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Randomized Trial of Postpartum Care After Hospital Discharge

Anita J. Gagnon, RN, MPH, PhD*‡; Geoffrey Dougherty, MDCM, MSc, FRCPC*§; Vania Jimenez, MD*储; and Nicole Leduc, PhD¶

ABSTRACT. Objective. Harmful effects of short post-partum hospital stays include dehydration and malnutri-tion of breastfed infants. These may be prevented by adequate breastfeeding frequency; however, rigorous re-search to determine the relative effectiveness of various follow-up strategies in supporting breastfeeding fre-quency is absent. This study addressed the question, “Is there a difference in breastfeeding frequency or infant weight gain for singleton infants discharged within 36 hours’ postpartum who received either community nurse (home visit) or hospital nurse (clinic) follow-up?”

Methods. A randomized, controlled trial was con-ducted at a university teaching hospital (3700 births/y) and affiliated community health centers. A consecutive sample of 586 healthy mother-infant pairs were recruited from January 1997 to September 1998 before discharge; 513 (87.5%) contributed data on 1 or more outcomes. Forty-eight-hour postpartum telephone contact and day 3 nurse contact in the home (experimental) or at the hos-pital (control) were provided. The main outcomes mea-sured were breastfeeding frequency and infant weight gain assessed at 2 weeks’ postpartum by maternal diary and weight at home by research assistants, masked to group allocation.

Results. No clinically important or statistically signif-icant group differences were found in daily breastfeed-ing frequency (mean difference experimental minus con-trol0.1 feeds [95% confidence interval:0.1– 0.3]) or daily rate of infant weight gain (1.1 g [2.5– 0.3]) based on intention-to-treat analyses.

Conclusions. Follow-up by nurses after short post-partum hospital stays, in either the home or a hospital-based clinic, of healthy infants discharged at<36 hours seems associated with satisfactory infant breastfeeding outcomes. Pediatrics 2002;109:1074 –1080; breastfeeding, nursing care, randomized controlled trials, dehydration, puerperium, community health, newborn.

ABBREVIATIONS. CI, confidence interval; RR, relative risk.

F

iscal constraint in the health sector has resulted in short postpartum hospital stays. Care pre-viously provided in the hospital has been replaced by nurse home visits, outpatient clinic visits, or other types of services or has not been replaced. Evidence for the effects of short post-partum hospital stays are discrepant.1–5 Reported detrimental effects of short postpartum stays in-clude hospital readmissions for dehydration and malnutrition of breastfed infants within 2 weeks of life. These events are infrequent; however, they have been associated with serious sequelae, including convulsions, hypoglycemia, focal neurologic deficits, disseminated intravascular coagulation, and ampu-tation.6 Unresolved infant jaundice, maternal and infant infection, maternal anxiety, and breastfeeding failure have also been reported. One important rea-son for the current variation in postdischarge fol-low-up is that data from rigorously conducted re-search studies assessing the relative effectiveness of various strategies are absent.7Our study was meant to gather data in this domain and, thus, to inform health care planners of the optimal mix of postpar-tum posthospitalization health care services.

Despite the beneficial effects of breastfeeding,8 several cases of malnutrition and dehydration have been reported in otherwise healthy, exclusively breastfed infants within their first month of life.6,9 –17 Symptoms of malnutrition included lethargy, poor feeding, and oliguria. Support for the relationship between short hospital stays and such adverse harm-ful health outcomes is also suggested in observa-tional studies showing increased severity of illness at subsequent admission and increased admissions.1,2,4 Furthermore, these studies suggest that the increased number and severity of admissions for dehydration, hypernatremia, and malnutrition may be a conse-quence of inadequate strategies for ensuring ade-quate breastfeeding success.

