Having Twins And More: A Parent's Guide to Multiple Pregnancy, Birth, and Early Childhood

Overview

Now in a third edition, the best-selling guide on multiple births, Having Twins - and More, covers everything from conception through childhood.

With ongoing advances in assisted reproduction, increasing numbers of women are having twins, triplets, and more, and they're having them later in life. Having Twins—and More is the original source parents consult for guidance through the multiple birth experience.
For three decades Elizabeth Noble, a ...

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Overview

Now in a third edition, the best-selling guide on multiple births, Having Twins - and More, covers everything from conception through childhood.

With ongoing advances in assisted reproduction, increasing numbers of women are having twins, triplets, and more, and they're having them later in life. Having Twins—and More is the original source parents consult for guidance through the multiple birth experience.
For three decades Elizabeth Noble, a respected name in the field, has provided expectant parents with everything they need to make informed, safe choices and give birth to healthy babies. This comprehensive handbook emphasizes optimal health as well as physical and emotional adjustments to bearing and raising multiples, and it offers striking new insights into risks, complications, and treatments—candid information that is gathered only in this book.

Featuring tips on setting goals, assembling help, and reducing anxiety the latest nutritional information for mother and child details about the dangers of drugs and bed rest essential exercises for pregnancy and recovery information on the benefits of vaginal birth and breastfeeding facts about cesarean section and recovery tips for helping siblings adjust recommendations for parenting multiples with special needs more than 100 new photographs, charts, and tables exhaustive resources, expanded to include the Internet

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Product Details

  • ISBN-13: 9780618138739
  • Publisher: Houghton Mifflin Harcourt
  • Publication date: 5/22/2003
  • Edition description: Third Edition
  • Edition number: 3
  • Pages: 592
  • Sales rank: 570,357
  • Product dimensions: 8.00 (w) x 9.00 (h) x 1.31 (d)

Meet the Author

Elizabeth Noble is the author of seven books, including Essential Exercises for the Childbearing Year, Childbirth with Insight, and Having Your Baby by Donor Insemination. She is the founder of the Obstetrics and Gynecology Section of the American Physical Therapy Association, and of the Maternal and Child Health Center in Cambridge, Massachusetts.

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Read an Excerpt

Introduction

Thanks to the ongoing interest and support of you, my readers, this book
has been published in multiple editions! Almost a quarter-century has passed
since I was first asked questions about twins I couldn't answer, and I
promised I would research the topic for those couples. In the late 1970s, I
found not a single book for parents expecting multiples; and back then
triplets and higher-order multiples were infrequent. What a huge difference
today with a daunting array of resources, especially on the Internet!

The research I undertook in the 1970s for the first edition of this
book convinced me that many problems can be prevented or alleviated by
optimal prenatal care; that is, by the mother's commitment to a vigilant
program of nutrition, hydration, exercise, rest, and education. In the
decades since the first edition, evidence has continued to mount in support of
this view. The focus of Having Twins — and More, then and now, is on the
physiological and psychological dimensions of the experience. Learning
how mothers successfully carried normal-birth-weight babies to term
empowers other women to do the same. Such mothers can still be found
despite the preoccupation with pathology that has occurred with the
medicalization of childbearing in general, and of multiple pregnancies in
particular.
This ever-increasing medicalization is a direct result of the focus
on potential problems in litigious societies and has undermined women's
confidence in their ability to give birth. Blood plasma volume expansion
(causing low hemoglobin levels), hypertension (increasingarterial blood
flow), and altered glucose tolerance (making more carbohydrate available for
the babies) should be interpreted as signs of successful placental activity,
not disease processes! Yet expectant mothers (especially of multiples) are
aggressively treated for anemia, high blood pressure, and gestational
diabetes!

Prevention Is the Key: Health Care Is Self-Care

The privilege of working with childbearing couples for more than thirty years
has helped me to clarify what is important. In this book I tackle, rather than
avoid, controversies, without the usual suggestion that readers consult their
doctors. As an independent observer, I am not obliged to be politically
correct in order to obtain grant money or to keep an academic or clinical
position.
Being pregnant today, especially if "high risk," is full of challenges
that our grandmothers never considered. More than ever, parents need to be
thoroughly informed and empowered to make choices and take
responsibility for their decisions. They need guidance right from the start to
face confidently the months and years ahead.
One of the drawbacks of gaining knowledge and insight is that
feelings of reproach and guilt can emerge over prior events. "If only . . ." is a
natural, though not a constructive, reaction. When natural childbirth, breast-
feeding, and genital integrity, for example, are endorsed, mothers who did
otherwise may become regretful. Therefore, many health care professionals,
in the well-intentioned attempt to spare women such feelings, fail to
recommend unequivocally the practices that are clearly best for mother and
babies. I call this the "white bread" philosophy. To explain with an example:
whole grain bread is healthier than white bread, but it is not widely available.
Therefore, let us reassure the people who get the inevitable white bread in
the store, restaurant, hospital, airplane, and school that it is just as good.
This type of philosophy promotes mistaken ideas about pregnancy and birth:
bottle-feeding is the equivalent of breast-feeding, the "abdominal birth canal"
(Caesarean section) is just another way to give birth, and bed rest, like
white bread, must be acceptable if so many people partake of it! Such
reassurances have back-fired; outcomes have worsened as interventions in
pregnancies and births have increased, and breast-feeding remains a low
priority in our society. Mothers end up feeling guiltier than ever!
It helps to explore all possible facets of any health challenge and
to resist suggestions that a problem is "all in the mind," when the evidence
is clearly in the body! Such exploration may include the study of
complementary holistic therapies that address physical, mental, and
emotional aspects of childbearing. In her book Molecules of Emotion,
research scientist Candace Pert showed how a single thought can set off a
chain of reactions throughout the body. Evidence has convinced me of the
value of natural remedies such as homeopathy and herbal supplements
along with visualization and affirmations for treating both the emotional and
physical aspects of some medical problems.
According to the Food and Drug Administration (FDA), during the
five years spanning 1993 to 1998, federal, state, and local agencies
reported a total of only 184 deaths from using herbs and supplements (most
of which were associated with weight loss formulas). Contrast this with the
figures for pharmaceuticals, discussed below, which are responsible for
almost 100 times more deaths annually!
Nutrition remains paramount. A builder cannot construct a house
without all the supplies, right down to specific screws and nails. If extra
rooms are added, more supplies are needed. Amultiple pregnancy is the
same. A contractor hires subcontractors; parents of multiples need to
assemble a team of helpers who will optimize the outcome.

