(~) Longman Group UK Ltd 1992 +++>
Midwifery
Early postpartum d i s c h a r g e - an alternative to traditional hospital care Iris E Campbell
I n a p r e d i c t i v e s t u d y o f e a r l y p o s t p a r t u m d i s c h a r g e d a t a w e r e collected to j u s t i f y a p r o p o s a l that was b e i n g d e v e l o p e d by a city hospital a n d the Local B o a r d o f H e a l t h to p r o v i d e m a t e r n i t y care f o r w o m e n w h o wished to be d i s c h a r g e d early f r o m hospital following childbirth. I n this p a p e r the findings o f the p r e d i c t i v e s t u d y are p r e s e n t e d a n d t h e n c o m p a r e d with the findings f r o m the e v a l u a t i o n o f the p r o j e c t which was i m p l e m e n t e d by t h e hospital a n d the Local B o a r d o f H e a l t h . Overall, the findings f r o m t h e p r e d i c t i v e s t u d y w e r e a c c u r a t e w h e n c o m p a r e d to the findings f r o m t h e e v a l u a t i o n study. T h e similarity o f findings in b o t h studies d e m o n s t r a t e s the value o f u n d e r t a k i n g a p r e d i c t i v e s t u d y p r i o r to p l a n n i n g c h a n g e s in d e l i v e r y o f h e a l t h c a r e to a specific p o p u l a t i o n .
INTRODUCTION Early postpartum discharge is a relatively new concept in North America. In the 1950s a seven to ten-day stay in hospital was thought to be 'proper' by many physicians and nurses (Hellman et al, 1962). However, increasing health care costs, shortage o f hospital beds and the desire of newly delivered women to return home at an earlier stage postpartum has necessitated the introduction of an alternative method of providing care for newly delivered women and their babies. Previous studies (Guerriero, 1943; Nabors & Herndon, 1956; Hellman et al, 1962) have demonstrated that early postpartum discharge at 8-72 h postpartum was safe, feasible and acceptable to women and their families. In Iris E Campbell RN, SCM, MTD, MN, Assistant Professor, Faculty of Nursing, University of Alberta, Edmonton, T6G 2G3, Canada. Manuscript accepted 25 April 1992 Requests for offprints to IEC
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the USA, two of the major factors for early discharge were the lack o f health care insurance coverage and the increasing costs of a hospital stay. Fortunately, these factors have no bearing on the choices of Canadian families so it must be postulated that Canadian families are selecting early discharge for other reasons. Some reasons cited in earlier studies were: family togetherness, parent satisfaction and involvement o f the father in care of the new-born baby (Scupholme, 1981; Thurston & Dundas, 1985). As a result of the opportunities for choice by Canadian families regarding the venue for postpartum care, a study was undertaken at the request of the Director of Nursing in a Women's Hospital in the city o f Edmonton, Western Canada, to determine the preferences of women and their families in relation to postpartum care. T h e need for this study was to collect data to justify a proposal that was being developed by the hospital and the Local Board of Health to provide care for women, at low obstetric risk, who wished to be discharged from hospital
MmWIFERY 133 before 72 h following an uncomplicated vaginal delivery and earlier than five days (120h) following an uncomplicated caesarean delivery. In this p a p e r the findings from this study will be reported and then discussed in relation to the evaluation of the early discharge project, comparing predictions and results where parallel data are available.
Literature Review Over the past 30 years many studies have been carried out that have demonstrated the safety of the practice of allowing newly delivered women and their babies who are at low risk for medical complications to leave the hospital a few hours after delivery. One of the most important criteria for allowing early discharge is neonatal stability; this has been considered reliable after six hours in babies born with a high Apgar score of eight or more (Thurston & Dundas, 1985; Norr & Nacion, 1987). One finding that was consistently reported in the literature was parent satisfaction with the early discharge p r o g r a m m e . In a study of middle class, English-speaking Americans, more women in the early discharge g r o u p were satisfied with their postpartum care than women in the traditional three-day hospital stay g r o u p (Yanover et al, 1976; Carty & Bradley, 1990). Family togetherness has been cited as being a source of parent satisfaction as has been the early involvement of the father in care of the new baby (Scupholme, 1981; T h u r s t o n & Dundas, 1985). However, a Swedish study by Waldenstrom (1987) reported that although 92% of the women in an early discharge p r o g r a m m e had positive experiences, parents with no interest in such a p r o g r a m m e had m o r e positive experiences with hospital care. In a study of early discharge in Oregon, women at low obstetric risk selected either the traditional three-day stay or early discharge (Patterson, 1987). T h e postpartum stay for the early discharge women was 4 0 h or less plus a required home visit by a nurse for two days. T h e n u m b e r of women who selected early discharge was approximately one-third of those eligible. MIDW.
D
Later in this study, the n u m b e r of women who selected early discharge increased to one half of those eligible but the reason for this was not discussed. T h e r e were no major demographic differences between the early discharge and traditional discharge groups but m o r e first-time mothers chose the traditional p r o g r a m m e . H o m e support was important and husbands were most often cited as the major source o f home support following discharge (92%). In the same study, women who chose the traditional stay cited the hospital as being the best place to rest and believed nurses were more helpful than family for gaining confidence (Patterson, 1987). Harrison (1990) suggests that early discharge p r o g r a m m e s provide greater opportunity to parents and siblings to establish earlier acquaintance and interaction with the new baby without the distractions o f a hospital routine. Also, decreasing the length of the hospital stay minimises both the women's and babies' exposure to infectious organisms commonly found in the hospital environment. Another advantage that has been cited in the literature is that early discharge helps to control maternity costs. However, there is controversy as to whether hospitals do in fact benefit f r o m short postpartum stays, although several hospitals have reported that costs were less even when they covered the post-hospital costs (Yanover et al, 1976; Mehl et al, 1976; Scupholme, 1981). Patterson (1987) reports that in Portland, Oregon, cost estimates for uncomplicated maternity stays in hospital ranged from $300-$600 per day, while home-care visits ranged from $35-$150 a visit. One difficulty with this is that administrative costs of a p r o g r a m m e may not be averaged into the h o m e visit costs. Another factor to be considered would be physician use by women discharged h o m e early. None o f the studies that were reviewed reported the influence of labour and delivery on early discharge choice, but thc decision was made to investigate this area in the predictive study. Also included were questions related to the baby's condition at birth and expectation about the time of discharge. T h e purpose of the initial study was to determine the percentage of eligible women who
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MIDWIFERY
would be interested in an early postpartum discharge p r o g r a m m e u n d e r the hospital's discharge plan and to identify the biographic characteristics of those women who would be interested in participating.
Research questions T h e following research questions guided the study: 1. What proportion of women eligible for early discharge postpartum would be interested in participating in a p r o g r a m m e in either current or subsequent pregnancies? 2. Do demographic characteristics influence choice? 3. Do obstetric factors influence choice?
METHODS In this study a survey was used to gather data. Two questionnaires were developed: one was distributed to pregnant women; the second to postpartum women. T h e population consisted of all postpartum women who delivered in the study hospital during the planned data collection period, providing they met the previously determined prog r a m m e inclusion critieria. W o m e n who attended prenatal classes or who were admitted in early labour constituted the p r e g n a n t population. Exclusion criteria: women who did not read English; women u n d e r 16 years of age; women who had a baby in neonatal intensive care for over 24h; single women who were returning to a residential home; women living outside the boundary of the City of Edmonton. A questionnaire was developed based on questions for which the institution required answers. Some demographic questions were based on information in the literature that identified
factors related to choice of early discharge in other studies. T h e first draft of the questionnaire was reviewed by nursing staff (the practice of midwifery is not legal in the province of Alberta) and physicians in the hospital and additions and a m e n d m e n t s were made. It was given to six women to read to establish face validity (level of understanding and reliability). T h e questionnaires were distributed to postpartum women on the day o f discharge by the nurses undertaking the discharge. When completed the questionnaires were put in sealed envelopes and placed in an orange box at the nursing station. As all these women had to report to the desk before leaving, this was considered to be a suitable place to leave them. T h e antepartum questionnaires were distributed to women in early labour or in antenatal classes. Questionnaires were distributed to 150 postpartum and 50 p r e g n a n t women and data were collected over a period of six weeks. Data were coded and entered into the computer. An SPSSx package including frequencies and histograms was used to examine distribution o f subjects across variables. Crosstabulation was carried out between demographic and obstetric variables and early discharge in current and subsequent pregnancies. Statistical significance between variables was assessed using the Chi square test.
