August, 2016 - SUPPORT Summary of a systematic review | print this article |

What are the effects of early postnatal discharge from hospital on healthy mothers and term infants?

The duration of postnatal hospital stays has declined dramatically over the last thirty years and whether spending less time in hospital is harmful or beneficial remains a controversial concern. In practice, what constitutes an ‘early discharge from hospital’ varies across different countries and according to standard patterns of care.

 

Key messages:

  • Early discharge may lead to little or no difference in the number of infant or maternal re-admissions.  

-Higher levels of postnatal support may influence this outcome.

  • Early discharge may lead to little or no difference in breastfeeding rates at two months.
  • The effect of early discharge on the cost of care is uncertain.  

-Although the costs of hospitalisation are probably lower in the early discharge group, the postnatal costs associated with early postnatal discharge from hospital and total costs are uncertain.  

  • All the included studies were conducted in high-income countries.

-The effects in low-income countries might be different because of differences in the availability of practical support for mothers who are discharged early, the availability of postnatal support in the community, and the quality of care in hospitals or other facilities.

Background

The length of postnatal hospital stays has continued to decline in a number of countries despite lack of clear evidence of its safety and effectiveness. Studies have reported patients being discharged from hospitals after 12 to 72 hours. Possible adverse outcomes of early postnatal discharge include delays in detecting and treating infant and maternal morbidity and a greater occurrence of breastfeeding problems. Possible advantages include a decrease in mother and infant exposure to nosocomial infections and enhanced maternal confidence in caring for the baby in the home environment.

This summary is based on a review published in 2002 (with updated searches in 2008) on the effects of early postnatal discharge from hospital for healthy mothers and term infants.



About the systematic review underlying this summary

Review objectivesAssess the safety, impact and effectiveness of a policy of early discharge for healthy mothers and term infants, with respect to the health and well-being of mothers and babies.
Type of What the review authors searched for What the review authors found

Study designs & interventions

Randomised trials that evaluate a policy of early postnatal discharge from hospital for healthy mothers and infants born at term.

10 trials of early discharge were included in the review. Early discharge defined as a discharge after <48 hours (5 studies), <60 hours (1), and after periods ranging from 12 to 72 hours (4).

Participants

Women who give birth in a hospital to a healthy infant that weighs at least 2,500 grams at term (37 to 42 weeks) and are deemed eligible for ‘early discharge’.

Women were recruited after the birth (4 studies) or during pregnancy (6 studies).

Settings

Hospital based.

Studies were undertaken in USA (3 studies), Canada (3), UK (1), Spain (1), Sweden (1) and Switzerland (1).

Outcomes

Infant or maternal readmissions (and duration of the later), maternal emotional well-being, breastfeeding problems, satisfaction and costs of care.

Infant readmissions (8 studies), maternal readmissions (8), maternal emotional well-being (5), breastfeeding problems (8), satisfaction with care (4), and costs of care (4).

Date of most recent search: December 2008.

Limitations: This is a well-conducted systematic review with only minor limitations.

Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews. 2002, Issue 3.

 

Summary of findings

Ten trials of early discharge from hospital were included in the review. All the studies were conducted in high-income countries.

 In some studies, co-interventions were administered, such as antenatal home visits (2 studies), postnatal home visits (6), postnatal home visits and phone calls (4), and a ‘preparation for discharge’ class (1).

Early discharge from hospital versus standard discharge:

  • Early discharge from hospital may lead to little or no difference in the number of infant readmissions in the first 8 weeks. The certainty of this evidence is low.
  • Early discharge from hospital may lead to little or no difference in the number of maternal readmissions within 3 to 6 weeks postpartum. The certainty of this evidence is low.
  • Early discharge from hospital may lead to little or no difference in breastfeeding rates at two months. The certainty of this evidence is low.
  • Early discharge from hospital may lead to little or no difference in the incidence of maternal depression one month after birth. The certainty of this evidence is low.
  • Early discharge from hospital may lead to little or no difference in women´s satisfaction with care. The certainty of this evidence is low.
  • It is uncertain whether early discharge from hospital affects the total cost of care including readmission.

Does early discharge affect neonatal or maternal health in healthy mothers and term infants?

