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Spina bifida disproportionally affects low-and-middle-income countries. We describe myelomeningocele surgical outcomes in Zambia and predictors of postoperative complications and mortality. This 2-center retrospective cohort study includes children who underwent surgical treatment for myelomeningocele in Lusaka, Zambia from 2017 to 2019. Primary outcomes included mortality and 30-day postoperative complications. Seventy-five patients were identified. Median age at first neurosurgical evaluation was 9 days (interquartile range [IQR], 6–21) and at surgery was 21 days (IQR 15–36). Lumbosacral myelomeningocele was most common (73%, n = 54). At first preoperative evaluation, 28% of the neural tube defects were deemed infected (n = 21), and 30% were leaking cerebrospinal fluid (n = 21). Postoperatively, 7% of patients died (n = 5), whereas 31% experienced a complication (n = 23). Most common complications included wound dehiscence (n = 10, 42%) and wound purulence (n = 6, 25%). Median follow-up duration was 41 days (IQR, 6–128). On univariable analysis, mortality was significantly associated with shorter follow-up duration (5 days [IQR, 2–7] vs. 46 days [IQR, 12–132]; P = 0.02) and any complication (P < 0.001). No variable was significantly associated with postoperative complication; however, 2 variables that notably neared significance were preoperative infection of the lesion (P = 0.05) and longer surgical delay (P = 0.06). Most patients born with myelomeningocele in Zambia present for first neurosurgical evaluation after 1 week of age. Preoperative infection of the lesion and postoperative complications are relatively common, and complications are a significant predictor of postoperative mortality. Further investigation into preoperative efforts to mitigate risk of postoperative complications and mortality is warranted. [ABSTRACT FROM AUTHOR]