Limitations of the study 1. Due to a lack of funding to translate the questionnaires the sample included only those women who read English. Over 85% of subjects were Canadian born, thus the sample did not reflect the new immigrant population served by the study hospital. 2. T h e numbers of subjects in some sub-groups of the sample were small. A comparison between pregnant and postpartum choices in relation to early discharge was not possible. 3. T h e r e were no relationships between variables which reached statistical significance. While trends are described, the n u m b e r of subjects representing each trend is small, thus the findings could have occurred by chance.
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FINDINGS T h e characteristics o f the participants are presented, followed by descriptive data on those women selecting early discharge. Analysis of relationships between d e m o g r a p h i c data and those women selecting early discharge complete the findings. T h e r e were 151 responses, of which 123 (81% of those given the questionnaires) were f r o m delivered women and 28 were f r o m pregnant women (56% return). T h e three postpartum units contributed 41, 39 and 43 subjects respectively.
Demographic characteristics of respondents T h e age range of responding w o m e n was f r o m 17 to 39 years of age, with the m o d e falling in the 26-30 year age group. T h e r e were six women u n d e r 20 years of age and 7 women over 36 years of age. Only 14 of the women had not completed high school. Fifty seven (38%) women had no education beyond high school, 21 (14%) had undertaken some college or university education but had not completed the courses, 52 (34%) had completed a college or university course. Four women did not respond, and three did not identify their education, responding 'other'.
Occupation Occupations were classified using the PineoPorter-McRoberts socio-economic classification (Pineo, 1984). T h e categories were professional - seven (5%), semi-professional - 36 (26%), skilled labour - 17 (12%); clerical-sales - 48 (34%); and unskilled l a b o u r - 1. Categories were also generated for students - 2, and homemakers (not working outside the home) - 28 (20%). Twelve subjects did not respond to this question. T h e largest n u m b e r of respondents were in the clerical-sales group. Using the PineoPorter-McRoberts classification (Pineo, 1984), semi-professionals include teachers, nurses, administrative secretaries, etc. and in this study, constituted the second largest group. Less than a quarter (20%) of the informants did not work
outside the h o m e or look for a job during pregnancy. Some data were missing. Work outside the h o m e One h u n d r e d and twenty five (73%) women reported having worked at some time during pregnancy. O f this 125, 44% reported working full-time while 10% worked full-time initially and changed to part-time during the pregnancy. T h e remainder worked part-time throughout. Over one third (37%) o f the women worked to within one month o f delivery, some to within one week. Eighty (54%) of the women had definite plans to return to work postpartum; 22 (16%) were undecided and 46 (32%) had decided not to return to work. T h r e e o f the women did not respond. T h e majority o f women (60%) were not planning to return to work until the baby was at least three months old and probably five months. Eleven women planned to return to work before the baby was three months old and 16 were not planning to work until after the baby was at least six months of age. Marital status One h u n d r e d and twenty of the women were married, nine were single, 18 lived in a stable relationship, one was divorced and three did not respond. Demographic data on partner T h e women were asked to report on the age, occupation and ethnic background of their spouse or partner. T h e ages ranged from 19 to 45 years. T h e majority o f partners were in three occupational categories: semi-professional (28%), skilled labour (27%) and unskilled labour (25%). Clerical/sales accounted for 11%, professional occupation was 6% and students 4%. T h e question on ethnicity a p p e a r e d to be misunderstood as some responses cited a religion, occupation or health status. This problem might have been prevented if a structured rather than an open-ended question had been used. However, 77% o f the men were reported to be Canadian born. T h e r e were four Canadian Indians, two blacks, four Asians and four Latin Americans.
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Children in the home Women with no children at h o m e accounted for 30% of the sample. O f the women who had children at home, 71 (47%) had pre-school age children, 15 (10%) had school-age children only and 14 (9%) had both pre-school and school-age children. Nine women gave no response. Adults at home Seven women reported that no other adults lived in the home. One h u n d r e d and thirty-two (87%) had one other adult at home and 12 (8%) had two other adults at home. Income T h e women were asked to estimate the combined annual family income to the nearest $10000. T h e range of income was f r o m less than $20000 (13: 9%) to over $60000 (19: 13%). T h e mode was $21000-$40000 (58: 38%). These figures are below the average combined family income for Edmonton which is reported to be about $45 000 annually. Twenty one per cent of the respondents did not answer this question.
Perceived difficulty of labour T h e women were asked to rate the ease or difficulty of labour based on a scale f r o m I to 10. One was labelled easy, five being moderate and 10 difficult. Five women who had a caesarean delivery also experienced labour and completed the scale. T h e women's perceptions of labour approximate a reasonably normal distribution. T h e modal g r o u p (17%) scored their labour at the middle of the scale (5.0). When the scale was divided into the three groups easy (1-3), moderate (4-7) and difficult (8-10), 31 women perceived labour to be relatively easy while 30 perceived labour to be relatively difficult. Baby's condition at birth and discharge Ninety-six of the respondents said that the baby was in good condition at birth. However, 22 expected that the baby would stay in hospital following their discharge while two were unsure. None of these selected early discharge. T h r e e women did not respond.
Preference for early discharge Obstetric history This question included responses f r o m the 124 postpartum women. One h u n d r e d and eight (88%) had had a normal delivery and 15 (12%) had had a caesarean delivery. Forty-six (31%) were primiparae and 101 (69%) were multiparae. Four women did not respond to this question. Twenty-eight women reported a n t e p a r t u m complications, 22 reported complications during labour, but in neither g r o u p were the complications identified.
Type of delivery O f the 124 postpartum women, there were 90 who indicated they had had an unassisted vaginal delivery, 13 who had had a forceps assisted delivery, one had had a vacuum extraction, two were unsure as to the type of delivery. Fifteen women (12%) reported having a caesarean section. Five women did not respond. T h e r e were 77 women (75% of those reporting a vaginal delivery) who also reporting having an episiotomy.
This pregnancy O f the total respondents, 40 women (27%) would have liked an early discharge with this pregnancy had the option been available. T h e r e were a further 29 (20%) who were uncertain as to whether or not they would have taken the opportunity had services been available. T h e majority of the respondents (78 women, 53%) were not interested (Table 1). Four women did not respond. Thirteen of the 15 women who had had a caesarean section would have liked discharge before the fifth day after delivery. Subsequent pregnancy A total of 24 women indicated a preference for early discharge in a subsequent pregnancy. Nine of these women expressed a desire for early discharge in both the current and a subsequent pregnancy. Nineteen of the women who would have liked early discharge with their current pregnancy were not planning a subsequent pregnancy. O f the women who did not want early discharge with the current pregnancy, 11
MIDWIFERY 137 Table 1 Preference of all participants for early discharge in current and subsequent pregnancy This pregnancy N
Preference Early discharge
Routine discharge Unsure Do not plan another baby No response
Subsequent pregnancy %
N
40 78 29 4
27 53 20 -
24 34 26 52 15
%
151
100
151
18 (29)* 25 (40)* 19 (31)* 38 100
*Based on w o m e n planning another pregnancy: missing data excluded Table 2 Preference of participants regarding time of discharge Time of
discharge (H post delivery) 12
12-24 25-48 49-72 73-106
Undecided No response
Vaginal Delivery N 2 26 38 8
% 3 35 51
11
10
missing
84*
100
Caesarean Section N
%
3 5 5 1
20 33 33 13
-
-
14
100
*Includes w o m e n w h o opted for early discharge plus some w h o were uncertain as to whether or not they w o u l d have selected the option. Includes w o m e n w h o responded to either 'this pregnancy' or 'subsequent pregnancy'. Those w h o selected 'both' are included once.
were unsure as to whether they would make the choice in a subsequent pregnancy but would consider the option. Of the women who were unsure about early discharge with the current pregnancy, 4 opted for early discharge with a subsequent pregnancy while one wanted regular discharge, 14 remained unsure about early discharge while 10 of them planned to have another baby. When the 84 women who planned to have a subsequent pregnancy were considered, early discharge was selected by 29% of the respondents. Regular discharge was chosen by 40% and 31% were unsure o f which option they would consider.
