Breastfeeding Multiples

*Jennifer Ayton and Emily Hansen*

#### **Abstract**

How do women experience breastfeeding multiples? Given the rising rate of multiple births and the global public health target of increasing the number of women exclusively breastfeeding up to the first 6 months, it is imperative that we understand why women who give birth to multiple babies breastfeed for shorter durations compared to those who have one baby. This chapter will explore the qualitative experiences of mothers who breastfeed twins/triplets and the social and physical capital women use to support multiple breastfeeding. Paying close attention to the mothers' personal accounts this chapter will detail the many resources women draw on to meet the challenges of breastfeeding twins and triplets.

**Keywords:** breastfeeding, mothers, twin, triplets, qualitative, capital, Bourdieu

#### **1. Introduction**

#### **1.1 Breastfeeding**

Substantial evidence exists to support the global public health recommendation of exclusive breastfeeding, meaning feeding young infants only breast milk for the first 6 months of life, whether directly from the breast or expressed (including milk from donors) [1, 2]. Short and long-term health benefits of exclusive and continued breastfeeding for up to 1–2 years of life in all contexts are well documented. These include reduced risk of breast and ovarian cancer, immunological protection for the infant against infections (including diarrheal, respiratory tract, and ear), no growth faltering, reduced incidence of diabetes and obesity in later life, and increased intelligence [2–5].

In high-income countries, a strong protective effect was found against sudden infant death syndrome (reduced risk of 36%)—and against infant and childhood infections, (diarrheal and respiratory tract), and dental malocclusions. There was also a reduced risk of childhood and adult obesity and diabetes and increases in intelligence. No relationship was found for allergic conditions (such as asthma) or cardiovascular-related diseases, including hypertension. The authors found an increase in tooth decay in children who breastfed nocturnally for longer periods, beyond 12 months of age. Across all settings, exclusive breastfeeding offered protection against life-threatening diseases such as gastroenteritis, and to a lesser extent respiratory infections [2]. The benefits are age and dose respondent; with extended exclusivity increasing protection into the second year of life. Combined observational and clinical trials provide strong evidence to support continued exclusive

breastfeeding for up to 6 months, showing that the delayed feeding of non-breast milk fluids (formula milk, water, teas, and juice) or foods did not cause any faltering in infant growth or nutritional compromise for infants in their first year of life [6, 7]. Despite the numerous health, economic, and social benefits.

#### **1.2 Patterns of exclusive breastfeeding**

The WHO and UNICEF 2015's Fifth Global Nutrition Target is to increase the rate of exclusive breastfeeding in the first 6 months by up to 50% [1]. This aligns with and supports the United Nations Sustainable Development Goals numbers 2—No hunger, 3—Good health and well-being, and 10-reduced inequalities [8]. Increasing exclusive breastfeeding could prevent 823,000 annual deaths in children younger than 5 years and 20,000 annual deaths from breast cancer [2].

Breastfeeding practices are highly variable across countries and settings. In low and middle-income countries rates of initiation within the first 24 hours range from 80 to 50% with a global weighted prevalence of 51.9%. In many well-resourced countries such as the United Kingdom and Australia, initiation rates are between 70 and 90% and the proportion of infants exclusively breastfeeding to 6 months is lower (2–35%) [9, 10] compared to low and middle-income settings, with the weighted prevalence of 45.7% 2010–2018 [11–13].

Indeed, there has been a noticeable downward trend in exclusive breastfeeding across the globe. It is estimated that two out of three infants worldwide are not exclusively breastfed [14] and only 32–37% of infants are exclusively breastfed worldwide [2].

Data from the first National Infant Feeding survey in Australia, in 2010 showed an initiation rate of 96%, noting a steady decline in exclusivity within the first 4 months after birth (39%) and any breastfeeding for each month of age after that [10]. The most recent data (2021) from Australia estimates that one in three (35.4%) of infants are exclusively breastfed to 6 months of age [9]. These rates fall dramatically short of global targets of 50% of infants exclusively breastfeeding feeding at 6 months [12, 15].

#### **1.3 Breastfeeding twins and triplets**

In 2020, multiple pregnancies (birth of two or mother infants) represented 1.5% of all births in Australia and have risen in other high-income counties. About 98% of multiple births are twins. Only 2% were "other multiples" such as triplets, quadruplets or higher. The proportion of multiple births is higher among older mothers, aged >40 years and lowest for young and teenage mothers aged <20 years (0.8%). These patterns are thought to be associated with an increase in the use of assisted reproductive technology (ART) for women aged >36 years [16, 17].

