I’ll never forget the look on the

face of a father during a delivery, when the

midwife, instead of producing a placenta,

delivered the head of a second baby

and exclaimed, “Oh, there’s another

one!” He seemed absolutely shocked.Thirty years ago, half of twin pregnancies were not

diagnosed until the mother was in labor. Back then,

few data on the subject were available, and parent sup-

port organizations, such as the National Organization

of Mothers of Twins Clubs, Inc. (NOMOTC), were in

their infancy—if they existed at all.

Elizabeth Bryan, MD, FRCP, FRCPCH

140 AWHONN Lifelines Volume 10 Issue 2

Since the advent of routine ultrasound scanning in devel-

oped countries, the situation has changed dramatically. Many

multiple pregnancies are diagnosed in the first trimester, and

nearly all of them are identified by 20 weeks. These days, the

diagnosis may be no less of a shock for the expectant parents,

but at least they have time to prepare themselves and learn all

they can about how to care for two or more babies at the same

time. As health care providers, we can help make sure that this

extra time is used to its full advantage.

There is clearly a need. In the past, mothers had difficulty

getting information from their doctors, nurses and midwives

(Spillman, 1992), and there was a dearth of literature on the

subject. Too few maternity units catered to the special needs of

these parents. Once the babies were born, parents often didn’t

receive practical advice on the care of multiple-birth children,

such as the need for individual attention and the promotion of

language development.

Multiple Births on the RiseThroughout the developed world, there has been a steady

rise in the incidence of twin births since the early 1980s

(Imaizumi, 2003; Kiely & Kiely, 2001) (see Box 1). In the

United States, twin births have increased 65 percent from 18.9

twins per 1,000 births in 1980 to 31.1 twins per 1,000 births in

2002. Triplet births have increased from 37 triplets per 100,000

live births in 1980 to 184 per 100,000 in 2002 (Martin et al.,

2003). In the United Kingdom, the rate of twin births has

increased from 9.0 per 1,000 births in 1980 to 14.67 per 1,000

in 2003. The incidence of triplets escalated even faster through

1998, quadrupling in 15 years. The rate of triplet births has

now started to decline again. (It is important to note that in the

United Kingdom, twin births are reported by number of births,

whereas in the United States, statistics reflect the number of

twin infants and therefore appear to be double those of the

United Kingdom.) The multiple-birth rate in Canada was 2.3

percent of the 380,342 live and stillbirths that were recorded in

1995 (Health Canada, 2000).

The increase in multiple births is known to be largely due to

the widespread use of poorly monitored ovulation induction

and to multiple embryo transfer following in vitro fertilization

(IVF) (Loos, Derom, Vlietinck, & Derom, 1998). In Canada in

2002, 35 percent of IVF treatment cycles resulted in live birth of

multiples (CFAS, 2004). In the United States, 56 percent of in-

fants born as a result of IVF were multiples in 1998 (CDC,

2002). Also, to a lesser extent, the phenomenon may be due to

Elizabeth Bryan, MD, FRCP, FRCPCH, is a medical consultant to

the Multiple Births Foundation at Queen Charlotte’s and Chelsea

Hospital in West London.

DOI: 10.1111/j.1552-6356.2006.00020.x

the rise in average maternal age (Kiely & Kiely, 2001) as an in-

creasing number of women delay childbearing. Spontaneous

twinning is known to increase until the late 30s (MacGillivray,

Sampier, & Little, 1988).

In most countries, accurate data on conception are only

available for multiple births that occur following IVF or gamete

donation; those due to ovulation induction alone are not

Box 1.

Vital Statistics

• Throughout the developed world, there has been a steady rise in the incidence of twin births since the early 1980s due, in part, to the increase in the number of women undergoing IVF.

• In the United States, twin births have increased from 18.9 twins per 1,000 births in 1980 to 31.1 twins per 1,000 births in 2002. Triplet births have increased from 37 triplets per 100,000 births in 1980 to 184 per 100,000 in 2002.

• Practices and protocols for screening in multiple pregnancy still vary between individual practitioners, and uniform protocols are lacking.

• Perinatal mortality is nearly five times higher in twins and eight times higher in triplets than in singletons.

April | May 2006 AWHONN Lifelines 141

recorded. The 2003 figures from the United Kingdom’s Human

Fertilisation and Embryology Authority (HFEA) report a mul-

tiple-birth rate of 24.1 percent following IVF, of which 23.6

percent was twins and 0.5 percent was triplets (HFEA, 2005).

