Upsala J Med Sci 105: 57-66,2000

Very Early Discharge from Hospital after Normal Deliveries
Elisabeth Darj and Boel StHlnacke

Department of Women 's and Children's Health, Section f o r Obstetrics and Gynaecology,
Uppsala University Hospital, Uppsala, Sweden

ABSTRACT
The aim of the present study was to investigate, in a descriptive study, how healthy

women experienced early discharge from hospital, 6 -12 hours, after normal deliveries.

Expecting couples were prepared for early discharge during pregnancy. The women

delivered at the University Hospital in Uppsala. All infants had two obligatory medical

examinations, one before leaving the hospital and one for metabolic screening after four

or five days. Both mothers and infants received postpartum care at home by midwives.

One hundred and three women participated and answered a questionnaire four to five

days after delivery. Twenty of the women were additionally interviewed by telephone

four months after delivery.

The average length of stay at the hospital after delivery was 8 hours. The families had,

on average, 1.9 visits at home. All women considered that they had received sufficient

care and advice from the midwives, although 40 percent felt uncertainty about

something in the postpartum period. Questions frequently raised concerned breast-

feeding. Two infants were readmitted to hospital due to mild neonatal

hyperbilirubinemia. All but three women wanted to repeat very early discharge after a

future uncomplicated delivery. Ninety-five percent of the women were still breast-

feeding after four months.

We conclude, that antenatal preparation and a well-organised, adequate postpartum

home-care is of the greatest importance, to establish safe early discharge after

uncomplicated deliveries. This concept of early discharge from hospital, with midwifery

home care provided, is safe and appreciated by the new parents.

INTRODUCTION
The length of hospitalisation after both vaginal and caesarean deliveries has declined

during recent years. Seven years ago, a non-randomised study of mandatory discharge

only four hours after child-birth, with a control group remaining in hospital, was

performed in Denmark ( 5 ) . The early-discharged women, who had home-visits by

midwives, were less satisfied with the postpartum period compared with the control

group. They experienced less support, mainly concerning breast-feeding and they made

67% more telephone consultations. The women felt that they were not satisfactorily

informed about the compulsory early discharge during pregnancy. An Australian study

(4) evaluated satisfaction with domiciliary midwifery care after early discharge as

compared with hospital care. The study showed that healthy women were largely

satisfied with the quality of the care programme they had favoured, due to different

expectations of postnatal care, regardless of the form of care they chose There have

been concerns, though, about whether women can choose freely or not. Data from the

1988 National Maternal and Infant Survey (8) suggest that economic factors have

become a driving force behind early discharge. Of the total number of women, 12.3%

were early discharged and left hospital after one night or less. These women had less

education, inadequate prenatal care and lack of private insurance. With increasing early

discharge from hospital, according to benefits for the families, there have been concerns

about safety for the new-born, as expressed in the Washington State Experience (6). In

another large study, 1200 women were followed in a programme for prenatal

preparation. Risk assessment, postpartum breast-feeding counselling and home visits

were studied (7). A moderate reduction of postpartum readmission to hospital was

found. No disadvantages for the neonates were shown when adequate postpartum

outpatient care was accessible. Other descriptive studies of low-risk populations could

not demonstrate differences in maternal competence, breast-feeding, neonatal

hyperbilirubinemia or readmission of infants to hospital, but implied psycho-social

benefits for some mothers and infants (2, 1). There are previous Swedish studies of

early discharge from hospital, where mother and child leave hospital within the first 72

hours after delivery, and are followed-up by home-care (1 1, 9). We wanted to make an

evaluation of the new programme with very early discharge after childbirth, before

introducing it on a large scale at the hospital. In Sweden almost 100% of the pregnant

women are registered in primary prenatal care. Ninety-nine percent of all antenatal care

is public and free of charge. All women are given individual antenatal care 9-10 times

during a normal pregnancy. No pregnancy or birth allowances are given. The mothers

have 450 days maternity leave and the fathers have 10 days paid leave in connection

with birth, to care for the new-born and for other children in the family. Preparation

classes, of 6-8 couples, are offered to all pregnant women and their husbands. They

meet on four to five occasions. In classes there is structural education about the progress

of a normal pregnancy, delivery and the first postpartum period. Breast-feeding is

discussed and encouraged. The view of breast-milk, as being natural, often

uncomplicated, inexpensive and exactly adapted to the babies need, decreasing infection

and allergy rates and giving a close body contact between mother and child, is

introduced.

