What information should the multiple birth family receive before, during and after the birth?

Is the mental health of couples with twins more at risk? Results from an Italian cohort study

Introduction

Our retrospective study aimed to investigate whether parents of twins encounter heightened psychological and emotional distress one year after childbirth, in comparison to parents of singletons within an Italian cohort.

Methods

Exclusion criteria included multiparity, preterm birth, congenital anomalies, stillbirth, >2 fetus pregnancies, and pre-existing maternal mental health disorders. Out of the 300 couples (600 parents) invited to participate, 286 parents (158 mothers, 128 fathers) successfully completed a self-administered survey. We analyzed three scores separately for mothers and fathers, differentiating between singleton and twin pregnancies: the Edinburgh Postnatal Depression Scale (EPDS) score, the State and Trait Anxiety Inventory (STAI)-Y1 score, and the STAI-Y2 score.

Results

Logistic models were used to assess the influence of age, BMI, marital status, education, and employment on the three binary scores (EPDS, STAI-Y1, and STAI-Y2), revealing no significant differences in absolute scores between parents of singletons and twins. Paired analysis revealed significantly higher EPDS (mean increase: 3.8, SD: 6.5), STAI-Y1 (mean increase: 5.4, SD: 12.5), and STAI-Y2 (mean increase: 4.5, SD: 12.4) scores for mothers (p < 0.0001). Approximately 10% of women and 8% of men reported suicidal thoughts.

Discussion

Contrary to expectations, no substantial psychological differences emerged between parents of twins and singletons. Adjusting for confounders through univariate analysis maintained nonsignificant trends. Nevertheless, caution in interpretation is warranted due to strict inclusion criteria favoring twin pregnancies with better outcomes. Unintended bias could have resulted from routine psychological support offered to mothers of twins in our clinic. This presents an important framework for future research, including randomized controlled trials comparing parents of multiples with psychological support to those without.Finally, the elevated prevalence of depression symptoms and suicidal thoughts in our cohort underscores the importance of mental health during pregnancy and early parenting. We advocate for the screening of parents for postpartum depression and various psychological conditions, encompassing a spectrum of anxiety disorders. Those at elevated risk of mental distress should be proactively offered appropriate support.

Monochorionic Twins and the Early Mother-Infant Relationship: An Exploratory Observational Study of Mother-Infant Interaction in the Post-Partum Period

The extraordinary increase in twin rates and specifically monochorionic twin pregnancies represents a major public health issue due to the associated increased risks for the mother, the child and their relationship. The aim of the present study was to examine the quality of mothers’ behaviour during mother–infant interaction in the early postpartum period by comparing mothers of twins and mothers of singletons during face-to-face interaction with their infants. Demographic and clinical information was collected by trained research psychologists from the mothers’ and the childrens’ clinical records and from interviews with the mothers. At three months (corrected for prematurity), the interactions of the dyads (11 mother-twin infant dyads and 11 mother-singleton dyads) were filmed at participants’ homes in accordance with the procedure of the Global Rating Scales. Maternal behaviour during interactions was assessed and rated by two trained research psychologists. With regard to the mothers’ interaction with each twin, no differences were found between mothers’ scores in every GRS subscale, indicating that mothers did not interact differently with their twins. Comparisons between mothers of MC twins and mothers of singletons showed that the quality of maternal sensitive behaviour during the interactions were lower in mothers of twins (0.35) Mothers of twins were also more distant during interactions with their babies and more likely to experience depression symptoms than mothers of singletons (0.05). Future research should examine mother-infant relationships following twin birth with larger samples. Such research will be especially useful in evaluating the potential benefits of interventions to promote positive mother-infant interactions.

Should parents be present during screening examinations for retinopathy of prematurity?

Purpose:

To investigate whether parents should be present during screening examinations for retinopathy of prematurity (ROP) by investigating the anxiety levels of parents using two different approaches.

Methods:

This cross-sectional and two-center study was carried out with the parents at the time of the first ROP screening examination of their premature infants. At one center, the parents accompanied the infants during the ROP examination (Group 1), and in the other center, they did not (Group 2). Anxiety levels were assessed with the State-Trait Anxiety Inventory (STAI), which consists of the State Anxiety (STAI-S) and Trait Anxiety (STAI-T) subscales and a visual analog scale (VAS).

