Public Comments

CDC Response to Public Comments and Recommendations on
Federal Register Notice [60day-09-0743]
Vol. 74, No. 21, pp. 5936-5937
Issued February 3, 2009
This report summarizes the characteristics and content of comments and recommendations that
CDC received and responded to after publishing the 60 Day Federal Register Notice (FRN) of
the proposed data collection, Assessment and Monitoring of Breastfeeding-Related Maternity
Care Practices in Intra-partum Care Facilities in the United States and Territories.
Between February 3, and March 25, 2009, CDC received 84 comments and recommendations to the
60 Day Federal Register Notice. Public comments expressed support for the proposed data
collection, sought further information about the methodology, or provided suggestions as to how to
expand or enhance the information collection.
CDC received comments on behalf of 51 different organizations and 33 individuals across the
United States. Comments addressed a wide range of aspects of the survey, including the act of
completing the survey, the utility of receiving individualized results, the impact on hospital
administrators and other stakeholders, and suggested additions or enhancements for future surveys.
Organizations that commented included local hospitals and clinics, universities, manufacturers, and
local, state, national, and international advocacy organizations, as well as state and local public
health agencies. Individual commenters included physicians, midwives, nurses, dieticians, health
educators, physical therapists, lactation consultants, epidemiologists, peer counselors, and mothers.
Each comment was logged, reviewed, and analyzed prior to receiving a response from CDC. The
comment log also allowed for synthesis of the content and recommendations in each comment,
identification of trends, similarities, and relevant commenter characteristics, and follow-up
monitoring. Each commenter received an email response from CDC expressing gratitude for their
input. In addition, CDC consulted subject matter experts for technical assistance in providing more
specific follow-up when necessary.
As a group, the comments to this FRN provided a rich understanding of the impact of this particular
proposed data collection. These comments demonstrated that people across the United States are
deeply aware of the public health importance of quality intrapartum clinical care and recognize the
inextricable relationship between maternity practices and infant nutrition and care. Individually,
these comments illustrated the wealth of compassionate and experienced clinical and public health
experts across the United States who support mothers and babies and improve health outcomes
nationwide. In particular, CDC was truly inspired by the perceptive insight of actual respondents to
the 2007 mPINC survey, as well as the wide range of individuals whose lives and work are touched
by CDC’s administration, analysis, and dissemination of findings of the mPINC survey.
The volume of comments received in response to this Federal Register Notice is unprecedented and
represents a vast breadth of viewpoints. Despite the wide range of perspectives, the consistent
theme throughout the comments is an urgent recommendation that CDC repeat the mPINC survey.

Summary of Public Comments
and CDC Response

Appendix B-2

page 1 of 7

Demographic Characteristics
Comments and recommendations were received from clinical health organizations, public health
agencies, health advocacy groups, universities, manufacturers, and individuals. The majority of
commenters (87%) identified either their organization or individual affiliation by background,
professional training, or field of work.
Three quarters of those who provided affiliation information indicated multiple types of
professional preparation. CDC analyzed the comments from these individuals and determined a
primary professional affiliation for each, based on the nature and scope of their comments.
Figure 1 illustrates the distribution of
comments received to the FRN by
organization.

Figure 1: Distribution of Commenters to 60 Day FRN
Hospital Systems
Hospitals

Black bars represent entities that directly
participate in the mPINC survey.

2007 mPINC Survey Respondents
Private Practices
Human Milk Bank

Hospital systems – Determine care practices across all
hospitals within the system, are able to effect system-wide
change using mPINC data, are one of the primary audiences
for facility-level data.

State Health Dept
Local Health Dept

Hospitals – mPINC survey unit of analysis, one of the
primary audiences for facility-level data.

WIC Agencies

2007 mPINC Survey Respondents – Staff members
who complete the mPINC survey on behalf of their facility,
responses to the survey are a reflection of usual practice
facility-wide. Respondents provide particular insight into the
feasibility, utility, and impact of providing the information
and receiving facility-specific results.

University/Coop Extension
Manufacturers

Grey bars are used for all other
commenters.

