Appx B-3 Summary of Public Comts

Appendix B-3
Summary of Public Comments to 60 Day Federal Register Notice and Extension of Public
Comment Period and CDC Response

CDC Acknowledgement for Public Comments and Letters of Support:
Hello,
Thank you for your comments concerning the CDC 60 Day Federal Register Notice for OMB
No. 60-Day 13-0743, Assessment and Monitoring of Breastfeeding-Related Maternity Care
Practices in Intra-Partum Care Facilities in the United States and Territories. We have given the
concerns you described careful consideration. For further information regarding the unique
mission of CDC, please refer to our website at www.cdc.gov.
Thank you for your interest,
CDC

From: Labbok, Miriam [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 11:26 AM
To: OMB-Comments (CDC)
Subject: Attn Kimberly Lane, re: funding for mPINC

Dear Kimberly or whomever it may concern:
mPINC data have been invaluable for creating the political will at the state and local level to continue
support for improving maternity practices so that all infants get the best start on life through
breastfeeding. Those first few days of support are essential, and the data available from mPINC help
hospitals to see how they are doing compared to others, and help public health professionals, such as
myself, to better understand the trends and issues.
Because of the commercial pressure from formula companies, unless we ensure that hospitals support
breastfeeding, the advertising wins. And the advertising is not there for the health of the child, but
rather for market share.
Let’s ensure that the USG funding continues to support healthy beginnings; one tool is unbiased
information, and that is what is gleaned from the mPINC efforts.
Thank you.

-----------------------------------------------------------------Miriam H Labbok, MD, MPH, IBCLC, FACPM, FILCA, FABM
Professor, Department of Maternal and Child Health
Director, Carolina Global Breastfeeding Institute (CGBI)
Gillings School of Global Public Health, University of North Carolina
Chapel Hill, NC USA 27599-7445

[email protected] 919-966-0928
http://www.sph.unc.edu/breastfeeding/
http://www.breastfeeding4health.com/

From: germaine lambergs [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 11:51 AM
To: OMB-Comments (CDC)
Subject: data collection for public comments for assessing breastfeeding related maternity care
practises.
Dear Ms. Lane, I strongly recommend that more assessments are done to really determine if
this effort actually improves the breastfeeding rates. specifically the post hospital support for the
communities. I work in a large tertiary hospital in Boston , Massachusetts. I am a board certified
lactation consultant (IBCLC)working with with mothers and assisting them in learning this new
skill. There is a strong need for more community support to enable mothers to get over the
rough spots. I believe that having a hospital based clinic /support group would enable mothers
to get the help they need. This would increase the length of nursing that a mother could provide.
The mpinc assessment would give real numbers to demonstrate to administration that adding
this support would be financial benefit for the hospital by bringing down the costs of care for
sick infants. The longer infants and children are breastfeed the healthier they are.
Administration looks at numbers and money spent. Therefore if mpincs are done frequently that
gives them the numbers and cost savings .
Thank you, Germaine Lambergs RN, IBCLC

From: McKeever, Joyce [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 1:30 PM
To: OMB-Comments (CDC)
Subject: CDC mPINC survey
The CDC’s mPINC survey serves as a valuable tool to help hospitals self assess whether they are
“on target” for evidence-based practice standards that have proven to enhance and support
breastfeeding. Our hospital has participated in the survey since 2007 and the results were
instrumental in helping us achieve the Baby-Friendly Designation in 2012. It helped our
Administrative team compare our practices with other hospital in our region, state and the
country to determine where we fell short. As we began to put quality improvements in place
that supported and protected breastfeeding mothers, we were able to track our progress and
celebrate successes. It also elevates the importance of breastfeeding as a public health
initiative that hospitals need to pay attention to. I support the continuation of the mPINC survey
every 2 years to track national progress towards a very important goal of improving
breastfeeding rates through hospital practices. Thank you.

Joyce McKeever, RN,MS,IBCLC, LCCE
Clinical Program Manager - Meridian Health, Baby-Friendly Hospital Initiative
Jersey Shore University Medical Center
1945 Rt. 33, Neptune, NJ 07754
Phone: 732-776-4541 Pager: 732-502-3345 Fax: 732-776-2344
[email protected]

A Baby-Friendly® birth facility.
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From: Ann Lown [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 1:59 PM
To: OMB-Comments (CDC)
Subject: Comment: repeating mPINC survey in 2013 and 2015
Dear Sir/Madam:
I believe OMB should most definitely approve repeating the mPINC survey biannually.
Comparing performance between hospitals is a POWERFUL motivator for hospital
administrations to support necessary clinical changes.
I was a lactation consultant for 12 years (prior to 2009), and I can tell you mPINC results
were a great help to me in getting my administrator's attention to address changes we
needed to make.
Recent evidence from Boston shows that a strong breastfeeding promotion environment
can practically eliminate racial and socioeconomic disparities in breastfeeding behavior.
Substantially improved breastfeeding rates are an economically viable way to help
address the current diabetes-obesity epidemic in our country.
Affordable health care DOES begin with breastfeeding!
And the mPINC survey is a good tool to help hospitals--which strongly influence
breastfeeding behavior--improve practices for supporting breastfeeding.
Thank you for this opportunity to give an opinion,
Ann Lown, RNC, IBCLC-RNC

From: Laura Mulligan [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 4:35 PM
To: OMB-Comments (CDC)
Subject: RE: mPINC survey

I believe the mPINC survey is an important tool for facilities to utilize in improving maternity practices
for breastfeeding support. However, I feel that the survey is too subjective and could be swayed to
make it appear that the facility is doing better or worse than it actually is. More specific measurements
should be included in the answers. This would increase reliability and value to the survey. Thank you

Laura S. Mulligan RN, BSN, IBCLC
Education Specialist/Lactation Consultant
Women & Children's Services
Crittenton Hospital Medical Center
248-652-5919
[email protected]

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From: Jeanette Panchula [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 7:36 PM
To: OMB-Comments (CDC)
Subject: OMB Control No. 0920-0743, Exp. 12/31/2011
(OMB Control No. 0920–0743, Exp. 12/31/2011)—Reinstatement—National Center for Chronic Disease Prevention and Health
Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC).
As a La Leche League Leader, International Board Certified Lactation Consultant, trainer and retired Public Health Nurse, I urge
the Office of Management and Budget (OMB) to approve the request of the Centers for Disease Control and Prevention (CDC) to
repeat the Maternity Practices in Infant Nutrition and Care survey (mPINC) for the years 2013 and 2015.
(a) Whether the proposed collection of information is necessary for the proper performance of the functions of the agency,
including whether the information shall have practical utility;
The CDC has reported and confirmed the importance of breastfeeding – especially exclusive breastfeeding – in the prevention of
expensive illnesses in the infant (NEC, hospitalizations for Lower Respiratory Tract Diseases, etc.). There are also a great deal of
studies related to the differences between children and adults who have breastfed vs. bottle fed in terms of obesity, diabetes, etc.
Exclusive breastfeeding begins in the hospitals – and despite the work of many agencies, it was not until the data was being
gathered and published that I observed, as a Public Health Nurse, IBCLC and breastfeeding trainer, an interest on the part of the
hospital administration in changing hospital policies and practices. Staff training without policy changes is ineffective and
expensive – and without a little “fire” there seemed to be little interest in improving maternity practices that would help mothers
and babies to breastfeed exclusively.
The mPINC reports are just beginning to make a difference – more and more hospitals are seeking Baby Friendly status, and even
those who are not, are taking seriously the importance of changing hospital practices to support mothers who want to breastfeed
to do so exclusively. The goal is not “Baby Friendly” as such – the goal is promoting and providing QI indicators that support
optimal, evidence-based maternity practices.
Stopping this data gathering at this point would, in my opinion, decrease the pressure for change at just the wrong moment –
when many are CONSIDERING and starting to make change. We need the pressure to continue – as it would be a shame to lose
the momentum now.
(b) the accuracy of the agency’s estimate of the burden of the proposed collection of information;
As the CDC has been conducting this study, and has developed great communication and collaboration among them and those of
us locally who are in Breastfeeding Coalitions, I have a great deal of confidence in their ability to estimate accurately.
(c) ways to enhance the quality, utility, and clarity of the information to be collected;
It has been the very way that the data has been collected until now that has made it so valuable…I hope there will not be any
major changes. California was able to prove that the data collected by mPINC was reliable when compared to the data collected
of infant hospital breastfeeding rates. If the mPINC was high, so were the rates, if it was low, so were the rates. They support
each other and increase the respect of their reports.
(d) ways to minimize the burden of the collection of information on respondents, including through the use of automated
collection techniques or other forms of information technology.
If there would be a standardized method, this would be an excellent additional goal - the development of Quality Improvement
tools that could be used locally, statewide and nationally.

Delia Jeanette Panchula, BA-SW, RN, PHN, IBCLC
Tel: 707-469-0705
Cell: 707-290-8200
_____________________________________
Perhaps most important for us is to realize that human milk is not simply a food but rather a complex, human infant support system.

From: Breastfeeding: A Clinical Imperative
Michelle G. Brenner, M.D., IBCLC, and E. Stephen Buescher, M.D.
Eastern Virginia Medical School, Pediatrics, Norfolk, Virginia.
Journal of Women's Health. December 2011, 20(12): 1767-1773. doi:10.1089/jwh.2010.2616.

From: [email protected] [mailto:[email protected]]
Sent: Tuesday, February 12, 2013 9:25 PM
To: OMB-Comments (CDC)
Subject: Essential to continue the 2013 and 2015 mPINC Surveys
RE:Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum Care
Facilities in the United States and Territories (OMB Control No. 0920–0743, Exp. 12/31/2011)—
Reinstatement—National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP),
Centers for Disease Control and Prevention (CDC).
The 2007, 2009, and 2011 survey data has been essential in convincing hospitals and health care
providers of their essential role in supporting a woman's decision to breastfeed, and thereby to reduce
health care costs by improving the short-term and long-term health of our infants, children, mothers,
families and communities. It is essential that it continue as we still have a long way to go.
Nancy E. Wight MD, IBCLC, FABM, FAAP
Neonatologist, San Diego Neonatology, Inc.
Secretary and Education Coordinator, San Diego County Breastfeeding Coalition
Medical Director, Sharp HealthCare Lactation Services
Sharp Mary Birch Hospital for Women and Newborns
3003 Health Center Dr
San Diego, CA 92123
Pager: 858-493-0198
Office: 858-939-4180
NICU: 858-939-4298
[email protected]
BREASTFEEDING: Your Baby's Best Health Insurance

From: [email protected] [mailto:[email protected]] On Behalf Of nleeguitar
Sent: Wednesday, February 13, 2013 8:44 AM
To: OMB-Comments (CDC)
Subject: mPINC comments
I am the lactation consultant for the Philadelphia Department of Public Health.
I would like the survey to be left alone....so each set of results can demonstrate changes with
the ones before.
Changing the survey would make comparisons between years difficult, if not impossible.
Also, people are learning, via repetition, what the survey is about. The more people are familiar
with the survey, the more compliance.
You all did a great job at the beginning. Let it be.
warmly,
Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI, ANLC, CKC Lactation Consultant, Philadelphia
Department of Public Health [email protected]

From: Sylvia Edwards [mailto:[email protected]]
Sent: Wednesday, February 13, 2013 11:11 AM
To: OMB-Comments (CDC)
Subject: mPINC survey
To Whom It May Concern:
I want to take this opportunity for public comment to support the proposed data collection using the
national survey of Maternity Practices in Infant Nutrition and Care (mPINC). I recommend funding this
survey implementation for 2013 and 2015. The survey has been very valuable in helping to motivate
needed changes in maternity care that support, promote and protect mother's decisions to
breastfeed. The impact on health care outcomes is significant when mothers can successfully establish
and maintain breastfeeding for the American Academy of Pediatrics and World Health Organization
recommended time frames. Many of our current practices undermine mothers' success. The mPINC
survey provides a benchmark for individual hospitals to compare their practices at the state and national
level. I can personally attest to the use of the mPINC survey to spear head changes in practice at my
institution. I have incorporated the data in the classes that I teach for nursing and medical students and
professionals. Without this benchmark data, it would have been much more difficult to convince
stakeholder that we needed to change practice. I am pleased to say University of Alabama at
Birmingham (UAB) Medical Center is now part of the National Institute of Child Health Care Quality
( NICHQ ) Best Fed Beginning project and well on our way to becoming a Baby Friendly Designated
Hospital. Please know that the mPINC data was a valuable tool in helping us to reach this point.
Sylvia Edwards, RN, MS, IBCLC RLC
Advanced Nursing Coordinator, Lactation Services
UAB Women's and Infants' Center, 176F 6236
1700 6th Ave. South
Birmingham, Al. 35249
Phone: 205-996-7351 Fax: 205-975-6803
E-mail: [email protected]

