Newborn early discharge revisited: are California newborns receiving recommended postnatal services?

Term Newborn Care Recommendations Provided in a Kenyan Postnatal Ward: A Rapid, Focused Ethnographic Assessment

BACKGROUND

Neonatal mortality (death within 0-28 d of life) in Kenya is high despite strong evidence that newborn care recommendations save lives. In public healthcare facilities, nurses counsel caregivers on term newborn care, but knowledge about the content and quality of nurses' recommendations is limited.

PURPOSE

To describe the term newborn care recommendations provided at a tertiary-level, public referral hospital in Western Kenya, how they were provided, and related content taught at a university nursing school.

METHODS

A rapid, focused ethnographic assessment, guided by the culture care theory, using stratified purposive sampling yielded 240 hours of participant observation, 24 interviews, 34 relevant documents, and 268 pages of field notes. Data were organized using NVivo software and key findings identified using applied thematic analysis.

RESULTS

Themes reflect recommendations for exclusive breastfeeding, warmth, cord care, follow-up examinations, and immunizations, which were provided orally in Kiswahili and some on a written English discharge summary. Select danger sign recommendations were also provided orally, if needed. Some recommendations conflicted with other providers' guidance. More recommendations for maternal care were provided than for newborn care.

IMPLICATIONS FOR PRACTICE

There is need for improved consistency in content and provision of recommendations before discharge. Findings should be used to inform teaching, clinical, and administrative processes to address practice competency and improve nursing care quality.

IMPLICATIONS FOR RESEARCH

Larger studies are needed to determine whether evidence-based recommendations are provided consistently across facilities and other populations, such as community-born and premature newborns, who also experience high rates of neonatal mortality in Kenya.

Newborn Clinic: A Novel Model to Provide Timely, Comprehensive Care to Newborns Following Nursery Discharge

Ensuring safe and timely follow-up after well baby nursery (WBN) discharge is an ongoing challenge. This study demonstrates the efficacy of a novel model for follow-up, the Newborn Clinic (NBC), in reducing time to outpatient follow-up after WBN discharge. Our retrospective chart review of 17 952 newborns found that time to follow-up visit decreased significantly following NBC establishment. Emergency department visits, a marker of infant morbidity, were slightly increased in the post-establishment cohort. There was no difference, however, in hospital readmissions. Analysis within the post-establishment cohort showed that newborns with jaundice, a high-risk group, were much more likely to have early follow-up if their visit was scheduled with NBC. Our study demonstrates that NBC is an effective model for decreasing time from WBN discharge to follow-up visit. It should be considered as an initiative to run concurrently with expedited newborn discharge initiatives so that safe follow-up need not be sacrificed.

Determinants of length of stay after cesarean sections in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Since Italy has the highest cesarean section (CS) rate (38.1%) among all European countries, the containment of health care costs associated with CS is needed, along with control of length of hospital stay (LOS) following CS. This population based cross-sectional study aims to investigate LoS post CS (overall CS, OCS; planned CS, PCS; urgent/emergency CS, UCS), in Friuli Venezia Giulia (a region of North-Eastern Italy) during 2005-2015, adjusting for a considerable number factors, including various obstetric conditions/complications. Maternal and newborn characteristics (health care setting and timeframe; maternal health factors; child's size factors; child's fragility factors; socio-demographic background; obstetric history; obstetric conditions) were used as independent variables. LoS (post OCS, PCS, UCS) was the outcome measure. The statistical analysis was conducted with multivariable linear (LoS expressed as adjusted mean, in days) as well as logistic (adjusted proportion of LoS > 4 days vs. LoS ≤ 4 days, using a 4 day cutoff for early discharge, ED) regression. An important decreasing trend over time in mean LoS and LoS > ED was observed for both PCS and UCS. LoS post CS was shorter with parity and history of CS, whereas it was longer among non-EU mothers. Several obstetric conditions/complications were associated with extended LoS. Whilst eclampsia/pre-eclampsia and preterm gestations (33-36 weeks) were predominantly associated with longer LoS post UCS, for PCS LoS was significantly longer with birthweight 2.0-2.5 kg, multiple birth and increasing maternal age. Strong significant inter-hospital variation remained after adjustment for the major clinical conditions. This study shows that routinely collected administrative data provide useful information for health planning and monitoring, identifying inter-hospital differences that could be targeted by policy interventions aimed at improving the efficiency of obstetric care. The important decreasing trend over time of LoS post CS, coupled with the impact of some socio-demographic and obstetric history factors on LoS, seemingly suggests a positive approach of health care providers of FVG in decision making on hospitalization length post CS. However, the significant role of several obstetric conditions did not influence hospital variation. Inter-hospital variations of LoS could depend on a number of factors, including the capacity to discharge patients into the surrounding non-acute facilities. Further studies are warranted to ascertain whether LoS can be attributed to hospital efficiency rather than the characteristics of the hospital catchment area.

Morbidity in Newborns Readmitted Into a Hospital After Discharge From a Maternity Unit During the First 28 Days of Their Lives - Results From the Rhine-Main Area, Germany

BACKGROUND

The neonatal period can be associated with a multitude of medical and social problems. Little is known about the reasons that lead to neonatal readmissions in a pediatric hospital and their individual outcomes.

OBJECTIVE

To record the diagnosis of neonatal admissions in a pediatric hospital after discharge from a maternity unit. Predictive parameters are to be identified and a possible trend over the years is to be examined.

METHODS

The medical history of newborns admitted to a pediatric hospital in the Rhine-Main area from 01/01/2004 to 31/12/2013 was retrospectively analyzed based on provided medical files.

RESULTS

The data of 2851 newborns was recorded. 72% of the patients were delivered by vaginal birth. During the period under examination, there was a certain fluctuation although no significant trend in the number of admissions per year (p=0.062). The most frequent primary diagnoses were jaundice (27%), newborn infection (12.4%), and feeding problems (12.3%). Exclusively breastfed newborns had fewer feeding problems than newborns with a mixed or purely formula diets (p < 0.001).

CONCLUSIONS

The results of this study showed that the hospital readmissions of newborns throughout the years did not increase. Unfortunately, owing to the retrospective character of the study, it is not possible to make a clear statement as to whether hospitalization can be prevented with more intensive preventative measures. A prospective study on this matter is being planned.

