Results from the CDC Results from the CDC National Survey of National Survey of Maternity Care Practices in Maternity Care Practices in Infant Nutrition and Care Infant Nutrition and Care (mPINC)(mPINC)
Laurence Grummer-Strawn, PhDLaurence Grummer-Strawn, PhD
Deborah Dee, MPH, PhDDeborah Dee, MPH, PhD
Katherine Shealy, MPH, IBCLC, RLCKatherine Shealy, MPH, IBCLC, RLC
Division of Nutrition, Physical Activity and ObesityDivision of Nutrition, Physical Activity and Obesity
National Center for Chronic Disease Prevention and Health National Center for Chronic Disease Prevention and Health PromotionPromotion
Centers for Disease Control and PreventionCenters for Disease Control and PreventionAtlanta, GAAtlanta, GA
32.1%
23.6%
18.5%
9.0%
5.1%
13.6%
0 1 2 3 4 5
Number of Number of Baby FriendlyBaby Friendly steps in place steps in place predicts risk of breastfeeding cessationpredicts risk of breastfeeding cessation
Source: Source: DiGirolamo et al., 2001DiGirolamo et al., 2001
Steps measured: Late bf initiation Supplemented feedings
Lack of rooming-in Scheduled feedings Pacifiers
Number of steps reported 5
0 25 50 75 100
Baby breastfed in 1st hour after birth
Baby fed only breastmilk in hospital
Baby stayed in same room with mother
Baby did not use pacifier in hospital
Hospital gave mother phone number to call forbreastfeeding help
Percent
No
Yes
Hospital practices are associated with Hospital practices are associated with breastfeeding continuation at 8 weeksbreastfeeding continuation at 8 weeks
Source: Source: Murray et al., 2007Murray et al., 2007 3
Evidence from PRAMSEvidence from PRAMS
● Breastfeeding mothers in Oregon Breastfeeding mothers in Oregon given given commercial hospital discharge packs were 39% more likely to supplement before 10 weeks of age.
4
Supplemental feeds Supplemental feeds in hospitalin hospital negatively impact infant health & bf negatively impact infant health & bf outcomesoutcomes
Source: Nylander, et al. 1991
In-hospital BehaviorsIn-hospital Behaviors ControlControl InterventionIntervention
Breastfeeds/24 hr on day 2Breastfeeds/24 hr on day 2 4.3 feeds4.3 feeds 6.4 feeds6.4 feeds
Supplementary feeds/24 h on day 2Supplementary feeds/24 h on day 2 4.8 feeds4.8 feeds 1.1 feeds1.1 feeds
Volume of breast milk on day 2 (ml)Volume of breast milk on day 2 (ml) 47 ml47 ml 132 ml132 ml
Volume of supplement on day 2 (ml)Volume of supplement on day 2 (ml) 188 ml188 ml 23 ml23 ml
Supplementing on day 2Supplementing on day 2 100%100% 2%2%
Total volume supplement consumed days 1-3Total volume supplement consumed days 1-3 565 ml565 ml 68 ml68 ml
Night-time breastfeedingNight-time breastfeeding 2%2% 98%98%
BF RatesBF Rates ControlControl InterventionIntervention
3 mo exclusive bf3 mo exclusive bf 57%57% 75%75%
6 mo exclusive bf6 mo exclusive bf 12%12% 22%22%
9 mo any bf9 mo any bf 47%47% 62%62%
6
CDC activities on maternity care CDC activities on maternity care practices related to breastfeedingpractices related to breastfeeding
● Formative research on barriers to changing Formative research on barriers to changing practicespractices
● Compilation of success stories in Baby-Compilation of success stories in Baby-Friendly hospitalsFriendly hospitals
● Numerous evaluation grants on hospital Numerous evaluation grants on hospital interventionsinterventions
● PRAMS survey modulePRAMS survey module
● Planning for strategic planning meetingPlanning for strategic planning meeting
7
Nationwide activities on maternity Nationwide activities on maternity care practices related to breastfeedingcare practices related to breastfeeding
● BFHIBFHI
● BanTheBags.orgBanTheBags.org
● National Quality Forum Voluntary Consensus National Quality Forum Voluntary Consensus StandardsStandards
● Performance incentives for MedicaidPerformance incentives for Medicaid
● Recommendations in HHS Blueprint & CDC Recommendations in HHS Blueprint & CDC Guide to Breastfeeding InterventionsGuide to Breastfeeding Interventions
8
What actually happens in What actually happens in maternity care settings?maternity care settings?
