The efficacy and safety of enhanced recovery after surgery (ERAS) protocols in cesarean delivery: a meta-analysis of randomized controlled trials

Abstract

Background

Given the concerns regarding maternal and neonatal safety, the application of enhanced recovery after surgery (ERAS) in cesarean delivery remains controversial and has not been adopted in some regions. This study aims to conduct a meta-analysis to compare the ERAS pathway with conventional postoperative care, in order to provide evidence on the safety and efficacy of the ERAS protocols.

Methods

PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, and CBM were searched from their inception until February 2025. Randomized controlled trials (RCTs) published in English or Chinese that compared the ERAS and standard care in cesarean section were eligible for inclusion. Two reviewers independently extracted the data and assessed the risk of bias using the Cochrane risk-of-bias tool. The analyses were conducted using RevMan 5.4 software, and the results were presented as forest plots.

Results

Out of 2817 records screened, 10 RCTs comprising 1934 participants met the inclusion criteria. The pooled analyses indicated that ERAS protocols significantly reduced the length of hospital stay (MD −14.13, 95% CI −25.36 to −2.90; p = 0.01), hospitalization costs (MD −447.85, 95% CI −687.04 to −208.66; p = 0.0002), time to first flatus (MD -9.82, 95% CI −13.54 to −6.10; p < 0.00001), time to first stool (MD −15.35, 95% CI −19.10 to −11.60; p < 0.00001), pain sores (MD −1.54, 95% CI −2.10 to −0.99; p < 0.00001), and postpartum hemorrhage (MD −47.75, 95% CI −69.94 to −25.55; p < 0.0001). No statistically significant differences were observed between ERAS and conventional standard recovery in terms of postoperative nausea and vomiting (PONV), urinary retention, postoperative infection, deep venous thrombosis (DVT), 30 days readmission rates, and NICU admission rates.

Conclusions

The adoption of ERAS protocols in cesarean delivery is associated with accelerated postoperative recovery without compromising maternal or neonatal safety. Nevertheless, these findings should be approached with caution due to the limited number and heterogeneity of the studies included.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-026-08392-5.

What does this study add to the clinical work?

Given concerns about maternal and neonatal safety, the implementation of Enhanced Recovery After Surgery (ERAS) protocols in cesarean delivery remains controversial. This study, based on a meta-analysis of randomized controlled trials, provides high-quality evidence regarding the safety and efficacy of ERAS protocols in obstetric care.

Introduction

Cesarean section (CS) has emerged as one of the most widespread surgical interventions globally, with approximately 21.1% of births being conducted through this method [1]. The prevalence of CS varies significantly across different regions, ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean [2]. Forecasts suggest that by 2030, 28.5% of women worldwide will undergo delivery via CS, with regional disparities spanning from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia.¹ Notably, many countries exhibit excessively high CS rates, partly driven by non-medically indicated maternal requests and institutional practices [3, 4]. Although CS is a critical life-saving procedure, its overuse is associated with complications such as thromboembolic events, surgical site infections and prolonged recovery periods. These complications impose significant burdens on healthcare systems, including increased bed occupancy, heightened costs, and delayed access to care for other patients [5–7]. These challenges highlight the urgent need to optimize perioperative management to reduce risks and improve resource efficiency, particularly in regions where CS rates remain consistently high.

Enhanced Recovery After Surgery (ERAS) represents a multimodal, evidence-based strategy aimed at optimizing perioperative management and accelerating postoperative rehabilitation, thereby revolutionizing perioperative care across a range of surgical specialties [8, 9]. These protocols have pioneered a novel paradigm in perioperative care by incorporating evidence-based practices rooted in a multidisciplinary and multimodal integrated treatment framework. This approach continually refines post-cesarean care, rendering postoperative interventions more targeted. For instance, postoperative gum chewing has been shown to facilitate the recovery of bowel function, while early mobilization helps prevent venous thromboembolism in the lower limbs [10, 11]. In particular, enhanced recovery care is an effective way to improve both clinical outcomes and health system efficiency for cesarean sections, as it facilitates faster rehabilitation and enables earlier patient discharge [12]. For example, a study by Wrench et al. reported that the rate of next-day discharge increased from 1.6% to 25% following the implementation of ERAS protocols for elective cesarean sections [13]. Historically, concerns regarding maternal and neonatal safety have significantly impeded the widespread adoption of ERAS. However, a growing body of evidence indicates that ERAS can reduce the risk of maternal postoperative complications without adversely affecting neonatal outcomes, thereby gradually increasing optimism about its implementation [14, 15]. It is plausible to assert that the ongoing refinement of ERAS protocols holds the potential to revolutionize perioperative care, optimize resource allocation, and reduce global maternal morbidity.