People: Healthy postpartum mothers and term infants
Settings
:  Hospital based
Intervention
: Early discharge
Comparison
: Standard discharge
Outcomes Impacts Relative effect (95% CI)
Number of participants (Studies) Certainty of the evidence
(GRADE)
Comments
Standard dis-charge
Early discharge
Proportion of infants readmitted within eight weeks Follow-up: Mean 8 weeks
18 per 1,000
24 per 1,000 (11 to 51)
RR 1.29 (0.6 to 2.79) 3,435 (7 studies) Low In one study, the majority of readmission visits during this period were for routine care or bilirubin monitoring.
Proportion of women readmitted within 6 weeks Follow-up: Mean 6 weeks 14 per 1,000 15 per 1,000 (7 to 33) RR 1.1 (0.51 to 2.4) 3,509 (8 studies) Low None of the studies reported data on the duration of maternal readmissions or on the total duration of the hospitalisation of mothers in the first six weeks after the birth.
Proportion of women not breastfeeding in first 8 weeks postpartum 440 per 1,000 >396 per 1,000 (334 to 466) RR 0.9 (0.76 to 1.06) 3,845 (8 studies) Low  
Proportion of women probably depressed Follow-up: Range 4 to 6 weeks post-partum 68 per 1000 45 per 1000 (26 to 76) RR 0.66 (0.39 to 1.12) 993 (3 studies) Low  
Proportion of women dissatisfied with postnatal care 363 per 1000 218 per 1000 (131 to 363) RR 0.60 (0.36 to 1.00) 841 (3 studies) Low  
Total cost of care Two studies reported outcomes on the cost of care. In both of these trials, the cost of hospitalisation was lower in the early discharge group. In one trial, the combined costs of community care and maternal and neonatal readmissions were higher in the early discharge group. In the other one, the combined costs were higher in the standard care group.
CI: Confidence Interval RR: Risk Ratio GRADE: GRADE Working Group grades of evidence (see above and last page)
24 per 1,000
(11 to 51)

Relevance of the review for low-income countries

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All the included studies were conducted in high-income countries.

 The effects in low-income countries might be different because of differences in the availability of practical support for mothers who are discharged early, the availability of postnatal support in the community, and the quality of care in hospitals or other facilities.
 Policies that promote shorter hospital stays may not always be implemented. In some of the studies, accompanying primary care support was provided in the days following discharge, but this may not always be done in practice. It remains unclear how important home midwifery or nursing support is to the safety and acceptability of early discharge programmes.
  • The effects in low-income countries might be different because of differences in the availability of practical support for mothers who are discharged early, the availability of postnatal support in the comunity, in the quality of care in hospitals or other facilities.
  • Policies that promote shorter hospital stays may not always be implemented. In some of the studies, accompanying primary care support was provided in the days following discharge, but this may not always be done in practice. It remains unclear how important home midwifery or nursing support is to the safety and acceptability of early discharge programmes.
EQUITY

The systematic review did not address equity issues.

  • Policies promoting early discharge from hospitals should also specify that some degree of accompanying home midwifery or nursing support should be provided. The infrastructural support for this type of care, however, may be less common in disadvantaged populations. Policies supporting early discharge from hospital may lead to inequity if they are implemented without the necessary support.
ECONOMIC CONSIDERATIONS

It is uncertain whether the intervention affects the costs of care. Cost data (when provided) were difficult to compare as different methods were used and different costs measured.

  • The evaluation of an early discharge policy needs to consider factors such as hospital costs, primary care support for women and infants following discharge from hospital (including midwife home visits, telephone follow-up, and other contacts with health professionals), and the costs incurred by women and their families for the practical support needed in the days immediately following a birth. Although hospitalisation costs appeared to be lower in the early discharge group, it is unclear how the postnatal associated interventions costs affected the total costs.
MONITORING & EVALUATION

Although early postnatal discharge appeared not to have adverse effects, the certainty of the evidence is low and none of the included studies were conducted in low-income countries.

  • The effects of changes in policies regarding postnatal discharge should be monitored and, ideally, evaluated in randomised trials.
  • Outcomes such as differences in mortality or readmissions require larger studies to detect or refute important differences. The low rate of women that consent to take part in the studies, may have compromised the results obtained thus far due to differences between the patients included in the studies and the non-participants.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods 

Additional information

Related literature

Conseil d’Evaluation des Technologies de la Sante du Quebec. Evaluation of the risks and benefits of early postpartum discharge. Report submitted to the Minister of Health and Social Services of Quebec. Quebec: CETS, 1997.

 

Braveman P, Egeter S, Pearly M, Marchi K, Miller C. Early discharge of newborns and mothers: a critical review of the literature. Pediatrics 1995;96:716–26.

 

This summary was prepared by

Sebastián García Martí and Agustín Ciapponi, Argentine Cochrane Centre IECS - Institute for Clinical Effectiveness and Health Policy - Iberoamerican Cochrane Network, Argentina.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Charles Okwundu, Charles Wiysonge, and Stephanie Brown.

 

This review should be cited as

Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews. 2002, Issue 3.

 

The summary should be cited as

García Martí S, Ciapponi A. What are the effects of early postnatal discharge from hospital on healthy mothers and term infants? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

 

Keywords

All Summaries: evidence-informed health policy, evidence-based, systematic review, health systems.

research, health care, low income countries, developing countries, primary health care.



Comments