Obstetric and medical factors rather than psychosocial characteristics explain why eligible women do not complete the enhanced recovery after elective caesarean (EREC) pathway: A prospective cohort study

Background: An Australian health-service implemented an ‘enhanced recovery after elective caesarean’ pathway with next-day discharge. Problem: Previous anecdotal reports indicated that a large percentage of eligible women were not discharged the next day and therefore were not regarded as having completed the pathway. Psychosocial factors were expected to be the leading reason for prolonged hospitalisation. Aim: The study objectives were to: enumerate the percentage of women assessed as eligible for EREC who subsequently did not complete the pathway and the reasons; and to describe women's antenatal satisfaction with preparation, preferences, and perceived support. Women who completed the pathway versus those who did not were compared on antenatal biopsychosocial characteristics. Methods: This exploratory prospective cohort study enrolled consenting eligible women from antenatal clinics and used patient records and questionnaire data. Comparative statistical techniques were used. Findings: 62 % of women did not complete the pathway, with medical and obstetric factors being the most common reasons (80 %). There was statistically significant evidence of lower antenatal stress levels for those who completed EREC (median=5) relative to those who did not (median=8; P = 0.035); although these findings may not be of clinical importance. Antenatally, 51 % of women felt prepared for early discharge, 36 % needed more information, 19 % disliked hospital, 93 % agreed that family togetherness after birth was important. Most agreed that staff (76 %) and family (67 %) supported the pathway. Conclusion: This study indicated that a large percentage of women assessed as eligible did not complete EREC and that obstetric and medical factors, rather than psychosocial characteristics, largely explained this. This provides reassurance to clinicians and women that discharge home is working as intended and is useful for planning similar models of care. Higher stress levels in the antenatal period were demonstrated for women who did not complete EREC suggesting the need for further research into how to support these women.