Title: Decision to delivery interval for emergency cesarean section and associated factors in
Africa: Systematic review and meta-analysis
Version: 1 Date: 08 Mar 2025
Reviewer's report:
Thank you for the opportunity to review this manuscript, which addresses an important topic in
maternity care. However, the following issues require further attention.
Introduction
Please ensure that all cited references are relevant and adequately support the statement made.
For example, double check whether reference [4] fully supports the statement “The majority of
authorities worldwide have mostly compiled with…”
Page 1 “…enhance the results for mothers and/or babies…” were you referring to maternal and
neonatal outcomes or birth outcomes?
“According to standard guidelines…” ——please add references
“In some clinical scenarios…” These should be more specific
The introduction section is somewhat underdeveloped and needs improvement in coherence and
flow. Please avoid briefly discussing topic X, then switching to topic Y if X and Y are not closely
relevant.
Although the background information on the decision to delivery interval (DDI) is presented,
it lacks logical structure. I recommend authors begin with a clear definition of DDI, followed
by an explanation of its significance. For example, specifying that a duration within 30 mins
could greatly improve maternal and neonatal outcomes, a cut-off point recommended by most
current guidelines. Then, provide prevalence data – highlighting countries that have successfully
achieve this target.
It is also important to justify the focus of DDI in Africa by presenting relevant contextual
information.
Are there any similar studies conducted in this setting?  A brief review of existing studies should
be included to justify the novelty of this study
Why is conducting a systematic review and meta-analysis important? How could findings benefit
the clinical practice? This should be discussed as well.
Methods
If web of science was searched, please included it as one of the databases searched.
Why were Embase and web of science not included (Figure 1)?
How did you choose the search terms for “associated factors”? This should be briefly described
in the manuscript. To avoid missing relevant articles, it would be better to include “factors”
as a search term Instead of “associated factors” or “risk factors”, which could lead to omitting
relevant studies. Additionally, including specific factors as search terms would add value. Please
seek assistance from a professional librarian regarding the search strategies in each database and
how to present them.
If, as stated, grey literature was searched, please specify the relevant databases.
From the search strategies provided in the appendix, it was uncertain if topic terms were used
(e.g. Mesh terms). In a systematic review, studies are typically selected based on the presence
of key terms in the titles and abstracts. Did you restrict the search to titles and abstracts, or did
you also include the full text?
If the heterogeneity was low, was a fixed-effect model used?
How did you define if “substantially heterogeneity” among studies?
The rationale for conducting the sensitivity analysis was not sufficiently accurate. Please seek
assistance from a professional statistician if possible.
Results
The results section should be formatted better
Discussion
Please ensure each statement is supported by relevant references. For example, “To reduce the
DDI…. For emergency cesarean sections”
If the abbreviation has been used in previous sections, there is no need to write it in full in later
text
What are the implications of these findings for clinical practice or future research? These were
not discussed.