BIRTH 17:4 December 1990
199
A Randomized, Controlled Evaluation of Early Postpartum Hospital Discharge Elaine M. Carty, R.N.,M.S.N., C.N.M., and Christine F. Bradley, Ph.D. ABSTRACT: A t approximately 37 weeks’ gestation, 131 women were randomly assigned to one of three postpartum hospital discharge times: 12 t o 24 hours, 25 to 48 hours, and 4 days. Depending on group assignment, the women received from one to five home visits by a maternity nurse clinician during the first 10 days postpartum. The results indicated the maternal and infant morbidity were low regardless of discharge time, although sample sizes were too small to detect signiJicant differences in the outcomes. More early discharge mothers were breastfeeding without supplement at 1 month than were mothers in the long stay group. Mothers in the two early discharge groups were signijicantly more satisfied with their care than were those who remained longer. Those hospitalized longer scored higher on measures of depression and lower on scores of confidence at selected time periods. (BIRTH 17:4, December 1990) Since 1962, studies of early postpartum hospital discharge programs have focused on whether it is safe to send women home within 24 hours after birth (1). Evidence from some studies suggested advantages with respect to family integration (2-4) and the mother recovering in the familiar environment of the home (5,6). Specific outcomes, however, such as infant and maternal morbidity and mothers’ psychological functioning after discharge within 12 to 48 hours compared to discharge after 4 days have not been assessed in a randomized, controlled trial. In their review of early discharge, Norr and Nacion (7) discussed many methodological deficiencies in published work, in particular, the paucity of controlled studies and lack of information with respect to patient satisfaction and other benefits. We therefore designed a randomized, controlled trial to assess whether discharge 12 to 48 hours postpartum resulted in improvement in maternal and infant physical and psychological health, duration of breastfeeding, and patient satisfaction (8).
Elaine M . Carty is Associate Professor, School of Nursing, University oflritish Columbia, Vancouver, B. C. Christine F. Bradley is Director of Research and Evaluation, Division of Nursing, Vancouver General Hospital, British Columbia’s Health Sciences Centre, Vancouver, B.C.
Methods Sample The study took place at a tertiary care maternity hospital in Vancouver. All women expecting a vaginal birth were eligible to participate. They were told by their physician, prenatal classes, or hospital tours that the investigators were studying women’s experience of alternative times of discharge from hospital. Women who agreed to be randomly assigned to one of three discharge times were visited at home by a project nurse at approximately 38 weeks’ gestation who explained the study in greater detail, obtained written informed consent, and assigned time of discharge. One hundred eighty-nine women volunteered to participate in the study. Of these, 1 had a home birth, 2 reversed their decision to participate, and 10 were dropped because they chose to go home at times other than the discharge times to which they had been assigned. After the birth, 45 women did not meet the study discharge criteria for mother and infant (cesarean section, forceps delivery, etc.) and were eliminated. Thus, the final sample consisted of 131 women. Discharge assignments were determined prior to the home visits at about 38 weeks. Using a table of random numbers, sealed, opaque envelopes containing the assignments were placed on the file of each prospective participant and opened by the
BIRTH 17:4 December 1990
200 nurse at the time of the home visit. Neither the nurse nor participant was aware of the assignment before this visit. The discharge schedules were as follows: Early discharge: Group 1, 12 to 24 hours ( n = 44) Group 2 , 25 to 48 hours ( n = 49) Traditional stay: Group 3, 4 days ( n = 38) Nurses The five project nurses had a baccalaureate degree in nursing, and had experience in both community health nursing and inpatient postpartum care in a tertiary-level maternity hospital. Before the study began they participated in a two-week in-service program developed to ensure that they would be working from a common theoretical and philosophical framework. The nurses made home visits to the women under their care according to the following schedule: group 1 on days 1, 2, 3, 5 , and 10 after delivery; group 2 on days 3, 5 , and 10; group 3 on day 10 only. At each visit the nurses provided similar nursing care to that received by women in hospital. They conducted a physical assessment of the mother and baby, dealt with the immediate concerns of the parents, assisted them with getting to know their baby, and dealt with the many facets of incorporating a new member into the family. After the 10-day visit, the nurses sent summaries of the assessments and nursing care to the attending physicians. Questionnaires were left with the participants to be completed at four time periods: 37 weeks’ gestation, during the hospital stay, 1 week postpartum, and 1 month postpartum. Hospital and project nurses were unaware of the content of questionnaires. Outcome Measures
Maternal and Infant Health The standardized forms used for examining mothers and infants in the hospital were used during each home visit to ensure consistency in the examination process. In this study, health problems were defined as maternal or neonatal problems requiring a referral to a physician. Maternal infections, neonatal infections, neonatal respiratory difficulties, and neonatal jaundice were the major problems one could expect to identify. Since the opinion among most health professionals in the community at the time of the study was that the hospital was the safest place to be during the first four to five days postpartum, the