The Nocebo Effect: The "Evil Twin" of the Placebo Effect

The attitude of a health care provider that something is wrong and needs to
be fixed leads to anxiety and stress. Nocebo effects refer to symptoms that
occur when the suggestions, instructions, and expectations are negative, in
contrast with placebo effects that occur when intent and expectations are
positive.
Stress affects women in all walks of life, especially those who are
poor, hungry, beaten, or isolated, for example. However, anxieties about the
pregnancy, and especially an unplanned one, have been shown to be more
serious stressors for the unborn babies. We must realize the role of stress
as a cause as well as an effect in pregnancy complications.
Affluent expectant mothers may be exposed to more prenatal
anxiety because they can afford perinatologists and the latest fetal
surveillance technology. They receive a heavy dose of the nocebo effect
when maternity care providers anticipate problems. One woman felt as
though she had contracted a rare disease when her family doctor referred her
to an obstetrician.
Countless women can attest to the nocebo effect from the
disclosure of the multiple pregnancy or the genders of their multiples. For
example, triplets are seen on an ultrasound scan and the doctor enters the
room to talk about selective fetocide. Or the technician announces, "I'm
sorry to say, four boys." Many couples have felt their panic thermostat rise
because of an unclear test result, even when everything turns out to be fine.
New research in genetics has turned some of our theories around.
First, the Human Genome Project showed that we have only 34,000 genes
(experts had anticipated three times as many!). Also surprising was the
discovery that cells cannot program themselves: influences that switch
them on or off come from the environment. Ninety-five percent of us come into
the world with an intact genome permitting a healthy life. The causes of
disease in this majority have not been studied as intensely as have the
defective genes in the other 5 percent.
Furthermore, scientist Bruce Lipton's research ("uncovering the
biology of belief") has shown that it is not just the environment that has an
impact on genes but a person's perception of that environment that
determines the kind of change that unfolds. The mother is the mediator of
the world outside and transmits her perceptions to the unborn babies. Her
perceptions, of course, are learned behaviors due to perceptions and beliefs
programmed at the beginning of her life by her mother and others.
Perceptions experienced by unborn babies affect their
development and function. The babies are awash in the biochemical brew of
their mother's emotions. These regulators cross the placenta and affect the
same target systems in each baby as in the mother. The development of
the fetal tissues and organs depends on the amount of blood received. A
mother experiencing chronic stress will impair her unborn babies' growth and
immunity. The hormone cortisol, secreted by the adrenal glands under
stress, is known to inhibit fetal growth.
Expectant parents of multiples need the facts on which to base
their decisions. By discussing complications and the associated medical
interventions to help parents make an informed decision, I do not
necessarily imply endorsement. I have played devil's advocate wherever I
believe safety and efficacy are questionable. Evidence-based practice is the
standard today, but studies of pregnancy and birth are frequently retroactive.
In most cases, evidence-based practice is driven by the
pharmaceutical industry because of the ease of randomized controlled trials
(RCTs) with a pill versus a placebo. However, RCTs are often difficult,
practically and ethically, with pregnant women. For example, how could
adequate nourishment be deliberately withheld in order to show that
nutrition has important benefits for mothers and babies? (For that "data" one
looks to pregnancy outcomes during famine.)
There is an impressive amount of clinical experience on nutrition
from the work of Higgins, Brewer, and Luke, and it is on those grounds that
I base my recommendations, risking criticism of "insufficient data" by those
who accept only the stringent methodology of RCTs.
Another issue is quantitative versus qualitative obstetrics. The
medical profession and insurance industry are increasingly invested in
numbers — arduous paperwork documenting size, ratios, monitoring strips,
and other test results — further driven by evidence-based practice. This
preoccupation overlooks the effect of the "soft data" — psychosocial
influences — which can be measured quite well. However, while total life
stress score measures alone have been insufficient to differentiate increase
in obstetrical complications, preterm birth, or growth retardation, prediction
is possible using perceived life stress. Lewis Mehl-Madrona, M.D., published
a study in the Fall 2002 issue of the Journal of Prenatal and Perinatal
Psychology and Health. The research found that such factors do influence
birth complications and that complications could be reduced if attention
was paid to a woman's fear of birth and lack of support from her partner.
Scrimshaw at the United Nations University Food and Nutrition
Program warns that psychological stressors cause metabolic responses
that are qualitatively similar to those observed with infections. Infections, no
matter how mild, increase catabolic nitrogen losses and divert protein for
the synthesis of immune proteins. Loss of appetite is an early characteristic
of acute infections, even before they are obvious. These issues are critical in
the outcome of multiple pregnancy.
Regrettably, it is the rare clinician who has the time to help
pregnant clients feel heard and respected as they describe their lives (which
is where midwives and doulas can play a critical role). Women who were
screened for psychological issues, once each trimester, were found to be
50 percent less likely to have a low-birth-weight or preterm baby.
A recent Japanese study found that one of the significant
indicators of high maternal attachment to the unborn child was the
statement by mothers who starting planning in pregnancy: "I plan the things I
will do with my baby." For mothers of multiples, it is hard to imagine life with
two or more babies, let alone plan for it, but this is a critical task discussed
in this book. Almost half of pregnancies are "unintended."
My focus is on strategies for prevention. For this book, I read
hundreds of studies and I quote from many of them, but I know that in a few
years any or all of them could be contradicted by other studies. (Such was
the case, for instance, with the controversial association between oral
contraceptives and twinning.)
Alternative health strategies are rarely acknowledged or used by
the medical establishment. Understandably, research into natural remedies
and one-on-one consultation are more time consuming than simply
prescribing one of the readily available products of the pharmaceutical
industry, even if the evidence fails to justify their use. In modern society, the
popular view is "better living through technology, drugs, chemicals" and
usually the conception, pregnancy, and birth of multiples reinforce this
position.

The Dangers of Drugs

A 1998 article in the Journal of the American Medical Association
estimated that more than 2 million people require hospitalization per year
because of the adverse side effects of drugs. Deaths due to prescribed
pharmaceutical drugs total more than 100,000 annually. The number of
patients killed in hospitals because of "medical errors" adds up to another
100,000 or so, according to the American Medical Association. Burton
Goldberg points out that "the ordained guardians of our health kill as many
people every week (in hospitals alone) as died in the September 11 terrorist
attacks."
The Physicians' Desk Reference (PDR) — the "pharmaceutical
bible" used by physicians — is compiled from information submitted by the
drug manufacturers themselves! The FDA approves drugs by reviewing such
studies, not by actual testing. Only two studies showing satisfactory
results are required for FDA approval, despite the existence of other studies
in greater numbers showing adverse reactions. Goldberg warns that many of
the articles published in medical journals discuss the efficacy of a drug in
studies paid for by the drug manufacturer. Physicians, academics, and
scientists are often listed as lead authors to lend credibility to such papers.
To read more about the many conflicts of interest between the FDA
committees, their advisors, and the pharmaceutical and insurance industries,
see http://www.alternativemedicine.com.

Old Traditions Linger Despite Research and Common Sense

Much medical care related to multiples is based more on assumptions than
on valid research; for example, the often-prescribed routine Caesarean
section and routine bed rest do not improve outcome. We must remember
that multiples were all born at home and breast-fed in the old days! Today
many women are confined to bed and pumped full of various drugs, only to
deliver a few days later babies who will spend weeks or months in the
neonatal intensive care unit (NICU). Some mothers eke out a few extra
days, or occasionally weeks, of pregnancy under great duress.
So much more needs to be available to parents who are struggling
every day to keep their babies alive before they are born and after.
Unfortunately, the media glamorizes multiple births and that's the only side
the general public sees or hears about until an unthinkable event happens
to them. The devastation of losing one or both twins, for example, is
long-lasting and affects every member of the family.
Most multiples are born to older couples whose expectations of
themselves and their offspring have increased with the years they have
waited to become parents. For these "premium pregnancies," Caesarean
birth unfortunately is almost routine. High hopes are dashed if disability or
death occurs among their multiples. In times of crisis, it is essential to have
a comprehensive guide at hand. Twins may be healthy and bring double
blessings, but they may also experience complications and developmental
delays.
Walking the tightrope between providing comprehensive
information and making common sense recommendations is a challenge.
Mothers who have lost a multiple understandably advocate total surveillance
and great caution. In contrast, those who enjoyed healthy pregnancies and
naturally birthed their babies at term feel that describing complications,
disability, or loss only makes parents fearful and sets them up to anticipate
problems. However, letters from readers with unfortunate outcomes have
made it clear how important it was for them to have the information and
resources available when needed, even though they had skipped those
chapters before.
I encourage mothers to trust their bodies and their intuition. We
have all witnessed car accidents, but we retain enough confidence to keep
driving. Likewise, the visibility of mothers with excellent outcomes must be
high, as in the case of one who wrote, "Your advice to focus on hydration,
nutrition, exercise and rest was key to my success in delivering 7 pound,
11 ounce and 8 pound, 9 ounce babies." Others have said that it was my
commitment to natural birth that helped them stay committed. Such are an
author's rewards.
My personal bias has always been toward respecting the body
and Mother Nature, and against intervention unless medically necessary —
which even then may lead to an ethical dilemma, such as when parents'
wishes for their babies' well-being conflict with professional opinions.
Circumcision is an example of this. No medical society in the world
recommends it, but individual physicians still prosper from this mutilation
and persuade parents to allow them to cut off a piece of their son's penis.
(Two cases presently in litigation, brought by victims who are now adults, and
the recent death in Vancouver, may soon end this practice in the United
States and Canada.)