The guidelines for perioperative care in cesarean delivery were first established in 2018 [16–18]. Since then, there has been a progressive increase in the implementation of ERAS protocols in cesarean sections. Nevertheless, the expanding body of literature on ERAS in cesarean sections remains fragmented, resulting in challenges in comprehensively evaluating ERAS in this context. Notably, there is an absence of a systematic review and meta-analysis specifically focused on RCTs. This study aims to analyze high-quality evidence from RCTs to assess the clinical efficacy and safety of ERAS protocols in cesarean sections. By synthesizing data on length of hospital stay, gastrointestinal recovery, pain management, maternal complications, and neonatal outcomes, this study seeks to address existing inconsistencies, quantify the benefits associated with ERAS, and inform evidence-based clinical practice. Given the increasing global rates of cesarean sections and rising healthcare costs, clarifying the role of ERAS in postpartum recovery has significant implications for maternal health, healthcare economics, and equitable resource allocation.

Methods

This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [19]. To ensure transparency and minimize potential bias, the study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251017467) prior to data extraction. As this study involved the synthesis of data from previously published trials, ethical approval was not necessary. The experimental group implemented the ERAS protocol, whereas the control group adhered to traditional recovery methods.

Search strategy

A comprehensive systematic search was conducted across seven electronic databases, namely PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Data, and the Chinese Biomedical Literature Database (CBM), covering the period from their inception through February 2025. The search strategy utilized a combination of Medical Subject Headings (MeSH) terms and free-text keywords relevant to "enhanced recovery after surgery," "ERAS," "enhanced recovery," "fast track," "enhanced recovery after cesarean," "ERAC," "cesarean," "caesarean," "cesarean section," "caesarean section," "cesarean delivery" and "caesarean delivery" (Supplementary Material 1). In addition, manual searches of reference lists from retrieved articles and relevant systematic reviews were conducted to identify further eligible studies. The search was restricted to publications in English and Chinese.

Eligibility criteria

The inclusion criteria for the studies were as follows: (1) Population: women undergoing either elective or emergency cesarean sections; (2) Intervention: implementation of an Enhanced Recovery After Surgery (ERAS) protocol; (3) Comparison: standard perioperative care without ERAS protocols; (4) Outcomes: reporting of at least one primary or secondary outcome; (5) Design: Randomized controlled trials. Studies were excluded if they were non-original works (such as reviews and editorials), employed non-RCT designs, lacked sufficient data for meta-analysis, were duplicate publications, or focused on non-cesarean obstetric surgeries. An initial screening of titles and abstracts was independently conducted by two reviewers to assess eligibility, followed by a thorough full-text evaluation of articles deemed potentially relevant. Any discrepancies in the review process were resolved through discussion or, if necessary, by consulting a third reviewer.

Data extraction

Data extraction was systematically carried out using a standardized form, which included the following categories: (1) Study Characteristics: author, publication year, country, sample size, and components of the ERAS protocol; (2) Participant Demographics: maternal age, gestational age, parity, and type of cesarean section; (3) Outcomes: length of stay (LOS) in hours, hospitalization costs, pain scores measured by the visual analog scale (VAS), time to first flatus or stool in hours, postpartum hemorrhage volume in milliliter, maternal complications such as postoperative nausea and vomiting (PONV), urinary retention, infection, and deep venous thrombosis (DVT), readmission rates, and neonatal outcomes, including neonatal intensive care unit (NICU) admission rates.

Quality assessment

The risk of bias for each eligible randomized controlled trial (RCT) was evaluated by two independent reviewers utilizing the Cochrane Collaboration's risk of bias tools. This assessment framework encompasses several domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting [20]. Based on the descriptions provided in each study, the risk in each domain was categorized as "low risk," "high risk," or "unclear risk." Any discrepancies between reviewers were addressed through discussion until consensus was achieved.