Multiple births are not without adverse risks for the mother and infant. It is estimated that there is a 50% increased risk of preterm birth (a baby born <37 completed weeks gestation), low birth weight (born <2500 g), congenital malformations and infant mortality. For the mother, they are more likely to have a caesarean section, delayed initiation of breastfeeding, mother-infant separation, lack of skin-to-skin, longer hospital admission and delayed recovery time [16].

Consequently, multiple births increase the challenges mothers and their partners face when choosing to breastfeed. Breastfeeding rates (initiation and exclusive) are lower for multiples compared to a singleton. Mothers of multiples are less likely to

choose to breastfeed, initiate and offer any breastfeeding [10]. Physical factors such as prematurity, and low birth weight, predispose the infant to developmental and physiological immaturity- contributing to poor temperature regulation and lengthy hospital stays in neonatal intensive care units, the inability to feed at the breast due to immature feeding reflexes. All these factors contribute to delays in initiation, demand for the mother to express breastmilk over lengthy periods, poor milk supply, motherinfant separation, maternal anxiety, and poor breastfeeding outcomes [18–20].

Research about breastfeeding has focused on the duration of exclusive and breastfeeding for singleton infants, and little attention has been given to the experiences of mothers who give birth to multiple babies. This study undertook a secondary analysis of qualitative data to explore the experiences of mothers who were feeding twins/ triplets and how they navigated multiple breastfeeding.

#### **2. Theoretical frameworks**

An important theoretical concept guiding the analysis of the findings in this study is the concept of capital as outlined by the French Sociologist, Pierre Bourdieu. Bourdieu's definition of *capital* includes three types economic (i.e., money), social (family, social groups) and cultural/symbolic (i.e., education) [21]. The value of capital is realised when other types of capital are exchanged to benefit the individual in their social context. For example, Bourdieu viewed the body as a type of biological and social "physical capital" used to gain social status and cultural capital in the form of higher educational attainment may be used to gain employment, and money [22].

#### **3. The study**

This study was conducted in Tasmania, Australia, a southern Island state with a population of 558,00, 2022. Approximately, 6000 women gave birth in 2015 when the study was first conducted, compared to 5,560,2020–1.8% of the total number of women who gave birth in Australia (291,710) [23]. The number of women giving birth in Tasmania, and therefore making decisions about how to feed their newborns has decreased over a 5-year period. Approximately 1.4% of those were multiple (twins/triplets) births. The proportion of mothers giving birth to twins/triplets is slightly higher in Tasmania, at 1.5% [23].

The Tasmanian Infant Feeding Study (TIF) was a mixed methods study that involved 127 mothers and their infants aged from 0 through to 36 months, conducted in 2015. The aim of the study was to explore how mothers spoke about their infant feeding practices and experiences. This mixed methods study consisted of multiple forms of qualitative data (focus groups and semi-structured interviews) researcher field notes recorded after focus groups and interviews and quantitative data from a short survey collecting information about mother and infant demographic and health-related information and feeding practices. Participants (mothers) completed a mother and infant demographic and infant feeding practices questionnaire prior to participating in either a semi-structured FG (22 focus groups were held) and/or a semistructured interview (19 interviews were conducted) reported elsewhere [28]. Of the 127 mothers who participated in the study, 6 had given birth to twins and 1 to triplets.

This current study consisted of secondary analysis of multiple forms of qualitative data, focus groups, interviews, researcher field notes and some quantitative

demographic survey data. Mixed methods have been heavily used within social sciences and public health research. It is common practice to rely on one of the methods (e.g., qualitative) to provide deeper insights into the specific phenomenon [24]. In this study integration of both quantitative demographic and qualitative data occurred at the point of data analysis and interpretation. The mothers' demographics were linked to the transcripts using the soft wear package NVivo through the unique demographic questionnaire identification number and pseudonyms. This facilitated cross-checking of participants' characteristics with emerging themes, sources, references, and ensured adequate participant representation and across and within the analytic categories [24].