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

Although length of stay (LoS) after childbirth has been diminishing in several high-income countries in recent decades, the evidence on the impact of early discharge (ED) on healthy mothers and term newborns after vaginal deliveries (VD) is still inconclusive and little is known on the characteristics of those discharged early. We conducted a population-based study in Friuli Venezia Giulia (FVG) during 2005-2015, to investigate the mean LoS and the percentage of LoS longer than our proposed ED benchmarks following VD: 2 days after spontaneous vaginal deliveries (SVD) and 3 days post instrumental vaginal deliveries (IVD). We employed a multivariable logistic as well as a linear regression model, adjusting for a considerable number of factors pertaining to health-care setting and timeframe, maternal health factors, newborn clinical factors, obstetric history factors, socio-demographic background and present obstetric conditions. Results were expressed as odds ratios (OR) and regression coefficients (RC) with 95% confidence interval (95%CI). The adjusted mean LoS was calculated by level of pregnancy risk (high vs. low). Due to a very high number of multiple tests performed we employed the procedure proposed by Benjamini-Hochberg (BH) as a further selection criterion to calculate the BH p-value for the respective estimates. During 2005-2015, the average LoS in FVG was 2.9 and 3.3 days after SVD and IVD respectively, and the pooled regional proportion of LoS > ED was 64.4% for SVD and 32.0% for IVD. The variation of LoS across calendar years was marginal for both vaginal delivery modes (VDM). The adjusted mean LoS was higher in IVD than SVD, and although a decline of LoS > ED and mean LoS over time was observed for both VDM, there was little variation of the adjusted mean LoS by nationality of the woman and by level of pregnancy risk (high vs. low). By contrast, the adjusted figures for hospitals with shortest (centres A and G) and longest (centre B) mean LoS  were 2.3 and 3.4 days respectively, among "low risk" pregnancies. The corresponding figures for "high risk" pregnancies were 2.5 days for centre A/G and 3.6 days for centre B. Therefore, the shift from "low" to "high" risk pregnancies in all three latter centres (A, B and G) increased the mean adjusted LoS just by 0.2 days. By contrast, the discrepancy between maternity centres with highest and lowest adjusted mean LoS post SVD (hospital B vs. A/G) was 1.1 days both among "low risk" (1.1 = 3.4-2.3 days) and "high risk" (1.1 = 3.6-2.5) pregnanices. Similar patterns were obseved also for IVD. Our adjusted regression models confirmed that maternity centres were the main explanatory factor for LoS after childbirth in both VDM. Therefore, health and clinical factors were less influential than practice patterns in determining LoS after VD. Hospitalization and discharge policies following childbirth in FVG should follow standardized guidelines, to be enforced at hospital level. Any prolonged LoS post VD (LoS > ED) should be reviewed and audited if need be. Primary care services within the catchment areas of the maternity centres of FVG should be improved to implement the follow up of puerperae undergoing ED after VD.

Interrelationships of physical activity in different domains: Evidence from the Geographic Research on Wellbeing (GROW) study

Research has rarely distinguished between non-work (NW) and work (W) active transport (AT) or investigated relationships to other domains of physical activity ([PA], like leisure time [LTPA] or work [WPA]). We investigated correlates of AT by employment status, accounting for LTPA and WPA, in a population-based sample of California mothers (N=2906) in the Geographic Research on Wellbeing (GROW) study (2012-2013). AT was measured by the National Household Travel Survey. LTPA was measured using the Stanford Leisure-Time Activity Categorical Item. WPA was measured with the Stanford Brief Activity Survey. Most employed mothers (53%) worked in sedentary jobs, and few (<10%) used NWAT or WAT. Over 20% of unemployed mothers used NWAT, although LTPA levels were similar to employed mothers. Multiple regression models found employed and unemployed with low education and income, and unemployed African American or Latina immigrant mothers had higher odds of using NWAT. Younger employed and unemployed mothers, and unemployed who had ≥4 children or had "light" LTPA had lower odds of using NWAT. Multiple regression models demonstrated that low education or income employed mothers, African American mothers, those who worked part time, and those with relatively low LTPA had higher odds of using WAT, while younger women had lower odds of using WAT, compared with reference groups (ps<0.05). WPA was associated with WAT in unadjusted models, but not in adjusted models. Different AT patterns were seen for employed vs unemployed women, but women who used AT did so for most trips. LTPA was associated with NWAT among unemployed mothers and with WAT among employed mothers. Most women were underactive across all domains, suggesting no compensatory effect of PA done in one domain reducing PA done in another domain, with few meeting minimal guidelines. Policy and practice strategies should support infrastructure to encourage a variety of domains of PA.

Early discharge following birth - What characterises mothers and newborns?

BACKGROUND

Early postnatal discharge has increased over the past 50 years and today we lack the knowledge on who is discharged early that would allow us to improve quality of postnatal care. The aim of this study was to describe maternal and infant predictors for early postnatal discharge in a country with equal access to health care.

METHODS

An observational study of 2786 mothers, recruited in pregnancy was conducted from April 2013 to August 2014 in four of the five regions in Denmark. Data were analysed using Kaplan-Meier method and multinomial regression models. Outcome variable was time of discharge after birth.

RESULTS

In total 34% mothers were discharged within 12 hours (very early) and 25% between 13 and 50 hours (early), respectively. Vaginal birth and multiparity were the most influential predictors, as Caesarean section compared to vaginal birth had an OR of 0.35 (CI 0.26-0.48) and primiparous compared to multiparous had an OR of 0.22 (CI 0.17-0.29) for early discharge. Other predictors for early discharge were: no induction of labour, no epidural painkiller, bleeding less than 500 ml during delivery, higher gestational age, early expected discharge and positive breastfeeding experience. Smoking, favourable social support and breastfeeding knowledge were significantly associated with discharge within 12 hours. Finally time of discharge varied significantly according to region and time of day of birth.

CONCLUSIONS

Parity and birth related factors were the strongest predictors of early discharge. Psycho-social predictors indicate that the parents are involved in the decision of when to be discharge.

Parent Language: A Predictor for Neurodevelopmental Follow-up Care Among Infants With Very Low Birth Weight

OBJECTIVE

Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.

METHODS

We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight <1500 g or gestational age ≤32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.

RESULTS

A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P = .008) and completed 8% more preventive visits (95% confidence interval 1-64, P = .019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.

CONCLUSIONS

Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

Social and Environmental Factors Related to Smoking Cessation among Mothers: Findings from the Geographic Research on Wellbeing (GROW) Study

OBJECTIVES

The current study examined associations between race/ethnicity and psychosocial/environmental factors with current smoking status, and whether psychosocial/environmental factors accounted for racial differences in smoking status in a population-based sample of mothers in California.

METHODS

Cross-sectional data from 542 women with a history of smoking were used. Analyses adjusted for age, partner status, and educational attainment.

RESULTS

In models adjusted for sociodemographics, black women had significantly lower odds, and Latina immigrants had significantly higher odds of being a former smoker compared to white women. Persons smoking in the home, having a majority of friends who smoke, having perceptions of their neighborhood as being somewhat or very unsafe, and experiencing food insecurity were associated with decreased odds of being a former smoker. When these variables were entered into a single model, only being a Latina immigrant and having a majority of friends who smoke were significantly associated with smoking status.