The Explosion of Multiple Pregnancies

Spontaneously conceived twins have actually been decreasing during the
past couple of decades, but drugs that stimulate ovulation and techniques
such as IVF (in vitro fertilization) have led to the current worldwide iatrogenic
increase of multiple births, often termed an epidemic in medical circles. In
Sweden, for example, the incidence of twin deliveries has increased nearly
80 percent during the last twenty years in contrast with a decline in the
1930s to half the rate two centuries before.
Assisted Reproductive Technology (ART) has become big
business globally, and some women travel to countries like India to save
thousands of dollars for these procedures. The medical questionnaire sent
out by The Triplet Connection to its members listed fourteen types of ART
in addition to spontaneous conception and adoption as ways to become
parents of multiples! Since 1980, the rate of multiple pregnancies due to
ART has been multiplied by 10. The prices paid are: increases in preterm
birth (82 percent of deliveries); perinatal mortality (74 percent); and transfers
to neonatal intensive care units (95 percent), which may not have room. In
1978, there were 68,000 twins born in the United States but by the year 2000
that number had jumped to more than 126,000! This does not take into
account the rise in cost per child, which increased by a factor of 1.9 for twins
and 3.7 for triplets.
The first surviving IVF twins were born in London in 1986. By
1998, in Australia, ART accounted for 1.5 percent of all births and the world's
first IVF registry started there. Two-thirds of twins and triplets and almost all
quadruplets and higher-order multiples are estimated to result from ART. A
Swedish registry study showed a twenty-fold increased risk of being born
as a multiple from an IVF conception. The World Collaborative Report on IVF
(1995) showed that about 45 percent of resulting births were multiples — 25
percent twins, 4.1 percent triplets, and 0.2 percent quadruplets. These
rates are higher in North America.
In Canada during 1999, there were 8,864 sets of twins born, 384
sets of triplets, and 20 sets of quadruplets. In 1991, 28 sets of quads were
born; that incidence has dropped. In contrast, the number of sets of triplets
born in 1991 was 237.
Clinics specializing in ART publish statistics that indicate high
success rates, such as pregnancy rate or number of babies born. However,
the number of babies born is obtained at the expense of the problems
associated with higher-order multiple pregnancies. Financial stress,
increased potential for pregnancy and birth complications, and the
challenges of caring for three or more babies can result from ART as it is
currently practiced.
Clearly, the great increase in large sets of multiples stimulates
further discussion about the rights, privileges, and responsibilities of such
assisted conceptions. For example, in countries such as the United
Kingdom that have a National Health Service, allocation of resources is an
issue. In 1999, a singleton birth cost £167, twins cost £1,712, and triplets
cost £7,185 — a staggering increase in cost per baby. The rate of triplets
could be halved if only two embryos were transferred, resulting in, for
example, nine-fold fewer NICU costs in the United Kingdom (where 85
percent of litigation involves brain-damaged infants at a cost of over £500
million).
A policy of birth per embryo transferred would focus on achieving
a healthy outcome from the transfer of a low number of embryos. However,
other forms of ART are harder to control. For example, women respond very
differently to ovulation induction (OI) — one mother conceived two
singletons, triplets, and then quads, all on progressively lower doses of
ovarian stimulants — and any physician can write the prescription. To further
complicate matters, women often undergo both OI and IVF together,
making outcomes even more unpredictable.
Consistent legal and professional standards in the administration
of IVF have not yet emerged. For example, one survey found that
twenty-two of thirty-seven countries permitted unlimited transfer of embryos.
In the United States, usually three or four are transferred with a 40 percent
multiple pregnancy rate. Between 1971 and 1998, the incidence of triplets
increased more (by 500 percent) than that of quads (100 percent), twins (80
percent), and single births (10 percent). These numbers reveal the need for
guidelines and greater prudence in the practice of ART. Moreover, each
additional baby reduces the term of the pregnancy by about three weeks.
Appendix 1 lists some differences between multiples conceived
spontaneously and by ART.
The desire to maximize the chance of a successful pregnancy by
creating or implanting several embryos is understandable, especially
considering expense. Some couples undergoing fertility treatments may
actually prefer to have twins and complete their family at the lowest cost
rather than pay for future rounds of fertility treatments. Many women who
delay childbearing and who are subfertile or single want to become mothers
by any means possible. But when they request such assistance, they may
be unaware of the possibility of conceiving and bearing (and later raising)
twins, let alone more infants, and the risks associated with bearing them.
In the zeal to achieve a pregnancy, both doctor and patient
frequently overlook the realities of life with multiples. Even the most well-
prepared parents are challenged — thus it is important to recognize the
stresses in advance. Scholz and team in 1999 assisted a birth of
quintuplets who spent 714 days in the NICU, which cost $600,000. Even
more sobering, their continuing care will cost more than $1 million. The father
is a baker and the mother was described as overburdened and suicidal, often
leaving the children alone. Although this case may seem extreme, it reveals
the medical, financial, and care-related ordeals attending the arrival of higher-
order multiples.
Since this book covers the many details involved in preparing for
multiple birth and caring for the offspring, it will be helpful for all those
considering ART.

More Babies = More Risks

ART has enabled the observation of early human development that has
been described as "remarkably imprecise." With losses more frequent in
humans than animals, up to 70 percent of embryos fail to implant and only 10
percent of transferred embryos produce full-term babies.
Although this book celebrates the special joys of bearing and
raising multiples, it would be irresponsible to avoid discussing the additional
risks involved. For example, the perinatal mortality is about five times higher
among twins compared with singletons. Risks for multiples include preterm
birth, smaller size, and a higher chance of disability or death occurring
through the first year of life. One study found that 43 percent of pregnancies
with quads produced one or more infants with cerebral palsy.
The risks associated with higher-order multiples is the price
parents pay to enter the club where formerly "only God chose the
members." Moreover, disabilities increase as birth weights decrease, leading
to neonatal and pediatric costs up to fifty times higher than for singletons.
Caesarean rates and prenatal and postpartum days in the hospital increase
for both mother and babies. Not just the babies are at risk. A 2002 report
from the Australian National Medical and Research Council and Australian
Institute for Health and Welfare stated that pregnancy-related deaths (for all
mothers) rose in the past three years by 70 percent! In the United States, the
incidence between 1987 and 1997 almost doubled.
As well, there are often heavy educational and remedial costs in
the early years. Indeed, the economic impact stretches beyond the health
sector and over the infants' lifetime. Regrettably, two significant
organizations that served this growth industry of multiples have met severe
funding obstacles. Twin Services in California was forced to shut down, and
the Multiple Births Foundation in the United Kingdom has downsized. They
were flourishing models for the rest of the world to emulate. Many women,
especially those with lower education, do not perceive the risks and do not
have equal access to information. Furthermore, information alone does not
translate into compliance with health guidelines and the financial means
that can improve outcomes.

