

WIC referral

Outpatient clinic referral

Phone # given

List of resources

Bfeeding assessment sheet

The most effective discharge care is also the rarest.

Percent of facilities reporting each practice

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94.4%

75.6%

40.7%

56.5%

New staff receive <18

hours of breastfeeding

training

Existing staff receive <5

hours of breastfeeding

training

Few/some staff received

any breastfeeding

education in last year

Staff competencies

assessed less than annually

Staff breastfeeding training and competency assessment is inadequate, especially for new staff.

Percent of facilities reporting each practice

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What’s not?

2&3. Why should we do something?

7. What can we do?

1. Who did this?

6. What else did CDC find?

4&5. How does my state measure up?

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What else did CDC find?

6.

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7. What can we

do?

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MethodologyMethodology

General and Detailed Results TablesGeneral and Detailed Results Tables

Downloadable filesDownloadable files● Survey instruments (hospital and birth center Survey instruments (hospital and birth center

versions)versions)● Sample Benchmark ReportSample Benchmark Report● Information sheets on:Information sheets on:

Maternity care practices and breastfeedingMaternity care practices and breastfeeding General mPINC informationGeneral mPINC information mPINC dimensions of caremPINC dimensions of care Benchmark ReportsBenchmark Reports

Central location for mPINC information: www.cdc.gov/mpinc

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State Example: Massachusetts

Roger Edwards, ScDBouvé College of Health Sciences Northeastern

Universityro.edwards@neu.edu

The project was designed to ensure a safe and healthy beginning for all newborns by testing measures, strategies, and tools based on the key aspects of the revised AAP hyperbilirubinemia guideline, including

1) the assessment of a newborn’s risk for severe hyperbilirubinemia,

2) support for breastfeeding mothers, and3) coordination of care between the newborn

nursery and primary care practice—the newborn’s medical home.As a result of this project, these tested tools are now available for widespread use. (http://www.aap.org/qualityimprovement/quiin/SHB.html)

Safe and Healthy Beginnings is a pilot project of the AAP Quality Improvement Innovation Network through a partnership with the Center for Health Care Quality at Cincinnati Children’s Hospital Medical Center.

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Standard healthy infant nutrition and care ensures all mothers and babies receive care that…

Ultimate Goal:

…utilizes best practices and…is free of policies, practices, and environmental influences that undermine maternal and child health and wellbeing.

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Many hands make light work…CDCCDC

Romeo ChristianRomeo ChristianDeborah DeeDeborah DeeRon ErgleRon ErgleLarry Grummer-Larry Grummer-StrawnStrawnRenita MacalusoRenita MacalusoCarol MacGowanCarol MacGowanPaulette MurphyPaulette MurphyRon NuseRon NuseKelley ScanlonKelley ScanlonAndrea SharmaAndrea SharmaKatherine ShealyKatherine ShealyThelma SimsThelma SimsJoanna StettnerJoanna StettnerGuijing WangGuijing Wang

BattelleBattelleJennifer CohenJennifer CohenMary Kay DuganMary Kay DuganDiane ManninenDiane ManninenEileen MilesEileen Miles

State Health DepartmentsState Health Departments

Mary Applegate (NY)Mary Applegate (NY)

Tina Cardarelli (IN)Tina Cardarelli (IN)

Jennifer Dellaport (CO)Jennifer Dellaport (CO)

Ken Rosenberg (OR)Ken Rosenberg (OR)

Laurie Tiffin (CA)Laurie Tiffin (CA)

Rosanne Smith (VA)Rosanne Smith (VA)

Sara Bonam Welge (NY)Sara Bonam Welge (NY)

Professional AssociationsProfessional AssociationsLauren Barone (AAP)Lauren Barone (AAP)Edward Newton (ACOG)Edward Newton (ACOG)Cinny Kittle (WV Hospital Cinny Kittle (WV Hospital Ass’n)Ass’n)Patricia Underwood (ANA)Patricia Underwood (ANA)Robert Wiskind (AAP)Robert Wiskind (AAP)

Universities/Med. SchoolsUniversities/Med. SchoolsElizabeth AdamsElizabeth AdamsAndrea Crivelli-KovachAndrea Crivelli-KovachAnn DiGirolamoAnn DiGirolamoRoger EdwardsRoger EdwardsLaurie Feldman-WinterLaurie Feldman-WinterAlla GrindblatAlla GrindblatJane HeinigJane HeinigCelia QuinnCelia Quinn

Breastfeeding Breastfeeding CoalitionsCoalitionsKirsten BerggrenKirsten BerggrenRachel ColchamiroRachel ColchamiroSarah GrosshueschSarah GrosshueschBecky MannelBecky MannelKaren PetersKaren PetersAmelia PsmytheAmelia PsmytheKim RadtkeKim RadtkeMegan RennerMegan Renner

Hospital PracticesHospital PracticesKarin Cadwell Karin Cadwell Debbi Heffern Debbi Heffern Michael LetteraMichael LetteraElaine LockeElaine LockeAnne MerewoodAnne MerewoodCarol MelcherCarol MelcherBarbara PhilippBarbara PhilippMolly PesslMolly PesslAmy SpanglerAmy SpanglerCindy Turner-MaffeiCindy Turner-MaffeiChristopher WadeChristopher Wade

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Thank you!

Katherine Shealy kshealy@cdc.gov

Deborah Dee ddee@cdc.gov

Roger Edwards ro.edwards@neu.edu

www.cdc.gov/breastfeeding

www.cdc.gov/mpinc