Prevalence and Factors Associated with the Delay in Diagnosis of Anorectal Malformations in Pediatric Surgery Patients Attended Muhimbili National Hospital, 2022–2023

Prevalence and Factors Associated with the Delay in Diagnosis of Anorectal Malformations in Pediatric Surgery Patients Attended Muhimbili National Hospital, 2022–2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and Factors Associated with the Delay in Diagnosis of Anorectal Malformations in Pediatric Surgery Patients Attended Muhimbili National Hospital, 2022–2023 Ruba Ibrahim, Aya Kambal, Rania Hassan, Alaa Bilal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7650819/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Objective: Anorectal malformations (ARMs) are congenital anomalies of the anus, rectum, and often the urinary or reproductive systems. They vary in severity and, if not diagnosed early, can cause serious morbidity and mortality. Despite advances in neonatal care, delayed diagnosis remains common, often due to inadequate perineal examinations or prolonged referral pathways. This study aimed to determine the prevalence of delayed diagnosis and its associated factors among pediatric surgery patients with ARMs at Muhimbili National Hospital, Tanzania. Methods: This retrospective study reviewed medical records of pediatric patients with ARMs admitted between January 2022 and December 2023. A total of 152 patients were included. Data were extracted using structured forms, and statistical analysis identified factors linked with delayed diagnosis. Results: Of 152 patients, 118 (77.6%) had delayed diagnosis, with a mean delay of 46.3 days (median 5.5). Mothers detected most abnormalities (104, 68.4%), while healthcare workers identified 48 (31.6%). Imperforate anus without fistula was the most frequent anomaly (33.6%). By gender, rectovestibular fistula predominated in females (40.2%) and imperforate anus without fistula in males (55.7%). Logistic regression showed that birth in a regional/district hospital significantly reduced the odds of delay (Exp(B) = 0.210, p = 0.018) compared with home births. Conclusion: Delayed diagnosis of ARMs was frequent, with most cases first identified by mothers rather than healthcare workers. Prematurity and place of birth were significantly associated with delay, underscoring the need for vigilant neonatal perineal examinations and stronger referral systems for timely detection and management. Anorectal malformations delayed diagnosis prematurity birthplace associated anomalies Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Introduction The reported incidence of anorectal malformations (ARMs) stands at approximately 1 in 5,000 live births according to Western literature [ 1 ]. However, obtaining accurate birth-incidence data for ARMs in Africa remains challenging due to the lack of formal birth registries, with most estimates relying on hospital-based reports. Among the most reliable population-based data are from South Africa, where the incidence of ARMs was documented at 1.79 per 10,000 live births in the Western Cape region and 3.26 per 10,000 live births on the West Coast [ 2 ]. These figures closely align with global incidence rates. Early diagnosis and timely surgical intervention are key to successful outcomes. Most cases should be identified within the first 24 hours of life; diagnosis beyond this timeframe constitutes delayed diagnosis [ 3 ]. ARMs are usually detected through careful perineal examination, yet some cases remain unrecognized until symptoms such as bilious vomiting or abdominal distension appear. Although routine neonatal examinations are widely recommended, delayed diagnosis of ARMs continues to be a common issue. Delays appear more frequent in female neonates due to fistulas that allow passage of meconium, masking the malformation [ 4 ]. Delayed diagnosis can result in serious complications. When ARMs are not promptly recognized, patients may present with bowel obstruction, chronic constipation, or intestinal perforation. These complications can be life-threatening, with mortality exceeding 50% in cases of perforation, particularly among premature neonates or those with associated anomalies [ 5 ]. Despite the significance of early diagnosis, challenges remain in many low-resource settings, including Tanzania. Limited awareness among healthcare providers, cultural beliefs, inadequate referral networks, and workforce shortages may all contribute to delays. Mothers are often the first to detect abnormalities, even when babies are born in hospitals. Such delays increase morbidity, compromise long-term functional outcomes, and negatively affect psychosocial development. Given these concerns, this study was undertaken to determine the prevalence of delayed diagnosis of ARMs and to identify associated factors among pediatric surgery patients at Muhimbili National Hospital. Methods Study design This was a retrospective descriptive hospital-based cross-sectional study. Study setting The study was conducted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania, between January 2022 and December 2023. MNH, established in 1910 and renamed in 1976, is the largest hospital in the country and serves as both a National Referral Hospital and University Teaching Hospital. It has a capacity of 1,500 beds, attends 1,000–1,200 outpatients per week, and admits 1,000–1,200 inpatients weekly. The pediatric surgery unit provides both inpatient and outpatient care. Study population The study included pediatric surgery patients with anorectal malformations (ARMs) managed at MNH during the study period. Inclusion criteria: Pediatric surgery patients from birth up to 18 years of age. Patients with any type of ARM, classified according to the Krickenbeck classification. Patients admitted between January 2022 and December 2023. Exclusion criteria: Pediatric surgery patients who only attended outpatient clinics. Sample size and sampling technique Based on hospital records, 245 pediatric patients with ARMs were identified during the study period. The sample size was calculated using the formula for finite populations: The sample size was calculated using the formula: n = N / [1 + (N × e²)] Where N = 245 (study population) and e = 0.05 (degree of accuracy). This yielded a sample size of 151.9, approximated to 152 participants. All 245 patient files were retrieved and assigned numbers from 1–245. Using a random number generator, 152 files were selected. Thus, a simple random sampling technique was employed. Data collection Data were collected using a structured survey tool designed in Google Forms. Information was extracted from patient medical records and categorized into three sections: Demographics and diagnosis-related data: sex, time of diagnosis, person who first noticed the ARM, type of ARM. Factors assessed for association with delayed diagnosis: prematurity, place of birth, associated anomalies. Clinical presentation: symptoms, signs, and complications. Data management and analysis Data were exported from Google Forms to Microsoft Excel 365 for cleaning and error checking, and subsequently imported into Statistical Package for the Social Sciences (SPSS, version 23). Descriptive statistics were presented in tables, pie charts, and bar charts. Chi-square test was used to assess associations between categorical variables, with significance set at p < 0.05. Linear regression analysis was used to explore relationships between continuous variables. Ethical considerations Ethical approval was obtained from the University of Medical Sciences and Technology, Faculty of Medicine, and permission