Introduction between 10 and 15 percent in


Currently, there is an ever increasing incidence of multiple births especially in the developed nations and this is mainly attributed to increase in assisted reproductive technologies. Such multiple pregnancies have well known risks on the infants as well as risks on the mother, more so related to premature births. Although there is a broad understanding of the risks that present with multiple births, there is paucity of knowledge on how multiple births are related to the well-being of the mother, particularly her mental wellbeing. There is need to examine the mental well-being of mothers with multiple birth since such parents are exposed to various risks which exacerbate the likelihood of developing postpartum depression (PPD).

Such risks include the stress of bearing and looking after multiple infants, the possibility of having high-risk pregnancy, social isolation, factors such as premature birth, cesarean delivery as well as risks related to assisted reproduction techniques. It is for these reasons that this paper examines the available knowledge on possible association between multiple pregnancies and postpartum depression as well as postpartum psychosis. In recognition of the paucity of information on the relationship between multiple pregnancies and postpartum depression, the paper reviews the likely relationship by understanding the two variables, multiple pregnancies and postpartum depression, in terms of their characteristics. Possible correlations are then suggested relating the adverse effects of multiple pregnancies and the possible links with various causes of postpartum depression. This paper therefore starts with defining postpartum depression, characteristic symptoms of the condition and the various possible causes which are then related with characteristics and circumstances surrounding multiple pregnancies.

Postpartum Depression

Postpartum depression is a depression condition that is experienced by women within a month to a period of three months postpartum. It is therefore evident that postpartum depression differs from other forms of depression generally due to the time when the depression occurs. Postpartum depression is usually misdiagnosed with other mental disorders such as peuperal psychosis as well as normal mental and behavioral changes that may occur after birth.

Differential diagnosis for PPD should therefore include baby blues, bipolar disorder as well as postnatal psychosis. The main characteristics of PPD include lowered self confidence, increased fatigue, irritability, sleep disturbance, panic, alcohol abuse and anxiety among others (Blicksten and Keith, p. 740). The likelihood of developing postpartum depression is higher in women who have had postpartum blues with the prevalence of postpartum depression standing at about 6 percent. The prevalence of PPD is reported to be between 10 and 15 percent in Western nations (Oppo et al, p.

239) with either major or minor depression within one year postpartum being between 6.5 and 12.9 percent. It is important to note that postpartum depression mainly occurs one to three months postpartum and an individual with a history of depression is at even a higher risk of developing postpartum depression.

Some other risk factors that elevate the probability of getting PPD include deprived social support, failure to breastfeed, and previous pregnancy loss among others. Postpartum depression is mainly characterized by symptoms such as reduced sexual drive, lack of good sleep, feelings of guilt, and poor mother-child bond (Feldman& Christensen, p. 115).

Differentiating postpartum depression from postpartum psychosis is an important thing while discussing the relationship between multiple pregnancies and PPD. Postpartum psychosis presents in form of serious depressed moods, hallucinations, disorganized thought system as well as psychotic thoughts and it usually starts close to delivery (O’hara, p. 1259). Postpartum psychosis is a psychiatric disorder which is associated with postpartum depression at its severe stages. It is common with women who have ever had other forms of mental illnesses and thus women who have had multiple births and had postpartum depression have a high likelihood of developing postpartum psychosis.

Risk factors for PPD

According to Oppo et al (p. 40), the most common risk factors for postpartum depression include presence of anxious thoughts during pregnancy, severe life stressors, and inadequate or absence of social support. The contribution of obstetric factors is significant but the effect size is small.

From the association of the above factors and PPD, it is possible to hypothesize that any eventuality that introduces or exacerbates any of the risk factors among mothers of multiple births would lead to PPD. The relationship between multiple pregnancies and postpartum depression can therefore be deduced from the risk factors since most women with multiple pregnancies become more vulnerable to the risk factors. Blicksten and Keith (p. 741) indicate that there is an increased incidence of psychiatric disorders among women who have had multiple births and that such disorders mainly occurr during postpartum period. Mothers of twins are particularly vulnerable to psychological disorders – postpartum depression and postpartum psychosis – during the first three months postpartum.

