Results from the CDC Results from the CDC National Survey of National Survey of Maternity Care Practices in Maternity Care Practices in Infant Nutrition and Care Infant Nutrition and Care (mPINC)(mPINC)

Laurence Grummer-Strawn, PhDLaurence Grummer-Strawn, PhD

Deborah Dee, MPH, PhDDeborah Dee, MPH, PhD

Katherine Shealy, MPH, IBCLC, RLCKatherine Shealy, MPH, IBCLC, RLC

Division of Nutrition, Physical Activity and ObesityDivision of Nutrition, Physical Activity and Obesity

National Center for Chronic Disease Prevention and Health National Center for Chronic Disease Prevention and Health PromotionPromotion

Centers for Disease Control and PreventionCenters for Disease Control and PreventionAtlanta, GAAtlanta, GA

32.1%

23.6%

18.5%

9.0%

5.1%

13.6%

0 1 2 3 4 5

Number of Number of Baby FriendlyBaby Friendly steps in place steps in place predicts risk of breastfeeding cessationpredicts risk of breastfeeding cessation

Source: Source: DiGirolamo et al., 2001DiGirolamo et al., 2001

Steps measured: Late bf initiation Supplemented feedings

Lack of rooming-in Scheduled feedings Pacifiers

Number of steps reported 5

0 25 50 75 100

Baby breastfed in 1st hour after birth

Baby fed only breastmilk in hospital

Baby stayed in same room with mother

Baby did not use pacifier in hospital

Hospital gave mother phone number to call forbreastfeeding help

Percent

No

Yes

Hospital practices are associated with Hospital practices are associated with breastfeeding continuation at 8 weeksbreastfeeding continuation at 8 weeks

Source: Source: Murray et al., 2007Murray et al., 2007 3

Evidence from PRAMSEvidence from PRAMS

● Breastfeeding mothers in Oregon Breastfeeding mothers in Oregon given given commercial hospital discharge packs were 39% more likely to supplement before 10 weeks of age.

4

Supplemental feeds Supplemental feeds in hospitalin hospital negatively impact infant health & bf negatively impact infant health & bf outcomesoutcomes

Source: Nylander, et al. 1991

In-hospital BehaviorsIn-hospital Behaviors ControlControl InterventionIntervention

Breastfeeds/24 hr on day 2Breastfeeds/24 hr on day 2 4.3 feeds4.3 feeds 6.4 feeds6.4 feeds

Supplementary feeds/24 h on day 2Supplementary feeds/24 h on day 2 4.8 feeds4.8 feeds 1.1 feeds1.1 feeds

Volume of breast milk on day 2 (ml)Volume of breast milk on day 2 (ml) 47 ml47 ml 132 ml132 ml

Volume of supplement on day 2 (ml)Volume of supplement on day 2 (ml) 188 ml188 ml 23 ml23 ml

Supplementing on day 2Supplementing on day 2 100%100% 2%2%

Total volume supplement consumed days 1-3Total volume supplement consumed days 1-3 565 ml565 ml 68 ml68 ml

Night-time breastfeedingNight-time breastfeeding 2%2% 98%98%

BF RatesBF Rates ControlControl InterventionIntervention

3 mo exclusive bf3 mo exclusive bf 57%57% 75%75%

6 mo exclusive bf6 mo exclusive bf 12%12% 22%22%

9 mo any bf9 mo any bf 47%47% 62%62%

6

CDC activities on maternity care CDC activities on maternity care practices related to breastfeedingpractices related to breastfeeding

● Formative research on barriers to changing Formative research on barriers to changing practicespractices

● Compilation of success stories in Baby-Compilation of success stories in Baby-Friendly hospitalsFriendly hospitals

● Numerous evaluation grants on hospital Numerous evaluation grants on hospital interventionsinterventions

● PRAMS survey modulePRAMS survey module

● Planning for strategic planning meetingPlanning for strategic planning meeting

7

Nationwide activities on maternity Nationwide activities on maternity care practices related to breastfeedingcare practices related to breastfeeding

