Identifying delays to emergency laparotomy in a low-resource setting using the Three Delays Model: a prospective observational study (DEL study)
Joshua Gazzetta, Poster Mutambo, Kelvin Shaba, Cyrus Phiri, Mwamba Mulenga, Mutimba Mpabalwani, Jade Nunez, Chengli Shen, Emmanuel Mwenda Malabo MakasaBackground
Over the last decade, there has been a global emphasis on prioritising disparities in surgical care in low- and middle-income countries. The Three Delays Model, originally developed for maternal mortality, has been increasingly applied to surgical and injury populations, yet few studies have quantified delay predictors for emergency abdominal surgery in sub-Saharan Africa. This study aims to identify where the longest delays in accessing emergency laparotomy are, determine factors associated with delays and identify delays associated with mortality.
Methods
We conducted a prospective observational study of 240 consecutive emergency laparotomy patients at a tertiary referral centre in Lusaka, Zambia (April 2024 to April 2025). Data were collected from patients or caregivers and medical record review by the research team during the postoperative phase of care using a questionnaire. Using the Three Delays Model, variables were collected for each of the following delays: (1) seeking care, (2) reaching care and (3) receiving care. The primary outcome was time spent in each delay. Multivariable linear regression on log₁₀-transformed delay times was used to identify predictors of the first and second delays across the full analytic cohort. Logistic regression assessed delays associated with in-hospital mortality.
Results
Among 240 patients, the median total time from symptom onset to emergency laparotomy was 34 hours. The longest delay occurred in the seeking care phase, with a median of 18.5 hours (IQR: 2–72 hours), followed by reaching care with a median of 7.5 hours (IQR: 3–29.5 hours) and receiving care with a median of 8 hours (IQR: 6–11 hours). On multivariable log10 linear regression, believing symptoms would resolve and being referred from another facility predicted prolonged first delay. Predictors of prolonged second delay included less urgent surgical indication, education status and referral status. There were 28 in-hospital deaths (11.7%). Time in the first delay was associated with mortality (OR 1.01, 95% CI 1.001 to 1.008, p=0.006).
Conclusions
The longest delays to emergency laparotomy in Zambia occurred before patients entered the health system. Symptom misperception and referral from other facilities were the strongest modifiable predictors of delay.