CONCLUSIONS

Black women demonstrated a notable disparity compared with white women in smoking status, accounted for by psychosocial/environmental factors. Immigrant Latinas demonstrated notable success in ever quitting smoking. Social networks may be important barriers to smoking cessation among women.

Individualized follow up programme and early discharge in term neonates

BACKGROUND

Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration.

METHODS

During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge.

RESULTS

During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%).

CONCLUSIONS

Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

Factors associated with timing of first outpatient visit after newborn hospital discharge

OBJECTIVE

To determine factors associated with newborns having their first outpatient visit (FOV) beyond 3 days after postpartum hospital discharge.

METHODS

Retrospective cohort analysis of all newborns born at a large urban university hospital during a 1-year period, discharged home within 96 hours of birth, and with an outpatient visit with an affiliated provider within 60 days after discharge.

RESULTS

Of 3282 newborns, 1440 (44%) had their FOV beyond 3 days after discharge. Newborns born to first-time mothers, breast-feeding, at high risk for hyperbilirubinemia, or with a pathological diagnosis were significantly (P < .05) less likely to have FOV beyond 3 days in adjusted multivariable analysis, while newborns born via Caesarian section, of older gestational age, with Medicaid insurance, or discharged on a Thursday or Friday were more likely to have FOV beyond 3 days. Discharging provider characteristics independently associated with FOV beyond 3 days included family medicine providers, providers out of residency longer, and providers practicing at the institution longer. In addition, practice of outpatient follow-up had an independent impact on timing of FOV. Having an appointment date and time recorded on the nursery record or first appointment with a home nurse decreased the odds that time to FOV was beyond 3 days of discharge.

CONCLUSIONS

Physician decisions regarding timing of outpatient visit after newborn discharge may take into account newborn medical and social characteristics, but certain patient, provider, and practice features associated with this timing may represent unrecognized barriers to care.

After Midnight: A Regression Discontinuity Design in Length of Postpartum Hospital Stays

Estimates of moral hazard in health insurance markets can be confounded by adverse selection. This paper considers a plausibly exogenous source of variation in insurance coverage for childbirth in California. We find that additional health insurance coverage induces substantial extensions in length of hospital stay for mother and newborn. However, remaining in the hospital longer has no effect on readmissions or mortality, and the estimates are precise. Our results suggest that for uncomplicated births, minimum insurance mandates incur substantial costs without detectable health benefits. (JEL D82, G22, I12, I18, J13)

Adherence to discharge guidelines for late-preterm newborns

OBJECTIVE

To evaluate trends in adherence to American Academy of Pediatrics recommendations for early discharge of late-preterm newborns and to test the association between hospital characteristics and early discharge.

PATIENTS AND METHODS

This study was a population-based cohort study using statewide birth-certificate and hospital-discharge data for newborns in California, Missouri, and Pennsylvania from 1993 to 2005. A total of 282 601 late-preterm newborns at 611 hospitals were included. Using logistic regression, we studied the association of early discharge with regional and hospital factors, including teaching affiliation, volume, and urban versus rural location, adjusting for patient factors.

RESULTS

From 1995 to 2000, early discharge decreased from 71% of the sample to 40%. However, by 2005, 39% were still discharged early. Compared with Pennsylvania, California (adjusted odds ratio [aOR]: 5.95 [95% confidence interval (CI): 5.03-7.04]), and Missouri (aOR: 1.56 [95% CI: 1.26-1.93]) were associated with increased early discharge. Nonteaching hospitals were more likely than teaching hospitals to discharge patients early if they were uninsured (aOR: 1.91 [95% CI: 1.35-2.69]) or in a health maintenance organization plan (aOR: 1.40 [95% CI: 1.06-1.84]) but not patients with fee-for-service insurance (aOR: 1.04 [95% CI: 0.80-1.34]). A similar trend for newborns on Medicaid was not statistically significant (aOR: 1.77 [95% CI: 0.95-3.30]).

CONCLUSIONS

Despite a decline in the late 1990s, early discharge of late-preterm newborns remains common. We observe differences according to state, hospital teaching affiliation, and patient insurance. Additional research on the safety and appropriateness of early discharge for this population is necessary.

Early postnatal hospital discharge: the consequences of reducing length of stay for women and newborns

The objective of this study is to examine the literature and identify most salient outcomes of early postnatal discharge for women, newborns and the health system. An electronic search strategy was designed including the following sources: Web of Science, Scopus, ProQuest and PubMed/MEDLINE, using the following terms: (early AND discharge) OR (length AND stay) AND (postpartum OR postnatal) AND (effect* OR result OR outcome). Content analysis was used to identify and summarise the findings and methods of the research papers. The evidence available is not enough to either reject or support the practice of early postnatal discharge; different studies have reported different outcomes for women and newborns. The need of systematic clinical research is discussed.

Father's education: an independent marker of risk for preterm birth

To explore the association between paternal education and preterm birth, taking into account maternal social and economic factors. We analyzed data from a population-based cross-sectional postpartum survey, linked with birth certificates, of women who gave birth in California from 1999 through 2005 (n = 21,712). Women whose infants' fathers had not completed college had significantly higher odds of preterm birth than women whose infants' fathers were college graduates, even after adjusting for maternal education and family income [OR (95% CI) = 1.26 (1.01-1.58)]. The effect of paternal education was greater among unmarried women than among married women. Paternal education may represent an important indicator of risk for preterm birth, reflecting social and/or economic factors not measured by maternal education or family income. Researchers and policy makers committed to understanding and reducing socioeconomic disparities in birth outcomes should consider paternal as well as maternal socioeconomic factors in their analyses and policy decisions.

Assignment to a hospital-based breastfeeding clinic and exclusive breastfeeding among immigrant Hispanic mothers: a randomized, controlled trial

A randomized controlled trial is used to determine whether assigning mixed feeders to a breastfeeding clinic within 1 week postpartum will increase exclusive breastfeeding at 1 month among Hispanic immigrants. Subjects are eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and 85% are monolingual Hispanic. Mothers (n = 522) of infants at low risk for hyperbilirubinemia are approached at bedside 20 to 48 hours after delivery and randomly assigned to treatment or control groups. Intent-to-treat analysis of feeding behavior at 4 weeks postpartum indicates that the intervention group is more likely to be exclusively breastfeeding (16.4% vs 10% in the control group, P = .03; adjusted odds ratio 1.87; 95% confidence interval, 1.07-3.26); that the incidence of formula supplementation does not differ between groups; and that the intervention group is less likely to supplement with water and tea (P < .002).

