"Nikoniko (Smile)"

(A child-care leaflet to support families of twins,triplets and over)

Asaka Public Health Center (Asaka Hokenjo at Saitama prefecture)

Preface

Congratulations on your pregnancy and childbirth of twins, triplets, quadruplets and over. Despite your joy, not a few people may feel anxious about delivery and following child-care due to lack of opportunity to receive advise from others in the same position.

Asaka Public Health Center started its "child-care support services" in 1996 (Heisei 8). Throughout service provision, we heard from many people that " We could have felt more secure if there was more information about twins since we became pregnant". Therefore, a child-care leaflet , "Nikoniko (Smile)", to support families of twins, triplets, quadruplets and over was published with cooperation from mothers who share the same experiences. Although the subject of this leaflet is shown as "twins", our hope and intention is that this leaflet will be found useful to the families of twins, triplets, quadruplets and over during pregnancy period and following child-care.

Table of Contents

Preface

Basic Knowledge

About Pregnancy

Support from the husband/partner and the family

Delivery

Child-rearing

Community Groups/Circles

Reference Information

Editorial Note

The child-care leaflet, "Nikoniko (Smile)", was first developed in 1999 and this revised edition was published in 2000. You can obtain both Japanese/English versions at the following internet address of Asaka Public Health Center. (http://www.d1.dion.ne.jp/~asakahkn/ )

Basic Knowledge

1 Probability of having twins

Twins were born at the ratio of one to 160 cases of delivery till 1951. It was a little higher in the western countries than in Japan. Especially in Nigeria (Africa) where the ratio is one to 17 cases. However, since 1991, it has been increasing in Japan. According to the survey in 1997, the ratio became one to 110 cases, which is caused by scientific progress of infertility treatment such as ovulation-inducing agents and in-vitro fertilization.

2 Cause of twin birth

There are two types of twins, "monozygotic twins" in which their faces are very similar and "dizygotic twins" whose faces have no greater similarity than their brothers/sisters. In monozygotic twins, an fecundated ovum (fertilized egg) is divided into two through an unknown cause.

In comparison, dizygotic twins are created when two eggs are ovulated, and fertilized with two different sperm. The multiple ovulation occurs due to mother's hormonal change, and it is conceivable that it is subject to the genetic inheritance to family line such as mother’s physical constitution.

3 Ratio of having "monozygotic twins" and "dizygotic twins"

In western countries, there are more dizygotic twins than monozygotic twins in natural breeding. In Asia, there are more monozygotic twins. In Japan, the proportion had been 2 (monozygotic) to 1 (dizygotic), due to multiple ovulation by infertility treatment, however, a recent trend shows a tendency to increase the number of dizygotic twins and over.

The general method to determine ovum type is by blood vessel of the placenta after the delivery. It is difficult to determine it by ultrasonic diagnosis during pregnancy. The two placentas of dizygotic twins may also look like one, so that it is inappropriate judgement method to count the number of placenta. On the other contrary, it is possible that placenta of monozygotic twins are split into two because cell division of a fertilized egg is occurred at very early stage of pregnancy and each egg is implanted at a distanced place of the uterine wall so that they develop two different placentas.

Another very useful judgement method is to compare similarity of twins. The most reliable one is blood type testing, not only ABO model but also more detailed blood testing such as Rh and MN model. Another methods are, earwax type, fingerprint and questionnaire.

About Pregnancy

1 The state of pregnancy and prenatal care

In a multiple pregnancy (pregnancy of twins and over), the size of the abdomen become remarkably big, about 100cm at the time of delivery. There are many people who have gone through hardships of morning sickness from the early stage of pregnancy and oppressing feelings on abdomen, dropsical swelling (dropsy) and backache after the middle stage.

In 70-80% of multiple pregnancy cases, women get hospitalized before delivery for various reasons. Especially, most of pregnant with triplets or over are hospitalized around the 28th week of pregnancy.

It is said that pregnant women (single baby) should exercise, but this is not true in the case of multiple pregnancy. You should take more time to lie down and rest not to overstrain yourself. This will prevent you from having complications during pregnancy as well as reducing risk of delivering lower weight baby (birth weight under 2,500g) and/or extremely premature baby.

You should follow the instructions of medical doctor and midwife at periodic medical check-ups. Multiple pregnancies are accompanied by various health risks. There are cases when unborn baby is at risk although the mother does not have subjective symptoms. Therefore, it is very important to have periodical medical check-ups on prenatal abnormality. It is necessary to have check-ups once in two weeks after 20 weeks of pregnancy. If you feel abdominal pain, sudden backache, hemorrhage (heavy blood loss) or any abnormality, you should call your family Dr. or health facility to get examined.

2 Complications during pregnancy

Anemia, spontaneous abortion/premature birth, hypertensive disorder, intrauterine growth retardation and polyhydramnios are possible complications during pregnancy.

(1)Anemia

The blood gets weak (hypervolemia) during pregnancy, because volume of blood flow inside of mother's body increases and also because baby absorb iron from mother to produce blood. The incidence of anemia among multiple pregnancy is twice as high as that of single pregnancy. It is important to fully think out your diet to prevent anemia.

