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Early discharge and postnatal depression: a prospective cohort study

Jane F Thompson, Christine L Roberts, Marian J Currie and David A Ellwood
Med J Aust 2000; 172 (11): 532-536.
Published online: 5 June 2000
Research

Early discharge and postnatal depression: a prospective cohort study

Jane F Thompson, Christine L Roberts, Marian J Currie and David A Ellwood

MJA 2000; 172: 532-536
For editorial comment see Lumley

Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' Details
- - More articles on Psychiatry


Abstract Objectives: To determine whether women discharged from hospital ≤ 72 hours after childbirth (early discharge) were at greater risk of developing symptoms of postnatal depression during the following six months than those discharged later (late discharge), their reasons for early discharge and their level of postnatal support.
Design and setting: Population-based, prospective cohort study with questionnaires at Day 4, and at 8, 16 and 24 weeks postpartum, conducted at all birth sites in the Australian Capital Territory (ACT).
Participants: Women resident in the ACT giving birth to a live baby from March to October 1997.
Main outcome measure: A score > 12 on the Edinburgh Postnatal Depression Scale (EPDS).
Results: 1295 (70%) women consented to participate; 1193 (92%) were retained in the study to 24 weeks and, of these, 1182 returned all four questionnaires. Of the 1266 women for whom length-of-stay data were available, 467 (37%) were discharged early and 799 (63%) were discharged late. There were no significant differences between the proportion of women discharged early who ever scored > 12 on the EPDS during the six postpartum months and those discharged late (17% v. 20%), even after controlling for other risk factors (adjusted OR, 0.67; 95% CI, 0.44-1.01). Of women discharged early, 93% had at least one postnatal visit at home from a midwife and 81% were "very satisfied" with the care provided. Most women (96%) reported they had someone to help in practical ways.
Conclusions: Women discharged early after childbirth do not have an increased risk of developing symptoms of postnatal depression during the following six months.


In Australia, and internationally, the length of time spent in hospital following childbirth has been steadily decreasing since the early 1980s. This has prompted concern about the consequences of early discharge for both mothers and babies.1,2 Postnatal depression (PND) is a common disorder with long-term consequences for both mother and infant.3,4 It has been associated with psychosocial and obstetric factors3,5-7 and possibly dissatisfaction with length of stay.8,9 The association with early discharge is not clear. A small randomised controlled trial of early discharge from Sweden10 reported no difference in depression, while in a similar Canadian study women discharged early were less likely to be depressed.11 In observational studies, women discharged early have been reported to be either equally8,9,12,13 or less likely14,15 to be depressed. A recent Australian study reported an increased risk of PND in women discharged early.16 However, this study made no detailed assessment of support available to women, a factor that may be critical to emotional wellbeing of new mothers.17

Here, we aimed to investigate whether early discharge following childbirth was associated with an increased risk of PND, why women elect early discharge, and to examine the social support available to women after discharge from hospital.


Methods
Participants This population-based, prospective cohort study included women resident in the ACT, planning to reside there for at least six months, aged ≥ 16 years, who gave birth to a live baby between March and October 1997 in any of the ACT's two public hospitals (one included a birth centre), two private hospitals, or at home. Women were excluded if their baby was admitted to the neonatal intensive care unit or adopted, if critically ill themselves, unable to give informed consent or complete the questionnaires for other reasons, or participating in another study. Participants were compared with all women who gave birth in the ACT during 1997 using data from the ACT Maternal and Perinatal Data Collection.18

Procedure The study was approved by the ACT Department of Health & Community Care Research Ethics Committee, and the ethics committees of participating hospitals. Postnatal ward or domiciliary midwives gave information sheets to women in the first few days after giving birth. Participants gave written informed consent when completing the first questionnaire as close to Day 4 as possible. They were then mailed questionnaires at eight, 16, and 24 weeks postpartum.

Questionnaires The first questionnaire covered sociodemographic characteristics of mother and partner, a nine-item personality scale identifying "vulnerable" and "resilient" personality dimensions;16 a maternity "blues" questionnaire;19 a subset of four items from the Medical Outcomes Study Social Support Scale;20 questions about availability of and satisfaction with practical support, emotional support from partner, and a single summary question assessing global satisfaction with partner scored on a five-point Likert scale. Three questions asked about the nature of women's past relationship with their parents in relation to warmth/care, overprotection/controlling and independent decision making, with responses on a four-point scale. Questions were also included about the mother's history of depression (at any time as well as during or after a pregnancy) and whether the infant was breastfed. In the second questionnaire, women were asked to indicate whether any of a list of 30 possible reasons for their actual length of stay applied to them and whether they thought their length of stay was too long, about right or too short. The third questionnaire included questions about the number of and satisfaction with domiciliary visits. Satisfaction was measured by quality of care, accessibility and convenience,21 and a single summary question assessing overall satisfaction with care.