Table 2. Seventy-four women who had a vaginal delivery and were either interested in, or undecided about, early discharge responded to this question. The largest n u m b e r 38 (51%), wanted to be discharged 25-48 hours postpartum. T h e second choice was 12-24hours for 26 (35%) women. The fifteen women who had had a caesarean section were given a range of 48h to 106h post surgery as choices for early discharge. Fourteen women responded to this quesuon. Five (33%) selected 4 9 - 7 2 h , five 73-106h, while three (20%) selected 2 5 - 4 8 h after surgery for early discharge.
Preference for time at which early discharge
Services required following early discharge
should occur
In this section the women who would have been interested in early discharge following this pregnancy (N = 40) were asked whether adult help would be available at home. They were then asked if they would be interested in a post-
This question was divided into two sections, the first was for women who had had a vaginal delivery, the second tor women who had had a caesarean section. T h e findings are presented in
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MIDWIFERY
partum h o m e visit by a nurse, h o m e - m a k e r or housekeeper services, or a telephone hotline to a nurse. T h e y were all asked if they would be willing to have a nurse f r o m the early discharge p r o g r a m m e visit them antenatally. Twenty four (63%) women already had adult help at home, 12 (31%) would have no help available and two were unsure. Two women did not respond. These data include data f r o m both vaginal and caesarean delivered women. Twenty eight (76%) women would have wanted a h o m e visit f r o m a nurse, four (11%) did not, five (14%) were unsure and three did not respond. T h e cross tabulation showed that the four subjects who did not want a h o m e visit had adult help in the home. T h e proportion of women who would have liked a h o m e - m a k e r was relatively small. Nine (23%) said 'yes', 22 (56%) said 'no' and seven (18%) were 'unsure'. Two women did not respond. Only six of the 151 respondents reported that they did not have a telephone at home, but three of these selected early discharge. Twenty-four women (63%) responded positively to an antenatal h o m e visit, nine (24%) said 'no', while five (13%) were unsure.
Demographicfactors: T h e r e were no statistically significant relationships for woman's age, education, marital status, place o f birth, occupation, work in pregnancy, a m o u n t of work, period of gestation at which work stopped, place of work, whether or not the w o m a n planned to work postpartum, or time o f return to work with views about early discharge (Table 3). No analysis was undertaken on ethnic background due to problems in data gathering. Age: there were only six subjects in the 16-20 age group, but o f these, four would have selected early discharge. T h e median age of the sample was 26-30 and although this was the median age g r o u p selecting early discharge it was also the median age g r o u p not selecting early discharge.
Early discharge in previous pregnancy
36 and over ×~ = 9.54, df = 8, p = 0.30
T h e r e were twenty two (14%) women who had had an early discharge following a previous delivery. O f these 15 (68%) had selected early discharge, while the remaining seven indicated their early discharge had been related to overcrowding on the postpartum floor. O f the 15 selecting early discharge, 13 (87%) had been satisfied, while two had not been satisfied. No reasons for this were sought in this study.
Relationship of early discharge to biographic variables T h e Chi square test was used to examine the relationship of the demographic, social and obstetric factors to the selection o f early postpartum discharge in the current or in subsequent pregnancies. T h e r e were relatively few subjects in some cells but, with the exceptions noted, regrouping of data would not have assisted in the analysis.
Table 3 Relationship of selected demographic factors to selection of early discharge in this pregnancy
Demographic factors
Selection of Early Discharge Yes N o U n s u r e
Woman's Age: 16-20 21-25 26-30 31-35
4 12 13
2 18 31
0 10 11
6 3
23 4
8 0
5 15
6 30
3 12
6 14
10 31
5 7
0
1
2
3 9 4 13
2 22 10 24
2 5 3 11
1 0
0 1
0 1
10
8
10
30 10
56 20
22 7
Education: Not completed HS High S c h o o l (HS)
Post Secondary University Other (unidentified) X2 = 7.01, df = 8, p = 0.50
Occupation: Professional Semi-Professional Skilled labour Clerical/Sales Unskilled L a b o u r Student Housewife X2 = 12.30, d f = 1 1 , p = 0.58
Work Outside Home Antenatally: Worked Did not work X2 = 3.72, d f = 4, p = 0.71
Missing observations were excluded from calculations
Plan to Work Postpartum: Yes No
Undecided X2 = 5.37, df = 4, p = 0.25
25 11
41 26
13 8
4
10
6
MIDWIFERY 139 T h e 21-25 year old age range was the second most frequent group to select early discharge. Occupation: there was no significant difference in these groups but women who did not work (and who were classified as home-makers) selected early discharge m o r e frequently than would be expected given their representation in the population. No trends were observed in relation to a subsequent pregnancy. Work during pregnancy: the a m o u n t of time worked in pregnancy (full-time, part-time) appeared to have no effect on decisions related to early discharge. Those who worked to within one week of delivery were less likely to select early discharge; those who did not work at all were more likely to select early discharge. Work postpartum: more women than expected who planned to return to work part-time selected early discharge or indicated they were uncertain, while fewer women than expected who planned to work full-time m a d e this choice. More women than expected who planned to work within three months selected early discharge; there was a relationship between this group and the under-20 age group, but this finding was not statistically significant. Partner: the age and occupation o f the spouse/ partner appeared to have no influence on the woman's choice.
Social factors Children: there was tendency for women with school-age children at h o m e to select early
discharge more frequently than expected. T h e r e did not a p p e a r to be a similar trend when pre-school children were present in the home. T h e n u m b e r of women with school-age children (15) was too small for statistical analysis. Adults: the n u m b e r of subjects with no adults in the h o m e was small (7). None selected early discharge.
Relationship of early discharge to obstetric variables T h e r e were t w o factors which a p p e a r e d to be related to preference for early discharge although neither was statistically significant. I f the woman had an episiotomy she was less likely to seek early discharge than a woman without an episiotomy (Table 4). Perception of labour was re-categorised into three categories, easy (scale 1-3), moderate (scale 4-7) and difficult (scale 8-10) and c o m p a r e d to early, regular and uncertain categories of discharge). More women who perceived their labour to be easy selected early discharge, while fewer women who perceived their labour as difficult did so, however, these differences were not significant.
Open-ended comments On the last page o f the questionnaire a space was provided for the women to add their comments on the proposed p r o g r a m m e . T h e r e was a total of 63 responses (42% of the respondents). Some of these were in favour of early discharge, some were against early discharge, and some
Table 4 Relationship of obstetric factors to selection of early discharge Obstetric factors Perceived difficulty of labour Easy Moderate Difficult ×2 = 8.02, df = 4, p = 0.26
Episiotorny sustained Yes No ×2 = 2.72, df = 2, p = 0.26
Parity Primiparae Multiparae
Selection o f early discharge No
Yes
Unsure
13
12
6
,14 4
29 21
9 5
18 13
46 19
13 9
12 28
25 53
13 16
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explained why they were uncertain as to whether or not they would select the option. Women who did not support early discharge: seven women believed that early discharge should not be an option for first-time mothers. T h e y cited a need fi)r support on a 24h a day basis and the need tor teaching and, in particular, assistance with breast feeding, as their reasons. Five women noted that it was better to stay in hospital as you get more rest and m o r e teaching. Another woman noted that she was afraid early discharge would encourage women to rush back h o m e and resume their home-making responsibilities before they were ready. Several women noted that three days was not an adequate time to recover physically or emotionally f r o m labour. Muhiparae were concerned that even with a h o m e - m a k e r there would not he adequate time tor rest if they had other children at home. One concern was that if the h o m e - m a k e r only came for a limited time and there was no other adult help, who would get the meals and care for the 'other little kids' if they were discharged? Another woman c o m m e n t e d that the only time she could give undivided attention to the new baby was in the hospital. One other concern centred on the risk of complications occurring at home. For this group the 24h hotline did not a p p e a r to provide adequate security, they believed that only in hospital could they obtain adequate care. One woman commented that a visiting nurse is a good substitute for a doctor, while others felt safer in an environment where nurses were present 24h a day 'should something go wrong'. Eight women believed that early discharge should be based on their own health and the health of their baby. Two also noted that women should not feel pressurised to take part in this p r o g r a m m e . One woman noted that she would not want to make a decision during pregnancy as she would not want to go h o m e early if she had a long labour.