Statistical analysis

Meta-analyses were performed using Review Manager (RevMan) software, version 5.4. For dichotomous variables, the relative risk (RR) and 95% confidence interval (CI) were calculated using the Mantel–Haenszel method (M-H). For continuous variables, the weighted mean difference (MD) and 95% CI were determined using the inverse-variance method (IV). Heterogeneity among the included studies was assessed using the Chi-square (χ²) test and quantified with the I² statistic, where an I² value exceeding 50% indicated substantial heterogeneity. A random-effects model was employed for meta-analysis when I² was greater than 50%; otherwise, a fixed-effects model was applied. In instances of significant heterogeneity, sensitivity analyses were conducted to evaluate the robustness of the results. The outcomes of each study were recalculated using pooled estimates to ascertain whether these recalculations would alter the findings [21]. Publication bias was assessed using funnel plots for outcomes with ten or more studies.

Results

Characteristics of included studies

Following an extensive review of 2,817 records sourced from seven databases, 10 randomized controlled trials (RCTs) encompassing a total of 1,934 participants (ERAS group: n = 970; control group: n = 964) met the inclusion criteria [22–31]. The literature screening process is illustrated in the Prisma 2020 flow diagram presented in Fig. 1. The included studies, published between 2019 and 2025, were conducted in diverse geographic locations, including China, India, East Africa, and North America. The fundamental characteristics of all eligible studies are detailed in Table 1. All trials evaluated the efficacy of ERAS protocols in comparison to conventional perioperative care within the context of cesarean deliveries, encompassing both elective and emergency procedures. Although the components of the ERAS protocols varied, they typically included preoperative counseling, early oral feeding, multimodal analgesia, early ambulation, and reduced catheterization duration. The demographic characteristics of the participants were comparable between the groups, with maternal ages ranging from 18 to 45 years and gestational ages between 34 and 41 weeks.

Fig. 1.

PRISMA flow diagram of the literature search

Table 1.

The detailed baseline characteristics of all included studies

Trial	Year	Country	Study design	ERAS (n)	Control (n)	Type of surgery	Outcome measures
Xue [22]	2019	China	RCT	286	286	Elective	2, 3, 4, 8, 9, 10
Baluku [23]	2020	Uganda	RCT	76	77	Emergency	4, 5, 6, 7, 8, 11
Teigen [24]	2020	USA	RCT	58	60	Elective	1, 8, 9, 11, 12
Pan [25]	2020	China	RCT	112	104	Elective	1, 2, 3, 6
Jing [26]	2021	China	RCT	50	50	Elective	1, 3, 4, 9
Ma [27]	2021	China	RCT	110	110	Elective	4, 5, 7, 9, 10
Xu [28]	2021	China	RCT	57	56	Elective	1, 4, 6, 12
Yao [29]	2021	China	RCT	50	50	Elective	4
Mundhra [30]	2024	India	RCT	71	71	Emergency	1, 3, 4, 5, 11
Xu [31]	2025	China	RCT	100	100	Elective	1

n, number of participants; RCT, randomized controlled trial; 1, postoperative length of stay; 2,hospitalization costs; 3, pain scores; 4, time to first flatus; 5, time to first stool; 6, postoperative nausea and vomiting; 7, urinary retention; 8, postoperative infection; 9, postpartum hemorrhage volume; 10, deep venous thrombosis; 11, maternal readmission rates; 12, NICU admission rates.

Risk of bias assessment

The risk of bias assessment, conducted utilizing the Cochrane Collaboration tool, indicated that all studies provided sufficient descriptions of random sequence generation (Fig. 2). However, allocation concealment was explicitly reported in only four studies. Due to the intrinsic characteristics of ERAS interventions, such as patient education and early mobilization, blinding of participants and personnel was deemed to be at high risk in all trials. Nevertheless, blinding of outcome assessment was successfully implemented in six studies. Attrition bias was determined to be low across all studies, as complete outcome data were consistently reported comprehensively. Furthermore, all studies reported complete outcomes, with no evidence of selective reporting.

Fig. 2.

