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PubMed1994

Working together to meet the needs of multiple-birth families.

Health visitors have an important role in providing postnatal support to multiple-birth parents, write Jill Walton et al. Here they describe how a series of joint parent/professional seminars helped raise awareness among health visitors of the special needs of multiple-birth parents for services and support, and the importance of developing closer links with voluntary and self-help groups at local and national level.

Community Health Nursing↗
PubMed1995

The desire for multiple births in couples with infertility problems contradicts present practice patterns.

Paradoxically, the attitude of infertility patients towards multiple births has never been investigated. We therefore generated a survey by questionnaire, which was sent to 3800 consecutive unselected couples with infertility problems: 582 responses were received (15% response rate) and analysed. The percentage distribution of the responses to 21 questions, addressing attitudes towards and knowledge about the risk of multiple gestations, was the main outcome. Worry about multiple births was expressed, independent of the number of multiples, although fear about multiple conceptions was rejected by a large majority (64%). The risk of a twin birth was not strongly perceived, but the perception of risk increased with increasing numbers of multiples: triplets (50-62%), quadruplets or more (71-72%). A desire for the conception of twins was expressed by 67-90% of couples, a desire for the conception of triplets was equally expressed and rejected, and for a multiple gestation beyond triplets was rejected by 73-82% of couples. Patients were educated about the risks of selective embryo reduction and responded in a bimodal fashion to the option of utilizing this procedure, with equal numbers being willing to consider or reject it. Age, parity and length of infertility did not affect the couples' worry or fear about multiples. The desire for twins and triples, however, was correlated significantly with age (twins, P = 0.032; triplets, P = 0.03); there was no such correlation for larger multiples. The length of infertility was correlated with a positive attitude towards multiples beyond triplets (P = 0.029) but was not correlated with a desire for twins or triplets. Prior parity did not affect the attitude towards multiples at all.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Euphoria or despair? Coping with multiple births from ART: what patients don't tell the clinics.

Patients' perception of family life after a multiple birth: euphoria or Pandora's box? The aim of this article is to explore the realities of parenting children from a multiple pregnancy as an aid to decision-making about the number of embryos transferred. Outcome research regarding parenting of children from twin, triplet and higher order births is described and, in particular, children of multiple births from assisted reproductive technology. Current understanding of interpersonal relationships in multiple birth families is also discussed. The evidence from these various sources is put in the framework of social risk factors as an aid to predicting outcomes and as an essential part of decision-making with the full participation of patients. The implications of such an approach is presented in relation to support for such families. Case studies are included of three triplet families. Reference is made to fetal reduction as an option.

Journal Article↗
PubMedDate not supplied

Mothers in the media: blamed and celebrated--an examination of drug abuse and multiple births.

The media has always had a profound interest in mothers and birth stories. This study examined the difference between media portrayal of "good" mothers and "bad" mothers. Did the media cover potential harm to fetuses and would-be children in the same way for two groups of mothers: (a) pregnant women addicted to illicit drugs and (b) women who chose to continue a high-order, multiple birth pregnancy? Two searches were conducted on Lexis-Nexis, one with keywords "McCaughey and birth" and another with the keywords "pregnancy and illegal drugs." A total of 210 articles were coded for the McCaughey search, and 90 articles were coded for the pregnancy and illegal drugs search. The media did not address potential harm in the same way in both cases. The harm from illegal drugs was exaggerated, while the harm from multiple births was downplayed. Consequently, the media response towards the two cases was dramatically different. In conclusion, the communal and regulatory responses to both drug-addicted pregnant women and large multiple births caused by infertility treatments needs to be rethought.

Female↗
PubMed1994

Perinatal mortality in single and multiple births in Japan, 1980-1991.

Perinatal mortality rates (PMR) decreased significantly per year in single, twin, triplet, quadruplet and quintuplet births during the period 1980-1991. The PMRs were 7.7 per 1000 livebirths for singletons, 45.6 for twins, 89.0 for triplets, 116.8 for quadruplets, and 476.2 for quintuplets during the 12 years. The relative risks of perinatal death in multiplets vs. singletons were 6 for twins, 12 for triplets, 15 for quadruplets and 62 for quintuplets. The PMR was significantly higher in males than females for singletons and twins, but there was no sex differential in PMRs for higher order of multiple births. The PMR increased with birth order in twins and triplets, whereas there was no birth order effect on the PMR for quadruplets. An increasing proportion of multiple births among perinatal deaths may be related to the increasing multiple birth rate in Japan.

Birth Order↗
PubMed2005

Risk factors for high-order multiple pregnancy and multiple birth after controlled ovarian hyperstimulation: results of 4,062 intrauterine insemination cycles.

