INTRODUCTION

Of the 590,453 babies born in the U.K. in 2002, just fewer than 9,000 were twins and multiple births. Approximately two-thirds of these are the result of fertility treatment, which carries with it a much greater chance of multiple pregnancy. Twins, which account for 95% of all multiple pregnancies, are much more common in older mothers and taller women. Although fraternal twins can sometimes be predicted, identical twins occur at random.

Carrying and giving birth to more than one baby places many extra demands on a mother, while caring for twins and multiples can raise a host of issues in addition to those faced by parents of single children. Breastfeeding, tracking down the right nursery equipment, managing childcare, making decisions about schooling and understanding the psychological dynamics of twins and multiples are just some of the challenges they face.

There are many resources on and off-line offering information and support with all of these issues as well as a chance to link up with other multiple birth families. Some parents find it useful to compare notes with other parents in the same boat while others, in their desire to be ‘normal’, prefer to avoid the multiple birth network.

PREGNANCY

Carrying multiples places all of the body systems under strain. Eating a good, balanced diet, keeping up your fluid intake and having plenty of rest are all essential for you and your developing babies. Some mothers may be advised to supplement their diet with iron and folic acid tablets if blood tests reveal deficiencies. Bedrest is often prescribed – and welcomed – once the babies reach a certain size and getting about becomes increasingly difficult.

There is no escaping the fact that the sort of discomfort or complaints that arise routinely in pregnancy (morning sickness, fluid retention, heartburn, haemorrhoids, anaemia, stretch marks) are usually exacerbated in multiple pregnancies. There is also a higher risk of complications such as raised blood pressure and pre-eclampsia. This is one reason why extra ante-natal care is provided.

Multiple pregnancies are not expected to reach full term and the babies’ birthweights are lower than the average weight for a single baby. These are the guidelines provided by the Multiple Births Foundation:

The average length of pregnancy is 37 weeks for twins, 34 weeks for triplets and 32 weeks for quads.

The average birthweight of a twin infant is 2.5kg (about 5lbs), of a triplet 1.8kg (about 3lbs) and a quad 1.4kg (about 2.5lbs).

There is also a greater risk of miscarriage with multiple pregnancies.

Twin to Twin Transfusion Syndrome (TTTS) is a disease of the placenta that can affect identical twins during pregnancy. Since the placenta is shared, it is possible for one twin to get too much of the blood supply and the other not enough. These cases are treated in hospital by specialist fetal consultants. The UK Twin to Twin Transfusion Syndrome Association and the US-based Twin to Twin Transfusion Syndrome Foundation are both useful resources. The UK site features first-person accounts of TTTS pregnancies (see the

GIVING BIRTH

There are many ways of approaching the birthing process and you can discuss the options with your GP or a midwife.

Obstetricians like to deliver twins vaginally whenever possible, although the high number of breech presentations increases the risk of complications. The majority of triplets and higher-order pregnancies are delivered by caesarean section, usually with a large number of professionals in attendance. The Twins List site has a Frequently Asked Questions (FAQ) section on labour and delivery, with birth stories provided by other parents of multiples.

Multiples are much more likely to be born prematurely than single babies, with correspondingly low birthweights. Although their prematurity makes them more vulnerable, modern obstetric care is generally able to ensure a healthy outcome for these babies. Parents of Premature Babies (Preemie-L) is a non-profit foundation supporting family and friends of babies born six weeks or more before due date – for more information visit their site.

AFTER THE BIRTH

Help, trained or otherwise, is at the core of the post-natal survival strategy. Any offers that will reduce the domestic burden are worth taking up. The challenge will probably be to spend as much individual time as possible with each of your babies and to create opportunities to catch up on lost sleep and have the odd breather.

Grandparents, godparents, relatives, friends and neighbours can all play a part in helping you to achieve this. The Multiple Births Foundation has a very useful information sheet listing sources of practical help. Take advantage of any service that promises to save you time and effort. On-line shopping, bulk deliveries of nappies, formula and baby food plus ready-made meals for frantic parents are simple ways to preserve your energy and sanity.

Multiple birth children and their families are often the object of enormous curiosity, which can come as a shock during the pregnancy and add to the pressures in the post-natal period. Both may need to prepare themselves in advance to be treated as public property. The Triplet Connection, a U.S. based non-profit organization, has expectant and new parent packets offering tips on what to expect in the first weeks home. Whether or not you have conceived your multiples as a result of IVF treatment, you can expect to be asked the question on a regular basis.

FEEDING

The decision about how you wish to feed your babies will be a personal one based on many considerations. There are advantages to both breast and bottle-feeding which you will doubtlessly weigh up as the pregnancy advances. Some mothers find mixed feeding, which combines the advantages of both approaches, the most practical solution for multiples. The reality of life with more than one - possibly premature - baby may be quite different to what you imagined, so you may find it worthwhile to read up on the subject and find out about other people’s experiences while you have the time.

