1 Leuven Research Centre for Parenting and Parenting Problems, 2 Centre for Methodology and 3 Centre for Family Pedagogy, Catholic University of Leuven, Department of Pedagogical Sciences, 3000 Leuven, Belgium
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Abstract |
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Key words: infertility/parenting stress/reproductive technology/twins
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Introduction |
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In recent years, several studies have been published comparing the parentchild relationship in families with singleton children conceived by reproductive technology and families with naturally conceived singletons (Raoul-Duval et al., 1993; Weaver et al., 1993
; Colpin et al., 1995
; Golombok et al., 1995
, 1996
; Van Balen, 1996
; McMahon et al., 1997
; Gibson et al., 1998
). The overall conclusion is that the quality of the parentchild relationship, the children's psychosocial development and the parents' psychosocial well-being is quite similar in families with children conceived naturally without any medical intervention or following hormonal treatment, families with children conceived by IVF and families with children conceived by AI, whether or not with donor semen. In some studies, IVF and AI parents even reported a more positive relationship with their child compared with naturally conceiving parents (Golombok et al., 1995
, 1996
; Van Balen, 1996
).
Families with twins conceived with the assistance of reproductive technology are in a particular position. On the one hand, the desire for a multiple birth among couples in infertility treatment may positively influence the later parent-twin relationship. On the other hand, it is possible that these couples, at this stage in the reproduction process and longing for a child, do not realize the consequences of having twins. It has been demonstrated that unrealistic prenatal expectations are a risk factor for the adjustment to parenthood (Belsky et al., 1986). Moreover, some of the medical and psychosocial risks associated with assisted reproduction might especially apply to multiple births. There is an increased risk of prematurity, low birth weight and perinatal mortality. Moreover, a multiple birth creates a special parenting situation, facing the parents with particular practical and emotional demands (Robin and Casati, 1994
). These issues may be particularly stressful for (future) parents, already having passed through a long process of infertility and reproductive treatment. In one study (Gibson et al., 1997
), IVF mothers of 1 year old twins were found to express more stress in parenting and more annoyance concerning their child's behaviour than IVF mothers of singletons.
Only a few small-scale studies have compared the parentchild relationship, the children's development and the parents' psychosocial well-being between families with twins conceived in different ways. Recently, a preliminary study of parenting quality, parental stress and child behaviour in 12 families with 48 year old twins conceived by IVF in comparison with 14 families with naturally conceived twins was published (Cook et al., 1998). No differences were found between the two groups of families in parenting quality or child behaviour. However, parents with IVF twins reported greater parenting stress compared with parents with naturally conceived twins. The latter finding may be due to `increased parental expectations amongst IVF parents and increased demands of twin parenting. An alternative explanation is that they are a reflection of greater previous parental experience among naturally conceiving parents: the majority of IVF twins in the study were first-born, whereas most naturally conceived twins had older siblings.' (p. 3245). One study (Gibson et al., 1999
) compared 17 first-time mothers of 1 year old IVF twins with 10 first-time mothers of naturally conceived twins. IVF mothers reported more maternal stress and were perceived by others as more protective towards their twin children than non-IVF twin mothers. These findings did not translate into observed differences in the motherchild relationship. Families with pre-school twins conceived in different ways have been studied (Munro et al., 1990
, 1992
). The groups were matched for the age of the twins and the order in the group of siblings. IVF parents' scores on the General Health Questionnaire were similar to those of parents who conceived without any medical assistance and both groups showed significantly less well-being than the group of parents having conceived following hormonal treatment. The authors point to an apparent paradox with respect to this finding: `Patients who present at infertility clinics are informed that the use of artificial ovulants is known to increase the incidence of multiple births and also that their chances of achieving a pregnancy in that way are fairly high. Presumably, this preparedness for the increased chance of twins helps the prospective parents to become socialized into the potential role of `parents of twins' This is in contrast to the IVF couples, who have to invest a great deal of themselves and financial resources in procedures that may not lead to a desired outcome with the knowledge that the success of IVF techniques, referred to by IVF teams as the `take-home-baby rate' is still very low (Munro et al., 1990, p. 335). Concerning social relationships, IVF parents reported deficient interactions, compared with non-IVF parents. This deficiency was both in size and in affective quality of their available relationships. The authors state as a potential explanation that the parents may be reacting to the high expectations being placed on them by society in their role as `IVF parents', so they become over-involved in parenting and family and friends are largely excluded, as are leisure pursuits. Alternatively, the knowledge of IVF origins of the twinship may cause members of the social network to wish not to burden IVF parents with demands in addition to those already perceived as resulting from the IVF process (Munro et al., 1992
).
