Memorandum submitted by Tamba (H&SC 20)
Health and Social Care Bill 2007
About the Twins and Multiple Births Association (Tamba)
1. Tamba exists to enable the families of twins, triplets and more to meet the challenges of their unique experience at every stage of their children's development. We have over 6,000 family and 160 club members across the UK.
Health in Pregnancy Grant
2. Tamba welcomes the proposal in the Health and Social Care Bill 2007 to pay a pregnancy grant to expectant mothers although amendments are required if it is to give multiple birth families the best possible start in life.
3. Compared to singleton pregnancies, multiple birth pregnancies have additional nutritional requirements and consequently there are additional costs to achieving healthy weight gain. Although the Government acknowledged these additional costs in other legislation, they have failed to recognize them in this Bill[i]. To ensure this is addressed, we propose that the grant be paid per expectant child rather than per pregnancy as this will help to ensure multiple birth babies have the greatest chance of survival. This amendment will ensure the Bill more closely resembles the eligibility criteria of the Sure Start Maternity Grant and the Healthy Start scheme which are also paid per expectant child rather than per pregnancy.
4. In multiple birth pregnancies, it is important for weight gain to be achieved as early as possible and consideration should be given to paying the grant at an earlier stage. Furthermore, improving access to information from health professionals, and increasing awareness of the added importance of good nutrition in multiple birth pregnancies among professionals also needs to be addressed. Although these pregnancies are high risk, the interim results of a recent survey of multiple birth mothers by Tamba found that only 9% were given advice on nutrition in multiple birth pregnancies.[ii] Of the 103 mothers whose babies required 'special care', less than 5% were given this advice.
5. Nevertheless, the requirement on expectant mothers to receive, "advice on matters relating to maternal health from a health professional"[iii] in order to become eligible for this grant provides an excellent opportunity to ensure mothers and health professionals are better informed of the importance of good nutrition during pregnancy. We would welcome further clarification from the Government on how they intend to use this opportunity to improve awareness of the added importance of nutrition in multiple birth pregnancies.
Multiple Birth Pregnancies
6. In the UK, about one in every 67 pregnancies results in a multiple birth. This equates to just over 10,000 births a year (10,533 in 2005). It is widely acknowledged that multiple births are relatively high risk pregnancies and this is usually due to multiples being born prematurely or under weight.[iv] The average length of singleton pregnancies is 40 weeks and the average birth weight is 3.5kg. This compares to twin pregnancies which average 37 weeks and triplets which average 34 weeks and their average birth weights are 2.5kg and 1.8kg respectively.[v] As a result, twins are also four times more likely to die during pregnancy when compared to singletons, seven times more likely to die shortly after pregnancy, ten times more likely to be admitted to a neonatal special care unit and have six times the risk of cerebral palsy. The best chance of survival for a premature baby is a healthy birth weight so unborn multiple babies need to be well and fully nourished pretty much from the moment of conception.[vi]
Nutrition & Weight Gain in Multiple Birth Pregnancies
7. A singleton pregnancy requires weight gain of around 0.25kg per week, for an eventual total of about 13kg, while mothers of twins need to gain more, usually at least 18kg, acquired at the rate of at least 0.5kg a week - and because of the increased risk of prematurity she needs to gain more of that weight in the first trimester.[vii] For the grant to bring about maximum benefit to expectant multiple birth mothers; it needs to be paid earlier than is currently proposed. This was confirmed by Professor Langley-Evans, Chair in Human Nutrition in the School of Biosciences at the University of Nottingham who raised the concern that to be effective the grant needs to be spent on improving the quality of pregnant mothers' diets and added that, "paying the money in the final trimester is too late - the optimal time for any intervention would be in early pregnancy."[viii]
8. According to the interim results of our ongoing survey of multiple birth mothers, it appears that many expectant mothers of multiple babies are unaware of the need to amend their diet.
