Table 1. Guidance from training materials, guidelines, and policies on identification and care for multiple pregnancies and babies born with their sibling.
| Subject | Country | |||||||
|---|---|---|---|---|---|---|---|---|
| Kenya | Malawi | Mozambique | Rwanda | Tanzania | Uganda | Zambia | Zimbabwe | |
| Twin pregnancy highlighted as risk factor for maternal and perinatal mortality | Risk factor for pre-eclampsia/eclampsia1; can be the cause of bleeding in pregnancy/threatened abortion1 | Risk factor for anaemia, hyperemesis gravidarum, hypertensive disorders, APH, thromboembolism, preterm labour, prolonged labour, and PPH2 | Risk factor for anaemia3, APH4, and fetal growth restriction4 | Risk factor for PPH5 and premature birth6 | High-risk pregnancy7; risk factor for PPH7 | Risk factor for miscarriage, APH, hypertensive disorders, PPH, stillbirths, and neonatal death8,9 | Risk factor for anaemia, hypertensive disorders, prematurity, LBW, APH, PPH, and mortality10,11 | |
| Identification of twin pregnancies during ANC | Mismatch in fundal height and gestational age, exaggerated pregnancy symptoms, multiple fetal parts1; family history of twins or previous twin pregnancy assessed during history taking1,12 | Mismatch in fundal height and gestational age, exaggerated pregnancy symptoms2; additional ANC visits2; to be checked by scan for chorionicity2 | Mismatch in fundal height and gestational age or increase in weight gain of more than 2 kg13 | Mismatch in fundal height and gestational age, 2 audible fetal heartbeats, multiple fetal parts, exaggerated symptoms of pregnancy4 | Mismatch in fundal height and gestational age5; excessive weight gain14 | Family history of twins15,; exclude multiple pregnancy (unspecific advice)7; hyperemesis might be sign for multiples, to be checked by scan7 | Exaggerated symptoms of pregnancy, family history, multiple fetal parts8,9; use scan8,9 | Mismatch in fundal height and gestational age, difficult palpation/several poles11; family history of twins11; use scan before 24 weeks to diagnose twin pregnancy10 |
| Special care during pregnancy | Admission to facility in case of pregnancy complication such as APH, preterm labour1; higher weight increase recommended1 | Additional caloric need2; scan every 2–3 weeks2; corticosteroids at 28 weeks for monoamniotic pregnancies2 | Check for anaemia3,16; can be the cause of threatened abortion3,16; monitor for associated obstetric complications, determine presentation, perform ultrasound4 | Manage multiple pregnancies (no details)14; look out for pre-eclampsia/eclampsia5 | Higher weight increase recommended17 | Ultrasound for dating and chorionicity and growth discordance, monthly (later biweekly) ANC visits, corticosteroids at 26 weeks of gestational age8; routine ANC unless there are complications9; increased caloric intake8,9 | Check for anaemia and urine for protein, watch blood pressure very closely, 3 scans, plan mode of delivery11 | |
| Advice on place of delivery | Comprehensive emergency obstetric care facility1 | In case of discordant growth or monoamniotic pregnancy, refer to Central Hospital2 | Comprehensive emergency obstetric care facility13 | Hospital4 | Hospital18 | Hospital9 | Specialised care (no other specifics)19; intrauterine fetal death of 1 twin is indication for referral to tertiary institution11 | |
| Advice on timing of delivery | No later than 39 weeks, monoamniotic pregnancy between 32–34 weeks of gestation2 | Consider; CS at 36 weeks of gestation if monoamniotic pregnancy8; plan delivery no later than 40 weeks8; induction of labour at 38 weeks of gestation9 | ||||||
| Advice on mode of delivery | Risk factor for obstructed labour1; consider CS if non-cephalic first twin, retained second twin, extreme prematurity, discordant or monozygotic twins, and >2 multiples1,20 | Vaginal delivery if first twin in cephalic presentation and no complication2 | Consider CS if first twin not cephalic, previous scar, and >2 fetuses4 | Consider CS if non-cephalic first twin or >2 multiples8; low threshold for CS8 | Labour is managed according to the presentation of the first twin, active management of delivery of second twin, watch out for fetal distress11 | |||
| Care during birth | Management of twin delivery part of a distinct chapter20 | Obstetric and paediatric registrars need to be present, prepare 2 delivery sets2; risk factor for resuscitation21 | Check for second twin before AMTSL22 | Risk factor for PPH16, deep vein thrombosis4, and pulmonary embolus4 | Risk factor for PPH5; rule out second twin before AMTSL14,23 | First twin at greater risk of HIV7; risk factor for obstructed labour7; exclude second baby after delivery7 | Registrar needs to be present for delivery, prepare 2 delivery sets, watch for intrauterine fetal death8; obstetrician and paediatrician should be present, active management of delivery of second twin, check very carefully for PPH9 | Registrar needs to be present for delivery11 |
| Advice on breastfeeding | Detailed guidance on how to support breastfeeding in twins24,25 | |||||||
| Postnatal care/advice on special neonatal care | Mentioned as risk factor1,20 | Mentioned as risk factor on child health card26 | Mentioned as risk factor on child health card27 | Special care and more frequent follow-up needed, keep longer in facility7 | ||||
1Kenya Ministry of Public Health and Sanitation and Kenya Ministry of Medical Services. National Guidelines for Quality Obstetrics and Perinatal Care.
