Releasing the pause button: mothering twins during the first year of life

Breastfeeding initiation, duration, and experiences of mothers of late preterm twins: a mixed-methods study

Background

Twins and late preterm (LPT) infants are at an increased risk of being breastfed to a lesser extent than term singletons. This study aimed to describe the initiation and duration of any and exclusive breastfeeding at the breast for mothers of LPT twins and term twins during the first 4 months and to explore the breastfeeding experiences of mothers of LPT twins.

Methods

A sequential two-sample quantitative–qualitative explanatory mixed-methods design was used. The quantitative data were derived from a longitudinal cohort study in which 22 mothers of LPT twins and 41 mothers of term twins answered questionnaires at one and four months after birth (2015–2017). The qualitative data were obtained from semi-structured interviews with 14 mothers of LPT twins (2020–2021), based on results from the quantitative study and literature. Analysis included descriptive statistics of quantitative data and deductive content analysis of the qualitative data, followed by condensation and synthesis.

Results

All mothers of LPT twins (100%) and most mothers of term twins (96%) initiated breastfeeding. There was no difference in any breastfeeding during the first week at home (98% versus 95%) and at 1 month (88% versus 85%). However, at 4 months, the difference was significant (44% versus 75%). The qualitative data highlighted that mothers of LPT twins experienced breastfeeding as complex and strenuous. Key factors influencing mothers’ experiences and decisions were their infants’ immature breastfeeding behaviors requiring them to express breast milk alongside breastfeeding, the burden of following task-oriented feeding regimes, and the lack of guidance from healthcare professionals. As a result, mothers started to question the worth of their breastfeeding efforts, leading to changes in breastfeeding management with diverse results. Support from fathers and grandparents positively influenced sustained breastfeeding.

Conclusions

Mothers of LPT twins want to breastfeed, but they face many challenges in breastfeeding during the first month, leading to more LPT twins’ mothers than term twins’ mothers ceasing breastfeeding during the following months. To promote and safeguard breastfeeding in this vulnerable group, care must be differentiated from routine term infant services, and healthcare professionals need to receive proper education and training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00507-3.

Mothering Twins During the First Year of Life: A Metaphor Analysis

This secondary qualitative analysis identified metaphorical expressions mothers of twins used to describe their first year caring for their infants. Data from the primary grounded theory study were reanalyzed using metaphor identification procedure and revealed eight metaphors: blur, life on hold, being an orchestrator, being a juggler, being an equalizer, being a quick-change artist, being a milk factory, and open invitation. These metaphors give clinicians an insider's view of the struggle's mothers of twins experience during the first year after birth. Being attentive to the metaphors mothers used can provide a unique approach to helping them. Lactation consultants are key to providing much needed support for mothers who are breastfeeding twins.

Is there something special about twin families? A comparison of parenting styles in twin and non-twin families

Twin comparisons offer a powerful quasi-experimental design to study the impact of the family of origin on children's life chances. Yet, there are concerns about the generalizability of results obtained from twin studies because twin families are structurally different and twins have a genetic resemblance. We examine these concerns by comparing mothers' reports on their parenting styles for twin and non-twin children between twin and non-twin families, as well as within twin families. We use two German studies for our comparisons: TwinLife and pairfam. Our results demonstrate that twins receive more differential treatment and more emotional warmth than non-twins; however, these differences are largely accounted for by age differences between children. Overall, our results indicate that results on parenting obtained from twin studies can be generalized to non-twin families.

Postpartum Mental Health Care for Mothers of Multiples: A Qualitative Study of New Mothers' Treatment Preferences

OBJECTIVES

Despite the expanding literature on empirically supported strategies for treating perinatal mental health concerns in new mothers, no published reports have examined tailored support interventions for parents of twins or higher-order multiples. The goal of this study was to improve our understanding of the unique postpartum experiences of new mothers of multiples, gauge interest in both traditional and e-health approaches to mental health care, and discuss aspects of mental health treatment viewed to be most helpful.

METHODS

Twenty-eight women who had given birth to their first set of multiples within the past year were recruited online. Participants completed self-report measures of depression, anxiety, and sleep disruption and took part in telephone focus groups.

