Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery

doi:10.1016/S0002-9378(98)70268-6

American Journal of Obstetrics and Gynecology

Volume 179, Issue 1, July 1998, Pages 166-171

https://doi.org/10.1016/S0002-9378(98)70268-6 Get rights and content

Abstract

OBJECTIVE: Our purpose was to determine whether length of hospital stay after vaginal delivery as determined by the discharging physician is associated with rehospitalizations or increased outpatient contacts by mothers and neonates and to assess the impact of home health care visits.

STUDY DESIGN: An inception cohort study of all rehospitalizations and outpatient contacts of mothers and neonates after vaginal delivery at St. Joseph Hospital, Denver, Colorado, was done from January 1, 1994, to September 30, 1995. All Kaiser Permanente mother-neonate pairs in which the delivery was vaginal (excluding those with multiple gestations or birth weight <2500 g) were included. Length of initial hospital stay was divided into three time periods: ≤24 hours, 25 to 48 hours, and >48 hours. The Colorado Kaiser Permanente Perinatal Database was used to identify perinatal and demographic factors that might have increased health care use. Additional information was sought in administrative databases, bill records, and inpatient charts. Mothers were followed up for 6 weeks and neonates for 28 days after delivery. Home care visits were provided to more than half the mothers and neonates by means of a standardized protocol. The main outcome measures were rehospitalizations and outpatient visits for mothers and neonate, controlling for home care visits.

RESULTS: A total of 4323 mother-neonate pairs were identified. For the mothers, a longer initial hospital stay (>48 hours) was significantly associated with both readmission (P < .01) and increased outpatient care use (P = .01) in the 6-week postpartum period. Thirty-five mothers (.81%) were rehospitalized by 6 weeks. Maternal factors associated with increased outpatient contacts were preeclampsia, preterm delivery, and instrument delivery. Sixty-seven neonates (1.55%) were readmitted to the hospital. Home care visits reduced the need for both readmissions and outpatient visits.

CONCLUSIONS: For mothers in this cohort a longer initial hospital stay was significantly associated with hospital readmission and increased outpatient care in the postpartum period. Further analysis revealed that mothers with recognized potential and observed problems were rarely discharged in ≤24 hours. We did not find statistically significant problems among neonates that were related to the length of their initial hospital stay. Those neonates receiving home care were less likely to require hospital readmission and less likely to seek outpatient care. It is unlikely that a single discharge policy will be appropriate for all mothers and neonates. (Am J Obstet Gynecol 1998;179:166-71.)

Section snippets

Study population

An inception cohort study was carried out on all Kaiser Permanente mother-neonate pairs with a vaginal delivery at St. Joseph Hospital, Denver, Colorado, from January 1, 1994, through September 30, 1995. Potential eligible subjects were identified in the Kaiser Permanente Perinatal Database. Multiple gestations, stillbirths, infants weighing less than 2500 g, and cesarean sections were excluded from our study. Mothers delivered outside the Kaiser network (n = 22), where perinatal information

Maternal outcomes

Maternal characteristics by length of hospital stay are presented in Table I.

. Maternal characteristics by postpartum length of stay

Empty Cell	≤24 h (n = 1838)	25-48 h (n = 2330)	>48 h (n = 155)	Total (N = 4323)
Age
<20 y	183 (10.0%)	230 (9.9%)	18 (11.6%)	431 (10.0%)
>20-35 y	1481 (80.5%)	1834 (78.7%)	113 (72.9%)	3428 (79.3%)
>35 y	174 (9.5%)	266 (11.4%)	24 (15.5%)	464 (10.7%)
Race
White	1167 (63.5%)	1445 (62.0%)	106 (68.4%)	2718 (62.9%)
Black	67 (3.6%)	97 (4.1%)	10 (6.4%)	174 (4.0%)
Hispanic	206 (11.2%)	237 (10.2%)	15 (9.7%)	458 (10.6%)

Comment

Our study was limited by the small number of readmissions of both mothers and neonates. We cannot provide information regarding patient satisfaction, although retention of patients in the system is high and may be an indication of satisfaction. We were unable to evaluate advice sought by phone, prenatal care use, mothers’ social/home situations, or length of hospital stay before delivery. Although we have used databases to identify conditions associated with a longer length of stay, we do not,

Acknowledgements

We thank Kimberly Bischoff and Paul Barrett, MD, MSPH.

References (9)

WF Guerriero
A maternal welfare program for New Orleans
Am J Obstet Gynecol
(1943)
EJ Bragg et al.
The effect of early discharge after vaginal delivery on neonatal readmission rates
Obstet Gynecol
(1997)
GC Nabors et al.
Home puerperal care following hospital delivery
Obstet Gynecol
(1956)
JA Gazamararian et al.
Maternity experiences in a managed care organization
Health Affairs
(1997)

There are more references available in the full text version of this article.

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Moreover, opinions differ regarding the impact of length of care on readmissions for healthy newborns. Some studies show that early discharge increases the risk of readmission compared with later discharge (Danielsen et al., 2000; Grupp-Phelan, Taylor, Liu, & Davis, 1999; Lee, Perlman, Ballantyne, Elliott, & To, 1995; Liu, Clemens, Shay, Davis, & Novack, 1997), whereas others report that there is no evidence of this (Edmonson, Stoddard, & Owens, 1997; Meikle et al., 1998). Lee et al. (1995) found that a shorter stay was linked to a greater number of readmissions, and the shorter the length of stay, the more newborns were readmitted because of jaundice.
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Despite the concerns that have been expressed over the years about the potential adverse effects on neonatal and maternal outcomes of decreasing postpartum LOS, maternal readmission has been infrequently studied.8,13-16,18-20 Published studies are limited by the small number of readmission cases and maternal morbidity and/or uncontrolled confounding variables.9,10 Clinical trials of early postpartum discharge have been unable to observe readmission adequately, because severe maternal morbidity that leads to hospitalization is rare after childbirth; therefore, very large numbers of subjects are required to ensure adequate statistical power.12,13,21,22
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^☆: From the Colorado Permanente Medical Group,^a and the Department of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center.^b

^☆☆: Supported by the Colorado Kaiser Permanente Research and Development Fund.

^★: Reprints not available from authors.

^★★: 0002-9378/98 $5.00 + 06/1/87879

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Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery☆,☆☆,★,★★

Abstract

Section snippets

Study population

Maternal outcomes

Comment

Acknowledgements

Am J Obstet Gynecol

Obstet Gynecol

Home puerperal care following hospital delivery

Obstet Gynecol

Maternity experiences in a managed care organization

Health Affairs