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Abstract

Background:

Evidence-based maternity practices advanced by the Baby-Friendly Hospital Initiative (BFHI) are associated with increased human milk feeding and improved maternal and infant health. However, inequitable distribution of BFHI facilities contributes to disparities in access to evidence-based practices. ENRICH Carolinas (ENRICH) provided technical assistance to birthing facilities across North and South Carolina to improve maternity practices by advancing toward BFHI or state-level designation.

Research Aim:

To compare changes in maternity practices for participating and non-participating facilities during the period of the technical assistance initiative using Maternity Practices in Infant Nutrition and Care (mPINC) data.

Method:

We obtained data from the United States Centers for Disease Control and Prevention (CDC) 2018, 2020, and 2022 mPINC surveys of birthing facilities in North and South Carolina (N = 98). The CDC calculates a total mPINC score for each facility to indicate its overall support for optimal infant feeding and subscores for immediate postpartum care, rooming-in, feeding practices, feeding education and support, discharge support, and institutional management. Scores range from 0 to 100, with higher scores indicating better practices. We conducted a longitudinal analysis using linear mixed-effects modeling to assess the association between participation in the ENRICH technical assistance initiative and changes in scores over time.

Results:

Findings show that facilities which participated in the technical assistance initiative had significantly larger increases in total mPINC scores from 2018 to 2022, with an average unadjusted total score 4.8 points higher (95% CI [0.6, 9.2, p = 0.03]) than non-participating facilities, despite scores not being significantly different at baseline. ENRICH facilities made particular progress in rooming-in and institutional management compared with non-ENRICH facilities.

Conclusions:

Facilities participating in a two state systems-level technical assistance initiative provide more optimal care and support for infant feeding practices than non-participating facilities, suggesting this initiative may improve access to evidence-based maternity care.

Keywords

Baby-Friendly Hospital Initiative breastfeeding lactation maternity practices mPINC program evaluation

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References

American College of Obstetricians and Gynecologists (ACOG). (2018). ACOG committee opinion No. 756: Optimizing support for breastfeeding as part of obstetric practice. Obstetrics and Gynecology, 132(4), e187–e196. DOI: 10.1097/AOG.0000000000002890

Ahluwalia

I. B.

Morrow

D’Angelo

(2012). Maternity care practices and breastfeeding experiences of women in different racial and ethnic groups: Pregnancy Risk Assessment and Monitoring System (PRAMS). Maternal and Child Health Journal, 16(8), 1672–1678. https://doi.org/10.1007/s10995-011-0871-0

Allen

J. A.

Perrine

C. G.

Scanlon

K. S.

(2015). Breastfeeding supportive hospital practices in the US differ by county urbanization level. Journal of Human Lactation, 31(3), 440–443. https://doi.org/10.1177/0890334415578440

Anstey

E. H.

Chen

Elam-Evans

L. D.

Perrine

C. G.

(2017). Racial and geographic differences in breastfeeding – United States, 2011–2015. MMWR Morbidity and Mortality Weekly Report, 66(27), 723–727. https://doi.org/10.15585/mmwr.mm6627a3

Araújo

R. G.

Fonseca

V. M.

de Oliveira

M. I. C.

Ramos

E. G.

(2019). External evaluation and self-monitoring of the Baby-friendly Hospital Initiative’s maternity hospitals in Brazil. International Breastfeeding Journal, 14, 1. https://doi.org/10.1186/s13006-018-0195-4

Baby-Friendly USA. (2026). https://www.babyfriendlyusa.org/

Barrera

C. M.

Beauregard

J. L.

Nelson

J. M.

Perrine

C. G.

(2019). Association of maternity care practices and policies with in-hospital exclusive breastfeeding in the United States. Breastfeeding Medicine, 14(4), 243–248. https://doi.org/10.1089/bfm.2018.0196

Bookhart

L. H.

Anstey

E. H.

Kramer

M. R.

Perrine

C. G.

Ramakrishnan

Young

M. F.

(2024). Unpacking breastfeeding disparities: Baby-friendly hospital designation associated with reduced in-hospital exclusive breastfeeding disparity attributed to neighborhood poverty. Maternal and Child Health Journal, 28(8), 1404–1412. https://doi.org/10.1007/s10995-024-03939-x

Centers for Disease Control and Prevention. (2022). Breastfeeding report card. https://www.cdc.gov/breastfeeding-data/media/pdfs/2024/06/CORRECTED_332395-B_2022-Breastfeeding-Report-Card_v12_508c.pdf

10.

