Cover image for Having twins--and more : a parent's guide to multiple pregnancy, birth, and early childhood
Having twins--and more : a parent's guide to multiple pregnancy, birth, and early childhood
Noble, Elizabeth, 1945-
Personal Author:
Third edition.
Publication Information:
Boston : Houghton Mifflin, [2003]

Physical Description:
xxvii, 560 pages : illustrations ; 23 cm
General Note:
Previous ed. published with title: Having twins.
Electronic Access:
Publisher description
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Material Type
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RG567 .N62 2003 Adult Non-Fiction Non-Fiction Area
RG567 .N62 2003 Adult Non-Fiction Open Shelf

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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.

Author Notes

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.



IntroductionThanks 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-CareThe 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 EffectThe 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 DrugsA 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 Traditions Linger Despite Research and Common SenseMuch 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 PregnanciesSpontaneously 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 RisksART 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 EditionThe 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 primalhealth, and www.michel 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 IsCriticisms of my book have been posted on 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 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. Excerpted from Having Twins and More: A Parent's Guide to Multiple Pregnancy, Birth, and Early Childhood by Elizabeth Noble, Leo Sorger All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.

Table of Contents

Louis Keith, M.D., F.A.C.O.G.
Forewordp. vii
Acknowledgmentsp. xi
Introductionp. xiii
1 The Fascination with Multiple Birthsp. 1
2 How Are Multiples Formed?p. 27
3 Who Has Multiples?p. 51
4 Awaiting Multiples: Parents' Feelings and Practical Considerationsp. 63
5 Bonding with Multiplesp. 87
6 Sharing Space: Twinship Experiences in Uterop. 101
7 Potential Hazards of Multiple Pregnancyp. 109
8 How to Give Your Babies the Best Chance with Optimal Nutritionp. 147
9 Prenatal Care and Screening Testsp. 195
10 How to Prepare for a Multiple Birthp. 213
11 Labor and Birth of Multiplesp. 233
12 Caesarean Delivery of Multiplesp. 269
13 The Feeding of Multiple Infantsp. 281
14 Caring for Two or Morep. 303
15 As Multiples Growp. 323
16 Having Supertwins: Triplets, Quads, and Morep. 335
17 The Older Sibling/sp. 357
18 Some Special Features of Twinshipp. 363
19 Treatments to Prolong Pregnancy--To Prevent Preterm Birth and Low Birth Weightp. 383
20 The Care of Multiples Born Too Soon (Premies)p. 405
21 Multiples with Special Needsp. 429
22 The Death of a Multiple: Parents' Perspectivesp. 435
23 Survivors of a Twin Pregnancyp. 453
Appendix 1 Assisted Reproductive Technology (ART)p. 469
Appendix 2 Declaration of the Rights and Statement of Needs of Twins and Higher-Order Multiplesp. 471
Appendix 3 Biography Becomes Biology!p. 477
Appendix 4 Summary of Essential Prenatal Exercisesp. 479
Appendix 5 Summary of Essential Postpartum Exercisesp. 481
Appendix 6 Summary of Essential Exercises after a Caesareanp. 483
Appendix 7 Posture Checklistp. 485
Appendix 8 Medical Risks of Epidural Anesthesia during Childbirthp. 487
Appendix 9 Plans for Parents and Hospital Personnel in the Event of Lossp. 489
Glossaryp. 495
Resourcesp. 503
Bibliography and Further Readingp. 529
Photo Creditsp. 546
Indexp. 547