Women who would have liked early discharge: women who would have liked early discharge noted that they would feel more comfortable and relaxed in their own home. T h e r e was a perception that home was better for m o t h e r and baby if both were well. One woman believed
having the baby 24h a day would facilitate breast feeding. Others talked o f the benefit to husband or siblings if they could establish a relationship with the baby soon after the birth. Several women (6) noted that they would not be interested in early discharge unless the proposed services were available, in particular the hotline. Two women c o m m e n t e d that a hotline would be o f value whether or not you opted for early discharge.
DISCUSSION T h e findings from the predictive study will be compared to the evaluation of the early discharge project which was implemented between N o v e m b e r 1989 and July 1990. T h e initial predictive study was carried out at the request of the Director of Nursing. T h e incumbent in the position changed and the researchers did not have any input into the evaluation study. Not all of the predictive variables were included in the Stewart and Corvino (1991) report of the evaluation study. T h e comparisons presented in this p a p e r are based on similar items from the two questionnaires. Findings f r o m the predictive study indicated that 28% o f the participants would select the early discharge option (Campbell & Field, 1990). In the early discharge project 171 of 773 eligible women participated. This was 22% of the eligible population (Stewart & Corvino, 1991). Data were not collected on all demographic variables in the early discharge project. In the predictive study the ages of the women ranged f r o m 17-39 years with 26-30 years being the mode. In the early discharge project the age range was 19-42 years and the mode was 25-30 years (different cut-off points were used in the evaluation study). In both studies the majority of the women were married (80%; 78%), and the n u m b e r of single women was similar (6%; 5%). In both the predictive study and the project the ratio o f m u h i p a r a e to primiparae was similar (2.2:1;2:1). In both studies the modal educational level of those who selected early discharge was high school (38%; 47%). No data were collected on the characteristics of the
MIDWIFERY
spouse/partner in the evaluation project. While no actual data were collected on the women's obstetric history in the project evaluation it is of interest to note that among the top ranked reasons for not selecting early discharge were the need for rest, sore suture lines and difficult labour. In the predictive study there was a trend for an episiotomy and a perceived difficult labour to be related to the woman's choice of a traditional hospital stay. In the Campbell and Field (1990) study, the anticipated modal time of discharge for women who had a normal delivery was 25-48 h. In the evaluation project, the breakdown o f hours was changed and the mode was within the 3 7 - 4 8 h period. For women who were discharged following a caesarean section, a bimodal prediction was identified, 49-72 and 73-106 h in the predictive study and 6 1 - 7 2 h in the project. In the predictive study, a telephone hotline was the service most desired by respondents (82%). It was only used by 21% of those who were discharged early in the evaluation project (Stewart & Corvino, 1991). While this does not negate the importance of such a service being available, it does indicate a lower level of concern than anticipated, following discharge by the women in the predictive study. Only 22% of the women indicated the need for home-maker services in the predictive study and 23% of the women in the evaluation project used this service. In the predictive study, women who indicated a preference for early discharge noted that they would prefer the relaxed environment at home. They also identified the benefits to their husband/partner and/or other children of early exposure to the new baby (Campbell & Field, 1990). In exploring women's satisfaction with early discharge, privacy and comfort of home, the choice of maternity care, the freedom to make their own decisions and an early opportunity for the family to be together were cited as sources o f satisfaction (Stewart & Corvino, 1991). Once again, consistency o f response between those selecting early discharge in the predictive study and those experiencing it in the evaluation project was apparent.
141
When comparing the findings of the predictive and evaluation studies to the literature the findings tend to be similar. The modal time of discharge was within the first 48h (Mehl et al, 1976; Noor & Nacion, 1987). The majority of the women have support at home, and while not used as frequently as anticipated, a telephone hotline service was seen as desirable (Noor & Nacion, 1987). In the current studies the educational level o f the women was lower than reported in previous studies, with high school with no further education being the mode (Avery et al, 1982; McIntosh & Ure, 1984; Yanover et al 1976; Thurston & Dundas, 1985). This difference may be a reflection of the population served by the study hospital. Enhanced opportunities for 'bonding', commented on by the women in the evaluation study has also been reported in earlier studies (Jansson, 1985; N o r r & Nacion, 1987). As with other studies, the early discharge women predicted the system would be beneficial and those taking part in the project evaluated it as beneficial to themselves and their families. Overall, the predictions held up with a reasonable degree of accuracy when the early discharge programme was implemented. This demonstrates the value of a predictive study when planning a change in the delivery of health care. The findings from these studies were also consistent with those of earlier research reports.
References Avery M D, Fournier L E, Jones P Let al 1982 An early postpartum discharge program..Journal of Obstetrics, Gynecologyand Neonatal Nursing 11: 233-235 Campbell I E & Field P A 1990 A survey of early discharge preferences of a group of postpartum mothers. Unpublished study, University of Alberta Carty E M, Bradley C F 1990 A randomized, controlled evaluation of early postpartum hospital discharge. Birth 17 (4): 199-204 Guerriero W F 1943 A maternal welfare program for New Orleans. American .Journal of Obstetrics and Gynecology46 (2): 312-313 Harrison L L 1990 Patient education in early postpartum discharge programs. American Journal of Maternal-Child Nursing 15 (1): 39
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Hellman L M, Kohl S, Palmer J 1962 Early hospital discharge in obstetrics The Lancet 1: 222-232 Jansson P 1985 Early postpartum discharge. American Journal of Nursing 85:547-550 McIntosh I, Ure D 1984 Maternity early discharge in a local authority. Canadian Journal of Public Health 76: 384-387 Mehl L, Peterson C H, Sokolosky W et al 1976 Outcomes of early discharge after normal birth. Birth and the Family Journal 3 (3): 101-107 Nabors G C, Herndon E T 1956 Home puerperal care following hospital delivery. Obstetrics & Gynecology 7 (2): 211-213 Norr K F, Nacion K W 1987 Outcomes of postpartum early discharge, 1960-1986 A comparative review. Birth 14 (3): 135-141 Patterson P K 1987 A comparison of postpartum early and traditional discharge groups. Quality Review Bulletin 13:365-371 Pineo P C 1984 Revision of the Pineo-Porter-McRoberts
socio-economic classification of occupations for the 1981 Census. McMaster University Press QSEP Research Report # 125, Hamilton Scupholme A 1981 Postpartum early discharge: an inner city experience. Journal of Nurse-Midwifery 26 (6): 19-22 Stewart M, Corvino S 1991 Short stay maternity program evaluation report. Unpublished study, Royal Alexandra Hospital and Edmonton Board of Health, Edmonton Thurston N, Dundas J 1985 Evaluation of an early postpartum discharge program. Canadian Journal of Public Health 76:384-387 Waldenstrom U 1987 Early discharge with domiciliary visits and hospital care. Scandinavian Journal of Caring Sciences 1 (2): 51-58 Yanover M, Jones D, Miller M 1976 Perinatal care of low risk mothers and infants: early discharge with home care. New England Journal of Medicine 294 (13): 702-705
Midwifery
Early postpartum d i s c h a r g e - an alternative to traditional hospital care Iris E Campbell
I n a p r e d i c t i v e s t u d y o f e a r l y p o s t p a r t u m d i s c h a r g e d a t a w e r e collected to j u s t i f y a p r o p o s a l that was b e i n g d e v e l o p e d by a city hospital a n d the Local B o a r d o f H e a l t h to p r o v i d e m a t e r n i t y care f o r w o m e n w h o wished to be d i s c h a r g e d early f r o m hospital following childbirth. I n this p a p e r the findings o f the p r e d i c t i v e s t u d y are p r e s e n t e d a n d t h e n c o m p a r e d with the findings f r o m the e v a l u a t i o n o f the p r o j e c t which was i m p l e m e n t e d by t h e hospital a n d the Local B o a r d o f H e a l t h . Overall, the findings f r o m t h e p r e d i c t i v e s t u d y w e r e a c c u r a t e w h e n c o m p a r e d to the findings f r o m t h e e v a l u a t i o n study. T h e similarity o f findings in b o t h studies d e m o n s t r a t e s the value o f u n d e r t a k i n g a p r e d i c t i v e s t u d y p r i o r to p l a n n i n g c h a n g e s in d e l i v e r y o f h e a l t h c a r e to a specific p o p u l a t i o n .
