Appx-E_mPINC_Survey_Scoring_Algorithm

Scoring Explanation for the 2007 CDC Maternity Practices
in Infant Nutrition and Care (mPINC) Survey
Labor and Delivery Care
Item #

Measure

Rationale

Explanation

Scoring algorithm

Reports how many patients experience motherinfant skin-to-skin contact for at least 30 minutes
within 1 hour of uncomplicated vaginal birth.

100=Most
70=Many
30=Some
0=Few

A9

Reports how many patients experience motherinfant skin-to-skin contact for at least 30 minutes
within 2 hours for uncomplicated cesarean birth.

100=Most
70=Many
30=Some
0=Few

A6

Reports what percentage of patients have the
opportunity to breastfeed within 1 hour of
uncomplicated vaginal birth

A4
Initial skin-to-skin
contact

A10

A5

Skin-to-skin contact is beneficial because it
improves infant ability to establish breastfeeding.
(1)

Early initiation of breastfeeding is beneficial
Initial breastfeeding because it increases overall breastfeeding duration
opportunity
and reduces a mother’s risk of delayed onset of
Reports what percentage of patients have the
milk production. (2)
opportunity to breastfeed within 2 hours of
uncomplicated cesarean birth.
Performing routine infant assessments skin-to-skin
is beneficial because it improves breastfeeding
Routine procedures
Reports how often patients have routine infant
outcomes by reducing unnecessary separation of
performed skin-toprocedures performed while mother and infant are
mother and infant and increases infant stability. It is
skin
skin-to-skin.
safe for mother and infant to perform these without
separating them. (3, 4)

Labor and Delivery Care
Subscale Score

mPINC Survey Scoring Algorithm

Score represents summary of facility practices
related to labor and delivery.

Appendix E

100=90%+
70=50-89%
30=10-49%
0=0-9%
100=90%+
70=50-89%
30=10-49%
0=0-9%

100=Almost Always
70=Often
30=Sometimes
0=Rarely

Mean of the 5 item scores

Page 1 of 11

Breastfeeding Assistance
Item #

Measure

Rationale

A3

Documentation of
feeding decision

Standard documentation of infant feeding decisions
Reports how often infant feeding decisions are
is important to adequately support maternal choice.
documented in hospital records.
(5)

A12

Breastfeeding
advice &
counseling

The American Academy of Pediatrics (AAP)
recommends pediatricians provide patients with
complete, current information on the benefits and
Reports how many patients who are breastfeeding
methods of breastfeeding to ensure that the feeding or intend to breastfeed are provided advice and
decision is a fully informed one.(6) Patient
instructions about breastfeeding.
education is important to establish breastfeeding.
(7, 8)

A13
Effective breastfeeding relies on feeding in direct
response to specific infant cues rather than
scheduled frequency or duration of feedings. (9)
A14

A15

Assessment &
observation of
breastfeeding
sessions

A16

A20

Pacifier use

Explanation

Scoring algorithm
100=Almost Always
70=Often
30=Sometimes
0=Rarely

100=Most
70=Many
30=Some
0=Few

Reports how many breastfeeding patients are
taught to recognize and respond to infant feeding
cues instead of feeding on a set schedule.

100=Most
70=Many
30=Some
0=Few

Reports how often breastfeeding patients receive
instructions to limit suckling at the breast to a
specific length of time.

100=Rarely
70=Sometimes
30=Often
0=Almost always

The AAP recommends formal evaluation of
breastfeeding performance by trained observers
during the first 24-48 hours of life. (6)

Reports how many breastfeeding patients receive a
directly observed breastfeeding assessment by
hospital staff.

100=Most
70=Many
30=Some
0=Few

Standardized breastfeeding assessment tools
improve comparability and validity of findings. (1012)

Reports whether breastfeeding is assessed using a
standardized or adapted assessment tool.

100=Yes
0=No

In-hospital pacifier use reduces duration of
exclusive breastfeeding. (13)

Reports how many breastfeeding patients are given
pacifiers by hospital staff.

100=Few
70=Some
30=Many
0=Most

Breastfeeding Assistance
Score

mPINC Survey Scoring Algorithm

Score represents summary of facility practices
related to breastfeeding assistance.

