CDC National Survey of maternity Care Practices in Infant Nutrition and Care (mPINC): Using State Reports to Inform, Influence, and Monitor Change

1
CDC National Survey ofmaternity Care Practices
in Infant Nutrition and Care (mPINC)Using
State Reports toInform, Influence, and Monitor
Change
Katherine Shealy, MPH, IBCLC, RLC 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 Atlanta,
GA DNPAO Teleconference August
13, 2009
2
Improving Healthy Infant Care in Medical Settings
3
OutlineI. CDC mPINC Survey background a.
Rationale b. Survey development and
implementation c. Survey findingsII.
Reporting mPINC findings a. Facility Benchmark
Reports b. www.cdc.gov/mpinc c. CDC State
Breastfeeding Report Card d. State mPINC
Reports III. Utilizing the State mPINC
Report a. Collaboration across facilities b.
Statewide collaborations c. Facility Quality
Improvement efforts d. Research opportunities
IV. Future plans a. Preparing for the 2009
mPINC Survey b. Reporting future mPINC findings
4
Why target the maternity hospital stay?
Public Health Impact

• In the US, gt99 of births occur in hospitals
• Characteristics of care are relatively consistent
  nationwide
• Length of stay
• Delivery of care
• The maternity stay is a time when new mothers
  have abundant access to health professionals.
• The focus is on preventive care
• in MOST instances the goal is to maintain
  existing health of the infant and mother, totally
  different from other in-patient hospital
  populations who are sick
• The first days of life are the most sensitive
  time for establishing breastfeeding.

5

• Breastfeeding at 8 weeks
• Percent of mothers (interviewed at 8 wks
  postpartum about hospital experiences)
• (Murray et al., 2007)

Hospital Experience
No Hospital Experience Yes
66 Breastfeeding in the 1st hour 77
65 No supplemented feeding 81
62 Rooming-in 74
69 No pacifiers 78
64 Phone number given to mothers 75
Approx mean diff 12
6
Receiving commercial discharge packs increases
likelihood to supplement within 10 weeks by
39. (Oregon PRAMS)
7
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

8
Hospital patients expect their medical care to be
evidence-based.

• Patients expect care decisions to be based on
  what is necessary and beneficial to their 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

9
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.
10
maternityPractices in Infant Nutrition and Care
11
What is the point of assessment and monitoring?

• Monitor progress

• Target problematic practices

• Provide data for advocacy for change

• Enable performance benchmarking

• Improve maternity care practices

• Establish these practices as standard aspects of
  perinatal care

• Improve health outcomes for mothers and their
  babies

12
What actually happens in maternity care settings?

• How common are positive practices?
• How common are negative practices?
• .
• Geographic variations?
• Predictors of variations?
• Birth census
• Population served
• Staffing
• Others?

13
mPINC Survey Concepts

• Practices and policies related to the WHO/UNICEF
  Ten Steps to Successful Breastfeeding
• Labor and birthing practices such as
• Induction augmentation
• Mode of delivery
• Postpartum care practices such as
• Infant location for routine procedures

14
Methodology

• Biennial national census of facilities routinely
  providing maternity services
• Private hospitals
• Public hospitals
• Free-standing birth centers
• Single key informant
• Assesses usual practice among
• healthy, term newborns

15
Methodology

• 52 questions
• 36 of the questions were categorized into 7
  dimensions of care.
• Points were assigned to responses to every
  question.
• Higher points were given for practices that are
  supportive of breastfeeding.

Subscores average of points for each question
in the dimension. Composite quality practice
scores average of care dimension subscores.
16
State Mean Composite Quality Scores (Quartiles),
2007
DC PR
DC PR
17
Typical maternity care in the US includes many
types of problematic practices.Most practices
are beyond the control of individual patients.
18
Inappropriate practices are common, especially
among surgical(cesarean) births.
Percent of facilities agreeing 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
19
Mothers and babies are separated for many
reasons, the cumulative effect may be
problematic.
Percent of facilities reporting each practice
20
Receiving infant formula free of charge
contradicts AMA policy recommendations and makes
it more difficult to adhere to HACCP plans.Yet
88 of facilitiesdo it anyway.
Does your facility receive infant formula free of
charge?
21
Almost three quarters of facilities provide
infant formula samples to breastfeeding mothers.
Are discharge packs containing infant formula
provided to breastfeeding mothers?
22
Benchmark Reports were mailed individually to
specific people at each respondent facility.

