A randomized, controlled trial of nurse home visiting to vulnerable families with newborns. Early discharge from obstetrics-pediatrics at the Hospital de Valme, with domiciliary follow-up. A randomized trial of a program of early postpartum discharge with nurse visitation. Randomized trial of postpartum care after hospital discharge. Patient, carer and health service outcomes of nurse-led early discharge after breast cancer surgery: a randomised controlled trial. Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial. Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. A pilot study of a nursing intervention protocol to minimize maternal-infant separation after Cesarean birth. Does continuity of care by well-trained breastfeeding counselors improve a mother's perception of support?
This project aimed to evaluate the impact of a home visiting programme that targeted families where the child, for environmental reasons, was at great risk of poor health and developmental outcomes.
                Women in the immediate postpartum period were recruited to a randomized double-blind controlled trial on the basis of self-reported vulnerability factors and were randomly assigned to receive either a structured programme of nurse home visiting, supported by a social worker and paediatrician (n = 90), or assigned to a comparison group receiving standard community child health services (n = 91). Parenting stress and maternal depression were measured at enrollment and at 6 weeks. Preventive health behaviour, service satisfaction and home environment outcomes were tested at 6 weeks, as were child health outcomes.
                At six weeks, women receiving the home-based programme had significant reductions in postnatal depression screening scores as well as improvements in their experience of the parental role and improvement in the ability to maintain their own identity. Maternal-infant interactions were more likely to be positive, with significantly higher (better) scores in aspects of the home environment related to optimal development in children, particularly maternal-infant secure attachment. Intervention group mothers were significantly more satisfied with the community child health service.
                This form of intervention for families is effective in promoting secure maternal-infant attachment, preventing maternal mood disorder and is welcomed by the families receiving it. These findings may predict long-term benefits for the healthy development of children otherwise at risk of a range of poor health and development outcomes. This study was undertaken to evaluate the advantages and disadvantages of a program of early obstetric-pediatric discharge (24 hours postpartum) with domiciliary follow-up, compared with the traditional postpartum hospital stay (more than 48 hours), according to the criteria described by reviewers of the subject.
                A randomized controlled trial of early obstetric discharge for healthy mothers and term infants, with postpartum randomization, with no prenatal preparation and with observational and clinical follow-up was performed. The participants were mothers with healthy, term neonates (37-42 weeks) weighing more than 2500 g and produced via vaginal delivery and with a verified normal evolution before discharge. The sample consisted of 430 cases (213 cases with early discharge, and 217 control cases) in which the following variables were evaluated: existence of complications in the mother and/or child that required rehospitalization or a medical consultation, existence of maternal problems of fatigue or anxiety/depression after the birth, continuity of lactation and its problems, satisfaction of the mother and family, and relative costs.
                After demonstrating the homogeneity of the groups, no significant differences were found in the rates of maternal rehospitalization (1.9% in the early discharge group vs 2.3% in the control group, relative risk 0.81, 95% CI 0.21-3.03) or in the rates of rehospitalization of the neonates (1.4% in the early discharge group vs 2.3% in the control group, relative risk 0.16, 95% CI 0.15-2.56). No increases were observed in maternal or neonatal disease, puerperal fatigue, or maternal anxiety/depression. A prolongation of maternal lactation to 3 months was observed in the early discharge group (P=.016 <.05 Fisher exact test). When the cost of early discharge is compared with that of traditional discharge with a minimum of 48 hours hospital stay, we find a saving of 18% to 20%. The level of maternal satisfaction with early discharge is better than 90%. Our purpose was to compare an early postpartum discharge program versus standard postpartum care.
                A randomized controlled trial in a 637-bed university hospital included 175 healthy women recruited at 32 to 38 weeks gestation from physicians' offices and sonograms. Experimental intervention consisted of discharge 6 to 36 hours post partum with nursing care available by telephone or at home at 34 to 38 weeks' gestation and at < or = 48 hours and at 3, 5, and 10 days post partum. The control included a postpartum stay of 48 to 72 hours and standard follow-up.