From: barbara sachau [mailto:[email protected]]
Sent: Wednesday, February 13, 2013 11:32 AM
To: OMB-Comments (CDC); [email protected]; [email protected]; [email protected];
[email protected]; [email protected]
Subject: Re: we need smaller less expensive govt - this is ludicrous wasteful spending to gouge
taxpayers - no way

public comment on federal register - i do not support fat cat bureaucrats in washington dc taking this
survey on breastfeeding. this is completely unnecessary and a gouging of us taxpayers. all doctors and
clinics and hospitals alrady encourage this and no further action is necessary. this appears to be a make
work project to save jobs at the cdc when the project has no need for being done at all. all of the clinics,
hospitals and mothers themsleves know about this. no need for making high salaries for yourselves out
of what is mothering. shut down this project. budget for this should be zero. this comment is for the
public record. jean public

From: Sue Bedard [mailto:[email protected]]
Sent: Wednesday, February 13, 2013 12:50 PM
To: OMB-Comments (CDC)
Subject: mPINC Attention Kimberly Land
To: Kimberly Lane
From: Sue Bedard RNC MSN IBCLC
RE: Feedback and comments on mPINC
The following is in response to the request for feedback on how we have used the mPINC
McKay Dee Hospital
4401 Harrison Blvd
Ogden Utah 84403
Facility ID H13488
Based on the 2007-2009-2011 McKay Dee has made the following positive changes
1. Mandatory Staff Education-Basics of Lactation is an 8 hours class for all RN’s who work in Women and
Newborn – big financial commitment and will be completed by 1/2014
2. Immediate skin to skin in L&D
3. Documented feeding assessments; Use of Latch scores in L&D and then twice in the first 24 hours of life
on Mother/Baby. Creation and use of modified LATCH scores in the NICU. This is a quality indicated and is
monitored and reported every month.
4. Delay bathing-babies are no longer bathed in L&D – bath is done after 2 to 3 hours on the mother/baby
unit
5. Limit M/B separation: We offer families the option to have lab work on the baby done at the bedside – all
doctors rounds at bedside
6. Consistent follow up after discharge: referrals to community made and consistent phone follow up on
high risk mother/babies. Outpatient Clinic for unresolved concerns. Return to primary caregiver within 48
hours of discharge
The areas for improvement
1. Reduce delays in first contact and breastfeeding opportunity
a. Routine procedures performed skin to skin
b. Baby left skin to skin to stabilize
c. Baby left skin to skin until the first feeding is completed
2. Eliminate unnecessary supplementation
a. Documented medical need
b. Not given formula as a routine – LPT or SGA
3. Encourage rooming in – baby in the room 23 hours per day
4. Stop distribution of formula gift packs
5. 18 hours of education – this may not happen – the cost to provide 18 hours cannot be absorbed.
Education hours will be obtained on quarterly staff meetings and yearly “skills lab” updates.
6. Feed on request – more focus on educating families on awake baby is a hungry baby and not on every 3
hour schedule.
Thank you for the opportunity to provide feedback and we look forward to the 2013 mPINC.
Sue Bedard RNC MSN IBCLC
Breastfeeding Matters @ Mckay Dee
4404 Harrison Blvd
Ogden Utah 84404
801-387-4132
[email protected]

We will never realized how funny and crazy we look like until we make a baby laugh!

From: Erin O'Reilly [mailto:[email protected]]
Sent: Wednesday, February 13, 2013 11:02 PM
To: OMB-Comments (CDC)
Subject: please continue the mPINC survey
I work in the community with breastfeeding mothers and babies who have gotten off to a bad
start with breastfeeding because of hospital practices that undermine breastfeeding.
Breastfeeding in the hospital needs to be monitored! Please continue the mPINC survey of
hospitals.
Thank you and Sincerely, Erin O'Reilly, RN,MSNR,IBCLC

From: McGorty Starla Jo [mailto:[email protected]]
Sent: Thursday, February 14, 2013 1:56 PM
To: OMB-Comments (CDC)
Subject: mPINC survey

I am writing in regard to the hospital mPINC survey for maternity care practices. As a hospital-based
International Board-Certified Lactation Consultant, I think the mPINC survey is an excellent tool to gauge
hospital care for mothers and infants. I do think that some additions would be helpful, such as including
how many full-time equivalent (FTE) positions that require an IBCLC certification are employed by the
hospital. A lack of IBCLC’s in the hospital setting is a serious issue that needs to be addressed. Currently
in South Carolina, approximately 25 IBCLC’s actually function in hospitals as a dedicated lactation
position and not serving as a staff nurse with a certification.
Thank you!
Starla McGorty
Starla McGorty BSN, RNC-LRN, IBCLC, RLC
Board Certified Lactation Consultant
Roper St. Francis Healthcare
2095 Henry Tecklenburg Drive
Charleston, SC 29414
office (843) 402-1356
cell (843) 729-0764
fax (843) 402-1863

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From: Martha Durbin [mailto:[email protected]]
Sent: Thursday, February 14, 2013 8:15 PM
To: OMB-Comments (CDC)
Subject: Advocacy for mPINC

CDC,
As an IBCLC, the continuation of the mPINC survey is very valuable tool. It is difficult to continue to seek
support from our institutions for which we work, without having protocols, processes and practices
initiated by such great data results demonstrating necessity. Please continue this tool for all of us
working with our families to increase the health of our nation.
Warmly,
Martha Durbin, BSN, IBCLC
Mount Vernon, OH 43050

Federal Register Number of [13–0743]

From: Nancy G. Powers [mailto:[email protected]]
Sent: Friday, February 15, 2013 3:43 PM
To: OMB-Comments (CDC)
Subject: Assessment and Monitoring of Breastfeeding-Related Maternity CarePractices in Intra-partum
Care Facilitiesin the United States and Territories(OMB Control No. 0920–0743, Exp. 12/31/2011)
This project is of utmost importance to mothers, infants, maternal-child health programs
and hospitals.
Breastfeeding is the optimal form of childhood feeding for health and development.
Breastfeeding is the optimal form of infant feeding for primary prevention in the mother.
Hospital policies and procedures in the first 3 days of life have impact on success of
breastfeeding up through 4 - 6 months pospartum for the mother-baby dyad.
Despite widespread recommendations to breastfeed, there are still many barriers in our
culture.
The continuation of this program is one way to address barriers to breastfeeding in the
health care setting.
Sincerely,
Nancy G. Powers, MD
3900 Edgemont St.
Wichita, KS 67208
316-304-2653 (cell)
e-mail: [email protected]

From: Viehmann, Laura R. MD [mailto:[email protected]]
Sent: Monday, February 18, 2013 12:02 PM
To: OMB-Comments (CDC)
Subject: mPinc
Dear Ms Lane
I am writing to express my support for continuing the mPINC survey. As a pediatrician in RI I am aware of a variety
of barriers to successful breastfeeding. I have used the mPINC data to demonstrate to my colleagues and to hospital
administrators how practices in our state are suboptimal (particularly regarding the number of babies supplemented
with formula before leaving the hospital). This survey provides concrete information to create achievable goals for
changing policy, habits and culture. Without the data I have minimal ability to impact change.
Thank you,
Laura Viehmann, MD
Mill River Pediatrics
126 Prospect St
Pawtucket, RI 029860

From: Ramsey Melanie [mailto:[email protected]]
Sent: Wednesday, February 20, 2013 10:52 AM
To: OMB-Comments (CDC)
Subject: mPINC survey

To Whom it May Concern:
I would like to advocate for the continuation of the mPINC survey. This information is helping hospitals
create and support more breastfeeding supportive environments. Additionally, the Joint Commission
for Accreditation of Hospitals (JACOH) has started to use breastfeeding rates as part of their
accreditation information.
The data from the mPINC survey is helping our facility re-evaluate how we deliver support to our
breastfeeding mothers and continuation of this data will be essential to evaluating our change process
and how we compare to other facilities.
Thank you for the opportunity to provide comment.
Melanie M Ramsey RN, BSN, IBCLC
Lactation Services
Mercy Regional Health Center
Manhattan, KS 66502
785-587-5432
785-587-5448-fax
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From: Johnson, Jan E. (LHD - Pike Co.) [mailto:[email protected]]
Sent: Wednesday, February 20, 2013 2:20 PM
To: OMB-Comments (CDC)
Subject: Public Comment for Continuation of mPINC Data Collection OMB Control No. 0920–0743

To Whom it May Concern,
I am writing in support of continuing the Maternity Practices in Infant Nutrition and Care (mPINC)
survey. The mPINC survey is well designed and the CDC has done an excellent job of distributing the
2007, 2009, and 2011 data. The individual state reports have been a fabulous gift to those of us who
work in public health promotion.
In Kentucky, the mPINC data has confirmed our suspicions about areas of practice that we long believed
to be weak, helped us to realize we are not quite as bad as expected in other areas and overall is helping
us more effectively target our efforts and limited funds. For example, in 2007 Kentucky was ranked
number 52 of 52, the very lowest we could go, for the percent of hospitals placing vaginally born infants in
skin to skin contact immediately after birth; a practice also known as kangaroo care. In 2009 Kentucky
was up to 32% of hospitals placing vaginally born infant skin to skin and was ranked number 40. The
cause of that improvement was an effort made by the University of Louisville Hospital to train their
surrounding hospitals on how to implement birth kangaroo care in their facilities. Recognizing the need
for skin to skin care across the state and the positive results from the Louisville area the Kentucky WIC
Program partnered with the University of Louisville Hospital and the Lactation Improvement Network of
Kentucky to roll out the Kentucky Kangaroo Care Initiative. Trainings began in the Fall of 2011. To date,
100% of the birthing hospitals in Kentucky have been trained on providing birth kangaroo care for vaginal
and cesarean deliveries and 94% of birthing hospitals have successfully implemented the standardized
practice. We are working with the last few hospitals to help them along. The individual hospitals are
tracking their breastfeeding rates and some have seen their rates jump by around 20%. The effects of
this great effort were not captured in the 2011 mPINC data as trainings had only begun in late 2011. We
need this survey to continue in 2013 and 2015 to give us a consistent measure of our success.
The continuation of the mPINC survey is extremely important to the endeavors of Kentucky in assessing
and addressing factors related to breastfeeding.
Thank you for your time and I truly hope this survey is continued.
Sincerely,
Janet Johnson, RD, LD, IBCLC
Regional Breastfeeding Promotion Coordinator
Pike County Health Department
119 River Drive
Pikeville, KY 41501
606-437-5500 ext. 590
[email protected]

From: Rebecca Costello [mailto:[email protected]]
Sent: Thursday, February 21, 2013 12:09 AM
To: OMB-Comments (CDC)
Subject: mPINC Survey

As a hospital-based International Board Certified Lactation Consultant, and with a background of a
master's in maternal and child health, I strongly encourage the CDC to repeat the mPINC survey.
Collecting information allows institutions to benchmark their current practices and indicators, and
compare themselves to other institutions regionally and nationally. Most institutions would never
receive this information otherwise and can be surprised by how they compare and, in many cases, how
easily changes can happen to improve their practices. It also allows public health quality improvement
initiatives to develop specific targets in areas that are found to be in need of improvement. Having this
national data is invaluable.
Rebecca Costello, IBCLC, MPH
University of North Carolina Women's Hospital, Lactation Services

From: ROSENBERG Ken D [mailto:[email protected]]
Sent: Friday, February 22, 2013 5:43 PM
To: OMB-Comments (CDC)
Cc: Marion Rice ([email protected]); Marion Rice Galford
([email protected])
Subject: Public comment: mPINC (OMB Control No 0920-0743)

[attachment]

PUBLIC HEALTH DIVISION
Office of Family Health
John A. Kitzhaber, MD, Governor

Feburary 22, 2013
Kimberly Lane
1600 Clifton Road, MS D-74
Atlanta, Georgia 30333

800 NE Oregon Street, Suite 825
Portland, OR 979232
Voice: 971-673-0352
FAX: 971-673-0240
TTY: 971-673-0372

Dear Ms. Lane:
I am writing in reference to your request for public comments about Assessment and Monitoring
of Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities in the United
States and Territories (OMB Control No 0920-0743, Exp 12/31/2011).
I am the maternal and child health epidemiologist for the Oregon Public Health Division. I was a
member of the Expert Panel (“Assessment of Maternity Care Practices Related to Breastfeeding
in the United States”), in October 2003, that recommended the Maternity Practices in Infant
Nutriton and care (mPINC) Survey.
The mPINC Survey has been enormously valuable to Oregon public health professionals in their
work to increase breastfeeding. It has provided assessments of the realms in which Oregon
hospitals needed improvement. It has been particularly helpful in assessing the extent to which
hospitals have been dispensing infant formula at discharge to mothers who were still
breastfeeding.
My only suggestion for improvement is that hospital-specific data be released to state health
departments and other qualified health professionals for quality improvement efforts.
Please allow CDC to continue the mPINC survey.
Thank you.