null hypothesis was that there would be less than a 1% difference between early discharge women and their babies and traditional stay women with respect to health problems. The nosocomial infection rate for mothers and newborns in our community is 2%. Therefore, a sample size of 4821 would be required to give an 80% chance of detecting a 1% difference at P < 0.05. Expected rates for neonatal jaundice and neonatal respiratory difficulties requiring treatment were difficult to obtain because of problems of definition. However, sample sizes of the same magnitude would be required to determine statistical differences. Thus, this study did not have the sample size necessary to assess statistical significance of these health problems. However, problems requiring physician referral are documented in the section on results. Breastfeeding On the questionnaire completed one month postpartum, women were asked to report whether they were breastfeeding only, bottle feeding only, or both breastfeeding and bottle feeding. The percentage of women breastfeeding without supplement at one month postpartum was 65% in a previous study in the same hospital (9). The hypothesis in this study was that 20% more women in the early discharge groups would be breastfeeding without supplements at one month than those in the traditional stay group. A sample of 140 would be required to give an 80% chance of detecting a 20% difference at P < 0.05. Patient Satisfaction Patient satisfaction with nursing care was assessed using a questionnaire developed for this study. It consisted of 22 items relating to maternal perception of nursing care rated on a 5-point Likert scale with a total possible score of 110. Cronbach’s alpha for this questionnaire was 0.97, indicating good internal consistency. It was hypothesized that women in the early discharge groups would be significantly more satisfied with nursing care than those who remained in hospital for the traditional time. Using one-half of a standard deviation to determine the effectiveness of the program, a sample size of 90 was required using alpha set at P < 0.05, with a power of 0.80, to detect this difference. Confidence in Mothering Role Confidence in mothering role was assessed using the subscale of a questionnaire developed for a previous study of women during their childbearing years. The original subscale consisted of seven items with a Cronbach’s alpha of > 0.80 (10). For a
20 1
BIRTH 17:4 December 1990
sample of 223 women, the means and standard deviation for the original questionnaire were 29.87 and 5.54, respectively. The number of items used for the present study was eight, and Cronbach’s alpha was 0.86. It was hypothesized that women in the early discharge groups would be more confident with respect to their mothering role than women in the traditional group. Once again, using one-half a standard deviation as the difference of interest, a sample size of 75 was required using alpha set at P < 0.05, with a power of 0.80.
Depression and Anxiety Standardized measures were used to assess depression and anxiety of the women. The State-Trait Anxiety Inventory (1 1) was used to assess levels of anxiety at the different time periods. Using the standardized population norms (mean 50, SD lo), it was decided that a difference of one standard deviation in group scores would be used to determine the effectiveness of the program. It was hypothesized that women in the early discharge program would be less anxious than those staying for the traditional length of stay. For this outcome, using alpha set at P < 0.05, with power of 0.80, a sample of 75 would suffice. The Beck Depression Index (12,13) was used to assess the level of depression; for the purpose of this study, the items related to weight were omitted. It was hypothesized that women in the early discharge groups would be less depressed than those discharged later. In a previous study of psychological functioning during the childbearing years, using a similar sample, the mean and standard deviation for the scores of 151 women were 4.90 and 4.52, respectively (14). Therefore, a sample size of 78 would give an 80% chance of detecting a difference of one-half a standard deviation. Statistical Assessment The statistical techniques used to analyze the data included chi-square and one-way analysis of variance for three groups. In the latter, if the F ratio was significant, the analysis was followed by multiple comparisons, using the Newman-Keuls procedure with alpha set at 0.05. Results
Participants Excluded from the Study Of the 10 women who were dropped from the study because they chose to go home at times other than those assigned, 5 went home later than assigned
and 5 earlier. Of the 45 women who did not meet early discharge criteria, it is of note that 40 were primiparous and 5 multiparous. It appears that programs that enroll participants during the prenatal period may expect to lose approximately one-third of primiparas due to complications during labor and delivery. The demographic characteristics of the women in the three groups did not differ significantly after randomization. The mean age of the participants was 30.24 years (SD 3.80) and of their husband or partner 32.87 years (SD 5.51). Over 95% of the women were Caucasian, 93% were married or living with their partner, 65% had completed junior college or university, and 58% had a combined family income over $40,000. Eighty-four percent of women worked during their pregnancy. Fifty-three percent were primiparas and 47% multiparas. Eighty-one percent were attended by a family physician during their pregnancy and birth; the remaining 19% received their care from obstetricians. There was a significant difference in length of hospital stay among the three groups (F[2,123] = 270.98; P < O.OOOl), with each group differing significantly from the others with respect to number of days in hospital (Table 1).