INTRODUCTION Early postpartum discharge is a relatively new concept in North America. In the 1950s a seven to ten-day stay in hospital was thought to be 'proper' by many physicians and nurses (Hellman et al, 1962). However, increasing health care costs, shortage o f hospital beds and the desire of newly delivered women to return home at an earlier stage postpartum has necessitated the introduction of an alternative method of providing care for newly delivered women and their babies. Previous studies (Guerriero, 1943; Nabors & Herndon, 1956; Hellman et al, 1962) have demonstrated that early postpartum discharge at 8-72 h postpartum was safe, feasible and acceptable to women and their families. In Iris E Campbell RN, SCM, MTD, MN, Assistant Professor, Faculty of Nursing, University of Alberta, Edmonton, T6G 2G3, Canada. Manuscript accepted 25 April 1992 Requests for offprints to IEC
132
the USA, two of the major factors for early discharge were the lack o f health care insurance coverage and the increasing costs of a hospital stay. Fortunately, these factors have no bearing on the choices of Canadian families so it must be postulated that Canadian families are selecting early discharge for other reasons. Some reasons cited in earlier studies were: family togetherness, parent satisfaction and involvement o f the father in care of the new-born baby (Scupholme, 1981; Thurston & Dundas, 1985). As a result of the opportunities for choice by Canadian families regarding the venue for postpartum care, a study was undertaken at the request of the Director of Nursing in a Women's Hospital in the city o f Edmonton, Western Canada, to determine the preferences of women and their families in relation to postpartum care. T h e need for this study was to collect data to justify a proposal that was being developed by the hospital and the Local Board of Health to provide care for women, at low obstetric risk, who wished to be discharged from hospital
MmWIFERY 133 before 72 h following an uncomplicated vaginal delivery and earlier than five days (120h) following an uncomplicated caesarean delivery. In this p a p e r the findings from this study will be reported and then discussed in relation to the evaluation of the early discharge project, comparing predictions and results where parallel data are available.
Literature Review Over the past 30 years many studies have been carried out that have demonstrated the safety of the practice of allowing newly delivered women and their babies who are at low risk for medical complications to leave the hospital a few hours after delivery. One of the most important criteria for allowing early discharge is neonatal stability; this has been considered reliable after six hours in babies born with a high Apgar score of eight or more (Thurston & Dundas, 1985; Norr & Nacion, 1987). One finding that was consistently reported in the literature was parent satisfaction with the early discharge p r o g r a m m e . In a study of middle class, English-speaking Americans, more women in the early discharge g r o u p were satisfied with their postpartum care than women in the traditional three-day hospital stay g r o u p (Yanover et al, 1976; Carty & Bradley, 1990). Family togetherness has been cited as being a source of parent satisfaction as has been the early involvement of the father in care of the new baby (Scupholme, 1981; T h u r s t o n & Dundas, 1985). However, a Swedish study by Waldenstrom (1987) reported that although 92% of the women in an early discharge p r o g r a m m e had positive experiences, parents with no interest in such a p r o g r a m m e had m o r e positive experiences with hospital care. In a study of early discharge in Oregon, women at low obstetric risk selected either the traditional three-day stay or early discharge (Patterson, 1987). T h e postpartum stay for the early discharge women was 4 0 h or less plus a required home visit by a nurse for two days. T h e n u m b e r of women who selected early discharge was approximately one-third of those eligible. MIDW.
D
Later in this study, the n u m b e r of women who selected early discharge increased to one half of those eligible but the reason for this was not discussed. T h e r e were no major demographic differences between the early discharge and traditional discharge groups but m o r e first-time mothers chose the traditional p r o g r a m m e . H o m e support was important and husbands were most often cited as the major source o f home support following discharge (92%). In the same study, women who chose the traditional stay cited the hospital as being the best place to rest and believed nurses were more helpful than family for gaining confidence (Patterson, 1987). Harrison (1990) suggests that early discharge p r o g r a m m e s provide greater opportunity to parents and siblings to establish earlier acquaintance and interaction with the new baby without the distractions o f a hospital routine. Also, decreasing the length of the hospital stay minimises both the women's and babies' exposure to infectious organisms commonly found in the hospital environment. Another advantage that has been cited in the literature is that early discharge helps to control maternity costs. However, there is controversy as to whether hospitals do in fact benefit f r o m short postpartum stays, although several hospitals have reported that costs were less even when they covered the post-hospital costs (Yanover et al, 1976; Mehl et al, 1976; Scupholme, 1981). Patterson (1987) reports that in Portland, Oregon, cost estimates for uncomplicated maternity stays in hospital ranged from $300-$600 per day, while home-care visits ranged from $35-$150 a visit. One difficulty with this is that administrative costs of a p r o g r a m m e may not be averaged into the h o m e visit costs. Another factor to be considered would be physician use by women discharged h o m e early. None o f the studies that were reviewed reported the influence of labour and delivery on early discharge choice, but thc decision was made to investigate this area in the predictive study. Also included were questions related to the baby's condition at birth and expectation about the time of discharge. T h e purpose of the initial study was to determine the percentage of eligible women who
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MIDWIFERY
would be interested in an early postpartum discharge p r o g r a m m e u n d e r the hospital's discharge plan and to identify the biographic characteristics of those women who would be interested in participating.
Research questions T h e following research questions guided the study: 1. What proportion of women eligible for early discharge postpartum would be interested in participating in a p r o g r a m m e in either current or subsequent pregnancies? 2. Do demographic characteristics influence choice? 3. Do obstetric factors influence choice?
METHODS In this study a survey was used to gather data. Two questionnaires were developed: one was distributed to pregnant women; the second to postpartum women. T h e population consisted of all postpartum women who delivered in the study hospital during the planned data collection period, providing they met the previously determined prog r a m m e inclusion critieria. W o m e n who attended prenatal classes or who were admitted in early labour constituted the p r e g n a n t population. Exclusion criteria: women who did not read English; women u n d e r 16 years of age; women who had a baby in neonatal intensive care for over 24h; single women who were returning to a residential home; women living outside the boundary of the City of Edmonton. A questionnaire was developed based on questions for which the institution required answers. Some demographic questions were based on information in the literature that identified
factors related to choice of early discharge in other studies. T h e first draft of the questionnaire was reviewed by nursing staff (the practice of midwifery is not legal in the province of Alberta) and physicians in the hospital and additions and a m e n d m e n t s were made. It was given to six women to read to establish face validity (level of understanding and reliability). T h e questionnaires were distributed to postpartum women on the day o f discharge by the nurses undertaking the discharge. When completed the questionnaires were put in sealed envelopes and placed in an orange box at the nursing station. As all these women had to report to the desk before leaving, this was considered to be a suitable place to leave them. T h e antepartum questionnaires were distributed to women in early labour or in antenatal classes. Questionnaires were distributed to 150 postpartum and 50 p r e g n a n t women and data were collected over a period of six weeks. Data were coded and entered into the computer. An SPSSx package including frequencies and histograms was used to examine distribution o f subjects across variables. Crosstabulation was carried out between demographic and obstetric variables and early discharge in current and subsequent pregnancies. Statistical significance between variables was assessed using the Chi square test.
