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pdfAssessment and Monitoring of Breastfeeding-Related Maternity Care
Practices in Intrapartum Care Facilities in the United States and Territories
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
2007 mPINC
Results Report
Nutrition Branch
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
May 19, 2009
2007 mPINC Results Report
Appendix C
p 1 of 11
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
2007 Results Report
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
This report summarizes findings from the CDC information collection approved by OMB entitled
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intrapartum Facilities in the
United States and Territories [Control No. 0920-0743] as requested by OMB in the July 17, 2007 Notice
of Action: “In the next submission of this collection to OMB for review and prior to the fielding of the 2009
iteration of the survey, CDC shall provide OMB with a report on the results of the 2007 collection.”
Executive Summary
The wealth of evidence of the many risks of not breastfeeding is now so unequivocal that national
and international health professional organizations, public health agencies, and hospital quality
experts * unanimously recommend exclusive breastfeeding as the standard for infant care.
Prior to 2007, specific maternity care practices in intrapartum facilities had been identified as key
determinants of breastfeeding but no accurate estimates existed of the prevalence or distribution
of these practices across the United States. Effective strategies to address problems in maternity
care practices could not be developed without this information. In 2007, CDC conducted the
survey described in ICR 0920-0743, Assessment and Monitoring of Breastfeeding-Related
Maternity Care Practices in Intrapartum Facilities in the United States and Territories. This
survey came to be known as the mPINC Survey, mPINC stands for Maternity Practices in Infant
Nutrition and Care.
The mPINC survey was sent to every hospital and free-standing birth center in the United States
and Territories that routinely provided intrapartum care, 82% of facilities responded. Among 7
dimensions of care in the survey, facilities scored lowest in hospital discharge care (40/100) and
highest in breastfeeding assistance (79/100). Overall, hospitals scored lower than free-standing
birth centers (62/100 v. 86/100), and the range of mPINC scores corresponded with the range of
breastfeeding rates at the state and regional levels, with lower scores in states with low
breastfeeding rates and vice versa.
CDC published summary findings from the mPINC survey in June, 2008 simultaneous with
launching a public informational website dedicated to the survey and hosting a national
teleconference for state breastfeeding coalition members about the survey and findings. CDC
staff have presented findings from the survey at 5 State Breastfeeding Coalition conferences and 4
national scientific meetings. Partner organizations and agencies have disseminated findings from
the survey as well.
CDC sent customized reports to specific leadership staff at each of the 2,690 respondent facilities.
These Benchmark Reports provided empiric information about the survey as well as the facility’s
detailed survey data benchmarked against peer facilities by state, facility size, and among all
respondents.
The first mPINC survey in 2007 marked an important first step to ensuring that maternity care
that is high-quality and evidence-based is available to all mothers and babies in the United States
because it established national, state, and facility-specific baselines from which improvements in
maternity care practices can be monitored. Continuation of the mPINC survey will enable
clinicians, hospitals, and public health leaders to carry out their work to protect and support
mothers’ and babies’ health nationwide.
*
These partners include: American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists
(ACOG), American Academy of Family Physicians (AAFP), Association of Certified Nurse Midwives (ACNM), Association of
Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Academy of Breastfeeding Medicine (ABM), World Health
Organization (WHO), United Nations Children’s Fund (UNICEF), and National Quality Forum (NQF), among others.
2007 mPINC Results Report
Appendix C
p 2 of 11
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
2007 Results Report
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
Background
Health professionals consistently recommend breastfeeding for at least 12 months1-4 because it
reduces risks for acute and chronic diseases,5 cognitive impairment,6 hospitalization, 7 and
death.7, 8 Still, in 2005 † more than 1 million newborns in the US never breastfed at all.9
Most new mothers in the US hope to breastfeed.10-14 Biologic inability to breastfeed is rare.15
Pivotal experiences in specific environments like hospitals16 shape many infant feeding
behaviors. Improving maternity care practices is patient-centered, 17, 18 evidence-based,16, 19-21
and cost-effective.22, 23
Assessing and Monitoring Maternity Care Practices across the United States
Clinical practice guidelines for quality maternity care24 are not consistently followed.25, 26
However, until recently, there was no reliable way to estimate the extent and scope of this
problem. State health departments, health care providers, and infant feeding experts called on
CDC to address this need.
