Newborn Early Discharge Revisited: Are California Newborns Receiving Recommended Postnatal Services?
* Robert Wood Johnson Clinical Scholars Program, University of Washington, Seattle, Washington
Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
California Department of Health Services, Sacramento, California
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ABSTRACT |
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Context. Responding to safety concerns, federal and state legislation mandated coverage of minimum postnatal stays and state legislation in California mandated coverage of follow-up after early discharge. Little is known about the postnatal services newborns are receiving.
Objective. To describe rates of early discharge and of timely follow-up for early-discharged newborns.
Design and Setting. Retrospective, population-based cohort study using a 1999 postpartum survey in California.
Participants. A total of 2828 infants of mothers with medically low-risk singleton births.
Main Outcome Measures. Rates of early discharge (
1-night stay after vaginal delivery and 3-night stay after cesarean section) and untimely follow-up (no home or office visit within 2 days of early discharge).
Results. Overall, 49.4% of newborns were discharged early. Of these, 67.5% had untimely follow-up. The odds of early discharge were greater with lower incomes: the adjusted odds ratios (AORs) (with 95% confidence intervals) were 2.06 (1.50–2.83) for incomes 100% of poverty, 2.20 (1.65–2.93) for incomes from 101%–200% of poverty, and 2.24 (1.63–3.08) for incomes from 201%–300% of poverty. Untimely follow-up was more likely for infants of women with incomes 100% of poverty (AOR = 1.89 [1.13–3.17]) and 201%–300% of poverty (AOR = 1.78 [1.09–2.91]), Medicaid coverage (AOR = 1.73 [1.20–2.47]), Latina ethnicity (AOR = 1.47 [1.02–2.14]), and non-English language (AOR = 1.72 [1.16–2.55]).
Conclusions. Despite an apparent decline in short stays after legislation, many newborns—particularly from lower-income families—continue to be discharged early. Most newborns discharged early—particularly those with Medicaid and those from low-income, Latina, and non–English-speaking homes—do not receive recommended follow-up. The most socioeconomically vulnerable newborns are receiving fewer postnatal services.
Key Words: infant • newborn • length of stay • early discharge • home visits • postnatal care • postpartum care
Abbreviations: AAP, American Academy of Pediatrics • ACOG, American College of Obstetricians and Gynecologists • NMHA, Newborns’ and Mothers’ Health Act of 1997 • NMHPA, Newborns’ and Mothers’ Health Protection Act • MIHA, Maternal and Infant Health Assessment • DHS, Department of Health Services • UCSF, University of California, San Francisco • LOS, length of stay • FPL, federal poverty level • OR, odds ratio • AOR, adjusted odds ratio
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INTRODUCTION |
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In the past decade, pressures to reduce hospital stays and contain costs have raised concerns that newborns’ needs are not adequately being met. Among healthy singleton vaginal deliveries in California in the first half of the 1990s, the rate of hospital stays of 1 night or less was as high as 85%1; high rates of short stays were noted nationally at this time as well.2–5 In 1992, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) defined early discharge as a postdelivery stay of <48 hours for vaginal deliveries and <96 hours for cesarean sections.6 In 1995, the AAP recommended that newborns receive follow-up care in the office or home within 48 hours of a short stay (<48 hours), based on a range of clinical concerns including the need for breastfeeding promotion and for timely detection of severe jaundice and other conditions that might not manifest during the first 1 to 2 days of life.7 Studies at single institutions around this time suggested that about one third to two thirds of early-discharged newborns were not receiving the recommended follow-up visits,8,9 but population-based data were unavailable.
