Appx C-6 2007 Survey customized Benchmark Report

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Centers for Disease Control
and Prevention (CDC)
Atlanta, GA 30341-3724

DATE
NAME
TITLE
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear NAME:
The Centers for Disease Control and Prevention (CDC) recently conducted the first national assessment
of Maternity Practices in Infant Nutrition and Care, known as the mPINC Survey. We thank you for
participating in the survey; your involvement was vital to its success.
Your hospital’s participation in this national initiative reflects your commitment to continuous quality
improvement. Your hospital was one of 2,690 birth facilities that responded to the survey, comprising
82% of all hospitals and birth centers nationwide that provide maternity services. Detailed information
about the survey, including scoring, rationale, and an article describing state and national results, can be
found at www.cdc.gov/mpinc .
The enclosed Benchmark Report provides a summary of breastfeeding-related maternity care practices
and policies within your hospital, compared with other hospitals and birth centers across the country. In
addition to highlighting practices and policies on which your hospital scored well, the Benchmark Report
also indicates your hospital’s opportunities for quality improvement.
There are many strategies to improve maternity care practices and policies (visit our website at
www.cdc.gov/breastfeeding for more information). This Benchmark Report is one tool you can use to
identify specific practices and policies in your hospital that can be changed to be fully supportive of
breastfeeding.
Thank you again for your dedication to quality improvement in this critically important area of health care
delivery. If you have any questions, please feel free to contact us at [email protected] for assistance.
Sincerely,

Laurence M. Grummer-Strawn, MPA, MA, PhD
Chief, Nutrition Branch
Division of Nutrition, Physical Activity, and Obesity
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Enclosure
cc:

Hospital Administrator/Chief Executive Officer
Director of Hospital Quality Improvement
Obstetrics Medical Director
Pediatrics Medical Director
Nurse Manager for Mother Baby Services
Survey Respondent

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(12) Awi DD, Alikor EA. Barriers to timely initiation of breastfeeding among mothers
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(14) Adlerberth I, Hanson L. Ontongeny of the intestinal flora. In: Sanderson I, Walker W,
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Monitoring and Treatment of Hypoglycemia in Breastfed Neonates. Breastfeeding
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(18) Lee TT. Nursing diagnoses: factors affecting their use in charting standardized care
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(19) Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ, Eidelman AI;
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human milk. Pediatrics. 2005 Feb;115(2):496-506.
(20) US Preventive Services Task Force. Behavioral interventions to promote breastfeeding:
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(21) Kronborg H, Vaeth M, Olsen J, Iversen L, Harder I. Effect of early postnatal
breastfeeding support: a cluster-randomized community based trial. Acta Paediatr 2007;
96(7):1064-1070.
(22) Riordan J. Breastfeeding and Human Lactation. Third ed. Sudbury, MA: Jones and
Bartlett, 2005.
(23) Kumar SP, Mooney R, Wieser LJ, Havstad S. The LATCH scoring system and
prediction of breastfeeding duration. J Hum Lact 2006; 22(4):391-397.
(24) Cakmak H, Kuguoglu S. Comparison of the breastfeeding patterns of mothers who
delivered their babies per vagina and via cesarean section: an observational study using
the LATCH breastfeeding charting system. Int J Nurs Stud 2007; 44(7):1128-1137.
(25) Benson S. What is normal? A study of normal breastfeeding dyads during the first sixty
hours of life. Breastfeed Rev 2001; 9(1):27-32.
(26) Howard CR, Howard FM, Lanphear B et al. Randomized clinical trial of pacifier use
and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;
111(3):511-518.
(27) Bystrova K, Widstrom AM, Matthiesen AS et al. Early lactation performance in
primiparous and multiparous women in relation to different maternity home practices.
A randomised trial in St. Petersburg. Int Breastfeed J 2007; 2:9.
(28) Buranasin B. The effects of rooming-in on the success of breastfeeding and the decline
in abandonment of children. Asia Pac J Public Health 1991; 5(3):217-220.
(29) Keefe MR. The impact of infant rooming-in on maternal sleep at night. J Obstet
Gynecol Neonatal Nurs 1988; 17(2):122-126.
(30) Svensson K, Matthiesen AS, Widstrom AM. Night rooming-in: who decides? An
example of staff influence on mother’s attitude. Birth 2005; 32(2):99-106.

