ERACS in National Health Insurance: Clinical Benefits and Economic Challenges
JEL Classification: I11, I13, I18, H51, D61
Abstract
Enhanced Recovery After Cesarean Section is a perioperative care pathway designed to improve maternal recovery and optimize healthcare resource utilization; however, its implementation within Indonesia’s National Health Insurance system remains constrained by fixed reimbursement mechanisms. This systematic review aimed to evaluate the clinical and economic outcomes of Enhanced Recovery After Cesarean Section in the context of national health insurance and to assess its policy implications. A systematic review was conducted of 27 studies involving more than 9,000 cesarean deliveries, with analysis focusing on length of hospital stay, hospitalization costs, pain control, postoperative complications, opioid use, and patient satisfaction. The findings demonstrate that Enhanced Recovery After Cesarean Section consistently shortens hospital stay, improves postoperative pain control, reduces opioid consumption and complication rates, and enhances maternal satisfaction without increasing readmissions. Several studies also reported reductions in direct hospital costs, primarily driven by decreased length of stay. Despite these benefits, the fixed case-based reimbursement system limits financial incentives for hospitals, creating a mismatch between clinical efficiency and economic returns. In conclusion, Enhanced Recovery After Cesarean Section provides significant clinical and economic advantages but requires reimbursement reform and policy alignment to enable sustainable implementation within Indonesia’s universal health coverage system.
References
Abilashini, G. D., Rao, D. R., & Gnanasekaran, V. (2025). Maternal outcomes following emergency cesarean delivery: Evaluating the enhanced recovery after surgery protocol in a randomized controlled trial. Journal of Pharmacy and Bioallied Sciences, 17(Suppl. 2), S1849–S1851. https://doi.org/10.4103/jpbs.jpbs_540_25
Afreen, U., Karim Faisal, F. E., Khalid, M., Rao, Z., Mustafa, R., & Afreen, S. (2024). Enhanced recovery after caesarean section: An improved pathway than conventional care for reducing hospital stay. Journal of Ayub Medical College Abbottabad, 36(1), 50–55. https://doi.org/10.55519/JAMC-01-12522
Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., & Khusun, H. (2019). Universal health coverage in Indonesia: Concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7
Baluku, M., Bajunirwe, F., Ngonzi, J., Kiwanuka, J., & Ttendo, S. (2020). A randomized controlled trial of enhanced recovery after surgery versus standard of care recovery for emergency cesarean deliveries at Mbarara Hospital, Uganda. Anesthesia & Analgesia, 130(3), 769–776. https://doi.org/10.1213/ANE.0000000000004495
Birchall, C. L., Maines, J. L., Kunselman, A. R., Stetter, C. M., & Pauli, J. M. (2022). Enhanced recovery for cesarean delivery leads to no difference in length of stay, decreased opioid use and lower infection rates. The Journal of Maternal-Fetal & Neonatal Medicine, 35(26), 10253–10261. https://doi.org/10.1080/14767058.2022.2113512
Combs, C. A., Robinson, T., Mekis, C., Cooper, M., Adie, E., Ladwig-Scott, E., & Richards, J. (2021). Enhanced recovery after cesarean: Impact on postoperative opioid use and length of stay. American Journal of Obstetrics and Gynecology, 224(2), 237–239. https://doi.org/10.1016/j.ajog.2020.10.018
Darwish, A., Mustafa, M., Youness, E., & Al-Harazi, B. (2022). Enhanced recovery after cesarean section (CS) versus conventional care in a lower middle-income country: A randomized controlled trial. Open Journal of Nursing, 12, 831–841. https://doi.org/10.4236/ojn.2022.1212058
Gohar, I. E., Ali, H. S. I., & Shoukhba, N. S. M. (2023). Effect of implementing enhanced recovery after surgery pathway for women undergoing cesarean section on maternal outcomes and satisfaction. Egyptian Journal of Health Care, 14(4), 1561–1580. https://doi.org/10.21608/ejhc.2023.374873
Gupta, S., Gupta, A., Baghel, A. S., Sharma, K., Choudhary, S., & Choudhary, V. (2022). Enhanced recovery after cesarean protocol versus traditional protocol in elective cesarean section: A prospective observational study. Journal of Obstetric Anaesthesia and Critical Care, 12(1), 28–33. https://doi.org/10.4103/JOACC.JOACC_16_22
Kanabar, H., Babariya, D. C., Desai, D., Shastri, A., & GMERS Medical College and Hospital. (2024). Enhanced recovery after surgery protocol compliance impact on recovery after cesarean section in primi patients as compared to conventional care. International Journal of Current Pharmaceutical Review and Research, 16(3), 145–149.
