Multiple births in sub-saharan Africa: epidemiology, postnatal survival, and growth pattern

Routine Antenatal Echocardiography in High-Prevalence Areas of Rheumatic Heart Disease: A WHO-Guideline Systematic Review

Background

Rheumatic Heart Disease (RHD) is the most common cause of valvular heart disease worldwide. Undiagnosed or untreated RHD can complicate pregnancy and lead to poor maternal and fetal outcomes and is a significant factor in non-obstetric morbidity. Echocardiography has an emerging role in screening for RHD. We aimed to critically analyse the evidence on the use of echocardiography for screening pregnant women for RHD in high-prevalence areas.

Methods

We searched MEDLINE and Embase to identify the relevant reports. Two independent reviewers assessed the reports against the eligibility criteria in a double-blind process.

Results

The searches (date: 4 April 2023) identified 432 records for screening. Ten non-controlled observational studies were identified, five using portable or handheld echocardiography, comprising data from 23,166 women. Prevalence of RHD varied across the studies, ranging from 0.4 to 6.6% (I2, heterogeneity >90%). Other cardiac abnormalities (e.g., congenital heart disease and left ventricular systolic dysfunction) were also detected <1% to 2% of cases. Certainty of evidence was very low.

Conclusion

Echocardiography as part of antenatal care in high-prevalence areas may detect RHD or other cardiac abnormalities in asymptomatic pregnant women, potentially reducing the rates of disease progression and adverse labor-associated outcomes. However, this evidence is affected by the low certainty of evidence, and lack of studies comparing echocardiography versus standard antenatal care.

Prospective Registration

PROSPERO 2022 July 4; CRD42022344081 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=344081.

Research question

'In areas with a high prevalence of rheumatic heart disease, should handheld echocardiography be added to routine antenatal care?'

Prevalence and adverse outcomes of twin pregnancy in Eastern Africa: a systematic review and meta-analysis

INTRODUCTION

Multiple pregnancies are much more common today than they were in the past. Twin pregnancies occur in about 4% of pregnancies in Africa. Adverse pregnancy outcome was more common in twin pregnancy than in singleton pregnancy. There is no pooled evidence on the burden and adverse pregnancy outcome of twin pregnancy in eastern Africa. Thus, this systematic review and meta-analysis were conducted to assess the prevalence and adverse pregnancy outcomes of twin pregnancies.

METHODS

This systematic review and meta-analysis covers published and unpublished studies searched from different databases (PubMed, CINAHL (EBSCO), EMBASE, DOAJ, Web of Sciences, MEDLINE, Cochrane Library, SCOPUS, Google Scholar, and Google search). Finally, 34 studies were included in this systematic review and meta-analysis. JBI checklist was used to assess the quality of included papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Data synthesis and statistical analysis were conducted using STATA Version 14 software. Heterogeneity and publication bias were assessed. A forest plot was used to present the pooled prevalence using the random effect model.

RESULTS

The prevalence of twin pregnancy in eastern Africa was 3% [95% CI: 2, 3]. The adverse pregnancy outcomes like neonatal intensive care unit admission (78%), low birth weight (44%), low APGAR score (33%), prematurity (32%), stillbirth (30%), neonatal mortality (12%) and maternal complications like hypertensive disorder of pregnancy (25%), postpartum hemorrhage (7%), Cesarean section (37%), premature rupture of membrane (12%) and maternal mortality are more common among twin pregnancy than singleton pregnancy.

CONCLUSION

One in every 33 children born a twin in east Africa; admission to neonatal intensive care unit, low birth weight, low APGAR score, prematurity, stillbirth, neonatal mortality and maternal complications are its associated adverse birth outcomes. Since twin pregnancy is a high-risk pregnancy, special care is needed during pregnancy, labor and delivery to reduce adverse pregnancy outcomes.

