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 Table of Contents  
Year : 2022  |  Volume : 22  |  Issue : 2  |  Page : 46-50

Prevalence and outcome of higher-order multiples in Ilesa, Nigeria

Department of Obstetrics, Gynaecology and Perinatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria

Date of Submission15-Mar-2022
Date of Decision19-May-2022
Date of Acceptance21-Oct-2022
Date of Web Publication21-Mar-2023

Correspondence Address:
Dr. O A Solaja
Department of Obstetrics, Gynaecology and Perinatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njhs.njhs_9_22

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Introduction: This study reviewed the current prevalence of higher-order multiples (HOMs) in our institution compared to earlier documentation in the 1970s. We also reviewed factors that influenced the observed changes.
Materials and Methods: This retrospective study of HOM was conducted between January 2015 and December 2020. We reviewed case records of the parturient with HOM. We retrieved relevant information from the case records obtained from the central record department.
Results: Eleven HOM (eight triplets and three quadruplets) out of the 4821 deliveries that occurred during the same period putting the prevalence at 0.23%. All the quadruplets were conceived via assisted reproductive technology. All the deliveries were through caesarean sections with no documented asphyxiated baby. There was a significant difference between the mean gestational age and mean birth weight at delivery (P = 0.029, P = 0.002) between the triplets and quadruplets' gestation, respectively. However, the mother's booking status and steroid administration did not significantly affect the foetal outcomes. There were three stillbirths in this review, and all were from the triplet gestation.
Conclusion: The prevalence rate of HOM in this study is higher than that of the 1970s. Assisted reproductive technology (ART) contributed mainly to this increase. Good antenatal care and quick referral, and early presentation when complication ensues reduced perinatal morbidity and mortality.

Keywords: Assisted reproductive technology, high-risk pregnancy, higher-order multiples, perinatal morbidity

How to cite this article:
Solaja O A, Fehintola A O, Ayegbusi O, Ajiboye A D, Fadare O O, Bakare O I. Prevalence and outcome of higher-order multiples in Ilesa, Nigeria. Niger J Health Sci 2022;22:46-50

How to cite this URL:
Solaja O A, Fehintola A O, Ayegbusi O, Ajiboye A D, Fadare O O, Bakare O I. Prevalence and outcome of higher-order multiples in Ilesa, Nigeria. Niger J Health Sci [serial online] 2022 [cited 2024 Feb 27];22:46-50. Available from: http://www.https://chs-journal.com//text.asp?2022/22/2/46/372263

  Introduction Top

Higher-order multiple (HOM) is the delivery of more than two foetuses during childbirth. It is equally termed higher-order pregnancy. The incidence of HOM worldwide was uncommon but increasing due to the advent of assisted reproductive technology (ART).[1],[2] HOM is associated with increased morbidity and mortality compared to singleton pregnancies or even twin pregnancies. The higher the number of foetuses, the higher the risk of developing complications.[3] These complications are not just limited to the mother and the foetuses; they also affect the family and society (in terms of financial burden).[1],[4] These complications are myriads and could include; miscarriage, gestational hypertension, preeclampsia, eclampsia, gestational diabetes, preterm pre-labour rupture of membrane and its sequelae. There is an increase in surgical intervention rate (e.g. caesarean section), and an increased incidence of antepartum and postpartum haemorrhage, to mention a few. These include; problems associated with prematurity such as respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage and cerebral palsy for the foetuses. Others include foetal anaemia, hypoglycaemia, congenital anomaly and low birth weight.[3]

The incidence of HOM being on the increase may be due to the increased use of assisted reproductive technology (ART); which includes in vitro fertilisation (IVF) and non-IVF treatments for infertility treatments, the other common factor which cannot be too separated from the above predisposing factor include, increase maternal age.[4],[5] In the United States of America (USA), the prevalence of HOM pregnancies has increased by about 4–8 folds over a decade ago, with 40% of the increase attributed to ovulation induction, 40% to ART (such as IVF with embryo transfer and intracytoplasmic sperm injection) and the remaining 20% occurring spontaneously.[6],[7] In the united states, the rate of HOMs Increased primarily during the 1980s and 1990s and peaked in 1998 at 193.5/100,000, it subsequently began to decline, and in 2018, it is put at 93.5/100,000.[3] The prevalence of HOM ranged between 0.04% in the north, 0.13% in the southeast and 0.32% in Lagos.[4]

In this hospital, the Wesley Guild Hospital (WGH), Ilesha, Mulligan in 1970 puts the prevalence of HOM at 0.20% while Nylander puts it at 0.16% or 1.6/1000 maternities in the southwest.[8],[9] It is necessary to review this prevalence and ascertain if factors influence any observed change in the trend of HOM in this centre.