Centers for Disease Control and Prevention. (2024a). Breastfeeding among US children born 2014–2021, CDC National Immunization Survey-Child. https://www.cdc.gov/breastfeeding-data/survey/results.html?CDC_AAref_Val=https://www.cdc.gov/breastfeeding/data/nis_data/results.html

11.

Centers for Disease Control and Prevention. (2024b). Maternity Practices in Infant Nutrition and Care (mPINC) Survey. https://www.cdc.gov/breastfeeding-data/mpinc/index.html

12.

Centers for Disease Control and Prevention. (2024c). mPINC National Report. https://www.cdc.gov/breastfeeding-data/mpinc/national-report.html

13.

Centers for Disease Control and Prevention. (2025). mPINC survey scoring. https://www.cdc.gov/breastfeeding-data/mpinc/scoring.html

14.

Duijts

Ramadhani

M. K.

Moll

H. A.

(2009). Breastfeeding protects against infectious diseases during infancy in industrialized countries. A systematic review. Maternal & Child Nutrition, 5(3), 199–210. https://doi.org/10.1111/j.1740-8709.2008.00176.x

15.

ENRICH Carolinas. (2026). https://sph.unc.edu/cgbi/enrich-carolinas/

16.

Feltner

Weber

R. P.

Stuebe

Grodensky

C. A.

Orr

Viswanathan

(2018). Breastfeeding programs and policies, breastfeeding uptake, and maternal health outcomes in developed countries. Agency for Healthcare Research and Quality (US), Rockville (MD), 2018. https://doi.org/10.23970/ahrqepccer210.

17.

Horta

B. L.

de Mola

C. L.

Victora

C. G.

(2015). Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and Type 2 diabetes: A systematic review and meta-analysis. Acta Paediatrica, 104(467), 30–37. https://doi.org/10.1111/apa.13133

18.

Jung

Nobari

T. Z.

Whaley

S. E.

(2019). Breastfeeding outcomes among WIC-participating infants and their relationships to baby-friendly hospital practices. Breastfeeding Medicine, 14(6), 424–431. https://doi.org/10.1089/bfm.2019.0004

19.

Labbok

M. H.

Taylor

E. C.

Nickel

N. C.

(2013). Implementing the ten steps to successful breastfeeding in multiple hospitals serving low-wealth patients in the US: Innovative research design and baseline findings. International Breastfeeding Journal, 8(1), Article 5. https://doi.org/10.1186/1746-4358-8-5

20.

Lynch

Bethel

Chowdhury

Moore

J. B.

(2012). Rural and urban breastfeeding initiation trends in low-income women in North Carolina from 2003 to 2007. Journal of Human Lactation, 28(2), 226–232. https://doi.org/10.1177/0890334411430086

21.

Marks

K. J.

Gosdin

O’Connor

L. E.

Hamner

H. C.

Grossniklaus

D. A.

(2024). Changes in maternity care policies and practices that support breastfeeding as measured by the Ten Steps to Successful Breastfeeding — United States, 2018–2022. BMC Pregnancy and Childbirth, 24(1), Article 475. https://doi.org/10.1186/s12884-024-06672-z

22.

Meek

J. Y.

Noble

, & Section on Breastfeeding. (2022). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 150(1), Article e2022057988. https://doi.org/10.1542/peds.2022-057988

23.

