Giving Birth, Going Home: Influences on when Low-Income Women Leave Hospital

"You should go so that others can come"; the role of facilities in determining an early departure after childbirth in Morogoro Region, Tanzania

BACKGROUND

Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited.

METHODS

Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders.

RESULTS

Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred.

CONCLUSION

Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth.

Lengthened predelivery stay and antepartum complications in women with depressive symptoms during pregnancy

Abstract Background: It is crucial to understand the timing and mechanisms behind depression's effect on peripartum stay because attempts to intervene will vary based on the time period involved. We designed this study to compare predelivery and postdelivery length of stay in women with and without elevated depressive symptoms during pregnancy.

METHODS

This study involved secondary data analysis of a larger study exploring antepartum depression. Each subject completed the Center for Epidemiological Studies Depression Scale (CES-D) during pregnancy at a mean of 25.8 weeks' gestation. We used time-stamped data to compare total peripartum, predelivery, and postdelivery lengths of stay in women with and without elevated depressive symptoms during pregnancy. In addition, we used a Cox proportional hazards regression model to evaluate potential mechanisms for depression's effect on length of stay.

RESULTS

The study sample included 802 pregnant women. Overall, 18% of study subjects scored ≥16 on the CES-D. Bivariate analyses demonstrated a significant association between elevated depressive symptoms and longer predelivery stays (time from admission to delivery). Interaction analyses demonstrated a significant interaction effect between depressive symptoms and parity, such that depressive symptoms were significantly associated with predelivery length of stay in multiparas but not so in primiparous subjects. In a multivariate model of multiparous subjects, depression's effect on length of stay was partially influenced by sociodemographic confounders but remained significant until antepartum complications were added to the model.

CONCLUSIONS

Depressive symptoms during pregnancy are significantly associated with a subsequent increase in predelivery length of stay, and this association is mediated in part by antepartum complications, even after controlling for sociodemographic factors. These longer hospital stays can present significant burdens to the patient, her family, and the healthcare system. Future studies should evaluate whether interventions for depression during pregnancy can impact this relationship among depressive symptoms during pregnancy, antepartum complications, and extensive predelivery hospitalizations.

Health preferences and decision-making needs of disadvantaged women

AIM

This paper reports the results of a survey of disadvantaged women in La Pintana, a municipality of Santiago, Chile, to determine their health decision-making needs.

BACKGROUND

Research is needed as there is no published community-based study focusing specifically on health decision-making needs of disadvantaged women.

METHODS

From April to November 1999, we conducted a cross-sectional interview survey of women registered at primary healthcare centres in La Pintana, an impoverished municipality of Santiago, Chile.

RESULTS

The survey participants were 554 adult women over 15 years of age. Seventy-five percent reported making current health-related decisions. Types of decisions were primarily about navigation: where, when and from whom to seek care. The most common role in decision-making was sharing the decision with others, specifically husbands and other family members. Fifty-four percent experienced decisional conflict or uncertainty about options. Those reporting more manifestations of decisional conflict were more likely to lack information on available options, pros and cons of the options, and chances of benefits and harms associated with the options; they were also more likely to be unclear about what was important to them, to feel pressure from others, lack skill or ability in decision-making and be older. The most common strategies used when making all types of decisions were obtaining information on options and recommendations, and getting support from others. Participants preferred to receive information about options through counselling from their physicians, rather than nurses, from printed materials and from discussion groups of people facing the same decision.

CONCLUSION

The majority of disadvantaged women were actively involved in decision-making and needed decision support to navigate the healthcare system. Nurses should play a more pivotal role in providing health decision support. This study needs to be replicated in other countries and cultural contexts.

Postnatal care in the community: report of an evaluation of birthing women's assessments of a postnatal home-care programme

For more than a decade, there has been a strong trend in many Western countries to decrease the length of time that women spend in hospital following childbirth. The research evidence regarding the consequences of early discharge for mothers and babies is mixed. Recent evidence has suggested that early discharge may not be randomly distributed across all sociodemographic groups of birthing women, and that the structures of home care have an important influence on maternal and child outcomes. In the context of decreasing lengths of hospital stay, the aim of the present study was to evaluate a new postnatal home support worker introduced into a geographically defined catchment area of a metropolitan hospital in South Australia. The evaluation included a formative process component to monitor recruitment strategies into the programme, as well as summative evaluation of a number of projected programme outcomes. The research methods used included interviews with antenatal women (n = 20) about their knowledge of and attitudes to the programme, and interviews with postnatal women (n = 63) about their transition home experience and assessment of the programme. Secondary analysis of client satisfaction surveys (n = 163) and aggregate breast-feeding data was also conducted. The results concur with previous research findings regarding the importance of rest and practical, home-based support in the postnatal period to maternal well-being, successful bonding and transition to motherhood. The results demonstrate the importance of well-structured home support services to maternal satisfaction and maternal well-being through the provision of physical, social and emotional care and support in the home.

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.