(31) Ball HL, Ward-Platt MP, Heslop E, Leech SJ, Brown KA. Randomised trial of infant
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(32) Lindenberg CS, Cabrera AR, Jimenez V. The effect of early post-partum mother-infant
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(34) Ingram J, Rosser J, Jackson D. Breastfeeding peer supporters and a community support
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(35) Chapman DJ, Damio G, Perez-Escamilla R. Differential response to breastfeeding peer
counseling within a low-income, predominantly Latina population. J Hum Lact 2004;
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(36) Committee on Healthcare for Underserved Women, Committee on Obstetric Practice.
ACOG Committee Opinion No. 361: Breastfeeding: Maternal and Infant Aspects.
Obstet Gynecol 2007 109: 479-480.
(37) Bliss MC, Wilkie J, Acredolo C, Berman S, Tebb KP. The effect of discharge pack
formula and breast pumps on breastfeeding duration and choice of infant feeding
method. Birth 1997; 24(2):90-97.
(38) Snell BJ, Krantz M, Keeton R, Delgado K, Peckham C. The association of formula
samples given at hospital discharge with the early duration of breastfeeding. J Hum Lact
1992; 8(2):67-72.
(39) Taveras EM, Li R, Grummer-Strawn L et al. Opinions and practices of clinicians
associated with continuation of exclusive breastfeeding. Pediatrics 2004;
113(4):e283-e290.
(40) Freed GL, Clark SJ, Sorenson J, Lohr JA, Cefalo R, Curtis P. National assessment of
physicians’ breast-feeding knowledge, attitudes, training, and experience. JAMA 1995;
273(6):472-476.
(41) Dykes F. The education of health practitioners supporting breastfeeding women: time
for critical reflection. Matern Child Nutr 2006; 2(4):204-216.
(42) Lu MC, Lange L, Slusser W, Hamilton J, Halfon N. Provider encouragement of
breast-feeding: evidence from a national survey. Obstet Gynecol 2001; 97(2):290-295.
(43) Cattaneo A, Yngve A, Koletzko B, Guzman LR. Protection, promotion and support of
breast-feeding in Europe: current situation. Public Health Nutr 2005; 8(1):39-46.
(44) Cattaneo A, Buzzetti R. Effect on rates of breast feeding training for the baby friendly
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(45) O’Hearne RM. A review of methods to assess competency. J Nurses Staff Dev 2006;
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(46) Whelan L. Competency assessment of nursing staff. Orthop Nurs 2006; 25(3):198-202.
(47) Arcand LL, Neumann JA. Nursing competency assessment across the continuum of
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(48) Gifford WA, Davies B, Edwards N, Graham ID. Leadership strategies to influence the
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(49) Reeves S, Lewin S. Interprofessional collaboration in the hospital: strategies and
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(50) Cummings GG, Estabrooks CA, Midodzi WK, Wallin L, Hayduk L. Influence of
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CPHRE Battelle
1100 Dexter Ave N., Suite 400
Seattle
WA 98109

Benchmark Report

For more information visit:
www.cdc.gov/mpinc
Division of Nutrition, Physical Activity, and Obesity
National Center for Chronic Disease Prevention
and Health Promotion
Centers for Disease Control and Prevention
Atlanta, GA USA
July
Octo2008
ber 2008

Facility ID:

T00002

Maternity Practices in Infant Nutrition and Care (mPINC) Survey
Quality Practice Measures—2007

department of health and human services
centers for disease control and prevention

CS118133

References Cited

CPHRE Battelle

Facility ID:

2007 Quality Practice Measures

V. S
 tructural & Organizational
Aspects of Care Delivery

Summary Information
Your Facility’s
Composite Quality
Practice Score:

Measure

31

Breastfeeding
policy

The Battelle Centers for Public Health Research and Evaluation conducted this survey for the Centers
for Disease Control and Prevention (CDC) between August and December 2007.

Composite Quality Practice Score Percentilesi

State

3

The AAP recommends inclusion of specific elements
in facility breastfeeding policies.19 The Academy
of Breastfeeding Medicine’s clinical protocol lists
components of a model breastfeeding policy.16

1

46

Subscore Percentiles
National
State
Comparable size

Explanation
This measure reports the number of model
breastfeeding policy elements in your facility’s
breastfeeding policy.

111 13
111111 27
1 5

0

100

Ideal
Your
Response Response

Your
Score

10

2

20

This measure reports the modes used to inform
staff about breastfeeding policies.
In person—In-service training, new staff
orientation, new staff training, staff meeting;
Printed/online materials—Policy posted,
newsletter.

Both
modes

Both
modes

100

Standardized documentation of patient decisions
allows for valid internal assessment, monitoring &
improvement of quality of care, & improves staff
collaboration & support of patients’ decisions.50

This measure reports your facility’s policy for
documentation of patient infant feeding plans &
practices.

Any point
during or
post-stay

No/not
sure

0

Employee
breastfeeding
support

The AMA & AWHONN recommend medical
facilities support all lactating employees by providing
appropriate time & facilities to express & store milk
during the working day.51,52 The US Breastfeeding
Committee recommends specific workplace supports.53

This measure reports how many supports are
provided to lactating staff.
Critical supports—Room to express milk,
electric breast pump for staff use, permission to
express milk on breaks;
Additional supports—On-site child care,
breastfeeding support group for staff, access to
lactation consultant/specialist, paid maternity
leave other than accrued leave.

3 criticalviii

3 critical,0
additional

100

Facility receipt
of free infant
formula

The ADA guidelines for mandatory elements of infant
formula HACCP plans54 apply to purchased & free
infant formula. The AMA recognizes the inherent
conflict of interest this kind of financial support
introduces.55,56

This measure reports whether your facility
receives infant formula free of charge from
manufacturers.

No

Yes

0

Prenatal
breastfeeding
instruction

Patient education about breastfeeding improves
breastfeeding rates.20

This measure reports whether breastfeeding
is a component of prenatal patient education
opportunities.

