This article was downloaded by: [Towson University]On: 08 October 2014, At: 09:04Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Women & HealthPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/wwah20

Type and Timing of Services Following PostnatalDischarge: Do They Make a Difference?Lise Goulet MD and PhD a b c , Danielle D'Amour RN and PhD a d & Raynald Pineault MD andPhD a e ca GRIS (Groupe de recherche interdisciplinaire en santé)b Department of Social and Preventive Medicine , University of Montrealc Québec National Institute of Public Healthd Faculty of Nursing , University of Montreale Direction de santé publique de MontréalPublished online: 17 Oct 2008.

To cite this article: Lise Goulet MD and PhD , Danielle D'Amour RN and PhD & Raynald Pineault MD and PhD (2007) Type andTiming of Services Following Postnatal Discharge: Do They Make a Difference?, Women & Health, 45:4, 19-39, DOI: 10.1300/J013v45n04_02

To link to this article: http://dx.doi.org/10.1300/J013v45n04_02

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Type and Timing of ServicesFollowing Postnatal Discharge:Do They Make a Difference?

Lise Goulet, MD, PhDDanielle D’Amour, RN, PhDRaynald Pineault, MD, PhD

ABSTRACT. Background: The debate continues as to what constitutesan adequate postnatal follow-up after an early hospital discharge. Themain objective of this study was to determine whether the type and tim-ing of postnatal services were associated with mothers’ and newborns’health, breastfeeding duration, and maternal assessment of the delay andusefulness of the services they received after discharge.

Methods: A telephone survey was conducted one month after a vagi-nal, uncomplicated delivery by 2,583 mothers who had given birth infive health regions of the Province of Québec, between 1999 and 2003.

Results: The response rate to the survey was 72.1%. Virtually all thenewborns (98.1%) had at least one routine contact with a health profes-sional after discharge. Within 72 hours of discharge, 26.0% of the moth-ers received only a telephone call, 44.3% were visited by a public healthnurse, 11.1% of the babies were examined by a physician and 49.5%

Lise Goulet is affiliated with GRIS (Groupe de recherche interdisciplinaire ensanté), and Department of Social and Preventive Medicine, University of Montreal;and Québec National Institute of Public Health.

Danielle D’Amour is affiliated with GRIS (Groupe de recherche interdisciplinaireen santé), and is Faculty of Nursing, University of Montreal.

Raynald Pineault is affiliated with GRIS (Groupe de recherche interdisciplinaire ensanté), Department of Social and Preventive Medicine, University of Montreal; Direc-tion de santé publique de Montréal; and Québec National Institute of Public Health.

Address correspondence to: Lise Goulet, Professor, Department of Social andPreventive Medicine, University of Montreal, CP 6128, succursale Centre-Ville,Montréal, Québec, Canada H3C 3J7.

Women & Health, Vol. 45(4) 2007Available online at http://wh.haworthpress.com

© 2007 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J013v45n04_02 19

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

were examined by a nurse or a physician. Newborns who had a first con-tact with a health professional within 72 hours of hospital dischargewere less likely to have been readmitted to the hospital (adjusted OddsRatio 0.45; 95% CI 0.21-0.97), while their mothers were less likely tohave signs of moderate to severe depression at one month postpartum(adjusted Odds Ratio 0.60; 95% CI 0.45-0.79). The sooner the telephonecall and the home visit were received the more likely the women were tohave found that the services were useful.

Conclusion: Our findings suggest that the timing, more than the type,of postnatal follow-up after an early obstetrical discharge could make adifference. doi:10.1300/J013v45n04_02 [Article copies available for a fee fromThe Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com>© 2007 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Postnatal care, postpartum care, home visits, length ofstay, women, mental health, newborn, hospital readmission, satisfaction

The length of hospital stay in Canadian obstetrics departments hasdecreased significantly in recent years. The average length of hospitalstay for childbirth went from 5.3 days in 1984-1985 to 3.0 days in 1994-1995, with similar trends for caesarean and vaginal delivery (Wen, Liu,Marcoux, & Fowler, 1998). This decrease resulted from both, a risingrate of early discharge (< 2 days) and a declining rate of delayed dis-charge (> 4 days). In the province of Québec, the average length of hos-pital stay for a vaginal delivery without complications was 2.4 days in2000-2001 (Québec’s Ministère de la santé et des services sociaux).Clearly, early postnatal discharge has become a common practice in Can-ada (Health Canada, 2000) and in Québec (Ministère de la santé et desservices sociaux, 1999). Several studies have shown a significant rela-tionship between early postnatal discharge and an increased risk of new-born readmission during the week following discharge (Lee, Perlman,Ballantyn, & Elliot, 1995; Liu, Clemens, Shay, Davis, & Novack, 1997;Lock & Ray, 1999; Johnson, Jin, & Truman, 2002; Maisels, & Kring,1998) but other studies have failed to show such an effect (Bragg, Rosen,Khoury, Miodovnik, & Siddiqi, 1997; Conrad, Wilkening, & Rosenberg,1989; Dalby, Williams, Hodnett, & Rush, 1996; Liu, Wen, McMillan,Trouton, Fowler, & McCourt, 2000; Norr & Nacion, 1987; Yanover,Jones, & Miller, 1976). Interestingly, Danielsen et al. (2000) found that,following a normal vaginal delivery, a length of stay as short as 24 hoursdid not increase the risk of readmission as long as the parents were well

20 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

prepared during the prenatal period and adequate postnatal follow-upwas provided.

