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CDC National Survey ofmaternity Care Practices in Infant Nutrition and Care (mPINC):
Using State Reports toInform, Influence, and Monitor Change
Katherine Shealy, MPH, IBCLC, RLCDeborah Dee, PhD, MPHDivision of Nutrition, Physical Activity and ObesityNational Center for Chronic Disease Prevention and
Health PromotionCenters for Disease Control and PreventionAtlanta, GA
DNPAO Teleconference August 13, 2009
ImprovingImprovingHealthy Infant Healthy Infant
Care in Medical Care in Medical SettingsSettings
ImprovingImprovingHealthy Infant Healthy Infant
Care in Medical Care in Medical SettingsSettings
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Outline:I. CDC mPINC Survey background
a. Rationaleb. Survey development and
implementationc. Survey findings
II. Reporting mPINC findingsa. Facility Benchmark Reportsb. www.cdc.gov/mpincc. CDC State Breastfeeding Report
Cardd. State mPINC Reports
III. Utilizing the State mPINC Report
a. Collaboration across facilitiesb. Statewide collaborationsc. Facility Quality Improvement
effortsd. Research opportunities
IV. Future plansa. Preparing for the 2009 mPINC
Surveyb. Reporting future mPINC findings
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Why target the maternity hospital stay?
In the US, >99% of births occur in hospitals:In the US, >99% of births occur in hospitals: Characteristics of care are relatively consistent nationwideCharacteristics of care are relatively consistent nationwide
• Length of stayLength of stay• Delivery of careDelivery of care
The maternity stay is a time when new mothers have abundant The maternity stay is a time when new mothers have abundant access to health professionals.access to health professionals.
The focus is on preventive care:The focus is on preventive care: [in MOST instances] the goal is to maintain existing health of [in MOST instances] the goal is to maintain existing health of
the infant and mother, totally different from other in-patient the infant and mother, totally different from other in-patient hospital populations who are sick hospital populations who are sick
The first days of life are the most ‘sensitive time’ for The first days of life are the most ‘sensitive time’ for establishing breastfeeding.establishing breastfeeding.
Public Health Impact
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Breastfeeding at 8 weeksPercent of mothers (interviewed at 8 wks postpartum about hospital experiences)
(Murray et al., 2007)
Hospital ExperienceNo Yes66 Breastfeeding in the 1st hour 77
65 No supplemented feeding 81
62 Rooming-in 74
69 No pacifiers 78
64Phone number given to
mothers75
Approx mean diff = 12%
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Receiving commercial discharge packs increases likelihood to supplement within 10 weeks by 39%.(Oregon PRAMS)
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30.0%
26.9%
21.5%
13.7%
6.2%
3.2%
15.5%
0 1 2 3 4 5 6
Number of Baby-Friendly steps mothers reported experiencing
Perc
ent of
mot
hers
who
bre
astfed
< 6
wee
ks
The number of supportive strategies that mothers experience predicts risk of breastfeeding cessation.
(DiGirolamo et al., 2008)
Steps measured: Early bf initiation Exclusive breastfeeding
Rooming-in On-demand feedings
No pacifiers Information provided
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Hospital patients expect their medical care to be evidence-based.
Patients expect care decisions to be based Patients expect care decisions to be based on what is necessary and beneficial to their on what is necessary and beneficial to their health.health.
Assumptions: All procedures and practices work towards
improving patient health outcomes Procedures and practices that undermine
patient health outcomes are discouraged and take into account:
• Risk benefit ratio• Extenuating circumstances• Rare exceptions
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However,
Some elements of maternity medical care, including…
…processes, policies, and practices,
…routine practices, traditions, habits,
…design, systems, and expectations…
…can interfere with healthy infant care.
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maternityPractices in Infant Nutrition and Care
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What is the point of assessment and monitoring?
