Video Abstract

Video Abstract

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CONTEXT:

Postnatal length of hospital stay has reduced internationally but evidence-based policies to support earlier discharge are lacking.

OBJECTIVE:

To determine the effects of early postnatal discharge on infant outcomes.

DATA SOURCES:

CENTRAL (Cochrane Central Register of Controlled Trials), Medline, Embase, Cumulative Index to Nursing and Allied Health Literature , and SCI (Science Citation Index) were searched through to January 15, 2018.

STUDY SELECTION:

Studies reporting infant outcomes with early postnatal discharge versus standard discharge were included if they met Effective Practice and Organisation of Care study design criteria.

DATA EXTRACTION:

Two authors independently assessed eligibility and extracted data, resolving disagreements by consensus. Data from interrupted time series (ITS) studies were extracted and reanalyzed in meta-analyses. Meta-analyses of randomized controlled trials (RCTs) used random effects models.

RESULTS:

Of 9298 studies, 15 met the inclusion criteria. RCT meta-analyses revealed that infants discharged <48 hours after vaginal birth and <96 hours after cesarean birth were more likely to be readmitted to the hospital within 28 days compared to standard discharge (risk ratio: 1.70; 95% confidence interval [CI] 1.34 to 2.15). ITS meta-analyses revealed a reduction in the proportion of infants readmitted within 28 days after minimum postnatal stay policies and legislation were introduced (change in slope: −0.62; 95% CI −1.83 to 0.60), with increasing impact in the first and second years (effect estimate: −4.27 [95% CI −7.91 to −0.63] and −6.23 [95% CI −10.15 to −2.32]).

LIMITATIONS:

Withdrawals and crossover limited the value of RCTs in this context but not ITS evidence.

CONCLUSIONS:

Infants discharged early after birth were more likely to be admitted within 28 days. The introduction of postnatal minimum length of stay policies was associated with a long-term reduction in neonatal hospital readmission rates.

Internationally, there is considerable variation in postnatal length of stay (LoS). Despite an increase in medical interventions during childbirth and more complex maternities, over the last 50 years there has been a reduction in the postnatal LoS for women and infants. Several high-income counties, including the United Kingdom, Australia, and Canada, have an average stay of 1.5, 2.8, and 1.7 days, respectively.1  Although a reduction in LoS reduces hospital costs,2  there is concern about whether earlier discharge from the hospital is safe and cost-effective. Although there is an existing Cochrane review3  of randomized controlled trials (RCTs) on this topic, it is limited by significant clinical and methodologic heterogeneity, and, thus, there is insufficient evidence to inform policy.

In this systematic review and meta-analysis, we addressed the same objectives and outcome measures as the Cochrane review3  but broadened the study design to include both RCTs and quasi-experimental studies because the intervention is often a policy change and other types of studies are important and necessary to evaluate organizational change.4  To reduce heterogeneity, unlike the Cochrane review, which used trial authors’ definitions, in this systematic review, we predefined early postnatal discharge as <48 hours after vaginal delivery and <96 hours after cesarean delivery.

The aim of this review was to determine the effects of a policy of early postnatal discharge for women and infants, specifically whether there is an association between early postnatal discharge and infant readmission to hospital. It was hypothesized that early postnatal discharge may increase infant use of health services.

The full systematic review protocol has been published5  and registered in PROSPERO (registration CRD42015020545). This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Electronic databases (CENTRAL, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and SCI) were searched for articles up to January 15, 2018, with the following search terms: postnatal care, postpartum period, puerperium, postpartum, length of stay, patient discharge, hospital stay*, and patient readmission. In the searches, we used free text and indexed terms combined by using Boolean operators, adjusted for each database (Supplemental Table 3). The search strategy was not limited by study design and time, language, or geographical restrictions. When applicable, authors of primary studies were contacted for further information.

All studies were eligible to be included in the review if they met the following criteria: women and infants considered “fit for discharge” by their health care practitioners; all births occurring in either obstetric-led (for which obstetricians have primary professional responsibility for women at high risk of complications during labor and birth and women are cared by a team of midwives and doctors) or midwife-led care settings (in which midwives take the primary professional responsibility for the labor care for low-risk women); studies had to compare a policy of early discharge from hospital in which early discharge referred to a hospital discharge that was <48 hours after birth (or <96 hours for cesarean delivery) and earlier than the standard care in the setting in which the intervention is implemented to be included. In the Cochrane review,3  the authors identified that RCTs alone on this topic are limited by poor compliance and clinical and methodologic heterogeneity, indicating that alternative study designs may be more helpful for assessing the effect of policy change. Therefore, as guided by Cochrane Effective Practice and Organisation of Care (EPOC),4  in addition to RCTs, non-RCTs, controlled before-after studies (CBAs), and interrupted time series (ITSs) were also eligible for inclusion in the review. ITSs can provide a method of measuring the effect of an intervention when randomization or identification of a control group are impractical.4  Multiple data points are collected before and after the intervention, and the intervention effect is measured against the preintervention trend.4 

Infant and maternal outcome measures were guided by the Cochrane review.3  The primary infant outcomes were the proportion of infants readmitted to the hospital within 7 days and within 28 days after birth. Maternal outcomes were the proportion of women readmitted for complications related to childbirth (postpartum hemorrhage, retained products of conception, infection, postpartum psychosis); the proportion of women breastfeeding (exclusively or partially) at 48 hours, 6 weeks, and 6 months after birth; and the proportion of women with a score indicating probable depression on a validated standardized instrument for measuring depression.

Citations were screened for inclusion independently and in duplicate. Articles were assessed unblinded, and differences in opinion were resolved through discussion or a third researcher. Data extraction was performed independently and in duplicate. The EPOC data collection form6  was adapted to answer review specific research questions. Data extraction forms were piloted on a sample of included studies. The methodologic quality of included studies was assessed independently and in duplicate by using EPOC criteria for the risk of bias tool7  and Cochrane RCT tool as appropriate.8 

Meta-analyses of RCT studies were conducted in RevMan (version 5.3)9  by using a random effects model, and, when significant heterogeneity was present, data were described in a narrative synthesis. When data from ITSs were presented graphically, data were extracted from graphs by using Plot Digitizer software10  and reanalyzed by using autoregressive integrated moving average with SPSS version 22 (IBM SPSS Statistics, IBM Corporation)11  as described in EPOC guidance.12 

We used the autoregressive integrated moving average analysis to estimate the effect of a policy change while taking into account the time trend and autocorrelation among the observations. Estimates for the regression coefficients correspond to 3 standardized effect sizes: change in level at 1 and 2 years post policy change and change in slope. The change in level was defined as the difference between the observed level at the intervention time point and that predicted by using the preintervention time trend.12  The change in slope was defined as the change in trend from pre- to postintervention reflecting the long-term effect of the policy intervention.12  Data were then standardized by dividing the level and slope and SE by the SD of the preintervention slope. The effect sizes for change in the level at 1 and 2 years and effect size for change in slope were entered into RevMan 5 and meta-analyzed by using the generic inverse variance method with random effects. The statistical significance was set at P <. 05. When data from the same region and time period were used in different studies, only 1 study was used for inclusion in the meta-analysis.

For RCTs, statistical heterogeneity was examined by inspection of confidence intervals (CIs) and the I2 statistic. Heterogeneity was also explored through subgroup analysis. Sensitivity analyses were planned to assess the effect of incomplete outcome data and fixed effects versus random effects analysis. On the basis of the Cochrane review, subgroup analyses were undertaken to compare trials with cointerventions (such as increased home visiting in the early discharge group or no cointervention). Further subgroup analyses were planned to explore the effect of the mode of birth, timing of discharge, type of hospital delivered at (consultant-led unit or midwife-led unit), gestation at birth, and level of risk (high risk or low risk); however, these were not possible because of lack of participant level data and small number of participants in most trials. For the ITSs, study methods to adjust for potential confounders were taken into account in interpreting results. There were insufficient studies to assess publication bias through the use of funnel plots.13 

We found 9303 studies from electronic sources and hand searches. After removal of duplicates and eligibility screening, 15 studies were identified for inclusion (Fig 1). Ten were RCTs that took place between 1976 and 2015 in several countries, including Canada, England, Egypt, Malaysia, Spain, Sweden, Switzerland, and the United States. All studies were conducted in obstetric-led hospital settings.1423  In the trials, the effects of a policy of early postnatal discharge were compared to a standard length of postnatal stay for women and infants. In contrast, in 4 population-based cohort studies with ITS analyses, researchers assessed the effect of state and federal legislation introduced in the United States prohibiting insurance plans from limiting coverage for postpartum hospital stay to <48 hours for normal vaginal deliveries and <96 hours for cesarean sections on various health related outcomes.2427  Before the legislation introduced in 1996–1997, there was no minimum length of postnatal stay in the United States. In the fifth ITS study, researchers examined the effect of a same-day discharge policy in 5 Danish counties introduced over the period 1990–2003.28  All study characteristics are summarized in Table 1, and Supplemental Table 7 illustrates which studies reported on the outcomes described in the review. Maternal outcomes are described in Supplemental Figs 48.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart selection of studies.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart selection of studies.