#### **3.1 Sampling**

In the original study a purposeful sampling was used to include a range of information-rich cases [25]. Mothers were recruited from rural and urban areas of Tasmania. The inclusion criteria included: mothers 16 years and over with infants aged between 0 and 36 months. Mothers did not have to be breastfeeding at the time of the data collection to support infant feeding to be explored in a wider context of women's everyday lives. Recruitment strategies included sampling from pre-existing mothers/parenting support groups, mothers, and health professionals, snowball sampling, advertising, and promoting the study within newspapers and posters at community clinics and hospitals.

For the secondary analysis purposeful sampling was used to identify women who had reported through the survey that they had given birth to twins or triplets.

#### **3.2 Data collection and analysis**

Mother and infant characteristics (age, highest educational attainment, employment, status, marital status, parity, singleton, multiple births, and postcode) and their current feeding practices were collected prior to the start of each interview and FG using a demographic questionnaire.

Participants could elect to participate in an interview or FG. All FGs (22) and interviews (19) were undertaken in the community setting at convenient times for the mothers and were either naturally occurring or constructed. Two members of the research team gathered the qualitative data using a question guide. Interviews were conducted in person with one researcher in the mother's home. Survey and qualitative data were linked through a unique participant ID number. For the secondary analysis, de-identified data (demographic and interview/FG transcripts) were extracted from the main data base using this ID and imported into a separated password protected data base.

#### **3.3 Data analysis**

This paper reports a secondary thematic analysis of data from the seven mothers who gave birth to multiples and of other mothers (n = 2 interviews and 4 FGs) where participants spoke with each other about infant feeding in relation to friends and family experiences. These conversations mainly took place in the FGs. Just over a quarter of the participants (N = 127) had referred to family or friends who had experienced multiple birth and feeding. This data was sought using text searches using the "query" option within NVivo to verify the frequency of use and relevance of key concepts [26] For example, all transcripts were searched for the terms *twin, multiple, triplet, babies*, this helped to identify and explain how mothers talked about their friends and family. Stata/SE 17.0 was used to descriptively analyse demographic data.

#### *Breastfeeding Multiples DOI: http://dx.doi.org/10.5772/intechopen.108916*

Preliminary data analysis allowed for a broad coding framework to be developed. Preliminary codes included: breastfeeding best for baby, care and helpers, multiple mumming, and "other" feeding. These were then thematically reduced into one large thematically driven parent node: capital. Thematically reducing the data using Bourdieu's concept of capital was achieved by selecting and abstracting, sorting and isolating patterns and relationships between variables, and finding commonalities and differences to support formalizing the emerging themes [27]. The node "capital" (and all references and sources) was expanded and reduced theoretically into two principal parent nodes (*physical and social capital*) with relevant sub-nodes. The final theme "Allofeeding" refers to the multiple resources (capital) mothers used to negotiate feeding multiple babies.

#### **4. Findings**

In this section pseudonyms and age are used to provide context. We begin by describing the mothers' characteristics analysis. This is followed by an interpretation and discussion of Capital and Allofeeding and related sub-themes using the findings of the analysis.

#### **4.1 Who participated in the study?**

Mothers in the TIF study were from a broad demographic and are reported elsewhere [28]. For those who had multiple births and were included in this analysis (N = 7) the mean age was 30.4 years (two mothers were aged <24 years), the highest education level achieved was a graduate diploma for five and three reported home duties/unemployed as occupation, with the reminder professional or sales/service. Four reported being married/living in with a partner, and three were single parents at the time of the study.

At the time of the study infants were > 12 months of age, mean age of 18 months. Three-quarters (5) of the infants were born <2500 g, and premature <37 completed weeks gestation. Only one mother had intended to mix feed (formula and breastmilk), with six intending to breastfeed after birth. None of the women were exclusively breastfeeding at the time of the study, two were mixed feeding (breastmilk and formula).

#### **4.2 Capital**

Bourdieu's concept of *capital* can be employed to explore how mothers exchange their physical and social resources during their struggle to breastfeed their twins or triplets. Bourdieu referred to three principal types of capital (economic, social and cultural): in the context of breastfeeding this included economic capital available for consumption/purchase such as money, formula milk, bottles, teats, feeding/shrouds blankets, pillows and sourcing advice via private consults with relevant health care practitioners cultural capital in the form of bodily characteristics and functions, education levels, knowledge, breastmilk, and social capital such as family, friends, fathers and relevant health professionals accessed via social networks [29].

