Effect of Decision-to-Delivery Time of Emergency Cesarean Section on Adverse Newborn Outcomes at East Gojjam Zone Public Hospital, Ethiopia, March 2023: Multicenter Prospective Observational Study Design

Figures & data

Figure 1 Schematic presentation of the sampling procedure.

Table 1 Socio-Demographic Characteristics of Study Participants at East Gojjam Zone, Ethiopia, March 2023

Variables	Categories	No	Percent
Hospital	Primary Hospital	42	12.6
	Referral Hospital	292	87.4
Age	<20	9	2.7
	20–24	79	23.7
	25–29	132	39.5
	30–35	86	25.7
	≥35	28	8.4
Marital status	Single	7	2.1
	Married	305	91.3
	Divorced	16	4.8
	Widowed	6	1.8
Level of education	Cannot read and write	62	18.6
	Read and write	30	9.0
	Elementary	67	20.1
	High school	76	22.7
	Preparatory	27	8.1
	Diploma and above	72	21.6
Occupation	House wife	157	47
	Government employee	52	15.5
	Daily labor	18	5.4
	Farmer	72	21.6
	Merchant	33	9.9
	Student	2	0.6
Residence	Urban	225	67.4
	Rural	109	32.6

Table 2 Obstetric Factor of the Study Population at East Gojjam Zone Public Hospital, March 2023

Variables	Categories	No	Percent
Stage of labor	Latent	176	52.7
	Active	108	32.3
	Second	50	14
Working time	Day	233	69.8
	Night	101	30.2
Gravid	Prim gravid	130	38.9
	Multigravida	204	61.1
ANC	Yes	319	95.5
	No	15	4.5
No of ANC contact	One	9	2.8
	Two	58	18.2
	Three	75	23.4
	Four and above	178	55.6
BPCR counseled	Yes	200	59.9
	No	134	40.1
Danger sign	Yes	38	11.4
	No	296	88.6
Type of Danger sign	Vaginal bleeding	18	47.4
	Blurred vision	9	23.7
	Severe headache	4	10.5
	Gush of fluid per vagina	7	18.4
Gestational Age	Term	242	72.4
	Postdate	81	24.3
	Post term	11	3.3
Referred from other facility	Yes	214	64.1
	No	120	35.9
History of emergency CS	Yes	75	22.5
	No	259	77.5
Immediate Consent accepted	Yes	299	89.5
	No	35	10.5

Abbreviations: ANC, Antenatal care; BPCR, birth preparedness complication readiness.

Table 3 Health Professional, Resource, and Procedure-Related Factors at East Gojjam Zone Public Hospital, March 2023

Variables	Categories /Level	No	%
Free functional OR table present while the women arrive OR	Yes	279	83.5
	No	55	16.5
OR material available while the women arrive at OR	Yes	287	85.9
	No	47	14.1
Surgeon	Oby-gyn specialist	78	23.4
	IESO	120	35.9
	MSc in clinical midwifery	47	14.1
	MSc in clinical midwifery student	89	26.7
Anesthetist	MSc holder	24	7.2
	BSc holder	140	41.9
	BSc student	149	44.6
	Level 5 holder	21	6.3
Midwifery	MSc/MPH Holder	28	8.4
	BSc holder	259	77.5
	Level IV holder	47	14.1
Type of anesthesia	Regional	318	95.2
	General	16	4.8
Procedure-related factor
Bladder flap	Yes	99	29.6
	No	235	70.4
Intraoperative difficulty	Yes	31	9.3
	No	303	90.7
Type of difficulty	Adhesions	15	48.4
	Abnormal uterine structure	4	12.9
	Bleeding	5	16.1
	Impacted head	7	22.6
Type of uterine incision	Lower uterine segment	330	98.8
	Others*	4	1.2

Notes:Others*: vertical, inverted T.

Figure 2 Indication of emergency cesarean section at east Gojjam zone public Hospital, Ethiopia 2023.