  Materials and Methods Top

Study setting

The WGH, Ilesha, is a branch of the Obafemi Awolowo University Teaching Hospitals Complex, it is a tertiary centre with specialist care for both maternal and foetal complications. This institution serves as a referral centre for the primary and secondary health facilities in Ilesha, its environs and even neighbouring states such as Ondo and Ekiti states.

Study population

The population was all parturient with HOMs in the year under review.

Study design

This retrospective study of all HOM deliveries in the hospital took place over 6 years from January 2015 to December 2020. Information on maternal age, parity, booking status, mode of conception, gestational age at delivery, mode of delivery, complications, days spent on admission and foetal outcomes were extracted from the case records of the parturient with HOM pregnancies. The socio-economic status of the women was stratified into classes 1–5 using the socio-economic stratification method by Olusanya et al.[10] This system scored the woman's educational status from zero to two and scored the husband's job description from one to three. Women with tertiary education are scored zero while primary or no formal education are scored two. Husbands who are professionals (e.g. lawyers, engineers and medical doctors) are scored 1 while those who are engaged in unskilled labours (e.g. Artisans) scored three. The addition of the husband's and the wife's scores will give the socioeconomic class of the woman. In this study, classes 1 and 2 were grouped as upper social class, class 3 as middle social class, while classes 4 and 5 were grouped as the lower social class to aid data analysis.

We retrieved records from the central record departments, the labour ward and the labour ward theatre register of the hospital.

Study objectives

The objective of the study is to know the current prevalence of higher-order pregnancy in the institution and to compare it with earlier documentation of the same institution.

Ethical consideration

Ethical clearance was obtained from the ethics and research committee of the hospital.

Inclusion/exclusion criteria

All case records of mothers who delivered triplets or more gestations were reviewed. In contrast, we excluded any mother with twin or single gestation from the study.

Data analysis

The data gotten were analysed using the Statistical Package for Social Sciences for Windows, version 22.0 (IBM Corp., Released 2013, Armonk, New York, USA). Demographic characteristics of the multiple birth mothers and the baseline characteristics of the HOM births were presented in frequencies and percentages and were compared using the Chi-square test. Continuous variables were expressed in means and standard deviation. An Independent t-test was used for continuous variables, and Chi-square was used to compare discrete variables. The association and relationships between different variables and neonatal outcomes were tested with Chi-square and Linear regression. All tests of significance were two-tailed, and we set the level of significance at <0.05 at 95% confidence interval.

  Results Top

During the 6 years under review, there were 4821 deliveries, out of which, there were 11 HOM gestations putting the overall prevalence at 0.23%, or one in 438. The HOM consisted of 8 triplets and three quadruplets' deliveries. There were no HOM births beyond quadruplets recorded, thus putting the prevalence of triplets and quadruplets at 0.17% and 0.06%, or one in 603 and one in 1607, respectively. All the quadruplets (i.e. 100%) were products of assisted reproductive technology (ART), whereas 75% (6) of the triplets were spontaneously conceived. Thus, 54.5% (6) of the HOM were conceived through ART, while five out of the six that had ART were nulliparous women. All the six mothers that underwent ART had it done for treatment of primary or secondary infertility. All the mothers with quadruplet gestations were conceived through ART. One of the multiparous mothers had a spontaneous twin gestation before spontaneous conception of a triplet gestation. The mothers' age ranged from 26 to 54 years, with a mean age of 37.55 (±9.19) years. Six (54.5%) of the patients were above 35 years of age as seen in [Table 1]. The 26-year-old mother was a nulligravida with a spontaneous conception of triplet, while the 54-year-old mother also had a delivery of triplet gestation, having received treatment for infertility through ART.
Table I: Demographic characteristics of the multiple birth mother

