The impact of multiple preterm births on the family

Elizabeth Bryan

Multiple births are important contributors to the preterm and low birthweight population and the numbers oftwin births have been steadily rising since the early 1980s in all developed countries. This is largely due to theincreased use of ovulation induction and multi-embryo transfer in the treatment of subfertility. Parents ofpreterm twins have been shown to be less responsive to their infants than those with singletons. Parental stresswith twins has also been demonstrated by the higher incidence of maternal depression and of child abuse inmultiple birth families. Furthermore, siblings of twins are more likely to have behaviour problems. Mortalityand long-term morbidity rates are greatly increased amongst multiple birth children. The problems of thesingle surviving twin and the unaffected co-twin of a disabled child are often underestimated as is thecomplexity of the bereavement of parents who still have surviving multiples. Addressing the cause ofthe epidemic of iatrogenic multiple births is likely to be the single most effective way to reduce the number ofpreterm infants and the long-term problems to which they are prone.

INTRODUCTION

Multiple births are increasingly large contributors to the

preterm and low birthweight population. The average

duration of pregnancy is 37 weeks for twins, 33.5 for

triplets and 31.5 for quads. About 40% of twins and nearly

all triplets and quads are born preterm (<37 weeks). Fifty

percent of twins, 90% of triplets and nearly all quads have a

birthweight of less than 2500 g. Half of the quadruplets

weigh less than 1500 g compared to a quarter of triplets, 1

in 10 twins and 1 in a 100 singletons1.

Several studies have found that in-vitro fertilisation (IVF)

twin infants have a still greater tendency to prematurity and

low birthweight than those that are naturally conceived2.

Concerning twin births in general, the incidence has

been steadily increasing in all developed countries, since

the early 1980s3,4. In the UK, it has risen from 9.0 to 14.2

per 1000 births in 2000. The incidence of triplets has been

rising much faster still and in the UK has quadrupled in the

last 15 years5.

The increase in multiple births is largely due to the

widespread use of poorly monitored ovulation induction

and to multiple-embryo transfer in the treatment of sub-

fertility. East Flanders in Belgium is the only region that

has so far provided accurate population-based data on the

origin of all multiple births6. In most countries, accurate

data on conception are only available for those multiple

births that arise following IVF or gamete donation. The

most recent Annual Report of the UK’s Human Fertilisation

and Embryology Authority showed 27.3% of pregnancies

following IVF were multiple births of which 3.3% were

triplets. After micromanipulation and donor insemination,

26.9% and 6.4% were multiple births, respectively7.

Due to the complications of preterm delivery and low

birthweight, the perinatal mortality and long-term morbid-

ity rates are substantially increased compared with single

born children, with IVF multiples being at greater risk than

those spontaneously conceived7,8.

Population studies have shown a three to seven-fold

higher incidence of cerebral palsy in twins compared to

singletons and over 10-fold higher in triplets9. The highest

rate of cerebral palsy being in surviving children whose co-

twin or triplet died in utero9,10. The chances of any

particular multiple pregnancy producing a bereaved family

or a disabled child are of course much greater still9,11.

Couples who have tried for years to have a child could

think they would be lucky to acquire two or even three at

once — and hence an instant family. They could well

picture two or three healthy, happy children. They would

rarely picture the medical risks to the children or to the

mother herself. Even less would such couples recognise the

practical, financial and emotional stresses that are likely to

result from having to cope with two or more children of the

same age.

In this paper, I consider the impact of multiple births

both on the children themselves and on their families.

Others authors will explore their increasing impact on

society in general.

IMPACTS ON THE CHILDREN

Although the development of most multiple birth children

is within the normal range, these children, for both medical

and environmental reasons, do face a higher risk of long-

term disability, learning difficulties and language delay in

particular12,13. Twin children have also been found to have

less good concentration and a higher incidence of attention

deficit hyperactivity disorder14.

BJOG: an International Journal of Obstetrics and GynaecologyApril 2003, Vol. 110 (Suppl 20), pp. 24–28

D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology

doi:10.1016/S1470-0328(03)00014-4 www.bjog-elsevier.com

International Society for Twin Studies, Quercwm,

Vowchurch, Hereford, UK

Correspondence: Dr E. Bryan, International Society for Twin Studies,

Quercwm, Vowchurch, Hereford, HR2 ORL, UK.

