The influence of multiple birth and bereavement on maternal and family outcomes 2 and 7years after very preterm birth

BACKGROUND

Psychological distress has been reported by mothers of infants born very preterm (VPT) and by mothers of multiples (twins and triplets). This study examined the influence of i) multiple birth and ii) bereavement associated with a multifetal pregnancy, on mental health, parenting stress and family functioning for mothers of children born VPT across early childhood.

METHODS

Participants were 162 mothers of 194 infants (129 singletons, 65 multiples) born at <30weeks' gestation or with a birth weight<1250g who completed questionnaires when their children were two and seven years corrected age. Fifteen mothers (9%) experienced bereavement associated with a multifetal pregnancy. Maternal mental health was assessed using the General Health Questionnaire at two years and Hospital Anxiety and Depression Scale at seven years. Parenting stress and family functioning were assessed using the Parenting Stress Index and Family Assessment Device.

RESULTS

Maternal mental health, stress and family functioning were similar in mothers of VPT singletons and multiples. However compared with mothers who had not experienced bereavement, mothers who had were 3.6 times [95% confidence interval (95% CI) 1.05, 12.5] more likely to report elevated anxiety symptoms and 3.6 times [95% CI 1.05, 12.3] more likely to report elevated depressive symptoms when their VPT child was seven years old.

CONCLUSIONS

The results of this study highlight the need for monitoring and offering ongoing support to bereaved mothers with surviving VPT children. However, within the context of VPT birth, multiple birth does not increase the risk for maternal psychological distress in early childhood.

Strategies to Support Sustained Breastfeeding of Late Preterm Multiple Birth Infants

Strategies to support sustained breastfeeding in late preterm multiple birth infants include developing a family-centered feeding plan in collaboration with the medical team, assessing and supporting breastfeeding sessions, promoting lactogenesis with pumping or manual expression, and activating a support system for families.

Methodological and hermeneutic reduction - a study of Finnish multiple-birth families

AIM

To describe reduction as a method in methodological and hermeneutic reduction and the hermeneutic circle using van Manen's principles, with the empirical example of the lifeworlds of multiple-birth families in Finland.

BACKGROUND

Reduction involves several levels that can be distinguished for their methodological usefulness. Researchers can use reduction in different ways and dimensions for their methodological needs.

DATA SOURCES

Open interviews with public health nurses, family care workers and parents of twins.

REVIEW METHODS

The systematic literature and knowledge review shows there were no articles on multiple-birth families that used van Manen's method.

DISCUSSION

This paper presents reduction as a method that uses the hermeneutic circle. The lifeworlds of multiple-birth families consist of three core themes: 'A state of constant vigilance'; 'Ensuring that they can continue to cope'; and 'Opportunities to share with other people'.

CONCLUSION

Reduction allows us to perform deep phenomenological-hermeneutic research and understand people's lifeworlds. It helps to keep research stages separate but also enables a consolidated view. Social care and healthcare professionals have to hear parents' voices better to comprehensively understand their situation; they also need further tools and training to be able to empower parents of twins.

IMPLICATIONS FOR RESEARCH/PRACTICE

The many variations in adapting reduction mean its use can be very complex and confusing. This paper adds to the discussion of phenomenology, hermeneutic study and reduction.

Psychiatric outcomes at age seven for very preterm children: rates and predictors

BACKGROUND

  Uncertainty remains about the rate of specific psychiatric disorders and associated predictive factors for very preterm (VPT) children. The aims of this study were to document rates of psychiatric disorders in VPT children aged 7 years compared with term born children, and to examine potential predictive factors for psychiatric diagnoses in VPT children.

METHODS

  Participants were 177 VPT and 65 term born children. Perinatal medical data were collected, which included brain abnormalities detected using magnetic resonance imaging. The Infant-Toddler Social-Emotional Assessment (ITSEA) and Strengths and Difficulties Questionnaire (SDQ) were administered at 2 and 5 years respectively. At 7 years of age, the Developmental and Well-being Assessment (DAWBA) was used to indicate psychiatric diagnoses.