Kleiman, A. M., Chisholm, C. A., Dixon, A. J., Sariosek, B. M., Thiele, R. H., Hedrick, T. L., Carvalho, B., & Tiouririne, M. (2020). Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery. International Journal of Obstetric Anesthesia, 43, 39–46. https://doi.org/10.1016/j.ijoa.2019.08.004
Lashin, M., Salem, A., Basha, A., & Alkader, A. (2024). Enhanced recovery after elective cesarean section delivery protocol: A randomized controlled clinical trial. Zagazig University Medical Journal. https://doi.org/10.21608/zumj.2024.327294.3629
Lester, S. A., Kim, B., Tubinis, M. D., Morgan, C. J., & Powell, M. F. (2020). Impact of an enhanced recovery program for cesarean delivery on postoperative opioid use. International Journal of Obstetric Anesthesia, 43, 47–55. https://doi.org/10.1016/j.ijoa.2020.01.005
Lin, D., Zhang, C., & Shi, H. (2021). Effects of clinical pathways on cesarean sections in China: Length of stay and direct hospitalization cost based on meta-analysis of randomized controlled trials and controlled clinical trials. International Journal of Environmental Research and Public Health, 18(11), 5918.
Mangala, J. K., Remadevi, C., Loganathan, P., R. S., Gopukrishnan, & Vasudevan, A. (2021). Enhanced recovery pathway as a tool in reducing post-operative hospital stay after caesarean section, compared to conventional care in COVID era: A pilot study. Journal of Obstetrics and Gynaecology of India, 71(Suppl. 1), 12–17. https://doi.org/10.1007/s13224-021-01461-6
Manoghna, G., Moharana, R., Dash, S., Jena, P., & Rath, S. K. (2024). Enhanced recovery after surgery (ERAS): A multimodal perioperative care pathway in cesarean deliveries. Indian Journal of Obstetrics and Gynecology Research, 11(4), 617–620. https://doi.org/10.18231/j.ijogr.2024.111
Mansour, H., Mohamed, M., Youssef, I., & Abdelzaher, T. (2025). Empowering mothers through enhanced recovery after cesarean section (ERACS): A comparative study on recovery quality and patient satisfaction. Egyptian Journal of Anaesthesia, 41, 1–9. https://doi.org/10.21608/egja.2025.389683.1105
Mullman, L., Hilden, P., Goral, J., Gwacham, N., Tauro, C., Spinola, K., Rosales, K., Collier, S., Holmes, L., Maccione, J., Pitera, R., Miller, R., & Yodice, P. (2020). Improved outcomes with an enhanced recovery approach to cesarean delivery. Obstetrics & Gynecology, 136(4), 685–691. https://doi.org/10.1097/AOG.0000000000004023
Mundhra, R., Gupta, D. K., Bahadur, A., Kumar, A., & Kumar, R. (2024). Effect of enhanced recovery after surgery (ERAS) protocol on maternal outcomes following emergency caesarean delivery: A randomized controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology: X, 22, 100295. https://doi.org/10.1016/j.eurox.2024.100295
Narkhede, H., Vipulachandra, Y., Bhanap, P., Karale, A., & Chavan, R. (2023). Enhanced recovery after surgery protocol implementation on elective cesarean delivery: A cross-sectional study. Journal of South Asian Federation of Obstetrics and Gynaecology, 14, 667–671. https://doi.org/10.5005/jp-journals-10006-2152
Özdemir, M. G., Gunaydin, B., Bayram, M., & Hirfanoglu, İ. M. (2025). Effect of enhanced recovery after surgery (ERAS) protocol on maternal and fetal outcomes following elective cesarean section: An observational trial. BMC Pregnancy and Childbirth, 25(1), 517. https://doi.org/10.1186/s12884-025-07583-3
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., et al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71.