The environment of a twin child (or triplet) differs in

many ways from that of a single born. From the start, twins

must share the maternal attention and communicate in a

threesome. This can be difficult for both the children and

the mother. Shortage of time and factors like safety will

also tend to deprive them of many stimulating opportu-

nities. Furthermore, multiples may never experience soli-

tude and the self-sufficiency that can develop from it. The

relationship between the twins themselves must also have

an effect on each child’s development, although little

research has been done on this.

Special needs

Having a chronically ill or disabled child will be hard for

any parent. Where twins are involved, the emotional and

practical upheavals are likely to be even greater. The twin

child with a disability will find it difficult to understand

why they and not their twin is affected. They will watch

their co-twin doing things they may never be able to do

and, if monozygotic (MZ), will have before them the

constant image of how they might have been. Jealousy,

anger and sometimes depression are not uncommon —and

not surprising15.

It is not unusual for the sibling of a child with a disability

to present with signs of psychological stress, as the disabled

child receives so much more attention. Where the sibling is

a twin there are likely to be extra difficulties. Jealousy in the

early years followed later by guilt and an excessive burden

of responsibility are common emotions of the unaffected

twin. They may spend much time caring for their twin at the

expense of their own activities and development.

Because most parents are proud of having twins they

may find it hard to stop treating them the same, despite

one having severe difficulties. This artificial imposition

of ‘twinness’ can burden both children. Indeed the devel-

opment of the more advanced child may be held back.

The single survivor

The child whose twin died in the perinatal period may

suffer not only from the loss of his companion but also the

grief of their parents. The parents may also come to

idealise, even idolise, the dead twin. Some survivors have

said their parents blamed them for the intrauterine death of

their twin or would have preferred the other child to have

survived especially if of the opposite sex16.

The surviving twin can have complex reactions to a

twin’s death17. Many feel angry with the twin for deserting

them; for causing such unhappiness to the family; for

making them feel guilty. They may be angry with their

parents for ‘allowing’ the twin to die. Others feel guilty to

have survived especially if at the expense of their twin as,

for example, in the twin–twin transfusion syndrome.

When a twin child dies early in life, he/she is too often

never mentioned. Teachers and even nursery staff may not

hear at all of the twin and therefore misinterpret symptoms

of unresolved grief or fail to note the bereaved child’s need

for comfort and explanation.

THE FAMILY

The mother and father

For many mothers, relating to one baby is a full-time

occupation both emotionally and physically. The complex-

ity of relating simultaneously to twins, in addition to the

extra practical strains, can often cause great stress —which

will be even greater if the babies are preterm or separated

from her.

It is unfortunately not unusual for sick preterm multiples

to have to be transferred from their hospital of delivery to

tertiary care neonatal units1. Moreover, the mother may be

unfit to travel with them. The babies themselves may be

separated by many miles when no single tertiary unit can

provide two or three intensive care cots at the time they are

needed. This can become a logistic nightmare for the father

as he tries to keep in touch with his partner and each baby

and an emotional one for both parents.

It is common for mothers of twins to have a further

emotional strain if one of the babies is notably more ill than

the other. Mothers are more likely to be attracted to the

healthier infant18. It is well established that mothers find it

more difficult to relate to babies from whom they have

been separated during their first days following delivery.

Size, appearance and responsiveness may also influence the

mother’s first feelings about the babies.

One twin may be ready to go home before the other, but

most units now try to discharge the babies together.

Otherwise the baby left behind may suffer in their rela-

tionship with their mother. Moreover, it has been shown

that early discharge from hospital is one of three factors

significantly affecting the self-esteem of a school-age

twin—the others being birth order and birthweight. Indeed

earlier discharge from hospital is the most important19.

Every mother aims to give her babies the same amount

of attention and to love them equally. She often feels guilty

if she doesn’t and cannot easily acknowledge that she

actually prefers one to the other. Where one baby is more

demanding, the mother may not only feel guilty that she is

depriving the other twin of attention but resentful of having

to spend so much time on a difficult baby at the expense of

a positively responsive one.

