The postpartum period is associated with significant physiologic changes that include major alterations in the immune system. Despite the recognized importance of the puerperium period in obstetric care, few data exist that describe puerperal morbidity beyond the period of the initial hospitalization for delivery. The few articles that have addressed postpartum readmission have focused primarily on the relationship between the route of delivery and the need for subsequent readmission rather than a comprehensive analysis of the conditions that necessitate readmission. This limited focus has prevented the acquisition of data that could facilitate the development of programs to prevent readmission. Such data may also allow a critical examination of the contribution of infectious or inflammatory processes that are not commonly associated with pregnancy to the overall readmission rate.

The prevention of morbidity is the primary goal of any such evaluation. However, hospital readmissions have critical economic implications, particularly in an era of health care reform, and may account for up to 20% of all health care costs. Indeed, the White House Office of Management and Budget has proposed a series of incentives and penalties to reduce readmission costs that include bundling of payments for hospitalization to include postacute care costs that are incurred within 30 days of discharge.

It was against this background that we sought to examine the indications for readmission after delivery. We hypothesized that both conditions, which are related directly to pregnancy and morbidity that traditionally have been believed to be unrelated to pregnancy, would contribute to readmission rates. Secondarily, we examined the incidence of readmission on the basis of delivery method.

Materials and Methods

We initially performed an internal quality-driven audit of ICD-9 discharge diagnosis codes for all women who delivered during 2007 who were readmitted within 6 weeks of the original delivery discharge date. This analysis involved 114 Hospital Corporation of America (HCA) hospitals in 21 states across the United States. In terms of delivery volume, these facilities ranged from <1000/year to >10,000/year (1 hospital). This population has been shown in previous publications to be representative of the US population as a whole. Because some women who delivered late in 2007 were not admitted until the first few weeks of 2008, readmission analysis for such women included some 2008 data. Readmissions were stratified according to readmission diagnosis and mode of delivery ( Tables 1 and 2 ).

TABLE 1

Readmissions within 42 days of delivery, 2007

Type of delivery	Number readmission, n	Number births, n	Readmission rate, %	Odds ratio (95% CI)
Vaginal	1168	140,746	0.83	—
Primary cesarean	986	46,639	2.1 a	2.58 (2.37–2.81) a
Repeat cesarean	482	35,366	1.4 a , b	1.65 (1.48–1.84) a
				0.64 (0.57–0.71) b
Total cesarean	1468	82,005	1.8 a , b	2.18 (2.02–2.35) a
				1.18 (1.09–1.29) b
Total readmissions	2636	222,751	1.2	—

 

CI , confidence interval.

Belfort. Hospital readmission after delivery. Am J Obstet Gynecol 2010.

a P < .001, indicates a significant difference when compared with vaginal delivery;

b P < .001, indicates a significant difference when compared with primary cesarean section delivery.

TABLE 2

Indications for readmission

Indication for readmission	Vaginal delivery, n	Rate per 10,000 deliveries	Cesarean delivery, n	Rate per 10,000 deliveries	Odds ratio (95% CI)
Gallbladder disease	152	10.8	124	15.1 a	1.40 (1.10–1.78)
Pneumonia	25	1.8	36	4.4 b	2.47 (1.48–4.12)
Appendicitis	25	1.8	18	2.2	1.24 (0.67–2.27)
Hypertension	231	16.4	196	23.9 b	1.46 (1.20–1.76)
Uterine infection	130	9.2	197	24.0 b	2.60 (2.09–3.25)
Urinary tract infection	115	8.2	72	8.8	1.07 (0.80–1.44)
Specific medical/surgical condition	85	6	102	12.4 b	2.06 (1.55–2.75)
Wound infection without disruption	0	0	172	21.0 b	NA
Hemorrhage	101	7.2	60	7.3	1.02 (0.74–1.40)
Symptoms without diagnosis/miscellaneous	47	3.3	93	11.3 b	3.40 (2.39–4.83)
Mastitis	81	5.8	41	5	0.87 (0.60–1.26)
Cardiomyopathy	37	2.6	49	6.0 b	2.27 (1.48–3.48)
Deep venous thrombosis	21	1.5	58	7.1 b	4.74 (2.88–7.81)
Wound disruption	0	0	79	9.6 b	NA
Other nonsurgical complications	0	0	45	5.5 b	NA
Psychiatric/drug abuse	24	1.7	18	2.2	1.29 (0.70–2.37)
Infection: nongenitourinary	17	1.2	17	2.1	1.72 (0.88–3.36)
Sepsis/bacteremia	13	0.9	19	2.3 a	2.51 (1.24–5.08)
Spinal headache	18	1.3	12	1.5	1.14 (0.55–2.38)
Pulmonary edema: nonspecific	3	0.2	24	2.9 b	13.73 (4.14–45.61)
Cellulitis	19	1.3	2	0.2 a	0.18 (0.042–0.78)
Intestinal obstruction/ileus/fistula	0	0	19	2.8 b	NA
Neoplasm	11	0.8	6	0.7	0.94 (0.35–2.53)
Episiotomy breakdown/fistula	5	0.4	0	0	NA
Sterilization	3	0.2	2	0.2	1.14 (0.19–6.85)
Vaginal/vulvar infection	3	0.2	1	0.1	0.57 (0.060–5.50)
Necrotizing fasciitis	0	0	4	0.5 a	NA
Foreign body	2	0.1	0	0	NA
Injury to pelvic organ	0	0	2	0.2	NA
T otals	140,746		82,005

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