Abstract
Objective. Short postpartum stays are common. Current guidelines provide scant guidance on how routine follow-up of newly discharged mother–infant pairs should be performed. We aimed to compare 2 short-term (within 72 hours of discharge) follow-up strategies for low-risk mother–infant pairs with postpartum length of stay (LOS) of <48 hours: home visits by a nurse and hospital-based follow-up anchored in group visits.
Methods. We used a randomized clinical trial design with intention-to-treat analysis in an integrated managed care setting that serves a largely middle class population. Mother–infant pairs that met LOS and risk criteria were randomized to the control arm (hospital-based follow-up) or to the intervention arm (home nurse visit). Clinical utilization and costs were studied using computerized databases and chart review. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks postpartum.
Results. During a 17-month period in 1998 to 1999, we enrolled and randomized 1014 mother–infant pairs (506 to the control group and 508 to the intervention group). There were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, early initiation of prenatal care, or postpartum LOS. There were no differences with respect to neonatal LOS or Apgar scores. In the control group, 264 mother–infant pairs had an individual visit only, 157 had a group visit only, 64 had both a group and an individual visit, 4 had a home health and a hospital-based follow-up, 13 had no follow-up within 72 hours, and 4 were lost to follow-up. With respect to outcomes within 2 weeks after discharge, there were no significant differences in newborn or maternal hospitalizations or urgent care visits, breastfeeding discontinuation, maternal depressive symptoms, or a combined clinical outcome measure indicating whether a mother–infant pair had any of the above outcomes. However, mothers in the home visit group were more likely than those in the control group to rate multiple aspects of their care as excellent or very good. These included the preventive advice delivered (76% vs 59%) and the skills and abilities of the provider (84% vs 73%). Mothers in the home visit group also gave higher ratings on overall satisfaction with the newborn's posthospital care (71% vs 59%), as well as with their own posthospital care (63% vs 55%). The estimated cost of a postpartum home visit to the mother and the newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother–infant pair; the cost of an individual 15-minute visit with a registered nurse was $52; the cost of a 15-minute individual pediatrician visit was $92; and the cost of a 10-minute visit with an obstetrician was $92.
Conclusions. For low-risk mothers and newborns in an integrated managed care organization, home visits compared with hospital-based follow-up and group visits were more costly but achieved comparable clinical outcomes and were associated with higher maternal satisfaction. Neither strategy is associated with significantly greater success at increasing continuation of breastfeeding. 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.
- KPMCP =
- Kaiser Permanente Medical Care Program •
- LOS =
- length of stay
Recently enacted federal legislation mandates insurance coverage of at least 48 hours of hospitalization after uncomplicated delivery of a newborn.1 In California, new legislation also mandates insurance coverage for maternal and neonatal follow-up visits within 48 hours if the postpartum hospital stay was <48 hours. Although the legislation's passage removed the political spotlight from postpartum care, important gaps in clinical knowledge remain. National guidelines focus primarily on the prevention of catastrophic morbidity (eg, severe hyperbilirubinemia, dehydration).2They provide far less guidance on how, where, and by whom routine follow-up of newly discharged mother–infant pairs should be performed to achieve optimal health outcomes.3–6
One potentially promising approach to providing postpartum follow-up of low-risk mother–infant pairs is to offer visits to groups of mothers and their infants. Although the concept of group (or “cluster”) visits in medicine may be gaining popularity because such visits are considered less expensive,7 use of this strategy antedates the current cost-conscious era.8 In pediatrics, the major reason for advocating group visits has been a concern with the limited amount of information transmitted in routine, one-on-one interchanges.9 ,10 Because a group visit permits more time for patients to absorb information, it is theoretically advantageous for handling situations in which the educational needs of a group of patients are similar. Consequently, group visits have been advocated for various populations, including those who have diabetes,7 those who are obese,11 older people with chronic illnesses,12 and the parents of pediatric patients who require anticipatory guidance.13
Past studies have evaluated the effectiveness of home visits for postpartum follow-up, usually in comparison with extended hospitalization or outpatient clinic visits.14–19However, we are unaware of any randomized studies that have compared group visits with home visits for postpartum follow-up. In 1996, the Department of Pediatrics at the Kaiser Permanente Medical Center in Santa Clara, California, implemented an innovative hospital-based program and changed its standard of care, offering group visits as routine postpartum follow-up. Taking advantage of the experience that we acquired in 2 recent studies,14 ,20 we compared this model with the use of home visits using a randomized, controlled trial study design. As was the case in our first trial, the population of interest consisted of low-risk mothers and newborns with postpartum hospital stays of 48 hours or less.