In 2007, CDC conducted the first national assessment of breastfeeding-related care practices in
intrapartum care facilities. It came to be known as the mPINC, for Maternity Practices in Infant
Nutrition and Care. The survey collected information on facility characteristics, maternity care
policies, staff training on breastfeeding instruction, management and support, and facility
discharge care.
This assessment was designed to provide baseline information in a planned four-year project and
to be repeated again in 2009. The selected methodology was the outcome of detailed input and
collaboration with external experts representing the diverse stakeholder groups for whom the
information is most important. The experts represented health care providers and administrators,
state health departments, and infant feeding experts and researchers.
They unanimously urged CDC to survey every facility in the U.S. and territories that routinely
provides maternity care, regardless of size, ownership, payer status, or other selection criteria, in
order to most effectively meet their needs. The resulting census design allowed CDC to provide
state-specific data and to create facility-level reports utilizing individual facilities’ data
benchmarked against their peers.
The 2007 mPINC survey was mailed to every hospital (n=3143) and free-standing birth center
(n=138) in the United States and Territories that routinely provided intrapartum care. Eligibility
was determined with a screening telephone call to verify the facility had registered maternity
beds.
In June, 2008, CDC launched a comprehensive website dedicated to the mPINC Survey.
The website www.cdc.gov/mpinc has a wide variety of resources for researchers, health care facility personnel,
public health professionals, and individuals.
Resources on the website include:
• Downloadable survey instruments, handouts about the survey, and comprehensive data tables;
• Information about the background, rationale, results, and future plans for the mPINC survey; and
• Links to related breastfeeding data.
†
The most recent year for which national breastfeeding data are available. Source: CDC National Immunization Survey
2007 mPINC Results Report
Appendix C
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Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
2007 Results Report
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
CDC Survey Documents National Need for Action
Fully 82% of all hospitals and birth centers responded to the CDC mPINC survey. These
facilities vary broadly by size and type. Facility types included urban/rural; profit/non-profit;
teaching/non-teaching; private/public; and serving economically disadvantaged
populations/serving high SES.
To facilitate reporting on the findings, results were scored on a 0-100 scale and were calculated
at the facility and state levels. Composite scores were made up of seven subscores that relate to
specific dimensions of care in the maternity setting.
Each facility or state’s mPINC Composite Score comprised the mean of their score on:
•
•
•
•
•
•
•
Labor and Delivery Care,
Feeding of Breastfed Infants,
Breastfeeding Assistance,
Contact Between Mother and Infant,
Facility Discharge Care,
Staff Training, and
Structural and Organizational Aspects of Care.
State mPINC scores were found to correlate with national and state breastfeeding rates. This
provides reassurance that the measurement in the mPINC survey is a real reflection of the
intended measures, as it indicates that the observed differentiation in scores is likely related to
breastfeeding outcomes.
Facilities’ performance was not uniform. Facility mean composite and subscale scores varied by
facility location, type, size, and patient population. Hospitals had lower scores than birth centers.
Larger facilities had higher scores on Staff Training and Structural and Organizational Aspects
of Care but lower scores on Labor and Delivery Care and Postpartum Contact Between Mother
and Infant. Facilities with higher c-section and epidural rates had the lowest scores.
Scores varied widely across states. State mPINC scores ranged from 48 in Arkansas to 81 in
New Hampshire and Vermont. Western and New England states had the highest scores;
Southern states had the lowest, especially Southeastern states. See Table 1, on the following
page, for the distribution of state scores.
