Trends in Length of Stay for Hospital Deliveries -- United States, 1970-1992

Obstetric delivery is the most frequent cause of hospital admission in the United States, reflecting the approximately 4 million births in this country each year (1). Because of steadily increasing hospital costs, overall lengths of hospital stay have declined. To assess national trends in length of stay for hospital deliveries, data were analyzed from CDC's National Hospital Discharge Survey (NHDS) from 1970 through 1992, by method of delivery. This report summarizes the results of the analysis.

Since 1965, the NHDS has collected data from U.S. nonfederal, short-stay hospitals. Each year, approximately 200,000 inpatient records are selected from approximately 400 hospitals; data are weighted to represent all hospitalizations nationally (2,3). Selected patient information (e.g., medical diagnoses and surgical procedures) is abstracted from each record. For this analysis, the NHDS provided information about mother's age and race/ethnicity; method of payment; and the hospital's ownership, size, and location. Estimates for average length of stay were derived from the 20,000-33,000 deliveries each year among all records sampled. Hospital stays of less than 24 hours were recoded as 0 days; these hospitalizations accounted for less than 1% of all deliveries and were relatively constant by year (i.e., 0.3% in 1970 to 0.7% in 1992). The proportion of all deliveries that occurred outside of hospitals also was stable from 1975 (0.9%) to 1990 (1.1%) (4).

In 1970, the average length of stay for all hospital deliveries was 4.1 days (median: 4 days). By 1992, the average had decreased by 37% to 2.6 days (median: 2.0 days). The average length of stay for women who gave birth vaginally decreased by 46% (from 3.9 to 2.1 days) and for those who gave birth by cesarean section by 49% (from 7.8 to 4.0 days) Figure_1. The decrease in the average length of stay for all deliveries was smaller than that for either method because the percentage of deliveries by cesarean section increased from 5.5% to 23.5% during this period (5).

The average length of stay also was analyzed by mother's age (less than 20, 20-29, 30-39, and greater than 39 years), race (white or black) *, hospital location (Northeast, Midwest, South, or West regions), hospital ownership (proprietary, government, or nonprofit), and hospital size (less than 100, 100-299, 300-499, and greater than 499 beds). From 1970 through 1992, the average length of stay decreased similarly for all these groups; decreases ranged from 39% to 52% for vaginal deliveries and from 38% to 53% for cesarean deliveries. NHDS began collecting information about method of payment (i.e., Blue Cross/Blue Shield **, other private insurance, Medicaid, and self-paying) in 1977. From 1977 through 1992, the average length of stay decreased for these payment groups; decreases ranged from 35% to 38% for vaginal deliveries and from 32% to 47% for cesarean deliveries. Reported by: Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Prevention Effectiveness Activity, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The length of stay associated with hospital deliveries steadily decreased during 1970-1992. Early hospital discharge results in reduced health-care costs and enables mothers to return home sooner with their newborns. However, careful postpartum follow-up is necessary to ensure prompt diagnosis and treatment of any maternal or neonatal complications. Early discharge should not preclude efforts traditionally conducted during postpartum hospitalization to educate women about breastfeeding, family planning, care of their newborn, and other topics important for new mothers.

The optimal length of stay for uncomplicated deliveries reflects several factors, including the presence of others in the home who can support the mother after discharge, the mother's awareness of complications, and access to health-care services. Guidelines published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists suggest that, when there have been no complications, the duration of postpartum hospital stays range from an average of 48 hours for vaginal delivery to an average of 96 hours for cesarean birth (excluding the day of delivery) (6). In addition, specific criteria should be met for a woman to be discharged early, especially within 24 hours of delivery.

One potential limitation of the analysis in this report is that data from the NHDS on length of stay does not distinguish the postpartum period from the rest of the hospitalization. Therefore, this analysis could not determine whether the decrease in the average length of stay resulted from a shorter antepartum stay or postpartum stay. However, since 1970, most of the efforts to decrease length of stay for hospital deliveries has been directed toward the postpartum period.

Since 1970, the rate of health-care costs has increased more rapidly than that of general inflation; efforts to decrease hospital health-care costs by reducing length of stay will probably intensify. Most studies have not detected an increased rate of morbidity in association with early postpartum discharge (7-9). However, these studies -- which were conducted among carefully selected women at low risk for postpartum complications -- documented rates of complications of up to 14% among women and 11% among their infants (7). In addition, home visits by nurse practitioners after discharge (a practice not routinely used by health-care providers) ensured prompt diagnosis and treatment of postpartum complications. These findings underscore the need to ensure adequate follow-up care for women and infants and to maintain the educational activities traditionally provided during postpartum hospitalization. The prevalence of complications also should be monitored to accurately determine the costs and benefits of early postpartum discharge.

References

1. Agency for Health Care Policy and Research. The national bill for diseases treated in U.S. hospitals, 1987. Washington, DC: US Department of Health and Human Services, Public Health Service, 1994. (Provider studies research note no. 19).

2. National Center for Health Statistics. 1985 Summary: National Hospital Discharge Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (PHS)86-1250. (Advance data no. 127).

3. Graves EJ. 1990 Summary: National Hospital Discharge Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1992; DHHS publication no. (PHS)92-1250. (Advance data no. 210).

4. NCHS. Advance report of final natality statistics, 1992. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994. (Monthly vital statistics report; vol 43, no. 17, suppl).

5. CDC. Rates of cesarean delivery -- United States, 1991. MMWR 1993;42:285-9.

6. American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists, 1992:105-8.

7. Welt SI, Cole JS, Myers MS, Sholes DM Jr, Jelovsek FR. Feasibility of postpartum rapid hospital discharge: a study from a community hospital population. Am J Perinatol 1993;10:384-7.

8. Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M. A randomized trial of early hospital discharge and home follow-up of women having cesarean birth. Obstet Gynecol 1994;84:832-8.

9. Norr KF, Nacion K. Outcomes of postpartum early discharge, 1960-1986: a compa

* Numbers from other racial/ethnic groups were too small for reliable analysis.

** Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

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