Enhanced Recovery After Surgery Protocols in Cesarean Delivery in International Settings: A Clinical Review of Implementation in Turkey and Croatia

Comment 1: Dear authors,

A comparative clinical review evaluated the implementation of ERAS protocols in cesarean deliveries in two hospitals, one in Croatia and one in Turkey.

ERAS protocols are established to optimize perioperative patient care, minimize perioperative stress and accelerate postoperative recovery. As evaluation of ERAS protocols may indicate the level of perioperative care, it is essential to conduct well designed study.

Study is designed upon evaluating ERAS protocols in two hospitals in two countries. Number of patients and medical workers included in the study should be introduced.

Response 1: Thank you for your comment. Details regarding the participants of the study, including the number of patients and medical workers, have been provided in the subsection "Sample" under the chapter "Materials and Methods" in the manuscript.

Comment 2: Results are presented in 3 tables and 1 graph concluding that implementation score is significantly better in hospital from Croatia.

Response 2: Thank you for your comment.

Comment 3: The major weakness of the study is comparison between the two centers in different countries. Differences in implementation score are reported, although it may be a bias. Authors acknowledge that limitation of the study is in those two centers, one in the capital city and the other in a small province. It is obvious that comparison between those centers cannot be considered valid. Comparison can be made between hospital in capital city and province hospital belonging to the same country, or between hospitals of the same range in two countries. I suggest authors to provide two studies or to rearrange this study in order to avoid present bias.

Response 3: Accepted. Thank you for your thoughtful comments regarding the validity of comparing the two centers in our study. To address your concerns, it's important to highlight the relative healthcare capacities of Zagreb and Yozgat. Despite being the capital city of Croatia, Zagreb's population size is approximately 772,122 and it hosts five major hospitals, reflecting a healthcare density typical of smaller European nations.

Conversely, Yozgat, while appearing smaller in the context of Türkiye's larger population, actually supports a substantial healthcare system with 15 medical facilities, including one city hospital, 11 state hospitals, one training and research hospital, and two private hospitals​. This robust presence of healthcare facilities is substantial and indicates a healthcare infrastructure that, per capita, is comparably equipped to that of Zagreb.

Given this context, the comparison between a hospital in Zagreb and one in Yozgat is based on their capacity to implement ERAS protocols within their respective healthcare environments, rather than merely contrasting a capital city with a smaller provincial town. This setup allows us to explore how different healthcare systems adapt and implement medical protocols, providing valuable insights that transcend the simple metrics of city size or country population.

We accepted your suggestion, and we have ensured to emphasize these points more clearly in Discussion Section to enhance understanding of the study’s framework and its implications, as follows:

In evaluating the healthcare environments of Zagreb and Yozgat, it's essential to consider both the relative healthcare capacities and the demographic contexts of each location. Zagreb, the capital of Croatia, has a population of approximately 772,122 within a country of about 4 million people. The city supports 21 state hospitals and 17 private health facilities, reflecting its role as a central healthcare hub in Croatia [15,16]. In contrast, Yozgat, despite being a smaller city in the much larger country of Türkiye, which has a population of around 87.6 million, also maintains a significant healthcare infrastructure. With a local population of approximately 419,095 [15], Yozgat is equipped with 15 medical facilities, including one city hospital, 11 state hospitals, one training and research hospital, and two private hospitals. These demographics and healthcare resources underline the importance of evaluating healthcare practices based on their delivery capabilities rather than merely their geographical or political prominence. By considering the healthcare infrastructure relative to the local population, we can ensure that our comparison of ERAS protocol implementation between a Croatian and a Turkish hospital reflects a comparison of comparable healthcare entities. This approach offers valuable insights into the adaptability and scalability of these protocols across different healthcare systems.

In response to your comment, we have added a detailed paragraph in the Discussion section of our manuscript where we elaborate on the existence of studies conducted between various types of healthcare centers. This discussion underscores how previous research has effectively examined how contextual and institutional differences affect the implementation of healthcare protocols across diverse settings. We have cited relevant studies that have similarly employed comparative analyses between different healthcare systems, including variations in economic status and institutional capabilities. These references support our methodological approach and highlight the potential benefits and insights gained from such comparisons.

By integrating this discussion, we aim to provide a comprehensive understanding of the complexities and challenges involved in implementing ERAS protocols globally, as well as the valuable perspectives these comparisons bring to light.

We believe this addition addresses the concerns you have highlighted and further strengthens the manuscript by providing a broader context to our comparative analysis.

