Impact of Short Hospital Stays on the Health and Survival of Newborns

Postpartum hospital stays for mothers and their newborns in the US declined dramatically from an average of 4 days in 1970 to 2 days in 1993, and then to 1 day or less by 1995.

Concerns about the impact of short hospital stays and so called "drive-through deliveries" on infants' health prompted the US Congress and most State legislatures to mandate that insurers cover minimum 48-hour hospital stays following vaginal deliveries and 96-hour stays following cesareans. The goal is to detect and treat infection, congenital heart disease, jaundice, and other problems that may show up in the first day or two after birth. Also, national guidelines call for a follow up visit on the 3rd or 4th postpartum day for infants discharged within 48 hours of birth.

A new study reported in the August 2000 issue of the journal Obstetrics and Gynecology (Vol.96 pp. 183-188) confirms the potentially adverse impact of early postpartum discharge. This is the first study to establish a significant association between early postpartum discharge and newborn death, especially due to delayed diagnosis of curable, life-threatening conditions such as congenital cardiac malformations and sepsis. It found that infants discharged home within 30 hours of birth were nearly four times more likely to die within 28 days of birth, and nearly twice as apt to die during the first year of life than newborns sent home later.

Newborns discharged early also were more likely to die of heart-related problems, infection, or other causes such as sudden infant death syndrome within a year of birth than newborns discharged later. Adjustment for clinical factors such as Apgar score, respiratory problems, seizures, assisted ventilation, and trauma had little impact on these findings.

Congenital heart malformations and infections can sometimes be cured if they are detected and treated quickly, explain the researchers, J.D. Malkin and colleagues. They analyzed data from Washington State and linked birth certificates, death certificates, and hospital discharge records of 47,879 live births in 1989 and 1990. The researchers compared the risk of death within the first year of life for infants discharged less than 30 hours after birth with the risk for infants discharged 30 to 78 hours after birth.

Another recent study by T.A. Lieu and colleagues (in the May 2000 issue of the journal Pediatrics Vol.105, pp.1058-1065) demonstrates that home visits on the 3rd or 4th postpartum day are more costly than pediatric clinic visits but have comparable infant outcomes and much higher maternal satisfaction.

Postpartum visits at 3 or 4 days after birth for newborns discharged within 48 hours are recommended to detect jaundice (hyperbilirubinemia), dehydration, and feeding problems, which are the leading causes of infant problems during the early postnatal period.

Although more costly than pediatric clinic visits (average of $255 vs. $120), home visits to low-risk mothers and their newborns result in equivalent outcomes for the infants and much greater satisfaction for the mothers, conclude these researchers. They randomly assigned 1,163 medically and socially low-risk mother-newborn pairs at Kaiser Foundation Hospital in Sacramento to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the 3rd or 4th postpartum day.

In contrast to the 20-minute clinic visits, the home visits were longer (median of 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother. There were no significant differences in clinical outcomes between the groups, such as maternal or newborn rehospitalization or urgent clinic visits within 10 days postpartum, breastfeeding discontinuation, or maternal depressive symptoms at the 2-week interview.

However, mothers were much more satisfied with the home visits. Home-visit versus clinic-visit mothers rated as excellent or very good the preventive advice delivered (80 vs. 44%), the provider's skills and abilities (87 vs. 63%), the newborn's posthospital care (87 vs. 59%), and their own posthospital care (75 vs. 47%). These findings suggest that either type of followup is clinically acceptable among medically and socially low-risk patients with good access to care. However, the results cannot be generalized to more socioeconomically disadvantaged or otherwise at-risk groups.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.