Maternal tobacco use and shorter newborn nursery stays

OBJECTIVE

Nationally, 10%-15% of women report smoking during the last 3 months of pregnancy. Because the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission) requires all U.S. hospitals to be smoke-free, and because tobacco is addictive, the maternal desire to smoke after childbirth could lead to requests for early hospital discharge for mothers and newborns. The authors hypothesized that maternal tobacco use would be associated with shorter newborn nursery hospital stays.

METHODS

Birth records from 405,622 singleton, "well" newborns, >or=35 weeks gestation born from 1998 to 2002 in Pennsylvania were merged with perinatal hospital record data and analyzed from 2006 to 2008. Perinatal data from 67,145 mothers self-reporting as having smoked cigarettes on the Certificate of Live Birth and data on their infants were compared 1:2 with data from mothers reporting to be nonsmokers and their infants via chi-square tests with odds ratios, 2-sample t-tests, and multiple linear regression.

RESULTS

In Pennsylvania, 16.6% of mothers smoked cigarettes during pregnancy. Tobacco-using mothers were more likely to be insured by Medicaid, unmarried, adolescent, not college educated, and have late onset of prenatal care. Their newborns were more likely to be low birth weight and be born at 35-36 weeks gestation. Nonetheless, these newborns had a significantly shorter mean length of stay (48.9 hours vs 52.4 hours; p<0.001), even after adjusting for confounders. A significant inverse relationship existed between number of cigarettes smoked per day by mothers and nursery length of stay for newborns.

CONCLUSIONS

Hospital smoking bans send a strong public health message regarding the risks of tobacco and protect patients and staff from secondhand smoke exposure. However, the association between maternal tobacco use and shorter newborn hospital stays may demonstrate an unintended consequence for the vulnerable population of newborns whose mothers smoke. This association should be considered during prenatal counseling, where smoking cessation can be emphasized, and at the time of mother and infant discharge. These findings are particularly important given the health and socioeconomic disparities between smoking mother-infant pairs and their nonsmoking counterparts.

Poverty, near-poverty, and hardship around the time of pregnancy

To describe income levels and the prevalence of major hardships among women during or just before pregnancy. We separately analyzed 2002-2006 population-based postpartum survey data from California's Maternal and Infant Health Assessment (n = 18,332) and 19 states participating in CDC's Pregnancy Risk Assessment Monitoring System (n = 143,452) to examine income and several hardships (divorce/separation, domestic violence, homelessness, financial difficulties, spouse/partner's or respondent's involuntary job loss or incarceration, and, in California only, food insecurity and no social support) during/just before pregnancy. In both samples, over 30% of women were poor (income </=100% of federal poverty level [FPL]) and 20% near-poor (101-200% FPL); and around 60% of low-income (poor or near-poor) women experienced at least one hardship. While hardship prevalence decreased significantly as income increased, many non-low-income women also experienced hardships; e.g., in California, 43% of all women and 13% with incomes >400% FPL experienced one or more hardships. These findings paint a disturbing picture of experiences around the time of pregnancy in the United States for many women giving birth and their children, particularly because 60% had previous births. The high prevalence of low income and of serious hardships during pregnancy is of concern, given previous research documenting the adverse health consequences of these experiences and recognition of pregnancy as a critical period for health throughout the life course. Low income and major hardships around the time of pregnancy should be addressed as mainstream U.S. maternal-infant health and social policy issues.

Urban women's socioeconomic status, health service needs and utilization in the four weeks after postpartum hospital discharge: findings of a Canadian cross-sectional survey

BACKGROUND

Postpartum women who experience socioeconomic disadvantage are at higher risk for poor health outcomes than more advantaged postpartum women, and may benefit from access to community based postpartum health services. This study examined socioeconomically disadvantaged (SED) postpartum women's health, and health service needs and utilization patterns in the first four weeks post hospital discharge, and compared them to more socioeconomically advantaged (SEA) postpartum women's health, health service needs and utilization patterns.

METHODS

Data collected as part of a large Ontario cross-sectional mother-infant survey were analyzed. Women (N = 1000) who had uncomplicated vaginal births of single 'at-term' infants at four hospitals in two large southern Ontario, Canada cities were stratified into SED and SEA groups based on income, social support and a universally administered hospital postpartum risk screen. Participants completed a self-administered questionnaire before hospital discharge and a telephone interview four weeks after discharge. Main outcome measures were self-reported health status, symptoms of postpartum depression, postpartum service needs and health service use.

RESULTS

When compared to the SEA women, the SED women were more likely to be discharged from hospital within the first 24 hours after giving birth [OR 1.49, 95% CI (1.01-2.18)], less likely to report very good or excellent health [OR 0.48, 95% CI (0.35-0.67)], and had higher rates of symptoms of postpartum depression [OR 2.7, 95% CI(1.64-4.4)]. No differences were found between groups in relation to self reported need for and ability to access services for physical and mental health needs, or in use of physicians, walk-in clinics and emergency departments. The SED group were more likely to accept public health nurse home visits [OR 2.24, 95% CI(1.47-3.40)].

CONCLUSION

Although SED women experienced poorer mental and overall health they reported similar health service needs and utilization patterns to more SEA women. The results can assist policy makers, health service planners and providers to develop and implement necessary and accessible services. Further research is needed to evaluate SED postpartum women's health service needs and barriers to service use.

The impact of early discharge laws on the health of newborns

Using an interrupted time series design and a census of births in California over a 6-year period, we show that state and federal laws passed in the late 1990s designed to increase the length of postpartum hospital stays reduced considerably the fraction of newborns that were discharged early. The law had little impact on re-admission rates for privately insured, vaginally delivered newborns, but reduced re-admission rates for privately insured c-section-delivered and Medicaid-insured vaginally delivered newborns by statistically significant amounts. Our calculations suggest the program was not cost saving.

Readmission for neonatal jaundice in California, 1991-2000: trends and implications

OBJECTIVE

We sought to describe population-based trends, potential risk factors, and hospital costs of readmission for jaundice for term and late preterm infants.

METHODS

Birth-cohort data were obtained from the California Office of Statewide Health Planning and Development and contained infant vital statistics data linked to infant and maternal hospital discharge summaries. The study population was limited to healthy, routinely discharged infants through the use of multiple exclusion criteria. All linked readmissions occurred within 14 days of birth. International Classification of Diseases, Ninth Revision, codes were used to further limit the sample to readmission for jaundice. Hospital discharge records were the source of diagnoses, hospital charges, and length-of-stay information. Hospital costs were estimated using hospital-specific ratios of costs to charges and adjusted to 1991.

