Att 3i_CDC MMWR 2008

Morbidity and Mortality Weekly Report
www.cdc.gov/mmwr

Weekly

June 13, 2008 / Vol. 57 / No. 23

Breastfeeding-Related Maternity Practices at Hospitals and Birth Centers
— United States, 2007
Breastfeeding provides optimal nutrition for infants and is
associated with decreased risk for infant and maternal morbidity and mortality (1); however, only four states (Alaska,
Montana, Oregon, and Washington) have met all five (2)
Healthy People 2010 targets for breastfeeding (3).* Maternity
practices in hospitals and birth centers throughout the intrapartum period, such as ensuring mother-newborn skin-to-skin
contact, keeping mother and newborn together, and not giving supplemental feedings to breastfed newborns unless medically indicated, can influence breastfeeding behaviors during
a period critical to successful establishment of lactation (4–9).
In 2007, to characterize maternity practices related to
breastfeeding, CDC conducted the first national Maternity
Practices in Infant Nutrition and Care (mPINC) Survey. This
report summarizes results of that survey, which indicated that
1) a substantial proportion of facilities used maternity practices that are not evidence-based and are known to interfere
with breastfeeding and 2) states in the southern United States
generally had lower mPINC scores, including certain states
previously determined to have the lowest 6-month
breastfeeding rates.† These results highlight the need for U.S.
hospitals and birth centers to implement changes in
maternity practices that support breastfeeding.
In 2007, in collaboration with Battelle Centers for Public
Health Research and Evaluation, CDC conducted the mPINC
survey to characterize intrapartum practices in hospitals and
* Breastfeeding objectives are increases in the proportions of mothers who
breastfeed their babies to meet the following targets: 75% in the early postpartum
period (16-19a), 50% at 6 months (16-19b), 25% at 1 year (16-19c), 40%
who exclusively breastfeed for 3 months (16-19d), and 17% who exclusively
breastfeed for 6 months (16-19e). Objectives 16-19d and 16-19e were revised
since the midcourse review. Additional information is available at ftp://ftp.cdc.
gov/pub/health_statistics/nchs/datasets/data2010/focusarea16/o1619d.pdf and
ftp://ftp.cdc.gov/pub/health_statistics/nchs/datasets/data2010/focusarea16/
o1619e.pdf.
† Available at http://www.cdc.gov/breastfeeding/data/nis_data/data_2004.htm.

birth centers in all states, the District of Columbia, and three
U.S. territories. The survey was mailed to 3,143 hospitals and
138 birth centers with registered maternity beds, with the
request that the survey be completed by the person most
knowledgeable of the facility’s infant feeding and maternity
practices.
Questions regarding maternity practices were grouped into
seven categories that served as subscales in the analyses: 1)
labor and delivery, 2) breastfeeding assistance, 3) mother-newborn contact, 4) newborn feeding practices, 5) breastfeeding
support after discharge, 6) nurse/birth attendant breastfeeding
training and education, and 7) structural and organizational
factors related to breastfeeding.§ The subscales were derived
§ Labor

and delivery = mother-newborn skin-to-skin contact and early
breastfeeding initiation. Breastfeeding assistance = assessment, recording, and
instruction provided on infant feeding; not giving pacifiers to breastfed
newborns. Mother-newborn contact = avoidance of separation during postpartum
facility stay. Newborn feeding practices = what and how breastfed infants are fed
during facility stay. Breastfeeding support after discharge = types of support
provided after mothers and babies are discharged. Nurse/birth attendant
breastfeeding training and education = quantity of training and education that
nurses and birth attendants receive. Structural and organizational factors related
to breastfeeding = 1) facility breastfeeding policies and how they are
communicated to staff, 2) support for breastfeeding employees, 3) facility not
receiving free infant formula, 4) prenatal breastfeeding education, and 5)
coordination of lactation care.
INSIDE

625 Escherichia coli 0157:H7 Infections in Children Associated
with Raw Milk and Raw Colostrum From Cows —
California, 2006
628 Cutaneous Anthrax Associated with Drum Making
Using Goat Hides from West Africa — Connecticut, 2007
631 Electronic Record Linkage to Identify Deaths Among
Persons with AIDS — District of Columbia, 2000–2005
634 Notice to Readers
635 QuickStats

depar
tment of health and human ser
vices
department
services
Centers for Disease Control and Prevention

622

MMWR

The MMWR series of publications is published by the Coordinating
Center for Health Information and Service, Centers for Disease
Control and Prevention (CDC), U.S. Department of Health and
Human Services, Atlanta, GA 30333.
Suggested Citation: Centers for Disease Control and Prevention.