The exchange of capital may occur in either a positive or negative way, generating additional resources or limiting the use of others. Duplication and mutations exist. For example, in this study, using breast milk—either expressed or directly feeding from the breasts—is exchanged for personal, social, and health profits (such as 'good mothering, self-esteem, the health of the baby) [21].

#### *Multiple Pregnancy - New Insights*

Capital in its symbolic (generating status) or material forms (money, education, breast milk) represents objective and subjective resources [29], that are available to the mother during her time mothering twins/triplets. For example, a mother's physical ability to lactate (produce milk) and choice to breastfeed are embodied as physical capital and provide know how. In the following quote, Sally (26) talks about her body as a resource to feed her triplets:

*they were born at 32 weeks by caesarean. Luke was in NICU, so he was being drip feed and had a gastric tube and the girls could breathe, but they were being tube feed. I was expressing colostrum like when you start and I found that really easy. It was like my body knew I had triplets and it was just producing huge amounts of colostrum. So that wasn't a problem, but they were being supplemented with formula through the tubes. They couldn't breastfeed because they were too small. It probably took the girls two weeks before they'd start to breastfeed and Luke much longer because he was small. So I was expressing and I reckon I got up to expressing two litres of breast milk a day. It was huge amounts. (Sally)*

This conscious and unconscious know how appears to come from both the acknowledgment of bodily physical capital [21], such as lactating breasts and experiences shared in the family cycle or peer social cycles.

#### **4.3 Allofeeding**

This thematic category uses the concept of capital to explore the practice of *allofeeding*. Allofeeding refers to "other-feeding" resources (forms of physical or material capital) that mothers spoke about and use to negotiate caring for and feeding their babies. Allofeeding does not replace the mother but facilitates and supports her in feeding her infant. It is essentially where the mother exchanges her body's physical capital (milk and breasts) and hands over her role as the physical feeder to another.

Allofeeding is therefore a form of capital exchange (breasts, milk, nipples, fathers, kin), that mothers have available as they navigate to feed. In this study, these fell into two groups, social (others) and physical forms of capital (breasts, bottles, other milk). Allofeeding, like the broader concept of allomothering means the shared care of the young infant. Anthropologist Blaffer Hrdy (2009), describes allomothering as:

*They [infants] have available to them [the mothers'] entire social world. The mother is the principal caretaker … suckling is frequent and often but by no means always on demand. Without allomothering we would not have a human race [30], p. 75–76*

For mothers who were breastfeeding multiples, allofeeding methods included bottles, teats, milk, their bodies, experts- such as lactation consultants, lay support organisations, and fathers, family, and friends. Allofeeding supports the exchange of "capital" offering the primary feeder support during the process of intensive feeding [21]. In the context of multiple mothering/feeding the mother proffers the role of the primary feeder [30] and thus exchanges her physical capital (breasts and milk) for another form of capital, such as expressing breast milk.

Women in this study employed multiple types of allofeeding to negotiate the breastfeeding of their twins and triplets. The women's accounts of what helped them feed their babies included the use of fathers/partners, and to a lesser degree "kin"—sisters, grandmothers and female friends or other mothers. Second to these

#### *Breastfeeding Multiples DOI: http://dx.doi.org/10.5772/intechopen.108916*

were consumable tools such as expressing equipment, dummies, bottles, and teats, expressing equipment. Mothers felt that these resources were "essential" for them to manage the day-to-day feeding of multiple babies.

#### **4.4 Exchange of social and physical capital**

Mothers were productive in their use of allofeeding, tailoring the use of commercial products such as bottles, dummies, teats, and formula as resources to suit their unique situation. Bottles, teats, and formula milk are consumer capital. As commodities they were a way to "keep sane," to give the mother a break and allow significant others to feed the babies. As a form of capital -these feeding tools, were converted into emotional and physical support. In the following quote, Alex (24) describes her desire to breastfeed and how she used bottles and formula to give her the commodity of time,

*I want to try and give it a go breastfeeding, because it's just like easier. Especially because I had the twins, just the bottles was were a nightmare. But whatever I can do. If I can do it, I can do it. See how it goes. It might be a bit easier just to bottle feed this time, because I've got the twins so I'm a bit flat out, so it will be just easier to make up formula. Instead of sitting down for two or three hours at a time trying to feed a baby, and then get up and do all the of it again…that's what they [health professionals] need to understand too, that mums like us have extra children, we don't have the time. Because bottle feeding can go much faster. When you've got other children you don't have the time to spend with them, and it does, it takes ages. (Alex, 24)*