Most of the multiple pregnancies resulting from ovulation

induction and multiembryo transfer are multizygotic (MZ); it

is the increase in dizygotic (DZ) twinning that is largely re-

sponsible for the current upward trends in twin births.

Although DZ twinning rates vary greatly in different parts of

the world (Imaizumi, 2003), the trends are similar wherever

new infertility treatment techniques are practiced. In general,

women of African origin have the highest rates of spontaneous

DZ twins, and women of Far Eastern origin have the lowest

(Bowers, 1998); rates among East Indians and Caucasians lie

between these two extremes.

Although the majority of “iatrogenic” twins are DZ, there

appears to be a higher than expected incidence of MZ twinning

following ovulation induction with or without embryo transfer

than there is for spontaneous conceptions. Until recently, and

unlike DZ twinning, the prevalence of MZ twin births had re-

mained constant in all societies worldwide at 3.5 per 1,000

pregnancies. Since the early 1990s, there has been a small in-

crease (Imaizumi, 2003).

Although health care providers now appreciate the impor-

tance of determining the chorionicity in a multiple pregnancy,

there may be some practitioners who unwittingly misinform

parents by telling them that their twins are definitely DZ be-

cause they have a dichorionic placenta (Ooki, Yokoyama, &

Asaka, 2004). In actuality, approximately one-third of MZ

twins also have dichorionic placentae (Derom & Derom, 2005)

The Implications of a Multiple PregnancyPrenatal screening of the fetuses in a multiple pregnancy

presents special problems, and parents often receive inadequate

information about potential problems. One particular dilemma

may occur when one fetus has an anomaly and the other is

normal. Practices and protocols for screening in multiple preg-

nancy still vary among individual practitioners, and uniform

protocols are lacking (Multiple Births Foundation, 2004).

Multiple pregnancies are more likely to bring complications

such as hypertension, pre-eclampsia and anemia, as well as

general discomfort and preterm labor. Women pregnant with

multiples may also find it harder to travel to appointments.

Prenatal classes should be started earlier than for a singleton

pregnancy—at least by 20 weeks.

Multiple-birth babies may experience complications from

being born preterm and/or of low-birth-weight (Alexander &

Salihu, 2005). There is indeed the consequent risk of death or

long-term disability. They may also suffer from specific com-

plications related to monochorionic placentation, such as the

twin-twin transfusion syndrome, cord complications in mono-

amniotic twins, the damaging effect of a fetal death on the co-

twin survivor and the higher incidence of lethal malformations,

such as acardia (or the twin reversed arterial perfusion se-

quence), in which one twin fetus has no heart and is therefore

dependent for survival on the other twin’s circulation. Perinatal

mortality is nearly five times higher in twins than in singletons

and eight times higher in triplets (Macfarlane & Mogford,

2000). There is also a 3- to 7-fold higher incidence of cerebral

palsy in twins and more than 10-fold higher incidence in trip-

lets (Topp et al., 2004).

Less appreciated than these potential physical hazards are

the problems that may arise when otherwise healthy twins have

to share attention from parents and other caregivers (see Box

2). Language development is commonly delayed (Hay, Prior,

Collett, & Williams, 1987; Thorpe, Rutter, & Greenwood,

2003), and this is often associated with later difficulties with

reading (Levy, Hay, McLaughlin, Wood, & Waldman, 1996).

Behavioral and disciplinary problems are common. Depression

in mothers of twins has been noted to be more common than

in mothers of singletons (Thorpe, Golding, MacGillivray, &

Greenwood, 1991) and is often associated with fatigue and

isolation combined with behavior problems in the twins’

siblings (Hay, McIndoe, & O’Brien, 1987). All these factors

increase the risk of child abuse in multiple-birth families

(Groothuis et al., 1982).

Where one or more of the children has special needs, the

problems concerning practical care and emotional stress are

clearly greater still. These sometimes include disturbed behav-

ior in the healthy child who may be jealous of the extra atten-

tion given to the sibling with special needs (Bryan, 1999).

If one twin dies, bereaved parents may face unusual and

complex difficulties in coping with the contradictory emotions

of grieving for one baby while celebrating the life of the other,

who, furthermore, constantly reminds them of the dead child

(Lewis & Bryan, 1988).