METHODS
Study Population
The target population consisted of low-risk mothers and newborns who delivered at the Kaiser Foundation Hospital in Santa Clara, California, during July 1998 through November 1999. All of these infants are cared for by the same Department of Pediatrics, which provides care at the Santa Clara, Mountain View, Marina Playa, and Milpitas clinics. Low-risk newborns whose families planned to seek follow-up care at these clinics were eligible. Mothers and newborns were excluded if they lived outside the Kaiser Permanente Medical Care Program (KPMCP) Santa Clara Home Health service area. Eligibility was restricted to those mother–infant pairs whose hospital length of stay (LOS) 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. This protocol is based on the guidelines published by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists.21
We excluded mother–infant pairs for medical reasons if the infant weighed <2500 or >4600 g at birth, was <36 or >42 weeks' gestation, or was admitted to the intensive care nursery or if the mother or the infant had a medical problem that warranted special follow-up by a pediatrician or a 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 LOS was >48 hours, usually because of cesarean delivery.
We excluded potential patients for social reasons: if the mother was 14 years old or younger; was 15 to 17 years old without a parent or a 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 of patients if the mother did not speak English; the newborn did not have Kaiser Foundation Health Plan, Inc, coverage or was being adopted; or if 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–infant pairs with multiple reasons for exclusion, we recorded only the first reason for exclusion on a hierarchically ordered list of exclusions.
The study was approved by the Kaiser Permanente Institutional Review Board for the Protection of Human Subjects. Written informed consent was obtained from all study subjects.
Hospital-Based Follow-up at the KPMCP Santa Clara Medical Center
Unless an infant is considered to be at high risk, first-time mothers at the KPMCP Santa Clara Medical Center are offered a package of services within 72 hours after discharge. These services are referred to as “the Newborn Club” and include group visits, one-on-one clinic visits, breastfeeding consultation, and prompt access to a neonatologist if necessary. The Newborn Club originally was funded as a demonstration project by the Kaiser Permanente Innovation Program to foster breastfeeding and to decrease short-term (within 2 weeks of birth) neonatal morbidity.22 Subsequently, the Santa Clara Medical Center elected to continue funding this program, making it the standard of care. This decision was based in part on the results of the Innovation project and on the experience of two other KPMCP facilities (Redwood City and Walnut Creek), which had used this approach for infant well-child visits and lactation counseling.
The Newborn Club, located at the Santa Clara facility, operates 7 days a week and focuses on the needs of first-time mothers. However, all women who are served by the Department of Pediatrics are given the option to participate in the group visit, which consists of a 1½- to 2-hour session that focuses on the newborn. Limited time is spent on maternal topics. Postpartum care or physical examination of the mother is not provided, although mothers may be referred to the Obstetrics and Gynecology clinic if necessary. Up to 8 mother–infant pairs can attend each session, although typical sessions involve 5 to 6 pairs. Sessions are led by a registered nurse who also is a certified lactation educator.
Physical assessment of the newborn occurs during the first 10 to 15 minutes of the group visit. The nurse weighs the infant and performs a partial physical examination that emphasizes checking the following: color, turgor, tone, condition of cord, head, fontanel, presence of eye drainage or clavicle fracture, any obvious deformities, and strength and quality of suck. If serious abnormalities are found, then the on-call neonatologist is paged immediately. For mild degrees of jaundice, the Newborn Club nurse notifies the on-call neonatologist and may order a serum bilirubin test. Home phototherapy is available at the neonatologist's discretion. The remaining time is spent on breastfeeding and basic infant care (eg, taking a temperature, when to call the advice nurse), preventive education, and anticipatory guidance. Women are instructed to nurse 8 to 12 times in 24 hours for 10 to 15 minutes per breast. The number of minutes per breast is an average and depends on the infant's weight and other characteristics. Whether the infant is receiving adequate nourishment also is reviewed (by recounting an individual infant's recent breastfeeding frequency and having parents count the number of wet diapers). Women with breastfeeding problems usually stay an additional 10 to 15 minutes after the group visit to discuss their specific concerns.