Risk of bias graph as percentages for all included studies

Meta-analysis results

Postoperative length of hospital stay

Six studies provided data on postoperative hospital length of stay (LOS). The pooled analysis revealed a statistically significant reduction in LOS for the ERAS group compared to the control group (MD −14.13, 95% CI −25.36 to −2.90; p = 0.01; I² = 99%) (Fig. 3). Substantial heterogeneity was observed, likely due to variations in discharge criteria and healthcare policies across different regions. Sensitivity analysis, conducted by sequentially excluding individual studies, indicated that the robustness of the findings was questionable. Specifically, when the study by Jing (2021) was excluded, the MD values changed to − 10.53 (95% CI − 21.79 to 0.72; p = 0.07) (Supplementary Material 2).

Fig. 3.

Forest plot of LOS

Hospitalization costs

Two studies assessed hospitalization costs, which were standardized to Chinese Yuan (RMB). The ERAS group demonstrated significantly lower costs compared to the control group (MD −447.85, 95% CI −687.04 to −208.66; p = 0.0002; I² = 95%) (Fig. 4). The observed heterogeneity is likely attributable to variations in healthcare pricing structures and components of the ERAS protocol, such as the utilization of costly analgesics. A sensitivity analysis was performed by modifying the effect model, yielding consistent results. (MD −399.57, 95% CI −455.87 to −353.27; p < 0.00001) (Supplementary Material 3).

Fig. 4.

Forest plot of hospitalization costs

Pain scores

In four studies, postoperative pain scores, assessed using the visual analog scale (VAS, 0–10), were significantly lower in the ERAS group (MD −1.54, 95% CI −2.10 to −0.99; p < 0.00001; I² = 94%) (Fig. 5). A sensitivity analysis, conducted by sequentially excluding individual studies, confirmed the robustness of these results, with MD values ranging from −1.87 (95% CI −2.21 to −1.62) to −1.38 (95% CI −2.51 to −0.61) (Supplementary Material 4).

Fig. 5.

Forest plot of pain scores

Gastrointestinal recovery

A meta-analysis of six studies demonstrated that the implementation of the ERAS protocols significantly reduced the time to first flatus (MD − 9.82, 95% CI − 13.54 to − 6.10; p < 0.00001; I² = 95%) and first stool (MD − 15.35, 95% CI − 19.10 to − 11.60; p < 0.00001; I² = 0%) following cesarean section, in comparison to conventional care (Fig. 6A, Fig. 6B). Notable heterogeneity was observed in the meta-analysis of the time to first flatus post-cesarean section. A sensitivity analysis, performed by sequentially excluding individual studies, confirmed the robustness of these results, with MD values ranging from − 11.33 (95% CI − 13.96 to − 8.69) to − 8.88 (95% CI − 12.73 to − 5.03) (Supplementary Material 5).

Fig. 6.

A Forest plot of time to first flatus. B Forest plot of time to first stool

Postpartum hemorrhage

Two studies evaluated postpartum hemorrhage, revealing a significant reduction in the ERAS group (MD − 47.75, 95% CI − 69.94 to − 25.55; p < 0.0001; I² = 53%) (Fig. 7). To assess robustness, a sensitivity analysis using an alternative effect model was performed, which produced consistent results. (MD −45.27, 95% CI −59.45 to −31.09; p < 0.00001) (Supplementary Material 6).

Fig. 7.

Forest plot of postpartum hemorrhage

Postoperative complications

Three studies assessed the incidence of postoperative nausea and vomiting (PONV), indicating that the ERAS protocols did not significantly influence PONV rates compared to conventional care (RR 0.64, 95% CI 0.26–1.60; p = 0.34; I² = 50%) (Fig. 8A). Two studies investigated urinary retention and found no significant differences between the groups (RR 1.01, 95% CI 0.18–5.69; p = 1.0; I² = 0%) (Fig. 8B). Postoperative infection rates were reported in three studies, with no significant differences observed (RR 0.53, 95% CI 0.21–1.34; p = 0.18; I² = 0%) (Fig. 8C). Additionally, two studies evaluated the incidence of deep venous thrombosis (DVT), indicating that the ERAS group did not exhibit an increased risk compared to the control group (RR 0.33, 95% CI 0.04–3.17; p = 0.34; I² = 0%) (Fig. 8D).

Fig. 8.

A Forest plot of PONV. B Forest plot of urinary retention. C Forest plot of postoperative infection. D Forest plot of DVT

Maternal readmission rates

Three studies examined readmission rates within 30 days following discharge. The analysis indicated no statistically significant difference between the ERAS group and the control group (RR 0.30, 95% CI 0.07–1.22; p = 0.09; I² = 26%) (Fig. 9).