Box 2.

Some potential developmental, behavioral and mental health issues facing multiple-birth children and their families

Delayed language development and difficulty readingBehavioral and disciplinary problemsDepression and fatigue in parentsJealousy in siblings (who may be jealous that multiple-birth children are receiving extra attention)Increased risk of child abuseIncreased complexity of grief if one twin dies and one survives

142 AWHONN Lifelines Volume 10 Issue 2

Helping Parents of MultiplesWith practical help and early intervention from professionals,

many of the potential longer term problems can be prevented

or lessened. It’s important for nurses caring for these families

to keep in mind the considerable practical, emotional and

financial stresses these families are likely to experience, all of

which are likely to be magnified in situations of higher birth

order (Botting, Macfarlane, & Price, 1990).

These issues have led to the development of a declaration of

rights and statement of needs of twins and higher order multi-

ples adopted by the Council of Multiple Birth Organizations of

the International Society for Twin Studies (Multiple Births

Canada, 2005). Supporting statements outlining key consider-

ations for care of twin pregnancies have been released by the

Association of Obstetricians and Gynecologists in the United

States (American College of Obstetricians and Gynecologists,

1999) and the Society of Obstetricians and Gynaecologists of

Canada (Barrett & Bocking, 2000a, 2000b).

The Multiple Births Foundation: A Case Study in Caring for Families of MultiplesThe Multiple Births Foundation (MBF) was established in

London in 1988 as the first organization worldwide to offer

support and resources to families of multiples and the health

care professionals who care for them. Among the resources the

MBF offered were “Twins Clinics” (Bendefy, Elliman, Prior, &

Bryan, 1994), which were run in three centers in the United

Kingdom and concentrated on problems that are caused or

increased by twinship, such as extreme rivalry, language delay,

difficulties over identity and behavior problems in older sib-

lings. The clinics also helped resolve uncertainty over zygosity.

Counselors and psychotherapists treated parents and older

twins needing psychological support. For families with more

than just twins, there were “Supertwins Clinic,” in which ex -

perienced volunteers—all parents of multiples themselves—

provided practical advice, support and reliable childcare

(Linney, Higgins, & Hallett, 1993).

The MBF also provided a telephone advisory service (Read,

Bryan, & Higgins, 1996), literature, and additional meetings in

the evenings, which focused on topics such as prenatal prepa-

ration, language, behavior, individuality and schooling. In ad-

dition to parents, grandparents and other caregivers were

encouraged to attend. The telephone advisory service provided

scheduled consultations of up to 30 minutes for both parents

and health care professionals. Many couples considering treat-

ment for infertility telephoned for information on the risks

and implications of a multiple pregnancy. Those who had al-

ready conceived sometimes wished to discuss the option of a

multifetal pregnancy reduction. Others who knew that one of

their fetuses had an anomaly wanted more information on se-

lective feticide. The Telephone Service was run by a counselor

who, when necessary, would refer cases to a pediatrician or

midwife. Much of the advice given could be supplemented by

an MBF booklet on the specific topic.

It soon became clear that one small charitable organization

could not provide sufficient support to all the families con-

cerned and that it was more appropriate for the health care

providers to give advice and support. The MBF, therefore, de-

cided to concentrate on the education of professionals. It shares

the services described as models for other professionals and

groups to follow. It also offers seminars and study days, and its

staff members lecture widely.

MBF staff have traveled worldwide to help other coun-

tries establish twin clinics and other services for families with

multiple-birth children. Many programs have now been es-

tablished on the MBF model, notably in Australia, Canada and

various European countries.

A network of midwives and community nurses in the

United Kingdom with a particular interest and expertise in

the care of multiple-birth families is being developed, includ-

ing regular seminars and free access to MBF staff and their

resources.

It has been shown that many parents do not have realistic

expectations of how the birth of twins will affect their family

(Hay et al., 1990), and many suffer weeks of unnecessary con-

fusion and anxiety. All hospitals should have a protocol and

Box 3.

