Psychosocial Aspects of Multi-fetal Pregnancy Reduction
Printer-friendly versionby Elizabeth Grill, PsyD FALL 2006
For many couples who have spent years of anticipation, time, energy, and money to conceive a pregnancy, multi-fetal pregnancy reduction is a painful irony. Pregnancy reduction can be an emotionally traumatic experience involving a variety of emotions ranging from relief and happiness (to be pregnant), to ambivalence, despair, grief, and guilt. The fact that the pregnancy loss is chosen makes it even more complicated and problematic to resolve. Couples are not routinely counseled about the risks associated with multiple gestation and multi-fetal pregnancy reduction. They often fantasize about what it would be like to have twins or triplets and overlook the potential complications of multiple gestation.
For many couples who have spent years of anticipation, time, energy, and money to conceive a pregnancy, multi-fetal pregnancy reduction is a painful irony. Pregnancy reduction can be an emotionally traumatic experience involving a variety of emotions ranging from relief and happiness (to be pregnant), to ambivalence, despair, grief, and guilt. The fact that the pregnancy loss is chosen makes it even more complicated and problematic to resolve. Couples are not routinely counseled about the risks associated with multiple gestation and multi-fetal pregnancy reduction. They often fantasize about what it would be like to have twins or triplets and overlook the potential complications of multiple gestation.
In the United States the ratio of triplets and higher-order multiple births for all age groups increased from 29 per 100,000 live-born infants in 1971 to 37 per 100,000 live-born infants in 1980. Following the introduction of assisted reproductive technology, circa 1980, the rate more than quadrupled to 174 in 1997 (Reynolds, 2003).
Multiple gestation may be associated with many physical and psychosocialcomplications. Women may experience more nausea, vomiting, fatigue, weight gain, heartburn, lack of sleep, and require extended periods of bed rest. Maternal risks may include high blood pressure, gestational diabetes, anemia, pre-eclampsia, increased risk of bleeding, premature labor/delivery, post-partum hemorrhage, higher caesarean-section rates, and loss of the entire pregnancy. Fetal/neonatal risks may include prematurity, low birth weight, developmental disabilities, respiratory complications, congenital anomalies, cerebral palsy, and death (American Society for Reproductive Medicine Patient’s Fact Sheet, 2001; RESOLVE, Infertility Treatment and Multiple-Gestation Pregnancy). Additionally, multiple gestation pregnancy and multiple birth can put a family at financial risk; the health care cost for delivery and newborn care for twins is four-fold higher when compared to a singleton birth. The stress of parenting, feeding and caring for several infants can lead to marital difficulties, depression, social isolation, and in extreme cases even child abuse (Garel et al, 1997; Hay, McIndoe, & O’Brien, 1987; Thorpe, Golding, MacGillivray, & Greenwood, 1991). Infants in higher order multiple sets are also at greater risk for neglect, scapegoating, and developmental delays (Goshen-Gottstein, 1980).
Parents who conceive multiples have the option to continue the entire pregnancy, abort the entire pregnancy, or reduce the number of fetuses. This decision is a complicated one, often involving profound ethical, moral, religious, and psychosocial issues. Those who choose not to intervene risk potential morbidity and mortality to the fetuses and those that intervene, face the certainty of loss of some of the fetuses and risk of loss of the entire pregnancy. In one study (Mckinney et al., 2003), a participant stated, “What’s difficult is the knowledge that in one sense or another you’re deciding who will live or die and playing God. How does one go about choosing who will live or who will die with your own children?”
Multi-fetal pregnancy reduction is a painful irony forcing parents to emotionally reconcile the relief and sense of achievement which accompany the likelihood of having a healthy pregnancy with the grief and sense of loss which accompany fetal reduction. Moral, ethical, and societal issues that are tied to beliefs about elective abortion may create a deeper ethical dilemma and lead to further isolation. Those who are opposed to abortion may find the procedure unacceptable while those who accept abortion must struggle with the dilemma of “saving some while sacrificing others.” Moreover, professionals working in reproductive medicine, whose careers are devoted to helping couples achieve pregnancy, may be uncomfortable with the subject and may withdraw emotionally from the couple further leaving them alone to cope with the decision (Greenfeld & Walther, 1993; Hobbins, 1988).