Several studies have examined factors related to early breastfeeding success.18 –21Maternal perception of insufficient milk, maternal anxiety, painful breast engorgement, sore nipples, and maternal lack of con-fidence in breastfeeding are among the factors shown to affect successful breastfeeding in the early post-partum period and subsequent duration of breast-feeding. It is therefore reasonable to expect that an intervention directed at early preventable breastfeed-ing problems could result in early breastfeedbreastfeed-ing suc-cess and reduce the risks associated with insufficient feeding. A systematic review of support for breast-feeding has been conducted under the auspices of From *McGill University, Montreal, Quebec, Canada; ‡McGill University

Health Centre-Royal Victoria Hospital Site, Montreal, Quebec, Canada; §McGill University Health Centre-Montreal Children’s Hospital Site, Mon-treal, Quebec, Canada;储Centre locale des services communautaires (CLSC) de Coˆte des Neiges, Montreal, Quebec, Canada; and ¶Universite´ de Mon-tre´al, Montreal, Quebec, Canada.

Presented, in part, at the Pediatric Academic Societies; May 1, 1999; San Francisco, CA.

Received for publication Apr 3, 2001; accepted Dec 17, 2001.

Address correspondence to Anita J. Gagnon, RN, MPH, PhD, School of Nursing, McGill University, 3506 University St, Montreal, Quebec H3A 2A7. E-mail: anita.gagnon@mcgill.ca

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the Cochrane collaboration.22These results suggest a beneficial effect of breastfeeding support on breast-feeding duration. The beneficial effects of frequent breastfeeding are particularly relevant to the first week postpartum. Infants who feed more frequently (every 3– 4 hours vs “on demand”) reach their max-imum weight loss sooner, lose less of their birth weight, experience a greater intake of breast milk during the first week, consume significantly more milk on day 15, and gain significantly more weight.23,24

The greatest number of published reports of the effects of postpartum home follow-up to families at low medical and social risk were those that examined nurse home visitation after a postbirth hospital stay of 5 to 7 days. We identified a single published study that compared modes of care after a short hospital stay (⬍48 hours).25 Breastfeeding discontinuation rates at 14 days, maternal depression and satisfac-tion, and clinic use were examined. This study found that either a single home visit by a nurse or a pedi-atric clinic visit is associated with equivalent clinical outcomes, although home visits were associated with markedly higher maternal satisfaction and with higher costs. The issue of breastfeeding frequency was not addressed.

In summary, breastfed infants discharged from the hospital after short postpartum hospital stays seem to be at increased risk for malnutrition, dehydration, hypernatremia, hyperbilirubinemia, feeding difficul-ties, and breastfeeding failure. Furthermore, the most severe of these harmful health outcomes and several less severe harmful effects are likely to be prevented with establishment and maintenance of adequate breastfeeding frequency in the early postpartum pe-riod. Controlled studies have shown the effective-ness of interventions directed at early breastfeeding support, although there is a paucity of rigorously conducted randomized studies examining the im-pact of such support in the context of short hospital stays.

Our research question was, “Is there a difference in breastfeeding frequency, infant weight gain, mater-nal anxiety, satisfaction with services, or community or health services use for singleton infants or their mothers discharged within 36 hours’ postpartum from an urban, university hospital who received ei-ther community nurse (home visit) follow-up or hos-pital nurse (clinic) follow-up?” Our hypothesis was that home visits would produce superior outcomes in these domains.

METHODS Protocol

Study Population

Women were recruited just before discharge from the postpar-tum unit of the Sir Mortimer B. Davis Jewish General Hospital, a McGill University teaching hospital with 3700 births per year, into a randomized controlled trial from January 15, 1997, to September 25, 1998. Research Ethics Committee approval was obtained before recruitment. Inclusion criteria were participation in the hospital’s short stay program, infant breastfed at least once in the hospital, and living in a defined catchment area proximal to the hospital. Mothers and newborn infants participated in the short stay pro-gram when certain health and psychosocial criteria were met. The

program included discharge within 36 hours of birth, telephone follow-up, and a hospital nurse clinic visit. Exclusions from the short stay program included cesarean birth, parityⱖ5, blood loss at birthⱖ500 mL, more than second-degree perineal tear, mater-nal inability to void adequately, nonreceipt of indicated RhoGAM, mother unable to care for self or infant, multiple birth, birth weight⬍2500 g, gestational age⬍37 weeks, abnormal neonatal examination, infant unable to maintain body temperature, breast-feeding not tolerated in hospital, language barrier, and the need for social services referral. The only exclusion criterion for this study was nonparticipation in the short stay program.

