Mothering Twins During First Year - 2002 PDF

QUALITATIVE Beck / RELEASING HEALTH THE PAUSE RESEARCH BUTTON / May 2002 Releasing the Pause Button: Moth...

QUALITATIVE Beck / RELEASING HEALTH THE PAUSE RESEARCH BUTTON / May 2002 Releasing the Pause Button: Mothering Twins During the First Year of Life Cheryl Tatano Beck The purpose of this grounded theory study was to investigate the basic social psychological problem mothers of twins experience during the first year after delivery and the process they use to resolve this fundamental problem. Life on hold was the basic social psychological prob- lem that mothers of twins experienced during the first year of their twins’ lives. Releasing the pause button was the four-stage process mothers progressed through as they attempted to resume their own lives. These four phases were (a) draining power, (b) pausing own life, (c) striving to reset, and (d) resuming own life. The most vulnerable period for mothers of twins is the first 3 months postpartum. Intensive interventions need to be in place to support women during this time. C urrently, the United States is experiencing the largest number of multiple births in recorded history. This upward trend in multiple births began in the 1970s and has increased steadily since that time. Over the last 2 decades, the inci- dence of twin births has increased by 33% and the number of higher order multiple births by 178% (DeLisi, 1999). During this same period, triplet-plus births increased 7 times the rate of single births. Contributing to this dramatic rise in multiple births is in vitro fertilization. Tough, Greene, Svenson, and Belik (2000), for example, reported that in vitro fertilization accounted for 21% of the twins born in Alberta, Canada, between 1994 and 1996. This multiple-birth explosion presents nursing with the challenge of providing optimal care for these high-risk families (Bowers, 1998). Nurses, however, must first have knowledge of the unique problems and needs of multiple-birth families before they can design and implement interventions specific to these unique health care problems. The purpose of this grounded theory study was to investigate (a) the nature of the specific social psychological problem that multiple-birth mothers encounter during the first year after delivery and (b) the process they use to resolve this fundamental problem. REVIEW OF THE LITERATURE In reviewing the literature, I found that most qualitative studies featuring mothers of multiple births were conducted outside the United States—in France, Great Brit- AUTHOR’S NOTE: This research was supported by the University of Connecticut Research Founda- tion. The author wishes to gratefully acknowledge Joan O’Connell, R.N., for her invaluable assistance in data collection. QUALITATIVE HEALTH RESEARCH, Vol. 12 No. 5, May 2002 593-608 © 2002 Sage Publications 593 594 QUALITATIVE HEALTH RESEARCH / May 2002 ain, Israel, and Taiwan. Goshen-Gottstein (1980) examined some of the basic issues that face mothers of multiple infants in Israel. Findings revealed the ambivalence encountered by mothers, their dealing with unusual demands, and the difficulty of relating to more than one child. The way mothers dealt with the overtaxing demands of tending to more than one infant at a time included some practical time and energy savers, such as treating the children equally as a unit. In Taiwan, Chang (1990) interviewed 166 mothers of twins about difficulties encountered while raising the children. The following rearing problems, along with the percentage of mothers who experienced them, were identified: inadequate sleep (49%), lack of time to care for other children (43%), mood fluctuations (39%), distur- bance in the marital relationship (22%), and financial strain (18%). All of these prob- lems, except for mood disturbance, gradually decreased with the growth of the twins. Robin and colleagues conducted a series of three studies focusing on mothers of twins in France. Problems connected with early mother-twin interaction and the family’s solutions to these problems were examined in the first study (Robin, Josee, & Tourette, 1988). During the first months of life, the overload of baby care left little time for engaging in a relationship based on pleasure or play. The impossibility of responding simultaneously to the demands of both twins and the problem of devel- oping relationships on an individual basis fostered the need for egalitarianism, that is, the mothers’ obligation to always do the same thing with both twins. Mothers had to contend with and try to balance their desire for early individualization of the twins with their effort to merge the twins into a single unit. In the second French study, child care patterns of 51 mothers of twins during the first year after delivery was the focus of research (Robin, Corroyer, & Casati, 1996). Robin and colleagues described the way mothers of twins organized infant care rou- tines as being on a continuum spread between two poles. At one end were mothers who sought maximal individualization in their relationship with each twin during child care activities. At the other end of the continuum were those who treated the two children as a