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Using a cohort of 3767 children with gastrointestinal anomalies in 74 countries (2018\u20132019), we assessed predictors of delay and compare 30-day risk of all-cause mortality (ACM) and complication among children with delayed ($&amp;gt;$24\u00a0hours of life) versus non-delayed ($\\le$24 of life) presentation to primary surgery. Children in low-and middle-income countries (LMICs) had greater probability of delay (PR: 1.79; 95% CI: 1.59, 2.02) and mortality risk for all anomaly types compared to children in high-income countries (HICs). Compared to non-delayed children, delayed children with gastroschisis (RR: 1.62; 1.07, 2.47), omphalocele (RR: 1.17; 0.62, 2.21), intestinal atresia (RR: 1.88; 1.34, 2.63), and esophageal atresia (1.54; 1.15, 2.05) had greater ACM risk. Delayed children with gastroschisis (1.48; 1.25, 1.75) and esophageal atresia (1.17; 1.05, 1.30) had greater complication risk. Probability of delay and risk of death was higher in LMICs than HICs. Compared to non-delayed children, delayed children with gastroschisis, omphalocele, intestinal atresia, and esophageal atresia had greater 30-day ACM risk and delayed children with gastroschisis and esophageal atresia had greater 30-day complication risk.<\/jats:p>","DOI":"10.1093\/aje\/kwaf160","type":"journal-article","created":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T11:51:46Z","timestamp":1753876306000},"page":"3332-3347","source":"Crossref","is-referenced-by-count":4,"title":["Delayed primary surgery and outcomes in children with gastrointestinal anomalies in 264 hospitals and 74 countries"],"prefix":"10.1093","volume":"194","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9870-8271","authenticated-orcid":false,"given":"Kelsey R","family":"Landrum","sequence":"first","affiliation":[{"name":"Gillings School of Global Public Health, Department of Epidemiology, University of North Carolina at Chapel Hill , Chapel Hill, NC 27599 ,","place":["United 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