Background High-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 findings We 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. Conclusions Despite 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.

Perinatal mortality remains high despite the downward trend, and the predominance of fetal mortality indicates recent changes in the profile of causes of death and impact on prevention activities. The quality of prenatal care with risk control and improving care during the delivery may reduce the occurrence of preventable causes of death.

Women's health is prioritised in national health policies and strategies in Mozambique. However, only 34.1% of women start antenatal consultations before the 16th gestational week and attend at least 4 visits – the reported lack of easy access to health facilities contributing to late initiation of antenatal care. Data from the Mozambique National Audit Committee of maternal, perinatal, and neonatal deaths demonstrate institutional maternal mortality ratio increased from 81 deaths per 100 000 live births in 2016 to 84 in 2019, highlighting the need for greater surveillance and a vigorous response to this increase. In Mozambique, there are opportunities for improving access to and quality of peripartum care to reduce maternal morbidity and mortality. Research is needed to uncover the major causes of maternal mortality and morbidity, particularly the role of cardiovascular disease.