whole. These mothers started their “collective mothering” meth- ods as early as possible and standardized child care schedules without regard for the individual needs of each twin, which led to limited mother-child relationships. Mothers’ representations of their 13-month-old twins and their childrearing attitudes and practices were investigated in the third study in France (Robin, Maner-Idrissi, & Corroyer, 1998). The purpose of their study was to examine how mothers of twins perceive the expressions of their twins’ differences and similarities and to determine if there is a connection between the mother’s representations of twinship and her childrearing practices and attitudes toward her twins. Interviews with 44 mothers of twins were analyzed for two aspects of their childrearing atti- tudes: individualization of child care routines and differentiation by “external signs of twinship,” such as clothing and first names. Robin and colleagues (1998) reported that the relationship between the childrearing practices of mothers and their per- ceptions of the twin couple was more complex and not as clear-cut as they had expected. Their hypothesis—that mothers who tended not to differentiate their twins by dressing them in identical clothes and by taking care of them collectively would have a greater tendency toward a unitary representation of the pair—was not totally supported.  Beck / RELEASING THE PAUSE BUTTON 595 In Canada, a grounded theory of how mothers develop a relationship with twins during their first year of life was generated by Anderson and Anderson (1990), who interviewed 10 mothers in their homes when the twins were 1, 4, 8, and 12 months. The core category that emerged was individuation, where the mother learns to adapt to the differences and needs of each twin. Polarization and differen- tiation were the two strategies mothers used to identify the differences between the twins and to help in the job of individuation. Conflicting with achieving individual- ization, however, was the mothers’ concerns that their twins be treated equally and fairly. Anderson and Anderson (1990) labeled this activity maternal justice. Support was crucial to facilitating a mother’s ability to develop a relationship with each twin. I found two studies in the literature review that had been conducted in the United States. In the first, the results of a mail survey of 104 mothers of twins indi- cated that accomplishing daily household activities presented major difficulties for more than 40% of the mothers, but this difficulty decreased in 3 months (Neifert & Thorpe, 1990). Sleeping problems were another major difficulty experienced by 64% of the women, and these problems continued to be a major issue for 38% of the sample at 3 months postpartum. In another American study, eight couples were interviewed regarding their perceptions of parenting multiple-birth infants in the early weeks after delivery (Holditch-Davis & Roberts, 1999). Three major themes were identified: the specialness of multiples, difficulties in the management of multiples, and attach- ment issues with multiples. Couples expressed both the positive and negative specialness of having more than one infant at a time. Specific difficulties the parents had with managing multiples included feeding, lack of time, physical care, support, and finances. Concerns related to attachment to multiple-birth infants involved dif- ferentiating between the infants, preferential attachment, and quality time. As evidenced by this cross-cultural literature review, mothering multiples and stress go hand in hand. Depression and anxiety disorders can affect more than 25% of multiple-birth parents during the prenatal and postpartum period (Leonard, 1998). Contributing to depression in multiple-birth families are such factors as a high incidence of premature deliveries, sleep deprivation, social isolation, and the constant demands of the infant twins. Williams and Medalie (1994) found that potential sources of stress for parents of twins clustered around increased rates of perinatal complications, fatigue/lack of sleep, management of daily needs of twins, loss of control over such factors as their time and privacy, and lack of time for them- selves. Thorpe, Golding, MacGillvray, and Greenwood (1991), for example, reported that in their British study of women 5 years after delivering twins, 34% of mothers who had two living twins and 53% of women who had delivered twins but had one die were clinically depressed. In summary, the qualitative studies in this literature review have indicated a number of different types of challenges facing mothers of multiples, such as psychosocial and physical issues. The one grounded theory study focused specifi- cally on developing mother-twin attachment (Anderson & Anderson, 1990). Research is needed now to examine the process mothers go through caring for their twins during the first year as they cope with these challenges and problems. 