Nat'l Health Professional Ass'n
State Health Advocacy Grp
Local Health Advocacy Grp

0

2

4

6

8

10

12

14

Number of Comments Received (total=84)

Figure 2 shows the distribution of comments
received to the 60 Day Federal Register Notice by
primary professional affiliation.
Figure 2: Distribution of Commenters’ Affiliations

Figure 3 illustrates that 100% of identifiable comments
came from the Health Sector. Fully 85% were clinically
trained medical professionals.
Figure 3: Health Sectors Represented
Public

Nurses
La Leche League
Leaders

Clinical

39%

Medical

Physicians

Care

14%

1%

85%

Physical Therapists

Health
10%
Mothers
5%

1%
PhD/DrPH
3%
Health Educators
3%

Lactation
Consultants

Mothers
4%

18%

MPH
4% Midwives
5%

Dieticians
8%

Summary of Public Comments
and CDC Response

Appendix B-2

page 2 of 7

16

Organization Characteristics

Table 1: Organizational Comments and Recommendations, by Category
12 Hospitals & Clinics

62% of comments and recommendations
received were submitted on behalf of
specific organizations.
All organizational comments were either
positive or neutral toward the proposed
data collection.
•

•

98% commented on the need to improve
maternity practices, the importance of data
to improve care, or urged renewal of the
mPINC survey.
2% sought further information or detail
about the proposed data collection.

“It is [our] hope that CDC will repeat the mPINC
survey in 2009.
This survey provides invaluable information about
real practices affecting breastfeeding in hospitals
across the country.”
Pennsylvania Hospital

Battle Creek Health System – Michigan
Brattleboro Memorial Hospital – Vermont
Family Birthplace Memorial Hospital – Florida
Mill River Pediatrics – Rhode Island
Miller Children's Hospital – California
North Suburban Medical Center – Colorado
Orange Regional Medical Center – New York
Pennsylvania Hospital – Pennsylvania
Piedmont Medical Center – South Carolina
St. Joseph Mercy Hospital – Michigan
St. Mary's Health Center – Missouri
Three Rivers Community Hospital – Washington

5 State Public Health Agencies
California Department of Public Health
Hawai'i Department of Health WIC Services
New Jersey Department of Health and Senior Services
Oregon Public Health Division Office of Family Health
South Carolina Department of Health

4 Local Public Health Agencies
City of Long Beach Nutrition Services Division, WIC Program – California
Tuolomne County Health Department WIC Program – California
Lexington-Fayette County Health Department – Kentucky
Haskell County Health Department – Oklahoma

2 Universities
University of California San Diego School of Medicine
University of Nevada Cooperative Extension

13 National & International Organizations
“Please consider continuing to collect data
regarding breastfeeding support in hospitals.
At our facility we found this data important for
supporting programs, identifying where we need
to do better, and how we compare.”
Battle Creek Health System

“Our organization works in partnership with
public and private organizations training
hundreds of health professionals annually.
The [2007] mPINC survey generated a great deal
of interest in monitoring and improving practices
among our trainees. We hope that CDC will
continue this landmark study to generate more
impetus for change throughout US hospitals.”
Healthy Children Project

“On behalf of the Association of Women’s Health,
Obstetric and Neonatal Nurses (AWHONN)…I strongly
urge that the [mPINC] survey be continued in 2009 and
beyond.
AWHONN is a national membership organization
representing 23,000 nurses and it is our mission to
promote the health of women and newborns”

Association of State and Territorial Public Health Nutrition Directors (ASTPHND)
Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN)
Baby-Friendly USA
Breastfeeding Coalition of the Uniformed Services
Bright Future Lactation Resource Centre
Coalition for the Improvement of Maternity Services
International Formula Council
Healthy Children Project
Lamaze International
Medela, Incorporated
National Alliance for Breastfeeding Advocacy
United States Breastfeeding Committee
Wellstart International

11 State Organizations
California WIC Association
District of Columbia Breastfeeding Coalition
Florida Breastfeeding Coalition
Illinois State Breastfeeding Task Force
North Carolina Breastfeeding Coalition
New Hampshire Breastfeeding Task Force
New York Statewide Breastfeeding Coalition
South Carolina Breastfeeding Coalition
Tennessee Lactation Coalition
Texas Breastfeeding Coalition
Utah Breastfeeding Coalition

4 Local Organizations
Breastfeeding Task Force of Greater Los Angeles – California
Greater Miami Valley Breastfeeding Coalition – Ohio
Inland Empire Breastfeeding Coalition – California
Tri County Breastfeeding Connection – Ohio

Association of Women’s Health, Obstetric and Neonatal Nurses

Summary of Public Comments
and CDC Response

Appendix B-2

page 3 of 7

Geographic Characteristics – National Representation
Nearly three-fourths (73%) of commenters identified the state in which they resided. In 45% of all
state-identified comments, CDC received multiple supportive comments from a given state.
Figure 4 illustrates that comments with identifiable state locations represented 29 of the US states.

