One set of twins is hard enough . . . but two sets?

FIONA O’NEILL HAD no idea she was expecting twins until she went into premature labour on her second pregnancy and the doctor remarked that either it was a big baby or there were two.

“I thought he was joking; I thought he was trying to lighten the mood,” says Fiona (37). It was a bitter-sweet occasion for Fiona and her husband Liam at the Midland Regional Hospital in Portlaoise that day in March 2006 because, being 13 weeks premature, there was grave concern over the twins’ health. She only got a glimpse of tiny Conor and James before they were whisked off to intensive care in the National Maternity Hospital in Holles Street, Dublin.

Having had an emergency Caesarean section, it was five days before Fiona could go up and see them and three months before they were home in Graiguecullen, on the Carlow-Laois border. With their eldest child Aaron only aged 18 months, it was “tough going” making frequent trips to Dublin to see the babies and Fiona swore, after that, there would be no more.

But time passed and they thought they would “try for the girl”. When Fiona had a scan at 11 weeks she remembers looking at the monitor and exclaiming to her husband straight away, “There’s two!”

About 1,200 women have multiple births in Ireland each year (see panel), but having two sets of twins is rare. However, once a woman has had one set of non-identical twins, the chances of her having twins again on a subsequent pregnancy increase, as it suggests she may be likely to release more than one egg per cycle.

Along with the rising numbers of births in the Republic in recent years, there has been an increase in the percentage of multiple births. The latest available Perinatal Statistics Report, for 2009, shows that the twinning rate was 15.9 per 1,000 maternities, up nearly 25 per cent on the rate in 2000.

All the complications of pregnancy, for both the mother and the baby are increased when a woman is carrying twins, says Prof Fionnuala McAuliffe of the Irish Institute of Obstetricians and Gynaecologists. Pre-term delivery is the biggest risk with twins and, in a recent, large all-Ireland study of twins, 17 per cent delivered before 34 weeks.

There are essentially three reasons for the increased twinning rate, explains Prof Sean Daly of the Coombe Women and Infants University Hospital in Dublin, where there is a dedicated multiple births clinic. About 150 sets of twins and six sets of triplets were delivered at the hospital last year.

First, women are having babies at an older age and older mothers are more likely to have twins.

Second, more African women are giving birth here and they, due to genetic factors, are more likely to have twins. The rate of identical twins is the same the world over but rates of non-identical twins vary – the highest being in Nigeria and the lowest in Japan.

The third reason is assisted reproduction, although standard practice internationally is moving towards single embryo transfer, says Prof McAuliffe. “When that starts to happen more in Ireland, you will see the multiple births going down and I think that would be welcomed.”

It is very important to diagnose what type of twins a woman is having, says Prof Daly, and the best time to do that is early in pregnancy. In the Coombe, every woman gets a scan when she books in, generally around 12 weeks, but that would be the exception in the Irish maternity system, where one anomaly scan at around 20 weeks is the norm. Although, if there is a medical indication for an earlier scan, such as “large for dates” there is no problem getting one, says McAuliffe.

About one quarter of twins are identical. “We manage the identical ones very differently from the way we manage the non-identical ones,” says Prof Daly.

Identical twins are scanned every two weeks from 16 weeks because of the risk of twin-to-twin transfusion, which requires the life-saving intervention of laser ablation. This was first performed in Ireland by Prof Fergal Malone in 2006 at the Rotunda Hospital and is also done now at the National Maternity Hospital.

The O’Neills’ second set of non-identical twins went to 38 weeks and four days, before delivery by Caesarean section last April, with Katie weighing in at just over 7lb and Sean 5lb 6oz.

After the health worries with Conor and James – “every time they sneezed you were wondering if they had a chest infection” – Katie and Sean have been “way easier”. And at least the older three are in school, which means the house is relatively peaceful in the mornings.

Liam is out of work at the moment but the positive side of that is that he can do things with the older boys while Fiona tends to the babies.

“Some days it gets stressful here all right,” says Fiona, but she sounds remarkably laid-back as she explains they have a good routine going with everybody knowing what is expected of them and when.

The most difficult thing, with five children, is getting a babysitter. She and Liam have not been out together for at least a year.

Another problem is shopping. If everybody is packed into their seven-seater car and the double-buggy is in the boot, there is no room for the groceries.Holidays are out of the question for the time being, apart from visiting her family home in Waterford. She dreams of the whole family heading off one day.

As we chat on the phone, there is not a sound out of the two small ones as they digest their breakfast. Katie is awake and comforting herself with her thumb while her brother is asleep.

The older twins, who are now very healthy, boisterous boys, will be in at 1.30 pm, Aaron at 2.30 pm and then it will be “full on” until all five are in their beds and asleep by 9pm.

Homework is a challenge and Fiona tries to stagger it, starting off the boys one at a time.

While Aaron can do his anywhere, she tries to separate Conor and James, otherwise they start fighting over the coloured pencils.

It is difficult to have one-on-one time with any of the children. One night in the kitchen she sat the three boys down and asked them to tell her something about their day, one at a time.