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TABLE 1

Characteristics of Included Studies

StudyMethodsParticipantsInterventionOutcomes MeasuresNotes
Bayoumi et al15  Design: RCT. Randomization method: sealed envelopes with discharge protocol opened after 24 h post birth. Recruited and randomly assigned: postnatal. Blinding: caregiver, women and outcome assessor unblinded. Length of follow-up: 6 wk. Type of analysis: Per protocol. Total incomplete outcome data: 788 (21%). Attrition: intervention: 263/1890 (13.9%), control: 205/1896 (10.8%), total: 468 (12.4%). Postrandomization exclusions: intervention: 132/1890 (7%), control: 188/1896 (9.9%), total: 320/3786 (8.5%). Duration of study: June 2012 to February 2014. Setting: Maternity hospital, Faculty of Medicine, Cairo University, Egypt No. eligible: 6340. No. recruited and randomly assigned: intervention: 1890, control: 1896. Inclusion criteria: women aged 20–40, no known medical condition, (eg, diabetes; hypertension; renal, cardiac, or chest problems; or connective tissue disease), no obstetric complications (eg, placenta previa, placenta accreta, accidental hemorrhage or preeclampsia), all term pregnancies, ≥37 wk, no fetal problems, intrauterine growth restriction, major congenital abnormality, and all patients discharged with their newborn. Exclusion criteria: <20 or >40 y old, patients with a known medical problem, any fetal problem diagnosed after delivery, or patients and newborn who did not meet the criteria of discharge at the 24 or 72 h interval chosen for their discharge. Fit for discharge criteria: no postpartum complications (eg, postpartum hemorrhage, urinary tract infection, chest complications), a febrile postoperative course defined as no temperature elevation >38.3°C during the first 24 h or >38°C after 24 h, bowel movement or passage of flatus, established urination, no neonatal problems (eg, respiratory complications, no jaundice, or vomiting). Characteristics of women: intervention: age 30.6 (SD 6.2), control: age 30.9 (SD5.7). Characteristics of infants: gestation at birth: intervention: 39.44 (SD 1.47), control: 39.07 (SD 1.28) Intervention: discharge 24 h after delivery; control: discharge 72 h after delivery Proportion of infants and women readmitted to hospital <6 wk. Women reporting symptoms: wound infection, abdominal infection, secondary postpartum hemorrhage, successful breastfeeding, intestinal ileus, fever, breast engorgement, stress incontinence, chest infection, pulmonary embolism, deep vein thrombosis, mood swings Actual LoS: unknown. Compliance to group allocation: 132/1890 from intervention did not stay 24 h and were removed from analysis; 188/1896 from control group who left earlier than 72 h were removed from analysis 
Boulvain et al16  Design: RCT. Randomization method: telephone call by using sealed envelopes. Recruited and randomly assigned: antenatal appointment at 37/40. Blinding: caregiver, women, and outcome assessor unblinded. Length of follow-up: 6 mo. Type of analysis: ITT. Total incomplete outcome data: 22 (4.7%). Attrition: 21 (4.6%). Postrandomization exclusions: 1 (0.1%). Duration of study: November 1998 to October 2000. Setting: Switzerland, tertiary level maternity unit No. eligible: 2324. No. recruited and randomly assigned: 460, intervention: 228, control: 231. Inclusion criteria: low-risk women, at low risk of cesarean delivery or postnatal complications, nulliparous or multiparous. Exclusion criteria: placenta previa, preeclampsia, diabetes treated with insulin, medical complication of pregnancy requiring postnatal hospital surveillance, past history of postnatal complication, difficult socioeconomic situation, multiple pregnancy, suspicion of IUGR, estimated fetal wt >95th percentile, fetal malformation or genetic disease, strong preference for length of postnatal stay. Characteristics of women: intervention: mean age 29 (SD 4.8), 137 (60%) nulliparous, 164 vaginal birth, 40 instrumental delivery, 24 cesarean delivery, 113 completed secondary education, mean birth wt: 3420 g (SD 435); control: mean age 29 (SD 5.5), 131 (57%) nulliparous, 149 vaginal birth, 55 instrumental delivery, 27 cesarean delivery, 118 women completed secondary education, mean birth wt 3480 (SD 405) Intervention: discharge 24–48 h after delivery; control: discharge 4–5 after vaginal birth (+2 d for cesarean delivery). Cointervention: minimum 2 nurse home visits and 10 phone calls, No. and timing dependent on needs of family Infants and women readmitted to hospital <28 d and 2–6 mo. Breastfeeding at 7 d/28 d/6 mo. Depression at 7/28 d. Infant feeding problems <28 d. SF-12 physical and mental summary score. Neonatal admissions for >24 h at 28 d post birth. Neonatal jaundice views about quality of postnatal care. Missed metabolic or endocrine congenital disease. Economic evaluation. Maternal satisfaction Actual length of postnatal stay (mean): intervention: 65 h, control: 106 h. Compliance to group allocation: 114/228 (50%) moved to control group from intervention, 67/231 (29%) moved to intervention from control 
Sainz Bueno et al23  Design: RCT. Method of randomization: opaque sealed envelopes, randomization by blocks (opaque sealed envelopes) defined by parity in postnatal ward. Recruited and randomly assigned: postnatal. Blinding: women and health professional unblinded, blinding of outcome assessment unclear. Length of follow-up: 6 mo. Type of analysis: ITT. Total incomplete outcome data: 5.1%. Attrition: 22 (5.1%). Postrandomization exclusions: none. Duration of study: April 1999 to April 2001. Setting: Seville, Spain (urban maternity hospital) No. eligible: unknown. No. recruited and randomly assigned: 430 recruited; intervention: 213; control: 217. Inclusion criteria: primiparous and multiparous women, term normal vaginal birth or assisted vaginal delivery; postnatal criteria: apyrexial, normotensive blood pressure, postpartum estimated blood loss <500 mL, and adequate uterine involution; neonate: term gestation with appropriate wt for gestational age, normal cardiorespiratory adaptation to extra uterine life, no evidence of sepsis or jaundice, normal temperature (36.1–37°C); physical examination by doctors, passed meconium and urine once, administration of vitamin K and other vaccinations. Exclusion criteria: third- or fourth-degree tear, maternal drug abuse, gestational diabetes, preeclampsia, rhesus isoimmunization, postpartum blood loss >500 mL, >20 km from hospital and/or difficulty getting to hospital. Characteristics of women: intervention: mean birth wt 3348 g, 29 completed secondary education, 187 vaginal birth, 26 assisted vaginal birth, 78 primiparous, 135 multiparous, maternal age (categories): 11 women <19 y, 115 women 20–30 y, 85 women 31–40 y, 4 women >40 y; control: mean birth wt 3335 g (SD 372), 28 women completed secondary education, 82 primiparous, 135 multiparous, 192 normal vaginal birth, 25 assisted vaginal birth, maternal age (categories): 7 women <19 y, 117 women 20–30 y, 88 women 31–40 y, 1 woman >40 y Intervention: discharge <24 h after delivery; control: minimum 48 h stay in hospital and monitored at 7–10 d postpartum. Intervention: home support for after 24–48 h by a nurse qualified in postnatal and neonatal care Proportion of infants readmitted to hospital <28 d, women readmitted <6 wk after giving birth, women breastfeeding at 1 wk or 1 and 6 mo, depression at 1 wk or 1 mo, maternal exhaustion or fatigue <4 wk postnatal, women physical health problems in first 6 mo, women and infants requiring health consultation, health consultation, maternal satisfaction, duration of rehospitalization, economic evaluation Actual length of postnatal stay (mean): intervention: 27.23 h (SD 9.12); control: 51.25 h (SD 7.29). Compliance to group allocation: not stated 
Carty and Bradley20  Design: RCT. Method of randomization: Sealed opaque envelopes opened by nurse at home visit. Recruited and randomly assigned: antenatal, 37 wk gestation. Blinding: women and health professional and outcome assessor unblinded. Length of follow-up: 1 mo. Type of analysis: not ITT. Total incomplete outcomes data: 30.7%. Attrition: 13 (6.9%). Postrandomization exclusions: 45 (24%). Duration of study: not reported. Setting: Vancouver, Canada, tertiary care maternity unit No. eligible: unknown. No. recruited and randomly assigned: 189 recruited and randomly assigned; intervention 1: n = 44; intervention 2: n = 49; control group: n = 38. Inclusion criteria: all women expecting a vaginal birth. Exclusion criteria: cesarean or forceps delivery. Characteristics of women (eg, maternal age of intervention and control): mean age 30.24 y (SD 3.80), >95% white, 93% married or cohabiting, 65% completed junior college or university, 50% combined household income > $40 000, mean paternal age 32.87 y, 53% primiparous, 47% multiparous (baseline characteristics table not reported to enable comparison of baseline characteristics by group allocation) Intervention 1: discharge 12–24 h after delivery; intervention 2: discharge 25–48 h after delivery; control: 3–4 d discharge. Cointervention: nurses had 2-wk training course; intervention 1: home visits on day 1, 2, 3, 5, and 10; intervention 2: home visits on 3, 5, and 10 Proportion of infants readmitted to hospital in first 6 wk, women readmitted for complication related to childbirth in first 6 wk, women breastfeeding at 1 mo, women scoring above cutoff for probable depression and anxiety, maternal satisfaction, confidence in mothering role, frequency of maternal problems requiring physician referral <10 d Actual LoS (mean): intervention 1: 1.12 d (SD 0.4); intervention 2: 2.06 d (SD 0.6); control: 4.03 d (SD 0.7). Compliance to group allocation: not stated 
Gagnon et al21  Design: RCT. Method of randomization: opaque sealed envelopes placed on medical file before antenatal home visit. Recruited and randomly assigned: antenatal recruitment from attendance physician’s office, hospital ultrasonography, or family planning clinic (3 recruitment sites) between 32 and 38 wk gestation. Blinding: women and health professionals and outcome assessor unblinded. Length of follow-up: 1 mo. Type of analysis: not ITT. Total incomplete outcome data: 51.4%. Attrition: 26 (7.2%). Postrandomization exclusions: 159 (44.1%). Duration of study: January 1900 to December 1990. Setting: Montreal, Canada 1354 women approached, 938 eligible, 360 recruited and randomly assigned. Intervention: 183,control: 177; final No. analyzed: intervention: 78, control: 97. Inclusion criteria: parity 0–4, normal pregnancy (eg, absence of medical conditions); cephalic presentation at 36 wk; ability to speak English, French, or Spanish; telephone availability; and residence within 30 min of hospital. Exclusion criteria: intrapartum exclusion: prolonged rupture of membranes >24 h before birth, cesarean delivery, estimated blood loss >500 mL, and third- or fourth-degree perineal tear; postpartum exclusion: excessive bleeding, inability to void adequately, reduced mobility. no receipt of Anti D when indicated, medical conditions requiring close supervision; infant exclusion: multiple birth, birth wt <2500 g, preterm (<37 wk), abnormal newborn physical examination, not established feeding. Characteristics of women: mean age: intervention: 29.6 (SD 4.7), control 29.1 (SD5.3); parity: intervention: 38% primiparous, control: 34% primiparous; mean birth wt: intervention: 3389 (SD 419), control: 3496 (SD 364); mean length time in education: intervention: 13.8 9 (SD 3.8), control: 14.0 (SD 3.9); recent migrant: intervention: 14.1%, control: 24.7%; mean gestational age at recruitment: intervention:34.5, control: 34.0; antenatal depression: intervention: 10.4%, control: 13%; smoking status: intervention: 23.1%, control: 9%; mode of birth intervention: 43.5% cesarean delivery, 56.3% vaginal birth; control: 39.2% cesarean delivery, 60.8% vaginal; mean gestational age at birth: intervention: 39.3 (SD 1.3), control: 39.5 (SD 1.1); intend to b/f: intervention: 70.5%, control: 54.6% Intervention: discharge 6–36 h after delivery; control: 48–72 h discharge. Cointervention: nursing care by telephone <48 h and at 10 d postpartum, home visits at 34–38 wk and 3–5 d postnatal Proportion of women predominantly breastfeeding at 1 mo, infants requiring a “health contact” at 10 d, maternal satisfaction, perceived maternal or parental competency Actual LoS: intervention: 37.5 h (SD 19.7); control: 54.3 h (SD 18.0). Noncompliance to group allocation: 26/78 (33%) in intervention group moved to control group 
McKeever et al22  Design: RCT. Method of randomization: unclear (by using central randomization methods). Recruited and randomly assigned: unknown method of recruitment, postnatal. Blinding: women and health professionals unblinded, blinding of outcome assessor unclear. Length of follow-up: up to 12 d postnatal. Type of analysis: ITT. Total incomplete outcome data: 26%. Attrition: 15 (14.9%). Postrandomization exclusions: 11 (11%). Duration of study: July 1999 to December 2000. Setting: Toronto, Canada No. eligible: 156. No. recruited and randomly assigned: recruited and randomly assigned postnatally: 156 recruited, 101 randomly assigned (stratified by gestation). Intervention: 53; control: 48. No. analyzed: term: intervention: 34, control: 41; near term: intervention: 15, control: 12. Inclusion criteria: live singleton within preceding 12 h, were at least 21 y, resided in metropolitan area, had a telephone, intended to breastfeed, were breastfeeding at discharge, would receive satisfactory support at home; infant inclusion: ≥35 wk gestation, breastfeeding at discharge, no congenital abnormalities or morbidities (including hyperbilirubinemia, blood group incompatibility, or sepsis). Exclusion criteria: non–English speaking, cesarean delivery, postpartum complications, and morbidities (such as fever, abnormal bleeding, chronic illness, or disabilities). Characteristics of women: Intervention term: mean age 32 (SD 4.2); 51.3% primiparous; 48.7% multiparous; 100% vaginal birth; gestational age: 38–40/40 = 92%, 41/40 = 8%; breastfeeding at discharge 87%. Intervention near term: mean age 32.1 (SD 2.9); 57.1% primiparous; 42.9% multiparous; breastfeeding at discharge 68%; gestational age: 35/40 = 10.5%, 36/40 = 42.1%, 37/40 = 47.4%. Control term: mean age 33.1 (SD 4.4); 45.5% primiparous; 54.5% multiparous; gestational age: 38–40/40 = 81%, 41/40 = 99%; breastfeeding at discharge 83%. Control near term: mean age 32.1 (SD 4.4); 80% primiparous; 20% multiparous; gestational age: 35/40 = 5.6%, 36/40 = 33.3%, 37/40 = 61.1%; breastfeeding at discharge 72% Intervention: discharge 24–36 h after delivery; control: discharge 48–60 h after delivery. Cointervention: breastfeeding clinic outpatient and encouraged to use the preexisting 24 h telephone helpline Proportion of women breastfeeding at 5–12 d after birth LoS: term group: intervention: 37 h (range 23–61), control: 44.1 h (range 15–107); near-term group: intervention: 45 h (range 25–86), control: 48.2 h (range 28–68). Compliance to group allocation: not stated 