[Article title]. MMWR 2008;57:[inclusive page numbers].
Centers for Disease Control and Prevention
Julie L. Gerberding, MD, MPH
Director
Tanja Popovic, MD, PhD
Chief Science Officer
James W. Stephens, PhD
Associate Director for Science
Steven L. Solomon, MD
Director, Coordinating Center for Health Information and Service
Jay M. Bernhardt, PhD, MPH
Director, National Center for Health Marketing
Katherine L. Daniel, PhD
Deputy Director, National Center for Health Marketing
Editorial and Production Staff
Frederic E. Shaw, MD, JD
Editor, MMWR Series
Teresa F. Rutledge
(Acting) Managing Editor, MMWR Series
Douglas W. Weatherwax
Lead Technical Writer-Editor
Donald G. Meadows, MA
Jude C. Rutledge
Writers-Editors
Peter M. Jenkins
(Acting) Lead Visual Information Specialist
Lynda G. Cupell
Malbea A. LaPete
Visual Information Specialists
Quang M. Doan, MBA
Erica R. Shaver
Information Technology Specialists
Editorial Board
William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Virginia A. Caine, MD, Indianapolis, IN
David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
Margaret A. Hamburg, MD, Washington, DC
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA
John K. Iglehart, Bethesda, MD
Dennis G. Maki, MD, Madison, WI
Sue Mallonee, MPH, Oklahoma City, OK
Stanley A. Plotkin, MD, Doylestown, PA
Patricia Quinlisk, MD, MPH, Des Moines, IA
Patrick L. Remington, MD, MPH, Madison, WI
Barbara K. Rimer, DrPH, Chapel Hill, NC
John V. Rullan, MD, MPH, San Juan, PR
Anne Schuchat, MD, Atlanta, GA
Dixie E. Snider, MD, MPH, Atlanta, GA
John W. Ward, MD, Atlanta, GA

June 13, 2008

from literature reviews and consultation with breastfeeding
experts. Researchers assigned scores to facility responses on a
0–100 scale, with 100 representing a practice most favorable
toward breastfeeding.¶ Mean scores were calculated for each
subscale, generally excluding questions that were unanswered
or answered “not sure” or “not applicable.” Mean subscale
and mean total scores for each state were calculated as an
average of scores from all facilities in the state; mean total
scores were rounded to the nearest whole number. U.S. scores
were calculated as the mean scores for all participating facilities. A subscale score was not calculated if more than half the
response data were missing, and mean total scores were not
calculated if more than half the subscale scores were missing.
Responses were received from 2,690 (82%) facilities; however, data from three respondent facilities in Guam and the
U.S. Virgin Islands were excluded from this analysis because
of disclosure concerns, resulting in a sample size of 2,687
facilities (2,546 hospitals and 121 birth centers) in the 50
states, the District of Columbia, and Puerto Rico.** The
response rate among birth centers (88%) was higher than
among hospitals (82%).
Among states, mean total scores ranged from 48 in Arkansas to 81 in New Hampshire and Vermont (Table 1), and
regional variation was evident (Figure). Mean total scores generally were higher in the western and northeastern regions of
the United States and lower in the southern region. Mean
total scores among facilities did not differ by annual number
of births, but were higher among birth centers (86 out of 100),
compared with hospitals (62) (Table 2).
Among the seven subscales, the highest mean score (80)
was for breastfeeding assistance (i.e., assessment, recording,
and instruction provided on infant feeding). Within this
subscale, 99% of facilities had documented the feeding decisions of the majority of mothers in facility records, and 88%
of facilities had taught the majority of mothers techniques
related to breastfeeding. However, 65% of facilities advised
women to limit the duration of suckling at each breastfeeding,
and 45% reported giving pacifiers to more than half of all
healthy, full-term breastfed infants, practices that are not
supportive of breastfeeding (7).
The lowest score (40) was for breastfeeding support after
discharge. For this subscale, 70% of facilities reported
providing discharge packs containing infant formula samples
to breastfeeding mothers, a practice not supportive of
breastfeeding (8). Although 95% of facilities reported provid¶

Additional information regarding survey questions and scoring is available at
http://www.cdc.gov/mpinc.
** In describing the results of this study, the District of Columbia and Puerto
Rico are referred to as states.

