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Obstetrics & Gynecology 2001;97:982-987
© 2001 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

In-Home Nursing Care for Women With High-Risk Pregnancies: Outcomes and Cost

MARGARET J. HARRISON, RN, PhD, KAYSI E. KUSHNER, RN, MN, KAREN BENZIES, RN, MN, CATHY KIMAK, RN, BScN, PHILIP JACOBS, PhD and B. F. MITCHELL, MD

From the Faculty of Nursing; the Department of Public Health Sciences; and the Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta; and the Community Health Promotion and Preventive Services, Capital Health, Edmonton, Alberta, Canada.

Address reprint requests to: Margaret J. Harrison, RN, PhD Faculty of Nursing University of Alberta 3rd Floor Clinical Sciences Building Edmonton, AB T6G 2G3 Canada E-mail: margaret.harrison{at}ualberta.ca


   Abstract
Top
Abstract
Materials and Methods
 Results
 Discussion
 References
 
Objective: To evaluate a program that provides in-home care to women with pregnancies threatened by preterm delivery (including preterm labor, preterm premature rupture of membranes, and multiple gestation) and women with pregnancy-related hypertension.

Methods: Data from hospital discharge summaries were used to compare birth outcomes and cost of care for women in the in-home program and a cohort of women who received in-hospital antenatal care before the new program. Birth outcomes included data for mothers and infants. The sample included 437 women with threatened preterm delivery (n = 228 in-home, n = 209 in-hospital) and 308 with hypertension (n = 155 in-home, n = 153 in-hospital). The cost per woman included all costs of services for mothers and infants.

Results: Women at risk of preterm delivery who received in-home care were half as likely to have their infants in the neonatal intensive care unit more than 48 hours (odds ratio 0.53, 95% confidence interval 0.36, 0.78). On average, their infants weighed more (2732 ± 716 g versus 2330 ± 749 g, P < .001) and were 2 weeks older at birth (36.1 ± 3.1 weeks versus 34.0 ± 4.0 weeks, P < .001). There was a wide range in the total cost per woman and no significant difference between cohorts. For women with hypertension, there were no significant differences between in-home and in-hospital cohorts in birth outcomes or costs of care per woman.

Conclusion: The program with current admission criteria, staffing, and guidelines for antenatal hospital admission provides safe care to women at similar cost to that of hospitalization.

In response to fiscal pressure and increased focus on health promotion, Canadian health care since the 1980s has emphasized community-based service alternatives to hospital-based care.1,2 Since 1984–85, Canadian hospitals have reported 25% fewer beds and a nearly 200% increase in day surgery, outpatient care.1 In the province of Alberta, health services were substantially restructured during that time. The Healthy Beginnings Antenatal Program was established in 1995 by Capital Health regional health authority in Edmonton and St. Albert (1996 combined population 663,629).3 Its goal was a safe alternative to antenatal hospital care through community-based services.

Service is provided to two groups, women whose pregnancies are threatened by preterm delivery, including preterm labor, preterm premature rupture of membranes (PROM), or multiple gestations, and women who have preeclampsia or essential hypertension. Diagnosis-specific criteria and protocols guide referrals from obstetricians to the Program and assessment by Program nurses of need for hospital referral. Women with antenatal hospital admissions might be returned to Program care once their condition stabilizes. Women who present with preterm labor are eligible for the Program if a diagnosis is established (uterine contractions less than 10 minutes apart or progressive cervical dilatation or effacement), gestation is 20–37 completed weeks, and cervical dilatation is no more than 3 cm. The interpretation of preterm labor is subjective, so the obstetricians’ decisions that referral to the Program is necessary are accepted as clinically appropriate criteria. Eligibility criteria for PROM include confirmed rupture of membranes and gestation greater than 24 weeks. Women with multiple gestations are eligible if gestation is 20–34 weeks and there is no evidence of PROM. Eligibility criteria for preeclampsia or essential hypertension include gestation 26–40 weeks, blood pressure(BP) 140/90 to 150/100 (sitting), protein no more than 1+, and no signs of central nervous system irritation. Women diagnosed with multiple complications must have met eligibility criteria for each complication. Women were ineligible for in-home care if they had diabetes, fetal growth restriction, oligohydramnios, vaginal bleeding, or chorioamnionitis.

