One too many? Families with multiple births

07 December 2018

It is not just medical complications that families with multiple births face. Ryan Scoats, Jane Denton and Merryl Harvey look at the financial, psychological and social support obstacles they must overcome.

Providing support for families with multiple births (FMBs) presents a range of challenges to both the family and health practitioners.

Recognition of these challenges is becoming increasingly imperative – the rate of multiple births in England and Wales has risen over the past 40 years, from 9.7 per 1000 maternities in 1977 to 15.73 per 1000 in 2016, (Office for National Statistics, 2017), because of a combination of fertility treatments, women having babies later in life (a predisposing factor for dizygotic twinning) and advances in obstetrics and intensive neonatal care.

As Nelms (2007) has suggested, FMBs are challenging to work with for a number of reasons. Multiple births often carry with them an elevated risk of medical complications (Glazebrook et al, 2004), including the babies being born preterm (Martin et al, 2012), with autism (Gardener et al, 2011), or with low birthweight (Glazebrook et al, 2004), alongside risks to the mother (Dudenhausen and Maier, 2010).

As Bowers (1998) highlights, multiple births are much more likely than singleton births to result in complications. Consequently, NICE recommends a specific range of specialised antenatal care guidelines for mothers of twins, triplets and higher-order multiples (Visintin et al, 2011). Aside from medical complications, however, there are a number of additional challenges for FMBs. The aim of this article is to highlight and discuss some of the most common issues faced by FMBs and outline the need for future research in specific areas.

Psychological wellbeing

Looking first at the long-term health of FMBs, there are a range of difficulties related to the psychological wellbeing of the mother/parents of multiples. Wenze et al’s (2015) review suggests parents of multiples have worse mental health outcomes compared with parents of singletons. Indeed, many studies support this suggestion that parents – in particular mothers – in FMBs have a higher risk of poor psychological health (Vilska and Unkila-Kallio, 2010; Damato, 2005; Glazebrook et al, 2004; Klock, 2004; Thorpe et al, 1991). Conversely, although clearly prevalent, elevated experiences of depression are not necessarily a universal experience for FMBs (Roca de Bes et al, 2009; Ellison and Hall, 2003).

In addition to higher rates of depression, a range of studies also supports the suggestion that mothers with multiples have higher levels of parental stress compared with singleton mothers (Wenze et al, 2015; Lutz et al, 2012; Glazebrook et al, 2004). The reasons for this stress are often varied, and will affect FMBs differently. For example, Bryan (2002) suggests some mothers feel embarrassed about finding it difficult to tell their babies apart. There is also the suggestion that attempting to bond with more than one child at once – or being able to bond with one child more easily – can be a great source of strain on mothers (Nelms, 2007; Bryan, 2003; 2002).

Exhaustion and isolation

An only child can feel unexpectedly ignored upon the arrival of twins, leading to feelings of isolation

Another potentially contributing stressor is the chronic tiredness/exhaustion that mothers of multiples often experience (Damato, 2005; Ellison and Hall, 2003). Further emotional strain may also be caused if one of the babies is sicker than the other, meaning the mother may be separated from one of the children (Bryan, 2003), or if infants are born preterm (Taubman-Ben-Ari et al, 2010; Petrou et al, 2006) – a more common occurrence for multiple births (Blondel et al, 2006; Kurdi et al, 2004; Kinzler et al, 2000).

Children may also be adversely affected if they are a sibling to multiples. Bryan (2002) cautions that an only child can feel unexpectedly ignored upon the arrival of twins, leading to feelings of isolation. While mothers may want to give more time to the siblings of multiples, the reality is that they often don’t have enough time to adequately meet the needs of all their children (Heinonen et al, 2016; Leonard and Denton, 2006).

In turn, this may put further emotional strain on the mother. One of the participants in Ellison and Hall’s (2003: 410) research described an example of this: ‘Today my older son said to me, “You didn’t give me any attention today.” That hurts; that hurts a lot.’

Practical pressures

In addition to these psychological pressures, there are a number of practical concerns. One of these potential pressures is the increased financial burden that multiples create over and above that of singleton births. Finite resources, such as money, must be divided to meet the needs of multiple children (Damato, 2005), and this may lead to financial difficulties (Campbell et al, 2004). Some of these costs are specifically associated with multiples, including childcare, specialist equipment, needing to move into a larger home, as well as two, three or more times the amount of clothes and nappies (Ellison and Hall, 2003). Mothers of multiple births may also take longer to return to work if they do at all (Glazebrook et al, 2004), further exacerbating financial difficulties (Campbell et al, 2004). Fathers, in contrast, may take on extra hours in order to make up for this shortfall in income (Strauss et al, 2008), adding to their overall stress and tiredness as well as reducing the number of hours they are at home.

At a glance: Problems faced by FMBs

  • Medical complications: preterm birth, autism, low birthweight
  • Psychological issues for parents: stress, depression, tiredness, difficulty bonding
  • Sibling problems: isolation, emotional strain
  • Practical problems: financial strain, additional employment
  • Feeding: difficulties with breastfeeding
  • Social networks: lack of understanding from other parents
  • Health professionals: limited contact or support


Feeding support

Feeding is often seen as logistically difficult as well as potentially contributing to chronic tiredness if children feed and sleep at different times (Heinonen et al, 2016). Although many mothers are encouraged to breastfeed, this can become a more difficult task with multiple babies. Accordingly, Geraghty et al (2004) found that a much lower proportion of twins and triplets in the US were breastfed than the recommended guidelines. Those breastfeeding twins (or higher-order multiples) will need extra support simply due to the time-intensive nature of feeding and expressing (Nelms, 2007). Consequently, those without adequate support may choose not to breastfeed. In other circumstances, worries about each of the children receiving enough milk and nutrients may also encourage some mothers to supplement or replace their milk (Cinar et al, 2013). The best way to encourage the breastfeeding of multiples is still not clear, although support and guidance appear of paramount importance (Whitford et al, 2017; Bennington, 2011).