Women who have had a previous child may opt to have a 15-minute individual provider visit at the Newborn Club rather than the group visit. Women who have many children may elect to have telephone follow-up only, although the latter option rarely is exercised. Some multiparous women elect to attend the group visit if they did not breastfeed their previous infant or to have their partners learn about infant care and breastfeeding.
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 of study participation on the mother's LOS, 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–infant pair to either hospital-based follow-up (the Newborn Club) or to a home health 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–infant pair was included in all analyses in the group to which they initially were assigned, regardless of actual care received.
We assigned each newborn in the control group to usual hospital-based follow-up care. We assigned each mother–infant pair in the intervention group to a home health visit within 48 hours after hospital discharge by a registered nurse from the KPMCP Home Health department. The month before the study, the home health nurses were given 20 hours of didactic instruction and 2-week-long preceptorships in breastfeeding instruction, newborn and maternal history and physical examination, and postpartum 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 home visit protocol was based on recommendations in Bright Futures, a national guideline document for preventive maternal and child health care,23 and included the following elements: 1) a general assessment of the home environment and mother–infant interaction; 2) obtaining a history and conducting a focused physical examination of both the newborn (to assess for signs of dehydration or jaundice) and the mother (which included examining the breasts, fundus, and perineum); 3) weighing the infant; 4) assessing feeding of the infant, using the LATCH score24 if appropriate; 5) providing instruction on infant care, infant feeding, maternal physical care, and maternal emotional changes; and 6) when necessary, drawing blood for bilirubin testing and arranging for follow-up of test results, including discussing results with the on-call neonatologist.
Data Collection
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 (eg, maternal depressive symptoms), and satisfaction with care received. Information on race/ethnicity was obtained from the KPMCP hospitalization database, which categorizes self-reported race/ethnicity according to the standard scheme used in California birth certificates. For analysis, respondents were classed as white (non-Hispanic), black, Hispanic, Asian/Pacific Islander, or other race. The Center for Epidemiologic Studies Depression Scale, a widely used 20-item instrument that has been validated in English and in Spanish, was used to evaluate maternal depressive symptoms. A cutoff score of 16 or more was considered to indicate the presence of a significant level of depressive symptoms.25 ,26 Questions on satisfaction with care were modified from a validated instrument developed for the Group Health Association of America.14 ,27
Clinic visits, emergency department visits, and hospitalizations were identified from KPMCP computerized databases using techniques that we have described elsewhere.28–35 The average regional costs of these services were derived using the KPMCP'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 on the basis of personnel time, mileage, space, administration, and overhead costs using methods similar to those used in the Cost Management Information System.
Outcome Measures
The primary study outcome was a combined clinical outcome measure that was considered present if either the mother or the newborn experienced any of the following: 1) rehospitalization, emergency department use, or urgent clinic visit use within 10 days after delivery; 2) occurrence of maternal depressive symptoms as documented by a telephone interview 2 weeks after delivery; and/or 3) discontinuation of breastfeeding as documented by a telephone interview 2 weeks after delivery. We searched KPMCP computerized databases, which use a common medical record number across the continuum of care, to identify rehospitalization, emergency department visits, and urgent clinic visits by the mother or the newborn during the 10 days after delivery. The 2-week interview contributed information on breastfeeding discontinuation and maternal depressive symptoms. Maternal satisfaction was assessed using questions from the aforementioned instrument on consumer satisfaction.