The Program provides in-home care by experienced antenatal nurses and homemaker services by family aides, and receives referrals 7 days a week. The Program includes nursing (ie, maternal assessment including laboratory sampling, fetal assessment including electronic fetal monitoring, maternal teaching, and counseling) and support services (ie, homemaker and in-home child care, financial aid for transportation, and subsidized nutrition, as needed). Program nurses maintain regular communication with obstetricians on medical care. Women continue antenatal visits with their obstetricians, who manage care individually and do not use standardized care protocols to manage women with preterm labor. Fewer than 20% of women in the Program who have threatened preterm delivery receive oral tocolytics. Women, in the Program or in-hospital, are encouraged to decrease physical activity, but strict bed rest is not prescribed.

The Program evaluation focused on birth outcomes for mothers and infants and cost. The hypotheses were that there is no difference in pregnancy-related birth outcomes between women who receive in-home care in the Program and women with the same pregnancy complications who received in-hospital care, and the cost per woman of service delivery is less for women in the Program than women cared for in-hospital.


   Materials and Methods
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Abstract
 Materials and Methods
Results
 Discussion
 References
 
A retrospective cohort design compared birth outcomes and cost for women who received in-home care in the Program and a historic cohort who received in-hospital care. Ethics approval was received from the University of Alberta and Capital Health. The in-home cohort included all women who received care in the in-home program between May 1996 and November 1997. The in-hospital cohort included all women, with the same high-risk diagnoses (preterm labor, PROM, multiple gestations, preeclampsia, or pregnancy-related hypertension), who received in-hospital care for their high-risk pregnancies at a tertiary hospital before implementation of the in-home program, and who gave birth between September 1992 and April 1995. It was not possible to conduct the evaluation with a prospective control group because restructuring of health care services in the Capital Health region led to full implementation of the Program.

The principal objective of the evaluation was to assess safety, so the primary birth outcome was infant admission to the neonatal intensive care unit (NICU) for longer than 48 hours. Length of stay in NICU was associated with severity of immediate and long-term infant morbidity, family disruption, and related social and health care costs.4–6 That indicator is a conservative measure because it rules out infants admitted to NICU for short observation periods, common with otherwise healthy low birth weight infants. Secondary birth outcome indicators included pregnancy complications factors that could be affected by method of antenatal care such as gestational age at birth, birth weight, Apgar score at 5 minutes, fetal growth restriction (birth weight below the 3rd percentile for gestational age), infant mechanical ventilation, infant intraventricular hemorrhage, clinical chorioamnionitis coded on the discharge abstract database, eclampsia, cesarean birth, perinatal or maternal death, and neonatal or maternal readmission to hospital within 14 days of discharge after infant’s birth. Data for birth outcomes were collected from Canadian Institute for Health Information Discharge Abstracts, a patient-specific database that contains selected clinical, demographic, and administrative data on patient discharge from hospital. Data on variables such as BP and cervical dilatation on admission, and use of antenatal steroids in hospital are not included in the discharge abstracts and were unavailable for the study. For data analyses, women were classified into one of two groups based on their primary International Classification of Diseases, 9th Revision7 codes for pregnancy complications: preterm labor (including pre-term labor, 644.00 to 644.21; PROM, 658.10 to 658.33; and multiple gestations, 651.00 to 651.03), and hypertension (preeclampsia or pregnancyrelated, 642.00 to 642.94).

The cost per woman is the sum of all costs for mother and infant. Services included in the cost measure were inpatient costs (antenatal, labor and delivery for mothers, and nursery and neonatal intensive care for infants); physician services (consultations in and out of hospital); laboratory tests; outpatient drugs (betamethasone and dexamethasone); nursing hours (clinic, in-home, travel, and telephone); taxi and home aide services. The cost of hospital stays was considered the full operating cost for associated Diagnosis Related Group (using Alberta provincial average costs). Physician visits were based on provincial billings; laboratory tests costs were based on financial costs per relative value unit, according to the financial department of the Royal Alexandra Hospital; drugs were assigned hospital acquisition cost; home nursing and home aide contact hours were evaluated on a sample of time per contact for each type of service, multiplied by nursing per hour wage; taxi expenses were based on average cost per trip.