Changes in Medical Practice and in This Edition

The increase in the use of ultrasound since the last edition has made
possible the early detection of a multiple pregnancy. Ultrasound can provide
three-dimensional color images, and it is now a rare event to discover an
extra baby at birth. However, today's machines are more powerful; and the
bio-effects are downplayed by the institutions and individuals that profit from
their use. Although the imaging of unborn babies has improved with
ultrasound technology and fetal deaths have decreased, each edition of this
book has reported an increase in preterm births and low-birth-weight babies.
Fetal reduction has become more prevalent as women expecting
ART supertwins (triplets, quadruplets, and other higher-order
multiples) "reduce down" to twins. Birthing fewer multiples in a set reduces
the risks of preterm birth and low birth weight that are associated with
cerebral palsy, which increases the burden of care. The decision, however,
creates a wrenching dilemma for the parents. Furthermore, the parents,
who are seeking to bear a child — not destroy a child — have to decide
quickly. Clearly, couples who cannot grapple with this choice should never
have more embryos implanted than they can willingly and safely bring into
the world.
I have added a separate chapter on the feeding of multiple infants,
specifically to encourage more breast-feeding — often the one mammalian
function left for women whose multiples have been deposited and extracted
by medical technology. The evidence continues to mount regarding the
value of colostrum and breast milk for the future health and intelligence of
offspring.
There are new chapters to guide you as your multiples grow, to
help any siblings adjust, and to advise parents who have multiples with
special needs or multiples who survive when one or more of the set dies.
In 1993, seventy-seven people from eleven countries co-founded
The Cochrane Collaboration. An almost exhaustive list of reviews is now
available on-line scrutinizing the evidence related to various medical
practices. Medicine in general, and obstetrics in particular, engages
in "information gathering" (many ultrasounds, for example) that may not
improve outcome. Yet once a practice is entrenched as "standard of care,"
evidence showing it to be useless or even harmful is often ignored, such as
routine bed rest in pregnancy or universal screening for gestational
diabetes. In most of the Cochrane database reviews that I have searched,
there is simply not enough evidence to make any recommendation!
Michel Odent, M.D., contrasts "circular epidemiology"
(continuation of epidemiological studies "beyond the point of reasonable
doubt") with "cul-de-sac epidemiology" — the publication of research on
topical issues in authoritative journals that are shunned by the medical
community and the media, and bypassed like a cul-de-sac. For example, a
Swedish study published in 1990 by Bertil Jacobson led to the conclusion
that certain obstetric drugs are risk factors for drug addiction in adult
offspring. Despite drug addiction being one of modern society's main
preoccupations, the results have never been confirmed or invalidated by
further research. Likewise, Nobel Prize winner Niko Tinbergen studied
autistic children and recognized risk factors for autism in the perinatal period,
such as anesthesia during labor and induction of labor. It was found that the
Kitasato University's method of delivery in Japan is a risk factor for autism.
Their obstetric practices combine sedatives, analgesics, and anesthesia,
together with an induced delivery a week before the due date. Further
details can be found on www.birthpsychology.com/ primalhealth,
www.birthworks.org/primalhealth and www.michel odent.com.
The increase in availability of organic foods in regular
supermarkets is another significant improvement in recent years. Good
nutrition is easier to achieve today than it has been after decades of
industrialization that progressively impaired our food supply.
Finding the cause and prevention of SIDS (crib death) in New
Zealand — wrapping mattresses to protect babies from the lethal gases —
is some of the best news of the 1990s. Unfortunately, such a simple solution,
like nutrition in pregnancy, does not readily find acceptance among those
whose incomes are derived from research into the syndrome.
I myself have learned since the second edition to remove the
words "don't" and "try" from my vocabulary — unless I wish to emphasize
the negative! Recommendations are in positive language, which is important
for communication skills and for effective parenting.
New terms have come into vogue, such as "multifetal" — which
sounds as if the fetuses themselves are pregnant (like "multimillionaire")!

Telling It How It Is

Criticisms of my book have been posted on Amazon.com by readers who
regard it as politically incorrect, for example, to question common medical
practices, to present medical facts about the consumption of dairy products
and the alleged adverse effects of ultrasound, and to discuss disability and
death that strike multiples much more than single-born babies.
With ever-more multiples being generated these days and
assisted conceptions resulting not just in twins, but in an explosion of
vulnerable higher-order multiples, the need for the whole truth is even
greater. My duty as an author is to inform, and to do so thoroughly. The
reader has the choice of not reading any information that could be disturbing.
But to gloss over the realities would be irresponsible. Indeed, the Multiple
Births Foundation in the United Kingdom recommends that, at diagnosis of a
multiple pregnancy, couples should be warned of the high risk of the loss of
a twin in the early weeks.
Others question my discussion of natural, home, or water birth.
Again, we must look at the most significant evidence — the outcome. The
outcomes of such pregnancies usually reveal such methods to be far
superior to the typical "medical brigade" of interventions. Every mother should
know these facts and have a full array of choices.
Fewer women give birth vaginally to twins and triplets each year.
With the perspective of thirty years in this field I know that women's bodies
haven't changed, but obstetrical evaluations and interventions, as well as
everyone's fears, have increased steadily. Unfortunately, such
developments have not reduced two serious and persistent problems: preterm
birth and low birth weight. In France, 80 percent of preterm labor results from
iatrogenic multiple pregnancy — although the preterm birth incidence in that
country is less than half what it is in the United States. (France also has a
heterogenous population from many of its former colonies.)
Advances in pediatric care, rather than obstetrical screening and
bureaucratic information-gathering, have allowed very tiny babies to survive.
However, well-nourished mothers continue to deliver healthy multiples who
do not need any obstetric or pediatric interventions.
People outside families of multiples often misunderstand the facts
about twinning. It is up to parents, teachers, and others who live and work
with multiples to provide education and help reduce "twinism" (the focus on
the "cute unit" rather than the individuals). Society needs to support a
sense of self-worth for each individual independent of the twinship or
membership in a collective entity. Pregnancy is the ideal time to begin
learning and sharing information — when everyone asks about your big belly!
I contend that if the money for expensive prenatal observation and
intervention were proportioned to pregnant women for organic food,
household help, regular exercise, rest, and personal care, most of their
babies would be born healthy. When maternal lifestyle becomes the priority,
outcomes will improve. The Web site BirthLove.com was founded in 1998 by
Leilah McCracken, mother of eight, as a venue to share her birthing
experiences, and to inform and inspire other women around the world about
the beauty, safety, and power of childbirth. Since inception, this Web site
has grown into a large and highly respected pregnancy, childbirth, and
parenting portal.
The privilege of working in women's health has cemented my
admiration for those who honor their power in childbearing — an activity that
is what women do, like fish swim and birds fly. Every woman knows how —
deep inside. Bearing more than one baby stretches one's limits, of course,
and challenges the expansion of that power. The voices of successful
outcomes on the pages that follow will guide you on your own path to
parenting twins — and more.

Copyright © 1980, 1991, 2003 by Elizabeth Noble. Reprinted by permission
of Houghton Mifflin Company.
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Table of Contents

Contents Foreword by Louis Keith, M.D., F.A.C.O.G. vii Acknowledgments xi Introduction xiii 1 The Fascination with Multiple Births 1 2 How Are Multiples Formed? 27 3 Who Has Multiples? 51 4 Awaiting Multiples: Parents’ Feelings and Practical Considerations 63 5 Bonding with Multiples 87 6 Sharing Space: Twinship Experiences in Utero 101 7 Potential Hazards of Multiple Pregnancy 109 8 How to Give Your Babies the Best Chance with Optimal Nutrition 147 9 Prenatal Care and Screening Tests 195 10 How to Prepare for a Multiple Birth 213 11 Labor and Birth of Multiples 233 12 Caesarean Delivery of Multiples 269 13 The Feeding of Multiple Infants 281 14 Caring for Two or More 303 15 As Multiples Grow 323 16 Having Supertwins: Triplets, Quads, and More 335 17 The Older Sibling/s 357 18 Some Special Features of Twinship 363 19 Treatments to Prolong Pregnancy—To Prevent Preterm Birth and Low Birth Weight 383 20 The Care of Multiples Born Too Soon (Premies) 405 21 Multiples with Special Needs 429 22 The Death of a Multiple: Parents’ Perspectives 435 23 Survivors of a Twin Pregnancy 453 Appendix 1: Assisted Reproductive Technology (ART) 469 Appendix 2: Declaration of the Rights and Statement of Needs of Twins and Higher-Order Multiples 471 Appendix 3: Biography Becomes Biology! 477 Appendix 4: Summary of Essential Prenatal Exercises 479 Appendix 5: Summary of Essential Postpartum Exercises 481 Appendix 6: Summary of Essential Exercises after a Caesarean 483 Appendix 7: Posture Checklist 485 Appendix 8: Medical Risks of Epidural Anesthesia during Childbirth 487 Appendix 9: Plans for Parents and Hospital Personnel in the Event of Loss 489 Glossary 495 Resources 503 Bibliography and Further Reading 529 Photo Credits 546 Index 547