Caesarean section and childhood obesity at age 3 years derived from the Japan Environment and Children's Study

Caesarean section (CS) birth is widely reported to be a risk factor for childhood obesity. Although susceptibility to childhood obesity is influenced by race and ethnicity, it is unclear whether this risk of childhood obesity with CS birth also applies in the Japanese population. We investigated the impact of CS birth on obesity at 3 years of age in Japanese children. We obtained data from 60,769 mother-toddler pairs in the Japan Environment and Children's Study, a large-scale birth cohort study. Obesity was determined by body mass index measured at 3 years of age. Analysis revealed that 11,241 toddlers (18.5%) had a CS birth and that 4912 toddlers (8.1%) were obese. The adjusted risk ratio for obesity at 3 years of age when born by CS compared with vaginal delivery, estimated using inverse probability of treatment weighting, was 1.16 (95% confidence interval 1.08-1.25). These results suggest that CS birth modestly increases the risk of obesity at 3 years of age in Japanese children.

Perinatal outcome of twin pregnancies among mothers who gave birth in Adama Hospital Medical College, Central Ethiopia

Introduction

Twin pregnancy carries a high risk of pregnancy-related complications including adverse perinatal outcomes. Although evidence from international studies indicated an increased risk of adverse perinatal outcomes in twin pregnancies, little is known about the adverse perinatal outcomes in twin pregnancies and associated factors in Ethiopia. The purpose of this study was, therefore, to estimate the incidence of twin pregnancies and related-adverse perinatal outcomes and identify factors associated with adverse perinatal outcomes in twin pregnancies in Ethiopia.

Methods

A hospital-based retrospective cross-sectional study was conducted among 322 mothers who gave twin birth at Adama Hospital Medical College between 08 July 2015 and 07 June 2017. In this study, the adverse perinatal outcome was defined as the presence of any of the following main conditions: low birth weight, preterm birth, stillbirth, low Apgar Scores, mal-presentation, Admission to neonatal Intensive Care Unit (NICU), and early neonatal deaths. The data were analyzed using SPSS version 20.0. Multivariable logistic regression was conducted to identify factors associated with adverse perinatal outcome at 95% CI or P-value of less than 0.05.

Result

Of 10,850 births recorded in the hospital, 354 births were twins and 322 of these paired records had complete perinatal information. One hundred ninety-nine (61.8%) of the 322 paired birth records had at least one adverse perinatal outcome on one or both twins. Low birth weight was the most common perinatal outcome followed by preterm birth. After adjusting for confounding factors, younger maternal age (AOR = 4.1, 95% CI; 1.3, 12.5) and not having ultrasound scan during antenatal care (AOR = 2.0, 95% CI: 1.2, 3.1) were significantly associated with adverse perinatal outcomes.

Conclusion

The incidence of adverse perinatal outcome in twin pregnancies was high, that is, in 61.8% of twin births, there was at least one adverse perinatal outcome on one or both twins. Moreover, younger maternal age at birth and not having an ultrasound scan during antenatal care were found to be strong predictors for the observed high incidence of adverse perinatal outcomes.

Twin reversed arterial perfusion (TRAP) sequence: A case report and a brief literature review

Twin reversed arterial perfusion (TRAP) sequence is rare in monochorionic twin pregnancies. TRAP sequence is distinct from other multifetal pregnancies in that one of the twins has normal anatomy while the other twin has a varied amount of characteristic abnormal features. In the literature, mortality is reported 100% in the abnormal twin. We report 1 case of TRAP sequence at our institution in which the diagnosis of TRAP sequence was missed in the first trimester at another hospital. The patient, a 33-year-old G1P0A0, did not have any follow-up after her first scan until the routine second-trimester ultrasound at our institution. Both the radiologist and the sonographer did not appreciate the differential diagnosis of TRAP sequence in their clinical decision-making. The TRAP diagnosis was established after the ultrasound performed at the fetal assessment unit in our hospital. Radiofrequency ablation (RFA) procedure was performed to give the normal twin a chance to survive, but unfortunately, the prognosis was poor in this case. We conclude that diagnosing a TRAP sequence is very important early in the pregnancy for a positive outcome in the normal twin. A robust collaboration among radiologists and obstetricians is vital for the best outcome of the normal twin.

