Characteristics of and Sources of Support for Women Who Breastfed Multiples for More than 12 Months

Abstract

Background and Objective:

Although rates of breastfeeding initiation for multiples may be similar to those of singletons, breastfeeding duration falls short. Evidence-based interventions tailored to families with multiples may help reduce the gap; however, these do not yet exist and will require a stronger knowledge base about factors related to successful breastfeeding of multiples for long durations.

To characterize mothers of multiples who breastfed for >12 months and identify support factors that were important.

Materials and Methods:

Mothers of multiples who breastfed for >12 months completed an online questionnaire about their breastfeeding experiences. Bivariate statistics and log-binomial regression were used to examine associations among maternal characteristics, influential factors, and sources of breastfeeding support.

Results:

This sample of 1,173 women commonly cited partner support, the nutritional/health benefits of breastfeeding, building a strong bond, and enjoyment of breastfeeding as important influences on their decision to breastfeed for >12 months. Younger women, women with less education, Hispanic or Latina women, and nonwhite women were more likely to indicate that cost was important in their decision to breastfeed for more than 12 months (all chi-square p < 0.02). Women with more children were less likely to discuss their decision with their friends or partner (e.g., women with 5+ versus 2 children, relative risk for partner = 0.65, 95% confidence interval: 0.52–0.81).

Conclusion:

Interventions to encourage long-term breastfeeding of multiples might consider promoting the cost, health, and relationship building benefits. Mobilizing a variety of supports—including partners and family—could help mothers of multiples sustain breastfeeding.

Introduction

In 2018, the United States Centers for Disease Control and Prevention (CDC) Breastfeeding Report Card reported that 83.2% of U.S. infants were breastfed postdelivery. By 6 postnatal months, the proportion dropped to 57.6%, and by 1 year to 35.9%.¹ Infant nutrition guidelines from the World Health Organization (WHO) recommend exclusive breastfeeding until infants are 6 months old and continued breastfeeding to 2 years of age with the proper supplemental food.² Although population-based estimates are not available for mothers who deliver multiples (twins, triplets, and so on), breastfeeding initiation rates appear to be almost as high as those of singletons, with around 70% or more mothers of multiples initiating breastfeeding.³ However, according to one prior study, at 6 months, only about 25% of twins and 15% of triplets receive breast milk.⁴ In addition to their higher probability of being born preterm, which can impede the establishment of successful breastfeeding, caring for multiples is particularly demanding, and this may lead some mothers to cease breastfeeding earlier than desired. Thus, mothers of multiples may benefit from breastfeeding support approaches tailored to their needs.

Unfortunately, no randomized trials have tested the effectiveness of any particular education or support intervention for mothers and their multiples. In fact, a recent Cochrane Review identified the “… need for well-designed adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.”⁵

To develop effective tailored approaches, a better understanding of what factors help mothers of multiples meet their breastfeeding goals is needed. Only a few prior studies have contributed such knowledge. For instance, several studies have found that early intervention and support from medical professionals, the woman's partner, and other significant persons were important for achieving breastfeeding goals for mothers of multiples,^6–9 while prematurity/hospitalization and mixed feeding have been highlighted as common reasons for early breastfeeding cessation.¹⁰ However, a majority of the research on breastfeeding multiples was published in the early 2000's, and many prior study samples were small. Thus, robust research findings based on contemporary samples are scant.

To contribute toward filling some of these gaps, the current study aimed to characterize a large sample of mothers of multiples who breastfeed for over a year and to identify the support factors that were most helpful to their experience. By focusing on mothers of multiples who were able to breastfeed for particularly long durations, the study aimed to provide a basis to support the development of tailored interventions for this population, and thereby help extend breastfeeding duration for multiples.

Materials and Methods

“Breastfeeding Beyond One Year of Age” was a cross sectional study that involved a self-administered online questionnaire hosted in SurveyMonkey and distributed in 2013 via international email and social media platforms affiliated with the La Leche League (LLL), a large international breastfeeding support organization. The original study was designed to gather quantitative and qualitative information regarding the breastfeeding experiences of women who had breastfed at least one of their children at least 1 year.

Study sample

Women aged 18 years and older who affirmed that they had breastfed at least two surviving infants in a set of multiples for more than 12 months were eligible for the present secondary data analysis project. Women who were breastfeeding group leaders or clinically credentialed professionals were excluded because their personal breastfeeding experiences may not be generalizable. Women whose breastfeeding experiences were in the distant past were excluded by omitting women whose oldest child was >25 years old. Women were not excluded if they breastfed one infant in a set of multiples longer than the other if the shortest duration remained more than 12 months.

Study measures

The questionnaire was written in English and distribution targeted U.S. women; however, women in other countries received the questionnaire from LLL affiliates or peers as well. The study questionnaire was developed de novo for this study and consisted of demographic questions, a breastfeeding history for the children, and a section focused on the woman's breastfeeding supports. Specifically, women were asked about 13 potential factors that may have had an important influence on the decision to breastfeed for more than 12 months. The second set of questions focused on whether the woman discussed the decision to breastfeed for more than 12 months with key individuals (the child's primary care provider; their own health care providers; their mother; their closest friend; and their spouse, partner, or significant other). Only women whose multiples were their oldest children who they breastfed for more than 12 months were included in the analysis of the second question set; women who had one or more older singletons who were breastfed for more than 12 months were not included in the analyses. For women who did not discuss the decision to breastfeed for more than 12 months with one or more of the listed health care providers, their reasoning was asked about in a third section of the questionnaire. Data contained no identifiers and no participation incentive was provided. The study was reviewed and approved by the Institutional Review Board of the North Shore-LIJ Health System. Participants indicated their consent to participate using a checkbox on the first screen of the questionnaire.