(2)Spontaneous abortion/premature birth

Multiple pregnant women's womb muscle stretch on a larger scale. This opens the cervical canal and uterine contraction may occur quickly which may lead to the premature birth. In single pregnancy, uterine contraction usually occurs after 36 weeks, but for multiple pregnancies, it sometimes occur around 24 weeks. When you feel stretching of your abdomen, lie down and rest soon. And if it comes quite often, you should have an early consultation or examination from medical doctor and/or midwife to prevent premature birth.

(3)Hypertensive disorder

Multiple pregnancies causes hypertensive disorder more often than single pregnancy, and often times leads to a serious case. You should take high quality protein, moderate caloric intake and very moderate salt content. Lack of sleep, overwork and stress can also cause hypertensive disorder for which you need special caution.

�@Influence on mother's body

Hypertension with albuminuria and edema causes intracerebral hemorrhage, liver dysfunction, heart failure, respiratory insufficiency and renal failure. Aftereffect of these diseases may require you to have long term medical care after delivery.

�AInfluence on baby's body

Complications decrease blood circulation from the womb to the placenta, which can develop a physically retarded child (intrauterine growth retardation) due to lack of oxygen and nutrients.

3 Things to be careful

(1)Diet

It is not necessary to double calorie intake for multiple pregnancy. Weight increase should be limited to 10kg to 12kg compared with pre-pregnancy. Unnecessary calorie intake and fat will impose a burden on mother's body which may lead to hypertensive disorder.(see 2-(3))

You should take iron, such as liver, shellfish and seaweed (Hijiki, Wakame, Konbu etc) to prevent anemia. Soybean products (Tofu,Natto etc), milk and seafood are good to supplement protein and also vegetable with lots of fiber (you can take more fibers in cooked vegetable than in fresh vege.) can prevent constipation. Salt content per day should be strictly limited under 10g (2 small spoon) to prevent hypertension. You have to be especially careful about the food made of fish paste (Kamaboko etc), ham and sausages, which usually have more salt than you think.

When you eat out, you should be aware that you might take too much sugar/fat/salt intake through strong seasoning, and also lack protein, vitamin, calcium and iron. In addition, you should be careful not to take to much processed food with additives, instant food and snacks. You should think out each meal of the day, and prepare for one soup and two or more side dishes (one staple food, main dish and side dish). You can get consultation on total caloric intake and receive practical example of recipe from family doctor or nutritionist light-heatedly. (Nutritionist is available at the hospital, local Public Health Center and Municipal Health Center)

(2)Exercise

Need moderate exercise, but should stop hard exercise before you get tired. If you want to begin maternity swimming or those who played sports before getting pregnant should consult with doctor to decide if it is acceptable. Shopping or going for walk should also not be too long.

(3) Rest

The bigger the womb becomes, the harder to get rest and sleep. In order to prevent backache and stretching of the abdomen, better lie down at least 1 hour each for morning and afternoon. When you lie down, it is easier for you to put your body aside and put a cushion under the abdomen to support your abdomen. In triplets or more babies, breathing is more difficult since the womb push up your lung, so place the upper half of the body higher by using a legless chair.

Support from the husband/partner and the family

1 Role of husband/partner during pregnancy

One third of pregnant mothers had greater fears than happiness when they found out about their multiple pregnancies. (*) It seems anyone can be worried when you get pregnant of twins. And also, compared with single pregnancy, there are more concerns and things, which need attention during pregnancy period. Therefore physical and mental support by husband/partner and families with good understanding of mother's feelings and thoughtfulness is crucial to reduce various anxieties during pregnancy. (*: twinkids club [survey on condition and consciousness of families with twins/triplets and over1997] )

2 Cooperation by husband/partner and families after delivery

The mother with infant (under 1 year old) can not sleep well and gets more and more tired for first 6 months due to breastfeeding during night and changing diapers etc.. If you have older child, it even increases exhaustion during daytime.

There are many women who worry about not giving enough child-care to each one of their children. In child care of twins or over, severe burden on mother's mental health can be reduced extremely by the support/help from the husband/partner. Not only actual support work of bathing, changing diaper, helping breastfeeding, laundry and other housekeeping, but also a little act of thoughtfulness/kindness and speak a word to mothers can ease mother's heart much greater than you can imagine. Other families can also help actual physical support as mentioned above, however husband/partner is the only one who can support the mother mentally. If possible, let mother enjoy her own free time of 2-3 hours per week (or even once a month), so that she can restore her energy by refreshing mentally and physically.

Delivery

1 Delivery timing

Delivery timing is usually a little earlier than 40 weeks. Statistics shows delivery occur the 36-38 week for twins with the average birth weight under 2000g-2500g and the 30-34 week in triplets with birth weight under 1200g-1800g.