RESULTS

  Compared with term born children, VPT children had three times the odds of meeting criteria for any psychiatric diagnosis at age 7 years (odds ratio 3.03; 95% confidence interval 1.23, 7.47, p = .02). The most common diagnoses were anxiety disorders (11% VPT, 8% term), attention-deficit/hyperactivity disorder (10% VPT, 3% term) and autism spectrum disorder (4.5% VPT, 0% term). For VPT children, those with severe global brain abnormalities (p = .02), those who displayed social-emotional problems at age 5 (p = .000) and those with higher social risk at age 7 (p = .001) were more likely to meet criteria for a psychiatric illness at age 7.

CONCLUSIONS

Compared with term born children, VPT children have higher rates of psychiatric diagnoses at early school age, predicted by neonatal brain abnormalities, prior social-emotional problems and social factors.

Is sibling rivalry fatal?: siblings and mortality clustering

Evidence drawn from nineteenth-century Belgian population registers shows that the presence of similarly aged siblings competing for resources within a household increases the probability of death for children younger than five, even when controlling for the preceding birth interval and multiple births. Furthermore, in this period of Belgian history, such mortality tended to cluster in certain families. The findings suggest the importance of segmenting the mortality of siblings younger than five by age group, of considering the presence of siblings as a time-varying covariate, and of factoring mortality clustering into analyses.

Higher order multiples--socioeconomic impact on family life

AIMS

Assisted reproduction led to an enormous increase of multifetal gestation. Apart from the obstetrical risks the physical, psychological and socioeconomic problems in families after the birth of higher order multiples often lack attention.

STUDY DESIGN

Anonymous questionnaires were sent to 92 families who had delivered higher order multiples at our hospital (1983--1998). In a retrospective analysis (rate of return: 70%) the study group included 54 families with triplets, nine families with quadruplets and one family with quintuplets. The questionnaire was divided into three sections: a joint section to be answered by both parents together, and two identical sections for each separately.

RESULTS

Most parents suffered from severe physical and psychological exhaustion mainly caused by worries about the multiples' development, handicaps and acute and chronic diseases as well as by personal and by financial problems. Nearly all of the families had to rely on additional manpower and on financial support. The inability to cope with the "self-inflicted" family-situation as a consequence of "optional" infertility treatment led to feelings of guilt.

CONCLUSIONS

Aside from psychological guidance, the need for personnel aid as well as financial and material support in families after the delivery of higher order multiples is striking.

Prenatal and birth complications in autism

OBJECTIVES

Prenatal and birth history as potential sources of risk factors in relation to the onset of autism were examined.

METHODS

A cohort of 164 families of autistic children referred to The Autism Center at New Jersey Medical School-UMDNJ, Newark, New Jersey, over a two-year period was studied. Intake prenatal and birth history information was obtained from each family and reviewed by a clinician.

RESULTS

Prevalence rates in this cohort for vaginal bleeding, prolonged labor and prematurity were higher than comparable rates reported nationally and in New Jersey. Clustering of multiple prenatal risk factors was observed. This clustering was associated with the age of the mother, but uncorrelated with birth order.

CONCLUSIONS

These findings support the general hypothesis that systemic problems at the prenatal stage may form a distinct dimension of risk associated with autism.

Meeting the educational needs of multiple birth children

There has been a significant increase in the number of twins and higher multiples so that one child in 33 is now a multiple. It is therefore not unusual for schools to have several sets of twins, as well as triplets and even higher multiples. By being the same age and in the same school year if not class, twins and higher multiples are not like brothers and sisters born closely together. Teachers and parents need to be aware of particular issues that may affect the physical, intellectual, personal, social and emotional development of multiple birth children, and to ensure that school policy and practice include this special group of children and parents. These issues include: preterm birth catch-up and implications for starting school; the balance of competition and cooperation among multiples; separation in school and the evidence from recent longitudinal studies; legislative and other initiatives on the development of school policy; the particular needs of higher multiples.

