A Randomized Comparison of Home and Clinic Follow-Up Visits After Early Postpartum Hospital Discharge

University of California, San Francisco, San Francisco, California, United States
PEDIATRICS (Impact Factor: 5.47). 06/2000; 105(5):1058-65. DOI: 10.1542/peds.105.5.1058
Source: PubMed

ABSTRACT Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up visit on the third or fourth postpartum day, but scant evidence exists about whether home or clinic visits are more effective.
We enrolled 1163 medically and socially low-risk mother-newborn pairs with uncomplicated delivery and randomly assigned them to receive home visits by nurses or pediatric clinic visits by nurse practitioners or physicians on the third or fourth postpartum day. In contrast with the 20-minute pediatric clinic visits, the home visits were longer (median: 70 minutes), included preventive counseling about the home environment, and included a physical examination of the mother. Clinical utilization and costs were studied using computerized databases. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks' postpartum.
Comparing the 580 pairs in the home visit group and the 583 pairs in the pediatric clinic visit group, no significant differences occurred in clinical outcomes as measured by maternal or newborn rehospitalization within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interview. The same was true for a combined clinical outcome measure indicating whether a mother-newborn pair had any of the above outcomes. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs 44%), the provider's skills and abilities (87% vs 63%), the newborn's posthospital care (87% vs 59%), and their own posthospital care (75% vs 47%). On average, a home visit cost $255 and a pediatric clinic visit cost $120.
For low-risk mothers and newborns in this integrated health maintenance organization, home visits compared with pediatric clinic visits on the third or fourth postpartum hospital day were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction. This study had limited power to identify group differences in rehospitalization, and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

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    • " ( 0 . 81 , 1 . 64 ) 0 . 76 ( 0 . 52 , 1 . 11 ) 0 . 97 ( 0 . 68 , 1 . 38 ) 1 . 00 ( 0 . 65 , 1 . 55 ) Cesarean section 1 . 37 ( 1 . 01 , 1 . 85 ) 0 . 80 ( 0 . 56 , 1 . 15 ) 1 . 56 ( 1 . 05 , 2 . 31 ) 0 . 62 ( 0 . 43 , 0 . 88 ) 1 . 86 ( 1 . 16 , 2 . 98 ) V . J . Flaherman et al . 6 improve breastfeeding ( Lieu et al . 2000 ; Porteous et al . 2000 ; Escobar et al . 2001 ; Dennis et al . 2002 ; Chapman et al . 2004 ; Graffy et al . 2004 ; Bonuck et al . 2005 ; Coutinho et al . 2005 ; Anderson et al . 2007"
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    ABSTRACT: Milk supply concern is the most common reason for breastfeeding discontinuation and maternal anxiety is also associated with reduced breastfeeding duration. Newborn excess weight loss (EWL) could trigger milk supply concern and anxiety and might be amenable to modification. Our objective was to determine the relationship between EWL and the development of milk supply concern and anxiety and the effect of such development on breastfeeding duration. We conducted a cohort analysis using data previously obtained from a randomised controlled trial comparing two post-hospital discharge follow-up strategies. For 1107 well, singleton infants born at ≥34 weeks, we extracted data on all inpatient infant weights. EWL was defined as the loss of ≥10% of birthweight. We surveyed mothers to obtain data on state anxiety and milk supply concern at birth and at 2 weeks. Our final outcome was breastfeeding at 6 months. Seventy (6.3%) infants developed EWL during the birth hospitalisation. At 2 weeks, milk supply concern and positive anxiety screen were more common (42% and 18%, respectively) among mothers whose infants had had EWL than among mothers whose infants had not had EWL (20% and 6%, respectively) (P < 0.001 for each comparison). Mothers with milk supply concern at 2 weeks were much less likely to be breastfeeding at 6 months, with odds ratio of 0.47 (0.30, 0.74) in multivariate analysis. EWL may increase milk supply concern and anxiety and these may reduce breastfeeding duration. Ameliorating EWL might alleviate milk supply concern and anxiety and improve breastfeeding duration. © 2015 John Wiley & Sons Ltd.
    Maternal and Child Nutrition 03/2015; DOI:10.1111/mcn.12171 · 3.06 Impact Factor
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    • "Domiciliary visits may be one of the best ways of giving individualised care [48-50]. Two studies from California [49,50] showed that, for low-risk mothers and newborns, home visits compared with hospital-based follow-up were associated with equivalent clinical outcomes and higher maternal satisfaction, although home visits were more costly. "
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    ABSTRACT: Women's evaluation of hospital postpartum care has consistently been more negative than their assessment of other types of maternity care. The need to further explore what is wrong with postpartum care, in order to stimulate changes and improvements, has been stressed. The principal aim of this study was to describe women's negative experiences of hospital postpartum care, expressed in their own words. Characteristics of the women who spontaneously gave negative comments about postpartum care were compared with those who did not. Data were taken from a population-based prospective longitudinal study of 2783 Swedish-speaking women surveyed at three time points: in early pregnancy, at two months, and at one year postpartum. At the end of the two follow-up questionnaires, women were asked to add any comment they wished. Content analysis of their statements was performed. Altogether 150 women gave negative comments about postpartum care, and this sample was largely representative of the total population-based cohort. The women gave a diverse and detailed description of their experiences, for instance about lack of opportunity to rest and recover, difficulty in getting individualised information and breastfeeding support, and appropriate symptom management. The different statements were summarised in six categories: organisation and environment, staff attitudes and behaviour, breastfeeding support, information, the role of the father and attention to the mother. The findings of this study underline the need to further discuss and specify the aims of postpartum care. The challenge of providing high-quality follow-up after childbirth is discussed in the light of a development characterised by a continuous reduction in the length of hospital stay, in combination with increasing public demands for information and individualised care.
    BMC Health Services Research 02/2007; 7(178):178. DOI:10.1186/1472-6963-7-178 · 1.71 Impact Factor
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    • "An economic evaluation in the UK in which early discharge combined with home midwifery support was compared with traditional postnatal hospital stay of 4-5 days found that the early discharge program significantly reduced costs without compromising the health and well-being of the mother and infant (Petrou et al., 2004). A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge in California, USA, showed that for low-risk mothers and newborns home visits were more costly, but were associated with equivalent clinical outcomes and markedly higher maternal satisfaction (Lieu et al., 2000). Finally, in the Canadian study Watt et al. (2005) conclude that neither health outcomes nor economies in service utilization were found to provide justification for an extended postpartum hospital stay for healthy women and infants. "
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    ABSTRACT: The overall aim of postpartum care is to detect health problems of the mother and/or baby at an early stage, to encourage breastfeeding and to give families a good start. This paper presents an overview of recent literature about postpartum care in several developed countries and elaborates on the Dutch model, which consists of professional postnatal care, provided by MCAs (maternity care assistants), who are supervised by midwives. The most important tasks of the maternity care assistant are, by becoming part of the family for a number of hours each day, being able to detect possible health problems, and to instruct, observe, and support the mother (and father) in establishing a new routine in their family life and help them to become confident in their parenting. (aut.ref.)
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