9. The American Dietetic Association suggested that for twin pregnancy an extra 500 kcal should be added to the dietary reference values for non-pregnant women, as soon as the multiple pregnancy is detected. According to Professor Simon Langley-Evans, "It is generally accepted that a multiple pregnancy increases energy requirements, but the level of requirement has not been defined. Rosello-Soberon and colleagues suggested that the extra energy requirement for the whole of a twin pregnancy was 35000 kcal, which works out at around 150kcal/day on top of the requirement for singleton pregnancy. The key element is achieving a healthy maternal weight gain."[ix]
Financial Pressures on Multiple Birth Families
10. According to our own membership surveys balancing household finances is one of the biggest problems faced by multiple birth families. The greatest period of financial strain occurs between the ages of 0-12 months.[x] Apart from the additional dietary costs of achieving a healthy pregnancy, there is considerable cost in preparing for more than one child at a time. According to the American Society for Reproductive Medicine, "The total cost of raising multiples is likely higher than the cost of raising the same number of singletons." [xi] Often families do not already have children and therefore cannot benefit from reusing existing resources. Although the Sure Start Maternity Grant and the Healthy Start scheme recognize the additional costs of raising a multiple birth family, Child Benefit and Child Tax Credit do not.[xii] As a result, multiple birth families receive an estimated £50 million less per annum from the Government towards the cost of living than other families and we are concerned that without amendment the Health and Social Care Bill 2007 will exacerbate this inequality.[xiii]
[i] Lord McKenzie of Luton's reply to Lord Jones of Cheltenham (HL Parliamentary Question 10 Dec 2007.  c WA7).
[ii] Tamba multiple birth families' survey, January 2008. Respondents were asked, "Were you given specific advice on your nutrition for a multiple pregnancy? 8.9% Yes, 91.1% No" (NB. Sample size 213 on 3 Jan 2008).
[iii] Health & Social Care Bill 2007, 140A, 3 (a)
[iv] HFEA Press release "HFEA calls for national strategy to reduce the biggest risk of fertility treatment - Multiple births" 4 December 2007.
[v] ONS, 2005
[vi] Everything You Need to Know to Have a Healthy Twin Pregnancy, Gila Leiter M.D, Dell 2000, page 86
[vii] Everything You Need to Know to Have a Healthy Twin Pregnancy, Gila Leiter M.D, Dell 2000, page 84
[viii] Email message between Professor Simon Langley-Evans, Chair in Human Nutrition in the School of Biosciences at the University of Nottingham and Keith Reed, CEO of Tamba, on 3 December 2007.
[ix] Email message between Professor Simon Langley-Evans, Chair in Human Nutrition in the School of Biosciences at the University of Nottingham and Keith Reed, CEO of Tamba, on 3 December 2007.
[x] Tamba Members survey 2004
[xi] American Society for Reproductive Medicine, Challenges of Parenting Multiples (Patients' Fact Sheet), Released January 2003, Available online: www.asrm.org/Patients/FactSheets/fact.html.
[xii] The Child Tax Credit is made up of three separate elements; the family element of £545, an amount payable per child in the family dependent on joint household income, and an additional baby element of £545 payable the year a child is born. The baby element, however, is only payable once, no matter how many children under 1 are in a family. This effectively discriminates against a family with twins compared with a family which has two children born, say, eighteen months apart: the family with twins would miss out on £545 of income. The problem is more acute with triplets or higher multiples. We have campaigned to increase child benefit to ensure that younger children get the same rate as the oldest child. At the moment the oldest child in the family receives £18.10 a week and the second and subsequent children in the family are awarded the lower rate of £12.10 - even if that second child is born on the same day and only younger by a matter of minutes.
[xiii] The cost of extending the Child Tax Credit so that parents receive a higher family element to reflect each child in a multiple birth would be approximately £5 million per year (HC Deb 13 June 2003 c 1089w). The annual extra cost in 2007-08 of paying the eldest child rate of child benefit in respect of multiple birth children is estimated to be approximately £50 million (HC Parliamentary Question  13 Dec 2007 c 810w).