PEDIATRICS Vol. 107 No. 2 February 2001, pp. 406-407

COMMENTARY:
What Lessons Should We Learn From Drive-Through Deliveries?

The first victim of the managed care backlash was rapid postpartum discharge, more commonly known as a "drive-through delivery." The issue was framed as a morality play, with corporate greed on one side and the health and safety of mothers and infants on the other. When a few horrific anecdotes were added to this mix, legislators understandably concluded that drive-through deliveries were an abusive practice that needed to be halted. Between 1995 and 1997, 40-odd states and Congress enacted legislation requiring insurers to defer to physician preferences as to an appropriate postpartum length of stay, or to cover a minimum of 48 hours (vaginal delivery) or 96 hours (cesarean section) of postpartum hospitalization.¹

Physician groups and individual physicians played a major role in the enactment of these laws, through testimony, lobbying, and critical commentary in news articles and medical journals. In testimony before Congress, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Medical Association denounced drive-through deliveries. Pediatrics published an inflammatory commentary titled Early Discharge in the End: Maternal Abuse, Child Neglect, and Physician Harassment,² and the New England Journal of Medicine published a slightly less inflammatory piece titled Women and Children First.³ This tone carried over into the political sphere; when legislation was debated in Congress, Senators from across the political spectrum condemned drive-through deliveries as "unconscionable" (Senators DeWine and Helms), and "scary" (Senator Biden), and suggested it was simply "common sense" for an insurance policy to include the mandated coverage (Senator Bradley).⁴ Riding this tide of bipartisan enthusiasm, the Newborns' and Mothers' Health Protection Act (NMHPA) passed the Senate 98-0, and took effect on January 1, 1998.⁵

The result of this state and federal legislation was the immediate reversal of a steady 25-year trend of decreases in the length of postpartum hospitalization. Between 1970 and 1995, the length of a postpartum hospitalization declined from 3.9 days to 1.7 days after a vaginal delivery, and from 7.8 days to 3.6 days after a cesarean section.⁶ One-day stays accounted for 7.6% of vaginal deliveries in 1980, 21.2% of vaginal deliveries in 1990, and almost 47% of vaginal deliveries in 1995.⁷ After legislation was enacted, these trends reversed, and postpartum lengths of stay began increasing. In 1998, the latest year for which figures are available, average postpartum hospitalization in the United States was 2.1 days after a vaginal delivery and 3.7 days after a cesarean delivery.⁷

The NMHPA required the Secretary of Health and Human Services to appoint an Advisory Panel to study the issue of postpartum care, and prepare periodic reports on the subject. This issue of Pediatrics includes a summary of the recommendations in the first interim report, prepared by the Secretary's Advisory Committee on Infant Mortality (SACIM).⁸ The report includes 5 recommendations and 8 questions requiring further study. The first 3 recommendations are the most critical ones; SACIM recommends that: 1) the policy focus should be broadened beyond length of stay to "the full range of preconception, prenatal, postnatal, and postpartum services needed for optimal health," 2) the goal should be reframed from the prevention of rare and catastrophic events to "optimal newborn and maternal health in the short- and long-term," and 3) we should focus on "ensur[ing] the delivery of health care needed after leaving the hospital, regardless of length of stay." The report understatedly notes that it may prove difficult to implement these recommendations in a coverage and delivery market in which clinical effectiveness, patient satisfaction, and cost-effectiveness are important considerations.

The most interesting feature of the report is that it offers no praise for the coverage provisions mandated by the NMHPA and analogous state legislation. Although the report asserts that the NMHPA is an "important achievement," it provides absolutely no evidence to support that claim. Indeed, the report implicitly criticizes the legislation for its focus on the number of hours of postpartum hospital care, instead of the "needs of the mother and newborn and ... the content and quality of the care they receive." If anything, the SACIM report is a striking repudiation of the tactics and goals of critics of drive-through deliveries.

Consider the anecdotal bad outcomes that were used to make the case that legislation was necessary. The SACIM report is clear that the issue is not and should not be only the prevention of such "rare and catastrophic events." Regardless, even if the focus is the prevention of such events, research has made it clear that extended postpartum hospitalizations as such have at most a limited nexus with the detection and prevention of problems likely to result in a catastrophic event.^9-31 Extended postpartum hospitalization is also a singularly inefficient way of addressing the problem of maternal inexperience, which is an important factor in many of the bad outcomes.¹

Worse still, because of the way the legislation was designed, it did nothing about the real issues at stake, including the availability of postdischarge services, the quality of services rendered before, during, and after postpartum hospitalization, the distortions created by hospitals' use of per-diem pricing, and the manner in which managed care organizations (MCOs) make coverage decisions.¹ The net result was thus the worst of all worldslegislation that eliminates the incentive for MCOs to develop and cover appropriate postdischarge care and undermines the incentives for them to engage in appropriately visible cost-containment, while simultaneously giving the public a false sense of security about the merits of the existing care and coveragepositions that are the precise opposite of what any sensible policy in this area should accomplish.

What lessons should we learn from drive-through deliveries? First, although sound bites are helpful in making the case for a policy change, they have a distinct tendency to crowd out the issue they were intended to dramatize. Once the problem was framed as "drive-through deliveries," the real issues at stake never made it onto the policy agenda. Second, beware of quick fixes. Most policy issues are issues because they do not have an obviously "right" solutionor because the obvious solutions cause more problems than they solve. Third, be alert to the self-interest of those advocating policy changes. It was hardly a coincidence that most of the providers advocating for extended postpartum hospitalizations were in the business of providing hospital-based servicesjust as it was hardly a coincidence that a majority of the states excluded Medicaid recipients and state employees from the ambit of their legislation.^1,32 Fourth, when legislators and the public look to the medical profession for guidance on such matters, they are entitled to expertisenot political gamesmanship or self-interest masquerading as technical knowledge. It is particularly troubling that representatives of the organized medicine used anecdotes and personal testimonials to help make the case against drive-through deliveries when the available empirical research did not support that position. Finally, legislators should consider mandating the preparation of postenactment reports, like the one contained in this issue of Pediatrics, as a matter of routine. Once the rhetoric and passions have cooled, a dispassionate look at the data can be quite productive. In this instance, the SACIM report makes it clear that the NMHPA and analogous state legislation were aimed at the wrong target.

David A. Hyman, MD, JD
University of Maryland School of Law
Baltimore, MD 21201

FOOTNOTES

Received for publication Sep 25, 2000; accepted Sep 25, 2000.

Address correspondence to David A. Hyman, MD, JD, University of Maryland School of Law, 515 W Lombard St, Baltimore, MD 21201. E-mail: dhyman{at}law.umaryland.edu

ABBREVIATIONS

NMHPA, Newborns' and Mothers' Health Protection Act; SACIM, Secretary's Advisory Committee on Infant Mortality; MCO, managed care organization.

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