According to Cassels and Barclay (para 2), there is a noted increase in the risk of postpartum depression among mothers with multiple births. It is specifically identified that the risk of getting postpartum depression increased by 43 percent if a woman had more than one birth compared to women who had only one birth. Cassels and Barclay (para 1) further report that a study conducted using data from the ECLSBC (Early Childhood Longitudinal Study-Birth Control Cohort) for children born in 2001 indicated an adjusted ratio of 1.43 in development of severe postpartum depression among mother with multiple birth relative to mothers of singletons. On trying to identify the reason behind women with multiple births having a higher record of postpartum depression, it is identified that having multiple births is mainly considered as a highly stressful life event in most cases.

This is because parenting multiple births presents with unique demands which leave the mother stressed, exhausted and in most cases socially isolated thus predisposing her to postpartum depression/psychosis. Blackstein and Keith (p. 725) indicate that mothers of multiples go through a hard time during breastfeeding and not many of them are able to handle exclusive breastfeeding which is usually emphasized during the first six months of the infant’s life. In specific, these authors report that the process of breastfeeding multiple infants calls for most women to stay awake as breastfeeding two infants during their first three months takes at least 45 minutes and this is done after every 3 to 4 hours. This leaves the mother stressed and predisposes her to mental illness and particularly postpartum depression. Blickstein and Keith (p. 729) emphasize that breastfeeding multiples calls for the mother to meet specific nutritional needs to ensure that there is enough volume and nutritional requirements in the milk and this, coupled with lack of sleep, presents as a stressful situation.

Issues of time management and hardships in the mode (including positions) of breastfeeding multiples may be a tough experience, especially for inexperienced mothers, that may subject the woman into stress. It is this and other forms of stress that spill over to the development of postpartum depression. It should be noted that multiple pregnancies are characterized by delivery via caesarian section in most cases and this may have deleterious effects on the mother’s health, more so the pain and discomfort that may occur during breastfeeding. Premature births are also common in multiple births with Keirse, Hanssens and Devlieger (p. 523) indicating that rates of preterm births in multiple pregnancies range from 44.

2 percent to 68.4 percent in Europe. This high rate of preterm births in multiple pregnancies implies that the mother undergoes through a stressful moment which requires a lot of support for successful progression from this stage. Lack of social support and the whole experience of delivering preterm infants are enough stressors to subject the mother into the path of postpartum depression. As noted earlier, taking care of multiple births is a tasking and stressing situation that places a woman at the risk of developing postpartum depression. The mother is likely to start feeling guilty when she thinks her ability to take care of the multiples and any other child that they may be having. It often becomes hard for the mother to give attention to all the children and makes the woman worried and guilty thus paving way for PPD.

Another challenge that may make the mother of multiple pregnancies become more anxious and depressed is the high likelihood of requiring intensive care for multiple infants who are born prematurely. According to Spath (p 242), the likelihood of requiring intensive care among multiple premature twins is 16 times higher than in singletons. Moreover, the infants have an elevated risk of up to 10 times of developing celebral palsy. Chances of the multiples dying are also high (3 – 4 times higher than in singletons). Such circumstances predispose the mother to anxiety, which may further be increased by existence of financial constraints of dealing with the circumstances. Overall, the mother of multiple births becomes more prone to postpartum depression. The fact that premature babies have to be under neonatal care, thus away from the mother may create anxiety in the mother or even make her depressed and eventually welcome postpartum depression. The vulnerability of multiple pregnancy mothers to postpartum depression is elevated by the fact that most multiple pregnancies result from an already stressful procedure, in vitro fertilization.

The stress associated with assisted reproduction and even the circumstances that lead a woman to seek assisted reproduction are enough to cause stress which later presents as PPD. Postpartum depression is even likely to be more probable after a woman bears multiple infants compared to bearing single infants severally. This is because handling multiple infants is obviously more tasking than handling a single infant. The presence of postpartum depression has also been said to be about five times common among multiple infants mothers compared to mothers with singletons thus making one conclude that the likelihood of having PPD among mothers of multiples is higher than among mothers of singletons. The reporting that up to 76 percent of mothers of twins experience constant exhaustion relative to only 8 percent of mothers to singletons is a good indicator that multiple pregnancies are more prone to PPD (Haddon, para 2).

Assisted reproductive technologies play a great role in the incidence of multiple births as reported by Barkehall-Thomas, Woodward and Wallace (p. 222). In a study conducted by the authors in Australia on the outcomes of triplet births, it was found that up to 59 percent of the triplets were due to assisted reproductive technologies. The incidence of preterm births was found to be high with the median gestation period being 32.

