Determinants of Length of Stay After Vaginal Deliveries in the Friuli Venezia Giulia Region (NorthEastern Italy), 2005–2015

Although length of stay (LoS) after childbirth has been diminishing in several high-income countries in recent decades, the evidence on the impact of early discharge (ED) on healthy mothers and term newborns after vaginal deliveries (VD) is still inconclusive and little is known on the characteristics of those discharged early. We conducted a population-based study in Friuli Venezia Giulia (FVG) during 2005–2015, to investigate the mean LoS and the percentage of LoS longer than our proposed ED benchmarks following VD: 2 days after spontaneous vaginal deliveries (SVD) and 3 days post instrumental vaginal deliveries (IVD). We employed a multivariable logistic as well as a linear regression model, adjusting for a considerable number of factors pertaining to health-care setting and timeframe, maternal health factors, newborn clinical factors, obstetric history factors, socio-demographic background and present obstetric conditions. Results were expressed as odds ratios (OR) and regression coefcients (RC) with 95% confdence interval (95%CI). The adjusted mean LoS was calculated by level of pregnancy risk (high vs. low). Due to a very high number of multiple tests performed we employed the procedure proposed by Benjamini-Hochberg (BH) as a further selection criterion to calculate the BH p-value for the respective estimates. During 2005–2015, the average LoS in FVG was 2.9 and 3.3 days after SVD and IVD respectively, and the pooled regional proportion of LoS>ED was 64.4% for SVD and 32.0% for IVD. The variation of LoS across calendar years was marginal for both vaginal delivery modes (VDM). The adjusted mean LoS was higher in IVD than SVD, and although a decline of LoS> ED and mean LoS over time was observed for both VDM, there was little variation of the adjusted mean LoS by nationality of the woman and by level of pregnancy risk (high vs. low). By contrast, the adjusted fgures for hospitals with shortest (centres A and G) and longest (centre B) mean LoS were 2.3 and 3.4 days respectively, among “low risk” pregnancies. The corresponding fgures for “high risk” pregnancies were 2.5 days for centre A/G and 3.6 days for centre B. Therefore, the shift from “low” to “high” risk pregnancies in all three latter centres (A, B and G) increased the mean adjusted LoS just by 0.2 days. By contrast, the discrepancy between maternity centres with highest and lowest adjusted mean LoS post SVD (hospital B vs. A/G) was 1.1 days both among “low risk” (1.1 = 3.4–2.3 days) and “high risk” (1.1 = 3.6–2.5) pregnanices. Similar patterns were obseved also for IVD. Our adjusted regression models confrmed that maternity centres were the main explanatory factor for LoS after childbirth in both VDM. Therefore, health and clinical factors were less infuential than practice patterns in determining LoS after VD. Hospitalization and discharge policies following childbirth in FVG should follow standardized guidelines, to be enforced at hospital level. Any prolonged LoS post VD (LoS> ED) should be reviewed and audited if need be. Primary care services within the catchment areas of the maternity centres of FVG should be improved to implement the follow up of puerperae undergoing ED after VD. At the beginning of the 20th century home births were the norm and hospital deliveries very rare. Women started to deliver in hospital during World War 2 (WW2), in facilities near the military areas where their respective partners were training. Tis trend continued in the decades following WW2, with standard length of stay afer childbirth (LoS) increasing up to 10 days. In the 70 ies some USA hospitals started to assess the health of mothers and newborn for eligibility to returnhome within 12–24 hours afer childbirth, with a midwife on call for domiciliary care up to 3 days for 2 weekspost discharge. In 1992 the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) formalized the most frequently shared defnition of early discharge (ED) afer childbirth worldwide as a LoS less than 48 h post spontaneous vaginal deliveries (SVD) and less than 96 h post cesarean section (CS). Tereafer the reduction of LoS expanded to other high-income countries, with increasing applications of ED. LoS afer childbirth remained however a controversial aspect of obstetric care, creating an open debate not only on its impact on the health of mothers and babies but also on health policies, state legislations and functioning of the respective health care systems. Nevertheless, ED of mothers and newborn has in fact increased dramatically in several high-income countries over the past 10–15 years. However, the evidence on the impact of ED on healthy mothers and term newborns (≥37 weeks) afer a vaginal delivery (VD) is still inconclusive and little is known of the characteristics of those discharged early. Since LoS has become a critical indicator of efciency of health care delivery, understanding its associated factors could provide information helpful in the reduction of health care costs, improvement in the delivery of obstetric care, containment of untoward events associated with comorbidities and complications requiring readmission. For instance, in Canada (excluding Quebec) from 2003 to 2010, neonatal readmission rates were lowest for LoS of 1–2 days following VD and 2–4 days afer CS. Several factors are reportedly associated with LoS in the open literature, including readiness for discharge (clinical and perceived) of the mother8,17–19. However, information on the impact of medical/obstetrical conditions associated with pregnancies is scarce or totally lacking. Using a comprehensive database with information on a considerable number of factors, we previously reviewed the case mix of hospital performance by LoS post SVD as well as instrumental vaginal deliveries (IVD) during 2005–2015 in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy. In this study we present the impact of the outstanding determinants on LoS following SVD and IVD, with the aim of inforing health care policy makers.