Maternity Care: Appropriate Follow-Up Services Critical With Short
Hospital Stays (Letter Report, 09/11/96, GAO/HEHS-96-207).

Pursuant to a congressional request, GAO reviewed issues surrounding
shortened postpartum hospital stays, focusing on: (1) the risks that are
attributable to short hospital stays for maternity care; (2) health plan
actions to ensure quality postpartum care for short-stay newborns; and
(3) state responses to concerns about patient protection.

GAO found that: (1) many medical personnel are concerned that early
hospital discharges for newborns delay detection of serious disorders
that are not apparent in the first 24 hours after birth; (2) 24 hours
may not be long enough to assess a new mother's abilities and readiness
to take care of her newborn child; (3) studies have not shown a
definitive correlation between early discharges and increased hospital
readmissions of newborns, but many of the studies' methodologies are
seriously flawed; (4) medical experts agree that the quality of
maternity care is more important than the length of hospitals stays and
that a full range of prenatal, delivery, and postpartum services should
be provided; (5) some hospitals and health care plans with early
discharge policies have developed programs to ensure that maternity
patients receive quality services such as prenatal assessment and
education, flexibility that allows physicians to make discharge
decisions, and direct, professional follow-up care within 72 hours of
discharge; (6) other plans may not provide all of these recommended
services and their follow-up care may consist only of a telephone
hotline number; (7) 30 states have enacted laws or regulations that
require insurers to cover minimum maternity stays, but these efforts
vary in scope; (8) self-funded employer insurance plans, and some state
Medicaid and employee plans are not subject to these state regulations;
(9) applicability questions also arise for those employees who live and
work in different states; and (10) Congress is considering legislation
to make maternity care more consistent and available to all privately
insured women.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-207
     TITLE:  Maternity Care: Appropriate Follow-Up Services Critical 
             With Short Hospital Stays
      DATE:  09/11/96
   SUBJECT:  Hospital care services
             Home health care services
             State law
             Health insurance
             Health maintenance organizations
             Insurance regulation
             Proposed legislation
             Infants
             Managed health care
IDENTIFIER:  Minneapolis (MN)
             St. Paul (MN)
             Maryland
             California
             New Jersey
             Virginia
             Massachusetts
             New Mexico
             Tennessee
             Rhode Island
             New York
             Ohio
             Alabama
             Florida
             Washington
             Federal Employees Health Benefits Program
             Civilian Health and Medical Program of the Uniformed 
             Services
             CHAMPUS
             National Hospital Discharge Survey
             
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Cover
================================================================ COVER


Report to the Honorable
Ron Wyden, U.S.  Senate

September 1996

MATERNITY CARE - APPROPRIATE
FOLLOW-UP SERVICES CRITICAL WITH
SHORT HOSPITAL STAYS

GAO/HEHS-96-207

Maternity Care

(108252)


Abbreviations
=============================================================== ABBREV

  AAP - American Academy of Pediatrics
  ACOG - American College of Obstetricians and Gynecologists
  ERISA - Employee Retirement Income Security Act of 1974
  HMO - health maintenance organization
  IPA - independent practice association
  PKU - phenylketonuria

Letter
=============================================================== LETTER


B-266282

September 11, 1996

The Honorable Ron Wyden
United States Senate

Dear Senator Wyden: 

In an effort to contain health care costs, some health care plans
have adopted guidelines to shorten hospital stays associated with
maternity care--the most common condition requiring hospitalization. 
Some plans have limited hospital coverage for mothers and their
newborns to a maximum of 24 hours after delivery, which has resulted
in a dramatic increase in 1-day postpartum stays.  Many in the
medical community have voiced concerns that these shortened stays
expose newborns to undue risks.  More than half of the states have
enacted maternity stay coverage requirements, and the Congress is
considering legislation that would support the state measures.\1

To better understand the issues involved, you asked us to (1)
identify the risks that are attributable to short hospital stays for
maternity care, (2) examine health plan actions to ensure quality
postpartum care for short-stay newborns, and (3) determine state
responses to concerns about patient protection.  To develop this
information, we obtained trend data on the length of inpatient stays
for newborns, reviewed pertinent literature, interviewed medical
experts on the health effects of abbreviated stays, and reviewed
relevant state statutes.  To collect information on how some
providers and plans are managing the trend toward shorter hospital
stays, we held discussions with staff at 8 hospitals and 13 health
plans identified by health care experts as having well-established
early discharge programs.  We also interviewed other key players in
the maternity care community, including home health agencies, medical
specialty societies, and health care trade associations.  We
conducted our review from October 1995 to July 1996 in accordance
with generally accepted government auditing standards. 


--------------------
\1 For example, the Senate recently passed legislation that included
the "Newborns' and Mothers' Health Protection Act."


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Many in the medical community are concerned that by discharging
newborns early from the hospital, serious disorders may not be
detected.  But research on the safety of short postpartum stays is
inconclusive.  More specifically, there are mixed results on the
association between newborn length of stay and rehospitalization, one
indicator of adverse outcomes.  One recent study of vaginal
deliveries found no association between the number of days a newborn
spends in the hospital and the rate of readmission, but other studies
indicate increased risk for newborns discharged within 48 hours of
birth.  Regardless, many of these studies have methodological
weaknesses that limit their conclusiveness.  Guidelines issued by the
American Academy of Pediatrics (AAP) and the American College of
Obstetricians and Gynecologists (ACOG) recommend that, when
complications are not present, postpartum hospital stays be at least
48 hours for vaginal deliveries and 96 hours for cesarean sections. 
However, the guidelines allow for shorter stays if criteria for
medical stability are met, if agreed to by a physician and patient,
and if provisions are made for follow-up care. 

Some hospitals and some health plans with early discharge policies
have developed programs to ensure that a full range of services is
provided to their maternity care patients.  This set of services
includes prenatal assessment and education, inpatient stays that give
physicians flexibility in applying early discharge policies, and
follow-up care provided by a trained professional at home or in a
clinic within 72 hours of discharge.  Other plans with shortened
postpartum stays, however, may not provide all recommended services. 
For example, some plans' follow-up care consists of telephone
hotlines to address patient concerns, which do not allow for the type
of direct observation recommended for mothers and newborns. 

Early discharge policies have prompted more than half the states to
enact laws or regulations that require insurers to cover minimum
maternity stays.  The requirements are similar but vary in detail and
are limited in scope.  Some are highly prescriptive, specifying, for
example, the minimum length of postpartum stay (generally 48 hours
following a normal delivery and 96 hours after a cesarean section),
who is authorized to make decisions on postpartum stays, and the
extent of follow-up care to be provided after discharge.  Some states
prohibit health plans from providing any incentive or disincentive
that might encourage physicians to shorten maternity stays. 
Regardless, these requirements do not apply to about half of
employer-sponsored insurance plans--those that are self-funded and,
thus, not subject to state regulation under the Employee Retirement
Income Security Act of 1974 (ERISA).  In addition, many states do not
apply such requirements to their Medicaid programs or to state
employee health plans.  Questions also arise when individuals live in
one state but work and receive employer-sponsored insurance in
another.  Therefore, the Congress is considering legislation to make
maternity care more consistent nationally and available to all
privately insured women. 