In a very short period of time, couples making this difficult decision must learn all they can about the procedure, connect with others who have had the procedure, learn about the risks to the mother and the remaining fetuses, and come to grips with losing one or more of their unborn children (Maifeld et al., 2003). In some cases, it may be helpful for couples to seek counsel from clergy or a rabbi to help them arrive at the decision that is right for them. Mental health professionals can also help patients base their decision on individual, ethical, moral, and personal beliefs as well as medical facts. If the woman has a partner, mental health professionals can help to ensure that both people are comfortable with the decision. Ultimately, mental health professionals can help patients through the difficult process of mourning fetal loss while bonding to the surviving fetus or fetuses (Greenfeld & Walther, 1993)
The stress of multi-fetal pregnancy reduction may initially lead to depressive symptoms, anxiety, distress, emotional conflicts, fear, sadness, feelings of grief, and guilt. For many, feelings of sadness, guilt, and grief persisted and even increased a year and a half after reduction especially for women who were younger and desired larger families, were religious, or frequently viewed their fetuses via ultrasonography. (Bergh et al., 1999; Garel et al., 1997; Schreiner-Engel et al., 1995) However, despite the concern for psychiatric morbidity, there seem to be few long-term problems for women who resolve their ambivalence and have a successful pregnancy outcome. When the pregnancy outcome had been successful, it seemed that the mother-child relationship was not hindered. The medical reasons given by the physicians to justify the need for intervention, the burden of parenting, and the achievement of parental goals appear to facilitate grief resolution (Bergh et al., 1999; Garel et al, 1997; Kanhai et al., 1994; Shreiner-Engel et al., 1995)
Research has shown that the intensity of grieving following multi-fetal pregnancy reduction is more closely related to the psychological attachment than the length of gestation. Each partner’s experience of the grief is unique based on the psychological fantasies, hopes, and wishes that each person had for the unborn child as well as for his/her own future. Planned terminations are often grieved and mourned in the same manner as spontaneous losses, although the social stigma associated with abortion may increase isolation and guilt about the chosen loss of a longed-for child. The loss of a pregnancy, whether it is spontaneous or planned, can be treated by others as a nonevent that may be glossed over or minimized. There are few socially acceptable avenues for the couple such as funerals, rituals, or cultural traditions that could otherwise help the couple acknowledge loss and facilitate mourning. If the couple is unable to acknowledge or discuss the loss, a deep sense of shame and personal failure may become intensified (Greenfeld & Walther, 1993).
Each woman’s response to multi-fetal pregnancy reduction will be affected by her personality, life situation, relationship with her partner, other interpersonal relationships, religious views, and characteristic manner of coping with ethical interventions. Each person must take into consideration the ethical, psychological and medical factors when deciding whether or not to reduce. The majority of couples that underwent multi-fetal pregnancy reduction stated that they would make the same decision again and emphasized that avoidance of high order pregnancies should be of primary importance (Bergh et al, 1999; Kanhai et al., 1994; Maifeld et al., 2003; Mc Kinney et al., 1996; Schreiner-Engel et al., 1995).
All couples should be adequately counseled about the risk of multiple pregnancy as well as the medical and psychological aspects of multi-fetal pregnancy reduction before using assisted reproductive technology so that patients have a say in their treatment. According to the American College of Obstetricians and Gynecologists (ACOG), “Patients struggle with the ethical and emotional issues of embryo reduction. Counseling for treatment of infertility should include the risks of multiple gestation, and the ethical issues surrounding embryo reduction should be discussed with patients before the initiation of any treatment that could increase the risk of multi-embryo pregnancy and should continue throughout the patient's care.” (ACOG Committee on Ethics: Committee opinion, 1999). If patients would not consider multi-fetal pregnancy reduction, they should advise the physician before the procedure and discuss the number of embryos to transfer. Counseling can help couples anticipate their emotional responses to the stress of multiple gestation or multi-fetal pregnancy reduction, support them throughout the process of making a decision, and assist with coping with multiples or positive grieving after the procedure. (Greenfeld & Walther, 1993). “Part of the resolution involves accepting responsibility for the decision, owning the loss, and finding a way to forgive oneself” (Kluger-Bell, 1998).
About the Author
Dr. Elizabeth Grill is a clinical psychologist at the Center for Reproductive Medicine and Infertility and Assistant Professor of Psychology at the New York Presbyterian Hospital-Weill Medical College of Cornell University.
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