Multiple gestations and assisted reproductive technologies: qualitative study of the discourse of health professionals in Spain

International Journal of Environmental Research and Public Health Article Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain Estefanía Jurado-García1,*, Alicia Botello-Hermosa 2, Francisco Javier Fernández-Carrasco 3,4 , Juan Gómez-Salgado 5,6 , Nazaret Navas-Rojano 7and Rosa Casado-Mejía2   Citation: Jurado-García, E.; Botello- Hermosa, A.; Fernández-Carrasco, F.J.; Gómez-Salgado, J.; Navas-Rojano, N.; Casado-Mejía, R. Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain. Int. J. Environ. Res. Public Health 2021,18, 6031. https://doi.org/10.3390/ijerph 18116031 Academic Editor: Domingo Palacios-Ceña Received: 28 April 2021 Accepted: 31 May 2021 Published: 3 June 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Department of Nursing, Escuela Universitaria de Osuna, University of Seville, 41640 Sevilla, Spain 2Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Sevilla, Spain; [email protected] (A.B.-H.); [email protected] (R.C.-M.) 3Department of Gynaecology and Obstetrics, Punta de Europa Hospital, 11207 Cádiz, Spain; [email protected] 4Department of Nursing and Physiotherapy, Faculty of Nursing, University of Cadiz, 11009 Cádiz, Spain 5Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain; [email protected] 6Safety and Health Postgraduate Programme, Espíritu Santo University, Guayaquil 092301, Ecuador 7EIS Methods, Empresa de Base Tecnológica (Spin Off), University of Huelva, 21007 Huelva, Spain; nazaretnar[email protected] *Correspondence: [email protected]g; Tel.: +34-955820289 Abstract: Multiple gestations have become an increasing phenomenon that has impacted public health globally, largely due to the application of assisted reproductive technologies. The objective of this work was to find out the discourse that the health professionals involved in its follow-up have in our context. For this, a qualitative methodology was chosen, with semi-structured interviews recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for this purpose, with the following analysis categories: the current trend of multiple gestations, impact, and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of the professionals interviewed. Professionals stated that the current socioeconomic and legal context hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the importance of the psychic impact of such gestations on the couple, on the mother in particular, as well as the economic effect on families, health, and society in general. They expressed the need to create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Work on specific models is needed to adequately size the impact of multiple gestations, as well as to generate social health policies that lead to co-responsible reconciliation measures that favour women having one pregnancy at a time. Keywords: multiple pregnancy; assisted reproductive technologies (ART); embryo transfer; advanced maternal age; health system; maternal psychosocial consequences; parenting; perinatal outcomes; maternal and perinatal morbidity 1. Introduction In the last fifty years, the incidence of multiple gestations has increased, acquiring epidemic dimensions, mainly due to delayed procreation and assisted reproductive technologies (ART). They have gone from representing 2% of births to 30–35% after the use of ART [1,2]. In this regard, it should be noted that much effort has been made to identify a correct algorithm that considers women’s age and ovarian reserve markers as a tool to optimise the initial dose of recombinant follicle stimulating hormone (rFSH) in intrauterine insemination Int. J. Environ. Res. Public Health 2021,18, 6031. https://doi.org/10.3390/ijerph18116031 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 6031 2 of 15 cycles. However, according to the current available evidence, applying this algorithm with respect to women with polycystic ovary syndrome, especially those with elevated anti- Mullerian hormone, does not seem appropriate [ 3 ]. Likewise, the current trend is to perform assisted reproduction treatments associated with ovarian stimulation, but in the case of obese women, these require significantly higher amounts of gonadotropins to achieve the success rates of in vitro fertilisation, similar to those of women with normal weight [4]. Multiple gestations deserve special attention for their disproportionate contribution to maternal and perinatal morbidity, which has a special impact on public health [ 5 ]. They imply increased risks of maternal adverse outcomes such as hypertensive pregnancy states, gestational diabetes, bleeding, and postpartum depression (40% more likely), among others. They also involve foetal and neonatal risks such as higher rates of prematurity (50% of births occur before 37 weeks) or perinatal mortality and longer-term neurological developmental disorders (the risk of cerebral palsy is four times higher than in a single gestation) [ 6 , 7 ]. In addition, there are complications typical of twin pregnancy, i.e., growth discordance, intra-uterus foetal death of one of the twins, and twin-to-twin transfusion syndrome [8]. In gestations based on ART, the risk of adverse maternal and neonatal outcomes is further accentuated not only by the higher incidence of multiple pregnancy, the most common undesirable side effect, but also by the manipulation involved in these processes [ 9 ]. This has led to the introduction of elective policies for the transfer of individual embryos and declarations of consensus at the international level [10]. The impact of multiple gestations is not only on maternal (physical and emotional) [ 11 ] and neonatal health, but also on the health system itself (greater clinical and economic burden), families, and society in general [ 12 ]. In Europe, this impact differs among countries, and the number of foetuses in multiple gestation is one of the indicators of the European Perinatal Health Report (Euro-Peristat) programme to measure perinatal health in Europe [2]. This study was raised with the aim of understanding the experience and perception that the involved specialists have through their discourse, hoping to contribute to improve the integral attention to multiple gestations. 