Giving moms, newborns more time in the hospital

THE BALTIMORE SUN

When she was wheeled out the hospital door with her newborn after just 24 hours, Stacey Berger thought she was prepared.

But as the snow piled up outside her Clarksville home that weekend, Mrs. Berger and her husband -- both attorneys who had painstakingly prepared for childbirth -- grew frightened. Mrs. Berger had trouble breast-feeding. Their tiny daughter, Melanie, kept crying.

When they finally made it to the doctor, they discovered the baby was malnourished and jaundiced.

Like other new parents, the Bergers were rushed out of the hospital as part of an effort to hold down health care costs. For several years, doctors have questioned this policy. Now they say they have proof it's a bad idea.

And they've persuaded the Maryland legislature to back them up.

A bill on Gov. Parris N. Glendening's desk would require insurance companies and health maintenance organizations to pay for 48 hours in the hospital after childbirth. If medically stable, mother and child could be discharged before 48 hours, but a nurse would have to visit them at home.

The bill, among the first such efforts in the country, would have made a big difference for the Bergers.

"I understand the early discharge and would not have a problem with it if there is some type of supervision of mother and baby," Mrs. Berger said. "But you don't get that, you're given this checklist."

Millions of first-time parents share her anxiety. As managed care and market forces have reduced the amount of time mothers and their babies stay in the hospital to roughly 24 hours, parents often find themselves struggling.

Some hospitals have responded by scheduling home visits or follow-up telephone calls by nurses, for which some insurance companies pay. Since the trend toward shorter stays started in Maryland four years ago, a mothers' support group at Greater Baltimore Medical Center has mushroomed from half-a-dozen participants to sometimes more than 30. Monthly calls to the hospital's breast-feeding specialist have almost doubled, from about 350 to about 700.

For years, studies of hospital maternity stays have yielded conflicting findings. Proponents of short stays say the mother and infant bond more quickly at home and aren't exposed as long to hospital germs.

Opponents counter that several serious illnesses that strike infants can't be detected until 24 hours after birth.

The controversy symbolizes the larger struggle over the future of health care in this country. Insurance companies and HMOs are looking to cut costs. One of their most successful tactics has been to reduce the number of days people spend in hospitals. But physicians and hospitals -- which are losing money because of the changes -- argue that quality care is being sacrificed.

Both sides are arguing over who draws the line -- who decides how much care patients get.

The often abstract debate becomes real for many new parents when they're told to pack up and leave the hospital long before they feel ready. Five years ago, the stay for childbirth was roughly three days; now it's about one. About 75,000 babies are born in Maryland annually. Nationwide, childbirth is among the top reasons for hospital admissions. It's an emotionally charged time.

Ellen O'Brien stayed at Greater Baltimore Medical Center with her baby for the standard 24 hours, until almost midnight, because she wanted the care and attention as long as possible. When she was informed that the child, her first, had respiratory problems and couldn't go home, she was crushed.

'This was the prize'

"It was, like, this was the prize," she said, holding up her 5-month-old son. "To think that I wouldn't get to take him home, and who knows what's going to happen to him . . . "

As she recalled that night, she began to cry, just as she had in the hospital before doctors relented and agreed to let her take Patrick home.

"I took him out of here in the middle of the night, in a pouring-down rainstorm," Ms. O'Brien said. "In hindsight, I should have let him stay, but I should have been able to stay with him," as a patient.

Doctors say that, more and more, mothers are discharged before their sick newborns, causing disruptions in breast-feeding and bonding. And even in normal, healthy deliveries, the shorter stay is causing problems, they say.

According to a state geneticist who tracks every Maryland birth, fewer newborns are being screened for genetic diseases, including some that can cause mental retardation or death if not detected early and treated.

In the first half of 1994, about one-third of Maryland's newborns were sent home within 24 hours, said Dr. Susan Panny, who heads the Office for Hereditary Disorders in the Department of Health and Mental Hygiene.

That renders worthless a routine test to screen for several genetic metabolic diseases and sickle cell anemia, she said. The baby must have 24 hours of milk feedings for the blood tests to pick up the disorders, so the early discharges are delaying valid screenings.

These tests are repeated later, by a nurse at home or in a doctor's office, but the later the illness is discovered, the worse it can be for the child, Dr. Panny said.