Tan et al18  Design: RCT. Method of randomization: random No. generator in random blocks of 4 or 8, numbered sealed envelopes; attached to medical charts and opened on day 1 on postnatal ward by health care provider to reveal allocation. Recruited and randomly assigned: postnatally. Blinding: women and health professional unblinded, outcome assessor, unclear. Length of follow-up: 6 wk. Type of analysis: ITT. Total incomplete outcome data: 5%. Attrition: 12 (3.3%). Postrandomization exclusions: 6 (1.6%). Duration of study: November 5, 2011 to February 15, 2012. Setting: Kuala Lumpur, Malaysia University Hospital, Kuala Lumpur, Malaysia No. eligible: 689 admitted for elective cesarean delivery, 329 either not eligible or not approach, unclear how many were ineligible. No. recruited and randomly assigned: 360 women randomly assigned postnatally, intervention: 179, control: 181. No. analyzed: intervention:170, control:172. Inclusion criteria: planned LSCS, aged >18 y, gestation ≥37, singleton pregnancy. Exclusion criteria: antenatal: known congenital abnormality, established medical problems or operative factors likely to preclude day 1 discharge (preeclampsia, cardiac disease, renal disease, connective tissue disease, ≥2 previous LSCS, major placenta previa); intrapartum: estimated blood loss >800 mL, hemoglobin level <80 g/L, immobile, not established voiding, febrile >38°C, abnormal blood pressure. Characteristics of women: Intervention: mean age 31.8 (SD 4.6), 179 had cesarean delivery, 67 completed higher education, mean birth wt = 3320 g (SD 0.51), 134 in employment; planned duration of breastfeeding (mo): no breastfeeding: 2 (1.1%) women, 1–2 mo: 12 women (6.7%), 3–6 mo: 44 women (24.6%), 7–12 mo: 20 women (11.2%), >12 mo: 101 women (56.4%). Control: mean age 31.5 (SD 4.1), 181 LSCS, 76 completed secondary education, mean birth wt 3160 g (SD 500), 137 women in employment; planned duration of breastfeeding: not planning to breastfeed: 0 women, 1–2 mo: 9 women (5%), 3–6 mo: 44 women (24.3%), 7–12 mo: 26 women (14.4%), >12 mo: 102 women (56.4%) Intervention: day 1 discharge after delivery; control: day 2 discharge after delivery. Cointervention: none Proportion of: infants readmitted <7 d and <6 wk, women readmitted to hospital <6 wk, women breastfeeding at 6 wk, depression score at 6 wk after birth, women attending medical consultation at 2 and 6 wk after birth, infant unscheduled medical consultation at 2 and 6 wk after birth, maternal satisfaction Actual length of postnatal stay: same day: intervention: 0 (0%), control: 1 (0.6%); next day: intervention: 94 (55.3%), control: 58 (33.7%); day 2: intervention: 66 (38.8%), control: 106 (61.6%); day 4: intervention: 1 (0.6), control: 6 (3.5%). Compliance to allocation: 28/170 (16.5%) in intervention group were not discharged on day 1; 24/172 (14%) were not discharged on day 2 (12 stayed longer, 12 went home earlier) 
Waldenström et al17  Design: RCT. Method of randomization: unclear. Recruitment and random assignment: recruitment method unknown, antenatal (30 wk gestation). Blinding: women and health professionals unblinded, outcome assessor unknown. Length of follow-up: 6 mo. Type of analysis: not ITT. Total incomplete outcome data: 36.6%. Attrition: 13 (7.9%). Postrandomization exclusions: 47 (28.7%). Duration of study: March 1984 to June 1985. Setting: Uppsala, Sweden No. eligible: 1604. No. recruited and randomly assigned: 1604 recruited, 164 randomly assigned (10.2%); intervention: 85, control: 79; subsequently analyzed: intervention: 50, control: 54. Inclusion criteria: low-risk normal delivery with no complications. Exclusion criteria: cesarean delivery, multiple birth, prematurity, birth wt <3000 g, significant morbidity in first 24 h. Characteristics of women: intervention: mean age 28, 20% primiparous, 44% completed education beyond secondary school, mean birth wt 3658 g, 60% in employment; control: mean age 27, 30% primiparous, 44% completed education beyond secondary school, mean birth wt 3481 g, 57% in employment Intervention: discharge <48 h after delivery; C: discharge >48 h after delivery. Cointervention: midwife home visits 3–4 times in the first week and antenatal visits, pediatric examination on day 5 after birth Proportion of infants readmitted to hospital <7 d after birth, mothers readmitted to hospital <6 wk after birth, women breastfeeding at 2 and 6 mo, infant health problems at 5 d identified during routine pediatric assessment, maternal fatigue at 14 d, maternal satisfaction with care Actual length of postnatal stay (average): intervention: 1.5 nights; control: 4.1 nights. Noncompliance: not stated 
Winterburn and Fraser19  Design: RCT. Method of randomization: sealed envelopes. Recruited and randomly assigned: antenatal at parent education sessions. Blinding: women and health professionals unblinded, unclear blinding of outcome assessor. Length of follow-up: 4 wk. Type of analysis: ITT and per protocol. Incomplete outcome data: 2.7%. Attrition: 7 (2.7%). Postrandomization exclusions: none. Duration of study: February 1996 to June 1998. Setting: North England, United Kingdom No. eligible: 255. No. recruited and randomly assigned: 255 recruited antenatal, 248 randomly assigned, intervention: 121, control: 127. Inclusion criteria: All women. Exclusion criteria: women who did not want to breastfeed or had strong preference for LoS. Characteristics of women: no data reported on baseline characteristics Intervention: discharge 6–48 h after delivery; control: discharge > 48 h after delivery. Cointervention: home support with community midwife Proportion of women breastfeeding at 4 wk Actual length of postnatal stay: intervention: <48 h = 31 women (25.6%), >48 h = 90 women (74.4%); control: <48 h = 20 women (15.7%), >48 h = 107 women (84.3%). Compliance to group allocation: 90/124 (74%) in intervention group moved to control group, 20/127 (17%) in control group moved to early discharge 
Yanover et al14  Design: RCT. Method of randomization: unclear. Recruited and randomly assigned: antenatal. Blinding: women and health professionals unblinded, outcome assessor unknown. Length of follow-up: 6 wk. Type of analysis: ITT. Total incomplete outcome data: 31.3%. Attrition: none (all described as postrandomization exclusions). Postrandomization exclusions: 4 (31.3%). Duration of study: not reported. Setting: San Francisco, CA No. eligible: unclear. No. recruited and randomly assigned: 271 approached, 143 not eligible, 128 recruited and randomly assigned, 40 postrandomization exclusions, subsequently analyzed: intervention: 44, control: 44.Inclusion criteria: 0 or 1 parity, mother aged between 19 and 35 y, low medical risk, completed secondary education, father willing to attend prenatal classes, prospective parents must be living together, converse in English, reside within 32 km of the hospital. Exclusion criteria: intrapartum: cesarean delivery, prolonged rupture of membranes, precipitous labor (<3 h), blood pressure >140/90 mm Hg, pyrexia; postnatal: maternal temperature >38°C, blood pressure <90/60 mm Hg or >140/90 mm Hg, excessive blood loss, dysuria; infant: birth wt <2.5 kg or >4.5 kg, gestation age >38 wk and <42 wk, Apgar score <7 at 1 min, abnormal vital signs, feeding difficulties, failure to void urine. Characteristics of women: no statistically significant differences between the intervention and control group in age, race, father’s occupation, planned pregnancy, duration of marriage, length of time to conceive, mother’s and father’s education, presence of another child in the home, or mother’s preference for antenatal classes, natural childbirth, or breastfeeding (but no data given by group allocation) Intervention: discharge 12–48 h after delivery; control: discharge > 48 h after delivery. Cointervention: family-centered perinatal care program: collaborative multidisciplinary working from A/N to PN care, antenatal classes, daily visits for 4 d. While on ward, infants went to nursery or 6 h Proportion of: infants readmitted in the first 6 wk, women readmitted in the first 6 wk after giving birth, maternal views about length of postnatal stay Actual postnatal length of postnatal stay: intervention: 12–24 h (n = 21), 25–48 h (n = 11), 49–72 h (n = 10), 73–96 h (n = 2), >96 h (n = 0); control: 12–24 h (n = 0), 25–48 h (n = 5), 49–72 h (n = 22), 73–96 h (n = 12), >96 h (n = 5). Compliance: 12/44 (27.2%) from intervention to control; 5/44 (11.3%) from control to intervention 
Evans et al24  Design: ITS. Data source: linked administrative record data provided by the State of California Office of Statewide Health Planning and Development. Time points measured: monthly. Length of follow-up: 28 d. Type of analysis: 2 stage least squares model, which combines first-stage and reduced form estimates into a 2-stage least squares estimate. Missing data: not known. Duration of study: July 1995 to December 2000. Setting: California, United States No. participants: 3 million (grouped into 6 categories): (1) Medicaid uncomplicated vaginal birth, (2) Medicaid complicated vaginal birth, (3) Medicaid LSCS delivery, (4) private uncomplicated vaginal birth, (5) private complicated vaginal birth, and (6) private LSCS delivery. Inclusion criteria: all mother-infant pairs. Exclusion criteria: not reported. Characteristics of women: age: < 20: group 1: 0.295, group 2: 0.232, group 3: 0.286, group 4: 0.089, group 5: 0.075, group 6: 0.043; 20–24 y: group 1: 0.338, group 2: 0.290, group 3: 0.286, group 4: 0.201, group 5: 0.171, group 6: 0.130; 24–30 y: group 1: 0.215, group 2: 0.237, group 3: 0.253, group 4: 0.317, group 5: 0.299, group 6: 0.282. Ethnicity: Black: group 1: 0.075, group 2: 0.086, group 3:0.094, group 4: 0.052, group 5:0.065, group 6: 0.067; other races: group 1: 0.080, group 2:0.090, group 3: 0.066, group 4: 0.168, group 5: 0.159, group 6: 0.160; Hispanic: group 1: 0.658, group 2: 0.607, group 3: 0.641, group 4: 0.281, group 5: 0.278, group 6: 0.258. Maternal education: less than secondary school education: group 1: 0.572, group 2: 0.563, group 3: 0.531, group 4: 0.140, group 5: 0.43, group 6: 0.115; higher degree: group 1: 0.403, group 2:0.411, group 3: 0.435, group 4: 0.534, group 5: 0.545, group 6: 0.535. Parity: multiparous: group 1: 0.628, group 2: 0.688, group 3: 0.650, group 4: 0.607 group 5: 0.610, group 6: 0.574 Federal law (1996 September): mandated insurance providers to >48 h vaginal birth, > 96 h cesarean delivery (Medicaid exempt). State law (August 1997): Californian insurers cover for home visit if discharged early. State law (August 1998): state legislature extending statute to all Medicaid patients in the state Proportion of infants discharged early in the prelegislative and postlegislative period; proportion of infants readmitted within 7 and within 28 d of birth — 
Datar and Sood25  Design: ITS. Data source: linked database (publicly available) of birth certificate, death certificate and hospital discharge data, available from California’s office of Statewide Health Planning and Development. Time point measured: yearly (pre-law and 1, 2 and 3 y post law). Length of follow-up: 28 d. Type of analysis: multivariate linear regression model and multivariate logistic regression. Missing data: not given. Duration of study: 1991–2000. Setting: California, United States. Unit of allocation: population. Funding: NICHHD grant Total population: not given. No. participants eligible: not given. No. participants recruited: 4 662 753 infants. Inclusion criteria: singleton live born births in Californian civil hospitals. Exclusion criteria: infants who died before discharge, were transferred to another facility, implausibly short or missing LoS or missing birth hour (3%), medically unattended births and fetal deaths, multiple birth, premature and low birth wt infants. Characteristics of women (covariates): Pre-law (1991–1997): ethnicity: 40.6% white, 6.2% Black, 41.6% Hispanic, 10.7% other; mother’s education 33.9% less than high school, 66.1% more than high school; maternal age: 4.6% <18 y, 82.9% 18–35 y, 12.6% >35 y; insurance type: 44.5% Medicaid, 49.7% non-Medicaid, 5.7% uninsured; parity: 61.0% multiparous; mode of delivery: cesarean 20.1%. Post law (1998–2000): ethnicity: 37.6% white, 5.6% Black, 43.7% Hispanic, 11.8% other; maternal education: 29.8% less than high school, 70.2% more than high school; maternal age at delivery: 3.9% <18 y, 80.8% 18–35 y, 15.3% > 35 y; insurance type: 40.1% Medicaid, 55.9% non-Medicaid, 4.0% uninsured; parity: 61.5% multiparous; mode of delivery: cesarean 21.1% California’s postpartum LoS legislation introduced December 1996, adopted August 1997 insurance covered women for >48 h (>96 for LSCS) and follow-up visits at home. Federal postpartum legislation adopted January 1998 covered at > 48 h postnatal stay in hospital (neither federal nor state law covered Medicaid recipients) Change in length of postnatal stay in hours post law at 1, 2, and 3 y compared with pre-law. Change in odds of infant readmission to hospital within 28 d (including cause-specific conditions: jaundice, infection, and respiratory problems). Change in 1 y infant mortality (mortality and cause-specific mortality within 1 year of birth) Yearly data available only: did not consider the impact of expanding the state law to all Medicaid patients in September 1998. LoS in h imputed by using hour of birth and nights hospitalized and assuming discharge at 5 pm if on the day born and at 1 PM if ≥1 night’s stay 
