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Personal Practice Indian Pediatrics 2001; 38: 1374-1381 |
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Immediate neonatal period is a period of rapid physiological changes in the baby, parental and familial psychological adjust-ment, initiation of successful breastfeeding and educating about family planning and infant care. It has been observed that uneventful transition period is predictive of subsequent low neonatal morbidity and careful monitoring during this period may serve as effective means of asserting health prior to discharge(1). Delivery in the hospital was uncommon prior to 1920’s, even in USA with less than 5% births taking place in hospital in 1900. With improved availability of trained obstetricians and increased use of techniques like anesthesia and Caesarean section, women realized hospital delivery was safer and more comfortable than at home. In US around 80% of births occurred in hospital by 1945 and nearly 100% by 1960(2). The idea of early discharge of these patients from the hospital originated as a response to a shortage of hospital beds resulting from a baby boom following the Second World War. In the late 1960’s and in 1970’s, a considerable reduc-tion was observed in postpartum length of stay(3,4). By 1980, the third payer party, i.e., the insurance companies, had started playing important role in health care system in the western countries. The move towards early discharge this time was triggered by the insurers who began reimbursing hospitals by case rather than by the length of stay(5). The shorter stay was financially better for any hospital, and the hospitals started discharging patients earlier. The United States appeared to have taken lead in the practice of early discharge and it was not uncommon to see a term newborn leaving the hospital at 12-24 hours postnatally. However, the practice of early discharge, whether motivated by social factor or financial policies was not backed by sound scientific evidence advocating its safety. What Constitutes Early Discharge The American Academy of Pediatrics (AAP) defines ‘early’ and ‘very early’ discharge as stays of 48 and 24 hours or less respectively after an uncomplicated vaginal delivery(6). Global Practices The issue of early newborn discharge has received widespread attention in the press as well as in medical literature. In United States, the average length of stay for all deliveries decreased by 37% between 1970 and 1992 from 4.1 to 2.6 days. The decrease was 46% for vaginal deliveries (3.9 to 2.1 days) and 49% for Caesarean deliveries (7.8 to 4 days)(7). After 1992, the length of of stay has decreased further with many infants being discharged at 24 hours or even less after vaginal and 72 hours or less after Caesarean birth. In Western US, stays of 12-24 hours or less after uncomplicated vaginal birth and 48-72 hours after normal Caesarean delivery are now standard. Routine neonatal follow-up after early discharge varies widely, with a first clinical evaluation of the newborn scheduled anytime from 1-14 days after discharge. The concept of early discharge started picking up fast in other countries like UK, Australia and Scandinavia where 6-10 days hopsital stay had been customary in the past. In Britain, the first program of planned early obstetric discharge commenced in Bradford in 1958(8). The earliest evidence to support the safety and acceptability of early obstetric discharge was the observation in 1966, that the perinatal mortality rate in city had fallen from 45.8 in 1956 to 31.8 in 1962. The rate of early discharge during this period commenced at 32% and rose to 52% of all deliveries. During first 12 months of scheme, only four babies were readmitted – all recovered and went home. No baby of early discharge group died within the first two weeks of life. The length of stay for mothers and neonates has declined worldwide because of the influence of many social, financial and other factors, whereas the timing of first follow-up visit has remained unchanged! Minimum and maximum lengths of post- natal stay following uncomplicated vaginal deliveries are reported from Saudi Arabia (1-1½ days) and Japan (5-6 days), respectively. Following a normal vaginal birth, postnatal stay of 1-2 days is a routine practice in US, Canada and England. Australia, Finland, France, Ireland, Israel, Sweden, Korea, and New Zealand report an average stay of 2-3 days. A stay of 2-4 days is observed in Germany, Hong Kong and Greece. Hungary and Switzerland share the maximum duration of stay, i.e., 5-6 days with Japan. Data is not available from rest of the countries(4). Out of the countries mentioned above, only Australia, Canada, Saudi Arabia, and Hungary are having a policy or guidelines influencing the perinatal stay, besides USA. Some recommendations are also being followed by Sweden, Israel and New Zealand(4). No published studies are available from the Indian subcontinent. However, we undertook a preliminary exercise in our hospital which is a tertiary care center associated with a medical school and on an average conducts around 8,000 deliveries a year. The newborn discharge is dictated more by the need of postnatal beds by the obstetricians rather than the neonatologists. However, it is ensured at discharge, that the child is term appropriate for age, has an uncomplicated vaginal birth, has no life threatening gross congenital anomaly, has passed urine and stool, is warm, has no clinical jaundice, is active, and accepting breast-feeds. The hospital follows a baby friendly policy and all mothers and relatives are counseled accordingly. In a retrospective analysis, we found that approximately 65% of all our uncomplicated vaginal deliveries are being discharged within 24 hours of birth; the average duration of stay for these newborns being 1.3 days (unpublished observations). However, we do not have a data on the follow-up of these children and their