2. Materials and Methods 2.1. Study Design This was a qualitative study within the hermeneutic phenomenological perspective, with the aim of knowing and understanding the discourses of Andalusian health professionals involved in the monitoring of multiple gestations. 2.2. Participants The sampling was intentional, starting from two key informant professionals who facilitated the selection of other participants, resulting in a snowball sampling technique. In total, eight professionals directly involved in the monitoring of multiple gestations in the city of Seville participated: 4 gynaecologists working in Assisted Reproductive Units (responsible for 30% of multiple gestations), and 4 primary care (PC) midwives, for their linkage to women throughout the pregnancy and postpartum process. The eight planned interviews were carried out until the saturation level was reached. The targeting criteria were sex and professional category, which originated four profiles, resulting in two interviews per profile. In addition, service time, age, and scope of work were included as attributes that would make it easier to obtain greater discursive power (Table 1). Int. J. Environ. Res. Public Health 2021,18, 6031 3 of 15 Table 1. Profiles of interviewees. Professionals Time of Service Sex Occupation Age (years) Place of Work P 1 15 years Female Midwife 58 PC P 2 30 years Male Midwife 55 PC P 3 20 years Female Midwife 62 PC P 4 30 years Female Midwife 57 PC P 5 12 years Male Gynaecologist 62 Public ART Unit P 6 7 years Female Gynaecologist 47 Public ART Unit P 7 3 years Female Gynaecologist 32 Private ART Unit P 8 24 years Male Gynaecologist 53 Private ART Unit ART, assisted reproductive technologies; PC, primary care. 2.3. Data Collection The fieldwork was carried out in the capital of the province of Seville, between January and February 2018. Semi-structured interviews were conducted. An ad hoc script (Supplementary Materials S1 and S2) was used from the main study dimensions: •Current trend of multiple gestations (embryo transfer policies). •Impact and consequences on the family, society, and the health system. •Monitoring of multiple gestations. •Demands on health administration (emerging category). It was the same script in the two groups, but some different questions were introduced to suit the idiosyncrasy of the assistance given by each group. The affected dimensions were Current Trend of Multiple Gestations with the question: “How do you address the issue of selective reduction?” in the script of gynaecologists and Follow-up with the question: “What strengths and weaknesses do you think the follow-up that is performed for pregnant women from primary care presents?” in that of midwives. Two scripts designed for the purpose (see Supplementary Materials S1 and S2) were used, adapted to each professional category and based on the main dimensions of the study: current trend of multiple gestations (its relationship with ART and embryo transfer policies), monitoring of multiple gestations, and their impact, while also incorporating another emerging category of relevance and interest (demands to the health administration). The interviews were recorded, lasting between 50 and 70 min. The exact date and place were set by the participants, with special consideration of the place, being free of interruptions, ensuring privacy and allowing them to be relaxed. Before starting each interview, the interviewer described the purpose of the study, explained the basic rules, and offered confidentiality guarantees. To minimise the variability of the interview process, all of them were performed by the same researcher who took field notes from each of them with the aim of detecting and recording nonverbal language. The researcher applied summary and paraphrase techniques to cross-validate the collected information from the interviewees and minimise the possibility of data distortion. The transcripts were carried out by an expert in the field from outside the research team. 2.4. Data Analysis Content analysis was used as an analysis technique to look closer at the experiences and knowledge of professionals, and to try to grasp the subjective meaning of their discourse regarding the categories of analysis raised [ 13 ]. This was carried out in terms of the main categories raised (current trend of multiple gestations, monitoring, and their impact) and incorporating another emerging category of relevance and interest (demands to the health administration). As an indicator of the validity of the results, a triple triangulation was performed that involved performing data triangulation, methodological (intra-method) triangulation, and triangulation of the research team. Atlas.ti textual analysis software (Windows v8.0, Microsoft, Redmond, WA, USA) was used as an analysis tool. All transcripts of interviews were encoded, grouped by nodes or topics (categories), and text fragments were assigned to previously established categories. Int. J. Environ. Res. Public Health 2021,18, 6031 4 of 15 Analysis of the interviews showed a series of arguments linked to the different categories of analyses created: •Opinion on multiple gestations. •Attribution of multiple gestations. •Approach to embryo transfer policies. • Circumstances, motivations, or needs to undergo an ART. Impact of ART on the couple, at the work and social level. •Motivations for the delay of maternity •Impact of multiple gestation. •Follow-up of pregnant women from primary care. •Emotional monitoring for women and couples undergoing ART. •Negative situation in emotional follow-up. •Follow-up in the postpartum. •Maternal mental health during follow-up. •Treatment of health administration of multiple gestations. •Role of the professionals of the administration in the treatment. •Suggestions. This qualitative analysis has been carried out through a rooting criterion, hierarchically categorising the generated codes. In this way, the codes with the highest number of appointments have been prioritised. For its part, the marked cut-off point is located at the lower limit of the second quartile of the distribution, using the codes found in the first two quartiles of the appointment distribution for the analysis. 2.5. Ethical Considerations This study adhered to the principles articulated in the Declaration of Helsinki, updated in 2013 in Brazil. To ensure anonymity, personal identifiable data were replaced by numbers. All the participants signed an informed consent. Authorisation was obtained from the Research Ethics Committee of the University Hospital Virgen Macarena in Seville, Spain, with code #09876, on 18 July 2014. The data collected in the study will be treated with absolute confidentiality in accordance with the provisions of Spanish laws, specifically Organic Law 3/2018, of December 5th, on the Protection of Personal Data and Guarantee of Digital Rights, and Law 41/2002, of November 14th, basic regulation of the autonomy of the patient and rights and obligations in matters of information and clinical documentation. 3. Results Data organisation made according to the categories of analysis facilitated the exposure of the results presented through the most relevant verbatims. Similarly, each category of analysis shows, through figures, the resulting cognitive maps from having raised issues to the participants to analyse these categories, complementing the information provided in the results. 3.1. Current Trend of Multiple Gestations (Embryo Transfer Policies) There is a coincidence in the increase in multiple gestations, mostly due to the use of ART. Although the current trend is to try and decrease them, it does not seem so easily applicable due to hindering social and legal connotations. It is considered that this may be due to variables such as the socioeconomic context of couples where multiple gestation is an advantage over only one (infertility treatments are very expensive and allowing more than one is highly unlikely), the employment situation of women (there is no real reconciliation that will protect them and shield their reproductive desires), and due to legal protection so as not to implement single transfer policies (Table 2) . Int. J. Environ. Res. Public Health 2021,18, 6031 5 of 15 Table 2. Current trend of multiple gestations (embryo transfer policies). Current Trend for Multiple Gestations (Embryo Transfer Policies) “Of course. The big increase has come since assisted reproductive . . . ” (p2). “Transferring three embryos is a bad practice, by all standards, even twin pregnancies are in question. But of course, as by law, it’s not illegal . . . That is, there are people who do it and are protected by law, and even there are some . . . a unique embryo transfer policy is being made in many . . . ” (p6). “It’s an individual ethical-personal issue, so I think the first thing is primary prevention, not transferring more than two embryos. In fact, the increasing trend is to transfer one” (p7). “The law in Spain . . . only three was authorised and this did a lot to correct multiple pregnancies and, currently, the goal is to reduce even the gestation of two” (p8). “Here is a very clear economic approach, everything achieved by that perverse incentive, which is that if I have two children at once, all the better, I have my family and once for in a year or two, I have already solved the problem and I return to my work and personal life” (p8). “But you understand that, for many women that age, they cannot stop working three times to have three children, with the maternal leaves this implies and everything it entails. Unfortunately, there is still a lot of machismo and micro-machismo, so many women in their jobs will not tolerate two pregnancies or three” (p6). “I also believe that if motherhood were better cared for with regard to maternity leave . . . But if there is no reconciliation, you reach 42 years old and you want to have everything arranged, for the nursery and all these things, you have no choice but to leave at 40–42 years. But if you have more facilities such as governments to help you, more reconciliation so that the father can access a good paternal leave . . . because perhaps you raise it younger because, well, the government helps me in this period, and my husband