“They all said afterwards, ‘can we have a talk again tomorrow night?’.” So she has made it a regular ritual.

“That is the one thing about having twins,” she adds, “you’re torn between everyone.”

AT HOME WITH TWO SETS OF TWINS: ‘THE WORST BIT WAS WHEN THEY DIDN’T SLEEP AND I STILL HAD TO FUNCTION FOR THE OLDER TWO’

IN THE FIRST month of having two sets of twins at home, the Cassidy household got through 450 nappies.

“Our impact on the environment was dreadful,” says French-born Marianne Cassidy (34), but, with four children under three, “I was not going to wash nappies, I’m sorry!”

She tried to have the first set of twins, Felix and Eloise, toilet-trained before their siblings were born in January this year but, as they were only two and a half, “they were not co-operating at all”.

However, they got the hang of it two months after the arrival of Judith and Celeste.

Having developed the life-threatening Hellp syndrome during her first twin pregnancy, Marianne was due to meet a doctor in the National Maternity Hospital in June 2010 to discuss the health implications if she were to become pregnant again. By the time the appointment came around, she already was.

She and her husband, Micheál (36), were “not averse to having a third child at some point” but it was not a planned pregnancy. And the fact that it turned out to be twins – again – was even more of a shock.

Marianne was told at the time that, having had one set of non-identical twins, the chances of having non-identical twins again was one in 50, compared with a one in 80 chance the first time.

However, she was also told the chances for any woman of child-bearing age with no children going on to have two sets of twins (taking into account such variables as deciding not to have any more children after one set) is one in 50,000.

Although she was “very tired” during her second pregnancy, she did not suffer Hellp syndrome this time. Meanwhile, one of her husband’s big concerns was, she says, “What car will we drive the babies back from hospital in?”

It is not easy to find a car which can accommodate four children’s car seats and with a boot big enough to take a double pram for the babies. “After many internet searches, a pimped-up panel van purchased on eBay in the UK is what we settled for.”

With any set of twins the first nine weeks are really tough, Marianne says, because they are often born early, they need a lot of feeding and tend not to sleep at night.

“When there are two and they don’t sleep at the same time, it means you get absolutely no sleep at all”.

So second time around, not only did she have this to cope with, but also the older two, in the throes of toilet-training. She was on a three-hour cycle expressing breast milk for the newborns.

It was getting “a bit much”, she explains, and they decided to put the older ones into creche two days a week – “that was all we could afford”.

Although her mother came over from France for a few weeks and her in-laws from Belfast help out as best they can, the couple do not have extended family within easy reach.

After nine weeks, it began to get a little bit easier – relatively speaking. “The worst bit was when they didn’t sleep and I still had to function for the older two. Once you are getting five or six hours, it is manageable.”

She even managed to start getting out of their house in Dundrum with the four of them. “I made a plan that I was going out at 11am regardless of what was happening – around the corner to the park or to the shops.”

It could be slow progress; not only does Marianne have a double buggy with two toddlers on the buggy board behind to push, but she is guaranteed to be stopped by curious passers-by.

Looking back over the past nine months, Marianne reckons the toilet-training and laundry have been the biggest challenges, after those early weeks of sleepless nights.

People sometimes remark that she dresses very smartly for a mother of two sets of twins. “If only they knew that how smart I dress is directly correlated with how far behind I am with the laundry. I know that I have hit crisis point when the only outfits I have left to wear are my pyjamas or those dresses I bought for one of my cousins wedding – a black tie affair!”

After she was hospitalised with a post-natal haemorrhage, the HSE provided her with a home help for a couple of hours a week. “That is brilliant – one afternoon less of doing laundry!”

She found it easier once Judith and Celeste started on solids, as meals lasted them a bit longer – they eat, mashed up, what the rest of the family has.

In September, the older two started in the French school in Clonskeagh, where they are in the equivalent of pre-school from 8.15am to 3pm. That gives her a chance to focus on the younger twins.

They are very good babies, she says, and have slept through the night since four months. Whereas she recalls Felix was still feeding at night, at nine months, when she went back to work. She will be returning to work again next January.

It is hard going having four children born within two and a half years of each other, Marianne adds, but even if they cannot get as much individual attention as other children, she hopes they will all benefit in some way from their family’s unusual make-up.

“At the moment, we have to do everything for them, but in a few years they will be more independent and have each other.”

Twins by numbers

1,186 sets of twins, 13 sets of triplets and one set of quadruplets were born in the Republic in 2009

Twinning rate is 15.9 per 1,000 maternities

The perinatal mortality is 12 per 1,000 live births and stillbirths for multiple births compared with 6.8 per 1,000 live births and stillbirths for singleton births

Almost two-thirds of mothers (63.8 per cent) have multiple births delivered by Caesarean section, compared with one-quarter (25.6 per cent) of those having singleton births

Average birth weight for multiples is 2,465 g (5lb 6.95 oz) as opposed to 3,499 g (7lb 11.42 oz) for singletons

45.4 per cent of multiples classed as low birth weight as opposed to 3.7 per cent of singletons

Source: Perinatal Statistics Report 2009