2Association of Obstetricians and Gynaecologists of Malawi. Obstetrics and Gynaecology Protocols and Guidelines. Version 3.0. April 2017.
3Rwanda Ministry of Health. Focused Antenatal Care. Reference Manual for Health Care Providers. 2014.
4Rwanda Ministry of Health. Gynecology and Obstetrics. Clinical Protocols & Treatment Guidelines. 2012.
5Tanzania Ministry of Health and Social Welfare. Learning Resource Package for Basic Emergency Obstetric and Newborn Care (BEmONC). Participant’s Handbook. 2010.
6Tanzania Ministry of Health and Social Welfare. Administration of Antenatal Corticosteroids in Pre-Term Labour. 2015.
7Uganda Ministry of Health. Uganda Clinical Guidelines. National Guidelines for Management of Common Conditions. 2016.
8University of Zambia Medical Education Partnership Initiative. Obstetrics & Gynecology Protocols and Guidelines. 2014.
9Lusaka School of Midwivery, Lecturer Mr Sikuyuba. Lesson Plan, Obstetrics and Midwifery Care, Multiple Pregnancies. 2017.
10Zimbabwe Ministry of Health and Child Welfare. National Guidelines on Key Interventions to Improve Perinatal and Neonatal Health Outcomes in Zimbabwe. 2017.
11University of Zimbabwe Department of Obstetrics and Gynaecology. Essential Guide to Management of Common Obstetric and Gynaecologic Conditions in Zimbabwe. 2012.
12Kenya Ministry of Health. Maternal & Child Health Booklet. Afya Ya Mama Na Mtoto.
13Mozambique Ministry of Health. Caderneta de Saúde da Mulher. 2015.
14Tanzania Ministry of Health and Social Welfare. Focused Antenatal Care. Malaria and Syphilis during Pregnancy. Learner’s Guide for ANC Service Providers and Supervisors. 2009.
15Uganda Ministry of Health. Ante-Natal Card.
16Rwanda Ministry of Health. Continuous Training in Emergency Basic and Comprehensive Obstetric and Neonatal Care. Reference Manual. 2015.
17Uganda Ministry of Health. Guidelines on Maternal Nutrition in Uganda. 1st edition. 2010.
18Tanzania Ministry of Health and Social Welfare. Kadi Ya Kliniki Ya Waja Wazito (Antenatal Card) RCH4. 2006.
19Zimbabwe Ministry of Health. Maternal and Neonatal Health Record.
20Kenya Ministry of Public Health & Sanitation. Emergency Obstetric and Neonatal Care Guidelines. A Harmonized Competency Based Training Curriculum for Kenya.
21Paediatrics and Child Health Association. Care of the infant and newborn in Malawi. The COIN Course. Participants Manual.
22Mozambique Ministry of Health. Padrões para Medição do Desempenho dos Serviços de Saúde Materna e Neonatal. 2016.
23Tanzania Ministry of Health and Social Welfare. Active Management of the Third Stage of Labor (AMTSL).
24Tanzania Ministry of Health and Social Welfare. Kangaroo Mother Care Guideline. 2008.
25Tanzania Ministry of Health and Social Welfare. Infant and Young Child Feeding. July 2013.
26Mozambique Ministry of Health. Cartáo de Saúde da Crianca.
27Tanzania Ministry of Health and Social Welfare. Kadi Ya Kliniki Ya Mtoto RCH 1.
AMTSL, active management of the third stage of labour; ANC, antenatal care; APH, antepartum haemorrhage; CS, cesarean section; LBW, low birth weight; PPH, postpartum haemorrhage.