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The mean gestational age for HOM in this study was 34.22 ± 2.95 with a range between 29.5 and 38.0 weeks, but there was a significant difference between the delivery age between the triplets' quadruplets (34.84 ± 2.01 weeks vs. 32.57 weeks ± 4.02, P = 0.029). There was also a significant statistical difference in birth weight between the triplets and the quadruplets (1763 g ± 308 g vs. 1558 ± 716 g, P = 0.002) though the birth weight range was 800–3000 g for the HOM as seen in [Table 2]. The booking status of the mothers is stated as represented in [Table 3]. Seven (63.6%) mothers were booked patients, while the remaining were referred for expert management when complications ensued. The booking status did not significantly affect the outcome of the foetus (P = 0.835). All the deliveries were through caesarean sections, while more of these surgeries were emergency 6 (54.5%), the remaining were via elective, which was statistically significant (P = 0.000). Although the type of caesarean section did not significantly impact the outcome of the foetuses in terms of living and stillbirths (P = 0.359). There was more male predominance in the gender distribution, which accounted for about 55.6% overall, though, this was accounted more by the triplet gestation with a 62.5% male preponderance, but for the quadruplets, it was more of the female with 58.3%. However, the male prevalence was not significantly different (P = 0.236). There was no significant difference in the outcome between foetuses that received steroids in both the triplets and quadruplets in live births and stillbirth (P = 0.250). All the quadruplet deliveries were live births, but three stillbirths within the triplet gestation group were not statistically significant. The blood loss at surgery ranged between 350–1200 ml, with a mean blood loss of 670 ± 324 ml. The mean blood loss was not statistically significant between the two groups (681.25 ± 354.50, 416.67 ± 401.040, P = 0.313). However, the length of days spent after surgery was significantly different (5.50 ± 2.138, 13.33 ± 15.373 P = 0.000). The length of days spent post-delivery ranged between 3 and 31 days.
Table II: The outcome of triplets and quadruplets gestation in Wesley Guild Hospital, Ilesa

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Table III: Association and relationship between some maternal/fetal characteristics and neonatal outcome in higher order multiples in Wesley Guild Hospital

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  Discussions Top

The prevalence of HOM in this study is 0.23% or one in 438, which is higher than 0.13% or one in 717 (0.13%) reported by Umeora et al. in Abakaliki in the southeast and 0.04% or one in 2,572 reported in Jos, in the North.[1],[11] It is also higher than that reported by Martin et al. in the United States, which put its prevalence at 0.11%.[12] The prevalence in this review is higher than what was reported in the 1970s by Nylander in the same facility. Nylander puts the prevalence at 0.20% or one in 491 maternities, with the prevalence of triplet and quadruplet gestation set at 0.19% and 0.009%, respectively.[9] In this review, the calculated prevalence of triplets and quadruplets is 0.17% and 0.06%, respectively, and in addition, putting the overall prevalence at 0.23%. The marginal increase in the overall prevalence than what was quoted over 5 decades ago in our facility resulted from an increase in the quadruplet gestation in this review. All the quadruplet pregnancies in this study were conceived through ART, and this must have accounted for the overall rise in the prevalence of HOM. Other studies alluded to the fact that there is an increase in HOM in their centres due to the increased use of ART. Fajolu et al. and Ezenwa et al. recorded 0.74% and 0.32%, respectively, and both alluded to the fact that the increase was due to the rise in the use of ART. While Ezenwa reported that almost all the HOM were via IVF, Fajolu stated that all the HOM information retrieved was via ART.[4],[6]

The increase of 0.74% recorded by Fajolu et al. from Lagos is much higher than our finding. The exact reason for this is not known. It may be because of the regional difference both in geographical and economical access to ART which is more predominant in lagos being an urban city compared to Ilesha which is a semi-urban city.

In this study, 54.5% of the HOM were via ART, higher than 40% recorded in the USA in 2010.[13] Though the HOM rate in the United States increased in 2010, it is on a constant decline due to regulations on the number of embryos transferred.[14],[15]

Multiparity increased maternal age, and treatment for infertility with ART are risk factors for the increased incidence of multiple pregnancies.[13],[16] The age range of the mothers was between 26 and 54 years, with a mean age of 37.55 (±9.19) years which is comparable to that reported by Ezenwa (34.4 ± 5.5).[6]

Although the booking status did not significantly affect the outcome of the babies, it is essential to register HOM pregnancies in facilities that can adequately manage both the mother and the foetus, such as to reduce complications that could occur during this high-risk pregnancy. Four (36.4%) of the patient had pregnancy-induced hypertension and its sequelae necessitating preterm deliveries, with one of the patients developing antepartum eclampsia. Nine (81.8%) of the patient had preterm deliveries, while 2 (18.2%) had preterm PROM.

The mean gestational age at delivery in this review is 34.1 (±2.99) weeks, and this is higher than what Ezenwa and Umeora reported in their reviews.[1],[6] The mean birth weight for HOM in this study was 1694 ± 483 g. When we compare the birth weights of triplets and quadruplets in this study with those reported by Fajolu et al., the weights in this study are higher.[4]

Three (27.3%) of the mothers had primary postpartum haemorrhage from overdistension leading to atony and this was promptly managed with oxytocics. Six of the mothers had steroids administered at one point before delivery, especially among the booked patient. The steroid has been noted to help improve lung maturity, enhance foetal birth weight and increase the chances of survival.[1],[17] However, there was no significant difference in the outcome in the foetuses of mothers that had steroids administered and those that did not have in this study.

