PEDIATRICS Vol. 107 No. 2 February 2001, pp. 400-403

COMMENTARY:
Early Postpartum Discharge: Recommendations From a Preliminary Report to Congress

Nearly 4 million women give birth in the United States each year, the vast majority of them in hospitals, making childbirth the most frequent reason for hospital admission.¹ According to generally accepted standards of maternity care, the health care needs of the newborn and mother in the immediate postnatal/postpartum period should be met at the delivery site. These needs include monitoring and support to ensure the infant's stabilization during the initial physiologic transition from intrauterine to extrauterine environments, performance of recommended immunizations, mandatory screening for genetic disorders, and initiation of feeding and assessment of major medical risk factors. Standard inpatient care for mothers in the immediate postpartum period has also included instruction on infant and self-care, and training in breastfeeding and lactation support.

Hospital length of stay after childbirth has decreased progressively during the past 25 years, initially in response to public pressure to demedicalize childbirth but then in a more accelerated fashion in response to cost-containment pressures. The trend toward increasingly shorter hospital stays has raised concerns about the potential consequences of reducing the length of time in which necessary care can be delivered to newborns and mothers in the hospital setting. In response to these concerns, the 1992 Guidelines for Perinatal Care, jointly published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), indicated that for otherwise uncomplicated deliveries: 1) the recommended postpartum hospital stay should range from 48 hours for vaginal delivery to 96 hours for cesarean delivery, excluding the day of delivery (most subsequent guidelines and legislation have not made the distinction "excluding the day of delivery"); and 2) discharge within 48 hours of birth is defined as early discharge and discharge in <24 hours as very early discharge.² Despite the issuance of these guidelines, an increasing number of insurers began refusing payment for a hospital stay that extended beyond 24 or even 12 hours after an uncomplicated vaginal delivery.³

Shorter lengths of hospital stay after birth have shifted the setting for much of the immediate postpartum recovery from the hospital to the home.⁴ Services that previously were provided in the hospital must be provided after discharge, either in an outpatient clinical setting or at home. Although routine postdischarge follow-up care has traditionally consisted of a check-up for the newborn at 2 weeks and a postpartum visit for the mother at 6 weeks, prevailing expert opinion recommends earlier follow-up for newborns and mothers after early discharge.^1,2,5 However, there is no well-accepted standard for addressing the follow-up needs of mothers and infants who stay 48 hours or more.

Widespread publicity in the past few years about "drive-through deliveries" and the possibility of associated adverse outcomes has prompted state and federal legislation. Since 1995, 43 states have mandated coverage for postnatal hospital stays of the standard duration recommended by the AAP and ACOG; 41 states have enacted legislation, while New Mexico and Vermont have adopted provisions through administrative rule.⁶ State laws vary in the scope and applicability of their provisions, but they typically place limits on the extent to which insurance plans may influence patients' and providers' decisions about timing of discharge.⁷ Many state laws include requirements regarding postdischarge home services for mothers and infants discharged before the standard lengths of stay.⁶ However, there is substantial variation in the types of services specified and in the extent to which insurers are responsible for covering the costs of early postdischarge home care.⁷