The present study was set up in 1997. In particular, we investigated whether parenting stress and the parents' psychosocial well-being differed between three groups of families, two of whom had a history of infertility: (i) families with twins conceived by IVF or AI, (ii) families with naturally conceived children following hormonal treatment and (iii) families with naturally conceived twins without any history of infertility.
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Materials and methods |
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All mothers of the 103 families agreed to participate. One of these mothers was single. Of 102 male partners, three refused to participate.
Multiple pregnancies that were naturally conceived comprised slightly more than half of the sample (54 families, 52%), 24% (25 families) were conceived following hormonal treatment and 24% (24 families) following AI (with spermatozoa of the social father) or IVF. The distribution of the method of conception was not significantly different from the national statistics (Bekaert et al., 1996).
The mean (±SD) maternal age was not significantly different between the three study groups (natural: 31.4 ± 3.2, hormonal: 31.5 ± 3.7, IVF/AI: 32.3 ± 2.9). The mean paternal age also did not differ (natural: 32.7 ± 6.4, hormonal: 33.6 ± 3.8, IVF/AI: 33.3 ± 3.6).
The parents' educational background and the distribution of prematurity (Table I) were not significantly different between the three study groups either. However, there was a significant difference between the groups for the presence of older children in the family (Fisher's exact, P = 0.006). Further analysis revealed that families with twins conceived by IVF or AI had older children significantly less often than families with naturally conceived twins (Fisher's exact test, P = 0.0028) and families with twins conceived following hormonal treatment (Fisher's exact test, P = 0.038). We found no significant difference concerning the presence of older children between families with naturally conceived twins and families with twins following hormonal treatment. The presence (or not) of older children in the family may influence the parenting of twins. Depression in the last trimester of pregnancy has been found to be more frequent among women who already had a child, compared with women for whom it was the first pregnancy (Hay and O'Brien, 1983
). Singleton studies have shown that the transition to parenthood is different among first-time parents compared with parents already having one or more children (Condon and Esuvaranathan, 1990
; Fish and Stifter, 1993
). Therefore, this variable was included and controlled for in the statistical analysis (see below).
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The parents' psychosocial well-being was evaluated using the General Health Questionnaire (GHQ-30) (Goldberg and Williams, 1988; Dutch version by Koeter and Ormel, 1991
). The GHQ was developed to detect people with emotional problems, such as anxiety and depression. The instrument is composed of questions referring to unusual and unpleasant emotions and the inability to continue normal functioning. The higher the score, the lower the well-being. The original GHQ consisted of 60 items. Several shorter versions have been developed. In our study, the 30-item version was used. Validity and reliability of the GHQ-30 have been demonstrated (Goldberg and Williams, 1988
; Koeter and Ormel, 1991
). In our study, Cronbach's
was 0.91 for the mothers and 0.94 for the fathers.
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Results |
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For the fathers, no significant interaction effects were found. For the mothers, significant interaction effects of the conception mode and the presence of older children were found for the PSI parent scales `sense of competence' (F2,97 = 4.58, P = 0.012) and `parent health' (F2,97 = 4.34, P = 0.015) and for the GHQ-30 (F2,97 =3.63, P = 0.030). Looking at the means in the combined categories (Table II), we found for the IVF/AI group and the `hormonal' group (but not for the group with naturally conceived twins) that first-time mothers showed significantly higher stress related to competence and health and lower psychosocial well-being compared with mothers who already had children.
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A significant main effect of the presence of older children in the family was found for the mothers' scores on PSI parent scales `competence' (F1,97 = 4.72, P = 0.032), `parent health' (F1,97 = 5.70, P = 0.019) and `relationship with spouse' (F1,99 = 4.21, P = 0.042): compared with mothers who already had children, first-time mothers showed significantly higher stress related to competence [for the first-time mothers, mean (adjusted) = 230, for the mothers with older children mean = 197], health (respectively mean = 322 and mean = 267) and the partner relationship (respectively mean = 272 and mean = 230). For the other PSI scales and the GHQ-30, no significant differences were found between first-time mothers and mothers who had older children. For the fathers, no significant effects of the presence of older children were found.