2 Delivery style

In natural delivery of twins, a baby closer to the opening of uterus is born before the other baby. In most of delivery cases, second baby is born within 10 minutes after the first born baby and it is rare that second baby does not come after 30minutes. In such case, or when the position of other babies is not appropriate, the doctor may perform a caesarian section to reduce burden of mother and child. The style of delivery should be left to the doctor's decision.

Since most of the twin babies' have low birth weights, the length of delivery is not necessarily longer than single delivery. There are mothers who even mention that it is easier than having just one baby. The impression that you have on delivery of multiple pregnancy may be "a difficult task". This is because long term hospitalization before delivery reduce physical strength of mothers and also because physical fatigue is accumulated by moving around with multiple babies in the abdomen.

It also takes time for womb of the mother who had twins to be contracted because it is stretched out and also labor pains after birth may be very strong. While you are pregnant, a lot of burden was on womb, so you need to rest enough after the delivery.

Child-rearing

1 When one of the babies is discharged from the hospital

When there is not much weight difference between two babies, bigger baby can also stay at the hospital until the other baby can grow big enough to be discharged from the hospital. Some hospitals allow attendance of mother discharged from hospital earlier than babies so that she can learn actual twins-care practices at the hospital.

However, there will be a case when she has to leave one of the babies at the hospital and being discharged with the other baby. In such a case, although she cares about the baby still at the hospital, the baby's existence may well be ignored because she's being swamped with care of the baby at home. This situation is quite usual, but the mother should come and visit to see and breastfeed the baby at hospital as often as the time allows. Unless having constant physical contact with the baby at the hospital, there will be mental distance between the mother and the infant so that the mother may start feeling the baby at home is more prettier than the other and there will be a risk that the mother become biased with the feeling that "I can't love both of them in a same way" or "I wish I just had one" .

It is quite surprising that there are many who have such biased feelings. You should not blame yourself that you are the only one to feel that way. It is a role of the public health nurse to protect healthy life of the community and they are the closest counselor in the community you can rely on, so you should be courageous enough to consult with public health nurse at the Public Health Center/ Municipal Health Center so that it will greatly benefit your future child-care process.

2 Take it easy

It is natural that child-care for two babies is very busy. Because with just one baby, the workload of mother is increased by midnight breastfeeding, child-care at day time and housekeeping activities. You may feel that you are pressed for time from early morning up to the midnight, but it is important to prioritize your workload whether it is immediate need or things can be done tomorrow so that you can do it one by one.

It is important to keep your own free time. When both babies sleep at the same time, when they play a little quieter, don't try to finish accumulated housework but keep it for your own time. Instead of being frustrated with not having your time because of babies, why don't you take a break, have a cup of tea with your favorite cup? Such small time can relax you.

3 Cheerful mother and bouncing baby

The most important thing in child-care is that mother is cheerful. If the mother is not fine, children sense it. Raising twins is more troublesome and takes more time than usual child rearing. What are the practical style for mother to stay cheerful while sleeping time is extremely reduced.

(1)Use convenient goods wisely

You should utilize useful child-rearing goods to save time and workload. It costs you more, but you should see things only from a rational point of view that "mother's health is a MUST". You can also make wise use of rental products.

For example, ? milk temperature adjustment pot: No need to pay attention to the temperature of hot water ? paper diapers: Most convenient goods which reduces laundry/drying/folding time. There are also lease company to wash and deliver the diapers ? feeding bottle sterilizer: There are many kinds, microwave use, antiseptic use, electric/steam use

(2)Mother alone should not work so hard (child-care, housekeeping)

There are many chores which can be shared by other family members. Don't try to be a "perfect Mom" to accomplish all. When you are too busy to do it alone, ask for help to the other families. Not only relying on your family, it is wise to utilize social services available at your area to overcome the most difficult time of child-care. Most important thing is that you are not too stressed out.

(3)Reduce total workload ( can be cut-corners/skimp your job?E)

Most important thing is not stick to general method or ordinal custom, but try to reduce amount of housekeeping and reduce trouble by applying new ideas. The busiest period is not very long, so be relax and allow you to skimp your job.

For example, ? Don't fold clothes and just pile up each one of the family members. You may also dry it inside f the house and not to put it in drawers. ? Shop in bulk for the whole month. Home delivery services and co-op (cooperative society) are also useful.

4 Child-care

When babies are discharged from hospital, real twin kids rearing starts. In the beginning, you may not be able to recognize daily rhythm of babies so that you feel like being pressed with time for breastfeeding, changing diapers and sleeping. But most important point here is how you can take the easy course of life so that you can survive and continue your vitality.

(1)Breast feeding (Mother's milk)

Recently, the merit and nutritional importance of mother's milk for newborn baby has reconsidered. Natural immunity contained in mother's milk not only protects child from infectious disease caused by virus and bacterium but also enhances intestinal activity and secretion of enzymatic action. The infant with lower birth weight is usually kept in an incubator so that they cannot suck mother's milk directly from mother, but the baby can be fed by fresh mother's milk in a bottle.