Maternal and Znfant Health Regardless of the time of discharge, the women experienced a generally healthy postpartum course. Reports in the literature indicate a maternal problem rate of 2.8% to 23% (7). A criticism of reported studies is the lack of specific information on the nature or definition of the problems encountered. The frequency of maternal problems requiring physician referral in the first 10 days postpartum was 5.3% (n = 5 ) in the early discharge groups and 7.9% ( n = 3) in the traditional stay group. One instance of each problem was reported, by group, as follows: group 1-urinary tract infection and episiotomy infection; group 2-mastitis, episiotomy infection, and subinvolution; and group 3-endometritis, episiotomy infection, and subinvolution. Of women referred to a physician, two (1.5%) were hospitalized within the first month postpartum: one from the earliest discharge group for a Table 1. Mean Length of Stay in Hospital by Group (days)
Group
X
SD
1 (n = 44) 2 (n = 49) 3 ( n = 38)
1.12 2.06 4.03
0.40 0.56 0.69
202 urinary tract infection, and the other, from the traditional stay group for endometritis. In the study by Hellman et al. (l), readmissions were higher in the early discharge group than in the control group, whereas Yanover et al. (15) reported no hospitalization in a sample of 88 women and their infants who were discharged early. The rate of infant problems reported in the literature ranges from 7.8% to 41%. It has been suggested that these differences can be accounted for by the definition of hyperbilirubinemia (7). In this study, only one baby in the early discharge groups was tested for bilirubin level. We believe that compliance with study nurses’ suggestion for early and frequent breastfeeding, and placement of babies near the window for daytime sleeping assisted in preventing hyperbilirubinemia. During the first 10 days postpartum, six (4.5%) babies were referred to physicians by study nurses. Reasons for referrals by group were as follows: group 1-hyperbilirubinemia; group 2-cord infection; and group 3-ABO incompatibility and diaper rash (1 each). In addition, two babies (3.8%) went to the hospital within the first six weeks postpartum for respiratory difficulties (groups 1 and 2). These conditions were assessed quickly by the visiting nurse and remedial action was taken. When broken down by groups, the frequency of problems requiring physician referral was 4.3% in groups 1 and 2 and 2.6% in group 3. The sample sizes were too small to detect significant differences in maternal and infant health. If this trial is replicated, a meta-analysis may suggest differences. We believe, however, that the potential for serious health problems highlights the necessity of employing nurses who have extensive experience in maternal-newborn nursing. Other authors stressed the importance of skilled nursing care as a component of successful early discharge programs (6,15). The nurses in this study used their critical care skills obtained from experience in a tertiarycare maternity hospital to carry out in-depth physical assessments of the mother and the baby. This was complemented by their community health experience, which resulted in recognition of the strength of the home environment in promoting family integration and physical recovery. Breastfeeding Duration On discharge from hospital, 98% of all women in the study were breastfeeding. At one month, 87% of the women in the early discharge groups and 79% in the traditional stay group were giving their babies breast milk only. This rate of breastfeeding at one month postpartum is, to our knowledge, one
BIRTH 17:4 December 1990
of the highest reported in the published literature. We have no way of knowing, however, whether the nonrespondents were breastfeeding or bottle feeding their infants at one month. The one-month questionnaires were returned by mail with a rate of return of 75%. There was no relationship between group participation and response rate (x2 = 2.74; P > 0.1). Return rates were 82%, 74%, and 66% for groups 1 to 3 , respectively. Psychological Functioning The responses of the women in the three groups did not differ significantly with respect to levels of trait anxiety. Neither were there significant differences among the groups on levels of state anxiety assessed prenatally, in hospital at one week, or at one month postpartum (Table 2). Depressive Affect. Women in the three groups did not differ on their prenatal scores on the Beck Depression Index. Those who stayed in hospital for 4 days scored significantly higher on that index at the 1-month follow up (F[2,88] = 4.13; P < 0.05) than did women who were discharged 12 to 24 hours postpartum. Confidence. At one week, women who were discharged within 24 hours scored significantly higher than those in the two other groups on the subscale assessing confidence regarding the mothering role (F[2,114] = 3.47; P < 0.03). There were no differences among the groups with respect to scores on this subscale completed at one month postpartum. This finding suggests that women who have complete responsibility for their baby earlier feel more confident initially than those who do not. Patient Satisfaction Previous studies of satisfaction with obstetric care in Canada revealed that most women are at least moderately satisfied with the care they receive (16). In this study all the women were satisfied with their care, as demonstrated by their responses on the patient satisfaction questionnaire. There was a significant difference in scores among the three groups, however (F[2,88] = 7.65; P < 0.0009). Women who were discharged earliest reported being significantly more satisfied than those discharged later. They also were significantly more satisfied with nursing care. It was suggested that women in group 3 may have felt disappointed that they were not randomly selected for the early discharge group, thus accounting for their lower scores. However, those randomized to the early discharge groups may have been equally upset that they had to leave hospital early. The data indicate that all women, in fact,
203
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Table 2. Means and Standard Deviations of Psychosocial Measures Completed at One Month
- Group 1 Anxiety, trait Anxiety, state Beck BDI Confidence Satisfaction ~~~
-
Group 2
X
SD
X
SD
43.02 40.18 4.5 39.71 96.97
10.17 12.57 2.54 4.68 11.25
44.38 42.57 5.35 38.73 91.55
1 1S O
10.09 4.36 5.12 16.55
Group 3
X
SD
P
47.31 43.04 7.83 36.53 80.45
11.60 13.72 6.46 5.83 20.96
NS NS < 0.05* < 0.03* < 0.0009*
~~
* SigniJicant difference between groups 1 and 3.