In response to widespread professional and public concerns about the safety of early discharge, 43 states mandated that third-party insurers provide coverage of postnatal stays of at least 48 hours after vaginal delivery and 96 hours after cesarean section.10 The California Newborns’ and Mothers’ Health Act of 1997 (NMHA)11 mandated coverage of home or office follow-up for vaginally-delivered newborns with stays <48 hours and cesarean-delivered newborns with stays <96 hours when prescribed by the physician in consultation with the mother. About half of all states enacted similar legislation covering clinic or home follow-up care for stays <48 hours for vaginal deliveries or 96 hours for cesarean deliveries, in accordance with the 1995 AAP guidelines12 (P. A. Braveman et al, "State Legislation on Early Discharge," unpublished report for the federal Maternal and Child Health Bureau, April 1998). In 1996, the federal government passed the Newborns’ and Mothers’ Health Protection Act (NMHPA), which mandated that health plans (including self-insured plans that are exempt from state legislation under the Employee Retirement Income Security Act of 1974) could not restrict benefits for hospital lengths of stay for the mother or newborn to <48 hours after vaginal delivery or <96 hours after cesarean delivery. The legislation allowed for an exception if the attending provider, in consultation with the mother, decides to discharge earlier.13 The federal legislation did not include provisions for follow-up services.
Both the widespread practice of early newborn discharge and enactment of the federal and state legislation reacting to it occurred without strong evidence regarding the safety of early newborn discharge—or the desirability of any particular length of stay.14–18 Several studies published since enactment of the legislation have found associations between early discharge and increased newborn morbidity,19–25 while others have not.26–28 Many of these studies had the same methodologic limitations as prior studies, however, including limited statistical power, lack of information on postdischarge services, and focus on a limited range of outcomes.25,29–32 Findings on health promotion outcomes, such as breastfeeding and immunization rates, have been particularly inconclusive.14,25,30,33–35
Despite the recognition that the effects of length of stay on newborn outcomes are likely to be influenced by the care received after discharge from the hospital,36,37 few studies of newborn early discharge have included information on postdischarge care, and findings regarding the independent effects of postdischarge follow-up services are limited.31,37 Receipt of routine follow-up services such as home or office visits by early-discharged newborns has been associated with decreases in newborn rehospitalization and urgent care visits compared with early discharge without follow-up services.26,38,39 However, these studies have limitations such as small size, limited power, lack of generalizability, and nonrandomized design.
Published data do not reflect utilization of postnatal services in the time period since enactment of federal and state legislation, nor do they provide generalizable information on utilization of recommended follow-up services. This study was designed to address the lack of evidence about current utilization of postnatal services, taking advantage of newly available population-based data on follow-up services for newborns. This study addresses questions highlighted by the Preliminary Report of the Secretary’s Advisory Committee on Infant Mortality as meriting additional research: "What postnatal/postpartum 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?"10 Our primary objectives were to examine: 1) the extent to which California newborns currently are discharged early and receive recommended follow-up services after early discharge, and 2) the characteristics of newborns who do not receive recommended services. To our knowledge, this study is the first to examine newborn length of stay and follow-up care using population-based data including extensive information on relevant maternal characteristics.
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METHODS |
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Study Sample
Data were obtained from the 1999 California Maternal and Infant Health Assessment (MIHA), a population-based survey of postpartum women identified through the Birth Information Database from the California Department of Health Services’ (DHS) Office of Vital Records and Statistics; MIHA is a collaborative effort of the DHS and the University of California, San Francisco (UCSF). Approval was obtained for MIHA from the UCSF Committee on Human Research and the California Health and Human Services Agency Committee for the Protection of Human Subjects. A women was eligible for MIHA if she was a California resident who had a live birth between February 1999 and May 1999, was age 15 or older, spoke English or Spanish, and had a gestation of triplets or smaller. Eligible mothers were grouped into strata defined by region of the state, educational attainment, and race/ethnicity; African Americans were oversampled. Surveys were mailed in English and Spanish at 10 to 14 weeks’ postpartum to 4967 women selected at random within the study strata. Women who did not return the survey were sent a reminder postcard and a second copy of the survey, after which attempts were made to survey them by phone, yielding a final response rate of 70% and sample characteristics that reflected the statewide maternity population. On average, surveys were completed between 3 and 5 months’ postpartum. Completed surveys were linked with birth certificate data, which provided information on type of delivery, birth weight, gestational age, abnormal newborn conditions, maternal age, parity, and delivery insurance status.