RESULTS

On average, participants had elevated depression and anxiety symptoms and notably disrupted sleep. Although some positive elements of the postpartum period were noted, most participants described this time as stressful, overwhelming, and exhausting. They identified experiences that were unexpected or unique to parenting multiples and indicated numerous desired aspects of mental health treatment. Interest in internet-delivered care was especially high.

CONCLUSIONS

This study lays the groundwork for the development of a targeted psychosocial intervention to address mental health concerns among new mothers of multiples, particularly those who are already engaged and seeking support and community online. This report also suggests myriad ways in which providers can best address the needs of this population (eg, utilize providers with expertise in multiples, deliver care in the home, use e-health approaches, and normalize unique stressors and negative moods).

Couples' psychological adjustment to twin parenthood: mode of conception (spontaneous versus assisted reproduction) and gender differences

Aim

To examine whether mode of conception and gender are associated with parents’ psychological adjustment across the transition to twin parenthood.

Background

There is limited knowledge on the psychological adjustment of couples to twin parenthood during pregnancy and early postpartum, especially for fathers. The available research suggests that first-time mothers of twins conceived by assisted reproduction techniques (ART) may experience lower psychosocial well-being than mothers of spontaneously conceived (SC) twins.

Methods

A total of 41 couples expecting twins, 25 of whom conceived spontaneously and 16 conceived by assisted reproduction techniques, completed measures of depressive and anxiety symptoms, marital relationship, attitudes to sex, and attitudes to pregnancy and the baby.

Findings

ART parents showed a decline in marital relationship quality, no changes in attitudes to pregnancy and the baby and no changes in attitudes to sex over the postpartum. In contrast, SC parents did not change their perception of the marital relationship, reported more positive attitudes to pregnancy and the baby, and more positive attitudes to sex over the postpartum. Compared with the other groups (SC mothers and fathers, ART fathers), ART mothers exhibited a higher increase in depressive and anxiety symptoms from pregnancy to postpartum and only anxiety symptoms exhibited a decline trend over the postpartum. These findings suggest that ART parents may experience more psychological difficulties during the transition to twin parenthood than SC parents. ART mothers, in particular, appear to be more at risk of high levels of postpartum depressive symptoms.

The Maternal Emotional Climate Predicts Twin Sibling Relationship Quality

We investigated the association between maternal expressed emotion and twin relationship quality, after controlling for a maternal questionnaire measure of the mother-child relationship. This was explored within a community sample of 156 mothers and their two young twin children (M child age = 3.69 years; SD child age = 0.37). Mothers reported on the twin-twin relationship and the mother-child relationship via questionnaire. They were also interviewed about each child using the innovative Preschool Five Minute Speech Sample (Daley et al., 2003), which yields information about relative positive:negative maternal expressed emotion. Mothers who expressed more family-wide positive emotion and less family-wide negative emotion also reported more positivity, but not negativity, within the twin relationship - even when controlling for questionnaire reports of the mother-child relationship. Counter to expectations, discrepancies in mothers' expressed emotion between their twins also predicted more positive sibling relationships. Our findings corroborate the well established spill-over effect, whereby families are viewed as emotional units of interdependent individuals, none of whom can be understood in isolation from one another. Most importantly, the Preschool Five Minute Speech Sample provides information about mothering that questionnaire reports may not, and thus it is a useful tool in better understanding the twin family system.

