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Large computer databases in general practice.

quarters ofthose expecting quadruplets were initially admitted for rest alone. Women varied in their views about such a policy, some feeling reassured, others feeling anxious and stressed -particularly about the effects on their families. The report highlighted the costs to the NHS and their families of admission, an intervention without evidence of benefit. Most reviews of managing triplet pregnancy concentrate on relating outcome to the mode of delivery.315 No consensus, however, has been reached about the optimum method as controlling for confounding variables, particularly gestational age, is difficult. In several studies only those women whose labours began very early were allowed to deliver vaginally. Although not helping to resolve this controversy, the survey by the Office of Population Censuses and Surveys highlighted the need for systematic evaluation of caesarean section. It also suggested open discussion with parents about the mode of delivery, likely neonatal problems, and possible outcomes. Multiple births are likely to be more complicated and to occur at even earlier gestational ages than twins. Birth weights in this survey were similar to those described 40 years agothat is, the more fetuses present the more likely they were to weigh less than 1500 g at birth.6 These very low birthweight infants require long periods of neonatal intensive care, which puts parents under severe strain. The report considers that liaison between hospitals, primary care, and social services could be improved. Better support-both advice and practical aid-could be provided, and this needs coordinating by someone other than the parents, which usually occurs at present. About 5% of triplets in this review had a congenital malformation. (Although high, this figure is not directly comparable with national data.) Also of concern is the increased prevalence of cerebral palsy and general ill health and disability in childhood. Because of the design of the follow up questionnaire and responses the authors believe that they have underestimated the size ofdevelopmental problems. They call for further long term follow up studies to assess physical and mental handicap and educational problems. Finally, the cost to the NHS is calculated-: each set of twins costs £5000, each set of triplets £12 000, and each set of quadruplets £25 000. Some 60% of the estimated cost is for neonatal care, and 20% is for antenatal care in hospital. The cost to parents of having three or more children at once is greater than having them in succession. Selective reduction in the first trimester has been suggested as an alternative management in higher order multiple births7 but raises difficult legal and ethical issues.8 Preventing high order multiple pregnancies is clearly the best option given the high costs to mothers, babies, and services. The onus is therefore on those treating infertility to keep multiple births to a minimum.