Vol. 57 / No. 23

MMWR

623

TABLE 1. Mean total and subscale maternity practice scores, by state — Maternity Practices in Infant Nutrition and Care Survey,
United States, 2007

State†

No. of
respondent
%
facilities§ responding

United States
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico

Standard
Mean error of the
total mean total
score¶
score

Labor
and
delivery

BreastMotherfeeding
newborn
assistance contact

Mean subscale scores*
BreastNurse/birth
feeding
attendant
Newborn
support
breastfeeding
feeding
after
training and
practices discharge
education

Structural
and organizational factors
related to
breastfeeding

2,687

82

63

0.3

60

80

70

77

40

51

66

47
24
36
27
201
42
23
7
4
95
70
9
26
109
84
74
68
43
45
30
29
36
76
85
38
58
30
48
13
23
46
20
110
71
17
103
49
53
101
5
37
19
64
190
31
11
49
65
27
93
15
11

87
100
71
60
80
86
77
100
57
75
81
75
81
59
88
91
90
78
82
91
81
77
79
84
84
81
88
80
65
92
77
67
75
84
94
89
82
95
87
71
86
83
88
75
79
92
82
88
84
90
83
36

55
73
62
48
69
66
70
63
76
68
56
62
65
60
62
61
59
57
54
77
61
75
64
65
50
63
63
57
57
81
60
64
67
61
59
67
57
74
61
77
57
61
57
58
61
81
61
72
55
69
68
55

1.9
3.1
1.9
2.3
1.1
1.9
2.1
7.0
8.5
1.5
1.3
1.4
3.0
1.2
1.4
1.2
1.6
1.9
2.0
2.3
2.3
1.5
1.6
1.4
2.1
1.4
3.0
1.9
4.4
1.7
1.5
3.9
1.1
1.4
3.2
1.1
1.7
1.9
1.3
7.1
2.7
2.5
1.7
1.2
1.8
2.3
2.0
1.5
2.5
1.3
2.7
3.2

45
79
58
43
63
65
73
47
89
64
48
79
68
48
60
50
57
52
44
78
55
72
63
62
42
61
65
60
52
82
47
54
61
54
59
59
57
76
54
64
47
56
53
52
67
89
53
77
53
68
78
41

71
81
80
67
82
80
84
81
90
84
75
76
83
78
81
78
74
76
75
89
79
86
81
82
69
79
77
74
75
90
82
81
84
81
80
83
74
86
80
93
74
79
74
73
77
95
78
86
76
85
80
74

55
90
75
57
77
77
72
77
73
76
64
83
80
64
69
66
75
59
51
79
69
72
74
71
48
70
74
74
69
85
57
76
66
66
64
68
70
85
62
72
55
68
61
64
66
81
61
89
58
71
76
61

69
86
76
62
77
84
92
86
80
79
71
80
78
74
77
76
78
69
59
85
77
87
79
76
63
79
75
73
74
89
72
76
77
76
72
80
71
88
78
86
66
78
73
69
79
92
79
85
71
82
83
48

27
69
34
24
49
33
31
34
53
44
25
14
35
35
31
44
35
28
33
69
26
61
33
54
28
32
41
32
29
72
25
48
48
31
31
48
21
57
37
75
41
36
26
35
26
72
32
53
25
51
46
42

53
34
52
29
61
53
66
39
71
56
50
38
46
54
49
44
38
53
54
66
48
72
47
41
43
55
46
30
42
63
62
49
57
53
47
55
47
49
50
68
48
45
47
52
48
63
58
43
44
51
48
58

63
60
62
53
70
70
74
72
80
70
63
60
69
67
66
64
54
63
61
78
69
79
68
65
55
66
59
53
59
83
72
60
76
68
62
75
58
71
68
85
62
67
62
59
64
74
67
64
58
74
62
53

* Maximum possible mean score is 100. Subscale definitions: Labor and delivery = mother-newborn skin-to-skin contact and early breastfeeding initiation.
Breastfeeding assistance = assessment, recording, and instruction provided on infant feeding; not giving pacifiers to breastfed newborns. Mother-newborn
contact = avoidance of separation during postpartum facility stay. Newborn feeding practices = what and how breastfed infants are fed during facility stay.
Breastfeeding support after discharge = types of support provided after mothers and babies are discharged. Nurse/birth attendant breastfeeding training
and education = quantity of training and education that nurses and birth attendants receive. Structural and organizational factors related to breastfeeding
= 1) facility breastfeeding policies and how they are communicated to staff, 2) support for breastfeeding employees, 3) facility not receiving free infant
formula, 4) prenatal breastfeeding education, and 5) coordination of lactation care. Additional information regarding survey questions and scoring is
available at http://www.cdc.gov/mpinc.
†
In describing the results of this study, the District of Columbia and Puerto Rico are referred to as states.
§
Hospitals and birth centers.
¶
The rounded mean of the subscale scores.