Most of the experts we contacted agree that the debate over
postpartum hospitalization needs to focus on overall quality of
maternity care rather than the length of stay.  What is more
important is applying early discharge decisions selectively and
ensuring that there is early, ongoing, and comprehensive care,
including prenatal education and appropriate follow-up services. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Childbirth is the most frequent reason for hospital admission in the
United States, with about 4 million deliveries each year.  Under
pressure to contain rising premiums, some health plans have adopted
guidelines to encourage early discharges of mothers and newborns from
hospitals after birth.\2 Prices negotiated between hospitals and
managed care plans are usually flat, per diem rates that are
all-inclusive for treatment, room, and supplies.  For example, a
normal birth may be paid at a rate of $1,000 a day, regardless of the
particular day in a patient's stay.  Since the services required by
the new mother and infant are not nearly as intense on the second
day, the price charged for the discretionary day encourages plans to
have new mothers and their babies discharged early from the hospital. 
The health plan would derive a savings of $1,000 from early
discharge, which may be partially offset by the cost of any
additional prenatal classes and follow-up care. 

Over the last 15 years, the amount of time most newborns stay in the
hospital has been reduced by nearly half.\3

Centers for Disease Control and Prevention data show that the
national average length of stay for all normal newborns (including
those delivered vaginally and by cesarean section) was 1.8 days in
1994, down from 3.2 days in 1980.\4

(See fig.  1.) Although this trend is evident in all regions of the
country, American Hospital Association survey data show regional
variation of almost a full day.\5 For the first half of 1995, the
longest newborn length of stay was 2.5 days in the mid-Atlantic and
West South Central regions and the shortest length of stay was 1.6
days in the Pacific region. 

   Figure 1:  Average Length of
   Stay for Normal Newborns,
   1980-94

   (See figure in printed
   edition.)

Source:  Centers for Disease Control and Prevention, National Center
for Health Statistics, National Hospital Discharge Survey. 

The percentage of 1-day stays for all newborns, which includes those
delivered vaginally and by cesarean section, increased dramatically
between 1980 and 1994.  In 1994, 39.8 percent of newborns were
discharged within 1 day, 33.7 percent at 2 days, and the rest stayed
longer.  By contrast, only 8.9 percent of newborns had 1-day stays in
1980.\6 (See fig.  2.) An analysis of about 180,000 deliveries in the
Minneapolis-St.  Paul metropolitan area from 1990 to 1994 indicated
that the percentage of 1-day stays for all normal newborns with
commercial indemnity coverage generally tracked that of infants with
private managed care coverage.\7

   Figure 2:  Distribution of All
   Newborn Lengths of Stay,
   1980-94

   (See figure in printed
   edition.)

Source:  Centers for Disease Control, National Center for Health
Statistics, National Hospital Discharge Survey. 

In addition to health plans' limits on maternity coverage, these
trends reflect changes in patient preferences, medical technology,
and the organization of health care delivery.  Since the 1970s, many
maternity patients have requested shorter hospital stays because of a
growing interest in less medical intervention for childbirth.  In
addition, improved use of anesthesia and the capacity to detect
potential problems and intervene early enabled women to recover more
quickly and deliver healthier newborns. 


--------------------
\2 The terms "early discharge" or "short stay" have been used
interchangeably.  AAP defines early discharge as a postpartum
hospital stay of less than 48 hours for a normal vaginal delivery and
less than 96 hours for a delivery by cesarean section. 

\3 There has also been a steady decline in the maternal lengths of
stay (measured as the period from admission to discharge).  Although
on average cesarean section stays are longer, the rate of decline in
lengths of stay for vaginal and cesarean deliveries has been about
the same.  The average stay for a vaginal delivery dropped from 3.2
days in 1980 to 2.0 days in 1993.  Similarly, for a cesarean section,
the average stay declined from about 6.5 days to 3.9 days over this
period.  See Centers for Disease Control and Prevention, National
Center for Health Statistics, National Hospital Discharge Survey. 

\4 National Hospital Discharge Survey. 

\5 American Hospital Association, Maternal and Newborn Length of Stay
(Chicago:  Dec.  1995). 

\6 National Hospital Discharge Survey. 

\7 Minnesota Hospital and Healthcare Partnership, Hospital Discharge
Patterns for Pregnancy, Seven County Metro Area, 1985-First Quarter
1995 (St.  Paul:  Jan.  1996).  In 1992, 44 percent of the population
in the Minneapolis-St.  Paul metropolitan area was enrolled in health
maintenance organizations (HMO). 


   EVIDENCE OF SHORT STAYS' EFFECT
   ON NEWBORNS' HEALTH IS
   INCONCLUSIVE, YET CONCERNS
   PROMPTED REVISION OF GUIDANCE
------------------------------------------------------------ Letter :3

Studies comparing the rates at which short-stay and longer-stay
newborns are readmitted to the hospital for treatment show
conflicting results.  Regardless, clinicians critical of short
postpartum stays assert that many health problems are not detectable
in the first 24 hours of life.  They are concerned that with a
shorter stay, many newborns are not properly screened for metabolic
and genetic disorders and many more leave the hospital with
undetected diseases.  Some also believe that shorter stays make it
difficult to assess the mother's ability and readiness to care for
her newborn.  Yet health plans and some medical experts are skeptical
that a slightly longer hospital stay will adequately address
newborns' health risks and, therefore, emphasize establishing
discharge criteria and comprehensive follow-up care. 


      RESEARCH SHOWS MIXED RESULTS
      ON RISK OF NEWBORN
      READMISSIONS
---------------------------------------------------------- Letter :3.1

There is no conclusive evidence that discharging women and their
babies less than 48 hours after childbirth has or does not have
adverse effects on the health and well-being of mothers and newborns. 
In December 1994, the Department of Health and Human Services'
Maternal and Child Health Bureau met to evaluate the results of
studies on whether the early discharge of newborns might affect
metabolic screening, breast-feeding, readmission rates, and mortality
rates.  Noting numerous methodological flaws in these studies, the
medical specialists found no conclusive evidence that early discharge
following delivery had adverse effects.  However, they noted that
"failing to prove that shorter hospital stays are unsafe .  .  .  is
not the same as proving they are safe."\8

Several recent studies on the effect of early discharge policies use
data on hospital readmissions as an indicator of an adverse outcome. 
If an adequate medical review before a newborn's discharge is not
conducted, medical conditions that require hospital treatment may not
be identified.  One such study, which looked at more than 123,000
vaginally delivered newborns, found no association between the number
of days a newborn spends in the hospital and the rate of readmission. 
The readmission rate for infants with a 1-day stay was 1.7 percent;
for a 2-day stay, 1.9 percent; and for a 3-day stay, 2.0 percent.\9

Similarly, statistics compiled by HMOs showed that the
rehospitalization rate of early discharge infants was comparable with
that of babies who were not discharged early.  For example, Kaiser
Permanente of Northern California examined data on about 19,000
infants born by vaginal delivery (without complications) at its
hospitals.  It reported no significant differences in
rehospitalization rates between newborns discharged before 24 hours
(2.7 percent) and those discharged 24 to 48 hours after birth (3.3
percent).\10

