Midwifery (1992)8, 170-177

Longman Group UK Ltd 1992

Midwifery

To stay or not to stay: are fears about shorter postnatal hospital stays justified? Rhonda Small, Judith Lumley and Stephanie Brown

C o m m o n concerns raised d u r i n g a Ministerial Review of Birthing Services in Victoria, Australia about the potential detrimental effects o f shorter hospital stays after birth were examined in a study of women's actual experiences o f and opinions about their hospital stays. Just u n d e r one in four w o m e n left hospital within five days o f the birth, with the greater majority staying five days or more. Satisfaction with length o f stay was high in the sample, with 82% of w o m e n feeling their stay had been about right, 11% feeling it had been too long and only 7% of women feeling their stay had been too short. A n u m b e r o f the concerns about the consequences o f shorter lengths of stay were not borne out. W o m e n who left hospital earlier than the traditional 5-7 day stay were not less likely to breast feed, nor were they more likely to be depressed 8-9 months after the birth. T h e y were also m u c h more likely to feel confident about looking after their baby when they went home than women who stayed five days or more. Implications for f u r t h e r research and for policy development concerning length o f stay are considered.

INTRODUCTION When the Victorian Ministerial Review of Birthing Services was established in June 1988 with one of its terms of reference to consider the question of shorter lengths of postnatal stay, there was quite vehement reaction both from women and from service providers. Such

Rhonda Small BA, Dip Ed, Grad Dip Lib, Research Officer. Judith Lumley MA, MB, BS, PhD, Director. Stephanie Brown BA(Hons), Research Officer. Centre for the Study of Mothers' and Childen's Health, Monash University, 463 Cardigan Street, Carlton Vic 3053, Australia. Manuscript accepted 2 September 1992 Requests for offprints to RS

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reaction was due in part to beliefs that shorter length of stay was to be considered simply for its cost cutting potential, in part due to concerns about the possible detrimental effects of shorter hospital stays for women and babies, and in part to anger that women themselves might have no say in deciding how long they should stay. There was also concern about whether shorter stays, if introduced, would be accompanied by the provision of appropriate domiciliary midwifery services (Having a Baby in Victoria, 1990). What constitutes an appropriate length of hospital stay after birth and thereibre what is meant by 'early discharge' are very much culturally determined. In Victoria-- and other parts of Australia - - a 5-7 day stay is the cultural norm. Unlike the UK there are no statutory regulations for home visiting by community

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midwives after hospital discharge and up to Day 10. T h e r e is little in the way of publicly funded domiciliary midwifery and nothing like the British D O M I N O scheme. In addition there has been a fall in recent years in the provision of community based support services (such as household help) to women after birth. In this context, the notion that m o r e women might he discharged earlier than Day 5 was b o u n d to raise concerns a m o n g women and their caregivers. Nevertheless, are these concerns justified? In particular, fears were expressed that shorter stays could result in lower breastfeeding rates, a higher incidence of postnatal depression and women feeling less confident about caring for their baby when they left hospital. Opinions about who would be disadvantaged by shorter lengths o f stay varied. Primiparous women, it was believed, would suffer because they would not develop the confidence to be gained by continual access to expert advice in hospital. Multiparous women might not get enough rest if they went h o m e early because of the demands of other children. And it was often stated that staying 5-7 days benefited all women because it released them f r o m household duties. Clearly a 5-7 day stay in hospital was a very firmly established cultural n o r m - - and a n o r m based on strongly held beliefs that women should stay in hospital to gain confidence, get rest and establish feeding. T h e r e were also concerns that large numbers of women were already being 'sent home' early (mostly on Day 3 or 4) without domiciliary midwifery support and before the women themselves were happy to leave. Indeed, f r o m about the middle of 1988 a n u m b e r of maternity hospitals in Victoria were being encouraged to reduce their average lengths of postnatal stay following uncomplicated vaginal birth through a specific State-Commonwealth funding initiative (Having a Baby in Victoria, 1990). T h e present study conducted during the time of the Review, enabled a n u m b e r of concerns about shorter length of stay to be examined in the light of actual experiences of hospital stay of a representative, population based sample of Victorian women.

METHOD A Consumer Survey of Satisfaction with Maternity Care was conducted in conjunction with the Victorian Ministerial Review of Birthing Services, involving a population based sample o f 1193 women who had given birth in one of two weeks during February or September 1989, and who were sent a postal survey 8-9 months after the birth of their baby. T h e response rate, after removal of questionnaires returned 'addressee not found', duplicates and unusable responses, was 72%, with 790 questionnaires coded for analysis. A detailed description of the survey methodology is provided elsewhere (Brown & Lumley, 1992). T h e survey elicited information about antenatal care, labour and delivery, postnatal care and a range of socio-demographic variables. T h e Edinburgh Postnatal Depression Scale (Cox et al, 1987) was also included to give a measure o f emotional well-being at the time women completed the survey. T h r e e questions included in the survey concerned length of hospital stay after birth, satisfaction with length of stay and confidence to look after the baby at home: how long did you stay in hospital after the birth of your baby? - - in your opinion was your stay: too long about right too short? - - when you had to look after the baby on your own at home, did you feel: very c o n f d e n t about this fairly-e-o~fid~nt definitely anxious about this? -

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Most research on length of stay after birth has interpreted early discharge as leaving hospital anything from 12 to 72 hours after birth (Norr & Nacion, 1987; Waldenstr6m et al, 1987a; Beck, 1991). Given the cultural context of length of stay in Victoria, where the traditional stay after an uncomplicated delivery is still 5 days or more, early discharge needs to be interpreted as the equivalent of discharge at any time before this.

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For this reason women's length of stay has for the most part been grouped for purposes of analysis into stays of less than 5 days and stays of 5 days or more. Analysis of the data and statistical tests were carried out using the Analysis and StatCalc components of EpiInfo 5.0.

FINDINGS

Table 2 Characteristics of women who went home before Day 5 • • • • • • •

Multiparous No private health insurance Family income

To stay or not to stay: are fears about shorter postnatal hospital stays justified?

Common concerns raised during a Ministerial Review of Birthing Services in Victoria, Australia about the potential detrimental effects of shorter hosp...
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