readmission rates. Early Discharge: Pros and Cons A shorter length of hospital stay may diminish the opportunity to supervise and respond to problems occurring during the transitional period. Adversaries of early discharge argue, that there is bound to be missed identification of congenital anomalies, nutrition and feeding problems, dehydration, jaundice, incomplete immunization, non initiation or premature cessation of breast-feeding, increased re-hospitalization rates, higher post neonatal mortality, incomplete newborn screening, increased parental anxiety, increased maternal infection and depression, and ultimately increased medical cost, all because of the neonate leaving the hospital untimely. Longer hospitalizations allow for proper establishment of feeding specially in a primi mother, and more teaching time and counseling sessions regarding infant care. Several neonatal cardiac and gastrointestinal problems may not manifest until the second or third day of life. Hyper- bilirubinemia may also peak later and lack of observation can lead to increased incidence of brain damage(9-15). Advocates of early discharge believe that increased exposure to nosocomial pathogens and artificial schedule of hospitalization may lead to aggressive assessment of normal variation in newborn physiology – leading to increased medical cost and iatrogenic risks. Early discharge is hypothesized to promote family bonding and attachment, reduce the hospital and patient costs, and improve patient satisfaction(16,17). In view of these two schools of thought, the timing of newborn discharge has been a crucial topic of debate for last few years and has generated much scientific literature both in favor and against early discharge. A summary of these efforts is presented below. Review of Literature No Indian studies are available to comment upon the appropriate timing of discharge of term healthy neonates. Most of the studies done in USA and other western countries either lacked appropriate com-parison group and provided inadequate description of participation criteria, or were plagued by limited outcome measures and loss to follow up. The sample size was too small to detect differences between the groups, the groups were non randomized, or controls were inappropriate. Different definitions of early discharge that have changed over time have been used. Thus, a formal meta-analysis of early discharge is unlikely. Braveman et al.(18) in an excellent attempt at reviewing the current evidence on early discharge of newborns grouped the available literature in 6 categories: (i) very early discharge (£24 hours) without compensatory follow-up - No studies; (ii) Very early discharge ( £ 24 hours) with follow up 1-3 days after discharge - 5 studies; (iii) Early discharge (24-48 hours) without com-pensatory follow-up - 3 studies; (iv) Early discharge (24-48 hours) with follow up 1-3 days after discharge - 10 studies; (v) Discharge after 48 hours without compen-satory follow-up - No studies; and (vi) Discharge after 48 hours with follow up services - 7 studies. It was found that no adequately designed study had examined discharge before 48 hours after delivery without additional post discharge services and follow-up. Few studies have examined the consequences of recommending a follow-up visit within the first three days after discharge. Some small studies suggest that early discharge is likely to be safe for selected populations but their results have limited generalizability. Some studies suggested adverse outcomes associated with early discharge even with early follow-up. It was concluded that published research provides little knowledge of the consequences of short hospital stays. The studies that have concluded that early discharge was safe were applied under restricted circumstances or were too small to detect clinically significant effects on important outcomes. Though the studies may have failed to prove that shorter hospital stays are unsafe, yet that does not necessarily mean that early discharge is safe. Rigorous studies of sufficient size are advocated to examine the impact of different hospital stays and follow up practices on a range of out-come variables in diverse populations and settings(18). Another review by Wallace et al.(19) on re-hospitalization rates indicated that the number of infant hospital re-admissions and infant mortality had increased and this was likely to be related to early discharge, though none of these studies in literature had adequate statistical power to detect doubling of neonatal or maternal readmission with statistical significance. It was concluded that early discharge in isolation may be dangerous, but if organized with appropriate follow-up care, it may be acceptable. In a recent cohort study(2), newborns discharged within 30 hours of birth were found to be at increased risk of death within the first year of life. Schwartz reviewed the policy conclusions drawn at the 1994 Boston Community Focus Meeting and suggested that significant benefit, such as parental education, is gained in additional hospital days(21). Therefore, the reviewed literature provides little scientific evidence to guide discharge planning for most apparently well newborns and their mothers. Current studies indicate minimal scientific basis for the claim that early discharge is safe in absence of careful pre-discharge preparation and inten-sive and repeated follow-up. Evolution of Guidelines for Newborn Discharge The first of the guidelines for hospital care of newborn infant was given in 1943 when AAP Committee of Fetus and Newborn (COFN) in cooperation with Children’s Bureau published its manual. These guidelines were modified from time to time. However, it was not until the 6th edition of this manual in 1977 that timing of infant discharge was specifically addressed "mature infants are usually discharged at 72-96 hours of life, although they may go home earlier, if they are stable". In 1980, the COFN