What constitutes an adequate postnatal follow-up that meets the needsof the mother and the newborn during this period has not yet made con-sensus (Eaton, 2001). Wide variations are observed in current postnatalfollow-up practices with respect to low-risk mothers and newborns.These variations pertain to how (through telephone calls, appointments orhome visits), when (how long after hospital discharge), where (hospital orcommunity-based services) and by whom (physicians or nurses) the ser-vices are provided and what they include (medically or psychosociallyoriented services) (American Academy of Pediatrics, 1997; Arnold &Bakewell-Sachs, 1991; Canadian Pediatric Society, 1996; Egerter, Brave-man, & Marchi, 1998; Escobar, Braveman, Ackerson, Odouli, Coleman-Phox, Capra, Wong, & Lieu, 2001; Gagnon, Dougherty, Jimenez, &Leduc, 2002; Lieu, Braveman, Escobar, Fischer, Jensvold, & Capra,2000; MacArthur, 1999; Maisels & Kring, 1997; Ministère de la santé etdes services sociaux, 1999; Rieger & Henderson-Smart, 1995; Rush &Hodnett, 1993; Stell O’Connor, Mowat, Scott, Carr, Dordland, & YoungTai, 2003). Professional agencies and health authorities recommend that,after an early postnatal discharge, all infants should be examined by ex-perienced health care providers within 48 (American Academy of Pediat-rics, 1997; Canadian Pediatric Sociey, 1996) or 72 hours of discharge(Maisels & Kring, 1997; Ministère de la santé et des services sociaux,1999). This is mainly because physiological changes occur during thisperiod, in particular increased neonatal bilirubin levels and breast milkproduction. These problems may result in hyperbilirubinemia and feed-ing difficulties which remain the main causes of morbidity and health ser-vices utilization during the first week of life (Catz, Hanson, Simpson, &Yaffe, 1995; Lee, Perlman, Ballantyn, & Elliot, 1995; Maisels, & Kring,1998). An intervention soon after discharge aims also at assessing moth-ers’ need and at supporting the family (Ministère de la santé et des ser-vices sociaux, 1999).

To prevent or detect problems, do all infants and mothers need to re-ceive postdischarge services within the prescribed time period? In otherwords, what is the rationale for universal postnatal follow-up of low-riskmothers and newborns? This is the main question addressed in this arti-cle. More specifically, we intended to determine whether the type (how)and timing (when) of postnatal services were associated with mother’sand newborns’ health, breastfeeding duration and mothers’ assessment ofthe services they received after discharge.

Goulet, D’Amour, and Pineault 21

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

METHODS

Design

A telephone survey was conducted in five health regions of the Prov-ince of Québec, Canada. Eligibility criteria were defined according tostandard practices of early discharge in the setting during the survey: apostpartum hospital length of stay < 60 hours, a vaginal delivery with-out complications at � 36 weeks of gestation of a single live baby weigh-ing � 2,300 grams, and fluency in French or English. Women who werefollowed by midwives were excluded because their number was toosmall.

Study Sample

Potential participants for the study were identified using the informa-tion available on the Birth Certificate (name, phone number, birth weight,gestational age, single live newborn, place of residence and hospital ofdelivery). All Birth Certificates were reviewed during the study periodwhich extended from March to May 1999 in one region, Montreal, andfrom January 2002 to January 2003 in the others. Women who, accordingto the Birth Certificate, delivered a single live baby weighing � 2,300grams, at � 36 weeks of gestation, were considered as potentially eligi-ble (N = 7,048). Since the type of delivery, the hospital length of stay,the fluency in French or English and a prenatal follow-up by a midwifewere not available on the Birth Certificate, eligibility had to be verified atthe beginning of the telephone call. Out of 7,048 potential participants,313 telephone numbers appeared not to be valid (A); 2,974 women werenot eligible (B); for 254, eligibility could not be assessed (C), and 879interviews (388 refusals) were not completed (D). The final study sam-ple included 2,583 mothers and newborns (E), 1,158 in Montreal and1,475 in the other regions. The overall response rate to the survey was72.1%. The response rate was calculated using the following formulathat takes into account the eligibility rate: E/[C* (D�E/B�D�E)]�D�E. In each region, participants were representative of the women whogave birth to a live born singleton aged � 36 weeks of gestation andweighting � 2,300 grams, during the same period, according to theirage and level of education.

22 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

Data Collection

One month after discharge (� 3 days), trained interviewers adminis-tered a structured telephone interview. The average duration of the in-terview was 25 minutes (range: 4-59 minutes). The interview includedquestions regarding:

1. Postpartum hospital length of stay: this was calculated by sub-tracting the date and hour of delivery from the date and hour ofhospital discharge.

2. Urban/rural region: health regions were divided into two catego-ries, urban or rural, in order to take into account the geographicalaccessibility to hospital resources. Statistics Canada definitionswere used. Two regions were urban and three were semi-urban,semi-rural.

3. Mothers’ characteristics: age, parity, education, place of birth,not living with a partner and occupation during pregnancy.

4. Mothers’ mental health: mental health status at one month post-partum was assessed using the 12-item version of the Center for Ep-idemiological Studies Depression Scale (CES-D Scale) (Radloff,1977). This abbreviated version has a coefficient of internal consis-tency (�) of 0.82 (Jenkins & Keating, 1999). The scores range from0 to 36. A score of 13 or more indicates the presence of signs ofmoderate or severe depression (Landy & Tam, 1996).

5. Breastfeeding: exclusively or partially, in hospital and at one monthpostpartum.

6. Newborns’ health: health problems during the hospital stay andafter discharge (signs of jaundice and any other health problemsreported by the mother), emergency visits and readmissions dur-ing their first month of life.

7. Post discharge follow-up services: type of service and provider(nurse’s telephone call, nurse’s home visit, appointment with a phy-sician scheduled before discharge for a physical examination of thebaby) and timing of the service (length of time between hospitaldischarge and service delivery, for the first service received in eachtype of service). A five category variable was created to classify thetype and timing of the services received within 72 hours: (1) anurse’s telephone call only; (2) a nurse’s home visit only (psycho-socially-oriented service); (3) an appointment with a physician only(medically-oriented service); (4) a home visit and an appointmentwith a physician (mixed type of follow-up); and (5) any kind of ser-

Goulet, D’Amour, and Pineault 23

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

vices received after 72 hours (reference category). Two other vari-ables were created: (1) a nurse’s home visit or an appointment witha physician � 72 hours (examination of the baby by an experiencedhealth care provider within the prescribed delay) and (2) any type ofservice received � 72 hours (at least one type of service receivedwithin the prescribed delay).

8. Maternal assessment of: the sufficiency of the services they re-ceived after discharge, the delay of the services received, theirusefulness and the difficulty of going out for an appointment witha physician that was scheduled before discharge.

All the information was collected by the interviewers. The mothers’or newborns’ medical charts were not reviewed.

