MJA: Buist, Counting the costs of early discharge after childbirth

Counting the costs of early discharge after childbirth

Home may not be where the help is . . .

MJA 1997; 167: 236-237

Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>".

Make a comment - Register to be notified of new articles by e-mail - Current contents list - ©MJA1997

Overmedicalisation of birth has been a frequent criticism of obstetric practice,¹ and, in response to this, early-discharge programs have been endorsed by health professionals and users.² Evaluation of these programs has been largely positive, but has relied on the choice for early discharge being made by the woman rather than being determined by extraneous factors.^2,3

One of the more unfortunate consequences of casemix funding has been the promotion of cost-effectiveness at the expense of choice in Australia; 32% of mothers were discharged less than four days after delivery in 1994, compared with 20.2% in 1991.⁴ Of these, public patients had an average stay of 3.9 days, compared with 5.7 days for private patients.⁴ Although private hospitals are now also supporting early discharge, this significant difference suggests that when the choice is more open the stay is likely to be longer.

We have clear evidence of the need for greater maternal supports.

Until now, studies of early discharge have not shown negative outcomes. Unfortunately, the only one with a randomised group⁵ had a small sample size and, in the evaluation of postnatal depression, did not separate the randomised group from those who chose early discharge. In this issue of the Journal, Hickey et al.⁶ used more rigorous criteria for the diagnosis of postnatal depression and found that early discharge was associated with an increased risk of developing the disorder. Nearly 10% of women developed postnatal depression over the six-month study period.

The findings of Hickey et al. have profound implications. Postnatal depression affects up to 14% of women,⁷ and has been associated with impaired mother-infant relationships,⁸ as well as a higher risk of cognitive and behavioural difficulties in children.^9,10 The cost of economic rationalism may not be just at the expense of choice but of long-term outcomes. Unfortunately, the study, because of its small sample size, is unable to examine postpartum psychosis. Although postpartum psychosis is less common, affecting 1 in 600 women,¹¹ it poses a life-threatening risk to both infant and mother. As this disorder often presents in the first week after delivery, most patients are diagnosed in hospital. Early discharge places the responsibility of diagnosis and accessing immediate treatment on to the family; this is, at best, stressful for the family and a risk for the mother and child but, at worst, a tragedy.

Another concern emanating from the study is that, with the exception of mothers who stayed longer in hospital because they or their infants had complications (and also had a higher rate of depression), those who were discharged early may well represent a needy group. These women were more likely to be multiparous and have risk factors for postpartum depression, including being less educated and reporting poor relationships with their parents. Therefore, they were more likely to need help but less likely to access services and have support available. These women were also more likely to bottlefeed rather than breastfeed, putting their infants at further disadvantage.

Multiparity was also associated with early discharge in Australiawide statistics.⁴ That such a needy group is being discharged early may reflect the obligation that multiparous women feel about returning home quickly to their other children. It may also reflect, more worryingly, the increased pressure for discharge, the belief by some obstetric and administrative staff that multiparous women need less help, and the lack of education regarding the risk factors for postnatal depression.

Although adequate community support services may be able to balance the negative aspects of early discharge, these services may not be readily available or accessible. In their study, Hickey et al. did not outline the postnatal services that were available; whatever services may have been available did not appear to be very effective. Cuts to maternal and child health services have significantly reduced their availability to new mothers, other maternal supports are patchy, psychiatric services are directed to the seriously mentally ill, and child protective services are stretched and able only to supervise the most severe cases. Struggling depressed mothers are often undiagnosed and unsupported, which leaves their children at long-term risk.

More research that considers ramifications beyond the presenting problem (which often in medicine, and more often in psychiatry, is not the principal problem) is urgently needed. We have, in the study by Hickey et al., clear evidence of the need for greater maternal supports. Changes to health delivery in the past five years have been marked; we must evaluate their effects urgently if we are to make an impact on the continuing service changes.

Postnatal depression may present across many medical specialties and may be recognised and managed by a variety of health professionals. Given its high prevalence and significant ramifications for future generations, it is an area of health delivery in which we must unite, rather than be divided by proponents of demedicalisation of birthing or economic rationalism. It is critical in an era placing emphasis on evidence-based medicine that evidence from studies such as this become incorporated into the feedback loop to influence service provision in appropriate directions. If patterns of health care delivery add to morbidity, then the prescription "first not to harm" is negated.

Medical specialists have an obligation to hear the requests of women and manage birth with better communication and awareness of postnatal psychological morbidity, which must be treated early and aggressively. Prevention in health care management is surely an even more appropriate option. Politicians have an obligation to respond to the evidence, both through further research funding for this important area and by appropriate changes in health care delivery.

Anne E Buist
Associate Professor of Psychiatry Austin and Repatriation Medical Centre, Melbourne, VIC

Having a baby in Victoria: final report of the ministerial review of birthing services 1990. Melbourne: Health Department of Victoria, 1990: 10-59, 112-126.
Kenny P, King M, Cameron S, Shiell A. Satisfaction with postnatal care -- the choice of home or hospital. Midwifery 1993; 9: 146-153.
Lemmer CM. Early discharge: outcomes of primiparas and their infants. J Obstet Gynecol Neonatal Nurs 1987; 16: 230-236.
Australian Institute of Health & Welfare, National Perinatal Statistic Unit. Australia's mothers & babies 1994. Sydney: AIHW, 1997.
Barnett I, McCarthy M. Patient preference and postnatal hospital stay. J Obstet Gynaecol 1982; 3: 43-47.
Hickey AR, Boyce PM, Ellwood D, Morris-Yates AD. Early discharge and risk for postnatal depression. Med J Aust 1997; 167: 244-247.
Dennerstein L, Lehert P, Riphagen F. Postpartum depression -- risk factors. J Psychosom Obstet Gynaecol 1989; 10: 53-65.
Field T. Infants of depressed mothers. Dev Psychopath 1992; 4: 49-66.
Coghill SR, Caplan HL, Alexander H, et al. Impact of maternal depression in cognitive development of young children. BMJ 1986; 292: 1165-1167.
Wrate RM, Roony AC, Thomas PF. Postnatal depression and child development. Br J Psychiatry 1985; 146: 622-627.
Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychosis. Br J Psychiatry 1987; 150: 662-673.

©MJA 1997