is also there” (p7). Figures 1and 2show the different codes that make up the opinion section on the number of multiple gestations in recent years and the relationships between them. In Figure 1, in the face of the possible situation of cycle reduction or multiple gestations, the importance of information meetings on reduction risks and multiple gestations is evident. Despite being much-desired pregnancies, both the mother and babies are exposed to risks that future parents should be aware of. As for ART, reference is made to the need for a specific unit of psychology, as traumatic situations occur during the procedure that require psychological support. The main views of participants regarding the number of multiple gestations in recent years are illustrated in a cognitive map below. With regard to Figure 2, it must be highlighted that this includes a possible disadvantage, since, for assisted reproductive treatments, there is an important waiting list due to its high demand, thus slowing down the gestation process. With regard to the attribution of multiple gestations, the discourses of the participants can be summarised as follows: Figure 1. Opinion on the number of multiple gestations in recent years. Source: Own elaboration. Int. J. Environ. Res. Public Health 2021,18, 6031 6 of 15 Figure 2. Multiple Gestation Attribution (ART). Source: Own elaboration; ART: Assisted Reproductive Technologies. Figure 3shows a “cognitive map” based on the circumstances, motivations, and needs for assisted reproductive treatment. For this issue, the interviewees allude to a series of clear ideas to be discussed below: Figure 3. Circumstances, motivations or needs to undergo an ART. Source: Own elaboration; ART: Assisted Reproductive Technologies. The fundamental reason for couples to decide to undergo ART is because they have been trying to get pregnant for over a year with no success. However, there is also a circumstance in which there is no real infertility and the recommended waiting times have not been respected. The people interviewed allude to several reasons in this regard: assisted Int. J. Environ. Res. Public Health 2021,18, 6031 7 of 15 reproductive treatments have been standardised, they can be relatively easily financed, and above all, the constant programming of peoples’ lives, where motherhood is not left to chance and is highly planned according to women’s work wishes, in particular. This leads them to unfailingly delay pregnancy because there is no family reconciliation that actually safeguards their reproductive and career desires together. 3.2. Impact of Multiple Gestation on Women, Partners, Society, and the Health System The collective of gynaecologists agrees on the serious emotional wear and tear of couples facing multiple gestations. Everyone, in the context of parenting, refers to the important psychic impact on mothers, because of the lack of time to internalise these emotional changes since all their energy and time are focused on this double upbringing. Stress is greatest in cases of prematurity, especially when there are differentiated needs between the two twins, and they feel they are providing unequal care. There is a sense of critical emptiness and frustration in mothers once husbands regain their former life, while they remain totally immersed in parenting. Fathers are often very involved in parenting and household chores, either because they have no choice when the mother is fully immersed in parenting or because they have had a hard time achieving that pregnancy and now they are enjoying a one-month parental leave that puts them at the forefront of the reality of parenting (although it is said that some fathers use these leaves for their personal time, often older men who are not involved). There is agreement regarding the family support network being critical for coping positively. The economic impact for couples is great, not only due to the investment made in reproductive treatments through private health, but also for what double upbringing implies. For the health system, there are economic demands as well, with the increasing maternal and perinatal morbidity associated with these gestations (Table 3). Table 3. Impact of multiple gestations on women, couples, society, and the health system. Impact of Multiple Gestations on Women, Couples, Society, and the Health System “To the woman, very emotionally, the whole issue of morbidity, postpartum depressions, any kind of psychiatric morbidity, everything is going to shoot up” (p1). “All kinds of couple crises can be seen in matters of reproduction and infertility, because it is a kind of vital crisis that can sometimes be very disturbing” (p8). “It’s not only physiological stress, it is also a psychic and economic stress. So, this strains the couple” (p8). “When they are premature . . . you have to spend 3 or 4 weeks at hospital . . . and that marks women a lot, huh, that . . . they end up shattered, because they are coming and going all the time . . . ” (p2). “They get exhausted and see that all the emotional resources are allocated to the children, they are the only ones who have the focus on them and they somehow recover “a life of man” (p8). “Of course, prematurity has this problem of these children, their early neonatal but also long-term intellectual performance” (p8). “In fact, there is a psychologist at the clinic who recently emailed us that all women undergoing treatment should do therapy” (p7). “But, come on, males put up with it worse. And it is true that we live in a very sexist society, very sexist, it is still very sexist and . . . and women . . . I increasingly admire women for their ability to hold on” (p6). Through Figure 4, an analysis is made on the impact of multiple gestations at the various levels contemplated in the research according to the testimonies collected through these interviews. This figure corroborates the above results, highlighting the relevance, as the study states, of the need for couples to have co-responsibility. It also clearly shows the idea that older males are less involved than younger males, and eventually mentions the important role of family in supporting multiple gestation. Int. J. Environ. Res. Public Health 2021,18, 6031 8 of 15 Figure 4. Impact of multiple gestation. Source: Own elaboration. 