published a brief statement on the criteria for early discharge. The statement recommended a minimum of 6 hours of hospitalization and emphasized imparting education to mother regarding skills of newborn care(22). AAP and American College of Obstetricians and Gynecologists ( ACOG) in a joint publication on "Guidelines for Perinatal Care" in 1983 stipulated, that healthy newborn should generally remain in the hospital for more than 24 hours, the usual time of discharge being 48-72 hours. A revision in 1988 extended the guidelines for vaginal and Caesarean deliveries; the recommended length of stay being 48 and 96 hours respectively, excluding the day of birth. Formal definitions of early and very early discharge were formulated in 1992 and a follow up within 48 hours was recommended for all early discharges(6). The most recent guidelines given by COFN, published in 1995, delineated the minimum criteria for early discharge with a statement that at least 48 hours are likely to be needed for their fulfillment. The committee further stressed that all infants having short hospital stay be examined by experienced health care persons within 48 hours of discharge. If this cannot be assessed, then the discharge should be deferred until mechanism for follow up evaluation is identified. These guidelines are presented in Table I(23). On September 26, 1996, the Newborn’s and Mothers’ Health Protection Act of 1996, signed into law by President Clinton, man-dated coverage by all insurers of a minimum of 48 and 96 hours of postpartum stay for mother and newborns, when delivered vagi-nally or by Caesarean section respectively(4). Any decision to discharge the mother or newborn earlier can be made only by the attending physician in consultation with the mother. This law came into effect from January 1, 1998 and ended almost five decades of pandemonium encompassing the issue of early newborn discharge. The effect of this law has already begun to be described. In one of the States, the length of stay appears to have increased from 1.4 to 1.8 days (an increment of 29%) and from 2.8 to 3.3 days (an increment of 18%) for uncompli-cated vaginal and Caesarean deliveries, respectively(24). Table I__AAP Committee on Fetus and Newborn Guidelines onHospital Stay of Healthy Term Newborn (1995)
The Indian Scene Newborn discharge has been the subject of much change, debate, and controversy in the west but failed to evoke the same enthusiasm and zeal in India. The Indian literature is silent on this particular aspect and no efforts have been made to formulate any sort of guidelines. One of the reasons for this could be diversity of the prevailing conditions; the situation being totally different in Government and private hospitals. While early discharge takes place perforce in the government hospitals, mainly due to scarcity of beds, it is not uncommon to observe prolonged hospital stays in private nursing homes just for the sake of inflating medical bills. Paradoxically, this could also be one of the reasons why a uniform approach is warranted. Guidelines given by AAP cannot be adopted in totality in Indian perspective because of limited resources, scarcity of hospital bed, illiteracy, unavailability of health services to remote areas and lack of follow up facilities. However, points 1-11 of COFN recommendation can be accepted in toto because they are feasible and require either a thorough clinical evaluation by experienced personnel, or proper counseling. It is important that mother’s knowledge and ability as well as confidence for breast-feeding is built up starting right from the antenatal period. Baby Friendly Hospital Initiative has been launched in a big way in India and already covered much of the lost grounds. Points 12-16 need modification keeping in mind the local policies and programs concerned with antenatal checkups, screening for metabolic disorders, immuniza-tion practices, and follow-up facilties. As the AAP guidelines are not acceptable in toto in Indian setting, there definitely is a need to formulate our own set of recommendations for timely discharge of the newborn. Studies are advocated on this aspect in this part of the world; IAP and NNF can take the lead and play a vital role to accomplish the task. Till that time, the length of post delivery hospitalization should be based on the unique characteristic of each mother and her newborn, taking into consideration their health and adequacy of support systems for follow up. The generally agreed inverse relationship of the length of stay with need for an early follow up visit should also be kept in mind. Apart from delineating the exact length of stay, the focus also has to be directed to the quality of follow-up services provided after discharge. Though the follow-up services appear to be the key to the safety and success of limited hospital stays, the potential of such necessary services has by and large remained unexplored. The current Post Partum Program can be effectively utilized to achieve this end. This may require a more complex conceptual model of postpartum care incor-porating the responsibilities of health care providers, patients, social and health services agencies as well as insurers. Research has not shown what length of hospital stay is ideal for neonates. Current research also provides little concrete information on the safety of "early" discharge or the efficacy of longer hospital stays. Concerns based on postpartum and postnatal physiology and studies suggesting adverse outcome justify that the emphasis should be on appropriate rather than early discharge. The decision is to be made cautiously and should be highly individualzed. Contributors: PG provided the framework and overall concept of the article. He will act as the guarantor of the paper. HJB collected the data and drafted the manuscript, which was edited by PG. Funding: None. Competing interests: None stated.
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