was granted by the Muhimbili National Hospital Board. All data were anonymized and assigned serial numbers to prevent identification. Because this was a retrospective study using anonymized records, patient consent was not required. The primary researcher declared no conflicts of interest. Results Prevalence and detection of delayed diagnosis Out of 152 patients, 118 (77.6%) had a delayed diagnosis of ARMs, while 34 (22.4%) were diagnosed within the first 24 hours of life (Table 1 , Fig. 1 ). Mothers detected the malformation in 104 cases (68.4%), compared with 48 cases (31.6%) identified by healthcare workers (Table 4 , Fig. 4 ). The cohort comprised 82 females (53.9%) and 70 males (46.1%) (Table 2 , Fig. 2 ). Table 1 Timing of diagnosis of anorectal malformations (ARMs) (n = 152). Timing of diagnosis n (%) Delay 118 (77.6) No delay 34 (22.4) Total 152 (100.0) Table 2 Distribution of study participants by gender (n = 152). Gender n (%) Female 82 (53.9) Male 70 (46.1) Total 152 (100.0) Table 4 Person who first noticed the anorectal malformation (n = 152). First noticed by n (%) Healthcare worker 48 (31.6) Mother 104 (68.4) Total 152 (100.0) Timing of diagnosis Among the 118 delayed cases, the mean delay was 46.3 days (SD 114.5), with a median of 5.5 days (range: 2–730). The most frequent delay duration was 2 days. The distribution was highly skewed (skewness = 4.34) (Table 3 ). Table 3 Duration of delayed diagnosis among patients with anorectal malformations (n = 118). Statistic Value Mean (days) 46.3 Median (days) 5.5 Mode (days) 2 Standard deviation 114.5 Minimum 2 Maximum 730 Types of ARMs and gender distribution According to the Krickenbeck classification, the most frequent anomaly overall was imperforate anus without fistula (51 cases, 33.6%). In females, the most common anomaly was rectovestibular fistula (33/82, 40.2%), followed by rectovaginal fistula (13/82, 15.9%). In males, imperforate anus without fistula predominated (39/70, 55.7%), followed by rectourethral fistula (10/70, 14.3%) (Table 5 , Table 6 , Figs. 5 – 6 ). Table 5 Types of anorectal malformations according to the Krickenbeck classification (n = 152). ARM type n (%) Imperforate anus without fistula 51 (33.6) Rectovestibular fistula 33 (21.7) Rectovaginal fistula 13 (8.6) Perineal fistula 12 (7.9) Rectourethral fistula 10 (6.6) Rectal atresia 9 (5.9) Perineal fistula: Bucket handle type 7 (4.6) Cloaca 6 (3.9) Rectovesical fistula 6 (3.9) Rectouterine fistula 3 (2.0) Anal stenosis 2 (1.3) Total 152 (100.0) Table 6 Types of anorectal malformations according to the Krickenbeck classification by gender (n = 152). ARM type Female n (%) Male n (%) Total n (%) Rectovestibular fistula 33 (40.2) 0 (0.0) 33 (21.7) Rectovesical fistula 1 (1.2) 5 (7.1) 6 (3.9) Rectovaginal fistula 13 (15.9) 0 (0.0) 13 (8.6) Rectouterine fistula 3 (3.7) 0 (0.0) 3 (2.0) Rectourethral fistula 0 (0.0) 10 (14.3) 10 (6.6) Rectal atresia 7 (8.5) 2 (2.9) 9 (5.9) Perineal fistula: Bucket handle type 0 (0.0) 7 (10.0) 7 (4.6) Perineal fistula 6 (7.3) 6 (8.6) 12 (7.9) Imperforate anus without fistula 12 (14.6) 39 (55.7) 51 (33.6) Cloaca 6 (7.3) 0 (0.0) 6 (3.9) Anal stenosis 1 (1.2) 1 (1.4) 2 (1.3) Total 82 (100) 70 (100) 152 (100) Factors associated with delayed diagnosis Logistic regression analysis revealed that place of birth was significantly associated with delayed diagnosis. Birth in a regional/district hospital reduced the odds of delay by 79% compared with home births (Exp(B) = 0.210, p = 0.018). Neither prematurity (p = 0.367) nor associated anomalies (p = 0.365) were independent predictors of delay. Prematurity Premature infants accounted for 6.6% of the cohort. Cross-tabulation showed a significant association between prematurity and delayed diagnosis (p = 0.03) (Tables 7 – 8 , Fig. 7 ). Table 7 Distribution of premature versus term neonates (n = 152). Prematurity n (%) No 142 (93.4) Yes 10 (6.6) Total 152 (100.0) Table 8 Association between prematurity and timing of diagnosis (n = 152). Prematurity Delay n (%) No delay n (%) Total n (%) Yes 5 (50.0) 5 (50.0) 10 (100) No 113 (79.6) 29 (20.4) 142 (100) Total 118 (77.6) 34 (22.4) 152 (100) p = 0.03. Place of birth Most patients were born in regional/district hospitals (90.8%), followed by tertiary hospitals (7.9%), and home births (1.3%). Place of birth was significantly associated with time of diagnosis (p = 0.005) (Tables 9 – 10 , Figs. 8 – 9 ). Table 9 Place of birth of study participants (n = 152). Place of birth n (%) Home 2 (1.3) Regional/District Hospital 138 (90.8) Tertiary Hospital 12 (7.9) Total 152 (100.0) Table 10 Association between place of birth and timing of diagnosis (n = 152). Place of birth Delay n (%) No delay n (%) Total n (%) Home 1 (50.0) 1 (50.0) 2 (100) Regional/District Hospital 112 (81.2) 26 (18.8) 138 (100) Tertiary Hospital 5 (41.7) 7 (58.3) 12 (100) Total 118 (77.6) 34 (22.4) 152 (100) p = 0.005. Associated anomalies Twenty-seven patients (18.4%) had associated anomalies, most commonly congenital heart defects (3.9%) and Down syndrome (3.3%). There was no statistically significant relationship between anomalies and delayed diagnosis (p = 0.132) (Table 11 , Figs. 10 – 11 ). Table 11 Association between associated anomalies and timing of diagnosis (n = 152). Associated anomalies Delay n (%) No delay n (%) Total n (%) Yes 18 (66.7) 9 (33.3) 27 (100) No 100 (80.0) 25 (20.0) 125 (100) Total 118 (77.6) 34 (22.4) 152 (100) p = 0.132. Signs, symptoms, and complications Among patients with delayed diagnosis, common presenting symptoms included absent anus (42.8%), no passage of meconium (36.8%), abdominal distension (29.6%), and stool via the vagina in females (28.3%). In females, stool via the vagina was the predominant sign (52.4%), while in males absent anus (55.7%) and no passage of meconium (54.3%) were most frequent (Fig. 12 ). Complications were relatively infrequent . The majority of patients (94.1%) had no complications. Among those affected, intestinal obstruction (4.6%) and sepsis (2.0%) were most common; one patient (0.7%) died due to dehydration and sepsis. No significant association was found between delayed diagnosis and complications (p = 0.991) (Table 12 , Fig. 13 ). Table 12 Association between timing of diagnosis and complications (n = 152). Timing of diagnosis No complications n (%) Complications n (%) Total n (%) No delay 32 (94.1) 2 (5.9) 34 (100) Delay 111 (94.1) 7 (5.9) 118 (100) Total 143 (94.1) 9 (5.9) 152 (100) p = 0.991. Discussion Anorectal malformations (ARMs) are prevalent congenital anomalies that are ideally identified during neonatal examination immediately after birth. Delayed diagnosis is not limited to resource-limited regions; even in developed nations, up to 53% of patients may experience delays [ 11 , 12 ]. Prevalence and detection of delayed diagnosis In our cohort, more than three-fourths (77.6%) of patients had delayed diagnosis, a prevalence notably higher than previously reported in the United Kingdom (38%) and Tanzania (58.7%) [ 6 , 7 , 13 ]. This underscores the complexity of diagnosing ARMs, particularly when clinical signs are subtle. Gender disparities were evident: delays were more frequent among females (85%) than males (68%). This aligns with prior research suggesting that the presence of fistulas in females allows partial passage of meconium, masking the anomaly [ 9 ]. Our findings also emphasize the pivotal role of mothers in detecting ARMs, as they identified the majority of cases. This highlights potential gaps in neonatal perineal examination practices by healthcare providers, reinforcing the need for systematic training and vigilance