Att 3a_Summary 2007-2015 Surveys

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Assessment & Monitoring of Breastfeeding-Related Maternity Care Practices in Intrapartum Care Facilities in the United States and Territories

Att 3a_Summary 2007-2015 Surveys

OMB: 0920-0743

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Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intrapartum Care Facilities in the United States and Territories

OMB Control No. 0920-0743

Expiration Date: 9/30/2016













Summary Report of

mPINC Findings

2007-2015















Nutrition Branch

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

February 7, 2017


Executive Summary


Prior to 2007, specific practices in maternity care facilities had been identified as key determinants of breastfeeding but no accurate estimates of the prevalence or distribution of these practices existed across the United States (U.S.). Effective strategies to address problems in maternity care practices could not be developed without this information. In 2007, the Centers for Disease Control and Prevention (CDC) first conducted the survey described in ICR 0920-0743, Assessment and Monitoring of Breastfeeding-Related Maternity Care Practices in Intrapartum Facilities in the United States and Territories. This survey came to be known as the mPINC survey, for Maternity Practices in Infant Nutrition and Care.

Since 2007, every hospital and free-standing birth center in the U.S. and territories that routinely provided maternity care has been eligible to participate in the biennial mPINC survey; 82–83% (n=2582–2742) of facilities have responded to each survey cycle. Overall scores, which indicate implementation of evidence-based maternity care practices in the U.S., are increasing from 63/100 in 2007 to 79/100 in 2015. Scores have also increased consistently across each of the 7 dimensions of care. While these improvements are encouraging, the mPINC data illustrate that many U.S. hospitals continue to use practices that are inconsistent with evidence-based, best-practice standards and do not support breastfeeding. In 2015, only 11.8% of all maternity care facilities were implementing the ideal standard on 9–10 practices (out of 10) described by the World Health Organization and UNICEF as the Ten Steps to Successful Breastfeeding.

Since 2007, CDC has sent more than 75,000 customized reports with hospital-specific data to leadership staff at each respondent facility. These Benchmark Reports provide empiric information about the survey as well as the facility’s detailed survey data benchmarked against peer facilities by state, birth census, and among all survey respondents.

Aggregate national data are published on CDC’s website as are state-specific reports. Additionally, the state-specific reports are emailed to the state health departments and other state-based stakeholders. State partners have used their states’ data for quality improvement efforts. The mPINC data have also been used for multiple peer-reviewed publications. Of note, data from the mPINC surveys were the basis of two CDC Vital Signs reports: “Hospital Support for Breastfeeding: Preventing Obesity Begins in Hospitals” and “Improvements in Maternity Care Policies and Practices That Support Breastfeeding – United States, 2007-2013.”

Continuation of the mPINC survey will allow for monitoring trends in evidence-based maternity care and identification of areas in need of improvement, thus enabling clinicians, hospitals, and public health leaders to carry out their work to protect and support mothers’ and babies’ health nationwide.

Background


Health professionals recommend exclusive breastfeeding (breast milk and any necessary medications or nutrients, but no other solids or liquids) for about the first 6 months of life, and continued breastfeeding for at least 12 months.1 Breastfeeding is a critical preventive health measure for the newborn, reducing the risk of infections and Sudden Infant Death Syndrome (SIDS) in infancy and of obesity and diabetes later in life.2-4 Additionally, the benefits of breastfeeding are far-reaching, including reduced risk of cardio-metabolic disease and breast and ovarian cancers for the mother and cost savings for employers and healthcare providers.4-6 Approximately 81% of mothers initiate breastfeeding but by 7 days of life approximately 20% of those infants have already been given infant formula.7

For women who plan to breastfeed, experiences and support during the first hours and days after birth influence their later ability to continue breastfeeding. Improving hospital practices to support breastfeeding is a national priority. In 2011, Surgeon General Regina Benjamin included “ensuring that maternity care practices throughout the United States are fully supportive of breastfeeding” as a specific action of the Surgeon General’s Call to Action to Support Breastfeeding.6 Improving hospital maternity care to support breastfeeding is also a recommendation of the National Prevention Strategy and is a Healthy People 2020 objective.8, 9


Assessing and Monitoring Maternity Care Practices across the United States


Before 2007 there was no reliable way to estimate the extent to which U.S. birth facilities were implementing evidence-based maternity care supportive of breastfeeding. State health departments, health care providers, and infant feeding experts called on CDC to address this need.

