Seeing Double: How the Rise of Twins Affects Pregnancy and Birth

Almost the second the ultrasound wand was pressed against my abdomen, two black sacs, each with a fuzzy white dot in the middle, showed up quite clearly.

“Noooooooo!” was my first response.

Twins. OMG.

No waves of maternal mother goddess love or whatever happens to other people. What I felt was stark fear: fear of carrying two babies, fear of people thinking they know my business (admit it, if you meet a woman of a certain age pregnant with twins, don’t you think “IVF”?), fear of being an only child and having to mother siblings in one fell swoop. Yes, I know how lucky we were compared to couples and women who struggle for years to get pregnant, and yes, I love my fuzzy white dots (who will be 3 years old in a couple of months), but at seven weeks pregnant and just getting used to the idea that those crazy expensive fertility drugs had worked, giving birth to twins just seemed insurmountable.

Would they both survive? Would they come too early? How would I take care of them? And myself?

I only knew one set of twins growing up, and now I know dozens. Granted, I’m on a listserv for twin parents and a Facebook group for moms of multiples, but independently of those, it seemed like every class I signed my girls up for always had another set of twins in it. At the playground, more twins. At the bookstore, more twins. At this point, most of us know way more twin kids than we ever knew when we ourselves were kids. And the numbers prove it.

Twin births rose an astonishing 76 percent between 1980 and 2009, and now 33 out of every 1,000 births are twins. (Triplet births rose more than 400 percent until 1998 and have declined 29 percent since then.) Surprising to absolutely no one, the main reason for the explosion is the increased success of fertility treatments and assisted reproductive technologies. Fertility drugs like Clomid that increase the number of eggs produced in a monthly cycle, often used in concert with IUI (intrauterine insemination) and IVF (in vitro fertilization), have all resulted in more women getting pregnant with multiples.

“Multiple gestations have flourished because of the success of fertility treatments,” said Laura E. Riley, MD, president of the Society for Maternal-Fetal Medicine and medical director of Labor and Delivery at Massachusetts General Hospital. “It has definitely changed the landscape. It’s not uncommon to have one or two sets of triplets on the labor floor.”

This outsized rise in multiples pregnancies and births has had a major effect on the women who bear them, the children they result in and the medical community who cares for them. Twin pregnancies increase the risk to mothers’ and babies’ health throughout pregnancy and during labor and delivery. Mothers of multiples are much more likely to have gestational diabetes and pre-eclampsia, along with many other complications, such as placenta previa and twin to twin transfusion syndrome, and are monitored more frequently, with more prenatal visits and ultrasounds, than women having singletons.

Because I was carrying twins and nearing 40, I was considered high risk and went to a maternal-fetal medicine group rather than a regular OB. I had monthly visits and frequent ultrasounds, and after around 32 weeks, I saw my doctors weekly. They checked my cervix, my blood pressure, my blood sugar and so on. My morning commute time nearly tripled—the 10-minute walk to the subway took 30 minutes. Going up the subway steps was a feat in itself, and I probably should have had my paycheck docked considering how long it took me to get from my desk to the ladies room and back again. Fortunately I worked from home after around 7.5 months and I never had to be on bed rest, but I basically ended up there anyway. I needed a walker just to get from my bedroom to the front door of my apartment.

Mothers of multiples are also more likely to have a C-section. This is because of risks to the babies or mother, or when one or both of the babies are in the breech position. Currently, growing numbers of obstetricians are untrained to perform a vaginal breech delivery—or are uncomfortable doing so—and will only deliver breech babies via C-section.

“People are more skilled at taking care of patients with twins, and there isn’t the same level of training now with a breech extraction,” said Riley. “Breech deliveries take a certain level of skill and practice.”

A pregnancy that ends with a C-section costs around $50,000, while one that ends with a vaginal delivery costs $30,000, according to The New York Times, and that’s in a singleton pregnancy. In twin deliveries, each baby gets its own team of doctors. In addition, mothers of twins are 13 times more likely to give birth before 32 weeks of gestation and six times more likely to give birth before 37 weeks, meaning that well over half of all twins are pre-term and are born at a low birth weight, which is defined as below 5 lbs., 8oz.

“The average gestational age for twins is 35 weeks. There is no question we have more premature births,” said Riley. These preemies are much more likely to spend time in a neonatal intensive care unit than singletons, which adds significantly to the costs of having a baby, both in dollars and in emotional and physical support. “Here in Massachusetts there are many more NICU beds than there were 20 years ago,” added Riley.

At 37 weeks, I was admitted to the hospital with pre-eclampsia, but I insisted on waiting for my own OB to come on call, because Baby B was breech (Baby A was vertex, or head down) and he did breech deliveries. The other doctors on call did not. The induction failed, as did my two epidurals—and after an exhausting 27 hours, I ended up in the OR with a C-section.

We were very lucky—one twin was nearly 7 lbs. and the other was well over 6 lbs., with no complications. And even though I was vigilant that every anesthesiologist and pediatrician we used was in-network, and our insurance covered 90 percent of the costs, the bills that did come in were still pretty significant.

But twin and multiple pregnancies are always going to be more expensive than single ones. “I think we are all feeling pressure to contain the costs, but the tough part with twins and triplets is we can only contain so much,” said Riley. “We have to give the best care that we can.”

On the upside, practitioners are more skilled at caring for multiples mothers and babies—residents see more of this type of patient and therefore get more training; neonatologists treat more preemies and learn better how to care for them. Research is being done on drugs, such as those that might prevent the uterus from contracting. But the facts remain that there aren’t medical solutions or cures for most of the health risks inherent in giving birth to more than one baby at a time. “We don’t have any treatments—we just monitor and react,” said Riley. “So if you want to improve the lives of pregnant women and children, it’s better to have one [baby] at a time.”

The American Society for Reproductive Medicine (ASRM) agrees. Their latest guidelines, released in 2012, call for a single embryo transfer for women under 35 undergoing their first or second round of IVF, known as elective single-embryo transfer or eSET: “[T]he optimal outcome of an IVF cycle is the birth of a healthy singleton.” And, in fact, with advancements in fertility methods and science, the rate of twins has leveled off, and in 2011 was down 1 percent from the 2010 rate.

“It’s really important to reduce the rate of multiple gestation,” claims Riley. “Ultimately it’s important to have healthy babies and it’s healthier to have them one at a time. Not adding risk is the main thing to me.”

But eSET has been slow to spread, especially since the costs of each round of IVF are high, and because many women suffering from infertility would rather chance having multiples than no babies. Fertility doctors are still likely to transfer more than one embryo to a patient who is over 35 and especially to those over 40—and patients will insist on it. Fertility drugs, particularly the injectable kind, affect each woman and each cycle differently—and the older she is, the more she might be willing to risk multiples. Also denial is powerful: I heard my doctor when he said there was a risk of twins, but I didn’t believe it would happen to me.

As the science of fertility grows more sophisticated, this might change. But for now, the phenomenon of twins is real and looks like it’s here to stay. And when I see my girls hug in the hallway or when one consoles her sister when she’s sad, I’m happy for their close relationship—despite the fact that two minutes later they might be pulling each other’s hair. They love each other—and more love is always a good thing to bring into the world.

Next up in the series: Twins in the classroom and educating multiple multiples.