The emotional and physical demands of breastfeeding multiple babies, as Samantha (28) said, being "the only one who can feed" and producing "enough milk" placed a great deal of strain on these mothers. They often spoke about what they perceived as their lack of freedom when breastfeeding, and the importance of being able to gain some respite from the constant demands of feeding:

*Yeah, I'm just exhausted I'm with them [twins] 24/7. (Alex 24)*

*Yeah, my friend had triplets and it [trying to breastfeed] nearly tipped her over the edge. (Samantha, 28)*

*Wow … couldn't do that (Petra, 30)*

The feeling of exhaustion does not reflect the mothers' deep personal desire to breastfeed [28]. Indeed, all seven women described the importance of providing breast milk either through expressing breast milk or feeding directly from the breast. However, there was a palpable need among the mothers to share the role so that they could continue breastfeeding. This often generated a feeling of conflict because of the desire "do it all" and "do what is right" and the need to "share the load" (Rose, 35). As the quote below suggests, this tension was heightened for mothers with twins as they talked about the demands of multiple mothering.

*I think it also takes a lot of energy to breastfeed twins, and you need to try and eat properly, and it also takes time …you spend a lot of time on the couch. But if you've just given birth, you're on the couch anyway…too much milk or too much supply, your boobs start to get really sore…there's too much of everything. (Petra, 30)*

Mothers expected themselves—and perceived that they were expected by others to breastfeed because "it is natural." This reification of 'natural' symbolises the ideology of a "good mother," a mother who sacrifices her body (physical capital) to meet the needs of her dependent infant [31]. However, for the mothers with twins/triplets, the message they received was to "lower their expectations" because it [breastfeeding] was not going to be as they expected. For this reason, women with multiples appeared to pragmatically accept the need for other commercial resources, bottles, teats, dummies and expressing equipment. These tools were all part of their role as the mother of multiples. The use of this type of commercial capital offered them opportunities to share their bodily capital, in exchange for a break, in exchange for a break as Rose describes below:

*…with breastfeeding that was something that was important to me, and knowing that I am doing the best thing for my babies. But also with bottle feeding, whether it was expressed milk or whether now it's cow's milk, I think it's nice for my husband to be able to bottle feed as well, so he can share the cuddling and that nice time, and I can sleep. (Rose, 35)*

Converting their bodily physical capital (breasts and milk) and mobilising others such as fathers and others (social capital) to provide relief and support through bottle feeding was a consistent issue raised by other women feeding twins/triplets in the study:

*I wanted to sleep, probably still wanted to sleep. So I'd twin feed two of them. I had a great breastfeeding pillow that you can't buy in the shops. It was made by a twin mum. So you could sit that on the couch around you and the two could twin feed and I could put a dinner plate in the middle and eat. I was constantly eating. So it never had that beautiful bonding breastfeeding that other people talk about and I'd either have my nanny or my husband for every feed giving a bottle to the third one and it would rotate. We'd have a roster up so that they all got equal amounts of breastfeeding and bottle feeding. (Rebecca, 31)*

The physical and emotional demands of simultaneously breastfeeding multiple infants were also experienced by women who bottle-fed (with breast milk or formula) while breastfeeding, in addition to those who exclusively bottle-fed using expressed breastmilk and formula milk. For these women, the advantage of bottles was that they could physically hand over (exchange) the baby and the feeding to another for the reward of returning to work, social outings:

*So the formula was introduced for the six pm and that gave me a bit of a break. We'd give the kids the six pm bottle and all the adults would have a glass of wine, that was the ritual. That was a lovely time, bottles and alcohol for everyone and then I stopped expressing, so they used up what was in the freezer and then they went to the formula for the third one and it's hard to remember now. When I was cutting it all out, I went back to just breastfeeding one of them… because I was worried about her allergies and then that's how I cut it down. Cutting down was really easy. I thought it would be hard, but it wasn't. Yeah, but what did it was me saying to my husband I can't cope and he said you have to and I thought okay well what do I do. All I can do is give up breastfeeding, so that's what I had to do. It was the only option left. (Deb, 30)*