Yes

Yes

100

Coordination
of lactation
care

A designated Lactation Coordinator demonstrates
consideration of lactation support as an essential &
necessary function of intrapartum care.57

This measure reports whether your facility has
a designated person who oversees lactation care
within the facility.

Yes

No

0

Infant feeding
documentation
policy

The Maternity Practices in Infant Nutrition and Care (mPINC) Survey is a national survey of infant
feeding practices in facilities that provide maternity care services.

1

Rationale

Communication Effective intra-professional communication increases
of breastfeeding the likelihood that a facility’s breastfeeding policy will
policy
be implemented appropriately.48,49

What is the mPINC Survey?

National

Subscore

T00002

Please visit www.cdc.gov/mpinc for detailed scoring information.

viii

Comparable Size

4

11

0

Next steps
100

National = Among all facilities nationwide
State = Among all facilities in your state
Comparable Size = Among US facilities of similar sizeii
FacilityName58charXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
C
PHRE Battelle reported 6000 births in the past year; this facility is in the size category of >=5reported
000 birth5char
s per year.
births in the past year; this facility is in the size category of 9charxxxx births per year.
Your facility’s percentile is the point below which the indicated percent of scores fall in each group. For example, if your National percentile is 50, then you are performing
better than half of all facilities nationwide. If your State percentile is 66 or 67, you are performing better than about two-thirds of the facilities in your state. If your Similar Size
percentile is 99, you are performing better than almost all other facilities nationwide with a similar number of births per year.
ii
Facility size estimates are based on annual birth census as reported by the mPINC survey respondent and/or the American Hospital Association (when respondent did not
provide data).
i

1

Examine the care dimension that was the most problematic in your facility compared to others in your state or
across the country, and choose one care process or policy to begin improving. For example:
I. L abor and delivery care—Reduce delays in first
contact and breastfeeding opportunities.

III. Facility discharge care—Ensure compliance with
AAP clinical practice recommendations.

II. Postpartum care:
a. Feeding of breastfed infants—Eliminate
unnecessary supplementation;
b. Breastfeeding assistance—Improve patient
education and assistance;
c. Contact between mother and infant—
Eliminate unnecessary separations between
mothers and infants.

IV. Staff training—Facilitate staff training on
breastfeeding management and support.
V. S
 tructural & organizational aspects of care
delivery—Improve your facility’s policies related
to breastfeeding.

6

CPHRE Battelle

Facility ID:

III. Facility Discharge Care

Measure

Subscore

Rationale

55

What’s in this report?

Subscore Percentiles
National
State
Comparable size

Explanation

111111111111111111 75
1111111111111111111 76
11111111111111111 70

0

100

Ideal
Response

Your
Response

Your
Score

Assurance of
ambulatory
breastfeeding
support

The AAP clinical practice guidelines recommend
examination of all infants by a qualified health care
professional within 48 hours of hospital discharge
to assess breastfeeding.33 Ensuring post discharge
ambulatory support improves breastfeeding
outcomes.34–35

This measure reports how many modes of
ambulatory breastfeeding support are offered:
Physical Contact—Home/hospital visit;
Active Reaching Out—Phone call to patient;
Referral—Providing information about:
available phone numbers, support groups,
lactation consultant/specialists, WIC,
outpatient clinics.

All 3
modes

Mode 3
only

10

Distribution of
“discharge packs”
containing infant
formula

The AAP & ACOG recommend against
distributing infant formula “discharge packs” 19,36
because it reduces exclusive breastfeeding rates &
implies health care professional endorsement of
specific commercial items.37–39

This measure reports whether breastfeeding
patients are given “discharge packs” containing
product marketing infant formula samples.

No

No

100

Your facility’s results from the 2007 CDC mPINC
Survey—CDC provides this resource to help you
improve outcomes by providing the best evidence-based
care to your patients.
•Summary Information—Examine your Composite
Quality Practice Score.iii Scores range from 0 to 100;
100 is the highest or “best” possible score. See how
your score compares to all other facilities: across
the US; in your state; and in your size category
nationwide.iv
•Care Dimension Information—Learn about your
subscoresv and percentiles in: labor and delivery care;
postpartum feeding of breastfed infants, breastfeeding
assistance, and contact between mother and infant;
staff training; and structural and organizational
aspects of care delivery. Accompanied with each score
are explanations of how and why CDC chose to
measure these particular practices.

What are the components
of infant feeding care best
practices?

IV. Staff Training

Measure
Preparation of
new staff

Continuing
education

Competency
assessment

Subscore

Rationale

Staff training ensures standard capacity to provide
evidence-based care, learn about new information,
& maintain patient support skills.39–42 Standard
18 hour staff training improves patient
breastfeeding outcomes facility-wide.43,44

Like other critical nursing competencies, regular
assessment of competency in breastfeeding
management & support improves delivery
of care.45–47

36

Subscore Percentiles
National
State
Comparable size

1111111 29
111 12

0

100

Ideal
Response

Your
Response

Your
Score

This measure reports how many hours of
breastfeeding education new nurses & other birth
attendants* receive.

>18

1 to 4

25

This measure reports how many hours of
breastfeeding education current nurses & other
birth attendants* received in the past year.

≥5

1 to 4

50

This measure reports how many nurses & other
birth attendants* received any breastfeeding
education in the past year.