Psychosocial risks associated with multiple births resulting from assisted reproduction

OBJECTIVE

To determine if increased psychosocial risks are associated with each increase in birth multiplicity (i.e., singleton, twin, triplet) resulting from assisted reproduction.

DESIGN

Stratified random sample (n = 249).

SETTING

An academic teaching hospital and private practice infertility center.

PATIENT(S)

Mothers raising 1- to 4-year-old children (n = 128 singletons, n = 111 twins, and n = 10 triplets) conceived through assisted reproduction.

INTERVENTION(S)

Self-administered, mailed survey.

MAIN OUTCOME MEASURE(S)

Scales measuring material needs, quality of life, social stigma, depression, stress, and marital satisfaction.

RESULT(S)

Using multivariate logistic regression models, for each additional multiple birth child, the odds of having difficulty meeting basic material needs more than tripled and the odds of lower quality of life and increased social stigma more than doubled. Each increase in multiplicity was also associated with increased risks of maternal depression.

CONCLUSION(S)

To increase patients' informed decision-making, assisted reproduction providers might consider incorporating a discussion of these risks with all patients before they begin fertility treatment, and holding the discussion again if the treatment results in a multiple gestation. These data may also help providers to identify appropriate counseling, depression screening, and supports for patients with multiple births.

[Mother-infant Interactions with Very Low Birth Weight multiple newborns (< 1500 g). A comparison of mother-multiple and mother-single births]

BACKGROUND

Assisted reproductive techniques and fertility enhancing therapies have increased the rate of multiple births and, therefore, the risk of prematurity. Our hypothesis is that mothers of preterm multiples are less able to provide such enhancing interactions than mothers of preterm singletons, resulting in a developmental disadvantage for preterm twins and triplets.

PATIENTS AND METHODS

Of 77 very low birth weight preterms (VLBW) who were examined prospectively with their mothers in a longitudinal study, 35 were multiples and 42 were singletons. At a corrected age of three months the quality of the mother-infant interaction with multiples vs. singletons was examined. The Mannheim Rating System, a 40-item standardized observation instrument based on a 10 minute videotaped sequence of interaction, was used.

RESULTS

The analyses showed several differences between mother-singleton and mother-multiple interactions. Mothers of multiples were less stimulating and reactive and showed less babytalk. Multiple infants were also less reactive than singletons. In mother-multiple dyads there were less verbal exchanges between mother and child.

CONCLUSIONS

There are definite differences in mother-multiple compared to mother-singleton interactions, so that VLBW multiples may be at even greater risk for negative mother-infant interactions than singletons.

Social stigma and compounded losses: quality-of-life issues for multiple-birth families

OBJECTIVE

To determine the quality-of-life domains most impacted by multiple births.

DESIGN

Focus groups, qualitative research.

SETTING

Human volunteers in a medical research environment.Forty-three mothers, 29 raising multiple-birth children, 13 raising singletons, identified from random and convenience samples.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Maternal self-reports of the psychosocial sequelae of multiple or singleton births, based on qualitative data analysis of transcribed group discussions.

RESULT(S)

The quality-of-life domains that were most impacted by raising multiple birth children were social stigma, pregnancy loss, marital satisfaction, children's health, unmet family needs, parenting stress, maternal depression, and the infertility experience.

CONCLUSION(S)

Qualitative methods identified two novel quality-of-life domains in iatrogenic multiple birth families: social stigma and compounded losses. An unexpected finding was the potential for increased marital solidification as parents coped with the inordinate stresses of multiple births. As anticipated, children's health, unmet family needs, maternal depression, and parental stress were key areas of concern. In addition, the infertility experience had a lasting impact. These findings are significant, given that at least 38% of all assisted conceptions result in a multiple birth. This study lays the groundwork for further research on the impact of iatrogenic multiple births.