Appendix E

Mean of the 7 item scores.

Page 2 of 11

Contact Between Mother and Infant
Item #

Measure

Rationale

Explanation

Scoring algorithm

A23

Separation of
mother & infant
during transition

Separation during transition to postpartum care is
unnecessary for stable patients. Mother-infant
contact is important during this time to establish
breastfeeding, maintain infant weight, and improve
regulation of infants’ neurologic states. (14)

Reports how many minutes mother-infant patient
pairs are separated after uncomplicated vaginal
births during the transition from labor and delivery
care to their receiving patient care units.

100: No separation
90: ≤30
70: 31-60
30: 61-90
0: >90

A24

A28

Reports how many hours breastfeeding motherRooming-in of mother-infant patient pairs increases infant patient pairs are separated at night.
infants’ opportunities to learn to breastfeed (15) and
Patient rooming-in
increases duration and quality of maternal sleep.
(16)
Reports what percentage of mother-infant patient
pairs room together ≥23 hours per day.

A26
Instances of
mother-infant
separation

Reports the number of reasons that infant patients
are removed from mothers’ rooms. Potential
reasons for removal included: pediatric rounds,
change of shift, visiting hours, hearing test, heel
stick, infant photos, infant's bath, mother bathing,
Understanding the reasons mother-infant patient
mother out of room. Only "mother bathing" and
pairs are separated (17) helps identify opportunities
"mother out of room" were considered valid
to reduce unnecessary separations. Bringing the
reasons for mother-infant separation. Individual
infant to the mother to breastfeed is important
reasons are counted (Few infants removed for the
because it reduces chances the infant will receive
reason=0; Some/Many/Most infants removed for
supplemental feeds. (18, 19)
the reason=1) and then summed.

A25

Reports how many breastfeeding patients who are
not rooming-in receive their infant from the nursery
for breastfeeding at night.

Contact Between Mother
and Infant Subscale Score

Score represents summary of practices facility
practices related to contact between mother and
infant.

mPINC Survey Scoring Algorithm

Appendix E

100: No separation
90: <3
70: 3-<5
30: 5-<8
0: ≥8
100=90%+
70=50-89%
30=10-49%
0=0-9%

100=No separation
70=1-3
30=4-6
0=7

100=Most
70=Many
30=Some
0=Few

Mean of the 5 item scores

Page 3 of 11

Feeding of Breastfed Infants
Item #

A7

A11

Measure

Rationale

Explanation

Reports what percentage of breastfeeding patients
receive breast milk as their first feeding after
Neonatal immune system development depends on
uncomplicated vaginal birth.
Initial feeding
transfer of specific antibodies through colostrum
received after birth and is significantly impaired by prior introduction of
Reports what percentage of breastfeeding patients
non-breast milk feeds. (20, 21)
receive breast milk as their first feeding after
uncomplicated cesarean birth.

A17
Supplementary
feedings
A19

The AAP & American College of Obstetricians and
Gynecologists (ACOG) Guidelines for Perinatal
Care (22) & Academy for Breastfeeding Medicine
guidelines for supplementing feedings in healthy
and hypoglycemic neonates all recommend against
routine supplementation with formula, glucose
water, or water. (23, 24)

Feeding of Breastfed
Infants Subscale Score

mPINC Survey Scoring Algorithm

Reports what percentage of breastfeeding infants
receive non-breast milk feedings.

Scoring algorithm
100=90%+
70=50-89%
30=10-49%
0=0-9%
100=90%+
70=50-89%
30=10-49%
0=0-9%
100=0-9%
70=10-49%
30=50-89%
0=90%+

Reports whether breastfeeding patients receive
glucose water and/or water.

100=Answer to both is No. 0=At
least one answer is Yes

Score represents summary of facility practices
related to feeding of breastfed infants.

