DOI: 10.1111/j.1471-0528.2007.01328.

Epidemiology

www.blackwellpublishing.com/bjog

Variation in rates of postterm birth in Europe:

reality or artefact?
J Zeitlin,a B Blondel,a S Alexander,c G Breartb and the PERISTAT Group
a INSERM, UMR S149, Epidemiological Research Unit on Perinatal and Womens Health, Paris, France, b Ho
pital Tenon, Universite Pierre et Marie
Curie-Paris 6, Paris, France, c Reproductive Health Unit, School of Public Health, Universite Libre de Bruxelles, Brussels, Belgium
Correspondence: Dr J Zeitlin, INSERM U149, Site St Vincent de Paul, 82 av. Denfert Rochereau, 75014 Paris, France.
Email zeitlin@cochin.inserm.fr

Accepted 5 February 2007. Published OnlineEarly 6 July 2007.

Objective To compare rates of postterm birth in Europe.

Design Analysis of data from vital statistics, birth registers, and

national birth samples collected for the PERISTAT project.

Setting Thirteen European countries.
Population All live births or representative samples of births for

the year 2000 or most recent year available.

Methods Comparison of national and regional rates of postterm

birth. Other indicators (birthweight, deliveries with

a non-spontaneous onset and mortality) were used to assess the
validity of postterm rates.
Main outcome measures The proportion of births at 42
completed weeks of gestation or later.
Results Postterm rates varied greatly, from 0.4% (Austria,
Belgium) to over 7% (Denmark, Sweden) of births. Higher
postterm rates were associated with a greater proportion
of babies with birthweight 4500 g or more. Fetal and early neonatal

mortality rates were higher among postterm births than

among births at 40 weeks. Countries with higher proportions of
births with a nonspontaneous onset of labour had lower postterm
birth rates. The shapes of the gestational-age distributions
at term varied. In some countries, there was a sharp cutoff in
deliveries at 40 weeks, while elsewhere this occurred at
41 weeks.
Conclusions These results suggest that practices for managing

pregnancies continuing beyond term differ in Europe and raise

questions about the health and other impacts in countries with
markedly high or low postterm rates. Some variability in these
rates may also be due to methods for determining gestational age,
which has broader implications for international comparisons of
gestational age, including rates of postterm and preterm births and
small-for-gestational-age newborns.
Keywords Gestational age distribution, perinatal health indicators,

postterm births.

Please cite this paper as: Zeitlin J, Blondel B, Alexander S, Breart G and the PERISTAT Group. Variation in rates of postterm birth in Europe: reality or artefact?
BJOG 2007;114:10971103.

Introduction
Babies born postterm, defined as a gestational age of 42 completed weeks and over, are at higher risk of poor perinatal
outcome.1 Accordingly postterm birth rates are commonly
proposed as an indicator for monitoring perinatal health.
Management of prolonged pregnancy usually follows one of
two general approaches: proposing induction to all pregnant
women before they reach 42 weeks of gestation or close monitoring of pregnancy after 41 weeks with selective induction in
case of fetal distress or a favourable Bishop score. A policy of
systematic induction appears to reduce the caesarean rate and
may be associated with a reduced perinatal mortality rate, but
not all studies are concordant.2,3 Systematically proposing
induction is a long-standing policy in many countries, includ-

ing France and Canada;2,4 in 2004, the American College of

Obstetricians and Gynecologists updated their guidelines to
promote a policy of systematic induction more actively but
recommended that women with unfavourable cervixes can
undergo labour induction or be managed expectantly.5
Studies from Australia, Canada, and the USA report recent
rates of births after 41 weeks of gestation,68 but European data
on these rates are not available. This analysis uses populationlevel data on gestational age to compare rates of births at 42 weeks
of gestation or later in European countries; these data were
collected as part of the PERISTAT project on perinatal health
indicators. Our aim is to describe postterm birth rates and to
compare current practices for postterm pregnancies in Europe.
Comparing postterm rates brings up the question of
how gestational age is determined. Using the date of the last

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1097

Zeitlin et al.

menstrual period (LMP) instead of ultrasound to date pregnancies increases the proportion of pregnancies reported as
postterm, in particular because LMP calculations assume that
ovulation occurs 14 days after the first day of the menstrual
period for all women, when actual cycle length varies considerably and is on average longer than 28 days.911 We address
this question by using other national-level indicators, including birthweight, induction practices, and gestation-specific
mortality to validate reported postterm rates.

