3. Psychological issues associated with twin pregnancy: the building of prenatal attachment

#### 3.1. What is prenatal attachment?

Research on the mother-infant relationship has its origins in Bowlby's attachment theory [49]. This theory is raised from different disciplines such as ethology, cybernetics, information processing, developmental psychology and psychoanalysis, and it originally focused both on the infant's biological need for a secure early attachment to the mother and on the mother's response [49, 50]. Starting from Bowlby's theory, Mary Ainsworth added to the attachment theory the emotional component, based on the idea that the infant's contribution to the attachment process was more than biological and included baby's affective evaluation of the mother's behaviors [51]. Starting from this theoretical framework, many researches investigated mother-infant attachment during infancy [52], adolescence and adulthood [53–55], focusing both on behavioral and emotional markers to measure attachment.

Attachment has been described as "the innate tendency of children to create privileged affective bonds with at least one adult person (the caregiver) who takes care of them from birth" [50]. The study of how children develop this bond with their caregiver has identified two main types: secure and insecure [51]. The first would be those children who could use their mother (the caregiver) as a "safe base" that allow the children to explore the environment. These children usually cry at the time of separation, but they are capable to comfort themselves at the time of the reunion with the mother, returning to play. On the other hand, children with insecure attachment explore the environment less and are anxious when a stranger stays with them in the same room, even if the caregiver is near them; moreover, they become anxious also at the moment of separation from their caregiver and they usually cannot be consoled at the moment of the reunion with their caregiver. On the basis of the attachment relationship experienced, children would build a sort of primary mental "representations," the Internal Working Models (IWMs), that will regulate their peculiar interactive patterns [56]. The IWMs develop from the internalization of recurring interactive experiences between the children and their caregiver and the quality of their organization depends on the quality of care received during childhood. In the secure attachment pattern, IWMs would consist of representing the attachment figure as available to respond positively and consistently to requests for help and comfort, while in insecure attachment patterns, the IWMs would be organized starting from the representation of the caregiver as not available to respond properly at the requests of help and comfort, an attachment figure that is not attuned to the needs of the child, that are usually distant and, sometimes, even hostile. In reality, further studies pointed out that IWMs does not depend exclusively on the quality of the care received, but in a more complex way on the meanings that the caregiver communicate to the child with their behavior and conduct.

rates and better perinatal conditions after birth [44]. Compared to term twin pregnancies, preterm twin pregnancies increase the risk of complications such as neonatal mortality, respiratory distress syndrome (RDS), sepsis, periventricular leukomalacia (PVL) and intraventricular hemorrhage (IVH). In addition, population-based studies from large databases have shown a higher risk of cerebral palsy in twins than in singletons. Studies found different risk profiles in relation to gestational age at birth. In particular, it was found that the presence of one or more of the above complications is present in 30% of moderately preterm infants (born between 32 and 33 + 6 weeks of GA), in 13% of late preterm infants (born between 34 and 36 + 6 weeks of GA) and only in 0.5% of twins born at term [21]. Therefore, all the complicated twin pregnancies have to be managed in tertiary level perinatal centers with both skilled

Finally, another relevant aspect that needs to be taken into account is breastfeeding. Mothers of risk infants, as some twins are, may not have the opportunity to experience breastfeeding. Additionally, also in the case of healthy twins, breastfeeding can result a challenge for mothers. It is documented that a mother's feelings and attitudes on breastfeeding can considerably influence on its initiation [45]. For mothers of twins, breastfeeding may be physically uncomfortable; some of them are not able to establish an adequate milk support for two babies [46]. Moreover, several mothers of twins find that their experience of breastfeeding two children is stressful and fraught. Additionally, Mitra et al. [47] observed that those mothers who were well prepared for the realities of breastfeeding had a more successful experience in terms of its duration. Mothers of twins usually feel ill-prepared for breastfeed their twins and reported a