Resources for Professionals and Patients

American College of Obstetricians and Gynecologists: http://www.acog.orgCenter for the Study of Multiple Birth: http://www.multiplebirth.com/index/htmlMedical University of South Carolina, Multiple Pregnancy Program: http://www.muschealth.com/women/services/multipregMultiple Births Canada: http://www.multiplebirthscanada.org/english/index.phpMultiple Births Foundation: http://www.multiplebirths.org.ukNational Organization of Mothers of Twins Clubs: http://www.nomotc.orgSunnybrook and Women’s College Health Sciences Centre, Multiple Births Pregnancy Health Centre: http://www.womenshealthmatters.ca/centres/pregnancy/multiples/index.htmlThe Triplet Connection: http://www.tripletconnection.orgTwins and Multiple Births Association (TAMBA): http://www.tamba.org.uk/html/home.htm

April | May 2006 AWHONN Lifelines 143

guidelines on the management of multiple pregnancies. Those

published by the MBF advise on the care of multiple-birth

families from before conception through adolescence (Bryan,

Denton, & Hallett, 2001).

Parent Support OrganizationsSeveral countries, including the United States, most European

countries, Japan, Australia, New Zealand, Sri Lanka, Nigeria,

South Africa, Indonesia, South Korea, Russia and India, now

have some sort of organization that provides information and

support to parents of twins and for twins themselves. While no

centralized organization similar to the MBF currently exists in

the United States, some regional tertiary medical centers have

developed specialized programs providing prenatal care and ser-

vices for multiple-birth families (Luke et al., 2003; Ruiz, Brown,

Peters, & Johnston, 2001) (see Box 3 for examples of these and

other organizations for both patients and professionals).

ConclusionsTwins and triplets can and do bring great joy to families. But

they are also at greater risk of both medical and psychosocial

complications. Before undergoing treatment that increases the

chances of a multiple pregnancy, parents should be given care-

ful counseling on the potential implications of having twins or

triplets. For those who conceive more than one baby, appropri-

ate and ongoing advice and support should be provided during

the pregnancy and throughout childhood.

Nurses in both the hospital and the community have a cru-

cial role from the start. They are vital to assessing the needs of

multiple-birth families, coordinating various services and

providing ongoing support. Although some nurses may have

limited experience with the special needs of such families,

fortunately, there are more resources than ever before for

caring with multiple-birth families.

References

Alexander, G. R., & Salihu, H. M. (2005). Perinatal outcomes of singleton and multiple births in the United States 1995-1998. In I. Blickstein & L. G. Keith (Eds.), Multiple pregnancy: Epidemiology, gestation and perinatal outcome (pp. 3-10). Abingdon, VA: Taylor & Francis.

American College of Obstetricians and Gynecologists (ACOG). (1999). Special problems of multiple gesta-tion. ACOG Educational Bulletin 253. International Journal of Gynaecology and Obstetrics, 64(3), 323-333.

Barrett, J., & Bocking, A. (2000a). The SOGC consensus statement: Management of twin pregnancies (part 1). Retrieved September 21, 2005, from http://www.sogc.org/sogcnet/sogc_docs/common/guide/pdfs/cs1Twins91.pdf

Barrett, J., & Bocking, A. (2000b). The SOGC consensus statement: Management of twin pregnancies (part 2). Retrieved September 21, 2005, from http://www.sogc.org/sogcnet/sogc_docs/common/guide/pdfs/cs2Twins92.pdf

Bendefy, I., Elliman, A., Prior, S., & Bryan, E. M. (1994). Is there a role for a Twins Clinic? An evaluation of parents’ responses. Acta Paediatrica Scandinavica, 83, 40-45.

TEN YEARS AGO.. .

The recommended serial assessment for twin pregnancies is described as beginning in the second trimester and comprising ultrasound observation on a regular basis with the addition of Doppler velocimetry and nonstress testing in the third trimester. Estimated fetal weight was regarded as the best discriminator for discordant growth.

Source: Devoe, D., & Ware, D. (1995). Antenatal assessment of twin gestation. Seminars in Perinatology, 19(5), 413-423.

Attempted vaginal delivery was regarded as appropriate for vertex-vertex twins.

Source: Udom-Rice, I., Skupski, D., & Chervenak, F. (1995). Intrapartum management of multiple gestation. Seminars in Perinatology, 19(5), 424-434.

A case report of delayed interval delivery of quadruplets reported that after the first baby was born at 26 weeks gesta-tion, ultrasound showed that the remaining three fetuses were in separate amniotic sacs. With bed rest and tocolysis, the second infant remained in utero until eight days later and after a further 36-hour delay, the remaining two babies were deli -vered. The first baby died at seven months; however, the other three were well at 1 year of age and developing normally.

