R Pingili, V Bamigboye, K Jegede
assisted reproductive technologies art., multiple gestation, multiple pregnancy, septuplets, the human fertilisation and embryology authority, twins
R Pingili, V Bamigboye, K Jegede. Multiple Pregnancy: a blessing or a curse?. The Internet Journal of Gynecology and Obstetrics. 2007 Volume 9 Number 2.
Multiple pregnancy rates have increased phenomenally since the mid-1980s in many countries such as the US and UK. This increase is largely due to the use of assisted reproductive technologies (ART) and the increase in maternal age at conception.
Multiple pregnancies are associated with increased health risks for the mother; pre-eclampsia, gestational diabetes, peripartum haemorrhage, and for the infants: prematurity, low birth weights, cerebral palsy and developmental disorders. Not only are there health risks, but also financial, social, psychological and ethical implications. This article summarizes the medical, economic, social and psychological arguments against multiple births based on a review of the literature, as well as discussing some options on how to prevent multiple pregnancies in the future.
In November 1997, the world's first set of surviving septuplets - the McCaughey Septuplets 1 were born to delighted parents Bobbi and Kenny McCaughey in Des Moines, Iowa. The babies- Kenneth, Alexis, Natalie, Kelsey, Nathan, Brandon and Joel, were delivered nine weeks premature by caesarean section and required intensive medical care in a neonatal intensive care unit (NICU) after birth. Their births resulted in an unprecedented level of media attention both in the United States and worldwide. To date, all the septuplets are still alive, although two children- Alexis and Nathan, developed cerebral palsy as a result of being born prematurely 2 . The increased costs of looking after the septuplets have been offset by the generous donations and offers of support to the family over the years, of which included a house, childcare assistance and even university scholarships 2 . The septuplets are now 9 years old and are still the object of media scrutiny and public fascination. This story ended successfully, but one must bear in mind that this case does not represent the majority of families living with multiples who are struggling to cope and who do not get as much media coverage.
A more typical case is of the Frustaci septuplets 3 - four boys and three girls, born in May 1985 to Sam and Patti Frustaci. Unlike the McCaugheys, their situation quickly became a story of heartbreak as one of the septuplets was stillborn, and three more of the infants died soon after. Further bad news occurred when the three surviving infants were then diagnosed with cerebral palsy and as being mentally retarded. Since then family has been through an ordeal of lawsuits 4 , coping with the children's handicaps, financial difficulties due to the increased living and medical expenses and the invasive media attention. 3
More often than not these cases end in tragedy with few of the infants born actually surviving into adulthood, and those that do more likely to have disabilities and medical conditions that severely impact on them and their families' quality of life.
These sensationalised stories of multiple births are very indicative of the very real public health epidemic that we are facing. Since the mid 1980s, there has been a phenomenal increase in the observed rates of multiple pregnancies. 5 In the US alone, between 1981 and 1997 the rates of twin gestations increased by 45% and triplets increased by 358%. 6 There are corresponding increases observed in Europe also, rates in England and Wales increased by 41% for twins and 273% for triplets during a similar time period 6 (1982-1997). France and Canada also reported notable increases in the rates of their multiple gestations. 6 Due to recent change in HFEA (The Human Fertilisation and embryology Authority) guidelines 7 which restrict the number of embryos to no more than two, there has been a reassuring stabilisation in the rate of triplets, 8 although the rate for twins remains unaffected, still continuing to rise despite increasing awareness of the risks associated with this state and universal consensus that this too, constitutes a high risk outcome.
These astounding increases in multiple gestation rates can be explained by social shift in women's attitudes to childbearing which has resulted in more and more women choosing to postpone childbearing in favour of work and career commitments. This delayed childbearing has resulted in an increased maternal age at conception 5,9 – one of the predisposing factors for conceiving multiples and need to use infertility treatments such as ovulation induction, IVF and ICSI 9 – as fertility decreases with age.