3. Psychological issues associated with twin pregnancy: the building of

Research on the mother-infant relationship has its origins in Bowlby's attachment theory [49]. This theory is raised from different disciplines such as ethology, cybernetics, information processing, developmental psychology and psychoanalysis, and it originally focused both on the infant's biological need for a secure early attachment to the mother and on the mother's response [49, 50]. Starting from Bowlby's theory, Mary Ainsworth added to the attachment theory the emotional component, based on the idea that the infant's contribution to the attachment process was more than biological and included baby's affective evaluation of the mother's behaviors [51]. Starting from this theoretical framework, many researches investigated mother-infant attachment during infancy [52], adolescence and adulthood [53–55],

Attachment has been described as "the innate tendency of children to create privileged affective bonds with at least one adult person (the caregiver) who takes care of them from birth" [50]. The study of how children develop this bond with their caregiver has identified two main

focusing both on behavioral and emotional markers to measure attachment.

gynecologists and neonatologists in this field.

86 Multiple Pregnancy - New Challenges

lack of information and support during pregnancy [4, 48].

prenatal attachment

3.1. What is prenatal attachment?

While the theory of neonatal attachment places the emphasis on the child, the theory of prenatal attachment emphasized the type of affective investment that parents, and especially mothers, have towards the child-to-be, an investment that begins and developed during the different stages of pregnancy. In fact, it was observed that the very early relationship between the mother and her babies does not start at birth [57], but it was recognized that it begins while the child is still a fetus [58]. With the perception of the fetal movements, the pregnant woman starts a process of psychological separation from the fetus and begins to view herself as a "mother" [59]. In particular, the concept of prenatal attachment is defined as "the unique relationship that develops between a woman and her fetus" [60] and "the emotional tie or bond which normally develops between the pregnant parent and her unborn infant" [61].

Different studies on prenatal attachment investigated its intensity during different period of gestation. Research that used a longitudinal design demonstrated a significant increase in terms of level of prenatal attachment measures during the entire course of the pregnancy [60, 62–64]. It was observed that immediately after the beginning of pregnancy, the level of prenatal attachment may depend on some situational factors, for example, if the woman has perceived fetal movement or if has seen an ultrasound image of the fetus [63]. It was also found that prenatal attachment develops in an orderly sequential way during the course of pregnancy [57, 58, 65]. In the first trimester, relatively low levels of prenatal attachment were observed, while with the increasing of gestational age, mothers start talking to the fetus, call the child-to-be per name [63] and, in the second and third trimesters, increase "nesting" behaviors. Also in a recent literature review on maternal-fetal attachment, Yarcheski et al. [66] suggested that the magnitude of this relationship is strongest during the third trimester of pregnancy.

Moreover, in recent years, different researches started to deeply investigate prenatal attachment, with particular attention to the link between the nature of this early mother-fetus relationship and the mother's early parenting experiences and attachment style in the postpartum period [67]. In fact, pregnancy could be considered a developmental process in which pregnant women start their transition into parenthood. This process implies different psychological changes and challenges that play an important role in the establishment of a successful parent-child relationship. Different researches showed that prenatal attachment could play an important role in identifying as soon as possible parents who found difficulties in developing a close and positive parent-child interaction during infancy [68].

A third descriptive correlational study by Damato investigated through an online survey the level of prenatal attachment for each twin in a sample of 202 expectant mothers. It was found that the mother experience a significant higher level of prenatal attachment for the twin that later has been born for second. In addition, it was also observed a small but significant correlation between prenatal attachment and both gestational age and fetal movement [75].

Prenatal Attachment in Twin Pregnancy http://dx.doi.org/10.5772/intechopen.79365 89

The same author conducted two other studies on prenatal attachment during twin pregnancy [19, 76]. In the first study, a predictive correlational descriptive design was used to evaluate the role played by demographic and biological factors, as well as personal resources in predicting the level of prenatal attachment during twin pregnancy in a sample of 241 women expecting twins. It was demonstrated that history of infertility treatment, older age and lower family income predicted lower level of prenatal attachment, while the presence of fetal movement, higher gestational age and higher self-esteem predicted higher level of prenatal attachment. However, it was observed that only a small portion of variance was explained by the pre-

The other study by Damato investigated the influence of prenatal attachment and other relevant perinatal variables such as method of delivery, mother's health and depression, infant birth weight and neonatal intensive care unit (NICU) admission, on postnatal attachment in a sample of 139 mothers of twins. A modest but significant relationship between prenatal and postnatal attachment was observed. Moreover, it was found that also maternal characteristics, such as depression, and the context of the perinatal experience, such as delivery method and

