Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis

Background: This meta-analysis explores the impact of enhanced recovery after cesarean delivery (ERAC) on maternal outcomes. Methods: We searched 4 databases (Web of Science, Embase, PubMed and CINAHL) in October 2020 without date limiters, for studies quantitatively comparing ERAC implementation to a control group. The primary outcome was length of hospital stay and secondary outcomes included time to mobilization and time to urinary catheter removal, opioid consumption, readmission rates and cost savings. Mean differences and odds ratios (MD and OR with 95% confidence intervals) were calculated. Levels of evidence were assessed using GRADE. Results: Twelve studies involving 17,607 patients (9693 without ERAC and 7914 with ERAC) were included. ERAC was associated with reduced: length of hospital stay (MD −0.51 days [−0.94, −0.09]; p = 0.018; I² = 99%), time to first mobilization (MD −11.05 h [−18.64, −3.46]; p = 0.004; I² = 98%), time to urinary catheter removal (MD −13.19 h [−17.59, −8.79]; p < 0.001; I² = 97%) and opioid consumption (MD -21.85 mg morphine equivalents [−33.19, −10.50]; p = < 0.001; I² = 91%), with no difference in maternal readmission rate (OR 1.23 [0.96, 1.57]; p = 0.10; I² = 0%). Three studies reported cost savings associated with ERAC. The GRADE levels of evidence were rated as low or very low quality for all study outcomes. Conclusion: ERAC is associated with reduction in length of stay, times to first mobilization and urinary catheter removal and opioid consumption. ERAC does not significantly affect maternal hospital readmission rates following discharge. Further studies are required to determine which ERAC interventions to implement and which outcomes best determine ERAC efficacy.