Ethics

The project was approved by the ethics committees of the Facultyof Medicine of the University of Montréal and of the hospitals whorequired it. In the Province of Québec, the Commission d’Accès àl’Information du Québec (the Commission responsible for the access topublic information) has the authority to give access to nominative infor-mation for research purposes, this without the written consent of thestudy participant. The Commission gave the authorization to each of thefive Regional health agencies so that the name and phone numbers ofthe mothers could be communicated to the Centre for Research on Pub-lic Opinion, a survey firm, which conducted the telephone interviews.Mothers received a letter of information during their hospital stay whichpresented the objectives and the methods of the project. In the letter, itwas clearly stated that they were free not to participate in the survey ei-ther by contacting the research team (name and telephone number of theprincipal investigator provided on the letter) or by refusing to be inter-viewed if they receive a call from the survey firm.

Data Analysis

Chi-square tests were used to examine relationships between thecategorical variables. To assess the associations between post dischargefollow-up services and the outcomes, potential confounders were firstidentified with univariate logistic regression analysis (p value of lessthan 0.20). Then multivariate logistic regression analyses were done,

24 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

using stepwise backward procedures. The p value for entering the mod-el and the p value for retention in the model were 0.10 and 0.05, respec-tively. At each step, when the change in the magnitude of the odds ratiosresulting from the exclusion of one variable exceeded 10%, the variablewas kept in the model. Analyses were done separately for Montréal andthe other regions. Given the similarity of the results from all regions forbreastfeeding and maternal mental health status, data were pooled andthe associations were reported for the whole study population. For new-borns’ readmission, results are presented for each of the two strata.Hosmer-Lemeshow goodness-of-fit statistic was computed for the mul-tivariate models. All statistical analyses were performed using the SASsystem for Windows V8.

RESULTS

During the study period, 98.1% of the mothers and newborns receivedat least one type of post discharge follow-up service (telephone call,home visit or appointment with a physician) in the first month followingdischarge; 86.4% received more than one service (Table 1). The major-ity of the mothers (93.4%) were contacted by phone within one week oftheir return home. Within 72 hours of discharge, 26.0% of the mothersreceived only a telephone call while 44.3% were visited by a publichealth nurse (38.4% received only a visit and 5.9% received a visit andtheir babies were also examined by a physician). A home visit was of-fered to 75.7% of the women, among which 14.8% refused the visit.Therefore 64.5% of the study population received a visit from a publichealth nurse, 88% during the first week after they returned home. Theaverage delay for the visit was 4.1 days. One baby out of ten had an ap-pointment with a physician scheduled before discharge. When all theservices were combined, 75.5% of the study participants received at leastone type of service and 49.5% of all the babies were examined by a healthprofessional, within the prescribed delay of 72 hours.

Statistically significant differences were observed between mothersand newborns who received at least one type of service within 72 hoursof discharge and those who did not receive services or received themlater (Table 2). Mothers who received at least one type of service weremore likely to live in a semi-urban, semi-rural region (p � .0001), to beaged between 20 and 29 years (p � .0001), to be primiparous (p � .01)and slightly more educated (p � .05), to live with a partner (p � .0001),

Goulet, D’Amour, and Pineault 25

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

to speak French at home (p � .0001), to have worked or been a studentduring pregnancy (p � .0001) and to have initiated breastfeeding in hos-pital (p � .01). They were less likely to be born outside North America(p � .0001), and to have shown moderate or severe signs of depres-sion one month after discharge (p � .0001). A lower proportion of theirbabies were boys (p � .05) but more had health problems during theirhospital stay (p � .01). Signs of jaundice ranked first on the list of new-born’s health problems reported by the mothers and accounted for 90%of the newborns’ health problems that occurred during the hospital stay.Babies who suffered from health problems before discharge were fol-lowed-up more closely. They received, on average, 1.8 home visitscompared to 1.4 for other newborns (p � .0001). No difference was ob-served for the average number of appointments with a physician (0.4 ineach group) or for the proportion of newborns readmitted to the hospital(3.1%). Jaundice was the main reason of readmission for 70% of the

26 WOMEN & HEALTH

TABLE 1. Post Discharge Follow-Up Services Received (N = 2,583)

N %

Number of services received1 (%)

0 50 1.9

1 301 11.6

2-4 1780 68.9

5� 452 17.5

Services received � 72 hours (%)

A phone call from a nurse only 672 26.0

A nurse’s home visit only2 994 38.4

An appointment with a physician only3 135 5.2

A nurse’s home visit and an appointmentwith a physician

151 5.9

A nurse’s home visit or an appointmentwith a physician

1280 49.5

At least one type of service4 1952 75.51Total number of services received during the first month after discharge irrespective of the type of service.These numbers excluded appointments with a physician that were not scheduled before discharge, new-borns’ emergency visits and readmissions.295% of the women who had a nurse’s home visit � 72 hours had a phone call from a nurse before the visit.3For the appointment with a physician, only appointments that were scheduled before discharge weretaken into account.4Phone call, home visit or appointment with a physician.

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

Goulet, D’Amour, and Pineault 27

TABLE 2. Characteristics of Mothers and Newborns, and Services ReceivedAccording to the Delay of Post Discharge Follow-Up Services (N = 2,583)

At Least One Typeof Service � 72 hrs

(N = 1,952)1

None or Later(N = 619)

Total(N = 2,583)

Region (%)****

Urban 52.0 84.8 59.9

Semi-urban, semi-rural 48.0 15.2 40.1

Mothers’ Characteristices and Health

Age (years) (%)****

16-19 2.3 4.5 2.8

20-29 54.4 44.6 52.1

30-34 29.5 35.1 30.8

35-39 12.2 13.9 12.6

40� 1.6 1.9 1.7

Parity (%)**

Primiparous 43.1 36.8 41.6

Education (%) *

Less than high school 11.0 15.4 12.0

High school 21.9 22.5 22.1

College 29.2 28.0 28.9

University 37.9 34.1 37.0

Place of birth (%)****

Outside North America 14.7 30.9 18.5

Living with a partner (%)**** 93.9 89.0 92.6

Language spoken at home (%)****

French 75.9 57.7 71.5

English 15.2 22.8 17.0

Other 8.9 19.6 11.5

Occupation during pregnancy (%)****

Homemaker 28.4 39.4 31.0

Worker/Student 71.6 60.6 69.0

Postpartum length of stay (hours) (%)