Interventions

Women were randomized to receive nurse telephone contact at 48 hours postbirth and a nurse visit at 3 to 4 days’ postpartum in 1 of 2 ways: 1) in the woman’s home by the community nurse (experimental) or 2) by the hospital nurse in the hospital clinic (control).

Experimental: Community Follow-up

The home visit was timed (3– 4 days) to coincide with peak bilirubin levels in breastfed infants26and other physical and

psy-chosocial needs of newborns and mothers.27 Home visits were

planned to last 1 hour, during which time “usual care” similar to that described in the literature on early postpartum care would be provided.27Nurse contacts continued when community follow-up

was judged to be required. All contacts and referrals were re-corded. These home visit nurses were baccalaureate prepared and had a minimum of 3 years of direct clinical experience in maternal-child health. All attended training sessions to ensure that their skills in maternal-newborn assessment and breastfeeding support were adequate.

Control: Hospital Follow-up

Usual care was a 48-hour postpartum telephone contact and a day 3 postpartum hospital visit. Clinic contacts lasted a maximum of 45 minutes, during which time a standardized plan of care was provided. The care provided during each contact (telephone and visit) is similar to that described in the literature on early post-partum care. Nurse contacts were terminated at the completion of the clinic visit, although referral for continued care was available.

Data Collection

Research assistants, blind to both treatment group and research questions, collected all data. Outcomes, measured at 2 weeks postbirth, included breastfeeding frequency (using a 2-day breast-feeding diary for days 12 and 13 postbirth) and infant weight gain (measured at home by research assistants using digital scales). Also measured at 2 weeks were maternal anxiety (using the State-Trait Anxiety Inventory), and postdischarge service satisfaction (using the Client Satisfaction Questionnaire). The State-Trait Anx-iety Inventory is validated in a varAnx-iety of population groups and languages including French.28 The Client Satisfaction

Question-naire 29 is reported to have adequate internal consistency and

validity to support its use.30Behavioral measures of satisfaction

including study withdrawal and noncompliance with treatment allocation were recorded. Health and community services use was measured at 2 months’ postpartum using a diary and medical record review.31Ancillary outcomes included insufficient

breast-feeding (defined by us as ⬍4.5 feeds per day), type of feeding (breastfeeding, formula, or mixed), and birth weight not regained at follow-up.

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Statistical Analysis

Subjects were examined for group differences on baseline char-acteristics. Intention-to-treat analyses were performed. Group dif-ferences (means and relative risks) and their corresponding 95% confidence intervals (CI) were estimated. Analyses were per-formed using SAS statistical software (SAS Institute, Cary, NC).

Assignment

Consenting women who met study criteria were contacted by either the research assistant (experimental) or the clinic nurse (control) by telephone within 24 hours of hospital discharge with notification of group assignment. Subjects were stratified by parity in blocks of 8 using a computer-generated table of random num-bers. Randomization was verified post hoc; no allocation errors were identified.

Masking

Given the nature of the intervention, masking of the women and health professionals was not possible. Different research as-sistants collected outcome data and notified women and clinicians of group assignment; outcome assessors were blind to group assignment and during any contact with subjects were instructed to ask subjects not to divulge their group status. Furthermore, research hypotheses were not divulged to the research assistants. Outcome data were not collected by clinical staff.

RESULTS Participant Flow and Follow-up

A total of 4385 women experienced vaginal single-ton births during the study interval. A total of 1683 (38.4%) were assigned to the short stay program (Fig 1). Data from 259 dyads (88.7%) randomized to the experimental group were available for analysis of 1 or more outcomes with 252 (86.3%) providing data on breastfeeding frequency. Data from 254 dyads (86.4%) randomized to the control group were

avail-able for analysis of 1 or more outcomes with 247 (84.0%) providing data on breastfeeding frequency.

Analysis

Baseline characteristics are described in Table 1. Women and infants in both groups were similar, in particular, on planning to breastfeed, planning to exclusively breastfeed forⱖ3 months, and length of postpartum stay. Overall, randomized women were well educated and ethnically heterogeneous.

Table 2 shows the study interventions received. More than 95% of women in both groups received the telephone contact. Infants in the experimental group were slightly older (3.5 hours), on average, at the time of that contact (95% CI: 2.8 – 4.2). The tele-phone contacts lasted 28% longer in the experimental group (3.8 minutes more [3.2– 4.4]). More than 94% of women in both groups received the home or clinic visit at an average time of just over 3 days of age (77 hours). Home visits lasted 82% longer (37.2 minutes more [35.0 –39.4]).

