Deliver, Then Depart

Diane Mensch had a quick labor last month -- after two other babies her body knew the routine -- and the day after Shimon was born, Valley Hospital in Ridgewood, N.J., sent them home. Mensch, 35, was still exhausted; she just didn't feel ready. But her insurer, Oxford Health Plan, does not pay for more than a 24-hour stay after an uncomplicated vaginal delivery. Three days later, Mensch detected yellowish tint on Shimon's skin. He bad newborn jaundice. Mensch rushed him to a clinic, where Shimon recovered well before the brain damage that untreated jaundice can cause, but Mensch has no doubt that the problem would have been caught sooner if the HMO had paid for another hospital day. "[Insurers] are trying to save money on the backs of vulnerable women and children," she says.

The days of new mothers resting in the maternity ward for a week went the way of forceps long ago. In 1970 women stayed, on average, 3.9 days after a complication-free vaginal delivery and the birth of a healthy baby; in 1993 that was down to two days, finds the U.S. Centers for Disease Control and Prevention. Insurers such as the HMOs Oxford Health Plan and U.S. Healthcare often refuse to pay for more than 24 hours of maternity care after a normal delivery, and in Los Angeles a Kaiser Permanente hospital discharges some healthy women and newborns eight hours after the birth. They didn't count on the wrath of legislators dealing with exhausted wives and newborns on hunger strikes, And politicians are always happy to lash out at a target as unpopular as insurance companies. Last week New Jersey Gov. Christine Whitman signed legislation requiring that insurers cover a minimum 48 hours of hospital care for mother and baby. Maryland adopted the requirement in May, and a bill mandating minimum coverage nationally is before the Senate.

"Shorter hospital stays [are] placing the health of newborns and their mothers at risk," says Sen. Nancy Kassebaum, cosponsor of the Senate bill. A mother may hemorrhage if she reinjures tissue torn during labor. Her episiotomy -- an incision made to prevent vaginal tearing -- can become infected. But it is the newborn who bears the real risk. Difficulty sucking is not always apparent at 24 hours. A day is also too soon to establish nursing, because milk does not flow until the second or third day. Last year, five dehydrated newborns landed in intensive care in a Cincinnati hospital when their inexperienced mothers didn't realize the babies weren't nursing; one baby required a leg amputation. Jaundice doesn't appear until 24 to 36 hours after birth. "We hadn't been seeing [severe jaundice] for 20 years," says Dr. Michael Mennuti, chairman of the American College of Obstetricians and Gynecologists' obstetrics committee. "Now it's turned up again. That's a red flag."

Lousy food: It's also, so far, just an anecdotal report. "There are no hard scientific data to either support or negate the concept of early discharge," says pediatrician William Oh, chairman of the Committee on the Fetus and Newborn of the American Academy of Pediatrics. The only studies so far though small and tracking just healthy women in stable families -- show that in 2 percent of "drive-through deliveries," the babies require readmission. "It makes no sense for us to discharge a mother or child too early; they'd come back and cost more," says Kaiser spokesman Ken Treleven. But it does make sense to send mothers home as soon as medically possible. Since 4 million women give birth every year, and hospitals typically bill $1,000 a day for a maternity room, kicking each woman out a day sooner would save insurers $4 billion a year, says Mennuti. Economics aside, there's justification for early discharge of a healthy mother and child. Constant intrusions and lousy food inhibit bonding and breast-feeding. And hospitals are breeding grounds of infection. Some 6 percent of women have their babies at home or at birthing centers for just these reasons.

A reasonable compromise would allow early discharge if it were followed by an at-home nurse visit. In fact, the New Jersey and Maryland laws allow 24-hour hospital coverage if insurers supplement it with at-home visits. More creatively, hospitals might cut their $1,000-per-day charge for mothers who need to stay an extra day or two to recuperate and learn how to care for their vulnerable little addition. Physicians have lost many wars with insurers, who continue to dictate which surgeries and how many hospital days are justified for procedures from heart bypasses to cataract removals. Maternity care is only the latest skirmish over who calls the shots.

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