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Objective To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials. Design Observational study over 15 months (2001–02). Setting Four district hospitals in southeast England. Population Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women. Methods Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs. Main outcome measures NHS mean costs of antenatal and obstetric care for different types of pregnancy. Results A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54–55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (£1,153) and multiple pregnancy (£1,048) were nearly double the costs for other two groups ( P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (£3,393) was £1,000 greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (£4,442) and for women with diabetes (£4,877). Conclusions Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate. [ABSTRACT FROM AUTHOR]