624

MMWR

FIGURE. Mean total maternity practice scores,* by quartile —
Maternity Practices in Infant Nutrition and Care Survey, United
States, 2007

TABLE 2. Mean total maternity practice scores,* by annual
number of births and facility type — Maternity Practices in
Infant Nutrition and Care Survey, United States, 2007
Characteristic

District of
Columbia
Puerto Rico

Quartile 1 (48–58)
Quartile 2 (59–62)
Quartile 3 (63–68)
Quartile 4 (69–81)

* Maximum possible mean score is 100. Additional information regarding
survey questions and scoring is available at http://www.cdc.gov/mpinc.

ing a telephone number for mothers to call for breastfeeding
consultation after leaving the birth facility, 56% of facilities
reported initiating follow-up calls to mothers. Facility-based
postpartum follow-up visits were offered by 42% of facilities,
and postpartum home visits were reported by 22% of facilities.
For newborn feeding, 24% of facilities reported giving
supplements (and not breast milk exclusively) as a general
practice with more than half of all healthy, full-term
breastfeeding newborns, a practice that is not supportive of
breastfeeding (7,10). When asked whether healthy, full-term
breastfed infants who receive supplements are given glucose
water or water, 30% of facilities reported giving feedings of
glucose water and 15% reported giving water, practices that
are not supportive of breastfeeding. In addition, 17% of
facilities reported they gave something other than breast milk
as a first feeding to more than half the healthy, full-term,
breastfeeding newborns born in uncomplicated cesarean births.
Reported by: AM DiGirolamo, PhD, Rollins School of Public Health,
Emory Univ, Atlanta, Georgia. DL Manninen, PhD, JH Cohen, PhD,
Battelle Centers for Public Health Research and Evaluation, Seattle,
Washington. KR Shealy, MPH, PE Murphy, MLIS, CA MacGowan,
MPH, AJ Sharma, PhD, KS Scanlon, PhD, LM Grummer-Strawn,
PhD, Div of Nutrition, Physical Activity, and Obesity, National Center
for Chronic Disease Prevention and Health Promotion; DL Dee, PhD,
EIS Officer, CDC.

Editorial Note: This report summarizes results from 2,687
hospitals and birth centers in the first survey of breastfeedingrelated maternity practices conducted in the United States.
These results provide information regarding maternity practices and policies in birthing facilities and can serve as a baseline
with which to compare future survey findings. Individual
facilities and states can use this information to improve

June 13, 2008

No. of
facilities

Mean
total score

Standard
error

Annual number of births
0–249
626
63
0.7
250–499
448
60
0.7
500–999
548
62
0.6
1,000–1,999
553
64
0.6
2,000–4,999
440
66
0.6
>5,000
71
63
1.5
Facility type
Birth center
121†
86
0.9
Hospital
2,546†
62
0.3
* Maximum possible mean score is 100. Additional information regarding
survey questions and scoring is available at http://www.cdc.gov/mpinc.
†
One birth center and 22 hospitals had missing data that prevented calculation of at least four subscales; therefore, a mean total score could not
be calculated.

maternity practices known to influence breastfeeding in the
early postpartum period and after discharge.
The findings indicate substantial prevalences of maternity
practices that are not evidence-based and are known to interfere with breastfeeding. For example, 24% of birth facilities
reported supplementing more than half of healthy, full-term,
breastfed newborns with something other than breast milk
during the postpartum stay, a practice shown to be unnecessary and detrimental to breastfeeding (7,10). In addition, 70%
of facilities reported giving breastfeeding mothers gift bags containing infant formula samples. Facilities should consider discontinuing these practices to provide more positive influences
on both breastfeeding initiation and duration (5,6,8).
The findings demonstrate that birth centers had higher mean
total scores, compared with hospitals. Facility size (based on
annual number of births) was not related to differences in
scores. Further research is needed to better understand the
difference in scores for birth centers and hospitals. Previous
research has indicated that the more breastfeeding-supportive
maternity practices that are in place, the stronger the positive
effect on breastfeeding (5,6,9). Comparison of the findings of
this report with state breastfeeding rates also suggests a correlation between maternity practice scores and prevalence of
breastfeeding. For example, in the 2006 National Immunization Survey, seven states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Oklahoma, and West Virginia) had the
lowest percentages (<30%) of children breastfed for 6 months.
The same seven states were among those with the lowest mean
total maternity practice scores (48–58) in mPINC.
The findings in this report are subject to at least one limitation. Data were reported by one person at each facility and
might not be representative of actual maternity practices in
use. However, CDC sought to prevent inaccuracies by request-