Meara et al26  Design: ITS of a population-based cohort study. Data source: Medicaid claims data and birth certificate data. Time points: quarterly prelegislation (July 1, 1991, to August 22, 1995), legislative (October 1, 1995, to September 30, 1996), postlegislative (October 17, 1996, to –May 30, 1998). Length of follow-up: 21 d after birth. Type of analysis: ITS segmented linear regression analysis. Missing data: not recorded. Duration of study: June 1991 and June 1998. Setting: Ohio Medicaid services, United States. Unit of allocation: population. Funding: Health Resources and Services Administration, Maternal and Child Health Bureau No. participants: 1 069 693 births in Ohio between July 1, 1991, and June 30, 1998; 288 808 infant Medicaid recipients with valid claims and still receiving Medicaid 31 d after birth. No. recruited: 155 352 infants (including 4.225 who were delivered vaginally and had short stays). Inclusion criteria: patients covered by Medicaid population; infants: normal infants who were born to Ohio Medicaid recipients. (normal = birth wt > 2000 g, gestational age >37 wk, and with a diagnosis related group 391). Exclusion criteria: neonates who were born to mothers who were enrolled in health maintenance organization plans, June births (inability to match births and claims across fiscal years), births between August 22, 1995, October 1, 1996, and October 16, 1996. Characteristics of women: Prelegislation (July 1, 1991 to August 22, 1995): n = 18 494, education less than high school: 36%, high school degree: 48%, post–high school: 17%; age: 29% <20 y, 2% > 35 y; ethnicity: 23% multiracial or people of color; 62% unmarried; parity: 0: 43%, 1–3: 53%, >4: 4%; 65% resided in metropolitan area; No. A/N visits: mean = 11 (SD = 4); cesarean delivery: 17%; rate of short stay: 17%. Legislative (October 1, 1995, to September 30, 1996): n = 19 229; education: less than high school degree 32%, high school degree 47%, post–high school 21%; age: 2% <20 y, 3% >35; ethnicity: 18% multiracial or people of color; 61% unmarried; 56% resided in the metropolitan area; parity: 0: 46%, 1–3: 51%, >4: 4%; No. A/N visits: mean 11(SD 3.9); cesarean delivery: 15%; rate of short stay: 55%. Postlegislative (October 16, 1996, to June 30, 1998): n = 27 629; education: less than high school degree 33%, high school degree 47%, post–high school 20%; age: 19% <20 y, 3% >35 y; ethnicity: 15% multiracial or people of color; 61% unmarried; 52% resided in metropolitan area; parity: 0: 45%, 1–3: 51%, >4: 3%; No. A/N visits: mean 11(SD 4.0); cesarean delivery: 15%; rate of short stay 33% Ohio legislation introduced August 22, 1995, passed July 1996, implemented October 17, 1996 mandating insurance coverage of minimum postnatal hospital stay (>48 h after birth and 96 h for cesarean delivery) and early follow-up visits by the age of 4 d.  Change in length of postnatal stay (expressed as proportion [%]) of infants having a short stay (defined as within 1 d of birth of vaginal birth and within 2 d for cesarean birth); rate of follow-up visits within 6 d of birth; rehospitalization within 10 d of birth: total, cause-specific: jaundice, infection and dehydration, and ED visits To avoid including births from 2 different legislative periods in a single quarter, authors excluded births between August 22, 1995, and September 30, 1995, and between October 1, 1996, and October 16, 1996. Excludes infants if mother had health maintenance organization plan because data deemed to be incomplete 
Madden et al27  Design: ITS of a population-based cohort study. Data source: Harvard Vanguard medical Associates automated medical records system and claims for reimbursement. Time points: quarterly. Length of follow-up: 10 d. Type of analysis: ITS regression. Missing data: birth wt n = 159, gestation n = 3121, 5-min Apgar score n = 1283, maternal age n = 9, parity n = 4 478 433, ethnic group n = 433. Duration of study: October 1990 to March 1998. Setting: Massachusetts, Harvard Vanguard Medical Associates, caring for 30 000 persons insured by Harvard Pilgrim Health Care. Funding: Agency for Healthcare Research and Quality, Harvard Pilgrim Child Health Foundation, Maternal and Child Health Bureau No. participants in population: 33 344 women and 30 228 infants detected. No. eligible: 20 366 mother and infant pairs. Inclusion criteria: infant: infants were required to have Harvard Pilgrim Health Care insurance for at least 45 of the first 60 d and at least 1 medical encounter (95.5% of newborns). Exclusion criteria: cesarean delivery (23.6%), LoS >4 d, unequal stays for mother and infant (3.2%), observations for the third quarter of 1994 and the first quarter of 1996 were omitted. Characteristics of women: maternal age: 4.5% of women <22 y, 31.2% of women 22–29 y, 39.2% of women 30–34 y, 25.1% of women >35 y; parity: 44.6% primiparous women; enrolled in Medicaid: 6.7%; census-based socioeconomic status indicators: living in low income: 6.7%, living in low education tract: 19.9%; ethnicity: 69.2% white, 17% Black, 6.6% Asian American, 4.9% Hispanic, 22% other. Infant characteristics: birth wt: 2.7% of infants <2.5 kg, 12.9% of infants 2.5–2.99 kg, 84.4% of infants >3.0 kg; gestational age: 6.6% of infants <38 wk, 27.1% of infants 38–39 wk, 66.3% of infants 40+ wk; 5-min Apgar score: 1.7% with <8, 6.7% with 8, 91.6% with 9–12. Vulnerable group: enrolled in Medicaid, living in neighborhood with median household income <$25 000 or neighborhood with one-third more residents ≥25 y with less than high school education or ages <22 y. No data on pre- and postlaw differences in characteristics of study population Intervention 1: ROLOS program, 1 night in hospital after a normal birth delivery and home visit by nurse within 48 h and enhanced assistance with lactation. Intervention 2: Massachusetts law >48 h minimum coverage for postnatal stay in hospital, or home visit if women were discharged from the hospital <48 h Proportion of infants discharged early in the prelegislative, legislative, and postlegislative periods. Proportion of mother-infant pairs with LoS <2 d, infants attending nonurgent and urgent health centers, infants readmitted in first 10 d, Infants admitted for avoidable conditions in first 21 d (jaundice and feeding problems), infants treated for phototherapy, women breastfeeding at 3 mo Excludes women who had an LSCS and those with no insurance. Teen-aged mothers and Medicaid recipients were underrepresented in study when compared with Massachusetts or the nation as a whole and women with health maintenance organization insurance are most likely to have higher levels of education and income compared with United States overall 
Sievertsen and Wüst28  Design: ITS of a population-based cohort study. Data source: Danish Inpatient Register (hospital medical records) and survey data from the Danish National Birth Cohort. Time points: yearly. Length of follow-up: 9 y. Type of analysis: 2-stage least squares estimates. Missing data: not recorded. Duration of study: 1985–2003. Setting: 5 counties in Denmark: Aarhus, Ringkobing, Viborg, Veijle, and Ribe. Funding: Danish Council for Independent Research grant 11-116669 No. participants in population: 733 373. Inclusion criteria: all multiparous women were in the sample (mothers and infants were not excluded if they had health problems, but rather estimates were compared with and without controls for health at birth). Exclusion criteria: primiparous women, complicated birth. Characteristics of women: maternal age: 30.85 (SD 4.46), maternal age <18 y: 0 (SD 0.01), cesarean delivery: 0.13 (SD 033), married: 0.63 (SD 0.48), higher education: 0.29 (SD 0.45), taxable income: 176.16 (SD 85.07), mothers unemployed: 0.13 (SD 0.34), in education: 0.02 (SD 0.14), mother readmitted: 0.02 (SD 0.14), mother readmitted <365 d: 0.10 (SD 0.29). Infant characteristics: male child: mean 0.51 (SD 0.50), birth wt: 3571.27 (SD 559.16), infant birth wt <2.5 kg: 0.03 (SD 0.17), preterm birth: 0.04 (SD 0.19), Apgar score <7: 0 (SD 0.07), child hospital nights at birth: 3.46 (SD 6.15), same-day discharge: 0.14 (SD 0.35), infant readmitted within 28 d: 0.04 (SD 0.20), infant readmitted within 365 d: 0.21 (SD 0.40) Mandated discharge on the day of birth: a same-day discharge without formal maternity ward admission for all uncomplicated births by multiparous women in the period 1990–2003 Proportion of infants readmitted <28 d and 1 y, child’s school achievement at aged 15 y, mothers readmitted within 28 d, mothers readmitted 1 y, breastfeeding at 4 mo, GP contacts for infants and maternal health problems at 1 mo Same-day discharge was defined as hospital discharge of the mother and child on the calendar day of birth; therefore, this will underestimate the prevalence of same-day discharge 
StudyMethodsParticipantsInterventionOutcomes MeasuresNotes
Bayoumi et al15  Design: RCT. Randomization method: sealed envelopes with discharge protocol opened after 24 h post birth. Recruited and randomly assigned: postnatal. Blinding: caregiver, women and outcome assessor unblinded. Length of follow-up: 6 wk. Type of analysis: Per protocol. Total incomplete outcome data: 788 (21%). Attrition: intervention: 263/1890 (13.9%), control: 205/1896 (10.8%), total: 468 (12.4%). Postrandomization exclusions: intervention: 132/1890 (7%), control: 188/1896 (9.9%), total: 320/3786 (8.5%). Duration of study: June 2012 to February 2014. Setting: Maternity hospital, Faculty of Medicine, Cairo University, Egypt No. eligible: 6340. No. recruited and randomly assigned: intervention: 1890, control: 1896. Inclusion criteria: women aged 20–40, no known medical condition, (eg, diabetes; hypertension; renal, cardiac, or chest problems; or connective tissue disease), no obstetric complications (eg, placenta previa, placenta accreta, accidental hemorrhage or preeclampsia), all term pregnancies, ≥37 wk, no fetal problems, intrauterine growth restriction, major congenital abnormality, and all patients discharged with their newborn. Exclusion criteria: <20 or >40 y old, patients with a known medical problem, any fetal problem diagnosed after delivery, or patients and newborn who did not meet the criteria of discharge at the 24 or 72 h interval chosen for their discharge. Fit for discharge criteria: no postpartum complications (eg, postpartum hemorrhage, urinary tract infection, chest complications), a febrile postoperative course defined as no temperature elevation >38.3°C during the first 24 h or >38°C after 24 h, bowel movement or passage of flatus, established urination, no neonatal problems (eg, respiratory complications, no jaundice, or vomiting). Characteristics of women: intervention: age 30.6 (SD 6.2), control: age 30.9 (SD5.7). Characteristics of infants: gestation at birth: intervention: 39.44 (SD 1.47), control: 39.07 (SD 1.28) Intervention: discharge 24 h after delivery; control: discharge 72 h after delivery Proportion of infants and women readmitted to hospital <6 wk. Women reporting symptoms: wound infection, abdominal infection, secondary postpartum hemorrhage, successful breastfeeding, intestinal ileus, fever, breast engorgement, stress incontinence, chest infection, pulmonary embolism, deep vein thrombosis, mood swings Actual LoS: unknown. Compliance to group allocation: 132/1890 from intervention did not stay 24 h and were removed from analysis; 188/1896 from control group who left earlier than 72 h were removed from analysis 
Boulvain et al16  Design: RCT. Randomization method: telephone call by using sealed envelopes. Recruited and randomly assigned: antenatal appointment at 37/40. Blinding: caregiver, women, and outcome assessor unblinded. Length of follow-up: 6 mo. Type of analysis: ITT. Total incomplete outcome data: 22 (4.7%). Attrition: 21 (4.6%). Postrandomization exclusions: 1 (0.1%). Duration of study: November 1998 to October 2000. Setting: Switzerland, tertiary level maternity unit No. eligible: 2324. No. recruited and randomly assigned: 460, intervention: 228, control: 231. Inclusion criteria: low-risk women, at low risk of cesarean delivery or postnatal complications, nulliparous or multiparous. Exclusion criteria: placenta previa, preeclampsia, diabetes treated with insulin, medical complication of pregnancy requiring postnatal hospital surveillance, past history of postnatal complication, difficult socioeconomic situation, multiple pregnancy, suspicion of IUGR, estimated fetal wt >95th percentile, fetal malformation or genetic disease, strong preference for length of postnatal stay. Characteristics of women: intervention: mean age 29 (SD 4.8), 137 (60%) nulliparous, 164 vaginal birth, 40 instrumental delivery, 24 cesarean delivery, 113 completed secondary education, mean birth wt: 3420 g (SD 435); control: mean age 29 (SD 5.5), 131 (57%) nulliparous, 149 vaginal birth, 55 instrumental delivery, 27 cesarean delivery, 118 women completed secondary education, mean birth wt 3480 (SD 405) Intervention: discharge 24–48 h after delivery; control: discharge 4–5 after vaginal birth (+2 d for cesarean delivery). Cointervention: minimum 2 nurse home visits and 10 phone calls, No. and timing dependent on needs of family Infants and women readmitted to hospital <28 d and 2–6 mo. Breastfeeding at 7 d/28 d/6 mo. Depression at 7/28 d. Infant feeding problems <28 d. SF-12 physical and mental summary score. Neonatal admissions for >24 h at 28 d post birth. Neonatal jaundice views about quality of postnatal care. Missed metabolic or endocrine congenital disease. Economic evaluation. Maternal satisfaction Actual length of postnatal stay (mean): intervention: 65 h, control: 106 h. Compliance to group allocation: 114/228 (50%) moved to control group from intervention, 67/231 (29%) moved to intervention from control 
Sainz Bueno et al23  Design: RCT. Method of randomization: opaque sealed envelopes, randomization by blocks (opaque sealed envelopes) defined by parity in postnatal ward. Recruited and randomly assigned: postnatal. Blinding: women and health professional unblinded, blinding of outcome assessment unclear. Length of follow-up: 6 mo. Type of analysis: ITT. Total incomplete outcome data: 5.1%. Attrition: 22 (5.1%). Postrandomization exclusions: none. Duration of study: April 1999 to April 2001. Setting: Seville, Spain (urban maternity hospital) No. eligible: unknown. No. recruited and randomly assigned: 430 recruited; intervention: 213; control: 217. Inclusion criteria: primiparous and multiparous women, term normal vaginal birth or assisted vaginal delivery; postnatal criteria: apyrexial, normotensive blood pressure, postpartum estimated blood loss <500 mL, and adequate uterine involution; neonate: term gestation with appropriate wt for gestational age, normal cardiorespiratory adaptation to extra uterine life, no evidence of sepsis or jaundice, normal temperature (36.1–37°C); physical examination by doctors, passed meconium and urine once, administration of vitamin K and other vaccinations. Exclusion criteria: third- or fourth-degree tear, maternal drug abuse, gestational diabetes, preeclampsia, rhesus isoimmunization, postpartum blood loss >500 mL, >20 km from hospital and/or difficulty getting to hospital. Characteristics of women: intervention: mean birth wt 3348 g, 29 completed secondary education, 187 vaginal birth, 26 assisted vaginal birth, 78 primiparous, 135 multiparous, maternal age (categories): 11 women <19 y, 115 women 20–30 y, 85 women 31–40 y, 4 women >40 y; control: mean birth wt 3335 g (SD 372), 28 women completed secondary education, 82 primiparous, 135 multiparous, 192 normal vaginal birth, 25 assisted vaginal birth, maternal age (categories): 7 women <19 y, 117 women 20–30 y, 88 women 31–40 y, 1 woman >40 y Intervention: discharge <24 h after delivery; control: minimum 48 h stay in hospital and monitored at 7–10 d postpartum. Intervention: home support for after 24–48 h by a nurse qualified in postnatal and neonatal care Proportion of infants readmitted to hospital <28 d, women readmitted <6 wk after giving birth, women breastfeeding at 1 wk or 1 and 6 mo, depression at 1 wk or 1 mo, maternal exhaustion or fatigue <4 wk postnatal, women physical health problems in first 6 mo, women and infants requiring health consultation, health consultation, maternal satisfaction, duration of rehospitalization, economic evaluation Actual length of postnatal stay (mean): intervention: 27.23 h (SD 9.12); control: 51.25 h (SD 7.29). Compliance to group allocation: not stated 