Most

Many

70

This measure reports how often nurses & other
birth attendants* are assessed for competency in
breastfeeding management & support.

At least
once a year

Never

0

Explanation

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

5

1111111 29

The following key clinical care processes, policies, and
staffing expectations are appropriate for care of all
perinatal patients, unless medically contraindicated:
I. Labor and delivery care—Upon delivery,vi the
newborn is placed skin-to-skin with the mother,
allowing uninterrupted time for breastfeeding.
II. Postpartum care:
a. Feeding of breastfed infants—The
breastfeeding infant is only offered pacifiers
and supplements (infant formula, water, and
glucose water) when medically indicated;

T00002

b. Breastfeeding assistance—Assistance is offered
to the breastfeeding mother and infant using
consistent standards for supportive patient
education and assessment;
c. Contact between mother and infant—The
infant is enabled to stay with the mother 24
hours per day, without unnecessary separation
or restrictions.
III. Facility discharge care—The breastfeeding mother
and infant are assured ambulatory breastfeeding
care; patient discharge gifts contain no infant
formula marketing samples.
IV. Staff training—All staff with primary
responsibility for care of the breastfeeding mother
and infant receive appropriate breastfeeding skills
training and assessment.
V. Structural & organizational aspects of care
delivery—Best practices policies are implemented
for staffing, care process, and communication
expectations in perinatal patient education and
care settings; are supportive of breastfeeding
employees; and are free from financial conflict
of interest.

Who responded to the mPINC
Survey?
All facilities were surveyed that provide intrapartum care
in the United States and Territories.
At each facility, surveys were completed by the person
most knowledgeable about the care processes and policies
involved in feeding healthy infants.
The survey response rate was 82%.vii

Maternity Care Practices and Infant Feeding
A group of specific interventions has been identified that, when implemented together as a consistent
system of care,1–3 results in better breastfeeding outcomes.4–8 Inpatient and ambulatory intrapartum
care strategies describe how infant feeding care is delivered across the perinatal period. These
strategies are designed to reduce the incidence of events and experiences that undermine mothers’
breastfeeding intentions and decisions.
The key components of this care system were identified using the best available science and evidence.
Like other clinical care models, this evidence spans a wide range, from results of randomized trials to
expert opinion, producing a set of connected best practices that make up a facility’s infant feeding
care system.
The Composite Quality Practice Score is a simple average of subscores from each care dimension.
 acility size estimates are based on annual birth census as reported by the mPINC survey respondent and/or the American Hospital Association (when respondent did not
F
provide data).
v
The care dimension subscore is the calculated simple average of scored items within each dimension.
vi
Immediate skin-to-skin contact and breastfeeding opportunities are possible and beneficial in both vaginal and Cesarean deliveries. These practices should be initiated within one
hour of vaginal birth and within two hours of Cesarean birth.
vii
Please visit www.cdc.gov/mpinc for detailed information on the scoring algorithm and other details about administration of the 2007 mPINC Survey.
iii
iv

2

CPHRE Battelle

Facility ID:

I. Labor and Delivery Care

Measure

Initial skin-to-skin
contact

Initial
breastfeeding
opportunity

Routine
procedures
performed
skin-to-skin

Rationale

Skin-to-skin contact improves infant ability to
establish breastfeeding.9

Early initiation of breastfeeding increases overall
breastfeeding duration & reduces a mother’s risk of
delayed onset of milk production.10
Performing routine newborn procedures &
assessments skin-to-skin increases infant
stability, is safe for mother & infant,11 & improves
breastfeeding outcomes by reducing unnecessary
separation of mother & infant.12

Subscore

0

II. P
 ostpartum Care—
Subscore
b. Breastfeeding Assistance

Subscore Percentiles
National
State
Comparable size

0
2
1

0

100

Ideal
Response

Explanation
This measure reports how many patients
experience mother-infant skin-to-skin contact
for at least 30 minutes within 1 hour of
uncomplicated vaginal birth.

Your
Response
Few

Most

Your
Score

Measure

0

Documentation of
feeding decision

This measure reports how many patients
experience mother-infant skin-to-skin contact
for at least 30 minutes within 2 hours of
uncomplicated Cesarean birth.

Most

Few

0

This measure reports what percent of patients
have the opportunity to breastfeed within 1 hour
of uncomplicated vaginal birth.

≥90

5

0

This measure reports what percent of patients
have the opportunity to breastfeed within 2 hours
of uncomplicated Cesarean birth.

≥90

This measure reports how often patients have
routine infant procedures performed while
mother & infant are skin-to-skin.

0

Almost
always

Rarely

Breastfeeding
advice &
counseling

0

0

Measure

Rationale

Initial feeding
received after birth

Neonatal immune system development depends on
transfer of specific antibodies through colostrum
& is impaired by prior introduction of non-breast
milk feeds.13,14

Supplementary
feedings

3

The AAP & ACOG Guidelines for Perinatal
Care15 & Academy for Breastfeeding Medicine
guidelines for supplementing feedings in healthy16
& hypoglycemic17 neonates all recommend against
routine supplementation with formula, glucose
water, or water.