Black shading illustrates that one
quarter of all comments described
utilization or impact of 2007 mPINC
data on improving care in their setting.

Grey shading show that nearly half
(48%) of the comments with state
identification indicated statewide
support for administration of the
mPINC survey.

Numbers in each shaded state describe
how many comments were received
from that state.

Each State Health Department receives funding through the Federal Title V Maternal Child Health
Block Grant. Regional collaboration is a fundamental aspect of this funding mechanism.
Additionally, breastfeeding promotion and support is a core element of the Title V program.
Figure 5 illustrates the 10 HRSA MCHB Title V regions.

This map illustrates that the states
from which comments were received
fully represent all 10 HRSA MCHB
Title V regions.

Summary of Public Comments
and CDC Response

Appendix B-2

page 4 of 7

Geographic Characteristics – State Comments
Comments with state identification were 18% more likely to come from states with low
breastfeeding rates (below the national mean for breastfeeding initiation i ) than from states with
higher rates.
Figure 6: Geographic Distribution of Comments by State Breastfeeding Rates and
40%

Figure 6 illustrates the distribution of
comments across states in quintiles of
breastfeeding rates and state 2007 mPINC
scores.

2007 mPINC Scores

Comments were received from 60% of the
states whose breastfeeding initiation rates fall
in the 4th and 5th quintiles, indicating
breastfeeding rates lower than the national
average.
3 comments were received from states where
less than half of all new mothers are
supported to begin breastfeeding.

Percent of Comments Received

35%

% of All Comments Received
% of Quintile Represented by Comments

30%
25%
20%
15%
10%
5%
0%
1st

2nd

(bf rate)(mPINC)

Table 2: Number of Comments, Breastfeeding Initiation
Ranks, and 2007 mPINC Ranks, by State*

State

California
Ohio
New York
Massachusetts
South Carolina
District of Columbia
Florida
Vermont
Mississippi
North Carolina
Michigan
Pennsylvania
Texas
Kentucky
Tennessee
Missouri
Wisconsin
Oklahoma
Rhode Island
Illinois
Georgia
New Jersey
New Hampshire
Nevada
Colorado
Hawai'i
Oregon
Washington
Utah

State
Number of Breastfeeding State 2007
mPINC Rank
FRN
Rank
Comments
(out of 25**)
(out of 51)

9
6
4
4
3
3
3
3
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

7
43
20
15
40
33
32
17
49
41
35
31
16
50
47
39
38
36
30
29
27
23
22
14
9
5
3
2
1

8
10
10
4
20
3
9
1
24
16
13
16
19
20
20
14
8
20
2
17
21
17
1
20
11
15
5
6
16

3rd

(bf rate)(mPINC)

(bf rate)(mPINC)

4th
(bf rate)(mPINC)

State Quintiles

“The [mPINC] survey results have facilitated our work
encouraging hospitals to improve their support for women who
want to breastfeed.”
Oregon Public Health Division Office of Family Health

“Nevada has such a low score, [with the results from the 2007
mPINC survey] we were able to stimulate interest in improving
our status.
I wholeheartedly support the proposed data collection
strategies for the 2009 mPINC survey.”
University of Nevada Cooperative Extension

“The mPINC survey has led many institutions to question their
current maternity practices (which are not evidence-based).
Renewing the mPINC survey may encourage other institutions
to seek [Baby-Friendly] certification.”
Illinois State Breastfeeding Task Force

“The [state] Steering Committee is very anxious to complete
the [2009] survey so that they can report the increased number
of patients who have access to the correct care practices to
support breastfeeding.
We need the mPINC repeat data to validate our research.”
University of Utah Hospital & Utah Breastfeeding Coalition

* States and values in bold represent states with breastfeeding
initiation rates lower than the national average.
**Several states’ mean mPINC scores were tied, states with identical
mean mPINC scores are ranked equivalent.
i

CDC 2005 National Immunization Survey www.cdc.gov/breastfeeding/data/NIS_data/index.htm