Table 3 shows health outcomes at 2 weeks. No differences were found in breastfeeding outcomes, including frequency (home minus clinic: 0.1 breast-feeds per day; 95% CI:⫺0.1– 0.3), insufficient breast-feeding (relative risk [RR]: 1.10; 95% CI: 0.71–1.68), or feeding type (RR for exclusive breastfeeding: 1.04; 95% CI: 0.94 –1.17). No differences were found in indicators of infant weight gain, including average daily weight gain from birth (⫺1.1 g/d; 95% CI: ⫺2.5– 0.3) and the proportion who had not regained their birth weight by the time of the follow-up visit (RR: 1.40; 95% CI: 0.54 –3.62). No differences were found in maternal state anxiety or service satisfac-tion. Power calculations showed⬎99% power to tect clinically relevant differences in outcomes de-fined a priori for breastfeeding frequency (2 feeds per day), state anxiety (4-point difference), and ser-vice satisfaction (2-point difference). There was 80% power to detect a 10% difference in insufficient breastfeeding, 72% power to detect a 10% difference in the proportion exclusively breastfeeding, 94% power to detect a 5 g/d difference in infant daily weight gain, and 34% power to detect a doubling in the proportion who did not regain their birth weight. Table 4 shows health and community service use at 2 months. No differences were found in the per-centage who ever made a visit to a physician or hospital or ever made or received a visit to/from a nurse or other health/community worker. The CI for the RR of visitation to/from other community work-ers is larger than the othwork-ers as a result of the small event rate. No differences were found in the percent-age who ever telephoned or received a telephone contact from a physician, other hospital employee, or other health/community worker. A statistically sig-nificant difference was found in the percentage who ever telephoned or received a telephone contact from a nurse, although a difference of 5% is unlikely to be clinically important. Post hoc power calculations var-ied. There was 93% power to detect a 10% difference in physician visits and 76% to detect such a differ-ence in physician telephone contacts. There was 62% power to detect a 10% difference in nurse visits with

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98% power to detect such a difference in nurse tele-phone contacts. Power available for the remaining service use comparisons ranged from 7% to 52%.

There were a total of 5 (1.9%) hospital admissions

in the experimental group: 3 infant admissions (2 for fever/viral episodes and 1 for whooping cough) and 2 maternal admissions (1 for trauma and 1 for respi-ratory arrest). There were a total of 9 (3.5%) hospital

TABLE 1. Baseline Characteristics by Group

Characteristic Community

Follow-up (n⫽292)

Hospital Follow-up

(n⫽294) Demographic

Mother born in Canada (%) 44.2 49.3

Maternal age (y; mean [SD]) 30.1* (4.8) 29.9† (4.7)

Christian faith (%) 43.3 50.5

Smoking history (%) 6.2 4.4

Attended postgraduate studies (%) 9.9 11.9

Living with spouse/partner (%) 94.9 93.5‡

Partner attended postgraduate studies (%) 16.8 15.7

Maternal–infant

Primiparity (%) 32.5 32.7

Prenatal class attendance (%) 20.9 23.1

Planning to breastfeed exclusively (%) 87.7 90.5

Planning to breastfeed forⱖ3 mo (%) 63.6§ 67.9㛳

Gestational age (wk; mean [SD]) 39.7 (1.1) 39.7 (1.0)

Birth weight (g; mean [SD]) 3476 (382) 3451 (420)

Male gender (%) 54.1 46.9

Hours of postpartum stay (mean [SD]) 30.2 (5.5) 29.5¶ (5.2)

Discharge weight (g; mean [SD]) 3288** (363) 3272†† (406)

Trait anxiety (STAI; mean [SD]) 32.6‡‡ (7.6) 32.2§§ (8.4)

State anxiety (STAI; mean [SD]) 30.9㛳㛳(7.4) 29.7¶¶ (7.7)

SD indicates standard deviation; STAI, State-Trait Anxiety Inventory. * Based onn⫽291.

