Early discharge and postnatal depression: a prospective cohort
Jane F Thompson, Christine L Roberts, Marian J Currie and David A
MJA 2000; 172: 532-536
For editorial comment see Lumley
More articles on Psychiatry
|| 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.
|| This population-based, prospective cohort study included women
resident in the ACT, planning to reside there for at least six months,
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
|| 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.
|| 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 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.
|| 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.
|| 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
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
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
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
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.
|| 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
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
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.
|| 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
Low levels of social support have been identified as a risk factor
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.
|| 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.
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(Received 7 Oct 1999, accepted 3 Apr 2000)
|| The Canberra Hospital, Garran, ACT.
Jane F Thompson, MSc, PhD, Senior Research Officer,
Women's & Children's Health.
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.
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.
Reprints: Dr J F Thompson, Women's and Childrens Health,
The Canberra Hospital, PO Box 11, Woden, ACT 2606.