during newborn screening. Types of ARMs and gender-based epidemiology The most frequent anomaly overall was imperforate anus without a fistula. Rectovestibular fistula was the most common ARM in females, while imperforate anus without a fistula predominated in males. These findings are consistent with reports from Kenya [ 15 ], although they differ from some African regions where rectourethral fistula has been reported as the most common anomaly in males [ 14 ]. Such variations may reflect differences in embryological patterns, genetic factors, and healthcare-seeking behavior across populations. Factors contributing to delayed diagnosis Prematurity accounted for only 6.6% of cases in our study, but half of these premature infants experienced delayed diagnosis. While prematurity itself has been linked with ARM risk [ 16 ], its association with diagnostic delay is less clear. Our findings suggest that comorbidities and atypical presentation in preterm infants may obscure timely detection. Place of birth was strongly associated with diagnostic delay. Infants born at regional hospitals experienced more delays than those born at tertiary centers, likely due to limited expertise and longer referral chains. Although only two home births occurred, both had delayed diagnoses. These results align with some reports linking home delivery to delays [ 8 ], but contrast with other studies where hospital deliveries also had high rates of missed diagnoses [ 18 ]. This highlights variability in the quality of neonatal examination across healthcare levels in Africa [ 17 ]. Associated anomalies Associated anomalies were present in 18.4% of patients, most frequently congenital heart defects and Down syndrome. Contrary to expectations, associated anomalies were not significantly linked with delays in diagnosis. While some studies in Australia and Hawaii reported associations [ 6 , 19 ], our findings may reflect heterogeneity of anomalies in this population. Signs, symptoms, and complications Presentation differed by gender: stool via the vagina was the most common symptom in females, whereas absent anus and failure to pass meconium were predominant in males. Complications were infrequent; only 5% of patients experienced intestinal obstruction, sepsis, or death. No significant association was found between delayed diagnosis and complications. This contrasts with studies in Ireland and Ethiopia, where delayed diagnosis contributed to higher morbidity and mortality [ 9 , 10 ]. Conclusion This study highlights a concerningly high prevalence of delayed diagnosis of anorectal malformations (ARMs) at Muhimbili National Hospital, with more than three-fourths of patients diagnosed beyond the neonatal period. Despite routine neonatal examinations, delays remain common, particularly among females, where fistulas can mask anomalies. Mothers were the first to detect most cases, underscoring gaps in healthcare provider recognition during newborn screening. While associated anomalies were not significant predictors, place of birth was strongly associated with delayed diagnosis. These findings emphasize the urgent need to strengthen neonatal examination practices, improve referral systems, and enhance awareness among healthcare providers to reduce diagnostic delays and optimize outcomes for children with ARMs. Implications for Practice and Policy The World Health Organization has long emphasized the importance of addressing congenital anomalies as major contributors to morbidity and mortality in low-resource settings [20]. Healthcare provider training — Targeted education programs for neonatal care teams to ensure thorough perineal examinations and recognition of key ARM signs. Standardized newborn screening protocols — Implementation of uniform protocols for perineal examination at birth across all levels of healthcare facilities. Improved referral networks — Strengthening referral pathways between district/regional hospitals and tertiary centers to reduce delays in specialist evaluation. Parental awareness — Community health education initiatives to empower families, particularly mothers, to recognize early warning signs and seek timely care. Health system investment — Improved access to pediatric surgical expertise and diagnostic resources, especially in lower-level facilities. By addressing these gaps, healthcare systems can reduce diagnostic delays, prevent avoidable complications, and improve long-term outcomes for children affected by ARMs. Declarations Ethics statements Ethics approval: Ethical approval was obtained from the University of Medical Sciences and Technology, Faculty of Medicine, and from the Muhimbili National Hospital Board. Patient consent for publication : Not required, as this study was retrospective and anonymized. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests The authors declare no competing interests. Data availability statement Data are available upon reasonable request from the corresponding author. Acknowledgements The authors would like to thank Dr. Zaitun Bokhary and Dr. Nurdin Swago for their invaluable supervision and guidance. We also acknowledge the support of the UMST Faculty of Medicine and Muhimbili National Hospital in facilitating this research. Finally, we are grateful to our families and colleagues for their continuous encouragement. Author contributions Ruba Ibrahim: Conceptualization, methodology, data curation, formal analysis, and writing original draft. Rania Hassan: Methodology, formal analysis, writing, review and editing, and supervision. Aya Kambal: Data collection, data curation, and writing, review and editing. Alaa Bilal: Data collection, validation, and writing, review and editing. All authors read and approved the final manuscript. References Levitt MA, Peña A. Anorectal malformations. 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Svenningsson A, Gunnarsdottir A, Wester T. Maternal risk factors and perinatal characteristics of anorectal malformations. J Pediatr Surg. 2018;53(11):2183–8. doi:10.1016/j.jpedsurg.2018.05.003 Kunkel M, Marete I, Cheng ER, et al. Place of delivery and perinatal mortality in Kenya. Semin Perinatol. 2019;43(5):252–9. doi:10.1053/j.semperi.2019.04.003 Sinha SK, Kanojia RP, Wakhlu A, et al. Delayed presentation of anorectal malformations. J Indian Assoc Pediatr Surg. 2008;13(2):64–8. doi:10.4103/0971-9261.43023 Kruger P, Teague WJ, Khanal R, Hutson JM, King SK. Screening for associated anomalies in anorectal malformations: the need for a standardized approach. ANZ J Surg. 2019;89(10):1250–2. doi:10.1111/ans.15373 World Health Organization. Services for the prevention and management of genetic disorders and birth defects in developing countries. The Hague: WHO Human Genetics Programme; 1999. Additional Declarations The authors declare no competing interests. 