Background. Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up visit on the third or fourth postpartum day, but scant evidence exists about whether home or clinic visits are more effective.
Methods. We enrolled 1163 medically and socially low-risk mother-newborn pairs with uncomplicated delivery and randomly assigned them to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the third or fourth postpartum day. In contrast with the 20-minute pediatric clinic visits, the home visits were longer (median: 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother.
Clinical utilization and costs were studied using computerized databases. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks' postpartum.
Results. Comparing the 580 pairs in the home visit group and the 583 pairs in the pediatric clinic visit group, no significant differences occurred in clinical outcomes as measured by maternal or newborn rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interview. The same was true for a combined clinical outcome measure indicating whether a mother-newborn pair had any of the above outcomes. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs 44%), the provider's skills and abilities (87% vs 63%), the newborn's posthospital care (87% vs 59%), and their own posthospital care (75% vs 47%). On average, a home visit cost $255 and a pediatric clinic visit cost $120.
Conclusions. For low-risk mothers and newborns in this integrated health maintenance organization, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.
During the past decade, postpartum hospital stays of 48 hours or less have become common practice throughout the United States. Recently enacted federal legislation mandates insurance coverage of at least 48 hours of hospitalization after vaginal delivery. However, it has been observed that even with a 48-hour coverage law in effect, most mothers and newborns with uncomplicated delivery continue to go home before the third postpartum day.1
For newborns discharged within 48 hours, national committees have recommended a follow-up visit within 48 hours by an experienced clinician because key physiologic events, including the peak of neonatal bilirubin and the increase in breast milk production, often occur on the third or fourth postpartum day.2Hyperbilirubinemia, dehydration, and feeding problems are the leading causes of morbidity and clinical service utilization in the early postnatal period.3,,4 National guidelines do not address whether the follow-up visit at 3 to 4 days postpartum should take place in the home or clinic setting. Current practices for posthospital follow-up of low-risk mothers and newborns vary widely.5,,6
Studies from Sweden and the United States during the 1970s and 1980s suggested that early postpartum discharge (at 48 hours or less) followed by at least 2 home visits was as effective as more prolonged hospital stays among carefully selected populations.7–10These results are difficult to apply to the current situation in which short postpartum hospital stays are standard for most deliveries in the United States. Early postpartum home visiting is universal in many European countries,11,,12 but has not been rigorously evaluated because its value has been assumed to be obvious. Studies of socially high-risk US mothers and newborns show improved outcomes with repeated prenatal and postpartum home visits.13,,14However, the high-intensity services in these studies would not be offered to low-risk populations because even a single nurse home visit is believed to be more costly than a pediatric clinic visit.
In the context of routine postpartum hospital stays of 48 hours or less, information is lacking on whether a single postpartum home visit is more effective than a similarly timed clinic visit. This question has been addressed by only 1 previous study, a retrospective analysis of medical records comparing low-risk mother-newborn pairs before and after implementation of a routine home visiting program in a university hospital population. This study found a decrease in the proportion of newborns brought for acute care visits in the home visit group compared with a clinic visit group, but the retrospective design made the findings inconclusive.15
This study's aim was to compare the clinical outcomes, maternal satisfaction, and costs of home visits and pediatric clinic follow-up visits given on the third or fourth postpartum day to low-risk mothers and newborns with postpartum hospital stays of 48 hours or less.
Low-risk mothers and newborns who delivered at the Kaiser Foundation Hospital in Sacramento, California during July 1996 through September 1997 were the target population. This hospital is linked to 5 Kaiser Permanente (KP) outpatient clinics. Low-risk newborns whose families planned to seek follow-up care at the Sacramento, Davis, Roseville, or South Sacramento clinics were eligible. Mothers and newborns were excluded if they planned to receive follow-up at KP's Rancho Cordova clinic because routine follow-up care at that site involved group pediatric clinic visits rather than the individual pediatric clinic visits used at the other sites.
