London School of Hygiene & Tropical Medicine

A substantial proportion of women in countries around the world do not stay in health facilities for long enough after giving birth, which could result in them receiving inadequate postnatal care, according to a new study published in PLOS Medicine.

The researchers from the London School of Hygiene & Tropical Medicine compiled and analysed information from databases and health surveys to look at the length of time women stay in health facilities after childbirth in 92 countries, and found wide variation.

They estimated that the average (mean) length of stay for women after they give birth to a single baby (singleton) via a vaginal birth ranged from 0.5 days in Egypt, to 6.2 days in Ukraine (data available for 71 countries). For caesarean-section deliveries, average length of stay ranged from 2.5 days in Egypt to 9.3 days in Ukraine (data available for 30 countries).

Among the high-income countries studied, lengths of stay have been decreasing since the 1970s, and currently women in the United Kingdom stay in childbirth facilities for the shortest period of time after singleton vaginal births, with a mean of 1.5 days.

Short stays can mean there is insufficient time to conduct checks and detect, diagnose or treat complications in mothers and newborns, which can increase the risk of death or illness. It can also mean there is not enough time to educate and support new mothers, which can lead to problems such as difficulties with breastfeeding and lack of maternal confidence.

Until now, the data available on length of stay after childbirth has been mainly for women in middle- and high-income countries.

The study authors found that across the 30 low-and-middle-income countries with Demographic and Health Surveys (DHS) data ^[4], the proportion of women with vaginal deliveries who stayed in health facilities for too short a period after childbirth (less than 24 hours, as defined by the World Health Organization) ranged from 0.1% (Ukraine) to 83.2% (Egypt). The proportion of women with caesarean-section deliveries who did not stay long enough (less than 72 hours, based on recommendations in the United States) ranged from 1.0% (Ukraine) to 75.3% (Egypt).

In half of the 30 countries with DHS data, more than 20% of women who had their babies in health facilities stayed for too short a period after giving birth.

Study lead author Oona Campbell, Professor of Epidemiology and Reproductive Health at the London School of Hygiene & Tropical Medicine, said: "Our new findings suggest that a substantial proportion of women around the world are leaving childbirth facilities too soon after giving birth. This is especially alarming in low-income countries where access to care after being discharged is often limited. It is crucial we make sure not only that childbirth facilities have skilled care attendants and effective monitoring and treatment, but also that women stay in hospital long enough so that they and their newborn babies can benefit from these.

"Labour and the hours that follow are the highest risk period for women and babies, and many women and their families undertake great efforts to reach health facilities to give birth, travelling long distances at expense. The challenge is to commit to achieving adequate lengths of stay for women in low- and middle-income countries, while ensuring any additional time is used to provide high-quality and respectful postnatal care."

The researchers also developed a framework to examine the factors influencing length of stay after childbirth. This looked at the woman or baby's need for care, the woman's characteristics and those of her family and community, the health system, the health facilities and the care providers. For example, a need to return home to care for other children may lead women to stay for a shorter period. In some countries poorer women are retained in health facilities until health care fees are paid, leading to longer stays.

In the analyses, caesarean-section delivery, low birthweight of the baby, multiple births (twins or triplets), and whether the baby survived, led to longer stays. The researchers also found that older women, poorer women, and women who delivered their babies with doctors, were more likely to have a longer length of stay.

The authors note limitations to the study, including lack of data on postnatal length of stay in many countries, which means additional research is needed, and the reliance on self-reporting in the DHS data. They also acknowledge that the wide variations in length of stay between countries are likely to be influenced by national norms and features of the national health systems (such as stipulation for minimum length of stay, or home visits after birth), as well as by the specific needs of mothers and newborns.

Prof Campbell added: "Ultimately, length of stay is an approximation of what we are really after, which is high quality care for women and babies. Future research should disentangle the variations of length of stay after child birth, taking into account the health status of mothers and babies, and assess the extent to which those staying the recommended amount of time are actually receiving the essential components of postnatal care."

Publication:

• Oona M.R. Campbell, Luca Cegolon, David Macleod, Lenka Benova. Length of Stay After Childbirth in 92 Countries and Associated Factors in 30 Low- and Middle-Income Countries: Compilation of Reported Data and A Cross-sectional Analysis from Nationally Representative Surveys in Low-and Middle-Income Countries. PLOS Medicine. DOI: 0.1371/journal.pmed.1001972

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