Understanding the knowledge of and potential challenges with implementation of Enhanced Recovery After Surgery in tertiary facilities in low-and middle-income countries for obstetric and gynecological surgery: A Qualitative Study

Background Access to safe and affordable surgery in low- and middle-income countries has been identified as a growing need and driver of health disparity. Within the field of obstetrics and gynecology, surgical care is necessary for safe pregnancy care and curative gynecologic oncology care. Standardized perioperative care guidelines, such as Enhanced Recovery after Surgery (ERAS), have been identified as key components of improving quality surgical care globally. This study aimed to explore stakeholders' knowledge of, attitudes towards, and understood barriers and facilitators of ERAS implementation within a tertiary care hospital in Ho, Ghana. Methods Semi-structured interviews were conducted among clinical stakeholders caring for obstetrics and gynecology patients at Ho Teaching Hospital, a tertiary care teaching hospital in the Volta Region of Ghana. The interviews were transcribed verbatim, and data were analyzed by two researchers until consensus on coding structure was reached through an iterative process. Results Seven interviews were completed of nine clinical stakeholders including house officers (n = 1), residents (n = 4), and nurses (n = 3). A priori knowledge of ERAS was common among physicians, but lacking in nursing staff and degree of knowledge varied. Three themes emerged as both barriers and potential facilitators of implementation: physical resources, monetary resources, and human resources. Participants also universally expressed an acceptance of the efficacy and safety of ERAS, even when the protocols were a change from common practice. Conclusions ERAS was viewed as a safe, effective, and realistic strategy to improve surgical outcomes among obstetrics and gynecology patients. Although physical, monetary, and human resource limitations were repeatedly noted as barriers to realization, they were also identified as strengths of the system and modifiable problems. Targeted strategies that understand these limitations, address them systematically, and acknowledge the inherent strengths of the healthcare system in place will be needed to realize the benefits of ERAS in such settings.