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First Chapter

Introduction

Thanks to the ongoing interest and support of you, my readers, this book has
been published in multiple editions! Almost a quarter-century has passed
since I was first asked questions about twins I couldn't answer, and I
promised I would research the topic for those couples. In the late 1970s, I
found not a single book for parents expecting multiples; and back then
triplets and higher-order multiples were infrequent. What a huge difference
today with a daunting array of resources, especially on the Internet!
The research I undertook in the 1970s for the first edition of this
book convinced me that many problems can be prevented or alleviated by
optimal prenatal care; that is, by the mother's commitment to a vigilant
program of nutrition, hydration, exercise, rest, and education. In the decades
since the first edition, evidence has continued to mount in support of this
view. The focus of Having Twins — and More, then and now, is on the
physiological and psychological dimensions of the experience. Learning how
mothers successfully carried normal-birth-weight babies to term empowers
other women to do the same. Such mothers can still be found despite the
preoccupation with pathology that has occurred with the medicalization of
childbearing in general, and of multiple pregnancies in particular.
This ever-increasing medicalization is a direct result of the focus
on potential problems in litigious societies and has undermined women's
confidence in their ability to give birth. Blood plasma volume expansion
(causing low hemoglobin levels), hypertension (increasing arterial blood flow),
and altered glucose tolerance (making more carbohydrate available for the
babies) should be interpreted as signs of successful placental activity, not
disease processes! Yet expectant mothers (especially of multiples) are
aggressively treated for anemia, high blood pressure, and gestational
diabetes!

Prevention Is the Key: Health Care Is Self-Care

The privilege of working with childbearing couples for more than thirty years
has helped me to clarify what is important. In this book I tackle, rather than
avoid, controversies, without the usual suggestion that readers consult their
doctors. As an independent observer, I am not obliged to be politically correct
in order to obtain grant money or to keep an academic or clinical position.
Being pregnant today, especially if 'high risk,' is full of challenges
that our grandmothers never considered. More than ever, parents need to be
thoroughly informed and empowered to make choices and take responsibility
for their decisions. They need guidance right from the start to face confidently
the months and years ahead.
One of the drawbacks of gaining knowledge and insight is that
feelings of reproach and guilt can emerge over prior events. 'If only . . .' is a
natural, though not a constructive, reaction. When natural childbirth, breast-
feeding, and genital integrity, for example, are endorsed, mothers who did
otherwise may become regretful. Therefore, many health care professionals,
in the well-intentioned attempt to spare women such feelings, fail to
recommend unequivocally the practices that are clearly best for mother and
babies. I call this the 'white philosophy. To explain with an example:
whole grain bread is healthier than white bread, but it is not widely available.
Therefore, let us reassure the people who get the inevitable white bread in the
store, restaurant, hospital, airplane, and school that it is just as good. This
type of philosophy promotes mistaken ideas about pregnancy and birth:
bottle-feeding is the equivalent of breast-feeding, the 'abdominal birth canal'
(Caesarean section) is just another way to give birth, and bed rest, like white
bread, must be acceptable if so many people partake of it! Such
reassurances have back- fired; outcomes have worsened as interventions in
pregnancies and births have increased, and breast-feeding remains a low
priority in our society. Mothers end up feeling guiltier than ever!
It helps to explore all possible facets of any health challenge and
to resist suggestions that a problem is 'all in the mind,' when the evidence is
clearly in the body! Such exploration may include the study of
complementary holistic therapies that address physical, mental, and
emotional aspects of childbearing. In her book Molecules of Emotion,
research scientist Candace Pert showed how a single thought can set off a
chain of reactions throughout the body. Evidence has convinced me of the
value of natural remedies such as homeopathy and herbal supplements along
with visualization and affirmations for treating both the emotional and physical
aspects of some medical problems.
According to the Food and Drug Administration (FDA), during the
five years spanning 1993 to 1998, federal, state, and local agencies reported
a total of deaths from using herbs and supplements (most of which
were associated with weight loss formulas). Contrast this with the figures for
pharmaceuticals, discussed below, which are responsible for almost 100
times more deaths annually!
Nutrition remains paramount. A builder cannot construct a house
without all the supplies, right down to specific screws and nails. If extra
rooms are added, more supplies are needed. Amultiple pregnancy is the
same. A contractor hires subcontractors; parents of multiples need to
assemble a team of helpers who will optimize the outcome.

The Nocebo Effect: The 'Evil Twin' of the Placebo Effect

The attitude of a health care provider that something is wrong and needs to
be fixed leads to anxiety and stress. Nocebo effects refer to symptoms that
occur when the suggestions, instructions, and expectations are negative, in
contrast with placebo effects that occur when intent and expectations are
positive.
Stress affects women in all walks of life, especially those who are
poor, hungry, beaten, or isolated, for example. However, anxieties about the
pregnancy, and especially an unplanned one, have been shown to be more
serious stressors for the unborn babies. We must realize the role of stress
as a cause as well as an effect in pregnancy complications.
Affluent expectant mothers may be exposed to more prenatal
anxiety because they can afford perinatologists and the latest fetal
surveillance technology. They receive a heavy dose of the nocebo effect when
maternity care providers anticipate problems. One woman felt as though she
had contracted a rare disease when her f referred her to an
obstetrician.
Countless women can attest to the nocebo effect from the
disclosure of the multiple pregnancy or the genders of their multiples. For
example, triplets are seen on an ultrasound scan and the doctor enters the
room to talk about selective fetocide. Or the technician announces, 'I'm sorry
to say, four boys.' Many couples have felt their panic thermostat rise
because of an unclear test result, even when everything turns out to be fine.
New research in genetics has turned some of our theories around.
First, the Human Genome Project showed that we have only 34,000 genes
(experts had anticipated three times as many!). Also surprising was the
discovery that cells cannot program themselves: influences that switch them
on or off come from the environment. Ninety-five percent of us come into the
world with an intact genome permitting a healthy life. The causes of disease
in this majority have not been studied as intensely as have the defective
genes in the other 5 percent.
Furthermore, scientist Bruce Lipton's research ('uncovering the
biology of belief') has shown that it is not just the environment that has an
impact on genes but a person's perception of that environment that
determines the kind of change that unfolds. The mother is the mediator of the
world outside and transmits her perceptions to the unborn babies. Her
perceptions, of course, are learned behaviors due to perceptions and beliefs
programmed at the beginning of her life by her mother and others.
Perceptions experienced by unborn babies affect their
development and function. The babies are awash in the brew of
their mother's emotions. These regulators cross the placenta and affect the
same target systems in each baby as in the mother. The development of the
fetal tissues and organs depends on the amount of blood received. A mother
experiencing chronic stress will impair her unborn babies' growth and
immunity. The hormone cortisol, secreted by the adrenal glands under
stress, is known to inhibit fetal growth.
Expectant parents of multiples need the facts on which to base
their decisions. By discussing complications and the associated medical
interventions to help parents make an informed decision, I do not necessarily
imply endorsement. I have played devil's advocate wherever I believe safety
and efficacy are questionable. Evidence-based practice is the standard
today, but studies of pregnancy and birth are frequently retroactive.
In most cases, evidence-based practice is driven by the
pharmaceutical industry because of the ease of randomized controlled trials
(RCTs) with a pill versus a placebo. However, RCTs are often difficult,
practically and ethically, with pregnant women. For example, how could
adequate nourishment be deliberately withheld in order to show that nutrition
has important benefits for mothers and babies? (For that 'data' one looks to
pregnancy outcomes during famine.)
There is an impressive amount of clinical experience on nutrition
from the work of Higgins, Brewer, and Luke, and it is on those grounds that I
base my recommendations, risking criticism of 'insufficient data' by those
who accept only the stringent methodology of RCTs.
Another issue is quantitative versus qua obstetrics. The
medical profession and insurance industry are increasingly invested in
numbers — arduous paperwork documenting size, ratios, monitoring strips,
and other test results — further driven by evidence-based practice. This
preoccupation overlooks the effect of the 'soft data' — psychosocial
influences — which can be measured quite well. However, while total life
stress score measures alone have been insufficient to differentiate increase
in obstetrical complications, preterm birth, or growth retardation, prediction is
possible using perceived life stress. Lewis Mehl-Madrona, M.D., published a
study in the Fall 2002 issue of the Journal of Prenatal and Perinatal
Psychology and Health. The research found that such factors do influence
birth complications and that complications could be reduced if attention was
paid to a woman's fear of birth and lack of support from her partner.
Scrimshaw at the United Nations University Food and Nutrition
Program warns that psychological stressors cause metabolic responses that
are qualitatively similar to those observed with infections. Infections, no
matter how mild, increase catabolic nitrogen losses and divert protein for the
synthesis of immune proteins. Loss of appetite is an early characteristic of
acute infections, even before they are obvious. These issues are critical in
the outcome of multiple pregnancy.
Regrettably, it is the rare clinician who has the time to help
pregnant clients feel heard and respected as they describe their lives (which
is where midwives and doulas can play a critical role). Women who were
screened for psychological issues, once each trimester, were found to be 50
percent less likely to have a low-birth-weight or preterm baby.
A recent Japanese study found that one of the significant
indicators of high maternal attachment to the unborn child was the statement
by mothers who starting planning in pregnancy: 'I plan the things I will do
with my baby.' For mothers of multiples, it is hard to imagine life with two or
more babies, let alone plan for it, but this is a critical task discussed in this
book. Almost half of pregnancies are 'unintended.'
My focus is on strategies for prevention. For this book, I read
hundreds of studies and I quote from many of them, but I know that in a few
years any or all of them could be contradicted by other studies. (Such was
the case, for instance, with the controversial association between oral
contraceptives and twinning.)
Alternative health strategies are rarely acknowledged or used by
the medical establishment. Understandably, research into natural remedies
and one-on-one consultation are more time consuming than simply
prescribing one of the readily available products of the pharmaceutical
industry, even if the evidence fails to justify their use. In modern society, the
popular view is 'better living through technology, drugs, chemicals' and
usually the conception, pregnancy, and birth of multiples reinforce this
position.

