Mortality among twins in Sub-Saharan Africa remains high: One-in-five dies before age five

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 90 Demographic and Health Surveys for 30 Sub-Saharan Africa countries held since 1995. We used information on 1 625 203 singleton and 56 484 twin live-births 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. We estimated the mortality burden among sub-Saharan African twins. Findings Under-5 mortality among twins has declined from 327·8 per 1000 live births in 1995–2001 to 213·0 in 2009-2014. This decline of 35% was much less steep than the 54% reduction among singletons. Twins account for an increasing share of under-5 deaths in Sub-Saharan Africa: currently almost 11% of under-5 mortality and 15% of neonatal mortality. We estimated that approximately 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 birth weight. The difference with singletons was especially stark for neonatal mortality (RR 5.0; 95%CI 4.4-5.7). Only half of women pregnant with twins reported receiving medical assistance at birth. Interpretation The fate of twins in Sub-Sahara Africa is lagging behind that of singletons. An alarming one-fifth of twins in the region dies before age 5, 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 increase the situation of this extremely vulnerable group.