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08:03:28","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85064,"visible":true,"origin":"","legend":"","description":"","filename":"rs76508190structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/fdc38042d8dddc8f3eaea72a.xml"},{"id":91962547,"identity":"e93a80ce-49b0-418a-86d4-a79e26db9628","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98500,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/d3c299d6c2d6ad6da953b29c.html"},{"id":91963348,"identity":"6e50c97e-6b7d-42ac-9e7f-9fce468c9c07","added_by":"auto","created_at":"2025-09-23 08:03:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15144,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTime of diagnosis of anorectal malformations (ARMs) n = (152)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/5d19b8e817321289b009c279.png"},{"id":91962522,"identity":"d9f12533-7acd-4909-9daf-366987ce2e30","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":15864,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eGender distribution of study participants (n=152)\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/bc14a0a1b02ec769e7f3ef04.png"},{"id":91963994,"identity":"a5c04d60-6238-4432-a3d2-cd6250a9b56a","added_by":"auto","created_at":"2025-09-23 08:11:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":18846,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eDistribution of time to diagnosis of anorectal malformations by gender (n=152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/542982d4b8706881b1dc9d57.png"},{"id":91962527,"identity":"816ef172-d8af-41d7-83ce-4dd16b65cd1d","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":17503,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003ePerson who first noticed the anorectal malformation n = (152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/da5e94669255daadc358fb4b.png"},{"id":91963995,"identity":"1f49b2c3-087f-4c84-bba0-94aa1bd5b66d","added_by":"auto","created_at":"2025-09-23 08:11:28","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":19388,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eTypes of anorectal malformations (Krickenbeck classification) n = (152)\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/fb2d490aedab14c050efdc8e.png"},{"id":91962525,"identity":"ce9b23ea-c6ef-49ee-8aa5-c54a14431943","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":20065,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eDistribution of anorectal malformation types by gender n = (152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/6cb8bdced09654f1157e3f05.png"},{"id":91963349,"identity":"3b093a7f-37f7-4f33-b3a2-d5b17d307422","added_by":"auto","created_at":"2025-09-23 08:03:28","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":14277,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eDistribution of premature versus term neonates n = (152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/59c516363c54ac791ac9baca.png"},{"id":91963350,"identity":"37500224-6e09-4ae8-abdb-51d17f1d3d8c","added_by":"auto","created_at":"2025-09-23 08:03:28","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":10172,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003ePlace of birth of study participants n = (152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/9d58de0220cd0545fdf13904.png"},{"id":91963354,"identity":"d9eb9507-4c92-4aea-97d3-f72b205d792e","added_by":"auto","created_at":"2025-09-23 08:03:28","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":10814,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eAssociation between place of birth and timing of diagnosis (n=152)\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/caea130d07dbb604b6fbee1c.png"},{"id":91963996,"identity":"2562fb03-9492-464a-aaf2-2852d69d89e9","added_by":"auto","created_at":"2025-09-23 08:11:28","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":13367,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDistribution of associated anomalies among patients with anorectal malformations n = (152)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/bae44d469bdbb65c8e9c9000.png"},{"id":91962537,"identity":"64296739-8bd6-437a-96ff-87f4bdb7c511","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":16248,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eAssociated anomalies in relation to timing of diagnosis n = (152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/d768971f1f5d4eb332ae54cb.png"},{"id":91962536,"identity":"54ef7a45-e3bd-4b20-a1fb-0d6c47445d50","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":21778,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eSigns and symptoms of anorectal malformations at presentation, stratified by gender n = (152)\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/53f69bc92bb99888b7eac42a.png"},{"id":91962533,"identity":"11b0300e-6131-466f-8f88-4b16c8e359a5","added_by":"auto","created_at":"2025-09-23 07:55:28","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":12636,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cem\u003e\u003cstrong\u003eComplications among patients with anorectal malformations (n=152).\u003c/strong\u003e\u003c/em\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"13.png","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/4062c629d5dc72a5d1ad8655.png"},{"id":91965094,"identity":"73034cb3-561a-471e-ba62-bec96079c8d1","added_by":"auto","created_at":"2025-09-23 08:20:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1599685,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7650819/v1/d2c42e7f-f6c7-4122-80f3-c4253a029624.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003ePrevalence and Factors Associated with the Delay in Diagnosis of Anorectal Malformations in Pediatric Surgery Patients Attended Muhimbili National Hospital, 2022–2023\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe reported incidence of anorectal malformations (ARMs) stands at approximately 1 in 5,000 live births according to Western literature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, obtaining accurate birth-incidence data for ARMs in Africa remains challenging due to the lack of formal birth registries, with most estimates relying on hospital-based reports. Among the most reliable population-based data are from South Africa, where the incidence of ARMs was documented at 1.79 per 10,000 live births in the Western Cape region and 3.26 per 10,000 live births on the West Coast [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These figures closely align with global incidence rates.\u003c/p\u003e\u003cp\u003eEarly diagnosis and timely surgical intervention are key to successful outcomes. Most cases should be identified within the first 24 hours of life; diagnosis beyond this timeframe constitutes delayed diagnosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. ARMs are usually detected through careful perineal examination, yet some cases remain unrecognized until symptoms such as bilious vomiting or abdominal distension appear. Although routine neonatal examinations are widely recommended, delayed diagnosis of ARMs continues to be a common issue. Delays appear more frequent in female neonates due to fistulas that allow passage of meconium, masking the malformation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDelayed diagnosis can result in serious complications. When ARMs are not promptly recognized, patients may present with bowel obstruction, chronic constipation, or intestinal perforation. These complications can be life-threatening, with mortality exceeding 50% in cases of perforation, particularly among premature neonates or those with associated anomalies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the significance of early diagnosis, challenges remain in many low-resource settings, including Tanzania. Limited awareness among healthcare providers, cultural beliefs, inadequate referral networks, and workforce shortages may all contribute to delays. Mothers are often the first to detect abnormalities, even when babies are born in hospitals. Such delays increase morbidity, compromise long-term functional outcomes, and negatively affect psychosocial development.\u003c/p\u003e\u003cp\u003eGiven these concerns, this study was undertaken to determine the prevalence of delayed diagnosis of ARMs and to identify associated factors among pediatric surgery patients at Muhimbili National Hospital.