Stillbirth and neonatal outcomes in South Australia, 1991-2000

OBJECTIVES: The purpose of this study was to determine the effect of maternal factors associated with impaired placental function on stillbirth and neonatal death rates in South Australia. STUDY DESIGN: From 1991 to 2000, the South Australian Pregnancy Outcome Unit's population database was searched to identify stillbirths and neonatal deaths in women with maternal medical conditions during pregnancy and in twin and singleton pregnancies. RESULTS: Women with hypertension and carbohydrate intolerance and who smoked during pregnancy had an increased risk of stillbirth. Women with twin pregnancies had a significantly higher stillbirth rate than for singletons at each week of gestational age. An increase in stillbirth rate at later gestations was seen with singletons, with a similar trend in twins but rising from 36 weeks' gestation. CONCLUSION: There is a clinical correlation between maternal factors associated with impaired placental function and increased risk of stillbirth, suggesting that intrauterine fetal death represents the mortality end point in a spectrum of intrauterine hypoxia.     

Mode of delivery and the risk of delivery-related perinatal death among twins at term: a retrospective cohort study of 8073 births

OBJECTIVE: To determine the risk of perinatal death among twins born at term in relation to mode of delivery. DESIGN: Retrospective cohort study. SETTING: Scotland 1985-2001. POPULATION: All twin births at or after 36 weeks of gestation, excluding antepartum stillbirths and perinatal deaths due to congenital abnormality (n= 8073). METHODS: The outcome of first and second twins was compared using McNemar's test and the outcome of twin pairs in relation to mode of delivery was compared using exact logistic regression. MAIN OUTCOME MEASURES: Intrapartum stillbirth or neonatal death of either twin. RESULTS: Overall, there were six deaths of first twins and 30 deaths of second twins (OR for second twin 5.00, 95% CI 2.00-14.70). The odds ratio for death of the second twin due to intrapartum anoxia was 21 (95% CI 3.4-868.5). The associations were similar for twins delivered following induction of labour and for sex discordant twins. However, there was no association between birth order and the risk of death among 1472 deliveries by planned caesarean section. There was death of either twin among 2 of 1472 (0.14%) deliveries by planned caesarean section and 34 of 6601 (0.52%) deliveries by other means (P= 0.05, odds ratio for planned caesarean section 0.26 [95% CI 0.03-1.03]). The association was similar when adjusted for potential confounders. Assuming causality, we estimate that 264 caesarean deliveries (95% CI 158-808) would be required to prevent each death. CONCLUSION: Planned caesarean section may reduce the risk of perinatal death of twins at term by approximately 75% compared with attempting vaginal birth. This is principally due to reducing the risk of death of the second twin due to intrapartum anoxia.     

The influence of obstetric intervention on trends in twin stillbirths: United States, 1989-99.

OBJECTIVE: Although twin stillbirth rates have declined substantially over the past two decades, the contribution of changes in obstetric interventions to reducing twin stillbirths has not been quantified. METHODS: We carried out a retrospective cohort study of twin live births and stillbirths in the United States between 1989 and 1999 (n=1,102,212). Changes in the rate of stillbirth (> or =22 weeks) before and after adjustment for changes in labor induction, Cesarean delivery and sociodemographic factors were estimated through ecological logistic regression analysis. This analysis was based on aggregating data by each state within the United States. RESULTS: Between 1989 and 1999, rates of labor induction and Cesarean delivery among twin live births increased by 138% (from 5.8% to 13.8%) and 15% (from 48.3% to 55.6%), respectively. These changes were accompanied by a 43% decline in the stillbirth rate between 1989 and 1999 (from 24.4 to 13.9 per 1000 fetuses at risk). After excluding births weighing < 500 g, rates of labor induction among twins at 22-27 weeks', 28-33 weeks' and > or =34 weeks' gestation increased by 95%, 131% and 127%, respectively, between 1989 and 1999. Cesarean delivery rates also increased by 55%, 29% and 2% in these same gestational age categories. The 48% (relative risk (RR) 0.52, 95% confidence interval (CI) 0.49-0.55) decline in stillbirth rate between 1989-91 and 1997-99 was reduced to a 25% (RR 0.75, 95% CI 0.72-0.79) decline after adjustment for changes in labor induction and Cesarean delivery. The decline in the rate of twin stillbirths was larger at later gestational ages (at > or =32 and > or =34 weeks) where the largest absolute increases in labor induction rates were observed. CONCLUSIONS: The use of Cesarean delivery and especially labor induction for twin pregnancies has increased substantially in the United States over the last decade and these changes have been associated with a large decline in the rate of stillbirth among twins.     