Multiple Gestation: Side Effects of Antepartum Bed Rest

The birth rate for higher order multiples has dramatically increased in recent decades. Multiple gestation pregnancies are considered to be at high obstetric risk. Antepartum bed rest is often prescribed to offset complications despite the lack of evidence for its effectiveness in preventing complications. This longitudinal repeated-measures study identified side effects of antepartum bed rest treatment for 31 hospitalized women with twin or triplet gestation. Maternal weight gain and infant birth weight were recorded. Antepartum stressors were measured by the Antepartum Stressors Hospital Inventory, and depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D). Antepartum and post-partum side effects of bed rest were also assessed by the Antepartum and Postpartum Symptom Checklists. The weekly rate of maternal weight gain during hospitalization was significantly less than recent recommendations for multiple gestation weight gain (t =– 2.14,p = .04). Infant birth weights were appropriate for gestational age. There were fewer than expected small-for-gestational-age infants. Concerns regarding family status and separation from family were the major antepartum stressors. Women reported a high number of symptoms during bed rest (M= 22), which did not significantly change across 2 weeks. CES-D scores for depressive symptoms were high on antepartum hospital admission. Postpartum symptoms were initially high but had significantly declined by 6 weeks: F(1, 27)= 15.68, p = .00. These findings suggest that interventions are needed to reduce antepartum maternal weight loss, stress, physiologic and psychosocial symptoms, and depressive symptoms, as well as reduce postpartum symptoms of maternal morbidity.

An ethnographic study of nurses' experience with nursing research and its integration in practice

AIM

To report from a study aimed at illuminating how French Registered Nurses experience and engage in nursing research in clinical practice.

BACKGROUND

Nursing research in France is mainly conducted by nurses working at clinical research units rather than by dedicated nurse researchers. Education, i.e. advanced degrees, in the field of nursing research is still in its infancy and not yet consistent with the international context. Outside France, the general perception is that nursing research is a unified part of professional nursing. Consequently, in-depth knowledge about how nurses in a French clinical context might experience and engage in nursing research is still lacking.

DESIGN

The design of this study was influenced by an ethnographic approach as described by the French anthropologists Beaud and Weber.

METHOD

Data, participatory observations, field notes and interviews (n = 6) were collected in a teaching hospital between April-August 2012. The field consisted of a wound-care unit and clinical research units. Collected data were analysed based on Beaud and Weber's description of analysis.

RESULTS

Three beliefs were identified: being a unified part of a research team, being an integral part of 'crosswise - across' activities and being part of research activities.

CONCLUSION/IMPLICATION FOR RESEARCH

Commitment to nursing research was strengthened by patient-related issues. Based on this context, nursing research would likely benefit from the support of a naturalized reciprocity between clinical practice and research.

Mixing a grounded theory approach with a randomized controlled trial related to intimate partner violence: what challenges arise for mixed methods research?

Little is known about how to systematically integrate complex qualitative studies within the context of randomized controlled trials. A two-phase sequential explanatory mixed methods study was conducted in Canada to understand how women decide to disclose intimate partner violence in emergency department settings. Mixing a RCT (with a subanalysis of data) with a grounded theory approach required methodological modifications to maintain the overall rigour of this mixed methods study. Modifications were made to the following areas of the grounded theory approach to support the overall integrity of the mixed methods study design: recruitment of participants, maximum variation and negative case sampling, data collection, and analysis methods. Recommendations for future studies include: (1) planning at the outset to incorporate a qualitative approach with a RCT and to determine logical points during the RCT to integrate the qualitative component and (2) consideration for the time needed to carry out a RCT and a grounded theory approach, especially to support recruitment, data collection, and analysis. Data mixing strategies should be considered during early stages of the study, so that appropriate measures can be developed and used in the RCT to support initial coding structures and data analysis needs of the grounded theory phase.

Childbirth education for multiple pregnancy: part 2: intrapartum and postpartum considerations

Women with a multiple pregnancy can expect a different labor and birth course than those with a singleton pregnancy. While the postpartum period is similar to that of families with a singleton, it is likely to be more hectic in families with multiple infants. In addition, a multiple pregnancy increases both maternal and neonatal risks; therefore, women with a multiple pregnancy may experience slight differences in care due to these potential risks, including additional monitoring and treatment. This article discusses the intrapartum and postpartum considerations families with a multiple pregnancy/birth may experience. This information is provided so that the childbirth educator can incorporate this content into courses, as appropriate, and assist families with a multiple pregnancy to anticipate a realistic birth and postpartum experience.