RESULTS

Readmission rates for jaundice generally rose after 1994 and peaked in 1998 at 11.34 per 1000. The readmission rate for late preterm infants (as a share of all infants) over the study period remained at <2 per 1000. Factors associated with increased likelihood of hospital readmission for jaundice included gestational age 34 to 39 weeks, birth weight of <2500 g, male gender, Medicaid or private insurance, and Asian race. Factors associated with a decreased likelihood of readmission for jaundice were cesarean section delivery and black race. The mean cost of readmission for all infants was $2764, with a median cost of $1594.

CONCLUSIONS

Risk-adjusted readmission rates for jaundice rose following the 1994 hyperbilirubinemia guidelines and declined after postpartum length-of-stay legislation in 1998. In 2000, the readmission rate remained 6% higher than in 1991. These findings highlight the complex relationship among newborn physiology, socioeconomics, race or ethnicity, public policy, clinical guidelines, and physician practice. These trend data provide the necessary baseline to study whether revised guidelines will change practice patterns or improve outcomes. Cost data also provide a break-even point for prevention strategies.

Potential implications of missing income data in population-based surveys: an example from a postpartum survey in California

OBJECTIVES

Income data are often missing for substantial proportions of survey participants and these records are often dropped from analyses. To explore the implications of excluding records with missing income, we examined characteristics of survey participants with and without income information.

METHODS

Using statewide population-based postpartum survey data from the California Maternal and Infant Health Assessment, we compared the age, education, parity, marital status, timely prenatal care initiation, and neighborhood poverty characteristics of women with and without reported income data, overall, and by race/ethnicity/nativity.

RESULTS

Overall, compared with respondents who reported income, respondents with missing income information generally appeared younger, less educated, and of lower parity. They were more likely to be unmarried, to have received delayed or no prenatal care, and to reside in poor neighborhoods; and they generally appeared more similar to lower- than higher-income women. However, the patterns appeared to vary by racial/ethnic/nativity group. For example, among U.S.-born African American women, the characteristics of the missing-income group were generally similar to those of low-income women, while European American women with missing income information more closely resembled their moderate-income counterparts.

CONCLUSIONS

Respondents with missing income information may not be a random subset of population-based survey participants and may differ on other relevant sociodemographic characteristics. Before deciding how to deal analytically with missing income information, researchers should examine relevant characteristics and consider how different approaches could affect study findings. Particularly for ethnically diverse populations, we recommend including a missing income category or employing multiple-imputation techniques rather than excluding those records.

Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project

OBJECTIVE

The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization.

METHODS

All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital.

RESULTS

Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of > or = 20% in > or = 1 newborn preventive service.

CONCLUSIONS

A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.

Perinatal Disparities for Black Mothers and Their Newborns

OBJECTIVES

In the United States, significant ethnic and racial health and healthcare disparities exist among our most vulnerable populations, new mothers and newborns. We sought to determine disparities in socioeconomic status, perinatal health, and perinatal healthcare for black mothers and their newborns cared for in well-baby nurseries compared with white mother/baby pairs in Pennsylvania.

METHODS

A retrospective analysis of a merged data set containing birth and clinical discharge records was conducted. Perinatal data from 44,105 black mothers and their singleton newborns, > or = 35 weeks gestational age cared for in Pennsylvania well-baby nurseries from 1998-2002 were compared with 88,210 white mother/baby pairs.

RESULTS

Black mothers were younger and were much more likely to receive Medicaid or be uninsured compared with white mothers. They were less likely to be college-educated, married, or have prenatal care beginning in the first trimester. Infants born to black mothers were less likely to be delivered via Cesarean section, but were more likely to be born between 35 and 38 weeks gestation and be of low birth weight.

CONCLUSIONS

Numerous significant disparities exist for black mothers and their newborns cared for in well-baby nurseries in Pennsylvania. Since most newborns are cared for in this setting as opposed to intensive care environments, recognition of the differences that exist for this group when compared to well newborns of white mothers can help to improve healthcare and its delivery to this population. Federal and local initiatives must continue efforts to eliminate racial disparities.

Mothers’ and fathers’ lateral biases for holding their newborn infants: A study of images from the World Wide Web

Photographic and direct-observation studies show that most adults hold infants on the left side. This basic directional effect is well established, but other details are still uncorroborated, uncertain, or inconsistent across studies. These include the overall strength of the bias, the role of the sex, parental status, and experience of the holder, and the sex and age of the infant. Given their importance for understanding the bias, we sought further information from a large sample of photographs of mothers and fathers, some of them first-time parents, others not, holding their infants in the first minutes, hours, or days after birth. The results confirmed the basic directional effect and provided information on the other variables. They also raise questions for further research, especially as it pertains to the use of photographs vs direct observation.

Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act

BACKGROUND

Congress passed the Newborns' and Mothers' Health Protection Act in 1996, reversing the trend of shorter newborn nursery lengths of stay. Hope existed that morbidities would lessen for this vulnerable population, but some reports indicate that the timeliness and quality of postdischarge care may have worsened in recent years.

OBJECTIVE

Our goal was to determine risk factors for the potentially preventable readmissions because of jaundice, dehydration, or feeding difficulties in the first 10 days of life in Pennsylvania since passage of the Newborns' and Mothers' Health Protection Act.

PATIENTS AND METHODS

Birth records from 407,826 newborns > or = 35 weeks' gestation from 1998 to 2002 were merged with clinical discharge records. A total of 2540 newborns rehospitalized for jaundice, dehydration, or feeding difficulties in the first 10 days of life were then compared with 5080 control infants. Predictors of readmission were identified by using multiple logistic regression analysis.

RESULTS

An unadjusted comparison of baseline characteristics revealed numerous predictors of readmission. Subsequent adjusted analysis revealed that Asian mothers, those 30 years of age or older, nonsmokers, and first-time mothers were more likely to have a readmitted newborn, as were those with diabetes and pregnancy-induced hypertension. For neonates, female gender and delivery via cesarean section were protective for readmission, whereas vacuum-assisted delivery, gestational age < 37 weeks, and nursery length of stay < 72 hours were predictors of readmission in the first 10 days of life.

CONCLUSIONS

Although readmissions for jaundice, dehydration, and feeding difficulties may be less common for some minority groups and Medicaid recipients in the era of the Newborns' and Mothers' Health Protection Act compared with nonminorities or privately insured patients, several predictors of newborn readmission have established associations with inexperienced parenting and/or breastfeeding difficulty. This is one indication that this well-intentioned legislation and current practice may not be sufficiently protecting the health of newborns and suggests that additional support for mothers and newborns during the vulnerable postdelivery period may be indicated.

State-mandated benefit review laws

OBJECTIVE

To determine which states have laws that require the review of mandated health insurance benefits and describe the various approaches states take in reviewing mandated benefits, as stated in the mandated benefit review (MBR) laws.

