Expert Panel Report

Final Report

Overview

A panel of experts in evaluation of hospital maternity care practices in the United States met in Orlando, Florida on October 30 and 31, 2003 to discuss the future of assessment and monitoring of maternity care practices related to breastfeeding. CDC convened the meeting specifically to identify current research and surveillance needs, discuss various monitoring methodologies, identify barriers to data collection, and explore future possibilities for national assessment and monitoring. This was the first such meeting, bringing together diverse experts from across the country to help shape a national system of monitoring breastfeeding-related maternity care.

Experts presented findings and experiences from different types of assessment and monitoring approaches. Presenters shared information on construction, implementation, administration, and analysis of surveys of hospital staff. They involved evaluation of hospital maternity care practice, surveys of mothers regarding individual maternity care hospital experiences, chart review of both mother and neonate maternity care experiences, and experiences related to the Baby Friendly Hospital Initiative.

Following the presentations of past experiences, the panel discussed as a group the many dimensions and issues in assessment and monitoring of breastfeeding-related hospital maternity care practices. Discussion focused on necessary and ideal characteristics of a proposed national system for monitoring breastfeeding-related maternity care practices.

This report summarizes the panel’s discussions regarding dimensions and issues in assessment and monitoring of breastfeeding-related hospital maternity care practices.

Background

In the initial portion of the meeting, attendees presented their experiences in construction, completion, and analysis of assessments of maternity care practices at the local and state levels. These presentations provided an overview and framework of work completed to-date in this area, allowing for in-depth discussion of development of the direction of future national monitoring of maternity care practices related to breastfeeding.

Surveillance of Individual Experiences

• Food and Drug Administration (FDA) Infant Feeding Practices Study (IFPS). National longitudinal study assessing various issues related to infant feeding, including maternity care experiences related to breastfeeding.

• Maternity Center Association Listening to Mothers Survey. National study assessing perinatal issues related to childbirth and birthing practices, practices related to breastfeeding were included.

• PRAMS, the Pregnancy Risk Assessment Monitoring System, is a surveillance project of the Centers for Disease Control and Prevention (CDC) and state health departments. PRAMS collects state-specific, population-based data on maternal attitudes and experiences prior to, during, and immediately following pregnancy, including breastfeeding items.

Surveillance of Institutional Policy and Practice

• New York State: This survey has been completed regularly by the Lactation Coordinator with results then copied to both the CEO and chief of neonatology for each facility. The Lactation Coordinator position is mandated by statute in NYS and therefore, every hospital in the state has a Lactation Coordinator.

• Oregon: This survey was completed by the perinatal nurse manager via telephone contact.

• California: This survey was completed by the hospital perinatal nurse manager, who was recommended to gain agreement from lactation staff before submitting the survey.

• Colorado: This survey was completed by a different individual for each facility, appropriate respondents were selected via introductory telephone call to the hospital administrator seeking his/her input as to the most appropriate respondent. As a result, respondents were nurses and other perinatal staff.

• Philadelphia, Pennsylvania: This survey was completed in person, at each hospital site, via committee, the director of maternity services received the initial correspondence about the survey and convened a group of informants related to that facilities perinatal care, including the Lactation Consultant, Labor and Delivery staff, Nursery staff, and Postpartum staff, among others.

• New Jersey: Monitoring was accomplished via representative chart review and complementary qualitative methods. The perinatal coordinator facilitated this work within the hospital, and the chief of neonatology as well as others provided pertinent information.

The detailed discussion focused on a series of dimensions which need to be considered when identifying the most appropriate course of action. Primary dimensions are the scope and unit of assessment, while secondary dimensions include periodicity and response rate requirements, indicators, access to respondents contributing data, research and programmatic access to data generated through the monitoring system, and overall system design. Those dimensions are summarized below.

Scope

Three realistic options for the scope of the monitoring system were discussed. First, the current practice could continue. This practice consists of state or academically generated studies of facilities and practices in circumscribed areas as possible through intermittent funding and interest. More formally, studies of practices within facilities in a given state could be state-administrated using a standard protocol. Data from such a system could be housed and maintained in a variety of ways, including federally, through state health departments, and through various academic institutions. A third and most uniform option of the three is a national survey of maternity care practices. Such a survey would be federally administered.

