Improving Decision-to-Incision Interval (DDI) of Emergency Cesarean Sections Through Mobile-Based Obstetric Emergency System (MORES) and Midwife-Led Triage in Bong County, Liberia: A Quasi-Experimental Study

HaEun Lee (), Sunghae Kim, Joseph Sieka, Wahdae-Mai Harmon-Gray, Philip T. Veliz and Jody R. Lori
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HaEun Lee: School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA
Sunghae Kim: School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA
Joseph Sieka: College of Health Sciences, University of Liberia, Capitol Hill P.O. Box 10-9020, Monrovia 1000, Liberia
Wahdae-Mai Harmon-Gray: College of Health Sciences, University of Liberia, Capitol Hill P.O. Box 10-9020, Monrovia 1000, Liberia
Philip T. Veliz: School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA
Jody R. Lori: School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA

IJERPH, 2025, vol. 22, issue 10, 1-13

Abstract: Background : Delays in emergency cesarean section (CS) remain a major contributor to maternal and neonatal morbidity in low-resource settings. This study evaluated the combined effect of a mobile-based obstetric emergency system (MORES) and a midwife-led triage program on the decision-to-incision interval (DDI) and related outcomes in Liberia. Methods : A quasi-experimental study with an interrupted time series design was conducted in Bong County across two district hospitals receiving referrals from 20 rural health facilities. Seventy-two women referred for emergency CS were observed at baseline, midline, and endline. MORES used WhatsApp-based communication to improve referral coordination, while the triage program trained midwives to rapidly assess cases using a color-coded system. Data were analyzed using descriptive statistics, Wilcoxon rank-sum, chi-squared tests, and logistic regression. Results : By endline, the median DDI decreased by 117.5 min compared to baseline (95% CI: −205.1 to −29.9). Women were significantly more likely to receive a CS within 75 min (AOR: 11.7; 95% CI: 1.32 to 104.5). No maternal deaths occurred. Neonatal mortality was observed but not significantly associated with DDI. Conclusions : MORES and midwife-led triage substantially improved the timeliness of emergency CS in a resource-constrained setting. These low-cost, feasible strategies warrant further evaluation for sustainability and impact on neonatal outcomes.

Keywords: emergency cesarean section; obstetric emergency; decision to incision; referral; midwife-led triage program; sub-Saharan Africa; mhealth (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2025
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