National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study
National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study
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DOI：
10.1371/journal.pmed.1002749
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发表时间：
2019-02-01
期刊：
影响因子：
15.8
通讯作者：
Benova, Lenka
中科院分区：
文献类型：
--
作者：
Hanson, Claudia;Munjanja, Stephen;Benova, Lenka
背景高危妊娠，如双胎妊娠，值得特别关注，因为这一组的死亡率非常高。为了为可持续发展目标的政策和国家指导方针的制定提供信息，我们审查了支持提供与双胞胎怀孕有关的护理的国家培训材料、指导方针和政策，并评估了在8个东部和南部非洲国家提供的双胞胎护理：肯尼亚、马拉维、莫桑比克、卢旺达、坦桑尼亚、乌干达、赞比亚、方法和发现我们通过审查国家知识库和联系专家系统地绘制国家地图，各级孕产妇和新生儿培训材料、准则和政策。我们提取了双胞胎产前、产中和产后护理的建议，这些建议通常应在双胞胎怀孕和分娩期间提供。我们比较了在产前、产中和产后期间为双胞胎母亲提供的护理与为单胞胎母亲提供的护理，并使用每个国家最新的人口与健康调查（DHS）数据计算了新生儿死亡率。缺乏专门针对双胞胎或多胞胎妊娠的护理指导：没有一个国家就增加产前护理访视次数或具体产前内容提供明确指导，而8个国家中有7个建议在综合产科和新生儿急诊护理设施中分娩双胞胎。人口和健康调查对73 462名活产婴儿（其中1 360名为双胞胎）的调查结果反映了这些结果，表明双胞胎怀孕没有得到更频繁或更强化的产前护理。在医院分娩的双胞胎比例从莫桑比克的25.3%到肯尼亚的63.0%不等，与单胎活产的妇女相比，双胞胎妇女在医院分娩的可能性高出5至27个百分点;这种差异在8个国家中的5个国家中显着（t检验p <0.05）。剖腹产双胞胎的比例从莫桑比克的9%到卢旺达的36%不等。双胞胎中的新生儿死亡率，调整产妇年龄和奇偶校验，是4.6至7.2倍，双胞胎相比，在所有8个countries. ConclusionsDespite有限的样本量和数量有限的临床相关服务评估，我们的研究提供的证据表明，双胞胎的母亲得到足够的照顾，双胞胎新生儿的死亡率是非常高的东部和南部非洲。大多数国家对双胞胎的护理没有足够的指导方针。虽然我们的数据不允许我们在不充分的指导和不充分的护理之间建立因果关系，但他们呼吁对政策进行评估和重新概念化，以降低东部和南部非洲双胞胎不可接受的高死亡率。
BackgroundHigh-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe.Methods and findingsWe located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries.ConclusionsDespite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.