Citing their lack of authority to regulate insurers whose policies were written in other states or self-insured plans that are exempt under the federal Employee Retirement Income Security Act (ERISA), state officials began to exert pressure for federal law to regulate the length of maternity stays.³ On September 26, 1996, President Clinton signed into law the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA), as an amendment to the Veterans Affairs and Housing and Urban Development (VA-HUD), and Independent Agencies Appropriations Act for 1997. The legislation establishes a general rule under which group health plans and health insurance issuers may not restrict benefits for hospital lengths of stay in connection with childbirth for the mother or newborn to <48 hours after a vaginal delivery or 96 hours after a delivery by cesarean section. However, the law also provides an exception to the general rule if the attending provider, in consultation with the mother, decides to discharge earlier. Moreover, the law also provides that providers cannot be required to obtain authorization from a group health plan or health insurance issuer for prescribing any length of stay required under the general rule. Unlike many state laws, the federal legislation does not include requirements for coverage of postdischarge follow-up services for mothers and newborns with shorter hospital stays. The federal legislation applies to women and newborns covered under group health plans as well as to women and newborns covered under individual market insurance policies. Although some state laws apply to Medicaid enrollees, the federal legislation extends only to those Medicaid recipients who are enrolled in capitated health plans, excluding those with fee-for-service coverage.⁸ State law, rather than the federal NMHPA requirements, applies to health insurance coverage (but not to self-insured group health plans) if the state law either: provides for coverage of minimum inpatient stays of 48/96 hours; meets guidelines issued by ACOG/AAP or other recognized professional medical associations; or provides that the length of stay is determined by the attending provider in consultation with the mother.⁸

The legislation also requires that the Secretary of Health and Human Services appoint an Advisory Panel to conduct studies of the factors affecting care for mothers and newborns, including both in-hospital and posthospital care in the period after childbirth. The studies are intended to be the basis for recommendations for improvements in care. The Secretary's Advisory Committee on Infant Mortality (SACIM) was designated to act as the Advisory Panel specified in the legislation. As part of that role, SACIM is responsible for preparing reports to Congress at 18 months, 3 years, and 5 years after enactment of the legislation. Submitted to Congress in January, 1999, the initial report had 3 main objectives: 1) to provide a broad conceptual framework for addressing concerns about postpartum length of stay; 2) to summarize current knowledge about appropriate care practices for newborns and mothers; and 3) to make recommendations related to promoting the health of newborns and mothers. A summary of key issues from the report is presented here along with SACIM's recommendations, which were intended to provide guidance both for ongoing policy and research and for specific activities to be accomplished between now and submission of the final 5-year report to Congress in 2001.

SUMMARY OF KEY ISSUES DISCUSSED IN THE INITIAL REPORT

To date, science, policy, and legislation addressing concerns about health care after childbirth have focused primarily on the number of hours of postpartum hospital stay, rather than on the needs of the mother and newborn and on the content and quality of the care they receive. To some extent, this focus undoubtedly reflects the fact that length of stay is easier to measure than the quality and effectiveness of services provided. Some providers and researchers have raised concerns that the widely accepted "minimum" hospital stay of 48 hours does not provide sufficient time for newborns and their mothers to receive needed postnatal and postpartum services. Current scientific knowledge does not provide conclusive evidence about ideal delivery length of stay, in-hospital services, or postdischarge services for the general population of infants and mothers. However, current knowledge about important physiologic changes during the first few days after birth does indicate that all newborns and mothers should be clinically evaluated by a professional primary care provider on the third or fourth day after delivery, regardless of when they leave the hospital.⁹ As suggested in a 1996 General Accounting Office report on maternity care, the legislation enacted in many states may actually be providing the public with a "false sense of security" by requiring that insurers cover either hospital stays of 48 hours or follow-up care when stays are shorter.¹ Although a hospital stay of 48 hours may allow for additional medical surveillance during those 2 days, a 48-hour hospital stay does not eliminate the need for services on the critical third or fourth postpartum days. More important, if early home or clinic follow-up care is only offered routinely to newborns and women who leave before 48 hours, those who opt for the minimum 2-day stay may actually forego care they otherwise would have received on the critical third and fourth day after birth.

Apart from clinical evaluation and timely intervention, routine health promotion services and building strong relationships with service systems that can provide social as well as health-focused services are likely to be a crucial component of care designed to lead to optimal health and well-being of newborns, mothers, and families. The currently available evidence on how different approaches to routine postpartum care affect outcomes is limited, in large part because this area has been relatively neglected as a focus for rigorous research. Until studies of adequate design are directed to questions about routine postpartum care, no single model of in-hospital and postdischarge services can be defined as a "best practice." Although routine lengths of stay following uncomplicated childbirth have been <3 or 4 days for many years, available evidence suggests that most mothers and infants with short stays do not receive early follow-up.^10-12 These findings suggest that the majority of apparently well women and infants should be receiving more intensive postdischarge services.