Limitations of the study 1. Due to a lack of funding to translate the questionnaires the sample included only those women who read English. Over 85% of subjects were Canadian born, thus the sample did not reflect the new immigrant population served by the study hospital. 2. T h e numbers of subjects in some sub-groups of the sample were small. A comparison between pregnant and postpartum choices in relation to early discharge was not possible. 3. T h e r e were no relationships between variables which reached statistical significance. While trends are described, the n u m b e r of subjects representing each trend is small, thus the findings could have occurred by chance.
MIDWIFERY 135
FINDINGS T h e characteristics o f the participants are presented, followed by descriptive data on those women selecting early discharge. Analysis of relationships between d e m o g r a p h i c data and those women selecting early discharge complete the findings. T h e r e were 151 responses, of which 123 (81% of those given the questionnaires) were f r o m delivered women and 28 were f r o m pregnant women (56% return). T h e three postpartum units contributed 41, 39 and 43 subjects respectively.
Demographic characteristics of respondents T h e age range of responding w o m e n was f r o m 17 to 39 years of age, with the m o d e falling in the 26-30 year age group. T h e r e were six women u n d e r 20 years of age and 7 women over 36 years of age. Only 14 of the women had not completed high school. Fifty seven (38%) women had no education beyond high school, 21 (14%) had undertaken some college or university education but had not completed the courses, 52 (34%) had completed a college or university course. Four women did not respond, and three did not identify their education, responding 'other'.
Occupation Occupations were classified using the PineoPorter-McRoberts socio-economic classification (Pineo, 1984). T h e categories were professional - seven (5%), semi-professional - 36 (26%), skilled labour - 17 (12%); clerical-sales - 48 (34%); and unskilled l a b o u r - 1. Categories were also generated for students - 2, and homemakers (not working outside the home) - 28 (20%). Twelve subjects did not respond to this question. T h e largest n u m b e r of respondents were in the clerical-sales group. Using the PineoPorter-McRoberts classification (Pineo, 1984), semi-professionals include teachers, nurses, administrative secretaries, etc. and in this study, constituted the second largest group. Less than a quarter (20%) of the informants did not work
outside the h o m e or look for a job during pregnancy. Some data were missing. Work outside the h o m e One h u n d r e d and twenty five (73%) women reported having worked at some time during pregnancy. O f this 125, 44% reported working full-time while 10% worked full-time initially and changed to part-time during the pregnancy. T h e remainder worked part-time throughout. Over one third (37%) o f the women worked to within one month o f delivery, some to within one week. Eighty (54%) of the women had definite plans to return to work postpartum; 22 (16%) were undecided and 46 (32%) had decided not to return to work. T h r e e o f the women did not respond. T h e majority o f women (60%) were not planning to return to work until the baby was at least three months old and probably five months. Eleven women planned to return to work before the baby was three months old and 16 were not planning to work until after the baby was at least six months of age. Marital status One h u n d r e d and twenty of the women were married, nine were single, 18 lived in a stable relationship, one was divorced and three did not respond. Demographic data on partner T h e women were asked to report on the age, occupation and ethnic background of their spouse or partner. T h e ages ranged from 19 to 45 years. T h e majority o f partners were in three occupational categories: semi-professional (28%), skilled labour (27%) and unskilled labour (25%). Clerical/sales accounted for 11%, professional occupation was 6% and students 4%. T h e question on ethnicity a p p e a r e d to be misunderstood as some responses cited a religion, occupation or health status. This problem might have been prevented if a structured rather than an open-ended question had been used. However, 77% o f the men were reported to be Canadian born. T h e r e were four Canadian Indians, two blacks, four Asians and four Latin Americans.
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MIDWIFERY
Children in the home Women with no children at h o m e accounted for 30% of the sample. O f the women who had children at home, 71 (47%) had pre-school age children, 15 (10%) had school-age children only and 14 (9%) had both pre-school and school-age children. Nine women gave no response. Adults at home Seven women reported that no other adults lived in the home. One h u n d r e d and thirty-two (87%) had one other adult at home and 12 (8%) had two other adults at home. Income T h e women were asked to estimate the combined annual family income to the nearest $10000. T h e range of income was f r o m less than $20000 (13: 9%) to over $60000 (19: 13%). T h e mode was $21000-$40000 (58: 38%). These figures are below the average combined family income for Edmonton which is reported to be about $45 000 annually. Twenty one per cent of the respondents did not answer this question.
Perceived difficulty of labour T h e women were asked to rate the ease or difficulty of labour based on a scale f r o m I to 10. One was labelled easy, five being moderate and 10 difficult. Five women who had a caesarean delivery also experienced labour and completed the scale. T h e women's perceptions of labour approximate a reasonably normal distribution. T h e modal g r o u p (17%) scored their labour at the middle of the scale (5.0). When the scale was divided into the three groups easy (1-3), moderate (4-7) and difficult (8-10), 31 women perceived labour to be relatively easy while 30 perceived labour to be relatively difficult. Baby's condition at birth and discharge Ninety-six of the respondents said that the baby was in good condition at birth. However, 22 expected that the baby would stay in hospital following their discharge while two were unsure. None of these selected early discharge. T h r e e women did not respond.
Preference for early discharge Obstetric history This question included responses f r o m the 124 postpartum women. One h u n d r e d and eight (88%) had had a normal delivery and 15 (12%) had had a caesarean delivery. Forty-six (31%) were primiparae and 101 (69%) were multiparae. Four women did not respond to this question. Twenty-eight women reported a n t e p a r t u m complications, 22 reported complications during labour, but in neither g r o u p were the complications identified.
Type of delivery O f the 124 postpartum women, there were 90 who indicated they had had an unassisted vaginal delivery, 13 who had had a forceps assisted delivery, one had had a vacuum extraction, two were unsure as to the type of delivery. Fifteen women (12%) reported having a caesarean section. Five women did not respond. T h e r e were 77 women (75% of those reporting a vaginal delivery) who also reporting having an episiotomy.
This pregnancy O f the total respondents, 40 women (27%) would have liked an early discharge with this pregnancy had the option been available. T h e r e were a further 29 (20%) who were uncertain as to whether or not they would have taken the opportunity had services been available. T h e majority of the respondents (78 women, 53%) were not interested (Table 1). Four women did not respond. Thirteen of the 15 women who had had a caesarean section would have liked discharge before the fifth day after delivery. Subsequent pregnancy A total of 24 women indicated a preference for early discharge in a subsequent pregnancy. Nine of these women expressed a desire for early discharge in both the current and a subsequent pregnancy. Nineteen of the women who would have liked early discharge with their current pregnancy were not planning a subsequent pregnancy. O f the women who did not want early discharge with the current pregnancy, 11
MIDWIFERY 137 Table 1 Preference of all participants for early discharge in current and subsequent pregnancy This pregnancy N
Preference Early discharge
Routine discharge Unsure Do not plan another baby No response
Subsequent pregnancy %
N
40 78 29 4
27 53 20 -
24 34 26 52 15
%
151
100
151
18 (29)* 25 (40)* 19 (31)* 38 100
*Based on w o m e n planning another pregnancy: missing data excluded Table 2 Preference of participants regarding time of discharge Time of
discharge (H post delivery) 12
12-24 25-48 49-72 73-106
Undecided No response
Vaginal Delivery N 2 26 38 8
% 3 35 51
11
10
missing
84*
100
Caesarean Section N
%
3 5 5 1
20 33 33 13
-
-
14
100
*Includes w o m e n w h o opted for early discharge plus some w h o were uncertain as to whether or not they w o u l d have selected the option. Includes w o m e n w h o responded to either 'this pregnancy' or 'subsequent pregnancy'. Those w h o selected 'both' are included once.
were unsure as to whether they would make the choice in a subsequent pregnancy but would consider the option. Of the women who were unsure about early discharge with the current pregnancy, 4 opted for early discharge with a subsequent pregnancy while one wanted regular discharge, 14 remained unsure about early discharge while 10 of them planned to have another baby. When the 84 women who planned to have a subsequent pregnancy were considered, early discharge was selected by 29% of the respondents. Regular discharge was chosen by 40% and 31% were unsure o f which option they would consider.
