Early Newborn Discharge Associated With Increased Infant Mortality

Abstract

Source: Malkin JD, Garber S, Broder MS, et al. Infant mortality and early postpartum discharge. Obstet Gynecol. 2000;96:183–188.Evidence regarding the outcome of early discharge from the hospital after term birth is limited. In order to assess the relationship of newborn and infant death to early discharge, Malkin and colleagues from the RAND Corporation and UCLA performed a historical cohort study using linked birth certificates, death certificates, and hospital discharge records from Washington state that included 47,879 live births in 1989 and 1990. Risk of death within the first year of life after early discharge (less than 30 hours after birth) compared with later discharge (30–78 hours after birth) was assessed using logistic regression, adjusting for mothers’ Medicaid status, marital status, parity, age, newborn gender and ethnicity. Length of stay was determined from date and time of birth and date of discharge. Infants who stayed longer than 78 hours and infants for whom it could not be determined whether their stay was shorter or longer than 30 hours were excluded from the logistic regression analysis. Newborns discharged early were more likely to die within 28 days of birth (adjusted odds ratio [OR]=3.65; 95% confidence interval [CI], 1.56–8.54), between 29 days and 1 year (OR=1.61; 95% CI, 1.10–2.36), and any time within the first year of life (OR=1.84; 95% CI, 1.31–2.60) than newborns sent home later. In analyzing causes of death, newborns discharged early were more likely to die of heart-related problems (OR=3.72; 95% CI, 1.25–11.04) and infections (OR=4.72; 95% CI, 1.13–19.67) within 1 year of birth than newborns discharged later.The implications of reduced length of hospital stay after uncomplicated births have been a source of both scientific and political interest.1 Although several studies have demonstrated increased readmission rates of uncertain clinical significance, until now none have found any difference in clinically important outcomes between newborns discharged early and those with longer stays.2,3 The database used in this study included the majority of infants born in Washington state; most of the unrepresented births occurred at home or in federal hospitals. The authors included only infants with birth weights >2,500 grams and gestational ages >37 weeks in the primary analyses. Infants whose length of stay could not be clearly defined as less than or greater than 30 hours were not included in the logistic regression. These infants (discharged sometime later than 6 hours but before 54 hours) represented almost 40% of the term infants in the database. The authors did examine the risk of death in this indeterminate discharge group and found it to be less than the early discharge group and greater than the late discharge group. These data support the conclusion that early discharge is associated with increased infant death, especially in the first month. The essential question is whether this rather strong association is causal, or whether infants at higher risk for early death (for reasons not accounted for in the multivariate analysis) are somehow being selected for early discharge. Though the authors controlled for a number of important factors in the analysis, they could not control for all potential confounders (eg, hospital of birth and quality of care could not be addressed). The biologic mechanism by which an extra 12–24 hours of hospitalization might prevent infant death many months later is not immediately obvious. The authors’ findings suggest that for every 1,400 term babies discharged early, one of them will die. The bottom line is that these data are alarming and must be confirmed or refuted as soon as possible.