Abstract
Sub-Saharan Africa has the world's highest under-5 and neonatal mortality rates as well as the highest naturally occurring twin rates. Twin pregnancies carry high risk for children and mothers. Under-5 mortality has declined in sub-Saharan Africa over the last decades. It is unknown whether twins have shared in this reduction. We pooled data from 90 Demographic and Health Surveys for 30 sub-Saharan Africa countries on births reported between 1995 and 2014. We used information on 1 685 110 singleton and 56 597 twin livebirths to compute trends in mortality rates for singletons and twins. We examined whether the twin-singleton rate ratio can be attributed to biological, socioeconomic, care-related factors, or birth size, and estimated the mortality burden among sub-Saharan African twins. Under-5 mortality among twins has declined from 327·7 (95% CI 312·0-343·5) per 1000 livebirths in 1995-2001 to 213·0 (196·7-229·2) in 2009-14. This decline of 35·0% was much less steep than the 50·6% reduction among singletons (from 128·6 [95% CI 126·4-130·8] per 1000 livebirths in 1995-2001 to 63·5 [61·6-65·3] in 2009-14). Twins account for an increasing share of under-5 deaths in sub-Saharan Africa: currently 10·7% of under-5 mortality and 15·1% of neonatal mortality. We estimated that about 315 000 twins (uncertainty interval 289 000-343 000) die in sub-Saharan African each year. Excess twin mortality cannot be explained by common risk factors for under-5 mortality, including birthweight. The difference with singletons was especially stark for neonatal mortality (rate ratio 5·0, 95% CI 4·5-5·6). 51·7% of women pregnant with twins reported receiving medical assistance at birth. The fate of twins in sub-Saharan Africa is lagging behind that of singletons. An alarming one-fifth of twins in the region dies before age 5 years, three times the mortality rate among singletons. Twins account for a substantial and growing share of under-5 and neonatal mortality, but they are largely neglected in the literature. Coordinated action is required to improve the situation of this extremely vulnerable group. None.
Highlights
We examined whether the twin–singleton rate ratio can be attributed to biological, socioeconomic, care-related factors, or birth size, and estimated the mortality burden among subSaharan African twins
Sub-Saharan Africa has the highest rate of naturally occurring twin births in the world.[1]
Whereas natural twinning rates are about six to nine twin births per 1000 maternities in east Asia and Latin America, and eight to 16 in Europe, North America, and the Middle East, they are as high as 18 per 1000 or more in the central African twinning zone that runs from Guinea, Liberia, and Côte d’Ivoire in the west of Africa to Tanzania, Mozambique, and the Comoros in the east.[1]
Summary
Sub-Saharan Africa has the highest rate of naturally occurring twin births in the world.[1]. Twins are extremely vulnerable and twin births and twin pregnancies have a high risk of complications for mother and child. Twin pregnancies and births are associated with obstetric complications such as anaemia, post-partum haemorrhage, hypertensive disorders, and increased maternal mortality.[2,3,4] Under-5 and neonatal mortality rates are two to five times higher than among twins compared with the largest relative differences found in regions with the lowest mortality rates.[5,6,7,8,9,10] For example, in Finland, which has one of the lowest infant mortality rates in the world, infant mortality among multiple births is considerably higher than among singletons (11·1 vs 1·9 deaths per 1000 livebirths in the period 2010–15; Ahokas E, Population Statistics, Statistics Finland, personal communication). Twins suffer more from congenital malformations and could be more vulnerable after the first year of life.[9]
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