Table 2. Seventy-four women who had a vaginal delivery and were either interested in, or undecided about, early discharge responded to this question. The largest n u m b e r 38 (51%), wanted to be discharged 25-48 hours postpartum. T h e second choice was 12-24hours for 26 (35%) women. The fifteen women who had had a caesarean section were given a range of 48h to 106h post surgery as choices for early discharge. Fourteen women responded to this quesuon. Five (33%) selected 4 9 - 7 2 h , five 73-106h, while three (20%) selected 2 5 - 4 8 h after surgery for early discharge.
Preference for time at which early discharge
Services required following early discharge
should occur
In this section the women who would have been interested in early discharge following this pregnancy (N = 40) were asked whether adult help would be available at home. They were then asked if they would be interested in a post-
This question was divided into two sections, the first was for women who had had a vaginal delivery, the second tor women who had had a caesarean section. T h e findings are presented in
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MIDWIFERY
partum h o m e visit by a nurse, h o m e - m a k e r or housekeeper services, or a telephone hotline to a nurse. T h e y were all asked if they would be willing to have a nurse f r o m the early discharge p r o g r a m m e visit them antenatally. Twenty four (63%) women already had adult help at home, 12 (31%) would have no help available and two were unsure. Two women did not respond. These data include data f r o m both vaginal and caesarean delivered women. Twenty eight (76%) women would have wanted a h o m e visit f r o m a nurse, four (11%) did not, five (14%) were unsure and three did not respond. T h e cross tabulation showed that the four subjects who did not want a h o m e visit had adult help in the home. T h e proportion of women who would have liked a h o m e - m a k e r was relatively small. Nine (23%) said 'yes', 22 (56%) said 'no' and seven (18%) were 'unsure'. Two women did not respond. Only six of the 151 respondents reported that they did not have a telephone at home, but three of these selected early discharge. Twenty-four women (63%) responded positively to an antenatal h o m e visit, nine (24%) said 'no', while five (13%) were unsure.
Demographicfactors: T h e r e were no statistically significant relationships for woman's age, education, marital status, place o f birth, occupation, work in pregnancy, a m o u n t of work, period of gestation at which work stopped, place of work, whether or not the w o m a n planned to work postpartum, or time o f return to work with views about early discharge (Table 3). No analysis was undertaken on ethnic background due to problems in data gathering. Age: there were only six subjects in the 16-20 age group, but o f these, four would have selected early discharge. T h e median age of the sample was 26-30 and although this was the median age g r o u p selecting early discharge it was also the median age g r o u p not selecting early discharge.
Early discharge in previous pregnancy
36 and over ×~ = 9.54, df = 8, p = 0.30
T h e r e were twenty two (14%) women who had had an early discharge following a previous delivery. O f these 15 (68%) had selected early discharge, while the remaining seven indicated their early discharge had been related to overcrowding on the postpartum floor. O f the 15 selecting early discharge, 13 (87%) had been satisfied, while two had not been satisfied. No reasons for this were sought in this study.
Relationship of early discharge to biographic variables T h e Chi square test was used to examine the relationship of the demographic, social and obstetric factors to the selection o f early postpartum discharge in the current or in subsequent pregnancies. T h e r e were relatively few subjects in some cells but, with the exceptions noted, regrouping of data would not have assisted in the analysis.
Table 3 Relationship of selected demographic factors to selection of early discharge in this pregnancy
Demographic factors
Selection of Early Discharge Yes N o U n s u r e
Woman's Age: 16-20 21-25 26-30 31-35
4 12 13
2 18 31
0 10 11
6 3
23 4
8 0
5 15
6 30
3 12
6 14
10 31
5 7
0
1
2
3 9 4 13
2 22 10 24
2 5 3 11
1 0
0 1
0 1
10
8
10
30 10
56 20
22 7
Education: Not completed HS High S c h o o l (HS)
Post Secondary University Other (unidentified) X2 = 7.01, df = 8, p = 0.50
Occupation: Professional Semi-Professional Skilled labour Clerical/Sales Unskilled L a b o u r Student Housewife X2 = 12.30, d f = 1 1 , p = 0.58
Work Outside Home Antenatally: Worked Did not work X2 = 3.72, d f = 4, p = 0.71
Missing observations were excluded from calculations
Plan to Work Postpartum: Yes No
Undecided X2 = 5.37, df = 4, p = 0.25
25 11
41 26
13 8
4
10
6
MIDWIFERY 139 T h e 21-25 year old age range was the second most frequent group to select early discharge. Occupation: there was no significant difference in these groups but women who did not work (and who were classified as home-makers) selected early discharge m o r e frequently than would be expected given their representation in the population. No trends were observed in relation to a subsequent pregnancy. Work during pregnancy: the a m o u n t of time worked in pregnancy (full-time, part-time) appeared to have no effect on decisions related to early discharge. Those who worked to within one week of delivery were less likely to select early discharge; those who did not work at all were more likely to select early discharge. Work postpartum: more women than expected who planned to return to work part-time selected early discharge or indicated they were uncertain, while fewer women than expected who planned to work full-time m a d e this choice. More women than expected who planned to work within three months selected early discharge; there was a relationship between this group and the under-20 age group, but this finding was not statistically significant. Partner: the age and occupation o f the spouse/ partner appeared to have no influence on the woman's choice.
Social factors Children: there was tendency for women with school-age children at h o m e to select early
discharge more frequently than expected. T h e r e did not a p p e a r to be a similar trend when pre-school children were present in the home. T h e n u m b e r of women with school-age children (15) was too small for statistical analysis. Adults: the n u m b e r of subjects with no adults in the h o m e was small (7). None selected early discharge.
Relationship of early discharge to obstetric variables T h e r e were t w o factors which a p p e a r e d to be related to preference for early discharge although neither was statistically significant. I f the woman had an episiotomy she was less likely to seek early discharge than a woman without an episiotomy (Table 4). Perception of labour was re-categorised into three categories, easy (scale 1-3), moderate (scale 4-7) and difficult (scale 8-10) and c o m p a r e d to early, regular and uncertain categories of discharge). More women who perceived their labour to be easy selected early discharge, while fewer women who perceived their labour as difficult did so, however, these differences were not significant.
Open-ended comments On the last page o f the questionnaire a space was provided for the women to add their comments on the proposed p r o g r a m m e . T h e r e was a total of 63 responses (42% of the respondents). Some of these were in favour of early discharge, some were against early discharge, and some
Table 4 Relationship of obstetric factors to selection of early discharge Obstetric factors Perceived difficulty of labour Easy Moderate Difficult ×2 = 8.02, df = 4, p = 0.26
Episiotorny sustained Yes No ×2 = 2.72, df = 2, p = 0.26
Parity Primiparae Multiparae
Selection o f early discharge No
Yes
Unsure
13
12
6
,14 4
29 21
9 5
18 13
46 19
13 9
12 28
25 53
13 16
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explained why they were uncertain as to whether or not they would select the option. Women who did not support early discharge: seven women believed that early discharge should not be an option for first-time mothers. T h e y cited a need fi)r support on a 24h a day basis and the need tor teaching and, in particular, assistance with breast feeding, as their reasons. Five women noted that it was better to stay in hospital as you get more rest and m o r e teaching. Another woman noted that she was afraid early discharge would encourage women to rush back h o m e and resume their home-making responsibilities before they were ready. Several women noted that three days was not an adequate time to recover physically or emotionally f r o m labour. Muhiparae were concerned that even with a h o m e - m a k e r there would not he adequate time tor rest if they had other children at home. One concern was that if the h o m e - m a k e r only came for a limited time and there was no other adult help, who would get the meals and care for the 'other little kids' if they were discharged? Another woman c o m m e n t e d that the only time she could give undivided attention to the new baby was in the hospital. One other concern centred on the risk of complications occurring at home. For this group the 24h hotline did not a p p e a r to provide adequate security, they believed that only in hospital could they obtain adequate care. One woman commented that a visiting nurse is a good substitute for a doctor, while others felt safer in an environment where nurses were present 24h a day 'should something go wrong'. Eight women believed that early discharge should be based on their own health and the health of their baby. Two also noted that women should not feel pressurised to take part in this p r o g r a m m e . One woman noted that she would not want to make a decision during pregnancy as she would not want to go h o m e early if she had a long labour.