Results:

A total of 147 parents of 127 infants were included in the study. STAI-T and -S levels were 40.5 ± 8 and 37.9 ± 7.5, respectively, in Group 1 and 39.6 ± 8.1 and 39.4 ± 9.1 in Group 2 before the examination. There were no statistically significant differences in terms of these values between the two groups (P > 0.05). The state anxiety levels increased by an average of 1.7 ± 8 in Group 1 and reached 39.6 ± 10.1 after the examination. In Group 2, these levels decreased by an average of − 2.7 ± 7.5 points to a score of 36.4 ± 10.3. This difference was found to be statistically significant (P = 0.001). A similar pattern was observed in the evaluation of the VAS data.

Conclusion:

As a preliminary opinion, it may be more appropriate for parents to not participate in screening examinations, but single-center controlled studies are required to confirm the results.

Raising multiples: mental health of mothers and fathers in early parenthood

The rate of twin and higher-order gestation births has risen dramatically in recent decades in the United States as well as other Western countries. Although the obstetrical and neonatal risks of multiple gestation pregnancies are well-documented, much less is known regarding the mental health impact on parents of multiples during the perinatal and early parenthood period. Given that parents of multiples face greater functional demands, as well as other pressures (financial, medical) this population may be at risk for heightened distress. We conducted a systematic review of quantitative, English language studies that assessed mental health outcomes of parents of multiples during pregnancy, in the first postpartum year, and in the period of early parenthood, including depression, anxiety, stress, and related constructs. Twenty-seven articles published between 1989 and 2014 met selection criteria and were included in the review. Studies utilized a wide range of methods and outcome constructs, often making comparisons difficult. Although some studies found no differences, most investigations that compared mental health outcomes in parents of multiples versus parents of singletons found that parents of multiples experience heightened symptoms of depression, anxiety, and parenting stress. We discuss gaps in the existing body of literature on parental mental health related to multiple gestation birth and conclude by discussing the need for novel intervention strategies to meet the needs of this growing population. Parents of multiples may experience worse mental health outcomes than parents of singletons. More research is needed, and future work should explore potential treatment and support options.

Twin parenthood: the midwife's role--a randomised controlled trial

OBJECTIVE

To determine whether a midwife-led intervention improved preparation for twin parenting and maternal psychosocial outcome.

DESIGN

Randomised controlled trial.

SETTING

Two maternity units in North East England.

POPULATION

A cohort of 162 women with uncomplicated twin pregnancy.

METHODS

Self-completion questionnaire at multiple time points.

MAIN OUTCOME MEASURES

The primary outcome was probable postnatal depression (measured with the Edinburgh Postnatal Depression Scale, EPDS) 26 weeks after delivery. Secondary outcomes included preparation for parenting, maternal anxiety, parenting stress, and maternal wellbeing.

RESULTS

The mean maternal EPDS scores at 26 weeks after delivery were 5.4 (SD 4.5) in the twin intervention (TI) group and 6.9 (SD 5.5) in the twin control (TC) group, and the mean difference between the groups was 1.5 (95% confidence interval, 95% CI, -0.2 to 3.3). The relative risk (RR) of having probable depression in the TI group compared with the TC group at 26 weeks was 0.48 (95% CI 0.19-1.20) for mothers and 0.84 (95% CI 0.42-1.70) for fathers. There were no statistically significant differences in maternal anxiety or parenting stress. TI mothers reported increased maternal wellbeing, reaction to motherhood, family support, mood, and greater self-confidence 26 weeks after delivery, and felt more prepared for parenting.

CONCLUSION

As a result of the limited sample size, the study was unable to detect a difference in maternal depression using the maternal EPDS mean score. The antenatal preparation for parenting programme did not improve postnatal maternal anxiety or parenting stress; however, it did improve postnatal maternal wellbeing, mood, self-confidence, reaction to motherhood, and better prepared mothers to parent twin infants. Midwives have a key role in preparing mothers to parent twins.