OBJECTIVE: To determine factors responsible for high-order multiple pregnancy (HOMP) and high-order multiple births when multiple cycles of controlled ovarian hyperstimulation-IUI (COH-IUI) are performed. DESIGN: Retrospective analysis. SETTING: Private infertility clinic. PATIENT(S): Women (n = 2,272) who underwent 4,067 consecutive COH-IUI cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): High-order multiple pregnancy rate, pregnancy rate (PR), and birth rate (PR) per cycle. RESULT(S): High-order multiple pregnancy was related to number of follicles of diameter > or = 10 mm, age, and treatment cycle. For age <32 years, HOMP was 6% for three to six follicles and 20% for seven or more follicles. For ages 32 to 37 years, HOMP was 5% for three to six follicles and 12% for seven or more follicles. In the first COH-IUI cycle, HOMP was 8% for three to six follicles and 15% for seven or more follicles. In the second cycle, HOMP did not occur unless there were more than six follicles. No HOMP occurred after the second cycle. Pregnancy rate did not increase significantly when there were more than four follicles. Continuing COH-IUI past the third cycle resulted in additional pregnancies in patients with one to eight follicles. CONCLUSION(S): High-order multiple pregnancy can be predicted by age and number of follicles of diameter > or = 10 mm. Controlled ovarian hyperstimulation is not necessary to achieve satisfactory overall pregnancy rates if ovulation induction is continued past the third cycle in low responders.

Adult↗
PubMed2001

The effects of assisted reproduction on the trends and zygosity of multiple births in England and Wales 1974-99.

Assisted reproductive techniques have led to an increase in the proportion of maternities that are multiple. Though predominantly dizygotic, they are at greater risk of monozygotic division than those spontaneously conceived. England and Wales data 1974-99 on stillbirths and livebirths were analysed for 4 periods: 1974-80 (pre-assisted reproduction; 1982-8; 1989-91 (pre-redefinition of stillbirth); 1993-9 (post-redefinition of stillbirth). For twin data, Weinberg's rule was applied to estimate the proportions that were mono- (MZ) and dizygotic (DZ). Compared with the period before assisted reproduction, the most recent period shows an increase in twin maternities of 3.81 per 1,000 comprised of 3.22 (95% CI 3.10 to 3.33; p < 0.0001) DZ and 0.60 (95% CI 0.51 to 0.68; p < 0.0001) MZ twins. It is estimated that 15.7% of assisted reproduction twins are MZ. Higher order multiple births showed an increase of 3.06 (95% CI 2.85 to 3.29; p < 0.0001) per 10,000 maternities. Stillbirth rates in MZ twins are of the same order of magnitude as those in higher order multiple births but higher than those in DZ twins. The improvement in stillbirth rates over the 26 year study period is of the same order magnitude in singletons, DZ and MZ twins and higher order multiples. Assisted reproduction has led to a significant increase in the proportion of MZ twins. These are at high risk of fetal death and this needs to be considered when local stillbirth and perinatal mortality rates are used in auditing obstetric services.

England↗
PubMed2002

[The increase in multiple births and its consequences on perinatal health].

OBJECTIVE: To describe the trends in multiple maternity rates and the main responsible factors, and to present the main medical risks associated with multiple births. METHOD: A review of studies describing the situation in Europe and America North. RESULTS: Multiple maternity rates have increased dramatically in France and in other Western countries since the mid 1970s. However the triplet maternity rates leveled off in the 1990s in several European countries. One-fourth to one-third of the increase in multiple maternities is explained by the increase in maternal age. Moreover 30 to 50% of twin maternities and at least three-fourths of triplet maternities would occur after fertility treatments, according to surveys or estimations made from various sources. Twins and triplets have high risks for mortality and morbidity. In France in 1995/98, among live birth twins, the proportion of births before 37 weeks was 43.7% and the proportion of births before 33 weeks was 8.1%. The risk fraction of preterm delivery (<37 weeks) attributable to twins rose from 13% in 1981 to 19% in 1995/98. This trend is explained by the increase in occurrence of multiple births as much as by an increase in preterm births among twins. A similar situation is found in Canada and the USA. Whereas triplets have very high risk of preterm birth, the risk fraction attributable to triplets is very much lower than for twins: in Canada it was 1.1% in 1995-97. CONCLUSION: These results suggest that research and preventive interventions should not be restricted to triplets, but should also include twins.

Computer Graphics↗
PubMed1997

Epidemiologic paradox in multiple births among Asians in Illinois. Correlation between risk factors and outcomes.