● BFHIBFHI

● BanTheBags.orgBanTheBags.org

● National Quality Forum Voluntary Consensus National Quality Forum Voluntary Consensus StandardsStandards

● Performance incentives for MedicaidPerformance incentives for Medicaid

● Recommendations in HHS Blueprint & CDC Recommendations in HHS Blueprint & CDC Guide to Breastfeeding InterventionsGuide to Breastfeeding Interventions

8

What actually happens in What actually happens in maternity care settings?maternity care settings?

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

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

..

Geographic variationsGeographic variations Predictors of variationsPredictors of variations

● Are practices changing over time?Are practices changing over time?

9

October, 2003 – Expert October, 2003 – Expert PanelPanel

● Two day working meetingTwo day working meeting

● Researchers with specific expertise Researchers with specific expertise and experience in assessment and and experience in assessment and monitoring of breastfeeding-related monitoring of breastfeeding-related maternity care practicesmaternity care practices Conducting state/regional surveysConducting state/regional surveys Assessing maternal experiences Assessing maternal experiences

during maternity careduring maternity care Assessing breastfeeding issuesAssessing breastfeeding issues

11

Expert Panel Expert Panel RecommendationRecommendation

Biannual national census of facilities routinely Biannual national census of facilities routinely providing maternity servicesproviding maternity services

Strong need for a census design to effectively utilize Strong need for a census design to effectively utilize data for advocacy and practice changedata for advocacy and practice change

Concerns about identification of respondent facilitiesConcerns about identification of respondent facilities Mail survey with telephone follow-up for non-Mail survey with telephone follow-up for non-

respondersresponders Single key informantSingle key informant Assess ‘usual practice’ including, but not limited to, Assess ‘usual practice’ including, but not limited to,

practices in WHO/UNICEF Ten Stepspractices in WHO/UNICEF Ten Steps Representation of practices at all different types of Representation of practices at all different types of

facilities in the USfacilities in the US 12

National SurveyNational Survey

● Biannual national census of facilities Biannual 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’Assesses ‘usual practice’

13

Survey IndicatorsSurvey Indicators

● WHO/UNICEF WHO/UNICEF Ten Steps to Successful Ten Steps to Successful BreastfeedingBreastfeeding

● Labor and birthing practicesLabor and birthing practices

● Postpartum care practicesPostpartum care practices

14

maternitymaternityPractices inPractices inInfantInfantNutrition andNutrition andCareCare

10

Current StatusCurrent Status

● Data were collected from Aug-Dec, 2007Data were collected from Aug-Dec, 2007

● MMWR to be published June 13, 2008MMWR to be published June 13, 2008

● Individualized Individualized Benchmark Reports Benchmark Reports will be sent to will be sent to respondent facilities in respondent facilities in early July early July

17

Design StrengthsDesign Strengths

● Representation of practices at all Representation of practices at all different types of facilities in the USdifferent types of facilities in the US

● State and regional analyses can be State and regional analyses can be donedone

● Routine, recurring administrationRoutine, recurring administration Trend analysis is possibleTrend analysis is possible Predictability – facilities will come to Predictability – facilities will come to

expect the surveyexpect the survey

16

mPINC DimensionsmPINC Dimensions

● Labor and delivery careLabor and delivery care

● Postpartum carePostpartum care Breastfeeding assistanceBreastfeeding assistance Contact between mother and infantContact between mother and infant Feeding of breastfed infantsFeeding of breastfed infants

● Discharge careDischarge care

● Staff trainingStaff training

● Structural and organizational Structural and organizational aspects of care deliveryaspects of care delivery

15

MethodologyMethodology● 52 questions52 questions

36 categorized into the 7 maternity 36 categorized into the 7 maternity practice dimensionspractice dimensions