● Monitor progressMonitor progress
● Improve maternity care Improve maternity care practicespractices
● Target problematic Target problematic practicespractices● Provide data for advocacy for Provide data for advocacy for
changechange● Enable performance Enable performance
benchmarkingbenchmarking
● Establish these practices as Establish these practices as standard aspects of perinatal standard aspects of perinatal carecare
● Improve health Improve health outcomes for mothers outcomes for mothers and their babiesand their babies
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What actually happens in maternity care settings?
● How common are positive How common are positive practices?practices?
● How common are negative How common are negative practices?practices?
..
Geographic variations?Geographic variations? Predictors of variations?Predictors of variations?
• Birth censusBirth census• Population servedPopulation served• StaffingStaffing• Others?Others?
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Practices and policies related to the Practices and policies related to the WHO/UNICEF WHO/UNICEF Ten Steps to Successful Ten Steps to Successful BreastfeedingBreastfeeding
Labor and birthing practices such as:Labor and birthing practices such as: Induction & augmentationInduction & augmentation Mode of deliveryMode of delivery
Postpartum care practices such as:Postpartum care practices such as: Infant location for routine proceduresInfant location for routine procedures
mPINC Survey Concepts
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● Biennial national census of facilities Biennial 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’ among Assesses ‘usual practice’ among healthy, term newbornshealthy, term newborns
Methodology
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Methodology52 questions52 questions
36 of the questions were categorized into 36 of the questions were categorized into 7 dimensions of care.7 dimensions of care.
Points were assigned to responses to Points were assigned to responses to every question.every question. Higher points were given for practices Higher points were given for practices
that are supportive of breastfeeding.that are supportive of breastfeeding.
SubscoresSubscores = average of points for each question = average of points for each question in the dimension.in the dimension.
Composite quality practice scoresComposite quality practice scores = average = average of care dimension subscores.of care dimension subscores.
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DC
PR
DC
PR
State Mean Composite Quality Scores State Mean Composite Quality Scores (Quartiles), 2007(Quartiles), 2007
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Composite Mean, 63
59
76 79
70
40
51
66
Labor and
Delivery
Care
Feeding of
Breastfed
Infants
Breastfeeding
Assistance
Mother-
Infant
Contact
Discharge
Care
Staff Training Structural &
Org Aspects
of Care
Typical maternity care in the US includes many types of problematic practices.
Most practices are beyond the control of individual patients.
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Inappropriate practices are common, especially among surgical(cesarean) births.
Percent of facilities agreeing
Vaginal births
Surgical births
Routine care for most mothers does not include skin-to-skin contact with the infant.
33.7% 51.2%
Less than half of breastfeeding patients begin breastfeeding within…
…1 hour
19.7%…2 hours
32%
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87.4%
65.5%
86.6%
66.4%
60.4%
60.3%
18.1%
3.4%
85.8%
Mother out of room
Mother bathing
Heel stick
Hearing test
Infant's bath
Infant photos
Pediatric rounds
Change of shift
Visiting hours
Mothers and babies are separated for many reasons, the cumulative effect may be problematic.
Percent of facilities reporting each practice
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Yes,
88.1%
No, 11.9%
Receiving infant formula free of charge Receiving infant formula free of charge contradicts AMA policy recommendations contradicts AMA policy recommendations and makes it more difficult to adhere to and makes it more difficult to adhere to HACCP plans.HACCP plans.
Yet 88% of facilitiesYet 88% of facilitiesdo it anyway.do it anyway.
Does your facility receive infant formula free of charge?
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Yes,
72.6%
No, 27.4%
Almost three quarters of facilities provide infant
formula samples to breastfeeding mothers.
Are discharge packs containing infant formula provided to breastfeeding mothers?
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Benchmark Reports were mailed individually to specific people at each respondent facility.
This multipurpose document is anThis multipurpose document is anintervention strategyintervention strategy developed to developed to
raise awarenessraise awareness, , provide motivators for changeprovide motivators for change, and , and identify barriers to changeidentify barriers to change that are specific to that are specific to
the facility.the facility.