In 2007, CDC conducted the first national Maternity Practices in Infant Nutrition and Care Survey, often called the “mPINC survey” for short. The survey collected information on facility characteristics, maternity care policies, staff training on breastfeeding instruction, infant feeding practices, breastfeeding management and support, and facility discharge care.

The assessment was designed to provide ongoing monitoring of maternity care practices in the U.S. The selected survey methodology was the outcome of detailed input and collaboration with external experts representing the diverse stakeholder groups for whom the information is most important. The experts represented health care providers and administrators, state health departments, and infant feeding experts and researchers.

Stakeholders unanimously urged CDC to survey every facility in the U.S. and territories that routinely provides maternity care, regardless of size, ownership, payer status, or other selection criteria. The resulting census design allows CDC to provide state-specific data and to create facility-level reports utilizing individual facilities’ data benchmarked against facilities of similar size, facilities within the same state, and all facilities participating in the survey.

The mPINC survey was sent to every hospital (n=2917 in 2015) and free-standing birth center (n=254 in 2015) in the U.S. and territories that routinely provided maternity care and agreed to survey participation. Eligibility was determined with a screening telephone call to verify the facility had registered maternity beds.

CDC Survey Documents National Need for Action


Fully 82–83% (n=2582–2742) of all hospitals and birth centers responded to the CDC mPINC survey in each of the five cycles that the survey has been administered. These facilities vary broadly by size and type. Facility types include urban/rural; private/public/government/military; teaching/non-teaching; and serving economically disadvantaged/advantaged populations.

To facilitate reporting on the findings, results were scored on a 0–100 scale. Each facility’s mPINC Total Score comprised the mean of their score on the following dimensions of care:

  • Labor and Delivery Care

  • Feeding of Breastfed Infants

  • Breastfeeding Assistance

  • Contact Between Mother and Infant

  • Facility Discharge Care

  • Staff Training

  • Structural and Organizational Aspects of Care


Facility mean Total and subscale scores vary by facility location, type, and size. Across survey years, hospitals had lower Total scores than birth centers and larger facilities had higher Total scores than smaller facilities. Scores varied widely across states, ranging from 60 in Mississippi to 96 in Rhode Island in 2015. The states in the Pacific and New England census regions had the highest scores while states in the West and East South Central census regions had the lowest. See the following pages for Total and subscale scores from 2007-2015 (Figure 1) and the distribution of state scores in 2015 (Table 1).


Figure 1. Mean total and dimensions of care mPINC scores by survey year, 2007-2015