But two other studies that used hospital readmissions as an indicator
of an adverse outcome indicate increased risk for newborns discharged
within 48 hours of birth.  An analysis of normal newborns in National
Perinatal Information Center hospitals\11 nationwide (61,991 births)
and Massachusetts hospitals (50,843 births) demonstrated an increased
risk of rehospitalization as the length of stay was shortened.  While
actual rates were low (varying between 1 and 2 percent), the authors
calculated that a 1-day stay had a readmission risk that was 30 to 40
percent higher than that for a 2-day stay.\12 Similarly, in a study
of 15,000 infants in New Hampshire hospitals, researchers found that
the risk for hospital readmission within the first 2 weeks of life
was 50 percent greater for infants discharged at less than 2 days of
life.\13

Regardless of their results, however, most of the studies have a
number of design weaknesses that limit their conclusiveness.\14
First, most studies are limited to readmissions that occur in the
same hospital where the infant was born.  Health professionals
acknowledge, however, that many infants with birth-related
complications go to specialty hospitals and would therefore not be
captured as readmissions.  Second, the studies do not control for
factors other than length of hospital stay that may contribute to
readmission rates.  A low readmission rate, for example, may be due
to good postpartum care--not to the length of stay.  Third, some
studies are based on relatively small numbers of observations or
geographically restricted areas, and some examine only highly
selected, healthy, and middle-class populations.  It is unclear,
then, whether the outcomes would be similar for other populations. 
Finally, most of these studies address only hospital readmissions, an
indicator of serious medical morbidity.  It is possible that early
discharges can lead to subtler problems evidenced by more frequent
nonadmission contacts with health professionals, such as emergency
room visits and unscheduled physician appointments. 


--------------------
\8 W.  Kessel, M.  Kiely, A.  Nora, and others, "Early Discharge:  In
the End, It Is Judgment," Pediatrics, Vol.  96, No.  4 (Oct.  1995),
pp.  739-42.  The Maternal and Child Health Bureau is sponsoring
further studies to evaluate the types of care provided in various
settings and the resulting outcomes. 

\9 The study also looked at data on 32,000 cesarean section
deliveries and found a significant association between length of stay
and readmissions:  4.3 percent of babies who had had 1-day stays were
readmitted, compared with 1.0 to 1.4 percent of babies who had had
stays of 2 days or more.  See Dave Foster and Linda Schneider,
Hospital Length of Stay and Readmission Rates for Normal Deliveries
and Newborns:  Relationship to Hospital, Patient, and Payer
Characteristics (Baltimore, Md.:  HCIA, Inc., July 1995). 

\10 Peter I.  Juhn, "Newborn Length-of-Stay and Hospital Readmission: 
Does Early Discharge Lead to Adverse Outcomes?" Health Services
Research:  Implications for Policy, Health Care Delivery and Clinical
Practice, proceedings of the AHSR 13th Annual Meeting (June 9-11,
1996), p.  53. 

\11 Nineteen perinatal facilities participate in the Center's
data-reporting service. 

\12 R.  Schwartz, Q.  Zhao, and R.  Kellogg, data presented at
Implications for Early Discharge of Mothers and Neonates From
Hospitals (Bethesda, Md.:  Maternal and Child Health Bureau, Dec.  2,
1994). 

\13 J.  Frank, data presented at Postpartum Stay:  A No-Win for
Managed Care?  (Washington, D.C.:  National Health Policy Forum, Feb. 
22, 1996). 

\14 For a comprehensive review of earlier investigations, see P. 
Braveman, S.  Egerter, M.  Pearl, and others, "Early Discharge of
Newborns and Mothers:  A Critical Review of the Literature,"
Pediatrics, Vol.  96 (1995), pp.  716-26. 


      EARLY DISCHARGE RAISES
      CONCERNS ABOUT DETECTING
      PREVENTABLE NEONATAL
      PROBLEMS
---------------------------------------------------------- Letter :3.2

Many health professionals believe that short hospital stays increase
the risk that neonatal problems will go undetected or that babies
will leave the hospital before accurate health screening results are
obtained.  Some pediatricians and obstetricians report seeing many
more babies with jaundice, infection, and dehydration caused by
difficulty in breast-feeding.\15 Clinicians also express concern that
mothers need more time to recuperate and learn how to care for their
newborns, as they see new mothers struggling with breast-feeding,
fatigued, and suffering from strep and urinary infections that could
have been detected with an extra day in the hospital. 

Severe metabolic diseases, such as phenylketonuria (PKU), may not be
accurately detected before 24 hours after birth and, if untreated,
can lead to mental retardation.  A test given earlier than 24 hours
after birth is more likely to show a false negative result and
requires retesting after the first day to be conclusive.  A 1995
study of PKU screenings found that in states that do not mandate
rescreenings, retesting for PKU occurred at only 48 percent of
nurseries that typically discharged newborns less than 24 hours after
birth.\16 In addition, the study found that only 64 percent of
pediatricians in these states rescreened for PKU, with some tests
performed as late as 28 days after birth--later than the optimal 21
days to begin treatment.  States that require rescreening have
considerably better retesting rates:  100 percent of pediatricians in
those states conducted rescreening, and 93 percent retested between
72 hours and 2 weeks. 

Although limited, some evidence exists that early discharges also may
have an effect on the mother's well-being and her ability to care for
the newborn.  In a study of about 900 middle-class HMO patients who
were discharged in less than 48 hours and received at least one home
visit, researchers found significant maternal transitory depression
and inadequate breast-feeding.\17 Another study reported a tendency
to discontinue breast-feeding among the early discharge group.\18
Data on the effect of early discharge on psychosocial stresses are
also limited, but a number of experts and practitioners we spoke with
are concerned that shorter hospital stays decrease the opportunity to
identify inexperienced, inept, or other potentially harmful behavior
toward the infant. 


--------------------
\15 Breast-feeding protects infants from infections and allergies and
has been linked to the optimal development of the brain and other
organs. 

\16 Laura N.  Sinai, Susan C.  Kim, Rosemary Casey, and others,
"Phenylketonuria Screening:  Effect of Early Newborn Discharge,"
Pediatrics, Vol.  96, No.  4 (Oct.  1995), pp.  605-608.  Many states
recommend repeat screenings 2 to 3 days after birth if initial tests
were done less than 24 hours after birth.  Rescreening is required in
only five states:  Nevada, New Mexico, Oregon, Texas, and Utah.  See
Council of Regional Networks for Genetic Screenings, Newborn
Screening Committee, "National Screening Report 1992" (Atlanta:  Dec. 
1995). 

\17 P.  Jansson, "Early Postpartum Discharge," American Journal of
Nursing, 1985, pp.  547-50. 

\18 Robert Dershewitz and Richard Marshall, "Controversies of Early
Discharge of Infants From the Well-Newborn Nursery," Current Opinion
in Pediatrics 1995, 7:494-501. 