DATA SOURCES

We queried online databases of the individual state statutes and reviewed the state statutes and state legislative agendas for all 50 states and Washington, DC to identify those states with active MBR laws as of September 2004.

STUDY DESIGN

We reviewed the identified MBR laws to catalog their various components. The components chosen for this analysis include: general review strategy, designated reviewers, time frame for conducting reviews, criteria used in the review, requirements to use actuaries, sources of funding, and state data collection systems. Two of the authors independently created analysis categories and coded the MBR laws to document details on the major components of the laws.

PRINCIPAL FINDINGS

We identified 26 state MBR laws active as of September 2004. A majority of the MBR laws specified a prospective review approach and only one law used an exclusively retrospective review approach. A substantial amount of variation was found with regards to the designated reviewers, time frames for conducting reviews, and criteria used in the review. Few states specified the use of actuaries, sources of funding, and state data collection systems.

CONCLUSIONS

The number of states that have enacted MBR laws has increased substantially in recent years, however, different states have structured the review of mandated benefits differently, according to the values and perceived needs of the state legislatures. It is important that states increasingly consider a broader scope of review criteria so state decision makers can position themselves to mandate only those benefits that add real value to the state's health care system.

Preserving Breastfeeding for the Rehospitalized Infant

The benefits of feeding newborns with human milk are well established. Unfortunately some hospital practices do not support successful breastfeeding; practices such as early hospital discharge after birth, lack of appropriate follow-up primary care providers, and lack of access to breastfeeding support services can contribute to breastfeeding failure, as well as morbidity and mortality in the infant. Infants experiencing breastfeeding difficulties are sometimes admitted to the hospital with diagnoses such as hyperbilirubinemia/jaundice, dehydration/hypernatremia, rule out sepsis, and weight loss/failure to thrive. This article describes a clinical pathway developed with the express purpose of maintaining and enhancing lactation in mother-infant dyads experiencing breastfeeding difficulties. The goal of the pathway is to maintain lactation and breastfeeding while returning the infant to a state of health. A key focus of the pathway is milk transfer, a concept that is missing from much of the research on lactation difficulties. The pathway considers breastfeeding from both a maternal and an infant perspective, with a goal of preserving breastfeeding. It uses technology to support the breastfeeding process and could be useful for all practitioners working with mother-infant dyads experiencing breastfeeding difficulties.

A comparison of morbidity rates attributable to conditions originating in the perinatal period among newborns discharged from United States hospitals, 1989-90 and 1999-2000

Perinatal conditions account for 60% of US neonatal deaths, yet little is known about rates of morbidity attributable to these conditions. To estimate these rates, we analysed newborn hospital discharges from the National Hospital Discharge Survey. We used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to classify discharge diagnoses among a weighted, nationally representative sample of newborns discharged from short-stay, non-federal US hospitals. We compared overall and cause-specific morbidity rates attributable to perinatal conditions (ICD-9-CM 760.0-779.9), as well as the average length of hospital stay among newborn discharges during 1989-90 and 1999-2000. The overall newborn morbidity rate declined from 36.3% in 1989-90 to 33.7% in 1999-2000 (P < 0.01), despite significant increases in high-risk births. The decline can be attributed to significant decreases in the reported rates of jaundice, fetal distress, birth trauma and birth asphyxia. Rates of jaundice decreased from 15.7% to 13.4% (P < 0.01). The average length of stay decreased among newborns with no morbid condition (2.37-2.04 days, P < 0.001) and among those with one perinatal condition (3.11-2.51, P < 0.001), but increased among those with multiple perinatal conditions (8.43-9.98, P < 0.05). Morbidity rates among newborns discharged from US hospitals declined. Shorter newborn hospital stays may have resulted in fewer cases of jaundice being diagnosed before discharge. Stricter diagnostic criteria and changes in obstetric practices may have led to a decline in the rates of fetal distress, birth trauma and birth asphyxia.

Early postnatal care among healthy newborns in 19 States: pregnancy risk assessment monitoring system, 2000

OBJECTIVE

To examine early postnatal care among healthy newborns during 2000 in 19 states.

METHODS

Using data from the Pregnancy Risk Assessment Monitoring System, a multistate population-based postpartum survey of women, we calculated prevalences of early discharge (ED; stays of < or =2 days after vaginal delivery and < or =4 days after Cesarean delivery) and early follow-up (within 1 week) after ED. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) describing how ED and lack of early follow-up were associated with state legislation and maternal characteristics.

RESULTS

While most healthy term newborns (83.5-93.4%) were discharged early, and most early-discharged newborns (51.5-88.5%) received recommended early follow-up, substantial proportions of early-discharged newborns did not. Compared with newborns in states where legislation covered both length of hospital stay (LOS) and follow-up, newborns in states without such legislation were more likely to have ED (aOR: 1.25; CI: 1.01-1.56). Lack of early follow-up was more likely among newborns in states with neither LOS nor follow-up legislation (aOR: 2.70, CI: 2.32-3.14), and only LOS legislation (aOR: 1.38, CI: 1.22-1.56) compared with those in states with legislation for both. ED was more likely among newborns born to multiparous women and those delivered by Cesarean section and less likely among those born to black and Hispanic mothers and mothers with less education.

CONCLUSIONS

Lack of early follow-up among ED newborns remains a problem, particularly in states without relevant legislation. These findings indicate the need for continued monitoring and for programmatic and policy strategies to improve receipt of recommended care.

Medicaid acceptance and availability of timely follow-up for newborns with Medicaid

OBJECTIVE

Decreased physician participation in Medicaid has been shown to affect adversely timeliness of adult acute care and pediatric specialty care, but it is not clear whether this is the case for newborn follow-up. The objectives of this study were to determine whether there is a difference within clinics in the timeliness of follow-up appointments that are given to newborns with Medicaid compared with newborns with private insurance and to determine whether there is a difference between clinics that do and do not accept Medicaid in the timeliness of appointments that are given for newborn follow-up.

METHODS

A randomized crossover study was conducted among general pediatric clinics and practices that were identified from the yellow pages and Internet searches of hospitals and health departments in 8 metropolitan areas from September 2003 to March 2004. A simulated parent telephoned clinics to find the earliest available appointment for a 1-day-old infant who needed routine follow-up after discharge that day. Clinics were randomly assigned to receive a first call from a patient with either Medicaid or private insurance; each clinic received the same call at least 3 weeks later with the patient's insurance status reversed. The main outcome measure was whether the appointment was timely (< or =2 days from the day of the call).