Table 1: Mean total and dimensions of care 2015 mPINC scores by state/territory


Total score

Labor & delivery care

Feeding of breastfed infant

Breast- feeding assistance

Mother/ infant contact

Discharge care

Staff training

Structural & Organizational Aspects

All States

79

85

86

89

83

68

64

77


Alaska

82

90

92

88

91

88

58

67

Alabama

72

76

81

83

69

52

69

75

Arkansas

67

68

74

80

71

52

57

63

Arizona

79

86

87

88

92

67

56

74

California

85

90

89

93

92

74

72

85

Colorado

85

91

90

93

93

74

70

82

Connecticut

83

91

89

92

83

66

71

86

District of Columbia

82

76

78

85

86

83

79

90

Delaware

90

91

96

99

90

80

77

97

Florida

80

86

86

89

90

65

65

77

Georgia

75

80

86

87

79

61

65

70

Hawaii

80

89

89

91

85

69

62

75

Iowa

75

85

88

88

75

64

55

72

Idaho

78

90

90

89

89

63

50

73

Illinois

81

85

84

90

86

65

75

80

Indiana

80

88

87

90

80

70

66

79

Island Territories

72

71

83

86

84

65

48

69

Kansas

76

88

90

83

86

69

47

66

Kentucky

73

88

79

88

71

52

63

72

Louisiana

76

80

83

89

72

66

65

77

Massachusetts

87

94

90

95

88

82

74

86

Maryland

82

86

86

90

86

74

71

84

Maine

84

94

91

90

85

85

63

76

Michigan

78

86

86

86

85

67

60

76

Minnesota

82

91

88

90

85

85

56

81

Missouri

75

87

87

87

79

57

56

74

Mississippi

60

65

76

81

62

36

42

60

Montana

82

90

91

88

92

71

65

74

North Carolina

78

80

82

89

84

68

66

76

North Dakota

73

84

85

85

72

60

51

75

Nebraska

71

83

87

83

84

57

35

68

New Hampshire

90

94

95

94

89

91

78

86

New Jersey

83

89

85

94

77

68

81

85

New Mexico

81

88

86

90

95

75

58

72

Nevada

75

72

86

85

84

59

64

75

New York

82

83

83

91

78

81

73

85

Ohio

80

85

86

88

79

70

69

81

Oklahoma

78

85

87

91

86

62

68

70

Oregon

86

94

95

94

95

77

68

82

Pennsylvania

78

80

89

88

77

68

65

77

Puerto Rico

69

67

68

81

65

67

73

62

Rhode Island

96

98

97

100

96

98

91

95

South Carolina

78

82

85

88

78

71

66

78

South Dakota

74

83

84

86

81

55

51

74

Tennessee

72

79

80

85

73

51

63

74

Texas

77

81

84

87

85

68

65

71

Utah

75

86

89

86

82

59

52

70

Virginia

80

87

89

92

80

68

69

77

Vermont

88

96

93

94

91

90

76

79

Washington

83

91

91

91

96

75

57

78

Wisconsin

82

90

92

92

83

77

62

80

West Virginia

73

84

81

83

77

72

46

71

Wyoming

77

92

91

87

91

70

47

62

*State abbreviation 'IT' is Island Territories, and includes American Samoa, Guam, Northern Mariana Islands, and US Virgin Islands.


Maternity Care Practices Vary Widely

Scores on the 7 dimensions of care ranged from 40 to 79 in 2007 and from 64 to 89 in 2015.


Discharge support

is inadequate:

Progress has been made in reducing distribution of formula marketing samples to breastfeeding mothers, from 73% in 2007 to 21% in 2015, but this practice is still pervasive in many geographic areas.

Staff training

is inconsistent:

Fewer than half of facilities and only one-tenth of small facilities provide ≥8 hours of training to new staff.

Better policies

are needed:

Although breastfeeding policies commonly exist in hospitals, most are limited in scope. In 2015, only 32% of hospitals had a model breastfeeding policy.

Unnecessary separation

is common:

Progress has been made in reducing separation of mothers and infants, which interferes with establishing breastfeeding, but many infants are still not staying with their mothers at least 23 hours a day as recommended.

Feeding supplementation

is excessive:

One-fifth of all facilities routinely supplement normal, healthy, full-term breastfed infants.


Quality Assessment and Reporting Supports Local Autonomy

One of the goals of the mPINC survey is to provide data to empower stakeholders to improve maternity care practices in the way that best meets their needs. Diverse reporting maximizes data utility for hospitals and birth centers, clinical health professionals, public health professionals, advocacy groups, and ultimately mothers and babies.

Interest in the survey is unprecedented:

The response rate has consistently remained >80%.

Respondents were interested in the survey, eager to participate, and appreciated CDC providing them with urgently needed information.