The major findings from the 2007 mPINC Survey, including state-by-state analyses, are the lead article the June 13,
2008 CDC publication, Morbidity and Mortality Weekly Report.27
This report: DiGirolamo A, et al. Breastfeeding-related maternity practices at hospitals and birth centers--United States,
2007. Morb Mortal Wkly Rep 2008 June 13;57(23):621-5 is available in print and online.
CDC includes a direct hyperlink to the report both on the main CDC breastfeeding website www.cdc.gov/breastfeeding
and on the mPINC site www.cdc.gov/mpinc. This publication is also attached at the end of this report.
2007 mPINC Results Report
Appendix C
p 4 of 11
2007 Results Report
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
Table 1: Mean total and subscale 2007 mPINC scores by state mean total. (adapted from MMWR article)
Mean Subscale Scores
Mean
Score
State
New Hampshire
Vermont
Rhode Island
Maine
District of Columbia
Massachusetts
Oregon
Alaska
Washington
Connecticut
Wisconsin
California
Wyoming
Florida
Ohio
New York
Colorado
Idaho
Minnesota
New Mexico
Michigan
Montana
Delaware
Missouri
Arizona
Indiana
Hawaii
Iowa
Pennsylvania
South Dakota
Virginia
North Carolina
Maryland
Utah
Illinois
New Jersey
North Dakota
Kansas
Texas
South Carolina
Nebraska
Nevada
Kentucky
Tennessee
Oklahoma
Georgia
Puerto Rico
Alabama
Louisiana
West Virginia
Mississippi
Arkansas
United States
81
81
77
77
76
75
74
72
72
70
69
69
68
68
67
67
66
65
64
64
64
63
63
63
62
62
62
61
61
61
61
61
61
61
60
60
59
58
58
57
57
57
57
57
57
56
55
55
54
54
50
48
63
2007 mPINC Results Report
(Resp
Rate%)
(92)
Labor/Delivery
82
Assistance
90
Contact
85
Feeding
88
Discharge
72
Training
63
Organization
83
(92)
89
95
81
92
72
63
74
(71)
64
93
72
86
75
68
85
(91)
78
89
79
85
69
66
78
(57)
89
90
73
80
53
71
80
(77)
72
86
72
87
61
72
79
(95)
76
86
85
87
57
49
71
(100)
79
81
91
82
69
34
60
(88)
77
86
90
83
53
43
64
(77)
73
84
72
91
31
66
74
(90)
68
85
71
81
51
51
74
(80)
63
82
78
77
49
61
70
(83)
78
80
77
83
46
48
62
(75)
64
84
77
77
44
56
70
(89)
59
83
68
79
48
55
75
(75)
61
84
66
77
48
57
76
(86)
65
80
78
84
33
53
70
(81)
68
83
81
78
35
46
69
(84)
62
82
71
75
54
41
65
(67)
54
81
77
74
48
49
60
(79)
63
81
74
78
33
47
68
(88)
65
77
75
75
41
46
59
(100)
47
81
78
86
34
39
72
(81)
61
79
70
79
32
55
66
(71)
58
80
75
75
34
52
62
(88)
60
81
69
76
31
49
66
(75)
79
76
83
80
14
38
60
(91)
50
78
67
76
44
44
64
(87)
54
80
62
77
37
50
68
(83)
56
79
68
78
36
45
67
(82)
53
78
61
79
32
58
67
(84)
54
81
67
76
31
53
68
(81)
55
79
69
76
26
48
69
(79)
67
77
68
79
26
48
64
(59)
48
78
64
74
35
54
67
(77)
47
82
58
72
25
62
72
(94)
59
80
65
72
31
47
62
(90)
57
74
75
76
35
38
54
(75)
52
73
65
66
35
52
59
(86)
47
74
57
66
41
48
62
(80)
60
74
74
72
32
30
53
(65)
52
75
71
74
29
42
59
(78)
52
76
59
69
28
53
63
(88)
53
74
62
72
26
47
62
(82)
57
74
70
71
21
47
58
(81)
48
75
64
70
25
50
63
(36)
41
74
61
48
42
58
53
(87)
45
71
55
69
27
53
63
(82)
44
75
51
59
33
54
61
(84)
53
76
58
69
25
44
58
(84)
42
69
49
63
28
43
55
(60)
43
67
58
62
24
29
53
(82)
60
80
70
76
40
51
66
Appendix C
p 5 of 11
2007 Results Report
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
Maternity Care Practices Vary Widely Across Dimensions
Scores on the 7 dimensions of care that contributed to overall scores ranged from 40 to 79.