† Based onn⫽293. ‡ Based onn⫽293. § Based onn⫽291.

㛳Based onn⫽290. ¶ Based onn⫽293. ** Based onn⫽277. †† Based onn⫽287. ‡‡ Based onn⫽288. §§ Based onn⫽292.

㛳㛳Based onn⫽291. ¶¶ Based onn⫽293.

TABLE 2. Study Interventions by Group

Characteristic of Intervention Community Follow-up

(n⫽292)

Hospital Follow-up

(n⫽294)

Mean Difference (Diff) or RR

(95% CI)

Received home or clinic telephone contact per study protocol (n[%])

283* (96.9%) 282† (95.9%) RR⫽0.97

(0.96–1.04)

Infant age at telephone contact (h; mean [SD])

56.7 (7.8) 53.2 (7.9) Diff⫽3.5

(2.8–4.2) Length of telephone contact

(min; mean [SD])

17.3‡ (7.2) 13.5§ (6.6) Diff⫽3.8

(3.2–4.4) Received home or clinic visit per

study protocol (n[%])

283㛳(96.9%) 277¶ (94.2%) RR⫽1.01

(0.97–1.05) Infant age at visit (h; mean [SD]) 77.4** (9.3) 77.1 (10.1) Diff⫽0.3

(⫺0.5–1.1) Length of visit (min; mean [SD]) 82.5†† (32.1) 45.4‡‡ (17.1) Diff⫽37.2

(35.0–39.4)

SD indicates standard deviation.

* Nine women were unable to be contacted. † Twelve women were unable to be contacted.

‡ Based onn⫽273; remaining records were missing data to permit this calculation. § Based onn⫽263; remaining records were missing data to permit this calculation.

㛳Nine women/infant dyads did not receive the home visit per study protocol: 3 went to the hospital clinic, 1 mother was not at home for the scheduled visit, 1 withdrew, 4 could not be contacted.

¶ Seventeen women/infant dyads did not receive the clinic visit per study protocol: 3 received a home visit, 3 received physician follow-up, 1 did not attend the scheduled visit, 4 cancelled their appointments, 6 could not be contacted.

** Based onn⫽278 as 5 visits were made by CLSC nurses whose records do not contain data permitting this calculation. †† Based onn⫽273; remaining records were missing data to permit this calculation.

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admissions in the control group, nearly twice that in the experimental group: 7 infant admissions (2 for jaundice, 2 for fever/viral episodes, 1 for cord infec-tion, 1 for ear infecinfec-tion, and 1 for lethargy) and 2 maternal admissions (both for mastitis).

DISCUSSION

In this randomized controlled trial of 2 approaches to nurse follow-up (home versus clinic visit) of in-fants discharged from the hospital at ⬍36 hours of age, we observed equivalent breastfeeding frequency (at power⬎99%), mean infant weight gain, maternal

anxiety, health service satisfaction, and health and community services use. In addition, the incidence of insufficient breastfeeding and insufficient weight gain were low and similar in both groups.

Alternative explanations for these findings might include analytical bias and insufficient strength of the experimental intervention. We believe that ana-lytic bias is unlikely in this study because careful attention was paid to study design, including blind-ing (when feasible) and reducblind-ing the potential effects of unmasking to group assignment. Furthermore, hospital nurses provided postdischarge care only for

TABLE 3. Health Outcomes at 2 Weeks’ Postpartum by Group

Outcome Community

Follow-up (n⫽259)

Hospital Follow-up

(n⫽254)

Mean Difference (Diff) or RR

(95% CI)

Breastfeeding

Breastfeeding frequency/d (mean [SD]) 6.9 (2.4) 6.8 (2.4) Diff⫽0.1 (⫺0.1–0.3) Insufficient breastfeeding (ⱕ4.5/d;n[%]) 38 (15.1) 34 (13.8) RR⫽1.10

(0.71–1.68) Type of feed

Breast milk only (n[%]) 183 (72.6) 171 (69.2) RR⫽1.04

(0.94–1.17) Mixed (breast milk and formula or water; [%]) 64 (25.4) 72 (29.2) RR⫽0.87

(0.65–1.16)

