# 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

## TL;DR

A mobile-based system and midwife-led triage reduced the time to emergency cesarean sections in Liberia, improving maternal and neonatal outcomes.

## Contribution

The study introduces a low-cost, mobile-based system and midwife-led triage to improve emergency cesarean section timing in low-resource settings.

## Key findings

- The median decision-to-incision interval decreased by 117.5 minutes by endline.
- Women were 11.7 times more likely to receive a cesarean section within 75 minutes.
- No maternal deaths were recorded during the study period.

## 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.