Vol. 57 / No. 23

MMWR

ing that the survey be completed by the person most knowledgeable about the facility’s maternity practices, in consultation with other knowledgeable persons when necessary. The
survey was pretested with key informants in nine facilities
across the country, with follow-up visits to each facility to
validate responses. Information from the key informants generally was found to be accurate. Further validation through
patient interviews or medical chart reviews has not been
conducted.
In July 2008, mPINC benchmark reports will be provided
to each facility that completed a survey, comparing the facility’s
subscale and total scores with the scores of all other participating facilities, other facilities in the state, and facilities of a
similar size nationally. These reports also will provide the
facility score for each item comprising the subscales, which
can help facilities identify specific maternity practices that
might be changed to better support breastfeeding. Aggregate
data will be shared with state health departments to facilitate
their work with birth facilities to improve breastfeeding care.
CDC plans to repeat the mPINC survey periodically to assess
changes over time.
The American Academy of Family Physicians,†† American
Academy of Pediatrics,§§ and Academy of Breastfeeding
Medicine¶¶ all recommend that physicians provide intrapartum care that is supportive of breastfeeding. Hospitals and
birth centers provide care to nearly all women giving birth in
the United States. Thus, improving maternity practices in these
facilities affords an opportunity to support establishment and
continuation of breastfeeding. Establishing these practices as
standards of care in birth facilities throughout the United States
can improve progress toward meeting the Healthy People 2010
breastfeeding objectives and improve maternal and child health
nationwide.

625

Centers for Public Health Research and Evaluation, Seattle, Washington; M Pessl, Evergreen Perinatal Education, Bellevue, Washington; L Feldman-Winter, MD, Univ of Medicine and Dentistry
of New Jersey, Newark, New Jersey; and A Spangler, MN, Amy’s
Babies, Atlanta, Georgia.
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infant health outcomes in developed countries. Rockville, MD: US
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pub/evidence/pdf/brfout/brfout.pdf.
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4. United Nations Childrens Fund/World Health Organization. Promoting, protecting, and supporting breastfeeding: the special role of
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5. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care practices: implications for breastfeeding. Birth 2001;28:94–100.
6. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase
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7. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors
for suboptimal infant feeding behavior, delayed onset of lactation, and
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Acknowledgments

This report is based, in part, on contributions by E Adams, PhD,
Oregon Health & Science Univ, Portland, Oregon; K Rosenberg,
MD, Oregon Dept of Human Svcs; A Grinblat, MD, State Univ of
New York at Buffalo; CL Quinn, MD, Albert Einstein College of
Medicine, Bronx, New York; M Applegate, MD, New York State
Dept of Health; K Cadwell, PhD, C Turner-Maffei, MA, BabyFriendly USA, East Sandwich, Massachusetts; A Crivelli-Kovach,
PhD, Arcadia Univ; E Declercq, PhD, Boston Univ School of Public Health; A Merewood, MPH, B Philipp, MD, Boston Medical
Center, Massachusetts; J Dellaport, RD, L Tiffin, MS, California
Dept of Health Svcs; MK Dugan, MA, E Miles, MPH, Battelle
††

Available at http://www.aafp.org/online/en/home/policy/policies/h/
hospuseinfantformulabreastfeeding.html.
§§ Available at http://aappolicy.aappublications.org/cgi/reprint/pediatrics;115/
2/496.pdf.
¶¶ Available at http://www.bfmed.org/ace-files/protocol/mhpolicy_abm.pdf.

Escherichia coli 0157:H7 Infections
in Children Associated with Raw Milk
and Raw Colostrum From Cows —
California, 2006
On September 18, 2006, the California Department of
Public Health (CDPH) was notified of two children hospitalized with hemolytic uremic syndrome (HUS). One of the
patients had culture-confirmed Escherichia coli O157:H7
infection, and both patients had consumed raw (unpasteurized) cow milk in the week before illness onset. Four additional cases of E. coli O157:H7 infection in children who had
consumed raw cow milk or raw cow colostrum produced by
the same dairy were identified during the following 3 weeks.