Although it is understandable mother's concern about amount of mother's milk is not enough or the style of breastfeeding for two babies, the mother should not give up breastfeeding. Although you may have to rely on milk at the end, it is enough if you could feed neogala (mother's milk with yellowish color which appears in early stage). You don't have to get depressed because it is milk. It is OK to start with mother's milk followed by artificial milk as long as you choose the easiest and best way you can.

*Merit of simultaneous breastfeeding

When babies cry at the same time, you can fulfill their needs at the same time

Daily living rhythm of two babies become uniform

Enhance secretion of mother's milk

*Important points to notice

�@When breast-feeding simultaneously, don't fix the right breast is for A and the left is for B. In addition, it is more likely that the babies vomit because they cannot belch at the same time.

�AWhen the baby belches and vomits at the time of breast-feeding with the bottle in fixed position, there is a risk that throw-ups may return back to the throat and causes suffocation. To prevent this, you should put head of baby a bit higher with the towel then put another rolled towel at the back so that whole body is tilt to prevent from suffocation.

�BYou should fix milk-bottle at some angle so that it won't accumulate air at the nipples. When the baby absorbs too much air, it reduces the amount of milk absorption or it causes vomiting.

�CYou should devise a means to find out the best way for both mother and baby.

�DCompared with feeding just one, you may feel lack of sense of unity with the baby, so it is recommended for you to see babies eyes by turns to make sure that you feel sense of unity.

*Style: You can refer to the pictures shown below when you consult with public health nurse or midwife to receive more practical advise.

(2)Bathing

Bathing is one of the child-rearing duties, which can be shared by husband/partner or family's support and also very helpful. However, when mother alone has to bath babies, you need to prepare for two bath towels, change of clothes, cooled boiled water in dressing room or near the bathroom. When the baby's neck is not stable, it is better to bath baby when mother stays standing by putting baby bath at kitchen sink or use of dressing table with shower (at washbasin) so that it reduces strain to mother's back. When two babies became able to bath with mother, you need to consider safety and style to retain warmth of the baby by preparing bathing net and nonskid mat and also put the baby in a big washball or in bucket.

Bathing is important for baby to be clean, exercise and for recreational purpose, but it is a heavy load if mother had to do it alone. Don't pressure yourself to bath the baby every day, but bathing can be done every other day in cold winter or it can also be one baby per one day. You can just wash baby's bottom, face and feet and hands when you don't bath to keep them clean. In summer, leave babies in water and play with shower to prevent from having prickly heat. Bathing babies is too hard for mother to wash herself. When you have support from husband/partner and other family, you should take a long bath time to wash yourself clean and relax.

(3)Sleeping

A few months old baby need frequent breast-feeding and even though you put one baby sleeping she/he might be woken up by the other baby's cry so that mother can not take enough sleep. Especially most difficult thing is baby's cry at night. There are several reasons for night cry. You better check daily life with the baby, such as time range and length of napping time, enough play around day time and he way you treat baby etc.. For example, if you take baby out when it's warm, they start napping around the same time and rhythm of daily lives of two babies becomes united. It is also important to fix the sleeping time, for example after breast-feeding after taking bath. However, there are some mysteries about the reason of night cry, so it is the most important to take it easy, "It will stop someday".

Instead of sleeping separately from the babies in the baby bed it is easier to put them in the middle of parents so that it reduces burden of standing up and dandle the baby. However, in this case, it is necessary to be careful that bedclothes (futon) or pajamas of parents will mistakenly close the mouth of the babies.

(4)Patterns (rhythms) of daily life of the babies

　It is useful to take child-care notes on breast feeding, changing diapers and sleeping patters to grasp daily life patterns (rhythms) of each baby. When you are too busy child rearing and housekeeping, you may forget important issues specific to one or the other baby. If you have this memo, not only yourself but also husband/partner can understand their rhythms. If you continue taking notes for a while, you can grasp patterns of each baby's daily life so that it is possible to adjust two babies?Elife patterns to uniformity, (for example, you can breast feed after the bath to adjust sleeping time of the two) so that it can reduce mother's workload. patterns to uniformity, (for example, you can breast feed after the bath to adjust sleeping time of the two) so that it can reduce mother's workload. For more information, please refer to the example below by using one page of notebook/day, on the left half is for A and the right for B. It is also helpful to write health conditions (body temperature, type of excreta.

<Example>

( ): amount of milk           Mother: Mother's milk        ↓: Sleep          ○: Excreta

(5)Meal

When the baby food period begins, you can choose any style of chair according to your house's life style, such as baby rack, baby chair etc. Food spilling on the floor can be avoided by putting a vinyl sheet or newspaper at the floor under the table so that clearing off is a lot easier.

It is useful to prepare baby food in bulk to be kept in freezer or use of ready-made baby food so that tasty baby food can be prepared in a short time. When two babies become able to eat by themselves, you need to prepare their own plate and spoon etc. They will gradually learn how to eat even though the beginning is difficult.

Instead of letting them eat continuously, you should eat freely for 15minutes then feed them rest of the food. Their appetite and the amount they eat is not always the same, so don't be depressed by that but try to let babies enjoy the food. In addition, you don't have to put full energy to prepare each meal, for example, if you give high priority to lunch, you can prepare dinner with whatever food is available as long as daily nutritional balance is kept even.