Carty and Bradley20  Design: RCT. Method of randomization: Sealed opaque envelopes opened by nurse at home visit. Recruited and randomly assigned: antenatal, 37 wk gestation. Blinding: women and health professional and outcome assessor unblinded. Length of follow-up: 1 mo. Type of analysis: not ITT. Total incomplete outcomes data: 30.7%. Attrition: 13 (6.9%). Postrandomization exclusions: 45 (24%). Duration of study: not reported. Setting: Vancouver, Canada, tertiary care maternity unit No. eligible: unknown. No. recruited and randomly assigned: 189 recruited and randomly assigned; intervention 1: n = 44; intervention 2: n = 49; control group: n = 38. Inclusion criteria: all women expecting a vaginal birth. Exclusion criteria: cesarean or forceps delivery. Characteristics of women (eg, maternal age of intervention and control): mean age 30.24 y (SD 3.80), >95% white, 93% married or cohabiting, 65% completed junior college or university, 50% combined household income > $40 000, mean paternal age 32.87 y, 53% primiparous, 47% multiparous (baseline characteristics table not reported to enable comparison of baseline characteristics by group allocation) Intervention 1: discharge 12–24 h after delivery; intervention 2: discharge 25–48 h after delivery; control: 3–4 d discharge. Cointervention: nurses had 2-wk training course; intervention 1: home visits on day 1, 2, 3, 5, and 10; intervention 2: home visits on 3, 5, and 10 Proportion of infants readmitted to hospital in first 6 wk, women readmitted for complication related to childbirth in first 6 wk, women breastfeeding at 1 mo, women scoring above cutoff for probable depression and anxiety, maternal satisfaction, confidence in mothering role, frequency of maternal problems requiring physician referral <10 d Actual LoS (mean): intervention 1: 1.12 d (SD 0.4); intervention 2: 2.06 d (SD 0.6); control: 4.03 d (SD 0.7). Compliance to group allocation: not stated 
Gagnon et al21  Design: RCT. Method of randomization: opaque sealed envelopes placed on medical file before antenatal home visit. Recruited and randomly assigned: antenatal recruitment from attendance physician’s office, hospital ultrasonography, or family planning clinic (3 recruitment sites) between 32 and 38 wk gestation. Blinding: women and health professionals and outcome assessor unblinded. Length of follow-up: 1 mo. Type of analysis: not ITT. Total incomplete outcome data: 51.4%. Attrition: 26 (7.2%). Postrandomization exclusions: 159 (44.1%). Duration of study: January 1900 to December 1990. Setting: Montreal, Canada 1354 women approached, 938 eligible, 360 recruited and randomly assigned. Intervention: 183,control: 177; final No. analyzed: intervention: 78, control: 97. Inclusion criteria: parity 0–4, normal pregnancy (eg, absence of medical conditions); cephalic presentation at 36 wk; ability to speak English, French, or Spanish; telephone availability; and residence within 30 min of hospital. Exclusion criteria: intrapartum exclusion: prolonged rupture of membranes >24 h before birth, cesarean delivery, estimated blood loss >500 mL, and third- or fourth-degree perineal tear; postpartum exclusion: excessive bleeding, inability to void adequately, reduced mobility. no receipt of Anti D when indicated, medical conditions requiring close supervision; infant exclusion: multiple birth, birth wt <2500 g, preterm (<37 wk), abnormal newborn physical examination, not established feeding. Characteristics of women: mean age: intervention: 29.6 (SD 4.7), control 29.1 (SD5.3); parity: intervention: 38% primiparous, control: 34% primiparous; mean birth wt: intervention: 3389 (SD 419), control: 3496 (SD 364); mean length time in education: intervention: 13.8 9 (SD 3.8), control: 14.0 (SD 3.9); recent migrant: intervention: 14.1%, control: 24.7%; mean gestational age at recruitment: intervention:34.5, control: 34.0; antenatal depression: intervention: 10.4%, control: 13%; smoking status: intervention: 23.1%, control: 9%; mode of birth intervention: 43.5% cesarean delivery, 56.3% vaginal birth; control: 39.2% cesarean delivery, 60.8% vaginal; mean gestational age at birth: intervention: 39.3 (SD 1.3), control: 39.5 (SD 1.1); intend to b/f: intervention: 70.5%, control: 54.6% Intervention: discharge 6–36 h after delivery; control: 48–72 h discharge. Cointervention: nursing care by telephone <48 h and at 10 d postpartum, home visits at 34–38 wk and 3–5 d postnatal Proportion of women predominantly breastfeeding at 1 mo, infants requiring a “health contact” at 10 d, maternal satisfaction, perceived maternal or parental competency Actual LoS: intervention: 37.5 h (SD 19.7); control: 54.3 h (SD 18.0). Noncompliance to group allocation: 26/78 (33%) in intervention group moved to control group 
McKeever et al22  Design: RCT. Method of randomization: unclear (by using central randomization methods). Recruited and randomly assigned: unknown method of recruitment, postnatal. Blinding: women and health professionals unblinded, blinding of outcome assessor unclear. Length of follow-up: up to 12 d postnatal. Type of analysis: ITT. Total incomplete outcome data: 26%. Attrition: 15 (14.9%). Postrandomization exclusions: 11 (11%). Duration of study: July 1999 to December 2000. Setting: Toronto, Canada No. eligible: 156. No. recruited and randomly assigned: recruited and randomly assigned postnatally: 156 recruited, 101 randomly assigned (stratified by gestation). Intervention: 53; control: 48. No. analyzed: term: intervention: 34, control: 41; near term: intervention: 15, control: 12. Inclusion criteria: live singleton within preceding 12 h, were at least 21 y, resided in metropolitan area, had a telephone, intended to breastfeed, were breastfeeding at discharge, would receive satisfactory support at home; infant inclusion: ≥35 wk gestation, breastfeeding at discharge, no congenital abnormalities or morbidities (including hyperbilirubinemia, blood group incompatibility, or sepsis). Exclusion criteria: non–English speaking, cesarean delivery, postpartum complications, and morbidities (such as fever, abnormal bleeding, chronic illness, or disabilities). Characteristics of women: Intervention term: mean age 32 (SD 4.2); 51.3% primiparous; 48.7% multiparous; 100% vaginal birth; gestational age: 38–40/40 = 92%, 41/40 = 8%; breastfeeding at discharge 87%. Intervention near term: mean age 32.1 (SD 2.9); 57.1% primiparous; 42.9% multiparous; breastfeeding at discharge 68%; gestational age: 35/40 = 10.5%, 36/40 = 42.1%, 37/40 = 47.4%. Control term: mean age 33.1 (SD 4.4); 45.5% primiparous; 54.5% multiparous; gestational age: 38–40/40 = 81%, 41/40 = 99%; breastfeeding at discharge 83%. Control near term: mean age 32.1 (SD 4.4); 80% primiparous; 20% multiparous; gestational age: 35/40 = 5.6%, 36/40 = 33.3%, 37/40 = 61.1%; breastfeeding at discharge 72% Intervention: discharge 24–36 h after delivery; control: discharge 48–60 h after delivery. Cointervention: breastfeeding clinic outpatient and encouraged to use the preexisting 24 h telephone helpline Proportion of women breastfeeding at 5–12 d after birth LoS: term group: intervention: 37 h (range 23–61), control: 44.1 h (range 15–107); near-term group: intervention: 45 h (range 25–86), control: 48.2 h (range 28–68). Compliance to group allocation: not stated 
Tan et al18  Design: RCT. Method of randomization: random No. generator in random blocks of 4 or 8, numbered sealed envelopes; attached to medical charts and opened on day 1 on postnatal ward by health care provider to reveal allocation. Recruited and randomly assigned: postnatally. Blinding: women and health professional unblinded, outcome assessor, unclear. Length of follow-up: 6 wk. Type of analysis: ITT. Total incomplete outcome data: 5%. Attrition: 12 (3.3%). Postrandomization exclusions: 6 (1.6%). Duration of study: November 5, 2011 to February 15, 2012. Setting: Kuala Lumpur, Malaysia University Hospital, Kuala Lumpur, Malaysia No. eligible: 689 admitted for elective cesarean delivery, 329 either not eligible or not approach, unclear how many were ineligible. No. recruited and randomly assigned: 360 women randomly assigned postnatally, intervention: 179, control: 181. No. analyzed: intervention:170, control:172. Inclusion criteria: planned LSCS, aged >18 y, gestation ≥37, singleton pregnancy. Exclusion criteria: antenatal: known congenital abnormality, established medical problems or operative factors likely to preclude day 1 discharge (preeclampsia, cardiac disease, renal disease, connective tissue disease, ≥2 previous LSCS, major placenta previa); intrapartum: estimated blood loss >800 mL, hemoglobin level <80 g/L, immobile, not established voiding, febrile >38°C, abnormal blood pressure. Characteristics of women: Intervention: mean age 31.8 (SD 4.6), 179 had cesarean delivery, 67 completed higher education, mean birth wt = 3320 g (SD 0.51), 134 in employment; planned duration of breastfeeding (mo): no breastfeeding: 2 (1.1%) women, 1–2 mo: 12 women (6.7%), 3–6 mo: 44 women (24.6%), 7–12 mo: 20 women (11.2%), >12 mo: 101 women (56.4%). Control: mean age 31.5 (SD 4.1), 181 LSCS, 76 completed secondary education, mean birth wt 3160 g (SD 500), 137 women in employment; planned duration of breastfeeding: not planning to breastfeed: 0 women, 1–2 mo: 9 women (5%), 3–6 mo: 44 women (24.3%), 7–12 mo: 26 women (14.4%), >12 mo: 102 women (56.4%) Intervention: day 1 discharge after delivery; control: day 2 discharge after delivery. Cointervention: none Proportion of: infants readmitted <7 d and <6 wk, women readmitted to hospital <6 wk, women breastfeeding at 6 wk, depression score at 6 wk after birth, women attending medical consultation at 2 and 6 wk after birth, infant unscheduled medical consultation at 2 and 6 wk after birth, maternal satisfaction Actual length of postnatal stay: same day: intervention: 0 (0%), control: 1 (0.6%); next day: intervention: 94 (55.3%), control: 58 (33.7%); day 2: intervention: 66 (38.8%), control: 106 (61.6%); day 4: intervention: 1 (0.6), control: 6 (3.5%). Compliance to allocation: 28/170 (16.5%) in intervention group were not discharged on day 1; 24/172 (14%) were not discharged on day 2 (12 stayed longer, 12 went home earlier) 
Waldenström et al17  Design: RCT. Method of randomization: unclear. Recruitment and random assignment: recruitment method unknown, antenatal (30 wk gestation). Blinding: women and health professionals unblinded, outcome assessor unknown. Length of follow-up: 6 mo. Type of analysis: not ITT. Total incomplete outcome data: 36.6%. Attrition: 13 (7.9%). Postrandomization exclusions: 47 (28.7%). Duration of study: March 1984 to June 1985. Setting: Uppsala, Sweden No. eligible: 1604. No. recruited and randomly assigned: 1604 recruited, 164 randomly assigned (10.2%); intervention: 85, control: 79; subsequently analyzed: intervention: 50, control: 54. Inclusion criteria: low-risk normal delivery with no complications. Exclusion criteria: cesarean delivery, multiple birth, prematurity, birth wt <3000 g, significant morbidity in first 24 h. Characteristics of women: intervention: mean age 28, 20% primiparous, 44% completed education beyond secondary school, mean birth wt 3658 g, 60% in employment; control: mean age 27, 30% primiparous, 44% completed education beyond secondary school, mean birth wt 3481 g, 57% in employment Intervention: discharge <48 h after delivery; C: discharge >48 h after delivery. Cointervention: midwife home visits 3–4 times in the first week and antenatal visits, pediatric examination on day 5 after birth Proportion of infants readmitted to hospital <7 d after birth, mothers readmitted to hospital <6 wk after birth, women breastfeeding at 2 and 6 mo, infant health problems at 5 d identified during routine pediatric assessment, maternal fatigue at 14 d, maternal satisfaction with care Actual length of postnatal stay (average): intervention: 1.5 nights; control: 4.1 nights. Noncompliance: not stated 
Winterburn and Fraser19  Design: RCT. Method of randomization: sealed envelopes. Recruited and randomly assigned: antenatal at parent education sessions. Blinding: women and health professionals unblinded, unclear blinding of outcome assessor. Length of follow-up: 4 wk. Type of analysis: ITT and per protocol. Incomplete outcome data: 2.7%. Attrition: 7 (2.7%). Postrandomization exclusions: none. Duration of study: February 1996 to June 1998. Setting: North England, United Kingdom No. eligible: 255. No. recruited and randomly assigned: 255 recruited antenatal, 248 randomly assigned, intervention: 121, control: 127. Inclusion criteria: All women. Exclusion criteria: women who did not want to breastfeed or had strong preference for LoS. Characteristics of women: no data reported on baseline characteristics Intervention: discharge 6–48 h after delivery; control: discharge > 48 h after delivery. Cointervention: home support with community midwife Proportion of women breastfeeding at 4 wk Actual length of postnatal stay: intervention: <48 h = 31 women (25.6%), >48 h = 90 women (74.4%); control: <48 h = 20 women (15.7%), >48 h = 107 women (84.3%). Compliance to group allocation: 90/124 (74%) in intervention group moved to control group, 20/127 (17%) in control group moved to early discharge 
Yanover et al14  Design: RCT. Method of randomization: unclear. Recruited and randomly assigned: antenatal. Blinding: women and health professionals unblinded, outcome assessor unknown. Length of follow-up: 6 wk. Type of analysis: ITT. Total incomplete outcome data: 31.3%. Attrition: none (all described as postrandomization exclusions). Postrandomization exclusions: 4 (31.3%). Duration of study: not reported. Setting: San Francisco, CA No. eligible: unclear. No. recruited and randomly assigned: 271 approached, 143 not eligible, 128 recruited and randomly assigned, 40 postrandomization exclusions, subsequently analyzed: intervention: 44, control: 44.Inclusion criteria: 0 or 1 parity, mother aged between 19 and 35 y, low medical risk, completed secondary education, father willing to attend prenatal classes, prospective parents must be living together, converse in English, reside within 32 km of the hospital. Exclusion criteria: intrapartum: cesarean delivery, prolonged rupture of membranes, precipitous labor (<3 h), blood pressure >140/90 mm Hg, pyrexia; postnatal: maternal temperature >38°C, blood pressure <90/60 mm Hg or >140/90 mm Hg, excessive blood loss, dysuria; infant: birth wt <2.5 kg or >4.5 kg, gestation age >38 wk and <42 wk, Apgar score <7 at 1 min, abnormal vital signs, feeding difficulties, failure to void urine. Characteristics of women: no statistically significant differences between the intervention and control group in age, race, father’s occupation, planned pregnancy, duration of marriage, length of time to conceive, mother’s and father’s education, presence of another child in the home, or mother’s preference for antenatal classes, natural childbirth, or breastfeeding (but no data given by group allocation) Intervention: discharge 12–48 h after delivery; control: discharge > 48 h after delivery. Cointervention: family-centered perinatal care program: collaborative multidisciplinary working from A/N to PN care, antenatal classes, daily visits for 4 d. While on ward, infants went to nursery or 6 h Proportion of: infants readmitted in the first 6 wk, women readmitted in the first 6 wk after giving birth, maternal views about length of postnatal stay Actual postnatal length of postnatal stay: intervention: 12–24 h (n = 21), 25–48 h (n = 11), 49–72 h (n = 10), 73–96 h (n = 2), >96 h (n = 0); control: 12–24 h (n = 0), 25–48 h (n = 5), 49–72 h (n = 22), 73–96 h (n = 12), >96 h (n = 5). Compliance: 12/44 (27.2%) from intervention to control; 5/44 (11.3%) from control to intervention 