Feeding supplementation
is excessive:
Staff training
is inconsistent:
h One quarter of all facilities and 1 out of 3 large hospitals routinely
supplement normal, healthy, full-term breastfed infants.
h The national average facility subscore was only 51 out of 100.
h Fewer than half of large hospitals and less than one in ten small
hospitals provide ≥9 hours of training to new staff.
h Hospitals that scored higher on staff training were:
•
•
•
•
•
Unnecessary separation
is common:
Discharge support
is inadequate:
Better policies
are needed:
Located in New England,
Located along the Pacific coast,
Larger hospitals,
Teaching hospitals,
Level 3 neonatal intensive care unit centers.
h Large hospitals and those in the Southeast are more likely to separate
mothers and infants, and to keep them apart for longer periods of time.
h Healthy, full-term infants that are born in hospitals that also provide care in
neonatal intensive care units are least likely to be brought to their mothers
to breastfeed at night.
h The national average facility subscore for discharge care is the lowest of
all seven subscales, at only 40 out of 100.
h Distribution of formula marketing samples to breastfeeding mothers is
pervasive across all geographic areas.
h Although breastfeeding policies commonly exist in hospitals, most are
limited in scope.
h Few hospital breastfeeding policies address exclusive breastfeeding and
pacifier use.
Figure 1: Percent of facilities reporting
insufficient training, by facilitygpractice
INADEQUATE NEW
Figure 2: Percent of facilities reporting
excessive supplementation, by facility practice
q
P e r ce n t o f f a c ilit ie s re p o r ti n g e a c h p ra ct ic e
94.4%
STAFF TRAINING
> 50% G ET
PR EL AC T EA L
FEED S
INADEQUATE
EXISTING STAFF
TRAINING
75.6%
>5 0 % G E T
FEW STAFF
TRAINED IN LAST 12
mo.
8 .8 %
S U PP L EM EN T
40. 7%
NO ANNUAL
CO MPETENCY
ASSESSMENT
S U P P w/
56.5%
H 2 0 /G L U C O S E H 2 0
Percent of facilities reporting each practice
2007 mPINC Results Report
Appendix C
2 4 .2 %
1 4 .8 %
p 6 of 11
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
2007 Results Report
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
Quality Assessment and Reporting Supports Local Autonomy
One of the goals of the mPINC survey is to provide data to empower stakeholders to improve maternity care
practices in the way that best meets their needs. Diverse reporting maximizes data utility for hospitals and birth
centers, clinical health professionals, public health professionals, advocacy groups, and ultimately mothers and
babies.
Interest in the survey is
unprecedented:
h
h
The response rate was ≥90% in 1 out of every 5 states.
Respondents were interested in the survey, eager to participate, and appreciated CDC
providing them with urgently needed information:
“Thank you for continuing to support studies of breastfeeding rates in the US.
All information gathered will enhance our nation's support for a more healthy
lifestyle.
The methodology for gathering the statistical information was not bothersome
and we would be happy to contribute on any level needed. The importance of
raising our national breastfeeding initiation and duration rates cannot be denied.
Please continue with this published data!”