(6)Clothes

Basic points to be covered when you choose baby clothes are 1)a pleasant texture, 2)absorb sweat, 3)Strong for continuous laundry and 4) easy to move around. In addition to those points, points such as 5) easy to change clothes, 6)no need to press and 7)easy to change diapers are also important in case of twins to save time. Decision to choose suits made of the same cloth or choose different cloth for twins is depending upon your idea. You may find it's helpful for helpers to define twins by color of the clothes. However, the bigger they become, they choose the color they like by themselves, sometimes they fight for the same color. On the other hand, there will be a time when they feel relieved when they wear the same color, so that it is necessary to respect what babies feel.

If you have older child above the twins, buying two same cloth for the older child can reduce damage of the cloth and they are handed down in a quite good shape. When the one has to change cloth, the other one want to change also. It would be nice if your neighbor or relatives hand down the cloths to your kids.

(7)Going out

When you go out, you may give ride on your back or carry in your arms, but baby car is the most useful way. For twins, here are various types of baby car from different makers. Lengthwise style is useful for walking sideways or go through cash register at the supermarket. Lateral style is useful to carry baggage on the back. Use rental or recycling baby cars in different ways according to the age (month, year) of your children.

When the babies grow up, bicycle is another useful method to enhance your range of activities. Tricycles for adults have big baggage basket for baby carrying. However, it needs special care because kids may move a lot or fall asleep on the bicycle/tricycle. It is also nice to walk together hand in hand.

(8)Child play and Toys

You need to prepare similar toys to satisfy their needs until two of them became able to play with one toy. Any belongings such as newspaper or boxes can be their toys. Twins are more likely to learn how to play with things and why "take turns" and "wait for one's turn", because there is always someone to play with and learn from.

Although you may feel going out with two babies is very hard, you should not hesitate at going out for walk or let them play at the park when the weather is nice outside. You cannot take your eyes off two children because two of them may not necessary play in a same way at the park, and this may rather increase your mental/physical tiredness. You may need to be courageous enough to go out for a walk often with your baby in a baby car when they are very small, because going out with babies is not an easy job. However, by doing so, mothers and children become acquainted with each other and also you can feel reassured by many adults who will be able to protect children. For example, when you have to run after one child, other mothers whom you can rely on can put an eye on the other child.

If you have triplets or more, the reality is that babies can only go out when your partner is around, however, it is no need to worry that “Is it OK that I have not taken my babies to the park yet?E because you can increasingly take them out when they become 2-3 years old.

(9)Quarrel and Friends

Quarrel of twins oftentimes begin by a scramble for materials (clothe, food or toys). They may hit, scratch or bite. Biting is seen while they are too immature to speak but it is decreased as they grow. It depends on their power relationship, however as long as there is no risk, you can leave them alone. This not only applies to twins but fighting or quarreling between brothers/sisters is important to develop their sociability.

They may also want to play themselves if they get along very well and dislike playing with the others. In such case, you may think, "They always play together, so it may not be necessary to play with the other kids". However, playing or building relationship with the other children is very important to build sociability. In the beginning, it may not be so easy, but you need to give them frequent chances. Even though they may not be able to play with the other friends outside, they may imitate what others did after they come home so that you can see they are aware of the others as they are. With such experiences, they can play well with the other friends when they start going preschools where you need to get used to collective behavior.

(10)Personality differences and Relationship between the two

You may think twins resemble in their appearances and characters, but they are two different individuals with different personalities. Those who raise twins want to raise them equally, but you may worry when you cannot treat babies equally, or when the difference of their growth is monozygotic. However, as long as you feel "both of them are equally pretty" and express your feeling in your attitude, it should be fine. It is very natural that they are different, so it is more important that you can accept their differences.

You and other care-takers need to be careful when you call their names. Don't call them together like "A and others", rather call each one's name "A, B" or "B, A" so that they can feel attention is paid to each one of them. Relationships between twins are different in every pair. Sometimes it depends on physical or personality differences and leadership may take turns. Some pairs have strong rivalry but others do not. Each individual child has different character. Child-rearing book do not have "HOW TO " instructions to each of these cases, but it is you who know best about your kids, so don't worry too much about it.

(11)Avoid accidents

Infants are likely to meet accidents inside of the house.

*First few months: suffocation (with vinyl bag, towel)

*Crawling stage: swallowing objects

*Start walking: get a bruise/external wound (pull tablecloth and things on the table drop down)

skin burn (turn down hot drinks on the table)

*Walking: get a bruise/external wound (hit head with the corner of the furniture) drowning (play

with water at the bath room)

It is necessary for you to understand risk of accidents changes according to child's development process. There are also many cases regarding tobacco use. For example, baby may eat tobacco, skin burn by touching tobacco, drink remaining juice which was used as an ashtray. If there are smokers in your house, all of your family members need to be careful.

