Vaginal delivery: how does early hospital discharge affect mother and child outcomes? A systematic literature review

In Western countries, there is a trend to shorten the postpartum length of stay in hospital driven by cost containment, hospital bed availability and a movement toward ‘demedicalisation’ of childbirth [1]. Although this trend was initiated as early as the 1940s in the United States [2] other countries followed later. Thus, while the average postpartum length of stay in Swedish hospitals was 6 days in the 1970s [3] it declined to 2.3 days in 2010 [4], reflecting a similar duration to that observed, the same year, in the Netherlands (2.1 days), New-Zealand, Ireland and the United States (2.0 days) [4]. In addition to shorter hospital stays, early postpartum discharge for healthy mothers and newborns was introduced to promote a more family-centred approach to birth allowing greater involvement of fathers, less sibling rivalry, improved rest and sleep for the mother, less exposure of the dyad mother-newborn to nosocomial infections, enhancement of maternal confidence in caring for the baby, and finally, less conflicting advice on breastfeeding [5]. However, concerns about early discharge arose regarding potential adverse outcomes such as delays in detecting and preventing maternal morbidities and neonatal pathologies [6], earlier weaning, lack of professional support, higher prevalence of postpartum depression and increased hospital readmissions for both mothers and infants [5]. Societal concerns about maternal and newborn welfare in the context of early discharge led the United States to vote the Newborns’ and Mothers’ Health Protection Act in 1996 making it mandatory for health insurers to cover postpartum hospitalisation for a minimum of 48 h after vaginal delivery and 96 h after a caesarean section [2]. Therefore, early discharge after vaginal birth is considered as less than 48 h in the United States. However, to date there is no standard definition of early postpartum discharge because of large variations in the usual average length of stay for vaginal delivery between countries (i.e. in 2011, the mean length of stay for single spontaneous delivery was 5.2 days in Hungary, 4.2 in France, 4.0 in Belgium, 2.8 in Australia, 1.7 in Canada and 1.5 in the United Kingdom) [4]. Consequently, early postpartum discharge varies from 12 to 72 h depending on the country [7].

As in some other Western countries, Belgium experiences an average hospital stay for vaginal deliveries of 4 days. Decision makers willing to introduce earlier hospital discharge need evidence based information about the effect of such policies on neonatal and maternal health outcomes. Therefore, this literature systematic review aims to determine how, early discharge policies with or without home care (support) affect health outcomes after a vaginal birth for healthy mothers and term newborns (≥ 37 weeks) in Western countries.

Based on the available evidence, early postpartum discharge seems to be clinically safe for both mothers and newborns. These results are in line with a previously published review [5] which was restricted to RCTs but included caesarean sections. Early hospital discharge in caesarean section deliveries did not seem to affect outcome such as breastfeeding rate, maternal and infant readmission. However, confounders such as type of health system (public versus private), opportunities for antenatal preparation and for postnatal domiciliary midwife support or type of postpartum intervention cannot be studied because of poor reporting. Therefore, mixing data from vaginal delivery and caesarean section must considered with caution. Despite of this precaution, evidence must be interpreted with caution for two main reasons.

Firstly, the concept of early hospital discharge and that of conventional length of stay varied greatly between trials, making an interpretation or comparison across studies difficult. Among the selected studies, a discharge was considered early when the mother-infant dyad was discharged from 6 h to 72 h after birth. Currently, there are considerable variations in length of stay between Western countries. In Sweden, early discharge corresponds to a length of stay of 6 h after birth [3, 37], while in France, a discharge after a length of stay of less than 72 h is considered as early [19]. In the US, a minimum period of 48 h is ensured by law after a resurgence of jaundice cases and an increase in re-admissions among both mothers and children [1, 2]. However, Evan et al. [1] demonstrated that the extension of the postpartum length of stay to 48 h had little impact on re-admission rates for vaginally delivered newborns and was not cost saving. A lack of home postpartum follow-up may explain the absence of saving. Many Western countries already practiced early postpartum discharge for more than a decade. For these countries, what was once considered early discharge is now a conventional length of postnatal stay. This may explain the lack of recent published RCTs on the subject. However, countries with longer lengths of stay such as France and Belgium may benefit from testing shorter lengths of stay in studies with an appropriate design.

The second reason to interpret the findings with caution relates to the quality of the included studies. GRADE assessment highlighted numerous limitations in methods leading to (very) low level of evidence (see Additional file 1), except for three outcomes with moderate level of evidence (counselling, neonatal mortality rate at 3 weeks, and need for neonatal health contact within 10 days). The outcome related to satisfaction, only reported in the RCTs, was not discussed in this systematic review because trials were performed from 10 to 39 years ago, and thus societal expectations on health care are likely to have dramatically changed. Among the main methodological limitations found in the included studies were: small sample sizes that lead to insufficient power, a large number of lost to follow-up, one study with poor reporting of outcomes using graphical presentation but no discussion on the data in numerical terms, and heterogeneity in results across studies, leading to conflicting conclusions.

In addition, the selection criteria of study participants in RCTs were too restrictive, including well-educated women, mothers living in a stable relationship with their partners and low socioeconomic risk, preventing the generalisation of findings to the real world population. Selection bias was also observed in one non-randomised study [27] because more healthy mothers and newborns without financial difficulties were included in the early discharged group.