Maternal risks and complications
Pregnancy related complications are more common in women pregnant with multiples as compared to singletons. The minor symptoms of pregnancy such as nausea, heartburn, fatigue and backache are exaggerated due to the mechanical and hormonal effects of multiple pregnancies. This results in prospective mothers to be hospitalised for bed rest 15 for prolonged periods before the birth of multiples increasing their risk for thromboembolism. Studies have shown that adverse outcomes such as pre-eclampsia, iron deficiency and folate deficiency anaemia, gestational diabetes, antepartum and postpartum haemorrhage are more common in women carrying multiple gestations. 16,17,18. The higher the order of multiple pregnancy the more likely is the mode of delivery to be by caesarean section this carries a mortality, at 1 in 100,000, 20 not to mention the added risks of infection, bleeding needing transfusion and associated risks of this, thrombo-embolism, injury to bladder, bowel which may eventually effect the quality of life 20 . Even in today's world of good obstetric care and improved outcomes, mothers of multiples still fare worse with the maternal mortality rate being three times higher 18 in women with multiples than in women with singleton pregnancies.
Fetal risks and complications
It is a well-proven fact that multiple gestation infants are significantly more likely to be born prematurely when compared to their singleton counterparts. 21 The mean length of gestation for twins, triplets and quadruplets is 35 weeks, 33 weeks and 29 weeks respectively, which is much reduced when compared to the mean for singletons at 39 weeks. 22 Premature infants are more likely to develop hypothermia, hypoglycaemia, Respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage which may be fatal. Apart from prematurity, studies have also shown that the infants suffer from intrauterine growth restriction and growth discordance. . The American National Centre for Health Statistics 24 in 1997, reported that 90% of triplets and higher-order multiples weigh less than 2500g compared to only 6% of singletons Twins have a 4-fold increase and triplets a 6-fold increase in perinatal mortality as compared to singletons. 25 Guyer et al. reported that 16% of all neonatal deaths occurred in multiples and that multiples were seven times more likely to die within the first year of life. Not only do multiples have higher perinatal mortality rates but they also have higher stillbirth rates 27 and an increased risk of being admitted to a neonatal intensive care unit. 21 Even if multiple gestation infants survive the immediate postnatal period, they continue to have an increased risk for long-term developmental problems and physical disabilities. 28,29,30 Cerebral palsy is one of the well-researched complications associated with multiple gestations and premature birth, and has up to a 6-fold and 20-fold increase respectively in twin and triplet pregnancies compared to singleton pregnancies. 31
Having multiples has effects on family dynamics and the ability of the parents to cope. Parents are faced with the incredible task of having to simultaneously meet the demands of the multiples and there older siblings. This may lead to mothers having to leave paid employment in order to be able to care for there children. 32 Considering the increased costs of medical bills , childcare and home-help, the loss of added income may very well put further financial stresses on a family. Many studies have reported higher rates of depression in mothers, parental stress 32 and marital disharmony in parents with multiples 33 when compared to couples with singleton births. The difficulties of raising multiples may be further multiplied if the children are physically or mentally challenged as this will place even more demands on the family. Child abuse 35 is more prevalent in multiples and their siblings. Older children may often feel neglected due to decreased attention from parents. This may lead to the older child growing to resent his/her younger siblings, manifesting in troubling behaviours, 36 aggressive or regressive behaviours such as soiling or bedwetting in a bid to divert some of the lost attention back on themselves. These families may have to face a social stigma due to the “unnaturalness” of having multiples 37.
Medical and technological advances and improvements in obstetric care have lead to improved survival rates for multiple gestation infants, but the technologies required to bring about this outcome have resulted in exorbitant medical costs. In their work, Callahan et al. 38 quoted that healthcare costs for a triplet infant is $36,588 and a twin infant is $18,974. This is twice and thrice respectively as expensive compared to the cost of a singleton infant, at just $9845. These increased costs are due to the need for more intensive monitoring of these infants and the complex medical and surgical procedures that are increasingly being performed in order to decrease mortality and improve their prognosis.
Even after the neonatal period, there is often still a burden on healthcare as these children are more likely to have disabilities and special needs that require ongoing paediatric care and specialist therapies, with recent work by Henderson et al estimating that the costs of care for 5 years for twins and triplets respectively being twice and eight times that of singletons. 39
Families are very much impacted financially. Not all families with multiples receive as much help as the McCaughey's, they are more likely to face a much tougher struggle with fewer donations and dwindling offers of help. 12
Countries such as the UK and Germany have guidelines that specify the maximum number of embryos to be transferred during IVF cycles. 7 These guidelines are only voluntary and some infertility centres choose to ignore these guidelines and employ approaches that increase multiples in their efforts to achieve competitive pregnancy rates. This leads to a remedial instead of preventative approach being taken and multifetal reduction offered to parents with high-order multiples.