– D.D., RN, IBCLC
Thornton, Colorado
h
National organizations and experts that have been underrepresented in the work to
improve maternity care practices related to breastfeeding have sought out more
information about the mPINC survey:
– The Institute for Healthcare Improvement (IHI)
– The American Hospital Association (AHA)
– The National Quality Forum (NQF)
– The National Association of County and City Health Officials
(NACCHO)
– The American Medical Association (AMA)
– The Indian Health Service (IHS)
The census design
is essential:
h
Reporting expands
utility of the data:
h
The breadth of reporting activities reflects CDC’s audience-driven approach and
highlights the unique ways this survey has already begun to inspire quality improvement
efforts nationwide.
“My dissertation was conducted on practicing obstetricians in Mississippi and their
involvement in breastfeeding education and support.
I continue to report my findings with CDC findings on this important health care issue
at national and regional meetings for health care professionals as well as educators in
the public school systems.”
– L.C.Mc., PhD, CHES, IBCLC, LLL
Starkville, Mississippi
Respondents anticipate
a 2009 survey:
h
The 2007 baseline assessment is part of a planned project to be repeated again in 2009.
“I am writing to support the continued survey of breastfeeding-related maternity
care practices. The initial surveys have already raised the awareness of the
importance of changing practices…Healthcare providers who experience the
changes in the hospital setting will be more motivated to make the changes
that they can implement in the post discharge period.”
– L.R.V., MD, Pediatrician
Pawtucket, Rhode Island
2007 mPINC Results Report
h
Assessing all facilities allows for authentic, localized comparisons between different
states, regions, and types of facilities.
Universal reporting allows CDC to provide meaningful data back to facilities and states
through a formalized benchmarking process.
Appendix C
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Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
2007 Results Report
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
CDC Builds New Quality Improvement Action Tools
CDC continually seeks to maximize the utility of the data for all stakeholder groups by creating and
carrying out tailored activities for them. These groups include hospitals and birth centers, clinical health
professionals, public health professionals, advocacy groups, who all ultimately serve mothers and babies.
The breadth of these activities reflects this audience-driven approach and highlights some of the unique
ways this survey has already begun to improve the quality of maternity care provided nationwide.
CDC launched a set of coordinated, multifaceted activities simultaneously to generate better awareness
and interest in the issues that were assessed in the mPINC Survey.
•
A national teleconference for every state breastfeeding coalition provided background
and data from the survey as well as an overview of future dissemination plans and their
role in improving maternity care practices.
•
The CDC home web page featured the issue as one of five public health priorities for the
week. The primary audience for CDC web features is the lay public and public health
professionals. This feature also directed readers to the newly published MMWR (see
attached) reporting both U.S. and state findings from the survey.
•
CDC incorporated the mPINC scores into the annual CDC Breastfeeding Report Card
that highlights policy and environmental support for breastfeeding at the state level. This
provided an opportunity to further assist hospitals, states, and breastfeeding coalitions to
interpret and use their data most effectively and to reach different types of audiences than
had previously been reached.
•
CDC launched a dedicated web site www.cdc.gov/mpinc to facilitate access to
information about the survey and findings for the broader public. This has provided a
venue for CDC to efficiently update and expand information sharing efforts.
The CDC Web Spotlight on the mPINC survey was the most heavily visited CDC site in the 12 months prior. It
generated more than twice as many hits as the next most widely visited site in that same time frame.
The Associated Press and Reuters developed stories based on the MMWR report that were featured in National
Public Radio, New York Times, Los Angeles Times, Washington Post, CNN, MSNBC, and NBC Today Show.
Benchmark Reports
CDC mailed 15,778 individualized reports (sample attached) to the 2,690 facilities that
responded to the survey. These were created to help hospital leadership better understand the
areas in most need in their facility, provide data and scientific rationale for each area, and enable
them to take on their own issues.
