Are US Hospitals

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Are US Hospitals Birth Centers Practicing
Breastfeeding-Supportive Maternity Care?
Results of the First National mPINC Survey
LT Deborah Dee, PhD, MPH Division of Nutrition,
Physical Activity, and Obesity National Center
for Chronic Disease Prevention and Health
Promotion Centers for Disease Control and
Prevention USPHS Scientific and Training
Symposium, Atlanta, GA June 2, 2009
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Objectives

• Background Breastfeeding, maternity practices
• Describe the Maternity Practices in Infant
  Nutrition and Care (mPINC) Survey
• Review results
• Discuss dissemination of findings
• Next steps

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Breastfeeding Optimal nutrition, reduced health
risks

• Infant
• Otitis media
• Respiratory infection
• Sudden infant death syndrome
• Necrotizing enterocolitis
• Type 2 diabetes
• Childhood obesity
• Leukemia

• Mother
• Type 2 diabetes
• Breast cancer
• Ovarian cancer

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Healthy People 2010 National Breastfeeding
Objectives

• 75 initiate breastfeeding
• 50 breastfeed at least 6 months
• 25 breastfeed at least 1 year
• New in 2007
• 40 exclusively breastfeed 3 months
• 17 exclusively breastfeed 6 months
• Problem few states meet all the goals

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Maternity care practices influence breastfeeding

• Period following childbirth crucial to
  breastfeeding
• Positive influence
• Skin-to-skin contact, initiation shortly after
  birth, rooming in
• Negative influence
• Non-breast milk feedings, giving breastfeeding
  mothers gift packs containing infant formula

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• Hospital practices are associated with
  breastfeeding continuation at 8 weeks

Source Murray et al., 2007
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Cumulative Effect of Maternity Practices

• Practices measured
• BF initiation within 1 hr
• Giving only breast milk
• Mother-newborn rooming in
• Breastfeeding on cue
• No pacifiers given
• Info on BF support given

Mothers Discontinuing BF Before 6 wks
Number of supportive practices experienced

• Individual practices significantly associated
  with reduced risk of ceasing breastfeeding before
  6 weeks (Plt.05).
• DiGirolamo et al., Pediatrics 2008122S43-S49

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Effect of Commercial Discharge Packs on Exclusive
Breastfeeding

• Breastfeeding mothers given commercial hospital
  discharge packs were 39 more likely to stop
  exclusive breastfeeding before 10 weeks
  postpartum
• (AOR1.39, 95 CI 1.05, 1.84)

Rosenberg et al. AJPH 200898290-295.
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What maternity practices are being implemented in
the US?

• How common are positive, negative practices?
• Geographic variations?
• Are practices changing over time?

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Maternity Practices in Infant Nutrition and Care
(mPINC) Survey, 2007

• First national survey of maternity practices
• Census of facilities routinely providing
  maternity services
• Private, public, military hospitals birth
  centers
• Asked about
• usual practice
• healthy, term newborns

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Survey implementation

• Pre-survey phone call to ID key informant
• Data collected August 2007 December 2007
• 52 questions
• Practices
• Facility characteristics

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Maternity Practice Subscales

• Labor delivery care
• Breastfeeding assistance
• Contact between mother newborn
• Feeding of breastfed newborns
• Breastfeeding support after discharge
• Staff training
• Structural organizational aspects of care

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Scoring

• Points assigned (0-100)
• Higher scores for supportive practices
• Subscale scores
• Average of points for each question in the
  subscale
• Overall score average of subscale scores

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Overall response rate 82
N2568
N122
N2690
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State Mean Overall Scores (Quartiles)
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National Mean Overall Score Subscale Scores
Overall
Labor Delivery
Mother-Newborn Contact
Post-Discharge BF Support
Struct/Orgl Aspects of Care
Feeding of Breastfed Newborns
BF Assistance
Staff Training
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Are mother and baby usually skin-to-skin while
staff are completing routine newborn procedures?
Yes 38
No 62
Routine procedures Apgar, foot printing, ID
banding, etc.
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Supplementary Feedings
Percent of facilities reporting the practice