The long-term effects of early mother–twin relation-

ships have yet to be established. A recent study of preterm

single-born and twins found that the mother of twins

showed fewer initiatives and responses to their babies and

were less responsive to both positive signals and to crying.

They also lifted, held, touched and patted their babies less

MULTIPLE PRETERM BIRTHS 25

D RCOG 2003 Br J Obstet Gynaecol 110 (Suppl 20), pp. 24–28

and talked less to them. When tested at 18 months, the

cognitive development of the twins was less advanced than

that of the single born controls and maternal behaviour in

the newborn period was predictive of the level of devel-

opment of the children at 18 months20. It is clearly vital that

the children are followed to see if the effects of these early

relationships persist into school.

Mothers of twins have been shown to suffer more from

lack of sleep and fatigue than mothers of singleborns21.

Furthermore, depression is more common well beyond the

infancy period22. Isolation and fatigue are probably both

contributory factors.

An increasing number of mothers of multiple births are

relatively old4 and may find the pregnancy as well as the

demands of caring for several young children especially

stressful. Many of these will also be inexperienced first-

time mothers.

Added stresses may derive from bereavement or having

a child with special needs. The difficulties are increased

by having to cope at the same time with children of the

same age, but with very different needs15. Moreover, the

parents, and often the child too, have a constant reminder

in the unaffected child of how they both might— indeed

should—have been. The special status of having or being

a parent of twins is effectively lost if the twins look very

different.

Parents who have lost a multiple but still have a

surviving twin or one or two of triplets, face special

problems17. They have a constant reminder of the dead

child in the surviving child—especially if a MZ twin.

Parents of multiple infants also lose what many of them

see as a proud status and their bereavement is often

underestimated by other people who may indeed tell them

that they are fortunate to still have a surviving child. All

these factors tend to inhibit a grieving process already

delayed by natural preoccupation with the survivor.

The loss of babies from a higher multiple set can be

particularly difficult23. After many years of infertility, a

mother may suddenly have three, four or more live babies

but then see one, two or more of them die soon after birth or

die one by one over what can be many painful weeks or

even months. Despite these deaths, a couple left with one

or two babies often receive remarkably little sympathy

about the death of the others. Some couples have to cope

with their grief over the death of one (or more) babies while

also having to face the daily difficulties and emotional

strain of caring for a disabled child at the same time.

Higher order births

Detailed insights into the lives of families with triplets

and higher order births first become available through the

United Kingdom National Study of Triplets and Higher

Order Births24. This population-based study of over 300

families with higher order birth British children born in

1980 and 1982–1985 covered medical and social aspects

from the time of conception until the children were in

school.

The report demonstrated that the practical difficulties of

looking after three babies at once are huge, even when all

are healthy. At the most simple level, no mother can carry

three babies at once. Only with the greatest difficulty can

she feed or transport them on her own. Many mothers

cannot take their babies out of the home and so become

housebound and isolated as a result.

The UK study repeatedly found that help for families,

both statutory and private, had been inadequate in amount

and slow to arrive. Too often the parents became ill and

exhausted before help was provided. On other occasions,

the discharge of the babies from the neonatal unit was

unnecessarily delayed because extra help at home had not

been arranged in time.

A mother simply cannot look after three babies on her

own. There are not enough hours in the day. A study by the

Australian Multiple Births Association showed that 197.5

hours per week were required to care for six-month-old

triplets and to carry out the necessary household tasks25.

Unfortunately a week only has 168 hours.

For a childless couple, the practical and emotional

difficulties of caring for two or more babies at the same

time may be particularly difficult to imagine. It has been

shown that parents do not have realistic expectations of

how the birth of twins will affect their life26. A preliminary

study of couples who have twins following IVF indicated

that they find parenting considerably less rewarding than

they had expected27. The authors compared families with

IVF twins and spontaneously conceived twins and found

that for both mothers and fathers parenting stress was

greater in the IVF group. The quality of parenting was

equally good but parental satisfaction was less. This could

well be due to the inevitable failure to reach the high

standards of parenting they had for so long expected to

achieve28.