5-24 1.2 2.1 1.4

25-48 52.0 50.2 51.6

49-60 46.8 47.7 47.0

Breastfeeding

in hospital (%)** 79.9 75.1 78.7

at one month postpartum (%) 65.6 63.2 65.0

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

28 WOMEN & HEALTH

TABLE 2 (continued)

At Least One Typeof Service � 72 hrs

(N = 1,952)1

None or Later(N = 619)

Total(N = 2,583)

Moderate or severe signs ofdepression one monthafter discharge (%)****

11.8 19.4 13.7

Newborns’ Characteristics and Health

Birth weight (grams) (%)

� 2500 0.9 0.3 0.8

2500-2999 14.8 16.2 15.1

3000-3499 41.3 35.7 39.9

3500-3999 33.4 37.4 34.4

4000� 9.6 10.4 9.8

Gestational age (weeks) (%)

� 37 2.5 2.8 2.6

37-39 50.4 50.2 50.3

40� 47.1 47.0 47.1

Sex (%)*

Male 48.2 52.8 49.3

Health problem (%)

during hospital stay** 24.0 17.9 22.5

after discharge 21.4 24.7 22.2

Readmission (%) 3.2 3.1 3.1

Emergency visits (%) 5.2 4.9 5.1

Services Received

Number of services received2 (%)****

0 0.0 7.6 1.9

1 6.4 28.0 11.6

2-4 72.4 58.3 69.0

5� 21.2 6.1 17.5

Maternal assessment:

Mothers considered that theservices they received afterdischarge were sufficient (%)****

91.7 83.1 89.7

112 women received a service but could not recall the timing of the service.2Sum of telephone calls, nurses’ home visits and appointments with a physician excluding appointmentswith a physician that were not scheduled before discharge, newborns’ emergency visits and readmissions.

*p � .05, **p � .01, ***p � .001, ****p � .0001

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

newborns. Mothers who were visited by a nurse soon after dischargewere more likely to have consulted at the hospital emergency for theirbabies’ heath problems (6.8% compared to 4.0%; p = 0.002). Finally,mothers who received services within 72 hours received more servicesduring the first month (p � .0001) and were more likely to have consid-ered that the services they received were sufficient (p � .0001).

For each category of services received in the non-Montreal regions,newborns who received services soon after discharge, were less likelyto have been readmitted to the hospital than newborns who receivedthem later (Table 3). When the services were combined (any type of ser-vice), the adjusted Odds Ratio was 0.45; 95% CI 0.21-0.97. In Montréal,a telephone call only and an appointment with a physician only, were as-sociated with non-significant increased odds ratios for newborns’ read-mission. In this region, physicians were involved in 18% of the earlypost discharge follow-up compared to 6% in the other regions.

Neither the type nor the timing of the follow-up services were asso-ciated with breastfeeding continuation up to one month postpartum.Mothers with the following characteristics were significantly less likelyto have continued to breastfeed: (1) Age: 16-19-years old (adjusted OddsRatio 0.27; 95% CI 0.13-0.55) or 20-29-years old (adjusted Odds Ratio0.47; 95% CI 0.31-0.70), compared to 40-years old or more, (2) Educa-tion level: highschool degree or less (adjusted Odds Ratio: 0.45; 95% CI0.32-0.63), compared to having a college or university degree, (3) Placeof birth: North America (adjusted Odds Ratio 0.50; 95% CI 0.36-0.68),compared to foreign-born mothers, and (4) Showing signs of moderateto severe depression at one month postpartum (adjusted Odds Ratio 0.50;95% CI0.36-0.68). Mothers who chose exclusive breastfeeding in hos-pital were more likely not to have stopped to breastfeed during the firstmonth (adjusted Odds Ratio 4.62; 95% CI 3.60-5.92).

Irrespective of the type of service they received (telephone call,nurse’s home visit or appointment with a physician), mothers who werein touch with a health professional soon after discharge were signifi-cantly less likely to show moderate or severe depressive symptoms atone month postpartum (adjusted Odds Ratio 0.60; 95% CI 0.45-0.79).

Mothers gave their assessment of the services they received after dis-charge (Table 4). The patterns were similar for the telephone call and thenurse’s home visit. Overall, the majority of the women (at least 75%)found that the timing of the services were adequate and that the serviceswere useful (more than 85%). Women who had received services soonerwere significantly more likely to have said that the delay was too short(p � .0001) but, on the other hand, that the service was useful (p �

Goulet, D’Amour, and Pineault 29

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

30 WOMEN & HEALTH

TABLE 3. Newborns’ Readmission, Breastfeeding Continuation and MaternalDepressive Symptoms, According to the Type and Timing of the Services TheyReceived (Adjusted Odds Ratios and 95% CI)1

Newborns’Readmission2

Newborns’Readmission2

BreastfeedingContinuation3

MaternalDepressive

Symptoms atOne Month4

Montréal Regions

Services received72 hours

p = .275 p = .270 p = .744 p = .002

Telephone call only 1.56(0.65-3.74)

0.54(0.20-1.46)

1.09(0.77-1.54)

0.63(0.46-0.87)

Nurse’s home visit only a 0.41(0.19-0.92)

1.02(0.75-1.39)

0.58(0.42-0.80)

Appointment with aphysician only

2.49(0.79-7.82)

0.44(0.05-3.68)

1.48(0.82-2.66)

0.78(0.46-1.33)

Home visit and appointmentwith a physician

a 0.76(0.19-3.05)

1.06(0.63-1.80)

0.38(0.20-0.71)

Services received after72 hours

1.00 1.00 1.00 1.00

Hosmer-Lemeshow statistic p = .947 p = .971 p = .442 p = .477

Nurse’s home visit orappointment with aphysician 72 hours

p = .287 p = .115 p = .884 p = .017

Yes 0.61(0.23-1.65)

0.61(0.33-1.12)

1.02(0.81-1.29)

0.74(0.57-0.95)

No 1.00 1.00 1.00 1.00

Hosmer-Lemeshow statistic p = .579 p = .955 p = .489 p = .643

Any type of service72 hours

p = .191 p = .043 p = .618 p .001

Yes 1.21(0.53-2.75)

0.45(0.21-0.97)

1.08(0.81-1.43)

0.60(0.45-0.79)

No 1.00 1.00 1.00 1.00

Hosmer-Lemeshow statistic p = .824 p = .951 p = .411 p = .7341Mothers who received no services during the first month after discharge (N = 50) were excluded from thiscategory.2Adjusted for region, newborn’s gestational age and newborns’ health problems during the hospital stay orduring the first 3 days after discharge.3Adjusted for maternal age, education, birth place, exclusive in hospital breastfeeding and mental healthstatus at one month postpartum.4Adjusted for maternal education, birth place, living with a partner, emergency visits for a newborn’s healthproblem, breastfeeding at one month postpartum and number of services received after discharge.aNewborns’ readmission cells with 0 count.

