General information of the participants
A total of 169 women in our hospital met the inclusion criteria during the study period. Their mean age was 32 years old, and they were all married. The mean gestational weeks at delivery was 33 weeks. Of these, 76 were conceived through assisted reproduction and 93 were conceived naturally. 134 pairs of twins were treated in the neonatal department.
We obtained the breastfeeding information of 100 women. Of which, 58 breastfed, but only 25 exclusively breastfed. Breastfeeding lasted from 2 to 14 months, with an average of 7 months. Finally, among the 100 women, 30 participants were included in the interview. The general information of the 30 participants are shown in table 1.
Qualitative interview results
Two themes emerged from the analysis of the texts: the barriers to breastfeeding and factors that contribute to successful breastfeeding.
Theme 1 Barriers to breastfeeding
Twin Pregnancy We found that twin pregnancy itself was responsible for the low rates and short duration of breastfeeding. During the interview, 80% of the participants firmly believed that twins could not be exclusively breastfed and mixed feeding was intended early in pregnancy. For example, one woman said, "My breast milk is definitely not enough for two babies. My babies have been mixed fed since birth." Some women chose to give up breastfeeding because they could not supply enough breast milk for two babies and they didn’t want to mixed feed. As one woman said, "Breast milk can only meet the needs of one baby. I don't know which child to breastfeed. While mixed feeding is too much trouble, so I just gave it up."
Separation of mother and newborns Twin pregnancy is associated with a higher risk of neonatal hospitalization, and the neonatal department in most Chinese hospitals currently prohibit visitation. Of the 30 women interviewed, 21 experienced neonatal hospitalization. During the separation period, they were particularly concerned about the health of their babies, and lack of identity as mothers, so they did not want to use breast pumps. As one woman said, "The babies were receiving treatment in the hospital. I was so worried about their safety that I was not in the mood to pump breast milk, and even if I did pump, the babies would not be able to eat immediately."
Lack of breastfeeding knowledge Postpartum regular and frequent nipple sucking has a great impact on the breast milk production. If the early milk production is less, it will directly lead to mixed feeding or give up breastfeeding. In China, there is a special custom of confinement and some traditional concepts that are not conducive to breastfeeding. For example, elders would think that sucking with a breast pump will cause great damage to the body. Women who were taken care of by their mother-in-law or mother during the confinement period were greatly affected by incorrect concepts of breastfeeding. Due to a lack of knowledge about proper breastfeeding, 83 percent of the women interviewed did not start sucking until 2 to 3 days after delivery and did not do so regularly. As one woman said, "No doctor told me to suckle right after delivery. My mother told me to suckle after I left the hospital. And for the first few days after delivery, I couldn't feel anything in my breasts and couldn't pump milk. After I left the hospital, I inhaled once when I felt it was swollen."
Convenience of breast milk substitutes. Caring for two newborns takes a lot of effort, and even with the help of family, mothers are still the primary caregivers, especially when it comes to breastfeeding two babies. Too much fatigue and the convenience of milk powder may directly discourage women from breastfeeding. One woman said: "I would be so tired if I breastfed. The two babies were not fed at the same time, and I felt like I was breastfeeding all the time. And my family couldn't help with breastfeeding. If I feed milk powder, my family can help. I also have my own rest time." In addition, due to the weak sucking ability of premature infants, they often needed to continue bottle feeding after discharge. It was unnecessary and intolerable work for women to suck milk into the bottle to feed, which might lead to failure of breastfeeding. As one woman said: "It's troublesome to suck breast milk into the bottle to feed babies. It's better to feed milk powder directly."
Poor maternal and infant health conditions Health issues include two aspects, one is the health of the newborn and the other is the health of the mother. Twin mothers generally believe that their babies are more vulnerable, so they are particularly concerned about the health of their newborns. So, if breastfeeding poses any threat to their child's health, they will consider stopping breastfeeding even if their doctor tells them they can continue. For example, some non-contraindications of neonatal breast milk intolerance, maternal pregnancy hypertension, etc. As a woman said, "My babies were bloated after breastfeeding. I stopped breastfeeding because I was worried that it would affect my babies’ health."
Work reasons Maternity leave in China is six months. During maternity leave, women will not stop breastfeeding, but returning to work is the reason for women to stop breastfeeding. The interviewees expressed that although their work units did not oppose breastfeeding, they did not provide conditions for breastfeeding, such as the place and time of breastfeeding. In order to adapt to work faster, they chose to give up breastfeeding, and they believed that 6 months of breastfeeding time was enough for their children. As one woman said, "I knew I would have to return to work after six months, so I tried to stop breastfeeding at five months." Another woman said: "It took a lot of energy to get used to my job, I didn’t have time to breastfeed or pump at work, and it was embarrassing for me to breastfeed in the workplace."
Theme 2: Factors that contribute to successful breastfeeding
Family emotional support After delivery, a mother may face the loss caused by the shift of family focus, or the grief of a mother and babies separated. If family members pay attention to maternal emotional changes and provide psychological and behavioral support, mothers would be more likely to breastfeed. Family support does not force mothers to breastfeed, but makes them feel that the family is working together to breastfeed. Other family members could help with auxiliary work such as preparing nutritious food, helping with breastfeeding or feeding the baby. For example, a woman said, "When my babies were in the hospital, my husband was always helping me suck breast milk and comforting me constantly. I could feel the happiness of his participation and I was more willing to breastfeed."
Proper breastfeeding guidance Approximately 90% of the women interviewed said they were aware of the advantages of breastfeeding and would like to breastfeed, and would continue breastfeeding if they were given professional breastfeeding guidance. Especially for women who had been separated from their babies. If the doctor recommended breastfeeding and told them how to suck properly, they would actively cooperate with the doctor. Among the women who participated in the interview, 6 of them started breastfeeding early under the guidance of medical personnel and galactagogue professionals, and 5 of them successfully breastfed. For example, a woman said: "After delivery, the galactagogue professional began to teach me how to pump milk, and I kept breastfeeding since breast milk came." Another woman said: "I felt like I needed to do something for my babies. I started pumping regularly under the guidance of nurses and doctors, and then I started delivering breast milk to my babies when they were in hospital."
Adequate breast milk The ability to produce sufficient milk in an intervention or non-intervention state is an important factor for new mothers to initiate and continue breastfeeding. The women interviewed felt that if they had plenty of breast milk, there was no reason not to breastfeed and no reason to stop. As one woman said, "I had a lot of breast milk at the beginning, so naturally I breastfed, exclusively until 11 months."
Economic pressure Bringing up twins means a heavier economic burden. Breastfeeding is a more economical way for twin mothers, so the high cost of twins is also a factor that promotes breastfeeding. As one woman said: "Raising twins is costly. Breastfeeding can save a lot of money."