596 QUALITATIVE HEALTH RESEARCH / May 2002 METHOD Research Questions (a) What is the specific basic social psychological problem mothers of twins encounter during the first year after delivery? (b) What social psychological process do mothers of twins use to resolve this fundamen- tal problem? Research Design Grounded theory (Glaser & Strauss, 1967) was the qualitative research method used to discover the substantive theory of mothering multiples. Symbolic interactionism (Blumer, 1969; Mead, 1934) provided the theoretical underpinnings of grounded theory. Symbolic interactionism focuses on the nature of social interaction among individuals. Basic principles central to symbolic interactionism included the fact that human beings act in relation to one another. They take each other’s acts into account as they themselves act and provide meaning to specific symbols in their lives. Implications for research can be derived from symbolic interactionism (Charon, 1995). To understand human behavior, one must examine the nature of social inter- action. Within natural settings, social behavior is examined from an individual and group perspective. The researcher examines the world from an individual’s per- spective and discovers how to interpret himself or herself in the context of others. As an observer, the researcher translates the meaning obtained from interactions into a language understood by others. Sample Women were recruited through Parents of Multiples Group, whose meetings were held monthly at a medical center in New England. Sixteen married mothers of twins participated in private interviews in their homes. Of these, 13 had attended the Par- ents of Multiples Group meetings, and 3 had not. The mean age of these mothers was 32, and ages ranged from 24 to 43 years. Fifteen were Caucasian, and 1 was Afri- can American. Six mothers (38%) had a high school diploma, and 10 women (62%) had a college degree. Ten mothers (63%) were primiparas, and 6 (37%) were multiparas. Twelve women (75%) had spontaneous twins, and 4 (25%) had twins as a result of infertility treatments. The twins ranged from 3 weeks to 17 months old when the mothers were interviewed; the mean age was 8 months. None of the women experienced serious physical complications stemming from the multiple birth; however, 3 (19%) reported postpartum depression. I used theoretical sampling that involved simultaneously collecting, coding, and analyzing data and then deciding what data to collect next to develop a grounded theory. Theoretical sampling continued until the categories of the sub- stantive theory were saturated. An example of theoretical sampling used in this study occurred when mothers referred repeatedly to the fact that they could not compare how being a mother of twins was different from being a mother of a  Beck / RELEASING THE PAUSE BUTTON 597 singleton because their twins were their only children. This prompted me to seek out women with additional children besides their twins to interview next. Data Collection After receiving approval from both the University of Connecticut and the hospital’s Human Subjects Review Boards, data collection began. Participant observation and unstructured interviews were the two main sources of data generation. For 10 months, I attended Parents of Multiples Group meetings in a hospital in New Eng- land. The group met once a month for 2 hours. At any given meeting, between 5 and 15 parents attended with their twins or triplets. The age range of the multiples brought to these meetings was 4 weeks to 2 1 2 years. After each meeting, I wrote in- depth field notes describing the interaction in the group and my own thoughts and reactions. After obtaining informed consent, I conducted interviews in the homes of the 16 mothers, which provided excellent opportunities for participant observation. Not only did I observe the mothers at home with their twins and other children, I partici- pated in caring for the twins, such as feeding and holding them. The interviews were audiotaped and lasted between 40 minutes and an hour. After each home visit, I recorded field notes. The interview process continually changed as the substantive theory devel- oped. At the beginning of data collection, I asked general questions of the mothers during the interviews, such as “What is it like being a mother of multiples?” As the core category emerged, the questions guiding the interviews became more specific. For example, some women shared that the first few months of caring for their twins was like a blur. The related questions would be, “Did you experience such a blur period? If so, could you please describe it for me?” Data Analysis Data from the interviews, field notes, and participant observation during support groups were analyzed using the constant comparative method (Glaser & Strauss, 1967). I used two types of code in analyzing the data: substantive and theoretical. Substantive coding focuses on the empirical substance of the research topic whereas theoretical coding is used to conceptualize how the substantive codes were related to each other. The following 10 of Glaser’s (1978) 18 coding families were used in the theoretical coding for this study: six C’s (causes, contexts, contingencies, conse- quences, covariances, and conditions), process, degree, strategy, cutting point, dimension, theoretical, ordering or elaboration, means-goals, and model. I analyzed the data using three levels of coding (Hutchinson, 1993). Level I codes, also called in vivo or substantive codes, are many times stated in the words the participants used. Level II codes, called categories, move the data along to a more abstract level. Level I codes are collapsed into Level II codes. Theoretical con- structs are Level III codes, which increase the scope of the theory being generated by adding new meaning. Figure 1 illustrates a partial audit trail for the construct of striving to reset. 