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

.0001). It is also interesting to point out that at least 10% of those whoreceived a telephone call or a nurse’s home visit after 72 hours foundthat the delay was too long. The sooner the appointment with a physi-cian took place, the more likely the mothers were to consider that thedelay was too short (21.9% compared to 9.1%, p � .0001) and that ithad been difficult for them to go to the appointment (30.2% comparedto 12.7%, p � .0001). They were slightly less likely to have foundthat the service they received was useful (87.6% compared to 93.4%,p � .0001).

DISCUSSION

This observational study addressed the rationale underlying the rec-ommendation of universal post discharge follow-up of low-risk mothersand newborns within three days of hospital discharge. More specifi-cally, we assessed the extent to which the type (how) and timing (when)of postnatal services could make a difference regarding mothers’ andnewborns’ health, breastfeeding duration and mothers’ assessment ofthe services they received.

Goulet, D’Amour, and Pineault 31

TABLE 4. Mothers’ Assessment of the Services They Received

Telephone Call� 72 Hours � 72 Hours(N = 1,761) (N = 674)

Nurse’s Home Visit� 72 Hours � 72 Hours(N = 1,035) (N = 646)

Appointment with aPhysician

� 72 Hours � 72 Hours(N = 286) (N = 784)

Mothers’ assessment of the delay of the service

p = .0001 p � .0001 p � .0001

Too short (%) 11.6 6.7 12.7 6.5 21.9 9.1

Adequate (%) 86.5 78.7 85.7 83.9 74.9 85.3

Too long (%) 1.9 15.2 1.6 9.6 3.1 5.6

Mothers’ assessment of the usefulness of the service

p = .0001 p � .0001 p = .002

Useful (%) 89.6 85.3 97.1 92.2 87.6 93.4

Mothers’ assessment of the difficulty of goingto the appointment with the physician

p � .0001

Difficult (%) 30.2 12.7

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

In our study population, 75% of all mothers and newborns had atleast one routine contact with a public health nurse or a physician within72 hours following discharge, but only 50% of the babies were exam-ined within the same delay. This result did not comply with the rec-ommendation that, after an early postnatal discharge, all newborns beexamined by an experienced health professional within 48 or 72 hoursof going home (Canadian Pediatric Society, 1996; American Academyof Pediatrics, 1997; Ministère de la santé et des services sociaux, 1999).The large gap between observed and recommended practices could beexplained by the absence of agreements on the way responsibility forpost discharge follow-up is shared among hospitals, local communityservices centers (LCSCs) and physicians in private practice (D’Amour,Goulet, Labadie, Bernier, & Pineault, 2003). Most of the time, nurses’home visits and appointments with physicians. were scheduled inde-pendently. The lack of resources for postnatal home follow-up by pub-lic health nurses in LCSCs, especially in Montréal, could also explainthe deviance from guidelines (Goulet, D’Amour, Labadie, Pineault,Séguin, & Bisson, 2000). By the end of 2002, resources have been al-located to Montréal LCSCs for postnatal home follow-up which im-proved the accessibility of mothers and newborns to follow-up servicesin the community.

In the province of Québec, the responsibility of universal postnatalfollow-up has been given to the public health sector (Ministère de la santéet des services sociaux, 1999). With limited resources, LCSCs estab-lished priorities for their follow-up practices and chose to target servicedelivery at mothers and newborns with greatest needs. The results ofour study showed that priorities were given to primiparous women, tobreastfeeding mothers and to newborns who had minor health problems(mainly signs of jaundice) before discharge. The targeted clientèle dif-fered also with respect to the region, and the place of birth and maritalstatus of the mothers. These findings are consistent with the lack of re-sources that characterized Montréal LCSCs in 1999. In Montréal, the pro-portion of foreign-born individuals who speak neither French nor Englishat home and the proportion of mothers who are not living with a partnerare significantly higher than in other regions of the Province of Québec(Institut de la statistique du Québec). All these potential confounderswere taken into account in the analysis.

Except in Montréal, newborns’ readmission was significantly associ-ated with any type of service received soon after discharge. The propor-tion of mothers who reported having consulted at the hospital emergencyfor their newborns’ health problem was also significantly higher among

32 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

those who were visited soon after discharge. Early identification andtreatment of newborns’ health problems could explain the less frequentresort to hospital. In Montréal, physicians were more involved in earlypost discharge follow-up than in the other regions. Access to specializedresources (neonatologists and tertiary care paediatric hospitals) mayhave resulted in the non-significant positive association between physi-cians’ follow-up and newborns’ readmission in Montréal.

An association was also found between the timing of the services re-ceived after discharge and the mothers’ mental health status one monthafter childbirth. Our study revealed that 13.7% of the mothers had moder-ate to severe depressive symptoms at the time of the survey. This findingis consistent with the published prevalence of postpartum depressionduring the first year following delivery which ranges from 8 to 15%(O’Hara & Swain, 1996). Our results also showed that after adjusting forconfounders, an early contact with a health professional after discharge,irrespective of the type of contact, was significantly associated with abetter maternal mental health status one month after childbirth. Beck(2001) identified at least ten risk factors for postpartum depressionamong which are the stress related to newborns’ care and the lack of so-cial support. Leaving a mother without the support of health professionalssoon after childbirth may contribute to psychological and physical prob-lems (Beck, 2001; Rubin, 1961; Rubin, 1975; Hans, 1986). Postpartumremains an important transitional period for the new mother, the baby andthe family. Health professionals should therefore be able to assess theway mothers cope with these changes (Health Canada, 2000).