Kenneth D. Rosenberg, MD, MPH
Maternal & Child Health Epidemiologist
Oregon Public Health Division
800 NE Oregon Street, Suite 850
Portland, OR 97232
Telephone: (971) 673-0237
Fax: (971) 673-0240
e-mail: [email protected]

From: Jesuthasan, Prema [mailto:[email protected]]
Sent: Tuesday, March 05, 2013 4:01 PM
To: OMB-Comments (CDC)
Subject: Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum
Care Facilities in the United States and Territories – Reinstatement
Good afternoon.
I am writing in reference to the Federal Register notice published by the CDC on February
12th, 2013, (http://www.gpo.gov/fdsys/pkg/FR-2013-02-12/pdf/2013-03194.pdf). We are
interested in providing comments but would like to first to know if there are any
supplementary materials (e.g. survey instrument) that we can look at.
Would you please either send me the materials (by e-mail/mail) or let me know where they
can be found online?
Thank you very much.
Regards,
Prema Jesuthasan
Information Manager,
Kellen Company
1100 Johnson Ferry Road NE
Suite 300, Center Pointe 1
Atlanta, GA 30342
[email protected]

From: Dawn Kersula [mailto:[email protected]]
Sent: Wednesday, March 06, 2013 4:14 PM
To: OMB-Comments (CDC)
Subject: mPINC continuation
I am writing to recommend that the CDC’s mPINC Survey be continued.
I am a national speaker about breastfeeding – and I began speaking to nurses and other healthcare
professionals around the country back in 2007, just after the first benchmarks were done. At that time, it
was not unusual for participants to state, “My hospital doesn’t do any of those baby-friendly practices,
there is no support from administration, and I don’t see how things will ever change.”
Instead, over the past six years, I have seen gradual but real change. Just becoming more aware of what
our own practices are, and then being able to rate our own practices and facilities compared to others in
our own state has made a real difference.
In addition, I’ve seen a good bit of competition between states when I speak. Staff know “who does it
right” in different regions – and the mPINC Survey has been a force for good in making changes.
I feel that we’ve received real value for the money expended – true change, coming from increased
knowledge and self-evaluation. Real changes in breastfeeding rates around the country – even with
populations that have not traditionally breastfed their babies. It doesn’t get much better than that.

Dawn M Kersula MA, RN, IBCLC, FACCE
Perinatal Specialist, Brattleboro Memorial Hospital, Brattleboro, Vermont
President, Vermont Lactation Consultants Association
Speaker, PESI Healthcare, Inc
_______________________________________________________________
The information contained in, or attached to, this e-mail, may contain confidential information and is intended solely for the use of the individual or entity
to whom it is addressed and may be subject to legal privilege. If you have received this e-mail in error you should notify the sender immediately by reply email, delete the message from your system and notify your system manager. Please do not copy it for any purpose, or disclose its contents to any other
person. The views or opinions presented in this e-mail are solely those of the author and do not necessarily represent those of the company. The recipient
should check this e-mail and any attachments for the presence of viruses. The company accepts no liability for any damage caused, directly or indirectly, by
any virus transmitted in this email.
_______________________________________________________________

From: Bailey, Doraine F (LHD-Lexington-Fayette Co) [mailto:[email protected]]
Sent: Monday, April 01, 2013 3:28 PM
To: OMB-Comments (CDC)
Subject: mPINC Comment - OMB Control No. 0920-0743
Dear Ms. Lane:
I am providing a comment on “Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum
Care Facilities in the United States and Territories (OMB Control No. 0920–0743, Exp. 12/31/2011)—Reinstatement—National
Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC).” In
the Federal Register posting of 2/12/2013 (http://www.gpo.gov/fdsys/pkg/FR-2013-02-12/pdf/2013-03194.pdf), there was a
request for comment on four areas: (a) Whether the proposed collection of information is necessary for the proper
performance of the functions of the agency, including whether the information shall have practical utility; (b) the accuracy of
the agency’s estimate of the burden of the proposed collection of information; (c) ways to enhance the quality, utility, and
clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information on respondents,
including through the use of automated collection techniques or other forms of information technology.
a)

b)

c)

d)

The information garnered in the mPINC survey has a high degree of practical utility in the functions of the agency to
protect, promote, and support breastfeeding. The hospital experience is an important marker for the quality of the
initiation of breastfeeding and ultimately its duration. The mPINC survey is the only tool utilized nationally to provide
data on the evidence-based practices of hospitals. In some cases, the data being requested was unfamiliar to the
hospitals with which I communicate, and created curiosity and some consternation about why their practices weren’t
‘up to standard’. It has helped to spur change in local hospital practice, in conjunction with changes at Joint
Commission on their Perinatal Core Measure Set, the NICHQ Best Fed Beginnings project, and coverage for women’s
preventive health services through the PPACA. This synergy is important to continue to capture – continuing the
mPINC survey will reinforce this value on in-patient breastfeeding services as well as report changes in a way that
provides meaningful trend and change-over-time analysis.
Unfortunately, I’m not in a position to judge the accuracy of the information collection time burden. However, as
other measure sets, as well as changes to Electronic Health Records (EHRs) through PPACA and the Baby-Friendly
Hospital Initiative, are requiring documentation and reporting of the infant feeding and maternity care practices,
hospitals will already be collecting much of this data. After three rounds of mPINC, facilities who participate are aware
of the data requirements and may have already instituted improvements to accommodate mPINC and the datareporting requirements of the other activities mentioned previously.
The one complaint I hear about mPINC data collection is that administrators receive the tool and do not enlist the
direct assistance of IBCLC staff in the collection and reporting of data for the survey. Stronger language in the survey
preparatory calls and cover letters urging direct input from front-line nursing and lactation staff, including
development of internal breastfeeding QI/QA committees, may help to assure/improve reliability and validity of
responses. Similarly, stronger language encouraging the facility to share their mPINC report back to these staff
strengthens the internal value of the data and analysis (and the time being spent). If Joint Commission added mPINC
reporting to their audits, at least with the Perinatal Core Measure, that could also increase the real and perceived
importance of accurately completing the survey.
The move to EHR through PPACA is one way to encourage mPINC collection, especially if the maternity care EHR
“standard” includes fields for data collected for mPINC. A maternity care EHR developed/dissemated by CDC/DHHS
should consider inclusion of such fields to set that standard as well as to give hospitals with smaller censuses an easyto-use, off-the-shelf product. Automating the data collection through an EHR also vastly improves the reliability and
validity of data through real-time collection rather than recall or sampled chart audits.

Thank you for this opportunity to comment. The mPINC survey is a unique tool and an important report to spur local hospitals,
consumers, regulators, health care professional associations and legislators to demand evidence-based, cost-effective, and
humane care to mothers and babies.
Most sincerely,
Doraine Bailey, MA, IBCLC
Breastfeeding Support Services
Lexington Health Dept.
859-288-2348

From: Hedrick, Theresa [mailto:[email protected]]
Sent: Tuesday, April 02, 2013 5:20 PM
To: OMB-Comments (CDC)
Subject: Comment Period Extension Request Re: Assessment and Monitoring of Breastfeeding-Related
Maternity Care Practices in Intra-partum Care Facilities in the United States and Territories
To Whom It May Concern,
Please see the attached letter from the International Formula Council regarding the Federal Register (60Day–13–0743) 60-day notice regarding the proposed reinstatement of the Centers for Disease Control
and Prevention (CDC) hospital survey on breastfeeding practices, Assessment and Monitoring of
Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities in the United States and
Territories.
Please confirm receipt of this letter.
Thank you,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist
International Formula Council
1100 Johnson Ferry Road, Suite 300
Atlanta, GA 30342
P (678) 303-2953
F (678) 252- 0774
E [email protected]

The International Formula Council is managed by the Kellen Company, an employee-owned association
management company providing association and meetings management, public relations, government
affairs, marketing, web site development and graphic design services. Offices in Atlanta, Chicago, New
York, Washington, Brussels and Beijing. www.kellencompany.com

1

April 2, 2013
Kimberly S. Lane
Deputy Director, Office of Scientific Inquiry
Centers for Disease Control and Prevention
1600 Clifton Road, MS D–74
Atlanta, GA 30333

Re: Request for Extension of
the Comment Period for the
Proposed Project
Assessment and Monitoring
of Breastfeeding-Related
Maternity Care Practices in
Intra-partum Care Facilities
in the United States and
Territories
Dear Ms. Lane:
The International Formula Council (IFC) is responding to the February 12, 2013 Federal
Register (60-Day–13–0743) 60-day notice regarding the proposed reinstatement of the
Centers for Disease Control and Prevention (CDC) hospital survey on breastfeeding
practices, Assessment and Monitoring of Breastfeeding-Related Maternity Care
Practices in Intra-partum Care Facilities in the United States and Territories. The IFC is
an association of manufacturers and marketers of formulated nutrition products, e.g.,
infant formulas and adult nutritionals, whose members are based predominantly in North
America.*
Since the publication of the 60-day notice, IFC has made numerous requests via email
and telephone for a copy of the survey instrument, which we believe is critical to
providing thoughtful comments on the proposed survey. To date, we have not received
a response from CDC or a copy of the survey instrument and, thus, are very concerned
we will not receive the instrument in enough time to review and provide comments by the
April 13 deadline.
Therefore, as we continue to contact the CDC for a copy of the proposed survey
instrument, IFC respectfully requests that the comment period be extended 60 days,
which will hopefully provide sufficient time to receive, review and provide comments on
the survey.
*

IFC members are Abbott Nutrition, Mead Johnson Nutrition, Nestlé Infant Nutrition and Perrigo Nutritionals.

2

If you have any questions, please contact me.
Sincerely,
Theresa Hedrick, MS, RD, LD

Scientific Affairs Specialist

From: Michelle Routh [mailto:[email protected]]
Sent: Monday, April 08, 2013 2:21 PM
To: OMB-Comments (CDC)
Cc: Melody; Kathy Walker; Gwendolyn Whittit; Janet Colson; Brenda Bandy; Martha Hagen
Subject: Public Comment: FR Doc. 2013–03194 Assessment and Monitoring of Breastfeeding-Related
Maternity Care Practices in Intra-partum Care Facilities in the United States and Territories

Dear Kimberly Lane:
The Kansas Breastfeeding Coalition, Inc. has created the attached letter of support for FR Doc. 2013–
03194 Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum
Care Facilities in the United States and Territories.
Thank you for your time and consideration of our perspective on this matter.
Respectfully,
Michelle Routh, MSN, RN, CBE
Secretary,
Kansas Breastfeeding Coalition, Inc.
[email protected]
(913)271-4331
.

