Historical overview
19th century
During the 19th century, most women across the world gave birth at home, in which postpartum mothers and newborns were taken care of by their friends, family and hired midwives. As such, 97% of births in 1892 were given at home in Sweden. In 1832, the Boston Lying-In Hospital in the United States was built as one of the first hospitals where women could give birth. The1940s – 1960s
Hospitalisation for childbirth was normalised during the 1940s due to the impacts of World War II (WWII). The Emergency Maternal and Infant Care program initiated by the United States government in 1944 subsidised postpartum care for wives of men in the military. This led to the increased accessibility and popularity of giving birth at hospitals. By 1945, 78.8% of American women gave birth at hospitals. During WWII, financial support such as the Emergency Maternal and Infant Care program in the United States and increases in birth rate led to shortages of staff and maternity beds in hospitals. These shortages forced hospitals to discharge mothers after a short postpartum period of 24 hours. Before the 1940s, average hospital stay was around 10 to 14 days for vaginal delivery but the effects of WWII led to the decrease in hospital days to around three to five days.1970s – 1990s
During the 1970s, 1980s and 1990s, the length of postnatal hospital stay had steadily decreased in western countries such as the United States, Australia, United Kingdom and Sweden due to improved infrastructure and scientific advancements. The increasing trend of short postnatal hospital stays, often referred to as drive-through deliveries, led to the enactment of early postnatal discharge laws at the state and federal level in the United States between 1995 and 1998. 32 states passed early postnatal discharge laws which typically included the prohibition of limiting insurance plan coverage of less than 48 hours for vaginal delivery and 96 hours for2000s – present
Since the 2000s, there has been a further international trend of decreasing length of postnatal hospital stay due to cost saving ability, availability of physical infrastructure such as less hospital beds and a movement away from medical intervention of childbirth. Western countries such as Australia indicate that 20% of mothers were discharged less than two days postpartum in 2013, compared with 11% in 2003, showing a decreasing trend of postnatal hospital stays. Similarly, postnatal hospital stays have declined to 2.3 days in Sweden, 2.1 days in the Netherlands and 2.0 days in the United States, Ireland and New Zealand in 2010.Health effects
The effects of early postnatal hospital discharge on mothers and newborns have been studied since the early 1960s when the first report on randomly controlled trial of early postnatal hospital discharge was published by Hellman and Palmer in 1962. Since then, there have been controversies on the safety of mothers and newborns regarding early postnatal discharge, in which studies have concluded adverse effects while others suggest no significant effects and positive effects. These divergent conclusions have been suggested to result from varying definitions of what constitutes early postnatal hospital discharge, differences in methodologies and clinical heterogeneity of interventions and programs.Mothers
Breastfeeding
Mothers participating in early discharge programs which include home-based follow-up care have been found to have higher rates of breastfeeding at three months postpartum as well as exclusive breastfeeding compared to later discharged mothers. Additionally, it has been found that mothers were significantly more satisfied with initiation of breastfeeding when they were discharged early, compared to mothers discharged later. In contrast, it has been suggested that mothers who were discharged early felt reduced positive emotions towards breastfeeding compared to mothers who were not discharged early postpartum. The length of postnatal hospital discharge has also been found to be a predictor of breastfeeding cessation, in which mothers discharged early were more likely to cease breastfeeding compared to mothers who were discharged at a conventional duration. No association between the duration of breastfeeding initiation and of the length of hospital stay postpartum has been found. In addition, it has also been suggested that the length of postnatal hospital stay does not influence breastfeeding rates and duration, in which mothers who were discharged early were equally likely to breastfeed their newborns at a similar rate as the mothers who were discharged later.Depression
Early postnatal hospital discharge may influence depression in mothers. Depression amongst mothers who were discharged within 48 hours of giving birth were found to be more likely at five to six months postpartum compared to mothers who were discharged after five days. In contrast, findings have also suggested that mothers' depression andNewborns
Morbidity