Attendees agreed that the monitoring system needs to be a recurring national census of facilities routinely providing maternity care. This suggestion was heavily supported by representatives from State health departments, who were concerned that a nationally representative sample of facilities would not allow for state-level analysis to address individual local research and policy needs. Additional concern centered around difficulties in characterizing ‘representative’ facilities given the broad diversity between maternity care facilities.

The panel agreed that no minimum cutoff of ‘maternity beds’ or annual birth census should be utilized, instead all facilities that consider maternity care as part of their routine practice should be included.

Unit of Assessment

Discussion of the monitoring system’s unit of assessment began with attendees sharing their experiences from their previously conducted surveys. Three national surveys assessed mothers’ individual assessments of their maternity care experiences. These surveys assessed many other issues and areas, with maternity care practices making up a small portion of the entire instrument. The remaining assessments analyzed maternity care facilities and the responses provided by key informants at each facility regarding usual practice and hospital policy on maternity care related to breastfeeding. New York State and Oregon both have surveys that have been completed more than once, whereas to-date the remaining surveys were one-time assessments.

The Expert Panel agreed that a variety of staff within each facility must provide input regarding maternity care practices. Suggestions for accomplishing this included contacting the hospital administrator or CEO and requesting distribution of the survey to multiple recipients, sending multiple copies of the survey to one facility, and providing suggested staff types that should provide input prior to returning the survey. Some were concerned about the added burden of multiple viewings of a given survey within a facility. Subsequently, the panel gravitated toward supporting administration of one survey to be completed, with guidance provided as to who should be consulted prior to returning the survey, without a requirement that such cross-disciplinary consultant be completed.

Response Rate

The Expert Panel agreed that high response rate is ideal, and discussed various methods for facilitating a high response rate. The suggestion to follow the model of the CDC Pregnancy Risk Assessment and Monitoring System (PRAMS) for achieving high response rate was made, comprised of two mail administrations and a telephone follow-up for non-responders.

Periodicity

Attendees discussed advantages and disadvantages of more and less frequent administration of the survey. Concern was raised at the prospect of long intervals of many years occurring between survey administrations, as this would make establishment of the monitoring system as an anticipated recurring activity a challenge. Attendees agreed that perceived legitimacy, importance, and consequences of response on the part of pertinent hospital staff were all important factors in establishing the monitoring system as routine. Some concern was raised as to how realistic it might be to expect more frequent administration alone to accomplish this goal, given high turnover among hospital staff and the concomitant losses in institutional wisdom inherent to such turnover. This discussion resulted in general agreement that the survey should be administered every other year, with an understanding that the initial iteration of the survey would involve much learning.

Indicators

In discussing indicators to be included in the survey, attendees focused on the role of the Ten Steps to Successful Breastfeeding. It is challenging to address all Ten Steps through information from either hospital staff or mothers alone, because some steps cannot realistically be answered by only one or the other. Despite inherent difficulties of monitoring adherence to the Ten Steps, attendees agreed that it is important to include items reflecting each of the Steps.

In addition to the Ten Steps, attendees agreed that additional aspects of the hospital maternity stay have been demonstrated to impact breastfeeding, and therefore should be included in the assessment. Examples of these additional aspects are characteristics of labor management, Cesarean section rate, facilitation of skin-to-skin contact between mother and neonate, location of neonate for routine procedures, frequency of standardized assessment of breastfeeding, charting of breastfeeding information, language and cultural barriers, limitations, and accommodations, and other perinatal factors.

Most attendees agreed that patient race/ethnicity information might be inaccurately reported and could be better gained through other means such as State health department statistics. There was interest in learning about proportion of publicly insured patients for a given maternity facility as well as discussion of the difficulties of determining such information in some states.

Access

A major issue in construction of a national monitoring system is identification of the key respondent completing the survey. This issue is not uniform across facilities, as demonstrated by the range of respondents used across various assessments done in various states as well as the methods used to gain access to respondents. It is clear that surveys directed to individual with a single title or occupation will not yield uniform access to respondents across facilities.

The issue of access to resultant data is complex, as hospital-specific data are highly guarded by both individual facilities and organizations representing hospitals and insurers. Some attendees felt that hospital-specific data should be available to state health departments, given that most are responsible for licensing and accreditation issues within the state, while others felt that such data should be retained only as part of the original, complete data set.