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Discussion |
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The finding (Munro et al., 1990) that parents of twins conceived following hormonal treatment showed significantly higher psychosocial well-being than parents of twins conceived naturally or by IVF and that IVF parents had deficient social relationships compared with the other two groups, were not confirmed in our study. Neither did we find greater parenting stress among parents with 1 year old IVF twins, compared with naturally conceived twins, unlike a study (Cook et al., 1998
) in families with older twins. These authors stated that their findings might be due to greater parental experience among naturally conceiving parents. Of interest in this context are the significant main effects we found of the presence of older children on the PSI parent scales `sense of competence', `relationship with spouse' and `health', and the interaction effects of the conception mode and the presence of older children in the family on feelings of competence and health and on psychosocial well-being among the mothers in our study. Since they are the only significant results in many tests, they should be interpreted with caution. Moreover, only self-reporting questionnaires were used. Further investigation, also including observational measures, about the significance of parity and conception mode for the parentchild relationship and the parents' psychosocial well-being is recommended.
The significant interaction effects support the findings by Gibson et al. (1999) of greater parental stress among first-time IVF mothers of twins, compared with first-time mothers of naturally conceived twins. Our results suggest that first-time motherhood of twins is a risk factor for parenting stress and psychosocial well-being. Moreover, first-time mothers with a history of infertility (whether they made use of hormonal treatment, IVF or AI), compared with first-time mothers without a history of infertility and mothers with a history of infertility who already had older children, are particularly at risk for parenting stress and lack of well-being. Their scores on the PSI dimension `health' and on the GHQ-30 were particularly high, compared with the normal values of the instruments. With the mean score for PSI health they belong to the 8th decile of the normal table for a non-clinical sample of mothers (de Brock et al., 1992). The means on the GHQ-30 were considerably higher than the conventional cut-off point of 4/5 (Goldberg and Williams, 1988
; Koeter and Ormel, 1991
), with scores above this point indicating lack of psychological well-being.
These findings might be (partly) explained by the infertility history. By facing infertility, the woman's well-being and self-esteem might be affected. Infertile women cannot become pregnant through simple sexual intercourse with a man. This may be perceived as a personal failure. Many infertile women do not feel like real women (Nijs, 1990). The transition to the `generativity stage' (the production of and care for the next generation; Erikson, 1963), one of the important stages in human development, cannot be achieved. Moreover, it has been suggested that, because of the long periods of waiting and investment in the child, the parents may develop unreasonably high expectations towards the child. The risk is that the parents will expect their long awaited child to compensate for all the suffering they have gone through. They may then be disappointed when forced to face reality (for review, see Colpin, 1994). When these women do eventually have a baby (in our study twins), it would not be surprising if they were to become increasingly strained with the attempt to be a good mother and feel less well compared with mothers not faced with infertility and mothers faced with infertility who already have one or more children and who probably are more realistic and feel more self-confident in the mother role. It has been suggested (Cook et al., 1998
) that parents of IVF twins might be in particular need of support. Our findings suggest it may be important to provide specific (pre- and postnatal) counselling and support to first-time mothers of twins, and in particular to those with a history of infertility.
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Acknowledgments |
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Notes |
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References |
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Bekaert, A., Martens, G. and Devlieger, H. (1996) Perinatale Activiteiten in Vlaanderen 1995. Studiecentrum voor Perinatale Epidemiologie, Brussels.
Bekaert, A., Martens, G. and Devlieger, H. (1998) Perinatale Activiteiten in Vlaanderen 1997. Studiecentrum voor Perinatale Epidemiologie, Brussels.
Belsky, J., Ward, M.J. and Rovine, M. (1986) Parental expectations, postnatal experience and the transition to parenthood. In Ashmore, R. and Brodzinsky, D. (eds), Thinking About the Family: Views of Parents and Children. Lawrence Erlbaum, Hillsdale-London, pp. 119145.
Colpin, H. (1994) Parents and children of reproductive technology: chances and risks for their well-being. Commun. Altern., 6, 4971.
Colpin, H., Demyttenaere, K. and Vandemeulebroecke, L. (1995) New reproductive technology and the family. The parentchild relationship following in vitro fertilization. J. Child Psychol. Psyc., 36, 14291441.
Colpin, H., Nys, K., Vandemeulebroecke, L. and De Munter, A. (1998) Prenatal attachment in future parents of twins. Early Dev. Parenting, 7, 223227.[ISI]
Condon, J.T., and Esuvaranathan, V. (1990) The influence of parity on the experience of pregnancy: A comparison of first- and second-time expectant couples. Br. J. Med. Psychol., 63, 369377.[ISI][Medline]
Cook, R., Bradley, S. and Golombok, S. (1998) A preliminary study of parental stress and child behaviour in families with twins conceived by in-vitro fertilization. Hum. Reprod., 13, 32443246.[Abstract]
Cronbach, L.J. (1970) Essentials of Psychological Testing. Harper & Row, New York.
De Brock, A.J.L.L., Vermulst, A.A., Gerris, J.R.M. and Abidin, R.R. (1992) [Nijmeegse Ouderlijke Stress Index. Handleiding.] Swets and Zeitlinger, Lisse.