Widely accepted severity scoring systems for rehospitalized newborns do not exist. Consequently, one of us (G.J.E.), who practices general pediatrics and neonatology and who was kept blinded to group assignment, reviewed all rehospitalizations using objective criteria. For example, with respect to newborns who were readmitted with feeding difficulties and/or jaundice, the degree of weight loss, highest serum sodium (if obtained), highest total serum bilirubin (if obtained), presence of significant neurologic signs, and total LOS were compared. Similarly, for newborns who were readmitted to “rule out sepsis,” maternal risk factors (eg, length of rupture of membranes, intrapartum antibiotic treatment) were assessed, and it was determined whether a positive culture was present or other confirmation of the presence of infection existed. Blinded review included both the birth hospitalization records and the rehospitalization records to determine whether the infant's illness might have been due to a problem that could have been detected or prevented during the birth hospitalization (eg, in the case of a newborn with reflux, was the infant feeding normally at time of discharge?). Maternal rehospitalizations were reviewed in a similar manner and in consultation with an adult cardiologist and an obstetrician, who also were blinded to group assignment.
Statistical Methods
With 500 people in each treatment group, we would have more than 85% power to detect a difference of 10% in the rate of the combined outcome, assuming that the rate in 1 of the 2 groups was 50%, the type I error rate was 5%, and a χ2 test was used. All analyses were conducted using intention-to-treat (ie, women were analyzed as being members of the group to which they were randomized regardless of whether they actually received the treatment to which they were assigned). Comparisons between the 2 groups were made using χ2 tests for categorical variables, 2-samplet tests for continuous variables, or Wilcoxon rank sum tests for ordinal variables.
RESULTS
Study Population
Of the 4295 deliveries at the KPMCP Medical Center in Santa Clara during the study period, 2547 met exclusion criteria. We excluded 1349 for the previously mentioned medical risk factors (eg, 795 women who had a cesarean section). An additional 96 women were ineligible because of social risk criteria; 493 because they lived outside the home health service area; 463 because the mother did not speak English; 9 for logistic reasons (eg, not having a telephone, planning to move out of the area); and 137 for other reasons. Among the 1748 eligible mothers, 235 were not approached (usually because the mother was discharged before a research nurse could contact her) and 499 declined to participate, leaving 1014 women who were randomized. Of the 499 women who declined to participate, 397 agreed to answer a limited set of questions. Women who declined to enroll did not differ from enrollees with respect to age, race/ethnicity, education, time of initiation of prenatal care, parity, infant's birth weight, Apgar scores, or LOS. Women who were not approached had infants with significantly lower LOS (mean ± SD: 28.3 ± 10.2 hours) than the enrollees (32.3 ± 10.4 hours; P < .001); however, they did not differ from enrollees with respect to age, race, parity, infant's birth weight, Apgar scores, or LOS (Fig 1).
Patient flow in randomized trial of home visits (intervention) versus hospital-based follow-up visits (control) after early postpartum hospital discharge. Note that 397 women who refused randomization did agree to participate in a telephone interview.
Among enrolled mother–infant pairs, 508 were randomized to home health visits and 506 to hospital-based follow-up. Among those randomized to a home health visit, 96% actually received a home visit and 4% received hospital-based follow-up care (Fig 1). An additional 75 of 508 (15%) mothers who were assigned to the home health group received hospital as well as home-based follow-up care. Only 1 infant in the home health group did not receive follow-up within 72 hours of discharge; none were lost to follow-up. Among those who were randomized to hospital-based care, 264 mother–infant pairs had an individual visit, 157 had a group visit, 64 had both a group and an individual visit, 4 had a home health visit and hospital-based follow-up, 13 did not have follow-up within 72 hours, and 4 were lost to follow-up. Table 1 shows that there were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, timing of initiation of prenatal care, and LOS. There were no differences with respect to neonatal LOS or Apgar scores.
Demographic Characteristics of Mothers in Randomized Trial of Home Versus Hospital-Based Follow-up After Early Postpartum Discharge, Kaiser Permanente, Santa Clara, 1998–1999
Clinical Outcomes
Table 2 shows data regarding clinical outcomes for the mother–infant pairs. No significant differences occurred between the 2 study groups with respect to maternal urgent visits, neonatal urgent visits, maternal rehospitalization, or neonatal rehospitalization. The 2-week interview was completed with 96% of enrolled mothers. There were no significant differences with respect to breastfeeding discontinuation or the occurrence of maternal depressive symptoms. Similar proportions (49% vs 48%; P = .8; Table 2) experienced the combined clinical outcome measure, which was scored as positive if either the mother or the newborn had any of the above outcomes. The home health and hospital-based follow-up neonatal visit groups did not differ in the proportion of mothers who made any calls to the pediatric advice nurse during the first 2 weeks (55% vs 53%) or in the number of calls that the mothers made.