Summary of Public Comments
and CDC Response

Appendix B-2

page 5 of 7

5th
(bf rate)(mPINC)

Specific Commenter Group – Survey Respondents
At each intrapartum care facility, an individual staff member completes the mPINC survey on
behalf of the facility in which she or he works. The respondent is selected through a specific
process to identify “the person most knowledgeable about infant feeding” at the facility.
Since the mPINC survey measures practices at the facility level, no personal identifier exists on
the survey instrument itself. This component of the survey demonstrates CDC’s respect for the
individuals who assist by completing the survey, reiterates that the mPINC survey gathers
information about the facility and not the individual who reports on the facility’s behalf, and
increases respondents’ ability to complete the survey instrument
“CDC fulfilled their obligation to
completely honestly.

protect the 2007 respondents – which is

greatly appreciated as respondents
Maintaining respondent anonymity is critically important to the
could have been identified if CDC did
mPINC survey. CDC’s concern and respect for the individuals
not maintain confidentiality as well as
involved precludes publishing each comment in its original form. If
they did.”
Survey Respondent
needed, CDC can provide to OMB directly the original comments.
Representative comments are provided here to illustrate the scope of
comments and retain the commenters’ trust as well as the essence of the comments and
recommendations they provided.
“I participated in the survey and found it easy to
complete.
I would be willing to do it every year if needed!”
Survey Respondent
“Now that administrators see that many things
the mothers have requested actually impact
health results by impacting breastfeeding
success, the hospital is putting greater value on
our efforts to create a breastfeeding supportive
environment.”
Survey Respondent

Themes from Survey Respondents:
1. Participating in the mPINC survey was:
• Straightforward, easy, not an undue burden;
• Helpful as an internal opportunity to assess practices in a way that was
safe;
•

intrapartum care; and
•

“Until now, the administrators didn’t know a
breastfeeding supportive environment really
mattered on a public health level.”
Survey Respondent
“Administrators where I work who are not
usually highly concerned with breastfeeding per
se were very interested to know how our
institution’s mPINC results compared to several
neighboring birth facilities who proudly
reported their results to the local press.”
Survey Respondent

“Thank you for doing all you can to continue
this very important [survey]!
And keep sending the results to the
administration.”
Survey Respondent

Motivating for supervisors, management, and others outside of
Galvanizing for their ongoing quality improvement efforts.

2. The mPINC survey supports and substantiates ongoing efforts of clinical
hospital staff to improve how they care for and support mothers in their
facility.
3. In order to ensure accuracy of the data reported, the survey must be
completed by the person most knowledgeable about infant feeding and
lactation services in the facility.
4. There are many possible enhancements or expansions that could be done
with the mPINC survey, as many more aspects of infant nutrition and care
beyond the scope of the current project also need to be assessed and
monitored at the facility level.
5. Hospital staff are eager to participate in this data collection effort and
appreciate CDC’s support of their work.
“Please continue this relatively simple
survey that has, in just one pass, put
some basic care practices that can
profoundly affect breastfeeding success
on the radar of key healthcare
administrators.”

“It is clear to me from my 16 years of work in
one of the largest maternity hospitals in the
country that we as a nation will only reach
goals for breastfeeding when evidence-based
hospital practices are implemented and
monitored to assure policy compliance by all
maternity caregivers.”
Survey Respondent

Summary of Public Comments
and CDC Response

Survey Respondent

Appendix B-2

page 6 of 7

CDC Responses to Comments
The overwhelming majority of commenters wrote to express support or gratitude to CDC for conducting the 2007 mPINC survey and urge its
renewal. After careful review of each individual comment, CDC determined that 5 of the 84 comments (6%) required more specific followup beyond that which was sent to all commenters.

Table 3: Detailed Responses to FRN Comments
Name
Organization

(Comment Number) Comment or Request

CDC Response

(2) Requests copy of report on results of 2007 survey being provided to OMB and confirmation
that methodology and survey for 2009 are identical to 2007.

Sent email providing MMWR report of results of
2007 survey, confirming identical methodology and
survey, and arranging for copy of results report to
be sent concurrent with provision to OMB.

C. B.

(16) Requests copy of data collection instruments and plans.

Outagamie
County Public
Health

Asks: “are there opportunities to report influence of formula advertising, including when the mother
received diaper bags with formula during her pregnancy or after delivery?”