Eligibility was restricted to those mother-newborn pairs whose hospital length of stay was expected to be 48 hours or less based on the hospital's clinical protocol for selecting mothers and newborns at low medical and social risk, which was similar to the guidelines published by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists.2 We excluded mother-newborn pairs for medical reasons if the infant weighed <2500 or >4600 g at birth, had stayed in the intensive care nursery, or if the mother or infant had a medical problem that warranted follow-up by a pediatrician or nurse practitioner. By clinical protocol, pediatricians ordered complete blood counts only for newborns with medical problems, eg, rule out sepsis. Newborns with a hematocrit of <40 or an absolute neutrophil count of <7000 at any time were ineligible for this study. We excluded mothers and newborns whose anticipated length of stay was >48 hours, usually due to cesarean delivery.
We excluded potential subjects for social reasons if the mother was 14 years old or younger; was 15 to 17 years old without a parent or guardian available for informed consent; had a positive toxicology screen for drugs of abuse after admission to labor and delivery; or if a social worker had requested, before eligibility assessment for the study, that a home visit be done. We also excluded pairs if the mother spoke a language other than English or Spanish, the newborn was not covered by the health maintenance organization (HMO) or was being adopted, the family lived outside the area served by the home health nurses, was not reachable by telephone, or was in the process of moving. For those mother-newborn pairs with multiple reasons for exclusion, we recorded only the first reason for exclusion on a hierarchically-ordered list of exclusions.
Enrollment and Interventions
Seven days a week, research nurses on the postpartum hospital floor reviewed charts and approached eligible mothers whose discharge was anticipated that day. To minimize any potential effects on the mother's length of hospital stay, the research nurses attempted to enroll mothers after the decision to discharge them had been made. For each enrolled mother, the research nurse completed informed consent and a baseline interview, then assigned the mother and newborn to either a pediatric clinic visit (usual care) or a home visit using a series of sealed, opaque, sequentially numbered envelopes containing study group assignments determined in advance by a random number generator. Once randomized, the mother-newborn pair was included in all analyses.
We assigned each newborn in the control group to usual follow-up care, a 20-minute pediatric clinic visit within 48 hours after hospital discharge. Nurse practitioners and pediatricians at 4 clinics conducted the visits, which included history and physical examination of the newborn, anticipatory guidance, and laboratory testing if indicated.
We assigned each mother-newborn pair in the intervention group to a home visit within 48 hours after hospital discharge by a registered nurse or public health nurse from the HMO's home health department. The 7 home health nurses who delivered these visits were registered nurses and public health nurses who had received 30 hours of training in newborn care 1 year before the study. The month before the study, the home health nurses were given an additional 16 hours of didactic instruction and preceptorship in breastfeeding, newborn and maternal history and physical examination, and anticipatory guidance. The clinical protocol and a standardized charting form specified the recommended elements of history, physical examination, and anticipatory guidance for the home visits, which were intended to last 60 to 90 minutes. The protocol was based on recommendations in Bright Futures, a national guideline document for preventive maternal and child health care.16
Research nurses used chart review and the enrollment interview on the postpartum floor to collect baseline data on clinical and demographic variables, as well as on maternal experiences and perceptions about prenatal care and breastfeeding. At 2 weeks' postpartum, a research interviewer contacted each mother by telephone to conduct a 15-minute interview about breastfeeding, other outcomes, and satisfaction. Race/ethnicity was self-reported with the mother asked to name all racial or ethnic identifications that applied; for analysis, respondents were categorized as white (non-Hispanic), black, Hispanic, Asian, multicultural white, or multicultural non-white (categorization algorithm available on request). The Center for Epidemiologic Studies Depression Scale (CES-D), a widely used 20-item instrument that has been validated in English and Spanish, was used to evaluate maternal depressive symptoms using a cutoff score of 16 or more.17,,18 Questions on satisfaction with care were modified from a validated instrument developed for the Group Health Association of America.19 We conducted a second telephone interview focusing on breastfeeding at 12 weeks' postpartum.
Clinic visits, emergency department (ED) visits, and hospitalizations were identified using the HMO's computerized databases. The average regional costs of these services were derived using the HMO's computerized Cost Management Information System, which estimates the costs of each unit of service (eg, a 10-minute urgent clinic visit) using standard step-down accounting methods. Personnel time, supply costs, and administrative overhead are factored into the cost of each unit of service. The cost of home health visits was estimated based on personnel time, mileage, space, administration, and overhead costs using methods similar to those used in the Cost Management Information System.