• This multipurpose document is an
• intervention strategy developed to
• raise awareness,
• provide motivators for change, and
• identify barriers to change that are specific to
  the facility.
• The report is customized to each respondent and
  provides detailed survey information.

23
The target audiences for the Benchmark Reports
were very narrowly defined, and content was
specifically tailored to meet audience needs.

• Hospital audience
• CEO/Administrator
• Director of Quality Improvement
• Director of Obstetrics
• Director of Pediatrics
• Mother Baby Nurse Manager
• Survey Recipient

• Birth Center audience
• Birth Center Owner
• Medical Director
• Head Midwife
• Key Informant

24
Additional Reports of mPINC FindingsCDC State
Breastfeeding Report Card
www.cdc.gov/breastfeeding/data/report_card.htm
25
State mPINC reports provide each state with a
targeted, concise, prioritized, action-oriented
summary of their data
Planned audience for each state includes

• 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

26
1.
STATE
2.
3.
4.
5.
27
1.
STATE OUTLINE
STATE
2.
3.
28
4.
29
5.
30
Some positive policy elements are already
widespread in most facilities.
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.
31
Almost 2/3 of facilities unnecessarily separate
mothers and infants within the first 30 minutes
of life.
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.
32
The most effective discharge care is also the
rarest.
Percent of facilities reporting each practice
33
Staff breastfeeding training and competency
assessment is inadequate, especially for new
staff.
Percent of facilities reporting each practice
34
(No Transcript)
35
6.
36
7. What can we do?
37
Central location for mPINC information
www.cdc.gov/mpinc

• Methodology
• General and Detailed Results Tables

• Downloadable files
• Survey instruments (hospital and birth center
  versions)
• Sample Benchmark Report
• Information sheets on
• Maternity care practices and breastfeeding
• General mPINC information
• mPINC dimensions of care
• Benchmark Reports

38
State Example MassachusettsRoger Edwards,
ScDBouvé College of Health Sciences Northeastern
Universityro.edwards_at_neu.edu
39
(No Transcript)
40
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 Childrens Hospital
Medical Center.
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
newborns risk for severe hyperbilirubinemia, 2)
support for breastfeeding mothers, and 3)
coordination of care between the newborn nursery
and primary care practicethe newborns medical
home. As a result of this project, these tested
tools are now available for widespread use.
(http//www.aap.org/qualityimprovement/quiin/SHB.h
tml)
41
Standard healthy infant nutrition and care
ensures all mothers and babies receive care that

• Ultimate Goal

utilizes best practices andis free of
policies, practices, and environmental influences
that undermine maternal and child health and
wellbeing.
42
Many hands make light work

• CDC
• Romeo Christian
• Deborah Dee
• Ron Ergle
• Larry Grummer-Strawn
• Renita Macaluso
• Carol MacGowan
• Paulette Murphy
• Ron Nuse
• Kelley Scanlon
• Andrea Sharma
• Katherine Shealy
• Thelma Sims
• Joanna Stettner
• Guijing Wang
• Battelle
• Jennifer Cohen
• Mary Kay Dugan

Breastfeeding Coalitions Kirsten
Berggren Rachel Colchamiro Sarah
Grosshuesch Becky Mannel Karen Peters Amelia
Psmythe Kim Radtke Megan Renner Hospital
Practices Karin Cadwell Debbi Heffern
Michael Lettera Elaine Locke Anne
Merewood Carol Melcher Barbara Philipp Molly
Pessl Amy Spangler Cindy Turner-Maffei Christop
her Wade
State Health Departments Mary Applegate
(NY) Tina Cardarelli (IN) Jennifer Dellaport
(CO) Ken Rosenberg (OR) Laurie Tiffin
(CA) Rosanne Smith (VA) Sara Bonam Welge
(NY) Professional Associations Lauren Barone
(AAP) Edward Newton (ACOG) Cinny Kittle (WV
Hospital Assn) Patricia Underwood (ANA) Robert
Wiskind (AAP) Universities/Med.
Schools Elizabeth Adams Andrea
Crivelli-Kovach Ann DiGirolamo Roger
Edwards Laurie Feldman-Winter Alla
Grindblat Jane Heinig Celia Quinn
43
Thank you!

• Katherine Shealy kshealy_at_cdc.gov
• Deborah Dee ddee_at_cdc.gov
• Roger Edwards ro.edwards_at_neu.edu
• www.cdc.gov/breastfeeding
• www.cdc.gov/mpinc