There are several preventative methods which are common to all families; lock the bath room, remove water from bathtub or from bucket, not to put step-ladder in veranda, put baby fence at the steps, don't put any hot materials within reach of the child, put small pocket cloth at the higher wall to put small articles.

However you need to be aware that wisdom of twins or kids with older brothers/sisters could be three times as much as a single child. They may behave something totally unthinkable to the adult. For example, closing door is no problem when there is just one child, but if there are two, the other might be at a risk of catching yourself/finger in the door. Or if the one become stepladder to the other, they can easily reach things at higher position. They suddenly become able to do things they could not do yesterday and that may often surprise you.

You need to be especially careful when kids are1-2 years old when they start walking and their range of activity is wider. When you try to avoid the accidents, don't just say "NO", but it is rather important to let them investigate around with full consideration of their safety. You need to teach about risky behaviors to avoid as they grow.

Community Groups/Circles

Join these circles and have friends who can share experiences, you will feel at easy not being occupied with worries and anxieties.

Twin Mothers Club Rep.name: Yukiko Amou Address: 1-5-10-722, Shimo Ochiai, Sinjuku-ku, Tokyo , 161-0033 <Established in 1968, has memberships all over Japan. Bulletin is published 5/year>

Super twins network Secretariat is same as Twin Mothers Club(see left) <Network of parents of triplets, quadruplets and over. When you become member of twin mothers club, you are introduced this network as well>

Twin kids club Rep. Name: Nanako Kubota (editor of this book) Address: 1637-5, Honjo, Saitama, 367-0031 http://www2q.biglobe.ne.jp/~twinkids/ <Has membership all over Japan. Bulletin is publish 6/year with full of information on child-rearing of twins/triplets>

Miracle KOBUTA house Rep. Name: Kumiko Ishikawa (cooperate editor) Address: 846-12, Imafuku, Kawagoe, Saitama < Network of parents of triplets, quadruplets and over. Activities at each branch and publishing bulletin 6/year>

Sakuranbo Rep. Name: Yukari Murata (editor) Address: 4-6-26, Sakae, Niiza, Saitama, 352-0014 <Network of parents of twins or over living near Niiza city. Meeting at community hall and 4/year bulletin publishing

NIKONIKO Circle Rep. Name: Toshiko Kobayashi (editor) Address: 3-1-22-109, Sakae-machi, Asaka, Saitama. <Graduates from child-care class conducted by Asaka Public Health Center formed the network. Meetings and playing outside are their main activities>

Twins &Super twins mailing list http://twins.mscom.or.jp/ Internet communication network of parents with multiple children <With its easy access, exchange information among husband/partner is also active. Off-line meeting is also held frequently.

Reference Information

1 About pregnancy

(1)Measures of pre/post delivery period for female workers

To ensure the protection of the health of the mothers under the Labor Standards Law, multiple pregnant workers can take a total of 22 weeks (14 weeks and 8 weeks of holidays before and after the delivery). If single pregnancy, the total of 14 weeks (6weeks and 8weeks before and after) holidays are assured.

And also, under the law on equal opportunity for employment, employers are ought to take measures on the following items to protect health of mothers. It is highly recommended that you use "Maternal health management consultation communication card" (bosei kenkou kanri shidou jikou renraku card) to let your employer know of your consultation from your medical doctor.

• Request for holiday to attend a hospital to take periodical medical checks and consultation
• Request for the followings to keep instruction by the medical doctors:

*Ease commuting hardships: adopt staggered working hours, reduce working hours, change

means & pathways of commuting

*Ensure taking rest : time extension, increase numbers, change time range

*Comply with the condition of the worker: limit workload, shorten working hours, take holiday

<For more information, please refer to your employer/occupational health doctor at your company, or Saitama Labor Bureau Equal Employment Department (Tel: 048-822-4273)>

(2)Household visit (ninsanpu houmon shidou)

Public health nurse will visit households to give consultations on pregnancy, delivery and child-care. Multiple pregnancies have higher risks of complications with hypertensive disorder, premature birth, so please call / use household visit consultation services. <For more information, please refer to the nearest Public Health Center >

2 About delivery

(1)One-off payment at delivery to assist with the costs of childbirths (shussan ikuji ichiji kin)

Health insurance is not applied for normal pregnancy/delivery because it is understood as physiological phenomenon. However it applies to Caesarian section. If you or your family has been a subscriber to the National Health Insurance system for more than 6months, you can apply for "one-off payment" of 300,000 yen per one child when you applied to health insurance union after the delivery. Or if you or your family is a subscriber to an Employees's health Insurance plan, you are also eligible.

<For more information, please contact your employer or National Health Insurance division of your local municipal office>

(2)Delivery allowance (shussan teate kin)

In the case that you have your own health insurance, you can obtain 60% (40% if you have no dependents under your insurance coverage) of standard salary during the period of pre and post delivery leave (98 days before expected delivery day and 56 days after the delivery) while you can not work. This allowance only applies to the health insurance of company workers and does not apply to the national health insurance services. <Please contact your employer>

3 Child-care

(1)Maternity/child-rearing leave, child-care time

Based on the law on child-care and nursing-care, either husband/partner or mother can take child-care leave by applying to the employer until your child becomes one year old. Also, based on Labor Standards Law, the mother of children under one year old can take 30minutes child-care rest twice (or you can combine them and take 1 hour/ day) .