Clinical Outcomes Among Mother–Infant Pairs in a Study of Follow-up Care After Early Postpartum Discharge, Kaiser Permanente, Santa Clara, 1998–1999
With 1 exception (maternal urgent care visits), clinical outcomes among mother–infant pairs in the hospital-based care group did not differ between those who had individual and those who had group visits (data available on request). In the hospital-based follow-up group, the rate of maternal urgent clinic visits was 18.8% among those who had a group visit and 10.2% among those who had an individual visit (P < .01).
In the hospital-based follow-up group, 81.3% of first-time mothers attended the group visit. In contrast, among the experienced mothers in the hospital-based follow-up group, only 12.7% attended the group visit; 83.7% made an individual visit.
Rehospitalizations Within 10 Days After Discharge
We compared the 2 study groups with respect to rehospitalization within 10 days after discharge. In the intervention group, a total of 9 of 508 infants were rehospitalized, whereas 5 of 506 of the hospital-based care infants where rehospitalized. This difference was not significant (P = .29). None of the 14 newborns who were rehospitalized had a severe illness (eg, requiring surgery or assisted ventilation), and none had evidence of neurologic problems at the time of discharge from the rehospitalization. None of the infections were judged to have been preventable by prolonging the birth hospitalization LOS or by postnatal follow-up care. In the intervention group, mean rehospitalization LOS was 79 hours (range: 23 to 317 hours). In the hospital-based follow-up group, mean rehospitalization LOS was 53 hours (range: 29 to 87 hours). There were 3 mothers who were hospitalized, 2 in the home health group and 1 in the hospital-based care group. In the home health group, 1 mother was hospitalized briefly because of spinal headache and 1 because of new onset of atrial flutter. In the hospital-based care group, 1 mother was hospitalized because she developed endometritis. None of these maternal hospitalizations were judged to have been preventable by prolonging the birth hospitalization LOS or by postnatal follow-up care.
Mothers in the home visit group were more likely than those in the hospital-based care group to rate multiple aspects of their care as excellent or very good (Table 3). We also compared maternal satisfaction according to type of care received (group visits vs individual provider visits) in the hospital-based care group. In general, women who attended the group visits were more satisfied with their care than those who had individual provider visits.
Patient Satisfaction Among Mother–Infant Pairs in a Study of Follow-up Care After Early Postpartum Discharge, Kaiser Permanente, Santa Clara, 1998–1999
The estimated cost of a postpartum home visit to the mother and newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother–infant pair, the cost of an individual 15-minute visit with a registered nurse was $52, and the cost of a 15-minute individual pediatrician visit was $92. Because the hospital-based 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 also was estimated at $92.
Subgroup Analyses
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 household income <$40 000, nonwhite mothers, teenage mothers, mother–infant pairs with postpartum hospitalization of 24 hours or less, and mothers with their first prenatal care visit after the first trimester. There were no significant differences found in these subgroup analyses. Breastfeeding discontinuation among first-time breastfeeders did not differ between the home visit and hospital-based follow-up groups (22% vs 19%; P = .39).
Patient Satisfaction Among Mothers Who Refused Enrollment
Table 4 shows patient satisfaction results among 397 mothers who refused enrollment and compares them with results among the home health group as well as the hospital-based follow-up group. In general, mothers who refused enrollment had satisfaction ratings that were very similar to those of the hospital-based follow-up group. The only exceptions to this were with respect to skills and abilities of the provider and with the availability of services/equipment, for which mothers in the hospital-based care group were more satisfied with their care than those who refused enrollment. Mothers who enrolled in the study were more satisfied with all aspects of their care than those who refused enrollment.