RESULTS

Of 401 participating clinics, 22% did not accept Medicaid. Among clinics that accepted Medicaid, availability of a timely appointment for a newborn with Medicaid was similar to that for a newborn with private insurance (87% vs 90%, respectively). Appointments that were provided to privately insured newborns were as likely to be timely in clinics that accept Medicaid as in clinics that do not accept Medicaid (89.5% vs 93.4%, respectively). However, providing timely appointments was significantly less likely in clinics that were in high-poverty locations compared with clinics that were not (86.1% vs 92.7%, respectively).

CONCLUSIONS

Although newborns with Medicaid did not have access to >20% of clinics because of their insurance, among clinics that did accept Medicaid, timeliness of available follow-up was similar for newborns with Medicaid compared with newborns with private insurance and similar between clinics that did and did not accept Medicaid. However, to the extent that care for newborns with Medicaid is concentrated in clinics in high-poverty areas, some newborns with Medicaid may not be able to receive timely appointments.

Longer postpartum hospitalization options--who stays, who leaves, what changes?

BACKGROUND

This paper examines the practice implications of a policy initiative, namely, offering women in Ontario Canada up to a 60-hour postpartum in-hospital stay following an uncomplicated vaginal delivery. This change was initiated out of concern for the effects of 'early' discharge on the health of mothers and their infants. We examined who was offered and who accepted extended stays, to determine what factors were associated with the offer and acceptance of this option, and the impact that these decisions had on post-discharge health status and service utilization of mothers and infants.

METHODS

The data reported here came from two related studies of health outcomes and service utilization of mothers and infants. Data were collected from newly delivered mothers who had uncomplicated vaginal deliveries. Questionnaires prior to discharge and structured telephone interviews at 4-weeks post discharge were used to collect data before and after policy implementation. Qualitative data were collected using focus groups with hospital and community-based health care managers and providers at each site. For both studies, samples were drawn from the same five purposefully selected hospitals. Further analysis compared postpartum health outcomes and post discharge service utilization of women and infants before and after the practice change.

RESULTS

Average length of stay (LOS) increased marginally. There was a significant reduction in stays of <24 hours. The offer of up to a 60-hour LOS was dependent upon the hospital site, having a family physician, and maternal ethnicity. Acceptance of a 60-hour LOS was more likely if the baby had a post-delivery medical problem, it was the woman's first live birth, the mother identified two or more unmet learning needs in hospital, or the mother was unsure about her own readiness for discharge. Mother and infant health status in the first 4 weeks after discharge were unchanged following introduction of the extended stay option. Infant service use also was unchanged but rate of maternal readmission to hospital increased and mothers' use of community physicians and emergency rooms decreased.

CONCLUSION

This research demonstrates that this policy change was selectively implemented depending upon both institutional and maternal factors. LOS marginally increased overall with a significant decrease in <24-hour stays. Neither health outcomes nor service utilization changed for infants. Women's health outcomes remained unchanged but service utilization patterns changed.

An approach to studying social disparities in health and health care

OBJECTIVE

We explored methods and potential applications of a systematic approach to studying and monitoring social disparities in health and health care.

METHODS

Using delayed or no prenatal care as an example indicator, we (1) categorized women into groups with different levels of underlying social advantage; (2) described and graphically displayed rates of the indicator and relative group size for each social group; (3) identified and measured disparities, calculating relative risks and rate differences to compare each group with its a priori most-advantaged counterpart; (4) examined changes in rates and disparities over time; and (5) conducted multivariate analyses for the overall sample and "at-risk" groups to identify particular factors warranting attention.

RESULTS

We identified at-risk groups and relevant factors and suggest ways to direct efforts for reducing prenatal care disparities.

CONCLUSIONS

This systematic approach should be useful for studying and monitoring disparities in other indicators of health and health care.

National Institute of Child Health and Human Development (NICHD) conference on kernicterus: a population perspective on prevention of kernicterus

This paper reviews barriers to the prevention of kernicterus. Reports of kernicterus cases persist. We do not know why kernicterus continues to occur or how best to prevent it. We need evidence for key recommendations that make clinical guidelines usable by practitioners caring for newborns, especially for practitioners providing ambulatory care in the first week of life. Data on prevalence and incidence, mortality and morbidity are essential for launching a kernicterus public health campaign. Modeling cost-effectiveness requires data on costs and benefits of alternative strategies for managing hyperbilirubinemia and preventing kernicterus and on parental preferences concerning follow-up in the first days of life. Understanding how existing patterns of care obstruct preventive care involves exploration of the roles of clinicians, health-care organizations, parents, and payers and purchasers of health care. Lastly, discovering how to motivate change in existing practices can provide the guidance needed to prevent kernicterus in the US.

Does making newborn follow-up appointments from the hospital improve compliance?

OBJECTIVE

To test a system of arranging the first newborn follow-up appointments made from the hospital prior to discharge.

METHODS

Prospective randomized study of 328 term healthy newborns divided into control and intervention groups. As there were multiple practices, we checked for clustering in the two groups and then compared them for patient compliance with the first newborn appointment. We also compared the control and intervention groups for compliance with regard to insurance status.

RESULTS

There was difference between the control and intervention group in timeliness for the first appointment (control, 84.9%, intervention group, 94.2%, p=0.0062). There was also improvement in privately insured patients (control 89.1%, intervention 96.5%, p=0.0263), as well as in Medicaid+noninsured patients (control 64.7%, intervention 90.2%, p=0.0245).

DISCUSSION

We conclude that arranging for follow-up appointments from the hospital is a worthwhile inexpensive intervention that could significantly improve patient compliance with the first newborn visit.

Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants

OBJECTIVE

There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: (1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, (2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and (3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing.

METHODS

We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2,800000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice.

RESULTS

With the base-case assumptions (current incidence of kernicterus 1:100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was 10,321463 dollars, 5,743905 dollars, and 9,191352 dollars respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively, 202,300671 dollars, 112,580535 dollars, and 180,150494 dollars. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of 46,179465 dollars for the cohort would result with strategy 2, if the incidence of kernicterus is high (1:10,000 births or higher) and the RRR is high (> or =0.7). If the incidence is lower or the RRR is lower, then the cost per case prevented ranged from 4,145676 dollars to as high as 77,650240 dollars.

CONCLUSIONS

Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale. However, universal follow-up may have benefits beyond kernicterus prevention, which we did not include in our model. Research is required to determine the epidemiology, risk factors, and causes of kernicterus; to evaluate the effectiveness of strategies intended to prevent kernicterus; and to determine the cost per quality-adjusted life year with any proposed preventive strategy.

Cost-effectiveness of postnatal home nursing visits for prevention of hospital care for jaundice and dehydration

OBJECTIVES

(1) To describe the relationship between postnatal home nursing visitation and readmissions and emergency department (ED) visits for neonatal jaundice and dehydration in the first 10 days of life. (2) To evaluate the cost-effectiveness of providing home nursing visits after newborn discharge with specific attention to prevention of jaundice and dehydration that require hospital-based services.