The aim of this study was to describe how healthy women experienced discharge from

labour ward, directly but after birth, after having first rested, initiated breast-feeding,

showered, having had a meal, and having prepared to go home. The postpartum care

continued in their own home with home-visits by trained midwives. Few studies have

examined the incidence of breast-feeding, comparing early discharged women with

those in regular care. Additionally, the frequency of breast-feeding differs greatly

between countries. In 1996, data from the National Board of Health and Welfare (lo),

98% of the Swedish women were breast-feeding when the baby was one week old. At

four months of age, 84% of all Swedish children are still breast-fed. While introducing

this new concept of very early discharge after child-birth, we think it is important to

maintain the high proportion of breast-fed infants and, furthermore, to evaluate how

many children or mothers were readmitted to the hospital during the first four months.

METHODS
During six months 1996-1997, healthy women at low-risk, medically and socially, were

offered the possibility to leave the hospital 6-12 hours after a normal delivery. The

study was approved by the Ethics Committee of the Medical Faculty at Uppsala

University. One hundred and three women were recruited after giving informed consent

to the study. All participating women had experienced an uncomplicated singleton

pregnancy. There were no signs of high blood pressure, intrauterine growth retardation,

gestational diabetes, macrosomia, bleeding, premature rupture of membranes or other

complicating factors. Before the women were included in the study, the delivery should

have passed without any complications and at term. The neonates were examined by a

paediatrician before leaving the hospital. They were all healthy and of normal weight.

The women were supposed to have good social support at home, meaning that the

husband, or another relative, stayed at home to manage the household the first 7-10

days. Early discharge included continued postpartum care at home, with visits by

specially trained midwives, taking care of both the mother and the child. All midwives

providing home care were employed by the Department of Obstetrics and Gynaecology

at the University Hospital. All families had at least one home-visit, but as many as they

needed. If a woman did not require firther home-visits, she none the less had a

telephone-call every day in the morning from the home-visiting midwives. The

midwives followed a structured protocol (table I), being in contact with the mother and

the child.

Table 1. Midwifery structured protocol, used at each home-visit after normal deliveries.
Neonate: Mother:
general status general status
elimination uterus
umbilicus perind tear or episiotomia
skin, icterus (1-3)
bilirubinemia if needed

Breast-feeding: Information:
position delivery
sucking technique diet
sucking willingness exercise
pacifier family relations and sexuality
intervals between breast-feeding

They had the possibility to draw venous blood from the infant if neonatal

hyperbilirubinemia was suspected. At the fourth or fifth day, all children were examined

a second time by a paediatrician at the hospital and a metabolic screening was

performed. The neonatal metabolic screening in Sweden includes blood samples for

some inborn errors of metabolism and congenital hypothyreoidism. The women were

asked at the same time to return the questionnaires in sealed envelopes. After the first

week, if everything was normal, the responsibility was transferred, from the Department

of Obstetrics and Gynaecology to the public and cost-free Child Health care

programme. Uppsala is a university city and most of the families were living near the

hospital. After four months, the first 20 women in the study were interviewed by

telephone.

The questionnaire included demographic questions concerning age, parity, marriage

status and profession (table 2).

