The COVID-19 pandemic has impacted Americans in a myriad of ways, including their use of the health care system for both COVID- and non-COVID related services. In this brief, we explore the ways in which the first year of the pandemic affected people for one of the most common hospital services – childbirth.
In 2020, the first year of the pandemic, more than 3.6 million babies were born in the United States. A key component of a birthing person's experience is how long they stayed in the hospital for the birth. We examined how this length of stay changed in 2020, compared to 2019. How long a birthing person stays in the hospital for childbirth has implications for the type of care and services that birthing people and newborns receive, as well as the costs of childbirth. Federal standards on length of stay for childbirth were established in 2008, requiring minimum insurance coverage of 48 hours (2 midnights) for a vaginal delivery and 96 hours (4 midnights) for a cesarean section (c-section).
Using HCCI's unique commercial claims dataset, which includes claims for over 55 million people with health insurance through their employer, we observe a small but noticeable decline in the length of stay for both c-sections (6%) and vaginal (4%) deliveries in 2020 compared to 2019. There is no evidence of declines in length of stay for childbirth in previous years in our data. The average length of stay for childbirth dropped most in April of 2020, following the declaration of COVID-19 as a public health emergency in the US and a pandemic by the World Health Organization. This early phase of the pandemic was also marked by the introduction of stay-at-home measures and reduced hospital capacity. Length of stay also dropped noticeably in December, when the U.S. experienced the highest COVID case and death rates in 2020.
Length of Stay Was Lower in 2020 than in 2019
In 2019, a birthing person with employer-sponsored insurance (ESI) who had a c-section stayed in the hospital for 4.24 days on average. A birthing person with ESI who had a vaginal delivery stayed for 2.96 days on average. In comparison, in 2020, the average length of stay in the hospital for a c-section among birthing people with ESI was 3.99 days, a 0.25-day (6%) reduction compared to 2019. The average length of stay in the hospital for a vaginal birth was 2.85 days in 2020, a 0.11-day (4%) reduction from 2019. We observed a drop in length of stay for c-sections in 42 of 45 states we examined and for vaginal birth in 43 of the 45 states, suggesting that the effects were nationwide as we might expect given the widespread impact of the COVID-19 pandemic (see Downloadable Data below).
In contrast, there was no change in average length of stay for either a c-section or a vaginal birth between 2018 and 2019 (average length of stay for a c-section was 4.24 days and for a vaginal birth, 2.96 days, in both years). Similarly, we do not see any major changes in the length of stay going back several years prior to 2020.
The Greatest Decline in Length of Stay in 2020 was Early in the Pandemic
To examine the length of stay in the context of COVID-19 more closely, we studied the average length of stay for c-sections and vaginal deliveries by month in 2018, 2019, and 2020. As can be seen in Figure 1 below, the average monthly ESI length of stay in 2019 was almost the same as in 2018, for both c-sections and vaginal deliveries.
In contrast, there were noticeable decreases in length of stay in 2020 relative to 2019, especially in April and December. A birthing person with ESI who delivered via c-section in April 2019 stayed in the hospital for 4.26 days on average; in April 2020, the average length of stay was 3.78 days (11% lower). A birthing person with ESI who had a vaginal birth stayed in the hospital for 2.94 days on average in April 2019 compared to 2.75 days in April 2020 (6% lower). The average length of stay increased for both c-sections and vaginal deliveries over the rest of 2020 but had not reached January-February levels by the end of the year, with another decrease in the average length of stay in December.
To visualize the month-over-month changes more clearly, we show the percent change in the average length of stay by month in 2019 compared to 2018 and in 2020 compared to 2019 in Figure 2. We see that while there was some fluctuation from 2018 to 2019, the month-over-month changes are small and increase in some months while they decrease in other months. In contrast, the declines from 2019 to 2020 are noteworthy, especially in April and December for c-sections and in April-May, July, and December for vaginal births.
Declines in Length of Stay During COVID-19 May Inform Future Policy
We observed a decline in the length of stay for childbirth in the first year of the COVID-19 pandemic among birthing people covered by ESI for both c-sections and vaginal births. A range of factors may have contributed to the declines in the average length of stay we observe. Birthing people may have been anxious to leave the hospital early if their health and that of their newborn allowed given policies restricting family members from being at the hospital and potentially due to fear of catching COVID in the hospital. Limitations in hospital capacity during the initial surge of cases also may have led hospitals to put in place short term policies to discharge healthy birthing people and newborns early.
Though more research is needed, early evidence suggests that reductions in length of stay for childbirth in the early phase of the pandemic were not associated with adverse effects for birthing people and babies (e.g., readmissions), however, it is unclear whether this shift had other unintended consequences, such as changes in practice patterns or intensity of services. It is important to understand the full effects of reductions in length of stay on the health and well-being of birthing people and newborns, both during the initial hospital stay for the birth and in the post-partum period. Further, we should monitor trends in length of stay in 2021 and after the height of the pandemic.
If true that shorter lengths of stay do not have adverse effects, then this evidence could inform adjustments of policy on the length of stay requirements. According to the American Academy of Pediatrics, length of stay recommendations should be based on maternal and infant health, home support, and access to follow-up care, rather than a minimum amount of time in the hospital. On one hand, the length of stay should be long enough to ensure that there are no maternal or newborn complications from labor. On the other hand, longer hospital stays increase the risk of infection as well as the overall cost of childbirth. If follow-up care can be safely continued in non-hospital settings, this would likely reduce costs for insurers and patients and increase hospital bed capacity, which is especially important during health crises such as a pandemic.
In this brief, we just start to scratch the surface of the effects of COVID on childbirth. Further work may examine the links between state caseloads and policies and length of stay as well as what shorter length of stay meant for the types of services that birthing people and newborns received in the hospital and associated costs. In the longer-term, optimizing the length of stay is an important component of efforts to ensure that birthing people and babies in the United States receive care that is high quality and affordable.
Using diagnostic information, we pooled 2019, 2019, and 2020 inpatient delivery claims resulting in a sample of more than 400,000 births each year. Claims had to be associated with a female member between the ages of 18 and 45 with standard insurance converge.
We defined a delivery admission by the unique combination of individual, diagnostic related group (DRG), and admission and discharge dates. We measured the average length of stay for childbirth by dividing the sum of inpatient days for childbirth by the number of admissions for childbirth within a year.
The DRGs to indicate a C-section and a vaginal birth are presented in the following table.
Cesarean section w
Cesarean section w/o cc/mcc
section w sterilization w mcc|
section w sterilization w cc|
section w/o sterilization w mcc|
section w/o sterilization w cc|
section w sterilization w/o cc/mcc|
section w/o sterilization w/o cc/mcc|
Childbirth (vaginal birth)
delivery w sterilization & or d&c
delivery w complicating diagnoses
delivery w/o complicating diagnoses|
delivery w sterilization/d&c w mcc|
delivery w sterilization/d&c w cc|
delivery w sterilization/d&c wo cc/mcc|
delivery w/o sterilization/d&c w mcc|
delivery w/o sterilization/d&c w cc|
delivery w/o sterilization/d&c w/o cc/mcc|
delivery w o.r. proc except steril &/or d&c|