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective descriptive hospital-based cross-sectional study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania, between January 2022 and December 2023. MNH, established in 1910 and renamed in 1976, is the largest hospital in the country and serves as both a National Referral Hospital and University Teaching Hospital. It has a capacity of 1,500 beds, attends 1,000–1,200 outpatients per week, and admits 1,000–1,200 inpatients weekly. The pediatric surgery unit provides both inpatient and outpatient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included pediatric surgery patients with anorectal malformations (ARMs) managed at MNH during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePediatric surgery patients from birth up to 18 years of age.\u003c/li\u003e\n \u003cli\u003ePatients with any type of ARM, classified according to the Krickenbeck classification.\u003c/li\u003e\n \u003cli\u003ePatients admitted between January 2022 and December 2023.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePediatric surgery patients who only attended outpatient clinics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size and sampling technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on hospital records, 245 pediatric patients with ARMs were identified during the study period. The sample size was calculated using the formula for finite populations:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated using the formula:\u003c/p\u003e\n\u003cp\u003en = N / [1 + (N × e²)]\u003c/p\u003e\n\u003cp\u003eWhere N = 245 (study population) and e = 0.05 (degree of accuracy). This yielded a sample size of 151.9, approximated to 152 participants.\u003c/p\u003e\n\u003cp\u003eAll 245 patient files were retrieved and assigned numbers from 1–245. Using a random number generator, 152 files were selected. Thus, a simple random sampling technique was employed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a structured survey tool designed in Google Forms. Information was extracted from patient medical records and categorized into three sections:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDemographics and diagnosis-related data: sex, time of diagnosis, person who first noticed the ARM, type of ARM.\u003c/li\u003e\n \u003cli\u003eFactors assessed for association with delayed diagnosis: prematurity, place of birth, associated anomalies.\u003c/li\u003e\n \u003cli\u003eClinical presentation: symptoms, signs, and complications.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eData management and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were exported from Google Forms to Microsoft Excel 365 for cleaning and error checking, and subsequently imported into Statistical Package for the Social Sciences (SPSS, version 23). Descriptive statistics were presented in tables, pie charts, and bar charts.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eChi-square test was used to assess associations between categorical variables, with significance set at p \u0026lt; 0.05.\u003c/li\u003e\n \u003cli\u003eLinear regression analysis was used to explore relationships between continuous variables.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Medical Sciences and Technology, Faculty of Medicine, and permission was granted by the Muhimbili National Hospital Board. All data were anonymized and assigned serial numbers to prevent identification. Because this was a retrospective study using anonymized records, patient consent was not required. The primary researcher declared no conflicts of interest.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence and detection of delayed diagnosis\u003c/h2\u003e\u003cp\u003eOut of 152 patients, 118 (77.6%) had a delayed diagnosis of ARMs, while 34 (22.4%) were diagnosed within the first 24 hours of life (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mothers detected the malformation in 104 cases (68.4%), compared with 48 cases (31.6%) identified by healthcare workers (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The cohort comprised 82 females (53.9%) and 70 males (46.1%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTiming of diagnosis of anorectal malformations (ARMs) (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTiming of diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e118 (77.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo delay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34 (22.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of study participants by gender (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82 (53.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70 (46.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerson who first noticed the anorectal malformation (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst noticed by\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e48 (31.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e104 (68.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTiming of diagnosis\u003c/h2\u003e\u003cp\u003eAmong the 118 delayed cases, the mean delay was 46.3 days (SD 114.5), with a median of 5.5 days (range: 2\u0026ndash;730). The most frequent delay duration was 2 days. The distribution was highly skewed (skewness\u0026thinsp;=\u0026thinsp;4.34) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDuration of delayed diagnosis among patients with anorectal malformations (n\u0026thinsp;=\u0026thinsp;118).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStatistic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMode (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStandard deviation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e730\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTypes of ARMs and gender distribution\u003c/h2\u003e\u003cp\u003eAccording to the Krickenbeck classification, the most frequent anomaly overall was imperforate anus without fistula (51 cases, 33.6%). In females, the most common anomaly was rectovestibular fistula (33/82, 40.2%), followed by rectovaginal fistula (13/82, 15.9%). In males, imperforate anus without fistula predominated (39/70, 55.7%), followed by rectourethral fistula (10/70, 14.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTypes of anorectal malformations according to the Krickenbeck classification (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eARM type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus without fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51 (33.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectovestibular fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33 (21.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectovaginal fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (8.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerineal fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectourethral fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10 (6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectal atresia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (5.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerineal fistula: Bucket handle type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (4.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCloaca\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectovesical fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectouterine fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnal stenosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (1.