There was much discussion about the potential of providing hospital-specific summary data to each pertinent facility with comparisons to other facilities, such as peer hospitals and/or neighboring hospitals. These data could then be used by hospitals for benchmarking and self-assessment of progress on implementation of various practices related to breastfeeding. Several attendees indicated that such data would be desirable to a hospital and be in a familiar format for them, since benchmarking has come to be routine throughout various aspects of hospital care and administration.

Other issues

Following is a list of some of the issues that were raised and not fully resolved. These issues will be further addressed in coming months as development of the plan progresses.

• Could some of the survey be completed via World Wide Web?

• Does there need to be a complementary methodology to assess mothers’ interpretations of their maternity care experience at a given facility?

• What is the best way to identify all facilities routinely providing maternity care services?

• Which existing questionnaire provides the most fitting model?

• How can concerns about the self-reporting nature of this design best be addressed?

• What are realistic opportunities for validation of responses/monitoring of actual practice?

• How can concerns about respondents’ pre-existing ideas about the Baby Friendly Hospital Initiative (which could skew responses and discourage submission of surveys) best be addressed?

• Should there be incentives for survey completion?

• Some of the barriers to collaboration with the Joint Commission for Accreditation of Health Care Organizations (JCAHO) and/or the American Hospital Association (AHA) were discussed, as was the need for identifying strategies to increase endorsement and support for the issue of breastfeeding support during the maternity care stay as a quality of care issue. These issues were unresolved at the conclusion of the meeting.

Conclusion

This meeting encompassed a wide range of issues surrounding maternity care practices and breastfeeding. Most striking was the pervasive interest and enthusiasm for pursuing development of an ongoing, national monitoring system of these practices. Based on continued input from the Expert Panel and ongoing research on this issue, representatives from CDC plan further development of this monitoring system.

Expert Panel Attendees

Elizabeth Adams, PhD

Assistant Professor

Food Science and Human Nutrition

Colorado State University

Fort Collins, Colorado

Mary Applegate, MD, MPH

Medical Director

Bureau of Women’s Health

New York State Department of Health

Albany, New York

Karin Cadwell, PhD, RN, IBCLC

Director

Baby Friendly USA

East Sandwich, Massachusetts

Andrea Crivelli-Kovach, PhD, CHES

Assistant Professor/Director of Community Health Programs

Department of Medical Science and Community Health

Arcadia University

Glenside, Pennsylvania

Eugene Declercq, PhD

Professor

Maternal and Child Health Department

Boston University School of Public Health

Boston, Massachusetts

Jennifer Dellaport, RD, MPH

WIC Breastfeeding Promotion Coordinator

WIC Supplemental Nutrition Program

Colorado Department of Public Health and Environment

Denver, Colorado

Ann DiGirolamo, PhD, MPH

Research Assistant Professor

Department of International Health

Rollins School of Public Health at Emory University

Atlanta, Georgia

Lori Feldman-Winter, MD, IBCLC, FAAP, FABM

Chairman, AAP SOBr Education Committee

Associate Professor of Pediatrics

University of Medicine and Dentistry of New Jersey

School of Osteopathic Medicine

Stratford, New Jersey

Laurence Grummer-Strawn, PhD

Branch Chief

Maternal and Child Nutrition Branch

Division of Nutrition and Physical Activity

CDC

Atlanta, Georgia

Anne Merewood, MA, IBCLC

Director of Research

Breastfeeding Center

Boston Medical Center

Boston, Massachusetts

Barbara Philipp, MD

Associate Professor of Pediatrics

Boston Medical Center

Boston, Massachusetts

Ken Rosenberg, MD, MPH

Maternal and Child Health Epidemiologist

Office of Family Health

Oregon Department of Human Services

Portland, Oregon

Katherine Shealy, MPH, IBCLC, RLC

Public Health Breastfeeding Specialist

Maternal and Child Nutrition Branch

Division of Nutrition and Physical Activity

CDC

Atlanta, Georgia

Laurie Tiffin, MS, RD

Chief

Breastfeeding Promotion Unit

WIC Supplemental Nutrition Branch

California Department of Health Services

Sacramento, California

Cindy Turner-Maffei, MA, IBCLC

National Coordinator
Baby-Friendly USA

East Sandwich, Massachusetts

Expert Panel Meeting Final Report – October 2003Appendix D page 7 of 7