Methods
Data come from the European PERISTAT I project, which
aimed to develop a recommended indicator set to describe
and to monitor perinatal health in Europe.12 These indicators
concerned child and maternal health, risk factors, and medical practices. The project also undertook a feasibility study in
the statistical offices and health departments of the participating countries to assess whether the recommended indicators could be collected with the definitions proposed. A
questionnaire was developed that requested data in the form
of numbers of events (births or deaths) for each indicator.
Participants were asked to provide national data for their
country, insofar as possible. Where data were not available
for all parts of a country, but population-based data were
available from one or more regions, these data could be
provided instead. The data used in this analysis came from
sources listed in the Appendix.
For this analysis, we used gestational age data, which were
requested according to week of gestation separately for live
births and stillbirths, as well as for singleton and multiple
births. Multiple births were excluded from the analysis. The
data collection instrument included a question asking how
gestational age was determined. Most providers stated that
it represented the obstetric estimate in the medical records
or that they did not know. The analysis includes data on
gestational-age distribution in Austria, Belgium (both the
Flanders region and the French community), Denmark,
Finland, France (data from the national perinatal survey,
a sample survey of 1 week of births in France), Germany (9
Bundeslander), Ireland, Italy, Luxembourg, the Netherlands,
Portugal, Sweden, and Northern Ireland and Scotland from
the UK. Data from Portugal were not available for multiples
and singletons separately, so all births were included in this
analysis. Portugal also provided data by gestational-age
groups rather than by week of gestation. Data cover the year
2000, except for France and Italy, whose data date from 1998,
the Netherlands (1999), and Austria (2001).
This analysis also considered the following additional indicators: the proportion of live births with a birthweight of
4500 g or more, the proportion of term deliveries with a nonspontaneous onset (i.e. induction of labour or caesarean section before labour), gestational-age-specific fetal mortality,

1098

early neonatal mortality at term and postterm, and the general

distribution of term births by gestational age. Not all countries
could provide information on mode of onset of labour. For
Luxembourg, data on mode of onset were available only for all
births and did not distinguish preterm from term or postterm
births. The gestational-age-specific stillbirth rate was computed as the number of fetal deaths at a given week of gestation
over the number of fetuses in utero at the start of that week.13,14
The gestational-age-specific risk of early neonatal death (<7
days) was calculated for all live births occurring that week. To
test associations between country-level variables, we used nonparametric Spearman rank correlation coefficients.

Results
Table 1 presents pregnancy outcomes for singleton live births in
the countries and regions contributing to the study. Postterm
rates varied widely, ranging from 0.4% (Austria, Belgium) to
over 7% (Denmark, Sweden) of all births. The proportion of
babies with a birthweight of 4500 g or more varied from less
than 1% (Belgium, France, Italy, Luxembourg, and Portugal) to
more than 3% (Denmark, Finland, Ireland, and Sweden).
Countries with higher postterm rates also had a higher proportion of babies weighing 4500 g or more, as shown by the correlation between these indicators (rank correlation coefficient,
rho = .76, P = .001, n = 15). The rate of nonspontaneous onset
of labour at term ranged from about 15% in Denmark and
Sweden to more than 40% in Flanders, Luxembourg, and
Northern Ireland. We also observed an association between
the postterm rates and nonspontaneous onset of labour at term
among the countries that could provide this indicator (rank
correlation coefficient, rho = .78, P = .008, n = 10).
In the five countries with a postterm birth rate of 4% or
higher (Denmark, Finland, Ireland, the Netherlands, and
Sweden), we studied gestational-age-specific mortality to
assess whether postterm births were at higher risk for unfavourable outcomes (Table 2). Analyses by country were not
possible because of the small number of births after 41 weeks.
Both fetal and neonatal mortality were higher at 42 than at 40
weeks of gestation; differences were statistically significant as
shown by the nonoverlapping confidence intervals.
Figure 1a,b shows the gestational-age distribution at and
after term for the five countries with postterm rates of 4% or
more and for the five countries with postterm rates of 1.5% or
less. In most countries with a relatively high postterm rate,
especially Denmark, the Netherlands, and Sweden, and to
a lesser extent Finland, the distribution of gestational ages
at term had a similar shape. Ireland, in contrast, exhibited
a more marked peak at 40 weeks. The shape of the gestational-age distribution varied more for the countries and
regions with a lower postterm rate. In particular, the proportion of births at 41 weeks varied considerably: in some countries, there was a sharp cutoff in deliveries at 40 weeks, and