We used the HMO's computerized databases to identify rehospitalization, ED visits, and urgent clinic visits by the mother or newborn during the 10 days after delivery. The 2-week interview contributed information on breastfeeding discontinuation and maternal depressive symptoms. A combined clinical outcome measure was considered present if either the mother or the newborn had experienced any of the above outcomes.
Because widely-accepted severity scoring systems for rehospitalized newborns do not exist, 2 pediatrician investigators (T.A.L. and G.J.E.) assigned severity of illness for each newborn rehospitalization after blinded review. Initial severity assignment relied on laboratory test results at the time of hospital readmission. We used a predefined classification system from a prior study; the system was based on the consensus of 3 physicians (a neonatologist, a pediatric health services researcher, and a pediatric infectious disease specialist). We reviewed medical records for those cases with discharge diagnoses other than hyperbilirubinemia, dehydration, and rule out sepsis, and revised severity assignments when appropriate. Maternal satisfaction was assessed using questions from a validated instrument on consumer satisfaction modified to address perinatal needs and services.
The initial sample size was selected to have 80% power to identify a 20% reduction in newborn urgent clinic visits at a 2-tailed α of .05. The primary analysis assigned patients by intention-to-treat. In preliminary analyses, we evaluated group differences using the χ2 test for categorical variables, and the Student's t test or the Wilcoxon rank-sum test for continuous variables. In the final analyses, we evaluated group differences in clinical outcomes and maternal satisfaction using multivariate logistic regression models to adjust for any differences in predictor variables observed in preliminary analyses.
Of the 3199 deliveries at the Kaiser Foundation Hospital in Sacramento during the study period, 402 were ineligible because they planned follow-up at the Rancho Cordova clinic, which was not included in the study. Among the remaining 2797 mothers, 1506 (54%) were eligible. Among the 2797 mother-newborn pairs, we excluded 564 (20%) for medical risk factors such as gestational age <36 weeks, 371 (13%) for anticipated length of stay of 48 hours or more (usually due to cesarean delivery), 78 (3%) for social risk criteria, and 278 (10%) for logistic reasons. Of the 1506 eligible mothers, 75 (5%) were not approached, usually because the mother was discharged before a research nurse could contact her.
Of the 1431 mothers who were offered enrollment, 1163 (81%) accepted. Those who declined enrollment did not differ from enrollees with respect to the infant's birth weight, Apgar scores, the mother's race/ethnicity, or the newborn's length of stay. Mothers who enrolled were slightly older than those who declined (median: 28 vs 86 years;P = .016).
Among enrolled mother-newborn pairs, we assigned 580 to home visits and 583 to pediatric clinic visits as routine follow-up within 2 days after hospital discharge. As Fig 1 shows, 96% of pairs in each group actually received the type of follow-up visit they were assigned. Two percent of the home visit group and 4% of the clinic visit group received no preventive follow-up visit. The home health visits had a median length of 70 minutes and required a median 1-way travel time of 30 minutes. Among those mother-newborn pairs who either were not approached or declined enrollment, 97% made a pediatric clinic visit at 2 to 5 days of life.
The randomized groups had 2 significant differences in demographic characteristics and prenatal experiences (Table 1). Mothers assigned to home visits were slightly less likely to have initiated prenatal care during the first 3 months of pregnancy (89% vs 93%; P = .03) and to have at least a high school degree (91% vs 94%; P = .05). All additional analyses were conducted both as unadjusted and adjusted for these variables.
No significant differences occurred between the groups assigned to home versus clinic visits in proportions experiencing maternal or newborn rehospitalization or urgent clinic visits during the first 10 postpartum days (Table 2). The 2-week telephone interview was completed with 1147 (99%) of enrolled mothers. Among mothers who initiated breastfeeding, a lower proportion of the home visit group (18%) than of the clinic visit group (22%) discontinued it by 2 weeks, but the difference was not statistically significant (P = .10). No group differences occurred in the proportion with maternal depressive symptoms at the 2-week interview. Among the home and clinic visit groups, similar proportions experienced the combined clinical outcome measure, which was scored as positive if either the mother or newborn had any of the above outcomes (Table 2, 56% vs 55%; P = .78).