Trends and Determinants of Underweight among Children under Five Years in Ethiopia: Further Analysis with Ethiopian Demographic and Health Survey 2005-2016-Multivariate Decomposition Analysis

Background

Underweight is one of the paramount major worldwide health problems, and it traces a big number of populations from infancy to old age. This study aimed to analyze the trends and predictors of change in underweight among children under five years in Ethiopia.

Method

The data for this study were accessed from three Ethiopian Demographic and Health Survey data sets 2005, 2011, and 2016. The trend was examined separately for the periods 2005–2011, 2005–2016, and 2011–2016. Multivariate decomposition analysis of change in underweight was employed to answer the major research question of this study. The technique employed the output from the logistic regression model to parcel out the observed difference in underweight into components, and STATA 14 was utilized for data management and analysis.

Result

Perceiving the overall trend, the rate of underweight was decreased from 38% in 2005 to 24% in 2016. The decomposition analysis results revealed that, about 12.60% of declines in underweight have been explained by the difference in population characteristics or endowments (E) over the study period. The size of the child at birth, husband's education, women's education, and household wealth index contributed significantly to the compositional decline in underweight.

Conclusion

The magnitude of underweight among children under five years indicates a remarkable decline over the last ten years in Ethiopia. In this study, two-twelfth of the overall decrease in underweight among children under five years over the decade was due to the difference in characteristics between 2005 and 2016. Continuing to educate the population and boost the population's economy is needed on the government side in Ethiopia.

Decomposition of factors associated with housing material inequality in under-five deaths in low and middle-income countries

Background

Low-and Medium-Income Countries (LMIC) continue to record a high burden of under-five deaths (U5D). There is a gap in knowledge of the factors contributing to housing materials inequalities in U5D. This study examined the contributions of the individual- and neighbourhood-level factors to housing materials inequalities in influencing U5D in LMIC.

Methods

We pooled data from the most recent Demographic and Health Surveys for 56 LMIC conducted between 2010 and 2018. In all, we analysed the data of 798,796 children living in 59,791 neighbourhoods. The outcome variable was U5D among live births within 0 to 59 months of birth. The main determinate variable was housing material types, categorised as unimproved housing materials (UHM) and improved housing materials (IHM) while the individual-level and neighbourhood-level factors are the independent variables. Data were analysed using the Fairlie decomposition analysis at α = 0.05.

Results

The overall U5D rate was 53 per 1000 children, 61 among children from houses built with UHM, and 41 among children from houses built with IHM (p < 0.001). This rate was higher among children from houses that were built with UHM in all countries except Malawi, Zambia, Lesotho, Gambia, Liberia, Sierra Leone, Indonesia, Maldives, Jordan, and Albania. None of these countries had significant pro-IHM inequality. The factors explaining housing inequalities in U5D include household wealth status, residence location, source of drinking water, media access, paternal employment, birth interval, and toilet type.

Conclusions

There are variations in individual- and neighbourhood-level factors driving housing materials inequalities as it influences U5D in LMIC. Interventions focusing on reducing the burden of U5D in households built with UHM are urgently needed.

Twinning rates in Chennai, India – A cross-sectional study

Context:

Aims:

Settings and Design:

Satistical Analysis Used:

Results:

Conclusions:

Outcomes in intervention and management of multiple pregnancies trials: A systematic review

OBJECTIVES

Twin pregnancy has risks of adverse outcomes for mother and baby. Data synthesis is required to gain evidence to aid recommendations but may be hampered by variations in outcome reporting.

STUDY DESIGN

Systematically review outcomes reported in twin pregnancy trials (PROSPERO - CRD42019133805). Searches were performed in MEDLINE, EMBASE, CINHAL, Cochrane library (inception-January 2019) for randomised control trials or their follow-up studies reporting prediction, prognosis, intervention or management outcomes in twin pregnancy. The study characteristics, outcomes definitions and measurements were extracted and descriptively analysed.