were satisfied with their experience; but the early discharge groups were significantly more satisfied. Discussion These findings are not surprising when one considers that the project nurses provided consistent one-to-one care over 10 days, believed early discharge and postpartum home care is a safe and satisfying option for many women, and believed in reinforcement and positive feedback as a way of helping develop maternal self-confidence and selfesteem. These beliefs on the part of health professionals may be critical to the success of such a program. For example, Patterson (17) found that the late stay group in her study were influenced by the hospital staff in making their decision about how long to remain in hospital. One woman in the present study who was in an early discharge group reported that the hospital nurses tried to talk her out of going home early. She felt that, had she been less strong in her desire to go home, her decision might easily have been undermined by the staff. Strengths and Limitations of the Study The strengths of the study include the experimental design with random assignment of the participants to the groups and the variety of measures used to evaluate the program. The studies on early discharge reported thus far, with the exception of that of Yanover et al. (15), have not demonstrated this level of rigor. Because participants were healthy, well-educated women and living in a stable relationship with their husbands or partners, the findings cannot be generalized to a high-risk population. Although the advantages of random assignment have been well documented, the disadvantage for a study such as this, which depends on volunteers, is that it takes a particular type of woman who is willing to experience postpartum care that ranges from going home within 12 to 24 hours after birth to a hospital stay of
4 days. This accounts, we suspect, for the welleducated, older sample. Our approach to the nurses for the study had both strengths and limitations. We did not organize the study so the same nurses provided inpatient care to the group 3 mothers; the regular staff cared for those women. One can only conjecture that some of the findings related to satisfaction, depression, and confidence in the mothering role might have been different if the study nurses had also provided in-hospital care. Other limitations are worthy of note. Recruitment took approximately one year longer than expected. Furthermore, only 10% of the 300 physicians who initially agreed to participate referred patients. Consequently, attaining an appropriate sample size was difficult. (It is of note that female family physicians were the greatest supporters of the study.) One possible explanation is that physicians had no incentive to recommend the study to their patients other than belief in the value of home care during the early postpartum period. Furthermore, having some patients in the hospital and some at home is more time consuming for the physician, who receives the same postpartum care fee no matter how long the patient stays in hospital. Because the people of British Columbia pay for their health care through federal and provincial taxes, there is little outlay of money at the time of any health care encounter. As a result, no financial incentive existed for the woman to participate. Thus motivation had to come from their beliefs about the advantages of being at home soon after birth. It is clear to us that these beliefs are not widely held in this metropolitan area. Conclusion The results of this study indicate that women who experienced a normal labor and birth and were discharged within 12 to 24 hours with five follow-up home visits by maternity nurses in the first 10 days were more satisfied with nursing care. In addition,
BIRTH 17:4 December 1990
these mothers reported themselves to be significantly less depressed at one month and more confident in providing infant care at one week than women who stayed in hospital for four days. This suggests that the nursing visits enhanced women's feelings of confidence regarding their mothering role. Although the sample size limits conclusions about safety, further studies may provide a basis for meta-analysis, and thus clarify whether significant health differences exist between mothers and infants discharged in 12 to 24 hours compared to those discharged at 4 days postpartum. References I . Hellman LM, Kohl SG, Palmer J. Early hospital discharge in obstetrics. Lancet 1962;1:227-232. 2. Jones D. Home early after delivery. A m J Nurs 1978;8: 1378-1380. 3. Scupholme A. Postpartum early discharge: An inner city experience. J Nurse Midwif 1981;26:19-22. 4. Thurston NE, Dundas JB. Evaluation of an early postpartum discharge program. Can J Public Health 1985;76: 384- 387. 5 . McCarty E. Early postpartum nursing care of mother and infant in the home care setting. Nurs Clin North A m 1980; 15:361-372. 6. Cam KC, Walton VE. Early postpartum discharge. JOGN Nurs 1982;11:19-30.
7. Norr KF, Nacion K. Outcomes of postpartum early discharge, 1960-1986: A comparative review. Birth 1987;14: 135-141. 8. Bradley CF, Carty E, Hall WA. An Evaluation of Early Postpartum Discharge from a Tertiary Care Maternity Hospital. Vancouver, Canada: University of British Columbia School of Nursing, 1989. 9. Ellis DJ, Hewat RJ. Breastfeeding: Motivation and outcome. J Biosoc Sci 1984;16:81-88. 10. Bradley CF. Psychological consequences of intervention in the birth process. Can J Behav Sci 1983;15(4):422-437. 11. Spielberger CD, Gorsuch RL, Luschene RE. Manuat for the Slate-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press, 1970. 12. Beck AT, Ward CH, Mendelson M, et al. Inventory for measuring depression. Arch Gen Psychiatry 1961;4:561571. 13. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck depression inventory: Twenty-five years of evaluation. Clin Psychiatry Rev 1988;8:77- 100. 14. Bradley CF. The Antecedents and Consequences of Maternal Adaptation in the Postpartum. Report to the Department of Health and Welfare. Vancouver, Canada: University of British Columbia, 1983. 15. Yanover MJ, Jones D, Miller MD. Perinatal care of lowrisk mothers and infants: Early discharge with home care. N Engl J Med 1976;294:702-705. 16. Obstetrics '87: A Report of the Canadian Medical Association on Obstetrical Care in Canada. Canadian Medical Association, 1987. 17. Patterson PK. A comparison of postpartum early and traditional discharge groups. Q Rev Bull 1987;365-371.
Additional Reading: Randomized Controlled Trials Waldenstrom U, Sundelin C, Lindmark G. Early and late discharge after hospital birth. Health of mother and infant in the postpartum period. Uppsala J Med Sci 1987;92:301-314.
-Early and late discharge after hospital birth: Breastfeeding. Acta Paediatr Scand 1987;76:727-732.
