Title: Decision to delivery interval for emergency cesarean section and associated factors in
Africa: Systematic review and meta-analysis
Version: 2 Date: 28 May 2025
Reviewer's report:
Aim:
This systematic review and meta-analysis aims to evaluate the time between the decision to
deliver emergency caesarean section and delivery (DDI) and the factors affecting this time in
the African continent.
Findings:
Delivery rate within 30 minutes in emergency caesarean section: 10.23% (95% CI: 8.34%–
12.12%)
Influencing factors:
Material lead time : AOR = 7.2 (CI: 3.2–16.4)
Surgeon's seniority : AOR = 3.57 (CI: 1.12–11.43)
Type of anesthesia (general vs. spinal) : AOR = 3.23 (CI: 1.07–9.74)
Transfer time (<15 min) : AOR = 4.05 (CI: 1.87–8.74)
Conclusion:
EmCS decision-to-delivery time in Africa lags well behind global guidelines (30 minutes),
highlighting need to improve system
Strengths:
A systematic method was used in accordance with the PRISMA 2020 guide.
PROSPERO registered: CRD42024561310
Comprehensive literature review, including both published and unpublished studies
Quality assessed using Joanna Briggs Institute (JBI) criteria
Meta-analysis:
Heterogeneity is very high : I² = 97.7%
Subgroup analyses: year, country, data type (primary vs. secondary) # but heterogeneity
unresolved
Publication bias: Egger test positive (p=0.000), funnel plot asymmetric
Limitations:
High heterogeneity: differences across studies make combined interpretation difficult
Data quality: many studies were small sample sizes and single-center
No meta-regression performed; lack of deep causality analysis
Clinical Significance:
Completion of DDI within 30 minutes reduces mortality, especially in cases of fetal distress.
In Africa, only 10% of cases have been shown to meet this target # there is a lack of prenatal
emergency services.
The main factors affecting the process are: lack of equipment availability, insufficient staff
(especially inexperienced), type of anesthesia and late arrival to the operating area.
Political and Systemic Recommendations:
A system that can provide 24-hour emergency obstetric care should be established.
Material logistics and drug supply should be accelerated
Intra-hospital transfer processes should be optimized
The number of trained and senior surgeons should be increased
Simulation-based training should be implemented (e.g. color-coded team coordination as in
Denmark)
Strengths:
Large data pool and systematic analysis
Targets a highly clinically significant gap
It makes a concrete contribution to the need for reform of health systems
Subgroup and sensitivity analyses were performed.
Weaknesses:
Very high heterogeneity: 97.7% # limits statistical reliability
Observational studies only: limited causal relationship
Performance and implementation capacity vary from country to country, generalization is risky
Some important variables (e.g. hospital type, ICU capacity, patient characteristics) are omitted
Recommendations for Future Research:
System-based DDI improvement efforts should be undertaken in each country (e.g. transaction
processes, staff accessibility)
RCT-like intervention-based studies (e.g., DDI measurement after simulation training)
Association with long-term maternal and neonatal outcomes should be made
Conclusion
This systematic review and meta-analysis shows that decision-to-delivery time for emergency
caesarean sections in Africa largely lags behind guidelines and is related to multi-faceted
(logistics, personnel, system) reasons. The findings clearly demonstrate the need to strengthen
emergency obstetric care , accelerate in-hospital processes and address the shortage of qualified
personnel .