RESULTS

49 RCTs and 8 follow-up studies evaluated 21 interventions, 1257 outcomes, categorised into 170 unique outcomes. 65 % of trials included all twin pregnancies, 12 % DCDA and 11 % MCDA only or MCMA and MCDA. Five (9 %) papers were prediction/ prognosis RCT's and 52 (91 %) related to an intervention. Of interventions, 40 (77 %) were medical, 34 (85 %) for preterm birth; 12 (23 %) surgical, 6 (50 %) related to TTTS interventions (83 % for monochrorionic studies). Commonest domains were: 'Neonatal' 77 %, 'Delivery' 70 % and 'Survival' 67 %. Least reported were longer term outcomes for 'Infant' or 'Parental'.

CONCLUSIONS

Twin pregnancy outcomes are diverse and complex. This is related to the need to address maternal, single and double fetal outcomes and different types of chorionicity. The lack of outcome standardisation in selection, definition and reporting hinders evidence synthesis and the selection of outcomes important to women and health care professionals thus limiting the effectiveness of research.

Pregnancy outcomes at Mizan-Tepi University Teaching Hospital: A Comparison to the Ethiopian Demographic and Health Surveys

Background:

To compare outcomes at Mizan-Tepi University Teaching Hospital to national and regional data and to plan quality improvement and research studies based on the results.

Methods:

This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women who delivered at Mizan-Tepi University Teaching Hospital.

Results:

Our convenience sample was young (median age 24 years) with a primarily school level or less of education (68.6%). Only about 5% of women had a history of prior cesarean birth, 2.1% reported they were human immunodeficiency virus seropositive, and the median number of prenatal visits was four. Women were commonly admitted in spontaneous labor (84.5%), transferred from another facility (49.2%; 96.8% of which were referred from a health center), and had their fetal heart rate auscultated on admission (94.7%). Only 5.2% of women did not deliver within twenty-four hours and the cesarean birth prevalence was 23.4%. Many women were delivered by midwives (73.2%; all unassisted vaginal births), 89.2% were term deliveries, and 92.5% of neonatal birthweights were 2500 grams or heavier. Less than five percent of women delivered stillbirths (4.3%) and 5.7% of livebirths experienced neonatal death by the day of discharge. There were no maternal deaths in the cohort.

Conclusion:

The prevalence of stillbirth and neonatal death were the most notable findings, while there was no maternal death in the cohort.

Gestational Weight Gain and Its Effects on Maternal and Neonatal Outcome in Women With Twin Pregnancies: A Systematic Review and Meta-Analysis

Background: The incidence of twin pregnancies has risen recently. Such pregnancies are associated with an increased risk for poor maternal and infant outcomes. Gestational weight gain, particularly in singleton pregnancies, has been well-linked with maternal and infant outcomes. The aim of the current meta-analysis was to evaluate the effects of gestational weight gain on maternal and fetal outcomes in women with twin pregnancies. Methods: A systematic search was conducted using the PubMed, Scopus, and Google Scholar databases. Studies, either retrospective or prospective in design, evaluating the effects of gestational weight gain (defined using Institute of Medicine (IOM) guidelines) maternal and/or fetal/neonatal outcomes in women with twin pregnancies were included. Statistical analysis was performed using STATA software. Results: Eleven studies were included in the meta-analysis. Mothers with inadequate weight gain had increased risk for gestational diabetes mellitus (OR 1.19; 95% CI: 1.01, 1.40) and decreased risk for gestational hypertension (OR 0.58; 95% CI: 0.49, 0.68) and cesarean section (OR 0.94; 95% CI: 0.93, 0.96). Neonates born to mothers with inadequate weight gain were susceptible to increased risk for preterm delivery (OR 1.17; 95% CI: 1.03, 1.34), very preterm delivery (gestational age <32 weeks) (OR 1.84; 95% CI: 1.36, 2.48), small for gestational age status (OR 1.41; 95% CI: 1.15, 1.72), low birth weight status (<2,500 g) (OR 1.27; 95% CI: 1.17, 1.38), and neonatal intensive care unit (NICU) admission (OR 1.16; 95% CI: 1.08, 1.24). The pooled findings indicate an increased risk for gestational hypertension (OR 1.82; 95% CI: 1.60, 2.06) and cesarean section (OR 1.07; 95% CI: 1.05, 1.08) among mothers with excessive weight gain. Neonates born to mothers with excessive weight gain were susceptible to increased risk for preterm delivery and very preterm delivery, but were associated with a decreased risk for low birth weight status and small for gestational age status. Conclusions: Gestational weight gain in twin pregnancy, either lower or higher than IOM recommended guidelines, is associated with poor maternal and neonatal outcomes. Our findings call for incorporating counseling on optimal weight gain during pregnancy as part of routine antenatal visits.

