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.

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.

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.

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.