Subscore 25

Assessment &
observation of
breastfeeding
sessions

National
State
Comparable size

Explanation

1 6

Measure

1 4

0

100

Your
Response

Your
Score

This measure reports what percent of
breastfeeding infants receive breast milk as their
first feeding after uncomplicated vaginal birth.

≥90

5

0

This measure reports what percent of
breastfeeding infants receive breast milk as their
first feeding after uncomplicated Cesarean birth.

≥90

This measure reports what percent of
breastfeeding infants receive non-breast milk
feedings.

<10

This measure reports whether breastfeeding
infants receive glucose water and/or water.

No

5

95
No

0

100

1

0

100

Ideal
Response

Your
Response

Your
Score

Almost
always

100

The AAP recommends pediatricians provide
parents with complete, current information on the
benefits and methods of breastfeeding to ensure
that the feeding decision is a fully informed one.19
Patient education is important in order to establish
breastfeeding. 20,21

This measure reports how many patients who
are breastfeeding, or intend to breastfeed,
are provided advice & instructions about
breastfeeding.

Most

Most

100

This measures reports how many patients are
taught to recognize & respond to infants’ cues
instead of feeding on a set schedule.

Most

Few

0

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

Rarely

Almost
always

0

The AAP recommends formal evaluation of
breastfeeding performance by trained observers
during the first 24–48 hours of life.19

This measure reports how many patients receive
a directly observed breastfeeding assessment by
facility staff.

Most

Few

0

Standardized breastfeeding assessment tools
improve comparability & validity of findings.23–25

This measure reports whether breastfeeding
is assessed using a standardized or adapted
assessment tool.

Yes

No

0

In-hospital pacifier use reduces duration of
exclusive breastfeeding.26

This measure reports how many breastfeeding
patients are given pacifiers by facility staff.

Few

Most

0

Rationale

Rooming-in of mother-infant pairs increases
Patient rooming-in infants’ opportunities to learn to breastfeed28 &
increases duration & quality of maternal sleep.29

Instances of
mother-infant
separation

0

Almost
always

Separation during transition to postpartum care
Separation of
is unnecessary for stable patients. Mother-infant
mother & newborn
contact is important during this time to establish
during transition
breastfeeding, maintain infant weight, & improve
to receiving units
regulation of infants’ neurologic states.27

0

0

This measure reports how often infant feeding
decisions are documented in medical records.

Subscore

25

Subscore Percentiles
National
State
Comparable size

2

Ideal
Response

Explanation

Subscore Percentiles

Standard documentation of infant feeding
decisions is important in order to adequately
support maternal choice.18

II. P
 ostpartum Care—
c. Contact Between
Mother and Infant

Subscore Percentiles
National
State
Comparable size

Rationale

Effective breastfeeding relies on feeding in direct
response to specific infant cues rather than
scheduled frequency or duration of feedings.22

Pacifier use

II. Postpartum Care—
a. Feeding of Breastfed
Infants

29

T00002

Understanding the reasons mother-infant pairs are
separated30 helps identify opportunities to reduce
unnecessary separations. Bringing the infant to the
mother to breastfeed reduces chances the infant
will receive supplemental feeds.31,32

1
0
2

0

100

Ideal
Response

Your
Response

Your
Score

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

No
Separation

180

0

This measure reports how many hours
breastfeeding mother-infant pairs are separated
at night.

No
Separation

8

0

≥90

No
response

---

0

1

70

Most

Some

30

Explanation

This measure reports what percent of
mother-infant pairs room together ≥23 hrs
per day.
This measure reports the number of reasons that
infant patients are removed from mothers’ rooms.
This measure reports how many patients who
are not rooming-in receive the infant from the
nursery for breastfeeding at night.

4

CPHRE Battelle

Facility ID:

I. Labor and Delivery Care

Measure

Initial skin-to-skin
contact

Initial
breastfeeding
opportunity

Routine
procedures
performed
skin-to-skin

Rationale

Skin-to-skin contact improves infant ability to
establish breastfeeding.9

Early initiation of breastfeeding increases overall
breastfeeding duration & reduces a mother’s risk of
delayed onset of milk production.10
Performing routine newborn procedures &
assessments skin-to-skin increases infant
stability, is safe for mother & infant,11 & improves
breastfeeding outcomes by reducing unnecessary
separation of mother & infant.12

Subscore

0

II. P
 ostpartum Care—
Subscore
b. Breastfeeding Assistance

Subscore Percentiles
National
State
Comparable size

0
2
1

0

100

Ideal
Response

Explanation
This measure reports how many patients
experience mother-infant skin-to-skin contact
for at least 30 minutes within 1 hour of
uncomplicated vaginal birth.

Your
Response
Few

Most

Your
Score

Measure

0

Documentation of
feeding decision

This measure reports how many patients
experience mother-infant skin-to-skin contact
for at least 30 minutes within 2 hours of
uncomplicated Cesarean birth.

Most

Few

0

This measure reports what percent of patients
have the opportunity to breastfeed within 1 hour
of uncomplicated vaginal birth.

≥90

5

0

This measure reports what percent of patients
have the opportunity to breastfeed within 2 hours
of uncomplicated Cesarean birth.

≥90

This measure reports how often patients have
routine infant procedures performed while
mother & infant are skin-to-skin.