Data analysis

The analysis was conducted using STATA 14 and SAS 9.4. Descriptive statistics were used to explore sample characteristics and factors that influenced women's decisions to breastfeed for more than 12 months. Chi-square and Fisher's exact tests evaluated relationships between demographic characteristics and the 13 potentially influential factors listed on the questionnaire. Log-binomial regression examined associations between maternal characteristics, influential factors, and sources of breastfeeding support.

Results

A total of 86,667 women completed questionnaires. Women (n = 12,041) who were breastfeeding group instructors or clinically credentialed professionals, women whose oldest child(ren) was >25 years of age at the time of the study (n = 3,202), and women younger than 18 years of age who errantly completed the questionnaire (n = 20) were excluded per the eligibility criteria. To focus the analysis on the experiences of women with multiples, women with only singletons were excluded (n = 85,494), leaving a final sample of 1,173 eligible women with multiples included in the main analyses. Of these 1,173 women, 638 had multiples who were the oldest children breastfed for more than 12 months and, therefore, were included in all analyses.

More than half of the women were between the ages of 30 and 39 years at the time of the questionnaire, and almost 60% of the women achieved a Bachelor's or higher degree (Table 1). The majority of the sample was from the United States and included mainly white, non-Hispanic/Latina women. Most women had more than two children (including the multiples), and about one-half breastfed more than two total children for more than 12 months.

Table 1.

Characteristics of Women Who Breastfed Multiples for More than 12 Months (2013, N = 1,173)

Characteristic	Total sample (N = 1,173)		Subset sample (N = 638)
Characteristic	N	%	N	%
Maternal age
18–29 Years	144	12.3	86	13.5
30–39 Years	620	52.9	326	51.1
40–50 Years	225	19.2	107	16.8
Missing	184	15.7	119	18.7
Maternal education
Some college degree or less	198	16.9	86	13.5
Associate's degree	103	8.8	44	6.9
Bachelor's degree	350	29.8	188	29.5
Master's degree	242	20.6	142	22.3
Professional or doctorate degree	98	8.4	60	9.4
Missing	182	15.5	118	18.5
Place of residence
United States	800	68.2	422	66.1
Europe	66	5.6	34	5.3
Canada	63	5.4	29	4.5
Other	63	5.4	36	5.6
Missing	181	15.4	117	18.3
Women living in the United States
New England	47	4.0	33	5.2
North Central	101	8.6	62	9.7
Mid Atlantic	146	12.4	83	13.0
South Atlantic	169	14.4	81	12.7
South Central	122	10.4	59	9.2
Mountain	67	5.7	31	4.9
Pacific	145	12.4	72	11.3
U.S. Territories or living abroad	2	0.2	0	0.0
Missing	1	0.1	1	0.2
Ethnicity
Non-Hispanic or Latina	945	80.6	494	77.4
Hispanic or Latina	44	3.8	25	3.9
Missing	184	15.7	119	18.7
Race
White	920	78.4	485	76.0
All others	69	5.9	34	5.3
Missing	184	15.7	119	18.7
No. of multiples
Twins	1,158	98.7	630	98.7
Triplets or higher order multiples	15	1.3	8	1.3
No. of children
2	405	34.5	394	61.8
3	435	37.1	165	25.9
4	192	16.4	45	7.1
5 or More	141	12.0	34	5.3
No. of children breastfed for more than 12 months
2	557	47.5	452	70.8
3	420	35.8	147	23.0
4	125	10.7	25	3.9
5 or More	71	6.1	14	2.2

Subset sample is the group of women whose oldest children were a set of multiples they breastfed for more than 12 months.

Although health care providers, family, and friends were not generally ranked as important in the decision to breastfeed for more than 12 months (<26% ranked these potential sources of support as very important), 70.6% indicated that support from their partner was very important/important (Table 2). The nutritional value of breast milk and the other health benefits to be gained from breastfeeding were indicated as very important/important by 98% of the women. Creating a strong bond with the child and the child enjoying breastfeeding were each ranked as very important/important by around 97% of the women. Eighty-seven percent of women indicated that their own enjoyment of breastfeeding was very important/important in their decision to continue for more than 12 months.

Table 2.