199
A Randomized, Controlled Evaluation of Early Postpartum Hospital Discharge Elaine M. Carty, R.N.,M.S.N., C.N.M., and Christine F. Bradley, Ph.D. ABSTRACT: A t approximately 37 weeks’ gestation, 131 women were randomly assigned to one of three postpartum hospital discharge times: 12 t o 24 hours, 25 to 48 hours, and 4 days. Depending on group assignment, the women received from one to five home visits by a maternity nurse clinician during the first 10 days postpartum. The results indicated the maternal and infant morbidity were low regardless of discharge time, although sample sizes were too small to detect signiJicant differences in the outcomes. More early discharge mothers were breastfeeding without supplement at 1 month than were mothers in the long stay group. Mothers in the two early discharge groups were signijicantly more satisfied with their care than were those who remained longer. Those hospitalized longer scored higher on measures of depression and lower on scores of confidence at selected time periods. (BIRTH 17:4, December 1990) Since 1962, studies of early postpartum hospital discharge programs have focused on whether it is safe to send women home within 24 hours after birth (1). Evidence from some studies suggested advantages with respect to family integration (2-4) and the mother recovering in the familiar environment of the home (5,6). Specific outcomes, however, such as infant and maternal morbidity and mothers’ psychological functioning after discharge within 12 to 48 hours compared to discharge after 4 days have not been assessed in a randomized, controlled trial. In their review of early discharge, Norr and Nacion (7) discussed many methodological deficiencies in published work, in particular, the paucity of controlled studies and lack of information with respect to patient satisfaction and other benefits. We therefore designed a randomized, controlled trial to assess whether discharge 12 to 48 hours postpartum resulted in improvement in maternal and infant physical and psychological health, duration of breastfeeding, and patient satisfaction (8).
Elaine M . Carty is Associate Professor, School of Nursing, University oflritish Columbia, Vancouver, B. C. Christine F. Bradley is Director of Research and Evaluation, Division of Nursing, Vancouver General Hospital, British Columbia’s Health Sciences Centre, Vancouver, B.C.
Methods Sample The study took place at a tertiary care maternity hospital in Vancouver. All women expecting a vaginal birth were eligible to participate. They were told by their physician, prenatal classes, or hospital tours that the investigators were studying women’s experience of alternative times of discharge from hospital. Women who agreed to be randomly assigned to one of three discharge times were visited at home by a project nurse at approximately 38 weeks’ gestation who explained the study in greater detail, obtained written informed consent, and assigned time of discharge. One hundred eighty-nine women volunteered to participate in the study. Of these, 1 had a home birth, 2 reversed their decision to participate, and 10 were dropped because they chose to go home at times other than the discharge times to which they had been assigned. After the birth, 45 women did not meet the study discharge criteria for mother and infant (cesarean section, forceps delivery, etc.) and were eliminated. Thus, the final sample consisted of 131 women. Discharge assignments were determined prior to the home visits at about 38 weeks. Using a table of random numbers, sealed, opaque envelopes containing the assignments were placed on the file of each prospective participant and opened by the
BIRTH 17:4 December 1990
200 nurse at the time of the home visit. Neither the nurse nor participant was aware of the assignment before this visit. The discharge schedules were as follows: Early discharge: Group 1, 12 to 24 hours ( n = 44) Group 2 , 25 to 48 hours ( n = 49) Traditional stay: Group 3, 4 days ( n = 38) Nurses The five project nurses had a baccalaureate degree in nursing, and had experience in both community health nursing and inpatient postpartum care in a tertiary-level maternity hospital. Before the study began they participated in a two-week in-service program developed to ensure that they would be working from a common theoretical and philosophical framework. The nurses made home visits to the women under their care according to the following schedule: group 1 on days 1, 2, 3, 5 , and 10 after delivery; group 2 on days 3, 5 , and 10; group 3 on day 10 only. At each visit the nurses provided similar nursing care to that received by women in hospital. They conducted a physical assessment of the mother and baby, dealt with the immediate concerns of the parents, assisted them with getting to know their baby, and dealt with the many facets of incorporating a new member into the family. After the 10-day visit, the nurses sent summaries of the assessments and nursing care to the attending physicians. Questionnaires were left with the participants to be completed at four time periods: 37 weeks’ gestation, during the hospital stay, 1 week postpartum, and 1 month postpartum. Hospital and project nurses were unaware of the content of questionnaires. Outcome Measures
Maternal and Infant Health The standardized forms used for examining mothers and infants in the hospital were used during each home visit to ensure consistency in the examination process. In this study, health problems were defined as maternal or neonatal problems requiring a referral to a physician. Maternal infections, neonatal infections, neonatal respiratory difficulties, and neonatal jaundice were the major problems one could expect to identify. Since the opinion among most health professionals in the community at the time of the study was that the hospital was the safest place to be during the first four to five days postpartum, the
