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

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Study Justification:
The study aimed to assess the association between twins and early neonatal mortality compared to singleton pregnancies in low- and middle-income countries. This is important because multiple pregnancies, which are more common in Central African countries, pose a higher risk of death for women and children due to obstetrical complications and poor management skills in these countries.
Highlights:
– Early neonatal mortality among twins was significantly higher compared to singleton neonates in the 60 countries studied.
– Even after adjusting for birth weight, early neonatal mortality was still higher among twins compared to singletons in countries with available data on birth weight.
– In countries with high rates of caesarean sections, twins delivered vaginally in health facilities had an increased risk of early neonatal mortality compared to twins delivered through caesarean sections.
– Home twin births without skilled birth attendance were associated with increased mortality compared to delivering at home with skilled birth attendance or vaginal birth in a health facility.
Recommendations:
– Institutional deliveries and increased access to caesarean sections should be considered for twin pregnancies in low- and middle-income countries to decrease early adverse neonatal outcomes.
Key Role Players:
– Policy makers in low- and middle-income countries
– Ministries of Health
– Health care providers
– Skilled birth attendants
– Community health workers
Cost Items for Planning Recommendations:
– Training programs for health care providers and skilled birth attendants
– Infrastructure and equipment for health facilities to support institutional deliveries and caesarean sections
– Outreach programs to improve access to skilled birth attendance in home births
– Monitoring and evaluation systems to track the impact of the recommendations on early neonatal mortality rates

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study conducted a secondary analysis of individual level data from 60 nationally-representative Demographic and Health Surveys, which provides a large sample size and representative data. The study used a multi-level logistic regression to account for homogeneity within country and twin pairs. The results show a significant association between twins and early neonatal mortality compared to singleton pregnancies. The study also examines the role of skilled birth attendants, mode of delivery, and caesarean sections on early neonatal mortality in twin pregnancies. However, the abstract could be improved by providing more information on the limitations of the study, such as potential confounding factors and the generalizability of the findings to other populations. Additionally, it would be helpful to include the specific years of the surveys included in the analysis and any potential biases in the data collection process.

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 521 867 singleton and 14 312 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.

