🟠 Moderate Evidence
A prospective observational study of 240 emergency laparotomy patients in Lusaka, Zambia has identified where surgical delays occur and which factors most significantly slow access to life-saving abdominal surgery. The research, conducted between April 2024 and April 2025 at a tertiary referral centre, found that patients waited a median of 34 hours from symptom onset to surgery—with the longest delays occurring before patients even sought medical care.
Key takeaways
- The median total delay from symptom onset to emergency laparotomy was 34 hours, with seeking care accounting for 18.5 hours (median)
- Patient beliefs that symptoms would self-resolve and referral from another facility were significant predictors of prolonged delays to initial care-seeking
- In-hospital mortality rate was 11.7% (28 of 240 patients), with delays to receiving care significantly associated with fatal outcomes
Study at a Glance
| Source | BMJ Global Health |
| Study type | Prospective observational cohort study |
| Sample size | N = 240 consecutive emergency laparotomy patients |
| Population | Emergency abdominal surgery patients at a tertiary referral centre |
| Country | Zambia (Lusaka) |
Where Delays Occur in Emergency Laparotomy Access
Median hours at each stage of the Three Delays Model, Lusaka, Zambia
Source: DEL study, BMJ Global Health, 2025 | Georgian Medical Journal News
Patient Beliefs Drive First Delay
The study, published in BMJ Global Health, applied the Three Delays Model—a framework originally developed to measure delays in maternal mortality—to emergency abdominal surgery in a sub-Saharan African setting. The research team collected data from patients or caregivers at a tertiary referral centre in Lusaka between April 2024 and April 2025, documenting the three critical delay phases: seeking care, reaching care, and receiving care.
The median delay to seeking care was 18.5 hours (interquartile range: 2–72 hours), significantly longer than the subsequent phases. On multivariable analysis, two factors independently predicted prolonged first delays: belief that symptoms would resolve without medical intervention, and prior referral from another health facility. This suggests that patients’ understanding of symptom urgency and prior healthcare experiences shape their decision to seek emergency care.
Transportation and Referral Status Compound Second Delay
Once patients decided to seek care, the median time to reach the tertiary centre was 7.5 hours (IQR: 3–29.5 hours). Predictors of prolonged second delay included less urgent surgical indications, lower education status, and referral from another facility. These findings indicate that patients with non-obvious abdominal emergencies, lower health literacy, and those transferred from peripheral facilities face cumulative barriers to rapid access.
The clinical implications are substantial: patients requiring transfer face both transportation delays and the logistical burden of inter-facility coordination, while education level emerges as a measurable social determinant of surgical access—a finding with relevance to health equity initiatives across low-resource settings.
Delays to Operating Theatre Linked to Mortality
The third delay—time from arrival at the tertiary centre to operating theatre—had a median of 8 hours (IQR: 6–11 hours). Among the 240 patients studied, 28 died in hospital, representing an 11.7% in-hospital mortality rate. Delays to receiving care (the third delay) were significantly associated with in-hospital mortality on logistic regression analysis, suggesting that once patients reach the referral centre, minutes and hours matter critically for survival.
The median total delay from symptom onset to emergency laparotomy was 34 hours, with seeking care accounting for 54% of the total delay time and being the longest single phase.
— DEL study team, University of Zambia and Lusaka tertiary centre (BMJ Global Health, 2025)
Implications for Low-Resource Surgery Programs
This research adds quantitative evidence to the growing policy focus on surgical disparities in sub-Saharan Africa. The finding that most delay occurs in the seeking care phase—before patients ever contact a health facility—suggests that awareness campaigns and community-level health education may be as important as improving transport or theatre efficiency.
The association between lower education and prolonged second delay highlights the need for targeted outreach to less-educated populations. The strong association between third-delay duration and mortality underscores the urgency of improving in-hospital processes once patients reach the referral centre, such as streamlined triage, pre-operative optimization, and theatre availability.
What this means
Frequently asked questions
What is the Three Delays Model?
The Three Delays Model was originally developed to measure factors contributing to maternal mortality. It categorizes delay into three phases: (1) seeking care—time from symptom onset to deciding to access healthcare; (2) reaching care—time to arrive at a health facility; and (3) receiving care—time from arrival to receiving the needed intervention. This study applies the model to emergency abdominal surgery, making it relevant to broader surgical emergencies.
Why do patients wait 18 hours before seeking care?
The study found that patients’ beliefs—specifically that symptoms would resolve without treatment—were a significant predictor of prolonged first delays. Cultural beliefs about abdominal pain, limited health literacy, prior poor experiences with healthcare, and lack of awareness of life-threatening conditions likely contribute. Community-level education and engagement with trusted health messengers may reduce this delay.
Can these findings apply beyond Zambia?
Yes, the patterns—especially the dominance of first-delay duration and the mortality association with third delays—are consistent with surgical delay studies from across sub-Saharan Africa and other low-resource settings. However, specific delay times and predictors vary by local context, healthcare infrastructure, geography, and population. Similar prospective studies in other countries would help contextualize these findings.
As surgical care becomes a recognised component of universal health coverage, quantifying where delays occur and which populations experience the longest waits is essential for designing targeted interventions. This Zambian cohort study provides a practical template for identifying delay bottlenecks and measuring progress toward equitable emergency surgical access across low-resource settings.
Source: Identifying delays to emergency laparotomy in a low-resource setting using the Three Delays Model: a prospective observational study (DEL study), BMJ Global Health, 2025
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