Double Trouble

Massachusetts has the highest rate of twin births in the nation. In and around Boston, it feels more like an epidemic. Which has this proud and very, very tired mother of twins wondering: is this a good thing—for anyone?


Photo by Carol Kaplan

Cathy Gruetzke-Blais knew her identical twins were a flight risk. At two years old, neither would sit in a shopping cart for more than a few minutes before trying to climb over the side and make a break for it. So on a trip to her local Target one spring day, the desperate Framingham mother strapped a tiny blue harness around each girl’s shoulders, then clipped a leash to their backs, convinced the contraption would thwart any escape attempts.

Wrong: As they approached the checkout aisle, Isabelle wriggled free of her mother’s grasp and sprinted away, leash and all. Knowing that she’d never catch her while also wrangling Allison and the shopping cart, Gruetzke-Blais tied Allison to the cart and gave chase. But when she returned with her fugitive in tow, Allison was gone.

Gruetzke-Blais soon discovered that her daughter had wandered down the aisle, dragging the cart behind her, and fallen down. She was lying on the floor—still attached to the leash—surrounded by gawking shoppers. “Here was this baby tied to a shopping cart like a sled dog,” recalls Gruetzke-Blais, who quickly scooped up her child, apologized, and paid for her purchases. The kids were fine, but when she finally had them safely in the car, she burst into tears, realizing (not for the first time) that with twins, nothing comes easy.

It’s an awareness no doubt shared by the 30,000 mothers around Massachusetts who have given birth to twins in the past decade. These are the women who have helped make ours the state with the highest rate of twins in the nation: more than 40 per 1,000 births—a whopping 34 percent above the U.S. average. The trend seems particularly concentrated in and around Boston, which will come as no surprise to those of you who have been run off the sidewalk by one of those SUV-size double-wide strollers now so ubiquitous on Newbury Street; or tried to enroll your child in a preschool class only to find many of the slots already claimed by twins; or heard tales about overcrowded neonatal units at area hospitals, where underweight twin newborns are tended to for weeks, sometimes months.

Indeed, twins have become so commonplace that one can easily overlook how hard it is to raise two babies at the same time. But for me—well, suffice it to say this reality has been impossible to ignore. In February 2006, I gave birth to fraternal twin boys. And two years into my own towheaded family invasion, I have to wonder if this deluge of doubles is a good thing for their parents—or for our area as a whole. I adore my boys and wouldn’t trade them for the world. But I would no more wish multiples on a couple than I would bubonic plague.


So what accounts for Boston’s status as the new Twin City? Is it that our residents are especially fertile? Not exactly. The truth is, we’re just especially well insured. In 1987, Massachusetts became one of the first states to require carriers to cover the cost of infertility treatments for otherwise healthy couples. While a dozen states now offer some kind of fertility coverage, the laws here remain among the most comprehensive in the nation.

One of the best-known treatments for infertility is in vitro fertilization (IVF), in which a woman’s eggs are extracted, fertilized with sperm, and then transferred back to her uterus. The more embryos transferred, the more likely a woman will become pregnant—and pregnant with multiples: The odds of conceiving twins through IVF are 29 percent, compared with just 2 percent for naturally occurring twins. It stands to reason if insurance companies cover this costly procedure, which can run $12,000 or more per cycle, more women will take advantage of it. And they do. Among all states, Massachusetts has the highest rate of use of assisted reproductive technology.

Another significant factor: Massachusetts has the highest average age of first-time mothers (28), and since 1996, the majority of babies here have been born to women age 30 and older. Such women are more likely to release multiple eggs during ovulation, resulting in twins. I fall into this category, although apparently there are twins way back in my family history (information that would have been helpful to know before my first ultrasound, Grandma!). I was 33 years old when Emmett and Phineas were born at 35 weeks, just two weeks shy of what doctors consider full term.

