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

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Study Justification:
– The study aims to examine the contribution of twins to neonatal and post-neonatal mortality in The Gambia.
– The high twinning rate and increased risk of mortality among twins contribute to the high burden of infant mortality in Africa.
– Understanding the factors that contribute to excess mortality among twins can help inform preventive interventions and prioritize resources.
Study Highlights:
– The study analyzed data from the Basse Health and Demographic Surveillance System (BHDSS) collected from January 2009 to December 2013.
– The analysis included 32,436 singletons and 1083 twins, with a twinning rate of 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, with adjusted odds ratios of 4.33 in the neonatal period and 2.61 in the post-neonatal period.
– Factors such as gender, season of birth, and access to clean water were found to interact with post-neonatal mortality among twins.
Study Recommendations:
– Preventive interventions targeting twins should be prioritized to reduce the burden of neonatal and post-neonatal mortality in The Gambia.
– Further research is needed to understand the specific factors contributing to excess mortality among twins and develop targeted interventions.
Key Role Players:
– Researchers and epidemiologists to conduct further studies and analyze data.
– Health policymakers and government officials to prioritize preventive interventions and allocate resources.
– Healthcare providers and community health workers to implement interventions and provide support to families with twins.
Cost Items for Planning Recommendations:
– Research funding for further studies and data analysis.
– Budget for implementing preventive interventions, such as healthcare services, education programs, and community outreach.
– Resources for training healthcare providers and community health workers.
– Monitoring and evaluation costs to assess the effectiveness of interventions and make necessary adjustments.

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.

We used data from the Basse Health and Demographic Surveillance System (BHDSS), which covers the south bank of the Upper River Region of The Gambia and included more than 170,000 individuals during the study period. In the BHDSS, trained field workers visit each household every four months and update demographic events in every household (i.e. pregnancies, births, deaths, in and out migrations). Additional information is transcribed from the antenatal cards and vaccination cards. The procedure is the same as that used in another demographic surveillance site in The Gambia, Farafenni HDSS, and described elsewhere [13]. Socio-economic data were collected in a survey conducted in 2011. The information collected in this survey included: (i) asset ownership (radio, television, video, car, motor cycle, refrigerator, bicycle), (ii) household material (such as roof, wall, floor), and (iii) toilet facility. We developed a socio-economical status (SES) index using theses data by primary component analysis. The SES index was categorized into 5 quintiles from 1st poorest to 5th wealthy [14]. Every pregnancy identified by field workers during demographic update rounds of the HDSS is followed up until termination. Information solicited from the woman on the outcome of the pregnancy include number of children resulting from the pregnancy and the number born alive. Therefore, pregnancies which terminated with two or more children born were classified as multiple births regardless of the number born alive; and all those with only one child born were confirmed as singletons. Deaths during the neonatal and the post-neonatal period were identified during routine household visits. All children born in the BHDSS from January 2009 to December 2013 were included in the analysis; triplets were excluded. Mortality rates for neonatal and post-neonatal periods were calculated by dividing the number of deaths by the number of live births. We compared the rate of mortality in twins and singletons using logistic regression to adjust for sex, ethnicity, season of birth, maternal age, birth order, SES index, access to clean water and birth interval (Model 2). Because many children were missing data on SES index, access to clean water and birth intervals, we also conducted an analysis (Model 1) where these variables were excluded from the model. The influence of socio-demographic factors on mortality in twins was compared to their influence in singletons. We used logistic regression to test for effect modification (i.e., different odds ratios in twins and singletons) and adjust for confounding. Confidence interval and p-values were computed using cluster-robust variance estimates to adjust for clustering by household. The probability of monozygotic and dizygotic twins were calculated using Weinberg zygosity estimation [15]. All analyses were conducted using Stata version 12. This study was approved by Gambia Government/Medical Research Council Joint Ethics Committee. Verbal consent of participants of HDSS was obtained by village leaders and individual household heads for household members.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Twin-specific prenatal care: Develop specialized prenatal care programs that cater specifically to women carrying twins. These programs could include more frequent check-ups, additional ultrasounds, and tailored nutritional guidance to ensure the health and well-being of both mother and babies.

2. Twin-focused postnatal support: Implement postnatal support programs that provide targeted assistance to mothers of twins. This could involve home visits by healthcare professionals to monitor the health of the mother and babies, offer breastfeeding support, and provide guidance on infant care for twins.

3. Improved access to clean water: Since the study found that lacking access to clean water was associated with increased post-neonatal mortality among twins, initiatives to improve access to clean water in communities could help reduce this risk. This could involve implementing water purification systems or providing education on safe water practices.

4. Strengthening healthcare infrastructure: Enhancing the healthcare infrastructure in areas with high twinning rates, such as The Gambia, could improve access to maternal health services. This could involve building or upgrading healthcare facilities, ensuring the availability of skilled healthcare professionals, and providing necessary medical equipment and supplies.

