“I feel a little unprepared going home today,” I said, requesting an extension of my postpartum stay in hospital. My pregnancy “story” had never unfolded well, and the latest episode was no different. This time, severe pelvic instability had confined me at home for months. One day I crashed a plate in the kitchen, lacking the core strength to simultaneously balance a gravid abdomen and a plate of food.
“We need to get this baby out,” my doctor said.
The baby was fine but not so the aftermath of the birth. The simple act of having a bundle in my hands made my gait unstable; I needed to steady myself against a wall, table, or humans I bumped into.
My first reaction was self-ridicule. Which fit young woman could not hold her own baby? But when the problem persisted, my apprehension grew. If I lacked the basic ability to carry a newborn, how would I navigate the stairs or the care of my other children? What if I dropped the baby?
Advised by the doctor that the charge nurse had dictated the “bed status”, I explained my plight to her. She replied simply, “No, you can’t stay.” More disappointing than her response was the implication that I was exploiting the system that she was trying to defend. But as a doctor I saw the full gamut of patients extending their stay after clinicians deemed them fit for discharge. Some hinted, others insisted and still others swore. Some threatened legal action. Others argued that they, too, paid their taxes. Some relatives promised daily that they would come to take someone home but never did. Other relatives arrived and changed their mind at the bedside to suit their needs. Sure, there were inappropriate and unsafe discharges but every clinician knew a patient with unreasonable expectations of the healthcare system.
Too upset to protest, I went home.
Since “it takes a village”, my saving grace was having that village – parents to drive and cook, aunties to rock the baby, friends to push a pram. It took weeks to walk properly and years before I realised how pregnancy had ravaged my body and how far a little understanding and professional advice would have gone.
When I read that nearly half of Australian women were being discharged as early as six hours after giving birth, my first reaction was embarrassment that I had stayed for four whole days after a “normal” birth – pure indulgence in today’s environment of scarce workers and scarce beds.
But, I wondered, if my four days had seemed paltry what a mere six hours must feel like. And even if some women were eager to go home after a shower, what was a reasonable standard for everyone else?
In 1971 half of first-time mothers in Australia were under 24. Fifty years later half are 30 years old and over and 17% are over 35. As life expectancy edges towards 90, pregnant women in their 30s are indeed young but they face a higher risk of pregnancy complications than those in their 20s: pain, infection and bleeding may not be immediately apparent.
So much has changed in the lives of modern women but not the debate and the ensuing guilt over whether, when it comes to feeding, breast is best. The WHO recommends exclusive breastfeeding for the first six months of life but less than 15% of Australian women meet the recommendation. Even migrant women with a strong culture of breastfeeding don’t reach that goal in a new country.
Negative breastfeeding experiences in the first post-partum week are associated with unattained goals, and the most vulnerable people are young women, first-time mothers and those lacking social support. Early discharge allows no time to counsel women about breastfeeding or equip them with sound advice about the alternatives. Where there is lack of information, there is room for myths, misconceptions and avoidable stress.
One of the best things a midwife taught me was how to swaddle a baby. It took a bit of practice (and a lot of feeling clumsy) but, once mastered, it made all the difference to my baby’s sleep and hence, mine.
Given the rise of mental illness and the (bidirectional) association between sleep disturbance and mood disorders, new parents need evidence-based tips on managing sleep. A hasty discharge precludes these valuable discussions and hopes for the best.
Experts warn that early cost-containment in the healthcare system could lead to missed opportunities for education and support that could eventually prove more expensive to society. But frontline workers counter that the modern-day hospital, run like a business, has lost its ability to provide the kind of person-centred care these women deserve, so they might as well go home, ideally to quiet and convenience.
So, when it comes to postpartum discharge, how early is too early? Alas, things that sound self-evident are not always so.
A 2021 Cochrane review of 17 trials involving more than 9,000 women found that the evidence for or against early discharge is uncertain. With early discharge, the risk of babies being readmitted to hospital is probably slightly higher but it does not translate into increased mortality. Moreover, differences between rates of maternal readmission, satisfaction, depression, breastfeeding, provider visits and cost of care are not clearly different.
But it’s difficult to know what to make of this data given the variations in the definition of an early discharge, intensity of antenatal preparation, provision of nurse visits and access to primary care, prompting the authors to recommend the use of standardised approaches to assess outcomes.
In retrospect, keeping me in another day or two would probably have changed nothing but listening to my concern, review by a physiotherapist and a community referral should have been the minimum condition for my discharge. For another woman, struggling with a different problem, a day or two extra might just be a lifeline, hence the importance of individual needs elicited by staff who are granted the time to provide holistic care.
Each year there are 140m births in the world. In low-income countries, about 40% of women experience postpartum complications and, for many, pregnancy is a life-threatening condition. Australia is one of the safest countries for the 315,000 babies born each year and their mothers. As we develop standardised guidelines to improve postpartum care, we should aspire to make them useful to women beyond our shores.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
