Early neonatal mortality in twin pregnancy: Findings from 60 low- and middle-income countries

Document Type



Obstetrics and Gynaecology (East Africa)


Background: Around the world, the incidence of multiple pregnancies reaches its peak in the Central African countries and often represents an increased risk of death for women and children because of higher rates of obstetrical complications and poor management skills in those countries. We sought to assess the association between twins and early neonatal mortality compared with singleton pregnancies. We also assessed the role of skilled birth attendant and mode of delivery on early neonatal mortality in twin pregnancies.

Methods: We conducted a secondary analysis of individual level data from 60 nationally-representative Demographic and Health Surveys including 521867 singleton and 14312 twin births. We investigated the occurrence of deaths within the first week of life in twins compared to singletons and the effect of place and attendance at birth; also, the role of caesarean sections against vaginal births was examined, globally and after countries stratification per caesarean sections rates. A multi-level logistic regression was used accounting for homogeneity within country, and homogeneity within twin pairs.

Results: Early neonatal mortality among twins was significantly higher when compared to singleton neonates (adjusted odds ratio (aOR) 7.6; 95% confidence interval (CI)=7.0-8.3) in these 60 countries. Early neonatal mortality was also higher among twins than singletons when adjusting for birth weight in a subgroup analysis of those countries with data on birth weight (n=20; less than 20% of missing values) (aOR=2.8; 95% CI=2.2-3.5). For countries with high rates (>15%) of caesarean sections (CS), twins delivered vaginally in health facility had a statistically significant (aOR=4.8; 95% CI=2.4-9.4) increased risk of early neonatal mortality compared to twins delivered through caesarean sections. Home twin births without SBA was associated with increased mortality compared with delivering at home with SBA (aOR=1.3; 95% CI=1.0-1.8) and with vaginal birth in health facility (aOR=1.7; 95% CI=1.4-2.0).

Conclusions: Institutional deliveries and increased access of caesarian sections may be considered for twin pregnancies in low- and middleincome countries to decrease early adverse neonatal outcomes

Publication (Name of Journal)

Journal of Global Health