Early mortality in twin pregnancies complicated by premature rupture of membranes in the United States.

There is little information on mortality among multiple gestations complicated by premature rupture of membranes (PROM). In this study, we estimated the occurrence of the components of early mortality (stillbirth, neonatal and infant mortality) among twin pregnancies using the generalised estimating equation framework to account for intra-cluster correlations. Using the population-attributable risk, we also computed the level of excess mortality that could be averted by preventing PROM. Our findings reveal that the likelihood of stillbirth (odds ratio (OR) = 1.88; 95% confidence interval (CI)=1.66-2.13), neonatal mortality (OR=3.45; 95% CI=3.18-3.74) and infant mortality (OR=3.26; 95% CI=3.03-3.50) was significantly higher among twin pregnancies exposed to PROM. Approximately 6% of all stillbirths, 15% of neonatal mortality and 14% of infant mortality among twins in the United States are attributable to PROM. We conclude that PROM is associated with an increased level of early mortality among twins.     

Relative contribution of ovarian stimulation versus in vitro fertilization and intracytoplasmic sperm injection to multifetal pregnancies requiring reduction to twins

The proportion of twins resulting from multifetal pregnancy reduction of higher-order multiples is increased in pregnancies resulting from hormone stimulation when compared with twins following in vitro fertilization/intracytoplasmic sperm injection treatment. These reduced twin pregnancies may carry a higher perinatal risk compared with other twin pregnancies, which should be taken into account when assessing the perinatal outcome of twin pregnancies after assisted reproduction.     

Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986-1995

OBJECTIVE: The epidemiologic characteristics of unexplained stillbirths are largely unknown or unreliable. We define sudden intrauterine unexplained death as a death that occurs antepartum and results in a stillbirth for which there is no explanation despite postmortem examinations, and we present risk factors for this type of stillbirth in singleton gestations.Study Design: Singleton antepartum stillbirths (n = 291) and live births (n = 582) in Oslo were included and compared with national data (n = 2025 and n = 575,572, respectively). Explained stillbirths (n = 165) and live births in Oslo served as controls for the cases of sudden intrauterine unexplained death (n = 76) in multiple logistic regression analyses. RESULTS: One fourth of stillbirths remain unexplained. The risk of sudden intrauterine unexplained death (1/1000) increased with gestational age, high maternal age, high cigarette use, low education, and overweight or obesity. Primiparity and previous stillbirths or spontaneous abortions were not associated with sudden intrauterine unexplained death. CONCLUSIONS: Risk factors for sudden intrauterine unexplained death are identifiable by basic antenatal care. Adding unexplored stillbirths to the unexplained ones conceals several risk factors and underlines the necessity of a definition that includes thorough postmortem examinations.     

