title: How twins differ: multiple pregnancy and the use of health care in the 2008 Nigeria Demographic and Health Survey.
abstract: OBJECTIVE
  To (i) document the incidence of multiplicity in Nigeria, (ii) compare healthcare utilization during pregnancy and at delivery for singleton and multiple pregnancies (iii)and investigate whether antenatal care modifies the relationship between multiplicity and likelihood of having skilled attendance.
  
  
  METHODS
  This observational study was a secondary analysis of the 2008 Nigeria Demographic and Health Survey and included 17,635 women who gave birth to a live infant between 2003 and 2008. Multivariate logistic regression with adjustment for weighting, clustering and confounding was used to investigate associations and look for effect modification.
  
  
  RESULTS
  There were 18.5 multiple pregnancies per 1000 maternities. Multiple births had nearly six times the chance of neonatal mortality (AOR 5.74). Mothers with multiple births had more skilled attendance (AOR 1.75), but similar antenatal care utilization (AOR 0.95) as women with a singleton pregnancy. Women with multiple pregnancies attending antenatal care had more visits (mean 9.0 vs. 8.2), blood pressure checks (OR 1.52) and urine tests (OR 1.51). Although antenatal care was strongly associated with skilled attendance, there was no evidence that this was more so for twins than singletons.
  
  
  CONCLUSIONS
  Multiplicity in Nigeria is not just a common occurrence, but an indicator of a high-risk pregnancy. The fact that the use of antenatal care by women with a multiple pregnancy is not associated with a disproportionately greater use of skilled delivery care raises questions about the quality of antenatal services. Services should encourage and link all women and especially high-risk women to skilled attendance at delivery.
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London, UK. a.mcdonald@imperial.ac.uk
authors.forename: Andrea M
authors.initials: AM
authors.lastname: McDonald
authors.forename: Oona M R
authors.initials: OM
authors.lastname: Campbell
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D009549:Nigeria; D011247:Pregnancy; D018566:Pregnancy, High-Risk; D011272:Pregnancy, Multiple / Q000706:statistics & numerical data*; D059285:Pregnancy, Twin / Q000706:statistics & numerical data*; D011295:Prenatal Care / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D014427:Twins / Q000706:statistics & numerical data*; D055815:Young Adult