Because we were interested in length of stay (LOS) and postdischarge follow-up for healthy term newborns, we excluded surveyed women whose infants: 1) were not medically low-risk, as indicated by gestations shorter than 37 weeks, birth weights <2500 g, nonsingleton gestations, or any abnormal conditions recorded on the birth certificate; 2) had died before leaving the hospital; or 3) were born at home or in freestanding birth centers. We also excluded women whose infants were no longer living with them, because information on their follow-up was not available. Additionally, we excluded women who provided inconsistent responses to key survey questions (eg, those who reported younger newborn age at postdischarge visits than at discharge). Of the 3483 women who completed the MIHA survey, 655 participants met 1 or more criteria for exclusion: 561 had infants who were not medically low risk, 12 had infants who died before discharge, 14 gave birth at home or in a freestanding birth center, 25 were no longer living with their infants, and 123 provided inconsistent responses. The final study sample included 2828 participants.
Variables
Timing of discharge (early versus later) and timing of follow-up (timely versus untimely) were used as primary dependent variables. In the survey, each mother was asked the number of nights her infant spent in the hospital and the infant’s age in days at initial follow-up. To approximate the NMHPA, NMHA, and AAP standards, we defined early discharge as a stay of 0 to 1 night for vaginal deliveries and 0 to 3 nights for cesarean deliveries; later discharge was defined as 2 or more nights and 4 or more nights, respectively. These cut-offs were chosen to ensure that no newborn in the early discharge group stayed >48 hours (or 96 hours for cesareans). Of 531 mothers with cesarean sections, 33 (6.1%) reported that their newborn was discharged after 0 or 1 night, an unusually short stay for a mother after a cesarean that could reflect inaccurate reporting. Because estimates did not change substantially when these participants were excluded from analyses, they were kept in the study sample.
Timeliness of follow-up was calculated using the difference between the newborn’s age at follow-up and age at discharge. Age in days at discharge was derived by adding 1 to the number of nights stayed. Timely follow-up for early-discharged newborns was defined as a home or office visit occurring within 2 days of discharge, in accordance with the NMHA and AAP standard; newborns who had a first visit >2 days after discharge or who had received no follow-up visit by the time of the survey were considered to have untimely follow-up.
We also studied the following characteristics potentially associated with timing of discharge and follow-up: maternal age and race/ethnicity, family income as a percentage of the federal poverty level (FPL), highest level of education completed by mother, delivery insurance (which was considered to be the insurer for the newborn in the month after delivery), timing of prenatal care initiation, whether the mother was married/living as married, primary language spoken at home, parity (including the index delivery), whether the newborn had ever been breastfed, and site of follow-up visit (home or provider’s office). All variables were obtained from women’s self-reports in the MIHA survey, with the exception of age, parity, and delivery insurance, which were obtained from birth certificate data.
Statistical Analysis
Analyses were conducted using SAS42 and SUDAAN (Survey Data Analysis) software.43 All analyses used survey data that were weighted for the sampling frame and adjusted for nonresponse to be representative of the distribution of live births in California for 1999; details of the weighting and adjustment are available on request. We first examined the prevalence of early discharge and untimely follow-up. To examine characteristics associated with early discharge and untimely follow-up, we first performed bivariate analyses and calculated unadjusted odds ratios (ORs). We then developed logistic regression models using independent variables chosen a priori based on their relevance in previous studies to the 2 dependent variables.1,19,26,27,40,41 Both models included age, parity, race/ethnicity, income, education, insurance, initiation of prenatal care, marital status, language, and breastfeeding; the model for untimely follow-up also included site of follow-up (home or office) as an independent variable. Because family income was not reported by 
12% of participants, we created a separate income category for women with missing income data. Participants with missing values for any of the other predictor variables in the models (5.1% of participants in the early discharge model and 5.8% in the untimely follow-up model) were excluded from the unadjusted and adjusted analyses; results were not substantially different when they were included.