5. Twin-specific health education: Develop educational materials and programs that specifically address the unique challenges and risks associated with twin pregnancies and childbirth. This could include information on proper nutrition, signs of complications, and strategies for managing the care of twins.

6. Community-based interventions: Implement community-based interventions that raise awareness about the importance of maternal health and provide support to pregnant women, especially those carrying twins. This could involve training community health workers to provide education, conduct regular check-ups, and facilitate referrals to healthcare facilities when needed.

It’s important to note that these recommendations are based on the specific findings of the study mentioned and may need to be adapted to the local context and resources available.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health and reduce neonatal and post-neonatal mortality in The Gambia is to prioritize preventive interventions targeting twins. This is because the study found that twins represented a significant proportion of neonatal and post-neonatal deaths, with higher mortality rates compared to singletons.

To implement this recommendation, the following steps can be taken:

1. Increase awareness and education: Conduct community-based awareness campaigns to educate families and healthcare providers about the increased risk of mortality among twins and the importance of early and regular prenatal care for twin pregnancies.

2. Antenatal care for twins: Strengthen antenatal care services to include specialized care for twin pregnancies, such as more frequent check-ups, ultrasounds, and monitoring for complications. This can help identify and manage any potential risks early on.

3. Skilled birth attendants: Ensure that skilled birth attendants, such as midwives or doctors, are available during twin deliveries to provide appropriate care and manage any complications that may arise.

4. Postnatal care and support: Provide postnatal care and support specifically tailored to the needs of mothers with twins, including breastfeeding support, guidance on infant care, and monitoring for any postnatal complications.

5. Access to clean water and sanitation: Improve access to clean water and sanitation facilities, as the study found that lack of access to clean water was associated with increased post-neonatal mortality among twins. This can be achieved through infrastructure development and community-based initiatives.

6. Collaboration and partnerships: Foster collaboration between healthcare providers, community leaders, and organizations working in maternal and child health to ensure a coordinated and comprehensive approach to improving access to maternal health for twins.

By implementing these recommendations, it is expected that the burden of neonatal and post-neonatal mortality among twins in The Gambia can be reduced, leading to improved maternal and child health outcomes.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase access to antenatal care: Implement strategies to ensure that pregnant women, especially those carrying twins, have access to regular antenatal check-ups. This can include mobile clinics, community health workers, or transportation support for women in remote areas.

2. Enhance twin-specific healthcare services: Develop specialized healthcare services that cater specifically to the needs of twin pregnancies. This can involve training healthcare providers on managing twin pregnancies, providing appropriate medical equipment, and establishing referral systems for high-risk cases.

3. Promote awareness and education: Conduct community-based awareness campaigns to educate women and their families about the risks and challenges associated with twin pregnancies. This can help increase early detection of complications and encourage timely seeking of healthcare services.

4. Strengthen postnatal care: Improve postnatal care services for mothers of twins, including regular check-ups, breastfeeding support, and counseling on newborn care. This can help reduce post-neonatal mortality rates among twins.

To simulate the impact of these recommendations on improving access to maternal health, a possible methodology could be:

1. Define the baseline: Gather data on the current access to maternal health services, including antenatal care, delivery services, and postnatal care, specifically for twin pregnancies. This can involve reviewing existing health records, conducting surveys, and interviewing healthcare providers and community members.

2. Develop a simulation model: Create a simulation model that incorporates the various factors influencing access to maternal health, such as geographical location, availability of healthcare facilities, transportation infrastructure, and socio-economic factors. This model should also consider the specific challenges faced by twin pregnancies.

3. Introduce the recommendations: Implement the recommended interventions, such as increasing access to antenatal care, enhancing twin-specific healthcare services, promoting awareness and education, and strengthening postnatal care. This can be done gradually or in specific target areas, depending on available resources.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on key indicators, such as the number of women accessing antenatal care, the rate of complications among twin pregnancies, and the postnatal mortality rate among twins. This data should be collected over a specific period of time.

5. Analyze the impact: Compare the data collected after the implementation of the recommendations with the baseline data. Analyze the changes in key indicators to assess the impact of the interventions on improving access to maternal health for twin pregnancies. This can involve statistical analysis, such as calculating odds ratios or conducting regression analyses, to determine the significance of the changes observed.

6. Refine and adjust: Based on the findings from the analysis, refine and adjust the interventions as needed. This can involve scaling up successful interventions, addressing any identified gaps or challenges, and continuously monitoring and evaluating the impact of the interventions.

By following this methodology, it is possible to simulate the impact of the recommended interventions on improving access to maternal health for twin pregnancies and make informed decisions on prioritizing and implementing effective strategies.

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