Following enactment of NMHPA, attention should now focus on the postnatal and postpartum services needed for the optimal health of newborns and mothers. The focus must shift from "early discharge" to "appropriate discharge,"¹³ and consensus must be reached about standards for postnatal/postpartum care in the context of the trend toward shorter hospital stays. That consensus must be grounded in the full body of scientific knowledge, including but not limited to evidence from formal scientific studies. There may or may not be net cost savings associated with providing better maternity and newborn care for the entire population, raising the question of what we as a society are willing to pay to assure optimal health for newborns and mothers. Although additional research is needed, science may never provide definitive evidence that any particular approach represents "best practices" for all newborns and mothers.¹⁴ However, given the importance of the first days of life and parenthood, good judgment suggests that it should be standard practice for every mother and newborn to receive appropriately timed postnatal/postpartum care, without waiting for conclusive evidence on the most effective and efficient approaches.

RECOMMENDATIONS

The following recommendations are based on SACIM's initial review of the important issues highlighted in the NMHPA, and rely heavily on an extensive process of discussion and consultation among scientific and clinical experts that occurred during the past 4 years under leadership of the Maternal and Child Health Bureau of the Health Resources and Services Administration (MCHB/HRSA):

• Recommendation 1. Broaden the focus of concern beyond the issue of length of stay to the multiple important factors affecting maternal and infant health.

The NMHPA was an important achievement. However, to fully address maternal and infant health issues, concern should now focus on: a) the full range of preconception, prenatal, postnatal, and postpartum services needed for optimal health of newborns and mothers in the heterogeneous US population, and b) how such practices can be implemented in the evolving health care environment in which clinical effectiveness and patient satisfaction as well as costs, reimbursement, and financial incentives are important considerations.

• Recommendation 2. The goal of postnatal and postpartum care should be good health and well-being, not only the prevention of rare catastrophic events.

The goal of postnatal and postpartum services should be to achieve optimal newborn and maternal health in the short- and long-term, and not only to prevent rare occurrences such as hospital readmission or catastrophic events leading to death. To obtain the information needed to guide future policy, studies must focus on outcomes reflecting important measures of health and well-being for newborns, mothers, and families with both short- and long-term implications. Such outcomes should include: initiation and continuation of breastfeeding; timely use of preventive and curative services for the infant (eg, immunizations) and mother (eg, family planning); the occurrence and severity of postpartum depression; the mother's physical comfort, overall functioning, and sense of competence with parenting; longer-term measures of child and family welfare; and the adoption of healthy lifestyles (eg, healthy diet, elimination of substance abuse). Funding levels for studies must be adequate for the inclusion of measures of maternal and newborn health and well-being; this is challenging considering the fact that most computerized databases currently do not routinely collect information on breastfeeding or other health measures apart from rehospitalizations or death.

• Recommendation 3. Ensure the delivery of health care needed after leaving the hospital, regardless of length of stay.

Current knowledge of physiologic events in the initial period after childbirth indicates that, regardless of length of stay, all newborns should receive clinical evaluation and health promotion services, and mothers should receive at least health promotion and education services and have ready access to clinical care if needed, on the third or fourth postnatal/postpartum day. The physical needs of the newborn and mother, as well as the psychosocial needs of the mother and family, should be addressed at this time using AAP/ACOG guidelines. Services must be tailored to the individual family's socioeconomic, psychosocial, and environmental circumstances as well as biomedical risk factors, and must be culturally appropriate; the case of the very young or inexperienced mother with limited family support may warrant special consideration. Current evidence does not provide clear guidance about how, where, and by whom these services should be provided; obtaining such evidence should be a priority for research.

