title: Mode and timing of twin delivery and perinatal outcomes in low- and middle-income countries: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health.
abstract: OBJECTIVE
  To describe the mode and timing of delivery of twin pregnancies at ≥34 weeks of gestation and their association with perinatal outcomes.
  
  
  METHODS
  Secondary analysis of a cross-sectional study.
  
  
  METHODS
  Twin deliveries at ≥34 weeks of gestation from 21 low- and middle-income countries participating in the WHO Multicountry Survey on Maternal and Newborn Health.
  
  
  METHODS
  Descriptive analysis and effect estimates using multilevel logistic regression.
  
  
  METHODS
  Stillbirth, perinatal mortality, and neonatal near miss (use of selected life saving interventions at birth).
  
  
  RESULTS
  The average length of gestation at delivery was 37.6 weeks. Of all twin deliveries, 16.8 and 17.6% were delivered by caesarean section before and after the onset of labour, respectively. Prelabour caesarean delivery was associated with older maternal age, higher institutional capacity and wealth of the country. Compared with spontaneous vaginal delivery, lower risks of neonatal near miss (adjusted odds ratio, aOR, 0.63; 95% confidence interval, 95% CI, 0.44-0.94) were found among prelabour caesarean deliveries. A lower risk of early neonatal mortality (aOR 0.12; 95% CI 0.02-0.56) was also observed among prelabour caesarean deliveries with nonvertex presentation of the first twin. The week of gestation with the lowest rate of prospective fetal death varied by fetal presentation: 37 weeks for vertex-vertex; 39 weeks for vertex-nonvertex; and 38 weeks for a nonvertex first twin.
  
  
  CONCLUSIONS
  The prelabour caesarean delivery rate among twins varied largely between countries, probably as a result of overuse of caesarean delivery in wealthier countries and limited access to caesarean delivery in low-income countries. Prelabour delivery may be beneficial when the first twin is nonvertex. International guidelines for optimal twin delivery methods are needed.
authors.affiliation: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Ganchimeg
authors.forename: N
authors.initials: N
authors.lastname: Morisaki
authors.forename: J P
authors.initials: JP
authors.lastname: Vogel
authors.forename: J G
authors.initials: JG
authors.lastname: Cecatti
authors.forename: J
authors.initials: J
authors.lastname: Barrett
authors.forename: K
authors.initials: K
authors.lastname: Jayaratne
authors.forename: S
authors.initials: S
authors.lastname: Mittal
authors.forename: E
authors.initials: E
authors.lastname: Ortiz-Panozo
authors.forename: J P
authors.initials: JP
authors.lastname: Souza
authors.forename: C
authors.initials: C
authors.lastname: Crowther
authors.forename: E
authors.initials: E
authors.lastname: Ota
authors.forename: R
authors.initials: R
authors.lastname: Mori
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa / Q000453:epidemiology; D001208:Asia / Q000453:epidemiology; D002585:Cesarean Section / Q000009:adverse effects / Q000401:mortality*; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D005865:Gestational Age; D019538:Health Care Surveys; D006801:Humans; D007231:Infant, Newborn; D007843:Latin America / Q000453:epidemiology; D008430:Maternal-Child Health Centers / Q000458:organization & administration; D008877:Middle East / Q000453:epidemiology; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011256:Pregnancy Outcome; D059285:Pregnancy, Twin; D050497:Stillbirth / Q000453:epidemiology*; D013997:Time Factors; D014427:Twins; D014944:World Health Organization; D055815:Young Adult
keywords: Neonatal morbidity; perinatal morbidity; perinatal mortality; planned caesarean section; stillbirth; timing of birth; twin pregnancy