      PROFESSIONAL GUIDELINES
      FOCUS ON DISCHARGE CRITERIA
      RATHER THAN TIMING
---------------------------------------------------------- Letter :3.3

Health plans and some medical experts we contacted assert that a
slightly longer hospital stay may not be enough to address newborn
risks, because many neonatal medical problems cannot be reliably
detected until 72 hours after birth.  These professionals, therefore,
believe that short postpartum hospital stays can be safe or safer
than traditional 48-hour stays if professionally recommended
discharge criteria are met and comprehensive follow-up care is
provided.  They further assert that screening services can be
appropriately provided at home or in a physician's office. 

To help ensure adequate maternal and newborn care, AAP and ACOG
jointly published guidelines for hospital maternity stays in 1992,
and AAP amplified this guidance in a 1995 policy statement.\19
AAP/ACOG recommended that mothers and newborns be hospitalized until
certain medical criteria and conditions are met.  These include an
absence of medical complications, completion of at least two
successful feedings, performance of certain laboratory tests, and a
documented ability of the mother to care for the baby.  (See app.  I
for more details.) AAP guidance recommends that most mothers and
newborns have a 48-hour hospital stay to complete testing and
monitoring.  It further states that the length of stay should be a
decision made by the mother and her doctor and not a policy
established by health plans.  "The fact that a short hospital stay
for healthy term infants can be accomplished does not mean that it is
appropriate for every mother and infant.  Each pair should be
evaluated individually to determine optimal time of discharge." In
cases where the mother and physician agree to discharge prior to 48
hours, a follow-up evaluation, including metabolic screening if
necessary, is recommended. 


--------------------
\19 See AAP Committee on Fetus and Newborn and ACOG Committee on
Obstetrics, Guidelines for Perinatal Care, 1992, and AAP, "Hospital
Stay for Healthy Term Newborns," Pediatrics, Vol.  96, No.  4 (Oct. 
1995). 


   INTEGRATED APPROACH TO
   MATERNITY CARE SHOULD ACCOMPANY
   EARLY DISCHARGE POLICIES
------------------------------------------------------------ Letter :4

Increasingly, health care providers believe that the debate over
postpartum hospitalization should focus on the provision of a full
range of maternity services, rather than on the length of the
hospital stay.  Health plans with early discharge programs contend
that these services can be effectively delivered in settings other
than the hospital where they are traditionally provided.  Many
physicians and other health care professionals we contacted agreed
that what matters most is whether mothers and newborns receive a
comprehensive set of services before, during, and after their
hospital stays. 

To provide a continuum of care, several large health plans and
hospitals with short-stay policies have established early discharge
programs.  These programs generally include an assessment and
education component during prenatal care, a hospital stay that is
determined by the attending physician, and a home visit by a maternal
and child health nurse within 48 to 72 hours after discharge. 
According to program officials, patients are more satisfied with
their care, and outcomes have improved--fewer rehospitalizations for
mothers and infants and fewer infant acute care visits.  There is
some evidence, however, that some health plans with early discharge
policies do not offer a well-integrated program that meets
recommended standards.  Studies have shown that a home visit
following a 1-day postpartum stay rarely occurs. 

Some plans' organizational structures may make it difficult to
develop a comprehensive approach that would help ensure that timely
and appropriate care is provided.  Physicians employed by group/staff
model HMOs may be well positioned to coordinate all patient care,
including prenatal and follow-up services.  But in fee-for-service
indemnity plans and other types of HMOs, physicians often make
discharge decisions with only limited information about the specific
follow-up services to be provided, and the responsibility for making
arrangements for such care is left to the mother.  Furthermore, in
some HMOs, financial incentives for physicians to discharge patients
early may unduly influence the decision-making. 


      ADDING ASSESSMENT AND
      EDUCATION COMPONENTS TO
      PRENATAL CARE MAY HELP
      REDUCE HEALTH RISKS
---------------------------------------------------------- Letter :4.1

Some health plans have added to their prenatal care an assessment
component to identify medical and psychosocial problems that may
complicate pregnancy or delivery.\20 Many of these plans use a
standardized checklist to assess the mother's overall health needs
and to tailor her care to meet those needs.  Health plans also use
the prenatal assessment to identify patients who are candidates for
early discharge after childbirth.  For example, obstetricians at a
large group/staff model HMO told us that only women who meet specific
program participation criteria developed by a team of physicians and
nurses are eligible for early discharge programs.  They do not
consider early discharge to be a viable option for patients who are
likely to have complicated pregnancies. 

Several of the programs we contacted also provide extensive prenatal
education to prepare women for a short hospital stay.  In addition to
classes on labor and delivery, these programs educate women on
self-care, such as smoking and substance abuse cessation, and
nutrition.  Some education that traditionally has been provided in
the hospital during the maternity stay is now being offered during
the prenatal period.  Many of these programs believe that because of
the range of hospital-related stresses, the immediate postpartum
period may not be the best time to educate the mother on
breast-feeding and caring for the baby at home.  In addition, plans
use the prenatal period to explain the benefits of a short hospital
stay, such as reducing the health risks that can occur with a longer
stay.  Studies show that the chances of newborn infection increase
the longer the newborn remains in the hospital. 

Not all women are assured of receiving prenatal education and
risk-screening.  Mothers in some plans are responsible for arranging
their own risk assessment and education classes.  One large
independent practice association (IPA) model HMO we visited entitles
patients to reimbursement of up to $40 for participation in prenatal
education classes, but it is the women's responsibility to find and
enroll in such a class and apply for reimbursement.  Similarly, the
HMO asks pregnant women to complete and return a questionnaire to
help the plan identify those at high risk. 


--------------------
\20 Although not all women have a prenatal care visit early in their
pregnancies, HMO enrollees are more likely to have visits.  A 1994
RAND Corporation study reported that 87 percent of women in HMOs have
a prenatal visit during the first trimester compared with the
national average of 76 percent.  See P.  Murata, E.  McGlynn, A. 
Sui, and others, "Quality of Care for Prenatal Care:  Comparison of
Care in Six Health Care Plans," Archives of Family Medicine, Vol.  3,
No.  1 (Jan.  1994), pp.  41-49. 


      GREATER PLAN FLEXIBILITY
      WOULD ENABLE PHYSICIANS TO
      MAKE DISCHARGE DECISIONS ON
      THE BASIS OF PATIENT NEEDS
---------------------------------------------------------- Letter :4.2

Health care professionals we contacted told us that within a program
that provides comprehensive care, early discharges were acceptable as
long as medical and social criteria are met and discharge decisions
are made by the attending physician.  With extensive prenatal
assessment and education and arrangements for follow-up care, most
mothers and newborns are deemed ready for discharge within 36
hours.\21 To meet typical discharge criteria, the mother and baby
must be medically stable; the mother must show competence in feeding
her baby; and any perceived psychosocial problems with the mother,
present family members, or both must be resolved.  Metabolic
screening tests for the infant must be done before discharge; if
performed before the infant is 24 hours old, arrangements must be
made to repeat the screen.  Arrangements for follow-up care also must
be made, including a home visit 2 to 3 days after discharge, an
emergency medical contact, and pediatric care. 