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Postterm births in Europe

Table 1. Pregnancy outcome for singleton live births in European countries participating in the PERISTAT I project
Country

Austria
Belgium (Flanders)
Belgium (French community)
Denmark
Finland
France (national survey)
Germany (9 Bundeslander)
Ireland
Italy
Luxembourg**
Netherlands
Portugal***
Sweden
UK: Northern Ireland
UK: Scotland
Rank correlation with postterm
birth rate (P value)

Total births

73 122
59 624
42 779
64 469
54 753
13 133
538 407
52 554
520 620
5275
192 621
120 071
86 583
21 045
50 683

Postterm rate
( 42 weeks of gestational age)

Births with
weight 4500 g

Term births
with nonspontaneous onset*

95% CI

95% CI

0.4
0.6
0.4
8.1
4.4
1.2
2.3
6.7
2.7
0.9
5.2
2.1
7.5
1.5
3.0

0.40.4
0.50.7
0.30.5
7.98.3
4.24.6
1.01.4
2.32.3
6.56.9
2.72.7
0.61.2
5.15.3
2.02.2
7.37.7
1.31.7
2.93.1

1.1
1.0
0.6
4.3
3.4
0.8
1.7
3.1
0.7
0.8
2.4
0.8
4.4
2.5
2.1
.76 (.001)

1.11.2
0.91.1
0.50.7
4.14.5
3.23.6
0.61.0
1.71.7
3.03.2
0.70.7
0.61.0
2.32.5
0.70.9
4.34.5
2.32.7
2.02.2

n/a
41.2
39.7
15.0
21.1
28.4
24.1
n/a
n/a
43.4
n/a
n/a
15.5
46.1
34.8
2.78 (.008)

95% CI

40.841.6
39.240.2
14.715.3
20.821.4
27.629.2
24.024.2

42.144.7

15.315.7
45.746.5
34.235.4

n/a, not available.

*Induced delivery or caesarean section before the onset of labour.
**Induction practices for all births, including preterm births.
***All births, including multiples.

elsewhere at 41 weeks. The percentage of births at 37 weeks

also varied more, ranging from 5 to 10% in countries with low
postterm rates and from 5 to 7% in the countries with a higher
postterm rate. Finally, the gestational-age curve in Austria
showed a marked shift to the left with a mode at 39 weeks.

Discussion
This analysis documented a large variation in postterm birth
rates in European countries: from a low of 0.4% to a high of
8%. We also found significant correlations between the postterm rate and other national- and regional-level indicators
that we expected would vary with the postterm rate. There
was a strong correlation between rates of postterm births and
of birthweights over 4500 g, which is consistent with studies
showing that high-birthweight babies are more common
among births after 41 weeks.15 Fetal and early neonatal mortality were higher among babies born at 42 weeks and later
compared with those born at 40 weeks in the five countries
with the highest postterm rates, as observed generally in studies of postterm babies.1 Finally, the proportion of deliveries
with a nonspontaneous onset was also significantly correlated
with the postterm rate in countries that could provide these
data, which shows that lower postterm rates were associated
with medical intervention. These results suggest that Euro-