Formula (formula and water;n[%]) 5 (2.0) 4 (1.6) RR⫽1.22

(0.33–4.51) Weight gain

Infant weight gain/d (g; mean [SD]) 27.5 (16.0) 28.6 (16.5) Diff⫽ ⫺1.1 (⫺2.5–0.3) Birth weight not regained by follow-up visit (n[%]) 10 (3.9) 7 (2.8) RR⫽1.40

(0.54–3.62) Other

State anxiety (STAI; mean [SD])† 28.7 (7.9) 28.4‡ (8.0) Diff⫽0.3

(⫺0.5–1.1) Service satisfaction (CSQ-8; mean [SD])§ 27.1 (4.8) 27.2 (4.2) Diff⫽ ⫺0.1

(⫺0.6–0.4) SD indicates standard deviation; CSQ-8, Client Satisfaction Questionnaire.

* Based onn⫽252 in the community follow-up group andn⫽247 in the hospital follow-up group. † Higher values indicate greater anxiety.

‡ Based onn⫽253.

§ Higher values indicate greater satisfaction.

TABLE 4. Health and Community Services Use During Initial 60 Days’ Postpartum by Group

Outcome Community

Follow-up

Hospital Follow-up

RR (95% CI)

Visits (n⫽259) (n⫽254)

Ever visited a physician (n[%]) 239 (92.3) 235 (92.5) RR⫽0.99

(0.95–1.05)

Ever visited a hospital (n[%]) 28 (10.8) 22 (8.7) RR⫽1.25

(0.73–2.12) Ever visited or received a visit from a nurse (in

addition to study protocol;n[%])

121 (47.8) 132 (52.0) RR⫽0.90 (0.75–1.07) Ever visited or received a visit from any other

health/community worker (n[%])

11 (4.3) 7 (2.8) RR⫽1.54

(0.61–3.91) Telephone contacts (excluding appointment scheduling) (n⫽222*) (n⫽214†)

Ever telephoned or received a telephone contact from a physician (n[%])

71 (32.0) 61 (28.5) RR⫽1.12

(0.84–1.49) Ever telephoned or received a telephone contact from

any hospital employee (n[%])

7 (3.2) 1 (0.5) RR⫽6.75

(0.83–54.38) Ever telephoned or received a telephone contact from

a nurse (in addition to study protocol;n[%])

204 (91.9) 207 (96.7) RR⫽0.95 (0.91–0.99) Ever telephoned or received a telephone contact from

any other health/community worker (n[%])

18 (8.1) 11 (5.1) RR⫽1.58

(0.76–3.26)

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the control group and community nurses only for the experimental group.

We believe that insufficient strength or appropri-ateness of the experimental intervention is unlikely. The quantity, timing, and content of the telephone visits and home contacts were thought to be correct on the basis of physiologic and psychological param-eters; skilled, experienced nurses provided the care. Nurses in the hospital arm were somewhat more familiar with early postpartum care, although re-fresher sessions were provided to the community nurses. There is no evidence of a systematic differ-ence in the professional background and experidiffer-ence of nurses who provided care in the 2 arms. Reasons for longer home than clinic visits remain unclear.

The current study adds to the existing body of literature on postpartum care by comparing the ef-fects of 2 administratively feasible modes of nursing care after short postpartum hospital stays on breast-feeding frequency and infant weight gain. Although home versus clinic visits were previously compared in a randomized, controlled trial,25 the population studied was part of a health maintenance organiza-tion, whereas ours is a general population delivering at a university teaching hospital. Our study included only infants who were breastfeeding at discharge. Care in both arms was provided exclusively by nurses (versus nurses and physicians). Clinical out-comes in the previous study were limited to breast-feeding discontinuation, maternal depression, and satisfaction. The comparison of breastfeeding discon-tinuation rates at 14 days had only 28.4% power to detect group differences according to our post hoc calculations. Furthermore, the examination of mater-nal depression is of general interest, although the literature suggests that maternal anxiety is a more relevant determinant of breastfeeding success. The earlier study did not measure breastfeeding fre-quency or infant weight gain. Our study examined these key outcome measures.

We believe that we have avoided several method-ological weaknesses identified in most previous in-tervention studies through randomization, control-ling other potential sources of analytic bias, clearly defining interventions and methods to verify their implementation, and using reliable and valid ques-tionnaires. Furthermore, losses to follow-up were minimized, and our sample size was large enough to estimate effects with adequate precision and power.

