One in five children born as a twin in sub-Saharan Africa dies before their fifth birthday, according to new research in the Lancet.
The study is the first to analyse death rates among twins in the region.
The report suggests improvements in survival for twins is lagging far behind other children.
The death rate among single-born children aged under-five halved between 1995 and 2014. For twins, the rate came down by a third.
Giving birth to twins is riskier than delivering just one baby – no matter which country a mother delivers in.
There is an increased risk of early delivery, low birth weight and mothers suffering severe blood loss.
But researchers say these risks are “compounded” by higher overall birth rates and poor maternal and newborn care in sub-Saharan Africa, where many mothers give birth at home.
In Finland for example – which has some of the best maternity care in the world – researchers say for every 1,000 twins born, 11 die before their first birthday.
According to the study, the equivalent figure for sub-Saharan Africa is 137 per 1,000 twins who die before they turn one.
And 213 in 1,000 die before their fifth birthday.