Multiple Birth Families With Children With Special Needs: A Qualitative Investigation of Mothers’ Experiences

Multiple birth remains prevalent, with prematurity and subsequent disability being common complications. However, little is known of the experiences of mothers living with the combined circumstances of multiple birth, prematurity, and special needs. This paper reports an exploratory study using the qualitative technique of thematic analysis, to describe and interpret the experiences of 10 mothers of prematurely born multiple birth children with diverse special needs. Mothers were shocked to learn they were carrying multiple fetuses, including those who underwent in vitro fertilization with dual embryo transfer. Most experienced protracted concern over one or more babies’ survival during pregnancy, and prescribed bed rest was frequently associated with increased anxiety and other adverse psychological effects. Some experienced disenfranchised grief, such as those grieving the opportunity to bear a single child. The contrast with experiences of mothers of healthy, term singletons caused considerable distress. Feelings of detachment and unreality were common in the immediate postpartum period, possibly due to transient depersonalization. Having more than one newborn created practical and psychological problems during the neonatal period, particularly when infants were separated due to differences in medical status. The extent to which hospitals accommodated the multiple birth relationship varied and significantly affected mothers’ postnatal experiences. Mothers often felt guilty, particularly regarding inequality of care and attention they were able to provide to each child. This was especially problematic for multiples discordant for special needs status. The presence of one normally developing child complicated adjustment to the other's difficulties, and several experienced chronic sorrow. Serious maternal mental health difficulties were common but not universal. Available formal supports were generally perceived as inadequate, addressing some, but not all, of the mothers’ needs. Further work is needed to advance understanding of the relationships between mothers and their multiples, and to explore the implications of special needs within multiple birth families.

How Couples Cope With the Death of a Twin or Higher Order Multiple

Fifty-two Australian couples who had experienced the death of at least one member of a multiple birth (twin or higher order), with at least one survivor of that birth, were interviewed about their experiences at the time of the death, and since. This study compared parents' coping after the twins' deaths using the Beck Depression Inventory II, Perinatal Grief Scale, and unstructured interviews with some structured queries. Parents provided information on the influence of family, community and medical staff. According to retrospective reports, mothers experienced significantly more depression and grief than fathers at the time of loss. Both parents found the death of their twins grievous, but fathers, unlike mothers, were not encouraged to express their emotions. Although parents generally agreed about what helped them cope, fathers believed that they should be able to cope regardless of their grief. The strength of parents' spiritual beliefs had increased significantly since their loss, and there was some evidence that depressed and grieving mothers turned to spiritual support. Parents whose children died earlier reported levels of depression similar to those reported by parents whose children died later. To date, this is the largest study of grief in couples who have experienced the death of a twin and who have a surviving twin or higher order multiple.

Feelings and the need for information and counselling of expectant parents of twins

In this study, expectant parents of twins were questioned about their feelings and need for information and counselling on the parenting of twins. Data were obtained from self-rating questionnaires and an interview with the expectant mother. From the results it is argued that expectant parents of twins need specific information and counselling about the medical, emotional and parenting issues of having twins. Guidelines for organising this counselling are proposed.

Twin gestation pregnancies: genetic counseling and testing experience

We report on the prenatal genetic counseling and testing experience in 343 pregnancies with twin or higher multiple gestations. By self-report, 8% (27/343) parents of these pregnancies reported meeting with a genetic counselor, and 23% (79/343) elected prenatal genetic testing. The most common testing procedures elected were maternal serum analyte screening and amniocentesis to identify fetuses with aneuploidy or neural tube defects. Use of prenatal genetic testing was correlated with advanced maternal age. No association was found between use of genetic testing and use of OI/ART or the length of time needed to conceive. Forty percent (11/27) of those who met with a genetic counselor opted to decline prenatal testing/screening. These data suggest that although clients with multiple gestation pregnancies would likely benefit from genetic counseling, many are not availing themselves of this service. Implications of these data for the genetic counseling profession are discussed.