Merewood

Bugg

Burnham

Krane

Nickel

Broom

Edwards

Feldman-Winter

(2019). Addressing racial inequities in breastfeeding in the Southern United States. Pediatrics, 143(2), Article e20181897. https://doi.org/10.1542/peds.2018-1897

24.

Nelson

J. M.

Grossniklaus

D. A.

Galuska

D. A.

Perrine

C. G.

(2021). The mPINC survey: Impacting US maternity care practices. Maternal & Child Nutrition, 17(1), Article e13092. https://doi.org/10.1111/mcn.13092

25.

Nelson

J. M.

Perrine

C. G.

Freedman

D. S.

Williams

Morrow

Smith

R. A.

Dee

D. L.

(2018). Infant feeding-related maternity care practices and maternal report of breastfeeding outcomes. Birth, 45(4), 424–431. https://doi.org/10.1111/birt.12337

26.

Noble

Hand

I. L.

Noble

(2023). The effect of breastfeeding in the first hour and rooming-in of low-income, multi-ethnic mothers on in-hospital, one and three month high breastfeeding intensity. Children (Basel), 10(2), Article 313. https://doi.org/10.3390/children10020313

27.

Patterson

J. A.

Keuler

N. S.

Olson

B. H.

(2018). The effect of Baby-friendly status on exclusive breastfeeding in US hospitals. Maternal & Child Nutrition, 14(3), Article e12589.

28.

Pérez-Escamilla

Martinez

J. L.

Segura-Pérez

(2016). Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: A systematic review. Maternal & Child Nutrition, 12(3), 402–417. https://doi.org/10.1111/mcn.12294

29.

Philipp

B. L.

(2021). Twenty years baby-friendly: Personal reflections on change. Breastfeeding Medicine, 16(10), 769–776. https://doi.org/10.1089/bfm.2020.0374

30.

Shing

J. S.

Lok

K. Y.

Fong

D. Y.

Fan

H. S.

Chow

C. L.

Tarrant

(2022). The influence of the Baby-Friendly Hospital Initiative and maternity care practices on breastfeeding outcomes. Journal of Human Lactation, 38(4), 700–710. https://doi.org/10.1177/08903344221086975

31.

Singh

G. K.

Kogan

M. D.

Dee

D. L.

(2007). Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003. Pediatrics, 119(Suppl. 1), S38–S46. https://doi.org/10.1542/peds.2006-2089G

32.

Sparks

P. J.

(2011). Racial/ethnic differences in breastfeeding duration among WIC-eligible families. Women’s Health Issues, 21(5), 374–382. https://doi.org/10.1016/j.whi.2011.03.002

33.

Spatz

D. L.

(2022). 2020 mPINC scores: Opportunities for improvement. MCN The American Journal of Maternal/Child Nursing, 47(2), Article 109. https://doi.org/10.1097/NMC.0000000000000797

34.

Thoma

M. E.

De Silva

D. A.

Kim

Hodges

Guthrie

(2023). Breastfeeding initiation trends by special supplemental nutrition program for women, infants, and children participation and race/ethnicity among medicaid births. Journal of Nutrition Education and Behavior, 55(3), 170–181. https://doi.org/10.1016/j.jneb.2022.09.006

35.

Victora

C. G.

Bahl

Barros

A. J.

Franca

G. V.

Horton

Krasevec

Murch

Sankar

M. J.

Walker

Rollins

N. C.

, & The Lancet Breastfeeding Series Group. (2016). Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490. https://doi.org/10.1016/S0140-6736(15)01024-7

36.

World Health Organization. (2017). Guideline: Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services. https://www.who.int/publications/i/item/9789241550086

37.

World Health Organization. (2018). Implementation guidance: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services—The Revised Baby-Friendly Hospital Initiative. https://www.who.int/publications/i/item/9789241513807

Moving the Needle on Maternity Practices in Infant Nutrition and Care: Using mPINC Data to Evaluate the Impact of the ENRICH Carolinas Project

Abstract

Background:

Research Aim:

Method:

Results:

Conclusions:

Keywords

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References