Data were analyzed using Pearson {chi}2, logistic regression, t tests for independent samples, Mann-Whitney U statistic where appropriate, with SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, IL) version 10 computer software. Statistical significance was P < .05 for all tests except when multiple t tests were used and alpha was set at .01. Results are reported as mean ± standard deviation, median with full range, or frequency and percentage. Costs are reported in year-adjusted Canadian dollars. Because the total cost data were skewed, data were transformed using the natural logarithm, and geometric means were compared. Women with multiple gestations had twin pregnancies. One infant was randomly selected for analyses using SPSS random sample of cases command. A sub-analysis found no significant differences in birth outcomes when either twin was selected. Family income was not available on the discharge abstract database, so it was estimated based on mean family income by postal code reported by Statistics Canada.3


   Results
Top
Abstract
 Materials and Methods
 Results
Discussion
 References
 
Among women at risk of preterm delivery, 228 were cared for in-home and 209 were cared for in-hospital (Table 1Go). Compared on sociodemographic variables, the only significant difference between them was family income. Women in the in-home program had higher estimated mean family income ($52,611 ± 11,784 versus $47,230 ± 11,180, P < .001), although mean incomes for both groups are considered middle income by household size.8 Infants of women at risk of preterm delivery who were cared for in-home were half as likely to be in NICU longer than 48 hours as infants in the in-hospital group (odds ratio 0.53, 95% confidence interval 0.36, 0.78). The addition of maternal age, parity, and family income to the logistic regression model did not significantly change the odds ratio.


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  		Table 1. Characteristics of Women and Infants
 
There were significant differences in three of the secondary birth outcomes (Table 2Go). Women cared for in-home had lower incidence of clinical chorioamnionitis (17 or 7.5% versus 31 or 14.8%, P < .014). At birth, infants of women in the in-home cohort were older (36.1±3.1 weeks versus 34.0 ± 4.0 weeks, P < .001) and weighed more (2732 ± 716 g versus 2330 ± 749 g, P < .001). Controlling for family income in the statistical analysis of the secondary birth outcomes did not change findings. No significant differences existed between cohorts for number of neonatal deaths. The in-home cohort included one fetal death with an unknown cause. There were no significant differences between cohorts for hospital readmissions. Four women were readmitted to hospital in the in-home cohort and three (one readmitted twice) in the in-hospital cohort. Eleven infants (4.8%) were readmitted in the in-home cohort and ten (4.8%) in the in-hospital cohort.


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  		Table 2. Secondary Birth Outcomes for Mothers and Infants
 
Women in the in-home and in-hospital cohorts were compared by gestational age on admission to the Program or hospital and the proportion with PROM or multiple gestations. Women were admitted to the in-home program at an earlier gestational age (31.0 ± 3.8 weeks versus 34.0 ± 4.1 weeks, P < .001), but had a lower incidence of PROM (75, or 32.9% versus 149, or 71.3%, P < .001) and twin pregnancies (19, or 8.3% versus 64, or 30.6%, P < .001). To assess possible effects of potential bias, statistical analyses were repeated excluding women in both cohorts who had antenatal lengths of stay less than 24 hours (Table 3Go). An antenatal length of stay of less than 24 hours was chosen as an indicator that women presented with imminent pre-term deliveries and would not have met criteria for admission to the Program. The statistically significant difference between the cohorts in the primary outcome, length of stay in NICU longer than 48 hours, was maintained. There was no longer a significant difference between cohorts in the proportion of women who had clinical chorioamnionitis, but women in the in-home cohort had infants with significantly greater birth weights and gestational ages at birth.


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  		Table 3. Comparison of Selected Birth Outcomes for Women Hospitalized at Least 24 Hours
 
Women at risk of preterm delivery who received in-home care (Table 4Go) had a shorter median postpartum stay (2 days versus 3 days, P < .001) but longer median antenatal hospitalization (3 days versus 0 days, P < .001) than women who received in-hospital care. There was no significant difference for the total cost per woman (Table 5Go).


