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Birth order of twins and risk of perinatal death related to delivery in England, Northern Ireland, and Wales, 1994-2003: retrospective cohort study

BMJ 2007; 334 doi: (Published 15 March 2007) Cite this as: BMJ 2007;334:576
  1. Gordon C S Smith, professor of obstetrics and gynaecology1,
  2. Kate M Fleming, senior data analyst2,
  3. Ian R White, senior scientist3
  1. 1Department of Obstetrics and Gynaecology, Cambridge University, Box 223, The Rosie Hospital, Cambridge CB2 2QQ
  2. 2Confidential Enquiry into Maternal and Child Health, London NW1 5SD
  3. 3Medical Research Council Biostatistics Unit, Institute of Public Health, Cambridge CB2 2SR
  1. Correspondence to: G C S Smith gcss2{at}
  • Accepted 18 January 2007


Objective To determine the effect of birth order on the risk of perinatal death in twin pregnancies.

Design Retrospective cohort study.

Setting England, Northern Ireland, and Wales, 1994-2003.

Participants 1377 twin pregnancies with one intrapartum stillbirth or neonatal death from causes other than congenital abnormality and one surviving infant.

Main outcome measures The risk of perinatal death in the first and second twin estimated with conditional logistic regression.

Results There was no association between birth order and the risk of death overall (odds ratio 1.0, 95% confidence interval 0.9 to 1.1). However, there was a highly significant interaction with gestational age (P<0.001). There was no association between birth order and the risk of death among infants born before 36 weeks' gestation but there was an increased risk of death among second twins born at term (2.3, 1.7 to 3.2, P<0.001), which was stronger for deaths caused by intrapartum anoxia or trauma (3.4, 2.2 to 5.3). Among term births, there was a trend (P=0.1) towards a greater risk of the second twin dying from anoxia among those delivered vaginally (4.1, 1.8 to 9.5) compared with those delivered by caesarean section (1.8, 0.9 to 3.6).

Conclusions In this cohort, compared with first twins, second twins born at term were at increased risk of perinatal death related to delivery. Vaginally delivered second twins had a fourfold risk of death caused by intrapartum anoxia.


  • Contributors: GCSS had the original idea and is guarantor. All authors discussed the study design and analytic approach. GCSS and KMF performed the statistical analysis. GCSS drafted the article and all authors contributed to and approved the final version.

  • Funding: None.

  • Competing interests: None declared.

  • Ethical approval: The directors of CEMACH approved the study.

  • Accepted 18 January 2007
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