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To determine whether an association exists between early postpartum discharge of newborn infants and feeding related hospital readmission during the first 28 days of life.
Population based, nested case control study, with record linkage of computerised birth certificate data, statewide hospital discharge data, and data on neonatal feeding from the Wisconsin Newborn Screening Program.
State of Wisconsin, USA.
210 case patients (newborn infants readmitted to hospital with feeding related problems at age 4–28 d) and 630 unmatched control infants (no feeding related admissions) were identified from a cohort of 120 290 singleton newborn infants who were delivered vaginally between 1 January 1991 and 31 October 1994, with birth weights ≥2500 g, continuous hospital stays until discharge, receipt of normal newborn care, and postpartum discharge records that could be linked to birth certificate data. Exclusion criteria were congenital anomalies, abnormal postpartum conditions, hospital transfer of mother before delivery, complications during pregnancy, labour or delivery, or postpartum maternal sterilisation.
Assessment of risk factors
Early discharge was defined as discharge from the birth hospital on the day of birth (day 1) or the next day (day 2). Conventional discharge was defined as discharge on day 3.
Main outcome measure
Feeding related hospital readmission at age 4–28 days, defined as direct admission of a newborn infant (who had been previously discharged from the birth hospital to home) with ≥1 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis code indicating a feeding problem, dehydration, or inadequate weight gain, and no ICD-9-CM code indicating a specific aetiology or disease process to which the above problems could be attributed.
255 newborn infants (31%) were discharged early from hospital. Of those infants readmitted for feeding related problems (case patients), 69 (33%) had been discharged early (day 1 or 2) compared with 186 (30%) infants in the control group. Feeding related readmission was not associated with early discharge (odds ratio [OR] 1.05, 95% CI 0.71 to 1.53, adjusted for sex, birth weight, preterm delivery, type of feeding, medical assistance, health maintenance organisation, maternal age, race/ethnicity, education, marital status, parity, first trimester care, place of residence, and year of delivery). Feeding related hospital readmission was independently associated with breast feeding (OR 2.6), preterm delivery (OR 2.3), primiparity (OR 1.8), low maternal education (OR 1.7), and Medicaid insurance (OR 1.7) (all p<0.05).
Early discharge of newborn infants from the birth hospital on the day of birth, or the day after birth, was not associated with increased feeding related hospital readmissions during the first 28 days.
Postpartum hospital stays have decreased dramatically over the past few decades to the present 12–48 hours for vaginal births and 4 days for caesarean births. Although initiated in response to consumer demands to “demedicalise” childbirth, this trend has continued and has intensified in response to pressures of cost containment.
Numerous studies have explored the safety of early postpartum discharge. Critical reviews of the literature have failed to reveal the optimum length of postpartum stay because of serious methodological flaws in the primary research including variable definitions of early discharge; small sample sizes with limited power; inadequate study designs lacking randomisation or appropriate control or comparison groups; limited generalisability because of selection bias, different inclusion criteria, and a variety of interventions before and after discharge; and diverse outcomes.1, 2
The studies by Liu et al and Edmonson et al explore the question of safety, while addressing the limitations of previous studies. Both studies are well designed and use similar methods, data sources, and time periods. They are population based, with case control designs and large sample sizes, enabling broad generalisability and increased power to draw meaningful conclusions. There initially appears to be a discrepancy in their results, but on further review this is because Liu et al looked at readmissions in general, whereas Edmonson et al looked only at feeding related readmissions, thus having a smaller sample size and lacking the statistical power to detect differences of the same magnitude. The 1 limitation associated with both studies is that no information is provided on predischarge or postdischarge practices, both of which can contribute to the safety of early discharge.
The results of these studies are important for postpartum nurses working in hospital and in the community. There are implications for clinical practice, education, research advocacy, and policy development.
Although most newborn babies remained healthy, there was an increased risk of readmission with early discharge in certain subgroups. This finding reinforces the need for nurses to carefully assess mothers and newborn babies before discharge. Screening criteria should be used to identify populations at increased risk and to assess readiness for discharge by considering biological, developmental, and psychosocial factors. Discharge decisions should not focus solely on timing but on readiness, which is individually determined.
Neither of the 2 studies gave information on services provided after discharge. Because early discharge was associated with increased risk of readmission for certain conditions, nurses need to provide close individual follow up within the first days of life. This would enable early identification of problems and subsequent intervention as well as promotion of child and family health and wellbeing. A range of comprehensive, flexible, and responsive postpartum discharge services which focus on neonatal and maternal assessment, breast feeding promotion, and teaching of infant care are needed. Given the current underfunding of community based postpartum discharge services, nurses must advocate for policy development and provision of funding for this range of options that ensures assessment and intervention at reasonable time intervals. Research will show whether the type, timing, intensity, and location of postpartum discharge follow up services are more crucial than the timing of hospital discharge.
Early postpartum discharge requires collaboration across sectors (hospitals, primary care, public health, and other community based programmes) and among providers (nurses, physicians, midwives, and other healthcare providers). Nurses can take a leadership role in collaborative planning and partnership building to create a “seamless” system of care and support for new mothers and their babies.
Nurses also have an important part to play in data collection and continuing research in this area. They can advocate for, and participate in, rigorous studies of sufficient size which examine the effect of different hospital stays and postdischarge practices on a range of outcomes for mothers and babies in diverse populations and settings. Only then can we inform practice, policy, and funding decisions.
Source of funding: not stated.
For article reprint: Dr M B Edmonson, Department of Pediatrics, H6/440 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792–4116, USA. Fax +1 608 263 0440.
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