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTypes of anorectal malformations according to the Krickenbeck classification by gender (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eARM type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectovestibular fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (40.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (21.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectovesical fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectovaginal fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (8.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectouterine fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectourethral fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectal atresia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (5.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerineal fistula: Bucket handle type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (4.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerineal fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus without fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (55.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51 (33.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCloaca\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnal stenosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with delayed diagnosis\u003c/h2\u003e\u003cp\u003eLogistic regression analysis revealed that place of birth was significantly associated with delayed diagnosis. Birth in a regional/district hospital reduced the odds of delay by 79% compared with home births (Exp(B)\u0026thinsp;=\u0026thinsp;0.210, p\u0026thinsp;=\u0026thinsp;0.018). Neither prematurity (p\u0026thinsp;=\u0026thinsp;0.367) nor associated anomalies (p\u0026thinsp;=\u0026thinsp;0.365) were independent predictors of delay.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePrematurity\u003c/strong\u003e\u003cp\u003ePremature infants accounted for 6.6% of the cohort. Cross-tabulation showed a significant association between prematurity and delayed diagnosis (p\u0026thinsp;=\u0026thinsp;0.03) (Tables\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of premature versus term neonates (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrematurity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e142 (93.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10 (6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between prematurity and timing of diagnosis (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrematurity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDelay n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo delay n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e113 (79.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29 (20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e142 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e118 (77.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34 (22.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ep\u0026thinsp;=\u0026thinsp;0.03.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePlace of birth\u003c/strong\u003e\u003cp\u003eMost patients were born in regional/district hospitals (90.8%), followed by tertiary hospitals (7.9%), and home births (1.3%). Place of birth was significantly associated with time of diagnosis (p\u0026thinsp;=\u0026thinsp;0.005) (Tables\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e, Figs.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePlace of birth of study participants (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlace of birth\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (1.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegional/District Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e138 (90.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between place of birth and timing of diagnosis (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlace of birth\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDelay n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo delay n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegional/District Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e112 (81.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26 (18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e138 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e118 (77.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34 (22.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ep\u0026thinsp;=\u0026thinsp;0.005.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAssociated anomalies\u003c/strong\u003e\u003cp\u003eTwenty-seven patients (18.4%) had associated anomalies, most commonly congenital heart defects (3.9%) and Down syndrome (3.3%). There was no statistically significant relationship between anomalies and delayed diagnosis (p\u0026thinsp;=\u0026thinsp;0.132) (Table\u0026nbsp;\u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e, Figs.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between associated anomalies and timing of diagnosis (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssociated anomalies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDelay n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo delay n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100 (80.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e125 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e118 (77.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34 (22.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ep\u0026thinsp;=\u0026thinsp;0.132.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSigns, symptoms, and complications\u003c/h2\u003e\u003cp\u003eAmong patients with delayed diagnosis, common presenting symptoms included absent anus (42.8%), no passage of meconium (36.8%), abdominal distension (29.6%), and stool via the vagina in females (28.3%). In females, stool via the vagina was the predominant sign (52.4%), while in males absent anus (55.7%) and no passage of meconium (54.3%) were most frequent (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eComplications were relatively infrequent\u003c/b\u003e. The majority of patients (94.1%) had no complications. Among those affected, intestinal obstruction (4.6%) and sepsis (2.0%) were most common; one patient (0.7%) died due to dehydration and sepsis. No significant association was found between delayed diagnosis and complications (p\u0026thinsp;=\u0026thinsp;0.991) (Table\u0026nbsp;\u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e12\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab12\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 12\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between timing of diagnosis and complications (n\u0026thinsp;=\u0026thinsp;152).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTiming of diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo complications n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplications n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo delay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e111 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e118 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e143 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ep\u0026thinsp;=\u0026thinsp;0.991.