null hypothesis was that there would be less than a 1% difference between early discharge women and their babies and traditional stay women with respect to health problems. The nosocomial infection rate for mothers and newborns in our community is 2%. Therefore, a sample size of 4821 would be required to give an 80% chance of detecting a 1% difference at P < 0.05. Expected rates for neonatal jaundice and neonatal respiratory difficulties requiring treatment were difficult to obtain because of problems of definition. However, sample sizes of the same magnitude would be required to determine statistical differences. Thus, this study did not have the sample size necessary to assess statistical significance of these health problems. However, problems requiring physician referral are documented in the section on results. Breastfeeding On the questionnaire completed one month postpartum, women were asked to report whether they were breastfeeding only, bottle feeding only, or both breastfeeding and bottle feeding. The percentage of women breastfeeding without supplement at one month postpartum was 65% in a previous study in the same hospital (9). The hypothesis in this study was that 20% more women in the early discharge groups would be breastfeeding without supplements at one month than those in the traditional stay group. A sample of 140 would be required to give an 80% chance of detecting a 20% difference at P < 0.05. Patient Satisfaction Patient satisfaction with nursing care was assessed using a questionnaire developed for this study. It consisted of 22 items relating to maternal perception of nursing care rated on a 5-point Likert scale with a total possible score of 110. Cronbach’s alpha for this questionnaire was 0.97, indicating good internal consistency. It was hypothesized that women in the early discharge groups would be significantly more satisfied with nursing care than those who remained in hospital for the traditional time. Using one-half of a standard deviation to determine the effectiveness of the program, a sample size of 90 was required using alpha set at P < 0.05, with a power of 0.80, to detect this difference. Confidence in Mothering Role Confidence in mothering role was assessed using the subscale of a questionnaire developed for a previous study of women during their childbearing years. The original subscale consisted of seven items with a Cronbach’s alpha of > 0.80 (10). For a
20 1
BIRTH 17:4 December 1990
sample of 223 women, the means and standard deviation for the original questionnaire were 29.87 and 5.54, respectively. The number of items used for the present study was eight, and Cronbach’s alpha was 0.86. It was hypothesized that women in the early discharge groups would be more confident with respect to their mothering role than women in the traditional group. Once again, using one-half a standard deviation as the difference of interest, a sample size of 75 was required using alpha set at P < 0.05, with a power of 0.80.
Depression and Anxiety Standardized measures were used to assess depression and anxiety of the women. The State-Trait Anxiety Inventory (1 1) was used to assess levels of anxiety at the different time periods. Using the standardized population norms (mean 50, SD lo), it was decided that a difference of one standard deviation in group scores would be used to determine the effectiveness of the program. It was hypothesized that women in the early discharge program would be less anxious than those staying for the traditional length of stay. For this outcome, using alpha set at P < 0.05, with power of 0.80, a sample of 75 would suffice. The Beck Depression Index (12,13) was used to assess the level of depression; for the purpose of this study, the items related to weight were omitted. It was hypothesized that women in the early discharge groups would be less depressed than those discharged later. In a previous study of psychological functioning during the childbearing years, using a similar sample, the mean and standard deviation for the scores of 151 women were 4.90 and 4.52, respectively (14). Therefore, a sample size of 78 would give an 80% chance of detecting a difference of one-half a standard deviation. Statistical Assessment The statistical techniques used to analyze the data included chi-square and one-way analysis of variance for three groups. In the latter, if the F ratio was significant, the analysis was followed by multiple comparisons, using the Newman-Keuls procedure with alpha set at 0.05. Results
Participants Excluded from the Study Of the 10 women who were dropped from the study because they chose to go home at times other than those assigned, 5 went home later than assigned
and 5 earlier. Of the 45 women who did not meet early discharge criteria, it is of note that 40 were primiparous and 5 multiparous. It appears that programs that enroll participants during the prenatal period may expect to lose approximately one-third of primiparas due to complications during labor and delivery. The demographic characteristics of the women in the three groups did not differ significantly after randomization. The mean age of the participants was 30.24 years (SD 3.80) and of their husband or partner 32.87 years (SD 5.51). Over 95% of the women were Caucasian, 93% were married or living with their partner, 65% had completed junior college or university, and 58% had a combined family income over $40,000. Eighty-four percent of women worked during their pregnancy. Fifty-three percent were primiparas and 47% multiparas. Eighty-one percent were attended by a family physician during their pregnancy and birth; the remaining 19% received their care from obstetricians. There was a significant difference in length of hospital stay among the three groups (F[2,123] = 270.98; P < O.OOOl), with each group differing significantly from the others with respect to number of days in hospital (Table 1).
