From 1980 to 1997 there was a 52% increase in twin births,1 a trend associated with wider use of assisted reproduction. However, relative to singleton pregnancies, twin gestations are associated with a higher incidence of maternal and neonatal complications.2 Correspondingly, the increasing frequency of twin pregnancies is a major public health concern, as these pregnancies consume a disproportionate amount of medical resources.3 The psychosocial costs of multiple pregnancy are also considerable and can increase affective disorders among mothers and marital strain in couples.4 Given the potential for adverse financial and marital consequences, it is important that couples undergoing infertility treatment are maximally aligned in their understanding of and desire for twin gestations. Although infertility programs may attempt to educate couples undergoing treatment about the maternal and fetal risks of multiple pregnancy, there is little information regarding the relationship between a patient's and her partner's perceptions of risk and their individual desires to conceive a twin pregnancy. In an effort to better understand these relationships, we conducted a cross-sectional survey at our institution to compare a woman's perceptions of a twin gestation with those of her partner.
MATERIALS AND METHODS
From November 1999 through February 2000, consecutive couples attending a university-based infertility clinic were invited to participate in an interviewer-administered survey. Both patient and partner were separately interviewed face to face by one of two research nurses. Both nurses had been trained to ensure that questions were asked in a standard fashion. This survey has been previously described.5 The first section of the survey ascertained patient and partner demographic data, including age, race, and level of education. It also assessed the duration of infertility and types of infertility therapy used. Patients and their partners were asked if they had been counseled regarding the incidence and risks of twins and, if so, how long the counseling session had lasted.
Interviewers then asked patients to rate the desirability of singleton and twin pregnancies using a Likert five-point scale, with 1 indicating a very undesirable outcome and 5 indicating a highly desirable outcome. Patients were also asked to choose whether a singleton or twin pregnancy was their most desired outcome.
The next set of questions attempted to ascertain the accuracy with which participants understand the maternal and neonatal risks of twin gestations. Thus, they were asked to provide percentage estimates of the risk of very preterm delivery (less than 32 weeks' gestation), the incidence of and mortality of very low birth weight infants (less than 1500 g), and the risks of preeclampsia and postpartum depression.
Finally, patients and partners were presented with three clinical scenarios in which a twin pregnancy was associated with stated probabilities for defined adverse outcomes (delivery of infant weighing less than 1500 g, preeclampsia, and postpartum depression). In the first (“low risk scenario”), the risks for the complications were 5%, 15%, and 10%, respectively; in the second (“medium risk scenario”), 10%, 30%, and 30%, respectively; and in the third (“high risk scenario”), 20%, 60%, and 60%, respectively. After being given each scenario, the patients were asked to quantify their desire for a twin gestation using the previously defined five-point Likert scale.
The McNemar χ2 for analysis of paired categoric data and χ2 analysis of nonpaired categoric data were used. Continuous data were analyzed using the paired Student t test, with the exception of time-based data, which were analyzed by the Mann–Whitney U test. Statistical significance was defined as P < .05. All statistical analyses were performed using Minitab 13 (Minitab Inc., State College, PA) and Stata 6.0 (Stata Corp., College Station, TX). The Institutional Review Board of Northwestern University approved this study.
Of the 94 couples approached, 90 (96%) agreed to participate in the study. The couples were predominantly heterosexual (98%) and had been attempting to conceive with unprotected intercourse for a median of 24 months (interquartile range 16–48). The median length of infertility treatment was 10 months (interquartile range 1–12). Fifty-eight percent of patients and 67% of partners recalled being counseled about the risks of multiple gestations (P > .05). The difference in median counseling time recalled by each group was also not statistically significant (5 versus 10 minutes, respectively). Table 1 compares the demographic factors of patients and partners, who did not differ in any factor other than age.
When patients and partners were asked to provide estimates of maternal and neonatal risks associated with twin gestations (Table 2), patients consistently provided significantly higher estimates of risk. Literature-based estimates are also presented in Table 2.4,6–9 Table 3 summarizes patient and partner responses when asked specifically about the desirability of a twin pregnancy. Despite patients' higher risk estimates for twin pregnancies, their desire for twins was similar to that of their partners. The majority of patients and their partners felt that a twin pregnancy was desirable or highly desirable (68% versus 64%, respectively).
As seen in Table 4, there was no difference between patients and partners when confronted with a low-risk scenario, but there was a statistically significant difference between patients and partners when presented with either a medium- or a high-risk scenario. This difference, in fact, was most significant for the high-risk scenarios.
Finally, patients and partners were asked to identify which plurality of pregnancy they found most preferable. In 58 cases (65%) both partners preferred a singleton, whereas in 13 cases (14%) both partners preferred a twin gestation. In 19 cases (21%) one partner but not the other believed that a twin gestation was most desirable. We attempted to ascertain factors that might be associated with this discordance within couples. Table 5 reveals that no identifiable factors could be elucidated.
Our study suggests that the patients and partners within a couple have significant differences in perception of the frequency of risks associated with twin pregnancy. Specifically, women undergoing therapy believe that the risks of twin pregnancy are greater than the risks perceived by their partners. No identifiable factor was clearly responsible for this difference, as demographic factors other than age were similar and the amount of counseling regarding twin gestations was comparable. Also, we believe that response bias was not responsible for this outcome, as we attempted to minimize the chance for this bias by using interviewer-administered surveys, a strategy that optimized response rate (96%).