The report is The report is customized to each respondentcustomized to each respondent and provides detailed survey information.and provides detailed survey information.
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Hospital audience:Hospital audience: CEO/AdministratorCEO/Administrator Director of Quality Director of Quality
ImprovementImprovement Director of ObstetricsDirector of Obstetrics Director of PediatricsDirector of Pediatrics Mother Baby Nurse ManagerMother Baby Nurse Manager Survey RecipientSurvey Recipient
Birth Center Birth Center audience:audience:
Birth Center OwnerBirth Center Owner Medical DirectorMedical Director Head MidwifeHead Midwife Key InformantKey Informant
The target audiences for the Benchmark Reports were very narrowly defined, and content was specifically tailored to meet audience needs.
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Additional Reports of mPINC Findings:CDC State Breastfeeding Report Card
www.cdc.gov/breastfeeding/data/report_card.htm
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● Breastfeeding Coalitions● Perinatal Associations● CDC Funded Obesity
Programs● Health Departments● WIC Agencies● Medicaid Programs● Insurance Commissions
● AAP Chapters● ACOG Chapters● ANA Chapters● AWHONN Chapters● ILCA Affiliates● Hospital Associations
Planned audience for each state includes:
State mPINC reports provide each state with a targeted, concise, prioritized, action-oriented summary of their data
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What is this & who did it?
Why change maternity care?
What’s going well?
What’s not?
Who cares about breastfeeding?
1.
2.
3.
4.
5.
STATE
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What is this?
Why change maternity care?
Who cares about breastfeeding?
1.
2.
3.
STATE OUTLINESTATE
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What’s going well?4.
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What’s not?5.
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92.5% of facilities include breastfeeding education as a routine element of their prenatal classes.
98.5% of facilities consistently ask about and record mothers’ infant feeding decisions.
Some positive policy elements are already widespread in most facilities.
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No
62%
Yes
38%
Are mother and baby usually skin-to-skin while staff are completing routine newborn procedures?
NB: Routine newborn procedures include Apgar, foot printing, ID banding, etc.
Almost 2/3 of facilities unnecessarily separate mothers and infants within the first 30 minutes of life.
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31.2%
21.4%
54.9%
40.9%
54.7%
71.3%
90.9%
27.0%
79.3%
51.5%
93.8%
Return clinic visit
Home visit
Telephone call
Center support group
Referral to support group
LC referral
WIC referral
Outpatient clinic referral
Phone # given
List of resources
Bfeeding assessment sheet
The most effective discharge care is also the rarest.
Percent of facilities reporting each practice
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94.4%
75.6%
40.7%
56.5%
New staff receive <18
hours of breastfeeding
training
Existing staff receive <5
hours of breastfeeding
training
Few/some staff received
any breastfeeding
education in last year
Staff competencies
assessed less than annually
Staff breastfeeding training and competency assessment is inadequate, especially for new staff.
Percent of facilities reporting each practice
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What’s not?
2&3. Why should we do something?
7. What can we do?
1. Who did this?
6. What else did CDC find?
4&5. How does my state measure up?
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What else did CDC find?
6.
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7. What can we
do?
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MethodologyMethodology
General and Detailed Results TablesGeneral and Detailed Results Tables
Downloadable filesDownloadable files● Survey instruments (hospital and birth center Survey instruments (hospital and birth center
versions)versions)● Sample Benchmark ReportSample Benchmark Report● Information sheets on:Information sheets on:
Maternity care practices and breastfeedingMaternity care practices and breastfeeding General mPINC informationGeneral mPINC information mPINC dimensions of caremPINC dimensions of care Benchmark ReportsBenchmark Reports
Central location for mPINC information: www.cdc.gov/mpinc
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State Example: Massachusetts
Roger Edwards, ScDBouvé College of Health Sciences Northeastern
The project was designed to ensure a safe and healthy beginning for all newborns by testing measures, strategies, and tools based on the key aspects of the revised AAP hyperbilirubinemia guideline, including
1) the assessment of a newborn’s risk for severe hyperbilirubinemia,
2) support for breastfeeding mothers, and3) coordination of care between the newborn
nursery and primary care practice—the newborn’s medical home.As a result of this project, these tested tools are now available for widespread use. (http://www.aap.org/qualityimprovement/quiin/SHB.html)
Safe and Healthy Beginnings is a pilot project of the AAP Quality Improvement Innovation Network through a partnership with the Center for Health Care Quality at Cincinnati Children’s Hospital Medical Center.