According to your comment, we have implemented the following text in to the Discussion Section:

The feasibility and effectiveness of ERAS protocols across various healthcare contexts have been substantiated by multiple studies, demonstrating significant improvements in perioperative outcomes not only in high-income countries but also in low- and middle-income countries (LMICs). For instance, a systematic review highlighted the successful implementation of ERAS protocols in LMICs, resulting in notable reductions in length of hospital stay despite facing significant barriers to perioperative optimization [26]. Similarly, in another study, the adoption of ERAS in both high and low/middle-income settings has been shown to effectively decrease the length of stay and, to a lesser extent, costs, indicating the adaptability and scalability of ERAS protocols across diverse economic landscapes [27]. Moreover, a study within 50 centers across the Europe observed that the implementation of ERAS varied significantly, with some centers fully integrating these protocols throughout the perioperative period, further supporting the variable yet promising adoption rates across different geographical healthcare settings [28]. These findings collectively underscore the potential of ERAS protocols to transcend geographical and economic barriers, suggesting that the strategic implementation of such protocols could be universally beneficial. This broad applicability affirms the approach taken in our study, where despite differing healthcare infrastructure, comparative analysis provides valuable insights into the impact of systemic and institutional factors on the adoption and efficacy of ERAS protocols.

Additionally, we have included a recommendation for further research in the Limitations subsection as follows: The primary limitation of this research is the inclusion of only one healthcare institution per country, which may limit the generalizability of the findings across different healthcare settings within each nation. As both hospitals in this study are located in urban areas, the findings may not fully reflect ERAS adherence in rural settings, where resource availability, staffing levels, and healthcare infrastructure may differ significantly. Rural hospitals often face additional challenges, such as limited access to specialized training, fewer multidisciplinary teams, and logistical constraints, all of which could impact the successful implementation of ERAS protocols. Future studies should aim to include both urban and rural healthcare settings to provide a more comprehensive assessment of ERAS implementation across diverse hospital environments. This limitation highlights an opportunity for future studies to examine a broader array of institutions, potentially offering a more comprehensive understanding of ERAS protocol implementation across various healthcare environments.

Point-by-point response to Comments and Suggestions for Authors

Comment 1: The abstract does a good job summarizing the study, but it could be even stronger if it were more concise and focused on the most striking findings, such as Croatia's high adherence and Turkey's challenges in preoperative care. Suggestion: Include quantitative information, for example, "In Croatia, 13 recommendations were implemented at a very high level, compared to 8 in Turkey".

Response 1: Accepted. We have revised the Results section of the Abstract, now stating: "In Croatia, 13 recommendations were implemented at a very high level, compared to 8 in Türkiye."

Comment 2: The introduction is well elaborated but could be summarized to identify the importance of cesarean delivery rates in both countries specifically, not just globally. Suggestion: Provide country-specific statistics on cesarean rates for the contextualization of Turkey and Croatia as subjects of focus.

Response 2: Accepted. Thank you for your suggestion to strengthen the introduction by emphasizing country-specific cesarean delivery rates for Croatia and Türkiye. We have incorporated this revision in the Introduction section, as follows:

"Cesarean delivery (CD) rates have been rising globally, with recent data indicating that cesarean sections now account for 21.1% of all births worldwide, expected to rise to 28.5% by 2030. While the United States reported cesarean deliveries representing 31.8% of all births in 2020, the focus of this study, Croatia and Türkiye, also show significant rates. Specifically, Croatia recorded 9,482 cesarean sections in 2022, constituting 28% of total births [1]. Türkiye, on the other hand, noted one of the highest rates globally at 584.2 per 1,000 live births in 2021 [2]. These high rates underscore the critical need for effective ERAS protocols to enhance recovery and reduce complications, motivating our comparative study of their implementation in these varied healthcare environments."

Comment 3: Outcomes are presented very straightforwardly. Still, it would be more helpful to include graphs or charts regarding the differences in the adherence rate across the different recommendations.

Response 3: Thank you for your suggestion. We appreciate the importance of visual representation for clarity. Graph 1 in the Results section already presents a comparison of ERAS protocol adherence levels between Croatia and Türkiye. This graph illustrates the differences in implementation across the 20 ERAS recommendations, as assessed using a five-point scale.

Comment 4: A bar chart comparing the levels of implementation (high, moderate, low) for each recommendation in Croatia and Turkey would further facilitate the readability of the text.

Response 4: Accepted. Thank you for your suggestion to enhance the readability of our manuscript through the inclusion of a bar chart comparing the levels of implementation (high, moderate, low) for each recommendation in Croatia and Turkey.

