Predictors of prolonged decision-to-delivery interval in emergency caesarean section in Northern Uganda: a historical cohort study

Abstract

Delays in decision-to-delivery interval (DDI) during emergency caesarean section (CS) may increase the risk of adverse maternal and neonatal outcomes. Evidence on health-system and provider-related factors influencing DDI in low-resource settings remains limited. We examined whether surgeon cadre, operating theatre location, and the presence of intern healthcare professionals were associated with prolonged DDI in a tertiary hospital in Northern Uganda. We conducted a historical cohort study at St. Mary’s Hospital Lacor, a tertiary hospital in Northern Uganda, involving women who underwent emergency CS (6 September 2022 to 1 June 2024). Logistic regression was used to examine the association between prolonged DDI (≥60 minutes) and surgeon cadre, operating theatre location, and intern presence, adjusting for confounders. Effect modification by emergency CS indication was assessed. Of the 760 participants enrolled (median DDI was 51 minutes [IQR: 36–67]), 36.0% had prolonged DDI. Emergency CS performed by junior doctors had twice the odds of prolonged DDI compared to fully-licensed doctors (adjusted odds ratio [aOR]: 2.07; 95% CI: 1.38–3.10). Theatre location and presence of interns showed no association with prolonged DDI (aOR: 0.89; 95% CI: 0.61–1.28) and (aOR: 0.71; 95% CI: 0.50–1.02), respectively. There was no statistically significant evidence that these associations differed by the CS indication. Emergency CS performed by junior doctors was associated with increased odds of prolonged DDI compared with procedures performed by fully-licensed doctors. These findings highlight the importance of strengthening supervision, mentorship and emergency obstetric training for junior doctors in resource-limited settings. Operating theatre location and the presence of intern healthcare professionals were not significantly associated with prolonged DDI. Emergency caesarean section (CS) is performed when a pregnant woman or her baby needs urgent delivery to prevent serious complications or death. Delays between the decision to perform the surgery and the actual delivery may increase the risk of poor outcomes for both the mother and baby, especially in low-resource settings. However, little is known about the hospital and healthcare worker factors that may contribute to these delays in Northern Uganda. We conducted a study at St. Mary’s Hospital Lacor, a tertiary hospital in Northern Uganda, involving 760 women who underwent emergency caesarean between September 2022 and June 2024. We examined whether the experience level of the surgeon, the location of the operating theatre, and the presence of intern healthcare professionals were associated with delays in delivery. We found that about one in every three women experienced delays of more than one hour between the decision for surgery and delivery. Emergency CSs performed by junior doctors were more likely to experience delays compared with those performed by fully licensed doctors. In contrast, the location of the operating theatre and the presence of intern healthcare professionals were not associated with delays. These findings suggest that improving supervision, mentorship and emergency obstetric training for junior doctors may help reduce delays in emergency CS delivery. Strengthening surgical training and emergency obstetric care systems may contribute to better maternal and newborn outcomes in resource-limited settings such as Northern Uganda.