Besides the cautions in evidence interpretation, approximating the number of mother-infant dyads that can benefit from early discharge is challenging. Yanover et al. estimated that 25% of all deliveries are eligible for early discharge (i.e. after approximately 1 day). The authors used the readiness of the family as a necessary condition for discharge [32]. This criterion is indeed crucial for a successful early discharge programme because of a positive association between unreadiness at postpartum discharge and, on the one hand, health care use and, on the other hand, poorer health outcomes within 4 weeks after discharge [18]. The readiness to be discharged can be defined as the agreement between the mother and the medical staff (i.e. paediatrician and obstetrician) that both mother and newborn will not be likely to benefit from a longer hospital stay. If one of the involved parties anticipates any potential benefits for mother or infant to stay longer, the dyad is considered as unready [18].

Therefore, early discharge criteria cannot only focus on clinical parameters as described in Sainz et al. [31] but should also include additional criteria regarding the prenatal preparation and the setting of home postpartum follow-up as foreseen in the French guideline on early postpartum discharge [38]. In addition, prenatal preparation, content, frequency and duration of home follow-up were extremely different across studies hampering our ability to highlight best practices in these domains. In a Cochrane systematic review, the authors assessed the outcomes for women and babies of different home-visit schedules up to 42 days after birth whatever the length of hospital stay [39]. They concluded that postnatal home visits may promote infant health and maternal satisfaction but the frequency, timing and duration of such postnatal care visits should be based upon local needs. As in our systematic review, an optimal package of home postnatal care cannot be defined. However, several countries are developing a range of strategies to deliver seamless individualized follow-up support using telemedicine tools such as video conferencing or apps [40]. Nevertheless, all those strategies are unlikely to respond fully to the existing concerns about continuity of care. In addition, the shift of the follow-up tasks from hospital to home with physically or virtually present carers raises concerns about medical responsibility and legal accountability. Finally, the availability of professionals to provide the home care is an essential prerequisite for the successful transition from hospital to postpartum home care without impairing the home care for other conditions [41], creating unmet needs, or using informal support workers as doulas [42]. Due to the risk of variations in content and quality of care provided by fragmented services across multiple carers, offering a seamless transition from hospital to home is challenging.

Cost containment is one of the drivers to endorse an early postpartum discharge policy. Only two trials included in our systematic review addressed the cost issue. In the first study implemented in the USA [32],the authors analysed an early discharge programme, which included 24 h hospital length of stay and daily home visits by trained nurses for 4 days after birth. From a hospital perspective, this programme provided a minimum of 30% immediate savings in daily costs versus conventional stay (48 h or more), excluding saving generated by allocating vacated beds and rooms to other patients or purposes. The cost calculation was based on expenses for salaries of nurse practitioners, paramedical personnel, and medical consultants, as well as automobile expenses and home-care supplies. In the second study performing a cost calculation from a payer perspective in Spain [31], the implementation of an early discharge programme provided savings ranging from 18 to 20% in comparison with convention hospital length of hospital stay. This early discharge programme was made up of a less than 48 h length of hospital stay, 1 home visit after discharge by nurses qualified in puerperal and neonatal care, a practice consultation between 7 to 10 days after birth and a follow-up by phone at 1, 3 and 6 months. By comparison, the conventional discharge programme followed the same pattern except for the length of stay, which was longer than 48 h and the absence of home visits. The cost calculation took into account costs related to length of hospital stay, maternal – neonatal readmission, maternal – neonatal consultations, maternal – neonatal reassessment at 1 week and costs related to telephone follow-up. Cost containment due to the implementation of an early discharge policy is highly dependent on the perspective taken into account as well as on the type of health insurance system in place.

Estimation of possible cost savings cannot be performed without developing well designed RCTs including costs data collection. The collection of cost data must be designed to take into account not only hospital or payer perspectives, but also the societal perspective. In addition, the hidden costs for new mothers created by a potential shift from publicly funded hospital maternity care to private home-based postpartum care must be carefully scrutinized to prevent gaps in quality and accessibility of care [42].

Finally, developing quality indicators to monitor each early postpartum discharge programme is also crucial. Quality indicator assessment allows for adjusting early postpartum discharge policy when needed. However, the development of indicators is challenging because some indicators (e.g. satisfaction, overall support, well-being …) are qualitative and, thus more difficult to standardize [43].

The current available literature provides little scientific evidence to guide postpartum discharge policy planning. The evidence based on RCTs is old, with the most recent trial published 10 years ago, and the quality of evidence of these trials is poor. The more recent evidence is based only on two very poor quality non-randomised studies. In addition, the concept of early discharge itself is very variable across studies leading to health outcomes being measured at variable times after delivery. Despite these limitations, early discharge seems to be safe for both mother and newborn. Breastfeeding did not seem to be affected. Because of the lack of robust clinical evidence and full economic evaluations, the current data neither support nor discourage the widespread use of early postpartum discharge. Before implementing an early discharge policy, Western countries with longer length of hospital stay such as France and Belgium may benefit from testing shorter length of stay in studies with an appropriate design (e.g. randomised). The issue of cost containment in implementing early discharge and the potential impact on the current and future health of the population exemplifies the need for publicly funded clinical trials in such public health area. Finally, trials testing the range of out-patient interventions supporting early discharge are needed in Western countries which implemented early discharge policies in the past.