Factors That Influenced Mothers with Multiples' Decision to Breastfeed for More than 12 Months (2013, N = 1,173)

Factors	Very important		Important		Somewhat important		Not important		Not applicable
Factors	N	%	N	%	N	%	N	%	N	%
Child's primary care provider's recommendation	64	6.6	136	14.0	166	17.0	295	30.3	313	32.1
Mother's doctor's recommendation	32	3.3	88	9.0	160	16.4	323	33.2	371	38.1
Spouse, partner, or significant other's support	422	43.3	266	27.3	166	17.0	64	6.6	56	5.8
Family members' recommendations	85	8.7	164	16.8	260	26.7	326	33.5	139	14.3
Friends' recommendations	66	6.8	179	18.1	288	29.6	326	33.5	115	11.8
Ethnic background and/or cultural beliefs	75	7.7	80	8.2	97	10.0	349	35.8	373	38.3
Breastfeeding is cheaper than buying formula	289	29.7	227	23.3	212	21.8	181	18.6	65	6.7
Nutritional value of breast milk	916	94.1	43	4.4	6	0.6	6	0.6	3	0.3
Other health benefits	899	92.3	57	5.9	9	0.9	7	0.7	2	0.2
Building a strong bond with child	881	90.5	70	7.2	14	1.4	6	0.6	3	0.3
Mother enjoys breastfeeding	676	69.4	169	17.4	85	8.7	32	3.3	12	1.2
Child enjoys breastfeeding	845	86.8	93	9.6	27	2.8	5	0.5	4	0.4
Child refuses to drink from bottle or cup	101	10.4	99	10.2	130	13.4	262	26.9	382	39.2

Missing data: 199 respondents for all factors.

A handful of differences by participant characteristics were noted to be influential factors to the decision to breastfeed more than 12 months. For instance, the support of a spouse, partner, or significant other was more likely to be a very important/important factor for Hispanic/Latina than non-Hispanic/Latina women (p = 0.04, Table 3). Younger women, women with less education, Hispanic or Latina women, and nonwhite women were more likely to indicate that breastfeeding being cheaper than formula was very important/important in their decision to breastfeed for more than 12 months (all p < 0.02). Maternal enjoyment of breastfeeding was found to be important as the number of children a woman had increased (p = 0.01). Hispanic/Latina women were more likely than non-Hispanic/Latina women to identify their children's refusal to drink from a bottle or cup as a very important/important factor (p = 0.04).

Table 3.

Associations Between Participant Characteristics and Factors That Influenced the Decision to Breastfeed Multiples for More than 12 Months (2013, N = 1,173)

Factors	Maternal age			p	Maternal education			p	Place of residence		p
	18–29 Years	30–39 Years	40–50 Years		High school/associate's degree	Bachelor's degree	Graduate degree		United States	Non-United States
	N (%)	N (%)	N (%)		N (%)	N (%)	N (%)		N (%)	N (%)
Child's primary care provider's recommendation
Very important/important	32 (32.7)	125 (29.4)	43 (31.2)	0.79	62 (30.9)	75 (31.3)	63 (28.6)	0.81	169 (31.2)	31 (26.1)	0.27
Somewhat/not important	66 (67.4)	300 (70.6)	95 (68.8)	0.79	139 (69.2)	165 (68.8)	157 (71.4)	0.81	373 (68.8)	88 (74.0)	0.27
Mother's doctor's recommendation
Very important/important	22 (24.2)	72 (18.8)	26 (20.3)	0.50	44 (23.2)	44 (19.4)	32 (17.2)	0.34	95 (19.6)	25 (21.4)	0.66
Somewhat/not important	69 (75.8)	312 (81.3)	102 (79.7)	0.50	146 (76.8)	183 (80.6)	154 (82.8)	0.34	391 (80.5)	92 (78.6)	0.66
Spouse, partner, or significant other's support
Very important/important	109 (78.4)	441 (76.3)	138 (68.7)	0.06	203 (74.1)	248 (75.4)	237 (75.2)	0.93	557 (75.4)	131 (73.2)	0.54
Somewhat/not important	30 (21.6)	137 (23.7)	63 (31.3)	0.06	71 (25.9)	81 (24.6)	78 (24.8)	0.93	182 (24.6)	48 (26.8)	0.54
Family members' recommendations
Very important/important	46 (34.3)	160 (30.4)	43 (24.6)	0.16	84 (33.3)	83 (27.4)	82 (29.3)	0.30	200 (29.7)	49 (30.4)	0.85
Somewhat/not important	88 (65.7)	366 (69.6)	132 (75.4)	0.16	168 (66.7)	220 (72.6)	198 (70.7)	0.30	474 (70.3)	112 (69.6)	0.85
Friends' recommendations
Very important/important	36 (27.1)	160 (29.8)	49 (25.9)	0.55	79 (31.1)	72 (23.5)	94 (31.5)	0.05	202 (29.2)	43 (25.8)	0.38
Somewhat/not important	97 (72.9)	377 (70.29)	140 (74.1)	0.55	175 (68.9)	235 (76.6)	204 (68.5)	0.05	490 (70.8)	124 (75.3)	0.38
Ethnic background and/or cultural beliefs
Very important/important	26 (24.8)	100 (27.1)	29 (22.8)	0.62	48 (23.9)	46 (21.9)	61 (32.1)	0.05	123 (25.1)	32 (28.8)	0.42
Somewhat/not important	79 (75.2)	269 (72.9)	98 (77.2)	0.62	153 (76.1)	164 (78.1)	129 (67.9)	0.05	367 (74.9)	79 (71.2)	0.42
Breastfeeding is cheaper than buying formula
Very important/important	90 (67.2)	336 (58.1)	90 (45.7)	<0.01	179 (63.7)	187 (57.9)	150 (49.2)	<0.01	423 (57.9)	93 (52.3)	0.17
Somewhat/not important	44 (32.8)	242 (41.9)	107 (54.3)	<0.01	102 (36.3)	136 (42.1)	155 (50.8)	<0.01	308 (42.1)	85 (47.8)	0.17
Nutritional value of breast milk
Very important/important	143 (100.0)	597 (98.4)	219 (99.1)	0.33^a	294 (99.7)	342 (99.1)	323 (97.6)	0.06^a	771 (98.7)	188 (99.0)	1.00^a
Somewhat/not important	0 (0.00)	10 (1.7)	2 (0.9)	0.33^a	1 (0.3)	3 (0.9)	8 (2.4)	0.06^a	10 (1.3)	2 (1.1)	1.00^a
Other health benefits
Very important/important	143 (100.0)	595 (97.9)	218 (98.6)	0.20^a	293 (99.7)	341 (98.8)	322 (96.7)	0.01^a	769 (98.5)	187 (97.9)	0.53^a
Somewhat/not important	0 (0.0)	13 (2.1)	3 (1.4)	0.20^a	1 (0.3)	4 (1.2)	11 (3.3)	0.01^a	12 (1.5)	4 (2.1)	0.53^a
Building a strong bond with child
Very important/important	142 (99.3)	590 (97.4)	219 (98.7)	0.29^a	292 (99.0)	340 (98.6)	319 (96.4)	0.05^a	765 (98.1)	186 (97.4)	0.57^a
Somewhat/not important	1 (0.7)	16 (2.6)	3 (1.4)	0.29^a	3 (1.0)	5 (4.5)	12 (3.6)	0.05^a	15 (1.9)	5 (2.6)	0.57^a
Mother enjoys breastfeeding
Very important/important	127 (90.7)	529 (88.0)	189 (85.5)	0.33	264 (90.1)	303 (88.3)	278 (85.3)	0.17	678 (87.6)	167 (88.8)	0.64
Somewhat/not important	13 (9.3)	72 (12.0)	32 (14.5)	0.33	29 (9.9)	40 (11.7)	48 (14.7)	0.17	96 (12.4)	21 (11.2)	0.64
Child enjoys breastfeeding
Very important/important	139 (97.2)	584 (96.5)	215 (96.9)	0.91^a	284 (96.3)	332 (96.5)	322 (97.3)	0.76	749 (96.2)	189 (99.0)	0.07^a
Somewhat/not important	4 (2.8)	21 (3.5)	7 (3.2)	0.91^a	11 (3.7)	12 (3.5)	9 (2.7)	0.76	30 (3.9)	2 (1.1)	0.07^a
Child refuses to drink from bottle or cup
Very important/important	30 (32.6)	128 (34.0)	42 (34.2)	0.97	70 (39.6)	73 (33.8)	57 (28.6)	0.08	163 (34.5)	37 (31.1)	0.49
Somewhat/not important	62 (67.4)	249 (66.1)	81 (65.9)	0.97	107 (60.5)	143 (66.2)	142 (71.4)	0.08	310 (65.5)	82 (68.9)	0.49