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAnorectal malformations (ARMs) are prevalent congenital anomalies that are ideally identified during neonatal examination immediately after birth. Delayed diagnosis is not limited to resource-limited regions; even in developed nations, up to 53% of patients may experience delays [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence and detection of delayed diagnosis\u003c/h2\u003e\u003cp\u003eIn our cohort, more than three-fourths (77.6%) of patients had delayed diagnosis, a prevalence notably higher than previously reported in the United Kingdom (38%) and Tanzania (58.7%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This underscores the complexity of diagnosing ARMs, particularly when clinical signs are subtle. Gender disparities were evident: delays were more frequent among females (85%) than males (68%). This aligns with prior research suggesting that the presence of fistulas in females allows partial passage of meconium, masking the anomaly [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our findings also emphasize the pivotal role of mothers in detecting ARMs, as they identified the majority of cases. This highlights potential gaps in neonatal perineal examination practices by healthcare providers, reinforcing the need for systematic training and vigilance during newborn screening.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eTypes of ARMs and gender-based epidemiology\u003c/h2\u003e\u003cp\u003eThe most frequent anomaly overall was imperforate anus without a fistula. Rectovestibular fistula was the most common ARM in females, while imperforate anus without a fistula predominated in males. These findings are consistent with reports from Kenya [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], although they differ from some African regions where rectourethral fistula has been reported as the most common anomaly in males [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Such variations may reflect differences in embryological patterns, genetic factors, and healthcare-seeking behavior across populations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eFactors contributing to delayed diagnosis\u003c/h2\u003e\u003cp\u003ePrematurity accounted for only 6.6% of cases in our study, but half of these premature infants experienced delayed diagnosis. While prematurity itself has been linked with ARM risk [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], its association with diagnostic delay is less clear. Our findings suggest that comorbidities and atypical presentation in preterm infants may obscure timely detection.\u003c/p\u003e\u003cp\u003ePlace of birth was strongly associated with diagnostic delay. Infants born at regional hospitals experienced more delays than those born at tertiary centers, likely due to limited expertise and longer referral chains. Although only two home births occurred, both had delayed diagnoses. These results align with some reports linking home delivery to delays [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but contrast with other studies where hospital deliveries also had high rates of missed diagnoses [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This highlights variability in the quality of neonatal examination across healthcare levels in Africa [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eAssociated anomalies\u003c/h2\u003e\u003cp\u003eAssociated anomalies were present in 18.4% of patients, most frequently congenital heart defects and Down syndrome. Contrary to expectations, associated anomalies were not significantly linked with delays in diagnosis. While some studies in Australia and Hawaii reported associations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], our findings may reflect heterogeneity of anomalies in this population.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eSigns, symptoms, and complications\u003c/h2\u003e\u003cp\u003ePresentation differed by gender: stool via the vagina was the most common symptom in females, whereas absent anus and failure to pass meconium were predominant in males. Complications were infrequent; only 5% of patients experienced intestinal obstruction, sepsis, or death. No significant association was found between delayed diagnosis and complications. This contrasts with studies in Ireland and Ethiopia, where delayed diagnosis contributed to higher morbidity and mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights a concerningly high prevalence of delayed diagnosis of anorectal malformations (ARMs) at Muhimbili National Hospital, with more than three-fourths of patients diagnosed beyond the neonatal period. Despite routine neonatal examinations, delays remain common, particularly among females, where fistulas can mask anomalies. Mothers were the first to detect most cases, underscoring gaps in healthcare provider recognition during newborn screening. While associated anomalies were not significant predictors, place of birth was strongly associated with delayed diagnosis. These findings emphasize the urgent need to strengthen neonatal examination practices, improve referral systems, and enhance awareness among healthcare providers to reduce diagnostic delays and optimize outcomes for children with ARMs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Practice and Policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe World Health Organization has long emphasized the importance of addressing congenital anomalies as major contributors to morbidity and mortality in low-resource settings [20].\u003c/p\u003e\n\u003cp\u003eHealthcare provider training — Targeted education programs for neonatal care teams to ensure thorough perineal examinations and recognition of key ARM signs.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStandardized newborn screening protocols — Implementation of uniform protocols for perineal examination at birth across all levels of healthcare facilities.\u003c/li\u003e\n \u003cli\u003eImproved referral networks — Strengthening referral pathways between district/regional hospitals and tertiary centers to reduce delays in specialist evaluation.\u003c/li\u003e\n \u003cli\u003eParental awareness — Community health education initiatives to empower families, particularly mothers, to recognize early warning signs and seek timely care.\u003c/li\u003e\n \u003cli\u003eHealth system investment — Improved access to pediatric surgical expertise and diagnostic resources, especially in lower-level facilities.\u003c/li\u003e\n \u003cli\u003eBy addressing these gaps, healthcare systems can reduce diagnostic delays, prevent avoidable complications, and improve long-term outcomes for children affected by ARMs.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval: Ethical approval was obtained from the University of Medical Sciences and Technology, Faculty of Medicine, and from the Muhimbili National Hospital Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot required, as this study was retrospective and anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dr. Zaitun Bokhary and Dr. Nurdin Swago for their invaluable supervision and guidance. We also acknowledge the support of the UMST Faculty of Medicine and Muhimbili National Hospital in facilitating this research. Finally, we are grateful to our families and colleagues for their continuous encouragement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRuba Ibrahim: Conceptualization, methodology, data curation, formal analysis, and writing original draft.\u003c/p\u003e\n\u003cp\u003eRania Hassan: Methodology, formal analysis, writing, review and editing, and supervision.\u003c/p\u003e\n\u003cp\u003eAya Kambal: Data collection, data curation, and writing, review and editing.\u003c/p\u003e\n\u003cp\u003eAlaa Bilal: Data collection, validation, and writing, review and editing.