pean countries differ significantly in their policies and practices for managing pregnancies that continue past term. This
interpretation is concordant with other studies that have
documented marked differences in the management of pregnancy and delivery in Europe.1619
Before we reach this conclusion, however, we must consider
to what extent differences in the measurement of gestational
age explain the variability between countries. A large literature
shows that the methods used to determine gestational age
influence the postterm rate. Postterm rates based on LMP are
about 3.5 times higher than postterm rates based on ultrasound
measures alone.9,11,20,21 Studies show that when ultrasound is
used to establish gestational age, its distribution shifts to the
left. Ultrasound use also results in fewer errors associated with
poor recall or irregular cycles. Since these errors are proportionally more important at the extremes of the distribution,
their reduction also contributes to a decrease in births recorded
as postterm. Randomised trials and observational studies both
report that the use of early ultrasound dating reduces induction
for postterm and the proportion of births that occur at 42
weeks and after,22,23 although one trial found no such difference.24 Other differences in the way that gestational age is
determined, such as rounding up instead of using completed
weeks25 or the use of different ultrasound curves,26 may also
affect estimates.

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Zeitlin et al.

Table 2. Stillbirth rates in each week per 1000 undelivered fetuses at the beginning of the week and rate of neonatal deaths per 1000 live births
in countries with a postterm rate of 4% or more*
Week of Fetuses undelivered Stillbirths
Stillbirth rate
gestation
at beginning
that week
per 1000
of week
undelivered fetuses
37
38
39
40
41
421

426 926
404 048
345 682
242 972
112 440
27 814

147
160
187
192
139
44

0.34
0.40
0.54
0.79
1.24
1.58

95% CI

0.290.40
0.330.46
0.460.62
0.680.90
1.031.44
1.112.05

Live births Early neonatal Early neonatal

deaths
deaths per 1000
(<7 days)
live births
22 731
58 206
102 523
130 340
84 487
27 770

61
87
89
86
73
37

2.68
1.49
0.87
0.66
0.86
1.33

95% CI

2.013.36
1.181.81
0.691.05
0.520.80
0.671.06
0.901.76

Births with unknown gestational age are excluded (n 5 1353 live births, 17 fetal deaths, and nine early neonatal deaths). At 43 weeks, there were
two fetal deaths, three neonatal deaths, and 1490 live births; these were combined with 42 weeks because of the large confidence intervals
around the mortality estimates.
*Denmark, Finland, Netherlands, Sweden, and Ireland.

There are several reasons to believe that the observed variation is not solely due to methods for determining gestational
age. First, the use of ultrasound for dating pregnancies is
a routine part of antenatal care in European countries, even
those with high postterm rates. A study of Swedish maternity
units found that all units routinely used ultrasound to date

(a)

40,0%
35,0%
30,0%
25,0%
20,0%
15,0%
10,0%
5,0%
0,0%
37
Denmark

(b)

38

39

Finland

40
Ireland

41

42

Netherlands

43
Sweden

40,0%
35,0%
30,0%
25,0%
20,0%
15,0%
10,0%
5,0%
0,0%
37
Austria

38
Be: Flanders

39

40
Be: French

41
France

42

43

UK:N Ireland

Figure 1. (a) Gestational-age distribution at term in countries with

a postterm rate of 4% or higher and (b) 1.5% or lower.