Table 4 Decision-to-Delivery and Decision to Different Activity Emergency Cesareans Section at East Gojjam Zone Public Hospital

Decision to Different Activity	N (%)	Shapiro–Wilk test	Measure of Summary
Decision to delivery interval			Median (IQR)
≤ 30 minute	73(21.9)	0.00	42(31–55)
31 −75 minute	251(75.1)
>75 minute	10(3)
Decision to OR transfer time (transfer time)		0.00	Median (IQR)
≤ 10 minute	176(52.7)		10 (9–15)
> 10 minute	158(47.3)
OR to skin incision interval time (Anesthesia time)			Median (IQR)
≤ 15 minute	34(10.2)	0.00	26 (18–35)
> 15 minute	300 (89.8)
Skin incision to fetal delivery time		0.001	Median (IQR)
≤ 5 minute	311(93.1)		4 (3–5)
> 5 minute	23 (6.9)
Operation time (skin incision to end of surgery)			Median (IQR)
≤ 24 minute	183(54.8)	0.00	23.5 (19 −27)
> 24 minute	151(45.2)

Abbreviations: IQR, Interquartile range; OR, Operation Room.

Table 5 Factors Cross-Tabulated with the Adverse Birth Outcome at East Gojjam Zone Public Hospital, 2023

Variables	Low Apgar 1st Minute	Low Apgar 5th Minute	NICU Admission	Stillbirth	Newborn Death
	n (%) 123	n (%) 38	n (%) 25	n (%) 4	n (%) 7
Level of Hospital
Primary hospital	12(9.8)	3(7.9)	2(8)	1(25)	0(0)
Comprehensive hospital	111(90.2)	35(92.1)	23(92)	3(75)	7(100)
Residency
Urban	76(61.8)	22(57.9)	14(56)	2(50)	4(57.1)
Rural	47(38.2)	16(42.1)	11(44)	2(50)	3(42.9)
Working time
Day	88(71.5)	25(65.8)	14(56)	3(75)	6(85.7)
Night	35(28.5)	13(34.2)	11(44)	1(25)	1(14.3)
Do you have ANC contact?
Yes	116(94.3)	37(97.4)	24(96)	3(75)	7(100)
No	7(5.7)	1(2.6)	1(4)	1(25)	0(0)
Do you have danger sign during pregnancy?
Yes	21(17.1)	8(21)	4(16)	2(50)	2(28.6)
No	102(82.9)	30(79)	21(84)	2(50)	5(71.4)
Referred from another facility
Yes	95(77.2)	33(86.8)	18(72)	4(100)	5(71.4)
No	28(22.8)	5(13.2)	7(28)	0(0)	2(28.6)
Do you have a previous emergency cesarean section
Yes	12(9.8)	2(5.3)	3(12)	0(0)	1(14.3)
No	111(90.2)	36(94.7)	22(88)	4(100)	6(85.7)
Immediately consent accepted
Yes	101(80.1)	28(73.7)	21(84)	4(100)	5(71.4)
No	22(17.9)	10(26.3)	4(16)	0(0)	2(28.6)
Indication of emergency cesarean section
APH	7(5.7)	2(5.3)	0(0)	1(25)	0(0)
Cord prolapse	4(3.2)	1(2.6)	1(4)	0(0)	0(0)
Obstructed labour	6(4.9)	4(10.5)	2(8)	1(25)	1(14.3)
GIII MSAF	19(15.5)	4(10.5)	4(16)	0(0)	0(0)
NRFHR	65(52.9)	17(44.7)	10(40)	1(0)	2(28.6)
CPD	5(4.1)	1(2.6)	1(4)	0(0)	0(0)
Two and above scar in labor	2(1.6)	0(0)	0(0)	0(0)	0(0)
Others	15(12.2)	9(23.7)	7(28)	1(25)	4(57.1)
Type of anesthesia
Regional	115(93.5)	33(87.8)	24(96)	1(25)	7(100)
General	8(6.5)	5(13.2)	1(4)	3(75)	0(0)
Number of regional anesthesia attempts
One	39(33.9)	7(21.2)	9(37.5)	0(0)	4(57.1)
Two	52(45.2)	16(48.5)	10(41.7)	1(100)	2(28.6)
Three and above	24(20.9)	10(30.3)	5(20.3)	0(0)	1(14.3)
Difficulty during procedure
Yes	8(6.6)	6(15.8)	5(20)	1(25)	2(28.6)
No	114(93.4)	32(84.2)	20(80)	3(75)	5(71.4)
Neonatal weight
<2.5 kg	5(4.1)	1(2.6)	4(16)	1(25)	0(0)
2.5–4.0 kg	116(94.3)	35(92.1)	19(76)	3(75)	5(71.4)
≥4.0 kg	2(1.6)	2(5.3)	2(8)	0(0)	2(28.6)
Fetal sex
Male	76(61.8)	25(65.8)	15(60)	1(25)	6(85.7)
Female	47(38.2)	13(34.2)	10(40)	3(75)	1(14.3)
Transfer time
≤ 10 minute	56(45.5)	17(44.7)	15(60)	2(50)	3(3(42.9))
> 10 minute	67(54.5)	21(55.3)	10(40)	2(50)	4(57.1)
Anesthesia time
<15 minute	10(8.1)	5(13.2)	2(8)	1(25)	2(28.6)
> 15 minute	113(91.9)	33(86.8)	23(92)	3(75)	5(71.4)
Decision-to-delivery time interval
≤ 30 minute	17(13.8)	5(13.2)	5(20)	1(25)	1(14.3)
>30 minute	106(86.2)	33(86.8)	20(80)	3(75)	6(85.7)