*Q. And you felt relief once you did?*

*A. Oh totally, yeah. Wish I'd done it sooner. I wish I'd had the bonding.*

For mothers with twins/triplets using multiple forms of capital (social and physical) such as getting someone else to help feed the baby was the great benefit of using bottles. Conversely, Samantha (28), who had four children including twins, described a sense of guilt because she could not meet the demands of multiple breastfeeding her twins while also caring for other young children:

*Having a double breast pump [laughter from the other mothers] was a real flattering look and caring for four young children and to try to get them on the boob … ehhh. It was okay when my partner was off work, but as soon as he went back … I just couldn't manage. (Samantha)*

#### **4.5 Pressure**

All mothers in the study referred to a feeling of "pressure to breastfeed." They discussed this in relation to their own "high expectations," partners'/husbands' feeding preferences, generic health information about the nutritional benefits of breastmilk and avoidance of bottles, and health professionals' advice. Many of the participants had no frame of reference for feeding and learning to breastfeed multiple babies. They describe how the reality was a shock because they had not been exposed to twin feeding before:

*Well I don't know for mums of one baby because I've just got no idea what that pressures like or to bottle feed or not. For me having experience of other twin mum's would have been good. Mum's that said no I didn't breastfeed because the books that they give you is all about the mum's that do twin breastfeed and how you can do it, go girl you can do this. Don't let people pressure you, that you should breastfeed, that you can do it. In the little booklet that they give you, there was nothing that said it's okay to have formula as well as breast milk. So that would have helped now… Some support that that's okay to do both. Don't give it up completely and go to formula. You can still do both. (Rebecca, 31)*

For mothers of twins and triplets, the pressure and sense of failure after stopping exclusive breastfeeding appeared mitigated by the increased care burden of multiple babies. Consequently, using formula milk was felt to be an acceptable outcome of a multiple births, as Petra (30) stated "you have twins how can you do it all." Unlike mothers of singleton infants [28], twin/triplet mothers did not appear to struggle with the same depth of guilt and regret about stopping breastfeeding. Their experiences of ceasing to breastfeed were related to the "relentless" demands of caring and the unrecognised strain this placed on their bodies and mental health [19]. As such breastfeeding directly from the breast was the one task that could be traded- exchanged to afford the mother a break and as many women explained some sanity. This often led to a pragmatic decision to use formula milk. In the following quote, Deb (30) describes the relief she felt when she stopped breastfeeding,

*The fact that I was doing it [breastfeeding] meant to me that I should keep doing it. What would be the signal to stop? There was no obvious signal because you can't assess your own mental health when you're in it. There was no warning light to say* 

*you're falling apart. It was not like my milk dried up or anything. It was just coming and coming and coming.*

*Q. How did you feel when you stopped?*

*A. Relief. I wished id done it sooner. (Deb)*

For Deb, exchanging her embodied capital (breasts and milk) with bottles and formula milk offered her the opportunity to protect her mental health and well-being; another form of capital necessary for her to meet the needs of her family and self.

#### **4.6 Expressing**

For Bourdieu capital is most valuable when it is exchanged. Expressing milk and the use of bottles is the result of the exchange of two forms of bodily capital (breast and milk) and commercial capital, the mother's purchase, and use of bottles and/or teats and expressing equipment. All seven mothers expressed breastmilk. Collectively experiencing expressing breastmilk as challenging, and time-consuming. For some mothers, the exchange of their milk and use of bottles and teats was a welcome form of allofeeding. Petra (30) described the practice of expressing for her twins as "gold… yeah, because you feed off one side and then express the other, but I didn't do that –just fed and then expressed if I needed to".

Others talked of expressing and bottle feeding as a loss of autonomy, but a necessity. Alex (24) like other mothers, felt she had little choice but to express breast milk because she was constantly exhausted. She counted herself lucky because of her excess milk supply, stating that she felt "blessed with a huge supply." Many women described how they had to and were advised to "double pump" soon after birth because their babies were too small to feed at the breast, otherwise, they would not "last the distance" and have enough for two babies. Others shared how it made them feel objectified… "like a cow." Sally (26) explained that "it [expressing] wasn't a tasteful thing to do and the expressing machines…quite gross too."

Expressing and using bottles had a role in helping mothers to negotiate the extra care burden of breastfeeding multiple babies. In this context expressing breastmilk is used as a resource that can be exchanged for social and bodily freedoms, allowing mothers to continue to provide some breastmilk, while exchanging breast milk as a product that can be shared and benefit the health of the baby. Moreover, the provision of expressed breastmilk allowed the mother to retain the social status of a good mother, doing the best for her baby and continuing to "do what is right and give them some breast milk" (Samantha, 28).