Maternal and Znfant Health Regardless of the time of discharge, the women experienced a generally healthy postpartum course. Reports in the literature indicate a maternal problem rate of 2.8% to 23% (7). A criticism of reported studies is the lack of specific information on the nature or definition of the problems encountered. The frequency of maternal problems requiring physician referral in the first 10 days postpartum was 5.3% (n = 5 ) in the early discharge groups and 7.9% ( n = 3) in the traditional stay group. One instance of each problem was reported, by group, as follows: group 1-urinary tract infection and episiotomy infection; group 2-mastitis, episiotomy infection, and subinvolution; and group 3-endometritis, episiotomy infection, and subinvolution. Of women referred to a physician, two (1.5%) were hospitalized within the first month postpartum: one from the earliest discharge group for a Table 1. Mean Length of Stay in Hospital by Group (days)
Group
X
SD
1 (n = 44) 2 (n = 49) 3 ( n = 38)
1.12 2.06 4.03
0.40 0.56 0.69
202 urinary tract infection, and the other, from the traditional stay group for endometritis. In the study by Hellman et al. (l), readmissions were higher in the early discharge group than in the control group, whereas Yanover et al. (15) reported no hospitalization in a sample of 88 women and their infants who were discharged early. The rate of infant problems reported in the literature ranges from 7.8% to 41%. It has been suggested that these differences can be accounted for by the definition of hyperbilirubinemia (7). In this study, only one baby in the early discharge groups was tested for bilirubin level. We believe that compliance with study nurses’ suggestion for early and frequent breastfeeding, and placement of babies near the window for daytime sleeping assisted in preventing hyperbilirubinemia. During the first 10 days postpartum, six (4.5%) babies were referred to physicians by study nurses. Reasons for referrals by group were as follows: group 1-hyperbilirubinemia; group 2-cord infection; and group 3-ABO incompatibility and diaper rash (1 each). In addition, two babies (3.8%) went to the hospital within the first six weeks postpartum for respiratory difficulties (groups 1 and 2). These conditions were assessed quickly by the visiting nurse and remedial action was taken. When broken down by groups, the frequency of problems requiring physician referral was 4.3% in groups 1 and 2 and 2.6% in group 3. The sample sizes were too small to detect significant differences in maternal and infant health. If this trial is replicated, a meta-analysis may suggest differences. We believe, however, that the potential for serious health problems highlights the necessity of employing nurses who have extensive experience in maternal-newborn nursing. Other authors stressed the importance of skilled nursing care as a component of successful early discharge programs (6,15). The nurses in this study used their critical care skills obtained from experience in a tertiarycare maternity hospital to carry out in-depth physical assessments of the mother and the baby. This was complemented by their community health experience, which resulted in recognition of the strength of the home environment in promoting family integration and physical recovery. Breastfeeding Duration On discharge from hospital, 98% of all women in the study were breastfeeding. At one month, 87% of the women in the early discharge groups and 79% in the traditional stay group were giving their babies breast milk only. This rate of breastfeeding at one month postpartum is, to our knowledge, one
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of the highest reported in the published literature. We have no way of knowing, however, whether the nonrespondents were breastfeeding or bottle feeding their infants at one month. The one-month questionnaires were returned by mail with a rate of return of 75%. There was no relationship between group participation and response rate (x2 = 2.74; P > 0.1). Return rates were 82%, 74%, and 66% for groups 1 to 3 , respectively. Psychological Functioning The responses of the women in the three groups did not differ significantly with respect to levels of trait anxiety. Neither were there significant differences among the groups on levels of state anxiety assessed prenatally, in hospital at one week, or at one month postpartum (Table 2). Depressive Affect. Women in the three groups did not differ on their prenatal scores on the Beck Depression Index. Those who stayed in hospital for 4 days scored significantly higher on that index at the 1-month follow up (F[2,88] = 4.13; P < 0.05) than did women who were discharged 12 to 24 hours postpartum. Confidence. At one week, women who were discharged within 24 hours scored significantly higher than those in the two other groups on the subscale assessing confidence regarding the mothering role (F[2,114] = 3.47; P < 0.03). There were no differences among the groups with respect to scores on this subscale completed at one month postpartum. This finding suggests that women who have complete responsibility for their baby earlier feel more confident initially than those who do not. Patient Satisfaction Previous studies of satisfaction with obstetric care in Canada revealed that most women are at least moderately satisfied with the care they receive (16). In this study all the women were satisfied with their care, as demonstrated by their responses on the patient satisfaction questionnaire. There was a significant difference in scores among the three groups, however (F[2,88] = 7.65; P < 0.0009). Women who were discharged earliest reported being significantly more satisfied than those discharged later. They also were significantly more satisfied with nursing care. It was suggested that women in group 3 may have felt disappointed that they were not randomly selected for the early discharge group, thus accounting for their lower scores. However, those randomized to the early discharge groups may have been equally upset that they had to leave hospital early. The data indicate that all women, in fact,
203
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Table 2. Means and Standard Deviations of Psychosocial Measures Completed at One Month
- Group 1 Anxiety, trait Anxiety, state Beck BDI Confidence Satisfaction ~~~
-
Group 2
X
SD
X
SD
43.02 40.18 4.5 39.71 96.97
10.17 12.57 2.54 4.68 11.25
44.38 42.57 5.35 38.73 91.55
1 1S O
10.09 4.36 5.12 16.55
Group 3
X
SD
P
47.31 43.04 7.83 36.53 80.45
11.60 13.72 6.46 5.83 20.96
NS NS < 0.05* < 0.03* < 0.0009*
~~
* SigniJicant difference between groups 1 and 3.