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RESULTS |
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Study Sample
As shown in Table 1, three fourths of women in the study sample were between 20 and 34 years old. They were diverse in terms of race/ethnicity, with Latinas comprising 45% of the sample. Forty percent of mothers primarily spoke a language other than English at home. About one third of the sample had incomes
100% FPL, while 22% had incomes >400% FPL. The majority (58%) had private health insurance for the delivery and over a third (38%) had Medi-Cal (California’s Medicaid program); only 1.8% were uninsured. Nineteen percent of women in the study sample were unmarried or not living as married, 40% were primiparous, and 17% did not initiate prenatal care in the first trimester. Eighty-one percent had vaginal deliveries and 19% had cesarean sections. The study sample appeared similar to the larger MIHA sample and the corresponding state population, except that more women in the study sample had at least high school educations and slightly fewer were teens and African Americans (data not shown).
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Timing of Discharge and Postdischarge Follow-up
Nearly half (49.4%) of all study newborns were discharged early. As shown in Table 2, we found that 44.2% of vaginally-delivered newborns and 71.4% of those delivered by cesarean section were discharged early. Thirty-two percent of all newborns had follow-up visits within 2 days of discharge and 55.5% had follow-up within 1 week of discharge (Table 3); <1% of newborns had not received any follow-up by the time of the survey (usually completed 3 to 5 months after birth). Contrary to expectations, timing of initial follow-up did not appear to vary by LOS. Among newborns discharged early, 32.5% had follow-up within 2 days of discharge, and 56.2% had follow-up within 1 week; the comparable percentages among newborns discharged later were 32.4% and 55.0%, respectively. Thirty-six percent of vaginally-delivered and 23% of cesarean-delivered newborns had timely follow-up after early discharge. Although the great majority of early-discharged newborns had follow-up visits in the office rather than at home (89.5% vs 10.5%), home visits were significantly more likely than office visits to be timely (66.0% vs 28.6%; P = .001).
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Predictors of Early Discharge and Untimely Follow-up
Findings from unadjusted analyses (Table 4) indicated that newborns were significantly more likely to be discharged early if their mothers were Latina, had incomes
400% FPL (or had missing income data), had not completed high school, had Medicaid coverage for delivery, or did not have first trimester prenatal care. Newborns were less likely to be discharged early if their mothers were African American, Asian/Pacific Islander, primiparous, or had ever breastfed them. In analyses adjusted for all of the variables listed in Table 4, early discharge was significantly more likely for infants whose families had lower incomes: for incomes 100% FPL, adjusted OR (AOR) = 2.06 (1.50–2.83); for incomes from 101%–200% FPL, AOR = 2.20 (1.65–2.93); and for incomes from 201%–300% FPL, AOR = 2.24 (1.63–3.08). Early discharge was significantly less likely if the mother was African American (AOR = 0.56 [0.42–0.74]), Asian/Pacific Islander (AOR = 0.67 [0.48–0.92]), or primiparous (AOR = 0.64 [0.53–0.77]).
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Based on unadjusted analyses (Table 5), newborns discharged early were more likely to have untimely initial follow-up if their mothers were African American, Native American/other, or Latina; had incomes
300% FPL or missing income data; had not completed high school; had Medicaid coverage for delivery; did not have first trimester prenatal care; primarily spoke a non-English language at home; or were unmarried or not living as married. Newborns who had ever breastfed or who received home rather than office follow-up were less likely to have received untimely follow-up. After adjusting for the other variables, we found that untimely follow-up was more likely with incomes 100% FPL (AOR = 1.89 [1.13–3.17]) and from 201–300% FPL (AOR = 1.78 [1.09–2.91]), Medicaid coverage (AOR = 1.73 [1.20–2.47]), Latina ethnicity (AOR = 1.47 [1.02–2.14]), and non-English language (AOR = 1.72 [1.16–2.55]). Untimely follow-up was less likely if the mother was 18 to 19 years old (AOR = 0.49 [0.28–0.86]) and markedly less likely if the initial follow-up visit occurred at home (AOR = 0.16 [0.10–0.25]). Among early-discharged newborns whose mothers had 1 or more characteristics associated with increased risk of untimely follow-up, those with home visits were more than twice as likely as those with office follow-up to have had visits within 2 days of discharge (data not shown).