● Points assigned to responses to every Points assigned to responses to every questionquestion Higher points for practices supportive of Higher points for practices supportive of

breastfeedingbreastfeeding

● Dimension scores: average of points Dimension scores: average of points for each item in the dimensionfor each item in the dimension

● Composite quality scores: average of Composite quality scores: average of dimension scoresdimension scores 18

ResultsResults

7

mPINC Response Rates: mPINC Response Rates: 2,690 birth facilities 2,690 birth facilities respondedresponded

81.788.4

82

0

10

20

30

40

50

60

70

80

90

100

Per

cent

Hospitals Birth Centers OverallN=2568 N=122 N=2690

20

DC

PR

DC

PR

State Mean Composite Quality Scores (Quartiles), 2007

21

Differences in Composite Differences in Composite Quality Score by Facility Size Quality Score by Facility Size & Type& Type

Number of Annual Births (Facility Size) N

MeanComposite Quality Score

Standard Error

0-249 626 63 0.68250-499 448 60 0.66500-999 548 62 0.58

1000-1999 553 64 0.572000-4999 440 66 0.58

≥5000 71 63 1.51

Facility TypeBirth Center* 121 86 0.85

Hospital† 2546 62 0.27

*1 birth center and 22 *1 birth center and 22 hospitals had no mean total hospitals had no mean total scorescore 22

National Mean Composite Quality National Mean Composite Quality Scores and Dimension SubscoresScores and Dimension Subscores

0

20

40

60

80

100

Composite

Labor & Delive

ry

BF Assistance

Mother-Newborn Contact

Postpartu

m Feeding

BF Support >Discharge

Staff Training

Structu

ral/Org'l

23

Lowest Score: Lowest Score: BF Support After DischargeBF Support After Discharge

● Mean US score: 40 out of 100Mean US score: 40 out of 100

● Questions:Questions: Does facility provide gift bags Does facility provide gift bags

containing infant formula to containing infant formula to breastfeeding mothers upon breastfeeding mothers upon discharge?discharge?

Types of BF support provided to Types of BF support provided to mothers upon dischargemothers upon discharge

24

Are discharge packs containing Are discharge packs containing infant formula samples given to infant formula samples given to breastfeeding mothers?breastfeeding mothers?

Yes

No

25

Types of BF Support Provided Types of BF Support Provided After DischargeAfter Discharge

0

20

40

60

80

100

PP follo

w-up vis

it at fac

ility

PP ho

me vis

it

PP Pho

ne ca

ll by s

taff

PP ph

one # for p

atien

t

Refer

rals

26

Newborn Feeding: Newborn Feeding: Supplementation of bf Supplementation of bf newbornsnewborns

0

10

20

30

40

50

Non Breast Milk(at least half)*

Water (any) Glucose Water(any)

*Percent of facilities that supplement at least half of all healthy, full-

term breastfed newborns with something other than breast milk 27

Benchmark ReportsBenchmark Reports

● Mailed individually to people at each Mailed individually to people at each respondent hospitalrespondent hospital

● Multipurpose documentMultipurpose document Customized, detailed survey informationCustomized, detailed survey information Intervention strategyIntervention strategy

• Raise awarenessRaise awareness• Provide motivators for changeProvide motivators for change• Identify barriersIdentify barriers

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Customized, detailed Customized, detailed survey informationsurvey information

● Composite Quality Practice ScoreComposite Quality Practice Score Subscores for each dimensionSubscores for each dimension Composite and Subscore PercentileComposite and Subscore Percentile

• NationalNational• StateState• Similar sizeSimilar size

For each item:For each item:• Measure, rationale, explanation, ideal, Measure, rationale, explanation, ideal,

actual, scoreactual, score

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Benchmark Report Target Benchmark Report Target AudiencesAudiences

Hospital:Hospital: CEOCEO Director of Quality Director of Quality

Assurance/ImprovementAssurance/Improvement Director of ObstetricsDirector of Obstetrics Director of PediatricsDirector of Pediatrics Mother Baby Nurse ManagerMother Baby Nurse Manager Key InformantKey Informant