0

Almost
always

Rarely

Breastfeeding
advice &
counseling

0

0

Measure

Rationale

Initial feeding
received after birth

Neonatal immune system development depends on
transfer of specific antibodies through colostrum
& is impaired by prior introduction of non-breast
milk feeds.13,14

Supplementary
feedings

3

The AAP & ACOG Guidelines for Perinatal
Care15 & Academy for Breastfeeding Medicine
guidelines for supplementing feedings in healthy16
& hypoglycemic17 neonates all recommend against
routine supplementation with formula, glucose
water, or water.

Subscore 25

Assessment &
observation of
breastfeeding
sessions

National
State
Comparable size

Explanation

1 6

Measure

1 4

0

100

Your
Response

Your
Score

This measure reports what percent of
breastfeeding infants receive breast milk as their
first feeding after uncomplicated vaginal birth.

≥90

5

0

This measure reports what percent of
breastfeeding infants receive breast milk as their
first feeding after uncomplicated Cesarean birth.

≥90

This measure reports what percent of
breastfeeding infants receive non-breast milk
feedings.

<10

This measure reports whether breastfeeding
infants receive glucose water and/or water.

No

5

95
No

0

100

1

0

100

Ideal
Response

Your
Response

Your
Score

Almost
always

100

The AAP recommends pediatricians provide
parents with complete, current information on the
benefits and methods of breastfeeding to ensure
that the feeding decision is a fully informed one.19
Patient education is important in order to establish
breastfeeding. 20,21

This measure reports how many patients who
are breastfeeding, or intend to breastfeed,
are provided advice & instructions about
breastfeeding.

Most

Most

100

This measures reports how many patients are
taught to recognize & respond to infants’ cues
instead of feeding on a set schedule.

Most

Few

0

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

Rarely

Almost
always

0

The AAP recommends formal evaluation of
breastfeeding performance by trained observers
during the first 24–48 hours of life.19

This measure reports how many patients receive
a directly observed breastfeeding assessment by
facility staff.

Most

Few

0

Standardized breastfeeding assessment tools
improve comparability & validity of findings.23–25

This measure reports whether breastfeeding
is assessed using a standardized or adapted
assessment tool.

Yes

No

0

In-hospital pacifier use reduces duration of
exclusive breastfeeding.26

This measure reports how many breastfeeding
patients are given pacifiers by facility staff.

Few

Most

0

Rationale

Rooming-in of mother-infant pairs increases
Patient rooming-in infants’ opportunities to learn to breastfeed28 &
increases duration & quality of maternal sleep.29

Instances of
mother-infant
separation

0

Almost
always

Separation during transition to postpartum care
Separation of
is unnecessary for stable patients. Mother-infant
mother & newborn
contact is important during this time to establish
during transition
breastfeeding, maintain infant weight, & improve
to receiving units
regulation of infants’ neurologic states.27

0

0

This measure reports how often infant feeding
decisions are documented in medical records.

Subscore

25

Subscore Percentiles
National
State
Comparable size

2

Ideal
Response

Explanation

Subscore Percentiles

Standard documentation of infant feeding
decisions is important in order to adequately
support maternal choice.18

II. P
 ostpartum Care—
c. Contact Between
Mother and Infant

Subscore Percentiles
National
State
Comparable size

Rationale

Effective breastfeeding relies on feeding in direct
response to specific infant cues rather than
scheduled frequency or duration of feedings.22

Pacifier use

II. Postpartum Care—
a. Feeding of Breastfed
Infants

29

T00002

Understanding the reasons mother-infant pairs are
separated30 helps identify opportunities to reduce
unnecessary separations. Bringing the infant to the
mother to breastfeed reduces chances the infant
will receive supplemental feeds.31,32

1
0
2

0

100

Ideal
Response

Your
Response

Your
Score

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

No
Separation

180

0

This measure reports how many hours
breastfeeding mother-infant pairs are separated
at night.

No
Separation

8

0

≥90

No
response

---

0

1

70

Most

Some

30

Explanation

This measure reports what percent of
mother-infant pairs room together ≥23 hrs
per day.
This measure reports the number of reasons that
infant patients are removed from mothers’ rooms.
This measure reports how many patients who
are not rooming-in receive the infant from the
nursery for breastfeeding at night.

4

CPHRE Battelle

Facility ID:

III. Facility Discharge Care

Measure

Subscore

Rationale

55

What’s in this report?

Subscore Percentiles
National
State
Comparable size

Explanation

111111111111111111 75
1111111111111111111 76
11111111111111111 70

0

100

Ideal
Response

Your
Response

Your
Score

Assurance of
ambulatory
breastfeeding
support

The AAP clinical practice guidelines recommend
examination of all infants by a qualified health care
professional within 48 hours of hospital discharge
to assess breastfeeding.33 Ensuring post discharge
ambulatory support improves breastfeeding
outcomes.34–35

This measure reports how many modes of
ambulatory breastfeeding support are offered:
Physical Contact—Home/hospital visit;
Active Reaching Out—Phone call to patient;
Referral—Providing information about:
available phone numbers, support groups,
lactation consultant/specialists, WIC,
outpatient clinics.