Their early arrival was not unusual. More than half of twins are born prematurely and at a low birth weight, which puts them at risk for everything from breathing difficulties to underdeveloped organs. Consequently, many local neonatal intensive care units (NICUs) are overburdened. When our twins were born at Beth Israel, the NICU had room for only one of the boys—talk about Sophie’s choice. Since Emmett was deemed the healthier of the two, Finn was whisked upstairs to the NICU; three days later, they swapped places when Emmett physically shut down, refusing to eat because he was overwhelmed by all the activity.

For years, doctors believed preemies caught up developmentally. But a 2000 Yale study coauthored by Dr. Bradley Peterson and published in the Journal of the American Medical Association upended that orthodoxy, reporting that premature babies’ brains are more vulnerable to developmental disturbances. More recently, the March issue of JAMA featured a study from Norway showing that preemies have an increased risk of death throughout childhood and lower rates of reproduction in adulthood. Such sobering statistics help explain why nearly half the twin moms I know were confined to bed rest during their pregnancy—some for as long as three months—to prevent them from going into early labor. (Women pregnant with multiples also face much greater odds of gestational diabetes, high blood pressure, and preeclampsia.)

Jamie Janoff of Wayland was confined to her couch beginning at 21 weeks. “It started off kind of nice…I did enjoy being pampered and served,” she says. “But it wore off after about a week.” Before he left for work each day, her husband would place a cooler of sandwiches and fruit beside the couch and a 2-gallon water dispenser next to her on the shelf, so she could just lean over and pull the spout.

The strain that today’s twin boom is putting on hospital—and parental—resources was not entirely unanticipated. Dr. Janet Hall is an endocrinologist specializing in reproduction at Mass General and the mother of 19-year-old twins. For years now, she has been warning about the consequences of allowing reproductive technology to advance unimpeded. Back in 1994, in a study she coauthored at Brigham and Women’s Hospital, she found that the total charge for a singleton delivery was $9,845, but for twins, it jumped to $18,974 per baby. Hall’s team concluded that if all multiple pregnancies resulting from assisted reproduction techniques had been singletons instead, the hospital would have saved over $3 million per year.

In their report, Hall and her coauthors recommended that fertility doctors consider reducing the likelihood of a multiple pregnancy by transferring only one embryo. They found, however, that their fellow reproduction specialists didn’t necessarily want to hear what they had to say. What they wanted were impressive success rates. And their clients…well, they just wanted babies to love, no matter how many. It took 10 years for the American College of Obstetricians and Gynecologists to release guidelines advocating that doctors restrict the number of embryos transferred.

Dr. Thomas Toth, director of the Vincent In Vitro Fertilization Unit at Mass General’s Fertility Center, echoes Hall’s concerns. He’s part of a growing minority of doctors promoting single-embryo transfers, for which his unit boasts a 60 percent pregnancy rate. Toth believes that for women who are good candidates for single-embryo transfer (in particular, those who are younger), the success rate is almost as high as with multiple-embryo transfer. After talking with Toth, I hang up the phone with a warm and fuzzy feeling. He doesn’t have twins himself, but he’s one of those rare OB/GYNs—the kind who think beyond a successful delivery to those disorienting few months when parents bring their babies home.


“I went from being someone who was up by 5 a.m., who had run assorted errands by 9 a.m., to someone who could not get out of bed,” says a Framingham mom of the birth of her twins at 31 weeks. One baby was ready to come home three weeks before the other, but refused to sleep at night longer than an hour at a time. “I was so exhausted that I didn’t have the energy to pack up baby number one and make the 40-minute trip to the hospital to visit baby number two. It got to the point that the hospital social worker suggested that I consider putting baby number two up for adoption because she thought I was not interested in him.” Her experience echoes another study I read, this one coauthored by Hall in 2005. It found, not surprisingly, that “the psychological burden of raising more than one infant at the same developmental stage put mothers at risk of exhaustion and depression.” Often, these feelings set in immediately after delivery.

Belmont mother Joanne Lynch and her husband, Brendan, spent 35 long days going back and forth to the Transitional Care Unit at Mass General to visit their twins, born at 34 weeks in October 2007. “It was heart-wrenching to have to go home every night; it was heart-wrenching not being able to breastfeed them without limits on how long they could be away from their incubator or bilirubin lights,” Lynch says. “Everything was turning out differently than I had imagined, and I felt cheated out of so many experiences.”