We have created the suggested bar chart. This graph has been incorporated into the Results section of our manuscript, providing a clear visual representation of the implementation levels across the two countries, as follows:

Graph 1. Categorical comparison of implementation levels of ERAS protocols for cesarean delivery between Croatia and Türkiye.

Graph 1 presents a comparative analysis of the implementation levels of ERAS protocols for cesarean delivery between Croatia and Turkey, categorized as high, moderate, and low. A high implementation level indicates regular application with high consistency and quality, moderate suggests intermittent application with room for improvement, and low reflects rare or non-existent protocol application.

Comment 5: The discussion amply interprets the results but could have gone further to explain how the findings might be used to enhance ERAS adherence in Turkey.

Suggestion: Give more concrete strategies to help overcome resource limitations in Turkey, such as government funding, education programs or reallocation of resources.

Response 5: Accepted. Thank you for your recommendation to provide concrete strategies for enhancing ERAS adherence in Türkiye. In response, we have incorporated the following text into the Discussion Section:

"To enhance ERAS adherence in Türkiye, several strategies could be implemented to overcome existing barriers. First, increased government funding for ERAS training programs and resource allocation could facilitate more widespread implementation, ensuring that hospitals, regardless of their location, have the necessary infrastructure to follow ERAS guidelines. Second, targeted education programs for healthcare professionals, including nurses, anesthesiologists, and obstetricians, could improve understanding and adherence to ERAS protocols. These programs should emphasize the benefits of ERAS, provide standardized training, and include workshops on overcoming logistical challenges. Lastly, reallocation of existing resources within hospitals could be considered, such as optimizing operating room schedules to reduce delays in implementing ERAS protocols, or prioritizing equipment purchases, such as warming devices, that directly impact compliance with ERAS recommendations."

Comment 6: Finally, provide whether Croatia's implementation practices serve as a model for Turkey and the similar group of countries.

Response 6: Thank you for your comment. While our study demonstrates a higher level of ERAS implementation in Croatia compared to Türkiye, we do not position Croatia’s practices as a direct model for Türkiye or other countries. This research was designed as a comparative assessment rather than a prescriptive framework, and no broader cross-country analysis was conducted beyond the two selected hospitals. However, the study identifies key differences in ERAS adherence and highlights potential areas for improvement in Türkiye, which could inform future discussions on best practices in ERAS implementation.

Comment 7: Limitation section is straightforward but lacks in-depth elaboration. For instance, what was the implication on generalisability by having one only a hospital per country?

Suggestion: Present generalisability findings to rural and urban health settings and how the difference in nature impacts compliance to the protocol.

Response 7: Accepted. Thank you for your suggestion to elaborate on the implications of including only one hospital per country and its effect on generalizability. In response, we have expanded the Limitations Subsection as follows:

The primary limitation of this research is the inclusion of only one healthcare institution per country, which may limit the generalizability of the findings across different healthcare settings within each nation. As both hospitals in this study are located in urban areas, the findings may not fully reflect ERAS adherence in rural settings, where resource availability, staffing levels, and healthcare infrastructure may differ significantly. Rural hospitals often face additional challenges, such as limited access to specialized training, fewer multidisciplinary teams, and logistical constraints, all of which could impact the successful implementation of ERAS protocols. Future studies should aim to include both urban and rural healthcare settings to provide a more comprehensive assessment of ERAS implementation across diverse hospital environments. This limitation highlights an opportunity for future studies to examine a broader array of institutions, potentially offering a more comprehensive understanding of ERAS protocol implementation across various healthcare environments.

Comment 8: While human participants are not directly involved in the study, a short statement on ethical compliance for institutional practices and data collection would add strength to the paper.

Response 8: Accepted. Thank you for your suggestion to strengthen the ethical compliance statement regarding institutional practices and data collection. In response, we have expanded the Ethical Guidelines subsection in the Materials and Methods section as follows:

As this study did not involve human participants, no ethical approval or informed consent was required. However, all institutional practices and data collection methods adhered to ethical standards established by the participating hospitals and relevant regulatory bodies. The study was conducted in accordance with institutional policies for quality assessment and research integrity, ensuring transparency and compliance with ethical principles. The data analyzed were drawn from published guidelines and institutional practices, ensuring compliance with all relevant ethical standards for clinical reviews.

Comment 9: The manuscript uses "Turkey" and "Türkiye" interchangeably. It is better to use one of them consistently in the text.

Response 9: Accepted. Thank you for your careful review and suggestion regarding the consistency of the country's name in the manuscript. In response, we have ensured that the term "Turkey" has been consistently replaced with "Türkiye" throughout the text, in accordance with the official spelling change recognized by the United Nations in June 2022.