Vaginal delivery: how does early hospital discharge affect mother and child outcomes? A systematic literature review

Abstract

BackgroundThere is an international trend to shorten the postpartum length of stay in hospitals, driven by cost containment, hospital bed availability and a movement toward the ‘demedicalization’ of birth. The aim of this systematic literature review is to determine how early postnatal discharge policies from hospitals could affect health outcomes after vaginal delivery for healthy mothers and term newborns.MethodsA search for systematic reviews, meta-analyses, and primary studies was carried out in OVID MEDLINE, Embase, CINAHL, Econlit and the Cochrane Library (Cochrane Database of Systematic Reviews, DARE and HTA databases). The AMSTAR checklist was used for the quality appraisal of systematic reviews. The quality of the retrieved studies was assessed by the Cochrane Collaboration’s tools. The level of evidence was appraised using the GRADE system.ResultsSeven RCTs and two additional observational studies were found but no comprehensive economic evaluation. Despite variation in the definition of early discharge, the authors of the included studies, concerning early discharge and conventional length of stay, reported no statistical difference in maternal and neonatal morbidity, maternal and neonatal readmission rates, infant mortality, newborn weight gain, neonatal hyperbilirubinemia, or breastfeeding rates. The authors reported conflicting results regarding postpartum depression and competence of mothering, ranging from no difference according to length of stay to better results for early discharge. The level of evidence of the vast majority of outcomes was rated as low to very low.ConclusionsBecause of the lack of robust clinical evidence and full economic evaluations, the current data neither support nor discourage the widespread use of early postpartum discharge. Before implementing an early discharge policy, Western countries with longer length of hospital stay may benefit from testing shorter length of stay in studies with an appropriate design. The issue of cost containment in implementing early discharge and the potential impact on the current and future health of the population exemplifies the need for publicly funded clinical trials in such public health area. Finally, trials testing the range of out-patient interventions supporting early discharge are needed in Western countries which implemented early discharge policies in the past.

Morbidities and mortality among infants of HIV-1-infected mothers with bacterial vaginosis in Kenya

“…Evans et al (2018) investigated the impact of early discharge on outcomes among infants and found no differences in the outcomes of early and late discharge. However, the authors conducted a meta-analysis on the same data and found no study that reported any differences, even though there was an international trend toward shortening the postpartum length of stay in hospitals among women who have undergone vaginal delivery to improve the mother's sleep, for proper bonding of the mother and infant, and to protect the infant-mother dyad from nosocomial infections (33). Our analysis showed a 1.95-fold increase in the frequency of maternal hospital admissions among exposed subjects compared to non-exposed subjects.…”

Determinants of Length of Stay After Vaginal Deliveries in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005–2015

“…Nevertheless, ED of mothers and newborn has in fact increased dramatically in several high-income countries over the past 10-15 years. However, the evidence on the impact of ED on healthy mothers and term newborns (≥37 weeks) after a vaginal delivery (VD) is still inconclusive and little is known of the characteristics of those discharged early [5][6][7][8][9][10][11][12][13] .…”

Does Shorter Postnatal Hospital Stay Lead to Postdischarge Complications? An Instrumental Variables Approach

“…Although RCTs are more appealing than others, a very narrow focus either to a hospital or a small community (Boulvain et al ., ; Brooten et al ., ) has made them unconvincing to generalize their results to a large population. Furthermore, it was not always possible to choose early and late discharge women (treatment and control groups) randomly, as women with delivery complications tend to stay longer and vice versa (Benahmed et al ., ). Most of the studies, including the two studies for developing countries, belong to NRCTs, which have estimated correlations or associations, as their treatment and control groups were not comparable in most of the cases.…”

“…As the previous studies have produced highly mixed results, recent systematic reviews have found inconclusive findings (Benahmed et al ., ; Jones et al ., ). Indeed, there is a lack of proper causal studies.…”