Evans et al24  Design: ITS. Data source: linked administrative record data provided by the State of California Office of Statewide Health Planning and Development. Time points measured: monthly. Length of follow-up: 28 d. Type of analysis: 2 stage least squares model, which combines first-stage and reduced form estimates into a 2-stage least squares estimate. Missing data: not known. Duration of study: July 1995 to December 2000. Setting: California, United States No. participants: 3 million (grouped into 6 categories): (1) Medicaid uncomplicated vaginal birth, (2) Medicaid complicated vaginal birth, (3) Medicaid LSCS delivery, (4) private uncomplicated vaginal birth, (5) private complicated vaginal birth, and (6) private LSCS delivery. Inclusion criteria: all mother-infant pairs. Exclusion criteria: not reported. Characteristics of women: age: < 20: group 1: 0.295, group 2: 0.232, group 3: 0.286, group 4: 0.089, group 5: 0.075, group 6: 0.043; 20–24 y: group 1: 0.338, group 2: 0.290, group 3: 0.286, group 4: 0.201, group 5: 0.171, group 6: 0.130; 24–30 y: group 1: 0.215, group 2: 0.237, group 3: 0.253, group 4: 0.317, group 5: 0.299, group 6: 0.282. Ethnicity: Black: group 1: 0.075, group 2: 0.086, group 3:0.094, group 4: 0.052, group 5:0.065, group 6: 0.067; other races: group 1: 0.080, group 2:0.090, group 3: 0.066, group 4: 0.168, group 5: 0.159, group 6: 0.160; Hispanic: group 1: 0.658, group 2: 0.607, group 3: 0.641, group 4: 0.281, group 5: 0.278, group 6: 0.258. Maternal education: less than secondary school education: group 1: 0.572, group 2: 0.563, group 3: 0.531, group 4: 0.140, group 5: 0.43, group 6: 0.115; higher degree: group 1: 0.403, group 2:0.411, group 3: 0.435, group 4: 0.534, group 5: 0.545, group 6: 0.535. Parity: multiparous: group 1: 0.628, group 2: 0.688, group 3: 0.650, group 4: 0.607 group 5: 0.610, group 6: 0.574 Federal law (1996 September): mandated insurance providers to >48 h vaginal birth, > 96 h cesarean delivery (Medicaid exempt). State law (August 1997): Californian insurers cover for home visit if discharged early. State law (August 1998): state legislature extending statute to all Medicaid patients in the state Proportion of infants discharged early in the prelegislative and postlegislative period; proportion of infants readmitted within 7 and within 28 d of birth — 
Datar and Sood25  Design: ITS. Data source: linked database (publicly available) of birth certificate, death certificate and hospital discharge data, available from California’s office of Statewide Health Planning and Development. Time point measured: yearly (pre-law and 1, 2 and 3 y post law). Length of follow-up: 28 d. Type of analysis: multivariate linear regression model and multivariate logistic regression. Missing data: not given. Duration of study: 1991–2000. Setting: California, United States. Unit of allocation: population. Funding: NICHHD grant Total population: not given. No. participants eligible: not given. No. participants recruited: 4 662 753 infants. Inclusion criteria: singleton live born births in Californian civil hospitals. Exclusion criteria: infants who died before discharge, were transferred to another facility, implausibly short or missing LoS or missing birth hour (3%), medically unattended births and fetal deaths, multiple birth, premature and low birth wt infants. Characteristics of women (covariates): Pre-law (1991–1997): ethnicity: 40.6% white, 6.2% Black, 41.6% Hispanic, 10.7% other; mother’s education 33.9% less than high school, 66.1% more than high school; maternal age: 4.6% <18 y, 82.9% 18–35 y, 12.6% >35 y; insurance type: 44.5% Medicaid, 49.7% non-Medicaid, 5.7% uninsured; parity: 61.0% multiparous; mode of delivery: cesarean 20.1%. Post law (1998–2000): ethnicity: 37.6% white, 5.6% Black, 43.7% Hispanic, 11.8% other; maternal education: 29.8% less than high school, 70.2% more than high school; maternal age at delivery: 3.9% <18 y, 80.8% 18–35 y, 15.3% > 35 y; insurance type: 40.1% Medicaid, 55.9% non-Medicaid, 4.0% uninsured; parity: 61.5% multiparous; mode of delivery: cesarean 21.1% California’s postpartum LoS legislation introduced December 1996, adopted August 1997 insurance covered women for >48 h (>96 for LSCS) and follow-up visits at home. Federal postpartum legislation adopted January 1998 covered at > 48 h postnatal stay in hospital (neither federal nor state law covered Medicaid recipients) Change in length of postnatal stay in hours post law at 1, 2, and 3 y compared with pre-law. Change in odds of infant readmission to hospital within 28 d (including cause-specific conditions: jaundice, infection, and respiratory problems). Change in 1 y infant mortality (mortality and cause-specific mortality within 1 year of birth) Yearly data available only: did not consider the impact of expanding the state law to all Medicaid patients in September 1998. LoS in h imputed by using hour of birth and nights hospitalized and assuming discharge at 5 pm if on the day born and at 1 PM if ≥1 night’s stay 
Meara et al26  Design: ITS of a population-based cohort study. Data source: Medicaid claims data and birth certificate data. Time points: quarterly prelegislation (July 1, 1991, to August 22, 1995), legislative (October 1, 1995, to September 30, 1996), postlegislative (October 17, 1996, to –May 30, 1998). Length of follow-up: 21 d after birth. Type of analysis: ITS segmented linear regression analysis. Missing data: not recorded. Duration of study: June 1991 and June 1998. Setting: Ohio Medicaid services, United States. Unit of allocation: population. Funding: Health Resources and Services Administration, Maternal and Child Health Bureau No. participants: 1 069 693 births in Ohio between July 1, 1991, and June 30, 1998; 288 808 infant Medicaid recipients with valid claims and still receiving Medicaid 31 d after birth. No. recruited: 155 352 infants (including 4.225 who were delivered vaginally and had short stays). Inclusion criteria: patients covered by Medicaid population; infants: normal infants who were born to Ohio Medicaid recipients. (normal = birth wt > 2000 g, gestational age >37 wk, and with a diagnosis related group 391). Exclusion criteria: neonates who were born to mothers who were enrolled in health maintenance organization plans, June births (inability to match births and claims across fiscal years), births between August 22, 1995, October 1, 1996, and October 16, 1996. Characteristics of women: Prelegislation (July 1, 1991 to August 22, 1995): n = 18 494, education less than high school: 36%, high school degree: 48%, post–high school: 17%; age: 29% <20 y, 2% > 35 y; ethnicity: 23% multiracial or people of color; 62% unmarried; parity: 0: 43%, 1–3: 53%, >4: 4%; 65% resided in metropolitan area; No. A/N visits: mean = 11 (SD = 4); cesarean delivery: 17%; rate of short stay: 17%. Legislative (October 1, 1995, to September 30, 1996): n = 19 229; education: less than high school degree 32%, high school degree 47%, post–high school 21%; age: 2% <20 y, 3% >35; ethnicity: 18% multiracial or people of color; 61% unmarried; 56% resided in the metropolitan area; parity: 0: 46%, 1–3: 51%, >4: 4%; No. A/N visits: mean 11(SD 3.9); cesarean delivery: 15%; rate of short stay: 55%. Postlegislative (October 16, 1996, to June 30, 1998): n = 27 629; education: less than high school degree 33%, high school degree 47%, post–high school 20%; age: 19% <20 y, 3% >35 y; ethnicity: 15% multiracial or people of color; 61% unmarried; 52% resided in metropolitan area; parity: 0: 45%, 1–3: 51%, >4: 3%; No. A/N visits: mean 11(SD 4.0); cesarean delivery: 15%; rate of short stay 33% Ohio legislation introduced August 22, 1995, passed July 1996, implemented October 17, 1996 mandating insurance coverage of minimum postnatal hospital stay (>48 h after birth and 96 h for cesarean delivery) and early follow-up visits by the age of 4 d.  Change in length of postnatal stay (expressed as proportion [%]) of infants having a short stay (defined as within 1 d of birth of vaginal birth and within 2 d for cesarean birth); rate of follow-up visits within 6 d of birth; rehospitalization within 10 d of birth: total, cause-specific: jaundice, infection and dehydration, and ED visits To avoid including births from 2 different legislative periods in a single quarter, authors excluded births between August 22, 1995, and September 30, 1995, and between October 1, 1996, and October 16, 1996. Excludes infants if mother had health maintenance organization plan because data deemed to be incomplete 
Madden et al27  Design: ITS of a population-based cohort study. Data source: Harvard Vanguard medical Associates automated medical records system and claims for reimbursement. Time points: quarterly. Length of follow-up: 10 d. Type of analysis: ITS regression. Missing data: birth wt n = 159, gestation n = 3121, 5-min Apgar score n = 1283, maternal age n = 9, parity n = 4 478 433, ethnic group n = 433. Duration of study: October 1990 to March 1998. Setting: Massachusetts, Harvard Vanguard Medical Associates, caring for 30 000 persons insured by Harvard Pilgrim Health Care. Funding: Agency for Healthcare Research and Quality, Harvard Pilgrim Child Health Foundation, Maternal and Child Health Bureau No. participants in population: 33 344 women and 30 228 infants detected. No. eligible: 20 366 mother and infant pairs. Inclusion criteria: infant: infants were required to have Harvard Pilgrim Health Care insurance for at least 45 of the first 60 d and at least 1 medical encounter (95.5% of newborns). Exclusion criteria: cesarean delivery (23.6%), LoS >4 d, unequal stays for mother and infant (3.2%), observations for the third quarter of 1994 and the first quarter of 1996 were omitted. Characteristics of women: maternal age: 4.5% of women <22 y, 31.2% of women 22–29 y, 39.2% of women 30–34 y, 25.1% of women >35 y; parity: 44.6% primiparous women; enrolled in Medicaid: 6.7%; census-based socioeconomic status indicators: living in low income: 6.7%, living in low education tract: 19.9%; ethnicity: 69.2% white, 17% Black, 6.6% Asian American, 4.9% Hispanic, 22% other. Infant characteristics: birth wt: 2.7% of infants <2.5 kg, 12.9% of infants 2.5–2.99 kg, 84.4% of infants >3.0 kg; gestational age: 6.6% of infants <38 wk, 27.1% of infants 38–39 wk, 66.3% of infants 40+ wk; 5-min Apgar score: 1.7% with <8, 6.7% with 8, 91.6% with 9–12. Vulnerable group: enrolled in Medicaid, living in neighborhood with median household income <$25 000 or neighborhood with one-third more residents ≥25 y with less than high school education or ages <22 y. No data on pre- and postlaw differences in characteristics of study population Intervention 1: ROLOS program, 1 night in hospital after a normal birth delivery and home visit by nurse within 48 h and enhanced assistance with lactation. Intervention 2: Massachusetts law >48 h minimum coverage for postnatal stay in hospital, or home visit if women were discharged from the hospital <48 h Proportion of infants discharged early in the prelegislative, legislative, and postlegislative periods. Proportion of mother-infant pairs with LoS <2 d, infants attending nonurgent and urgent health centers, infants readmitted in first 10 d, Infants admitted for avoidable conditions in first 21 d (jaundice and feeding problems), infants treated for phototherapy, women breastfeeding at 3 mo Excludes women who had an LSCS and those with no insurance. Teen-aged mothers and Medicaid recipients were underrepresented in study when compared with Massachusetts or the nation as a whole and women with health maintenance organization insurance are most likely to have higher levels of education and income compared with United States overall 
Sievertsen and Wüst28  Design: ITS of a population-based cohort study. Data source: Danish Inpatient Register (hospital medical records) and survey data from the Danish National Birth Cohort. Time points: yearly. Length of follow-up: 9 y. Type of analysis: 2-stage least squares estimates. Missing data: not recorded. Duration of study: 1985–2003. Setting: 5 counties in Denmark: Aarhus, Ringkobing, Viborg, Veijle, and Ribe. Funding: Danish Council for Independent Research grant 11-116669 No. participants in population: 733 373. Inclusion criteria: all multiparous women were in the sample (mothers and infants were not excluded if they had health problems, but rather estimates were compared with and without controls for health at birth). Exclusion criteria: primiparous women, complicated birth. Characteristics of women: maternal age: 30.85 (SD 4.46), maternal age <18 y: 0 (SD 0.01), cesarean delivery: 0.13 (SD 033), married: 0.63 (SD 0.48), higher education: 0.29 (SD 0.45), taxable income: 176.16 (SD 85.07), mothers unemployed: 0.13 (SD 0.34), in education: 0.02 (SD 0.14), mother readmitted: 0.02 (SD 0.14), mother readmitted <365 d: 0.10 (SD 0.29). Infant characteristics: male child: mean 0.51 (SD 0.50), birth wt: 3571.27 (SD 559.16), infant birth wt <2.5 kg: 0.03 (SD 0.17), preterm birth: 0.04 (SD 0.19), Apgar score <7: 0 (SD 0.07), child hospital nights at birth: 3.46 (SD 6.15), same-day discharge: 0.14 (SD 0.35), infant readmitted within 28 d: 0.04 (SD 0.20), infant readmitted within 365 d: 0.21 (SD 0.40) Mandated discharge on the day of birth: a same-day discharge without formal maternity ward admission for all uncomplicated births by multiparous women in the period 1990–2003 Proportion of infants readmitted <28 d and 1 y, child’s school achievement at aged 15 y, mothers readmitted within 28 d, mothers readmitted 1 y, breastfeeding at 4 mo, GP contacts for infants and maternal health problems at 1 mo Same-day discharge was defined as hospital discharge of the mother and child on the calendar day of birth; therefore, this will underestimate the prevalence of same-day discharge 