	Ethnicity			Race
	Hispanic or Latina	Non-Hispanic or Latina	p	White	All Others	p
	N (%)	N (%)	p	N (%)	N (%)	p
Child's primary care provider's recommendation
Very important/important	12 (1.82)	188 (30.1)	0.77	182 (29.7)	18 (36.7)	0.31
Somewhat/not important	25 (3.78)	436 (69.9)	0.77	430 (70.3)	31 (63.3)	0.31
Mother's doctor's recommendation
Very important/important	9 (27.3)	111 (19.5)	0.28	106 (19.2)	14 (28.0)	0.13
Somewhat/not important	24 (72.7)	459 (80.5)	0.28	447 (80.8)	36 (72.0)	0.13
Spouse, partner, or significant other's support
Very important/important	37 (88.1)	651 (74.3)	0.04	639 (74.6)	49 (80.3)	0.32
Somewhat/not important	5 (11.9)	225 (25.7)	0.04	218 (25.4)	12 (19.7)	0.32
Family members' recommendations
Very important/important	15 (37.5)	234 (29.4)	0.28	232 (29.9)	17 (29.3)	0.93
Somewhat/not important	25 (62.5)	561 (70.6)	0.28	545 (70.1)	41 (70.7)	0.93
Friends' recommendations
Very important/important	12 (30.8)	233 (28.4)	0.75	232 (29.0)	13 (22.4)	0.29
Somewhat/not important	27 (69.2)	587 (71.6)	0.75	569 (71.0)	45 (77.6)	0.29
Ethnic background and/or cultural beliefs
Very important/important	12 (34.3)	143 (25.3)	0.24	144 (26.0)	11 (23.4)	0.70
Somewhat/not important	23 (65.7)	423 (74.7)	0.24	410 (74.0)	36 (76.6)	0.70
Breastfeeding is cheaper than buying formula
Very important/important	32 (74.4)	484 (55.9)	0.02	469 (55.4)	47 (74.6)	<0.01
Somewhat/not important	11 (25.6)	382 (44.1)	0.02	377 (44.6)	16 (25.4)	<0.01
Nutritional value of breast milk
Very important/important	43 (97.7)	916 (98.8)	0.43^a	895 (98.8)	64 (98.5)	0.57^a
Somewhat/not important	1 (2.3)	11 (1.2)	0.43^a	11 (1.2)	1 (1.5)	0.57^a
Other health benefits
Very important/important	43 (97.7)	913 (98.4)	0.53^a	892 (98.4)	64 (98.5)	1.00^a
Somewhat/not important	1 (2.3)	15 (1.6)	0.53^a	15 (1.7)	1 (1.5)	1.00^a
Building a strong bond with child
Very important/important	43 (97.7)	908 (98.0)	0.61^a	886 (97.9)	65 (98.5)	1.00^a
Somewhat/not important	1 (2.3)	19 (2.1)	0.61^a	19 (2.1)	1 (1.5)	1.00^a
Mother enjoys breastfeeding
Very important/important	40 (93.0)	805 (87.6)	0.47^a	791 (88.2)	54 (83.1)	0.22
Somewhat/not important	3 (7.0)	114 (12.4)	0.47^a	106 (11.8)	11 (16.9)	0.22
Child enjoys breastfeeding
Very important/important	44 (100.0)	894 (96.5)	0.39^a	876 (96.9)	62 (93.9)	0.27^a
Somewhat/not important	0 (0.0)	32 (3.5)	0.39^a	28 (3.1)	4 (6.1)	0.27^a
Child refuses to drink from bottle or cup
Very important/important	14 (51.9)	186 (32.9)	0.04	183 (33.3)	17 (40.5)	0.34
Somewhat/not important	13 (48.2)	379 (67.1)	0.04	367 (66.7)	25 (59.5)	0.34