5 weeks with a significant 43 percent of the infants being born prior to 32 weeks of gestation. Other than the high prevalence of preterm births in multiple pregnancies, several complications that have the capacity to cause depression in mothers were identified. For instance it was noted that cases of preterm labor as well as rapture of membrane before term were reported. Moreover, almost all the women (93%) gave birth through caesarean section with some suffering complications during the procedure. From this study, it is evident that multiple pregnancies are accompanied by a myriad of problems and circumstances that predispose the mother to the risk of developing postpartum depression. There is also a high prevalence of prenatal complications that accompany multiple pregnancies and these can have an effect on the development of postpartum depression.

Some of these complications include antepartum hemorrhage, cervical incompetence and pre-eclampsia (Barkehall-Thomas, Woodward & Wallace, p. 224). Elsewhere, it is reported that mothers of multiple pregnancy often experience hypertension as a main complication. It is important to note that hypertension is also related to stress and therefore it is possible that multiple pregnancies are related to postpartum depression by way of increased incidences of hypertension. The combination of these complications cannot be underestimated in the development of postpartum depression since they are events that leave the mother anxious or stressed (Rosello-Soberon, Fuentes-Chaparro & Casanueva, p. 297).


Postpartum depression is a well acknowledged mental condition among women and it occurs within one month to three months after delivery. On the other hand, multiple pregnancies have been on the rise more so with the advancement and penetration of assisted reproduction technologies.

A well understood phenomenon associated with multiple pregnancies is the occurrence of several complications among them being preterm birth. Despite this knowledge, the above review of literature identifies that there is paucity of information and research focusing on the relationship between postpartum depression and multiple pregnancy. It is however notable that the available information indicates that postpartum depression cases are higher among mothers of multiple infants compared to mothers of singletons. In addition, it is also evident from this review that there are several factors related to the observation that postpartum depression is more common among mothers of multiple pregnancies. The circumstances surrounding multiple pregnancies and multiple births are found to be sufficient enough to cause stress and anxiety among multiple pregnancy mothers.

As such, these stressful and anxious events give way to the development of postpartum depression. Among the main stressful conditions that have been identified in this research include problems associated with assisted reproduction (such as preterm births, caesarean section and other health conditions), the stress of taking care of the multiple infants more so in breastfeeding the baby, the trauma of caesarian section and possible complications as well as lack of social support. Despite a relationship being identified that postpartum depression is related to multiple pregnancies, the direction of causality as well as the explanations on how the two happen has not been thoroughly explained in literature.

It is therefore pertinent that more research is conducted on this topic to shed more light on this relationship and eliminate dependence on speculations. It is however notable that the identification that multiple pregnancies are related to more instances of postpartum depression can be useful in heightening assessment for PPD among this group of women. This would help in early diagnosis and treatment of PPD before these women are overwhelmed by the condition.

Works Cited

Barkehall-Thomas Andrea, Woodward, Louise and Wallace Euan M. Maternal and neonatal outcomes in 54 triplet pregnancies managed in an Australian tertiary centre. Australian and New Zealand Journal of Obstetrics and Gynaecology, 44; (2004): 222–227. Blickstein, Isaac and Keith Louis G.

Multiple pregnancy: epidemiology, gestation & perinatal outcome. Second edition. Boca Raton, FL: Taylor & Francis, 2006. Cassels Caroline and Barclay Laurie. Multiple birth increases postpartum depression risk.

2009. Mediscape Medical News. Retrieved 12 March 2011 from http://www. Feldman, Mitchell D. and Christensen John F. Behavioral medicine: a guide for clinical practice. Third edition. New York, NY: McGraw-Hill Professional, 2007.

Haddon, Lynda P. Postpartum depression and mothers of multiples. N.d. Multiple Births: Prenatal Education.

Retrieved 14 March 2011 from O’hara, Michael W. Postpartum depression: What we know. Journal of Clinical Psychology, 65.

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et al. Risk factors for postpartum depression: the role of the Postpartum Depression Predictors Inventory-Revised (PDPI-R). Arch Womens Mental Health 12; (2009):239–249 DOI 10.1007/s00737-009-0071-8 Rosello-Soberon, Maria E., Fuentes-Chaparro Laiza and Casanueva Eshter.

Twin pregnancies: Eating for three? Maternal nutrition update. Nutrition Reviews, 63. 9; (2005): 295–302. Spath, Dona Berarelli.

The problem of multiple pregnancies. Reproductive Biomedicine Online, 41.2; 2007:242-245.


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