More people are having twins. How can we make births safer?

More twins are being born across the world, but many mothers are not receiving the treatment required to ensure a safe pregnancy.

Susie Lee from the Max Planck Institute for Demographic Research in Germany told DW "an important task remains to ensure that these twins can survive their early life" just as singletons do.

This goes especially for countries in Sub-Saharan Africa and South Asia, where many expectant mothers already have limited access to health care. 

Lee co-authored a recent study that found more twins are being born in low-income countries.

In general, this is simply due to population growth — even if the proportion of twins being born does not change, more people having children means more twins being born.

But in some places, such as Nigeria, twin birth rates are higher than the global average. The country is expected to almost double its population size by 2050. That means more twins, in absolute numbers.

Women are also having children at increasingly older ages when fertility naturally declines. 

Many prospective parents, mostly in high-income countries, are turning to medically assisted reproduction (MAR). A common form is in vitro fertilization (IVF), in which eggs are fertilized in a lab and the resulting embryos transferred into the uterus.

A matter of life and death

While all pregnancies need a high standard of health care, twin pregnancies present a higher risk to both mother and children with more medical attention required before, during and after birth.

In countries with limited access to health care, some women, especially those living in rural areas, never have a medical examination. This can endanger the life of the developing child and also increase the risk of the mother getting sick or even dying.

About 80% of all twin births occur in Asia and Africa, where mortality rates are also high.

In Nigeria, about three in every 100 pregnancies result in twins; compared to the global average of around one in 100. Across Sub-Saharan Africa, one in five twins dies before the age of five, according to a 2017 study.

Twin pregnancies also have a substantially higher risk of miscarriage or death after birth.

Ultrasounds provide basic care

Generally, medical care should start before babies are born.

"In so many countries the percentage of women who get what the WHO [World Health Organization] recommends; — at least one ultrasound examination between before the 24th week — is still shockingly low," said Christiaan Monden, a sociologist from the University of Oxford, UK.

Ultrasounds are important to spot a twin pregnancy and detect possible irregularities. 

"There's such a high number of women in that situation who don't have that very basic service and are vulnerable," said Monden.

It can worsen in hospitals that lack access to electricity, which is needed for ultrasound devices.

In their study, Lee and her co-author Kieron Barclay called for "more public health attention and societal support to be paid to twins and their families in low-income countries, given that twins are at higher risk of developmental challenges and health disadvantages."

Hope in AI and new technologies

New technologies could pave the way for better access to health care.Ultrasound machines are often bulky and only available in city hospitals. This can force mothers in rural areas to travel, a cost they also need to bear.

Portable ultrasound machines could provide more affordable ways for midwives in rural areas to detect twin pregnancies and provide family support. 

To overcome the long training required to interpret ultrasound scans, artificial intelligence (AI) could soon be able to support local staff in diagnosing and interpreting results. This could reduce training times and improve the accuracy of diagnoses, according to a University of Massachusetts radiologist, Young H Kim, in 2021.

While these services are not available everywhere yet, Monden hopes that they will provide better basic health care for pregnant women in the future. 

"I hope that we don't need to have a discussion about the fact that there are women who do not get these kinds of scans and actually go in to give birth, not knowing for sure whether they are having twins or not."

Edited by Matthew Ward Agius