Description of included documents
We identified 348 policy and guideline documents, of which 26 met the inclusion criteria (see Fig. 1). In addition, we identified a total of 1544 research or other literature documents from database searches, of which 46 met the inclusion criteria. One of the research documents is in Bulgarian; it has not been translated and is referenced but not cited in the report . Additional file 2 includes a full list of included documents and their characteristics and Tables 2 and 3 summarise key characteristics.
Just under half the policy and guideline documents were ‘guidelines’ (n = 12) and of these 10 were national and two global (Table 2). The three professional society statements were developed by the American College of Obstetricians & Gynecologists (n = 1) and the Canadian Paediatric Society (n = 1). The remainder of the documents were checklists (n = 3), scales to assess discharge readiness (n = 2), and one each of the following: a clinical protocol, handbook, poster, technical consultation and a toolkit. These are referred to as policy documents throughout. The majority of documents originated in the United States of America (USA) (n = 8) or were global (n = 7); the remainder were from the United Kingdom (UK) (n = 5), Canada (n = 2), Spain (n = 1), India (n = 1), Iran (n = 1) and Northern Ireland (n = 1).
The research and other literature included published research articles (n = 35), conference abstracts (n = 2), evaluations or reports (n = 2), theses (n = 3), commentaries (n = 2) and a medical news article (n = 1) (Table 3). These documents are referred to as ‘research documents’ throughout. Most research was conducted in Europe (England (n = 2), France (n = 3), Ireland (n = 1), Poland (n = 1), Spain (n = 3), Sweden (n = 2), Turkey (n = 6), UK (n = 1)) and North America (Canada (n = 2), USA (n = 15); the remainder in the Middle East (Iran (n = 1), Israel (n = 1), Jordan (n = 1), Lebanon (n = 1)), Africa (Tanzania (n = 1)), Asia (Taiwan (n = 1), Thailand (n = 1)) and South America (Brazil (n = 1), Venezuela (n = 1)). Most of the documents concerned postnatal discharge (n = 36); others concerned discharge of pre-term infants (n = 6), hospitalised children (n = 2) and one was a generic discharge programme. More documents focused on discharge readiness (n = 22) than discharge preparation (n = 16); six focused on both and in one the focus was unclear. The study designs of included research articles were largely descriptive (cross-sectional, correlational or descriptive (n = 11), before and after type studies (n = 6) or qualitative (n = 6). Other studies used prospective designs (n = 5), quality improvement or knowledge translation approaches (n = 4); three were randomised controlled trials, four were review articles and one a reliability study.
Definitions of discharge preparation and readiness
We found few explicit definitions of discharge preparation or readiness in the research and policy documents. The only policy document that defined discharge preparation stated that it requires a systematic and multidisciplinary approach, that parents should have an active role and health care providers should ensure that the family achieves competencies during the transition to home . Research documents offered loose defnitions of discharge preparation, most of which emphasised the ‘provision of education, information or instructions’ to mothers about taking care of the newborn and their own health after birth [14, 15, 25,26,27,28,29,30]. Some specifically referred to preparation for the ‘transition home’ or to adapt to ‘changes’ in the woman’s and newborn’s lives [12, 26, 27, 31, 32]. More recent research articles mentioned empowering parents or helping them take control and make their own decisions as an important step in discharge preparation [30, 31].
Policy documents offered defintions of discharge readiness that mentioned assessment of physical or medical readiness for discharge, but acknowledged that confidence of the mother, social risk factors, support available at home and access to follow up care were also important [24, 33, 34]. Defnitions in research documents recognised that the decision to discharge was ‘complex’ and varied depending on the confidence of the mother to take care of the baby at home, support and stability at home, access to follow up care, social vulnerabilities and psychological adaptation [30, 35, 36]. In three research documents defnitions mentioned ‘joint assessment ‘or ‘agreement’ between the mother, family and health professionals that both the mother and infant were ready for discharge [9, 10, 31].
Mapping of discharge readiness criteria
Thirteen policy documents reported discharge readiness criteria [24, 33, 34, 37,38,39,40,41,42,43,44,45,46]. Seventeen research documents reported readiness criteria, and these included nine research studies [11, 12, 25, 31, 32, 35, 47,48,49], three review articles [36, 50, 51], two commentaries [52, 53], a thesis , a medical news article  and an unpublished evaluation report . Policy documents were from the United States (n = 3), Canada (n = 2), India (n = 2), England (n = 1) and five of the policy documents had a global focus. Research documents came from the USA (n = 5), France (n = 3), Turkey (n = 2), England (n = 1), Poland (n = 1), Chile (n = 1), Spain (n = 1), Ireland (n = 1), Canada (n = 1) and Venezuela (n = 1). Table 4 shows the mapping of discharge readiness criteria contained in the included research and policy documents.