Postnatal depression
Postnatal depression was assessed at eight, 16 and 24 weeks using the 10-item Edinburgh Postnatal Depression Scale (EPDS), a self-report measure of depression developed for use in the postpartum period.22-24 Women scoring above 12 are likely to be suffering from a depressive illness.

Length of stay
For comparability with previous Australian research,16 and in keeping with ACT definitions, early discharge was defined as discharge up to 72 hours after giving birth, and late discharge as more than 72 hours after giving birth.

Power of study
A sample size of 944 is sufficient to detect with 95% confidence and 80% power an increase in prevalence of PND in the early discharge group at eight, 16 or 24 weeks from 7% to 14%,16 assuming 30% are discharged early and an overall attrition rate of 25%. To allow for variations in these assumptions, we set a target sample size of 1200 women.

Statistical analyses
The prevalences of EPDS scores greater than 12 were compared between women discharged early and late by means of contingency tables and unconditional logistic regression. We used logistic regression to assess the effect of previously identified risk factors on the association between early discharge and high EPDS scores. Six separate models were fitted for women ever scoring > 12 during the six postpartum months; for those who scored > 12 at eight weeks, 16 weeks or 24 weeks; and for women who scored > 12 on either two occasions or all three occasions. Results are expressed as crude and adjusted odds ratios (OR) with 95% confidence intervals.


Results

Study population
Of 1961 ACT residents asked to participate in the study, 105 were ineligible and 1295 (70%) of the remainder agreed to participate. After 24 weeks, 1193 (92%) remained in the study. Of the 1295 who agreed to participate, 869 (67%) gave birth in a public hospital, 411 (32%) in a private hospital, and 15 (1%) at home, of whom six were transferred to hospital. Compared with all women who gave birth in 1997, participants were slightly older, more likely to be married or in a defacto relationship, to have given birth in a private hospital, and to have been discharged late (Box 1).

The 102 (8%) who were lost to follow-up differed from those who remained in that they were significantly (P ≤ 0.001) more likely to be aged < 25 years (32% v. 12%), unmarried (14% v. 4%), born in a non-English-speaking country (19% v. 9%), and public patients (74% v. 56%). They were not significantly more likely to be in the early discharge group (46% v. 36%), but were significantly (P ≤ 0.001) less likely to be in paid employment in the previous 12 months (56% v. 74%), to have a paid position to resume after maternity leave (43% v. 63%) and to have been educated beyond Year 11 (60% v. 82%). They did not differ with respect to the following factors known to be associated with PND: vulnerable personality, level of social support, past history of depression, dissatisfaction with relationship with partner, or dissatisfaction with past relationship with mother.

Length of stay
After excluding the nine women who gave birth at home and were not transferred to hospital, and the 20 with missing data, there were length-of-stay data for 1266 (98%) women, 467 (37%) with early and 799 (63%) with late discharge. The early discharge group was significantly (P ≤ 0.001) more likely to be aged < 25 years (21% v. 10%), public patients (80% v. 44%) or to have delivered in a public hospital (94% v. 52%), multiparous (61% v. 54%), and to have given birth at > 39 weeks' gestation (85% v. 75%). Women discharged early were also significantly (P ≤ 0.001) more likely to have had a spontaneous onset of labour (74% v. 55%), an unassisted vaginal birth (90% v. 56%) and to formula-feed their infant from birth (10% v. 5%). They were significantly (P ≤ 0.001) less likely to have been in paid employment in the past 12 months (68% v. 76%), to have a paid position to resume (55% v. 66%) and to have been educated beyond Year 11 (74% v. 84%). They were significantly (P ≤ 0.001) less likely to rate their length of stay as "about right" than women discharged late (72% v. 82%), and more likely to rate their length of stay as "too short" (23% v. 8%). There were no statistically significant differences in vulnerable personality (17% v. 16%), level of social support (median score, 7 for both groups), past history of depression (29% v. 29%), maternity blues score (median score, 4 v. 5), dissatisfaction with partner (8% v. 6%), and past relationship with mother (not warm/caring, 6% v. 5%; overprotective/controlling, 52% v. 52%; did not encourage independent decision-making, 20% v. 21%).