National organizations and experts that have been underrepresented in the work to improve maternity care practices related to breastfeeding have sought out more information about the mPINC survey:

The Institute for Healthcare Improvement (IHI)

The Indian Health Service (IHS)

The American Hospital Association (AHA)

The National Quality Forum (NQF)

The National Association of County and City Health Officials (NACCHO)

The American Medical Association (AMA)

The census design

is essential:

Assessing all facilities allows for authentic, localized comparisons between different states, regions, and types of facilities.

Universal reporting allows CDC to provide meaningful data back to facilities and states through a formalized benchmarking process.

Data are used by multiple stakeholders::

  • Independent researchers use the data to answer their research questions.

  • Many state health departments use their data to improve maternity care within their states. For example, the California Department of Health has used the mPINC data to create California regional Benchmark Reports to provide Regional Perinatal Programs of California Coordinators and other breastfeeding stakeholders with local data to facilitate their work in improving breastfeeding support. http://www.cdph.ca.gov/data/statistics/Pages/CaliforniamPINCSurveyData.aspx

  • Baby-Friendly USA, the organization responsible for overseeing the World Health Organization/UNICEF Baby-Friendly Hospital Initiative in the U.S., uses mPINC scores as a part of helping hospitals identify areas for improvement and achieve Baby-Friendly designation.





CDC Provides Quality Improvement Action Tools

CDC maintains a set of coordinated, multifaceted activities to generate better awareness and interest in the issues assessed in the mPINC survey.

  • mPINC scores are incorporated into the annual CDC Breastfeeding Report Card that highlights policy and environmental support for breastfeeding at the state level. http://www.cdc.gov/breastfeeding/data/reportcard.htm

  • CDC maintains a dedicated web site www.cdc.gov/mpinc to facilitate access to information about the survey and findings for the broader public. This has provided a venue for CDC to efficiently update and expand information sharing efforts.

  • CDC maintains a dedicated email box ([email protected]) to respond to facility and public inquiries about the mPINC survey. Typical inquiries include facilities looking for their current or previous Benchmark Reports and questions about survey methodology.


Hospital-specific Benchmark Reports

Since 2007 CDC has mailed more than 75,000 individualized reports to facilities that responded to the survey. These were created to help hospital leadership better understand the areas in most need in their facility, provide data and scientific rationale for each area, and enable them to develop quality improvement activities on issues in their facility. The Benchmark Reports also provides an opportunity for CDC to thank facilities for participating in the survey.


State-specific Reports

Data from the survey are also used to create customized state-specific reports for key decision-makers (i.e., state health departments, health professional and hospital administrator organizations, medical boards, etc.). These reports are structured specifically to respond to the challenges this diverse audience has identified and meet their unique needs in improving care at the state level.


National Web Tables

Aggregated national data are posted on CDC’s website. Data are presented by hospital characteristic (e.g., size, teaching status) and by state.





The Need for Continued Assessment and Reporting

CDC’s mPINC activities underscore the need for regular and continued national assessment and monitoring of hospital infant feeding practices. This demonstrates CDC’s responsiveness to the audiences’ needs and enables them to maintain quality improvement efforts.

The survey instruments were designed to capture incremental changes that CDC anticipates will be taking place at the hospital level. Most facilities have abundant opportunities to improve the quality of the care they provide to mothers and babies during the maternity stay.

The two-year timeframe for follow-up is ideal because it allows enough time for these changes to be implemented based on feedback from the prior survey, while being close enough to capture progress in changes as they are being made.



Publications and Resources


Publications (select):

Kahin SA, McGurk M, Hansen-Smith H, et al. Key Program Findings and Insights from the Baby-Friendly Hawaii Project. J Hum Lact. 2017. DOI: 10.1177/0890334416683675.

Nelson JM, Perrine CG, Scanlon KS, et al. Provision of Non-breast Milk Supplements to Healthy Breastfed Newborns in U.S. Hospitals, 2009 to 2013. Matern Child Health J. 2016; DOI 10.1007/s10995-016-2095-9.