In Maryland, from 1978 to 1988, more than 95 percent of cases of one metabolic disorder -- phenylketonuria, or PKU -- were picked up by the first screening test. By 1994, because of shorter hospital stays, that number had dropped to 66 percent, Dr. Panny said.

The screening also has prevented a significant number of deaths from sickle cell anemia, she said. Infants with the disease are prescribed medication to prevent infection. More babies may die, she said, if they aren't screened at the right time.

Diagnosing difficulties

Experts cited other problems with the short stays. Certain heart problems and neurological conditions may not be diagnosed if a baby is discharged too early.

Dr. Mel Stern, chairman of the Maryland chapter of the American Academy of Pediatrics' legislative committee, said the drop in screenings made clear that the short stays weren't working, and that more follow-up support was needed at home.

Healthy babies aren't the only ones affected by the early discharge policy. Sick babies are being sent home in less than 24 hours as well, state statistics show.

Michael H. Fox, deputy director of policy and health statistics in the state Department of Health and Mental Hygiene, said he found that sick Medicaid babies who were discharged after only a day were twice as likely to be readmitted than similar infants who stayed longer.

Often, a mother hasn't begun to breast-feed yet. Once she is home, she often doesn't have the teaching help of nurses. Many women become frustrated and give up. Others say even though they took classes, they still struggled with how to hold, bathe and feed the baby correctly.

Sharon Cash, who recently gave birth to a daughter, said she was overwhelmed by all the information she was expected to absorb in a 24-hour hospital stay.

"It's like, 'Wait a minute, I just had a baby, and you want to tell me how to care for her right this minute? I can't even sit down yet,' " Mrs. Cash said.

But the Maryland Association of HMOs and other critics of the proposed legislation say hospital stays should not be chiseled into law.

"It's really a slippery slope in terms of legislating medicine," said Kala Ladenheim, a health care expert who monitors state policy at George Washington University.

While Maryland may become a pioneer in this area, New Jersey lawmakers are considering a similar bill. Arkansas has a new law that requires insurers to pay for a newborn's hospital stay until the mother is discharged, or up to five full days, whichever is less, which at least ensures that baby and mother remain together.

Some impartial observers believe state legislatures are not the right arenas in which to hash out these conflicts.

"The easy thing to do is mandate hospital stays, and it's especially attractive because the hospital industry loves it, and the doctors love it because it puts more power back in their hands," said Dr. Jonathan Moreno, a bioethicist and member of the president's advisory committee on human radiation experiments.

"It doesn't really answer the question, 'Is this likely to result in healthier people?' "

Frustrated physicians, meanwhile, say they tried to work with insurers, but got fed up. And they point out that a 48-hour stay is recommended by two national organizations of pediatricians and obstetricians.

"The payers are trying to reduce costs, as they should," said Dr. Stern. "What's changed is they can no longer do that with impunity. The public is now saying, 'Wait a minute.' "

Dr. Robert Kritzler, associate medical director for Kaiser Permanente's mid-Atlantic region, said the giant HMO still is analyzing what Maryland's bill would mean. He said Kaiser doctors prefer to have the mother and baby seen by a physician in one of the HMO's offices rather than in a home visit.

But Maryland's largest insurer, Blue Cross and Blue Shield of Maryland, already has decided to routinely pay for home nurse visits. Many physicians predicted that's exactly what all insurers will do. Rather than pay the several hundred dollars for another night in the hospital, they will pay about $75 for the home visit, where mother and baby are checked.

'Lots of moms need support'

In one visit last week, nurse Beverly Hoffman sat down beside new mother Chanda Crudup, chatting with her about how she felt and advising her not to do laundry or vacuum. The nurse drew blood for the screening test from 2-day-old Khayla and listened to her heart.

Ms. Hoffman complimented Ms. Crudup on how she was holding the baby.

"Lots of moms need support. They need someone to reassure them they're doing the right things," Ms. Hoffman said. She believes home visits are a better way to teach new mothers.

On her comfortable cream-colored couch, swaddling her newborn in a pale green blanket, Ms. Crudup seemed content. She was glad she only spent a day in the hospital.

"I felt they did all they could do," she said. "It was time for me to do what I could do."

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