Among newborns who were rehospitalized, the severity of illness at the time of hospital admission did not differ between the home visit and clinic visit (P = .36 by Fisher's exact test). Of the 31 rehospitalized newborns, 10 had mild illness, 15 had moderate illness, and 6 had severe illness based on chart review and laboratory studies at the time of admission. The most common principal diagnoses for rehospitalized newborns were jaundice (International Classification of Diseases, Ninth Revision [ICD-9] codes 773 and 774) and rule out sepsis (ICD-9 code V29.0). None of the rehospitalized infants required mechanical ventilation; all were discharged to home. The length of hospital stay did not vary between rehospitalized newborns in the home visit and clinic visit groups (median: 2 days for both groups; P = .77 by Wilcoxon rank-sum test).
The home and clinic visit groups did not differ in the proportion of mothers who made any calls to the pediatric advice nurse during the first 2 weeks (54% vs 54%) or in the numbers of calls the mothers made. For each clinic or ED visit other than the preventive follow-up visit, mothers were asked whether the visit was a) recommended by a doctor or nurse at a previous visit, or b) made for a new problem noticed by the family. Although there were no differences between groups in the incidence of urgent newborn visits, mothers in the home visit group were more likely to report that the newborn had made an urgent visit for a new problem noticed by the family as opposed to for a problem noted by a clinician (17% vs 12%; P= .03).
Maternal Satisfaction and Costs
Mothers in the home visit group were more likely than those in the clinic visit group to rate multiple aspects of their care as excellent or very good (Table 3). These included the preventive advice delivered (80% vs 44%; P = .001) and the skills and abilities of the provider (87% vs 63%;P = .001). In addition, mothers in the home visit group gave higher ratings on overall satisfaction with the newborn's posthospital care (87% vs 59%; P = .001), their own post-hospital care (75% vs 47%; P = .001), and on the overall perinatal care received by them and the newborn (80% vs 68%; P = .001). They were also more likely to say that their overall opinion of the HMO was “much better” as a result of their experience of having a baby (26% vs 21%;P = .02).
The estimated cost of a postpartum home visit to the mother and newborn was $255. In contrast, the cost of a 20-minute pediatric clinic visit was $120. Because the pediatric clinic visits did not formally address the medical needs of the mother, we also evaluated the cost of a 10-minute visit to the obstetric-gynecologic clinic; this was estimated at $82.
We conducted analyses limited to subgroups with demographic risk factors, including first-time mothers, first-time breastfeeders, mothers with less than a high school degree, families with income ≤200% of the federal poverty level, non-white mothers, teenage mothers, mother-newborn pairs with postpartum hospitalization of 24 hours or less, and mothers with their first prenatal care visit after the first trimester. These subgroup analyses found no significant differences on the combined clinical outcome measure. Breastfeeding discontinuation among first-time breastfeeders did not differ between the home and clinic visit groups (25% vs 27%; P = .60).
Compared with pediatric clinic visits on the third or fourth postpartum day, similarly timed home visits for low-risk mothers and newborns were more costly, but had equivalent clinical outcomes and markedly higher maternal satisfaction. These findings suggest that either type of follow-up is clinically acceptable among medically and socially low-risk patients with good access to care. However, mothers who received home visits reported markedly greater satisfaction not only with the visit itself, but also with their overall maternal and newborn postpartum care.
Clinical and Legislative Context
In January 1998, a federal law (the Bradley bill) mandating insurance coverage of 48 hours of postpartum hospitalization after uncomplicated vaginal delivery took effect nationally.20The same month, a California law (the Figueroa legislation) took effect that had the same provision for coverage of up to 48 hours of postpartum hospitalization but additionally mandated insurance coverage of a follow-up visit either at home or in clinic for both the mother and newborn (not only the newborn) within 48 hours if the postpartum hospital stay was <48 hours.21 The California legislation implies that in settings such as this HMO where outpatient obstetric and pediatric services are delivered in separate clinics, clinic-based follow-up would require 2 visits: 1 visit for the mother and 1 visit for the newborn. In this case, the cost of a home visit, which includes care for both the mother and newborn, would be more similar to those of clinic-based care.