Table 2. Demographic distribution of 103 women with experience of early discharge after delivery

mean (range) f SD
women’s age 29.6 years (21-40) f 4.4
men’s age 32.3 years (22-57) f 6.1

children’s birth length 51.1 cm (48-55) f 1.8
hospitalisation 8.0 hours (6-12) f 2.0

children’s birth weight 3696 g (2750-4730) f 425

home visits 1.9 visits (1-4) f 0.8

Further questions focused on the information they had received and when. Experiences

of the home-visit and care and support from the midwives were estimated on a scale 1 -

7. The women’s worries about the baby, breast-feeding and extra contact with the

hospital was registered. There were also open questions to both the mother and father or

other relative about the first days at home.

A statistical calculation of the study was performed before start. In order to draw

general conclusions of the experiences from a whole population choosing very early

discharge after child-birth, from the small present descriptive study of 100 women, it

was estimated that at least 70% of them (confidence interval 61-79%), should be

satisfied with the postpartum care given and wanted to repeat very early discharge after

a future uncomplicated delivery

RESULTS
In the study, 20 women (20%) were primiparas and 82 (80%) multiparas. Fifty-two

women had had their second child, 20 women their third, four women their fourth, one

woman her fifth and one woman her eighth child. There were incomplete data from five

women in this respect. Ninety-seven percent of the couples were married or living

together. Twenty-eight percent of the women had an academic occupation, while 11%

were out of work. The women had received information initially on early discharge,

mainly from midwives and doctors in prenatal care units (table 3).

Table 3. Sources of information about early discharge after delivery

n (YO)
prenatal care, midwife or doctor 85 (82.5yo)
relatives or friends 24 (23.3%)
preparing visit at the hospital 15 (14.6%)

other 2 (1.9%)
newspapers 10 (9.7%)

Most of them (95%) were satisfied with the information they had received. All but one

of the women had the intention of breast-feeding the baby, but all of them did so before

leaving the hospital. The families had, on average, 1.9 visits at home by a midwife.

Thirty-six percent had one visit, 40% had two visits, 22% had three visits and 2% had

four visits. Forty percent of the women felt uncertainty about something in the

postpartum period (table 4). The most frequent questions concerned breast-feeding.

Table 4. Insecurity of following alternatives.

n (YO)
mother: breast-feeding 25 (24%)

breast, nipples 17 (16.3Yo)
bleeding 5 (4.8%)
other 4 (3.8%)

crying 8 (7.7%)

sleeping 5 (4.8Yo)

infant: behaving at the breast 11 (10.6Y0)

vomiting 7 (6.7%)

breathing 5 (4.8Yo)
other 12 (11.5%)

Fourteen percent of the women called a midwife or the maternity ward for advice. All of

the participating women (1 00%) assessed that they had received sufficient comfort and

care by the midwives. Ninety-four percent experienced early discharge to be positive or

very positive (scale 6-7) and 93% experienced midwifery home visits as positive or very

positive (table 5).

Table 5. Assessment of experience with early discharge and home visits of 103 mothers after delivery (on
a scale 1-7)

Very negative Very positive
1 2 3 4 5 6 7

early discharge 1 2 3 11 86
home visits 1 1 5 15 81

Comments from the three who were not positive to the concept, concentrated on that the

mother or the father was tired, they wanted more help, possibly given by hospital staff,

they felt insecure or had questions about how to deal with elder brothers or sisters. One

woman and two children (3%) required an extra visit to a physician. They were

readmitted for treatment. Both of the infants had mild jaundice, discovered at home by

the midwife, who took blood samples at the home-visit. Maximum serum levels of

bilirubin were 332 pmol/L and 328 pmolL, respectively. The two children had light

therapy and stayed in the hospital for another 39 and 70 hours, respectively. One woman

had problems related to breast-feeding. This, was a Swedish woman who had been living

abroad and registered late, after 36 gestational weeks, at the prenatal unit. She had not

been able to attend all prenatal preparation classes. She was readmitted to the hospital,

after two days at home, for extra support and stayed in the hospital for four days, until

she was comfortable with the breast-feeding. The baby was healthy. Answering the

questionnaire during the first week after delivery, all women but three expressed the

hope that they would be able to leave hospital early after a coming delivery, with

domiciliary care. One woman had had her first child, and suspected that next time it

could be exhausting with siblings and a new baby at home. The other two women

expressed that they needed more rest before going home after childbirth; one had had

her first and the other her second child. All women initiated breast-feeding. In our small

study of the telephone-interviewed women, all but one, %YO, were breast-feeding after

four months and the women were content with the support they had received at the

home-visits.