	No. of multiples			No. of children			No. of children breastfed for >12 months
	Twins	Triplets or more	p	2 or 3	4 or More	p	2 or 3	4 or More	p
	N (%)	N (%)	p	N (%)	N (%)	p	N (%)	N (%)	p
Child's primary care provider's recommendation
Very important/important	197 (30.3)	3 (27.3)	1.00^a	147 (30.5)	53 (30.3)	0.96	171 (31.0)	29 (26.6)	0.36
Somewhat/not important	453 (69.7)	8 (72.7)	1.00^a	335 (69.5)	122 (69.7)	0.96	381 (69.0)	80 (73.4)	0.36
Mother's doctor's recommendation
Very important/important	118 (19.9)	2 (20.0)	1.00^a	81 (18.9)	38 (22.4)	0.34	99 (19.9)	21 (19.8)	0.98
Somewhat/not important	475 (80.1)	8 (80.0)	1.00^a	348 (81.1)	132 (77.7)	0.34	398 (80.1)	85 (80.2)	0.98
Spouse, partner, or significant other's support
Very important/important	680 (75.1)	8 (66.7)	0.51^a	506 (75.6)	175 (72.6)	0.35	584 (75.7)	104 (71.2)	0.26
Somewhat/not important	226 (24.9)	4 (33.3)	0.51^a	163 (24.4)	66 (27.4)	0.35	188 (24.4)	42 (28.8)	0.26
Family members' recommendations
Very important/important	246 (30.0)	3 (25.0)	1.00^a	187 (30.5)	57 (26.8)	0.31	214 (30.4)	35 (26.5)	0.37
Somewhat/not important	577 (70.0)	9 (75.0)	1.00^a	427 (69.5)	156 (73.2)	0.31	489 (69.6)	97 (73.5)	0.37
Friends' recommendations
Very important/important	242 (28.6)	3 (25.0)	1.00^a	182 (28.7)	61 (28.1)	0.87	209 (28.8)	36 (27.3)	0.73
Somewhat/not important	605 (71.4)	9 (75.0)	1.00^a	452 (71.3)	156 (71.9)	0.87	518 (71.3)	96 (72.7)	0.73
Ethnic background and/or cultural beliefs
Very important/important	153 (25.8)	2 (25.0)	1.00^a	116 (27.4)	38 (22.1)	0.18	134 (26.9)	21 (20.6)	0.19
Somewhat/not important	440 (74.2)	6 (75.0)	1.00^a	308 (72.6)	134 (77.9)	0.18	365 (73.2)	81 (79.4)	0.19
Breastfeeding is cheaper than buying formula
Very important/important	507 (56.7)	9 (64.3)	0.57	359 (55.2)	152 (61.0)	0.11	423 (56.1)	93 (60.0)	0.37
Somewhat/not important	388 (43.4)	5 (35.7)	0.57	292 (44.9)	97 (39.0)	0.11	331 (43.9)	62 (40.0)	0.37
Nutritional value of breast milk
Very important/important	945 (98.8)	14 (100.0)	1.00^a	691 (98.7)	259 (98.9)	1.00^a	797 (98.6)	162 (99.4)	0.70^a
Somewhat/not important	12 (1.3)	0 (0.0)	1.00^a	9 (1.3)	3 (1.2)	1.00^a	11 (1.4)	1 (0.6)	0.70^a
Other health benefits
Very important/important	942 (98.3)	14 (100.0)	1.00^a	691 (98.4)	257 (98.5)	1.00^a	796 (98.3)	160 (98.8)	1.00^a
Somewhat/not important	16 (1.7)	0 (0.0)	1.00^a	11 (1.6)	4 (1.5)	1.00^a	14 (1.7)	2 (1.2)	1.00^a
Building a strong bond with child
Very important/important	937 (97.9)	14 (100.0)	1.00^a	685 (97.9)	257 (98.1)	0.82	789 (97.8)	162 (98.8)	0.55^a
Somewhat/not important	20 (2.1)	0 (0.0)	1.00^a	15 (2.1)	5 (1.9)	0.82	18 (2.2)	2 (1.2)	0.55^a
Mother enjoys breastfeeding
Very important/important	833 (87.9)	12 (85.7)	0.68^a	595 (86.1)	241 (92.0)	0.01	694 (87.0)	151 (92.1)	0.07
Somewhat/not important	115 (12.1)	2 (14.3)	0.68^a	96 (13.9)	21 (8.0)	0.01	104 (13.0)	13 (7.9)	0.07
Child enjoys breastfeeding
Very important/important	926 (96.9)	12 (85.7)	0.08^a	675 (96.6)	254 (97.0)	0.77	777 (96.4)	161 (98.2)	0.34^a
Somewhat/not important	30 (3.1)	2 (14.3)	0.08^a	24 (3.4)	8 (3.1)	0.77	29 (3.6)	3 (1.8)	0.34^a
Child refuses to drink from bottle or cup
Very important/important	200 (34.2)	0 (0.0)	0.10^a	137 (33.4)	63 (35.0)	0.71	161 (32.8)	39 (38.6)	0.26
Somewhat/not important	385 (65.8)	7 (100.0)	0.10^a	273 (66.6)	117 (65.0)	0.71	330 (67.2)	62 (61.4)	0.26