The influence of IVF, multiple gestation and miscarriage on the acceptance of genetic amniocentesis

OBJECTIVES

To determine the effect of in vitro fertilization (IVF), multiple gestation, and history of unkaryotyped miscarriage on the acceptance of genetic amniocentesis.

METHODS

We studied women expected to be at least 35 years of age at the estimated date of delivery without family history of chromosomal abnormalities or fetal structural anomalies. The influence of IVF, multiple gestation, and history of miscarriage on the acceptance rate of genetic amniocentesis was evaluated. Chi-square test and logistic regression were used for analysis.

RESULTS

In singleton pregnancies, the acceptance rate of genetic amniocentesis was 70.7% (58/82) in the IVF group compared to 77.9% (1837/2356) (P = 0.14) in the women who conceived spontaneously. The corresponding values in multiple gestation pregnancies were 71.1% (37/52) and 62.9% (34/54) respectively (P = 0.41). There was no difference in the acceptance rate of amniocentesis between singletons (70.7%) and multiple gestations (71.1%) after IVF (P = 0.96), while in women who conceived spontaneously, the acceptance rate of 78% in singletons was significantly higher than the acceptance rate of 63% in multiple gestations (P = 0.008). Adjusting for confounding variables, women with multiple gestations were about 40% less likely to accept genetic amniocentesis (OR = 0.63, 95% CI = 0.39-1.00, P = 0.05), while women with a history of miscarriage were about 17% less likely to accept genetic amniocentesis (OR = 0.83, 95% CI = 0.68-1.00, P = 0.05). Adjusting for multiple gestation and previous miscarriage, IVF was not independently associated with acceptance of genetic amniocentesis (OR = 0.84, 95% CI = 0.54-1.29, P = 0.42).

CONCLUSIONS

There is no difference in the acceptance rate of genetic amniocentesis among women with IVF pregnancies compared with those who conceive spontaneously, after adjusting for multiple gestation and previous miscarriage. Unlike women who conceive spontaneously, the decision to accept amniocentesis appears not to be influenced by the presence of multiple gestation in women with IVF pregnancies.

The impact of multiple preterm births on the family

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

Pittsburgh Registry of Infant Multiplets (PRIM)

This paper describes the Pittsburgh Registry of Infant Multiplets (PRIM; Pittsburgh, Pennsylvania), the results of pilot research conducted in this registry, and the plans for future studies. The main focus of the registry is on psychological development and the risk for behavioral disorders. Particularly, characteristics associated with antisociality and the risk for substance use disorders (e.g., aggressivity, hyperactivity/impulsivity), as well as language development and other traits (e.g., dental health) are among the research targets.

Less is more: the risks of multiple births. The Institute for Science, Law, and Technology Working Group on Reproductive Technology

OBJECTIVE

To review the medical, social, and financial risks caused by the birth of multiples that need to be addressed in policy and practice.

RESULT(S)

Many risks of multiple births are described in the literature. The medical risks to the offspring include death, low birth weight, deformational plagiocephaly, and other physical and mental disabilities. Risks to the women include premature labor, premature delivery, pregnancy-induced hypertension, toxemia, gestational diabetes, and vaginal-uterine hemorrhage. Children born in multiples face difficulty socializing, developmental delays, and behavioral problems, whereas their parents risk exhaustion, depression, and anxiety. In addition to personal costs faced by families, society often bears the financial costs of overburdened hospitals, caps on insurance and/or inability of parents to cover expenses.

CONCLUSION(S)

Multiple births present potential acute and long-term medical risks to the pregnant woman and her children. However, more long-term follow-up research and more research on outcomes with higher-order multiples are needed. In designing practices and policies to improve the success of IVF while reducing the risk of multiples, it is important to balance the many interests involved. At a minimum, providers and patients need to be educated about the risks of multiple gestation so that steps can be taken to prevent adverse outcomes.

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.