Many of the programs we visited stressed the importance of
flexibility in early discharge decision-making.\22 At an HMO with
about 2,000 maternity cases each year, women learn about the
discharge program early in the pregnancy, but they are encouraged to
wait until delivery to decide about their length of stay.  Many women
have longer than a 1-day stay because they or their physicians
determine that they are not ready to be discharged.  At a plan
considered by experts to have an outstanding short-stay program, this
flexibility, along with strict eligibility screening, has resulted in
about 60 percent of the plan's maternity patients being discharged
early.\23

Some plans, however, provide financial incentives for physicians to
reduce maternity stays, according to the physicians and health policy
experts that we contacted.  Plans may keep profiles on their
physicians' practice patterns and may drop them from the networks or
reduce their payment depending on their conformance with early
discharge policies.  In some cases, plans require documentation or
utilization review and preauthorization before agreeing to pay for an
extended hospital stay or for a follow-up visit.  In addition, with
the dozens of varied health plan policies to work with, providers are
often uncertain about the circumstances surrounding an early
discharge.  The physicians we met with also told us discharge
decisions were sometimes made without knowing whether prenatal
education was provided or appropriate follow-up care would be
available. 

Furthermore, many health care professionals assert that the practice
of early hospital discharge may not allow for intensive education
about breast-feeding or maternal and infant follow-up care.  A
nationwide representative survey of over 2,000 parents of young
children found that short hospital stays provide little time for
helping parents learn about newborn care.\24 Less than half of
first-time parents reported feeling very confident about caring for
their newborns when they left the hospital.  According to one
California physician, in his experience, postpartum education usually
consists of minimal guidance about breast-feeding, a handout about
common postpartum problems, and a short talk before discharge. 


--------------------
\21 Most of the plans and hospitals we contacted consider the mother
and baby to be a pair for discharge purposes.  Separating the pair
may have an adverse effect on maternal-infant bonding and on
breast-feeding, which has long-term health benefits. 

\22 Some insurers provide coverage for longer maternity stays. 
Because most hospitals are not aware of the specific coverage limits
for each patient, however, they defer to the discharge policy that is
generally held by insurers in their community for all maternity
patients. 

\23 Responding to health plans' policies of covering only 24 hours of
postpartum care, some hospitals provide mothers and newborns with a
48-hour postpartum stay at no cost to the patient, even if not
covered by the insurer.  At one hospital that adopted such a policy,
nearly all eligible patients (those with uncomplicated vaginal
deliveries) accepted the offer of an extra day on the maternity ward. 

\24 K.  Young, K.  Davis, and C.  Schoen, The Commonwealth Fund
Survey of Parents With Young Children (New York:  The Commonwealth
Fund, Aug.  1996). 


      FOLLOW-UP CARE HELPS ENSURE
      THE HEALTH AND WELL-BEING OF
      MOTHERS AND NEWBORNS
---------------------------------------------------------- Letter :4.3

Because most common neonatal problems become evident about 48 to 72
hours after birth, continued medical observation of the newborn is
critical.  The early discharge programs of several health plans and
hospitals take steps to ensure that every short-stay patient receives
a follow-up home visit within 24 to 72 hours of discharge by a
qualified health professional.  Some health plans provide a
comprehensive home visit by a registered nurse with maternal and
child care experience.  The nurse specialist's role begins before
discharge with discharge planning, instruction, and counseling. 

Outpatient care generally includes an in-home visit, 24-hour
telephone access to a nurse, and several nurse-initiated telephone
contacts over a 2-week period.  At the home, nurses use a standard
protocol to structure the visit and direct further follow-up.  All
protocols we obtained provide guidance for a maternal and newborn
physical assessment; a psychosocial assessment of the mother; newborn
screening tests, if indicated; parent and family education on baby
and maternal care; a home safety assessment; and the opportunity for
referral to additional services if a need has been identified. 
(Table 1 shows a home visit protocol used by a large New England
hospital.)



                     Table 1
     
        Typical Protocol for a Home Visit
            Following Early Discharge

------------------  ----------------------------
Maternal            Health history: allergies,
assessment          prenatal vitamins, birth
                    history, postpartum course

                    Physical examination: vital
                    signs, uterine exam,
                    incision healing, breast
                    changes, signs of postpartum
                    complications

                    Maternal adaptation:
                    activity level, maternal-
                    infant attachment,
                    postpartum depression,
                    social support, parenting
                    issues, environmental risks

Newborn physical    Vital signs: cardiac,
examination         respiratory, circulatory,
                    neurological

                    Skin integrity

                    Head circumference

                    Abdomen

                    Nutrition: weight, feeding,
                    elimination pattern, sleep/
                    wake cycles, circumcision,
                    collection of lab specimens
                    (PKU/metabolic screens,
                    bilirubin)

Parent and family   Maternal postpartum self-
education           care

                    Newborn care and safety

                    Newborn feeding

                    Normal newborn behavior and
                    capabilities

                    Developmental stimulation

                    Consoling techniques

                    Family adaptation

                    Primary health care for
                    mother and newborn

                    Immunization

                    Well-child care

Follow-up           Primary care providers:
communication and   appointment for postpartum
referrals           and family planning,
                    appointment for pediatric
                    visit

                    Referral to other health
                    care professionals, as
                    indicated: lactation
                    consultant, social services,
                    parent support resources

                    Home visit report sent to
                    appropriate primary care
                    providers
------------------------------------------------
Some programs have developed special arrangements to help ensure that
their early discharge patients get home visits.  For example, a plan
serving a large inner-city population has arranged for local police
escorts for nurses who are reluctant to visit patients living in
areas that are considered unsafe; plan nurses also use a buddy system
when they enter potentially unsafe areas.  Another health plan with a
mandatory home visit component requires nurses to immediately notify
the patient's physician if the mother refuses to schedule a home
visit.  Several hospital-based maternity care programs we visited
provide at least 90 percent of their early discharge patients with a
follow-up home visit. 

Nevertheless, many short-stay maternity patients are not receiving
recommended follow-up care.  A recent nationwide study found that
home visits following discharge occurred in a minority of cases. 
Only 20 percent of parents with children under age 3 reported a home
visit by a nurse or other health professional to teach them about
infant care and to check the baby.\25 Similarly, a study in the
Minneapolis-St.  Paul metropolitan area found that the percentage of
normal newborn discharges with home care was 9.6 percent for 1-day
stays and 7.9 percent for 2-day stays in 1995.\26 Possible
explanations for these low rates are that parents are not aware of
the importance of home care or do not know that it may be a covered
service.  Also, many first-time mothers may not know how to arrange
for follow-up care.  One large, multistate HMO with a 24-hour
discharge policy relies on mothers to request and schedule a home
nurse visit after discharge from the hospital. 

In addition, some follow-up services do not meet recommended
standards.  One plan serving a large rural population specified in
its contract with a home health agency that follow-up service consist
of a single telephone call to the mother, which does not allow for
the type of direct observation that AAP/ACOG guidelines and other
experts recommend.  One contracted home health agency has employed an
oncology nurse for home visits, although experts recommend that these
visits be conducted by professionals experienced in maternal and
child health care.  Some home health agencies have reduced follow-up
home care visits to 10 to 15 minutes--which is not enough time to
conduct a comprehensive assessment.  Some home health agencies have
failed to conduct the assessment within the recommended 2 to 3 days
after discharge or have failed to conduct the assessment at all. 
According to home health agency officials, these weaknesses are due,
in part, to the increased demand for follow-up services, which has
strained the capacity of their home health nurses. 


