Parents of multiples

One’s crying. Now the other. Amid the freeze of an Edmonton winter, I somehow teleport myself to the couch in their nursery and start nursing in the “double football hold” I’ve perfected since my preemie twins came home from the hospital two months ago.

Their slurping makes me thirsty. Can’t…reach…water glass. Instead, I drink in the silence, a rare gift for parents of multiples. Our legion grows in Canada by thousands each year. We anxiously fill neonatal intensive care units and gobble up daycare spaces with our wriggling broods; we are those oblivious, bed-headed wonders who clog traffic at farmers’ markets with our obscenely wide strollers. For us, the early days of parenthood are more liquid than solid — sleepless nights and oldies radio, hoping to get our babies changed, fed, burped and back to sleep in under two hours.

According to Statistics Canada’s most recent figures, in 2006 more than 11,000 Canadian couples relied on greasy takeout and second-hand clothes to survive their first year with two, three or more babies. One in every 33 Canadian births is a multiple now, and the bulk of those (96 percent) are twins — a rate that’s increased threefold since 1995. The stats for triplets are tougher to come by, but we do know the rate of triplet births tripled between 1985 and 2000 (though it’s now levelling off). As one US scholar put it, we’re in the midst of a demographic hurricane in North America and we don’t know its full impact — on hospitals and health services for frail babies; on teachers and classrooms; on family dynamics, shopping cart designs and government programs.

Postponing childbearing

My mother, who raised a Brady Bunch of six, insisted I delay childbearing until I was educated and independent. But in heeding her advice, did I squander my most fertile years? When women of my generation can’t get pregnant at 37, we can pay doctors the equivalent of a good used car to implant a spoonful of embryos, like I did, or take a chance with fertility drugs — less expensive but also less precise.

Once the bliss of finally holding their longed-for babies wears off, how are parents of engineered multiples coping? Sure, we’re helping top up a stagnant birth rate, but what new issues arise from this demographic blip? Formal studies about the impact of multiples on families and society are few and mostly foreign. One thing’s certain, though: There are more multiples now than ever. And if Canadian governments start paying for reproductive technologies, as some European countries now do, the wave of duets and ensembles may soon crest.

I arrive at Jon Barrett’s Toronto office to a note on the door: “Lisa, please go to the delivery suite, 3rd floor of the hospital across the street.” Our scheduled meeting will have to wait until after he’s delivered what has to be the 4,000th baby of his 20-year career, so I wander through Women’s College Hospital and read People in the lounge until Barrett arrives, a compact man in scrubs with a fuzzy beard and a soothing smile. One of the country’s leading specialists in multiple pregnancy and birth, he launched Canada’s first multidisciplinary twin clinic in 1996 to offer obstetrical and health advice to couples expecting multiples. That is, once he figured out what to tell them. Soon after the clinic opened, he realized there were no standards of care for women carrying more than one fetus; all of the existing guidelines were based on the prenatal care and delivery of singletons.

Mulitple studies

After organizing an international symposium, Barrett helped draft a multiples consensus statement for the Society of Obstetricians and Gynaecologists of Canada (SOGC), to address issues ranging from preterm birth prevention to clinical depression in mothers of multiples. His next quest is determining the safest birthing method: Despite record statistics, physicians worldwide still don’t know whether vaginal birth or C-section is preferable for delivering multiples. A $9 million international study led by Barrett is expected to answer that question within two years.

Barrett’s patients are generally 35 or older, educated and financially fit. While their age makes them naturally more likely to conceive twins (older women frequently release two eggs during ovulation), most have become pregnant through in vitro fertilization (IVF). All meet him for the first time after confirming the news that they are expecting. “When people come to my office, I see them in a bubble. They’re so excited. They were infertile; now they have a twin pregnancy,” he says. Trouble is “they don’t know what the risks of twin pregnancies are and they’ve got no clue how difficult it is to look after twins…. I try not to burst the bubble, but over time, I slowly deflate it.”

Parents expecting triplets don’t often require deflation — they’re already anxious. And they’ve become more common. Barrett’s father was an OB/GYN for 50 years, and delivered three sets of triplets in his lifetime; Barrett often sees three patients a month who are pregnant with triplets. But he says recent guidelines adopted jointly by the SOGC and the Canadian Fertility and Andrology Society have resulted in fewer embryos implanted during IVF, and that’s trimming the number of triplets and other “high-order multiples” or HOMs. Other checks and balances come from Assisted Human Reproduction Canada, the federal regulatory agency that oversees issues related to assisted reproductive technologies, including the licensing and inspection of fertility clinics.

Although multiples make up only three percent of births in Canada, they account for one-quarter of patients in neonatal intensive care units (NICUs). Compared to singletons, twins are born, on average, three weeks earlier and two pounds lighter, suffer more frequently from physical and mental disabilities, and experience more childhood hospitalization and surgeries. Nearly all HOMs are born early (90 percent) and thus even more likely to have a low birth weight and require extensive and ongoing medical intervention. A neonatologist once told me the two months my daughters spent in the NICU probably cost the health care system about $500,000.

Funding IVF

The man responsible for getting me pregnant (aside from my husband and his, er, handy contribution) says that funding IVF would dramatically reduce Canada’s rate of multiple births. Cal Greene, medical director of the Regional Fertility Program in Calgary, explains that the odds of getting pregnant generally increase if you implant multiple embryos. So why would a couple, paying $10,000 for drugs and treatment, ignore those odds, especially if they can afford only one shot? And fertility clinics with poor success rates might encourage multiple implantation to boost their stats in an increasingly competitive market. (Just how competitive? Consider there are 16 fertility clinics in the Toronto area alone.)

