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BACKGROUND: The interval between the decision for an emergency cesarean section and the delivery of the fetus should be made within 30 minutes. In a setting like Ethiopia, the recommendation of 30 minutes is unrealistic. Decision to delivery interval should, therefore, be considered as vital in improving perinatal outcomes. This study aimed to assess the decision to delivery interval, its perinatal outcomes, and associated factors. METHODS: A facility-based cross-sectional study was employed, and a consecutive sampling technique was used. Both the questionnaire and the data extraction sheet were used, and data analysis was done using a statistical package for social science version 25 software. Binary logistic regression was used to assess the factors associated with decision to delivery interval. P-value < 0.05 level of significance with a 95% Confidence interval was considered statistically significant. RESULTS: Decision-to-delivery interval below 30 minutes was observed in 21.3% of emergency cesarean sections. Category one (AOR=8.45, 95% CI, 4.66, 15.35), the presence of additional OR table (AOR=3.31, 95% CI, 1.42, 7.70), availability of materials and drugs (AOR=4.08, 95% CI, 1.3, 12.62) and night time (AOR=3.08, 95% CI, 1.04, 9.07) were factors significantly associated. The finding revealed that there was no statistically significant association between prolonged decisions to delivery interval with adverse perinatal outcomes. CONCLUSION: Decision-to-delivery intervals were not achieved within the recommended time interval. The prolonged decision to delivery interval and adverse perinatal outcomes had no significant association. Providers and facilities should be better equipped in advance and ready for a rapid emergency cesarean section. [ABSTRACT FROM AUTHOR]