3.3. Follow-Up All interviewees express the need for a specifically emotional, multidisciplinary and protocolised follow-up. Although there is no differentiated protocol, midwives agree that their differentiated follow-up is much greater and that the primary-specialised inter-level relationship for proper gestation monitoring is satisfactory. Infertility specialists refer to the fact that infertility is poorly sized, starting in primary care by family physicians, which delays and negatively impacts the follow-up of these couples, and emphasises the role of primary care midwives to be relevant and necessary for the successful monitoring of these gestations (Table 4). Table 4. Follow-up of multiple gestations. Follow-Up of Multiple Gestations “You have to further control: these women . . . you have to follow up much more. So, it’s pregnancies that you have to control them more . . . ” (p1). “When I see that it’s a twin pregnancy, I like to do the home visit, see the conditions these kids are going to be in” (p2). “Protocols tell the same old thing, but then you have to have your internal protocol that we all have that is given by experience” (p3). “I do. Normally, you’re required a post-night visit by the administration. If I, to a normal woman with one child, I don’t have enough because I give her an appointment her and then I do it again to remove the stitches, then I give these women five appointments because with the tits they need more care” (p4). “And me, for instance, in twin pregnancies, streptococcus [¿?] I perform it a bit earlier, on my own account. This is not protocolised, but I know this woman needs it (p2)”. “Then I start preparing these women separately, a little earlier; in the remaining pregnant women, I start at week 27; in those, I start at week 24 or 23, so . . . just in case” (p2). “They need the midwife more than the . . . that norm . . . patients with a single pregnancy” (p6). 3.4. Demands to the Health Administration Midwives demand recognition of the differentiated care that they provide. Many postnight visits are not counted, so the problem of multiple gestations cannot really be sized and Int. J. Environ. Res. Public Health 2021,18, 6031 9 of 15 their impact on the system remains unnoticed. Public health gynaecologists understand that reproductive medicine is a second-rate specialty and that no investment is made in the resources needed for its proper development, which translates, for example, into unmanageable waiting lists for many women who require assisted reproductive treatment (Table 5). Table 5. Demands to the health administration. Demands to the Health Administration “More midwives must be demanded considering the women” (p3). “I think with the twins there should be more visits because, besides, many are C-sections, and coming with the two children is more complicated. What’s more, the visits I make are for twins or if there has been some complication in the postpartum” (p4). “To contemplate that, if it is a twin pregnancy, the ten days should not count because since the children are admitted, that woman does not come until twenty days later, and now you see her at 20 days and the visit does not count. So, this is very hard, but in public health it’s a disaster” (p4). “Yes, yes, they consider it to be . . . a slightly absurd specialty, . . . should be more recognised and that goes through the economic issue, above all” (p6). “And in the end, they choose to go to a private clinic to speed things up, because in the public system, waiting times are often unsustainable, then more investment to speed up times” (p7). “Like public medicine, I believe that . . . that does not live up to the circumstances, most of the . . . couples have to resort to the private ones that take less time, and couples are taken care of more psychologically” (p5). Figure 5shows the perception that women with multiple gestations have of the followup made from primary care. It also reflects the differentiated care that midwives refer to in their follow-up, demanding to be recognised in order to make this work visible. Figure 5. Follow-up to pregnant women from primary care. Source: Own elaboration; ART: Assisted Reproductive Technologies. 3.5. Suggestions Among the suggestions provided by professionals to address the problem of multiple gestations are: raising awareness among women and their partners about the risks of multiple gestations for both them and their offspring; educating about the importance of the age of the first pregnancy and how that age will have a definite impact on women’s fertility; and generating multidisciplinary protocols that specifically deal with the emotional sphere and strengthen the economic support for these families (Table 6).