Postnatal depression
Of the 1252 (97%) women with complete data at eight weeks postpartum, 129 (10%) scored > 12 on the EPDS. At 16 weeks, 91 of 1219 (8%) and at 24 weeks 90 of 1187 (8%) scored > 12. The cumulative incidence of an EPDS score > 12 over the six months of follow-up was 224/1295 (17%). Among women with complete data, 37/1172 (3%) had EPDS scores > 12 on two occasions and 23/1172 (2%) on all three occasions.

Length of stay and postnatal depression
Women discharged early were not more likely to ever score > 12 on the EPDS during the six months of follow-up than women discharged late: 72/429 (17%) compared with 150/751 (20%). The association between length of postnatal stay and PND symptoms remained statistically non-significant after adjusting for other risk factors (Box 2). This finding was robust for other outcome measures (Box 3). For all outcomes there was a consistent trend towards a reduced risk of PND symptoms for women discharged early.

Reasons for choosing early discharge
Reasons were given by 447 women (96%). The most common reason was a preference to be at home with their partner or family (74%). Other reasons were feeling confident with their baby and preferring to be at home (73%); so the father could be more involved in baby care (47%); being unhappy in hospital and unable to sleep or rest (41%); greater privacy (41%); to rest or recover after the birth (40%); not liking hospitals (34%); to establish breastfeeding (33%); and to have time to focus on the baby (32%). Of the women discharged early, 15% said they did not feel they had a choice about length of stay, and 14% felt under pressure from midwives to leave early. Women discharged early who felt they had no choice about length of stay were not significantly more likely to ever score > 12 on the EPDS (17% v. 17%), and neither were those who felt pressured to leave early (21% v. 16%; P = 0.4).

Early discharge and postnatal support
All women discharged within three days were eligible for home visits from midwives. Data were available on the number and nature of these visits for 432 women discharged early (93%). Of these, 404 (94%) had at least one visit, and 176 (41%) were visited up to Day 7. The maximum number of visits in the first seven days was 12, and 107 women (27%) were visited at least once after seven days. Eighty-eight per cent of the women thought the number of visits was "just right", while 8% thought it "not enough" and 4% "too many". Overall, 81% of these women said they were "very satisfied" with the care provided at home, 15% "satisfied in some ways but not in others" and 4% "very dissatisfied".

Some women discharged after 72 hours were also eligible for and received home visits. The participating public hospitals' policy was for home visiting to be available up to Day 3, but sometimes this extended beyond 72 hours depending on the time of birth. Home visits were also available in cases of special need, and community-based maternal and child health nurses and midwives also offer some home visiting. Of the women discharged late, 364 (47%) received at least one visit at home from a midwife.

In addition to support provided by health professionals, 96% of women discharged early reported that they had someone to help in practical ways in the first eight weeks postpartum. For 92% this was a partner, and for 47% their mother. Other family members (22%), friends (20%) and mothers-in-law (19%) were the next most common sources of help. The help received was satisfactory for 90% of the respondents; however, 23% said that they would like to know more people who could be asked for help. There were no statistically significant differences between women discharged early or late in availability of and satisfaction with practical help.


Discussion The postnatal stay has become shorter without being properly evaluated in randomised controlled trials (RCTs). As shorter stays have become standard practice, the window of opportunity for conducting an appropriate RCT may have been lost.25 The best alternatives are prospective studies with heterogeneous samples of sufficient size to detect clinically significant effects of short postnatal stays.

We found that women resident in the ACT electing short postnatal stays were not at increased risk for developing symptoms of PND. Our finding is consistent with those from two Victorian surveys,8,13 but differs from that of a study in Sydney which found a significantly increased risk of PND during the first six months in mothers discharged within three days.16 There are several possible explanations for the discrepant results between this study and our own, including differences in the outcome measures, population characteristics, postnatal support and reasons for early discharge.