Multifetal reduction creates a ethical issues to the doctors involved. The “lifeboat” analogy 40 in which the chances of survival and prognosis are improved by selective termination rather than the death or significant morbidity of all the fetuses is used to justify what would otherwise be seen as an objectionable procedure. Nevertheless, parents who have strong religious and ethical beliefs may still be opposed to this procedure. One must also note that the procedure itself carries an 8% risk of miscarriage of the entire pregnancy 41 and the emotional impact of having to undergo a multifetal reduction is not to be understated. Parents are very deeply affected by multifetal reductions with up to a third still experiencing feelings of guilt, grief or depression up to 2 years after the procedure. 42
These issues bring up the question of whether multifetal reduction is really the solution to the problem of multiple pregnancies. Despite evidence showing that it does improve outcome for multiple gestation infants, 41 it seems that prevention of multiple pregnancy is a more sensible and preferable option than an emotionally and ethically challenging reduction.
Impact on healthcare and society: the bigger picture
The increase in multiple births is straining already overburdened medical facilities with some hospitals having to expand their NICU (neonatal intensive care units) in order to cope. 12 Apart from healthcare systems, other institutions such as schools and social services also face similar challenges - especially if the children are disabled and have special needs.
Prevention of multiple pregnancies
In 2000, the European Society of Human Reproduction and Embryology (ESHRE) stated that “prevention is the most important means of decreasing multiple gestation rates”. 43 This has lead to a number of alternatives being proposed. One option being put forward is to reduce the mean number of embryos transferred in IVF/ICSI cycles. The elective single-embryo transfer (eSET) 44 has been reported to reduce multiple pregnancy rates whilst not adversely affecting the overall pregnancy rates significantly, another option, the technique of blastocyst transfer, 45 involves culturing embryos for 5 days rather than the typical 3 days before transferring them to a woman's uterus. This allows the better selection of embryos that would be more likely to implant successfully, thereby reducing the need to transfer more embryos although more studies and reviews need to be performed to determine the validity of these approaches.
An option of pre-treatment counselling 47 of infertile patients has also been suggested and this seems like a very valuable strategy. Many infertile couples desire multiples as they are often ill-informed of the hazards associated with multiple pregnancy, or perceive these risks to be less than they are. 47 By providing couples with information from the outset about not only the medical risks to mother and children, but also the financial, psychological and social impact that multiples bring to the family, this will allow couples to make more informed choices.
The role of the media in propagating a distorted view of multiple pregnancies also needs to be examined. The media needs to be more responsible in the way it portrays multiple pregnancies and should aim not only to emphasise the positive but the negative aspects associated with multiple pregnancies.
Multiple pregnancies, due to their rarity and novelty are a subject of fascination, with the general public as regarding them as medical miracles and some infertile couples desiring them. They are becoming less rare, due in part to the increasing maternal age at conception and the use of assisted reproductive technologies.
Contrary to media portrayal, the increase in multiples can not be a good thing for families and society, with the infants having higher mortality and morbidity. Mothers are faced with increased hospitalisation for reasons ranging from bed rest and obstetric monitoring to major medical conditions such as pre-eclampsia and peripartum haemorrhage.
Families are burdened, due to the increased demands and stresses placed upon them resulting in adverse consequences of increased parental dissatisfaction, financial strain, marital difficulties and child abuse.
Society and healthcare are faced with bearing and funding the increased demands that families with multiples place upon it, not only in the immediate period but in the long-term as well.
Due to the increasing problem that multiples represent, many in this field of medicine have championed a preventative approach to reducing multiples instead of the alternative of an ethically and emotionally charged multifetal reduction. A number of strategies and newly emerging techniques are suggested, some with more success than others- although more comprehensive research is needed. What is clear is that we all have our own part to play, right from the media to the couples themselves in reducing the incidence of what has been demonstrated to be an adverse outcome.