The Dangers of Drugs

A 1998 article in the Journal of the American Medical Association estimated
that more than 2 million people require hospitalization per year because of
the adverse side effects of drugs. Deaths due to prescribed pharmaceutical
drugs total more than 100,000 annually. The number of patients killed in
hospitals because of 'medical errors' adds up to another 100,000 or so,
according to the American Medical Association. Burton Goldberg points out
that 'the ordained guardians of our health kill as many people every week (in
hospitals alone) as died in the September 11 terrorist attacks.'
The Physicians' Desk Reference (PDR) — the 'pharmaceutical
bible' used by physicians — is compiled from information submitted by the
drug manufacturers themselves! The FDA approves drugs by reviewing such
studies, not by actual testing. Only two studies showing satisfactory results
are required for FDA approval, despite the existence of other studies in
greater numbers showing adverse reactions. Goldberg warns that many of the
articles published in medical journals discuss the efficacy of a drug in studies
paid for by the drug manufacturer. Physicians, academics, and scientists are
often listed as lead authors to lend credibility to such papers.

Old Traditions Linger Despite Research and Common Sense

Much medical care related to multiples is based more on assumptions than
on valid research; for example, the often-prescribed routine Caesarean
section and routine bed rest do not improve outcome. We must remember
that multiples were all born at home and breast-fed in the old days! Today
many women are confined to bed and pumped full of various drugs, only to
deliver a few days later babies who will spend weeks or months in the
neonatal intensive care unit (NICU). Some mothers eke out a few extra days,
or occasionally weeks, of pregnancy under great duress.
So much more needs to be available to parents who are struggling
every day to keep their babies alive before they are born and after.
Unfortunately, the media glamorizes multiple births and that's the only side
the general public sees or hears about until an unthinkable event happens to
them. The devastation of losing one or both twins, for example, is long-lasting
and affects every member of the family.
Most multiples are born to older couples whose expectations of
themselves and their offspring have increased with the years they have waited
to become parents. For these 'premium pregnancies,' Caesarean birth
unfortunately is almost routine. High hopes are dashed if disability or death
occurs among their multiples. In times of crisis, it is essential to have a
comprehensive guide at hand. Twins may be healthy and bring double
blessings, but they may also experience complications and developmental
delays.
Walking the tightrope between providing comprehensive
information and making common sense recommendations is a challenge.
Mothers who have lost a multiple understandably advocate total surveillance
and great caution. In contrast, those who enjoyed healthy pregnancies and
naturally birthed their babies at term feel that describing complications,
disability, or loss only makes parents fearful and sets them up to anticipate
problems. However, letters from readers with unfortunate outcomes have
made it clear how important it was for them to have the information and
resources available when needed, even though they had skipped those
chapters before.
I encour mothers to trust their bodies and their intuition. We
have all witnessed car accidents, but we retain enough confidence to keep
driving. Likewise, the visibility of mothers with excellent outcomes must be
high, as in the case of one who wrote, 'Your advice to focus on hydration,
nutrition, exercise and rest was key to my success in delivering 7 pound, 11
ounce and 8 pound, 9 ounce babies.' Others have said that it was my
commitment to natural birth that helped them stay committed. Such are an
author's rewards.
My personal bias has always been toward respecting the body
and Mother Nature, and against intervention unless medically necessary —
which even then may lead to an ethical dilemma, such as when parents'
wishes for their babies' well-being conflict with professional opinions.
Circumcision is an example of this. No medical society in the world
recommends it, but individual physicians still prosper from this mutilation and
persuade parents to allow them to cut off a piece of their son's penis. (Two
cases presently in litigation, brought by victims who are now adults, and the
recent death in Vancouver, may soon end this practice in the United States
and Canada.)