All 3
modes

Mode 3
only

10

Distribution of
“discharge packs”
containing infant
formula

The AAP & ACOG recommend against
distributing infant formula “discharge packs” 19,36
because it reduces exclusive breastfeeding rates &
implies health care professional endorsement of
specific commercial items.37–39

This measure reports whether breastfeeding
patients are given “discharge packs” containing
product marketing infant formula samples.

No

No

100

Your facility’s results from the 2007 CDC mPINC
Survey—CDC provides this resource to help you
improve outcomes by providing the best evidence-based
care to your patients.
•Summary Information—Examine your Composite
Quality Practice Score.iii Scores range from 0 to 100;
100 is the highest or “best” possible score. See how
your score compares to all other facilities: across
the US; in your state; and in your size category
nationwide.iv
•Care Dimension Information—Learn about your
subscoresv and percentiles in: labor and delivery care;
postpartum feeding of breastfed infants, breastfeeding
assistance, and contact between mother and infant;
staff training; and structural and organizational
aspects of care delivery. Accompanied with each score
are explanations of how and why CDC chose to
measure these particular practices.

What are the components
of infant feeding care best
practices?

IV. Staff Training

Measure
Preparation of
new staff

Continuing
education

Competency
assessment

Subscore

Rationale

Staff training ensures standard capacity to provide
evidence-based care, learn about new information,
& maintain patient support skills.39–42 Standard
18 hour staff training improves patient
breastfeeding outcomes facility-wide.43,44

Like other critical nursing competencies, regular
assessment of competency in breastfeeding
management & support improves delivery
of care.45–47

36

Subscore Percentiles
National
State
Comparable size

1111111 29
111 12

0

100

Ideal
Response

Your
Response

Your
Score

This measure reports how many hours of
breastfeeding education new nurses & other birth
attendants* receive.

>18

1 to 4

25

This measure reports how many hours of
breastfeeding education current nurses & other
birth attendants* received in the past year.

≥5

1 to 4

50

This measure reports how many nurses & other
birth attendants* received any breastfeeding
education in the past year.

Most

Many

70

This measure reports how often nurses & other
birth attendants* are assessed for competency in
breastfeeding management & support.

At least
once a year

Never

0

Explanation

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

5

1111111 29

The following key clinical care processes, policies, and
staffing expectations are appropriate for care of all
perinatal patients, unless medically contraindicated:
I. Labor and delivery care—Upon delivery,vi the
newborn is placed skin-to-skin with the mother,
allowing uninterrupted time for breastfeeding.
II. Postpartum care:
a. Feeding of breastfed infants—The
breastfeeding infant is only offered pacifiers
and supplements (infant formula, water, and
glucose water) when medically indicated;

T00002

b. Breastfeeding assistance—Assistance is offered
to the breastfeeding mother and infant using
consistent standards for supportive patient
education and assessment;
c. Contact between mother and infant—The
infant is enabled to stay with the mother 24
hours per day, without unnecessary separation
or restrictions.
III. Facility discharge care—The breastfeeding mother
and infant are assured ambulatory breastfeeding
care; patient discharge gifts contain no infant
formula marketing samples.
IV. Staff training—All staff with primary
responsibility for care of the breastfeeding mother
and infant receive appropriate breastfeeding skills
training and assessment.
V. Structural & organizational aspects of care
delivery—Best practices policies are implemented
for staffing, care process, and communication
expectations in perinatal patient education and
care settings; are supportive of breastfeeding
employees; and are free from financial conflict
of interest.

Who responded to the mPINC
Survey?
All facilities were surveyed that provide intrapartum care
in the United States and Territories.
At each facility, surveys were completed by the person
most knowledgeable about the care processes and policies
involved in feeding healthy infants.
The survey response rate was 82%.vii

Maternity Care Practices and Infant Feeding
A group of specific interventions has been identified that, when implemented together as a consistent
system of care,1–3 results in better breastfeeding outcomes.4–8 Inpatient and ambulatory intrapartum
care strategies describe how infant feeding care is delivered across the perinatal period. These
strategies are designed to reduce the incidence of events and experiences that undermine mothers’
breastfeeding intentions and decisions.
The key components of this care system were identified using the best available science and evidence.
Like other clinical care models, this evidence spans a wide range, from results of randomized trials to
expert opinion, producing a set of connected best practices that make up a facility’s infant feeding
care system.
The Composite Quality Practice Score is a simple average of subscores from each care dimension.
 acility size estimates are based on annual birth census as reported by the mPINC survey respondent and/or the American Hospital Association (when respondent did not
F
provide data).
v
The care dimension subscore is the calculated simple average of scored items within each dimension.
vi
Immediate skin-to-skin contact and breastfeeding opportunities are possible and beneficial in both vaginal and Cesarean deliveries. These practices should be initiated within one
hour of vaginal birth and within two hours of Cesarean birth.
vii
Please visit www.cdc.gov/mpinc for detailed information on the scoring algorithm and other details about administration of the 2007 mPINC Survey.
iii
iv

2

CPHRE Battelle

Facility ID:

2007 Quality Practice Measures

V. S
 tructural & Organizational
Aspects of Care Delivery

Summary Information
Your Facility’s
Composite Quality
Practice Score:

Measure

31

Breastfeeding
policy

The Battelle Centers for Public Health Research and Evaluation conducted this survey for the Centers
for Disease Control and Prevention (CDC) between August and December 2007.