Kimberly S. Lane
Deputy Director, Office of Scientific Integrity, Office of the Associate Director for Science, Office of the Director,
Centers for Disease Control and Prevention
1600 Clifton Road
MS D-74
Atlanta, GA 30333
Re: FR Doc. 2013–03194 Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum
Care Facilities in the United States and Territories
Dear Ms. Lane,
The Kansas Breastfeeding Coalition, Inc. strongly supports the continuation of the Maternity Practices in Infant Nutrition
and Care (mPINC) survey. Results of this survey are imperative in sustaining improved birthing hospital breastfeeding
support practices and in encouraging hospitals to increase their efforts. Hospitals use this survey as a measure of their
progress toward meeting their breastfeeding support goals. Many Kansas hospitals are just now planning how to improve
their mPINC scores. In addition, many states have developed 5- or 10-step best practice programs to help birthing
hospitals improve mPINC scores. Discontinuation of the mPINC would undermine the success of these programs. The
mPINC report provides valuable cumulative state data to state breastfeeding coordinators and state coalitions offering a
way to track improvements over several years.
The Kansas Breastfeeding Coalition utilizes mPINC data results to assist health care initiatives across the state develop
programs to improve hospital maternity care practices. An example of one such program is Kansas’ High 5 for Mom and
Baby Hospital Program that was created using data from Kansas’ mPINC scores. For further information on the High 5
for Mom and Baby program, please visit www.High5Kansas.org.
Over three-fourths of babies born each year in the United States initiate breastfeeding. However, many mothers have
already stopped breastfeeding their infant or have already made the choice to offer some artificial baby milk by the time
they leave the hospital. The use of artificial baby milk undermines a mother’s confidence in her ability to breastfeed her
infant. So much so, that by six months of age only 14.8% of those initiating breastfeeding are receiving breastmilk
exclusively. The American Academy of Pediatrics and breastfeeding advocates recommend exclusive breastmilk feedings
for six months for infants, as well as breastfeeding women, to receive all the health benefits breastfeeding and breastmilk
feeding has to offer. Best practices for breastfeeding education and support in hospitals help mothers succeed in meeting
their individual breastfeeding goals.
Continuation of the mPINC survey is imperative to support the increasing number of mothers who have set the goal to
breastfeed exclusively for six months and provide nutrition that is biologically intended for their infants.

Sincerely,

Melody Ward, IBCLC, RLC
Kansas Breastfeeding Coalition, Inc.
President

Kathy Walker, MSN, ARPN, IBCLC
Past President

Michelle Routh, MSN, RN, CBE
Secretary

Gwen Whittit, RN, IBCLC
Vice President

Janet Colson, IBCLC
Treasurer

From: S Long [mailto:[email protected]]
Sent: Monday, April 08, 2013 10:39 PM
To: OMB-Comments (CDC)
Subject: mPINC Comments

To Whom It May Concern:
Attached you will find comments from the DC Breastfeeding Coalition for the CDC mPINC survey.
Please contact me if you have any questions.
Sincerely,
Sahira Long, MD, FAAP, IBCLC
President
DC Breastfeeding Coalition, Inc.
www.dcbfc.org

COVER SHEET
To:

Office of Management and Budget
Centers for Disease Control and Prevention
[email protected]

From:

Sahira Long, MD, FAAP, IBCLC
President, DC Breastfeeding Coalition
[email protected]

Re:

Public Comments [60-Day–13–0743] on OMB Control No. 0920–0743,
Exp. 12/31/2011)—Reinstatement—National Center for Chronic Disease
Prevention and Health Promotion (NCCDPHP), Centers for Disease
Control and Prevention (CDC)

Pages:

2

Date:

March 20, 2013

Comments:
Please find attached comments from the DC Breastfeeding Coalition.

March 20, 2013

To Whom It May Concern:
I am writing on behalf of the DC Breastfeeding Coalition (DCBFC), to strongly urge the
reinstatement of the Centers for Disease Control and Prevention (CDC) Maternity Practices in
Infant Nutrition and Care (mPINC) survey. As you know, despite governmental
recommendations, national health outcome targets, mounting scientific evidence, and national
promotion campaigns, breastfeeding rates in the United States continue to fall short of national
goals. These rates, however, have been increasing over time and continue to do so. I suspect that
this is, in part, due to the focus that has been placed on improving maternity care practices so that
women who choose to breastfeed get off to a good start.
Completion of the 2007, 2009 and 2011 mPINC surveys has allowed CDC to identify, document,
and share information related to incremental changes in practices and care processes over time at
the hospital, state, and national levels. Specifically, in the District, the state reports available on
the CDC website and individual facility reports that have been voluntarily shared with the
DCBFC by the facilities who have participated have been instrumental in allowing our coalition
to determine the gaps in maternity care practices being offered throughout the nation’s capital.
This knowledge allows us to target these areas for improvement through our collective efforts and
resources.
Of particular note is that one of the Joint Commission’s Perinatal Care Core Measures includes
“exclusive breastfeeding at hospital discharge”. Beginning in January 2014, this measure set will
be required for facilities that have more than 1100 births per year. With more pressure on
maternity facilities to report breastfeeding outcomes as a measure of quality, the ability to
continue benchmarking maternity practices and share best practices across the nation remains
more important than ever.
The DCBFC, established in 2004, is a non-profit organization dedicated to enhancing the health
of families in the District through improved breastfeeding initiation and duration rates. The
DCBFC unites breastfeeding advocates, health care providers, and families, providing a forum for
the development and exchange of resources to establish human lactation as the societal norm.
Please do not hesitate to contact me if I can answer any questions.
Sincerely,

Sahira Long, MD, FAAP, IBCLC
President, DC Breastfeeding Coalition
[email protected]

NEW YORK CITY DEPARTMENT OF
HEALTH AND MENTAL HYGIENE

Health

Andrew Goodman, MD, MPH
Deputy Commissioner
Division of Health Promotion
And Disease Prevention
Gotham Center
42-09 28th Street, 9th Floor
CN#24
Queens, NY 11101-4132
[email protected]
1-347-396-4206 tel
1-347-396-4358 fax

Thomas Farley, MD, MPH

Commissioner

April 8, 2013
RE: CDC - Assessment and Monitoring of Breastfeeding-Related Maternity
Care
[FR Doc No: 2013-03194]
To Whom It May Concern:
The New York City Department of Health and Mental Hygiene
(DOHMH) has reviewed the Centers for Disease Control and
Prevention's (CDC) proposed collection of information and offers the
following comments.
• We agree that it is important to collect data on breastfeeding practices in
hospitals providing maternity services because such data can be used to help
hospitals improve their services and increase the number of women who
breastfeed successfully. In NYC over 80% of women attempt to breastfeed
and need more support to continue.
• We would strongly encourage increased outreach to hospitals as part of an
effort to improve participation. While the response rates presented (82% and
83%) are good, the goal should be 95% and include the entire U.S.
• While we have found the data to be fairly accurate, in our discussions with
hospitals they have voiced some confusion as to who is completing the survey
and who receives the results. We would recommend that survey results be sent
to multiple staff members in the hospital so there is no delay in reviewing the
results. Examples of key hospital administrators who should receive these data
include the Chief Executive Officer, the Vice President of Nursing, the Chairs
of Obstetrics and Gynecology, Pediatrics, and Family Medicine as well as the
contact person who completed the survey (if it was not submitted by one of
these individuals).
• To enhance the partnership between local and state health departments and
hospitals on the issue of breastfeeding, we recommend the disclosure of
individual hospital names and data (rather than aggregate data). By seeing how
each institution is performing as related to the metrics discussed in this
proposal, local and state health departments can work with hospitals directly to
improve practices related to breastfeeding.

CDC- Assessment and Monitoring

•

2.

April 8,2013

With regard to the 2013 and 2015 surveys, it would be useful to know when the CDC
will make the data available, so hospitals can anticipate when to look for the results of
the surveys.

We appreciate the opportunity to provide comments on the proposed data collection.
Sincerely,

~ObH
Deputy Commissioner
Health Promotion and
Disease Prevention

From: [email protected] [mailto:[email protected]]
Sent: Thursday, April 11, 2013 11:00 AM
To: OMB-Comments (CDC)
Cc: [email protected]; [email protected]
Subject: MPINC letter from NH

(See attached file: MPINC letter from NH.pdf)

STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
29 HAZEN DRIVE, CONCORD, NH 03301-6527
603-271-4546 1-800-852-3345 Ext. 4546
Fax: 603-271-4779 TDD Access: 1-800-735-2964

Nicholas A. Toumpas
Commissioner
José Thier Montero
Director

April 11, 2013
Kimberly Lane
CDC, 1600 Clifton Road
MS D–74
Atlanta, GA 30333
Dear Ms Lane:
Thank you for the opportunity to provide comments to the Centers for Disease Control and Prevention on
continuation of the Maternity Practices in Infant Nutrition and Care survey (mPINC) for 2013 and 2015.
As a State who has seen hospitals improve their breastfeeding support through changes in practices and care
processes over time, New Hampshire has greatly appreciated the value of the mPINC survey.
•

Is the proposed collection of information necessary for the proper performance of the functions of the agency,
including whether the information has practical utility?
For the New Hampshire Division of Public Health Service, the mPINC survey reinforces that maternity practices and
policies are key to breastfeeding initiation, duration and exclusivity. It also provides timely feedback regarding areas
in need of improvement which helps to tailor technical assistance from State Programs and resources in these needy
areas. For community agencies, the trend data is important and helps to identify communities with solid policies and
those that are making improvements.

•

The accuracy of the agency’s estimate of the burden of the proposed collection of information
Unable to comment on this area as we do not do the data collection.

•

Ways to enhance the quality, utility, and clarity of the information to be collected
Would like to see NH compared to the US, especially in the section called Strengths and Needed Improvements, ie,
provide the national percentage for each strength or improvement. Would also like to see a reference for each of the
rationales provided for each strength or improvement. Would like to see a listing of the composite scores by NH
hospital so that the State Agency may offer assistance in specific areas to those hospitals that need the support, as
well as who completed the survey for the hospital. Or at the least, a listing of the NH hospitals that participated in
the survey. We also suggest that the title of the survey be changed to include breastfeeding in the title, as that is the
primary focus of the survey.

•

Ways to minimize the burden of the collection of information on respondents, including through the use of
automated collection techniques or other forms of information technology.
Unable to comment on this area as we do not do the data collection.
Sincerely,

Lisa Richards, MS, RD, Nutrition Services Manager
Healthy Eating and Physical Activity Section
Division of Public Health Services

The Department of Health and Human Services’ Mission is to join communities and families
in providing opportunities for citizens to achieve health and independence.

From: Karen Farley [mailto:[email protected]]
Sent: Thursday, April 11, 2013 3:26 PM
To: OMB-Comments (CDC)
Subject: Comments: FR Doc. 2013-03194 9924-9925

Please accept our comments in support of the Centers for Disease Control and Prevention Maternity
Practices in Infant Nutrition and Care (mPINC) survey 2013 and 2015.
Karen Farley RD, IBCLC | California WIC Association | 1490 Drew Avenue, Suite 175 | Davis, CA 95618 |
Phone:530-750-2280 | Cell: 530-400-5842 | Fax: 530-758-7780 | www.calwic.org

Public Comments on the Assessment and
Monitoring of Breastfeeding-Related Maternity
Care Practices in Intra-partum Care Facilities in
the United States and Territories Publication of the
60-Day-13-0734 FR Doc. 2013-03194
April 10, 2013
Kimberly Lane
Deputy Director, Office of Scientific Integrity
Office of the Associate Director for Science
Office of the Director
Center for Disease Control and Prevention
1600 Clifton Road, MS D-74,
Atlanta, GA 30333
Telephone: 404-639-7570
Email: [email protected]
On behalf of the California WIC Association and the 84 local California WIC agencies, we are
writing in strong support of the renewal of the Centers for Disease Control and Prevention
Maternity Practices in Infant Nutrition and Care (mPINC) 2013 and 2015 surveys. CWA also
submitted support comments for the 2009 and 2011 surveys. These surveys have been very
useful and effective in California communities, and nationally, by providing hospitals and birthing
centers with important information pertinent to improving maternity practices. The multi-year data
is very important to implementing state and national improvements in maternity care, which is a
long term strategy.
With the The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding,
the mPINC survey is even more valuable, and provides the ability to benchmark maternity
practices and share best practices across the nation, and over time. It is also very helpful to be
able to support efforts to improve breastfeeding and maternity care practices with federal data,
particularly from the CDC.
The mPINC survey data is very useful in a variety of ways to help, or advocate for, California’s
over 260 perinatal hospitals improve their maternity care practices, especially related to
breastfeeding. Local breastfeeding professionals and coalitions use the mPINC results to work
individually with their local hospitals. The California Department of Public Health has developed
useful regional data for hospitals using the mPINC data, targeting areas with low breastfeeding
rates.