Conséquences psychologiques des naissances multiples

Since the mid 1970s, the number of multiple births has dramatically increased in our country and most European countries. This paper summarizes the psychological consequences of multiple births based on a review of the literature and on our clinical experience. During pregnancy mothers experience great physical problems linked with increased medical risks for themselves and for the children. These risks cause psychological difficulties: hospitalisation and separation from the family, fear of a premature delivery and anxiety for the children. After delivery the children are often hospitalized, which makes the attachment process difficult. The mortality of multiple children is high and mourning for one child creates particular problems for parents who simultaneously face grieving and attachment processes. After hospital discharge, the overload of work mothers experience leads to physical and nervous fatigue, which does not make easier individual relationship with the children. Mothers have a high level of psychological vulnerability and an increased risk of depression. The satisfactory development of each twin or triplet child requires individualized relationship with his/her mother and his/her father. That is how he/she will be able to build his/her identity and future autonomy. It is important to be aware of the problems experienced by the families and to improve the way material help and psychological support are provided to them.

Preparation for parenting multiple birth children

The experience of expecting and parenting multiples is decidedly different from that of a singleton pregnancy and parenthood. Multiple births are associated with substantial medical, health care, socio-emotional, developmental, educational and economic consequences for both families and society. This paper aims to advise health professionals on how best to help families prepare for and successfully respond to the demands of multiple pregnancy and the first 5 years of parenthood after the births of twins, triplets or more. Four inter-related principles of good practice are vital to the care of multiple birth families: the involvement of a range of disciplines, of the family and of the multiple birth community; the provision of specialised care; coordinated services; and the building of family competency including the capacity to make informed decisions. Preparation should include education on the special aspects of multiple pregnancy and parenting using multiples-focused resources, health promotion and risk modification strategies, infant care and feeding, child development and advice on securing help and support while ensuring family participation in all care decisions.

Two cycles with single embryo transfer versus one cycle with double embryo transfer: a randomized controlled trial

BACKGROUND

With the aim of reducing the number of multiple pregnancies after IVF we investigated the effectiveness of two cycles with single embryo transfer (SET) and one cycle with double embryo transfer (DET) after IVF and calculated the cost-effectiveness of both strategies.

METHODS

A randomized controlled trial was performed in 107 women, aged <35 years, in their first IVF cycle, with at least one good quality embryo. They were randomized to the SET (n = 54) or DET (n = 53) group using a computer-generated random block number table, stratified for primary or secondary infertility.

RESULTS

The cumulative live birth rates per woman randomized of two consecutive cycles of SET [41%; 95% confidence interval (CI) 27-54] versus one cycle of DET (36%; 95% CI 23-49) were comparable, whereas the multiple pregnancy rate was significantly higher: 37% (95% CI 15-59) in the DET and 0% in the in the SET group (P = 0.002). Combining the medical costs of the IVF treatments (where 1.5 more SET cycles were required to achieve each live birth) and of pregnancies up to 6 weeks after delivery, the total medical costs of DET per live birth were 13,680 and 13,438 for SET.

CONCLUSIONS

Two cycles with SET were equally effective as one cycle with DET, and the medical costs per live birth up to 6 weeks after delivery were the same. However, if lifetime costs for severe handicaps are included, more than 7000 per live birth will be saved after implementing SET. Because of the high probability of multiple pregnancies in this group of IVF patients, only SET should be performed.

Psychological aspects of prenatal diagnosis and its implications in multiple pregnancies

Couples expecting twins are often unrealistically optimistic and are therefore unprepared for the complications as well as the practical and emotional impact the birth of twins can have on the family. All such couples will need information and support throughout the pregnancy and beyond. In this review, the various aspects that should be addressed are discussed, in particular, health care workers and counsellors need to be aware of the stress experienced by parents who have been through prolonged treatment for infertility or who face the special problems associated with the loss of one twin (implies the loss could be other than death).

Economic and social implications of multiple birth

This paper provides the background statistics and trends on multiple births. It highlights a number of factors that influence parents with multiples, including social situation, psychological adjustment and economic circumstances. It is often assumed that these areas of concern arise only after the babies have been born, but clinicians should be aware that many are seen in the antenatal period as well. Apart from the socioeconomic cost to individual families, multiple births also carry a cost to society. A number of self-help groups and voluntary organisations can assist parents of multiples. This is especially important if parents find that family and friends cannot or will not come forward.

