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Katherine Shealy, MPH, IBCLC, RLC Deborah Dee, PhD, MPH

CDC National Survey of maternity Care Practices in Infant Nutrition and Care (mPINC): Using State Reports to Inform, Influence, and Monitor Change. Katherine Shealy, MPH, IBCLC, RLC Deborah Dee, PhD, MPH Division of Nutrition, Physical Activity and Obesity

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Katherine Shealy, MPH, IBCLC, RLC Deborah Dee, PhD, MPH

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  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. Outline:I. CDC mPINC Survey backgrounda. Rationale b. Survey development and implementation c. Survey findingsII. Reporting mPINC findingsa. Facility Benchmark Reports b. www.cdc.gov/mpinc c. CDC State Breastfeeding Report Card d. State mPINC ReportsIII. Utilizing the State mPINC Report a. Collaboration across facilities b. Statewide collaborations c. Facility Quality Improvement efforts d. Research opportunitiesIV. Future plansa. Preparing for the 2009 mPINC Survey b. Reporting future mPINC findings

  4. Why target the maternity hospital stay? Public Health Impact In the US, >99% 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) 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. mPINC maternityPractices inInfant Nutrition and Care

  11. What is the point of assessment and monitoring? • Target problematic practices • Monitor progress • 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.

  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 Findings:CDC State Breastfeeding Report Card www.cdc.gov/breastfeeding/data/report_card.htm

  25. 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 State mPINC reports provide each state with a targeted, concise, prioritized, action-oriented summary of their data Planned audience for each state includes:

  26. What is this & who did it? Why change maternity care? Who cares about breastfeeding? What’s going well? What’s not? 1. STATE 2. 3. 4. 5.

  27. What is this? Why change maternity care? Who cares about breastfeeding? 1. STATE OUTLINE STATE 2. 3.

  28. What’s going well? 4.

  29. What’s not? 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. 2&3. Why should we do something? 1. Who did this? 4&5. How does my state measure up? 6. What else did CDC find? 7. What can we do? What’s not?

  35. What else did CDC find? 6.

  36. 7. What can we do?

  37. 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 Central location for mPINC information: www.cdc.gov/mpinc

  38. State Example: MassachusettsRoger Edwards, ScDBouvé College of Health Sciences Northeastern Universityro.edwards@neu.edu

  39. 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. 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, and 3) 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)

  40. 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.

  41. Many hands make light work… 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 Christopher 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 Ass’n) 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 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 Diane Manninen Eileen Miles

  42. Thank you! Katherine Shealy kshealy@cdc.gov Deborah Dee ddee@cdc.gov Roger Edwards ro.edwards@neu.edu www.cdc.gov/breastfeeding www.cdc.gov/mpinc

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