Composite Quality Practice Score Percentilesi

State

3

The AAP recommends inclusion of specific elements
in facility breastfeeding policies.19 The Academy
of Breastfeeding Medicine’s clinical protocol lists
components of a model breastfeeding policy.16

1

46

Subscore Percentiles
National
State
Comparable size

Explanation
This measure reports the number of model
breastfeeding policy elements in your facility’s
breastfeeding policy.

111 13
111111 27
1 5

0

100

Ideal
Your
Response Response

Your
Score

10

2

20

This measure reports the modes used to inform
staff about breastfeeding policies.
In person—In-service training, new staff
orientation, new staff training, staff meeting;
Printed/online materials—Policy posted,
newsletter.

Both
modes

Both
modes

100

Standardized documentation of patient decisions
allows for valid internal assessment, monitoring &
improvement of quality of care, & improves staff
collaboration & support of patients’ decisions.50

This measure reports your facility’s policy for
documentation of patient infant feeding plans &
practices.

Any point
during or
post-stay

No/not
sure

0

Employee
breastfeeding
support

The AMA & AWHONN recommend medical
facilities support all lactating employees by providing
appropriate time & facilities to express & store milk
during the working day.51,52 The US Breastfeeding
Committee recommends specific workplace supports.53

This measure reports how many supports are
provided to lactating staff.
Critical supports—Room to express milk,
electric breast pump for staff use, permission to
express milk on breaks;
Additional supports—On-site child care,
breastfeeding support group for staff, access to
lactation consultant/specialist, paid maternity
leave other than accrued leave.

3 criticalviii

3 critical,0
additional

100

Facility receipt
of free infant
formula

The ADA guidelines for mandatory elements of infant
formula HACCP plans54 apply to purchased & free
infant formula. The AMA recognizes the inherent
conflict of interest this kind of financial support
introduces.55,56

This measure reports whether your facility
receives infant formula free of charge from
manufacturers.

No

Yes

0

Prenatal
breastfeeding
instruction

Patient education about breastfeeding improves
breastfeeding rates.20

This measure reports whether breastfeeding
is a component of prenatal patient education
opportunities.

Yes

Yes

100

Coordination
of lactation
care

A designated Lactation Coordinator demonstrates
consideration of lactation support as an essential &
necessary function of intrapartum care.57

This measure reports whether your facility has
a designated person who oversees lactation care
within the facility.

Yes

No

0

Infant feeding
documentation
policy

The Maternity Practices in Infant Nutrition and Care (mPINC) Survey is a national survey of infant
feeding practices in facilities that provide maternity care services.

1

Rationale

Communication Effective intra-professional communication increases
of breastfeeding the likelihood that a facility’s breastfeeding policy will
policy
be implemented appropriately.48,49

What is the mPINC Survey?

National

Subscore

T00002

Please visit www.cdc.gov/mpinc for detailed scoring information.

viii

Comparable Size

4

11

0

Next steps
100

National = Among all facilities nationwide
State = Among all facilities in your state
Comparable Size = Among US facilities of similar sizeii
FacilityName58charXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
C
PHRE Battelle reported 6000 births in the past year; this facility is in the size category of >=5reported
000 birth5char
s per year.
births in the past year; this facility is in the size category of 9charxxxx births per year.
Your facility’s percentile is the point below which the indicated percent of scores fall in each group. For example, if your National percentile is 50, then you are performing
better than half of all facilities nationwide. If your State percentile is 66 or 67, you are performing better than about two-thirds of the facilities in your state. If your Similar Size
percentile is 99, you are performing better than almost all other facilities nationwide with a similar number of births per year.
ii
Facility size estimates are based on annual birth census as reported by the mPINC survey respondent and/or the American Hospital Association (when respondent did not
provide data).
i

1

Examine the care dimension that was the most problematic in your facility compared to others in your state or
across the country, and choose one care process or policy to begin improving. For example:
I. L abor and delivery care—Reduce delays in first
contact and breastfeeding opportunities.

III. Facility discharge care—Ensure compliance with
AAP clinical practice recommendations.

II. Postpartum care:
a. Feeding of breastfed infants—Eliminate
unnecessary supplementation;
b. Breastfeeding assistance—Improve patient
education and assistance;
c. Contact between mother and infant—
Eliminate unnecessary separations between
mothers and infants.

IV. Staff training—Facilitate staff training on
breastfeeding management and support.
V. S
 tructural & organizational aspects of care
delivery—Improve your facility’s policies related
to breastfeeding.

6

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CPHRE Battelle
1100 Dexter Ave N., Suite 400
Seattle
WA 98109

Benchmark Report

For more information visit:
www.cdc.gov/mpinc
Division of Nutrition, Physical Activity, and Obesity
National Center for Chronic Disease Prevention
and Health Promotion
Centers for Disease Control and Prevention
Atlanta, GA USA
July
Octo2008
ber 2008

Facility ID:

T00002

Maternity Practices in Infant Nutrition and Care (mPINC) Survey
Quality Practice Measures—2007

department of health and human services
centers for disease control and prevention

CS118133

References Cited