A/N, antenatal; Anti D, anti-D antibodies; b/f, breastfeeding; ITT, intention to treat; IUGR, intrauterine growth restriction; LSCS, lower segment cesarean section; NICHHD, National Institute for Child Health and Human Development grant; PN, postnatal; ROLOS, reduced obstetrical length of stay program; SF-12, short form survey; —, not applicable.

TABLE 2

ITS Studies With Reporting on Secondary Outcomes: Infant Readmissions for Jaundice, Primary Care Use, and Attendance at EDs

OutcomeStudy
Datar and Sood25 Meara et al26 Madden et al27 Sievertsen and Wüst28 
Infant readmissions for jaundice First year after legislation: 7% increase compared with the prelegislation trend (P <  .05). Second year after legislation: 5.4% decline in the odds of jaundice-related readmissions. Third year after legislation: 11% decline in the odds of jaundice-related readmissions  Start of legislative period: 0.1% increase (P = .057 for level change). End of the period: 0.103% points per quarter decrease from 0.78% to 0.47% (P = .034 for change in trend) Constant at 0.5% Not reported 
Primary care use Not reported Not reported Nonurgent visits had increased by 10.2% (P < .001). After legislation, nonurgent visits decreased 1% per quarter (P < .001) continuing after the mandate GP contacts in the first month. Risk stratified propensity score: 1–33 point estimatea 0.209 (P < .05); 34–66 point estimatea 0.203 (P < .1); 67–100 point estimatea 0.217 (P < .05) 
Attendances
at ED 
Not reported Prelegislative period: increase in ED visits within 10 d from 2.7% to 3.8% (P < .001 for trend); increase in ED visits within 21 d from 6.1% to 8.0% (P < .001 for trend). One year after introduction: fall in ED use within 10 d from 4.2% to 3.8% (P = .088 for change in trend), leveling off in the postlegislative period fall in ED use within 21 d from 9.1% to 8.0% (P = .016 for change in trend), leveling off during the postlegislative period No change in of urgent visits rate in association with early discharge or minimum stay legislation Not reported 
Breastfeeding Not reported Not reported No significant changes at 3 mo for either policy intervention group >4 mo exclusive breastfeeding. Propensity score: 1–33 point estimate (SE)a 0.311 (0.139); 34–66 point estimate (SE)a 0.213 (0.146); 67–100 point estimate (SE)a −0.015 (0.244) 
OutcomeStudy
Datar and Sood25 Meara et al26 Madden et al27 Sievertsen and Wüst28 
Infant readmissions for jaundice First year after legislation: 7% increase compared with the prelegislation trend (P <  .05). Second year after legislation: 5.4% decline in the odds of jaundice-related readmissions. Third year after legislation: 11% decline in the odds of jaundice-related readmissions  Start of legislative period: 0.1% increase (P = .057 for level change). End of the period: 0.103% points per quarter decrease from 0.78% to 0.47% (P = .034 for change in trend) Constant at 0.5% Not reported 
Primary care use Not reported Not reported Nonurgent visits had increased by 10.2% (P < .001). After legislation, nonurgent visits decreased 1% per quarter (P < .001) continuing after the mandate GP contacts in the first month. Risk stratified propensity score: 1–33 point estimatea 0.209 (P < .05); 34–66 point estimatea 0.203 (P < .1); 67–100 point estimatea 0.217 (P < .05) 
Attendances
at ED 
Not reported Prelegislative period: increase in ED visits within 10 d from 2.7% to 3.8% (P < .001 for trend); increase in ED visits within 21 d from 6.1% to 8.0% (P < .001 for trend). One year after introduction: fall in ED use within 10 d from 4.2% to 3.8% (P = .088 for change in trend), leveling off in the postlegislative period fall in ED use within 21 d from 9.1% to 8.0% (P = .016 for change in trend), leveling off during the postlegislative period No change in of urgent visits rate in association with early discharge or minimum stay legislation Not reported 
Breastfeeding Not reported Not reported No significant changes at 3 mo for either policy intervention group >4 mo exclusive breastfeeding. Propensity score: 1–33 point estimate (SE)a 0.311 (0.139); 34–66 point estimate (SE)a 0.213 (0.146); 67–100 point estimate (SE)a −0.015 (0.244) 
a

From first-stage and 2-stage least squares regression models.

The pooled result of the 7 trials that reported on infant readmission to hospital within 28 days after birth revealed that infants were significantly more likely to be readmitted to hospital within 28 days after birth if they were discharged from the hospital <48 hours compared with infants discharged >48 hours (risk ratio [RR]: 1.70 [95% CI 1.34 to 2.15]; Fig 2).1418,20,23  A planned subgroup analysis of RCTs with a cointervention and RCTs with no cointervention was conducted. In the 2 trials without a cointervention, the researchers happened to include only women who had cesarean delivery. These subgroups revealed no change in the direction of the effect: the no cointervention RR was 1.61 (95% CI 1.00 to 2.68; I2 = 14%) compared with the cointervention RR of 1.74 (95% CI 0.82 to 6.68; I2 = 0%). There were insufficient data to provide a meta-analysis for readmissions within 7 days. This outcome was only reported in 1 study, in which the authors reported a RR of 3.24 (95% CI 0.13 to 77.63) in favor of the control group.18 

FIGURE 2

Forest plot of RCTs for the proportion of infants readmitted within 28 days after birth: early discharge versus standard LoS. df, degrees of freedom; M-H, Mantel-Haenszel.