                At 1 month no significant differences were seen in perceived maternal competence (Experimental-Control = 4.3 points [95% confidence interval-7.7 to 16.3]), infant weight gain (1.2 gm/ day [-2.8 to 5.2]); identification of significant neonatal hyperbilirubinemia (rate ratio 0.50 [0.10 to 2.51]), infant utilization of health services (rate ratio 0.88 [0.45 to 1.73]), or predominant breast-feeding (adjusted odds ratio 1.25 [0.88 to 1.75]). Program participants did have significantly less frequent infant bilirubin testing (rate ratio 0.39 [0.17 to 0.94]). The program also enhanced perceived maternal competence in recent immigrants (26.9 points [2.7 to 51.5]).
                Early postpartum discharge coupled with prenatal, postnatal, and home contacts leads to no apparent disadvantage and may yield benefits for some mothers and infants. Harmful effects of short postpartum hospital stays include dehydration and malnutrition of breastfed infants. These may be prevented by adequate breastfeeding frequency; however, rigorous research to determine the relative effectiveness of various follow-up strategies in supporting breastfeeding frequency 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?"
                A randomized, controlled trial was conducted 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 hospital (control) were provided. The main outcomes measured 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.
                No clinically important or statistically significant group differences were found in daily breastfeeding frequency (mean difference experimental minus control = 0.1 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.
                Follow-up by nurses after short postpartum 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. Patients with breast cancer who require axillary clearance traditionally remain in hospital until their wound drains are removed. Early discharge has been shown to improve clinical outcomes, but there has been little assessment of the psychosocial and financial impact of early discharge on patients, carers and the health service. This study aimed to evaluate the effectiveness of a nurse-led model of early discharge from hospital. Main outcome measures were quality of life and carer burden. Secondary outcomes included patient satisfaction, arm morbidity, impact on community nurses, health service costs, surgical cancellations and in-patient nursing dependency. A total of 108 patients undergoing axillary clearance with mastectomy or wide local excision for breast cancer were randomised to nurse-led early discharge or conventional stay. Nurse-led early discharge had no adverse effects on quality of life or patient satisfaction, had little effect on carer burden, improved communication between primary and secondary care, reduced cancellations and was safely implemented in a mixed rural/urban setting. In total, 40% of eligible patients agreed to take part. Nonparticipants were significantly older, more likely to live alone and had lower emotional well being before surgery. This study provides further evidence of the benefits of early discharge from hospital following axillary clearance for breast cancer. However, if given the choice, most patients prefer to stay in hospital until their wound drains are removed. Adverse childbirth experiences can evoke fear and overwhelming anxiety for some women and precipitate posttraumatic stress disorder. The objective of this study was to assess a midwife-led brief counseling intervention for postpartum women at risk of developing psychological trauma symptoms.
                Of 348 women screened for trauma symptoms, 103 met inclusion criteria and were randomized into an intervention (n = 50) or a control (n = 53) group. The intervention group received face-to-face counseling within 72 hours of birth and again via telephone at 4 to 6 weeks postpartum. Main outcome measures were posttraumatic stress symptoms, depression, self-blame, and confidence about a future pregnancy.
                At 3-month follow-up, intervention group women reported decreased trauma symptoms, low relative risk of depression, low relative risk of stress, and low feelings of self-blame. Confidence about a future pregnancy was higher for these women than for control group women. Three intervention group women compared with 9 control group women met the diagnostic criteria for posttraumatic stress disorder at 3 months postpartum, but this result was not statistically significant.
                A high prevalence of postpartum depression and trauma symptoms occurred after childbirth. Although most women improved over time, the intervention markedly affected participants' trajectory toward recovery compared with women who did not receive counseling.