#### **4.7 Fathers**

For coupled mothers' collaborative partnerships with the father of the infant appeared to be beneficial. Mothers described feeling less burdened by the "full-time" demands of breastfeeding twins/triplets when they were able to share some of the care demands with their partners. It was clear that support from the infants' fathers created an opportunity for continued breastfeeding. Rose (30), talked about how sharing the role of feeding with her partner allowed her to work through feeding issues while feeding her twins:

*Breastfeeding Multiples DOI: http://dx.doi.org/10.5772/intechopen.108916*

> *…it wasn't so bad when my other half was off work but as soon as he went back to work it was, just had no time all I was doing was pretty much feeding the twins flat out because I was doing one at a time because one wouldn't latch on properly and it just hurt like crazy. (Rose)*

The father's/partners investment in the mother and infants places them in the position of an allofeeder. In the context of multiple births, this role appeared to be separate from other external forms of commercial or social capital as multiple birth support groups, family members, nannies, economic support from government sources, and twin pillows. As in other studies, it was clear that the father of the infant was the most significant form of social capital for the breastfeeding mother with twins/triplets. As Rebecca (31) said, "because he [the father of the infant] was very involved, and I really supported him being involved right from the start." However, for some women who felt pressured to breastfeed the fathers' involvement generated some tension. In the following quote, Sally (26) a mother of triplets shares how the exchange of capital (father's time and investment) can be both positive and negative. Sally gains some symbolic capital (social acceptance and standing) by successfully breastfeeding her triplets – being a "good mother" but this is felt as both a gain and a loss.

*The breastfeeding was going well, but I felt pressured because it was going well and everyone was telling me what a wonderful job I was doing. But I didn't want to be doing it and I felt guilty because I didn't want to be doing it. But everyone was going oh aren't you great, aren't you wonderful and my husband was bragging to everyone, but deep down I was like oh please I wish I didn't have to do this [breastfeeding]. (Sally, 26)*

Overall, allofeeding, particularly when the father of the baby is involved, appeared to provide some benefits to the mother and father collectively as a care and feeding unit. The mother's partner and her physical capital (breast and milk) appeared to be exchanged as capital for the benefit of the multiple-family unit.

#### **5. Conclusion**

In this chapter, we have explored how Bourdieu's concept of capital helps to view the mother's breastfeeding body as a form of physical capital that offers a profitable return for multiple birth families- mother, father/partner, and babies. The return is often increased social status, such as a perception of being a good mother and improving the health of the babies through providing breastmilk. In this secondary analysis of women's experiences of feeding their twins/triplet babies, women used many forms of physical and social capital to help them negotiate the increased care and feeding demands. These included using fathers/partners, bottles, formula milk, expressing equipment and teats and all represent a form of allofeeding.

While the challenges of breastfeeding may be higher for the mothers of multiples the pressure to breastfeed (exclusively or any) appeared to be mitigated by the perceived demands of a multiple births. The use of allofeeding (of bottles, teats, formula milk, and expressing equipment) was accepted and normalised as part of the process of feeding multiple babies. For the twin/triplet mother the need to convert social and physical capital to manage the extra care demands was palpable. The conversion

of capital, therefore, supports the mental and emotional well-being of the mother by allowing her to share the care and pressures to breastfeed. In turn, the act of breastfeeding multiples whether through expressed breastmilk and or feeding from the breast generates numerous types of capital for both mother and baby, including symbolic capital—where the mother's body is used to double the social return—reinforcing the social ideology of "good mothering" [31, 32].

### **Acknowledgements**

We would like to acknowledge the funding from the Tasmanian Early Years Association and the contribution of the women who participated in this study.

### **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Jennifer Ayton1 \* and Emily Hansen<sup>2</sup>

1 School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Australia

2 School of Social Sciences, College of Arts Law and Education, University of Tasmania, Hobart, Australia

\*Address all correspondence to: jennifer.ayton@utas.edu.au

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] World Health Organisation/ UNICEF. Global Nutrition Targets 2025: Breastfeeding Policy Brief. Geneva: World Health Organization (WHO); 2014

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Section 4 Complication

#### **Chapter 9**