Women who would have liked early discharge: women who would have liked early discharge noted that they would feel more comfortable and relaxed in their own home. T h e r e was a perception that home was better for m o t h e r and baby if both were well. One woman believed
having the baby 24h a day would facilitate breast feeding. Others talked o f the benefit to husband or siblings if they could establish a relationship with the baby soon after the birth. Several women (6) noted that they would not be interested in early discharge unless the proposed services were available, in particular the hotline. Two women c o m m e n t e d that a hotline would be o f value whether or not you opted for early discharge.
DISCUSSION T h e findings from the predictive study will be compared to the evaluation of the early discharge project which was implemented between N o v e m b e r 1989 and July 1990. T h e initial predictive study was carried out at the request of the Director of Nursing. T h e incumbent in the position changed and the researchers did not have any input into the evaluation study. Not all of the predictive variables were included in the Stewart and Corvino (1991) report of the evaluation study. T h e comparisons presented in this p a p e r are based on similar items from the two questionnaires. Findings f r o m the predictive study indicated that 28% o f the participants would select the early discharge option (Campbell & Field, 1990). In the early discharge project 171 of 773 eligible women participated. This was 22% of the eligible population (Stewart & Corvino, 1991). Data were not collected on all demographic variables in the early discharge project. In the predictive study the ages of the women ranged f r o m 17-39 years with 26-30 years being the mode. In the early discharge project the age range was 19-42 years and the mode was 25-30 years (different cut-off points were used in the evaluation study). In both studies the majority of the women were married (80%; 78%), and the n u m b e r of single women was similar (6%; 5%). In both the predictive study and the project the ratio o f m u h i p a r a e to primiparae was similar (2.2:1;2:1). In both studies the modal educational level of those who selected early discharge was high school (38%; 47%). No data were collected on the characteristics of the
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spouse/partner in the evaluation project. While no actual data were collected on the women's obstetric history in the project evaluation it is of interest to note that among the top ranked reasons for not selecting early discharge were the need for rest, sore suture lines and difficult labour. In the predictive study there was a trend for an episiotomy and a perceived difficult labour to be related to the woman's choice of a traditional hospital stay. In the Campbell and Field (1990) study, the anticipated modal time of discharge for women who had a normal delivery was 25-48 h. In the evaluation project, the breakdown o f hours was changed and the mode was within the 3 7 - 4 8 h period. For women who were discharged following a caesarean section, a bimodal prediction was identified, 49-72 and 73-106 h in the predictive study and 6 1 - 7 2 h in the project. In the predictive study, a telephone hotline was the service most desired by respondents (82%). It was only used by 21% of those who were discharged early in the evaluation project (Stewart & Corvino, 1991). While this does not negate the importance of such a service being available, it does indicate a lower level of concern than anticipated, following discharge by the women in the predictive study. Only 22% of the women indicated the need for home-maker services in the predictive study and 23% of the women in the evaluation project used this service. In the predictive study, women who indicated a preference for early discharge noted that they would prefer the relaxed environment at home. They also identified the benefits to their husband/partner and/or other children of early exposure to the new baby (Campbell & Field, 1990). In exploring women's satisfaction with early discharge, privacy and comfort of home, the choice of maternity care, the freedom to make their own decisions and an early opportunity for the family to be together were cited as sources o f satisfaction (Stewart & Corvino, 1991). Once again, consistency o f response between those selecting early discharge in the predictive study and those experiencing it in the evaluation project was apparent.
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When comparing the findings of the predictive and evaluation studies to the literature the findings tend to be similar. The modal time of discharge was within the first 48h (Mehl et al, 1976; Noor & Nacion, 1987). The majority of the women have support at home, and while not used as frequently as anticipated, a telephone hotline service was seen as desirable (Noor & Nacion, 1987). In the current studies the educational level o f the women was lower than reported in previous studies, with high school with no further education being the mode (Avery et al, 1982; McIntosh & Ure, 1984; Yanover et al 1976; Thurston & Dundas, 1985). This difference may be a reflection of the population served by the study hospital. Enhanced opportunities for 'bonding', commented on by the women in the evaluation study has also been reported in earlier studies (Jansson, 1985; N o r r & Nacion, 1987). As with other studies, the early discharge women predicted the system would be beneficial and those taking part in the project evaluated it as beneficial to themselves and their families. Overall, the predictions held up with a reasonable degree of accuracy when the early discharge programme was implemented. This demonstrates the value of a predictive study when planning a change in the delivery of health care. The findings from these studies were also consistent with those of earlier research reports.
References Avery M D, Fournier L E, Jones P Let al 1982 An early postpartum discharge program..Journal of Obstetrics, Gynecologyand Neonatal Nursing 11: 233-235 Campbell I E & Field P A 1990 A survey of early discharge preferences of a group of postpartum mothers. Unpublished study, University of Alberta Carty E M, Bradley C F 1990 A randomized, controlled evaluation of early postpartum hospital discharge. Birth 17 (4): 199-204 Guerriero W F 1943 A maternal welfare program for New Orleans. American .Journal of Obstetrics and Gynecology46 (2): 312-313 Harrison L L 1990 Patient education in early postpartum discharge programs. American Journal of Maternal-Child Nursing 15 (1): 39
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Hellman L M, Kohl S, Palmer J 1962 Early hospital discharge in obstetrics The Lancet 1: 222-232 Jansson P 1985 Early postpartum discharge. American Journal of Nursing 85:547-550 McIntosh I, Ure D 1984 Maternity early discharge in a local authority. Canadian Journal of Public Health 76: 384-387 Mehl L, Peterson C H, Sokolosky W et al 1976 Outcomes of early discharge after normal birth. Birth and the Family Journal 3 (3): 101-107 Nabors G C, Herndon E T 1956 Home puerperal care following hospital delivery. Obstetrics & Gynecology 7 (2): 211-213 Norr K F, Nacion K W 1987 Outcomes of postpartum early discharge, 1960-1986 A comparative review. Birth 14 (3): 135-141 Patterson P K 1987 A comparison of postpartum early and traditional discharge groups. Quality Review Bulletin 13:365-371 Pineo P C 1984 Revision of the Pineo-Porter-McRoberts
socio-economic classification of occupations for the 1981 Census. McMaster University Press QSEP Research Report # 125, Hamilton Scupholme A 1981 Postpartum early discharge: an inner city experience. Journal of Nurse-Midwifery 26 (6): 19-22 Stewart M, Corvino S 1991 Short stay maternity program evaluation report. Unpublished study, Royal Alexandra Hospital and Edmonton Board of Health, Edmonton Thurston N, Dundas J 1985 Evaluation of an early postpartum discharge program. Canadian Journal of Public Health 76:384-387 Waldenstrom U 1987 Early discharge with domiciliary visits and hospital care. Scandinavian Journal of Caring Sciences 1 (2): 51-58 Yanover M, Jones D, Miller M 1976 Perinatal care of low risk mothers and infants: early discharge with home care. New England Journal of Medicine 294 (13): 702-705