“We talk to patients a lot more about multiple pregnancy now than when you came in [five],” Greene tells me, “offering them fewer embryos — but they’re not very accepting of it. They say, ‘That’s nice, I’ll take my two.’” If costs were covered, he says, couples would be more willing to implant just one embryo at a time. Or a public health care system footing the bill could make it mandatory, like in Sweden, where the state-funded IVF program insists on single-embryo transfer with few exceptions. Greene has lobbied the Alberta government for years, arguing it would cost the province roughly $20 million annually to cover IVF, a paltry sum compared to what’s currently spent on high-risk multiple pregnancies and preemies. While Ontario pays for IVF in certain circumstances (see Fertility facts), Quebec will likely be the first province to fully fund a variety of reproductive technologies. A bill to that effect is now before Quebec’s National Assembly.

While the 2006 IVF guidelines Barrett mentioned recommend transferring as few embryos as possible, “to optimize healthy live births and minimize multiple pregnancies,” there are no laws in Canada governing how many embryos can be implanted during IVF. Like any licensed physician, Greene says, a fertility doctor should have some flexibility, within prescribed guidelines, to make a prognosis and begin treatment based on factors, such as a woman’s age, cause of infertility, history of pregnancy and miscarriage, etc. Accordingly, if a woman is 40 or older and the prognosis is poor, the guidelines indicate she and her doctor should consider implanting three or more embryos. Theoretically, within this hazy legal environment, quints, sextuplets or even octuplets could result, but that’s unlikely to happen in Canada. The kind of rogue fertility doctor who treated the Octomom in California doesn’t exist here, says Greene, and even if one did, governing bodies would ensure he or she didn’t get away with the practice for long.

Parenting twins

Twins are usually more demanding in the beginning because they often need the same thing at the same time, says Patricia Malmstrom, who, as the mother of both two singletons and a set of identical twins, is well-equipped to comment. (As the founder and director of Twin Services Consulting in California, holder of a master’s degree in early childhood and special education and co-author of The Art of Parenting Twins, she’s also professionally qualified.) “It elevates our frustration that we can’t give everything to one child when that child needs it, especially early on when infants need attentive care.”

Like the time my girls were vomiting simultaneously. My journalist husband, Dan, was away on assignment in Florida, leaving me on my own with no nearby grandparents to call on for help. For a week. Four arms outstretched from soiled cribs, two frightened, feverish faces, me repeating “It’s OK, it’s OK, Mommy’s going to take care of you,” while I agonized over what to do next.

Multiples do pose unique dilemmas. Multiple Births Canada (MBC), the national advocacy and support group, has compiled anecdotes suggesting elevated levels of postpartum depression, abuse, divorce and addictions in families with multiples, yet few social programs exist to help head off these problems.

Parental leave

Well aware of the siege awaiting them, an Ottawa couple with newborn twins is applying for double parental leave rather than accepting the shared 35 weeks of Employment Insurance benefits allowed to parents of singletons. When MBC launched a campaign around this issue, some non-multiple families denounced the idea as special treatment, says MBC chair Gail Moore, herself a mom of four, including twins. “Nobody except a parent of multiples can understand what the first two or three years of the newborns’ lives are like,” she says. “The parents actually lose themselves in the physical demands of taking care of those children.”

Once the physical demands abate, the mental ones emerge. Now that my girls are four, I’m learning about how twins learn. The Ottawa-Carleton District School Board, where my girls are enrolled in junior kindergarten, allows parents — in consultation with teachers and staff — to decide whether or when to separate twins into different classrooms. Conventional wisdom held that twins should be separated to nurture individual identities, but that’s been debunked. Each pair, new studies conclude, should be assessed annually because some twins flourish together while others don’t, and that changes over time — especially if one has a disability. For now, Daisy and Maggie are together, but questions about their development linger in my mind. Will they always be friends? Will they always help each other grow or be jealous rivals? Will they like being twins or hate it?

I was melting chocolate on the stove last week, with Maggie and Daisy standing on chairs beside me. I warned them not to touch the hot element, but the urge was overwhelming. “No, Maggie!” Daisy shouted, but it was too late. I whisked Maggie to the tap and held her finger under the cold water, admonishing her. Maggie, unfazed, stared at her finger to examine the tiny red line. When I turned around, Daisy was weeping. “Maggie’s going to be burned forever,” she said. “She should have listened.”

Twins develop empathy earlier than other children, and they grow that empathy, first for their co-twin and later, for other siblings and friends, Malmstrom says.

“I have a hope; it may be quixotic, but wouldn’t it be nice if twins’ increased numbers seeded a greater empathy in the human race? That may be overreaching, but we certainly need it,” she laughs. “They learn so young to take the other person’s point of view, they might end up being a wonderful cohort of diplomats.”

I’ve struggled to be a good mom even though nature might not have intended I be one. And during those early days at home with two newborns, I sometimes questioned the wisdom of chasing down motherhood at any cost. But my girls are big and healthy now, dressing and feeding themselves, and hugging me when I’m sad and telling me, “You draw a heart, Mommy, and I’ll cut it out and give it to you.”

If what Malmstrom says about empathy holds true, I’ve now got it made. Times two.

Fertility facts

35 Number of fertility clinics in Canada listed on the Canadian Fertility and Andrology Society website, cfasonline.ca

1,000 Approximate number of IVF treatments performed at the Regional Fertility Program in Calgary last year

$6,000 Cost of one IVF treatment cycle in Ontario (if you are a woman under 40 and both your fallopian tubes are blocked, OHIP pays)

$3,500 Average cost of IVF-related drugs, over and above the $6,000-per-cycle fee