Fig. 9.

Forest plot of maternal readmission rates

Neonatal intensive care unit (NICU) admission rates

Regarding neonatal outcomes, as reported in two studies, there was no statistically significant difference in NICU admission rates between the groups (RR 0.76, 95% CI 0.18–3.33; p = 0.72; I² = 0%) (Fig. 10).

Fig. 10.

Forest plot of NICU admission rates

Discussion

This meta-analysis, encompassing 10 randomized controlled trials (RCTs) with a total of 1,934 participants, indicates that Enhanced Recovery After Surgery (ERAS) protocols in cesarean delivery significantly expedite postoperative recovery in comparison to traditional perioperative care. Notable advantages of ERAS include a reduction in hospital length of stay (LOS) by an average of 14.13 h, a decrease in hospitalization costs by 447.85 RMB, and a shortened time to first flatus and stool by 9.82 h and 15.35 h, respectively. Additionally, postoperative pain scores, measured by the Visual Analog Scale (VAS), were reduced by 1.54 points, and postpartum hemorrhage decreased by 47.75 mL. Importantly, the implementation of ERAS protocols did not lead to an increase in maternal complications, such as urinary retention, postoperative nausea and vomiting (PONV), postoperative infections, deep venous thrombosis (DVT), or 30-day readmission rates. Furthermore, neonatal outcomes, including rates of admission to the neonatal intensive care unit (NICU), were unaffected. These results corroborate existing literature that supports ERAS as a safe and effective approach for enhancing recovery following cesarean delivery, while ensuring the safety of both mothers and neonates.

The reduction in LOS observed in this analysis is clinically significant, particularly in resource-constrained settings where overcrowded maternity wards place a strain on healthcare systems. For instance, in Uganda, the implementation of ERAS protocols led to an 18.5-h reduction in LOS for emergency cesarean deliveries, facilitating earlier discharges and allowing hospital resources to be allocated to other patients [23]. ERAS protocols accomplish this through optimized perioperative workflows, which include early mobilization, timely catheter removal, and the use of multimodal analgesia, collectively expediting functional recovery [32]. Nonetheless, substantial heterogeneity was observed in the meta-analysis results concerning LOS, indicating considerable variability among the included studies. This variability may be attributed to the absence of standardized discharge criteria following cesarean sections, as well as disparities in medical resources across different regions, which can significantly impact hospitalization duration. Additionally, LOS is influenced by regional economic conditions, healthcare policies, and community health standards [33]. Despite these variations, the majority of studies have consistently demonstrated that ERAS contributes to a reduction in hospital stay duration.

A reduced LOS not only eases institutional pressures but also decreases direct medical expenses, a crucial consideration in low- and middle-income countries (LMICs) where out-of-pocket costs for cesarean deliveries disproportionately impact families [34]. Although this study's cost data were confined to Chinese research, the observed financial savings likely result from diminished drug utilization, shorter LOS, and a reduction in complications. In high-income countries (HICs), comparable savings have been linked to the implementation of standardized ERAS pathways, which minimize unnecessary interventions [35]. For instance, a study conducted in the United Kingdom documented a 23.6% increase in day 1 discharges after CS following the adoption of ERAS, thereby reducing bed occupancy and staffing expenses [15]. These advantages are particularly pronounced in LMICs, where ERAS could reallocate limited resources to benefit underserved populations.

Postoperative gastrointestinal function are particularly common, which could delay postoperative recovery, prolong hospital stay, increase costs, and decrease patient satisfaction [36]. In this meta-analysis, the results showed significantly reduced time to first flatus and first stool following cesarean section, in comparison to conventional care. ERAS protocols facilitate gastrointestinal recovery through evidence-based interventions, including early oral feeding, carbohydrate loading, and opioid-sparing analgesia [37]. Early oral feeding promotes gut motility, while the avoidance of prolonged fasting mitigates insulin resistance and metabolic stress, thereby expediting the normalization of bowel function [38, 39]. A 2024 meta-analysis determined that initiating oral feeding within two hours post-cesarean section is comparably safe to delayed oral feeding and can expedite the restoration of normal bowel function [40]. Early oral intake constitutes a pivotal approach in meeting the nutritional needs of postpartum mothers. A substantial body of high-quality research conducted over recent decades has rigorously investigated the implications of early postoperative feeding, consistently endorsing early oral intake following surgical procedures [41].