We conducted an analysis based on publicly available data sets from the Demographic and Health Surveys (DHS) [14]. We included data from 60 countries which represented the latest country DHS over the last 15 years with available data on mortality and caesarean sections in single and multiple pregnancies (Table 1). List of countries and years under study DHS are cross-sectional nationally-representative household surveys that provide data for a wide range of maternal and infant health and nutrition indicators [14]. With more than 300 surveys in 90 countries, the DHS program is considered the best available way of obtaining cross-sectional information on health indicators in developing countries. In these surveys, women are interviewed about their reproductive history with survival of their offspring as well as their personal and household socioeconomic characteristics. Standard DHS surveys have large sample sizes (usually between 5 000 and 30 000 households) and typically are conducted about every 5 years, to allow comparisons over time. They are conducted by trained personnel using a standardized questionnaire and strict methods for sampling and data collection. The figures obtained from the DHS refers to births that occurred up to 5 years previous to the data of the survey [14]. We included all singleton and twin births over the five years preceding from the most recent standard country-survey within the last fifteen years. We excluded triplets and higher order multiple births as well as all neonatal deaths occurring after the first week of life. We merged country data sets into one cross-sectional database. Our main outcome was death during the first week of life (days 0-6, “early neonatal deaths”). We explored the association between the main outcome and the type of pregnancy regarding the number of foetuses (singleton vs twin pregnancies). Additionally, we examined the association between mode of delivery (caesarean section vs vaginal delivery) and early neonatal mortality separately for singleton and twins for those births taking place in health facilities. Subgroup analysis was performed after stratifying countries according to overall caesarean section rates as low (15%) [15]. We also investigated the result of place and attendance at birth on early mortality for the twins under study. Place and attendance at birth were based on women reports and were categorized as follows: births at home without skilled birth attendance (SBA), births at home with SBA and births in health facilities. In addition, the association between early neonatal mortality in twins and low birth weight (LBW) was studied, with LBW defined as weight at birth less than 2500 g. In the logistic regression, we adjusted for the following co-variates: a wealth index [16] derived from an index of household assets, the number of antenatal visits, mother’s education, maternal age at birth of child, parity and previous birth interval categorized in “less than 18 months”, “18-23 months”, “18-35 months” and “more than 35 months”. After the exclusion of triplets and higher order of multiple pregnancies and the exclusion of late neonatal deaths, 536 179 births, 521 867 singletons and 14 312 twins, were eligible for this analysis (Figure 1). Study participants flowchart. We initially tabulated the distribution of livebirths and early neonatal deaths, singletons and twin births by country and by World Health Organization (WHO) region. WHO classifies the 194 Member States in six regions: African Region (AFR, n = 47), Region of the Americas (AMR, n = 35), South-East Asia Region (SEAR, n = 11), European Region (EUR, n = 53), Eastern Mediterranean Region (EMR, n = 21), and Western Pacific Region (WPR, n = 27). We also tabulated the distribution of caesarean sections as well as place and attendance at delivery for all singleton and twin pregnancies by country, WHO region and the total. We conducted a descriptive analysis of selected maternal and delivery characteristics in singleton and twin pregnancies. A logistic regression was performed to calculate unadjusted and adjusted odds ratio for the association between early neonatal mortality and type of pregnancy (singleton and twin). The pooled OR for early neonatal mortality among twins vs singletons was adjusted for the following confounders: the presence of at least one antenatal care visit, mode of delivery (vaginal/caesarean section), household wealth (as a proxy for socio-economic status), and other birth-related confounding variables like birth spacing [17,18]. The pooled OR for early newborn mortality was adjusted for these confounders. We used a random effect model to control for unobserved factors at primary sampling unit and country levels [19]. The model also accounted for the clustering of twins within mothers, which is often overlooked and can affect the precision of estimates [20]. In consideration of the likely confounding effect of birthweight in the association of early neonatal death with singleton/twin pregnancies we conducted a subgroup analysis using logistic regression on the pooled data set of 20 countries having less than 20% of missing data on weight at birth. These are Albania 2008/09, Armenia 2010, Azerbaijan 2006, Bolivia 2008, Congo (Brazzaville) 2011/12, Dominican Republic 2013, Gabon 2012, Guyana 2009, Honduras 2011/12, Indonesia 2012, Jordan 2012, Kyrgyz Republic 2012, Maldives 2009, Moldova 2005, Peru 2012, Philippines 2013, Sao Tome and Principe 2008/09, Swaziland 2006/07, Taijikistan 2012, Ukraine 2007. Data on the type of birth (vaginal or CS) for health facility births was available for 9 732 twins (99.0%) and for 315 635 singletons (99.0%). To explore the association between early neonatal mortality and place and attendance at birth for the twin pregnancies population, 14 096 newborns (98.5%) with data on the exposure variables remained. Throughout the analysis, p-values of <0.05 were considered significant. Statistical analysis was performed with STATA 13.1 SE (StataCorp LP, College Station TX, USA) [21]. This study used existing data obtained from ORC Macro through formal request mechanisms. No additional ethical review for the secondary analysis was required since each country and the institutional review board of ORC Macro (Calverton, MD, USA) approved the DHS data collection procedures.

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The study titled “Early neonatal mortality in twin pregnancy: Findings from 60 low- and middle-income countries” provides several recommendations to improve access to maternal health for twin pregnancies. These recommendations can be developed into innovations as follows:

1. Innovation: Mobile health clinics for prenatal care
Description: Implementing mobile health clinics that travel to remote areas can provide prenatal care to pregnant women, including those with twin pregnancies. These clinics can offer regular check-ups, ultrasounds, and education on twin pregnancy management. This innovation improves access to skilled birth attendants and necessary medical interventions.

2. Innovation: Telemedicine consultations for twin pregnancies
Description: Establishing telemedicine platforms that connect pregnant women with healthcare providers can improve access to specialized care for twin pregnancies. Through video consultations, healthcare providers can remotely monitor the progress of the pregnancy, provide guidance, and address any concerns. This innovation reduces the need for travel and increases access to expert advice.

3. Innovation: Twin pregnancy education programs
Description: Developing educational programs specifically tailored to twin pregnancies can increase awareness and knowledge among pregnant women and their families. These programs can be delivered through community health workers, online platforms, or mobile applications. By providing information on the unique challenges and risks associated with twin pregnancies, this innovation empowers women to make informed decisions and seek appropriate care.