Finally, the most recent study that investigated prenatal attachment during twin pregnancy aimed at exploring the level of prenatal attachment in a sample of 83 expectant mothers during dichorionic pregnancies, uncomplicated monochorionic pregnancies and monochorionic pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). In particular, it was showed that the increase of prenatal attachment in the last trimester of pregnancy, usually described in singleton pregnancies [78], was observed both in dichorionic and uncomplicated monochorionic pregnancies, while this intensification was not observed in pregnancies complicated by TTTS. The fear represented by the high risk associated to TTTS pregnancies, the uncertainty for the pregnancy outcome and the doubt for the health of the fetus seemed to

Starting from the existing literature on prenatal attachment both in singleton and in twin pregnancies and from those studies that investigate possible threat associated to twin pregnancies considering both medical and psychological risks factors, it is possible to suppose and infer which further variables may play a relevant role during twin pregnancy in impairing the building process of prenatal attachment or, on the contrary, in promoting the building of a

Previous studies showed that the presence of medical risk and the higher prevalence of complication during pregnancy are generally associated to psychological suffering in mothers [14]. It

the NICU admission of the babies, influence the attachment process [76].

3.3. Risk and protective factors for prenatal attachment in twin pregnancy

dictors considered in the study.

reduce prenatal attachment [13].

close positive mother-fetus relationship.

Other studies focused on the examination of potential risk or protective factors that could influence prenatal attachment. It was observed that fetal movement and increased gestational age were positively related with attachment [62, 64]. There are also pieces of evidence that some demographic variables, such as maternal age and education, may correlate with attachment [19]. Positive correlations have also been found between prenatal attachment and the quality of marital status [58, 61, 68], as well as between prenatal attachment and perceived social support during pregnancy. In addition, other researches identified other situational risk factors that could modify the quality and the intensity of expression of prenatal attachment [63] as loss or stillbirth in a previous pregnancy [69, 70], medical risk during pregnancy [71], physical symptoms [72, 73], depression and anxiety [74] and twin pregnancies [19, 75, 76].

#### 3.2. Prenatal attachment in twin pregnancy: a review of existing literature

Focusing on prenatal attachment in twin pregnancy, it is possible to observe that it may be different from singleton ones [18]. In fact, during a twin pregnancy, the mother-to-be has to deal with an identification process with two babies simultaneously and has to build a space that allows her to make representation of both children. This process includes representations of physical and emotional characteristics of two different fetuses and of the interactions between the mother and her child-to-be, as well as dreams and expectations about both the babies.

Despite previous works on prenatal attachment in mother of twins observed that it may be a risk factor for the development of a close and positive relationship between the mother and the babies, as far as we know, only six studies explored prenatal attachment in twin pregnancies [13, 19, 48, 75–77].

In a descriptive study of 10 women using grounded theory methodology, Van der Zalm observed that the process of prenatal attachment depends on zygosity. In particular, in the case of identical twin, mothers used to view their babies as a pair with similar characteristics, while in the case of fraternal twin mothers used to think about their babies as individuals with different characteristics [77].

A second study conducted by Colpin and colleagues aimed to evaluate the quality of prenatal attachment in a sample of 61 mothers expecting twins at the beginning of the last trimester of pregnancy. Higher quality of prenatal attachment was predicted by higher maternal psychosocial well-being and by higher marital satisfaction. However, it was observed that these variables explained only a small portion of variance of the quality of maternal attachment [48]. A third descriptive correlational study by Damato investigated through an online survey the level of prenatal attachment for each twin in a sample of 202 expectant mothers. It was found that the mother experience a significant higher level of prenatal attachment for the twin that later has been born for second. In addition, it was also observed a small but significant correlation between prenatal attachment and both gestational age and fetal movement [75].

