mPINC Ten Steps Assessment Tool

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Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions. Have a written infant feeding policy that is routinely communicated to staff and parents. Establish ongoing monitoring and data-management systems*

Hospital Policies
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†
Compliance with the Code: Acquisition of infant formula	Indicates how your hospital acquires infant formula.	Institutional Management	G4_a1	Pays fair market price Not ideal: Receives Free or Unknown/Unsure
Compliance with the Code: Distribution of infant formula or formula-related supplies/ coupons as gifts	Indicates whether your hospital gives mothers any of these items free of charge (not including items prescribed as part of medical care): a) infant formula, b) feeding bottles/nipples, nipple shields, or pacifiers, or c) coupons, discounts, or educational materials from companies that make or sell infant formula or feeding products.	Discharge Support	G5_a1/G5_a2/ G5_a3	No to all three items Not ideal: Yes to any item
Written infant feeding policies	Indicates whether your hospital has a policy requiring… …documentation of medical justification or informed consent for giving non-breast milk feedings to breastfed newborns.	Institutional Management	G2_a1	Yes Not ideal: No
Written infant feeding policies	…formal assessment of staff’s clinical competency in breastfeeding support.	Institutional Management	G2_a2	Yes Not ideal: No
Written infant feeding policies	…documentation of prenatal breastfeeding education.	Institutional Management	G2_a4	Yes Not ideal: No
Written infant feeding policies	…staff to teach mothers breastfeeding techniques AND staff to show mothers how to express milk.	Institutional Management	G2_a5/G2_a6	Yes to both items Not ideal: No to either item
Written infant feeding policie	…purchase of infant formula and related breast milk substitutes by the hospital at fair market value AND a policy prohibiting distribution of free infant formula, infant feeding products, and infant formula coupons.	Institutional Management	G2_a8/G2_a12	Yes to both items Not ideal: No to either item
Written infant feeding policies	…staff to provide mothers with resources for support after discharge.	Institutional Management	G2_a9	Yes Not ideal: No
Written infant feeding policies	…placement of all newborns skin-to-skin with their mother at birth or soon thereafter.	Institutional Management	G2_a7	Yes Not ideal: No
Written infant feeding policies	…the option for mothers to room-in with their newborns.	Institutional Management	G2_a11	Yes Not ideal: No
Monitoring and data-management system	Indicates whether your hospital records/tracks exclusive breastfeeding throughout the entire hospitalization.	Institutional Management	G1	Yes Not ideal: No

Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding*

Staff Competency
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Staff competency to support breastfeeding	Indicates which competency skills are required of nurses: – Placement and monitoring of the newborn skin-to-skin with the mother immediately following birth. – Assisting with effective newborn positioning and latch for breastfeeding. – Assessment of milk transfer during breastfeeding. – Assessment of maternal pain related to breastfeeding. – Teaching hand expression of breast milk. – Teaching safe formula preparation and feeding.	Institutional Management	F4_a1/F4_a2/ F4_a3/F4_a4/ F4_a5/F4_a6	Required for all items Not ideal: Not required for any item
Assessment of staff competency to support breastfeeding	Assesses whether formal assessment of clinical competency in breastfeeding support and lactation management is required of nurses.	Institutional Management	F3	Required at least once per year OR Required less than once per year Not ideal: Not required

Discuss the importance and management of breastfeeding with pregnant women and their families*

Prenatal Care
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Prenatal breastfeeding education^§	Indicates women who deliver at your hospital have the opportunity to receive prenatal breastfeeding education (in either group or individual settings) provided by your hospital and/or a hospital-affiliated clinic or service.^§	Not included in mPINC Hospital Report	A5	Yes Not ideal: No or Not Sure

Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth*

Care Right After Birth
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Immediate skin-to-skin contact after vaginal delivery	After vaginal delivery, percent of newborns who remain in uninterrupted skin-to-skin contact with their mothers immediately after birth… …if breastfeeding, until the first breastfeeding is completed. …if not breastfeeding, for at least one hour.	Immediate Postpartum Care	C1_a1/C1_a2	Most to both items Not ideal: Many, Some, or Few to either item
Immediate skin-to-skin contact after Cesarean-delivery	After Cesarean-delivery, percent of newborns who remain in uninterrupted skin-to-skin contact with their mothers as soon as the mother is responsive and alert after birth… …if breastfeeding, until the first breastfeeding is completed. …if not breastfeeding, for at least one hour.	Immediate Postpartum Care	C2_a1/C2_a2	Most to both items Not ideal: Many, Some, or Few to either item

Support mothers to initiate and maintain breastfeeding and manage common difficulties*