Neurological outcome of children from twin pregnancies

The neurological outcome is an important issue regarding twin pregnancies. In fact, twin pregnancy is clearly associated with an important neurological morbidity, roughly 4 times higher than singleton pregnancy. It is possible to distinguish some high-risk situations, making it possible to calculate more accurately the individual risk. The different aetiologies are analysed: hypotrophy, prematurity, malformations, prenatal occurrence of anoxic and ischemic lesions, and particularly the link with monochorionicity. The neurological outcome is mainly depending on hypotrophy and prematurity. However, the rate of long-term neurological complications is not different between twins and singletons after adjustment for term and birth weight. An increased risk of malformation is associated with twin pregnancies, essentially a high rate of abnormal neural tube closing (RR=2). Monochorionic pregnancies have a specific morbidity, not related to these aetiologies, with characteristic anoxic and ischemic lesions. Cerebral palsy is observed in 10-20% of the monochorionic pregnancies, vs 3.7% of the bichorionic ones. These complications are linked to the constant vascular anastomoses, between the circulations of the two monochorionic twins. When the twin-to-twin transfusion syndrome is severe, a poor neurological outcome is observed in 4 to 18% of the surviving children. However, this rate depends on studies, treatments, and methods of neurological evaluation. The laser destruction of anastomoses could decrease this morbidity. The stillbirth rate, either associated or not with twin to twin transfusion syndrome, is increased by monochorionicity. The death of one of the twins is associated with a 20% higher risk of neurological sequelae for the surviving co-twin.     

Perinatal outcomes with intrahepatic cholestasis of pregnancy in twin pregnancies

Objective: To describe perinatal outcomes of twin pregnancies complicated by intrahepatic cholestasis of pregnancy (ICP).

Methods: We conducted a retrospective cohort study of women delivered at a large tertiary obstetric center in Shanghai, China from January 2006 to May 2014. Delivery data were abstracted from medical records of all twin gestations delivered at the hospital.

Results: A total of 129/1922(6.7%) twin and 1190/92?273 singleton (1.3%) pregnancies were complicated by ICP. An increased risk of stillbirth among twin pregnancies was observed (3.9% and 0.8% in the ICP and non-ICP groups, respectively; aOR 5.75, 95% CI 2.00–16.6). Stillbirths with ICP and twins occurred between 33 and 35 weeks gestation compared to 36–38 weeks gestation among singletons. ICP in twins was also associated with an increased risk of preterm birth (<37 weeks) with an aOR of 4.17 (95% CI 2.47–7.04) and an aOR of 1.89 (95% CI 1.26–2.85) for delivery <35 weeks. Twin pregnancies complicated by ICP also had increased meconium staining of amniotic fluid and lower birth weight.

Conclusions: Twin pregnancies with ICP have significantly increased risks of adverse perinatal outcomes including stillbirth and preterm birth. Stillbirth occurs at an earlier gestational age in twin gestation compared to singletons, suggesting that earlier scheduled delivery should be considered in these women.     

Single intrauterine death in twin pregnancy: Evidenced-based counselling and management

Twins have a significantly higher risk of stillbirth, preterm delivery, perinatal morbidity and mortality. Single intrauterine fetal death is a relatively common and devastating occurrence for families and clinicians alike. Monochorionic twins are up to 13 times more likely to suffer an intrauterine death when compared to singletons. Additionally, longer term neurological sequelae affect monochorionic twins disproportionately. The timing of the death of the co-twin and the fetal order at the time of death have an impact on the outcome for the survivor. The risk in dichorionic pregnancies is lower with respect to neurological injury; however, the risk of prematurity remains high, particularly where the leading twin dies in utero. Recent published studies report lower rates of neurological injury in monochorionic twin pregnancies that incur an intrauterine fetal death after foetoscopic laser ablation for twin-to-twin transfusion syndrome – an important finding for patient counselling.Tweetable abstractSingle intrauterine fetal death in twins is a relatively common and devastating occurrence for families and clinicians alike. Adhering to collegiate guidelines will likely reduce but not eliminate the incidence of SIUD in twins.     