<For more information, please refer to your employer or Saitama Labor Bureau Equal Employment Department (Tel: 048-822-4273)>

(2)Provision of child-rearing leave/ Exemption of health insurance and pension

If beneficiaries of employment insurance take child-care leave, they can receive 20% of salary every month and an additional 5% of the salary after returning to the work. Health insurance fee and pension fee is excluded during this period.

<For more information, please refer to employer, public employment security office (hello-work) for your child-rearing benefit and employer, insurer, your health insurance union>

(3)Visiting newborn baby by Public Health Center staff (Shin seiji houmon)

As soon as babies are born, please send the Birth Notification Card attached inside of Mother-and-Child Health Handbook (Boshi Techo) to the nearest Public Health Center of your town. If you don't have enough time to send it, your family should call Public Health Center. If required, a public health nurse will visit your home to counsel and assist you with any problems you’re your physical/mental conditions and also with your children. It is also a good occasion for you to ask questions and obtain necessary information on child rearing from the public health nurse. <For more information, please refer to your nearby Municipal Public Health Center>

(4)Child allowance (Jido teate)

For those raising children under 3 years of age and income level is under certain amount, there is an allowance of 5,000 yen for the first and second child, and 10,000 yen for each additional child. (In addition, from June 2000, beneficiary age group will be upgraded from 3 years old till the end of the year when the child became 6 years old) <For more information, please refer to child welfare section of your city >

4 Child-care support

(1)Short time nursery

You can leave your baby in nursery care if you are in an emergency situation when family member is sick and needs care, or at delivery, or sudden business trip or any work related troubles.

<For more information, please refer to child welfare section, welfare office, and child counseling office in your city >

(2)Nursery school (Hoiku jo/Hoiku en)

Nursery schools offer day care services for new-borns to children who are just about to enter elementary school, whose parents are unable to take care of them at home because they are both working or sick. Some cities also provide day-care services. For more information, please refer to each office since the conditions are different according to local authority.

<Contact child welfare section or welfare office in your city >

(3)Housekeeping helper service (Kaji enjo service)

There are social welfare council, community participatory welfare user fee service providers which are available for families who need temporary support. For more information, please refer to each office since the conditions are different in each organization.

<For more information, please refer to the nearest city council or Saitama Prefecture Social Welfare Council >

Name of organization: Saitama ken Shakai Fukushi Kyougikai (Saitama Prefecture Social Welfare Council)

Address: 7-4-17, Kishimachi, Urawa, Saitama

Phone: 048-822-1191 (main number) Planning/Consultation Department

<For more information, please refer to the Saitama Prefecture Aged Worthy Life Promotion Foundation >

Name: Saitama Koureisha Ikigai Shinkou Zaidan (Saitama Prefecture Aged Worthy Life Promotion Foundation)

Address: 519, Kamiookubo, Urawa, Saitama

Phone: 048-855-0200 (main number) Employment promotion Department

(4)Baby-sitter

It is useful to use program in which private homes are approved and registered for day care services. Some may charge you an admission fee.

<For more information, please refer to the yellow page or the following organization >

Name: Japan baby-sitter association (incorporated)

Phone: (HQ) 03-3797-5020

(West Japan office) 06-6309-7011

5 Medical care

(1)Premature Child Support Medical Fees (Mijukuji youiku iryo kyuufu)

If the baby is born premature and weighs less than 2,000 grams, the medical expenses that would normally be borne by the family will be borne partly or entirely by the prefecture (depending on the financial status of the family) provided that it is cared for in a specified hospital. The prefecture will continue to bear these costs until the child's first birthday.

<For more information, please refer to the nearest public health center>

(2)Medical Allowance Policy for Physically Disabled Children (shintai shogaiji ikusei iryo kyuufu)

The medical expenses of physically disabled children (legs, hands, body, eyes, ears, phonetic/speech impediment defect, heart/kidney disorder, congenital visceral disorder>) under the age of 18 which must be met by the family will be borne partly or entirely by the prefecture (depending on the financial status of the family), provided that the treatment is carried out at the designated institution and there is a reasonable chance of improvement or recovery. <For more information, please refer to the nearest public health center>

(3)Medical Treatment for Children with Specific Diseases (Shoni mansei tokutei shikkan iryo kyuufu)

When the child genetically inherited or contracted a specific disease, which falls under the following disease category, you can receive medical cost provision (in some disease only hospitalized cost is covered) to secure child's development and cure for the disease up to 18 years of age (In some disease, 20 years of age) by Saitama Prefecture.