Erikson, E. (1963) Childhood and Society. Norton, New York.
Fish, M., and Stifter, C.A. (1993) Mother parity as a main and moderating influence on early motherchild interaction. J. Appl. Dev. Psychol., 14, 557572.
Gibson, F.L., Ungerer, J.A., Leslie, G.I. et al. (1997) Twins and Singleton Children Conceived Through IVF: a Comparison of Maternal and Child Adjustment at 1 Year Post Partum. Paper presented at the XVI Annual Scientific Meeting (The Fertility Society of Australia), Adelaide (Australia), December 1997.
Gibson, F.L., Ungerer, J.A., Leslie, G.I. et al. (1998) Development, behavior and temperament: a prospective study of infants conceived through in-vitro fertilization. Hum. Reprod., 13, 17271732.[Abstract]
Gibson, F.L., Ungerer, J.A., Leslie, G.I. et al. (1999) Maternal Attitudes to Parenting and Observations of the MotherChild Relationship and Interaction with IVF Twins. Paper presented at the 11th World Congress on In Vitro Fertilization and Human Reproduction Genetics, Sydney (Australia), May 1999.
Gleicher, N., Campbell, D.P., Chan, C.L. et al. (1995) The desire for multiple births in couples with infertility problems contradicts present practice patterns. Hum. Reprod., 10, 10791084.[Abstract]
Goldberg, D.P. and Williams, P. (1988) A User's Guide to the General Health Questionnaire. Nfer Nelson, Windsor.
Golombok, S., Cook, R., Bish, A. and Murray, C. (1995) Families created by the new reproductive technologies: quality of parenting and social and emotional development of the children. Child. Dev., 66, 285298.[ISI][Medline]
Golombok, S., Brewaeys, A., Cook, R. et al. (1996) The European study of assisted reproduction families: family functioning and child development. Hum. Reprod., 11, 23242331.[Abstract]
Hay, DA, and O'Brien, P.J. (1983) The LaTrobe Twin Study. A genetic approach to the structure and development of cognition in twin children. Child. Dev., 54, 317330.
Koeter, M.W.J. and Ormel, J. (1991) General Health Questionnaire. Nederlandse bewerking. Swets and Zeitlinger, Lisse.
Leiblum, S.R., Kemmann, E. and Taska, L. (1990) Attitudes toward multiple births and pregnancy concerns in infertile and non-infertile women. J. Psychosom. Obstet. Gynecol., 11, 197210.[ISI]
McMahon, C.A., Ungerer, J.A., Tennant, C. and Saunders, D. (1997) Psychosocial adjustment and the quality of the motherchild relationship at four months postpartum after conception by in vitro fertilization. Fertil. Steril., 68, 492500.[ISI][Medline]
Moore, D.S. and McCabe, G.P. (1993) Introduction to the Practice of Statistics (2nd edition). Freeman and Company, New York-Oxford.
Munro, J.M., Ironside, W. and Smith, G.C. (1990) Psychiatric morbidity in parents of twins born after in vitro fertilization (IVF) techniques. J. ln Vitro Fert. Embryo Transfer, 7, 332336.
Munro, J.M., Ironside, W. and Smith, G.C. (1992) Successful parents of in vitro fertilization (IVF): The social repercussions. J. Assist. Reprod. Genet., 9, 170176.[ISI][Medline]
Nijs, P. (1990) Man en vrouw ... schiep hij hen (2 volumes). Peeters, Leuven.
Nys, K., Colpin, H., De Munter, A. and Vandemeulebroecke, L. (1998) Feelings and the need for information and counselling of expectant parents of twins. Twin Res., 1, 142149.[Medline]
Raoul-Duval, A., Bertrand-Servais, M. and Frydman, R. (1993) Comparative prospective study of the psychological development of children born by in vitro fertilization and their mothers. J. Psychosom. Obst. Gyn., 14, 117126.
Robin, M. and Casati, I. (1994) Are twins different from singletons during early childhood? Early Dev. Parenting, 3, 211221.[ISI]
Van Balen, F. (1996) Child-rearing following in vitro fertilization. J. Child Psychol. Psyc., 37, 687693.
Van Balen, F. (1998) Development of IVF children. Dev. Rev, 18, 3046.[ISI][Medline]
Weaver, S.M., Clifford, E., Gordon, A.G. et al. (1993) A follow-up study of `successful' IVF/GIFT couples: socialemotional well-being and adjustment to parenthood. J. Psychosom. Obstet. Gynecol., 14, 516.[ISI][Medline]
Submitted on May 24, 1999; accepted on August 27, 1999.