title: Twin Pregnancy and Severe Maternal Outcomes: The World Health Organization Multicountry Survey on Maternal and Newborn Health.
abstract: OBJECTIVE
  To evaluate maternal complications (potentially life-threatening conditions, maternal near miss, and maternal death) that are mutually exclusive and severe maternal outcomes (maternal near miss or maternal death) associated with twin pregnancies.
  
  
  METHODS
  We performed a secondary analysis of a cross-sectional World Health Organization Multicountry Survey, which was implemented in 29 countries. Data from 4,756 twin deliveries were compared with 308,111 singleton deliveries. Factors associated with maternal morbidity and twin pregnancies were reported with adjusted prevalence ratio (95% confidence interval).
  
  
  RESULTS
  Potentially life-threatening conditions, maternal near miss, severe maternal outcomes, and maternal deaths were 2.14 (1.99-2.30), 3.03 (2.39-3.85), 3.19 (2.58-3.94), and 3.97 (2.47-6.38) times higher, respectively, among twin pregnancies. Maternal age older than 20 years, having a partner, multiparity, and elective cesarean delivery were associated with twin pregnancies. Postpartum hemorrhage and chronic hypertension were more frequently associated with severe maternal outcomes among twin pregnancies. Conditions indicating organ dysfunction (maternal near miss) were twofold to fivefold higher for twins. Poisson multiple regression analysis identified several factors independently associated with a severe maternal outcome, but not twin pregnancies.
  
  
  CONCLUSIONS
  Twin pregnancy is associated with greater severe maternal morbidity and a higher rate of maternal death than singleton pregnancy.
authors.affiliation: Department of Obstetrics and Gynecology, University of Campinas, Campinas, and the Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil; Pakistan Institute of Medical Sciences, Islamabad, Pakistan; the Maternal & Child Morbidity & Mortality Surveillance Unit, Family Health Bureau, Ministry of Health, Colombo, Sri Lanka; the Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya; and the Department of Reproductive Health Research from the World Health Organization, Geneva, Switzerland.
authors.forename: Danielly S
authors.initials: DS
authors.lastname: Santana
authors.forename: José G
authors.initials: JG
authors.lastname: Cecatti
authors.forename: Fernanda G
authors.initials: FG
authors.lastname: Surita
authors.forename: Carla
authors.initials: C
authors.lastname: Silveira
authors.forename: Maria L
authors.initials: ML
authors.lastname: Costa
authors.forename: João P
authors.initials: JP
authors.lastname: Souza
authors.forename: Syeda B
authors.initials: SB
authors.lastname: Mazhar
authors.forename: Kapila
authors.initials: K
authors.lastname: Jayaratne
authors.forename: Zahida
authors.initials: Z
authors.lastname: Qureshi
authors.forename: Maria H
authors.initials: MH
authors.lastname: Sousa
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Vogel
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D006306:Health Surveys; D006801:Humans; D007231:Infant, Newborn; D008423:Maternal Age; D008428:Maternal Mortality; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data; D010298:Parity; D016012:Poisson Distribution; D011247:Pregnancy; D011248:Pregnancy Complications / Q000209:etiology / Q000401:mortality*; D011256:Pregnancy Outcome; D059285:Pregnancy, Twin / Q000706:statistics & numerical data*; D015995:Prevalence; D012044:Regression Analysis; D014944:World Health Organization; D055815:Young Adult