Abstract
BACKGROUND: Length of postnatal hospital stay has declined dramatically in the past 50 years. There is ongoing controversy about whether staying less time in hospital is harmful or beneficial. This is an update of a Cochrane Review first published in 2002, and previously updated in 2009.
OBJECTIVES: To assess the effects of a policy of early postnatal discharge from hospital for healthy mothers and term infants in terms of important maternal, infant and paternal health and related outcomes.
SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (21 May 2021) and the reference lists of retrieved articles.
SELECTION CRITERIA: Randomised controlled trials comparing early discharge from hospital of healthy mothers and term infants (at least 37 weeks' gestation and greater than or equal to 2500 g), with the standard care in the respective settings in which trials were conducted. Trials using allocation methods that were not truly random (e.g. based on patient number or day of the week), trials with a cluster-randomisation design and trials published only in abstract form were also eligible for inclusion.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted and checked data for accuracy, and assessed the certainty of evidence using the GRADE approach. We contacted authors of ongoing trials for additional information.
MAIN RESULTS: We identified 17 trials (involving 9409 women) that met our inclusion criteria. We did not identify any trials from low-income countries. There was substantial variation in the definition of 'early discharge', ranging from six hours to four to five days. The extent of antenatal preparation and midwifery home care offered to women following discharge in intervention and control groups also varied considerably among trials. Nine trials recruited and randomised women in pregnancy, seven trials randomised women following childbirth and one did not report whether randomisation took place before or after childbirth. Risk of bias was generally unclear in most domains due to insufficient reporting of trial methods. The certainty of evidence is moderate to low and the reasons for downgrading were high or unclear risk of bias, imprecision (low numbers of events or wide 95% confidence intervals (CI)), and inconsistency (heterogeneity in direction and size of effect). Infant outcomes Early discharge probably slightly increases the number of infants readmitted within 28 days for neonatal morbidity (including jaundice, dehydration, infections) (risk ratio (RR) 1.59, 95% CI 1.27 to 1.98; 6918 infants; 10 studies; moderate-certainty evidence). In the early discharge group, the risk of infant readmission was 69 per 1000 infants compared to 43 per 1000 infants in the standard care group. It is uncertain whether early discharge has any effect on the risk of infant mortality within 28 days (RR 0.39, 95% CI 0.04 to 3.74; 4882 infants; two studies; low-certainty evidence). Early postnatal discharge probably makes little to no difference in the number of infants having at least one unscheduled medical consultation or contact with health professionals within the first four weeks after birth (RR 0.88, 95% CI 0.67 to 1.16; 639 infants; four studies; moderate-certainty evidence). Maternal outcomes Early discharge probably results in little to no difference in women readmitted within six weeks postpartum for complications related to childbirth (RR 1.12, 95% CI 0.82 to 1.54; 6992 women; 11 studies; moderate-certainty evidence) but the wide 95% CI indicates the possibility that the true effect is either an increase or a reduction in risk. Similarly, early discharge may result in little to no difference in the risk of depression within six months postpartum (RR 0.80, 95% CI 0.46 to 1.42; 4333 women; five studies; low-certainty evidence) but the wide 95% CI suggests the possibility that the true effect is either an increase or a reduction in risk. Early discharge probably results in little to no difference in women breastfeeding at six weeks postpartum (RR 1.04, 95% CI 0.96 to 1.13; 7156 women; 10 studies; moderate-certainty evidence) or in the number of women having at least one unscheduled medical consultation or contact with health professionals (RR 0.72, 95% CI 0.43 to 1.20; 464 women; two studies; moderate-certainty evidence). Maternal mortality within six weeks postpartum was not reported in any of the studies. Costs Early discharge may slightly reduce the costs of hospital care in the period immediately following the birth up to the time of discharge (low-certainty evidence; data not pooled) but it may result in little to no difference in costs of postnatal care following discharge from hospital, in the period up to six weeks after the birth (low-certainty evidence; data not pooled).