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DISCUSSION |
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Our findings indicate that, even after enactment of federal and state early-discharge legislation, nearly half of California newborns had hospital stays that were short according to professional guidelines; 44.2% of newborns born vaginally and 71.4% of those with cesarean births were discharged early as defined by AAP and legislated criteria. Although this represents a decline in short stays since 1995, when rates of discharge for vaginal deliveries in a similar study population of California births were
85%,1 it indicates that the practice of early discharge remains highly prevalent. Perhaps more importantly, we found that most newborns discharged early in 1999 did not receive timely follow-up, despite AAP recommendations and state legislation. Only 32.5% of early-discharged newborns had follow-up within the recommended 2 days of discharge; 44% had received no follow-up within 1 week of discharge. Given evidence that poor children are more likely both to be at risk for adverse health outcomes and to benefit from increased access to care,44 it is particularly concerning that newborns of low-income mothers appeared more likely to be discharged early without timely follow-up according to current professional guidelines. Although more evidence is needed about optimal LOS and follow-up practices, one can reasonably postulate that in general, low-income mothers and newborns should receive more, not fewer, services than their socioeconomically better-off counterparts. The pattern observed here, at least at first glance, is inequitable. Our findings indicate that the issuance of professional guidelines and legislation alone cannot ensure adequate postnatal services, particularly among the groups of socioeconomically vulnerable newborns who are least likely to receive appropriate services. Despite the AAP guidelines and legislation, the findings in the literature are inconclusive and there may be inadequate professional consensus about the optimal approach to newborn LOS and follow-up; this may help explain the limited impact of the legislation. The substantial rates of early discharge and untimely follow-up among newborns discharged early may reflect both provider and patient behaviors. California’s legislation mandates coverage for 48-hour postpartum stays and for early follow-up after shorter stays only if prescribed by the physician in consultation with the mother. In this study, providers were not surveyed about what influenced their decisions about discharge and follow-up, and mothers were not asked either about their preferences regarding LOS and follow-up or about what influenced when they obtained follow-up. These issues merit additional investigation to better understand specific barriers to appropriate follow-up care and how they should be addressed.
Evidence suggests that some providers may not be recommending that their patients stay 48 hours45 or return for follow-up within 2 days of early discharge8,46; some studies have found this practice to be more likely for providers with large populations of publicly insured patients,45 while others have not.46 If providers do not routinely offer early follow-up services because of lack of awareness, educating them about guidelines may improve timeliness of scheduled follow-up.47 However, some providers may feel that short stays without early follow-up are safe in certain low-risk situations, and financial disincentives for extra visits may reinforce a lack of firm conviction among providers about the need for early follow-up.48 Under capitated reimbursement systems, providers may tend to minimize follow-up visits as well as feel pressure from hospitals to minimize LOS. Consensus building among providers, professional organizations, hospital administrators, and insurers may be important.
Women’s preferences also affect discharge timing and receipt of follow-up services after delivery. Some mothers may prefer early discharge,17 and low-income mothers may feel additional pressure to return home early to fulfill other caretaker responsibilities. However, other mothers have reported that short stays did not meet their needs4,25 and led to greater fatigue and worry.24 Low-income mothers or their families may be less likely to request longer stays because they feel less empowered to state their preferences and/or because they fear out-of-pocket expenses with less adequate third-party coverage.
Information from our data source only allowed us to examine whether follow-up care was received; we lacked information on whether early visits had been recommended by clinicians and/or scheduled. Some newborns may not be brought in for scheduled follow-up, particularly in low-income populations.49 Some parents may perceive that early follow-up is unnecessary8,17,25 and/or experience a range of barriers to care. We found that follow-up after early discharge was least likely to be timely among newborns whose mothers were low-income, Latina, had Medicaid coverage, and were non-English speakers. Other studies have shown that these populations often have decreased access to health care,50–55 facing multiple barriers to access including problems with language, child care, transportation, and other financial stresses.40,53,55,56 Children with Medicaid face obstacles including a limited number of providers willing to accept Medicaid patients57 and longer waits to get appointments, particularly in California,58,59 which ranks in the bottom fifth of states in the percentage of pediatricians who accept all Medicaid patients who contact them.60
Our evidence suggests that home visits were more likely to be timely than office visits, although only 10.5% of early-discharged newborns received home visits. Home visits may provide easier access to newborn follow-up care for mothers who have problems with transportation, child-care, lack of support, long waits for office appointments, fatigue, or their own postpartum medical issues. Additionally, mothers who receive newborn home visits report greater satisfaction than those with routine office care.4,35,41 However, some women do not want home visits,8,25 and some high-risk patients may be difficult to reach for home visits. Although the higher costs of home visits relative to office visits may explain their lower utilization,9,41,61 home visiting may be cost-effective if it reduces acute care visits and rehospitalizations62 or safely allows for shorter hospital stays,63 and may be particularly appropriate for providing recommended early follow-up to newborns in low-income families, who may be more likely to experience a number of the obstacles noted above.