4. Innovation: Twin pregnancy referral networks
Description: Establishing referral networks between primary healthcare centers and specialized facilities can ensure timely access to appropriate care for twin pregnancies. This innovation involves training healthcare providers at primary care centers to identify high-risk twin pregnancies and refer them to facilities equipped to handle complications. It also includes establishing communication channels for seamless transfer of patients.

5. Innovation: Financial incentives for institutional deliveries
Description: Introducing financial incentives, such as cash transfers or insurance coverage, for pregnant women who choose to deliver in health facilities can encourage institutional deliveries. This innovation addresses the financial barriers that may prevent women from accessing skilled birth attendants and necessary medical interventions for twin pregnancies.

By implementing these innovations, countries can improve access to maternal health for twin pregnancies, reduce early neonatal mortality, and enhance overall outcomes for mothers and babies.
AI Innovations Description
Based on the findings from the study titled “Early neonatal mortality in twin pregnancy: Findings from 60 low- and middle-income countries,” the following recommendation can be developed into an innovation to improve access to maternal health:

1. Increase institutional deliveries: Encouraging pregnant women, especially those with twin pregnancies, to give birth in health facilities can help improve access to skilled birth attendants and necessary medical interventions. This can reduce the risk of early neonatal mortality.

2. Improve access to caesarean sections: In countries with high rates of caesarean sections, ensuring access to this surgical procedure for twin pregnancies can significantly reduce early neonatal mortality. This may involve training healthcare providers, improving infrastructure, and addressing barriers to accessing caesarean sections.

3. Enhance skilled birth attendance: Promoting the presence of skilled birth attendants during twin births, both at home and in health facilities, can contribute to better outcomes. This may involve training and deploying more skilled birth attendants, particularly in regions with high rates of twin pregnancies.

4. Strengthen antenatal care: Increasing the number of antenatal care visits and improving the quality of care provided during these visits can help identify and manage potential complications in twin pregnancies. This can contribute to reducing early neonatal mortality.

5. Address socioeconomic factors: Considering the association between household wealth and early neonatal mortality, addressing socioeconomic factors such as poverty and inequality can help improve access to maternal health services for vulnerable populations.

By implementing these recommendations, countries can work towards reducing early adverse neonatal outcomes in twin pregnancies, particularly in low- and middle-income settings.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Data Collection: Collect data on the current rates of institutional deliveries, access to caesarean sections, skilled birth attendance, and antenatal care in the target countries. This can be done through surveys, interviews, or by accessing existing data sources such as national health databases or reports.

2. Baseline Assessment: Analyze the current situation and assess the existing barriers and challenges to accessing maternal health services for twin pregnancies in each country. This can include factors such as geographical location, socioeconomic status, cultural beliefs, and availability of healthcare facilities.

3. Intervention Design: Develop an intervention plan based on the recommendations mentioned in the abstract. This may involve strategies to increase institutional deliveries, improve access to caesarean sections, enhance skilled birth attendance, strengthen antenatal care, and address socioeconomic factors.

4. Simulation Modeling: Use simulation modeling techniques to estimate the potential impact of the intervention plan on improving access to maternal health services for twin pregnancies. This can involve creating a mathematical model that takes into account various factors such as population size, healthcare infrastructure, and the effectiveness of the interventions.

5. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the simulation model and to understand the potential variations in the outcomes based on different assumptions or scenarios. This can help identify the key factors that influence the impact of the interventions.

6. Evaluation and Monitoring: Implement the intervention plan in selected pilot areas or communities and closely monitor the outcomes. Collect data on key indicators such as institutional delivery rates, access to caesarean sections, skilled birth attendance, and early neonatal mortality rates among twin pregnancies.

7. Analysis of Results: Analyze the data collected during the implementation phase and compare it with the baseline assessment. Evaluate the impact of the interventions on improving access to maternal health services for twin pregnancies and assess the effectiveness of each recommendation.

8. Scaling Up: Based on the findings from the evaluation, develop a plan to scale up the interventions to a larger population or to other regions/countries. Consider the feasibility, cost-effectiveness, and sustainability of the interventions.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of the recommendations mentioned in the abstract and make informed decisions to improve access to maternal health services for twin pregnancies in low- and middle-income countries.

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