Association Between Mothers' Problematic Internet Use and the Thinness of Their Children

This study aimed to clarify the association between mothers' problematic Internet use (PIU) and the thinness of their children. We analyzed data collected from health examinations of young children aged 4 months, 1.5 years, and 3 years of age performed in Matsue city, Japan, between April 2016 and March 2017. The subjects comprised 1,685 (866 boys, 819 girls) children aged 4 months, 1,728 (898 boys, 830 girls) aged 1.5 years, and 1,672 (802 boys, 870 girls) aged 3 years. Logistic regression analysis was used to clarify the association between mothers' PIU (Young's Diagnostic Questionnaire for Internet Addiction score: ≥4) and the thinness (body mass index: <15) of their children after adjusting for covariates such as birth weight, nutritional form, parental smoking status, maternal age, skipping breakfast, eating snacks, sleeping late, outdoor play, and daytime caregiver. Analysis after stratification by sex and age revealed that the mothers' PIU was significantly associated with their children's thinness only in boys aged 4 months or 1.5 years (odds ratio [OR] = 3.16, 95% confidence interval [CI] = 1.00-9.96 and OR = 2.68, 95% CI = 1.04-6.89, respectively). Mothers' PIU may promote thinness among boys aged <3 years. As the nutritional status of children aged <3 years is affected by maternal feeding attitudes, our findings suggested that mothers who exhibit PIU do not provide adequate care for their children, particularly regarding feeding. In contrast, no association between mothers' PIU and their children's thinness was observed in girls.

Demographic Seasonality

The seasonality of demographic data has been of great interest. It depends mainly on the climatic conditions, and the findings may vary from study to study. Commonly, the studies are based on monthly data. The population at risk plays a central role. For births or deaths over short periods, the population at risk is proportional to the lengths of the months. Hence, one must analyze the number of births (and deaths) per day. If one studies the seasonality of multiple maternities, the population at risk is the total monthly number of confinements and the number of multiple maternities in a given month must be compared with the monthly number of all maternities. Consequently, when one considers the monthly rates of multiple maternities, the monthly number of births is eliminated and one obtains an unaffected seasonality measure of the rates. In general, comparisons between the seasonality of different data sets presuppose standardization of the data to indices with common means, mainly 100. If one assumes seasonality as 'non-flatness' throughout a year, a chi-squared test would be an option, but this test calculates only the heterogeneity and the same test statistic can be obtained for data sets with extreme values occurring in consecutive months or in separate months. Hence, chi-squared tests for seasonality are weak because of this arbitrariness and cannot be considered a model test. When seasonal models are applied, one must pay special attention to how well the applied model fits the data. If the goodness of fit is poor, nonsignificant models obtained can erroneously lead to statements that the seasonality is slight, although the observed seasonal fluctuations are marked. In this study, we investigate how the application of seasonal models can be applied to different demographic variables.

Clinical Application of Epilepsy Genetics in Africa: Is Now the Time?

Over 80% of people with epilepsy live in low- to middle-income countries where epilepsy is often undiagnosed and untreated due to limited resources and poor infrastructure. In Africa, the burden of epilepsy is exacerbated by increased risk factors such as central nervous system infections, perinatal insults, and traumatic brain injury. Despite the high incidence of these etiologies, the cause of epilepsy in over 60% of African children is unknown, suggesting a possible genetic origin. Large-scale genetic and genomic research in Europe and North America has revealed new genes and variants underlying disease in a range of epilepsy phenotypes. The relevance of this knowledge to patient care is especially evident among infants with early-onset epilepsies, where early genetic testing can confirm the diagnosis and direct treatment, potentially improving prognosis and quality of life. In Africa, however, genetic epilepsies are among the most under-investigated neurological disorders, and little knowledge currently exists on the genetics of epilepsy among African patients. The increased diversity on the continent may yield unique, important epilepsy-associated genotypes, currently absent from the North American or European diagnostic testing protocols. In this review, we propose that there is strong justification for developing the capacity to offer genetic testing for children with epilepsy in Africa, informed mostly by the existing counseling and interventional needs. Initial simple protocols involving well-recognized epilepsy genes will not only help patients but will give rise to further clinically relevant research, thus increasing knowledge and capacity.

Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: a pooled analysis of data from 90 Demographic and Health Surveys in 30 countries

BACKGROUND

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.

METHODS

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.

FINDINGS

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.

INTERPRETATION

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.

FUNDING

None.

Differential effects of young maternal age on child growth

BACKGROUND

The association of early maternal birthing age with smaller children has been widely observed. However, it is unclear if this is due to confounding by factors such as socioeconomic status, or the age at which child growth restriction first occurs.

OBJECTIVE

To examine the effect of early maternal birthing age on the first-born child's height-for-age in a sample of developing countries in Africa, Asia, and Latin America.

DESIGN

Cross-sectional data from Demographic Health Surveys from 18 countries were used, to select the first-born child of mothers aged 15-24 years and a range of potential confounding factors, including maternal height. Child length/height-for-age z-scores (HAZs) was estimated in age bands of 0-11, 12-23, 24-35, 36-47, and 48-59 months; HAZ was first compared between maternal age groups of 15-17, 18-19, and 20-24 years.

RESULTS

1) There were significant bivariate associations between low child HAZ and young maternal age (71 of 180 possible cases; at p<0.10), but the majority of these did not persist when controlling for confounders (41 cases, 23% of the 180). 2) For children <12 months, when controlling for confounders, three out of seven Asian countries showed a significant association between lower infant HAZ and low maternal age, as did six out of nine African countries (15-17 or 15-19 years vs. the older group). 3) The association (adjusted) continued after 24 months in 12 of the 18 countries, in Africa, Asia, and Latin America. 4) The stunting differences for children between maternal age groups were around 9 percentage points (ppts) in Asia, 14 ppts in Africa, and 10 ppts in Latin America. These data do not show whether this is due to, for example, socioeconomic factors that were not included, an emerging effect of intrauterine growth restriction, or the child feeding or caring behaviors of young mothers. The latter is considered to be the most likely.

CONCLUSIONS

The effect of low maternal age on child height restriction from 0 to 11 months occurred in half the countries studied after adjusting for confounders. Poorer growth continuing after 24 months in children of younger mothers was observed in all regions, but needs further research to determine the causes. The effects were about double (in stunting prevalence terms) in Africa, where there was an increase in 10 ppts in stunting for children of young mothers.

The large contribution of twins to neonatal and post-neonatal mortality in The Gambia, a 5-year prospective study

BACKGROUND

A high twinning rate and an increased risk of mortality among twins contribute to the high burden of infant mortality in Africa. This study examined the contribution of twins to neonatal and post-neonatal mortality in The Gambia, and evaluated factors that contribute to the excess mortality among twins.

METHODS

We analysed data from the Basse Health and Demographic Surveillance System (BHDSS) collected from January 2009 to December 2013. Demographic and epidemiological variables were assessed for their association with mortality in different age groups.

RESULTS

We included 32,436 singletons and 1083 twins in the analysis (twining rate 16.7/1000 deliveries). Twins represented 11.8 % of all neonatal deaths and 7.8 % of post-neonatal deaths. Mortality among twins was higher than in singletons [adjusted odds ratio (AOR) 4.33 (95 % CI: 3.09, 6.06) in the neonatal period and 2.61 (95 % CI: 1.85, 3.68) in the post-neonatal period]. Post-neonatal mortality among twins increased in girls (P for interaction = 0.064), being born during the dry season (P for interaction = 0.030) and lacking access to clean water (P for interaction = 0.042).

CONCLUSION

Mortality among twins makes a significant contribution to the high burden of neonatal and post-neonatal mortality in The Gambia and preventive interventions targeting twins should be prioritized.