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reastfeeding-Related Maternity Practices at Hospitals and Birth Centers United States, 2007
stfeeding provides optimal nutrition for infants and is ted with decreased risk for infant and maternal morand mortality (1); however, only four states (Alaska, ina, Oregon, and Washington) have met all five (2) y People 2010 targets for breastfeeding (3).* Maternity es in hospitals and birth centers throughout the intraperiod, such as ensuring mother-newborn skin-to-skin t, keeping mother and newborn together, and not givplemental feedings to breastfed newborns unless medindicated, can influence breastfeeding behaviors during d critical to successful establishment of lactation (4-9). 07, to characterize maternity practices related to eeding, CDC conducted the first national Maternity es in Infant Nutrition and Care (mPINC) Survey. This summarizes results of that survey, which indicated that bstantial proportion of facilities used maternity pracat are not evidence-based and are known to interfere eastfeeding and 2) states in the southern United States ly had lower mPINC scores, including certain states usly determined to have the lowest 6-month eeding rates. These results highlight the need for U.S. als and birth centers to implement changes in ity practices that support breastfeeding.
007, in collaboration with Battelle Centers for Public Research and Evaluation, CDC conducted the mPINC to characterize intrapartum practices in hospitals and eding objectives are increases in the proportions of mothers who ed their babies to meet the following targets: 75% in the early postpartum 16-19a), 50% at 6 months (16-19b), 25% at 1 year (16-19c), 40% lusively breastfeed for 3 months (16-19d), and 17% who exclusively ed for 6 months (16-19e). Objectives 16-19d and 16-19e were revised : midcourse review. Additional information is available at ftp://ftp.cdc. /health_statistics/nchs/datasets/data2010/focusarea16/01619d.pdf and .cdc.gov/pub/health_statistics/nchs/datasets/data2010/focusarea16/
birth centers in all states, the District of Columbia, and three U.S. territories. The survey was mailed to 3,143 hospitals and 138 birth centers with registered maternity beds, with the request that the survey be completed by the person most knowledgeable of the facility's infant feeding and maternity practices.
Questions regarding maternity practices were grouped into seven categories that served as subscales in the analyses: 1) labor and delivery, 2) breastfeeding assistance, 3) mother-newborn contact, 4) newborn feeding practices, 5) breastfeeding support after discharge, 6) nurse/birth attendant breastfeeding training and education, and 7) structural and organizational factors related to breastfeeding. The subscales were derived
Labor and delivery mother-newborn skin-to-skin contact and early breastfeeding initiation. Breastfeeding assistance = assessment, recording, and instruction provided on infant feeding; not giving pacifiers to breastfed newborns. Mother-newborn contact = avoidance of separation during postpartum facility stay. Newborn feeding practices = what and how breastfed infants are fed during facility stay. Breastfeeding support after discharge = types of support provided after mothers and babies are discharged. Nurse/birth attendant breastfeeding training and education = quantity of training and education that nurses and birth attendants receive. Structural and organizational factors related to breastfeeding = 1) facility breastfeeding policies and how they are communicated to staff, 2) support for breastfeeding employees, 3) facility not receiving free infant formula, 4) prenatal breastfeeding education, and 5) coordination of lactation care.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
The MMWR series of publications is published by the Coordinating Center for Health Information and Service, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested Citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2008;57:[inclusive page numbers].