The same assessment tool to identify possible cases was used in the Victorian,8,13 Sydney16 and ACT studies, but in the Sydney study a psychiatric interview was added to confirm the diagnosis of PND. The use of a psychiatric examination is unlikely to explain differences in the results, as high scores on the EPDS coincide closely with diagnoses of PND. A validation study in Australian women found the EPDS to be highly sensitive (100%) and specific (96%), with a positive predictive value of 70%.22

Differences in the characteristics of women discharged early may also contribute to the different outcomes observed. In both the Sydney and the ACT studies, women discharged early were more likely to be multiparous, to have a lower level of education and to formula feed their infants in the first week than women discharged late. However, the women discharged early in the Sydney study16 were more likely than those in our study to report a poor relationship with parents and to have a history of depression; these associations were controlled for in the statistical analyses in the Sydney study and so cannot fully explain their different findings.

Low levels of social support have been identified as a risk factor for PND,5 and another possible explanation for the differences in findings is that the two populations differed in the extent, nature of and satisfaction with postnatal support provided to women through early discharge programs and non-professional contacts. The authors of the Sydney study reported that only half of the women who elected early discharge participated in an early discharge program with domiciliary midwifery care.26 In our study, 94% of the women discharged early had had at least one visit from a midwife at home and the level of satisfaction with this care was high. Also, only 4% of women discharged early said they had no one to provide practical support at home. An overwhelming majority reported that their partners assisted them and most were satisfied with the level of help.

Early discharge was introduced partly to offer more choices in care in a climate of increasing consumer participation in decisions. However, economic imperatives to increase patient throughput may lead to increasing pressure on women to leave hospital earlier than they would otherwise choose. The Sydney study26 did not report reasons for early discharge. Reasons given by women for leaving ACT hospitals early were generally positive, although 15% felt they did not have a choice and 14% felt pressured to leave (not mutually exclusive reasons).

Several things should be considered when interpreting the results of our study. Firstly, as the Sydney study found double the rate of PND after early discharge,16 we formed our null hypothesis (that early discharge makes no difference) in the expectation that it would be disproved. Instead, we found no evidence of a significant difference in the rate of PND; in fact, early discharge tended to a protective effect (but this was not statistically significant). Our study does not prove that there is not an increased rate of PND for early discharge. However, in this population, it is unlikely that the true risk for early discharge was double that for late discharge. Secondly, although only 70% of women approached participated in the study, the characteristics of women who did participate were similar in important respects to those of the source population. However, our findings may not be generalisable to populations with differing PND risk factors or early discharge programs. Lastly, the women in our study selected their length of postnatal stay. Although we have controlled for known determinants, confounding by unknown determinants for PND cannot be excluded.

We found that women who selected early discharge from hospital after childbirth and received midwifery support at home, and who were well supported by other family members, were not more likely to experience depressive symptoms in the first six months after childbirth. Very few women in this study were discharged early without home support, so it was not possible to determine whether early discharge without support was associated with an increased risk of PND symptoms. It may be important to ensure that all women discharged early after childbirth, in particular those lacking other sources of support, receive additional help from the healthcare system. What constitutes adequate postnatal support could be examined by RCTs comparing different patterns of home visiting.



Acknowledgements
This work was supported by a project grant from The Canberra Hospital Private Practice Fund. Additional funding was provided by The Canberra Hospital Auxiliary, the Nurses' Board of the ACT, and the ACT Department of Health & Community Care. The assistance of the midwives in recruiting women for this study is gratefully acknowledged. Robyn Attewell provided statistical advice. We are especially grateful to the women of the ACT who so generously gave their time to complete this study.


References
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(Received 7 Oct 1999, accepted 3 Apr 2000)



Authors' Details
The Canberra Hospital, Garran, ACT.

Jane F Thompson, MSc, PhD, Senior Research Officer, Women's & Children's Health.
Marian J Currie, BapplSc, GDPH, Midwife, Maternity and Gynaecology Outpatients and Fetal Medicine Unit.
David A Ellwood, FRANZCOG, Dphil, Professor of Obstetrics and Gynaecology, The Canberra Clinical School.

New South Wales Centre for Perinatal Health Services Research, Departments of Obstetrics and Gynaecology and Public Health and Community Medicine, School of Population Health Services Research, University of Sydney, NSW.

Christine L Roberts, MB BS, MHP, Senior Lecturer.

Reprints: Dr J F Thompson, Women's and Childrens Health, The Canberra Hospital, PO Box 11, Woden, ACT 2606.
jane.thompsonATact.gov.au

©MJA 2000

Received 19 November 2018, accepted 19 November 2018

  • Jane F Thompson
  • Christine L Roberts
  • Marian J Currie
  • David A Ellwood


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