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Breastfeeding Assistance
Infant feeding decisions routinely documented
Breastfeeding mothers routinely receive
breastfeeding advice instructions
Mothers routinely taught to respond to infant
feeding cues
Most mothers instructed to limit infant's
suckling time
Breastfeeding not routinely assessed via direct
observation
Standardized assessment tool used
Pacifiers routinely provided to bf infants
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Instances of separation
.
Percent of facilities reporting separation
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Post-Discharge Breastfeeding Support
REFERRALS
ACTIVE REACHING OUT
Percent of facilities providing the support
PHYSICAL CONTACT WITH MOTHER
Postpartum follow-up visit at facility
Postpartum home visit
BF Helpline given to patient
Staff calls patient
Referrals
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Are discharge packs containing infant formula
provided to breastfeeding mothers?
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Breastfeeding training assessment of staff
skills are inadequate
Percent of facilities reporting each practice
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Structural Organizational Aspects of Care

• Breastfeeding policy
• Communication of policy
• Infant feeding documentation policy
• Employee breastfeeding support
• Receipt of free formula
• Prenatal bf instruction offered
• Coordination of lactation care

Average
Score
66 out of 100
Notice anything?
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Does your facility receive infant formula free of
charge?

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Dissemination Benchmark Reports, October 2008

• Facility-specific
• Intervention strategy raise awareness, motivate
  change, identify barriers to change/evidence-based
  care

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Benchmark Reports Mailed to Targeted Individuals

• Hospital
• CEO/President
• Director of Quality Assurance/Improvement
• Director of Obstetrics
• Director of Pediatrics
• Mother-Baby Nurse Manager
• Survey Recipient

• Birth Center
• Birth Center Owner
• Medical Director
• Head Midwife
• Survey Respondent

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Each Benchmark Report includes

• Overall score
• Subscale scores
• Item details
• Rationale, explanation, ideal response, actual
  response, score
• Percentiles to compare themselves to other
  facilities
• Nationally
• Within own state
• Of similar size (annual births)

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Limitations

• Some facilities may have been omitted
• Respondent may not have been person most
  knowledgeable about policies practices
• Responses not validated
• No standardized method for scoring subscales
  equally weighted

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Strengths

• First national survey of breastfeeding-related
  maternity care practices
• High response rate, represents practices at all
  types of facilities in the US
• State, regional analyses possible
• Customized benchmark reports to improve maternity
  practices to support breastfeeding

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Conclusions

• Many facilities
• Are not practicing evidence-based maternity care
  that supports breastfeeding
• Routinely, unnecessarily separate mother
  newborn
• Do not provide adequate breastfeeding support
  after discharge

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Conclusions

• Many facilities
• Supplement healthy, term, breastfed infants
  without medical indication
• Distribute formula discharge packs to
  breastfeeding mothers

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Next Steps

• Disseminate state reports
• Examine association of maternity practices and
  breastfeeding rates
• Review survey administration procedures
• Develop recommendations to improve
  breastfeeding-related maternity practices

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Acknowledgments
CDC Ann DiGirolamo Deborah Galuska Laurence
Grummer-Strawn Carol MacGowan Paulette
Murphy Kelley Scanlon Andrea Sharma Katherine
Shealy Battelle Jennifer Cohen Diane Manninen
State Health Departments Ken Rosenberg Laurie
Tiffin Rosanne Smith Hospitals/Health
Professionals Lauren Barone Karin Cadwell Anne
Merewood Carol Melcher Barbara Philipp Molly
Pessl Amy Spangler Cindy Turner-Maffei
Breastfeeding Coalitions Kirsten Berggren Karen
Peters Amelia Psmythe Kim Radtke Universities/Med
. Schools Andrea Crivelli-Kovach Laurie
Feldman-Winter Jane Heinig Celia Quinn
coauthors
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Additional Information

• www.cdc.gov/mpinc
• www.cdc.gov/breastfeeding
• ddee_at_cdc.gov

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Do overall scores differ by facility size or
facility type?
Facility Size ( of annual births)
Facility Type
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24-hour rooming in is not standard practice at
most facilities
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Types of postpartum bf support provided
Percent of facilities reporting each practice
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Elements in Facilities Breastfeeding Policies
Percent of facilities reporting each element
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