Beate Danielsen , Anne G . Castles , Cheryl L . Damberg and Jeffrey B . Gould Newborn Discharge Timing

Context. Hospital stays for newborns and their mothers after uncomplicated vaginal delivery have decreased from an average of 4 days in 1970 to 1.1 days in 1995. Despite the lack of population-based research on the quality-of-care implications of this trend, federal legislation passed in 1996 mandated coverage for 48-hour hospital stays after uncomplicated vaginal delivery. Objective. To assess the impact of very early discharge (defined as discharge on the day of birth) on the risk of infant readmission during the neonatal period in a California healthy newborn population. Design. Retrospective cohort study, based on a linked dataset consisting of the birth certificate, newborn, and maternal hospitalization record, and linked infant readmission records for all healthy, vaginally delivered, and routinely discharged California newborns from 1992 to 1995. Outcome Measures. Very early discharge and infant readmission during the first 28 days of life. Results. The percentage of infants discharged very early or early (after a 1-night stay) increased from 71% in 1992 to 85% in 1995. The percentage of infants discharged very early increased from 5.0% in 1992 to 5.7% in 1993 and 7.0% in 1994, then decreased to 6.7% in 1995. Characteristics that have been previously associated with suboptimal pregnancy outcomes were found to decrease the likelihood of very early discharge, eg, maternal complications, primiparity, and Hispanic, African American, South East Asian, or other Asian race/ethnicity. The rate of readmission in the neonatal period initially decreased from 27.6 infants per 1000 in 1992 to 25.67 infants per 1000 in 1994, then increased to 30.2 infants per 1000 in 1995. For infants discharged early, no statistically significant increase in the risk of readmission was observed, compared with infants discharged after a 21night stay. The adjusted odds ratio (OR) for readmission was statistically significantly higher for infants who were discharged very early, compared with infants discharged early (OR: 1.27), first order births (OR: 1.21), infants born to mothers who experienced complications (OR: 1.11), infants with Medicaid insurance (OR: 1.23), and infants born to mothers who received adequate plus prenatal care (OR: 1.15). The risk was statistically significantly lower for female infants (OR: 0.75). The proportion of infants rehospitalized for dehydration and low-risk infections over the 4 study years combined was statistically significantly higher in infants discharged very early (4.37‰ and 10.30‰, respectively), compared with infants discharged early (3.59‰ and 8.16‰, respectively) or after a 21-night stay (2.91‰ and 7.95‰, respectively). The proportion of infants rehospitalized for dehydration increased statistically significantly from 2.89‰ in 1992 to 4.52‰ in 1995. Conclusions. One-night stays with adequate antenatal and postnatal care outside the hospital do not increase the risk of readmission for healthy, vaginally delivered infants born in California. However, the decision to discharge infants on the day of birth should be applied conservatively because of the increased risk of infant readmission associated with very early discharge. Pediatrics 2000;106:31–39; neonatal length of stay, early discharge, readmission. ABBREVIATIONS. DRG, diagnosis-related group; AAP, American Academy of Pediatrics; OR, odds ratio; CI, confidence interval. Hospital stays for newborns and mothers after uncomplicated vaginal delivery have decreased steadily since birth in the hospital setting became common. In the 1950s, the recommended postpartum hospital stay was 6 days.2 In the United States, hospital stays after vaginal deliveries gradually decreased from an average of 4 days in the 1970s to ;2 days in 1992.1 In 1995, the mean length of stay for healthy, vaginally delivered, and routinely discharged infants in California was 1.1 days. Reducing the number of days in the hospital after birth has several advantages: 1) the risk of iatrogenic infections is decreased; 2) mother and infant recover in a familiar home environment; and 3) hospital costs of caring for the infant and mother are reduced. However, concerns have also been expressed about potential disadvantages of early discharge: 1) breastfeeding is not established until the third or later postpartum day; 2) a number of conditions do not manifest themselves until 2 or more days after the delivery; 3) time is reduced for inhospital teaching on breastfeeding, infant care, women’s health needs, and family planning and for psychosocial care.3–5 Although there are many published studies on the early discharge of infants, several reviews of this literature have pointed out a number of methodological difficulties, such as self-selected populations, small sample size, lack of controls, limitation of outcomes to death and readmission, and lack of knowledge on postdischarge follow-up care.2,5 Braveman et al5 concluded that “the currently available literature provides little scientific evidence to guide discharge planning for most apparently well newborns and From *Health Information Solutions, ‡Pacific Business Group on Health, and §University of California, Berkeley, School of Public Health, Berkeley,