Siblings

A little recognised problem is the effect on other

children in the family, particularly on the single toddler

who has been the centre of the family, when he or she is

suddenly displaced by an attention-attracting pair or trio.

It has been shown that a sibling is likely to be more

disturbed by the arrival of twins than of a single sibling

and that behaviour problems in the older child are more

common29.

Multifetal reduction

As the number of higher multiple pregnancies has

escalated, so have the number of couples who feel they

26 E. BRYAN

D RCOG 2003 Br J Obstet Gynaecol 110 (Suppl 20), pp. 24–28

should maximise the chances of having a healthy baby or

twins by reducing the number of viable fetuses.

A recent international survey30 of 15 years experience of

the procedure at 11 centres and a total of 3,513 cases

showed that with increasing experience there has been a

considerable improvement in the outcomes. There have

been decreases in rates of pregnancy loss and of extreme

prematurity and the reduction of quads as well as triplets

down to twins now produce outcomes as good as those for

unreduced twin gestations.

Nevertheless, multifetal pregnancy reduction (MFPR) is

never an easy or uncontroversial solution and carries its

own risk of medical and emotional complications23. Some

parents will feel a lasting grief and guilt over the death of

one or more potentially healthy children. Nevertheless it

appears that the great majority of parents feel that they had

made the right decision.

SUPPORT FOR FAMILIES WORLDWIDE

Families will continue to need informed advice and

support from those who care for them. The Multiple Births

Foundation (MBF) was established in the UK in 1988 as

the first organisation to offer professional support to

families with twins, triplets and more as well as informa-

tion, advice and training to the many medical, educational

and social work staff concerned with their care. It has

published five sets of Guidelines for the professional on the

care of multiple birth families from before conception

through to adolescence31.

Despite a limit in many countries of three embryos to be

transferred in any one IVF cycle, the high and increasing

incidence of multiple births in the most developed countries

continues to cause concern. While as many as three

embryos continue to be transferred, triplets will occur —

and even quads. Monozygotic twinning is probably several

times higher amongst pregnancies involving ovulation

induction and embryo transfer32.

For many couples, a multiple pregnancy is too high a

price to pay for their infertility treatment. An increasing

number of European centres, particularly those in Scandi-

navia, are therefore now advocating single embryo transfers

in selected women33.

References

1. Macfarlane AJ, Price FV, Bryan EM, Botting BJ. Early days. In: Bot-

ting BJ, Macfarlane AJ, Price FV, editors. Three, Four and More.

London: HMSO, 1990:80– 98 (Chapter 6).

2. Lambalk CB, van Hooff M. Natural versus induced twinning and

pregnancy outcome: a Dutch nationwide survey of primiparous dizy-

gotic twin deliveries. Fertil Steril 2001;75:731– 736.

3. Imaizumi Y. Trends of twinning rates in ten countries, 1972–1996.

Acta Genet Med Gemellol 1997;46:209– 218.

4. Kiely JL, Kiely M. Epidemiological trends in multiple births in the

United States, 1971– 1998. Twin Research 2001;3:131– 133.

5. Office of National Statistics Series DH3, no. 32. London, 2000.

6. Loos R, Derom C, Vlietinck R, Derom R. The East Flanders Prospec-

tive Twin Survey (Belgium): a population-based register. Twin

Research 1998;1:167– 175.

7. The Human Fertilisation and Embryology Authority Ninth Annual

Report. London, HFEA, 2000.

8. Hurst T, Lancaster P. Assisted Conception in Australia and New Zea-

land 1999 and 2000. Assisted Conception Series 2001, no. 6. Sydney,

AIHW.

9. Petterson B, Stanley F, Henderson D. Cerebral palsy in multiple

births in Western Australia. Am J Med Genet 1990;37:346 –351.

10. Glinianaia SV, Pharoah POD, Wright C, Rankin JM. Fetal or infant

death in twin pregnancy: neurodevelopmental consequence for the

survivor. Arch Dis Child Fetal Neonatal Ed 2002;86:F9– F15.

11. Yokoyama Y, Shimizu T, Hayakawa K. Prevalence of cerebral palsy

in twins, triplets and quadruplets. Int J Epidemiology 1995;24:

943– 948.