Discordant lower urinary tract obstruction in early twin gestations: management and outcome

OBJECTIVE: To report our experience with the management of twin pregnancies discordant for lower urinary tract obstruction. METHODS: Cases of twin pregnancies discordant for lower urinary tract obstruction were identified from our fetal medicine database. Information on ultrasonographic findings, antenatal course, pregnancy complications, and perinatal outcome was obtained by reviewing medical records or contacting the referring obstetricians. RESULTS: Five twin pregnancies discordant for lower urinary tract obstruction were diagnosed between 11 and 15 weeks of gestation. There were 3 dichorionic and 2 monochorionic pregnancies (1 diamniotic and 1 monoamniotic). The dichorionic pregnancies were managed conservatively, resulting in a pregnancy loss of both twins in 1 case, a single fetal death at 29 weeks in 1 case, and an early neonatal death due to lung hypoplasia of the affected twin in 1 case. On the other hand, both monochorionic twin pregnancies were managed with serial vesicocenteses. In both cases, the prenatal course was complicated, 1 by premature rupture of the membranes and the other by cord entanglement, requiring delivery at 29 and 31 weeks, respectively. Among the 4 continuing pregnancies with complete perinatal outcome, none of the affected twins survived, and the structurally normal twins were delivered between 29 and 36 weeks and discharged from the hospital in good condition. CONCLUSION: Twin pregnancies discordant for lower urinary tract obstruction are at high risk of perinatal death and premature delivery. Prenatal intervention seems not to be associated with an improved perinatal outcome of the affected twin, but it may be beneficial in selected cases to attain viability of the unaffected twin.     

Birth weight discordancy and adverse perinatal outcomes among twin gestations in the United States: the effect of placental abruption

OBJECTIVE: We evaluated whether the relationship between birth weight discordancy of twins and stillbirth, neonatal deaths, and preterm births was modified by the presence of abruption. STUDY DESIGN: We used the 1995 to 1997 matched multiple birth file for United States twin births (n = 269287). Birth weight discordancy was defined as the ratio of the difference in birth weight of the heavier from the lighter twin to that of the heavier twin and was categorized as <5%, 5% to 9%, 10% to 14%, 15% to 19%, 20% to 29%, 30% to 39%, and >or=40%. We evaluated the risks of stillbirth (>or=20 weeks of gestation), neonatal deaths (within 28 days after birth), and preterm birth (< 32 weeks) in the presence and absence of abruption. Associations between birth weight discordancy and these perinatal outcomes were expressed as adjusted relative risks and were derived from multivariable logistic regression models, based on the method of generalized estimating equations. Risk of these outcomes were derived for each stratum of birth weight discordancy and abruption status, with the <5% birth weight discordancy, nonabruption status labeled as the reference group. All analyses were performed separately for same and different sex twins. RESULTS: A birth weight discordancy of >or=20% among same sex (adjusted relative risk, 1.2; 95% CI, 1.1, 1.4), and >or=40% among different sex twins (relative risk, 2.2; 95% CI, 1.7, 2.8) conferred increased risk for abruption. Among nonabruption births, a birth weight discordancy of >or=15% among same sex and >or=30% among different sex twins increased the risk of stillbirths, neonatal deaths, and preterm births. Among abruption births, however, the risks were increased even in the lowest birth weight discordancy category (<5%). The relative risks of stillbirths and neonatal deaths among abruption births were significantly higher for each birth weight discordancy group, both for same and different sex twins, compared with the reference group. The association between birth weight discordancy and preterm birth was not modified by either the presence or absence of abruption. CONCLUSION: Birth weight discordancy of >or=15% for same sex and >or=30% for different sex confer greatest risk of adverse perinatal outcomes in the absence of abruption. In the presence of placental abruption, these risks are further compounded. The results underscore the need for careful monitoring of twin pregnancies.     