1100

pregnancies by the early 1990s.27 In Denmark, in a study of

postterm births before 1994,28 almost all the women were
offered ultrasound in cases where LMP was uncertain, and
a 1995 study of ultrasound use found that 93% of all women
had at least one ultrasound scan during pregnancy, and 74%
before 21 weeks.29
Second, even systematic use of ultrasound to date pregnancies would not result in postterm rates close to zero, as we
observed in several countries, unless they also had an active
policy to induce postterm births. Studies comparing ultrasound to LMP for pregnancy dating9,11,20,21 showed that use
of ultrasound alone yielded postterm rates from 2 to 3.5% in
North American, British, and Finnish populations. When a
7-day rule is used, i.e. gestational age is adjusted if there is
more than a 7-day discrepancy with the LMP estimate, rates
of postterm vary from 2.5 to 4.5%. In all these observational
studies, the rates of postterm births reflect decisions made by
obstetricians to induce delivery for prolonged pregnancy, as
well as the methods used to determine gestational age.
The comparison of gestational-age distributions provides
further evidence that real differences exist between countries.
Inductions for prolonged pregnancy should lead to an increase
in deliveries at 41 weeks,30 whereas systematic use of ultrasound
leads to an overall shift of the distribution to the left and
a decrease in extreme values. The curve of the gestational-age
distributions in countries with a high postterm rate was bell
shaped and started to decline gradually at 40 weeks. It, thus,
differed from the curve in countries with a lower postterm rate,
where there was a clear drop-off at either 40 or 41 weeks.
Nonetheless, the shapes of these distributions also raise questions about measurement differences: for instance, compared
to other countries, the curve in Austria was shifted to the left, as
might be predicted by consistent use of ultrasound for dating,
while the curve in Ireland had a peak at 40 weeks of gestation,
which might be suggestive of lumping at 40 weeks. While all

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Postterm births in Europe

countries may use ultrasound routinely in antenatal care, the

use of information from ultrasound to determine gestational
age may well differ. For example, one factor that may affect use
of ultrasound information is its timing. Obstetricians may be
more willing to make changes to gestational-age estimates after
very early ultrasound. One randomised study from the USA
comparing first versus second trimester ultrasound found that
41% of women randomised to the first trimester group had
their estimated date of confinement (EDC) adjusted; the rule
for adjustment was to change the EDC if the LMP and ultrasound estimates differed by 5 days or more. In the group
assigned to a second trimester scan, a 10-day rule was used
and resulted in adjusting 11% of estimates.22 A Swedish study
on practices before the universal adoption of ultrasound found
that 31% of women receiving care in hospitals offering routine
ultrasound dating had their EDC adjusted, with interhospital
differences of 18 to 65%.27 A more recent randomised study,
however, only found that 5.7% of women receiving a scan
between 8 and 12 weeks had their dates readjusted with a
5-day decision rule.24 To our knowledge, there are no comparative studies on how ultrasound scans are used for dating
pregnancies within or between countries in Europe.
Disentangling the issue of measurement from that of
obstetric practices may not be possible since decisions to
induce delivery or to plan a caesarean section depend on
the accuracy of the gestational-age estimate. An obstetrician
would be more likely to induce delivery at 41 weeks if it is
determined by ultrasound early in pregnancy than if gestational age is uncertain or if the ultrasound is done later, when
the margin of error is larger. Furthermore, reliance on ultrasound alone to date pregnancies may be more common in
more medicalised contexts where induction or planned caesareans are more common anyway.
The differences in postterm rates raise questions about
potential health and other impacts. We found that babies born
at 42 weeks or later in countries with a relatively high postterm
rate had higher fetal and neonatal mortality than babies born
at 40 weeks of gestation. This finding suggests that more active
management of these pregnancies might help lower mortality
in these countries. A study from a region in Norway with
a postterm rate of 7.6% reached a similar conclusion after
documenting excess mortality, lower Apgar scores, and more
neonatal intensive care admissions among postterm babies.31
Studies in the USA and Canada have linked increasing induction of labour at term to declining fetal mortality rates.30,32
However, an assessment of these practices must include all
pregnancies, as more active policies to induce postterm pregnancies tend to be associated with more active intervention
for all pregnancies. Several recent studies report that decreasing postterm rates are accompanied by a shift to the left of the
gestational-age distribution and a concomitant increase in the
proportion of elective caesarean deliveries and inductions of
labour at 38 and 39 weeks as well as late preterm births.6,8 We

also observed a higher proportion of deliveries at 37 weeks in

some countries with low postterm rates than in those with
high postterm rates. A valid health assessment of these practices must, therefore, include all births. This analysis was
not possible with our country-level data as we could not
control for known demographic, socio-economic, and medical
factors that influence perinatal mortality and which vary
between the countries in this study. Other trade offs, related
to the resources used for induction of deliveries, the potential
complications of inductions, and planned caesareans,2 as well
as womens preferences about the onset of delivery, should
also be considered in evaluations of these practices.33,34
Our data come from birth registers at the regional or national
level and thus provide limited possibilities for pursuing these
questions. We feel that our results underscore the value of these
data, which can provide valuable insights, especially when they
reveal marked variation in outcomes or practices. The analysis
of routine birth or medical registers cannot substitute for specific epidemiological studies where preexisting protocols avoid
the pitfalls of measurement error and unavailable data on key
confounders; however, it does provide a context for assessing
practices and helps to frame questions for future research.