Breastfeeding duration was associated with neither the type nor thetiming of the follow-up. This result is in agreement with what Jirojwonget al. have reported (Jirojwong, Rossi, Wlaker, & Ritchie, 2005). Mater-nal age and education (Ertem, Votto, Leventhal, 2001; Ludvigsson, &Ludvigsson, 2005; Evers, Doran, & Schellenberg, 1998), birth place(Evers, Doran, & Schellenberg, 1998), exclusive in-hospital breastfeed-ing (Marques, Lira, Lima, DaSilva, Filho, Huttly, & Ashworth, 2001;Martens, Phillips, Cheang, & Rosolowich, 2000; Piper & Parks, 1996;Victoria, Behague, Barros, Anselmo Olinto, & Weiderpass, 1997; Vogel,Hutchison, & Mitchell, 1999; Wright, Rice, & Wells, 1996) and mother’smental health status one month after discharge (Abou-Saleh, Ghubash,Karim, Krymski, & Bhai, 1998; Cooper, Murray, & Stein, 1993; Dunn,Davies, McCleary, Edwards, & Gaboury, 2006; Fergerson, Jamieson, &Lindsay, 2002; Hatton, Harrison-Hohner, Coste, Dorato, Curet, & Mc-Carron, 2005; Henderson, Evans, Straton, Priest, & Hagan, 2003; Misri,Sinclair, & Kuan, 1997) are strong determinants of breastfeeding con-

Goulet, D’Amour, and Pineault 33

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

tinuation. These variables were also significantly associated with breast-feeding duration in our study.

Mothers’ assessment of the services they received revealed interestingfindings. When the services were received within 72 hours, mothers wereabout twice more likely to have considered that it was too early. On theother hand, it seems that the telephone call or the home visit receivedsoon after discharge were justified since the mothers were more likely tohave found these services useful. When the same services were receivedafter 72 hours, mothers were more likely to have said that the delay wastoo long, which may reflect unmet needs and should be examined moreclosely. It is not surprising to find out that nearly one-third of the motherswho had to go out to see a physician within 3 days of discharge found itdifficult to do. This indicates that consideration should be given to the al-ternatives to the appointment.

Our study had strengths such as its large sample size, the fact that thesurvey was conducted in both rural and urban areas and the adjustmentfor potential confounders. It also had limitations. With a response rateof 72%, selection bias was possible. When participants were comparedto women in the same region, who gave birth to a single live baby weigh-ing � 2,300 grams with a gestational age of � 36 weeks, during thesame period, no significant differences were seen with respect to theirage and education level. Knowing that these maternal attributes are im-portant determinants of many perinatal outcomes and considering thestrength of the associations for newborns’ readmission and maternalmental health status, selection bias as well as unmeasured confounderswere probably less likely to explain our results.

One may also question the validity of the responses given by themothers. Since the information was collected retrospectively, recall biascannot be excluded. Interviewers were told to use a calendar to helpwomen recall when they got each type of service. They used questionssuch as “According to what you told me, you were discharged on Friday.On what day after discharge did you receive the visit of a nurse?” Thisprocedure could have decreased the likelihood of misclassification whichwould have led to a biased estimation of the true associations. Othersources of measurement errors may have biased our results to some ex-tent. In fact, the identification of newborns’ health problems dependedon statements made by the mothers. Most of the time, mothers were toldby hospital physicians or nurses, or by nurses during the home follow-up visit, that their newborn had health problems. The validity of the in-formation provided by the mothers seemed to be good, considering thatour findings for newborns’ readmission rate (3.2%) and the contribu-

34 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

tion of jaundice to readmission (70%) were consistent with other studies(readmission rates of 0 to 6% and three-fourths of these readmissionsdue to hyperbilirubinemia) (Agence d’évaluation des technologies et desmodes d’intervention en santé, 1997; Danielsen, Castles, Damberg, &Gould, 2000; Lee, Perlman, Ballantyn, & Elliot, 1995; Liu, Clemens,Shay, Davis, & Novack, 1997; Liu, Wen, McMillan, Trouton, Fowler, &McCourt, 2000; Lock & Ray, 1999). Sensitive questions, such as thepresence of a partner, symptoms of depression and refusal of the nurse’shome visit, may have led to social acceptability response biases.

The survey was conducted three years apart in Montréal and inthe other regions. Since no major changes have occurred in Montréalbetween 1999 and 2003, we are confident that if women had been sur-veyed at the same time period we would have found similar results.Mothers who did not speak French or English, those who had been fol-lowed-up by midwives or who had a caesarean delivery were excluded.Therefore any attempt to generalize the results to these populations mustbe made with caution since these mothers could have expressed differ-ent needs.

The major limitation of our study was its design, which made it moredifficult to interpret some of the results. By using the birth certificates,we tried to reconstitute a cohort of women and newborns and assessedexposure and outcomes retrospectively. Therefore, reverse causality can-not be ruled out. Ideally, a randomized controlled trial to compare dif-ferent types and timing of services should be conducted to answer thisquestion.

In conclusion, our results seem to support the recommendation for anearly follow-up of low-risk mothers and newborns. Timing more thanthe type of postnatal follow-up after an early obstetrical discharge couldmake a difference. The outcome measures used in our study did not en-compass all the needs of the mothers and their newborns after an earlypostnatal hospital discharge. Nevertheless newborns’ readmission, moth-ers’ mental health and maternal assessment of the services they receivedcould be sensitive indicators to be used to measure the effect of an earlypostnatal intervention.

REFERENCES

Abou-Saleh, M.T., Ghubash, R., Karim, L., Krymski, M., and Bhai, I. 1998. Hormonalaspects of postpartum depression. Psychoneuroendocrinology, 23, 465-475.

Goulet, D’Amour, and Pineault 35

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

Agence d’évaluation des technologies et des modes d’intervention en santé (theQuébec government agency responsible for health services and technology assess-ment). Evaluation of the risks and benefits of early postpartum discharge. ScientificReport. Montréal, 1997. Accessed December 15, 2006. Available at: http://www.aetmis.gouv.qc.ca.

