While scientists, clinicians and policymakers debate whether or not early hospital discharge of newborns endangers their health, they neglect a critical issue -- what services mothers and newborns receive on the third and fourth day after delivery -- says a UCSF researcher.

In the absence of definitive research, there should be more emphasis on good judgment when deciding postpartum hospital stays, says Paula Braveman, MD, MPH, associate professor of family and community medicine and epidemiology and biostatistics, in a commentary in today’s issue of the Journal of the American Medical Association .

Early discharge of newborns following routine vaginal delivery has become a common practice in the United States as hospitals and third-party payers attempt to reduce health care costs. Widespread concern that this practice compromises the safety of both the mother and the newborn has led to recent national legislation mandating coverage of a minimum 48-hour hospital stay, according to Braveman.

Current scientific knowledge and good judgment, however, suggest that the length of stay is unlikely to be the key issue, she says. Services received at home or in the clinic during the first three to four days are crucial, but recent legislation does not address this critical concern, she argues.

In the commentary, Braveman and colleagues interpret the implications of two large studies published in the current JAMA that reach seemingly contradictory conclusions about the safety of short postpartum hospital stays. One study, from the University of Washington, finds that newborns who are discharged from the hospital within 30 hours of birth are at an increased risk for rehospitalization during the first month of life, especially during the first week. Another study, from the University of Wisconsin, finds that early postpartum discharge has little effect on the risk of rehospitalizations due to feeding problems in healthy newborns born to healthy moms.

The studies, which are the largest yet to look at early discharge, may not actually be discrepant, according to Braveman, because the Wisconsin study lacked sufficient statistical power to support its conclusions. However, Braveman points out neither study reveals the optimal length of postpartum stay for well newborns and mothers.

"The clinical, scientific and policymaking communities need to discuss what should be done when science doesn't provide conclusive evidence to convince a third party that providing a given service is necessary," Braveman says. "Scientists and policymakers who depend on science to guide public policy must be aware of the potential consequences of unquestioning devotion to outcomes research without adequate considerations of science and ethics."

In the case of early discharge, science does not and probably cannot supply airtight evidence that longer stays are more effective compared with other approaches, according to the commentary. However, when considering what is currently known about early postpartum and neonatal health, Braveman says good judgment and the weight of existing information suggest a range of options to ensure timely assessment and intervention during the early postpartum period.

"Good judgment says that it is not acceptable to await conclusive evidence on the most efficient approach to postpartum hospital stays before ensuring that every mother and newborn receives some kind of health-promoting care," Braveman says.

Early discharge after uncomplicated vaginal delivery currently is defined as an apparently well newborn and mother leaving the hospital within 48 hours. The conditions most likely to result in readmission after early discharge are neonatal jaundice, dehydration and feeding difficulties, and timely detection and intervention for these problems require direct contact between mothers, newborns and healthcare providers skilled in neonatal assessment and in infant feeding promotion, according to the UCSF commentary.

By Rebecca Higbee

1st appeared 7/23/97