The California WIC Association, in partnership with the Human Lactation Center at the University
of California Davis, since 2006 has produced reports on hospital breastfeeding rates, using
publicly available state data. These reports have been instrumental in more hospitals either
becoming Baby Friendly, or adopting model hospital breastfeeding policies, recommended by the
California Department of Public Health. We committed to multi-year reports in order to maintain
the momentum of change. Hospital staff, breastfeeding advocates and WIC staff welcome these
reports as useful and effective tools for implementing changes in hospital policies.
Not all states have access to the breastfeeding data that is available for California hospitals. We
are fortunate to have the commitment of the Maternal Child and Adolescent Health Division in the
California Department of Public Health to provide data . The mPINC survey provides hospitals in
all states with useful maternity practice data that empowers hospital staff and local health
professionals and advocates to work on quality of care improvement for breastfeeding.
The mPINC survey also fits in exactly with the framework of the Affordable Care Act and the
focus on preventive strategies, which includes breastfeeding as a key health strategy especially
for obesity prevention. Hospitals are essential to helping mothers and babies start breastfeeding,
and the research indicates that mothers who deliver in hospitals with breastfeeding supportive
maternity care practices, breastfeed for longer and more exclusively, which impacts our national
breastfeeding rates and health equity.
In order to reach our national breastfeeding goals, our hospitals need information, like that
provided in the mPINC surveys, on their maternity practices that support breastfeeding.
Sincerely,

Karen Farley RD, IBCLC
Program Manager

From: Hedrick, Theresa
Sent: Friday, April 12, 2013 3:35 PM
To: [email protected]
Subject: Comments Re: Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intra-partum Care Facilities in the United States and Territories
To Whom It May Concern,
Please see the attached letter from the International Formula Council regarding the Federal Register (60Day–13–0743) 60-day notice regarding the proposed reinstatement of the Centers for Disease Control
and Prevention (CDC) hospital survey on breastfeeding practices, Assessment and Monitoring of
Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities in the United States and
Territories.
Please confirm receipt of this letter.
Thank you,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist
International Formula Council
1100 Johnson Ferry Road, Suite 300
Atlanta, GA 30342
P (678) 303-2953
F (678) 252- 0774
E [email protected]

The International Formula Council is managed by the Kellen Company, an employee-owned association
management company providing association and meetings management, public relations, government
affairs, marketing, web site development and graphic design services. Offices in Atlanta, Chicago, New
York, Washington, Brussels and Beijing. www.kellencompany.com

April 12, 2013

Kimberly S. Lane
Deputy Director, Office of Scientific Inquiry
Centers for Disease Control and Prevention
1600 Clifton Road, MS D–74
Atlanta, GA 30333

Re: Comments on the Proposed Project
Assessment and Monitoring of
Breastfeeding-Related Maternity Care
Practices in Intra-partum Care Facilities
in the United States and Territories
Dear Ms. Lane:
The International Formula Council* (IFC) is responding to the February 12, 2013 Federal Register
(60-Day–13–0743) 60-day notice regarding the proposed reinstatement of the Centers for
Disease Control and Prevention (CDC) hospital survey on breastfeeding practices, Assessment
and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities
in the United States and Territories (mPINC survey). The IFC is an association of manufacturers
and marketers of formulated nutrition products, e.g., infant formulas and adult nutritionals, whose
members are based predominantly in North America.
IFC member companies represent the center of excellence for important scientific research and
education in the area of global infant nutrition with a strong focus on infant growth, development,
and positive health outcomes. The IFC agrees with the American Academy of Pediatrics (AAP)
and other health care professional organizations that breastfeeding is the ideal and
recommended first choice for infant feeding, as it offers specific child and maternal health
benefits. We also agree that more can be done to support and encourage breastfeeding in
hospitals and to assess and monitor care practices.
IFC is very interested in providing comments on the mPINC survey, and IFC has provided
comments regarding this survey in the past. However, we are unable to comment on the
proposed reinstatement, since the survey has not been made available, even after multiple
requests via email and telephone. We have also requested an extension of the comment period -

2
to provide sufficient time to comment on the survey if it was shared - but to date have not
received a response. In summary, we are concerned about the lack of transparency and do not
believe it is in the public interest to move forward with reinstating this survey if there has been no
opportunity for public review of the survey instrument.
If CDC has any questions or requires clarification of any aspects of these comments, please
contact me.
Sincerely,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist

From: Hedrick, Theresa [mailto:[email protected]]
Sent: Tuesday, April 16, 2013 5:21 PM
To: OMB-Comments (CDC)
Subject: Comments Re: Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intra-partum Care Facilities in the United States and Territories
To Whom It May Concern,
The letter from the International Formula Council regarding the Federal Register (60-Day–13–0743) 60day notice regarding the proposed reinstatement of the Centers for Disease Control and Prevention
(CDC) hospital survey on breastfeeding practices, Assessment and Monitoring of Breastfeeding-Related
Maternity Care Practices in Intra-partum Care Facilities in the United States and Territories submitted on
April 12 was missing a footnote. Please disregard it and use this version of the letter instead.
Thank you,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist
International Formula Council
1100 Johnson Ferry Road, Suite 300
Atlanta, GA 30342
P (678) 303-2953
F (678) 252- 0774
E [email protected]

April 12, 2013

Kimberly S. Lane
Deputy Director, Office of Scientific Inquiry
Centers for Disease Control and Prevention
1600 Clifton Road, MS D–74
Atlanta, GA 30333
Re: Comments on the Proposed Project
Assessment and Monitoring of
Breastfeeding-Related Maternity Care
Practices in Intra-partum Care Facilities
in the United States and Territories
Dear Ms. Lane:
The International Formula Council* (IFC) is responding to the February 12, 2013 Federal Register
(60-Day–13–0743) 60-day notice regarding the proposed reinstatement of the Centers for
Disease Control and Prevention (CDC) hospital survey on breastfeeding practices, Assessment
and Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities
in the United States and Territories (mPINC survey). The IFC is an association of manufacturers
and marketers of formulated nutrition products, e.g., infant formulas and adult nutritionals, whose
members are based predominantly in North America.
IFC member companies represent the center of excellence for important scientific research and
education in the area of global infant nutrition with a strong focus on infant growth, development,
and positive health outcomes. The IFC agrees with the American Academy of Pediatrics (AAP)
and other health care professional organizations that breastfeeding is the ideal and
recommended first choice for infant feeding, as it offers specific child and maternal health
benefits. We also agree that more can be done to support and encourage breastfeeding in
hospitals and to assess and monitor care practices.
IFC is very interested in providing comments on the mPINC survey, and IFC has provided
comments regarding this survey in the past. However, we are unable to comment on the
proposed reinstatement, since the survey has not been made available, even after multiple
________________________________________________
*
IFC members are Abbott Nutrition, Mead Johnson Nutrition, Nestlé Infant Nutrition and Perrigo Nutritionals.

2
requests via email and telephone. We have also requested an extension of the comment period to provide sufficient time to comment on the survey if it was shared - but to date have not
received a response. In summary, we are concerned about the lack of transparency and do not
believe it is in the public interest to move forward with reinstating this survey if there has been no
opportunity for public review of the survey instrument.
If CDC has any questions or requires clarification of any aspects of these comments, please
contact me.
Sincerely,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist

From: Jean Public [mailto:[email protected]]
Sent: Tuesday, April 23, 2013 3:22 PM
To: OMB-Comments (CDC); [email protected]; [email protected]; [email protected]
Subject: Fw:public commenton federal register american taxpayers dont need to be gouged for tax
dollars for this non needed info

taxpayers are beleaguered and pummeled with the high taxes we are paying these days. we need
smaller cheaper govt. we do not need this survey at all. it is highly unnecessary and completely wasteful.
the taxpayers do want the cdc to develoip a priority list on the numbers of projects they have with
priority schedules and how much taxpayer dollars they are spending on each issue because there seems
to be a lot of crap projects that nobody in America wants or needs being funded. this is one of them. this
comment is for the public record. jean public

From: Rothenberger, Amy [mailto:[email protected]]
Sent: Thursday, April 25, 2013 8:21 AM
To: OMB-Comments (CDC)
Subject: Comments and Recommendations for Federal Register request 2/12/13

Hello,
The Pennsylvania Department of Health is submitting the attached comments and recommendations in
response to the request published in the Federal Register Vol. 78, No. 29, February 12, 2013, concerning
proposed data collection for the Assessment and Monitoring of Breastfeeding-Related Maternity Care
Practices in Intra-Partum Care Facilities in the United States and Territories. We understand that the
comment period has probably expired by this date, however, we would be very pleased to have these
comments accepted anyway.
Thank you for your consideration.
Amy Rothenberger| Chief, Media Outreach and Promotion Section
Pennsylvania Department of Health | Bureau of Family Health
7th Floor, East Wing
625 Forster Street| Harrisburg, PA 17120-0701
Phone: 717.772.2763 | Fax: 717.772.0323
www.health.state.pa.us

Proposed Public Comments and Recommendations for Federal Register request

The Pennsylvania Department of Health has utilized the mPINC surveys since its first issuance
in 2007 for the purposes of information sharing, program planning, trend analysis and
reporting. The survey is the only instrument focused on breastfeeding in maternity care
facilities that is conducted and utilized in Pennsylvania, and as such has been invaluable in
providing direction (programming, funding, staffing) to our Breastfeeding Awareness and
Support Program.
The individual hospital reports provide valuable information to each of the
hospitals, namely outlining what is going well and what needs improvement, and can be used to
prioritize their efforts to improve their support of breastfeeding. Knowing that the tool is
comparable across survey years assists with trend analysis and reporting, allowing us to
understand where Pennsylvania is making progress and how/where, as a state, improvements can
be made.
We believe the estimates of the burden of the completion of the survey are accurate and the
overall response rate of 83% indicates that facilities do not see this burden as troublesome and
are willing to complete the survey.
The quality, utility, and clarity of information surely has to
be a challenge with the variety of practices and policies in effect across hospitals and
states. We have heard from employees (maternity care and others) at several hospitals in
Pennsylvania that they are not aware of who has completed the mPINC survey in their hospital
(if at all), that results have not been shared with them if completed, and that no specific activities
related to the improvements suggested are taking place afterwards. While we have made an
effort to provide statewide results to our hospitals and encourage individuals to locate their
individual hospital’s results, additional encouragement at the level of the surveyors would be
welcome. Along those same lines, individuals completing the survey should be encouraged to
solicit the input of others in the hospitals, and perhaps the time to do that type of activity should
be built into the time frames for completion.
It is important to continue to explore other methods of collecting data, but we offer no particular
means of doing so other than what is already employed.