Figure 3 Adverse fetal outcome emergency cesarean section at East Gojjam zone Public Hospital, Ethiopia 2023.

Table 6 Factors Associated with Adverse Fetal Outcome at East Gojjam Zone Public Hospital March 2023

Variables	Low 1st Minute Apgar	Low 5th Minute Apgar	NICU Admission
	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Residency	a
Urban		1	1
Rural		1.04(0.5–2.3)	2.2(0.9–5.4)
Do you have danger sign during pregnancy?			a
Yes	2.9(1.1–7.8)*	2.1(0.7–6.1)
No	1
Referred from other facility			a
Yes	2.6(1.5–4.6)*	2.7(0.9–7.6)
No
Immediately consent accepted		a	a
Yes	1
No	2(0.9–4.8)
Indication of emergency cesarean section		a	a
APH	1
Cord prolapse	4.3(0.5–38)
Obstructed labour	2.2(0.4–12)
GIIIMSAF with LFSOL	3.3(0.74–14)
NRFHR	4.2(1.1–17)*
CPD	0.5(0.09 −2.9)
Two and above Cesarean scar in labour	0.2(0.03–1.7)
Others	1.5(0.36–6.6)
Working time	a	a
Day			1
Night			1.6(0.6–3.4)
Type of anesthesia		a	a
Regional	0.5(0.1–2.5)
General	1
Number of regional anesthesia attempts	a		a
One		1
Two		2.3(0.8–6)
Three and above		3.3(0.9–10)
Difficulty during procedure	a	a
Yes			1.9(0.5–7)
No
Neonatal weight	a	a
<2.5 kg			9.8(2.5–37)*
2.5–4.0 kg			1
≤ 4.0 kg			4.2(0.6–27)
Transfer time			a
≤10 minute	1	1
>10 minute	1.3(0.7–2.3)	1.2(0.5–2.6)
Anesthesia time			a
<15 minute	1	1
>15 minute	0.6(0.2–1.7)	0.15(0.03–0.8)*
Decision-to-delivery time interval
≤ 30 minute	1	1	1
>30 minute	2.6(1.1–6)*	3.2(0.6 −16)	0.78(0.3–3)

Notes: Others: failed instrument, failed induction, preeclampsia or eclampsia, previous cesarean scar opted for cesarean, chorioamnitis, malpresentation or malposition, cervical dystocia.a: variables with a COR of p-value >0.25; “*”p-value ≤ 05.

Abbreviations: AOR, adjusted odds ratio; APH, antepartum hemorrhage; CI, confidence interval; CPD, Cephalopelvic disproportion; LFSOL, latent first stage of labor.

Table 7 Table of Binary Logistic Regression Between Decision-to-Delivery Time Interval and Fetal Outcomes

DDI	Adverse fetal outcome		COR(95% CI)	P-value
	First minute Apgar score
	< 7 Apgar	≥ 7 Apgar
≤ 30 minute	17(23.3)	56(76.7)	1
> 30 minute	106(40.6)	155(59.4)	2.3(1.2–4.1)	0.008
	Fifth minute Apgar score
	< 7 Apgar	> Apgar
≤ 30 minute	5(6.9)	68(93.1)	1
> 30 minute	33(12.6)	228(87.4)	1.9(0.7–5.2)	0.082
	NICU admitted
	Yes	No
≤ 30 minute	5(6.9)	68(93.1)	1
> 30 minute	20(7.7)	241(92.3)	1.1(0.4–3)	0.525
	Stillbirth		Did not fulfill the chi-square assumption for regression
	Yes	No
≤ 30 minute	1(1.4)	72(98.6)
> 30 minute	3(1.2)	258(98.8)
	Neonatal death
	Yes	No
≤ 30 minute	1(1.4)	71(98.6)
> 30 minute	6(2.3)	252(97.7)