• Recommendation 4. Incorporate lessons learned from birth centers and approaches in other countries.

Future policy and practice recommendations need to incorporate lessons learned from other models of preconception, prenatal, postnatal, and postpartum care, including the experiences of birth centers and model early discharge programs in the United States, long-standing approaches in European countries, and innovative approaches in developing countries. These models of care need to be included among the options whose effectiveness and costs are evaluated by research on "best practices."

• Recommendation 5. Undertake studies required by the legislation.

Funding must be provided to ensure that certain studies are undertaken immediately to meet the requirements of the legislation (which specifies a final report on study results by September 30, 2001, and an interim progress report by September 30, 1999). Under MCHB/HRSA's leadership, the appropriate federal agencies should collaborate to select the highest priority research questions relevant to this legislative mandate and to ensure the timely and efficient conduct of the studies needed to address those questions, making optimal use of existing knowledge and expertise. Involvement of private foundations should be sought. Following are examples of questions that should be considered in developing the short-term research agenda for the legislative reporting period, as well as recommendations for a longer-term agenda for essential research needed to guide improvements in care for newborns and mothers. The terms "postnatal" and "postpartum" as used in SACIM's recommendations refer to the period of approximately 60 days after childbirth for the infant and the mother, respectively.

Questions a through d are general questions that are raised explicitly or implicitly by the legislation itself:

a) What are the "best practices" that can be recommended for postnatal and postpartum care, based on existing knowledge and considering the optimal attainable health of newborns, mothers, and families, rather than only the prevention of catastrophes? In addition to strictly biomedical criteria, what individual characteristics of a mother and a family should be considered in selecting an appropriate approach to their postnatal and postpartum care? How can these recommendations be disseminated most effectively and how should adherence to them be monitored?

b) What postnatal/postpartum services (including hospital, outpatient, and home-based services) actually are being received by newborns and mothers in the United States? Are there particular groups who are not receiving the recommended postnatal/postpartum services? If so, who are they, and what approaches seem most promising (with respect to effectiveness and costs, including third-party reimbursement) to overcome their barriers?

c) What modifications could and should be made in existing data systems in the public and private sectors, including electronic medical records, program information, and information from vital records and population-based surveys, to permit ongoing monitoring of postnatal and postpartum health status and health services? Modifications in existing data systems should reduce the need for expensive special studies requiring new data collection in the future.

d) What have been the effects of the NMHPA? Do the specific requirements of the Act appear to be appropriate? (See Section 606 (b)(1)(B) of the legislation.)

The following questions (e through h) are more specific than those stated above. These questions were not specifically raised by the legislation, but have arisen in SACIM's discussions as deserving consideration for possible inclusion in the relevant research agenda.

e) What are the unmet postnatal and postpartum health needs of newborns and mothers eligible for care through Medicaid? During 1993, 40% of all hospital births in the United States were covered by Medicaid¹⁵; however, the federal law extends only to those Medicaid-covered newborns and mothers in capitated health plans.

f) What are the unmet postnatal and postpartum health needs of newborns and mothers who lack private health insurance but are not eligible for Medicaid, such as uninsured low-income workers whose income exceeds Medicaid criteria, immigrants, and seasonal migrant farmworkers?

g) In addition to essential postnatal services for the newborn, what are the essential health services (including either clinical evaluation or health promotion or both) that mothers should receive around the third or fourth postpartum day? How, where, and by whom should these services be delivered to mothers and how can these be coordinated with delivery of services to the newborn, taking into consideration effectiveness, costs, and comfort and convenience of the mother and the family?

h) What are the demographic, socioeconomic, or psychosocial characteristics of mothers and families that can be readily detected prenatally and used as reliable markers of the need for more intensive postnatal/postpartum services than those recommended for the general population? Practical risk assessment instruments need to be developed and disseminated.