FIGURE 2

Forest plot of RCTs for the proportion of infants readmitted within 28 days after birth: early discharge versus standard LoS. df, degrees of freedom; M-H, Mantel-Haenszel.

Close modal

In results from 4 primary ITS studies in the United States, in contrast to the RCTs, researchers looked at the reverse intervention: a policy of a minimum postnatal length of hospital stay. Datar and Sood25  found that once a minimum legislation was introduced, there was a significant reduction in the odds of neonatal readmission in California from −9.3 per 1000 live births in the first year postlegislation to −11.8 per 1000 live births in second year postlegislation and −19.7 per 1000 live births in the third year postlegislation [P < .01]). This trend was observed across all subgroups including mother’s education, mother’s age at birth, race, parity, delivery type, and antenatal complications (Supplemental Table 4). Evans et al24  found that in California the legislation was most beneficial for infants of cesarean delivery, complicated vaginal delivery, or a Medicaid recipient with complicated vaginal delivery, with little evidence that readmission rates were reduced for newborns from uncomplicated vaginal deliveries. Madden et al29  and Meara et al26  found no significant change over the prelegislative, legislative, or postlegislative period for neonatal readmission to hospital. In the fifth ITS study, which was conducted in Denmark, Sievertsen and Wüst28  found that the same-day discharge policy resulted in a 3% increase in infant readmission rates within 28 days of birth (0.031; SE: 0.11; P < .01; Supplemental Table 4).

The results of the meta-analysis of 3 digitized and then reanalyzed ITSs reveal that when the preslope trend was taken into account, there was a decrease in the proportion of infants readmitted within 28 days after the minimum postnatal stay policies and legislation were introduced, and this became statistically significant in the first and second year (change in slope: −0.62 [95% CI −1.83 to 0.60]; change in level first year: −4.27 [95% CI −7.91 to −0.63]; change in level second year: −6.23 [95% CI −10.15 to −2.32]; Fig 3).

FIGURE 3

Forest plots of reanalyzed ITS studies for infant readmission to hospital within 28 days of birth: change in slope, change in 1-year level and 2-year level. df, degrees of freedom; IV, inverse variance.

FIGURE 3

Forest plots of reanalyzed ITS studies for infant readmission to hospital within 28 days of birth: change in slope, change in 1-year level and 2-year level. df, degrees of freedom; IV, inverse variance.

Close modal

The I2 statistic for assessment of heterogeneity was 19% for the change in level and 0% for the change in level at 1 year and change in level at 2 years: therefore, further investigations for heterogeneity were deemed unnecessary.

In 3 ITSs, researchers reported on the effect of postpartum legislation on readmissions for treatment of jaundice25,26,29  (Table 2). Meara et al26  found a significant decrease in readmissions for jaundice after the minimum postnatal stay legislation, whereas Datar and Sood25  found a nonsignificant reduction in the readmissions for jaundice in the second and third years after the legislation. Madden et al27  found no difference in jaundice-related readmissions after introduction of the minimum stay law (Table 2).

In 2 ITSs, researchers reported on primary care use. Results from Madden et al29  suggest that after adjustment for baseline trends, primary care use increased after implementation of the early discharge program, which slowly decreased by 1% per quarter (P < .01) after the minimum postnatal stay mandate (Table 2). Sievertsen and Wüst28  found a significant increase in general practitioner (GP) contacts for infants who were discharged on the same day across all propensity groups (Table 2).

In 2 ITS studies, researchers reported on this outcome and found that attendances at emergency departments (EDs) decreased after introduction of the postnatal minimum stay mandate (Table 2).

No significant differences in the proportion of women breastfeeding at 48 hours postpartum were found in the meta-analysis of 3 trials that reported this outcome (RR: 1.05 [95% CI 0.99 to 1.11]; Supplemental Fig 5). No significant differences in the proportion of women breastfeeding between 1 and 2 months after birth were found in the 8 trials that reported this outcome1521,23  (pooled estimate RR: 1.01 [95% CI 0.94 to 1.09]) or 6 months after birth (RR: 1.18 [95% CI 0.98 to 1.43]; Supplemental Figs 6 and 7). The conclusion remained unchanged when Tan et al18  and Bayoumi et al15  were removed in subgroup analysis (RR: 1.05 [95% CI 0.98 to 1.12]).

In 2 ITSs, researchers reported on the proportion of infants breastfed before and after implementation of the law (Table 2). Madden et al27  found no evidence of an effect on breastfeeding rates at 3 months. Sievertsen and Wüst28  assigned a propensity score (based on whether the mother was married, unemployed, employed, and/or in education; higher education degree; and maternal age) and found that women in the lowest propensity score sample were less likely to breastfeed exclusively for at least 4 months if discharged on the day of birth (−0.311; P < .05), but the breastfeeding rates of women in the middle and highest propensity score groups were not affected (−0.213 [SE: 0.146] and −0.015 [SE: 0.244], respectively).

Researchers in only 1 trial assessed the proportion of women reporting infant feeding problems in the first 4 weeks after birth,16  showing significantly fewer (RR: 0.65 [95% CI 0.48 to 0.89]) in the first 4 weeks after birth in the standard LoS group.

The quality of individual studies was variable (Supplemental Figs 9 through 12). Risk of bias was assessed by using the EPOC criteria,7  which considers 4 domains: selection bias, performance bias, attrition bias, and reporting bias for both RCTs and ITSs (Supplemental Tables 5 and 6). The largest RCT with the greatest weight in the meta-analyses for the primary outcome was of reasonable quality, although attrition bias may have been an issue with >10% incomplete outcome data and differential noncompliance: 132 of 1890 participants refused to be discharged early in intervention group compared with 188 of 1896 who refused to be discharged at 72 hours.

Sensitivity analyses allowing for loss to follow-up in the RCTs was deemed inappropriate given the large proportion of participants lost to follow-up in many trials and considerable variation in how protocol violations were managed.

Overall, the quality of the 5 ITSs was good (Supplemental Figs 11 and 12). In all studies, the researchers reported outcomes that were described in the Methods section and had an intervention that did not affect data collection. In all ITS analyses, the slope of the intervention was prespecified, and authors acknowledged the potential effect other factors that may have coincided with the passage of the law (including changes to service mix, breastfeeding rates, physician awareness, and flu outbreaks).2427,29  Sievertsen and Wüst28  also compared the trends in readmissions of primiparous women and women who had a cesarean delivery (who were not eligible for same-day discharge) to determine if additional policies (such as new medical routines at birth) had an effect on the outcomes.

This systematic review is, to our knowledge, the first to include evidence from both RCTs and ITSs with a predefined description of early discharge (<48 hours after vaginal birth and <96 hours after cesarean delivery) to assess the effect of a policy of early postnatal discharge and minimum LoS on health related outcomes. The pooled results of the 7 trials on infant readmission to the hospital indicated that more infants who were discharged early were readmitted compared with infants who had a >48 hours stay in hospital. The meta-analysis of ITSs, providing the next best available evidence on the subject, revealed that the US minimum stay law was an effective policy change, increasing postnatal LoS in hospital and providing evidence of a long-term reduction in infant readmission rates within 28 days of birth after this policy change. Because of lack of primary data, it was not possible to examine the effect of LoS on infant readmissions within 7 days.

In this review, we included 2 additional RCTs not included in the existing Cochrane review last updated in 2008.3  The authors of that review used evidence provided by study designs appropriate for policy intervention, both RCTs and ITSs, including those evaluating the impact of US federal and state legislation, and, therefore, provides a better understanding of the effect of postnatal LoS in both an experimental trial and naturalistic setting. By using EPOC criteria for study selection, a wider range of evidence was able to be included without compromising the quality of the findings, taking advantage of the evidence provided by good quality, well designed ITSs. This, in contrast to the RCTs, clearly demonstrated that interventions to institute a policy of early discharge actually resulted in increased early discharge of women and infants, allowing assessment of outcomes and, therefore, enhancing our knowledge of infant health outcomes in relation to early postnatal discharge policy in a “real life” setting.

This is the first study to conduct an ITS meta-analysis on this topic and provide an insight into the effect of federal and state law across several different state populations in the United States. Through our inclusion of these studies, we have also provided an understanding of the health-related outcomes for all infants, regardless of medical status or gestation at birth. A sensitive and broad search ensured that relevant evidence with any study design was included. Our review has also clearly defined early postnatal discharge, allowing more meaningful comparison across trials.

The limitations of this review also are reflected in poor trial quality and poor reporting. Despite the status of RCTs as the gold standard design for intervention studies, in this area, they have already been described as problematic because they feature high rates of postrandomization exclusions, crossover, and withdrawal. Many of the RCTs were low quality, lacking intention to treat analysis with resultant systematic differences between participants in the intervention and control group. In many trials, researchers did not adhere to current trial reporting standards, and, therefore, the findings from the RCT data should be treated with caution. We did not have any individual patient data, which may have provided more insight into subgroup analysis. Trials took place in several different countries where postnatal provision in the community may have varied considerably. The RCT analysis was insufficiently powered to explore early discharge without the addition of additional post discharge support in the community. There was also considerable clinical heterogeneity among the RCTs with regard to mode of delivery, with the largest RCT trial (providing 88% of the weight in the meta-analysis) only including women who had given birth via cesarean delivery. In light of the problematic participant dropout and crossover in the RCTs, the evidence from the ITS studies is particularly useful.

Nevertheless, findings from our review are the best evidence to date and, given problems with undertaking trials and other high-quality studies in this area, may well remain so. Differences found in meta-analysis of trial data for the neonatal readmission outcome are from one large study which only included women who had delivered via cesarean delivery: the findings must be treated with caution. There were no differences in outcomes related to maternal readmission or maternal depression, which might reflect insufficient power to detect these differences given relatively low incidence sample attrition. Breastfeeding rates were not measured in several studies. It was not possible to adequately report the effects of early postnatal discharge on primary care use. Across the trials, it was difficult to ascertain the proportion of mothers and infants who accessed primary care services, outpatient services, and unintentional injury and emergency care, and there were inconsistent definitions of primary care use and wide-ranging measurement methods. The data from ITSs were inconsistent, with researchers reporting both an increase and decrease in use after the postnatal mandate.

The definition of early discharge for this review (<48 hours for vaginal delivery and <96 hours for cesarean delivery) does not reflect the average length of postnatal stay for many high- and middle-income countries.1  There was no evidence to support early discharges (<24 hours) from the hospital, a common practice internationally.30  Although there is an assumption of reduced cost from earlier discharge, this may be off-set by increased costs associated with readmission or greater alternative care usage, and the cost-effectiveness of early discharge is unknown. Further research is needed to examine whether there are particular subgroups of infants who are most at risk for readmission if they and their mothers are discharged early or subgroups for whom early discharge is safe. Research on the impact of the short postnatal stays experienced in some settings is also needed. Research designs could build on the American Academy of Pediatrics’ Policy Statement on Hospital Stay for Healthy Term Newborn Infants31  to evaluate standardizing the discharge process through the use of predischarge checklists.

The use of state and federal law appeared effective in increasing the postnatal LoS for women and infants and resulted in a long-term reduction in the neonatal admission rate to hospital. Following the lead of the American Academy of Pediatrics statement,31  postnatal LoS policies should incorporate the needs of mothers and infants and not be led health services capacity or third party payers, ensuring that standardized systems are in place to ensure that women and infants are discharged at a time more appropriate to their needs.

Taken together, evidence from this meta-analysis and review of RCTs and ITSs of legislation mandating policies of a minimum stay postnatally and of minimum stay discharge policies has revealed that shorter postnatal stay in hospital (<48 hours after vaginal birth and <96 hours after cesarean delivery) is associated with increased infant readmissions to the hospital within 28 days of birth.

Dr Jones designed the study, adapted data collection tools, collected data, conducted data analyses and interpretation, drafted the initial manuscript, and revised the manuscript; Dr Cummins conceptualized and designed the study, adapted data collection tools, collected data, conducted analyses, and revised the manuscript critically for important intellectual content; Drs Taylor and MacArthur conceptualized and designed the study, interpreted data, and critically reviewed and revised the manuscript for intellectual content; Mrs Bradshaw collected data, conducted analyses and interpretation of data, and critically reviewed and revised the manuscript; Dr Hope collected data and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and are accountable for all aspects of the work.

FUNDING: Supported by a National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West Midlands grant. The views expressed are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

     
  • CBA

    controlled before-after study

  •  
  • CI

    confidence interval

  •  
  • EPOC

    Effective Practice and Organisation of Care

  •  
  • GP

    general practitioner

  •  
  • ITS

    interrupted time series

  •  
  • LoS

    length of stay

  •  
  • RCT

    randomized controlled trial

  •  
  • RR

    risk ratio

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data