Centers for Disease Control and Prevention
Tanja Popovic, MD, PhD
Chief Science Officer
James W. Stephens, PhD Associate Director for Science
Steven L. Solomon, MD
Director, Coordinating Center for Health Information and Service Jay M. Bernhardt, PhD, MPH
Director, National Center for Health Marketing
Katherine L. Daniel, PhD
Deputy Director, National Center for Health Marketing
Editorial and Production Staff
Frederic E. Shaw, MD, JD
Editor, MMWR Series
Teresa F. Rutledge
(Acting) Managing Editor, MMWR Series
Douglas W. Weatherwax
Peter M. Jenkins
(Acting) Lead Visual Information Specialist
Lynda G. Cupell
Malbea A. LaPete
Visual Information Specialists
Quang M. Doan, MBA
Erica R. Shaver
Information Technology Specialists
William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN
David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
Dixie E. Snider, MD, MPH, Atlanta, GA
from literature reviews and consultation with breastfe experts. Researchers assigned scores to facility responses 0-100 scale, with 100 representing a practice most faver toward breastfeeding. Mean scores were calculated for subscale, generally excluding questions that were unansw or answered "not sure" or "not applicable." Mean subso and mean total scores for each state were calculated as average of scores from all facilities in the state; mean t scores were rounded to the nearest whole number. U.S. sco were calculated as the mean scores for all participating fac ties. A subscale score was not calculated if more than haf response data were missing, and mean total scores were calculated if more than half the subscale scores were missin Responses were received from 2,690 (82%) facilities: ho ever, data from three respondent facilities in Guam and U.S. Virgin Islands were excluded from this analysis beca of disclosure concerns, resulting in a sample size of 2,60 facilities (2,546 hospitals and 121 birth centers) in the states, the District of Columbia, and Puerto Rico." T response rate among birth centers (88%) was higher tha among hospitals (82%).
Among states, mean total scores ranged from 48 in Arka sas to 81 in New Hampshire and Vermont (Table 1). a regional variation was evident (Figure). Mean total scores ge erally were higher in the western and northeastern regions the United States and lower in the southern region. Me total scores among facilities did not differ by annual numb of births, but were higher among birth centers (86 out of i compared with hospitals (62) (Table 2).
Among the seven subscales, the highest mean score (8 was for breastfeeding assistance (i.e., assessment, recordin and instruction provided on infant feeding). Within subscale, 99% of facilities had documented the feeding de sions of the majority of mothers in facility records, and s of facilities had taught the majority of mothers techniq related to breastfeeding. However, 65% of facilities ac women to limit the duration of suckling at each breastfeedi and 45% reported giving pacifiers to more than half healthy, full-term breastfed infants, practices that are supportive of breastfeeding (7).
The lowest score (40) was for breastfeeding support discharge. For this subscale, 70% of facilities report providing discharge packs containing infant formula sam to breastfeeding mothers, a practice not supportive breastfeeding (8). Although 95% of facilities reported pr
"Additional information regarding survey questions and scoring is availa http://www.cdc.gov/mpinc.
** In describing the results of this study, the District of Columbia and Rico are referred to as states.
E 1. Mean total and subscale maternity practice scores, by state - Maternity Practices in Infant Nutrition and Care Survey, d States, 2007
um possible mean score is 100. Subscale definitions: Labor and delivery mother-newborn skin-to-skin contact and early breastfeeding initiation. feeding assistance = assessment, recording, and instruction provided on infant feeding; not giving pacifiers to breastfed newborns. Mother-newborn t = avoidance of separation during postpartum facility stay. Newborn feeding practices = what and how breastfed infants are fed during facility stay. feeding support after discharge types of support provided after mothers and babies are discharged. Nurse/birth attendant breastfeeding training lucation = quantity of training and education that nurses and birth attendants receive. Structural and organizational factors related to breastfeeding cility breastfeeding policies and how they are communicated to staff, 2) support for breastfeeding employees, 3) facility not receiving free infant 1, 4) prenatal breastfeeding education, and 5) coordination of lactation care. Additional information regarding survey questions and scoring is le at http://www.cdc.gov/mpinc.
cribing the results of this study, the District of Columbia and Puerto Rico are referred to as states.
als and birth centers.
unded mean of the subscale scores.
* Maximum possible mean score is 100. Additional information regarding survey questions and scoring is available at http://www.cdc.gov/mpinc.
ing a telephone number for mothers to call for breastfeeding consultation after leaving the birth facility, 56% of facilities reported initiating follow-up calls to mothers. Facility-based postpartum follow-up visits were offered by 42% of facilities, and postpartum home visits were reported by 22% of facilities.