ACKNOWLEDGMENTS

Members of the SACIM are Antoinette Parisi Eaton, MD (Chairperson), Ohio State University, Columbus, OH; Peter C. van Dyck, MD, MPH (Executive Secretary), Maternal and Child Health Bureau, Rockville, MD; Kerry P. Nesseler, RN, MS (Senior Advisor), Maternal and Child Health Bureau, Rockville, MD; Larry R. Anderson, MD, Sumner County Family Practice Center, Wellington, KS; Polly Arango, Family Voices, Algodones, NM; Paula Braveman, MD, MPH, University of California at San Francisco, San Francisco, CA; Denise Ferris, RD, LD, DrPH, West Virginia Department of Health and Human Resources, Charleston, WV; Nancy L. Fisher, RN, MD, MPH, Regence BlueShield, Seattle, WA; Fredric D. Frigoletto, Jr, MD, Harvard Medical School, Boston, MA; David E. Gagnon, National Perinatal Information Center, Providence, RI; Verona P. Greenland, RN, CNM, MPH, Morris Heights Health Center, Bronx, NY; Fernando A. Guerra, MD, MPH, San Antonio Metropolitan Health District, San Antonio, TX; Elizabeth H. Hadley, MPH, JD, Chevy Chase, MD; Robert E. Hannemann, MD, Lafayette, IN; Agnes Hinton, RD, MS, DrPH, University of Southern Mississippi, Hattiesburg, MS; Bette R. Keltner, PhD, Georgetown University, Washington, DC; Thomas W. Langfitt, MD, Wynnewood, PA; Darlene A. Lawrence, MD, IMANI Health Care, Washington, DC; Tracy A. Lieu, MD, MPH, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA; Charles S. Mahan, MD, University of South Florida, Tampa, FL; Marsha McCabe, Texas Instruments, Plano, TX; Linda A. Randolph, MD, MPH, The National Center for Education in Maternal and Child Health, Arlington, VA; E. Albert Reece, MD, Temple University School of Medicine, Philadelphia, PA; Carolina Reyes, MD, Cedars-Sinai Medical Center, Los Angeles, CA; Heather Reynolds, MSN, CNM, Yale University School of Nursing, New Haven, CT; Julius B. Richmond, MD, Harvard Medical School, Boston, MA; Reverend Janice M. Robinson, Grace Episcopal Church, Silver Spring, MD; Kathleen Filip Waleko, PhD, MBA, Magee Womens Hospital, Pittsburgh, PA; Deborah Klein Walker, EdD, Massachusetts Department of Public Health, Boston, MA; Grace M. Wang, MD, MPH, Seattle King County Department of Public Health, Seattle, WA.

The SACIM would like to acknowledge the leadership of Paula Anne Braveman, MD, MPH, Chairperson of the Early Postpartum Subcommittee and Susan Egerter, PhD, as well as the contributions of the Expert Working Group on a Research Agenda Focused on Early Postpartum and Postnatal Services in researching the findings presented and in the preparation of this report.

Antoinette Parisi Eaton, MD
Department of Pediatrics
Ohio State University
Children's Hospital
Columbus, OH 43205

FOOTNOTES

Received for publication Feb 22, 2000; accepted Jun 9, 2000.

Reprint requests to (P.C.D.) Maternal and Child Health Bureau, Health Resources and Services Administration, 5600 Fishers Ln, Room 18-05, Rockville, MD 20857. E-mail: pvandyck{at}hrsa.gov

ABBREVIATIONS

AAP, American Academy of Pediatrics; ACOG, American College of Obstetricians and Gynecologists; ERISA, Employee Retirement Income Security Act; NMHPA, Newborns' and Mothers' Health Protection Act of 1996; VA-HUD, Veterans Affairs and Housing and Urban Development; SACIM, Secretary's Advisory Committee on Infant Mortality; MCHB/HRSA, Maternal and Child Health Bureau of the Health Resources and Services Administration.

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