Social networks

The social support available to FMBs is also of great importance, as it can help limit a range of negative factors (Harvey et al, 2014). Indeed, Feldman et al (2004) found social support was correlated with lower stress for mothers with newborn multiples. This need for social support starts before birth, and helps women feel aware that they have others who can aid them in the care of their children (Benute et al, 2013). Social support, in the form of relatives or care workers, can often aid in the context of household chores, bonding with each child individually, and enabling the mother to leave the family home (Heinonen et al, 2016).

The physical support of others is often vital in allowing a parent to leave the house on basic errands. Strauss et al (2008: 149) describes these inherent difficulties: ‘Simple but essential out-of-home routines such as shopping turned out to be a serious problem for most families, caused by handling with one or even two multiples’ buggies additionally to the shopping trolley or keeping an eye on three to five infants while shopping.’

Thus, without this social support, multiples may consequently contribute to social isolation as some tasks are simply not possible (Campbell et al, 2004).

Aside from family members and health workers, another important form of support comes from the parents of other multiples. Owing to the limited statutory help provided to FMBs in the UK, volunteer groups and organisations have filled the gap (Campbell et al, 2004). Rather than offering physical assistance, these groups provide practical tips and a depth of understanding not perceived possible from parents of singletons (Jenkins and Coker, 2010). Other parents of multiples can provide one of the best sources of information to new parents (Bryan, 2002), although these experienced others are not necessarily easy to find, nor necessarily cater for the needs of fathers (Jenkins and Coker, 2010). In addition, Heinonen (2017a) suggests that while peer support is valuable, it cannot replace the support of healthcare professionals.

The Elizabeth Bryan Multiple Births Centre

The Elizabeth Bryan Multiple Births Centre (EBMBC) was established at Birmingham City University in 2017 as a collaboration with the Multiple Births Foundation. The aims of the EBMBC include extending knowledge and developing an evidence base on the best ways to meet the needs of FMBs. Workstreams are currently in progress to address these aims. Find out more at bcu.ac.uk/ebmbc

Health practitioners’ experiences

While there is research documenting the needs of FMBs, there is a dearth of literature illuminating the experiences of the healthcare professionals working in these contexts (Heinonen, 2017a). Accordingly, it is difficult to know the extent to which health professionals are able to provide adequate advice and care for FMBs.

Research highlighting the experiences of those working with FMBs presents poor evidence that these practitioners are adept at working with these groups. For example, Spillman (1992) found that some healthcare professionals were lacking an awareness of appropriate literature that was available to recommend. More recently, Heinonen (2017b) found healthcare professionals to show some capacity to offer support to FMBs. Public health nurses were aware of the special needs related to FMBs, and acknowledged that advice for single-parent families needed to be adapted. Nevertheless, this process was not easy for the nurses, and Heinonen (2017b: 6) concluded that ‘their own capacity and means to help a multiple-birth family were considered limited’.

Given the increased range of problems FMBs may face in comparison to single birth families, it can also be difficult for health professionals to gain a sufficient grasp of each families’ specific situation (Heinonen et al, 2016). Consequently, limited contact between health professionals and FMBs may limit the extent to which they are seen as effective.

A need to improve

Given the lack of literature on health professionals’ attitudes and experiences of working with FMBs, it is extremely beneficial to look at FMBs’ attitudes toward practitioners. We again find evidence to suggest that the support offered by healthcare services is inadequate (Harvey et al, 2014). Spillman’s research (1992: 364) suggested that ‘many felt that their health visitors were unaware of the stresses experienced by families with newborn twins or triplets’. Another participant in one study went as far as saying: ‘The health visitor? She doesn’t have a clue, she doesn’t have any answers’ (Harvey et al, 2014: 30). Shortfalls in knowledge and support that mothers identified included advice on feeding more than one child at a time, understanding how to interact with multiple children, and understanding the particularities of their life circumstances (Heinonen et al, 2016).

Also of note is the importance placed on external support networks. Groups in the UK such as the Multiple Birth Foundation (MBF), the Twins and Multiple Births Association (Tamba), as well as local community groups exist to provide additional support to FMBs. Although it is suggested that the experiences of other FMBs can provide vital experiential knowledge for new families (Jenkins and Coker, 2010; Damato, 2005; Bryan, 2002), there is potential that these groups are seen as beneficial specifically because FMBs are unable to get the same level of support and information from health professionals (Campbell et al, 2004). Consequently, FMBs’ additional needs are fulfilled via these groups. Unfortunately, not everyone will necessarily have the same access to these organisations (Jenkins and Coker, 2010).

Research suggests that there is support available for FMBs, but it is unclear the extent to which health practitioners are comfortable and capable of delivering what these families desire (Heinonen, 2016). Accordingly, more research is needed to explore the educational and professional development needs of practitioners, so to better support FMBs. Furthermore, it would be beneficial if this research focused on practitioners’ attitudes and experiences, as this is where the research is most lacking.

Ryan Scoats is research assistant; Jane Denton is co-lead at the EBMBC and director of the MBF; and Merryl Harvey is professor of nursing, all at the Faculty of Health, Education and Life Sciences at Birmingham City University.


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