For newborn feeding, 24% of facilities reported giving supplements (and not breast milk exclusively) as a general practice with more than half of all healthy, full-term breastfeeding newborns, a practice that is not supportive of breastfeeding (7,10). When asked whether healthy, full-term breastfed infants who receive supplements are given glucose water or water, 30% of facilities reported giving feedings of glucose water and 15% reported giving water, practices that are not supportive of breastfeeding. In addition, 17% of facilities reported they gave something other than breast milk as a first feeding to more than half the healthy, full-term, breastfeeding newborns born in uncomplicated cesarean births. Reported by: AM DiGirolamo, PhD, Rollins School of Public Health, Emory Univ, Atlanta, Georgia. DL Manninen, PhD, JH Cohen, PhD, Battelle Centers for Public Health Research and Evaluation, Seattle, Washington. KR Shealy, MPH, PE Murphy, MLIS, CA MacGowan, MPH, AJ Sharma, PhD, KS Scanlon, PhD, LM Grummer-Strawn, PhD, Div of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion; DL Dee, PhD, EIS Officer, CDC.
Editorial Note: This report summarizes results from 2,687 hospitals and birth centers in the first survey of breastfeedingrelated maternity practices conducted in the United States. These results provide information regarding maternity practices and policies in birthing facilities and can serve as a baseline with which to compare future survey findings. Individual facilities and states can use this information to improve
Maximum possible mean score is 100. Additional information regardin survey questions and scoring is available at http://www.cdc.gov/mpr One birth center and 22 hospitals had missing data that prevented ca lation of at least four subscales; therefore, a mean total score could be calculated.
maternity practices known to influence breastfeeding in the early postpartum period and after discharge.
The findings indicate substantial prevalences of maternit practices that are not evidence-based and are known to inter fere with breastfeeding. For example, 24% of birth faciliti reported supplementing more than half of healthy, full-term breastfed newborns with something other than breast milk during the postpartum stay, a practice shown to be unneces sary and detrimental to breastfeeding (7,10). In addition. 70% of facilities reported giving breastfeeding mothers gift bags com taining infant formula samples. Facilities should consider continuing these practices to provide more positive influenc on both breastfeeding initiation and duration (5,6,8).
The findings demonstrate that birth centers had higher mea total scores, compared with hospitals. Facility size (based annual number of births) was not related to differences scores. Further research is needed to better understand difference in scores for birth centers and hospitals. Previo research has indicated that the more breastfeeding-suppor maternity practices that are in place, the stronger the posit effect on breastfeeding (5,6,9). Comparison of the findings this report with state breastfeeding rates also suggests a co lation between maternity practice scores and prevalence breastfeeding. For example, in the 2006 National Immun tion Survey, seven states (Alabama, Arkansas, Kentucky, Lou siana, Mississippi, Oklahoma, and West Virginia) had lowest percentages (<30%) of children breastfed for 6 mec The same seven states were among those with the lowest me total maternity practice scores (48-58) in mPINC.
The findings in this report are subject to at least one limit tion. Data were reported by one person at each facility at might not be representative of actual maternity practices use. However, CDC sought to prevent inaccuracies by reque
that the survey be completed by the person most knowlable about the facility's maternity practices, in consultawith other knowledgeable persons when necessary. The ey was pretested with key informants in nine facilities ss the country, with follow-up visits to each facility to ate responses. Information from the key informants geny was found to be accurate. Further validation through ent interviews or medical chart reviews has not been lucted.