Missing data and “not applicable” answer selection: 512 child's primary care provider's recommendation, 570 mother's doctor's recommendation, 255 spouse, partner, or significant other's support, 338 family members' recommendations, 314 friends' recommendations, 572 ethnic background and/or culture beliefs, 264 breastfeeding is cheaper than buying formula, 202 nutritional value of breast milk, 201 other health benefits, 202 building a strong bond with the child, 211 mother enjoys breastfeeding, 203 child enjoys breastfeeding, and 581 child refuses to drink from bottle or cup.

Some p-values presented are from Fisher's exact test due to small cell sizes for some variables.

Among women whose oldest children were the set of multiples they breastfed more than 12 months (n = 638), ∼70% of the sample discussed the decision to breastfeed for more than 12 months with their mother (73.3%) or their closest friend (70.0%), and 92.8% discussed with their partner. Slightly over half (54.4%) of the women did not discuss the decision to breastfeed their multiples beyond 12 months with their children's health care provider. Almost three-fourths did not discuss the decision with their obstetric care provider (73.0%) or the primary provider of their own general health care (73.9%).

The oldest women were the least likely to have discussed the decision with their closest friend (relative risk [RR] = 0.72, 95% confidence interval [CI] = 0.58–0.91) or spouse, partner, or significant other (RR = 0.89, 95% CI = 0.81–0.98) (Table 4). Women with a higher level of education were less likely to discuss the decision with their own primary care provider (RR = 0.09, 95% CI = 0.01–0.81). Women who lived outside the United States were less likely than U.S. women to discuss with their child's health provider (RR = 0.62, 95% CI = 0.49–0.79) or with their spouse, partner, or significant other (RR = 0.93, 95% CI = 0.87–0.99). Nonwhite women were almost 80% more likely to discuss with their obstetric care provider than white women (RR = 1.79, 95% CI: 1.35–2.39). As the number of children and the number breastfed more than 12 months increased, the likelihood of discussing their decision to breastfeed more than 12 months with their closest friends and partners decreased.

Table 4.

Associations Between Participant Characteristics and Whether Women Discussed the Decision to Breastfeed for More than 12 Months with Various Individuals Who Were Potential Sources of Support (2013, N = 638)