Maternal risk factors for cause-specific stillbirth and neonatal death

BACKGROUND: To study specific effects of four maternal risk factors: age, parity, educational level, smoking, for specific causes of stillbirth and neonatal death according to a previously described hierarchic classification. METHODS: The study is based on 9,785 stillbirths or neonatal deaths among infants born in Sweden, 1983-1995 (n=1,412,754) and identified with various Swedish health registers. Statistical analysis is performed using Mantel-Haenszel analysis. RESULTS: Some risk factors, known from the literature, were confirmed and could be quantified. In addition, high parity was shown to increase the risk for death associated with multiple births (OR=2.49, 95% CI 2.07-3.01) and low educational level seems to be protective for such death (OR=0.75, 95% CI 0.60-0.93). If the infant is SGA, the risk for death is higher at high than at low parity (1.70, 95% CI 1.19-2.43, and 1.0, 95% CI 1.06-1.15, respectively). Maternal smoking seems to aggravate the placental abruption because the death risk in the presence of abruption increases when the mother smoked (OR = 1.74, 95% CI 45-2.08). CONCLUSIONS: The study shows that the groups of the classification system used (NICE) differ in their association with known risk factors for stillbirth and neonatal deaths and an analysis based on specific causes of death can therefore unravel risk factors hidden when total mortality is used. The computerized method of classification and the cause-of-death classification developed by us is clearly useful for such analyses which requires large materials.     

The influence of obstetric intervention on trends in twin stillbirths: United States, 1989–99

Objective: Although twin stillbirth rates have declined substantially over the past two decades, the contribution of changes in obstetric interventions to reducing twin stillbirths has not been quantified.

Methods: We carried out a retrospective cohort study of twin live births and stillbirths in the United States between 1989 and 1999 (n?=?1?102?212). Changes in the rate of stillbirth (???22 weeks) before and after adjustment for changes in labor induction, Cesarean delivery and sociodemographic factors were estimated through ecological logistic regression analysis. This analysis was based on aggregating data by each state within the United States.

Results: Between 1989 and 1999, rates of labor induction and Cesarean delivery among twin live births increased by 138% (from 5.8% to 13.8%) and 15% (from 48.3% to 55.6%), respectively. These changes were accompanied by a 43% decline in the stillbirth rate between 1989 and 1999 (from 24.4 to 13.9 per 1000 fetuses at risk). After excluding births weighing <?500?g, rates of labor induction among twins at 22–27 weeks', 28–33 weeks' and ??34 weeks' gestation increased by 95%, 131% and 127%, respectively, between 1989 and 1999. Cesarean delivery rates also increased by 55%, 29% and 2% in these same gestational age categories. The 48% (relative risk (RR) 0.52, 95% confidence interval (CI) 0.49–0.55) decline in stillbirth rate between 1989–91 and 1997–99 was reduced to a 25% (RR 0.75, 95% CI 0.72–0.79) decline after adjustment for changes in labor induction and Cesarean delivery. The decline in the rate of twin stillbirths was larger at later gestational ages (at ??32 and ??34 weeks) where the largest absolute increases in labor induction rates were observed.

Conclusions: The use of Cesarean delivery and especially labor induction for twin pregnancies has increased substantially in the United States over the last decade and these changes have been associated with a large decline in the rate of stillbirth among twins.     

Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies

OBJECTIVE: This study was undertaken to estimate the cumulative risk of perinatal death associated with delivery at each gestational week both at term and post term. STUDY DESIGN: The numbers of antepartum stillbirths, intrapartum stillbirths, neonatal deaths, and surviving neonates delivered at between 37 and 43 weeks' gestation in Scotland, 1985-1996, were obtained from national databases (n = 700,878) after exclusion of multiple pregnancies and deaths caused by congenital abnormality. The numbers of deaths at each gestational week were related to appropriate denominators: antepartum stillbirths were related to ongoing pregnancies, intrapartum stillbirths were related to all births (excluding antepartum stillbirths), and neonatal deaths were related to live births. The cumulative probability of perinatal death associated with delivery at each gestational week was estimated by means of life-table analysis. RESULTS: The gestational week of delivery associated with the lowest cumulative risk of perinatal death was 38 weeks' gestation, whereas the perinatal mortality rate was lowest at 41 weeks' gestation. The risk of death increased more sharply among primigravid women after 38 weeks' gestation because of a greater risk of antepartum stillbirth. The relationships between risk of death and gestational age were similar for the periods 1985-1990 and 1991-1996. CONCLUSION: Delivery at 38 weeks' gestation was associated with the lowest risk of perinatal death.     