This study was conducted shortly before the federal and California state laws took effect. The mean postpartum hospital stay among the mothers and newborns we studied was approximately 30 hours. After Massachusetts implemented similar length-of-stay legislation in 1996, it found that 45% of vaginal deliveries were discharged before 48 hours and the average length of stay was 49.5 hours.1Thus, even with the federal legislation in effect, postpartum hospitalization in uncomplicated vaginal deliveries seems unlikely to extend beyond the second postpartum day. Because important physiologic changes, including the peak of jaundice and the increase in breast milk production, occur on the third or fourth postpartum day, an increase in length of stay to 48 hours may not have important clinical consequences. If it did have an effect, a longer postpartum stay would tend to narrow any differences in clinical outcomes between the home and clinic visit groups. Hence, this study's findings of equivalent clinical outcomes are generalizable to the current situation.
Several aspects of the home and pediatric clinic visits were not equivalent, and we could not assess their independent effects. The home visits were scheduled to last 1 hour or more, in contrast with the 20-minute pediatric clinic visit. The protocol for the home health visits' content was more rigorously standardized and most likely devoted more time to anticipatory guidance. The home visits routinely included a brief physical examination and discussion of health needs of the mother, a service that would not be routine in pediatric clinic visits.
Mothers may have preferred the home visits because of their greater convenience, inclusion of preventive counseling about the home environment, inclusion of care specifically focused on the mother, and/or longer visit time. Clinic visits might have achieved higher maternal satisfaction if they had been lengthened to 1 hour and designed to address the physical needs of the mother as well as the newborn. However, this would substantially increase the cost of a clinic visit and would be considered impractical in most standard pediatric clinic settings. In this study's HMO setting, the $255 cost of the home visit to mother and newborn—2 new patients—appears to fall within the nationally-reported range (median: $70–$212 for each new patient visit).22 The $120 cost of a 20-minute pediatric clinic visit was also in range of the $47 to $164 median cost of new patient office visits nationally.22
Another major difference between the home and clinic visits was the type of provider. The home health nurses in this study, although experienced in home health care for adults, had less training and experience in pediatric care than the nurse practitioners and physicians in the pediatric clinic. Despite recruitment efforts, the home health department in this geographic area was unable to hire more experienced pediatric or postpartum home health nurses. The home visits might have achieved better clinical outcomes if nurse practitioners or physicians, or more experienced pediatric home health nurses, had made them. However, physician or nurse practitioner home visits would be much more costly, and many geographic areas may have limited availability of experienced pediatric home health nurses. This study's approach of giving additional training to experienced adult home-health nurses was considered more generalizable than one relying on a type of provider that would not be widely available.
This study was unique in comparing the effectiveness and costs of the 2 major clinical approaches to postdischarge follow-up currently provided for mothers and newborns with postpartum hospital stays of 48 hours or less. The results raise several issues that deserve further exploration. Although 88% of all mothers in this study initiated breastfeeding, 19% of those who started breastfeeding had stopped by 14 days after delivery. These findings are similar to those in a previous study in this HMO23 and highlight the need for additional research on breastfeeding promotion. One in 5 mothers had depressive symptoms on the telephone interview at 14 days' postpartum; this was higher than the 9% reported in a previous study using telephone surveys at 3 weeks' postpartum in a Massachusetts HMO.24 Although the CES-D has been validated in many populations, it has not been extensively used in postpartum mothers; however, it is the most reliable measure currently available. These results suggest that postpartum depressive symptoms, even when not diagnosed as full-blown postpartum depression, are common and deserve more study to identify effective interventions.
This study's major limitation stems from the low-risk population and setting in which it was conducted. The mothers in the study had diverse racial/ethnic backgrounds, but nearly two-thirds had at least some college education and <10% had less than a high school degree. The HMO in this study primarily serves families with employment-based, comprehensive health insurance coverage; the study population's median income was higher than that of the general population. Social and medical screening criteria for the study were fairly stringent; only about half of all births at the facility during the study period were considered eligible.
