Howard Markel, MD, PhD


April 05, 2005

During my medical career, I have attended hundreds of newborn deliveries. But last week was particularly special because I entered the delivery room not as a pediatrician but as an expectant father. Fortunately, the labor was short and, thanks to a superb staff of obstetricians and nurses, our beautiful 6-pound, 14-ounce daughter, Samantha Louise, entered the world in excellent health.

In the days since, however, I have been troubled by how much the birthing business has changed over the past few decades. Today, thanks to insurance reimbursement rules, new mothers are typically discharged after 24 hours following an uncomplicated vaginal delivery and 48 to 72 hours after an uncomplicated cesarean section. By way of comparison, in 1970, the average stay for uncomplicated vaginal deliveries was 4.1 days and for uncomplicated C-sections, 8 days. By 1992, the hospital stay following delivery was reduced to 2.5 and 4 days, respectively.

Several studies of these reductions in hospital stays, not to mention a slew of health insurance companies, have heralded them as important safe, cost-saving measures. For example, pediatricians reported in the June 2004 issue of Pediatrics that emergency room visits and hospital admissions for newborns have remained stable over the past 8 years of reduced maternity hospital stays.[1] Another study, published in the October 2004 issue of Pediatrics , found that thanks to postnatal home nursing visits, only 0.6% of the quickly discharged babies studied required readmission to the hospital for common medical problems such as hyperbilirubinemia or dehydration.[2] It is also important to note that physicians and nurses are not springing these babies loose without any health supervision. Standard practice calls for a visit to the pediatrician and a nurse's visit to the home within 3 days following delivery.

Until this week, I used to heartily cite such studies to my patients' parents and reassure them that going home sooner was not only safe, it was a good thing for them. Real-life experience with the so-called "drive-by delivery" compels me to revise that advice.

To begin with, we know that home visits are underused even in states where insurance companies pay for them. And when it comes to a visit to the pediatrician on the baby's third day of life, parents freely tell doctors that while they appreciate the brief, troubleshooting sessions, they do little to ameliorate the intense fatigue and stress parents typically experience.

Many assume that new parents will get help from family members. But with today's long-distance families, the arrival of a new grandchild may bring far-flung grandparents and siblings to the home but these are now often "state occasions" of visiting and entertaining rather than a critical means of getting sustainable, trustworthy, and affordable help.

Over the past several days, I have watched my wife, Kate, struggle to get back on her feet after delivering her second child while assuming the huge tasks of inculcating a routine of breastfeeding for Samantha and remaining a parental presence for our older daughter Bess. By all accounts, my wife is a magnificent mother. But what this week has taught me -- better than any medical journal article ever could -- is that the prevailing medical view of the early discharge of babies overlooks a plethora of negatives that cannot be measured purely in terms of medical mishaps or undiagnosed maladies of the newborn.

Simply put, these economic savings in hospital stay reductions deny new mothers the chance to begin their recoveries before returning home. First-time mothers are also short-changed on the opportunity to learn some of the fundamentals of caring for newborns from a readily available hospital staff. And no matter how involved the father is during this process, in most American households the onus of care still falls on the exhausted and recuperating mother.

In an era when healthcare expenses comprise more than 14% of the GNP, creating new economies of expensive treatments and practices is essential. However, as we cut these expenses, doctors and insurers need to listen better to those most affected by them. We need to encourage families to be more vociferous about what constitutes a healthy practice even when the experts defend their policies as safe and cost-effective. If we all agree that children are our greatest assets, then the mental and physical health of new mothers must be a bigger part of the equation.


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