Surrogacy: the parents' story

This qualitative study explored the experiences of 26 parents who were involved in surrogate parenting arrangements in a California-based surrogacy program. Participants were mostly white (n = 23). married (n = 25), females (n = 24), with high levels of education and income. The mean age at the time of the first child's birth was 39 yr. (SD = 5.06). The majority of parents reported having one (n = 10) or two (n = 8) children. All subjects reported infertility as their reason to explore surrogacy as a method of building a family. 18 participants chose in vitro fertilization as heir method of conception. Telephone interviews explored their decision-making, ethod of fertilization, their relationship with their surrogate, and the support that they received during the surrogacy process. Results indicate that parents were able to nticipate some potential pitfalls prior to their experience but did not realize the imortance of other potential difficulties. A conceptual model is presented with implications for helping professionals.

Educating families, before, during and after a multiple birth

Couples who are expecting twins and higher order births need specific information and support to help them prepare for the care of their babies. Professionals caring for such families should be aware of their special needs and ensure close liaison in order to provide a coordinated service throughout the pregnancy and early childhood.

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.

Patient perceptions of multiple gestations: an assessment of knowledge and risk aversion

OBJECTIVE

To determine whether knowledge of the increased risk of certain pregnancy complications affects a woman's desire to achieve a multifetal gestation.

STUDY DESIGN

Women who attended an infertility clinic were given an interviewer-administered survey that ascertained how intensely they desired a multifetal pregnancy and how accurately they perceived the risks of multifetal complications. In addition, 5-point Likert scales were used to assess how different perceptions of risk affected the desire for gestations of different plurality.

RESULTS

Most respondents (67%) expressed the desire to conceive a twin pregnancy, although they could not accurately estimate the probability of risks associated with this type of pregnancy. Nevertheless, their desire was affected by perceptions of pregnancy-associated risk. On the basis of ordinal regression, desire for twins was more likely after in vitro fertilization (P <.01) but less likely as a woman's estimation of the risk of pregnancy complications increased (P <.05). When women were presented with scenarios of differing pregnancy-associated risk magnitudes, their desire for twin pregnancy decreased as risk magnitudes increased (median Likert score decrease from 4 to 3 to 2, P <.01). After being confronted with the actual probabilities of specified perinatal complications associated with a twin pregnancy, women were less desirous of having a twin pregnancy (median Likert score decrease from 4 to 3, P <.001) than they had originally expressed.

CONCLUSION

Women who undergo treatment for infertility are not well aware of the risks of perinatal complications associated with multiple gestations. Moreover, these women are risk sensitive and change their desires on the basis of their perception of overall risk.

Depression and anxiety disorders during multiple pregnancy and parenthood

Depression or anxiety disorders may affect more than 25% of multiple birth parents during the perinatal period. Such parents often are uninformed, suffer in silence and fear, and are reticent to seek help. When depression, panic attacks, and obsessive-compulsive disorder are not recognized or are left untreated, parent health, parent-infants interaction, child development, and family stability may be seriously compromised. Nurses, as partners in care at the family and community levels, have a pivotal role to play in prevention-focused health, education, and social support programs; the identification of parents at risk; and the early recognition and support of women and families affected by these disorders.

Is there a role for a twins clinic? An evaluation of parents' responses

To evaluate parental responses to the Twins Clinic, postal questionnaires were sent to the parents of 141 pairs of twins, born outside the maternity hospital who were referred to the clinic in the first three years. The main outcome measures were: the sources of, and reasons for, referral; previous attempts to find help; experiences at the clinic and outcome of the visit. One hundred and thirteen families (80%) replied, of whom 101 (89%) were self-referred. The most common problems for which twins were referred related to behaviour (34) and development (28). In 99 (88%) cases, parents had already sought assistance from other sources (39 from health professionals) but only 29 had found this helpful. In 95 (84%) cases, parents felt there had been a positive outcome from attending the clinic, in the form of reassurance (87), change of management (39), successful support for applications (19) or information (11). Parents' responses indicate that the Twins Clinic meets the needs of families with multiples who are inadequately served by existing sources of help. These will only be improved through education of health professionals (and of the community as a whole) so as to obviate the need for Twins Clinics.