�@malignant cancer,�Achronic kidney failure,�Basthma,�Cchronic heart failure (treated by an internist)�Dinternal secretion related diseases,�Ediffuse collagen disease, �Fdiabetes,�Gcongenital metabolic disorder�Hhemophilia�Imental/muscular disease <For more information, please refer to your local Public Health Center>

(4)Medical Treatment for Specific Diseases (tokutei sikkan iryou kyuufu)

For specific diseases (incurable disease) whose causes are unknown and treatment methods are not established, you can receive medical cost except for user-fees. Not only nationally designated diseases, but also diseases specifically designated by local government may apply to this benefit. (no age limitation) <For more information, please refer to public health center>

(5)Medical Treatment for Infants (nyuyoji iryouhi kyuufu)

For medical treatment cost for infants, you can receive reimbursement of user-fees when other medical benefit does not fit. <For more information, please refer to child welfare section at your city>

6 Consulting Organization

(1)Public Health Center, Municipal Health Center (Public Health Nurse, Nutritionist)

Public health nurse give advise to MCH (maternal and child health) related issues such as pregnancy and child-rearing. Each public health nurse is responsible for specific work and specific area, so you can readily ask general to specific questions such as "how to spend time during pregnancy" or "I live in XXX area, I would like to ask for advise on child-rearing". Almost every organization has a nutritionist to whom you can ask about nutrition management, baby food, and any other issue related to nutrition and diet.

(2)Nursery school

At nursery school for newborn and above, experienced nurse can give consultation on child rearing. It also plays key role as an accessible child-rearing station in the community, which gives phone advice but also opens a nursery school and/or organizes the community (mothers/children) to have a place to exchange communication and to establish network. When you pass through a gate of a nursery school, you will see many of them will welcome you and your children.

(3)Family and Child Counseling Office

You can readily ask for advise on any issues regarding your child or your family. It is stationed inside of the city council and/or public health and human services center and there are child and family welfare counselors.

(4)Children's Counseling Office

It covers relatively wider area and main activities are psychological testing, child-rearing notebook, take necessary measures to refer child to a nursery or sheltered institution or in charge of emergency protective custody. There are six offices in Saitama, which are run by the prefectural government and offer a general counseling and support service for children under 18 years of age.

Editorial Note

"When I found that I was pregnant with triplets, I was very worried although I pretended to keep myself calm. After the delivery, I tried to involve my husband to instruction and explanations at the hospital as much as he could and we tried to think about it as a family issue. I was introduced to mothers of triplets who later became important support for me. Such experiences became precious things through which I could expand network of many people who have similar experiences. I wish this leaflet will be sent at hand of pregnant mothers and support their life." By Kumiko Ishiyama of "Miracle KOBUTA house"

"There is much information on general child-rearing, but very little information on twins. I had the pleasure to work with others to make this leaflets to support child rearing of multiple children. My twins have grown up now, but when I remember the hardest time when they were 0 to 2 years old, I flatter myself that I did well. For those who are very busy now, there will be the time you feel easy, please keep your family's pace. " by Nanako Kubota of "Twin Kids Club"

"I had a chance to listen to senior mother with twins when my twins were just 5months old. It was very encouraging to me since I was very tired at that time. I also met mothers like me who have been encouraging and supporting each other even now. I have a strong feeling that child rearing can be successful only when necessary information is available and you have fellow members. Working with others to create this leaflet was a good opportunity for me to study. Now I started feeling that "I" have to be prepared to be good senior twin mother. " by Toshiko Kobayashi of "NIKONIKO circle".

"I remember when I was surprised and pleased knowing that I was pregnant with twins of 7weeks old. Although I had very had labor after being hospitalized at the latter term of pregnancy, I regret myself being angry about my daughters unintentionally. Child rearing of twins is a continuous attack of pleasure and hardships. But I wish we continued to support and encourage each other positively and overcome the hardships because the god gave twins for such parents with vitality. " by Shuuyo Takano of "NIKONIKO circle (illustration)"

"When I was pregnant with twins, there were not as much information or chance to get information as you can get now and I used to think " It would be nice if there are mothers who have twins". Later, I had a chance to meet many such mothers and became able to share pleasure and hardships of child rearing. I am very glad this leaflet is published. Because I was supported by many people, I would like to support and enjoy child-rearing together with other members." By Yukari Murata of "Sakuranbo"

"Since we started child-care support for twins or over, we have come to understand how difficult it is to raise multiple children compared with single child-rearing and how much mental and physical burden mother has when they are pushed by dairy child-rearing and housekeeping while they can not afford to ask for advise from somebody. We wish pregnant mother can find relief by getting information from this leaflet and also knowing that there are many members who are doing their best and enjoying child-rearing with support from each other. And also as the closest place to get advise from, please readily ask for advise from us, public health nurses in your town." by Etsuko Shibukawa of Public Health Nurse at Asaka Public Health Center

Asaka Public Health Center (Asaka Hokenjo) at Saitama Prefecture

Aobadai1-10-5, Asaka-shi, Saitama ken 351-0016

Tel: 048-461-0468

Internet Address: ~asakahkn/

Published in March, 2000 by Asaka Public Health Center

Originally published in 1998 in Japanese

Revised Japanese edition was published in 2000

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