In additional, multiple randomized clinical trials have demonstrated that chewing gum, a form of simulated eating, is associated with a more rapid recovery of gastrointestinal function following cesarean section (CS) [36, 42]. The act of chewing mimics the process of eating, which enhances electrical signaling within the intestines and stimulates muscle contractions, thereby facilitating the movement of intestinal contents. Additionally, chewing activates neural pathways involving the vagus nerve, transmitting signals from the brain to the gastrointestinal tract to enhance digestive activity. This mechanism triggers the release of digestive hormones and neurotransmitters that inhibit µ opioid receptors, preventing a reduction in bowel motility and consequently improving intestinal movement. Elkan et al. reported that the use of xylitol-containing chewing gum in the early postpartum period serves as an effective and convenient method to expedite bowel movements [43]. Ultimately, the incorporation of chewing gum into postoperative care protocols may provide a valuable strategy for improving patient outcomes and expediting recovery, particularly when used in conjunction with comprehensive and individualized postoperative care plans.

Multimodal analgesia, which includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and regional anesthesia, has been shown to significantly decrease opioid consumption, a factor known to impede gastrointestinal transit [44]. A retrospective cohort study conducted in the United States revealed that patients following ERAS protocols required 42.2% fewer opioids postoperatively, thereby underscoring the effectiveness of multimodal pain management strategies [45]. In our meta-analysis, findings indicated a significant reduction in VAS scores within the ERAS group, substantiating the superior analgesic effect of multimodal analgesia. Notably, the reduction in postoperative pain scores was not accompanied by increased opioid consumption. Meng et al. reported that pain relief was primarily attributed to the multimodal analgesia approach and the implementation of ERAS protocols, rather than excessive opioid use [46]. Additionally, ERAS protocols emphasize non-pharmacologic interventions, such as preoperative counseling and regular pain assessments, which help alleviate anxiety and enhance coping mechanisms [47, 48].

This meta-analysis identified a significant reduction in postpartum hemorrhage within the ERAS group. Evidence suggests that early postoperative ambulation and breastfeeding could promote uterine contraction, thereby reducing the risk of postpartum hemorrhage [23]. In a study conducted by Gupta S et al. in India, involving women undergoing elective cesarean delivery, it was demonstrated that the time to first ambulation was significantly reduced in the ERAS group compared to those adhering to standard protocols (7.73 ± 1.80 h vs. 63.63 ± 6.76 h, p < 0.0001) [49]. Similarly, Duygu et al. reported that the time to initiate breastfeeding and resume activities of daily living was significantly shorter in the ERAS group [50]. Consequently, this study suggests that ERAS protocols may reduce the risk of postpartum hemorrhage by promoting early ambulation and facilitating breastfeeding. As primary postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, severe PPH significantly increases the risk of hysterectomy, ICU admission, and blood transfusion [51]. Therefore, implementing ERAS to reduce the risk of PPH is critical for improving maternal outcomes. Nonetheless, it is imperative to acknowledge the limitations of this study. Notably, two of the studies included in this meta-analysis did not specify the protocols for hemorrhage prevention and pharmacologic management, which are critical factors influencing postpartum hemorrhage.

Critics of ERAS protocols have raised concerns regarding the potential compromise of maternal safety due to expedited recovery processes. However, this analysis found no significant differences in PONV, urinary retention, postoperative infection, DVT, or readmission rates when comparing ERAS with traditional care approaches. These findings indicate that the protocols' focus on evidence-based practices, such as the administration of prophylactic antibiotics, thromboprophylaxis, and standardized fluid management, is both effective and safe. For example, early removal of catheters has been demonstrated to reduce the incidence of urinary tract infections without increasing urinary retention rates, while early ambulation has been associated with a decreased risk of DVT [52]. Moreover, the rapid recovery of gastrointestinal function enables patients to resume a regular diet at the earliest opportunity, thereby facilitating the intake of balanced nutrients and promoting swift physical recovery. The prompt restoration of organ function also supports normal immune function and diminishes the risk of postoperative infections. Additionally, we observed that the incidence of PONV was 2.9% in the ERAS group and 4.7% in the control group. Although this difference did not reach statistical significance, a downward trend in PONV incidence was evident in the ERAS group. This trend may be attributed to the early recovery of gastrointestinal function and the avoidance of high-dose neuraxial opioids. Importantly, the ERAS protocol significantly accelerated recovery following cesarean section without compromising safety or increasing the incidence of complications [53].