Characteristics	Child's primary care provider		Health care provider for pregnancy and delivery		Mother's primary care provider		Mother's mother		Mother's closest friend		Spouse, partner, significant other
Characteristics	RR	95% CI	RR	95% CI	RR	95% CI	RR	95% CI	RR	95% CI	RR	95% CI
Maternal age
18–29 Years (Ref.)
30–39 Years	1.00	0.80–1.25	0.83	0.61–1.12	1.05	0.72–1.53	0.91	0.82–1.01	0.85	0.76–0.95	0.94	0.90–0.99
40–50 Years	1.00	0.64–1.55	0.68	0.38–1.25	1.11	0.52–2.34	0.82	0.67–1.01	0.72	0.58–0.91	0.89	0.81–0.98
Maternal education
Some college degree or less (Ref.)
Associate's degree	1.09	0.80–1.48	1.11	0.74–1.65	0.55	0.32–0.95	1.09	0.91–1.30	1.01	0.84–1.22	1.01	0.92–1.11
Bachelor's degree	1.18	0.64–2.18	1.23	0.55–2.73	0.30	0.10–0.90	1.18	0.82–1.69	1.02	0.71–1.48	1.02	0.84–1.23
Master's degree	1.29	0.51–3.22	1.36	0.41–4.50	0.17	0.03–0.85	1.28	0.75–2.19	1.03	0.59–1.80	1.03	0.78–1.36
Professional or doctoral degree	1.40	0.41–4.76	1.50	0.30–7.43	0.09	0.01–0.81	1.39	0.68–2.85	1.04	0.50–2.18	1.04	0.71–1.51
Place of residence
United States (Ref.)
Non-United States	0.62	0.49–0.79	0.78	0.58–1.05	1.28	0.98–1.68	0.90	0.80–1.01	0.91	0.80–1.03	0.93	0.87–0.99
Ethnicity
Not Hispanic or Latino (Ref.)
Hispanic or Latino	1.00	0.71–1.41	0.87	0.50–1.51	1.41	0.87–2.28	0.93	0.74–1.17	0.76	0.56–1.02	1.02	0.92–1.12
Race
White (Ref.)
Other	0.96	0.72–1.30	1.79	1.35–2.39	1.27	0.85–1.90	0.84	0.68–1.03	0.92	0.76–1.12	1.00	0.92–1.09
No. of multiples
Twins (Ref.)
Triplets or higher order multiples	1.30	0.82–2.06	0.78	0.28–2.14	1.21	0.53–2.80	1.03	0.74–1.44	1.37	1.15–1.64	0.93	0.91–0.95
No. of children
2 (Ref.)
3	0.86	0.54–1.38	1.64	0.79–3.37	1.02	0.46–2.26	0.77	0.59–1.00	0.65	0.79–0.88	0.77	0.67–0.88
4	0.82	0.44–1.54	1.93	0.73–5.06	1.03	0.35–2.96	0.70	0.50–1.00	0.57	0.38–0.84	0.71	0.59–0.84
5 or More	0.78	0.35–1.71	2.27	0.68–7.58	1.03	0.27–3.89	0.64	0.42–1.00	0.49	0.30–0.81	0.65	0.52–0.81
No. of children breastfed for more than 12 months
2 (Ref.)
3	1.08	0.69–1.70	1.55	0.79–3.04	1.62	0.78–3.38	0.82	0.63–1.07	0.63	0.47–0.85	0.78	0.67–0.89
4	1.11	0.61–2.02	1.80	0.74–4.39	1.90	0.71–5.08	0.77	0.54–1.09	0.54	0.36–0.81	0.71	0.59–0.86
5 or More	1.14	0.53–2.41	2.08	0.68–6.36	2.24	0.66–7.62	0.72	0.46–1.12	0.46	0.28–0.76	0.66	0.52–0.83

Total sample size is 638, which is the number of women whose oldest children were a set of multiples they breastfed for more than 12 months (Ref.), and it indicates which category was used as the reference group in the regression model. Missing data: 125 for child's health care provider, 127 for health care provider for pregnancy and delivery, 159 for maternal primary care provider, 137 for mother's mother, 145 for mother's closest friend, 122 for spouse, partner or significant other.

CI, confidence interval; RR, relative risk.

In terms of reasons why women did not discuss breastfeeding for more than 12 months with their health care providers, ∼50% of women did not see their obstetric care provider or their own primary care provider around that time. Most of the women (72%) in the sample who did not discuss their decision to breastfeed for more than 12 months felt no additional support from their child's primary care provider was needed, and ∼46% felt no support was needed from one or more of the other health care providers mentioned. Of concern, small but notable percentages of women were afraid that they would not be supported or did not feel comfortable (Table 5).

Table 5.

Reasons Women Indicated for Choosing Not to Discuss Their Decision to Breastfeed for More than 12 Months with Three Types of Health Care Providers (2013, N = 478)

Reasons	Child's primary care provider		Health care provider for pregnancy and delivery		Mother's primary care provider
	N = 279		N = 373		N = 354
	n	%	n	%	n	%
I did not see this health care provider around the time that I decided to nurse beyond 12 months of age	0	0.00	189	50.67	178	50.28
I did not feel comfortable discussing it with my health care provider	13	4.66	9	2.41	7	1.98
I was afraid my health care provider would not support my decision	23	8.24	5	1.34	10	2.82
I felt I did not need additional support from my health care provider	201	72.04	172	46.11	164	46.33
I felt socially pressured by my family to not seek support from my health care provider	5	1.79	2	0.54	0	0.00
I felt socially pressured by my friends to not seek support from my health care provider	3	1.08	2	0.54	0	0.00
I do not know or remember	10	3.58	10	2.68	9	2.54
Other	67	24.01	41	10.99	34	9.60

Total percentages add up to more than 100% because some respondents chose multiple reasons. Missing: three for child's primary care provider, three for health care provider for pregnancy and delivery, two for mother's primary care provider.

Discussion

Breastfeeding support interventions tailored to the needs of families with multiples may have significant benefits, but evidence-based interventions for this population are lacking. As the United States aims to increase breastfeeding rates, assuming mothers of multiples cannot or do not want to breastfeed for a long duration may result in a significant missed opportunity, particularly as the number of multiple births continues to grow. A majority of the sample who participated in this study of women who breastfed multiples for more than 12 months lived in the United States and included predominantly white, non-Hispanic, and well-educated women who were between the ages of 30 and 39 at the time of the questionnaire. Women commonly cited several important influences on their decision to breastfeed for more than 12 months—including partner support, the nutritional and other health benefits of breastfeeding, building a strong bond with their children, and the woman and child enjoying breastfeeding. Factors typically ranked as not important/somewhat important by women included physician recommendations, family and friend recommendations, and factors related to their ethnic background.