Moreover, in recent years, different researches started to deeply investigate prenatal attachment, with particular attention to the link between the nature of this early mother-fetus relationship and the mother's early parenting experiences and attachment style in the postpartum period [67]. In fact, pregnancy could be considered a developmental process in which pregnant women start their transition into parenthood. This process implies different psychological changes and challenges that play an important role in the establishment of a successful parent-child relationship. Different researches showed that prenatal attachment could play an important role in identifying as soon as possible parents who found difficulties in developing a

Other studies focused on the examination of potential risk or protective factors that could influence prenatal attachment. It was observed that fetal movement and increased gestational age were positively related with attachment [62, 64]. There are also pieces of evidence that some demographic variables, such as maternal age and education, may correlate with attachment [19]. Positive correlations have also been found between prenatal attachment and the quality of marital status [58, 61, 68], as well as between prenatal attachment and perceived social support during pregnancy. In addition, other researches identified other situational risk factors that could modify the quality and the intensity of expression of prenatal attachment [63] as loss or stillbirth in a previous pregnancy [69, 70], medical risk during pregnancy [71], physical symptoms [72, 73], depression and anxiety [74] and twin pregnancies [19, 75, 76].

Focusing on prenatal attachment in twin pregnancy, it is possible to observe that it may be different from singleton ones [18]. In fact, during a twin pregnancy, the mother-to-be has to deal with an identification process with two babies simultaneously and has to build a space that allows her to make representation of both children. This process includes representations of physical and emotional characteristics of two different fetuses and of the interactions between the mother and her child-to-be, as well as dreams and expectations about both the babies.

Despite previous works on prenatal attachment in mother of twins observed that it may be a risk factor for the development of a close and positive relationship between the mother and the babies, as far as we know, only six studies explored prenatal attachment in twin pregnancies

In a descriptive study of 10 women using grounded theory methodology, Van der Zalm observed that the process of prenatal attachment depends on zygosity. In particular, in the case of identical twin, mothers used to view their babies as a pair with similar characteristics, while in the case of fraternal twin mothers used to think about their babies as individuals with

A second study conducted by Colpin and colleagues aimed to evaluate the quality of prenatal attachment in a sample of 61 mothers expecting twins at the beginning of the last trimester of pregnancy. Higher quality of prenatal attachment was predicted by higher maternal psychosocial well-being and by higher marital satisfaction. However, it was observed that these variables explained only a small portion of variance of the quality of maternal attachment [48].

close and positive parent-child interaction during infancy [68].

88 Multiple Pregnancy - New Challenges

3.2. Prenatal attachment in twin pregnancy: a review of existing literature

[13, 19, 48, 75–77].

different characteristics [77].

The same author conducted two other studies on prenatal attachment during twin pregnancy [19, 76]. In the first study, a predictive correlational descriptive design was used to evaluate the role played by demographic and biological factors, as well as personal resources in predicting the level of prenatal attachment during twin pregnancy in a sample of 241 women expecting twins. It was demonstrated that history of infertility treatment, older age and lower family income predicted lower level of prenatal attachment, while the presence of fetal movement, higher gestational age and higher self-esteem predicted higher level of prenatal attachment. However, it was observed that only a small portion of variance was explained by the predictors considered in the study.

The other study by Damato investigated the influence of prenatal attachment and other relevant perinatal variables such as method of delivery, mother's health and depression, infant birth weight and neonatal intensive care unit (NICU) admission, on postnatal attachment in a sample of 139 mothers of twins. A modest but significant relationship between prenatal and postnatal attachment was observed. Moreover, it was found that also maternal characteristics, such as depression, and the context of the perinatal experience, such as delivery method and the NICU admission of the babies, influence the attachment process [76].

Finally, the most recent study that investigated prenatal attachment during twin pregnancy aimed at exploring the level of prenatal attachment in a sample of 83 expectant mothers during dichorionic pregnancies, uncomplicated monochorionic pregnancies and monochorionic pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). In particular, it was showed that the increase of prenatal attachment in the last trimester of pregnancy, usually described in singleton pregnancies [78], was observed both in dichorionic and uncomplicated monochorionic pregnancies, while this intensification was not observed in pregnancies complicated by TTTS. The fear represented by the high risk associated to TTTS pregnancies, the uncertainty for the pregnancy outcome and the doubt for the health of the fetus seemed to reduce prenatal attachment [13].
