by Marilyn Muizelaar

The great debate. Most multiple birth parents have encountered parents with singletons close in age (less than one and a half years apart). Many comments are verbalized such as "Oh, they are 18 months apart, it's just like having twins." To which the multiple birth parent thinks, "Yeah, right! You don't know what you're talking about!"

In order to write this article, a survey was prepared and circulated throughout Canada mostly via the Internet. Multiple birth families and families with singletons close in age were invited to participate and many responses were received. Responses came from Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick and Nova Scotia. These two groups are different. However, they also share some striking similarities.

When asked how the pregnancy was confirmed, home pregnancy tests were the most common in both groups accounting for 60% of the pregnancies. Singleton families reported the balance (40%) was confirmed by their doctor whereas multiple birth families reported 28% by their doctors and the balance (12%) via ultrasound. Ultrasound testing was performed earlier in multiple birth pregnancies than in singleton. Forty-six percent of multiple birth families had ultrasounds prior to ten weeks compared to thirty-eight percent of singleton birth families. Fifty-four percent of multiple birth families and sixty-two percent of singletons had ultrasounds at approximately 20 weeks.

The reactions of new parents to the ultrasound pictures were very interesting. Singleton parents reported feeling scared (17%), elation (66%) and a combination of scared, shocked, and elation (17%). Multiple birth parents reported feeling scared (8%), elation (22%), shock (31%) and a combination of scared, shocked, and elation (31%). There were a few that did not fit any of these categories including one multiple birth mom who simply laughed.

There are many tests available to the pregnant woman. Here is a chart showing the tests and the percentages of women in each group having them performed:

	Multiple Birth	Singleton Birth
No tests	6%	18%
Gestational Diabetes	26%	29%
Maternal Screening	10%	11%
Non-Stress Tests	27%	11%
Amniocentesis	7%	0%
High level Ultrasound	20%	18%
RH factor	1%	0%
TTTS	1%	0%
Placenta Previa	1%	5%
Vascular Ultrasound	0%	5%

In order to clarify a couple of these tests further, although the percentages of non-stress tests are not very different, the frequency of non-stress tests varied greatly between the two groups. Singleton families experienced on average 1-3 tests; multiple birth families experienced on average 8-10 (and some as many as 20 plus). The result of the high level ultrasounds being similar was a surprise.

Multiple birth families tended to have more restrictions on them than their singleton counterparts:

	Multiple Birth	Singleton Birth
No restrictions	33%	44%
Feet elevated	26%	14%
Bedrest at home	26%	28%
Bedrest at hospital	15%	14%

Although the restrictions tended to be more for multiple birth families, the level of restrictions on singleton births is surprising.

When asked about pregnancy symptoms, the degree of severity was much higher in the multiple birth group. Many women reported "morning sickness" at a rating of 10 plus on a scale of one to ten. The highest rating for morning sickness in the singleton group was a 5 with many others reporting one or two. Fatigue also was reported at ratings of 10 plus by the multiple birth group. Only one person in the multiple birth group reported no fatigue. A few of the singleton group reported ratings around 7 and one person reported a 10. Mood swings were reported equally among the two groups. Frequency and urgency of bathroom visits were reported at higher ratings from the multiple birth group. This increased when responding in relation to the end of the pregnancy when some women reported a feeling of a "cracking" pelvis from the pressure. The singleton group had no such comments.

The statistics for natural birth versus caesarian birth are not surprising. Seventy-eight percent of singleton births were by natural (vaginal) birth; twenty-two percent were performed by caesarian section. The reasons for caesarian delivery in this group were emergencies such as a placenta breaking away completely, and previous caesarian sections had been performed as a result of a multiple birth pregnancy.

In the multiple birth group sixty percent were by natural (vaginal) birth; thirty-eight percent by caesarian section and two percent by a combination of natural and caesarian section. Various reasons for the necessity of caesarian section were given including positions not conducive to natural birth, placenta previa, and emergencies involving the well being of the mother and babies.

When asked if their babies were brought to cuddle and/or breastfeed immediately, the women in the singleton group reported that seventy-nine percent were brought to them; twenty-one percent reported the babies were not brought. The major reason for them not being brought was prematurity of the babies. This group also reported babies being brought to them after a caesarian section as well as after natural birth.

The multiple birth group reported three responses. Fifty-five percent reported that no babies were brought to them. Twelve percent reported that one baby was brought and thirty-three percent reported that the babies were brought. The majority of those who reported that their babies were brought to them experienced natural birth. Those who experienced caesarian birth or premature babies were given a quick visual of their babies at the most. Many mothers expressed regret that they did not get to connect with their babies for many hours after birth.

