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Objective: The objective of the study was to determine the decision to delivery interval and the associated maternal and neonatal outcomes at Thika level five hospital. Design: Ambidirectional study Setting: Secondary Level Hospital in Kenya Subjects: Four hundred and nineteen mothers who underwent emergency caesarean section and their newborns Main outcome measure: Decision to delivery interval, maternal and neonatal outcomes. Results: The median decision to delivery interval was 248 minutes. Only 1% attained the recommended decision to delivery interval of ≤30 minutes. Majority of the participants (40.1%) had a decision to delivery interval above 300 minutes. Six percent of the mothers developed complications among which postpartum haemorrhage accounted for 1.9% (n=8), wound sepsis 0.7% (n=3), ruptured uterus 0.5% (n=2) and maternal deaths recorded were 0.5% (n=2). There was no significant association between DDI and maternal complications. Of the newborn admissions, meconium aspiration syndrome accounted for 17.6%, respiratory distress syndrome 17.6% and birth asphyxia 12.0%. Perinatal deaths recorded were 1.4%, fresh and macerated still births were 2.6% and 1%, respectively. There was a significance association between prolonged DDI and neonatal outcome (p=0.024) Conclusions: Decision to delivery interval at Thika Level Five Hospital was longer than the recommended. There was no significant association between the decision to delivery interval and the maternal complications and prolonged duration of hospital stay. Prolonged decision to delivery interval significantly influenced the neonatal outcome. [ABSTRACT FROM AUTHOR]