Stillbirth Associated With Birth Weight Discordance in Twin Gestations

Objective

Stillbirth is an important adverse outcome associated with twin pregnancy. We aimed at investigating the association between birth weight discordance (BWD) and stillbirth.

双胎妊娠一胎宫内死亡34例临床分析

目的:探讨双胎妊娠一胎宫内死亡的原因、临床处理及预后。方法:回顾性分析2005年1月至2009年12月,我院双胎妊娠一胎宫内死亡34例患者的临床资料。结果:双胎妊娠一胎宫内死亡占我院双胎妊娠的5.2%,34例中单羊膜囊双胎3例,单绒毛膜双胎23例,双绒毛膜双胎8例;及时终止妊娠23例(单羊膜囊双胎均及时终止妊娠),期待治疗11例,平均期待时间单绒毛膜双胎为4.7±5.6周,双绒毛膜双胎为8.6±1.2周;单绒毛膜双胎发现死胎时的孕周、分娩孕周及存活儿的出生体重均小于双绒毛膜双胎。除引产外的30例存活儿发生围生儿死亡6例,随访24例存活新生儿中,2例失访,22例随访中发生脑瘫(四肢瘫,语言障碍)3例,存在其他脑损害(语言或运动发育延迟)4例,余健康存活。结论:单绒毛膜双胎更易发生双胎妊娠一胎宫内死亡,绒毛膜性质和孕周是影响围生儿结局和远期预后的重要因素,存活儿无胎儿窘迫,孕妇无严重妊娠并发症及合并症情况下,期待治疗是一种有效的处理方式。     

Obstetric and neonatal risk of pregnancies after assisted reproductive technology: a matched control study

BACKGROUND: The aim of the study was to evaluate the obstetric and neonatal outcome of pregnancies after assisted reproduction technology (ART) in comparison with matched controls from spontaneous pregnancies. METHODS: A total of 12 920 deliveries at the Department of Obstetrics and Gynecology, University of Szeged, from 1 January 1995 to 31 December 2001 were subjected to retrospective analysis. Two hundred and eighty-four singleton, 75 twin and 17 triplet pregnancies after ovulation induction (n = 114; 30.3%), intrauterine insemination (n = 33; 8.8%) and in vitro fertilization (n = 229; 60.9%) were evaluated. The pregnancy outcome of the singleton and twin pregnancies was compared with that for controls matched with regard to age, gravidity and parity and previous obstetric outcome after spontaneous pregnancies. RESULTS: Twenty-four percent of the assisted reproductive pregnancies were multiple pregnancies. The incidences of singleton intrauterine growth retardation (IUGR) and preterm birth were reasonably similar to those among the controls (IUGR: 6.3% vs. 4.2%; preterm births: 13.0% vs. 9.9%, for the cases and the controls, respectively). As compared with the controls, there was an increased incidence of cesarean section among the singleton (41.2% vs. 34.5%, p = 0.12; OR 1.33; 95% CI 0.95-1.87) and twin assisted reproduction pregnancies (66.7% vs. 60.0%), but without significant differences. CONCLUSIONS: Increased obstetric risk could be observed concerning threatened preterm delivery and cesarean section rate in the study group. The perinatal outcome of singleton and twin pregnancies following assisted reproductive techniques is comparable with that of spontaneously conceived, matched pregnancies.     

Perinatal mortality in twin pregnancies: a 3-year analysis in Seine Saint-Denis (France).