From: susan vierczhalek [mailto:[email protected]]
Sent: Thursday, May 02, 2013 11:36 AM
To: OMB-Comments (CDC)
Subject: mPINC survey

I wish to express enthusiastic support for the mPINC survey. As a pediatrician working in a
public safety-net hospital, it has had a profound impact on hospital leadership and staff who now
view exclusive breastfeeding as a valuable goal to work for. The survey has helped to change
thinking and direct resources into breastfeeding promotion in my institution in my hospital and in
many others in NY city and NY state. It has had a big impact and should be continued.
thank you,
Susan Vierczhalek, MD

From: Flynn, Karen [mailto:[email protected]]
Sent: Thursday, May 02, 2013 1:12 PM
To: OMB-Comments (CDC)
Subject: mPINC, Comments regarding: Assessment and Monitoring of Breastfeeding-Related Maternity
Care Preactices in intra-partum Care Facilities.
Kimberly S. Lane
Deputy Director, Office of Scientific Integrity
Office of the Associate Director for Science,
Office of the Director, Centers for Disease Control and Prevention
1600 Clifton Road,
MS D-74,
Atlanta, GA 30333
May 2, 2013
Comments regarding: Assessment and Monitoring of Breastfeeding-Related Maternity Care Preactices in intra-partum Care
Facilities.
Whether the proposed collection of information is necessary for the proper performance of the functions of the agency,
including whether the information shall have practical utility…in support of the public health need for mPINC data.
1. The State of Vermont has recently used the 2007 mPINC data to implement a quality improvement project in 10 of 12
birthing hospitals, with particular focus on improving dimensions of care of care with low sub-scores. Despite
Vermont’s high overall ranking, opportunities to support improvement exist. We initiated a QI collaborative to
encourage changes in hospital practices in support of increasing exclusive breastfeeding at discharge. The mPINC
data influenced participating hospitals to strive to improve their individual hospital score and to work collaboratively
to share successes, supporting other hospitals to also improve.
2. mPINC data has filled a knowledge gap and provides invaluable data by which to measure key dimensions of
maternity care in hospitals. The data is relevant and allows for progress toward optimal birthing practices in our
maternity facilities to be compared over time. Surveys planned for 2013 and 2015 will further quality improvement
efforts by providing a consistent source of data to measure change.
3. The CDC, August 2011 Vital Signs, a summary of mPINC findings, which highlighted improving hospital maternity
practices as a priority provided a useful tool to engage stakeholders and move partners to action.
Ways to enhance the quality, utility and clarity of the information to be collected…
4. It is not clear that the most informed and appropriate staff are the ones actually completing the CDC mPINC
survey. Hospitals participating in our collaborative are more aware of when the mPINC is being conducted and will
assert themselves into the process. Ultimately, then, those at the state policy level can be more confident that the
mPINC results are indeed reliable.
5. Knowing which staff/s types completed the survey would also be helpful ….our hospital partners recommend
requiring the survey to be completed by a team that includes an IBCLC.
6. A shorter turnaround time would make it easier to use the data (support broader use) in State level QI
initiatives…2011 survey data not available until early 2013.
Sincerely,
Karen Flynn
WIC Program Administrator
Vermont Department of Health

Karen Flynn • WIC Program Administrator
Vermont Department of Health • healthvermont.gov/wic
108 Cherry Street • PO Box 70 • Burlington, VT 05402
[email protected]
802.652.4171 • 802.863.7229

State of Vermont
Department of Health
Division of Maternal and Child Health
108 Cherry St. PO Box 70
Burlington, VT 05402
healthvermont.gov

[phone]
[fax]

802-863-7333
802-863-7229

Agency of Human Services

Kimberly S. Lane
Deputy Director, Office of Scientific Integrity
Office of the Associate Director for Science,
Office of the Director, Centers for Disease Control and Prevention
1600 Clifton Road,
MS D-74,
Atlanta, GA 30333
May 2, 2013
Comments regarding: Assessment and Monitoring of Breastfeeding-Related Maternity Care Preactices in intra-partum
Care Facilities.
Whether the proposed collection of information is necessary for the proper performance of the functions of the agency,
including whether the information shall have practical utility…in support of the public health need for mPINC data.
1. The State of Vermont has recently used the 2007 mPINC data to implement a quality improvement project in 10
of 12 birthing hospitals, with particular focus on improving dimensions of care of care with low sub-scores.
Despite Vermont’s high overall ranking, opportunities to support improvement exist. We initiated a QI
collaborative to encourage changes in hospital practices in support of increasing exclusive breastfeeding at
discharge. The mPINC data influenced participating hospitals to strive to improve their individual hospital score
and to work collaboratively to share successes, supporting other hospitals to also improve.
2. mPINC data has filled a knowledge gap and provides invaluable data by which to measure key dimensions of
maternity care in hospitals. The data is relevant and allows for progress toward optimal birthing practices in our
maternity facilities to be compared over time. Surveys planned for 2013 and 2015 will further quality
improvement efforts by providing a consistent source of data to measure change.
3. The CDC, August 2011 Vital Signs, a summary of mPINC findings, which highlighted improving hospital maternity
practices as a priority provided a useful tool to engage stakeholders and move partners to action.
Ways to enhance the quality, utility and clarity of the information to be collected…
4. It is not clear that the most informed and appropriate staff are the ones actually completing the CDC mPINC
survey. Hospitals participating in our collaborative are more aware of when the mPINC is being conducted and
will assert themselves into the process. Ultimately, then, those at the state policy level can be more confident
that the mPINC results are indeed reliable.
5. Knowing which staff/s types completed the survey would also be helpful ….our hospital partners recommend
requiring the survey to be completed by a team that includes an IBCLC.
6. A shorter turnaround time would make it easier to use the data (support broader use) in State level QI
initiatives…2011 survey data not available until early 2013.
Sincerely,
Karen Flynn
WIC Program Administrator
Vermont Department of Health

From: Hedrick, Theresa [mailto:[email protected]]
Sent: Friday, May 03, 2013 11:28 AM
To: OMB-Comments (CDC)
Subject: Comments Re: Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in
Intra-partum Care Facilities in the United States and Territories
To Whom It May Concern,
Please see the attached letter from the International Formula Council regarding the Federal Register (60Day–13–0743) 30-day extension notice on the proposed reinstatement of the Centers for Disease Control
and Prevention (CDC) hospital survey on breastfeeding practices, Assessment and Monitoring of
Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities in the United States and
Territories.
Please confirm receipt of this letter.
Thank you,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist
International Formula Council
1100 Johnson Ferry Road, Suite 300
Atlanta, GA 30342
P (678) 303-2953
F (678) 252- 0774
E [email protected]

May 3, 2013
Kimberly S. Lane
Deputy Director, Office of Scientific Inquiry
Centers for Disease Control and Prevention
1600 Clifton Road, MS D–74
Atlanta, GA 30333

Re: Comments on the Proposed Project
Assessment and Monitoring of
Breastfeeding-Related Maternity Care
Practices in Intra-partum Care Facilities
in the United States and Territories
Dear Ms. Lane:
The International Formula Council* (IFC) is responding to the April 22, 2013 Federal Register (60Day–13–0743) 60-day notice regarding the proposed reinstatement of the Centers for Disease
Control and Prevention (CDC) hospital survey on breastfeeding practices, Assessment and
Monitoring of Breastfeeding-Related Maternity Care Practices in Intra-partum Care Facilities in
the United States and Territories (mPINC survey). The IFC is an association of manufacturers
and marketers of formulated nutrition products, e.g., infant formulas and adult nutritionals, whose
members are based predominantly in North America.
IFC has reviewed the proposed 2013 and 2015 mPINC survey instrument, and has several
comments on it. First, we note that several points that we raised in comments on earlier surveys
were addressed in this version, and appreciate the CDC’s attempts to make the survey more
robust.
The International Formula Council (IFC)* offers the following comments on the topics mentioned
in the April 22, 2013, Federal Register [78 FR 09367]:
(a) “Whether the proposed collection of information is necessary for the proper
performance of the functions of the agency, including whether the information
shall have practical utility.”
IFC Comment: The survey focuses almost entirely on breastfeeding, and does not ask
questions on what guidance/information is given to formula feeding mothers or how staff
is trained to provide information on formula feeding although the Healthy People 2010
goals (set at 75% of mothers initiate breastfeeding in the hospital) acknowledge that up to
1
25% of newborns will be fed a breast milk alternative.
We are concerned that there is a gap in education efforts on breastfeeding and formulafeeding/supplementing. Parents who choose to feed infant formula need education on
the selection, safe preparation, and proper use of infant formulas. Research has
documented that while mothers recognize the benefits of breastfeeding, those who bottlefeed with infant formula do not receive adequate information and support from their

healthcare providers. A 2008 study by the Centers for Disease Control and Prevention
(CDC) and Food and Drug Administration (FDA) found that by two months, 88% of
parents report not having received instruction on infant formula preparation from their
2
healthcare provider. Research has also found that mothers who did not receive bottlefeeding information from their healthcare providers often turned to family and friends for
guidance—a trend which can perpetuate errors in infant formula preparation and
3
handling. Without appropriate education, parents may be making mistakes, errors and
other variations in formula-feeding that may have both short- and long-term health
consequences for their infants.
We acknowledge that a survey on breastfeeding may not be the optimal place to address
formula-feeding; however, we believe it is important this be addressed in some venue
e.g., by gathering the following information on formula-feeding to optimize care delivered
to the infants who do not receive breastmilk. When formula-feeding is addressed, we
recommend asking the following questions:
On average, how many hours do nurses spend in education on safe and
appropriate formula feeding, including hygienic preparation, time from
reconstitution to use, temperature of storage, and time until unused portion is
discarded?
On average, how many hours do other health care professionals spend in
education on safe and appropriate formula feeding, including hygienic
preparation, time from reconstitution to use, temperature of storage, and time
until unused portion is discarded?
Does hospital staff provide education on how to properly prepare and feed infant
formula?
How many mothers received information on safe formula preparation and use?
How often are nurses assessed for competency in formula feeding instruction?
How often are mothers assessed for their competency in formula reconstitution
and proper formula handling?
Does hospital staff observe mother/infant pairs while being bottle fed to ensure
proper latching to various nipples and burping techniques?
Do prenatal classes inform mothers on hygienic preparation and use of formula?
Does the neonatal intensive care unit (NICU) uses only liquid formulas?
A second concern is that this survey, while yielding information on hospital practices, will
not provide practical information on how to overcome two of the largest barriers to
breastfeeding in the US: lack of workplace support for breastfeeding mothers and the
availability of free infant formula through the WIC program.
(b) “The accuracy of the agency's estimate of the burden of the proposed collection of
information.”
IFC Comment: It was noted in the background of the mPINC survey that ―The health
care system is one of the most important and effective settings to improve breastfeeding
initiation rates because hospital practices strongly influence infant feeding outcomes.‖
However, hospitals practices are not a major barrier to increased breastfeeding rates in
the United States. In the last ten years, hospital breastfeeding initiation rates have
increased. Most US mothers (71%) report they made the decision about what to first
feed their newborn baby before giving birth. And mothers overwhelmingly know that
breastfeeding is best for babies (3 out of 4 women—75%) say breastfeeding is "healthier
4
for the child." And, a recent study found that the Baby-Friendly Hospital Initiative (BFHI)
accreditation does not have a positive impact on short-and medium-term breastfeeding
5
rates. Other methods to help states increase breastfeeding rates by reducing true
barriers may be more productive than a hospital survey.

In addition, below are some general and specific comments on the survey instrument, which we
believe would improve the quality of the survey.
General IFC Comments on the Survey
When asked to give ranked answers (i.e., few, some, many, most, not sure), the percentages
corresponding to each of those categories shifted slightly. For example, ―Few‖ was previously
defined as ―0%-10%‖ but was changed to ―0%-9%‖ and so on. This change is not recommended
as it could introduce error when comparing results to those of past surveys.
IFC Comments Regarding Individual Survey Questions
A11.
“Approximately how many mothers are encouraged to hold their healthy full-term
infants skin-to-skin for at least 30 minutes within two hours after delivery for
uncomplicated cesarean births?”
What is the measure of ―encouraged‖? A single mention? How often is encouragement
given, and under what conditions is encouragement discontinued? Should this question
be repeated for times other than the two hours after delivery?
A12.

“Approximately what percentage of healthy full-term breastfed infants are put to
the breast for the first time during the specified period after delivery for
uncomplicated cesarean sections?”
This question seems to pertain to all infants, not only breastfed infants.

A13.

“Approximately what percentage of healthy full-term breastfed infants are given
the following as a first feeding after uncomplicated cesarean section births?”
This question seems to pertain to all infants, not only breastfed infants.

A15.