All four minimum discharge readiness criteria defined by the AAP  were reported in the policy and research documents. Nearly all policy (n = 12) and research (n = 15) documents mentioned assessment of maternal and infant physiological stability as a criterion. In policy and research documents components for assessing the condition of the newborn (physical examination of the newborn and nutrition and weight status of the newborn) were mentioned more often than assessment of maternal status.
Almost all policy (n = 11) and research documents (n = 13) reported assessment of knowledge, ability and confidence regarding self-care for the woman and infant care. Policy documents were more likely to report use of written educational materials (n = 10), commonly covering topics such as breastfeeding, care of the newborn, danger signs and family planning. Four policy documents mentioned assessment of aspects of maternal confidence and knowledge, including identification of danger signs and confidence in caring for the baby. The research documents were more likely to report components to do with assessing maternal confidence and knowledge (n = 11).
Policy (n = 8) and research (n = 8) documents mentioned assessment of availability of obstetric and infant care following discharge. Assessing timely follow-up arrangements was the most frequently reported component (policy documents n = 7; research documents n = 9). Other components mentioned for this criterion included identification of a medical facility in case of emergency (policy documents n = 3; research documents n = 4), family must have a general practitioner (research documents n = 4), link to community postnatal services (policy documents n = 3), follow up instructions or plan (policy documents n = 2; research documents n = 1), and immunisations arranged (policy documents n = 2).
Assessment of availability of support at home was much more frequently reported in research documents (n = 15) than policy documents (n = 3). Research documents mentioned a broad range of home environment factors considered important to assess at discharge including family support (n = 9), domestic violence (n = 2) and financial concerns (n = 4). Psychosocial concerns (n = 6), alcohol or substance misuse (n = 3), and social risk factors included language barriers (n = 4), local residence or access barriers to services (n = 2) and age of the mother (n = 2).
Mapping of discharge preparation steps
Fifteen policy documents [2, 4, 24, 34, 37, 42, 45, 46, 57,58,59,60,61,62,63] and 11 research documents [14, 25,26,27, 36, 64,65,66,67,68,69] reported discharge preparation steps. Table 5 shows the mapping of discharge preparation steps contained in the included research and policy documents.
Our mapping identified six commonly reported steps: a) provide information to women and families on a range of topics; b) assess need or refer to services; c) plan follow-up care; d) provide opportunity to talk about birth experience and ask questions about care received; e) complete home-based record for the woman and the baby; and f) provide a discharge care plan. Of these common steps, nearly all the policy (13/15) and research documents (9/11) reported a step in the process for providing information to women and their families. Topics for discharge education or information ranged from self-care for the woman, care of the newborn, advice on danger signs, home, family and social support, and follow-up care. Three research articles mentioned the format of information – mainly written materials or teaching delivered by discharge educators.
Few research documents reported on additional discharge preparation steps besides providing information: assess need or refer to services (n = 5); provide opportunity to talk about birth experience and ask questions about care received (n = 0); complete home-based record for the woman and the baby (n = 0); and provide a discharge care plan (n = 3); plan follow-up care (n = 2). Policy documents were more likely to report on additional steps in the discharge preparation process: assess need or refer to services (n = 12); plan follow-up care (n = 5); provide opportunity to talk about birth experience and ask questions about care received (n = 4); complete home-based record for the woman and the baby (n = 3); and provide a discharge care plan (n = 2).
