She is exhausted after an awkward ninth month of pregnancy, a sleepless night, 14 hours of difficult labor. She is sore, uncomfortable, beginning to feel the effects of rapid hormonal changes, worried about coping with her new baby.
But she may not be able to count on her hospital to help much. It’s now likely to push her out in less than a day–sometimes as little as six hours–after giving birth.
Turning childbirth into little more than an out-patient procedure or a “drive-through delivery” is one of the newest big efforts by insurance companies and managed care organizations to wring savings–and corporate profits–out of health care.
The cuts may be good for the balance sheets and stock prices of HMOs, insurance companies and employers, which now seem to hold more power over American health care than do doctors. But it may put the well-being of some mothers and new babies in jeopardy.
“The routine imposition of a short and arbitrary time limit on hospital stay that does not take maternal and infant need into account could be equivalent to a large, uncontrolled, uninformed experiment that may potentially affect the health of American women and their babies,” said the American College of Obstetricians and Gynecologists last month.
Yesterday, the American Medical Association adopted a policy saying hospital maternity stays should not be arbitrary financial decisions but should be up to the physician, based on judgments about the physical condition of each mother and child, emotional factors involved and the social environment and support system at home.
Hospital stays for women who gave birth vaginally decreased by 46 percent–from 3.9 days to 2.1 days–between 1970 and 1992, according to the Centers for Disease Control and Prevention. Mothers who had a Cesarean delivery were in the hospital an average of 7.8 days in 1970 compared to 4 days in 1992, a drop of 49 percent.
Now, said the AMA, typical hospital stays have dwindled to 24 hours or less for uncomplicated vaginal deliveries and two to three days for Cesarean births. Some HMOs, insurers and hospitals are aiming at a limit of six to eight hours.
For example, Kaiser Permanente, the California-based HMO with 6 million members, has started a pilot program to discharge new mothers who have had uncomplicated vaginal births in about eight hours.
Some mothers are eager to get home with their newborn infants as quickly as possible for good reasons. It’s easier to bond with a baby at home, without the interference of hospital rules and routines. There’s less danger of infection. Family members can be closer and more supportive. No one wants to be in a hospital unless it’s medically necessary.
But what women want isn’t the driving force behind cutting back on maternity stays. The change is being pushed primarily by “financial motivations,” as the American College of Obstetricians and Gynecologists pointed out. And it could hold serious dangers for both new mothers and new babies.
Many women just aren’t physically ready to go home a few hours after giving birth. Some may not have adequate help at home and may be overwhelmed with the care of a newborn who cries a lot at night when they are still recuperating themselves. Fewer than two percent require rehospitalization, according to the AMA.
After birth, infants need to be checked out for cardiac and other abnormalities, respiratory problems and infections. Feeding–either by breast or bottle–may not go smoothly at first and should be established before the baby goes home to avoid risks of dehydration.
Newborn jaundice, a common liver condition, is the major reason babies are readmitted to the hospital. It usually doesn’t appear until 24 to 36 hours after birth and is easy to treat with high levels of light. But left undetected and untreated, it can cause brain damage within a few days.
The screening programs designed to prevent illness and death by early diagnosis of medical problems and congenital disorders are another consideration. Blood for these tests should usually be drawn the second or third day after birth because they are much less accurate earlier.
Promoters of shorter maternity stays usually say mothers will get a follow-up home visit from a nurse, or at least a phone call. Or they may be told to bring their baby back to the hospital in a day or two for a check-up and screening tests. But the visits and calls don’t always happen. And some babies are lost to the health care system before they have had essential care.
Some sketchy research seems to show that maternity stays can be reduced safely. But the AMA and the ACOG are critical and skeptical of the findings. The studies are too small, involve only healthy volunteers at low medical risk living in a stable home environment and rely only on hospital readmissions as a measure of success.
“There is relatively little scientific data on the ideal length of hospital stay for delivery,” said ACOG. “Studies have not yet conclusively demonstrated the safety of early discharge.”
The obstetricians’ association is calling for a “timeout,” a moratorium on further reductions in hospitalization following childbirth “until we have the data that clearly demonstrate the safety of early discharge for women and their babies.”
But doctors need to do more than pass resolutions and lament changes in health care. They are the only ones who can stand up for patients against those who are eager to experiment with cuts in health services for financial–not medical–reasons. Drive-through deliveries is a good place to make that stand.