                A brief, midwife-led counseling intervention for women who report a distressing birth experience was effective in reducing symptoms of trauma, depression, stress, and feelings of self-blame. The intervention is within the scope of midwifery practice, caused no harm to participants, was perceived as helpful, and enhanced women's confidence about a future pregnancy. To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction.
                Randomised controlled trial.
                Large maternity teaching hospital in Melbourne, Australia.
                1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64).
                Maternal depression (score >/=13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum.
                917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1. 37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= -2.31, 95% confidence interval -10.48 to -0.84).
                Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded. To pilot test a standardized intraoperative and postoperative nursing intervention protocol to minimize maternal-infant separation after Cesarean.
                Randomized-controlled trial.
                A 250-bed acute care community hospital labor/delivery/recovery/postpartum unit with approximately 150 repeat Cesarean deliveries per year.
                Fifty women having a live, term, singleton, repeat Cesarean delivery and their newborns.
                A standardized nursing intervention protocol was designed and administered to minimize the amount of maternal-infant spatial, tactile, olfactory, auditory, and visual separation post-Cesarean.
                Maternal outcomes included maternal pain, anxiety, and childbirth perception. Infant outcomes included respiratory rate, temperature, stress (infant salivary cortisol), and breastfeeding rates.
                Compared with the control group, the intervention group experienced earlier first physical contact and feedings and a longer interval until the infant first bath. Differences were found between treatment groups for infant temperatures and respiratory rates. Three infants in the control group experienced suboptimal temperatures. Infants in the intervention group had significantly higher salivary cortisol levels but were within the normal upper level range. No differences were noted in maternal pain, maternal anxiety, or perception of birth experience among treatment groups.
                The pilot was valuable in examining intervention feasibility, appropriate outcome measures, and data collection strategies. The standardized intervention protocol shows promise for positively affecting maternal-infant outcomes after Cesarean delivery and merits further testing. Social support has been shown to be greatly important for breastfeeding success. The objective of this study was to investigate if mothers who were attended by midwives and nurses specially trained in breastfeeding counseling perceived better continuity of care and emotional and informative breastfeeding support than mothers who received only routine care.
                Ten municipalities, each with an antenatal center and child health center, in southwest Sweden were randomized either to intervention or control municipalities. The intervention included a process-oriented training in breastfeeding counseling and continuity of care at the antenatal and child health centers. Primiparas were asked to evaluate the care given, and those living in the control municipalities were divided into control groups A and B. Data collection took place at different points in time for the two control groups. The 540 mothers responded to 3 questionnaires at 3 days and at 3 and 9 months postpartum. The perception of support provided by the health professionals and from the family classes was rated on Likert scales.
                Intervention group mothers rated the breastfeeding information given during the family class as significantly better during pregnancy than both control groups, and better than control group B mothers at 3 months postpartum; compared with both control groups, intervention group mothers perceived that they received significantly better overall support and that postnatal nurses provided better information about breastfeeding and the baby's needs. At 9 months, intervention group mothers were more satisfied with knowledge about social rights, information about the baby's needs, and their social network than control group B mothers. Both intervention group and control group B mothers perceived better overall support than control group A during pregnancy. At 3 and 9 months, intervention group mothers perceived that postnatal nurses were more sensitive and understanding compared with both control groups.
                After implementation of a process-oriented breastfeeding training program for antenatal midwives and postnatal nurses that included an intervention guaranteeing continuity of care, the mothers were more satisfied with emotional and informative support during the first 9 months postpartum. The results lend support to family classes incorporating continuity of care.
The pooled trials have inadequate power to detect increases in rare outcomes, such as infant and maternal mortality or readmissions.
Policies of earlier postnatal discharge of healthy mothers and term infants do not appear to have adverse effects on breastfeeding or maternal depression when accompanied by a policy of offering women at least one nurse-midwife home visit post discharge.
Large well-designed trials of early discharge programs incorporating process evaluation to assess the uptake of co-interventions, and using standardized approaches to outcome assessment are needed.