Interventions to improve delivery of discharge preparation
Nine research papers reported interventions to improve the delivery of discharge preparation in normal vaginal birth and in normal term infants (Table 6). The studies were mainly small-scale pilots or evaluations involving fewer than 250 participants and predominantly comparing delivery of education through provision of written materials and training sessions to routine care. The studies were conducted in Europe (Turkey n = 2), North America (Canada n = 1 and USA n = 3), South America (Brazil n = 1), Middle East (Israel n = 1, Lebanon n = 1). Seven studies included an education component or information provision for mothers, in varying formats. Written materials included a modified discharge letter , written booklets or brochures . One study included a discharge folder and educational resources provide by a designated nurse . Two studies implemented an education session before discharge [70, 71]; One study implemented a designated nurse and an educational material to provide discharge education to mothers . One study reported a programme to enhance the discharge experience including interactive education and sensing sessions for women, adding emergency information to discharge instructions ; one study reported on a test of content through educational sessions using group dynamic activities prior to discharge  and one evaluated an innovative model of postnatal care to improve discharge preparation . Two studies assessed the effectiveness of discharge education or information provision for mothers [64, 69] and reported effects on women’s satisfaction with care, postpartum visits to a health professional after discharge, and discharge readiness as measured on a scale. Other studies were descriptive (n = 2), cross-sectional (n = 3) or used quality improvement approaches (n = 2) and reported various outcomes including maternal recall of discharge intructions, maternal satisfaction with discharge procedure, and maternal readiness for discharge. Of those studies that reported on timing of intervention use, one was designed for use on admission , five at or around the time of discharge [14, 56, 64, 70, 71]. Two studies do not specify when the intervention is initiated [29, 69].
Other types of intervention reported in our included studies were one non-randomised study assessing the effect of discharge education through sessions starting at 32–36 weeks of pregnancy until 4–6 weeks after childbirth compared with routine care among women with healthy infants , and four studies of interventions to improve the delivery of discharge preparation for low birth weight or preterm babies [25, 65, 68, 74].
Stakeholder perspectives on postnatal discharge
Six studies reported the perspectives of women, fathers and midwives on postnatal discharge using qualitative research methods. The studies were conducted in England, Sweden, Tanzania, and USA and number of participants ranged from 12 to 324. Two papers reported specifically on experiences of first-time mothers and fathers [75, 76] and two on the experience of early hospital discharge [76, 77]. Midwives’ and student midwives’ experiences are included in two papers [15, 78]. A qualitative evidence synthesis of these studies will be reported separately.
Conceptual frameworks and theories of discharge readiness
Five research documents included conceptual frameworks or theories to help contextualise and understand the concepts of discharge preparation and readiness [11, 27, 32, 75, 77]. The theories and models reported in research articles were used in different ways. In some papers existing theories were used to guide the research being conducted and conceptualise linkages between the study variables [11, 27]. These frameworks represent mid-range theories, concerned with highly contextualised systems and processes of discharge [11, 27, 32]. For example, transitions theory helps place discharge preparation and readiness in the broader context of a ‘transition’ from facility to home, stipulating what is required to ensure the transition is as safe and effective as possible [11, 27]. In two qualitative papers, theoretical models were developed based on empirical findings [75, 77]. The lack of prepardnness model  and the sense of security model  represent micro-level theories, that help explain individual level behaviours and actions in relation to discharge. They prompt consideration of women’s and partners/father’s experiences of childbirth and the postnatal period, and emphasise the importance of customised approaches to facilitate acquisition of the knowledge and skills parents need to care for themselves and the baby. One paper reported developing a model of key drivers of successful discharge to help inform development of a quality improvement programme .
Scales for measuring or scoring discharge readiness
Eleven research documents reported on scales for assessing or scoring readiness for discharge. Study designs included a RCT (n = 1), prospective cohort studies (n = 2), a before and after (n = 1), descriptive correlational studies (n = 4), cross sectional (n = 2) and a reliability study (n = 1). The studies were conducted in Europe (Poland n = 1; Turkey n = 3)), North America (US n = 5), Middle East (Jordon n = 1) and Asia (Taiwan n = 1). The scales reported in these studies were used to assess discharge learning needs or the quality of discharge teaching (n = 5), conduct readiness for discharge assessments (n = 6), and to conduct readiness assessments to support infant discharge from neonatal intensive care (n = 3).
Some scales were newly developed and not yet tested for reliability and validity (e.g. the Perceived Learning Needs (PLN) scale , the Neonatal Discharge Assessment Tool (N-DAT) , the maternal confidence scale and the caring knowledge scale . The most commonly reported scale in use was the Readiness for Hospital Discharge Scale (RHDS), which was originally developed and validated in the US [11, 12, 27, 30, 31, 49]. Several adaptations of the RHDS exist – for new mothers, parents and nurses – and it appears to be the most comprehensive scale in use for assessing discharge readiness. The 23-item scale measures more than perceptions of physical health and includes an holistic assessment of the woman and her circumstances including emotional and psychological wellbeing, and expected social support and support in the home environment.