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

Abstract

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.

Fig 1 Odds ratio for perinatal death related to delivery of second twin for all causes and deaths caused by anoxia, stratified by gestational age. Numbers of deaths are actual numbers of losses of first and second twins, confined to births where other twin survived

Fig 2 Odds ratio for perinatal death related to delivery of second twin at term gestation for all deaths and deaths caused by anoxia, stratified by method of delivery. Numbers of deaths are actual numbers of losses of first and second twins, confined to births where the other twin survived (excludes cases with missing record of method of delivery)