ERAS protocols have not led to an increase in NICU admission rates, thereby supporting the assertion of neonatal safety. Although direct neonatal outcomes are infrequently documented, there are potential indirect benefits, notably through enhanced maternal-infant bonding. The promotion of early skin-to-skin contact and breastfeeding, made possible by reduced maternal pain and increased mobility undergoing the ERAS protocols, contributes positively to neonatal thermoregulation, glucose stability, and immune function [54]. A retrospective study documented a 12.8% increase in exclusive breastfeeding rates among patients undergoing ERAS, which was attributed to enhanced maternal comfort and confidence [55]. Additionally, the study revealed that, in comparison to traditional care, the ERAS group exhibited a reduced incidence of hypoglycemia (4.8% vs. 12.6%, p = 0.014) and jaundice (20.7% vs. 31.1%, p = 0.036). Given the current rates of NICU admissions, it is apparent that ERAS does not negatively impact neonatal outcomes following cesarean sections. However, the available evidence remains limited, necessitating further research that focuses on neonatal indicators such as Apgar scores, incidence of hypoglycemia, and long-term developmental outcomes.

The anticipated rise in the global cesarean delivery rate to 28.5% by 2030 underscores the urgent need for strategies to mitigate the associated risks and costs. ERAS programs present a viable solution by systematically optimizing perioperative care. The efficacy of ERAS is evidenced by its capacity to decrease length of stay, reduce costs, minimize opioid dependence, and lower postpartum blood loss, while also accelerating gastrointestinal functional recovery—an advantage crucial for both HICs and LMICs. Safety is ensured through strict adherence to perioperative dietary guidelines, multimodal analgesia, infection prevention, and thromboembolic prophylaxis. Importantly, ERAS is not a standardized protocol but rather a flexible framework that can be tailored to local resources and patient needs.

This study is subject to several limitations. Firstly, the heterogeneity in ERAS protocols may confound the pooled estimates. Secondly, the limited number of included RCTs and participants constrains the statistical power, particularly concerning rare outcomes such as DVT. Thirdly, the randomization methods were not clearly described in some of the included studies, potentially introducing selection bias. Fourthly, performance bias is inherent due to the unblinded nature of ERAS interventions. Fifthly, the cost data were derived exclusively from Chinese studies, thereby limiting the generalizability of the findings. Lastly, long-term outcomes and patient-reported metrics, such as satisfaction, were inadequately reported. Future research should prioritize larger multicenter trials and cost-effectiveness analyses across diverse healthcare settings. Despite these limitations, this meta-analysis provides valuable insights into the effectiveness and safety of ERAS protocols in cesarean delivery.

Conclusions

In conclusion, the present meta-analysis provides robust evidence supporting the efficacy and safety of ERAS protocols as a strategy for optimizing recovery following cesarean delivery. The adoption of ERAS is linked to reductions in hospital stays, healthcare costs, pain scores, postpartum blood loss, he duration of gastrointestinal functional recovery, and the incidence of PONV, urinary retention, postoperative infections and DVT, all without compromising maternal or neonatal safety. This approach aligns with global initiatives aimed at improving the quality and efficiency of obstetric care. While further high-quality randomized controlled trials are necessary to address current limitations, the existing body of evidence advocates for the integration of ERAS protocols into perioperative care for cesarean deliveries.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

LJC worked on project design, data collection and analysis, and manuscript write up. GF worked on project design, data collection and analysis, and manuscript revision. All authors read and approved this manuscript.

Funding

This research received no specifc grant from funding agencies in the public, commercial, or not-for-proft sectors.

Data availability

Data are available upon reasonable request. The data extracted from included studies and analysed in this review are available from the corresponding author upon reasonable request.

Declarations

Conflict of interests

The authors declare no competing interests.

Ethics approval

Not applicable because this study is a review article and a meta-analysis.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication

Not applicable.