SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
The duration of postnatal hospital stays has declined dramatically over the last thirty years and whether spending less time in hospital is harmful or beneficial remains a controversial concern. In practice, what constitutes an ‘early discharge from hospital’ varies across different countries and according to standard patterns of care.
Key messages:
-Higher levels of postnatal support may influence this outcome.
-Although the costs of hospitalisation are probably lower in the early discharge group, the postnatal costs associated with early postnatal discharge from hospital and total costs are uncertain.
-The effects in low-income countries might be different because of differences in the availability of practical support for mothers who are discharged early, the availability of postnatal support in the community, and the quality of care in hospitals or other facilities.
Persons making decisions about early postnatal discharge.
Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews. 2002, Issue 3.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
The length of postnatal hospital stays has continued to decline in a number of countries despite lack of clear evidence of its safety and effectiveness. Studies have reported patients being discharged from hospitals after 12 to 72 hours. Possible adverse outcomes of early postnatal discharge include delays in detecting and treating infant and maternal morbidity and a greater occurrence of breastfeeding problems. Possible advantages include a decrease in mother and infant exposure to nosocomial infections and enhanced maternal confidence in caring for the baby in the home environment.
This summary is based on a review published in 2002 (with updated searches in 2008) on the effects of early postnatal discharge from hospital for healthy mothers and term infants.
| Review objectives: Assess the safety, impact and effectiveness of a policy of early discharge for healthy mothers and term infants, with respect to the health and well-being of mothers and babies. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
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Study designs & interventions |
Randomised trials that evaluate a policy of early postnatal discharge from hospital for healthy mothers and infants born at term. |
10 trials of early discharge were included in the review. Early discharge defined as a discharge after <48 hours (5 studies), <60 hours (1), and after periods ranging from 12 to 72 hours (4). |
|
Participants |
Women who give birth in a hospital to a healthy infant that weighs at least 2,500 grams at term (37 to 42 weeks) and are deemed eligible for ‘early discharge’. |
Women were recruited after the birth (4 studies) or during pregnancy (6 studies). |
|
Settings |
Hospital based. |
Studies were undertaken in USA (3 studies), Canada (3), UK (1), Spain (1), Sweden (1) and Switzerland (1). |
|
Outcomes |
Infant or maternal readmissions (and duration of the later), maternal emotional well-being, breastfeeding problems, satisfaction and costs of care. |
Infant readmissions (8 studies), maternal readmissions (8), maternal emotional well-being (5), breastfeeding problems (8), satisfaction with care (4), and costs of care (4). |
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Date of most recent search: December 2008. |
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Limitations: This is a well-conducted systematic review with only minor limitations. |
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Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews. 2002, Issue 3.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Ten trials of early discharge from hospital were included in the review. All the studies were conducted in high-income countries.
In some studies, co-interventions were administered, such as antenatal home visits (2 studies), postnatal home visits (6), postnatal home visits and phone calls (4), and a ‘preparation for discharge’ class (1).
Early discharge from hospital versus standard discharge:
Does early discharge affect neonatal or maternal health in healthy mothers and term infants? |
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| People: Healthy postpartum mothers and term infants Settings: Hospital based Intervention: Early discharge Comparison: Standard discharge |
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| Outcomes | Impacts | Relative effect (95% CI) |
Number of participants (Studies) | Certainty of the evidence (GRADE) |
Comments | ||
| Standard dis-charge |
Early discharge |
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| Proportion of infants readmitted within eight weeks Follow-up: Mean 8 weeks |
18 per 1,000 |
24 per 1,000 (11 to 51) |
RR 1.29 (0.6 to 2.79) | 3,435 (7 studies) |
Low |
In one study, the majority of readmission visits during this period were for routine care or bilirubin monitoring. | |
| Proportion of women readmitted within 6 weeks Follow-up: Mean 6 weeks | 14 per 1,000 | 15 per 1,000 (7 to 33) | RR 1.1 (0.51 to 2.4) | 3,509 (8 studies) |
Low |
None of the studies reported data on the duration of maternal readmissions or on the total duration of the hospitalisation of mothers in the first six weeks after the birth. | |
| Proportion of women not breastfeeding in first 8 weeks postpartum | 440 per 1,000 | >396 per 1,000 (334 to 466) | RR 0.9 (0.76 to 1.06) | 3,845 (8 studies) |
Low |
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| Proportion of women probably depressed Follow-up: Range 4 to 6 weeks post-partum | 68 per 1000 | 45 per 1000 (26 to 76) | RR 0.66 (0.39 to 1.12) | 993 (3 studies) |
Low |
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| Proportion of women dissatisfied with postnatal care | 363 per 1000 | 218 per 1000 (131 to 363) | RR 0.60 (0.36 to 1.00) | 841 (3 studies) |
Low |
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| Total cost of care | Two studies reported outcomes on the cost of care. In both of these trials, the cost of hospitalisation was lower in the early discharge group. In one trial, the combined costs of community care and maternal and neonatal readmissions were higher in the early discharge group. In the other one, the combined costs were higher in the standard care group. | ||||||
| CI: Confidence Interval RR: Risk Ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Relevance of the review for low-income countries
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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All the included studies were conducted in high-income countries. |
The effects in low-income countries might be different because of differences in the availability of practical support for mothers who are discharged early, the availability of postnatal support in the community, and the quality of care in hospitals or other facilities.
Policies that promote shorter hospital stays may not always be implemented. In some of the studies, accompanying primary care support was provided in the days following discharge, but this may not always be done in practice. It remains unclear how important home midwifery or nursing support is to the safety and acceptability of early discharge programmes.
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| EQUITY | |
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The systematic review did not address equity issues. |
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| ECONOMIC CONSIDERATIONS | |
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It is uncertain whether the intervention affects the costs of care. Cost data (when provided) were difficult to compare as different methods were used and different costs measured. |
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| MONITORING & EVALUATION | |
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Although early postnatal discharge appeared not to have adverse effects, the certainty of the evidence is low and none of the included studies were conducted in low-income countries. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods
Related literature
Conseil d’Evaluation des Technologies de la Sante du Quebec. Evaluation of the risks and benefits of early postpartum discharge. Report submitted to the Minister of Health and Social Services of Quebec. Quebec: CETS, 1997.
Braveman P, Egeter S, Pearly M, Marchi K, Miller C. Early discharge of newborns and mothers: a critical review of the literature. Pediatrics 1995;96:716–26.
This summary was prepared by
Sebastián García Martí and Agustín Ciapponi, Argentine Cochrane Centre IECS - Institute for Clinical Effectiveness and Health Policy - Iberoamerican Cochrane Network, Argentina.
Conflict of interest
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by: Charles Okwundu, Charles Wiysonge, and Stephanie Brown.
This review should be cited as
Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews. 2002, Issue 3.
The summary should be cited as
García Martí S, Ciapponi A. What are the effects of early postnatal discharge from hospital on healthy mothers and term infants? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org
Keywords
All Summaries: evidence-informed health policy, evidence-based, systematic review, health systems.
research, health care, low income countries, developing countries, primary health care.