AUTHORS' CONCLUSIONS: The definition of 'early discharge' varied considerably among trials, which made interpretation of results challenging. Early discharge probably leads to a higher risk of infant readmission within 28 days of birth, but probably makes little to no difference to the risk of maternal readmission within six weeks postpartum. We are uncertain if early discharge has any effect on the risk of infant or maternal mortality. With regard to maternal depression, breastfeeding, the number of contacts with health professionals, and costs of care, there may be little to no difference between early discharge and standard discharge but further trials measuring these outcomes are needed in order to enhance the level of certainty of the evidence. Large well-designed trials of early discharge policies, incorporating process evaluation and using standardized approaches to outcome assessment, are needed to assess the uptake of co-interventions. Since none of the evidence presented here comes from low-income countries, where infant and maternal mortality may be higher, it is important to conduct future trials in low-income settings.
Original language | English |
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Article number | CD002958 |
Number of pages | 88 |
Journal | The Cochrane Library |
Volume | 2021 |
Issue number | 6 |
DOIs | |
Publication status | Published - 8 Jun 2021 |
Bibliographical note
Funding Information:Adverse infant outcomes between the term standard care and experimental groups, such as hyper-bilirubinaemia, dehydration, or weight loss Co-interventions: “As a matter of standard hospital care, mothers of near-term infants in both groups were made aware of the outpatient hospital breastfeeding clinic, and were encouraged to use a pre existing 24-hour telephone help line. Mothers of term infants in both groups were also provided with information on these services.” Dates of study: July 1999 to December 2000 Funding sources: “This project was supported by a grant from the Health Transition Fund, Canada,Ottawa,and by a financial contribution from The Hospital for Sick Children Foundation,Toronto,Ontario, Canada.” Declarations of interest: not reported
Funding sources: "This research was supported by a grant from the Fraser Fund of the Royal Vistoria Hospital and a computer equipment grant form the Faculties of Graduate Studies and Research and Meidcine of McGill University"
Funding sources: "This study was supported by grants from The Swedish Ministry of Health and Social Affairs, Commission for Social Research (Project no. F 83/18)"
Beck Taylor: is supported by the UK National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Stephanie Brown: salary and project support from the Australian National Health and Medical Research Council.
Funding sources: "Supported by Kaiser Foundation Research Institute, General Research Support, under a grant (5 501 RR05521-10) from the US Public Health Service
Funding sources: "Funded by a grant from Le Fonds de la Recherche en Santé du Québec. A.J.G. was supported by the Medical Research Counil and the National Health Research and Development Program of Canada"
Funding sources: "This study was supported by a grant (Pol-NR-01859) from the National Institute for Nursing Research, National Institutes of Health"
Two trials reported funding from other sources: Brodene Hartmanns Foundation (Kruse 2021); the Salaried Specialists (Thompson 1999).
Funding sources: "The study was supported by a grant from the Northern General Hospital Trust Research Committee."
Our thanks to Caroline Crowther, Judith Lumley and Lyn Watson for comments on the review protocol, and Judith Lumley for comments on the original review. Our thanks also to Rhonda Small, Ann Krastev, Sara Kenyon and Brenda Argus for their involvement in the previous update of the review. We are also grateful to Dr Anne Kruse for providing information about her trial. As part of the prepublication editorial process, this updated review has been commented on by three peers (an editor and two referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser. The authors are grateful to the following peer reviewers for their time and comments: Dr Edgardo Abalos, Vice Director, Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina; Dr Andrew G Symon;?University of Dundee; and Rachel Plachcinski, Cochrane Consumer. This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Evidence Synthesis Programme, the NIHR, National Health Service (NHS) or the Department of Health and Social Care.
Funding sources: "The study received financial support from the Swiss National Science Foundation (grant #32-52954.97) and from the Quality of Care Program, Geneva University Hospitals."
Publisher Copyright:
Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Keywords
- Bias
- Breast Feeding/statistics & numerical data
- Depression, Postpartum/epidemiology
- Female
- Humans
- Infant
- Infant Mortality
- Length of Stay
- Patient Discharge
- Patient Readmission/statistics & numerical data
- Postpartum Period
- Pregnancy
- Term Birth
- Time Factors
ASJC Scopus subject areas
- Pharmacology (medical)