The Explosion of Multiple Pregnancies

Spontaneously conceived twins have actually been decreasing during the
past couple of decades, but drugs that stimulate ovulation and techniques
such as IVF (in vitro fertilization) have led to the current worldwide iatrogenic
increase of multiple births, often termed an epidemic in medical circles. In
Sweden, for example, the incidence of twin deliveries has increased nearly 80
percent durin the last twenty years in contrast with a decline in the 1930s to
half the rate two centuries before.
Assisted Reproductive Technology (ART) has become big
business globally, and some women travel to countries like India to save
thousands of dollars for these procedures. The medical questionnaire sent
out by The Triplet Connection to its members listed fourteen types of ART in
addition to spontaneous conception and adoption as ways to become
parents of multiples! Since 1980, the rate of multiple pregnancies due to ART
has been multiplied by 10. The prices paid are: increases in preterm birth (82
percent of deliveries); perinatal mortality (74 percent); and transfers to
neonatal intensive care units (95 percent), which may not have room. In 1978,
there were 68,000 twins born in the United States but by the year 2000 that
number had jumped to more than 126,000! This does not take into account
the rise in cost per child, which increased by a factor of 1.9 for twins and 3.7
for triplets.
The first surviving IVF twins were born in London in 1986. By 1998,
in Australia, ART accounted for 1.5 percent of all births and the world's first
IVF registry started there. Two-thirds of twins and triplets and almost all
quadruplets and higher-order multiples are estimated to result from ART. A
Swedish registry study showed a twenty-fold increased risk of being born as
a multiple from an IVF conception. The World Collaborative Report on IVF
(1995) showed that about 45 percent of resulting births were multiples — 25
percent twins, 4.1 percent triplets, and 0.2 percent quadruplets. These rates
are higher in North America.
In Canada during 1999, there were 8,864 sets of twins born, 384
sets of triplets, and 20 sets of quadruplets. In 1991, 28 sets of quads were
born; that incidence has dropped. In contrast, the number of sets of triplets
born in 1991 was 237.
Clinics specializing in ART publish statistics that indicate high
success rates, such as pregnancy rate or number of babies born. However,
the number of babies born is obtained at the expense of the problems
associated with higher-order multiple pregnancies. Financial stress,
increased potential for pregnancy and birth complications, and the challenges
of caring for three or more babies can result from ART as it is currently
practiced.
Clearly, the great increase in large sets of multiples stimulates
further discussion about the rights, privileges, and responsibilities of such
assisted conceptions. For example, in countries such as the United Kingdom
that have a National Health Service, allocation of resources is an issue. In
1999, a singleton birth cost £167, twins cost £1,712, and triplets cost
£7,185 — a staggering increase in cost per baby. The rate of triplets could be
halved if only two embryos were transferred, resulting in, for example, nine-
fold fewer NICU costs in the United Kingdom (where 85 percent of litigation
involves brain-damaged infants at a cost of over £500 million).
A policy of birth per embryo transferred would focus on achieving a
healthy outcome from the transfer of a low number of embryos. However,
other forms of ART are harder to control. For example, women respond very
differently to ovulatio (OI) — one mother conceived two singletons,
triplets, and then quads, all on progressively lower doses of ovarian
stimulants — and any physician can write the prescription. To further
complicate matters, women often undergo both OI and IVF together, making
outcomes even more unpredictable.
Consistent legal and professional standards in the administration
of IVF have not yet emerged. For example, one survey found that twenty-two
of thirty-seven countries permitted unlimited transfer of embryos. In the
United States, usually three or four are transferred with a 40 percent multiple
pregnancy rate. Between 1971 and 1998, the incidence of triplets increased
more (by 500 percent) than that of quads (100 percent), twins (80 percent),
and single births (10 percent). These numbers reveal the need for guidelines
and greater prudence in the practice of ART. Moreover, each additional baby
reduces the term of the pregnancy by about three weeks. Appendix 1 lists
some differences between multiples conceived spontaneously and by ART.
The desire to maximize the chance of a successful pregnancy by
creating or implanting several embryos is understandable, especially
considering expense. Some couples undergoing fertility treatments may
actually prefer to have twins and complete their family at the lowest cost
rather than pay for future rounds of fertility treatments. Many women who
delay childbearing and who are subfertile or single want to become mothers
by any means possible. But when they request such assistance, they may
be unaware of the possibility of conceiving and bearing (and later raising)
twins, let more infants, and the risks associated with bearing them.
In the zeal to achieve a pregnancy, both doctor and patient
frequently overlook the realities of life with multiples. Even the most well-
prepared parents are challenged — thus it is important to recognize the
stresses in advance. Scholz and team in 1999 assisted a birth of quintuplets
who spent 714 days in the NICU, which cost $600,000. Even more sobering,
their continuing care will cost more than $1 million. The father is a baker and
the mother was described as overburdened and suicidal, often leaving the
children alone. Although this case may seem extreme, it reveals the medical,
financial, and care-related ordeals attending the arrival of higher-order
multiples.
Since this book covers the many details involved in preparing for
multiple birth and caring for the offspring, it will be helpful for all those
considering ART.

More Babies = More Risks

ART has enabled the observation of early human development that has been
described as 'remarkably imprecise.' With losses more frequent in humans
than animals, up to 70 percent of embryos fail to implant and only 10 percent
of transferred embryos produce full-term babies.
Although this book celebrates the special joys of bearing and
raising multiples, it would be irresponsible to avoid discussing the additional
risks involved. For example, the perinatal mortality is about five times higher
among twins compared with singletons. Risks for multiples include preterm
birth, smaller size, and a higher chance of disability or death occurring
through the first year of life. One study found th percent of pregnancies
with quads produced one or more infants with cerebral palsy.
The risks associated with higher-order multiples is the price
parents pay to enter the club where formerly 'only God chose the members.'
Moreover, disabilities increase as birth weights decrease, leading to neonatal
and pediatric costs up to fifty times higher than for singletons. Caesarean
rates and prenatal and postpartum days in the hospital increase for both
mother and babies. Not just the babies are at risk. A 2002 report from the
Australian National Medical and Research Council and Australian Institute for
Health and Welfare stated that pregnancy-related deaths (for all mothers)
rose in the past three years by 70 percent! In the United States, the
incidence between 1987 and 1997 almost doubled.
As well, there are often heavy educational and remedial costs in
the early years. Indeed, the economic impact stretches beyond the health
sector and over the infants' lifetime. Regrettably, two significant organizations
that served this growth industry of multiples have met severe funding
obstacles. Twin Services in California was forced to shut down, and the
Multiple Births Foundation in the United Kingdom has downsized. They were
flourishing models for the rest of the world to emulate. Many women,
especially those with lower education, do not perceive the risks and do not
have equal access to information. Furthermore, information alone does not
translate into compliance with health guidelines and the financial means that
can improve outcomes.

Changes in Medical Practice and in This Edition

The increase in the use ultrasound since the last edition has made
possible the early detection of a multiple pregnancy. Ultrasound can provide
three-dimensional color images, and it is now a rare event to discover an
extra baby at birth. However, today's machines are more powerful; and the
bio-effects are downplayed by the institutions and individuals that profit from
their use. Although the imaging of unborn babies has improved with
ultrasound technology and fetal deaths have decreased, each edition of this
book has reported an increase in preterm births and low-birth-weight babies.
Fetal reduction has become more prevalent as women expecting
ART supertwins (triplets, quadruplets, and other higher-order
multiples) 'reduce down' to twins. Birthing fewer multiples in a set reduces
the risks of preterm birth and low birth weight that are associated with
cerebral palsy, which increases the burden of care. The decision, however,
creates a wrenching dilemma for the parents. Furthermore, the parents, who
are seeking to bear a child — not destroy a child — have to decide quickly.
Clearly, couples who cannot grapple with this choice should never have more
embryos implanted than they can willingly and safely bring into the world.
I have added a separate chapter on the feeding of multiple infants,
specifically to encourage more breast-feeding — often the one mammalian
function left for women whose multiples have been deposited and extracted
by medical technology. The evidence continues to mount regarding the value
of colostrum and breast milk for the future health and intelligence of offspring.
There are new chapters t you as your multiples grow, to
help any siblings adjust, and to advise parents who have multiples with
special needs or multiples who survive when one or more of the set dies.
In 1993, seventy-seven people from eleven countries co-founded
The Cochrane Collaboration. An almost exhaustive list of reviews is now
available on-line scrutinizing the evidence related to various medical
practices. Medicine in general, and obstetrics in particular, engages
in 'information gathering' (many ultrasounds, for example) that may not
improve outcome. Yet once a practice is entrenched as 'standard of care,'
evidence showing it to be useless or even harmful is often ignored, such as
routine bed rest in pregnancy or universal screening for gestational diabetes.
In most of the Cochrane database reviews that I have searched, there is
simply not enough evidence to make any recommendation!
Michel Odent, M.D., contrasts 'circular epidemiology'
(continuation of epidemiological studies 'beyond the point of reasonable
doubt') with 'cul-de-sac epidemiology' — the publication of research on
topical issues in authoritative journals that are shunned by the medical
community and the media, and bypassed like a cul-de-sac. For example, a
Swedish study published in 1990 by Bertil Jacobson led to the conclusion
that certain obstetric drugs are risk factors for drug addiction in adult
offspring. Despite drug addiction being one of modern society's main
preoccupations, the results have never been confirmed or invalidated by
further research. Likewise, Nobel Prize winner Niko Tinbergen studied autistic
children and recognized risk factor for autism in the perinatal period, such
as anesthesia during labor and induction of labor. It was found that the
Kitasato University's method of delivery in Japan is a risk factor for autism.
Their obstetric practices combine sedatives, analgesics, and anesthesia,
together with an induced delivery a week before the due date.
The increase in availability of organic foods in regular
supermarkets is another significant improvement in recent years. Good
nutrition is easier to achieve today than it has been after decades of
industrialization that progressively impaired our food supply.
Finding the cause and prevention of SIDS (crib death) in New
Zealand — wrapping mattresses to protect babies from the lethal gases — is
some of the best news of the 1990s. Unfortunately, such a simple solution,
like nutrition in pregnancy, does not readily find acceptance among those
whose incomes are derived from research into the syndrome.
I myself have learned since the second edition to remove the
words 'don't' and 'try' from my vocabulary — unless I wish to emphasize the
negative! Recommendations are in positive language, which is important for
communication skills and for effective parenting.
New terms have come into vogue, such as 'multifetal' — which
sounds as if the fetuses themselves are pregnant (like 'multimillionaire')!