Patient Satisfaction of Women Refusing to Participate Versus Women Agreeing to Participate, Kaiser Permanente, Santa Clara, 1998–1999
DISCUSSION
We found that group postnatal visits and home visits achieved equivalent clinical outcomes. However, group visits had far lower costs, whereas home visits had markedly higher maternal satisfaction.
Although cost may be a strong impetus for the adoption of group visits, patient satisfaction and choice also are appropriate drivers of decisions about postpartum services. Health care providers may choose to make home visits available despite their higher cost, especially when they view women of childbearing age as an important group to attract and retain. Within KPMCP's Northern California region, early postpartum follow-up visits have been offered by all medical centers since 1995, but there is wide variation in whether such visits are offered in the home, hospital, or pediatric clinic setting, as well as whether they are individual or group visits. This study, like our previous comparison of home visits with pediatric clinic visits in Sacramento, suggests that such variation likely has not resulted in variation in health outcomes.
Our study differs from previous work in this area in several important ways. First, it was conducted after the implementation of federal and state laws mandating insurance coverage of up to 48-hour hospital stays after uncomplicated delivery. We are not aware of any other randomized trials that have addressed postnatal or postpartum care after uncomplicated deliveries conducted after the aforementioned legislation. In fact, we are not aware of any rigorously designed randomized studies of early postpartum care for well newborns after uncomplicated vaginal delivery since the 1980s, and all of these used multiple home visits rather than the single visit in this study.16 ,17 ,36 ,37 This study also is unique in that it specifically addresses services provided after short stays. We are not aware of other controlled studies since the legislation took effect that focus on services after short stays (rather than focusing primarily on LOS). Finally, other studies of group visits have assigned patients to either group or traditional one-on-one visits.9 ,38 In this study, group visits were part of hospital-based follow-up, but mothers had the option of attending a group visit, an individual visit, or both.
It is important to note the relevance of our study for another reason, namely, that short postpartum LOSs are likely to remain common. Although LOSs may have increased as a result of the legislation,39 large numbers of newborns still are going home after stays of <48 hours. Recent data from a statewide, population-based survey in California showed that in 1999, 44.2% of vaginally delivered healthy term newborns had stays of 0–1 nights (A. Galbraith, University of California, San Francisco, personal communication, March 2, 2001). Hospital stays of <48 hours after normal vaginal delivery of <48 hours are likely to remain common in the United States, and it is likely, therefore, that improvements in postpartum services will focus on postdischarge services.5
First-time mothers in this study generally chose the group visits, and experienced mothers chose the individual visit. Newborn Club staff believed that experienced mothers chose individual visits because they no longer felt the need to get all of the information provided in group visits. However, not all experienced mothers requested individual visits with a physician but often requested individual visits with the Newborn Club nurse, with whom they may have established a relationship after the birth of a previous child. Thus, our observations reflect a situation in which individuals are allowed to self-select the service that they believe best fits their needs. This is a realistic situation in that clinicians in the KPMCP and elsewhere believe that attending a group visit rather than an individual visit should be optional.40 It seems likely that other health plans also would emphasize giving their members similar options.
Limitations
It is important to keep in mind that our study focused on a socioeconomically low-risk population in an integrated health care setting. More than two thirds of the mothers had at least some college education, more than 90% had a high school degree, and the majority had annual household incomes of >$60 000. Furthermore, the KMPCP has an unusually high degree of integration between hospital and outpatient services, and the mothers in this study had ready access to multiple services. These included telephone advice nurses and urgent care clinics that may play a significant role in keeping rates of adverse outcomes low. Although our population was ethnically diverse, our results cannot necessarily be generalized to more socioeconomically disadvantaged populations, to families who receive care in less integrated settings, or to settings in which screening for risk is less careful. Additional research involving such populations and settings is needed. Furthermore, we did not test an arm with no follow-up care because our previous work20 ,41 ,42 and national guidelines43 suggest that failing to provide follow-up visits is bad clinical practice. We have heard anecdotal reports that many mothers and newborns in the United States are not receiving early postpartum follow-up. The consequences of this practice should be studied, and appropriate action should be taken.