METHODS

A retrospective analysis of a financial database allowed for review of the discharge disposition and subsequent care for all neonates who were born at a single center from January 2000 through December 2002. Financial data reflect reimbursement values and costs of care from the payers' perspective at the single center. We performed a deterministic cost-effectiveness analysis using a decision tree that reflected the costs and probabilities of infants in each particular health state after nursery discharge.

RESULTS

A total of 73 (2.8%) of 2641 newborns who did not receive a home visit were readmitted to the hospital in the first 10 days of life with jaundice and/or dehydration compared with 2 (0.6%) of 326 who did receive a home visit. Similarly, 92 (3.5%) of 2641 newborns who were discharged without subsequent home nursing care had an ED visit for these reasons in the first 10 days of life compared with 0 (0%) of 326 who did have such a visit. Of infants who received a home visit, 324 (99.4%) of 326 did not require subsequent hospital services in this time period compared with 2497 (94.5%) of 2641 of those who did not receive a visit. After nursery discharge, the average cost per child who received a home health visit was 109.80 dollars compared with 118.70 dollars for each newborn who did not receive a visit. The incremental cost-effectiveness ratio of a routine home visit strategy compared with a no visit strategy was -181.82 dollars.

CONCLUSIONS

A home nursing visit after newborn nursery discharge is highly cost-effective for reducing the need for subsequent hospital-based services.

Impact of early newborn discharge legislation and early follow-up visits on infant outcomes in a state Medicaid population

OBJECTIVE

Scant information exists on the effects of legislation mandating coverage of minimum postnatal hospital stays on infant health outcomes. There are also gaps in knowledge regarding the effectiveness of early follow-up visits for newborns. The objective of this study was to determine the impact of 1) legislation mandating coverage of minimum postnatal hospital stays and 2) early follow-up visits by the age of 4 days on infant outcomes during the first month of life.

METHODS

A retrospective analysis was conducted of Ohio Medicaid claims data linked with birth certificate data for the period 1991-1998. The impact of the legislation was evaluated using interrupted time-series analysis of health-related utilization. The effects of early follow-up visits for vaginally delivered newborns with short stays were analyzed using the day of the week on which the birth occurred (eg, Monday, Tuesday) as an instrumental variable to account for potential confounding. A total of 155,352 full-term newborns who were born to mothers who receive Medicaid were studied. The main outcomes measured were rehospitalizations, emergency department (ED) visits, and diagnoses of dehydration and infection within 10 and 21 days of birth.

RESULTS

Few outcomes exhibited significant changes after legislation mandating coverage of minimum postnatal hospital stays. Rates of rehospitalization for jaundice within 10 days of birth fell from 0.78% to 0.47% in the year after legislation was introduced but leveled off after the legislation took effect. Rates of ED visits within 21 days increased from 6.0% to 10.4% during periods of increasing short stay but fell to 8.0% during the year after introduction of the legislation and leveled off when the legislation took effect. Rates of all-cause rehospitalization, dehydration, and infection diagnoses showed no consistent relationship to Ohio's legislation. Using instrumental variable analysis, newborns who received early follow-up visits were significantly less likely to have rehospitalizations within the first 10 days of life than those who did not.

CONCLUSIONS

In this state Medicaid population, legislation mandating coverage of minimum postnatal hospital stays was associated with reductions in the rates of rehospitalization for jaundice and ED visits. For newborns with short stays, early follow-up visits may reduce rehospitalizations in the early postpartum period.

Does postpartum length of stay affect breastfeeding duration? A population-based study

BACKGROUND

Short postpartum hospital stays may leave inadequate time for women to receive assistance with breastfeeding. Women leaving the hospital early may also have household responsibilities that could interfere with breastfeeding. This study examined the relationship between postpartum length of stay and breastfeeding cessation.

METHODS

This study used data from 10,519 respondents to the California Maternal and Infant Health Assessment (MIHA) surveys from 1999 to 2001. MIHA is an annual statewide stratified random sample, population-based study of childbearing women in California. Survival analysis was used to examine the relationship between length of stay and length of time breastfeeding. Women were asked about the number of nights their infant stayed in the hospital at birth, whether they breastfed, and if so, the age of the child when they stopped. Hospital stay was defined in three categories: standard (2 nights for a vaginal delivery, 4 nights for a cesarean section), or shorter or longer than the standard stay.

RESULTS

Approximately 88 percent of women initiated breastfeeding. Unadjusted predictors of breastfeeding cessation included short or long postpartum stay; young maternal age; Hispanic, African American, or Asian/Pacific Islander race/ethnicity; being unmarried; low income or education level; primiparity; being born in the 50 United States or the District of Columbia; smoking during pregnancy; and low infant birthweight. After adjustment for potential confounders, women with a short stay remained slightly more likely to terminate breastfeeding than women with a standard stay (relative risk, 1.11, 95% confidence interval 1.01, 1.23).

CONCLUSION

Women who leave the hospital earlier than the standard recommended stay are at somewhat increased risk of terminating breastfeeding early.

Infant sleep position: associated maternal and infant factors

OBJECTIVE

To determine the maternal and infant characteristics associated with the back sleep position for infants to guide efforts to increase its use and reduce the risk of Sudden Infant Death Syndrome.

METHODS

Cross-sectional survey of 3349 mothers delivering in California, February-May 1999.

RESULTS

Fifty-two percent of infants were placed in the back sleep position. Factors associated with a lower likelihood of using the back position included all levels of maternal education less than college (eg, for education eighth grade or less--adjusted odds ratio [OR] 0.59; 95% confidence interval [CI], 0.40-0.86); income at or below federal poverty level (OR, 0.65; 95% CI, 0.47-0.90); multiparity (OR, 0.80; 95% CI, 0.67-0.95); race/ethnicity African American (OR, 0.49; 95% CI, 0.37-0.65) and Asian/Pacific Islander (OR, 0.65; 95% CI, 0.48-0.89); speaking a non-English language (OR, 0.69; 95% CI, 0.55, 0.86); and infant age over 7 months (OR, 0.70, 95% CI, 0.52-0.96). Women in Los Angeles (OR, 0.57; 95% CI, 0.42-0.77) and urban areas other than San Diego (OR, 0.70; 95% CI, 0.53-0.92) were less likely to use the back position than those in San Francisco.

CONCLUSIONS

Greater efforts are needed to promote the back sleep position among families with mothers who lack education beyond some college; live in poverty; and who are African American, Asian/Pacific Islander, multiparous, or non-English speaking.