Early postnatal discharge from hospital for healthy mothers and term infants
The current evidence is insufficient to support the policy of early postnatal discharge from hospital as routine practice. Early discharge after childbirth has already been implemented in many resource-poor countries for economic reasons. Health administrators need to be aware that the risks and benefits of this policy have not been adequately assessed, particularly in developing countries
RHL Commentary by Nardin JM, Mignini L
1. INTRODUCTION
Public health-care facilities in many countries (especially in low- and middle-income countries, and sometimes even in some high-income countries) face major problems with respect to shortages of financial and human resources and inadequacies of technical and administrative skills. Hospital care is becoming prohibitively expensive, especially for the socially disadvantaged groups who rely on public health-care facilities for care. These facilities are often understaffed and overburdened with demand. Procedures that reduce hospital stay through various means, such as minimally invasive surgery, are increasingly becoming popular. Early discharge following uncomplicated term delivery has been debated for more than three decades as a way to reduce crowding in maternity units.
A faster turnover in maternity units could improve the efficiency of the health system and the staff, provided that it is safe and does not lead to increased use of services afterwards. Opponents of early discharge think that it might lead to increased risks for the newborn (increased incidence of jaundice, feeding problems and infections), but the evidence to support these claims is not compelling. On the other hand, some health-care providers believe that early discharge could actually be beneficial, allowing mothers to recover in the home environment and thereby facilitating bonding between the baby and the parents.
This review was first published in 2002 and was updated in 2009 (1) with two new trials involving 889 women. It sought to "assess the safety, impact and effectiveness of a policy of early discharge for healthy mothers and term infants, with respect to the health and well-being of mothers and babies, satisfaction with postnatal care, overall costs of health care and broader impacts on families".
2. METHODS OF THE REVIEW
All adequately randomized controlled trials that could be identified have been included. The study outcomes selected for the review were complete and adequate. The reviewers included outcomes relevant for low-, middle- and high-income countries, such as health outcomes for the infant and parents' satisfaction with care and costs. Subgroup analyses were appropriately planned beforehand, reducing the probability of bias. The data have been appropriately extracted and presented in graphs and in the text.
3. RESULTS OF THE REVIEW
Overall, a total of 10 trials involving 4489 women were included. Although there is no evidence for any adverse outcome associated with early postnatal discharge, the methodological limitations of most of the trials and the heterogeneity among the included studies with respect to relevant issues such as the definitions of standard and early discharge (length of postnatal hospital stay for the group of ‘early discharge’ in some studies overlap with the standard length of hospital stay in other settings), information and preparation of the participants and health care after discharge, rendered the findings inconclusive.
When compared to standard care, the policy of early postnatal discharge did not show statistical differences on any of the main outcomes assessed in the systematic review, including re-admissions to hospital of both mothers and infants, maternal depression and breastfeeding prevalence. However, due to the methodological variations among trials, it was difficult to draw conclusions about women’s views of postnatal care. Finally, with respect to the economic impact of early discharge, only three trials provided information about costs. The data extracted from these trials indicate that hospitalization costs were significantly lower in the early discharge groups. The difference between the intervention and control groups remained statistically significant in favour of early discharge even when the costs of follow-up nurse/midwife home visits were included.
4. DISCUSSION
4.1 APPLICABILITY OF THE RESULTS
Apart from the limited data on lower cost of the intervention, there is no conclusive evidence in favour of or against the policy of early postnatal discharge. The randomized trials included in the review to date were all conducted in developed countries. Hence, care should be taken in extrapolating the results of these and future trials from countries with good socioeconomic conditions to communities where the resources are scarce. Consideration should also be given to different settings even within the same country such as urban versus rural and the cultural contexts where the trials are conducted.
4.2 IMPLEMENTATION OF THE INTERVENTION
Early postnatal discharge from hospital has already been implemented in many developing countries for economic reasons. It is important for health administrators to be aware that the risks and benefits of this policy have not been adequately assessed, particularly in under-resourced communities.
4.3 IMPLICATIONS FOR RESEARCH
Given the methodological limitations of the trials included in the systematic review and the lack of strong and reliable evidence to support the introduction into clinical practice of the policy of early postnatal discharge, there is an urgent need for large well-designed trials comparing this intervention with standard care, especially in under-resourced settings.
Sources of support: Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
Acknowledgement: Guillermo Carroli
References
- Brown S, Small R, Argus B, Davis PG, Krastev A. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews 2002;Issue 3. Art. No.: CD002958; DOI: 10.1002/14651858.CD002958.
This document should be cited as: Nardin JM, Mignini L. Early postnatal discharge from hospital for healthy mothers and term infants : RHL commentary (last revised: 1 October 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.