Sent email providing copies of hospital and birth
center data collection instruments and MMWR
report of results of 2007 survey.

R. R.

International
Formula Council

Comments that formula marketing strategies are pervasive across all but 77 hospitals in the US
and strategies provide financial disincentive to consistent support for breastfeeding.
Comments: “The main barrier I see is conflicting recommendations mothers receive from all health care
providers. Even when providers are supportive of breastfeeding, the formula advertisements they allow
to be given to their patients at their office or in the hospitals gives a conflicting message to new mothers.
Also there are many instances during the hospital stay that hospital staff members negatively impact
breastfeeding, most of the time not realizing the long-term effects of their actions.”

R. Y.

(17) Requests copy of data collection instruments and plans.
Comments: “I believe this survey is vital to identifying how well hospitals are providing education and
support re: breastfeeding. A role of the CDC is to identify and establish protocols for prevention and
control of disease processes. So many chronic disorders are influenced by the absence of breastfeeding.
It is clear that women in the United States need greater support and education to successfully
breastfeed. Hospitals can use the results of the survey to make recommendations for policy changes
that will protect, support, and promote breastfeeding.”

Identified survey items and findings related to
distribution of formula advertising and promotional
materials to patients and explained survey
methodology limitation to intrapartum care facilities,
which precludes asking about distribution of these
materials to women prior to their intrapartum
hospital stay.
Sent email providing copies of hospital and birth
center data collection instruments, MMWR report
of results of 2007 survey, and OMB Supporting
Statement B.
Confirmed identical methodology and survey to
2007 mPINC survey.

Suggests: “1/2 hour for survey administration is probably sufficient, as are estimates for the screening
calls. Utilizing a web-based survey tool is a wonderful alternative to a mailed survey. It is good that you
have already developed this methodology.”
B. W.-C.

(19) Comments: “I remain concerned about the lack of access to care faced by breastfeeding women
after hospital discharge. Inconsistent, incorrect, or inadequate breastfeeding advice negatively impacts
breastfeeding duration rates. It is the working poor and middle class women who often find that there is
no help for them once they go home.”
Comments: “Too little goes into educating physicians to actively and accurately manage breastfeeding.
Too little support exists for public policy regarding breastfeeding. In Texas, we’ve lobbied for the past 15
years for bills to remove barriers to breastfeeding. We’ve had aides tell us the formula reps are always
right on our heels, attempting to paint breastfeeding advocates as “fanatics.””

Sent email providing MMWR report of results of
2007 survey and sample facility Benchmark Report.
Identified survey items and findings related to each
of the concerns raised and explained survey
methodology limitation to intrapartum care facilities,
which precludes asking about utilization of IBCLCs
in private physician outpatient office settings.

Requests: “The CDC plays an important role. Please do more to further specific clinical training
regarding breastfeeding management. Please push physicians to hire LCs for their offices.”
R. C.

Orange Regional
Medical Center,
Middletown, NY

(20) Asks: “Who did the survey go to?”
Provides specific suggestions for the 2009 mPINC survey:
“Make it mandatory that all hospitals HAVE to fill out the survey.
Have the survey go to the IBCLC who is practicing there. If there is no IBCLC, that is a problem and you
know then how well the breastfeeding education is going. If need be the manager has to sign off on the
completed form so management is involved.
Ask the question if there is an IBCLC working at the facility and if so, how many hours is she working and
what is the breastfeeding rate in relation to the birth rate.
Make the information public with names of facilities.”
Comments: “Until some of these steps are in place you will not get an accurate count of breastfeeding
mothers and the type of service our facilities are giving. If this is to be a “real survey” then it has to be
counted as such!”

Sent email providing copies of telephone screening
instrument, hospital data collection instrument,
MMWR report of results of 2007 survey and sample
facility Benchmark Report.
Explained CDC’s lack of authority to mandate
survey participation.
Identified indicators of success of current
methodology despite lack of a mandate.
Described mPINC survey design and telephone
screener protocol as a valid method to identify
appropriate survey respondent within each facility.
Identified survey items and findings related to each
of the concerns raised.
Explained mPINC methodology decision to refrain
from publicizing facility identity information.
Confirmed identical methodology and survey to
2007 mPINC survey.

Summary of Public Comments
and CDC Response

Appendix B-2

page 7 of 7