Pan, J., Hei, Z., Li, L., Zhu, D., Hou, H., Wu, H., Gong, C., & Zhou, S. (2020). The advantage of implementation of enhanced recovery after surgery (ERAS) in acute pain management during elective cesarean delivery: A prospective randomized controlled trial. Therapeutics and Clinical Risk Management, 16, 369–378. https://doi.org/10.2147/TCRM.S244039
Pineyro, M. O. S., Villegas-Cruz, C., Hernandez-Bazaldua, M., Pineyro-Cantu, A., Gaston-Locsin, T., & Sordia-Hernandez, L. H. (2023). Effect of the implementation of an enhanced recovery after surgery protocol (ERAS) in patients undergoing an elective cesarean section. Ginekologia Polska, 94(2), 141–145. https://doi.org/10.5603/GP.a2023.0003
Puspitasari, C. D. C., Paripurna, Y., & Trianasari, N. (2024). Comparison of operating costs and LOS of cesarean section patients using ERACS and non-ERACS method. Jurnal Jaminan Kesehatan Nasional, 4(1), 1–12.
Puspitasari, C. D. C., Paripurna, Y., & Trianasari, N. (2024). Comparison of operating costs and LOS of cesarean section patients using ERACS and non-ERACS method. Jurnal Jaminan Kesehatan Nasional, 4(1), 1–12. https://doi.org/10.53756/jjkn.v4i1.142
Sadzali, A., & Rosa, E. M. (2024). Cost efficiency of cesarean section surgery with ERACS method compared to the conventional method. Indonesia Journal of Biomedical Science, 18, 16–19.
Sadzali, A., & Rosa, E. M. (2024). Cost efficiency of cesarean section surgery with ERACS method compared to the conventional method. Indonesia Journal of Biomedical Science, 18(1), 16–19. https://doi.org/10.15562/ijbs.v18i1.528
Sravani, P., Pravalina, R., Sahoo, G., & Pati, B. K. (2023). Comparative study between ERAS protocol and conventional perioperative care in elective cesarean section patients in a tertiary care centre of eastern India. Journal of Public Health and Development, 21(3), 94–106. https://doi.org/10.55131/jphd/2023/210308
Sultan, P., Sharawi, N., Blake, L., Habib, A. S., Brookfield, K. F., & Carvalho, B. (2021). Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis. Anaesthesia Critical Care & Pain Medicine, 40, 100935. https://pubmed.ncbi.nlm.nih.gov/34390864/
Sultan, P., Sharawi, N., Blake, L., Habib, A. S., Brookfield, K. F., & Carvalho, B. (2021). Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis. Anaesthesia Critical Care & Pain Medicine, 40(5), 100935. https://doi.org/10.1016/j.accpm.2021.100935
Tamang, T., Wangchuk, T., Zangmo, C., Wangmo, T., & Tshomo, K. (2021). The successful implementation of the Enhanced Recovery After Surgery (ERAS) program among caesarean deliveries in Bhutan to reduce the postoperative length of hospital stay. BMC Pregnancy and Childbirth, 21(1), 637. https://doi.org/10.1186/s12884-021-04105-9
Tanner, L. D., Chen, H. Y., Chauhan, S. P., Sibai, B. M., & Ghebremichael, S. J. (2021). Enhanced recovery after scheduled cesarean delivery: A prospective pre-post intervention study. The Journal of Maternal-Fetal & Neonatal Medicine, 35(25), 9170–9177. https://doi.org/10.1080/14767058.2021.2020237
Teigen, N. C., Sahasrabudhe, N., Doulaveris, G., Xie, X., Negassa, A., Bernstein, J., & Bernstein, P. S. (2020). Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: A randomized controlled trial. American Journal of Obstetrics and Gynecology, 222(4), 372.e1–372.e10. https://doi.org/10.1016/j.ajog.2019.10.009
van Niekerk, J. A., Kleyenstuber, T., & Jooma, Z. (2025). Evaluating the impact of an enhanced recovery programme on the Obstetric Quality-of-Recovery score (ObsQoR-10) after elective Caesarean section in a South African public hospital: A prospective before-after study. BJA Open, 13, 100373. https://doi.org/10.1016/j.bjao.2024.100373
Walker, M., Sobel, M., Siddiqi, N., Carvalho, J. C. A., Jahan, N., Santini, S., Watts, N., Dart, K., Wang, S., Huszti, E., & Thomas, J. (2025). Implementation of enhanced recovery after surgery for caesarean delivery: A quality improvement initiative. BMJ Open Quality, 14(3), e003391. https://doi.org/10.1136/bmjoq-2025-003391
Xu, Y., Zhong, M., & Li, S. (2025). Opioid-free anesthesia in enhanced recovery after surgery for gastrointestinal surgery: Current status, challenges, and prospects. Frontiers in Pharmacology, 16, 1662818. https://doi.org/10.3389/fphar.2025.1662818
Copyright (c) 2026 Journal La Bisecoman
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