One can feel reasonably confident that our results reflect the statewide situation in California, given the large, population-based nature of the MIHA survey. Our data relied on maternal self-reports to define the number of nights the infant stayed in the hospital and days of age at follow-up, measures that can only approximate a range of hours and may not be accurately recalled; however, there is no reason to suspect a systematic bias in the reporting of LOS according to maternal characteristics such as income level. Our method of defining early discharge as a 0- to 1-night stay has been used by others,1 and provides a conservative estimate of the number of newborns with stays <48 hours (the criteria used by the AAP, NMHPA, and NMHA); thus, the prevalence of early discharge may have been underestimated. Our method for conservatively defining untimely follow-up may also have led to underestimates of the prevalence of untimely follow-up; when we increased the window for timely follow-up from 2 days to 1 week after discharge, however, 44% of early-discharged newborns still lacked timely follow-up.
Because newborns in our sample were not randomized to receive early versus later discharge and timely versus untimely follow-up, unmeasured variables are likely to have influenced selection into these groups. Although we attempted to exclude newborns with significant medical problems, we were not able to measure medical factors such as presence of jaundice that may have affected LOS and follow-up. Our sample probably did include some newborns with medical problems, as suggested by the small proportion of newborns with LOS >6 days. However, there were no substantial differences in our results when analyses of timing of discharge excluded newborns with longer than average stays (those staying >3 nights for vaginal deliveries or >5 nights for cesarean deliveries) who presumably were sicker (data not shown).
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Despite AAP guidelines and state and federal early-discharge legislation, many newborns continue to be discharged early and most do not receive recommended and mandated timely follow-up after early discharge. We observed a pattern of postnatal primary care services that appears inequitable: early discharge and lack of untimely follow-up after early discharge were particularly likely among newborns from low-income and Latina families, those covered by Medicaid, and those whose mothers were most likely to face language barriers. Legislation does not appear to have adequately addressed the lack of timely follow-up services for most early-discharged newborns, particularly socioeconomically vulnerable newborns. Additional research and consensus-building are needed to develop an optimal and equitable evidence-based approach to newborn LOS and follow-up, so that policy and practice regarding postnatal services can best promote the health and well-being of all newborns.
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ACKNOWLEDGMENTS |
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This work was done while Dr Galbraith was a Fellow at the Institute for Health Policy Studies at the University of California, San Francisco, with funding support from National Research Service Award T32 HS00086–03 from the Agency for Healthcare Research and Quality, and subsequently as a Robert Wood Johnson Clinical Scholar at the University of Washington, with funding support from the Robert Wood Johnson Foundation. Participation by Drs Egerter and Braveman and Ms Marchi was funded primarily by the Maternal and Child Health Bureau of the Health Resources and Services Administration (grant MCJ-067951).
We thank Colin Sox, MD, Hal Luft, PhD, and the Writing Seminar at the Institute for Health Policy Studies at UCSF for helpful comments on earlier drafts. We greatly appreciate the help of Carol Miller, MD, of UCSF, in piloting the MIHA survey.
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FOOTNOTES |
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Received for publication Feb 27, 2002; Accepted Aug 29, 2002.
Address correspondence to Alison A. Galbraith, MD, Robert Wood Johnson Clinical Scholars Program, University of Washington, H-220 Health Sciences Center, Box 357183, Seattle, WA 98195-7183. E-mail: agalb{at}u.washington.edu
The analyses, interpretations, and conclusions of this article are solely the product of the authors and do not necessarily represent the views of the California Department of Health Services or the State of California.
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