--------------------
\25 In the surveyed group, half of the mothers who delivered
vaginally were discharged in 1 day or less.  See The Commonwealth
Fund Survey of Parents With Young Children. 

\26 Hospital Discharge Patterns for Pregnancy, Seven County Metro
Area, 1985-First Quarter 1995. 


   GROWING NUMBER OF STATES ARE
   PASSING MATERNITY CARE
   LEGISLATION
------------------------------------------------------------ Letter :5

State legislatures have become increasingly concerned about the
potential consequences of short maternity stays.\27

Since Maryland became the first state to pass maternity care
legislation in 1995, 29 states have taken similar action.\28 In 25
states, the requirements are consistent with AAP/ACOG guidelines.\29
Another three states and the District of Columbia are actively
considering such legislation.  California, however, recently became
the 10th state to consider but not enact a mandatory maternity stay
bill.\30 (For a list of states that enacted laws, see app.  II.)

States typically require insurers to cover a minimum length of stay
or follow-up care if mothers and newborns are discharged early.  The
laws are similar but vary in detail and are not applicable to
self-insured employer health plans because under ERISA provisions
states cannot regulate them.  Advocates of a proposed federal
maternity care law contend that comprehensive legislation that
applies to all insurers is necessary to protect patients from unsafe
early discharges.  The millions of uninsured women, however, would
not benefit from the consumer protections afforded by the
legislation. 


--------------------
\27 For an overview of state requirements, see, ACOG, "State Laws and
Regulations Requiring Insurance Coverage for Postpartum Care," August
1996, and addendum. 

\28 Twenty-eight states have passed laws.  New Mexico has promulgated
regulations.  Tennessee promulgated emergency rules that, although
they expired Aug.  4, 1996, were subsequently ratified by the state
legislature when a law was enacted authorizing the promulgation of
permanent rules. 

\29 Maternity care legislation in South Carolina establishes a
maximum of 48 and 72 hours for vaginal and cesarean delivery,
respectively, while Washington law provides that coverage be based on
"accepted medical practice."

\30 Other states that considered but did not enact maternity care
legislation are Arizona, Colorado, Hawaii, Mississippi, Nebraska,
Utah, Vermont, West Virginia, and Wisconsin. 


      STATE REQUIREMENTS ARE
      SIMILAR BUT DETAILS VARY
---------------------------------------------------------- Letter :5.1

Although not identical, most state requirements include similar
provisions prescribing a minimum length of stay, who should make the
discharge decision, follow-up coverage, physician protections, and
enforcement mechanisms. 


         MINIMUM COVERAGE FOR
         INPATIENT CARE
-------------------------------------------------------- Letter :5.1.1

Nineteen states require that health plans cover a minimum postpartum
stay in the hospital of 48 hours following uncomplicated deliveries
and 96 hours following a cesarean section.  To ensure that the
mandatory minimum does not begin when the woman enters the hospital
in labor, such laws generally specify that coverage begin at the time
of delivery. 

Since enactment of the New Jersey law in June 1995, postpartum stays
for uncomplicated deliveries at four hospitals there increased by 10
to 12 hours.  The average length of stay for vaginal deliveries
increased 29 percent, from 1.4 days to 1.8 days; for cesarean
deliveries, the average stay increased 18 percent, from 2.8 days to
3.3 days.\31 Medical staff at one New Jersey HMO told us patients
have learned that they can extend their stay (to slightly less than
48 hours) and still receive a follow-up visit at home.  According to
the staff, the law has significantly increased the HMO's expenses
because it must cover a slightly extended inpatient stay as well as
the costs associated with home visits.  As a result, they are
concerned that they may have to implement the 48-hour minimum stay
and discontinue their home visit program. 

Some states do not stipulate coverage for a specific inpatient stay. 
Although they do not mandate a specific time per se, seven states
mandate that insurers cover maternity stays in accordance with the
medical criteria outlined in the AAP/ACOG guidelines.  Providers in
Virginia, which requires that coverage be in accordance with AAP/ACOG
guidelines but not for a minimum length of stay, told us that there
has been little effect on the length of inpatient maternity stays in
the state. 

Most state maternity care laws allow for exceptions to the inpatient
care requirements.  They recognize that an early discharge may be
acceptable for some women and newborns if appropriate follow-up
services are promptly provided.  Consistent with AAP/ACOG guidelines,
states generally provide such exceptions where follow-up care, such
as home visits, parent education, and performance of clinical tests,
is available. 


--------------------
\31 A study comparing lengths of stay 6 months before and 6 months
after enactment included data on 9,000 births, representing 8 percent
of births statewide.  See Centers for Disease Control and Prevention,
"Average Postpartum Length of Stay for Uncomplicated Deliveries--New
Jersey, 1995," Mortality and Morbidity Weekly Report (Aug.  16,
1996). 


         DISCHARGE DECISION-MAKING
-------------------------------------------------------- Letter :5.1.2

States with maternity care requirements provide that the authority to
make decisions on postpartum stays rests with the attending
physician, patient, or both.  In 11 states, early discharge is
permitted only upon the recommendation of the attending physician and
then only if the mother consents or is at least consulted.\32 Seven
other states provide for the decision to be made by the attending
physician, usually based on medical necessity or whether the mother
and newborn meet the AAP/ACOG guidelines.  In Kentucky, New York, and
New Jersey, the decision about when to go home rests solely with the
mother. 

Under the original Maryland law, the insurer could choose to cover
less than a 48- to 96-hour stay if a newborn met the AAP/ACOG
criteria for medical stability and at least one postpartum home visit
(including newborn screening) was authorized.  Because the home visit
was much less expensive than another day of hospital care, many
insurers chose early discharge.  This was of such concern to Maryland
legislators that the law was subsequently amended to provide that the
decision regarding length of stay be made by the mother after
conferring with her physician. 


--------------------
\32 Missouri and Ohio laws prohibit insurers from offering money or
gifts to encourage mothers to choose early discharge. 


         PROVIDER INDEPENDENCE
-------------------------------------------------------- Letter :5.1.3

Where state requirements provide for physicians to decide how long a
hospital stay is needed, a physician can determine, on the basis of
medical necessity, that early discharge is not appropriate or a stay
beyond the days stipulated in the law is required.  Because health
plans must cover additional inpatient care, however, physicians may
be reluctant to prescribe longer hospital stays out of concern that
this will jeopardize their participation or good standing in provider
networks.  Many managed care organizations monitor physician
performance to ensure compliance with contract provisions governing
utilization and reimbursement.  Many physicians we spoke with said
dependence on managed care plans to sustain a viable practice was an
influence in decisions regarding early discharge. 

