Background and Objective: Multiple gestation pregnancies present significant challenges in rural tertiary care settings. This study evaluated maternal characteristics, neonatal outcomes, and clinical profiles of multiple gestations to identify risk factors and improve care protocols. Methods: A prospective observational study of 161 multiple gestation pregnancies (158 twin pairs, 3 triplet sets; 325 neonates) was conducted over 24 months at a rural tertiary hospital. Maternal demographics, obstetric outcomes, neonatal parameters, and clinical complications were analyzed using appropriate statistical methods.Results: Mean maternal age was 27.3±4.8 years with 56.3% primigravida mothers. Assisted reproductive technology contributed to 29.1% of pregnancies, associated with increased hypertensive disorders (RR=1.8). Preterm delivery occurred in 82.3% with mean gestational age 34.2±2.8 weeks. Monochorionic diamniotic placentation predominated (54.4%). Birth weight discordance >25% affected 13.9% of twins, significantly increasing NICU admissions (87.5% vs 52.7%, p<0.001). A consistent second twin disadvantage emerged across parameters, with significantly higher mortality (7.6% vs 5.1%, p=0.038) and longer NICU stays (11.4 vs 9.2 days, p=0.032). Chorionicity dramatically influenced mortality: MCMA (25.0%), MCDA (7.6%), DCDA (3.7%), with monochorionic twins having 3.2-fold higher risk. Triplet mortality was 33.3% versus 6.3% for twins (p=0.002), showing progressive increase by birth position. Respiratory distress syndrome was the leading cause of death (40.0%). Conclusion: Despite achieving 93.7% twin survival, multiple gestations face persistent challenges. Chorionicity-based risk stratification, position-specific monitoring, and specialized protocols for higher-order multiples are essential for optimizing outcomes in resource-limited settings.