New mothers’ rates of breast-feeding remained unchanged despite two policy reversals regarding hospital length of stay within an eastern Massachusetts HMO, according to a study published in the journal Pediatrics on March 3. This remained true for all categories of women, regardless of race, age, or socioeconomic status.
The findings are good news for mothers and babies because breast-feeding is widely acknowledged to benefit both. Breast-feeding is recommended by the American Academy of Pediatrics and promoted in the national program Healthy People 2000/2010. The new study indicates that changes in length-of-stay policies do not necessarily threaten breast-feeding practices.
Researchers from Harvard Medical School and Harvard Pilgrim Health Care Department of Ambulatory Care and Prevention exploited a unique opportunity for study provided by a pair of policy changes: first, in 1994, Harvard Vanguard Medical Associates and the insurer Harvard Pilgrim Health Care implemented a program calling for a single overnight stay in the hospital following uncomplicated vaginal delivery. Then in 1996, the Massachusetts legislature (as part of a public backlash against what were termed “drive-through deliveries”) passed a 48-hour coverage mandate.
The short-stay program offered improved prenatal care, a postnatal home visit from a nurse specialist within 48 hours of discharge, and stepped-up breast-feeding assistance at health centers. The Massachusetts law establishing a 48-hour minimum stay allowed a woman to go home earlier if both she and her doctor consented and if she was offered a home visit.
“Critics feared short stays could be dangerous, and specifically worried about a drop in breast-feeding,” said Jeanne Madden, the study’s lead author and a research fellow in the Harvard Medical School and Harvard Pilgrim Health Care Department of Ambulatory Care and Prevention. “On the other hand, advocates felt that because the short-stay program offered compensatory benefits such as home visits and improved outpatient services – and because the home visit may be a more comfortable context for patient education, and also comes a little later in time, when breast-feeding difficulties may be just starting to appear – the likelihood of breast-feeding success might actually increase as a result of this HMO program.”
In the study, the researchers looked at 20,366 pairs of infants and mothers over a seven-and-a-half-year period, collecting demographic and utilization data as well as information on how infants were fed during the first 90 days of life. Not surprisingly, they found that the length of time women stayed in the hospital after delivery changed significantly following the two policy modifications: 29.0 percent of mothers stayed for one postpartum night just before implementation of the HMO early discharge policy, while 64.6 percent did so afterwards. When the Massachusetts law came into effect, this rate plummeted to 15.2 percent.
The rate of breast-feeding initiation, by contrast, rose gradually over the entire study period, from 70.1 percent in 1991 to 81.9 percent in 1998, with no significant changes following either of the abrupt shifts in length of stay. Meanwhile, breast-feeding continuation among those who initiated was constant over the years. Even when researchers analyzed breast-feeding initiation and continuation among the most socially vulnerable subgroups, such as young or first-time mothers, those with low income or education indicators, or those of nonwhite race, the finding of no harm due to early discharge remained the same.
“There was neither a danger nor a particular advantage to either of these changes,” Madden said. “This means either that these two ways of delivering care were equivalent in terms of real influence on breast-feeding, or that, at least in this setting, women’s intentions to breastfeed and their success at sustained breast-feeding simply aren’t much influenced by such changes in patterns of care.”