I know how she felt. My twins were a decent weight at 4 pounds, 15 ounces, each, and needed to stay in the NICU only a few days. But it soon became apparent that Emmett had severe reflux. That meant I had to hold him upright for 30 minutes after feeding—and even then, he was likely to throw up the entire bottle. Then we’d have to start from scratch with another. I couldn’t go anywhere because Emmett inevitably threw up all over the car. He didn’t get “tummy time” because I was afraid to lay him on his stomach (everything usually spilled out when I did), so he was slower to sit up and crawl than his brother.

In the weeks after the boys’ birth, I sank into a postpartum funk. In my former life, I’d been the managing editor of this magazine, helping oversee a staff of 15, but I soon realized that because of my two needy preemies I wouldn’t be able to go back to work. I found myself thinking—and it’s something I’ve never admitted to my husband or family—that if one of the babies didn’t make it, it wouldn’t be so bad: My life could go back to the way it was.

It pains me to write that now, of course, but I felt so isolated. When we found out we were having twins, we had to sell our adorable third-floor walkup in Jamaica Plain; there was no way I was going to be able to lug two babies and a stroller up and down the stairs. We bought a house in the suburbs, where we knew no one. We hadn’t spent a single night there when I went in for a routine exam and ended up delivering the boys by emergency C-section. Ultimately, when the boys were three weeks old, I went on Ativan, an antianxiety medication, which, sadly—although probably for the better—meant an end to breastfeeding.

Hall’s 2005 study found that such feelings of desperation can be even more acute in those who used assisted reproductive technology. One mother of 11-month-old twins sums up her emotions this way: “I am torn because I very much regret the decision to transfer two embryos, and yet I don’t want my children to ever think they were unplanned or unwanted.” There’s also a sense among IVF moms that they can’t complain because they “asked for it,” says Terri Chebot, a mother of college-age twins who leads a weekly support group for moms with multiples through Jewish Family & Children’s Service in Newton. “It’s amazing the stuff that people will say to you,” says Chebot, “like: ‘You have no right to complain…you spent so much money on this…you worked so hard for it.’ It’s assaulting.”

And none of this takes into account the drain on the family finances: double everything, including, most significantly, childcare if a mother has to go back to work. Luckily, our out-of-pocket medical expenses were just a few thousand. Not everyone is so fortunate. As one uninsured mom whose twins were born at 31 weeks relays to me, “Both twins have asthma, and one has life-threatening food allergies to eggs and nuts. One twin had eight bouts of pneumonia in 15 months…. I had zero debt when my children were born. Six years later, our debt is now in the six-figure range due to medical and childcare expenses.”

On top of all this are the daily essentials. Our tally for diapers (at least 20 a day) and formula (16 bottles a day) for the first year was about $5,000. Add to that the clothing, furniture, and gear (to wit: double stroller, double jogger, double snap-n-go stroller, two highchairs, two playpens, two infant car seats, two toddler car seats, two cribs, two swings, two bouncy seats, two baby Bjorns…), and we probably spent $15,000. Not that any of this stuff made it easier to get out the door for even the simplest errand.

Needless to say, the financial and emotional stress of the babies can extend to stress on a marriage. In the two years that I’ve been part of a vast local twin-mom e-mail network, I’ve seen more than a few “I need a good divorce lawyer” messages passed around.


As twins move out of their first year, with luck, parents can stop worrying about whether or not their babies will survive, and concentrate on new challenges. Namely, the rigors of corralling two toddlers who hit the age of exploration and mobility at exactly the same time. It’s a peculiar aspect of twins that they often forge a joint identity while inevitably wanting to move in two different directions at once. At two and a half years old, my boys have very distinct personalities: Emmett is a little troublemaker, Finn a more serious engineer-in-training type who wants to know how everything works. The contrast is a recipe for regular meltdowns. Consider this episode from a recent ill-fated trip to the Stride Rite at the Natick Collection: Halfway through trying on shoes, Emmett bolted out of the store at a full sprint. I threw Finn at the saleslady, then charged out the door. Good Samaritans who saw my panicked face pointed me in the direction of the Build-A-Bear Workshop next door. I found Emmett knocking over boxes in the back room.