Source: Olatunbosun, O., Turnell, R., Sankaran, K., & Ninan, A. (1995). Delayed interval delivery in quadruplets. Inter national Journal of Gynaecology and Obstetrics, 50(3), 287-290.

TEN YEARS FROM NOW.. .

IVF techniques will allow for the successful implantation of a single embryo that is healthy with a resultant decrease in the number of multiple pregnancies and compromised neonates. Twin pregnancies will be a natural and happy occurrence for most parents rather than an iatrogenic effect. We will have effective interventions for delaying preterm labor and delivery of multiple pregnancies, and most twins or triplets will be born at or close to 40 weeks gestation.

144 AWHONN Lifelines Volume 10 Issue 2

Botting, B. J., Macfarlane, A. J., & Price, F. V. (Eds.). (1990). Three, four and more: A study of triplet and higher order births (pp. 60-62). London: Her Majesty’s Stationery Office.

Bowers, N. A. (1998). The multiple birth explosion: Implications for nursing practice. Journal of Obstetric, Gynecologic & Neonatal Nursing, 27, 302-310.

Bryan, E. (1999). Twins with special needs. In A. C. Sandbank (Ed.), Twin and triplet psychology (pp. 61-69). London: Routledge.

Bryan, E., Denton, J., & Hallett, F. (2001). Guidelines for pro-fessionals: Multiple births and their impact on families. London: Multiple Births Foundation.

Canadian Fertility and Andrology Society (CFAS). (2004). Human assisted reproduction live birth rates for Canada. Retrieved September 21, 2005, from http://www.cfas.ca/english/news/dec5_2004.asp

Centers for Disease Control and Prevention (CDC). (2002, February 8). Use of assisted reproductive technology—United States 1996 and 1998. MMWR. Morbidity and Mortality Weekly Report, 51(05), 97-101.

Derom, R., & Derom, C. (2005). Placentation. In I. Blickstein & L. G. Keith (Eds.), Multiple pregnancy: Epidemiology, gestation and perinatal outcome (pp. 157-167). Abingdon, VA: Taylor & Francis.

Groothuis, J. R., Altemeir, W. A., Robarge, J. P., O’Connor, S., Sandler, H., Vietz, P., et al. (1982). Increased child abuse in families with twins. Pediatrics, 70, 769-773.

Hay, D. A., Gleeson, C., Davies, C., Lorden, B., Mitchell, D., & Paton, L. (1990). What information should the multiple birth family receive before, during and after the birth? Acta Geneticae Medicae et Gemellologiae, 39(2), 259-269.

Hay, D. A., McIndoe, R., & O’Brien, P. J. (1987). The older sibling of twins. Australian Journal of Early Childhood, 13, 25-28.

Hay, D. A., Prior, M., Collett, S., & Williams, M. (1987). Speech and language development in pre-school twins. Acta Geneticae Medicae Gemellologiae, 36, 213-223.

Health Canada. (2000). Perinatal health indicators for Canada: A resource manual. Ottawa, Canada: Minister of Public Works and Government Services Canada. Retrieved September 21, 2005, from http://www.phac-aspc.gc.ca/rhs-ssg/phic-ispc/index.html

Human Fertilisation and Embryology Authority (HFEA). (2005). The HFEA guide to infertility and directory of clinics (p. 57). London: HFEA.

Imaizumi, Y. (2003). A comparative study of zygotic twinning and triplet rates in eight countries, 1972-1999. Journal of Biosocial Science, 35(2), 287-302.

Kiely, J. L., & Kiely, M. (2001). Epidemiological trends in multiple births in the United States, 1971-1998. Twin Research, 3, 131-133.

Levy, F., Hay, D., McLaughlin, M., Wood, C., & Waldman, I. (1996). Twin sibling differences in parental reports of ADHD speech, reading and behavior problems. Journal of Child Psychology & Psychiatry, 37, 569-578.

Lewis, E., & Bryan, E. M. (1988). Management of perinatal loss of a twin. British Medical Journal, 297, 1321-1323.

Linney, J., Higgins, R., & Hallett, F. (1993). Partners in care. London: Multiple Births Foundation.

Loos, R., Derom, C., Vlietinck, R., & Derom, R. (1998). The East Flanders Prospective Twin Survey (Belgium): A population-based register. Twin Research, 1, 167-175.