OBJECTIVE: To determine if the plural birth rate, maternal risk factors and neonatal outcomes among Asian American populations residing in Illinois are homogeneous or heterogeneous with regard to maternal risk factors and neonatal outcomes and to attempt to establish correlations between maternal risk factors and neonatal outcomes. STUDY DESIGN: A total of 1,145,962 computerized birth certificate files were analyzed for 11 Asian subgroups giving birth in Illinois in the years 1989-1994. RESULTS: The multiple birth rates varied between 6 per 1,000 (Vietnamese) to 15 per 1,000 (Cambodian) (heterogeneity among all groups, P < .005). The percent of neonates born at gestational ages 22-33 weeks varied between 0 (Cambodian) to 28 (Thai). Japanese women showed the highest rate of neonates with birth weight less than 2,500 g after adjustment for race: 15.38 per 1,000. Women from Cambodia and Laos had the highest sum of maternal risk factors; those from the Philippines and Thailand had the least. The lowest collective adverse neonatal outcomes were in infants born to women from Cambodia and Laos. CONCLUSION: The 11 subgroups of Asians living in Illinois demonstrate heterogeneity with respect to multiple birth rate, selected maternal risk factors and adverse neonatal outcomes. After considering all maternal risk factors and neonatal outcomes, the two groups (Cambodians and Laotians) with the poorest maternal risk factors had the lowest rate of poor neonatal outcomes. This is the first time that this epidemiologic paradox has been observed in twins of Asian ancestry.

Adolescent↗
PubMed2002

Mourning and psychological issues in multiple birth loss.

Grief after the death of some or all multiples differs from mourning for a singleton loss in many important respects. A review of the unique features of grief for a multiple birth loss is followed by practical suggestions for empathic care. Cherished mementos and photos, and disposition options for deceased children are discussed. Counselling needs of parents and siblings are detailed, and management options for many complex pregnancy and infant loss scenarios are presented. The abundant resources listed will help caregivers and families better cope with one of the most difficult complications of plural parenthood.

Bereavement↗
PubMed2004

Role of multiple births in very low birth weight and infant mortality.

OBJECTIVE: To determine the percentage of very-low-birth-weight (VLBW) infants (<1500 g) and infant deaths attributable to multiple births in the general population and in women aged 35+. STUDY DESIGN: The year 2000 Massachusetts birth certificate database with linked births-deaths was examined. Etiologic fractions (EF) for VLBW and infant mortality attributable to multiples were calculated for the general population and the 35+ age group. The percentages of multiples occurring in the 35+ age group were calculated. Infant deaths due to congenital anomalies and "perinatal conditions" were calculated. RESULTS: There were 81,582 resident births in Massachusetts in 2000. Of them 4.3% were multiples. Of the 1090 VLBW infants, 26.1% (95% CI: 23.5-28.8) were in twins and 7.7% (95% CI: 6.2-9.5) in higher-order multiples, yielding an EF of 30.8% for multiples in VLBW. In the 35+ age group, the multiple birth ratio was 6.6% (95% CI: 6.3-7.0). The EF for multiples and VLBW in this age group was 33.7%. The 35+ age group accounted for 32.4% (95% CI: 30.8-34.0) of twins and 45.5% (95% CI: 39.1-52.0) of higher-order multiples born in 2000. Of the 392 infant deaths, 57 (14.6%; 95% CI: 11.2-18.4) were attributed to congenital anomalies, and 236 (60.2%; 95% CI: 55.2-65.0) to "perinatal conditions." Multiples were responsible for 8 (14%; 95% CI: 6.3-25.8) of deaths due to anomalies, and 73 (30.9%; 95% CI: 25.1-37.3) due to "perinatal conditions." CONCLUSION: Over 30% of VLBW infants, nearly 20% of infant mortality and >30% of infant mortality due to perinatal conditions could be attributed to multiples. Multiple pregnancy is a significant public health problem.

Adult↗
PubMed2006

Data collection on multiple births -- establishing twin registers and determining zygosity.

Twins are a valuable resource not only for studies on multiple births themselves, but on the etiology of diseases and other phenotypes. The method of ascertainment and selection of twins can be crucial for such studies and population based twin registries are thus of great importance as tools of research. Accurate determination of zygosity and chorionicity is essential in all studies of multiple births and in their professional care. The parents and the multiples ask for it. It is of pre-and postnatal medical importance and now considered as a prerequisite in several domains of twin research. It is also important for educational reasons as it helps the multiples and their parents and teachers to ascertain identity. The methods are briefly described and a plea is made to the obstetricians and pediatricians to use them systematically at birth. The distribution of zygosity and chorionicity types among spontaneous and induced twin births are illustrated.

Data Collection↗
PubMed2005

Preterm birth in Sweden 1973-2001: rate, subgroups, and effect of changing patterns in multiple births, maternal age, and smoking.