American Academy of Pediatrics (AAP), American College of Obstetrics and Gyne-cology (ACOG). (1997). Postpartum and follow-up care. In: J.C. Hauth and G.B.Merenstein (Eds.), Guidelines for Perinatal Care. 4th ed. Elk Grove Village, IL:American Academy of Pediatrics.

Arnold, L.S., and Bakewell-Sachs, S. (1991). Models of perinatal home follow-up.Journal of Perinatal and Neonatal Nursing, 5, 18-26.

Beck, C.T. (2001). Predictors of postpartum depression: An update. Nursing Research,50 (5), 275-285.

Bragg, E.J., Rosen, B.M., Khoury, J.C., Miodovnik, M., and Siddiqi, T.A. (1997). Theeffect of early discharge after vaginal delivery on neonatal readmission rates.Obstetetrics and Gynecology, 89, 930-933.

Canadian Pediatric Sociey (1996). Facilitating discharge home following a normalterm birth. A joint statement with the Society of Obstetricians and Gynaecologistsof Canada. CPS Statement: FN96-02.

Catz, C., Hanson, J.W., Simpson, L., and Yaffe, S.J. (1995). Summary of workshop:Early discharge and neonatal hyperbilirubinemia. Pediatrics, 96, 743-745.

Conrad, P.D., Wilkening, E.B., and Rosenberg, A.A. (1989). Safety of newborn dis-charge in less than 36 hours in an indigent population. American Journal of Dis-eases in Children, 143, 98-101.

Cooper, P.J., Murray, L., and Stein, A. (1993). Psychosocial factors associated withthe early termination of breastfeeding. Journal of Psychosomatic Research, 37,171-176.

Dalby, D.M., Williams, J.L., Hodnett, E., and Rush, J. (1996). Postpartum safety andsatisfaction following early discharge. Canadian Journal of Public Health, 87,90-94.

D’Amour, D., Goulet, L., Labadie, J.F., Bernier, L., and Pineault, R. (2003). Accessi-bility, continuity and appropriateness: Key elements in assessing integration ofperinatal services. Health and Social Care in the Community, 11 (5), 397-404.

Danielsen, B., Castles, A.G., Damberg, C.L., and Gould, J.B. (2000). Newborn dis-charge timing and readmissions: California, 1992-1995. Pediatrics, 106(1), 31-39.

Dunn, S., Davies, B., McCleary, L., Edwards, N., and Gaboury, I. (2006). The relation-ship between vulnerability factors and breastfeeding outcome. Journal of Obstet-rics Gynecology and Neonatal Nursing, 35(1), 87-97.

Eaton, A. (2001). Early postpartum discharge: recommendations from a preliminaryreport to Congress. Pediatrics, 107, 400-404.

Egerter, S.A., Braveman, P.A., and Marchi, K.S. (1998). Follow-up of newborns andtheir mothers after early hospital discharge. Clinical Perinatology, 25, 471-481.

Ertem, I.O., Votto, N., and Leventhal, J.M. (2001). The timing and predictors of theearly termination of breastfeeding. Pediatrics, 107, 543-548.

Escobar, G.J., Braveman, P.A., Ackerson, L., Odouli, R., Coleman-Phox, K., Capra,A.M., Wong, C., and Lieu, T.A. (2001). A randomized comparison of home visits

36 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

and hospital-based group follow-up visits after early postpartum discharge. Pediat-rics, 108, 719-727.

Evers, S., Doran, L., and Schellenberg, K. (1998). Influences on breastfeeding rates inlow-income communities in Ontario. Canadian Journal of Public Health, 89,203-207.

Fergerson, S.S., Jamieson, D.J., and Lindsay, M. (2002). Diagnosing postpartum de-pression: can we do better? American Journal of Obstetrics and Gynecology, 186,899-902.

Gagnon, A.J., Dougherty, G., Jimenez, V., and Leduc, N. (2002). Randomized trial ofpostpartum care after hospital discharge. Pediatrics, 109, 1074-1080.

Goulet, L., D’Amour, D., Labadie, J.F., Pineault, R., Séguin, L., and Bisson, J. Évalua-tion de l’impact des modalités de suivi postnatal sur la mère et le nouveau-né dansle contexte du cong‚ précoce en obstétrique. Rapport de recherche du GRIS(R01-12), 67 p., octobre 2001.

Hans, A. (1986). Postpartum assessment: the psychological component. Journal ofObstettrics Gynecology and Neonatal Nursing, 15(1), 46-51.

Hatton, D.C., Harrison-Hohner, M.S.N., Coste, S., Dorato, V., Curet, L.B., andMcCarron, D.A. (2005). Symptoms of postpartum depression and breastfeeding.Journal of Human Lactation, 21(4), 444-449.

Health Canada. (2000). Family-Centred Maternity and Newborn Care: NationalGuidelines. Ottawa: Public Works and Government Services Canada.

Henderson, J.J., Evans, S.F., Straton, J.A., Priest, S.R., and Hagan, R. (2003). Impact ofpostnatal depression on breastfeeding duration. Birth, 30 (3), 175-180.

Institut de la statistique du Québec (ISQ). Statistics are available on the Web site of theISQ at: www.stat.gouv.qc.ca/regions/recens2001_06.

Jenkins, J., and Keating, D. (1999). Les risques et la résistance chez les enfants de six etde dix ans. Ottawa: Applied Research Branch, Strategic Policy. Human ResourcesDevelopment Canada.

Jirojwong, S., Rossi, D., Walker, S., and Ritchie, B. (2005). What were the outcomes ofhome follow-up visits after postpartum hospital discharge? Australian Journal ofAdvanced Nursing, 23(1), 22-30.

Johnson, D., Jin, Y., and Truman, C. (2002). Early discharge of Alberta mothers post-delivery and the relationship to potentially preventable newborn readmissions. Ca-nadian Journal of Public Health, 93(4), 276-280.

Landy, S., and Tam, K.K. (1996). Les pratiques parentales influencent bel et bien ledéveloppement des enfants du Canada, In Statistique Canada et Développement desressources humaines Canada, Grandir au Canada, Enquête nationale longitudinalesur les enfants et les jeunes. Ottawa: Ministère de l’Industrie, no 89-550-MPF, aucatalogue, 117-134.