The setting for this study, an integrated HMO, could have played a major role in the outcomes observed. Patients had ready access to telephone advice from nurses and urgent care clinic services for both newborn and mother. The results cannot be generalized to more socioeconomically disadvantaged populations, to families who receive less coordinated or more limited health care services, or to settings with less careful procedures for identifying social or medical risk. Additional research is needed on the effects of alternative postpartum services in higher-risk populations, as well as on group preventive visits and on other postpartum services to promote optimal maternal and newborn health.
It is also important to note that the comparison tested in this study was between a home visit and a clinic visit within 2 days after postpartum discharge; there was not an arm of the study in which mothers and newborns were assigned to receive no routine follow-up on the third or fourth postpartum day. A separate study we conducted suggests that routinely providing follow-up visits within 48 hours after early postpartum discharge results in better outcomes than not consistently providing follow-up visits.25 The results of the previous and current study do not suggest that early postpartum discharge without early clinical follow-up is either safe or advisable.
The study's sample size had better than 80% power to identify a relative difference of 20% in the combined outcome measure between groups, but it had more limited power to identify differences between subgroups. It had only 6% power to detect a 20% relative difference in newborn rehospitalization rates. To detect a 20% relative reduction in a newborn rehospitalization rate of 2% with 80% power, >17 000 newborns would be needed in each group.
For low-risk mothers and newborns in this integrated HMO, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to less affluent or otherwise higher-risk populations without comparable access to integrated hospital and outpatient care.
For home visits, the value of higher maternal satisfaction with the postpartum experience will need to be weighed against their additional cost. Decisions among alternative postpartum follow-up services ideally should incorporate the perspectives of all parties in these decisions, including clinicians, insurers, and the mothers and families themselves.
This work was supported by the Innovation Program of Kaiser Permanente, Northern California, Grant MCJ 067951 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services, and the Agency for Healthcare Research and Quality.
We are grateful to Susan Egerter, PhD, and Kristen Marchi, MPH, of the Department of Family and Community Medicine at the University of California, San Francisco, for their thoughtful advice on the design and interpretation of this study. We greatly appreciate the efforts of Bev Johnson, RN, Barbara Mitchell, PHN, and many other nurses and staff of the Kaiser Permanente home health group who developed and implemented the home health visits. This research relied on the excellent work of our research nurses, Linda Miller, RN, Susan Abbott-Rogge, NP, Sandra Bartlett, RN, and our research assistants, Kate Delaplane, Heather Malm, and Ritu Mukerji.
We thank Colleen Hendershott, MD, for advice on obstetric protocols and services, and Cindy Bastian, LVN, CLE, for conducting training in breastfeeding support. This study would not have been possible without the support of Karla Meeink, RN, and the postpartum floor staff of Kaiser Permanente's Sacramento hospital. We are grateful to Peter Juhn, MD, Paul Phinney, MD, James Makol, MD, Donald Bouchard, MD, and the Sacramento area pediatricians, obstetrician-gynecologists, and nurse practitioners of Kaiser Permanente for their support. We acknowledge the very helpful input of our study advisors, David Grimes, MD, William Oh, MD, and Anita Stewart, PhD, and Haya Rubin, MD, MPH. Nancy Krieger, PhD, advised us on the analysis of race/ethnicity data, and Lynn Ackerson, PhD, provided biostatistical consultation. We thank Francis J. Crosson, MD, for his sponsorship, and Joe Selby, MD, MPH, for advice and support throughout the study.
- Received March 25, 1999.
- Accepted July 21, 1999.
Reprint requests to (T.A.L.) Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, 126 Brookline Ave, Ste 200, Boston, MA 02215. E-mail:
- KP =
- Kaiser Permanente •
- HMO =
- health maintenance organization •
- CES-D =
- Center for Epidemiologic Studies Depression Scale •
- ED =
- emergency department •
- ICD-9 =
- International Classification of Diseases, Ninth Revision.
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- ↵American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG). Postpartum and follow-up care. In: Hauth JC, Merenstein GB, eds. Guidelines for Perinatal Care. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997
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- ↵Bradley W. Newborns' and Mothers' Health Protection Act of 1996 (HR-3666). Title VI of Public Law 104-204. Washington, DC: United States Government Printing Office; 1996
- ↵Figueroa E. California State Assembly. Assembly Bill No. 38: Chapter 389. Newborns' and Mothers' Act of 1997. August 26, 1997
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