Mean of the 4 item scores

Appendix E

Page 4 of 11

Facility Discharge Care
Item #

Measure

Rationale

A30

Assurance of
ambulatory
breastfeeding
support

Reports how many modes of post-discharge
breastfeeding support patients are offered. To get
credit for the mode, at least one support strategy
The AAP clinical practice guidelines recommend
within the mode had to be reported. Mode
examination of all infants by a qualified health care 1=Physical Contact (strategies: home visit, hospital
professional within 48 hours of hospital discharge postpartum followup visit);
to assess breastfeeding. (25) Ensuring postMode 2=Active Reaching Out (strategy: followup
discharge ambulatory support improves
phone call to patient after discharge);
breastfeeding outcomes. (26, 27)
Mode 3=Referrals (strategies: hospital phone
number to call, hospital-based support group, other
breastfeeding support group, lactation
consultant/specialist, WIC, outpatient clinic).

A29

Distribution of
"discharge packs"
containing infant
formula

The AAP (6) and ACOG (28) recommend against
distributing infant formula “discharge packs”
Reports whether breastfeeding patients are given
because it reduces exclusive breastfeeding rates & "discharge packs" containing product marketing
implies health care professional endorsement of
infant formula samples.
specific commercial items. (29-31)

Facility Discharge Care
Subscale Score

mPINC Survey Scoring Algorithm

Explanation

Score represents summary of facility practices
related to discharge care.

Appendix E

Scoring algorithm

100=All 3 modes
90=Modes 1 and 2
75=Modes 1 and 3
65=Mode 1 only
35=Modes 2 and 3
25=Mode 2 only
10=Mode 3 only
0=No modes

100=No
0=Yes

Mean of the 2 item scores

Page 5 of 11

Staff Training
Item #

B1

Measure

Rationale

Reports how many hours of breastfeeding
education are received by new nurses and other
birth attendants†.

Preparation of new
staff

B4
Continuing
education

Staff training ensures standard capacity to provide
evidence-based care, learn about new information, Reports how many hours of breastfeeding
and maintain patient support skills. (31-34)
education current nurses and other birth
Standard 18-hour staff training improves patient
attendants† received in the past year.
breastfeeding outcomes facility-wide. (35, 36)
Reports how many nurses and other birth
attendants† received any breastfeeding education
in the past year.

B3

B5

Competency
assessment

Explanation

Like other critical nursing competencies, regular
assessment of competency in breastfeeding
management and support improves delivery of
care. (37-39)

Staff Training
Subscale Score

mPINC Survey Scoring Algorithm

Scoring algorithm
100: >18
75: 9 to 18
50: 5 to 8
25: 1 to 4
0: <1
100: ≥5
50: 1 to 4
0: <1
100=Most
70=Many
30=Some
0=Few

Reports how often nurses and other birth
attendants† are assessed for competency in
breastfeeding management and support.

100: At least once a year
50: Less than once a year
0: Not assessed

Score represents summary of facility practices
related to staff training.

Mean of the 4 item scores

Appendix E

Page 6 of 11

Structural & Organizational Aspects of Care Delivery
Item #

B11

Measure

Rationale

Breastfeeding
policy

Reports the number of model written breastfeeding
policy elements in the facility's communication of
breastfeeding policy. Aspects include a) in-service
training, b) prenatal breastfeeding classes, c)
asking about mothers' feeding plans, d) initiating
breastfeeding within 60 minutes of uncomplicated
vaginal birth, e) initiating breastfeeding after
recovery for uncomplicated cesarean sections, f)
The AAP recommends inclusion of specific
showing mothers how to express milk and maintain
elements in a facility's breastfeeding policies. (6)
The Academy of Breastfeeding Medicine's clinical lactation if separated from infant, g) giving only
protocol lists components of a model breastfeeding breast milk to breastfed infants, h) 24 hr / day
rooming-in, i) breastfeeding on-demand and
policy. (23)
duration and frequency of feedings, j) pacifier use
by breastfed infants, k) referral of mothers with
breastfeeding problems, l) referral of mothers to
appropriate community breastfeeding resources at
discharge. Aspects worth 10 points each except: 10
points given for 'd' and/or 'e'; 10 points given for 'k'
and/or 'l'.