● How common are positive How common are positive practices?practices?
● How common are negative How common are negative practices?practices?
..
Geographic variationsGeographic variations Predictors of variationsPredictors of variations
● Are practices changing over time?Are practices changing over time?
9
October, 2003 – Expert October, 2003 – Expert PanelPanel
● Two day working meetingTwo day working meeting
● Researchers with specific expertise Researchers with specific expertise and experience in assessment and and experience in assessment and monitoring of breastfeeding-related monitoring of breastfeeding-related maternity care practicesmaternity care practices Conducting state/regional surveysConducting state/regional surveys Assessing maternal experiences Assessing maternal experiences
during maternity careduring maternity care Assessing breastfeeding issuesAssessing breastfeeding issues
11
Expert Panel Expert Panel RecommendationRecommendation
Biannual national census of facilities routinely Biannual national census of facilities routinely providing maternity servicesproviding maternity services
Strong need for a census design to effectively utilize Strong need for a census design to effectively utilize data for advocacy and practice changedata for advocacy and practice change
Concerns about identification of respondent facilitiesConcerns about identification of respondent facilities Mail survey with telephone follow-up for non-Mail survey with telephone follow-up for non-
respondersresponders Single key informantSingle key informant Assess ‘usual practice’ including, but not limited to, Assess ‘usual practice’ including, but not limited to,
practices in WHO/UNICEF Ten Stepspractices in WHO/UNICEF Ten Steps Representation of practices at all different types of Representation of practices at all different types of
facilities in the USfacilities in the US 12
National SurveyNational Survey
● Biannual national census of facilities Biannual national census of facilities routinely providing maternity servicesroutinely providing maternity services
Private hospitalsPrivate hospitals Public hospitalsPublic hospitals Free-standing birth centersFree-standing birth centers
● Single key informantSingle key informant
● Assesses ‘usual practice’Assesses ‘usual practice’
13
Survey IndicatorsSurvey Indicators
● WHO/UNICEF WHO/UNICEF Ten Steps to Successful Ten Steps to Successful BreastfeedingBreastfeeding
● Labor and birthing practicesLabor and birthing practices
● Postpartum care practicesPostpartum care practices
14
Current StatusCurrent Status
● Data were collected from Aug-Dec, 2007Data were collected from Aug-Dec, 2007
● MMWR to be published June 13, 2008MMWR to be published June 13, 2008
● Individualized Individualized Benchmark Reports Benchmark Reports will be sent to will be sent to respondent facilities in respondent facilities in early July early July
17
Design StrengthsDesign Strengths
● Representation of practices at all Representation of practices at all different types of facilities in the USdifferent types of facilities in the US
● State and regional analyses can be State and regional analyses can be donedone
● Routine, recurring administrationRoutine, recurring administration Trend analysis is possibleTrend analysis is possible Predictability – facilities will come to Predictability – facilities will come to
expect the surveyexpect the survey
16
mPINC DimensionsmPINC Dimensions
● Labor and delivery careLabor and delivery care
● Postpartum carePostpartum care Breastfeeding assistanceBreastfeeding assistance Contact between mother and infantContact between mother and infant Feeding of breastfed infantsFeeding of breastfed infants
● Discharge careDischarge care
● Staff trainingStaff training
● Structural and organizational Structural and organizational aspects of care deliveryaspects of care delivery
15
MethodologyMethodology● 52 questions52 questions
36 categorized into the 7 maternity 36 categorized into the 7 maternity practice dimensionspractice dimensions
● Points assigned to responses to every Points assigned to responses to every questionquestion Higher points for practices supportive of Higher points for practices supportive of
breastfeedingbreastfeeding
● Dimension scores: average of points Dimension scores: average of points for each item in the dimensionfor each item in the dimension
● Composite quality scores: average of Composite quality scores: average of dimension scoresdimension scores 18