“Of mothers who are breastfeeding, or intend to breastfeed, approximately how
many do you teach breastfeeding techniques (e.g. comfortable positioning,
holding infant, how to express milk, assessing the effectiveness of
breastfeeding)?”
How is intention assessed?

A18.

“Of mothers who are breastfeeding, approximately how many mother-baby
couples are directly observed and assessed by staff for breastfeeding
effectiveness during the maternity care hospital stay?”
The survey should include the following questions, similar to that above: ―Do mothers
limit the opportunities for observations? Does staff state expectation that observations
will be conducted?‖

A20.

“Approximately what percentage of healthy full-term breastfed infants are
supplemented with something other than breast milk? (If your hospital does not
formally track this information, please provide your best estimate.)”
This question seems to pertain to all infants, not only breastfed infants.

A21.

“Are healthy full-term breastfed infants who are supplemented ever given the
following types of supplementary feedings?”
This question seems broad and the reasons are not clearly explained.

A22.

“Of the healthy full-term breastfed infants who are supplemented with infant
formula, what percentage are supplemented for the following reasons?”
We noted that ―Other (please specifiy)‖ was added as an answer choice to address the
reasons for supplementing with infant formula that are not captured by the ―Doctor’s
orders,‖ ―Nurse’s recommendation,‖ or ―Mother’s choice‖ options. The IFC suggests the
survey also include the following questions, similar to that above: ―Of the healthy full-term
formula fed infants, what percentage is fed formula for the following reasons? What

percentage of all infants has some medical or physiological reason for not breastfeeding?
What are the most common reasons?‖
A25.

“Does your hospital receive free infant formula?”
Will the respondent be likely to know the answer to this question?

A32.

“Are discharge packs/bags containing infant formula samples given to
breastfeeding mothers?”
Why is this question focused on only infant formula? Mothers obtain information and
samples of many other items. A description of the full content of the discharge bags (i.e.,
diapers, coupons, other information, toys, accessories, etc.) would be more informative.

A30.

“What support does your hospital routinely (most of the time) offer to
breastfeeding mothers at discharge? (check all that apply)”

a. Postpartum telephone call by hospital staff
b. Telephone number for patient to call
c. Postpartum follow-up visit at hospital after discharge
d. Home follow-up visit after discharge
e. Referral to hospital-based breastfeeding support group
f. Referral to other breastfeeding support groups
g. Referral to lactation consultant/specialist
h. Referral to WIC (for those eligible)
i. Referral to an outpatient lactation clinic
j. List of resources for breastfeeding help
k. Breastfeeding assessment sheet
l. Other (please specify) _________________________
The answer choices for this question were changed from ―Yes,‖ ―No‖ or ―Not Sure‖ to
―Check all that apply.‖ This alteration in the way the question can be answered could
affect interpretation and comparison of this survey to those of past years.
It would be helpful to know what percentage of breastfeeding mothers utilize these
services and what these services cost the hospital. An additional question that would be
helpful is, ―In addition, what support does your hospital routinely offer to formula feeding
mothers at discharge?‖ The questions related to breastfeeding should be removed (e, f,
g, i, k, remove ―breastfeeding‖ from j) based on the assumption that formula-feeding
mothers cannot reverse their decision and initiate breastfeeding after discharge. Also
add questions, ―What percentage of non-breastfeeding mothers utilize the above
services?‖ and ―What do these services cost the hospital?‖
B11.

“Does your hospital have a written policy addressing…
“b. prenatal classes informing mothers of the benefits of breastfeeding
This question should follow c. The survey should include the following question:
―prenatal classes informing mothers on usual problems encountered in breastfeeding.‖
“c. asking about mothers’ feeding plans”

The survey should include the following questions: ―do hospitals continue to give
breastfeeding information and encouragement when a mother has informed that her
intention is to formula feed?‖

If CDC has any questions or requires clarification of any aspects of these comments, please
contact me.
Sincerely,

Theresa Hedrick, MS, RD, LD
Scientific Affairs Specialist

References
1. U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics. Healthy People 2010. Available at:
http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf.
2. Labiner-Wolfe J, Fein SB, Shealy KR. Infant formula handling education and safety.
Pediatrics. 2008. 122(Suppl2):S85-90.
3. Lakshman R OD, Ong K. Mothers' experiences of bottle feeding: a systematic review of
qualitative and quantitative studies. Arch Dis Child. 2009. 94(8):596-601
4. Greenberg Quinlan Rosner Research (GQRR) and Public Opinion Strategies (POS).
―Mothers Survey Regarding Hospital Experience following Childbirth and Influences on
Infant Feeding Decisions.‖ Nationally Representative, 2012. Available:
http://www.momsfeedingfreedom.com/general/national-survey-shows-mothers-want-supporttheir-infant-feeding-choices.
5. Brodribb et al. Baby-Friendly Hospital Accreditation, In-Hospital Care Practices, and
Breastfeeding. Pediatrics. 2013. doi:10.1542/peds.2012-2556.

International Formula Council comments on the proposed continuation of the 
CDC project Assessment and Monitoring of Breastfeeding‐Related Maternity 
Care Practices in Intra‐partum Care Facilities in the United States and 
Territories, National Center for Chronic Disease Prevention and Health 
Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC) 
June 3, 2013 
1

The International Formula Council (IFC)  offers the following comments on the topics mentioned in the April 
22, 2013, Federal Register [78 FR 09367]: 
(a)  “Whether the proposed collection of information is necessary for the proper performance of the 
functions of the agency, including whether the information shall have practical utility.”  
IFC Comment: The survey focuses almost entirely on breastfeeding, and does not ask questions on what 
guidance/information is given to formula feeding mothers or how staff is trained to provide information 
on formula feeding although the Healthy People 2010 goals (set at 75% of mothers initiate breastfeeding 
in the hospital) acknowledge that up to 25% of newborns will be fed a breast milk alternative. 
CDC Response: This is a survey that assesses hospital maternity care practices that have been shown in 
controlled intervention trials to be associated with increased rates of breastfeeding exclusivity and 
continuation. 
IFC Comment: We are concerned that there is a gap in education efforts on breastfeeding and formula‐
feeding/supplementing. Parents who choose to feed infant formula need education on the selection, safe 
preparation, and proper use of infant formulas. Research has documented that while mothers recognize 
the benefits of breastfeeding, those who bottle‐feed with infant formula do not receive adequate 
information and support from their healthcare providers. A 2008 study by the Centers for Disease Control 
and Prevention (CDC) and Food and Drug Administration (FDA) found that by two months, 88% of 
parents report not having received instruction on infant formula preparation from their healthcare 
provider. Research has also found that mothers who did not receive bottle‐feeding information from 
their healthcare providers often turned to family and friends for guidance—a trend which can perpetuate 
errors in infant formula preparation and handling. Without appropriate education, parents may be 
making mistakes, errors and other variations in formula‐feeding that may have both short‐ and long‐
term health consequences for their infants. 
We acknowledge that a survey on breastfeeding may not be the optimal place to address formula‐
feeding; however, we believe it is important this be addressed in some venue e.g., by gathering the 
following information on formula‐feeding to optimize care delivered to the infants who do not receive 
breastmilk. When formula‐feeding is addressed, we recommend asking the following questions: 
•  On average, how many hours do nurses spend in education on safe and appropriate formula feeding, 
including hygienic preparation, time from reconstitution to use, temperature of storage, and time 
until unused portion is discarded? 
•  On average, how many hours do other health care professionals spend in education on safe and 
appropriate formula feeding, including hygienic preparation, time from reconstitution to use, 
temperature of storage, and time until unused portion is discarded? 
•  Does hospital staff provide education on how to properly prepare and feed infant formula? 
•  How many mothers received information on safe formula preparation and use? 
•  How often are nurses assessed for competency in formula feeding instruction? 

1

 The IFC is an international association of manufacturers and marketers of formulated nutrition products (e.g., 
infant formulas and adult nutritionals) whose members are predominantly based in North America. IFC members 
are: Abbott Nutrition, Mead Johnson Nutrition, Nestlé Infant Nutrition, and Perrigo Nutritionals. 

•  How often are mothers assessed for their competency in formula reconstitution and proper formula 
handling? 
•  Does hospital staff observe mother/infant pairs while being bottle fed to ensure proper latching to 
various nipples and burping techniques? 
•  Do prenatal classes inform mothers on hygienic preparation and use of formula? 
•  Does the neonatal intensive care unit (NICU) uses only liquid formulas? 
CDC Response: We agree that this is not the optimal place to address these issues. Further, as the Food and 
Drug Administration (FDA) is the agency that is responsible for the assessment of safe and appropriate 
preparation of infant formula, questions of this nature are beyond the scope of CDC’s purview. 
IFC Comment: A second concern is that this survey, while yielding information on hospital practices, will not 
provide practical information on how to overcome two of the largest barriers to breastfeeding in the US: 
lack of workplace support for breastfeeding mothers and the availability of free infant formula through 
the WIC program. 
CDC Response: We agree that there are multiple barriers to breastfeeding in the United States.The 
proposed continuation of the established assessment and monitoring project is one of many initiatives 
to address these issues. We are concurrently working in several arenas including multiple 
complementary initiatives to improve workplace support for breastfeeding mothers, dissemination of 
information about the evidence supporting breastfeeding interventions in multiple settings, improving 
the breadth and depth of breastfeeding support in the WIC program, and expanding utilization of 
breastfeeding data. 
(b)  “The accuracy of the agency's estimate of the burden of the proposed collection of information.” 
IFC Comment: It was noted in the background of the mPINC survey that “The health care system is one of the 
most important and effective settings to improve breastfeeding initiation rates because hospital 
practices strongly influence infant feeding outcomes.” However, hospitals practices are not a major 
barrier to increased breastfeeding rates in the United States. In the last ten years, hospital breastfeeding 
initiation rates have increased. Most US mothers (71%) report they made the decision about what to first 
feed their newborn baby before giving birth. And mothers overwhelmingly know that breastfeeding is 
best for babies (3 out of 4 women—75%) say breastfeeding is "healthier for the child."4 And, a recent 
study found that the Baby‐Friendly Hospital Initiative (BFHI) accreditation does not have a positive 
impact on short‐and medium‐term breastfeeding rates.5 Other methods to help states increase 
breastfeeding rates by reducing true barriers may be more productive than a hospital survey. 
CDC Response: Hospital practices are a known barrier to breastfeeding initiation. Indeed, despite 
widespread understanding of the benefits of breastfeeding, many mothers’ desire to breastfeed cannot 
be fulfilled due to institutional barriers to breastfeeding experienced in the maternity care setting. 
General IFC Comments on the Survey 
IFC Comment: When asked to give ranked answers (i.e., few, some, many, most, not sure), the percentages 
corresponding to each of those categories shifted slightly. For example, “Few” was previously defined as 
“0%‐10%” but was changed to “0%‐9%” and so on. This change is not recommended as it could introduce 
error when comparing results to those of past surveys. 
CDC Response: We agree that the ability to compare results of upcoming surveys to past surveys is one of 
the biggest strengths of the mPINC survey. CDC has never changed or shifted any percentage categories 
corresponding to ranked answers (i.e., few, some, many, most, not sure) in any iteration of the mPINC 
survey fielded since its’ inception 6 years ago, and these categories in CDC’s planned 2013 and 2015 
editions of the mPINC survey (provided as part of the 60 Day FRN) continue to remain exactly the same 
as they have been since the initial 2007 mPINC survey. 

IFC Comments Regarding Individual Survey Questions 
A11. 

“Approximately how many mothers are encouraged to hold their healthy full‐term infants skin‐to‐
skin for at least 30 minutes within two hours after delivery for uncomplicated cesarean births?” 
IFC Comment: What is the measure of “encouraged”? A single mention? How often is encouragement given, 
and under what conditions is encouragement discontinued? Should this question be repeated for 
times other than the two hours after delivery? 
CDC Response: This question doesn’t need to be repeated for other times, a) because that would add to the 
burden on respondents, and b) because we are concerned about delaying that skin‐to‐skin contact. 
Since the item specifically asks about “uncomplicated cesarean births,” it is beyond the scope of the 
survey to ask under what conditions encouragement is discontinued. The scope of this survey is to 
measure routine practice within a maternity care facility. This item is specifically designed to 
measure the respondent’s perception of their own behavior in the given situation (management of 
mother baby dyads within the first two hours after uncomplicated cesarean births). 
A12. 