To curb health plan attempts to limit hospital stays, many states
have additional requirements to protect physicians under contract
with health plans when they prescribe postpartum care.  Seventeen
states that mandate minimum stays for new mothers or require that
maternity care decisions be consistent with AAP/ACOG guidelines also
provide some degree of protection to physicians making such
decisions.  For example, in Massachusetts, where HMOs have about 40
percent of the market, insurers may not terminate services; reduce
capitation payments; or penalize an attending physician,
nurse-midwife, or hospital for not discharging a maternity patient
early.  In New Mexico, regulations prohibit insurers from providing
any financial incentive or disincentive to a provider to encourage
early discharge. 


         FOLLOW-UP CARE
-------------------------------------------------------- Letter :5.1.4

According to AAP/ACOG guidelines, if a patient is discharged from the
hospital with less than the minimum stay, a follow-up visit by
providers competent in postpartum care must be furnished within 48
hours.  Twenty-three states have requirements addressing postpartum
outpatient care.  The types of follow-up services required in cases
of early discharge vary, but such services are generally required
only for mothers and newborns who are discharged early. 

Most states with this type of requirement prescribe home visits and
specify their timing and content.  New Jersey specifically requires a
minimum of three home visits be covered.  New Mexico does also,
unless the attending physician or home care provider determines that
one or two visits are sufficient.  Other states specify that one or
two visits must be covered.  New York, which specifies at least one
visit, prohibits the charging of deductibles, coinsurance, or
copayments for the visit. 

States that do not specify a number of visits generally provide that
insurers must cover care that is "medically necessary" or considered
necessary by the attending provider.  Under Tennessee's recently
enacted law, rules must be promulgated to establish minimum standards
of insurance coverage, but it is unclear whether insurers will be
required to cover or simply offer minimum benefits.  While they
address follow-up care, the laws in Massachusetts and Rhode Island do
not explicitly require insurers to provide coverage for such care. 

Regardless of the legal provisions in place, states may not be able
to ensure that home visits are of adequate quality or that they take
place at all.  A potential problem may arise if an insurer offers
appropriate outpatient services after early discharge but does not
ensure follow-up care takes place.  While an insurer may comply with
the requirement because coverage is provided for home visits, such
visits may not be made because the mother does not know that such
visits would be covered and, for that or other reasons, does not
schedule them.  Thirteen states require insurers to provide notice of
coverage to policyholders, while New York requires hospitals to give
all pregnant women they admit a leaflet developed by the state
explaining coverage. 


         IMPLEMENTATION AND
         ENFORCEMENT
-------------------------------------------------------- Letter :5.1.5

In general, state insurance departments are responsible for
overseeing and enforcing state maternity care requirements, including
the promulgation of any implementing regulations.  Seven states
expressly provide for the promulgation of implementing regulations. 
As with any insurance requirement, consumers can report violations of
the maternity care requirements to their state insurance department. 

States have taken somewhat different approaches to the implementation
and enforcement of maternity care requirements.  Some states, for
instance, require notification of one type or another.  For example,
New York provides notification to new parents by requiring its Health
Department to add language to the explanatory leaflet pregnant women
receive when they are admitted to the hospital, suggesting that
parents check their insurance policies.  In New Mexico, where early
discharge is permitted only if the mother consents, each insurer is
required to provide notification to the state through periodic
reports that identify instances of early discharges of either mothers
or newborns that were against the mothers' wishes. 

States have also established explicit penalties for noncompliance. 
In Alabama, for instance, the Department of Insurance has the express
authority to suspend or revoke an insurer's license and impose
penalties on any insurer that violates the law.  In Ohio, insurers
that violate the maternity care provisions are subject to penalties
for engaging in unfair and deceptive acts under the state insurance
code. 

Finally, some states have required studies of the effects of
maternity care measures.  Florida, which has issued voluntary
practice guidelines, has directed its Agency for Health Care
Administration to evaluate the clinical effects of shorter postpartum
hospital stays and the effect of the state's law, and to report back
to the legislature by January 1, 1998.  Washington's Health Care
Policy Board must analyze the effects of the Washington law--if funds
are available--and submit a final report to the legislature by
December 15, 1998. 


      MANY HEALTH PLANS ARE NOT
      COVERED BY STATE
      REQUIREMENTS
---------------------------------------------------------- Letter :5.2

Not all health plans are required to comply with state maternity care
requirements.  As a result, millions of patients are unlikely to
benefit from such state laws because they receive health coverage
through employer or government-sponsored health plans, or an insurer
outside the jurisdiction of their state.  To address these
limitations, some contend that a federal maternity stay law is needed
to back up state laws. 

Under ERISA, states can regulate insurers but cannot directly
regulate self-insured employer-sponsored health plans.  As a result,
employers who self-insure--that is, they pay their employees' health
care claims directly rather than purchasing health care coverage from
an insurer--do not have to provide coverage specified in state
laws.\33 We estimate that about 44 million people in the United
States have hospital insurance not regulated by state law because
they or their spouses are employed by companies that self-insure. 
Massachusetts and New York have partially overcome this limitation by
imposing requirements directly on hospitals to provide minimum
postpartum stays.  This ensures that women have access to adequate
care (even if they are uninsured) but is independent of requirements
related to coverage for such care.  In those states, hospitals are at
risk of losing state licensure if they do not provide such care, but
self-insured employer health plans would not be required by state law
to pay for that care. 

In addition, not all states made their maternity care laws applicable
to state-employee health plans or Medicaid programs.\34 Of the 29
states with maternity care requirements, 11 made them applicable to
the state Medicaid program and 10 to state employees.  Although they
may choose to comply with state requirements in many cases, the
Federal Employee Health Benefit Plan and the Civilian Health and
Medical Program of the Uniformed Services have statutory authority to
disregard state requirements related to health insurance. 

In addition, difficulties often arise when a person lives in one
state but works or receives care in another state.  States may
regulate only those businesses that have certain minimum contacts
within their borders.  As a result, state laws do not cover a health
plan operating outside the state.  If a woman receives care through a
plan that is based in another state, it is unlikely that she will be
protected by her home state's maternity care requirements. 

Legislation is being considered in the 104th Congress that would
impose a single federal standard applied to self-insured plans as
well as commercial insurers.  For example, on September 5, 1996, the
Senate passed provisions\35 that would mandate coverage for a minimum
48-hour hospital stay for normal vaginal deliveries and 96-hour stays
for cesarean section deliveries unless the attending provider, in
consultation with the mother, makes the decision to discharge early
and coverage is provided for prescribed timely follow-up care. 
Timely care would be defined as care that meets the health care needs
of the mother and newborn, provides for appropriate monitoring of
their conditions, and occurs within 24 to 72 hours immediately
following discharge.  Each state would generally be obligated to
enforce the federal maternity care standards within its borders, but
the Secretary of Labor would enforce them where states did not meet
this obligation.  Under the Senate measure, ERISA's preemption
provision would not be affected or modified, but with respect to
employee health benefit plans, the maternity care requirements would
be enforced by the Secretary of Labor just as certain ERISA
requirements are currently enforced. 

If enacted, the legislation would provide nationwide protection--at
least to mothers and newborns with health insurance.  It would
expressly apply to state employees, but there is no provision
respecting its application to state Medicaid program recipients. 