were satisfied with their experience; but the early discharge groups were significantly more satisfied. Discussion These findings are not surprising when one considers that the project nurses provided consistent one-to-one care over 10 days, believed early discharge and postpartum home care is a safe and satisfying option for many women, and believed in reinforcement and positive feedback as a way of helping develop maternal self-confidence and selfesteem. These beliefs on the part of health professionals may be critical to the success of such a program. For example, Patterson (17) found that the late stay group in her study were influenced by the hospital staff in making their decision about how long to remain in hospital. One woman in the present study who was in an early discharge group reported that the hospital nurses tried to talk her out of going home early. She felt that, had she been less strong in her desire to go home, her decision might easily have been undermined by the staff. Strengths and Limitations of the Study The strengths of the study include the experimental design with random assignment of the participants to the groups and the variety of measures used to evaluate the program. The studies on early discharge reported thus far, with the exception of that of Yanover et al. (15), have not demonstrated this level of rigor. Because participants were healthy, well-educated women and living in a stable relationship with their husbands or partners, the findings cannot be generalized to a high-risk population. Although the advantages of random assignment have been well documented, the disadvantage for a study such as this, which depends on volunteers, is that it takes a particular type of woman who is willing to experience postpartum care that ranges from going home within 12 to 24 hours after birth to a hospital stay of
4 days. This accounts, we suspect, for the welleducated, older sample. Our approach to the nurses for the study had both strengths and limitations. We did not organize the study so the same nurses provided inpatient care to the group 3 mothers; the regular staff cared for those women. One can only conjecture that some of the findings related to satisfaction, depression, and confidence in the mothering role might have been different if the study nurses had also provided in-hospital care. Other limitations are worthy of note. Recruitment took approximately one year longer than expected. Furthermore, only 10% of the 300 physicians who initially agreed to participate referred patients. Consequently, attaining an appropriate sample size was difficult. (It is of note that female family physicians were the greatest supporters of the study.) One possible explanation is that physicians had no incentive to recommend the study to their patients other than belief in the value of home care during the early postpartum period. Furthermore, having some patients in the hospital and some at home is more time consuming for the physician, who receives the same postpartum care fee no matter how long the patient stays in hospital. Because the people of British Columbia pay for their health care through federal and provincial taxes, there is little outlay of money at the time of any health care encounter. As a result, no financial incentive existed for the woman to participate. Thus motivation had to come from their beliefs about the advantages of being at home soon after birth. It is clear to us that these beliefs are not widely held in this metropolitan area. Conclusion The results of this study indicate that women who experienced a normal labor and birth and were discharged within 12 to 24 hours with five follow-up home visits by maternity nurses in the first 10 days were more satisfied with nursing care. In addition,
BIRTH 17:4 December 1990
these mothers reported themselves to be significantly less depressed at one month and more confident in providing infant care at one week than women who stayed in hospital for four days. This suggests that the nursing visits enhanced women's feelings of confidence regarding their mothering role. Although the sample size limits conclusions about safety, further studies may provide a basis for meta-analysis, and thus clarify whether significant health differences exist between mothers and infants discharged in 12 to 24 hours compared to those discharged at 4 days postpartum. References I . Hellman LM, Kohl SG, Palmer J. Early hospital discharge in obstetrics. Lancet 1962;1:227-232. 2. Jones D. Home early after delivery. A m J Nurs 1978;8: 1378-1380. 3. Scupholme A. Postpartum early discharge: An inner city experience. J Nurse Midwif 1981;26:19-22. 4. Thurston NE, Dundas JB. Evaluation of an early postpartum discharge program. Can J Public Health 1985;76: 384- 387. 5 . McCarty E. Early postpartum nursing care of mother and infant in the home care setting. Nurs Clin North A m 1980; 15:361-372. 6. Cam KC, Walton VE. Early postpartum discharge. JOGN Nurs 1982;11:19-30.
7. Norr KF, Nacion K. Outcomes of postpartum early discharge, 1960-1986: A comparative review. Birth 1987;14: 135-141. 8. Bradley CF, Carty E, Hall WA. An Evaluation of Early Postpartum Discharge from a Tertiary Care Maternity Hospital. Vancouver, Canada: University of British Columbia School of Nursing, 1989. 9. Ellis DJ, Hewat RJ. Breastfeeding: Motivation and outcome. J Biosoc Sci 1984;16:81-88. 10. Bradley CF. Psychological consequences of intervention in the birth process. Can J Behav Sci 1983;15(4):422-437. 11. Spielberger CD, Gorsuch RL, Luschene RE. Manuat for the Slate-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press, 1970. 12. Beck AT, Ward CH, Mendelson M, et al. Inventory for measuring depression. Arch Gen Psychiatry 1961;4:561571. 13. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck depression inventory: Twenty-five years of evaluation. Clin Psychiatry Rev 1988;8:77- 100. 14. Bradley CF. The Antecedents and Consequences of Maternal Adaptation in the Postpartum. Report to the Department of Health and Welfare. Vancouver, Canada: University of British Columbia, 1983. 15. Yanover MJ, Jones D, Miller MD. Perinatal care of lowrisk mothers and infants: Early discharge with home care. N Engl J Med 1976;294:702-705. 16. Obstetrics '87: A Report of the Canadian Medical Association on Obstetrical Care in Canada. Canadian Medical Association, 1987. 17. Patterson PK. A comparison of postpartum early and traditional discharge groups. Q Rev Bull 1987;365-371.
Additional Reading: Randomized Controlled Trials Waldenstrom U, Sundelin C, Lindmark G. Early and late discharge after hospital birth. Health of mother and infant in the postpartum period. Uppsala J Med Sci 1987;92:301-314.
-Early and late discharge after hospital birth: Breastfeeding. Acta Paediatr Scand 1987;76:727-732.
