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.

Reduced length of hospital stay after caesarean section: A systematic review examining women's experiences and psychosocial outcomes.

BACKGROUND: Globally, reducing hospital stays after caesarean section is becoming more prevalent. Whilst this reduction in length of stay after caesarean section has not been found to be associated with adverse maternal health outcomes, the psychosocial impact and women's experiences have not been systematically reviewed. This review aims to evaluate the literature on women's experiences and psychosocial outcomes (including infant feeding) associated with a reduced hospital stay after caesarean section. METHODS: A mixed methods systematic review examining records between 1980 and 2019 was undertaken. The review included research which defines a reduced length of stay in comparison with standard care or a comparator with a longer discharge time. It considered data related to the antenatal period, time of discharge and postnatal period. The following databases were searched: PsycINFO, CINAHL, PubMed, Embase and ProQuest Dissertations and Theses. 13,760 records were identified, after duplicates were removed, 10,902 articles were reviewed for suitability by title and abstract. 78 full text articles were assessed, and the final review included 8 articles. RESULTS: A total of 8 articles were included, and four areas were examined: satisfaction with care, mental wellbeing, infant feeding and pain. Articles were of mixed quality when assessed using the Mixed Methods Appraisal Tool. CONCLUSIONS: This review indicated no evidence of a systematic negative impact on women's psychosocial outcomes and experiences. The review also identifies a number of characteristics of care associated with more positive experiences and psychosocial outcomes. These include the provision of support systems, access to pain management before and after discharge and continued care with home midwifery. The limited number of studies point to the need for more research, and especially those using qualitative methods.

Women's experiences with enhanced recovery after elective caesarean section with next day discharge: A qualitative study.

BACKGROUND: A maternity service in Australia recently implemented an 'Enhanced recovery after Elective Caesarean' pathway, which includes antenatal preparation and facilitates an active role in postnatal recovery such as encouraging mobility and early cessation of fasting. The pathway includes next day discharge for women and their babies after elective caesarean section and safely transitions maternity care from hospital to home with community midwifery care. While enhanced recovery has been implemented in a number of surgical procedures to reduce hospital stay and to improve patient outcomes it has only been considered for elective caesarean sections in more recent years. Given this, enhanced recovery is not well established or researched in obstetric contexts. Furthermore, women's experiences with reduced hospital stays post-caesarean, particularly next day discharge, is limited. A qualitative explorative descriptive study of women's experiences with the pathway and the associated early transition home will help to inform clinical practice and the research evidence base. METHODS: Eleven interviews were conducted with women who had experienced the pathway and next day discharge. Thematic analysis was conducted. FINDINGS: Three major themes and twelve sub-themes emerged from the data. Major themes identified were women's general experience of an enhanced recovery pathway, their experiences following arrival at home and support at home. All women interviewed were satisfied with the pathway and home recovery. However, there are a number of aspects of care that are essential to a positive experience. This includes excellent support from social networks, healthcare staff and home midwifery care; well managed pain relief; and adequate and timely information, including reassurance that they or their baby could remain in hospital if required. CONCLUSION: This study takes a woman-centred perspective adding to both literature and practice.