BACKGROUND: The objectives of this report are to evaluate changes in the preterm birth rate in Sweden 1973-2001. Furthermore, describe the proportion of spontaneous and indicated preterm births and assess risk factors for the subgroups of preterm birth during the period from 1991 to 2001. METHODS: A population-based register study of all births occurring in Sweden from 1973 to 2001 registered in the Swedish Medical Birth Register was designed. The analysis of subgroups was restricted to the period 1991-2001. Gestational age was calculated using last menstrual period and best estimate. Odds ratio for preterm birth related to risk factors was calculated for the subgroups' spontaneous and indicated preterm birth. RESULTS: After an increase in the beginning of the 1980s, the preterm birth rate has decreased from 6.3% in 1984 to 5.6% in 2001 (P < 0.0001). The proportion of multiple births born preterm of the total birth rate increased from 0.34% in 1973 to 0.71% in 2001 (P < 0.0001). Spontaneous preterm births account for 55.2% and iatrogenic preterm births for 20.2% of all preterm births. The strongest association with maternal smoking in early pregnancy was found at gestational age <28 weeks and spontaneous preterm birth [odds ratio (OR) smoking versus no smoking: 1.55, 95% confidence intervals (CI): 1.42-1.69]. The strongest association for maternal age was found between gestational age <28 weeks and indicated preterm birth (OR 5-year increase: 1.34, 95% CI: 1.21-1.47). CONCLUSIONS: The preterm birth rate in Sweden has decreased since the mid 1980s. The composition of different subtypes of preterm birth in a Scandinavian low-risk population seems to be similar to populations with higher incidence of preterm birth and perinatal infections.

Adult↗
PubMed1999

Early parental interactions with and perceptions of multiple birth infants.

The perceptions and interactions of mothers and fathers of seven sets of twins and one set of triplets were compared to those of parents of 49 singleton infants. Couples were typically interviewed together three times during the pregnancy and at 1 week and 3 months post-partum. Two-weekly observations of mother-father-infant interactions were conducted after the first postnatal interview. Three major themes were apparent in the interviews--the positive and negative specialness for multiple births, difficulties involved in managing more than one infant, and attachment issues--that were also evident during the observations. Although there were few differences in care-giving and interactive behaviours between the multiple birth and singleton parents, the logistics of caring for more than one infant dictated that multiple birth infants were left alone more and looked at, talked to and held less often. Couples used different strategies to care for their infants, varying in both the extent to which they interacted preferentially with the infants and in the relative involvement of the mother, father and others.

Analysis of Variance↗
PubMed1987

The recent trends in multiple births and stillbirth rates in Japan.

The twinning rate remained nearly constant up to 1968, then decreased in 1974 and gradually increased with the year. The triplet birth rate remained nearly constant up to 1974, then increased up to 1982, where the rate was 1.8 times higher than in 1968, and decreased thereafter. On the other hand, the quadruplet birth rate remained nearly constant up to 1968, was eightfold in 1975, then decreased until 1984 and suddenly increased to 8 per million births in 1985. The higher multiple birth rates since 1974 was attributed to the higher proportion of mothers treated with ovulation-inducing hormones in Japan. The stillbirth rates decreased to 2/5 for male twins and to 1/3 for female twins during the 25-year period from 1960, to 2/5 for triplets and to 1/5 for quadruplets during the 34-year period from 1951.

Birth Rate↗
PubMedDate not supplied

How low birthweight and gestational age contribute to increased inpatient costs for multiple births.

The dramatic rise in the number of multiple gestation births has led to concerns about heavy resource use by these newborns and the design of cost-effective interventions. This study uses medical records data to compare single and multiple births in terms of hospital charges by cost center, length of stay, neonatal intensive care unit (NICU) days, and discharge status. Potential mediators examined were gestational age and birthweight. These factors, respectively, accounted for 50% and 40% of the increase in total charges due to multiple gestation. The remaining "direct effect" was due primarily to longer hospital stays among twins and higher daily charges among higher-order multiples. Room and board charges were higher for multiples, while charges in other categories were actually lower, after controlling for birthweight and gestational age. Birthweight and gestational age accounted fully for the increased use of NICU services among multiples. These results show that while prevention of multiple gestation, where possible, is of paramount importance, strategies that decrease preterm delivery and/or increase birthweight should attenuate the adverse economic impact of multiple gestation pregnancies.

Boston↗
PubMed2002

The impact of the increasing number of multiple births on the rates of preterm birth and low birthweight: an international study.

OBJECTIVES: We studied the effects of twins and triplets on perinatal health indicators in the overall population in the 1980s and 1990s in Canada, England and Wales, France, and the United States. METHODS: Data were derived mostly from live birth registration. We used rates, relative risks, and population attributable risks for twins and triplets separately. RESULTS: In each country, the increase in multiple births, and the increase in preterm delivery among multiple births, contributed almost equally to the rise in or stabilization of the overall rates of preterm delivery. Twins contributed a much larger proportion of the preterm deliveries and low-birthweight newborns than did triplets. CONCLUSIONS: Twins have a major population-based impact on the trends of perinatal health indicators.

Canada↗