B12

Effective intra-professional communication
Communication of
increases the likelihood that a facility’s
breastfeeding
breastfeeding policy will be implemented
policy
appropriately. (40, 41)

C5

Infant feeding
documentation
policy

Explanation

100=10
90=9
80=8
70=7
60=6
50=5
40=4
30=3
20=2
10=1
0=0

Reports how staff are informed about breastfeeding
policies. Strategies for informing staff were divided
into two modes - "in person" and "printed / online
materials." Strategies categorized as being "in
100=In person & printed/online
person" included: in-service training, new staff
materials
orientation, new staff training, and staff meeting.
70=In person only
Strategies categorized as being "printed / online
30=Printed/online materials only
materials" included: policy is posted and newsletter.
0=None
At least one strategy from the mode had to be
reported for the mode to be counted.

Standardized documentation of patient decisions
allows for valid internal assessment, monitoring and
Reports the hospital’s policy for documentation of
improvement of quality of care, and improves staff
patient infant feeding plans and practices.
collaboration and support of patients' decisions.
(42)

mPINC Survey Scoring Algorithm

Scoring algorithm

Appendix E

100=Any point after admission
25=At admission only
0=No / not sure

Page 7 of 11

Reports how many of 3 critical and 4 additional
supports are provided to lactating staff after
returning to work. Critical supports are room to
The American Medical Association (AMA) (43) and
express milk (a), electric breast pump for staff use
Association of Women's Health, Obstetric, and
(c), permission to use work breaks to express milk
Neonatal Nurses (AWHONN) (44) recommend
(d). Additional supports are on-site child care (b),
medical facilities support all lactating employees by
breastfeeding support group for staff (e), lactation
providing appropriate time and facilities to express
consultant/specialist available for consult (f), paid
and store milk during the working day. The US
maternity leave other than accrued vacation or sick
Breastfeeding Committee recommends specific
leave (g). If yes to all 3 critical supports: 100. If yes
workplace supports. (45)
to ≤2 critical supports, 35 points for each critical
support and 5 points for each additional support.
0=no to all supports

B13

Employee
breastfeeding
support

A21

The American Dietetic Association (ADA)
guidelines for mandatory elements of infant formula
Facility receipt of
Hazard Analysis and Critical Control Points plans
Reports whether the facility receives infant formula
free infant formula (46) apply to purchased and free infant formula.
free of charge from manufacturers.
The AMA recognizes the inherent conflict of interest
this kind of financial support introduces. (47, 48)

A1

Prenatal
breastfeeding
instruction

Patient education about breastfeeding is important Reports whether breastfeeding is a component of
because it improves breastfeeding rates. (43)
prenatal patient education opportunities.

B08

Coordination of
lactation care

A designated Lactation Coordinator demonstrates a
Reports whether the facility has a designated
facility's consideration of lactation support as an
person who oversees lactation care within the
essential and necessary function of intrapartum
facility.
care. (49)

Structural &
Organizational Subscale
Score

mPINC Survey Scoring Algorithm

Score represents summary of facility practices and
policies related to structural and organizational
aspects of care.

Appendix E

100=All 3 critical (with or without
any additional)
90=2 critical, 4 additional
85=2 critical, 3 additional
80=2 critical, 2 additional
75=2 critical, 1 additional
70=2 critical, 0 additional
55=1 critical, 4 additional
50=1 critical, 3 additional
45=1 critical, 2 additional
40=1 critical, 1 additional
35=1 critical, 0 additional
20=0 critical, 4 additional
15=0 critical, 3 additional
10=0 critical, 2 additional
5=0 critical, 1 additional
0=No supports

100=No
0=Yes

100=Yes
0=No / Not Sure
100=Yes
0=No

Mean of the 7 item scores

Page 8 of 11

Overall Materity Practices Score

OVERALL MATERNITY
PRACTICES SCORE

The 7 subscale scores are labor & delivery,
breastfeeding assistance, contact between mother
Overall score represents summary of maternity
and infant, feeding of breastfed infants, facility
care practices provided by the facility.
discharge care, staff training, and structural &
organizational aspects of care.

Mean of the 7 subscale scores.

*Unless otherwise noted, missing/not sure/not applicable values were denoted as "missing" and not included in the scores.
†

In free-standing birth centers, these questions were asked among "birth attendants" to accommodate the range of attendants to births in these facilities.

mPINC Survey Scoring Algorithm

Appendix E

Page 9 of 11

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mPINC Survey Scoring Algorithm

Appendix E

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