12. Hay DA, Prior M, Collett S, Williams M. Speech and language de-

velopment in pre-school twins. Acta Genet Med Gemellol 1987;

36:213– 223.

13. McMahon S, Dodd B. A comparison of the expressive communica-

tion skills of triplet, twin and singleton children. Eur J Disorders

Communication 1997;32:328 –345.

14. Levy F, Hay D, McLaughlin M, Wood C, Waldman I. Twin sibling

differences in parental reports of ADHD speech, reading and behav-

iour problems. J Child Psychol Psychiatry 1996;37:569 –578.

15. Bryan EM. Twins with special needs. In: Sandbank AC, editor.

Twin and Triplet Psychology. London: Routledge, 1999a:61 – 69

(Chapter 5).

16. Woodward J. The Lone Twin. Understanding Twin Bereavement and

Loss. London: Free Association Books Ltd., 1998.

17. Bryan EM. The death of a twin. In: Sandbank AC, editor. Twin

and Triplet Psychology. London: Routledge, 1999b:186 – 200

(Chapter 11).

18. Goldberg S, Perrotta M, Minde K, Corter C. Maternal behavior and

attachment in low-birth-weight twins and singletons. Child Devel

1986;57:34– 46.

19. Hay DA, O’Brien PJ. Early influences on the school social adjustment

of twins. Acta Genet Med Gemellol 1987;36:239– 248.

20. Ostfeld BM, Smith RH, Hiatt M, Hegyi T. Maternal behaviour to-

ward premature twins: implications for development. Twin Research

2001;3:234– 241.

21. Taylor EM, Emery JL. Maternal stress, family and health care of

twins. Children and Society 1988;4:351–366.

22. Thorpe K, Golding J, MacGillivray I, Greenwood R. Comparison of

prevalence of depression in mothers of twins and mothers of single-

tons. Br Med J 1991;302:875– 878.

23. Bryan E. Loss in higher multiple pregnancy and multifetal pregnancy

reduction. Twin Research 2002;5:169– 174.

24. Botting BJ, Macfarlane AJ, Price FV, editors. Three, Four and More.

A Study of Triplets and Higher Order Births. HMSO, 1990.

25. Australian Multiple Births Association. Proposal submitted to the Fed-

eral Government concerning ‘Act of Grace’ payments for triplet and

quadruplet families. Australian Multiple Births Association, Coogee,

Australia, 1984.

26. Hay DA, Gleeson C, Davies C, Lorden B, Mitchell D, Paton L. What

information should the multiple birth family receive before, during

and after the birth? Acta Genet Med Gemellol 1990;39:259–269.

27. Cook R, Bradley S, Golombok S. A preliminary study of parental

stress and child behaviour in families with twins conceived by in-vitro

fertilisation. Hum Reprod 1998;13:3244–3246.

28. Mushin D, Spensley J, Barreda-Hansen M. Children of IVF. Clin

Obstet Gynecol 1985;12:865– 876.

29. Hay DA, McIndoe R, O’Brien PJ. The older sibling of twins. Aus J

Early Child 1987;13:25– 28.

MULTIPLE PRETERM BIRTHS 27

D RCOG 2003 Br J Obstet Gynaecol 110 (Suppl 20), pp. 24–28

30. Evans MI, Berkowitz RL, Wapner RJ, et al. Improvement in out-

comes of multifetal pregnancy reduction with increased experience.

Am Journal Obstet Gynecol 2001;184:97– 103.

31. Bryan E, Denton J, Hallett F. Guidelines for Professionals: Multiple

Births and Their Impact on Families. London: Multiple Births Foun-

dation, 2001.

32. Derom R, Derom C, Vlietinck R. The risk of monozygotic twinning.

In: Blickstein I, Keith LG, editors. Iatrogenic Multiple Pregnancy.

London: Parthenon Press, 2000.

33. Vilska S, Tiitinen A, Hyden-Granskog C, Hovatta O. Elective trans-

fer of one embryo results in an acceptable pregnancy rate and elim-

inates the risk of multiple births. Hum Reprod 1999;14:2392– 2395.

28 E. BRYAN

D RCOG 2003 Br J Obstet Gynaecol 110 (Suppl 20), pp. 24–28