mPINC Response Rates: mPINC Response Rates: 2,690 birth facilities 2,690 birth facilities respondedresponded
81.788.4
82
0
10
20
30
40
50
60
70
80
90
100
Per
cent
Hospitals Birth Centers OverallN=2568 N=122 N=2690
20
Differences in Composite Differences in Composite Quality Score by Facility Size Quality Score by Facility Size & Type& Type
Number of Annual Births (Facility Size) N
MeanComposite Quality Score
Standard Error
0-249 626 63 0.68250-499 448 60 0.66500-999 548 62 0.58
1000-1999 553 64 0.572000-4999 440 66 0.58
≥5000 71 63 1.51
Facility TypeBirth Center* 121 86 0.85
Hospital† 2546 62 0.27
*1 birth center and 22 *1 birth center and 22 hospitals had no mean total hospitals had no mean total scorescore 22
National Mean Composite Quality National Mean Composite Quality Scores and Dimension SubscoresScores and Dimension Subscores
0
20
40
60
80
100
Composite
Labor & Delive
ry
BF Assistance
Mother-Newborn Contact
Postpartu
m Feeding
BF Support >Discharge
Staff Training
Structu
ral/Org'l
23
Lowest Score: Lowest Score: BF Support After DischargeBF Support After Discharge
● Mean US score: 40 out of 100Mean US score: 40 out of 100
● Questions:Questions: Does facility provide gift bags Does facility provide gift bags
containing infant formula to containing infant formula to breastfeeding mothers upon breastfeeding mothers upon discharge?discharge?
Types of BF support provided to Types of BF support provided to mothers upon dischargemothers upon discharge
24
Are discharge packs containing Are discharge packs containing infant formula samples given to infant formula samples given to breastfeeding mothers?breastfeeding mothers?
Yes
No
25
Types of BF Support Provided Types of BF Support Provided After DischargeAfter Discharge
0
20
40
60
80
100
PP follo
w-up vis
it at fac
ility
PP ho
me vis
it
PP Pho
ne ca
ll by s
taff
PP ph
one # for p
atien
t
Refer
rals
26
Newborn Feeding: Newborn Feeding: Supplementation of bf Supplementation of bf newbornsnewborns
0
10
20
30
40
50
Non Breast Milk(at least half)*
Water (any) Glucose Water(any)
*Percent of facilities that supplement at least half of all healthy, full-
term breastfed newborns with something other than breast milk 27
Benchmark ReportsBenchmark Reports
● Mailed individually to people at each Mailed individually to people at each respondent hospitalrespondent hospital
● Multipurpose documentMultipurpose document Customized, detailed survey informationCustomized, detailed survey information Intervention strategyIntervention strategy
• Raise awarenessRaise awareness• Provide motivators for changeProvide motivators for change• Identify barriersIdentify barriers
28
Customized, detailed Customized, detailed survey informationsurvey information
● Composite Quality Practice ScoreComposite Quality Practice Score Subscores for each dimensionSubscores for each dimension Composite and Subscore PercentileComposite and Subscore Percentile
• NationalNational• StateState• Similar sizeSimilar size
For each item:For each item:• Measure, rationale, explanation, ideal, Measure, rationale, explanation, ideal,
actual, scoreactual, score
29
Benchmark Report Target Benchmark Report Target AudiencesAudiences
Hospital:Hospital: CEOCEO Director of Quality Director of Quality
Assurance/ImprovementAssurance/Improvement Director of ObstetricsDirector of Obstetrics Director of PediatricsDirector of Pediatrics Mother Baby Nurse ManagerMother Baby Nurse Manager Key InformantKey Informant
Birth Center:Birth Center: Birth Center OwnerBirth Center Owner Medical DirectorMedical Director Head MidwifeHead Midwife Key InformantKey Informant
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Preliminary Plan for 2008-2009Preliminary Plan for 2008-2009
● Summer & Fall, 2008 - submit OMB Summer & Fall, 2008 - submit OMB package requesting 2009 surveypackage requesting 2009 survey
● Fall & Winter, 2008Fall & Winter, 2008 Disseminate state-based reports of Disseminate state-based reports of
aggregate dataaggregate data October – Present findings at APHAOctober – Present findings at APHA Create 2009 surveyCreate 2009 survey
● Ongoing – preparation of manuscripts for Ongoing – preparation of manuscripts for peer review publicationspeer review publications
35
Measure Rationale ExplanationIdeal
ResponseYour
ResponseYour Score
Initial skin-to-skin contact
Skin-to-skin contact is beneficial because it improves infant ability to establish breastfeeding.9
This measure reports how many patients experience mother-infant skin-to-skin contact for at least 30 minutes within 1 hour of vaginal birth.