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  		Table 4. Hospital Service Use
 

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  		Table 5. Patient Costs
 
Among women with hypertension, 155 women were cared for in-home and 153 in-hospital. Compared on sociodemographic variables (Table 1Go), more women in the in-home program were having their first children (P < .001) and had higher mean family incomes ($51,632 ± 10,160 versus $48,014 ± 10,412, P = .002). Both income values show middle income by household size.8 For women cared for in-home and in-hospital with hypertension, there was no statistical difference in probability of having an infant in NICU longer than 48 hours. There were no significant differences in any of the secondary birth outcomes for women or their infants between in-home and in-hospital cohorts (Table 2Go). Controlling for family income and parity in statistical analysis did not change the findings. When analyses were repeated excluding women who had antenatal lengths of stay shorter than 24 hours (Table 3Go), there were no differences in findings. Four women in the in-home cohort and four women in the in-hospital cohort were readmitted to hospital after birth. Eleven infants (7.1%) were readmitted in the in-home cohort and 11 (7.2%) in the in-hospital cohort.

Women in the in-home program (Table 4Go) had a shorter median postpartum hospitalization (3 days versus 4 days, P < .001), but there was no significant difference in the length of antenatal hospitalization. There was no significant difference for the total cost per woman (Table 5Go).


   Discussion
Top
Abstract
 Materials and Methods
 Results
 Discussion
References
 
Compared with infants of women who received inhospital care, infants of women at risk of preterm delivery and who received in-home care had significant reduction in length of stay in NICU and greater birth weight and gestational age. A limitation of a retrospective study is the potential for noncomparable groups and lack of availability of important information. There are several potential biases that might explain the findings of this study. Information on cervical dilatation on admission and history of preterm birth, two predictors of preterm delivery, was not available. To address potential bias, women in both groups who had antenatal hospitalization under 24 hours were excluded from the sample. Women who received in-home care still had infants with greater birth weights and gestational ages who required significantly shorter stays in NICU. Differences in gestational age at admission to the Program or hospital did not explain the findings because women who received in-home care were admitted to the Program at an earlier gestational age than women who received in-hospital care. More women cared for inhospital had PROM or twin pregnancies, another potential source of bias. Although the cohorts were not strictly comparable, women who received in-home care were as safe as women in the retrospective cohort who received in-hospital antenatal care.

No significant differences in birth outcomes between the cohorts were found for women with hypertension. There was a 3% difference between cohorts in proportion of women who had infants in NICU longer than 48 hours. Given the small effect size, a sample of 3000 women in each group would have been needed for a power of approximately .80 in the regression analysis. The study was limited by lack of data on the women’s BP on admission and medication during antenatal hospitalization. Adding that information as covariates in the logistic regression model in future research could increase power in analyses.

There were no significant differences in total cost per woman between in-home and in-hospital cohorts. Also, the antenatal length of stay in hospital did not decrease for women who received in-home care, whether they were at risk of preterm delivery or with hypertension. These unexpected findings might be related to data collection methods. Nurses working in the Program follow protocols to determine which women should be referred to hospital. Women who are hospitalized are discharged back to the in-home program if their conditions stabilize. Target pregnancies could be identified and linked to all hospitalizations for women in the in-home program whether hospitalization was at the hospital of infants’ births or other hospitals in the region. However, data for the in-hospital cohort included only antenatal admissions at birth hospitals. For that cohort, we could not link data from the infants’ birth hospitals to data for mothers’ antenatal hospitalizations (and related costs) at other hospitals in the region. Therefore, antenatal lengths of stay and related costs for the in-hospital cohort probably are underestimated. Another possible explanation for increased antenatal length of stay for the women in the preterm labor group on the Program is the increasing caution exercised by health professionals in the care of pregnant women in response to increased concern about malpractice lawsuits.

The postnatal length of stay decreased for women at risk of preterm delivery and women with hypertension. That finding shows the trend in Canada since the 1980s to shorter postnatal hospitalization. By the start date of our study, the mean length of postnatal hospital stay had already decreased from 5.0 days (1984) to 2.9 days (1994).9 In 1994, the mean length of postnatal hospital stay in Alberta was 2.5 days.9 A short-stay postnatal program was implemented that year by Capital Health.