Eganhouse DJ, Gutierrez L, Cuellar L, et al. Becoming Baby-Friendly and Transforming Maternity Care in a Safety-Net Hospital on the Texas-Mexico Border. Nurs Womens Health. 2016;20(4):378-90.

Spatz DL. What is Your mPINC Score? MCN Am J Matern Child Nurs. 2016;41(4):254.

Perrine CG, Galuska DA, Dohack JL, et al. Vital Signs: Improvements in Maternity Care Policies and Practices That Support Breastfeeding – United States, 2007 – 2013. Morb Mortal Wkly Rep. 2015;64(39):1112-17.

Nelson JM, Li R, Perrine CG. Trends of US Hospitals Distributing Infant Formula Packs to Breastfeeding Mothers, 2007 to 2013. Pediatrics 2015;135(6): DOI 10.1542/peds.2015-0093.

Allen JA, Perrine CG, Scanlon KS. Breastfeeding Supportive Hospital Practices in the US Differ by County Urbanization Level. J Hum Lact 2015;31(3):440-43.

Allen JA, Belay BB, Perrine CG. Using mPINC to Measure Breastfeeding Support for Hospital Employees. J Hum Lact 2014;30(1):97-101.

Edwards RA, Dee D, Umer A, et al. Using Benchmarking Techniques and the 2011 Maternity Practices Infant Nutrition and Care (mPINC) Survey to Improve Performance among Peer Groups across the United States. J Hum Lact 2014;30(1):31-40.

Li CM, Li R, Ashley CG, et al. Associations of Hospital Staff Training and Policies with Early Breastfeeding Practices. J Hum Lact 2014;30(1)88-96.

Lind JN, Perrine CG, Li R, et al. Racial Disparities in Access to Maternity Care Practices That Support Breastfeeding – United States, 2011. Morb Mortal Wkly Rep. 2014;63(33):725-28.

Labbok MH, Taylor EC, Nickel NC. Implementing the Ten Steps to Successful Breastfeeding in Multiple Hospitals Serving Low-wealth Patients in the US: Innovative Research Design and Baseline Findings. Int Breasfeed J. 2013;8(5):

Perrine CG, Shealy KR, Scanlon KS. Vital Signs: Hospital Practices to Support Breastfeeding—United States, 2007 and 2009. Morb Mortal Wkly Rep. 2011;60(30):1020-1025.

Edwards RA, Phillips BL. Using maternity practices in infant nutrition and care (mPINC) survey results as a catalyst for change. J Hum Lact. 2010;26(4):399-404.

DiGirolamo A, Manninen D, Cohen J et al. Breastfeeding-related maternity practices at hospitals and birth centers--United States, 2007. Morb Mortal Wkly Rep. 2008;57(23):621-5.


CDC Web Resources:

mPINC Survey: www.cdc.gov/mpinc


References



1. Eidelman AI. Breastfeeding and the use of human milk: an analysis of the American Academy of Pediatrics 2012 Breastfeeding Policy Statement. Breastfeed Med. 2012;7(5):323-324.

2. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol. 2005;162(5):397-403.

3. Hauck FR, Thompson JM, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011;128(1):103-110.

4. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007(153):1-186.

5. Perrine CG, Nelson JM, Corbelli J, Scanlon KS. Lactation and Maternal Cardio-Metabolic Health. Annu Rev Nutr. 2016;36:627-645.

6. Services. USDoHaH. The Surgeon General's Call to Action to Support Breastfeeding. In: Services USDoHaH, editor. Washington, DC: Office of the Surgeon General; 2011.

7. Prevention. CfDCa. National Immunization Survey (NIS). https://www.cdc.gov/BREASTFEEDING/DATA/NIS_data/. Published 2016. Accessed February 3, 2017.

8. Council. NP. National Prevention Strategy. In: Services USDoHaH, editor.2011.

9. Services. USDoHaH. Healthy People 2020: Maternal Infant Child Health Objectives. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed February 3, 2017.



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