Support Mothers with Breastfeeding
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Practical support to initiate and maintain breastfeeding and manage common breastfeeding problems	Percent of breastfeeding mothers who are taught or shown how to… …position and latch their newborn for breastfeeding. …assess effective breastfeeding by observing their newborn’s latch and the presence of audible swallowing. …assess effective breastfeeding by observing their newborn’s elimination patterns. …hand express breast milk.	Feeding Education	E2_a2/E2_a3/ E2_a4/E2_a6	Most to all items Not ideal: Some, or Few to any item

Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated*

Supplementing
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†
Non-medically indicated supplementation	Percent of healthy, term breastfed newborns who are fed infant formula.	Feeding Practices	D3_a1	<20% Not ideal: ≥20%
Counseling on the importance of exclusive breastfeeding	Frequency that staff counsel breastfeeding mothers who request infant formula about possible health consequences for their infant and the success of breastfeeding.	Feeding Practices	E3	Almost always Not ideal: Often, Sometimes, or Rarely
Instruction of formula feeding techniques and safe preparation, and handling of formula	Among mothers whose newborns are fed any formula, percent of mothers taught……appropriate formula feeding techniques. …how to safely prepare and feed formula.	Feeding Education	E4_a1/E4_a2	Most to both items Not ideal: Many, Some, or Few to either item

Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day*

Rooming-in
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†
Mother-infant separation after birth	Percent of vaginally-delivered newborns separated from their mothers before starting rooming-in.	Immediate Postpartum Care	C3	Few Not ideal: Some, Many, Most, or Not an option
Rooming-in for 24 hours/day	Percent of newborns who stay in the room with their mothers for 24 hours/day (not including separation for medical reasons).	Rooming-in	C4_a1	80%+ Not ideal: <80%
Mother-infant separation while rooming-in	Indicates usual location of newborns during… …pediatric exams/rounds. …hearing screening. …pulse oximetry screening. …routine labs/blood draws/injections. …newborn bath.	Rooming-in	C6_a1/C6_a2/C6_a4/C6_a5/C6_a6	In mother’s room for all situations Not ideal: Not in a mother’s room for any situation
Observation of mother-infant dyads to ensure safety	Indicates whether your hospital has a protocol requiring frequent observations of high-risk mother-infant dyads by nurses to ensure safety of the infant while they are together.	Rooming-in	C7	Yes Not ideal: No

Support mothers to recognize and respond to their infants’ cues for feeding*

Responsive Feeding
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Support recognition and response to infant feeding cues	Percent of breastfeeding mothers who are taught or shown how to… …recognize and respond to their newborn’s feeding cues. …breastfeed as often and as long as their newborn wants.	Feeding Education	E2_a1/E2_a5	Most to both items Not ideal: Many, Some, or Few to either item

Counsel mothers on the use and risks of feeding bottles, teats (nipples), and pacifiers*

Bottles, Nipples, and Pacifiers
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Counseling on the risks of artificial teats (nipples) and pacifiers	Percent of breastfeeding mothers who are taught or shown how to… …understand the use and risks of artificial nipples and pacifiers.	Feeding Education	E2_a7	Most Not ideal: Many, Some or Few

Coordinate discharge so that parents and their infants have timely access to ongoing support and care*

Discharge
Ten Steps Competency¹	mPINC Item	mPINC Domain	mPINC Data Element	Ideal Response^†	Hospital Response	Did the Hospital Select the Ideal Response?
Coordination of discharge to ensure appropriate follow-up care	Indicates whether your hospital’s discharge criteria for breastfeeding newborns requires scheduling of the first follow-up visit with a health care provider.	Discharge Support	E5_a3	Yes Not ideal: No
Coordination of discharge to ensure ongoing breastfeeding support	Indicates whether your hospital’s routine discharge support to breastfeeding mothers includes: a) in-person follow-up visits/appointments for lactation support, b) personalized phone calls to mothers to ask about breastfeeding, or c) formalized, coordinated referrals to lactation providers in the community when additional support is needed.	Discharge Support	E6_a1/E6_a2/ E6_a3	Yes to any item Not ideal: No to all items

Note: This tool does not correspond to or replace Baby-Friendly USA’s on-site assessments or Baby-Friendly designation.

*Although this tool assesses many aspects of each of the Ten Steps, it does not assess every aspect. Every aspect of each Step cannot be assessed using mPINC data alone.

^†Ideal responses are in bold.

^§This item was not scored and therefore not included in mPINC Hospital Reports. Please use your knowledge of hospital practice to answer this question. If you have requested access to mPINC data from CDC, this item corresponds with mPINC Data Element A5.

References

World Health Organization. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: implementing the revised Baby-friendly Hospital Initiative. Geneva: World Health Organization; 2018.

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