--------------------
\33 ERISA generally blocks states from imposing requirements on
employer-sponsored health plans.  Because the act specifically
permits states to regulate insurers, states can indirectly regulate
many such plans by imposing requirements on the insurance these plans
purchase.  There is an increasing trend for employers to self-insure. 
In such cases, although the employer may contract with a third party
administrator to manage the plan, the employer pays the health care
expenses for its employees directly.  In such cases, state maternity
care laws will have no direct effect on maternity coverage. 

\34 Disabled women under age 65 who are covered by Medicare would
also not be covered by state maternity care requirements. 

\35 These provisions are part of the Department of Veterans Affairs
appropriations bill.  The House of Representatives version of this
bill does not include these provisions, and differences between the
two bills will be resolved in conference. 


   CONCLUSION
------------------------------------------------------------ Letter :6

Although the public debate over maternity care has focused on the
shortening of the hospital stay after childbirth, the critical issue
is whether mothers and newborns are receiving all necessary services. 
Some services traditionally given in the hospital may be just as
effectively furnished in other settings.  For example, prenatal care
at a clinic or physician's office can provide education regarding
parenting and infant care.  Medical professionals can conduct
breast-feeding instruction and metabolic screening tests at a
patient's home or a clinic. 

Discharging mothers and babies after a postpartum stay of less than
48 hours appears safe in those cases where the policy is selectively
and flexibly applied to uncomplicated vaginal deliveries and where
proper follow-up services are provided.  Some health plans have
established comprehensive early discharge programs demonstrating that
short stays do not result in adverse outcomes.  However, not all
patients are assured of receiving the full range of appropriate
services.  There is evidence that women and newborns are being
discharged early without much follow-up care.  Even when follow-up
care is provided, it is not always delivered in a timely manner by
properly trained health professionals. 

Requiring insurers to either cover hospital stays of 48 hours for
vaginal births or cover follow-up care within 72 hours of discharge
may be giving the public a false sense of security.  Extending
hospital stays to 48 hours may provide for more medical surveillance,
but it does not include the period when many neonatal problems
usually occur--at 3 days of age.  Follow-up care can be a safety net
to protect mothers and newborns who are discharged early only if the
appropriate services are actually provided. 


   COMMENTS
------------------------------------------------------------ Letter :7

Because information in this report did not deal specifically with
federal agencies, we did not seek agency comments.  We did, however,
circulate a draft of the report to outside experts, who generally
agreed with the presentation of material.  The technical suggestions
they offered were incorporated where appropriate. 


---------------------------------------------------------- Letter :7.1

We are sending copies of this report to other interested Members of
Congress and will make copies available to others upon request. 

Please call me on (202) 512-7119 if you or your staff have any
questions.  Other major contributors include Rosamond Katz, Ann
White, Martha Elbaum, and Craig Winslow. 

Sincerely yours,

Sarah F.  Jaggar
Director, Health Services Quality
 and Public Health Issues


MATERNITY CARE RECOMMENDATIONS
FROM OBSTETRIC AND PEDIATRIC
PROVIDERS
=========================================================== Appendix I

Assessment category                 Criteria
----------------------------------  -----------------------------------------------------
Maternal health                     Antepartum, intrapartum, and postpartum courses are
                                    uncomplicated

                                    Vaginal delivery

Newborn health                      Single birth at 38 to 42 weeks' gestation

                                    Vital signs are normal and stable

                                    Newborn urinating and stooling successfully

                                    At least two successful feedings documented

                                    No abnormalities that require continued
                                    hospitalization

                                    No excessive bleeding at circumcision site for at
                                    least 2 hours

                                    No significant jaundice in the first 24 hours of life

Maternal and family education       Demonstrated knowledge of breast-or bottle-feeding
                                    and of cord, skin, and infant genital care

                                    Ability to recognize signs of illness and common
                                    infant problems, particularly jaundice and
                                    dehydration

                                    Proper infant safety, for example, car seat use,
                                    positioning for sleep

                                    Family or other support persons available who are
                                    familiar with lactation and newborn care and
                                    illnesses

Immunization and screening tests    Maternal syphilis and hepatitis B surface antigen
                                    status

                                    Cord or infant blood type and direct Coombs test
                                    result as clinically indicated

                                    State regulated screening tests--if performed before
                                    24 hours of milk feeding, a system for repeating the
                                    test must be ensured during the follow-up visit

                                    Hepatitis B vaccine administered or an appointment
                                    made within the first week of life for its
                                    administration

Outpatient care                     Identified physician-directed source of continuing
                                    medical care for both mother and baby

                                    If discharged less than 48 hours after birth,
                                    definitive appointment made for the baby to be
                                    examined within 48 hours of discharge; follow-up can
                                    take place in a home or clinic as long as personnel
                                    are competent in newborn assessment and the results
                                    are reported to the infant's physician on the day of
                                    the visit

                                    Evaluation should include general health, hydration,
                                    feeding pattern and technique, stool and urine
                                    patterns, maternal/infant interaction, review of
                                    laboratory test results or screening tests performed
                                    as indicated

Family, environmental, and social   Untreated parental substance abuse
risk factors
                                    History of child abuse, neglect, or parental mental
                                    illness

                                    Lack of social support, particularly for single,
                                    first-time mothers

                                    No fixed address

                                    Teen mother
-----------------------------------------------------------------------------------------
Source:  Excerpted from AAP Committee on Fetus and Newborn and ACOG
Committee on Obstetrics, Guidelines for Perinatal Care, 1992, and
AAP, "Hospital Stay for Healthy Term Newborns," Pediatrics, Vol.  96,
No.  4 (Oct.  1995). 


STATES WITH MATERNITY CARE
REQUIREMENTS AS OF SEPTEMBER 1,
1996
========================================================== Appendix II

State                                   Effective date
--------------------------------------  ------------------
Alabama                                 October 1, 1996

Alaska                                  June 1, 1996

Connecticut                             May 24, 1996

Florida                                 October 1, 1996

Georgia                                 July 1, 1996

Illinois                                September 15,
                                        1996\a

Indiana                                 July 1, 1996

Iowa                                    July 1, 1996

Kansas                                  April 11, 1996

Kentucky                                July 12, 1996

Maine                                   April 5, 1996

Maryland                                October 1, 1995\b

Massachusetts                           February 19, 1996

Minnesota                               March 20, 1996

Missouri                                August 28, 1996

New Hampshire                           January 1, 1997

New Jersey                              June 28, 1995

New Mexico                              March 1, 1996

New York                                January 1, 1997

North Carolina                          October 1, 1995

Ohio                                    October 17, 1996

Oklahoma                                May 14, 1996

Pennsylvania                            August 31, 1996

Rhode Island                            September 1, 1996

South Carolina                          October 1, 1996

South Dakota                            July 1, 1996

Tennessee                               May 13, 1996

Virginia                                July 1, 1996

Washington                              June 6, 1996\c
----------------------------------------------------------
\a For state employees, effective on July 17, 1996. 

\b Significant amendments effective on July 1, 1996. 

\c For state employees, effective on January 1, 1998. 

Source:  ACOG, "State Laws and Regulations Requiring Insurance
Coverage for Postpartum Care," August 1996 and addendum. 


*** End of document. ***