Correlates of negative and positive mood state in mothers of twins

Relationships between parenting distress, social support, and sense of competence and negative and positive maternal mood were assessed in 162 mothers with twins younger than 2 years. Women with lower satisfaction scores on the sense of competence scale reported higher negative mood (adjusted R(2) = 21.7%, p < .001). Women with lower parenting distress and higher efficacy scores on the sense of competence scale reported higher positive mood (adjusted R(2) = 39.4%, p < .001). Neither instrumental nor subjective social support contributed to variance in maternal mood. Interventions should be aimed at decreasing parenting distress and increasing sense of competence for mothers of twins.

Sleep patterns and fatigue in parents of twins

OBJECTIVE

To examine patterns of postpartum parental sleep and levels of fatigue at 2, 12, and 20 weeks following hospital discharge of newborn twins.

DESIGN

Descriptive longitudinal pilot study.

SETTING

Recruitment from 2 hospital postpartum units. Data collected in parents' homes.

PARTICIPANTS

Eight primiparous parents caring for twins delivered at 33 to 38 weeks gestation.

METHODS

Home visits to deliver and retrieve study equipment: wrist actigraphy and sleep diaries to measure sleep, standardized instrument to measure fatigue, and an investigator-developed form to measure demographics and related variables.

RESULTS

Fathers had significantly less night sleep (5.4 hours) and less 24 hour sleep (5.8 hours) than mothers (6.2 and 6.9 hours, respectively) at 2 weeks after twins were discharged. Sleep efficiency increased significantly over time in a linear fashion for both parents. Morning and evening fatigue levels were not significantly different between parents and remained constant over time.

CONCLUSION

Pilot data suggest that mothers and especially fathers of twins experience sleep disturbances after discharge of their twins. Further study is needed to more fully describe the evolution of sleep patterns and clarify factors that influence sleep in parents of twins.

Together or apart? A behavioural and physiological investigation of sleeping arrangements for twin babies

OBJECTIVE

the pros and cons of co-bedding for healthy twin babies on the postnatal ward and in the home are issues with which midwives need to be familiar; however, little objective research has been conducted on which to base policies and recommendations. In this two-part study, I explore the behaviour and physiology of twin babies sleeping separately and together.

DESIGN, SETTING AND PARTICIPANTS

in part one, 10 twin baby pairs aged between 1 and 3 months were videoed sleeping together at home in head to head and side by side configurations. In part two, 14 twin pairs under 3 months of age participated in a two-condition trial with behavioural and physiological monitoring while sleeping together and apart in the sleep lab.

FINDINGS

in part one, sleep variables were unaffected by co-bedding configuration. Babies positioned side by side were observed to occasionally impinge on, but not obstruct, one another's airways, with an arm across the other's face. In part two, no difference was found in their duration of sleep, frequency of waking, core temperature or head covering in the two conditions; co-bedded twins showed synchronous sleep states.

CONCLUSIONS

the co-bedding of term twin babies less than 3 months of age does not seem to be associated with the negative attributes that concern some parents. There may also be advantages of sleep synchrony and ease of care. These results can be used by health professionals in formulating guidance for parents of twins.

Theoretical sampling and category development in grounded theory

Theoretical sampling is a hallmark of grounded theory methodology, and yet there is little guidance available for researchers on how to implement this process. A review of recently published grounded theory studies in Qualitative Health Research revealed that researchers often indicate that they use theoretical sampling to choose new participants, to modify interview guides, or to add data sources as a study progresses, but few describe how theoretical sampling is implemented in response to emergent findings. In this article, two issues that arose relative to theoretical sampling in an ongoing grounded theory study are discussed. A theoretical sampling guide that was developed by the authors' research team to facilitate systematic decision making and to enhance the audit trail relative to theoretical sampling is described, and an example of how the guide was used to develop a category is presented.

The seeking of baby-feeding information by Canadian women pregnant with twins

OBJECTIVE

To analyse baby-feeding information needs and seeking described by Canadian women pregnant with twins.

DESIGN

Qualitative; data were collected by in-depth semi-structured interviews. Transcripts provided the data for discourse analysis of the use of two interpretative repertoires.

SETTING

Ontario, Canada.

PARTICIPANTS

19 women pregnant with twins.