Despite their belief that twin pregnancies were more risky, women undergoing treatment were as desirous of twins as their partners. This similar desire for twins in the setting of greater perception of risk suggests that women are less risk averse than their partners with respect to twin pregnancies. This interpretation is further supported by the analysis of different risk scenarios (Table 4). When risks were low, patients and their partners did not differ in desire for twin pregnancy. As risks became greater, however, partners became less sanguine regarding a twin conception. The exact cause for women's increased tendency to accept risk is not immediately evident as, aside from age, no factor clearly differed between women and their partners. As most couples were heterosexual and therefore most partners were male, the differences may be due to a woman's greater desire for cessation of infertility treatment10 or a greater motivation for parenting. This desire to have a child “at all costs” has been noted by Leiblum et al11 in their study of infertile women. Men may be considering other factors, such as income, treatment costs, and treatment-related stress,12 and these concerns may explain the lower desirability of twins in this group. These considerations at this point are speculative and should be further elucidated. Nevertheless, we believe it is most important to realize that this dynamic exists and to tailor discussions with couples to minimize any disruptive influence it may engender.
Indeed, the counseling provided by reproductive endocrinologists may help to inform both patients and partners of the actual risks of a twin pregnancy, to elucidate the differences between patients and partners, and to provide an avenue for greater discussion and engagement regarding treatment-related decisions. The adverse medical consequences of iatrogenic multiple pregnancy are well known, but the subsequent stability of a couple's relationship has been less well studied.13,14 Nevertheless, those investigators who have evaluated couples after delivery of a twin pregnancy have also found that the health of the relationship can be adversely impacted. For example, it has been shown that the stressors associated with twin pregnancy, such as the financial burden and increased time constraints of caring for preterm twins, can cause strain between couples. There are also increased risks of postpartum depression and need for psychologic counseling, which can further impact a relationship (Garel M, Blondel B, Kaminski M. Multiple births in couples with infertility problems [letter]. Hum Reprod 1995;10:2748). We have demonstrated that differences within a couple with regard to risk aversion and desire for a twin gestation exist even before conception, and we hypothesize that couples who are aligned preconceptionally may be more able to negotiate this difficult time. Although there is presently no evidence to demonstrate that increased concordance between couples regarding risks and incidence of twin pregnancy before conception makes this difficult transition any easier, further investigation needs to clairfy the causative relationship between discordant perceptions and subsequent marital stress after a twin delivery.
1. Martin JA, Park MM. Trends in twin and triplet births; 1980–1997. Natl Vital Stat Rep 1999;47(24):99–1120.
2. Alexander GR, Kogan M, Martin J, Papiernik E. What are the fetal growth patterns of singletons, twins and triplets in the United States? Clin Obstet Gynecol 1998;41:115–25.
3. Callahan TL, Hall JE, Ettner SL, Christiansen CL, Greene MF, Crowley WF Jr. The economic impact of multiple gestation pregnancies and the contribution of assisted-reproduction techniques to their incidence. N Engl J Med 1994;331:244–9.
4. Thorpe K, Golding J, MacGillivray I, Greenwood R. Comparison of prevalence of depression in mothers of twins and mothers of singletons. BMJ 1991;302:875–8.
5. Grobman WA, Milad MP, Gillette K, Thomas H, Stout J, Klock S. Patient perceptions of multiple gestations. An assessment of knowledge and risk aversion. Am J Obstet Gynecol 2001;185:920–4.
6. Kovacs B, Kirschbaum T, Paul R. Twin gestations: Antenatal care and complications. Obstet Gynecol 1989;74:313–7.
7. Alexander GR, Kogan M, Martin J, Papiernik E. When does intrauterine growth of multiples begin to differ from singletons? Clin Obstet Gynecol 1998;41:116–26.
8. Long P, Oats J. Preeclampsia in twin pregnancy: Severity and pathogenesis. Aust N Z J Obstet Gynaecol 1987;27:1–5.
9. MacDorman M, Minino A, Strobing D, Guyer B. Annual summary of vital statistics—2001. Pediatrics 2002;110:1037–52.
10. Berg BJ, Wilson JF. Patterns of psychological distress in infertile couples. J Psychosom Obstet Gynaecol 1995;16:65–78.
11. Leiblum SR, Kemman E, Taska L. Attitudes toward multiple births and pregnancy concerns in infertile and non-fertile women. J Psychosom Obstet Gynaecol 1990;11:197–210.
12. Andrews FM, Abbey A, Halman LJ. Is fertility-problem stress different? The dynamics of stress in fertile and infertile couples. Fertil Steril 1992;57(6):124–53.
13. Keith LG, Blickstein I, eds. Iatrogenic multiple pregnancy: Clinical implications. London: Parthenon Publishing Group, 2001.
© 2003 The American College of Obstetricians and Gynecologists
14. Keith L, Oleszczuk JJ. Iatrogenic multiple birth, multiple pregnancy and assisted reproductive technologies. Int J Gynaecol Obstet 1999;64:11–25.