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Standard healthy infant nutrition and care ensures all mothers and babies receive care that…
Ultimate Goal:
…utilizes best practices and…is free of policies, practices, and environmental influences that undermine maternal and child health and wellbeing.
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Many hands make light work…CDCCDC
Romeo ChristianRomeo ChristianDeborah DeeDeborah DeeRon ErgleRon ErgleLarry Grummer-Larry Grummer-StrawnStrawnRenita MacalusoRenita MacalusoCarol MacGowanCarol MacGowanPaulette MurphyPaulette MurphyRon NuseRon NuseKelley ScanlonKelley ScanlonAndrea SharmaAndrea SharmaKatherine ShealyKatherine ShealyThelma SimsThelma SimsJoanna StettnerJoanna StettnerGuijing WangGuijing Wang
BattelleBattelleJennifer CohenJennifer CohenMary Kay DuganMary Kay DuganDiane ManninenDiane ManninenEileen MilesEileen Miles
State Health DepartmentsState Health Departments
Mary Applegate (NY)Mary Applegate (NY)
Tina Cardarelli (IN)Tina Cardarelli (IN)
Jennifer Dellaport (CO)Jennifer Dellaport (CO)
Ken Rosenberg (OR)Ken Rosenberg (OR)
Laurie Tiffin (CA)Laurie Tiffin (CA)
Rosanne Smith (VA)Rosanne Smith (VA)
Sara Bonam Welge (NY)Sara Bonam Welge (NY)
Professional AssociationsProfessional AssociationsLauren Barone (AAP)Lauren Barone (AAP)Edward Newton (ACOG)Edward Newton (ACOG)Cinny Kittle (WV Hospital Cinny Kittle (WV Hospital Ass’n)Ass’n)Patricia Underwood (ANA)Patricia Underwood (ANA)Robert Wiskind (AAP)Robert Wiskind (AAP)
Universities/Med. SchoolsUniversities/Med. SchoolsElizabeth AdamsElizabeth AdamsAndrea Crivelli-KovachAndrea Crivelli-KovachAnn DiGirolamoAnn DiGirolamoRoger EdwardsRoger EdwardsLaurie Feldman-WinterLaurie Feldman-WinterAlla GrindblatAlla GrindblatJane HeinigJane HeinigCelia QuinnCelia Quinn
Breastfeeding Breastfeeding CoalitionsCoalitionsKirsten BerggrenKirsten BerggrenRachel ColchamiroRachel ColchamiroSarah GrosshueschSarah GrosshueschBecky MannelBecky MannelKaren PetersKaren PetersAmelia PsmytheAmelia PsmytheKim RadtkeKim RadtkeMegan RennerMegan Renner
Hospital PracticesHospital PracticesKarin Cadwell Karin Cadwell Debbi Heffern Debbi Heffern Michael LetteraMichael LetteraElaine LockeElaine LockeAnne MerewoodAnne MerewoodCarol MelcherCarol MelcherBarbara PhilippBarbara PhilippMolly PesslMolly PesslAmy SpanglerAmy SpanglerCindy Turner-MaffeiCindy Turner-MaffeiChristopher WadeChristopher Wade
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Thank you!
Katherine Shealy [email protected]
Deborah Dee [email protected]
Roger Edwards [email protected]
www.cdc.gov/breastfeeding
www.cdc.gov/mpinc