OBJECTIVES: Our purpose was to evaluate perinatal mortality in twins and to investigate factors associated with this mortality. STUDY DESIGN: A prospective study on the perinatal mortality was performed in the department of Seine-Saint-Denis. Out of all the perinatal deaths, we have retrospectively isolated those arising from twin pregnancies. RESULTS: There were 54 twin pregnancies complicated with perinatal death. The perinatal mortality rate in twin pregnancy was 78.0 per 1000 twin babies delivered. Out of 86 twin deaths, 38 (44.2%) were born before 28 weeks gestation and out of 82 twin perinatal deaths, 37 (45.1%) weighed less than 1000 g. Chorionicity was recorded in 44 twin pairs: 21 (47.7%) were dichorionic and 23 (52.3%) monochorionic. Finally, out of 48 twin sets there were four (8.3%) monoamniotic pregnancies. CONCLUSIONS: The present data show that extreme prematurity represents nearly half of perinatal mortality in twins. This study indicates also a significant proportion of monochorionic placentation among twin pregnancies with poor outcome.     

Fetoscopic surgery in triplet pregnancies: a multicenter case series

OBJECTIVE: The purpose of this study was to evaluate the feasibility of fetoscopic surgery in complicated monochorionic and dichorionic triplet pregnancies. STUDY DESIGN: This was a case series of fetoscopic surgery in 12 cases of monochorionic (n = 5) or dichorionic (n = 7) triamniotic triplets complicated by severe feto-fetal transfusion (n = 8), twin reversed arterial perfusion sequence (n = 3), or discordant for an anomaly (n = 1). Six underwent cord occlusion, and 6 had laser coagulation of the vascular anastomoses. RESULTS: All procedures were successfully completed, and the outcome was comparable to that reported for similar procedures in twins. Eighty-three percent of fetuses survived, and 13% had long-term problems. CONCLUSION: Fetoscopic surgery may be considered as a therapeutic option in complicated triplet pregnancies, with results similar to those found in twins.     

Racial disparity in stillbirth among singleton, twin, and triplet gestations in the United States

OBJECTIVE: We investigated the relationship between maternal race and stillbirth among singletons, twins, and triplets. METHODS: We conducted a retrospective cohort study on 14,348,318 singletons, 387,419 twins, and 20,953 triplets delivered in the United States from 1995 through 1998. We compared the risk of stillbirth between pregnancies of black and those of white mothers using the generalized estimating equations framework to adjust for intracluster correlation in multiples. RESULTS: The proportion of black infants was 16%, 18%, and 8% among singletons, twins, and triplets, respectively. Crude stillbirth rate among singletons was 6.6 per 1,000 and 3.5 per 1,000 for black and white fetuses, respectively. Among twins, 796 stillbirths (11.6 per 1,000) were recorded for black mothers versus 3,209 stillbirths (10.1 per 1,000) among white mothers, whereas among triplets there were 233 stillbirths, of which 39 stillbirths were black fetuses (24.6 per 1,000) and 194 stillbirths were white fetuses (10.0 per 1,000). Black singletons, twins, and triplets weighed 278 g, 186 g, and 216 g less than white fetuses, respectively (P <.001). Risk of stillbirth was elevated in black fetuses compared with white fetuses among singletons (adjusted odds ratio [OR] 2.9, 95% confidence interval [CI] 2.8-3.0) and twins (OR 1.3. 95% CI 1.2-1.4) but comparable among triplets (OR 1.2, 95% CI 0.7-2.1). This decreasing trend was significant (P for trend <.001). CONCLUSION: The disparity of stillbirths between black and white fetuses still persists among singletons and twins. Among triplet gestations, however, the 2 racial groups have a comparable risk level. Our findings highlight the need for a rigorous research agenda to elucidate causes of stillbirth across racial/ethnic entities in the United States. LEVEL OF EVIDENCE: II-2