@article{3056814,
    title = "Variations in multiple birth rates and impact on perinatal outcomes in Europe",
    author = "Heino, A. and Gissler, M. and Hindori-Mohangoo, A.D. and Blondel, B. and Klungsøyr, K. and Verdenik, I. and Mierzejewska, E. and Velebil, P. and Ólafsdóttir, H.S. and Macfarlane, A. and Zeitlin, J. and Haidinger, G. and Alexander, S. and Pavlou, P. and Mortensen, L. and Sakkeus, L. and Lack, N. and Antsaklis, A. and Berbik, I. and Bonham, S. and Cuttini, M. and Misins, J. and Jaselioniene, J. and Wagener, Y. and Gatt, M. and Nijhuis, J. and Van Der Pal, K. and Klungsoyr, K. and Szamotulska, K. and Barros, H. and Horga, M. and Cap, J. and Mandić, N.T. and Bolúmar, F. and Gottvall, K. and Berrut, S. and Klimont, J. and Zhang, W.-H. and Dramaix-Wilmet, M. and Van Humbeeck, M. and Leroy, C. and Minsart, A.-F. and Van Leeuw, V. and Martens, E. and De Spiegelaere, M. and Verkruyssen, F. and Willems, M. and Aelvoet, W. and Tafforeau, J. and Renard, F. and Walckiers, D. and Cuignet, D. and Demoulin, P. and Cloots, H. and Hendrickx, E. and Kongs, A. and Stylianou, D. and Kyprianou, T. and Skordes, N. and Roos, J.L. and Anderson, A.-M.N. and Mortensen, L.H. and Ritvanen, A. and Colle, M.-H.B. and Ego, A. and Rey, G. and Heller, G. and Scharl, A. and Drakakis, P. and Bjarnadottir, R.I. and Hardardóttir, H. and Ragnarsdóttir, B. and Stefánsdóttir, V. and Haraldsdóttir, S. and Mulligan, A. and Tamburini, C. and Boldrini, R. and Prati, S. and Loghi, M. and Castagnaro, C. and Marchetti, S. and Burgio, A. and Da Frè, M. and Zile, I. and Isakova, J. and Gaidelyte, R. and Jaselione, J. and Billy, A. and Touvrey-Lecomte, A. and Van Der, K. and De Bruin, P. and Achterberg, P. and Hukkelhoven, C. and De Winter, G. and Ravelli, A. and Rijninks-Van Driel, G. and Tamminga, P. and Groesz, M. and Elferink-Stinkens, P. and Osen, A. and Ebbing, M. and Correia, S. and Cucu, A. and Novak-Antolič, Ž. and Jane, M. and Vidal, M.J. and Barona, C. and Mas, R. and Alcaide, A.R. and Lundqvist, E. and König, C. and Schmid, M. and Dattani, N. and Chalmers, J. and Monteath, K. and Climson, M. and Marr, L. and Gibson, R. and Thomas, G. and Osborne, R. and Brown, R. and Sweet, D. and Evans, J. and Magill, S. and Graham, A. and Reid, H. and Falconer, T. and McConnell, K. and McComb, N. and Euro-Peristat Scientific Committee",
    journal = "PLOS ONE",
    year = "2016",
    volume = "11",
    number = "3",
    publisher = "Public Library of Science",
    doi = "10.1371/journal.pone.0149252",
    keywords = "adverse outcome;  Article;  birth rate;  controlled study;  Europe;  female;  gestational age;  human;  maternal age;  multiple birth rate;  multiple pregnancy;  newborn death;  newborn mortality;  outcome assessment;  parameters concerning the fetus, newborn and pregnancy;  perinatal outcome;  premature labor;  risk assessment;  risk factor;  stillbirth;  adult;  birth rate;  fetus death;  fetus mortality;  infant;  infant mortality;  meta analysis;  mortality;  multiple pregnancy;  newborn;  perinatal death;  pregnancy;  Premature Birth, Adult;  Birth Rate;  Europe;  Female;  Fetal Death;  Fetal Mortality;  Humans;  Infant;  Infant Mortality;  Infant, Newborn;  Maternal Age;  Perinatal Death;  Pregnancy;  Pregnancy, Multiple;  Premature Birth;  Stillbirth",
    abstract = "Objective: Infants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level. Methods: We used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with randomeffects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups. Results: In 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1-9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0-12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl1.5-3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1-8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8-20.2) versus 9.8% (95% Cl 9.6-11.0) for neonatal death and 29.6% (96% CI 28.5-30.6) versus 17.5% (95% CI 15.7-18.3) for very preterm births, respectively). Conclusions: Wide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health. © 2016 Heino et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited."
}