After four months, 18 out of 20 fathers had spent some of the first two weeks with the

baby and the wife at home, on average 9.2 days. In 30 % another person was staying in

the home for the first few days, with or without the husband at home simultaneously.

Twelve of the twenty telephone-interviewed women had, during the first four months,

experienced some kind of difficulty. Five had had problems while initiating breast-

feeding, two had had sore nipples and five had some other kind of problem at home

(e.g. jealousy from siblings, fear of thoughts of sexuality). At the interview all but one

woman was still breast-feeding. This woman had quit breast-feeding after one month.

Four months after the delivery all interviewed women wanted, after a normal future

delivery, to leave the hospital as early as this time, being supported by a home-visiting

midwife.

DISCUSSION
In the Danish study (5) the aim of discharging the mothers and new-born very early was

cost-saving, but this could not be confirmed in the investigation. Others have been able

to show cost-effectiveness (2, 9). The Danish mothers felt uninformed about the

compulsory early discharge and were dissatisfied with the postpartum care. This

emphasises the importance of seeing the pregnancy, delivery and postpartum period as

linked together and influencing each other. The parents have to know what to expect

after the delivery, if it has been uncomplicated. Data from the national study in the

United States supported a legal decision mandating a minimum of 48 hours hospital-

stay postpartum (8). The legislation was suggested to secure that discharge from

hospital should be individually based on medical and social factors and not on the

economic situation. The availability of adequate postnatal care should be general. We

think that there is no need of such a law in Sweden, but fully agree with an individual

evaluation based on medical and social factors, and that sufficient and high-quality care

is crucial for accepting this method of postpartum home-care. We do not let the mother

and infant leave the hospital if the obstetrician, paediatrician, or midwife has concerns

regarding medical or psycho-social safety.

There are limitations with descriptive studies such as ours. Randomised controlled trials

are difficult to perform in this respect and most studies published are descriptive.

Gagnon et a1 (3) however, in a randomised study, with both groups equally prepared

antenatally, found no apparent disadvantages, but observed emotional benefits for the

family after early discharge. No control group was identified during our study.

However, the University Hospital in Uppsala regularly distributes questionnaires to

women in the Maternity ward asking about their satisfaction with the care, before

leaving the hospital. Newly delivered mothers stay on average 2.3 days in the ward, 97

% and 96 YO of them were generally satisfied with their hospital stay in 1996 and 1997,
respectively. In the present study we found the same estimation of satisfaction in

mothers who left hospital very early. These figures may reflect the women’s satisfaction

according to their own expectation of postpartum care, as others already have shown (4,

7). Comments from the participating women in our study were commonly that the

fathers and siblings got to know the baby sooner and were more involved in the care.

The safety for the neonates was discussed in the Washington State Experience (6). The

authors conclude that new-borns discharged less than 30 hours of age are at risk for

rehospitalization within the first month. Subgroups at special risk in the report are

children of young mothers < 18 years, primiparas or after rupture of membranes.

Prematures, new-borns with serious medical conditions, multiple births and babies born

after caesarean section, were excluded, but there is no information on how the women

or families were prepared and risk-evaluated before delivery. Thirty per cent were

reported to have had complications during delivery and 25% had less than adequate

prenatal care. In our hospital these mothers would not have been included in the very

early discharge programme. Although 40 % of the women study felt uncertainty in some

aspect, only 14% made an extra telephone call for advice, but 100% felt that they had

received adequate care and appreciated it. They were comforted by the daily visits by

midwives or that the midwives called them every morning.

