title: Perinatal outcomes of multiple-gestation pregnancies in Kenya, Zambia, Pakistan, India, Guatemala, and Argentina: a global network study.
abstract: OBJECTIVE
  To determine the rates of multiple gestation, stillbirth, and perinatal and neonatal mortality and to determine health care system characteristics related to perinatal mortality of these pregnancies in low- and middle-income countries.
  
  
  METHODS
  Pregnant women residing within defined geographic boundaries located in six countries were enrolled and followed to 42 days postpartum.
  
  
  RESULTS
  Multiple gestations were 0.9% of births. Multiple gestations were more likely to deliver in a health care facility compared with singletons (70 and 66%, respectively, p < 0.001), to be attended by skilled health personnel (71 and 67%, p < 0.001), and to be delivered by cesarean (18 versus 9%, p < 0.001). Multiple-gestation fetuses had a relative risk (RR) for stillbirth of 2.65 (95% confidence interval [CI] 2.06, 3.41) and for perinatal mortality rate (PMR) a RR of 3.98 (95% CI 3.40, 4.65) relative to singletons (both p < 0.0001). Neither delivery in a health facility nor the cesarean delivery rate was associated with decreased PMR. Among multiple-gestation deliveries, physician-attended delivery relative to delivery by other health providers was associated with a decreased risk of perinatal mortality.
  
  
  CONCLUSIONS
  Multiple gestations contribute disproportionately to PMR in low-resource countries. Neither delivery in a health facility nor the cesarean delivery rate is associated with improved PMR.
authors.affiliation: Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya.
authors.forename: Irene
authors.initials: I
authors.lastname: Marete
authors.affiliation: Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya.
authors.forename: Constance
authors.initials: C
authors.lastname: Tenge
authors.affiliation: Department of Community Health Services, Aga Khan University, Karachi, Pakistan.
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.affiliation: Jawaharlal Nehru Medical College, K.L.E. University, Karnataka, Belgaum, India.
authors.forename: Shivaprasad
authors.initials: S
authors.lastname: Goudar
authors.affiliation: University Teaching Hospital, Lusaka, Zambia.
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.affiliation: Lata Medical Research Foundation, Maharashtra, Nagpur, India.
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.affiliation: Institute for Clinical Effectiveness, Buenos Aires, Argentina.
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.affiliation: Multidisciplinary Health Institute, Francisco Marroquin University, Guatemala City, Guatemala.
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.affiliation: Research Triangle Institute International, Durham, North Carolina.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.affiliation: Department of Community Health Services, Aga Khan University, Karachi, Pakistan.
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.affiliation: Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya.
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.affiliation: Jawaharlal Nehru Medical College, K.L.E. University, Karnataka, Belgaum, India.
authors.forename: Bhala S
authors.initials: BS
authors.lastname: Kodkany
authors.affiliation: Institute for Clinical Effectiveness, Buenos Aires, Argentina.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Belizan
authors.affiliation: Christiana Care Health System, Wilmington, Delaware.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.affiliation: Divsion of Global Health, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.affiliation: Department of Pediatrics, University of Colorado, Denver, Colorado.
authors.forename: Nancy
authors.initials: N
authors.lastname: Krebs
authors.affiliation: School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana.
authors.forename: Pierre
authors.initials: P
authors.lastname: Buekens
authors.affiliation: Columbia University, New York, New York.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
authors.affiliation: Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.affiliation: Research Triangle Institute International, Durham, North Carolina.
authors.forename: Dennis
authors.initials: D
authors.lastname: Wallace
authors.affiliation: Research Triangle Institute International, Durham, North Carolina.
authors.forename: Janet
authors.initials: J
authors.lastname: Moore
authors.affiliation: National Institute of Child Health and Human Development, Bethesda, Maryland.
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.affiliation: National Institute of Child Health and Human Development, Bethesda, Maryland.
authors.forename: Linda L
authors.initials: LL
authors.lastname: Wright
authors.affiliation: Department of Pediatrics, Riley Hospital, Indiana University, Indianapolis, Indiana.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
mesh_terms: D000328:Adult; D003906:Developing Countries; D005260:Female; D014943:Global Health; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D054238:Perinatal Mortality; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology*; D011272:Pregnancy, Multiple / Q000706:statistics & numerical data*; D059285:Pregnancy, Twin / Q000706:statistics & numerical data; D012306:Risk; D050497:Stillbirth / Q000453:epidemiology; D055815:Young Adult