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLevitt MA, Pe\u0026ntilde;a A. Anorectal malformations. Orphanet J Rare Dis. 2007;2:33. doi:10.1186/1750-1172-2-33\u003c/li\u003e\n\u003cli\u003eTheron A, Numanoglu A. Birth prevalence of anorectal malformations for the Western Cape Province, South Africa, 2005 to 2012. Eur J Pediatr Surg. 2017;27(5):449\u0026ndash;54. doi:10.1055/s-0036-1597945\u003c/li\u003e\n\u003cli\u003eBolia R, Joshi P. Timely diagnosis of anorectal malformations: a stitch in time saves nine! Indian J Pediatr. 2022;89(6):531\u0026ndash;2. doi:10.1007/s12098-022-04189-x\u003c/li\u003e\n\u003cli\u003eMurthi GVS, McEwan T, Walker GM, et al. Missed or delayed diagnosis of anorectal malformations: a review of the literature, current training and practice in the UK in relation to detection via the NIPE programme. Arch Dis Child Fetal Neonatal Ed. 2024;109(1):4\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eAdejuyigbe O, Abubakar AM, Sowande OA, et al. Experience with anorectal malformations in Ile-Ife, Nigeria. Pediatr Surg Int. 2004;20(11\u0026ndash;12):855\u0026ndash;8. doi:10.1007/s00383-004-1297-1\u003c/li\u003e\n\u003cli\u003eKruger P, Teague WJ, Khanal R, Hutson JM, King SK. Delayed diagnosis of anorectal malformations in neonates. ANZ J Surg. 2019;89(10):1253\u0026ndash;5. doi:10.1111/ans.15374.\u003c/li\u003e\n\u003cli\u003eMfinanga RJ, Massenga A, Mashuda F, Gilyoma JM, Chalya PL. Clinical profile and outcome of surgical management of anorectal malformations at a tertiary care hospital in Tanzania. Tanzan J Health Res. 2018;20(1).\u003c/li\u003e\n\u003cli\u003ePerveen S, Ali S, Jabbar A, Fatima B. Place and person involved in delivery: factors leading to delay in diagnosis of anorectal malformation in newborns. Pak J Med Sci. 2022;38(1):297\u0026ndash;301. doi:10.12669/pjms.38.1.4156\u003c/li\u003e\n\u003cli\u003eTareen F. Delayed diagnosis of anorectal malformation: a persistent problem [Internet]. 2013 [cited 2025 Sep 17]. Available from: http://hdl.handle.net/10147/302402\u003c/li\u003e\n\u003cli\u003eMohammed M, Amezene T, Tamirat M. Intestinal obstruction in early neonatal period: a 3-year review of admitted cases from a tertiary hospital in Ethiopia. Ethiop J Health Sci. 2017;27(4):393\u0026ndash;400. doi:10.4314/ejhs.v27i4.10\u003c/li\u003e\n\u003cli\u003eSharma S, Mazingi D, Imam S, et al. Anorectal malformations in low- and middle-income countries: spectrum, burden and management. Semin Pediatr Surg. 2023;32(6):151349. doi:10.1016/j.sempedsurg.2023.151349\u003c/li\u003e\n\u003cli\u003eTurowski C, Dingemann J, Gillick J. Delayed diagnosis of imperforate anus: an unacceptable morbidity. Pediatr Surg Int. 2010;26(11):1083\u0026ndash;6. doi:10.1007/s00383-010-2691-5\u003c/li\u003e\n\u003cli\u003eMurthi GVS, McEwan T, Walker GM, Bustani P. Missed or delayed diagnosis of anorectal malformations: a review of the literature, training and practice in the UK in relation to detection via the NIPE programme. Arch Dis Child Fetal Neonatal Ed. 2023;109(1):4\u0026ndash;9. doi:10.1136/archdischild-2022-324667\u003c/li\u003e\n\u003cli\u003eGama M, Tadesse A. Management of anorectal malformation: experience from Ethiopia. Ann Afr Surg. 2018;15(1):29\u0026ndash;33. doi:10.4314/aas.v15i1.6\u003c/li\u003e\n\u003cli\u003eKuradusenge P, Kuremu RT, Jumbi G, Saula PW. Pattern of anorectal malformations and early outcomes of management at Moi Teaching and Referral Hospital, Eldoret, Kenya. East Afr Med J. 2014;91(11):430\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eSvenningsson A, Gunnarsdottir A, Wester T. Maternal risk factors and perinatal characteristics of anorectal malformations. J Pediatr Surg. 2018;53(11):2183\u0026ndash;8. doi:10.1016/j.jpedsurg.2018.05.003\u003c/li\u003e\n\u003cli\u003eKunkel M, Marete I, Cheng ER, et al. Place of delivery and perinatal mortality in Kenya. Semin Perinatol. 2019;43(5):252\u0026ndash;9. doi:10.1053/j.semperi.2019.04.003\u003c/li\u003e\n\u003cli\u003eSinha SK, Kanojia RP, Wakhlu A, et al. Delayed presentation of anorectal malformations. J Indian Assoc Pediatr Surg. 2008;13(2):64\u0026ndash;8. doi:10.4103/0971-9261.43023\u003c/li\u003e\n\u003cli\u003eKruger P, Teague WJ, Khanal R, Hutson JM, King SK. Screening for associated anomalies in anorectal malformations: the need for a standardized approach. ANZ J Surg. 2019;89(10):1250\u0026ndash;2. doi:10.1111/ans.15373\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Services for the prevention and management of genetic disorders and birth defects in developing countries. The Hague: WHO Human Genetics Programme; 1999.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Medical Sciences and Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anorectal malformations, delayed diagnosis, prematurity, birthplace, associated anomalies","lastPublishedDoi":"10.21203/rs.3.rs-7650819/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7650819/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Objective:\u003c/h2\u003e\u003cp\u003eAnorectal malformations (ARMs) are congenital anomalies of the anus, rectum, and often the urinary or reproductive systems. They vary in severity and, if not diagnosed early, can cause serious morbidity and mortality. Despite advances in neonatal care, delayed diagnosis remains common, often due to inadequate perineal examinations or prolonged referral pathways. This study aimed to determine the prevalence of delayed diagnosis and its associated factors among pediatric surgery patients with ARMs at Muhimbili National Hospital, Tanzania.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eThis retrospective study reviewed medical records of pediatric patients with ARMs admitted between January 2022 and December 2023. A total of 152 patients were included. Data were extracted using structured forms, and statistical analysis identified factors linked with delayed diagnosis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eOf 152 patients, 118 (77.6%) had delayed diagnosis, with a mean delay of 46.3 days (median 5.5). Mothers detected most abnormalities (104, 68.4%), while healthcare workers identified 48 (31.6%). Imperforate anus without fistula was the most frequent anomaly (33.6%). By gender, rectovestibular fistula predominated in females (40.2%) and imperforate anus without fistula in males (55.7%). Logistic regression showed that birth in a regional/district hospital significantly reduced the odds of delay (Exp(B)\u0026thinsp;=\u0026thinsp;0.210, p\u0026thinsp;=\u0026thinsp;0.018) compared with home births.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eDelayed diagnosis of ARMs was frequent, with most cases first identified by mothers rather than healthcare workers. Prematurity and place of birth were significantly associated with delay, underscoring the need for vigilant neonatal perineal examinations and stronger referral systems for timely detection and management.\u003c/p\u003e","manuscriptTitle":"Prevalence and Factors Associated with the Delay in Diagnosis of Anorectal Malformations in Pediatric Surgery Patients Attended Muhimbili National Hospital, 2022–2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:55:23","doi":"10.21203/rs.3.rs-7650819/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0c9c9b2b-afac-410e-987b-c46867e4b9ea","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-23T07:55:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 07:55:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7650819","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7650819","identity":"rs-7650819","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}