Luke, B., Brown, M. B., Misiunas, R., Anderson, E., Nugent, C., van de Ven, C., et al. (2003). Specialized prenatal care and maternal and infant outcomes in twin pregnancy. American Journal of Obstetrics & Gynecology, 189, 934-938.

Macfarlane, A., & Mogford, M. (2000). Characteristics of babies. In A. Macfarlane & M. Mogford (Eds.), Birth counts (pp. 165-189). London: Her Majesty’s Stationery Office.

MacGillivray, I., Sampier, M., & Little, J. (1988). Factors affecting twinning. In I. MacGillivray, D. M. Campbell, & B. Thompson (Eds.), Twinning and twins (pp. 67-98). West Sussex: John Wiley.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Munson, M. L. (2003). Births: Final data for 2002. National Vital Statistics Reports, 52(10).

Multiple Births Canada. (2005). Declaration of Rights and Statement of Needs of Twins and Higher Order Multiples. Retrieved February 13, 2005, from http://www.multiplebirthscanada.org/english/declarerightsmb.php

Multiple Births Foundation. (2004). A report based on a seminar entitled “Multiple births: The way forwards in antenatal screening.” Unpublished manuscript.

Ooki, S., Yokoyama, Y., & Asaka, A. (2004). Zygosity misclassification of twins at birth in Japan. Twin Research, 7(3), 228-232.

Read, B., Bryan, E., & Higgins, R. (1996). Time to talk: A telephone service for families. London: Multiple Births Foundation.

Ruiz, R. J., Brown, C. E., Peters, M. T., & Johnston, A. B. (2001). Specialized care for twin gestations: Improving newborn outcomes and reducing costs. Journal of Obstetric, Gynecologic & Neonatal Nursing, 30, 52-60.

Spillman, J. R. (1992). A study of maternity provision in the UK in response to the needs of families who have a multiple birth. Acta Geneticae Medicae Gemellologiae, 41, 353-364.

Thorpe, K., Golding, J., MacGillivray, I., & Greenwood, R. (1991). Comparison of prevalence of depression in mothers of twins and mothers of singletons. British Medical Journal, 302, 875-878.

Thorpe, K., Rutter, M., & Greenwood, R. (2003). Twins as a natural experiment to study the causes of mild language delay: II: Family interaction risk factors. Journal of Child Psychology & Psychiatry, 44, 342-355.

Topp, M., Huusom, L. D., Langhoff-Roos, J., Delhumeau, C., Hutton, J. L., & Dolk, H. (2004). Multiple birth and cerebral palsy in Europe: A multicenter study. Acta Obstetrica Gynecologiae Scandinavica, 83, 548-553.

Joseph Schulman, USA

April 2004 / 160 pp / PB / 0727918338$32.00 / £20.00

Contents

PART 1: Systems

Systems and our work

The work of the NICU

Working with process mapping: an example

Activity without value: Muda

Diagnostic testing and Muda

Needless complexity in our care process

More tools for "drilling down"

PART 2: Data

Measuring outcomes: What? How?

Characterising variation in our measurements

Understanding variation in our measurements

PART 3: Action

Benchmarks and benchmarking

Keeping track of what you decided tomeasure

Change and people

The gap is never closed completely

Joseph Schulman, USA

April 2004 / 160 pp / PB / 0727918338$32.00 / £20.00

Contents

PART 1: Systems

Systems and our work

The work of the NICU

Working with process mapping: an example

Activity without value: Muda

Diagnostic testing and Muda

Needless complexity in our care process

More tools for "drilling down"

PART 2: Data

Measuring outcomes: What? How?

Characterising variation in our measurements

Understanding variation in our measurements

PART 3: Action

Benchmarks and benchmarking

Keeping track of what you decided tomeasure

Change and people

The gap is never closed completely

Evaluating theProcesses of NeonatalIntensive CareThinking Upstream to Understand Downstream Processes

Evaluating theProcesses of NeonatalIntensive CareThinking Upstream to Understand Downstream Processes

• Practical "how to" book on evaluation and quality improvement

• Written by a neonatologist with an understanding of the needsof those in the specialty

• Based on sound outcomes research

• Practical "how to" book on evaluation and quality improvement

• Written by a neonatologist with an understanding of the needsof those in the specialty

• Based on sound outcomes research