“Approximately what percentage of healthy full‐term breastfed infants are put to the breast for the 
first time during the specified period after delivery for uncomplicated cesarean sections?” 
IFC Comment: This question seems to pertain to all infants, not only breastfed infants. 
CDC Response: The scope of this survey is breastfeeding and factors related specifically to breastfeeding. It 
is not pertinent to ask about the time until the infant is first put to the breast if the infant is not 
breastfed. 

A13. 

“Approximately what percentage of healthy full‐term breastfed infants are given the following as a 
first feeding after uncomplicated cesarean section births?” 
IFC Comment: This question seems to pertain to all infants, not only breastfed infants. 
CDC Response: The scope of this survey is breastfeeding and factors related specifically to breastfeeding. 
A15. 

“Of mothers who are breastfeeding, or intend to breastfeed, approximately how many do you teach 
breastfeeding techniques (e.g. comfortable positioning, holding infant, how to express milk, 
assessing the effectiveness of breastfeeding)?” 
IFC Comment: How is intention assessed? 
CDC Response: The purpose of this question is not to assess intention. The question assesses whether 
hospital staff teach breastfeeding techniques to women they think are or are going to breastfeed. 
A18. 

“Of mothers who are breastfeeding, approximately how many mother‐baby couples are directly 
observed and assessed by staff for breastfeeding effectiveness during the maternity care hospital 
stay?” 
IFC Comment: The survey should include the following questions, similar to that above: “Do mothers limit the 
opportunities for observations? Does staff state expectation that observations will be conducted?” 
CDC Response: This item is assessing prevalence of an existing standard of nursing care. 
A20. 

“Approximately what percentage of healthy full‐term breastfed infants are supplemented with 
something other than breast milk? (If your hospital does not formally track this information, please 
provide your best estimate.)” 
IFC Comment: This question seems to pertain to all infants, not only breastfed infants. 
CDC Response: The scope of this survey is breastfeeding and factors related specifically to breastfeeding. 
A21. 

“Are healthy full‐term breastfed infants who are supplemented ever given the following types of 
supplementary feedings?” 
IFC Comment: This question seems broad and the reasons are not clearly explained. 

CDC Response: This item is assessing prevalence of use of the only liquids healthy full‐term breastfed infants 
are given by mouth to supplement breast milk feeds and has nothing to do with the reasons any of 
the supplements would be given. 
A22. 

“Of the healthy full‐term breastfed infants who are supplemented with infant formula, what 
percentage are supplemented for the following reasons?” 
IFC Comment: We noted that “Other (please specify)” was added as an answer choice to address the reasons 
for supplementing with infant formula that are not captured by the “Doctor’s orders,” “Nurse’s 
recommendation,” or “Mother’s choice” options. The IFC suggests the survey also include the 
following questions, similar to that above: “Of the healthy full‐term formula fed infants, what 
percentage is fed formula for the following reasons? What percentage of all infants has some 
medical or physiological reason for not breastfeeding? What are the most common reasons?” 
CDC Response: We agree that there are multiple reasons. We developed the responses in consultation with 
hospitals and pre‐tested the response categories in a range of hospitals with low and high 
breastfeeding rates. We initially had response categories that included medical and physiological 
reasons for supplementation but found during pre‐testing that respondents could not answer this 
question. 
A25.  “Does your hospital receive free infant formula?” 
IFC Comment: Will the respondent be likely to know the answer to this question? 
CDC Response: Pre‐testing indicated a clear understanding by respondents of the purchasing of infant 
formula. 
A32.  “Are discharge packs/bags containing infant formula samples given to breastfeeding mothers?” 
IFC Comment: Why is this question focused on only infant formula? Mothers obtain information and samples 
of many other items. A description of the full content of the discharge bags (i.e., diapers, coupons, 
other information, toys, accessories, etc.) would be more informative. 
CDC Response: The scope of the survey is breastfeeding and factors related specifically to breastfeeding. 
Discharge packs containing infant formula samples have been shown to affect breastfeeding 
patterns. 
A30. 

“What support does your hospital routinely (most of the time) offer to breastfeeding mothers at 
discharge? (check all that apply)” 
a. Postpartum telephone call by hospital staff 
b. Telephone number for patient to call 
c. Postpartum follow‐up visit at hospital after discharge 
d. Home follow‐up visit after discharge 
e. Referral to hospital‐based breastfeeding support group 
f. Referral to other breastfeeding support groups 
g. Referral to lactation consultant/specialist 
h. Referral to WIC (for those eligible) 
i. Referral to an outpatient lactation clinic 
j. List of resources for breastfeeding help 
k. Breastfeeding assessment sheet 
l. Other (please specify) _________________________ 
IFC Comment: The answer choices for this question were changed from “Yes,” “No” or “Not Sure” to “Check 
all that apply.” This alteration in the way the question can be answered could affect interpretation 
and comparison of this survey to those of past years. 

It would be helpful to know what percentage of breastfeeding mothers utilize these services and 
what these services cost the hospital. An additional question that would be helpful is, “In addition, 
what support does your hospital routinely offer to formula feeding mothers at discharge?” The 
questions related to breastfeeding should be removed (e, f, g, i, k, remove “breastfeeding” from j) 
based on the assumption that formula‐feeding mothers cannot reverse their decision and initiate 
breastfeeding after discharge. Also add questions, “What percentage of non‐breastfeeding mothers 
utilize the above services?” and “What do these services cost the hospital?” 
CDC Response: CDC only once improved the answer choices for this question, prior to the 2009 fielding, and 
the answer choices in CDC’s planned 2013 and 2015 editions of the mPINC survey (provided as part 
of the 60 Day FRN) continue to remain exactly the same as they have been since that improvement 
more than 4 years ago. 
The improvement of answer choices for this question to “Check all that apply” was among a set 
of improvements made to the mPINC survey instrument following the initial 2007 fielding, in part in 
response to OMB’s request. At that time, CDC eliminated answer choices that had inadvertently 
created unnecessary burden for respondents (such as yes/no/unsure when ‘check all that apply’ 
would suffice) and re‐ordering a several survey items to correspond with the cognitive clinical 
categories respondents would expect to see in a particular order (i.e., grouping together all items 
pertaining only to uncomplicated vaginal births as well as all items pertaining only to uncomplicated 
cesarean births). 
A30 was only the number for this item in the very first mPINC survey, in 2007, and that was the 
only time the answer choices were yes/no/not sure. Since then, it has always been A33 and asked 
respondents to ‘check all that apply’ (see www.cdc.gov/mpinc for samples of the 2007, 2009, and 
2011 mPINC surveys for further detail). 
While the information listed above would be interesting, it is beyond the scope of the 
assessment. 
B11. 

“Does your hospital have a written policy addressing… 
“b. prenatal classes informing mothers of the benefits of breastfeeding 
IFC Comment: This question should follow c. The survey should include the following question: “prenatal 
classes informing mothers on usual problems encountered in breastfeeding.” 
“c. asking about mothers’ feeding plans” 
IFC Comment: The survey should include the following questions: “do hospitals continue to give 
breastfeeding information and encouragement when a mother has informed that her intention is to 
formula feed?” 
CDC Response: These items are intentionally worded neutrally and succinctly to capture the pertinent 
information necessary for addressing known problems in delivery of maternity care services related 
to breastfeeding without subjectively steering respondents in any way that might increase 
subjectivity and undermine the credibility of the data gathered. These questions have been in this 
order for the past 6 years and CDC has no indication of a need to change the order of them. 

From: Megan Renner [mailto:[email protected]]
Sent: Friday, May 03, 2013 8:27 PM
To: OMB-Comments (CDC)
Subject: Comments: 60-Day–13–0743

Dear Sir or Madam:
Please find attached the United States Breastfeeding Committee’s response to the request for Public
Comments [60-Day-13-0743] on the Assessment and Monitoring of Breastfeeding-Related Maternity
Care Practices in Intra-partum Care Facilities in the United States and Territories (OMB Control No.
0920-0743, Exp. 12/31/2011)—Reinstatement.
Thank you for extending the deadline for this opportunity to comment.
Best regards,
***********************
Megan E. Renner
Executive Director
United States Breastfeeding Committee (USBC)
2025 M Street, NW, Suite 800
Washington, DC 20036
Phone: 202.367.1132 x22
Fax: 202.367.2132
[email protected]
www.usbreastfeeding.org
www.facebook.com/usbreastfeeding
Twitter: @usbreastfeeding
Advancing breastfeeding on our Nation’s agenda through Collaboration, Leadership, and
Advocacy. Join our work to make a difference for our Nation's families:
www.usbreastfeeding.org/Friends

Public Comments [60-Day-13-0743] on the Assessment and
Monitoring of Breastfeeding-Related Maternity Care Practices in
Intra-partum Care Facilities in the United States and Territories
(OMB Control No. 0920-0743, Exp. 12/31/2011)—Reinstatement
May 3, 2013
To Whom It May Concern:
The United States Breastfeeding Committee (USBC) strongly urges the renewal of the Centers for Disease
Control and Prevention Maternity Practices in Infant Nutrition and Care (mPINC) survey. As you know, despite
governmental recommendations, national health outcome targets, mounting scientific evidence, and national
promotion campaigns, breastfeeding rates in the United States continue to fall short of national goals.
While the initial and subsequent mPINC surveys have provided a snapshot of maternity care practices in the U.S.
(and found widespread use of practices that are not evidence-based and are known to interfere with
breastfeeding), it will be a waste of taxpayer money and a wasted opportunity to promote the health of mothers
and babies if the survey is not continued. It is only with the information provided by ongoing data collection that
maternity care facilities will be able to set quality improvement goals and benchmark with similar facilities in
their states and across the country to improve breastfeeding care. The mPINC survey has indeed proven to be a
motivating influence for the improvement of breast-feeding related maternity care practices. Outcomes from
the 2011 survey confirmed that scores continue to rise, demonstrating that this type of appraisal tool positively
influences quality improvement initiatives.
Of particular note is that The Joint Commission has announced that the Perinatal Care core measure set will
become mandatory for all hospitals with 1,100 or more births per year, effective January 1, 2014; this measure
set includes “exclusive breast milk feeding.” Additionally, the digital Clinical Quality Measure “Exclusive Breast
Milk Feeding in Infants (NQF 0480) is one of multiple measures eligible hospitals and critical access hospitals
may select as part of the HITECH Act’s Stage 2 “meaningful use” reporting. With more pressure on maternity
facilities to report breastfeeding outcomes as a measure of quality, the ability to benchmark maternity practices
and share best practices across the nation becomes more important than ever.
The USBC is a collaborative coalition of organizations, representing governmental agencies, non-governmental
organizations, and health professional associations. Guided by its mission to improve the Nation’s health by
working collaboratively to protect, promote, and support breastfeeding, the USBC continues to work to achieve
the Healthy People 2020 national breastfeeding goals.
Respectfully submitted,

Cathy Carothers, IBCLC, FILCA
Chair
2025 M Street, NW, Suite 800 ▪ Washington DC 20036 ▪ Phone: (202) 367-1132 ▪ FAX: (202) 367-2132
E-mail: [email protected] ▪ Web site: www.usbreastfeeding.org

From: Alfieri, Patricia [mailto:[email protected]]
Sent: Tuesday, May 07, 2013 9:49 AM
To: OMB-Comments (CDC)
Subject: mPINC Survey

Thank you for instituting this valuable benchmark. It has propelled our hospital to improve our
breastfeeding care and begin the process of becoming Baby-Friendly designated.
However, it would be fewer “burden hours” if the CDC evaluated breastfeeding rates in the same
manner as Baby-Friendly Hospital Initiative or The Joint Commission Perinatal Core Measures.
Patricia Alfieri, RN, IBCLC
Lactation Consultant

The Hospital of Central Connecticut
100 Grand Street
New Britain, CT 06050
860 224 5226 tel
860 224 5994 fax
www.thocc.org
www.hartfordhealthcare.org

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