All the mothers in this review were delivered through caesarean section, which follows the National Institute for Health and Care Excellence (NICE) guideline,[18],[19] which helps prevent the complications associated with a vaginal delivery as noted and discussed by Umeora.[1] These complications include cord prolapse of the second, third, or fourth foetus, as the case may be, foetal collision reduced placental perfusion, and bleeding from separating placentae. These complications were also responsible for the high rate of asphyxiated babies reported by umeora.[1],[20] Umea et al. reported different levels of asphyxia amongst foetuses delivered by vaginal delivery compared to those delivered through caesarean section. In this study, no form of asphyxia was recorded amongst the live foetuses, giving credence to the recommendation for elective caesarean section by NICE.[19] Although there was no significant difference between stillbirths amongst the triplets and quadruplets, there was a difference in the birth weights, with quadruplets having significantly lower birth weights than the triplet gestations at delivery.


The limitations of this study being retrospective are that there could be other risk factors for HOM that were not looked for nor noted while documenting for the mothers. Furthermore, retrospective studies can only determine association and not causation.

  Conclusion Top

The overall incidence of HOM has not significantly increased compared to 5 decades ago, while there is a trend towards an increase in the number of quadruplets possibly attributable to ART. HOM is a high-risk pregnancy associated with an increased incidence of complications both to the mother and the foetus compared with a singleton foetus. Quick recognition and early diagnosis of these complications will help to reduce adverse outcomes for both the mother and the baby.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Umeora OU, AneziOkoro EA, Egwuatu VE. Higher-order multiple births in Abakaliki, Southeast Nigeria. Singapore Med J 2011;52:163-7.  Back to cited text no. 1
Harrison KA. Child-bearing, health and social priorities: A survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria. Br J Obstet Gynaecol 1985;92 Suppl 5:1-119.  Back to cited text no. 2
American College of Obstetricians and Gynecologists' Committee on Practice Bulletins – Obstetrics, Society for Maternal-Fetal Medicine. Multifetal gestations: Twin, triplet, and higher-order multifetal pregnancies: ACOG Practice Bulletin, Number 231. Obstet Gynecol 2021;137:e145-62.  Back to cited text no. 3
Fajolu IB, Ezeaka VC, Adeniyi OF, Iroha EO, Egri-Okwaji MT. Prevalence and outcome of higher order multiple pregnancies in Lagos, Nigeria. J Matern Fetal Neonatal Med 2013;26:1342-5.  Back to cited text no. 4
Kulkarni AD, Kissin DM, Adashi EY. Fertility treatments and multiple births in the United States. N Engl J Med 2014;370:1070-1.  Back to cited text no. 5
Ezenwa B, Oseni O, Akintan P, Aligwekwe P, Chukwukelu B, Fashola O, et al. Higher order multiple births in Nigeria: Experiences, challenges and neonatal outcomes in a private health facility. Niger J Clin Pract 2017;20:1439-43.  Back to cited text no. 6
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Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final data for 2002. Natl Vital Stat Rep 2003;52:1-113.  Back to cited text no. 7
Mulligan TO. Personal Communication. West Afr J Med 1966;1;643.  Back to cited text no. 8
Nylander PP. The incidence of triplets and higher multiple births in some rural and Urban populations in Western Nigeria. Ann Hum Genet 1971;34:409-15.  Back to cited text no. 9
Olusanya O, Okpere E, Ezimokhai M. The importance of social class in voluntary fertility control in a developing country. West Afr J Med 1985;4:205-11.  Back to cited text no. 10
Mutihir JT. Triplet pregnancy as seen in the Jos University Teaching Hospital. Niger Postgrad Med J 2007;14:281-4.  Back to cited text no. 11
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Martin JA, Hamilton BE, Osterman MJ, Driscoll AK. Births: Final data for 2019. Natl Vital Stat Rep 2021;70:1-51.  Back to cited text no. 15
Reynolds MA, Schieve LA, Martin JA, Jeng G, Macaluso M. Trends in multiple births conceived using assisted reproductive technology, United States, 1997-2000. Pediatrics 2003;111:1159-62.  Back to cited text no. 16
Roberts D, Brown J, Medley N, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2017;3:CD004454.  Back to cited text no. 17
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  [Table 1], [Table 2], [Table 3]


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