The Benchmark Reports also provided an opportunity for CDC to thank facilities for
participating and announce the dedicated email address [email protected] . This email address
was established to facilitate input back to CDC and provide an easy way for respondents to
inform us of problems or other feedback they wished to share.
Data from the survey are being used to create customized state-level reports to key decisionmakers (state health departments, health professional and hospital administrator organizations,
medical boards, etc.). These reports are being structured specifically to respond to the challenges
this diverse audience has identified and meet their unique needs in improving care at the state
level.
2007 mPINC Results Report
Appendix C
p 8 of 11
2007 Results Report
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
The Need for Continued Assessment and Reporting
CDC’s mPINC activities underscore the need for regular and continued national assessment and
monitoring of practices. This demonstrates CDC’s responsiveness to the audiences’ needs and
enables them to maintain quality improvement efforts.
The mPINC Survey was designed as an initial baseline survey with a follow-up two years later.
The survey instruments were designed to capture incremental changes that CDC anticipates will
be taking place at the hospital level. Most facilities have abundant opportunities to improve the
quality of the care they provide to mothers and babies during the maternity stay.
The two-year timeframe for follow-up is ideal because it allows enough time for these changes to
be implemented based on feedback from the prior survey, while being close enough to capture
progress in changes as they are being made. Therefore, the second survey in 2009 will identify
changes in practices over time.
Assessment and Monitoring as an Intervention Strategy – CDC’s Innovative Approach
Feedback from participating facilities underscores the need for an assessment and monitoring system that can also meet the
needs of multiple groups within the hospital system:
“I work in a hospital that has 8000+ births/year and now, thanks to [the CDC mPINC
Survey], the CEO has just realized that breastfeeding is an issue! Bless her!
We’re working hard on education of key administrators since the time seems so ripe to let
them know about [these] practices.
Today, our CEO asked “So what are the barriers here at this hospital?””
– Debbi Heffern, RD, IBCLC
St. Louis, Missouri
“The [Public Relations] people at [our hospital] in Milwaukee, WI (8000 births last year)
want to know if the Maternity Care Practices Survey results will be back out to the hospitals
in time to use for media press during World Breastfeeding Week.
This is the first time we’ve celebrated World Breastfeeding Week, the hospital is now finally
ready to help us with it!”
– Carol Moyer, RN, BSN
Milwaukee, Wisconsin
“Please continue the survey every other year. My hospital took the result seriously and had
us re-score for 2008. Because of these expected standards and our changing our process
we scored higher in almost every section.
I'm proud of [my hospital’s] commitment to excellence in all aspects of patient care and
satisfaction.”
– Camille Foretich, IBCLC/OB Educator
Jackson, Mississippi
2007 mPINC Results Report
Appendix C
p 9 of 11
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intrapartum Care Facilities in the United States and Territories
2007 Results Report
OMB Control No. 0920-0743
Expiration Date: 7/31/2009
Samples of mPINC Publications and Resources Are Attached
National and State mPINC Findings:
DiGirolamo A, Manninen D, Cohen J et al. Breastfeeding-related maternity practices at hospitals and
birth centers--United States, 2007. MMWR Morb Mortal Wkly Rep 2008 June 13;57(23):621-5.
Facility Benchmark Reports:
Centers for Disease Control and Prevention. Maternity Practices in Infant Nutrition and Care (mPINC)
Survey: Quality Practice Measures--2007, Benchmark Report. Atlanta, GA: Department of Health and
Human Services, Centers for Disease Control and Prevention; 2008.
CDC Web Resources:
mPINC Survey: www.cdc.gov/mpinc
Breastfeeding: www.cdc.gov/breastfeeding
2007 mPINC Results Report
Appendix C
p 10 of 11
Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
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Expiration Date: 7/31/2009
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2007 mPINC Results Report
Appendix C
p 11 of 11
| File Type | application/pdf |
| File Title | Survey Report |
| Author | Battelle |
| File Modified | 2009-05-19 |
| File Created | 2009-05-19 |