Lee, K., Perlman, M., Ballantyn, M., and Elliot, I. (1995). Association between dura-tion of neonatal hospital stay and readmission rate. Journal of Pediatric, 172,758-766.

Lieu, T.A., Braveman, P.A., Escobar, G.J., Fischer, A.F., Jensvold, N.G., and Capra,A.M. (2000). A randomized comparison of home and clinic follow-up visits afterearly postpartum hospital discharge. Pediatrics, 105, 1058-1065.

Goulet, D’Amour, and Pineault 37

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

Liu, L.L., Clemens, C., Shay, D., Davis, R., and Novack, A. (1997). The safety of new-born early discharge: the Washington State experience. Journal of the AmericanMedical Association, 8, 278-293.

Liu, S., Wen, S.W., McMillan, D., Trouton, K., Fowler, D., and McCourt, C. (2000).Increased neonatal readmission rate associated with decreased length of hospitalstay at birth in Canada. Canadian Journal of Public Health, 91(1), 46-50.

Lock, M., and Ray, J.G. (1999). Higher neonatal morbidity after routine early hospitaldischarge: Are we sending newborns home too early? Canadian Medical Associa-tion Journal, 161(3), 249-253.

Ludvigsson, J.F., and Ludvigsson, J. (2005). Socio-economic determinants, maternalsmoking and coffee consumption, and exclusive breastfeeding in 10 205 children.Acta Paediatrica, 94 (9), 1310-1319.

Maisels, M.J., and Kring, E. (1997). Early discharge from the newborn nursery-effecton scheduling of follow-up visits by pediatricians. Pediatrics, 100, 72-74.

Maisels, M.J., and Kring, E. (1998). Length of stay, jaundice and hospital readmission.Pediatrics, 101, 995-998.

Marques, N.M., Lira, P.I.C., Lima, M.C., DaSilva, N.L., Filho, M.B., Huttly, S.R.A.,and Ashworth, A. (2001). Breastfeeding and early weaning practices in NortheastBrazil: a longitudinal study. Pediatrics, 108(4), E66.

Martens, P.J., Phillips, S.J., Cheang, M.S., and Rosolowich, V. (2000). How baby-friendly are Manitoba hospitals? The provincial infant feeding study. CanadianJournal of Public Health, 91(1), 51-57.

MacArthur, C. (1999). What does postnatal care do for women’s health? Lancet, 353,343-344.

Ministère de la santé et des services sociaux. (1999). Proposition d’organisation desservices dans le cadre d’un programme de congé précoce en périnatalité. Québec:Gouvernement du Québec.

Ministère de la santé et des services sociaux. Statistical data are available on the Website of Québec’s Ministère de la santé et des services sociaux at www.msss.gouv.ca.

Misri, S., Sinclair, D., and Kuan, A. (1997). Breastfeeding and postpartum depression:is there a relationship? Canadian Journal of Psychiatry, 42, 1061-1065.

Norr, K.F., and Nacion, K. (1987). Outcomes of postpartum early discharge, 1960-1986. Birth, 14, 135-141.

O’Hara, M.W., and Swain, A.M. (1996). Rates and risk factors of postpartum depres-sion: a meta-analysis. International Review of Psychiatry, 8, 37-54.

Piper, S., and Parks, P.L. (1996). Predicting the duration of lactation: evidence from aNational Survey. Birth, 23(1), 7-12.

Radloff, L.S. (1977). The CES-D scale: a self-report depression scale for research inthe general population. Applied Psychological Measurement, 1, 385-401.

Régie régionale de la santé et des services sociaux de Montréal-Centre. (2000). Rôles etmodalités d’articulation en périnatalité: Centres hospitaliers accoucheurs / CLSC /médecins traitants (période postnatale). Montréal: RRSSM-C.

Rieger, I.D., and Henderson-Smart, D.J. (1995). A neonatal early discharge and homesupport programme: shifting care into the community. Journal of Paediatrics andChild Health, 31, 33-37.

Rubin, R. (1961). Puerperal change. Nursing Outlook, 9, 753-755.

38 WOMEN & HEALTH

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4

Rubin, R. (1975). Maternity nursing stops too soon. American Journal of Nursing, 10,1680-1685.

Rush, J., and Hodnett, E. (1993). Community support for early maternal and newborncare (the early discharge project): A report of demonstration projects Windsor-Leamington and Sudbury in 1991-1992. A maternal-newborn initiative. Toronto:Ontario Ministry of Health.

Statistics Canada definitions: www12.statcan.ca/français/census01/products/reference/dict/geo042_f.htm and ge042_f.htm.

Stell O’Connor, K.O., Mowat, D.L., Scott, H.M., Carr, P.A., Dordland, J.L., andYoung Tai, K.F. (2003). A randomized trial of two public health nurse follow-upprograms after early obstetrical discharge: an examination of breastfeeding rates,maternal confidence and utilization and costs of health services. Can J PublicHealth, 2003, 94(2), 98-103.

Victoria, C.G., Behague, D.P., Barros, F.C., Anselmo Olinto, M.T., and Weiderpass, E.(1997). Pacifier use and short breastfeeding duration: cause, consequence, or coin-cidence? Pediatrics, 99(3), 445-453.

Vogel, A., Hutchison, B.L., and Mitchell, E.A. (1999). Factors associated with the du-ration of breastfeeding. Acta Paediatrica, 88, 1320-1326.

Wen, S.W., Liu, S., Marcoux, S., and Fowler, D. (1998). Trends and variations inlength of hospital stay for childbirth in Canada. Canadian Medical AssociationJournal, 158, 875-880.

Wright, A., Rice, S., and Wells, S. (1996). Changing hospital practices to increase theduration of breastfeeding. Pediatrics, 97(5), 669-677.

Yanover, M.J., Jones, D., and Miller, M.D. (1976). Perinatal care of low-risk mothersand infants. Early discharge with home care. New England Journal of Medicine,295(13), 702-705.

doi:10.1300/J013v45n04_02

Goulet, D’Amour, and Pineault 39

Dow

nloa

ded

by [

Tow

son

Uni

vers

ity]

at 0

9:04

08

Oct

ober

201

4