Conclusion
We conclude from these data and our review of the literature
that differences between European countries in the proportion of births after 41 weeks represent more than a measurement artefact. These results raise questions about the impact
of these differences on maternal and child health, resource
use, and womens experiences of delivery in European countries. However, we also believe that some of the variability
reflects differences in the measurement of gestational age,
although we were unable to assess the magnitude of this effect
in this study. Key perinatal health indicators are based on
gestational age; these include not only the postterm rate but
also the preterm birth rate and the proportion of small-forgestational-age births.35 Further research on practices for
determining gestational age and on how these practices affect
the gestational-age distribution is essential for comparisons of
these indicators between countries and perhaps between
regions or even maternity hospitals within countries.

The PERISTAT group

Steering committee
J Zeitlin, K Wildman, G Breart, France (project coordinators);
S Alexander, Belgium; H Barros, Portugal; B Blondel, France;
S Buitendijk, the Netherlands; M Gissler, Finland; A Macfarlane, UK.

Scientific advisory committee

C Bakoula, Greece; F Bolumar, Spain; J Bottu, Luxembourg;
S Cnattingius, Sweden; M Cuttini, Italy; P Defoort, Belgium;

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Zeitlin et al.

J-B Gouyon, France; L Krebs, Denmark; W Kunzel, Germany;

N Lack, Germany; M Langer, Austria; J Langhoff-Roos,
Denmark; G Lindmark, Sweden; S Marchant, UK; N Montenegro, Portugal; F Morcillo, Spain; M Newburn, UK; JG Nijhuis, the Netherlands; S Prati, Italy; A Staines, Ireland; M
Virtanen, Finland; N Vitoratos, Greece; C Vutuc, Austria; Y
Wagener, Luxembourg.

Acknowledgement
The PERISTAT study was partially funded by the Directorate
for Health and Consumer Protection (DG-SANCO) of the
European Commission. j

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Postterm births in Europe

Appendix. Data sources used for constructing tables

Country

Coverage (if not national)

Austria
Belgium

Flanders

Belgium
Denmark
Finland
France
Germany
Ireland
Italy

French Community

Representative sample
9 Bundeslander**

Luxembourg
Netherlands

Portugal
Spain
Sweden
UK

Scotland

UK

Northern Ireland

Data source*
Statistics Austria
SPE (Studiecentrum voor
Pernatale Epidemiologie)
ONE (Office de la Naissance et de lEnfance)
Danish perinatal database
Medical birth registrySTAKES
National Perinatal Survey
BAQperinatal survey
National Perinatal Reporting System
ISTAT, Civil birth and death registration.
Discontinued in 1998
FIMENA 2000
Merged database from professional registers. Landelijke
Verloskunde Registratie (National Perinatal Register):
data on course of pregnancy and delivery. Landelijke
Neonatologie Registratie (National Neonatology Register):
diagnoses of the child, duration of hospital stay, treatments
Estatisticas Demograficas,Estatisticas de Saude, INE,
Instituto Nacional de Estatistica
National Institute for Statistics (INE)
Medical Birth Register
Information and Statistics Division, SMR2 Maternity
Discharge Sheet
Perinatal Information, Northern Ireland, aggregated
data from child health systems

Year
2001
2000
2000
2000
2000
1998
2000*
1999
1998
2000
1999

1999
1999
2000
2000
2000

*More detail on data sources available in Macfarlane et al.13

**Bayern, Baden-Wurttemberg, Berlin, Hessen (data from 2001), Niedersachsen and Bremen, Nordrhein, Sachsen, Thuringen, Westfallen-Lippe,
representing 72.6% of all births.

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