Most Many 70
This measure reports how many patients experience mother-infant skin-to-skin contact for at least 30 minutes within 2 hours for Cesarean birth.
Most Few 0
Initial breastfeeding
opportunity
Early initiation of breastfeeding is beneficial because it increases overall breastfeeding duration & reduces a mother’s risk of delayed onset of milk production.10
This measure reports what percent of patients have the opportunity to breastfeed within 1 hour of uncomplicated vaginal birth
≥90 75 70
This measure reports what percent of patients have the opportunity to breastfeed within 2 hours of uncomplicated Cesarean birth.
≥90 40 30
Routine procedures performed skin-to-skin
Performing routine infant procedures & assessments without separating mother & infant is beneficial because it improves breastfeeding outcomes by reducing unnecessary separation of mother & infant & increases infant stability. It is safe for mother & infant to perform these procedures skin-to-skin.11,12
This measure reports how often patients have routine infant procedures performed while mother & infant are skin-to-skin.
Almost always
Rarely 0
Labor and Delivery Care Score 3433
Accessing Information Accessing Information About mPINCAbout mPINC
● www.cdc.gov/mpincwww.cdc.gov/mpinc
● MMWR publication – June 13, 2008MMWR publication – June 13, 2008
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AcknowledgementsAcknowledgements
Elizabeth AdamsElizabeth Adams
Mary ApplegateMary Applegate
Karin CadwellKarin Cadwell
Jennifer CohenJennifer Cohen
Andrea Crivelli-KovachAndrea Crivelli-Kovach
Eugene DeclercqEugene Declercq
Jennifer DellaportJennifer Dellaport
Ann DiGirolamoAnn DiGirolamo
Mary Kay DuganMary Kay Dugan
Laurie Feldman-WinterLaurie Feldman-Winter
Alla GrinblatAlla Grinblat
Carol MacGowanCarol MacGowan
Diane ManninenDiane Manninen
Anne MerewoodAnne Merewood
Eileen MilesEileen Miles
Paulette MurphyPaulette Murphy
Molly PesslMolly Pessl
Barbara PhilippBarbara Philipp
Celia QuinnCelia Quinn
Ken RosenbergKen Rosenberg
Kelley ScanlonKelley Scanlon
Andrea SharmaAndrea Sharma
Amy SpanglerAmy Spangler
Laurie TiffinLaurie Tiffin
Cynthia Turner-MaffeiCynthia Turner-Maffei
36
Thank you!Thank you!
www.cdc.gov/breastfeedingwww.cdc.gov/breastfeeding
www.cdc.gov/mpincwww.cdc.gov/mpinc
Laurence Grummer-Strawn Laurence Grummer-Strawn [email protected]@cdc.gov
Deborah Dee Deborah Dee [email protected]@cdc.gov
Kat Shealy Kat Shealy kshealykshealy@@cdccdc..govgov
37
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