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

30

31

Preliminary Plan for 2008-2009Preliminary Plan for 2008-2009

● Summer & Fall, 2008 - submit OMB Summer & Fall, 2008 - submit OMB package requesting 2009 surveypackage requesting 2009 survey

● Fall & Winter, 2008Fall & Winter, 2008 Disseminate state-based reports of Disseminate state-based reports of

aggregate dataaggregate data October – Present findings at APHAOctober – Present findings at APHA Create 2009 surveyCreate 2009 survey

● Ongoing – preparation of manuscripts for Ongoing – preparation of manuscripts for peer review publicationspeer review publications

35

32

Measure Rationale ExplanationIdeal

ResponseYour

ResponseYour Score

Initial skin-to-skin contact

Skin-to-skin contact is beneficial because it improves infant ability to establish breastfeeding.9

This measure reports how many patients experience mother-infant skin-to-skin contact for at least 30 minutes within 1 hour of vaginal birth.

Most Many 70

This measure reports how many patients experience mother-infant skin-to-skin contact for at least 30 minutes within 2 hours for Cesarean birth.

Most Few 0

Initial breastfeeding

opportunity

Early initiation of breastfeeding is beneficial because it increases overall breastfeeding duration & reduces a mother’s risk of delayed onset of milk production.10

This measure reports what percent of patients have the opportunity to breastfeed within 1 hour of uncomplicated vaginal birth

≥90 75 70

This measure reports what percent of patients have the opportunity to breastfeed within 2 hours of uncomplicated Cesarean birth.

≥90 40 30

Routine procedures performed skin-to-skin

Performing routine infant procedures & assessments without separating mother & infant is beneficial because it improves breastfeeding outcomes by reducing unnecessary separation of mother & infant & increases infant stability. It is safe for mother & infant to perform these procedures skin-to-skin.11,12

This measure reports how often patients have routine infant procedures performed while mother & infant are skin-to-skin.

Almost always

Rarely 0

Labor and Delivery Care Score 3433

Accessing Information Accessing Information About mPINCAbout mPINC

● www.cdc.gov/mpincwww.cdc.gov/mpinc

● MMWR publication – June 13, 2008MMWR publication – June 13, 2008

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AcknowledgementsAcknowledgements

Elizabeth AdamsElizabeth Adams

Mary ApplegateMary Applegate

Karin CadwellKarin Cadwell

Jennifer CohenJennifer Cohen

Andrea Crivelli-KovachAndrea Crivelli-Kovach

Eugene DeclercqEugene Declercq

Jennifer DellaportJennifer Dellaport

Ann DiGirolamoAnn DiGirolamo

Mary Kay DuganMary Kay Dugan

Laurie Feldman-WinterLaurie Feldman-Winter

Alla GrinblatAlla Grinblat

Carol MacGowanCarol MacGowan

Diane ManninenDiane Manninen

Anne MerewoodAnne Merewood

Eileen MilesEileen Miles

Paulette MurphyPaulette Murphy

Molly PesslMolly Pessl

Barbara PhilippBarbara Philipp

Celia QuinnCelia Quinn

Ken RosenbergKen Rosenberg

Kelley ScanlonKelley Scanlon

Andrea SharmaAndrea Sharma

Amy SpanglerAmy Spangler

Laurie TiffinLaurie Tiffin

Cynthia Turner-MaffeiCynthia Turner-Maffei

36

Thank you!Thank you!

www.cdc.gov/breastfeedingwww.cdc.gov/breastfeeding

www.cdc.gov/mpincwww.cdc.gov/mpinc

Laurence Grummer-Strawn Laurence Grummer-Strawn LXG8@cdc.govLXG8@cdc.gov

Deborah Dee Deborah Dee ddee@cdc.govddee@cdc.gov

Kat Shealy Kat Shealy kshealykshealy@@cdccdc..govgov

37