July 2008, mPINC benchmark reports will be provided ch facility that completed a survey, comparing the facility's cale and total scores with the scores of all other particing facilities, other facilities in the state, and facilities of a ar size nationally. These reports also will provide the ty score for each item comprising the subscales, which help facilities identify specific maternity practices that it be changed to better support breastfeeding. Aggregate will be shared with state health departments to facilitate work with birth facilities to improve breastfeeding care. plans to repeat the mPINC survey periodically to assess ges over time.
e American Academy of Family Physicians, American emy of Pediatrics, and Academy of Breastfeeding icine¶¶ all recommend that physicians provide intraparcare that is supportive of breastfeeding. Hospitals and centers provide care to nearly all women giving birth in United States. Thus, improving maternity practices in these ties affords an opportunity to support establishment and nuation of breastfeeding. Establishing these practices as ards of care in birth facilities throughout the United States mprove progress toward meeting the Healthy People 2010 tfeeding objectives and improve maternal and child health nwide.
Centers for Public Health Research and Evaluation, Seattle, Washington; M Pessl, Evergreen Perinatal Education, Bellevue, Washington; L Feldman-Winter, MD, Univ of Medicine and Dentistry of New Jersey, Newark, New Jersey; and A Spangler, MN, Amy's Babies, Atlanta, Georgia.
1. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2007. Available at http://www.ahrq.gov/downloads/ pub/evidence/pdf/brfout/brfout.pdf.
2. CDC. Breastfeeding trends and updated national health objectives for exclusive breastfeeding-United States, birth years 2000-2004. MMWR 2007;56:760-3.
3. US Department of Health and Human Services. Healthy people 2010 midcourse review. Washington, DC: US Department of Health and Human Services; 2005. Available at http://www.healthypeople.gov/ data/midcourse.
4. United Nations Childrens Fund/World Health Organization. Promoting, protecting, and supporting breastfeeding: the special role of maternity services. Geneva, Switzerland: United Nations Childrens Fund/World Health Organization; 1989.
5. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care practices: implications for breastfeeding. Birth 2001;28:94–100.
6. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase breastfeeding duration: results from a population-based study. Birth 2007;34:202-11.
7. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant feeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607-19.
8. Rosenberg KD, Eastham CA, Kasehagen LJ, Sandoval AP. Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding. Am J Public Health 2008;98:290–5. 9. Chien LY, Tai CJ, Chu KH, Ko YL, Chiu YC. The number of baby friendly hospital practices experienced by mothers is positively associated with breastfeeding: a questionnaire survey. Int J Nurs Stud 2007; 44:1138-46.
10. Swenne I, Ewald U, Gustafsson J, Sandberg E, Ostenson CG. Interrelationship between serum concentrations of glucose, glucagon, and insulin during the first two days of life in healthy newborns. Acta Paediatr 1994;83:915–9.
is report is based, in part, on contributions by E Adams, PhD, on Health & Science Univ, Portland, Oregon; K Rosenberg, Oregon Dept of Human Svcs; A Grinblat, MD, State Univ of York at Buffalo; CL Quinn, MD, Albert Einstein College of cine, Bronx, New York; M Applegate, MD, New York State of Health; K Cadwell, PhD, C Turner-Maffei, MA, Babyily USA, East Sandwich, Massachusetts; A Crivelli-Kovach, Arcadia Univ; E Declercq, PhD, Boston Univ School of Pubalth; A Merewood, MPH, B Philipp, MD, Boston Medical 1, Massachusetts; J Dellaport, RD, L Tiffin, MS, California of Health Svcs; MK Dugan, MA, E Miles, MPH, Battelle
ilable at http://www.aafp.org/online/en/home/policy/policies/h/
ilable at http://aappolicy.aappublications.org/cgi/reprint/pediatrics;115/ 96.pdf.
ilable at http://www.bfmed.org/ace-files/protocol/mhpolicy_abm.pdf.
Escherichia coli 0157:H7 Infections in Children Associated with Raw Milk and Raw Colostrum From Cows
On September 18, 2006, the California Department of Public Health (CDPH) was notified of two children hospitalized with hemolytic uremic syndrome (HUS). One of the patients had culture-confirmed Escherichia coli O157:H7 infection, and both patients had consumed raw (unpasteurized) cow milk in the week before illness onset. Four additional cases of E. coli O157:H7 infection in children who had consumed raw cow milk or raw cow colostrum produced by the same dairy were identified during the following 3 weeks.