Predictors and Factors Associated With Delayed Primary Cleft Surgery in Bangladesh

Background Delayed primary cleft surgery remains a major challenge in low- and middle-income countries (LMICs), where barriers to timely access coexist with medically necessary postponements. Understanding factors associated with delayed surgery and the relative contribution of presentation-related and medical reasons may help improve comprehensive cleft care. This study aimed to identify predictors of delayed primary cleft surgery, characterize the distribution of reasons for surgical delay, and evaluate factors associated with delayed presentation among patients treated in a comprehensive cleft care program in Bangladesh. Methods A retrospective cohort study was conducted at the National Institute of Burn and Plastic Surgery (NIBPS), Dhaka, Bangladesh. Medical records of patients undergoing primary cleft surgery between January 2016 and December 2020 were reviewed. Of 792 records screened, 424 met the eligibility criteria after exclusion of secondary or revision procedures, syndromic clefts, and incomplete records. Delayed primary surgery was operationally defined as primary cleft lip repair performed after 9 months of age or primary cleft palate repair performed after 18 months of age, according to predefined study criteria. Demographic and clinical variables were analyzed using univariate and multivariable binary logistic regression to identify factors associated with delayed primary surgery. A secondary multivariable analysis evaluated factors associated with operationally defined delayed presentation. Six prespecified predictor variables were included in the multivariable models. Results Among 424 patients, 132 (31.1%) underwent delayed primary cleft surgery. Operationally defined delayed presentation was the most frequently identified reason for delayed surgery, accounting for 70 (53.0%) delayed cases, followed by congenital heart disease (16.7%), anaemia (12.1%), and other causes (18.2%). In multivariable analysis, urban residence was independently associated with lower odds of delayed primary surgery compared with rural residence (adjusted OR 0.642, 95% CI 0.418-0.988; p=0.044), whereas congenital heart disease was associated with higher odds of delayed primary surgery (adjusted OR 2.720, 95% CI 1.424-5.197; p=0.002). For delayed presentation, congenital heart disease was independently associated with lower odds of delayed presentation (adjusted OR 0.205, 95% CI 0.048-0.876; p=0.032). Residence, gender, cleft phenotype, other congenital anomalies, and anaemia were not significantly associated with delayed presentation. Conclusion Nearly one-third of patients experienced delayed primary cleft surgery, with delayed presentation being the most frequent documented contributor. Rural residence and congenital heart disease were independently associated with delayed primary surgery, whereas residence was not independently associated with delayed presentation. Congenital heart disease was independently associated with lower odds of delayed presentation, a finding that should be interpreted cautiously. These findings highlight the need to distinguish potentially preventable access-related delays from medically indicated postponements when planning strategies to improve timely cleft care.