The study did not include a comparison group of women discharged to home without nursing or home aide support, so it was not possible to know whether women who remained in the community without Program services would have similar birth outcomes as women in the in-home program. Additionally, evaluation did not examine which aspects of the in-home program might influence birth outcomes. The Program included in-home electronic fetal monitoring and nursing support. For women at risk of preterm delivery, some researchers identified beneficial effects of home uterine monitoring without nursing support.10–12 Others found that when regular nursing contact was provided, addition of uterine activity monitoring was not linked to earlier diagnosis of preterm labor or lower rates of preterm birth.13

The Program with current criteria for service, staffing, and guidelines for antenatal hospital admission provides safe care, but no significant cost saving, to women at risk of preterm delivery and those with preeclampsia or hypertension. Such a program represents an opportunity to shift hospital care to in-home care and maintain standards of safety. These findings support evaluations of other programs of antenatal in-home care,14,15 but do not address the question of whether women can be safely cared for in-home without the services described.


   Footnotes
 
We acknowledge the financial support of the University of Alberta Perinatal Research Centre and Capital Health region, both in Edmonton, Alberta.

PII S0029-7844(01)01360-6

Received June 8, 2000. Received in revised form January 16, 2001. Accepted February 15, 2001.


   References
Top
Abstract
 Materials and Methods
 Results
 Discussion
 References
 
1. Canadian Institute for Health Information. Health care in Canada 2000: A first annual report. Ottawa, Ontario: Canadian Institute for Health Information, 2000.

2. Health Canada. Canada health action: Building on the legacy. Publications of the National Forum on Health, Volume 1—Final report [online] 1997. Available from http://wwwnfh.hc-sc.gc.ca/publicat/finvol1/5financ.htm. Accessed 2000 April 15.

3. Statistics Canada. 1996 Census of Canada [custom tabulation]. Ottawa, Ontario: Statistics Canada, 1998.

4. Brandt P, Magyary D, Hammond M, Barnard K. Learning and behavioral-emotional problems of children born preterm at second grade. J Pediatr Psychol 1992;17:291–311.[Abstract/Free Full Text]

5. Goldberg S, DiVitto B. Parenting children born preterm. In: Bornstein MC, ed. Handbook of parenting, vol. 1. Mahwah, New Jersey: Lawrence Erlbaum, 1995:209–31.

6. Speechley KN, Avison WR. Admission to a neonatal intensive care unit as a predictor of long- term health: A 12-year follow-up. J Dev Behav Pediatr 1995;16:397–405.[Medline]

7. World Health Organization. International Classification of Diseases, 9th Revision. Geneva: World Health Organization, 1977.

8. Statistics Canada. National population health survey. Ottawa, Ontario: Ministry of Industry, 1995.

9. Wen SW, Liu S, Fowler D. Trends and variations in neonatal length of in-hospital stay in Canada. Can J Public Health 1998;117:115–9.

10. Dyson DC, Crites YM, Ray DA, Armstrong MA. Prevention of preterm birth in high-risk patients: The role of education and provider contact versus home uterine monitoring. Am J Obstet Gynecol 1991;164:756–62.[Medline]

11. Colton T, Kayne HL, Zhang Y, Heeren T. A meta-analysis of home uterine activity monitoring. Am J Obstet Gynecol 1995;173:1499–505.[Medline]

12. Corwin MJ, Mou SM, Sunderji SG, Gall S, How H, Patel V, et al.Multicenter randomized clinical trial for home uterine activity monitoring: Pregnancy outcomes for all women randomized. Am J Obstet Gynecol 1996;175:1281–5.[Medline]

13. The Collaborative Home Uterine Monitoring Study (CHUMS) Group. A multicenter randomized controlled trial of home uterine monitoring: Active versus sham device. Am J Obstet Gynecol 1995;173:1120–7.[Medline]

14. Helewa M, Heaman M, Robinson M, Thompson L. Community-based home-care program for the management of pre-eclampsia: An alternative. CMAJ 1993;149:829–34.[Abstract]

15. West C, Palmer L, Tier T. High-risk antepartum patients: No place like home. Can Nurse 2000;96:32–4.[Medline]





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