Telling It How It Is

Criticisms of my book have been posted on Amazon.com by readers who
regard it as politically incorrect, for example, to question common medical
practices, to present medical facts about the consumption of dairy products
and the alleged ad effects of ultrasound, and to discuss disability and
death that strike multiples much more than single-born babies.
With ever-more multiples being generated these days and
assisted conceptions resulting not just in twins, but in an explosion of
vulnerable higher-order multiples, the need for the whole truth is even greater.
My duty as an author is to inform, and to do so thoroughly. The reader has
the choice of not reading any information that could be disturbing. But to
gloss over the realities would be irresponsible. Indeed, the Multiple Births
Foundation in the United Kingdom recommends that, at diagnosis of a
multiple pregnancy, couples should be warned of the high risk of the loss of a
twin in the early weeks.
Others question my discussion of natural, home, or water birth.
Again, we must look at the most significant evidence — the outcome. The
outcomes of such pregnancies usually reveal such methods to be far superior
to the typical 'medical brigade' of interventions. Every mother should know
these facts and have a full array of choices.
Fewer women give birth vaginally to twins and triplets each year.
With the perspective of thirty years in this field I know that women's bodies
haven't changed, but obstetrical evaluations and interventions, as well as
everyone's fears, have increased steadily. Unfortunately, such developments
have not reduced two serious and persistent problems: preterm birth and low
birth weight. In France, 80 percent of preterm labor results from iatrogenic
multiple pregnancy — although the preterm birth incidence in that country is
less than half what it is in the States. (France also has a
heterogenous population from many of its former colonies.)
Advances in pediatric care, rather than obstetrical screening and
bureaucratic information-gathering, have allowed very tiny babies to survive.
However, well-nourished mothers continue to deliver healthy multiples who do
not need any obstetric or pediatric interventions.
People outside families of multiples often misunderstand the facts
about twinning. It is up to parents, teachers, and others who live and work
with multiples to provide education and help reduce 'twinism' (the focus on
the 'cute unit' rather than the individuals). Society needs to support a sense
of self-worth for each individual independent of the twinship or membership in
a collective entity. Pregnancy is the ideal time to begin learning and sharing
information — when everyone asks about your big belly!
I contend that if the money for expensive prenatal observation and
intervention were proportioned to pregnant women for organic food, household
help, regular exercise, rest, and personal care, most of their babies would be
born healthy. When maternal lifestyle becomes the priority, outcomes will
improve. The Web site BirthLove.com was founded in 1998 by Leilah
McCracken, mother of eight, as a venue to share her birthing experiences,
and to inform and inspire other women around the world about the beauty,
safety, and power of childbirth. Since inception, this Web site has grown into
a large and highly respected pregnancy, childbirth, and parenting portal.
The privilege of working in women's health has cemented my
admiration for those who power in childbearing — an activity that
is what women do, like fish swim and birds fly. Every woman knows how —
deep inside. Bearing more than one baby stretches one's limits, of course,
and challenges the expansion of that power. The voices of successful
outcomes on the pages that follow will guide you on your own path to
parenting twins — and more.

Copyright © 1980, 1991, 2003 by Elizabeth Noble. Reprinted by permission
of Houghton Mifflin Company.
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Sort by: Showing all of 7 Customer Reviews
  • Anonymous

    Posted June 25, 2006

    First book I actually threw away so no one else would read it.

    I bought this book when I was expecting twins. Now my twins are 8 months old. This book will make you unnecessarily anxious and upset and the author tries to push her own opinions on childbirth and pretend they have a scientific basis. The fact opf the matter is a lot of twin moms end up having c-sections. This isn't just because doctor's are c-section happy but because it is often medically necessary. Just one exapmple of how evil this book is, is that it pertrays a c-section as a very scary and horrible thing for the mom and the babies. In fact, she even goes on to imply that your babies may have some horrible lasting memories of their traumatic c-section birth that they will ask you about in later years. Give me a break! Also, read with caution the 5-star reviews of this book. It is my opinion that these folks either work for the publisher or are in cahoots with the author.

    1 out of 1 people found this review helpful.

    Was this review helpful? Yes  No   Report this review
  • Posted November 12, 2014

    I Also Recommend:

    I hated this book and am returning it.  It's preachy, one-sided,

    I hated this book and am returning it.  It's preachy, one-sided, and insists on some pretty outrageous concepts (like that babies are traumatized by C-sections and will remember them)  To boot, the paragraphs are not well-written.  They don't flow, they jump around, and the section headings often don't make sense.  This book made me angry, and I just don't need that during my twin pregnancy.  I'm not looking for rainbows and unicorns either, but I do want real, science-backed advice.. 

    Was this review helpful? Yes  No   Report this review
  • Anonymous

    Posted December 27, 2009

    Not quite what I expected or was looking for

    I am a new mom-to-be blessed with twins and was looking for a book that would give me the "what to expect when you're expecting twins" type read. Unfortunately, this book doesn't quite go that route. Instead it spends a good deal of time discussing the history of twins (and multiples), the scientific basis of how twins are formed and develop in utero, etc. Luckily, I do find that type of information interesting, but it just wasn't want I was looking for. If you want a week by week guide to your pregnancy and afterwards, or things to expect that are a different from a singleton pregnancy, this probably isn't the book for you.

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  • Posted June 21, 2009

    Sanctimonious "Guide" Dispensing Potentially Dangerous "Advice"

    This book is written by a woman who is well-versed in the exercise side of physical fitness, particularly with pregnant women. It appears that she has gotten some crazy ideas from her hippie cohorts over the years that have made her believe that she knows more than all the doctors and their recommendations.
    While she firmly supports her own hypothesis for the "overmedicalization of pregnancy," she should be publishing these ideas in a scientific journal, not in an advice-dispensing format for novice mothers-to-be. Expectant mothers (of multiples, no less!!) not only don't need dairy, they will thrive on a dairy free diet??? I'm sure that if the ACOG wanted me to be dairy-free, they would make that recommendation! Gestational diabetes is no big deal?! Not really a medical condition, she says!
    Just a couple of examples, as the list goes on and on!
    I would recommend, if you read this book, that you talk to your doctor very seriously before going ahead with any of her "advice."
    Noble should stick to the pre/postnatal exercise books and keep from pitching out iffy advice to unsuspecting moms.

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  • Anonymous

    Posted February 23, 2009

    A must read if you're expecting twins and are open to ideas outside the main stream

    This is a fabulous book for well-informed parents, those who work in partnership with their medical team. The author has strong opinions in promoting healthy pregnancies, natural birth and breast feeding. With her guidance, you increase your odds of overcoming main the stream beliefs that with twins, premature deliveries are the norm, c-sections are inevitable, and breastfeeding is too difficult. See especially the part on increasing protein intake during pregnancy to help avoid premature delivery.

    People who will like this book are those interested in avoiding medications, in natural birth, and in optimizing breastfeeding. This book is not for you if you are already overwhelmed with your pregnancy and if alternative approaches are frightening to you.

    0 out of 1 people found this review helpful.

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  • Anonymous

    Posted August 27, 2008

    Don't buy it!!!

    This book is way too synical and objective for someone to read if pregnant with mulitiples. It can cause more harm than good. I got some interesting medical facts but to read a lenghty book on the negatives and trials of having twins made me more nervous, stressed, and almost disapppointed that I was having them. if you must read it then borrow it. Don't buy it and have it sit on your coffee table for your entire pregnancy reminding you of all the possible problems and difficulties.

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  • Anonymous

    Posted February 17, 2009

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