Although conclusions on the effects of early postnatal hospital discharge on morbidity of newborns remain unclear, it has been suggested that newborns discharged within 24 hours of birth are more likely to require readmission by one month compared to newborns discharged after 24 hours. The main reason for newborn readmission wasGuidelines and policies
Canada
The Healthy Babies Healthy Children program initiated by the Ontario Ministry of Health and Long-Term Care includes a policy for hospitals to provide mothers with the option of staying at the hospital postpartum for up to 60 hours. The policy was put in place in 1999, supported by the provision of government funds as a part of the Healthy Babies Healthy Children Postpartum Enhancement, which aims to encourage hospital care for all mothers and newborns. This policy of guaranteed optional 60 hours postnatal hospital stay was implemented due to a case in which a newborn died after being discharged from hospital early, as well as pronouncements made by theUnited States
In the United States, the Newborns' and Mothers' Health Protection Act of 1996 requires health insurance providers and health plans to provide benefits for hospital stays related to childbirth of less than 48 hours for vaginal delivery and 96 hours for cesarean delivery. Early discharge is permitted as an exception if both the insurance or health plan provider and mother are in agreement. TheUnited Kingdom
The Heart of England NHS Foundation Trust (HEFT) offers guidelines of early postnatal discharge for obstetric and midwifery staff within HEFT. HEFT requires that the minimum time for infant discharge following delivery is two hours, with criteria involving the need for normal labor and no adverse medical or obstetric history. One study done by John Bowers and Helen Cheyne in the U.K. investigated if reducing the length of the patients stay could be possible and safe. In the U.K. having a baby is the number one reason for hospital visits, with 800,000 babies being born annually. These numbers are costing the NHS (National Health Service) 2.5 billion pounds per year. They considered making the stay shorter due to the number of women who use midwives and have access to postnatal care, without hospital involvement. Their study found that while they could reduce the postnatal stay without jeopardizing the patients it would not save the hospitals enough money to make the reduction worthwhile. A UK study based on interviews with 40 pregnant women highlighted a fear of having to leave the hospital too early or having to stay too long. According to their feedback, the ideal situation would be more control over the length of stay and making a joint decision with staff.Statistics
Campbell, Cegolon, Macleod and Benova in 2016 investigated the average duration of hospital stay after facility births in 92 countries. Data was gathered using existing database and health surveys from the Organisation for Economic Co-operation and Development (OECD), Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and the US Centers for Disease Control and Prevention Reproductive Health Survey (CDC-RHS). The average length of postnatal hospital stay for vaginal delivery ranged from 0.5 days (Egypt) to 6.2 days (Ukraine) in 71 countries whereas cesarean delivery ranged from 2.5 to 9.3 days in 30 countries.Controversy
In a study done by Kay M. Tomashek et al., they researched the rate of infant morbidity in late preterm and term infants and their discharge time. Of the 1004 late preterm and 24,320 term infants in our study, 4.3% and 2.7% of infants, respectively, were either readmitted or had an observational stay. Late preterm infants were 1.5 times more likely to require hospital-related care and 1.8 times more likely to be readmitted than term infants. Among infants who were breastfed, late preterm infants were 1.8 times more likely than term infants to require hospital-related care and 2.2 times more likely to be readmitted. Jaundice and infection accounted for the majority of readmission's. Their findings suggest that late preterm infants discharged early experience significantly more neonatal morbidity than term infants discharged early; however, this may be true only for breastfed infants.Preparedness
A study done by Gabriella Malagon-Maldonado et al., researched the antepartum, intrapartum, and postpartum predictors of discharge readiness, including nursing educational practices that are predictive of postpartum mothers' perceptions of readiness for hospital discharge. Their results found that mothers with three or more children, delivery mode, bottle-feeding, the delivery of education, and the difference between educational content received and needed, were significant predictors that accounted for 42% of the variance in readiness for hospital discharge. Nurses' skill in teaching and educational content received were significant predictors even with parity, feeding, and delivery mode in the model.References
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