Experiences with home-visits revealed no disadvantages, concerning readmission rate to

hospital, frequency of breast-feeding, when a prenatal risk-assessment was performed.

In the study, the two neonates that developed mild jaundice requiring light therapy were

both discovered by the midwife and diagnosed by blood tests performed at home. The

families appreciated the care provided and 97% wanted to go home early after a normal

h t u r e delivery.

As very early discharge after labour is encouraged in the Scandinavian countries,

we emphasise the importance of antenatally preparing the parents for fairly prompt

hospital-discharge and, furthermore, giving a structured and adequate home-care by

specially knowledgeable midwives. We do not consider it a failure if a child or a woman

needs to be readmitted for some days. Our conclusion is that a healthy well-prepared

woman with a healthy child, born at term after an uncomplicated pregnancy and

delivery, can leave the hospital as early as after 6-12 hours, given that there is a well

established programme for continued care at home.

ACKNOWLEDGEMENTS
The authors would like to thank the Foundation for Development at the University
Hospital in Uppsala, for financially supporting the study.

5- 1OO126 65

10.

11.

REFERENCES
Bragg, E., Rosenn, B., Khoury, J., Miodovnik, M.& Siddiqi T.: The Effect
of Early Discharge After Vaginal Delivery on Neonatal Readmission
Rates. Obstet Gynecol 89: 930-933, 1997.

Brumfield, C., Nelson, K., Stotser, D., Yarbaugh, D., Patterson, P. &
Spraybeny, N. : 24-hour Mother-Infant Discharge With a Follow-up
Home Health Visit: Results in a Selected Medicaid Population. Obstet
Gynecol88: 544-548, 1996.

Gagnon, A,, Edgar, L., Kramer, M., Papageorgiou, A., Waghorn, K. &
Klein, M.: A ratidomised trial of a program of early postpartum discharge
with nurse visitation. Am J Obstet Gynecol 176: 205-21 1, 1997.

Kenny, P., King, M.T., Cameron, S. & Sheill, A.: Satisfaction with
postnatal care - the choice of home or hospital. Midwifery 9: 146-153,
1993.

Kirkegaard, O., Engstrom, H., Naested, H. & Briand, A.: Barselperiodens
forlerb efter tvungen ambulant fndsel. (Danish). Ugeskr Laeger 154: 1 19-
123, 1992.

Liu, L., Clemens, C., Shay, D., Davis, R. & Novack, A,: The Safety of
Newborn Early Discharge. The Washington State Experience. JAMA 278:
293-298, 1997.

Mandl, K., Brennan, T., Wise, P., Tronick, E. & Homer, C.: Maternal and
Infant Health. Effects of Moderate Reductions in Postpartum Length of
Stay. Arch Pediatr Adolesc Med 15 1 : 91 5-921, 1997.

Margolis, L., Kotelchuck, M. & Chang, H-Y.: Factors Associated With
Early Maternal Postpartum Discharge From the Hospital. Arch Pediatr
Adolesc Med 15 1 : 466-72, 1997.

Odelram, H., Nilsson, B., Pehrsson-Lindell, D.& Ljungkvist, E. : Early
discharge after delivery a safe and cost-effective form of care. (Swedish)
Lakartidningen 95: 3190-3 194, 1998.

The National Board of Health and Welfare. : Breastfeeding, children
born 1996. Centre of Epidemiology 1997:7, 1997.

Waldenstrom, U. : Early discharge after hospital birth (dissertation)
Uppsala universitet. Acta Universitas Uppsaliensis 79, 1987.

Address for reprints: Elisabeth Darj, M.D., Ph.D.
Department of Women’s and Children’s Health
Section for Obstetrics and Gynaecology
University Hospital, S-75 1 85 Uppsala, Sweden