Breastfeeding success was similar between the two groups. Multiple birth families reported a forty-four percent rating for no problems; singletons reported forty percent. Four percent of multiple birth families reported major problems but were eventually successful. Twenty-one percent of multiple birth families and thirty-three percent of singleton families reported that it took time to adjust to the experience of breastfeeding. Thirty-one percent of multiple birth families and twenty-seven percent of singleton families were either unsuccessful or did not attempt breastfeeding.

Both groups experienced a desire the "just get home" from the hospital after the birth of their babies. Fifty percent of both groups expressed this was their desire. The remainder of feelings were split between a feeling of exhilaration and exhaustion.

When asked about postpartum care from nurses, the responses from the singleton community were positive. Most felt that their care was sufficient even if they "just wanted to go home". Those who had premature babies felt that the nurses were extremely helpful and often acted as an important mediator between patients and doctors.

The postpartum nursing care for multiple birth babies was disturbing. If births were uneventful the mothers usually found the care to be acceptable. Occasionally mothers who were nurses themselves felt that they were neglected because they should be able to handle things on their own. Not a good assumption with multiple birth recoveries. Here are a few of the quotes from mothers who were satisfied with their postpartum care:

"twins care exceptional; maternal very poor"
"dedicated and helpful"
"complied with request not to use bottles and cup fed in night so she could rest"
"because of extended stay prior to births, nurses were helpful since she knew them"
"struggled to get proper help - finally did on day of release"
"student nurses willing to help"
"uneventful delivery - did not require help"

Many horror stories were relayed to the writer. Comments like the nurses had no time for them, no help with breastfeeding, no help to see other twin in special care nursery, had to ask for everything - mother required to do most things herself, every shift offered new nurses with differing opinions on how things should be done, not supportive of breastfeeding - some hospitals have started to require their nursing staff to attend special seminars as a result, woke up constantly for post-op vitals, day nursing staff told mother to ask for night respite but mother was told by the night shift that she should have thought of that before having twins!!

A mother from Ontario relays the following sequence of events. She was forced to stay in a ward as no semi private or private care was available to her. She was sent home too early and came back hemorrhaging. She had trouble getting the babies on and was buzzing for nurses to come. It took them 30 minutes to come. Had she been hemorrhaging she could have died waiting for the nurses to come. After having no help, putting up with tons of visitors for other patients and phones ringing, she wanted to be at home where people would help when it was needed and she could have her own bed.

Another mother from Ontario shared mixed feelings. The nurses took care of the babies well and they were nice. However, they needed to be summoned for everything and she had to beg for medication. After a rough caesarian section with improper administration of anesthesia she was in great pain. The nurses continued to call her down to the special care nursery throughout the night. After four nights and a total of seven hours sleep, she was exhausted and overwhelmed. She also experienced contradiction from nurses and lactation people. The nurses insisted on the necessity of "top up" making it seem impossible to breastfeed.

Ontario seems to have a lot of stories to tell. Another mother tells of how the nurses did not think she should attempt to breastfeed. One nurse came and sat on her bed, said they had been talking about her in the care unit and she was voted to come to speak to her about how "unfair she was being to her babies". They were not supportive probably due to a lack of education regarding multiple birth issues.

The last story comes from Ontario. She remembers almost having to bribe the nurses to take a shower. "On my third day, I remember that I brought the babies to the nursing station to get a shower. Exhausted I came out of the shower and heard that family had arrived to visit and had a baby. So I reached at the nursing station and took the next baby nearest me - a little redhead - not mine! In my exhaustion I thought that I didn't recognize him from sleeplessness. Oops! They forgot to say, by the way that they had brought both babies down - Duh!"

The last three items in the pregnancy category on the survey asked if babies were born preterm, with special needs or if the families had experienced loss. It should be noted that loss here refers to babies of "survivable" gestation - beyond 24 weeks. There were numerous families who experienced early miscarriages and late miscarriages. For all losses we acknowledge the loss whether it was early on or later. The babies were very real and the loss for many remains all too real.

	Multiple Birth Families	Singleton Families (refers to second child)
Preterm	42%	50%
Special Needs	5%	25%
Loss	10%	17%

In conclusion, it appears that the two groups examined here are not so different after all. There are distinct differences in areas such as nursing care and pregnancy symptoms. Areas where there are surprising similarities are in the preterm, special needs and loss categories. Whether this is due to the body not having time to recover between pregnancies, it's not known. The writer acknowledges that the singleton group was not as large as the multiple birth. This topic was of interest to the writer because of the situations she had witnessed in her singleton birth friends. Many situations mimicked that of the multiple birth community.