MEASUREMENTS AND FINDINGS

The first interpretative repertoire represented caring for twins as fundamentally distinct from caring for singly born babies, and therefore emphasised the commonality of mothers of twins regardless of their background or situation. The second highlighted the uniqueness and individuality of each person. These repertoires intersect with discourses of baby feeding and good mothering, resulting in a complex discursive interplay of similarity and difference, commonality and individuality, information seeking, baby feeding and good mothering. Participants used the two interpretative repertoires to (1) frame information needs; (2) construct complex accounts of the biomedical, experiential and personalised authority of information sources; (3) describe the helpfulness of information sources independent of their authority; and (4) describe the barriers encountered in the finding appropriate sources of baby-feeding information in pregnancy.

IMPLICATIONS

Understanding and respecting the discursive constructions of pregnancy and mothering can help practitioners understand the complex discursive interplay underlying participants' baby-feeding decisions, and may facilitate more sensitive support for women's individual needs and understandings.

Postpartum Depression

Postpartum depression is a crippling mood disorder, historically neglected in health care, leaving mothers to suffer in fear, confusion, and silence. Undiagnosed it can adversely affect the mother-infant relationship and lead to long-term emotional problems for the child. This article differentiates postpartum depression from other postpartum mood and anxiety disorders and addresses these aspects of postpartum depression: symptoms, prevalence, risk factors, interventions, and the effects on relationships and child development. Instruments available to screen for postpartum depression are also reviewed.

The Grounded Theory Method and Maternal-Infant Research and Practice

Perinatal nurses have found qualitative methods helpful in capturing the social, cultural, and relational aspects of their work with women and their families. This article describes the components of the grounded theory method and illustrates each with examples from recent maternal-infant studies. Grounded theory is an inductive method of qualitative analysis that generates theory from data. The grounded theory method includes several key strategies such as theoretical sensitivity, theoretical sampling, constant comparison, increasingly abstract consideration of the data, and discovery of a core variable or basic social process that describes the pattern of the phenomenon under study. This method may strengthen qualitative nursing studies because of its generalizability and applicability across settings. By remaining grounded in and connected to the data, grounded theory can be adapted to many contexts, making it useful to the practicing nurse. Knowledge generated from grounded theory has great potential to assist us in our inquiry into the needs of mothers, fathers, infants, and their families.

Prenatal attachment and other correlates of postnatal maternal attachment to twins

PURPOSE

To determine the relationship of prenatal attachment and other selected perinatal contextual variables (method of delivery, maternal self-reported health, depression, infant birthweight, need for neonatal intensive care unit [NICU] admission) to postnatal attachment in mothers of twins.

SUBJECTS

Two hundred fourteen women were initially recruited from a national mothers of twins support group for a study of maternal prenatal attachment. Of the 168 women who agreed to be contacted after delivery, 142 returned completed questionnaires (82.7% response rate), with 139 study-eligible women included in the analysis for this report.

STUDY DESIGN

Correlational design with longitudinal follow-up at 1 month after expected delivery date.

METHODS

Self-administered, mailed questionnaires completed by women with twin gestations prenatally and postnatally 1 month after their expected delivery dates. Descriptive analysis, correlations, and regression equations were performed.

MAIN OUTCOME MEASURES

The Maternal Attachment Inventory.

PRINCIPLE RESULTS

A modest correlation was found between prenatal and postnatal attachment ( r = 0.38, P < 0.001). Prenatal attachment and postpartum depression explained 26.1% of the variance in postnatal attachment ( F = 5.06, P < 0.001). Depression, method of delivery, and need for admission to the NICU had moderator effects on the relationship between prenatal attachment and postnatal attachment. The addition of these interaction terms nominally increased the adjusted R 2 to explain 27.9% to 29.6% of the variance in postnatal attachment.

CONCLUSIONS

Although the study findings support a modest relationship between prenatal and postnatal attachment in mothers of twins, maternal depression was also significant in explaining postnatal attachment. Postpartum depression, having a cesarean delivery, and the experience of a NICU admission for 1 or both twins further influenced the relationship between prenatal attachment and postnatal attachment. When fostering attachment in mothers of twins, nurses should assess for symptoms of depression and pay particular attention to those women who have an infant requiring a NICU admission.