Finn would never attempt such a stunt, yet the boys have a remarkable solidarity. For the first two years of their lives, they both thought their name was Emmett. So when one of them did something bad, we’d say, “Who knocked this over?” and each would say, “Emmy did it.” Even today, if one gets a time-out and is banished to a chair in the corner, the other will climb up and join his brother.

The sense of shared identity can manifest itself in good ways and bad. Recently, Jamie Janoff’s two-year-old son, Alex, had finally fallen asleep for the night after a good 45 minutes of lullabies. His twin sister, Natasha, sang softly to herself a foot away in her own crib. But as Janoff gently closed the door and tiptoed away, she heard Natasha whisper, “Alex!” And then, more insistently, “Alex! Aaaalex!” Janoff opened the door to find Natasha shouting into Alex’s crib. Startled awake, the little boy began to cry hysterically. Natasha grinned, satisfied that her companion was now awake with her, and lay back down.

There seems to be some law of physics that the mischief made by two children of the same age is exponentially greater tha
n that made by one. When I found out I was pregnant with my sons, I went to visit a friend who had two-year-old twin boys. I peeked into her sons’ room and was surprised to see two cribs…and nothing else. No changing table, no wall hangings, no bookshelf—not even curtains. Noticing my confusion, she explained: “I would go in after naptime and find they had gotten out of their cribs and, together, thrown every single piece of clothing out of the drawer, knocked the books off the shelf, torn down the shades, and pulled every diaper wipe out of the box.” She looked down at my growing belly and smiled.

Lest you be tempted to think you’re not affected by all this (all you gloating parents of singletons!), think again. Massachusetts’ astronomical twin birth rate means our state is now home to untold thousands of kids who were born prematurely—kids who could still be suffering from developmental delays that have the potential to overburden our medical and special education systems, and quite possibly require either cuts to other programs or tax increases to help pay for their care. As long as moms here keep having twins at current levels, the resource pinch will only get worse.

Then there’s the not-insignificant matter of how the twin boom will affect your doted-upon singleton’s chances of getting into a good preschool. If Framingham’s Over the Rainbow Nursery School is any indication, it might be tough. The school—owned by yet another twin mom—has nine sets of twins among just 107 kids. And though they come without the competition for spots, public school classrooms are no less crowded. In Newton, for example, there are 122 sets of twins in the elementary schools alone.

At the risk of sounding self-interested, I have to confess that I find numbers like those reassuring. They remind me how much company I have. For me, living in a city with such a huge twin population has been a godsend. As tough as it’s been the past two years, I can only imagine that having twins anywhere else would have been almost too much to bear. Here, there’s a more than decent chance your daycare director, obstetrician, pediatrician—even your mail carrier!—will have twins of their own and won’t raise an eyebrow as you let one baby wail inconsolably, because they understand that you’re wrestling his brother into the stroller.

But perhaps most important (at least for me that first year) is the community of educated, professional women struggling with issues of work-life balance that mothers of non-twins can’t even begin to understand. My own network has ballooned to 500 mothers, all fellow members of the Western Suburban Chapter of the Massachusetts Mothers of Twins Association, one of the largest such groups in the country. Meetings are held monthly—though I quickly learned that most of our interaction is over e-mail, since, for the vast majority of us, getting out the door on time for anything, really, is a daydream. My in-box fills up with 20 to 30 e-mails a day with queries like “If one of my twins wakes up early, do I have to wake the other to keep them on the same schedule?” I realize questions about sleep schedules could be answered by a mom in California. But where else would I get the volume of responses from people with firsthand knowledge when I ask: How do you get a double stroller down the steps at Fenway?