Date Published: February 19, 2019
Publisher: Public Library of Science
Author(s): Claudia Hanson, Stephen Munjanja, Agnes Binagwaho, Bellington Vwalika, Andrea B. Pembe, Elsa Jacinto, George K. Chilinda, Kateri B. Donahoe, Sikolia Z. Wanyonyi, Peter Waiswa, Muchabayiwa F. Gidiri, Lenka Benova, Gordon C Smith
Abstract: BackgroundHigh-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe.Methods and findingsWe located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries.ConclusionsDespite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.
Partial Text: Large improvements in child mortality in low- and middle-income settings within the past 25 years have led to greater attention to early life as well as high-risk groups, including multiple gestation pregnancies [1–3]. Pooling data from 30 sub-Saharan African countries, Monden and Smits reported a 5-fold higher neonatal mortality in twins compared to singletons (2009–2014) . Similarly, smaller studies from sub-Saharan Africa reported 3- to 4-fold higher neonatal risk ratios in twins compared to singletons [4–8]. While we lack information from low-income countries, 5-fold higher stillbirth rates are seen in twins compared to singletons in high-income settings [9–11]. Multiple pregnancies are also associated with an increased occurrence of hypertensive disorders, anaemia, and ante- and postpartum bleeding [8,12], resulting in higher rates of potentially life-threatening conditions in mothers of twins compared to mothers of singletons, partially compounded by the fact that twin births are more likely in older mothers .
The 8 Eastern and Southern African countries were selected based on availability of recent DHS data  and collaborators interested in joining the research team to conduct this mixed-methods study.
The reviewed training materials, guidelines, and policies indicated limited guidance in regard to twin or multiple pregnancies in 8 Eastern and Southern African countries: Recommendations to diagnose twin or multiple pregnancies were based on unspecific symptoms, such as aggravated symptoms of pregnancy. None of the countries provided clear guidance on additional care and number of ANC visits. In 7 of the 8 countries, at least 1 document recommended twins to be delivered in a hospital or comprehensive emergency obstetric and neonatal care facility. Only 2 of 5 identified emergency obstetric and neonatal care training materials included a session on management of twin or multiple delivery. The deficits in guidance and advice were mirrored by the observed care received: Twin pregnancies did not receive earlier, meaningfully more frequent, or intensified ANC. Still, women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals; this difference was significant in 5 of the 8 countries. The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% Rwanda. Newborn mortality rate was 4.5 to 6.9 times higher for twins compared to singletons in the 8 countries.