At least three clinically relevant conclusions may be drawn from the results of this study. First, most women did not discuss the decision to breastfeed for more than 12 months with any health care provider. The most common reason cited was that women felt that no additional support was needed. Perhaps this sample of women, because they were particularly successful with breastfeeding, was unusual in this way. The U.S. Preventative Services Task Force, upon conducting a thorough analysis of breastfeeding interventions in 2016, stated the following: “Primary care clinicians can support women before and after childbirth by providing interventions directly or through referral to help them make an informed choice about how to feed their infants and to be successful in their choice.”¹¹ While physician support before delivery and at initiation was not examined in the current study, physician support has been shown to be influential early in infancy. Women in the current study, who had been successfully breastfeeding for at least 12 months, may not have been experiencing any difficulties that would have led them to seek physician support. However, a small proportion of women indicated that they did not discuss their decision with a health care provider because they were uncomfortable or feared not being supported, which suggests a need for more consistent support throughout infancy and toddlerhood for families who breastfeed for a long duration.

A second key conclusion from the study was that breastfeeding being cheaper than formula was an important factor in the breastfeeding decision of young or less educated women, minorities, and women with more children. Each of the these groups is often associated with lower levels of breastfeeding initiation and duration, and having multiple infants to feed and care for may have increased the importance of breastfeeding and the impact of cost for the sample.^12–15 Breastfeeding interventions to assist women from racial and ethnic minority groups, women with less education, and younger women could emphasize the economic benefits of breastfeeding multiples to encourage longer durations. Internationally, low breastfeeding rates are recognized to have a substantial societal cost.^16–18 Incentive-based breastfeeding interventions may be useful in reducing the breastfeeding disparities seen in the United States. Washio et al. conducted a randomized two-arm parallel group study in Puerto Rico, in which one group of women received monthly financial incentives contingent on breastfeeding for 6 months.¹⁹ The financial incentives positively impacted breastfeeding duration; however, the results may not be generalizable to multiples. Future research could examine the impact of emphasizing the cost-effectiveness of breastfeeding compared to formula. Breastfeeding can incur some additional costs, largely those associated with pumping supplies, and those costs vary depending on the circumstances and preferences of the woman and child. Promoting the economic benefits of breastfeeding multiples may encourage more women to continue breastfeeding, especially longer term.

A third major finding of the study was that many women reported that the nutritional value of breast milk, the other health benefits associated with breastfeeding, and the bond and enjoyment the woman and child receive from breastfeeding were important influencing factors to support long-duration breastfeeding. Several studies on singletons confirm the motivating influence of the nutritional value of breast milk.^20,21 To increase breastfeeding rates for mothers of multiples, health care professionals and educational materials should emphasize the health and relationship benefits that breastfeeding can bring. Emphasizing the positive outcomes of breastfeeding may help mothers of multiples to persevere through challenges they face.

Strengths and Limitations

A major strength of the study was the large sample size (1,173) of women who breastfed multiples for more than 12 months. The sample's common long breastfeeding duration, combined with the large sample size, provided a unique opportunity to focus on a previously poorly characterized subpopulation. In addition, the study benefited from the diverse geography of the sample.

The online questionnaire was mainly distributed via LLL, which may limit the generalizability of the results to all mothers of multiples who breastfeed for a long duration. The questionnaire did not include a question directly asking if the participant was involved in LLL or questions on how much support LLL provided. Unfortunately, a small proportion of the sample was of Hispanic ethnicity or of a race other than white, and this precluded more detailed analysis of demographic factors. Population-based data characterizing women who breastfeed multiples beyond infancy are not available for the United States or other nations, to our knowledge, making it challenging to evaluate the representativeness of our sample to the larger population. However, some comparisons with data for U.S. women of reproductive age are possible: 75% of U.S. women aged 15–44 identify their race as white, comparable to the current study with 78% of the sample who reported their race as white.²² However, in the current study, 5.9% reported race other than white, compared to 25.1% nationally.²² Also, all women in the sample breastfed for a long duration, which precluded comparison to a group who breastfed for a short time. Finally, the infants in this study may have had less complicated neonatal medical histories than average, thus permitting less complicated establishment of breastfeeding. The current study did not collect data allowing exploration of the neonatal period. Future studies may benefit from exploring the importance of the neonatal period further.

Conclusion

The unique breastfeeding challenges that families with multiples face may be addressed by effective tailored supports; however, such evidence-based interventions do not yet exist. The findings from the present study suggest that interventions to encourage long-term breastfeeding of multiples might consider focusing on education about the health benefits of breastfeeding and emphasizing the relationship that can be fostered with their children. In addition, mobilizing a variety of sources of support from the woman's partner and their community may help to sustain breastfeeding. Improving breastfeeding rates in the United States beyond infancy would have a major positive impact on children's outcomes, including protection from childhood illnesses and promotion of healthy development.²³ Sets of multiples stand to benefit from improved breastfeeding rates because of the increased incidence of high-risk medical complications and additional support that may be needed. Future research can be directed toward extending the evidence for breastfeeding support to families with multiples.

Footnotes

Acknowledgments

We thank the women who participated in the study and La Leche League (LLL) (Debbi Heffern).

Disclosure Statement

The authors have no relevant conflicts of interest to disclose.

Funding Information

Funding from the Research Scholar Award, in the amount of $1,000, from The Ohio State University assisted completion of the study.

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