The study's sample size had better than 85% power to identify a relative difference of 10% 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. It has far less power to detect differences for more rare outcomes such as severe dehydration, which has an incidence of 2.6 per 1000 live births, or severe hyperbilirubinemia (total serum bilirubin ≥24.9 mg/dL), which has an incidence of 1.4 per 1000 live births.44 ,45 To detect a 20% relative reduction in a newborn rehospitalization rate of 2% with 80% power, more than 17 000 newborns would be needed in each group.
Our ability to gauge patient satisfaction suffers from some limitations as well. Many mothers did not respond to all questions reported inTables 3 and 4, raising the question of whether they may not have understood some of the questions.
Future Research
It is both disappointing and discouraging that breastfeeding discontinuation was high in both arms of this trial, a result similar to what we found in our previous 2 studies.14 ,20 This suggests that to improve breastfeeding rates, future studies should not focus simply on the type of any single postpartum visit; rather, it may be more useful to study what knowledge mothers actually absorb in any given educational context, how this knowledge is applied, and how much one can expect from a single encounter. Reisinger and Bires10 showed that the amount of time that pediatricians devote to individual anticipatory guidance topics is brief, often lasting only a few seconds. Group visits may have a distinct advantage over one-on-one visits because they give mothers more time to absorb and discuss information. However, serial group visits, as suggested by Taylor et al,46 may have stronger effects than the single group that visit we studied here.
CONCLUSION
For low-risk mothers and newborns in this integrated health maintenance organization, group visits and home visits on the third or fourth postpartum hospital day had equivalent clinical outcomes. Group visits were less costly than home visits but were associated with lower maternal satisfaction. For home visits, the value of increased maternal satisfaction 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. Future research also must explore the limited effectiveness of current strategies with respect to desirable outcomes such as continuation of breastfeeding.
ACKNOWLEDGMENTS
This project was supported by Grant MCJ #R40 MC 0010303 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services; Grant #9003 from the Sidney Garfield Memorial Fund; Grant #970005 from the Innovation Program of The Permanente Medical Group, Inc.; and Grant #1998-6861 from the David and Lucile Packard Foundation's Center for the Future of Children.
We thank 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 Nancy G. Jensvold, MPH, during the initiation of this project and the study nurses (Kim Banks, RN; Rosemary Eddington, RN; Eileen Fulk, RN; and Linda Hoeber, RN) and interviewers (Julie Holsopple, Regina Mason, Nydia Medina, Diana Reiss-Koncar, and Ayawnna Smith). The study could not have succeeded without the generous assistance received from the Kaiser Permanente Santa Clara Home Health department and nurses (Jeanne Davis, RN, MS; Bing Tenorio, RN; Vickie Johnson, RN; Fran Koperniak; Faith Blicharz, RN; Sandra Skoda; Vanette Braddock, RN; Deseree Arcangel-Primo; Angeles Cayabyab, RN; Nancy Cullen; Jane DeMaestri, RN; Bev Curry; Yilei Hsu, RN; Julie Vaday; Susan Lee, RN; Jennifer Lu, RN; and Mary Lou Serrano, RN) and from the staff of the Kaiser Permanente Santa Clara Newborn Club (Leslie Krauss, RN; Kim Gilderoy; Claire Langdon, RN; Mikala Perez; Jovita Penegra, RN; and Kathy Prows, RN). Donna McGill, RN, Susan Perry, RN, and Daniel Faletti also provided valuable input. We also thank Francis J. Crosson, MD, for his sponsorship; Joe Selby, MD, MPH, for advice and support throughout the study; Andy L. Avins, MD, MPH, for reviewing the manuscript; and Emily M. Breed for editing the manuscript.
Footnotes
- Received December 13, 2000.
- Accepted April 13, 2001.
Reprint requests to (G.J.E) 3505 Broadway Ave, Oakland, CA 94611. E-mail: gabriel.escobar{at}kp.org
REFERENCES
- Copyright © 2001 American Academy of Pediatrics
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- Hospital Stay for Healthy Term Newborns
- Quality Measures for Children's Health Care
- The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the US Preventive Services Task Force
- Clinician Support and Psychosocial Risk Factors Associated With Breastfeeding Discontinuation