Limitations

Certain limitations to our study remain. Recipients of care were not masked to treatment, a common problem in trials of health services. Exactly what nurses said during the telephone conversations and did during the home or clinic visits is not precisely known. Generalizability of our findings may be re-duced because the study was conducted in a single setting. The results may not apply to high-risk pop-ulations. Our study was not designed to study dif-ferences in admission rates or mortality. It is inter-esting to note that although none of the experimental group admissions seem to have been preventable, 6 of the 9 control group admissions may have been

preventable (mastitis, jaundice, cord infection, and lethargy). We achieved only 20% power for these differences; higher power would have required a much larger study.

Implications and Conclusion

Future research should address the effectiveness of physician visits and telephone “visits.” Women and infants at high-risk for medical or social complica-tions also need to be studied. The precise medical or nursing activities provided need to be measured di-rectly.

In many places in North America, insurers are required to pay for a 48-hour length of stay. How-ever, because jaundice and significant breast milk production do not occur before the third or fourth postpartum day, close surveillance of infants dis-charged after 48 hours remains important for at least the first 4 days of life. Thus, our study results remain relevant to the current clinical context.

Our results suggest that either mode of nursing care delivery postpartum, hospital clinic or commu-nity home care, is appropriate for a population of women and children at low risk of social and health complications. Furthermore, hospital follow-up seems to require fewer overall resources and is ac-ceptable to women. It may be more cost-effective, although a detailed economic analysis was not part of the current report.

CONCLUSION

Community and hospital nursing follow-up both are associated with satisfactory outcomes for the clinical dimensions measured in this study, although experimental-arm nurse telephone contacts were longer and home visits took nearly twice as long as clinic visits. The variables most directly linked to harmful infant health outcomes— breastfeeding fre-quency and infant weight gain— did not differ at 14 days postdischarge. These results suggest that either approach to follow-up is clinically reasonable for the majority of low-risk infants.

ACKNOWLEDGMENTS

This study was conducted at the Sir Mortimer B. Davis Jewish General Hospital and referring community health centers. It was supported by the Fonds de la recherche en sante´ du Que´bec (FRSQ). Drs Gagnon and Dougherty are research scholars of the FRSQ. At the time of this study, Dr Gagnon was also a research scholar of the Fondation de recherche en sciences infirmie`res du Que´bec. Dr Leduc is a research scholar of the National Health Research and Development Program of Health Canada.

We thank Kathy Waghorn for study coordination, Tamara Rader for administrative support, and the staff of the Sir Mortimer B. Davis Jewish General Hospital Postpartum Unit and Birthing Center and the affiliated CLSCs for facilitating the study.

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INFANTICIDE REDISCOVERED

“. . . The risk of being killed by someone is greater during the first year of life than at any other time before age 17. . . Infant homicide victims were most likely to be killed during their first week, with 82% of the killings committed on the day of birth, the Centers for Disease Control and Prevention said. The second peak occurred between the sixth and eighth weeks, when babies cry more persistently . . . The agency studied more than 3,300 death certificates from 1989 –1998.”

New York Times.March 8, 2002

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DOI: 10.1542/peds.109.6.1074

2002;109;1074

Pediatrics

Anita J. Gagnon, Geoffrey Dougherty, Vania Jimenez and Nicole Leduc

Randomized Trial of Postpartum Care After Hospital Discharge

Services

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http://pediatrics.aappublications.org/content/109/6/1074

including high resolution figures, can be found at:

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This article cites 27 articles, 9 of which you can access for free at:

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DOI: 10.1542/peds.109.6.1074

2002;109;1074

Pediatrics

Anita J. Gagnon, Geoffrey Dougherty, Vania Jimenez and Nicole Leduc

Randomized Trial of Postpartum Care After Hospital Discharge

http://pediatrics.aappublications.org/content/109/6/1074

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

Fig 1. Participant flow diagram for a randomized trial of post-partum care after hospital discharge.
TABLE 1.Baseline Characteristics by Group
TABLE 4.Health and Community Services Use During Initial 60 Days’ Postpartum by Group

References

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