Unsurprisingly, many mothers feel daunted by the idea of breastfeeding multiples and fear that they will not be able to provide the necessary volume of milk. The hyperefficient supply and demand mechanism that governs the production of breast milk (i.e. the more milk that is needed, the more is produced) means that breastfeeding twins, triplets and quads is within a determined mother’s grasp. Breastfeeding premature babies will involve expressing milk – ideally using a hospital-grade double pump – in order to maintain the supply. Storing bottles of expressed milk also gives mother of multiples more flexibility.

Establishing breastfeeding after a multiple birth requires time and perseverance. Practical help and support from a partner and access to professional help can make a significant difference in the early stages. Community midwives have a useful role to play in the post-natal phase - find about more about their role from your GP. Positioning (and repositioning) two babies at the breast will require practice and possibly the assistance of another person. Twin nursing pillows are regarded as essential aids. Consult the following page for suggestions about nursing positions for twins.

La Leche League is an international organisation dedicated to providing information and support for mothers who want to breastfeed. Their Breastfeeding Multiples page contains a number of helpful articles. You can also ring their 24-hour helpline on 020 7242 1278 to get hold of a local representative.

There is a very useful Q & A section on the www.breastfeeding.com website which addresses all of the issues likely to concern mothers of multiples. Another useful breastfeeding site is twinslist.org.

Bottle-feeding multiples presents a completely different set of logistical challenges at home and on the move. It also allows fathers, older siblings and other helpers the chance to take part in the feeding process and gives mothers the possibility of delegating some of the sleep-depriving night feeds.

If you are keen to get your babies on a schedule, you might want to look at the Twins List FAQ section on routines.

SUPPLIES & SERVICES

Bringing up multiples inevitably has financial implications. The need to provide two children or more of the same age at the same time with clothing, toys, books, nursery equipment etc. involves repeated multiple expenditures.

Twins Clubs are an invaluable source of advice on what to and what not to buy and a good place to go for second-hand clothes equipment. Twins List and Triplet Connection are brimming over with specific recommendations and suggestions to help you avoid making expensive mistakes when shopping for multiples. Both sites are based in California but a lot of the advice will be generally applicable.

Membership of the Twins and Multiple Births Association (TAMBA) entitles you modest discounts on pushchairs, buggies and other nursery equipment, books, shoes, clothing, play equipment, activities and excursions as well as a selection of other relevant services.

PARENTING ISSUES

Bringing up multiples presents parents with a unique set of challenges. The practical implications of looking after two or more babies of the same age simultaneously means that parents have fewer opportunities to spend time alone with each child and lay the foundations for a close one-to-one relationship. The fact that the twins and other multiples are able to offer each other instant companionship means that they can often satisfy each other’s emotional needs without reference to their parents. This self-sufficiency may create a situation where the parents have to work even harder to forge the sort of relationship they might expect to have with a single child.

The more involved that fathers are able to be in the care and rearing of multiples the better, although the importance of a good support network of mature adults and responsible teenagers to help out with childcare is hard to overstate. Clearly, continuity and long-term arrangements are the ideal, but any relationships outside the immediate family that provide the children with opportunities for regular one-to-one interaction will be hugely beneficial.

The similarities that exist between multiples are one of the main reasons for the public fascination with them. The consequence of those apparent similarities are that twins and other multiples tend to be regarded and treated as a unit rather than as individuals, and so come to see themselves in that way. One of the special responsibilities of parents and other adults involved in the care of multiples is to help each child from an early stage to develop a separate identity and a sense of their own independence, so that he or she will be able to flourish as an individual in the adult world.

Exciting though it is for an existing child or children to know that there will soon be two or more new babies in the family, the adjustment to life with multiples is hard for older siblings. While the sense of displacement is inevitably intensified, the attention and commotion that surrounds multiples can make older children feel overwhelmed and excluded, as well as envious. One of the more effective ways to prepare them for these changes is to talk about how they might realistically help to look after the babies after they are born.

SUPPORT NETWORKS & SPECIALIST GROUPS

There is a wealth of practical advice available to parents of twins, triplets, quadruplets and higher order births on a diverse range of issues from childproofing, potty training, discipline and speech delays to zygosity testing and decisions about schooling.

The Twins and Multiple Births Association (TAMBA) operates a twin line on evenings and weekends to field calls from parents of twins, triplets and more, while their Twins Clubs are a valuable source of parent-to-parent support. They also run a number of specialist support groups.

4 or More is an online resource for larger families in the UK, set up by a mother of five who found out she was carrying twins more than halfway into her third pregnancy.

USEFUL PUBLICATIONS

The Multiple Births Foundation and TAMBA offer a range of leaflets and other publications on issues affecting parents of twins, triplets and higher order births from pre-conception through to adolescence.