598 FIGURE 1: Partial Audit Trial for the Construct of Striving to Reset  Beck / RELEASING THE PAUSE BUTTON 599 FIGURE 2: Life on Hold: Releasing the Pause Button The emerging substantive theory of mothering twins during the first year of life was validated with the parents who attended one of the multiple-birth parent meet- ings at the medical center. At that meeting, 10 parents were present: 9 mothers and 1 father. I had interviewed 3 of the 9 mothers previously. During this meeting, I pre- sented my findings to date and provided the parents with a handout of the model of the developing theory. At the end of the presentation, I asked if there was anything that should be changed or added to the developing theory. All parents replied in the negative. It “fit” their experiences. RESULTS Life on hold was the basic social psychological problem of mothering twins during the first year of life. As one mother of 6-month-old twins expressed, “I would say that my life is on hold since the twins were born. It is a rare occasion when I can undo the pause button.” Another mother of 12-month-old twin boys explained, “You just have to think in terms that this year is a year out of your life. You’re not going to do anything; you’re not going to go anywhere. You have to mentally prepare for that.” Releasing the pause button was the basic social psychological process of moth- ering twins over the first year of life. This refers to the four-phase process (see Figure 2) mothers progressed through as they attempted to resume their lives. These four phases were (a) draining power, (b) pausing own life, (c) striving to reset, and (d) resuming own life. 600 QUALITATIVE HEALTH RESEARCH / May 2002 Draining Power In this first phase, mothers’ physical and emotional strength was taxed to the limit. Three conditions of draining power occurred during this first phase: unrelenting demands, vanishing time, and torn between two. Unrelenting demands. The first word out of most women’s mouths when they were asked what it was like to mother multiples was “overwhelming.” One woman summed it up by saying, “The constant demands on me, well, I felt like my body was abused.” These demands bombarded mothers from all directions: feeding the twins, changing diapers, bathing the twins, the never-ending piles of laundry, housecleaning, cooking, caring for other children besides the twins, and so on. “It’s like being a servant to two very demanding people. It’s draining because you have to nurture two.” Due to chronic sleep deprivation, exhaustion became a grueling way of life for mothers of twins, especially during the first few months. For women who had been on bed rest during their pregnancy, this lack of sleep was an especially potent shock to their systems. As one woman recalled, When the twins were first born, it was so hard, ’cause they were awake every 2 hours. It was just that going from complete bed rest while you’re pregnant, to being awake 24 hours a day, it was so hard. I was bone-weary. During this initial 3-month period, some mothers would go 24 hours or more without sleep. When asked to add up how many hours of sleep they would get in a 24 hour period on a typical day, the mothers’ responses clustered around “4 hours!” Torn between two. As the mothers’ physical resources were being depleted, so were their emotional resources. One of the most difficult situations that mothers had to contend with was when both their babies were crying at the same time. Being torn between the two infants left mothers feeling guilty, concerned, and stressed. The women expressed their concern over not giving each baby enough individual time. The following quote highlights this worry: I feel like there is not enough of me to give to each baby individually. Everything they do, they do together, like feeding time. They always feed together. So much of the time is shared time, the feeding time, the bath time. Everything is kind of rushed and shared. I have to divide my time between the twins all of the time and I do want my private time with each baby. Another mother of 11-month-old twins shared, When they are both crying, sometimes I just get really stressed out. You can’t help it when you have two screaming kids and you pick up one and then the other one starts screaming harder because you picked the other one up. Vanishing time. Compounding the unrelenting demands and the situation of being torn between the twins is the disappearance of any available time for the mothers to care for themselves. No time to sleep, no time to eat, no time to shower, and no time to exercise. A mother of multiples’ time is not her own anymore. The following excerpt illustrates this constant state of affairs:  Beck / RELEASING THE PAUSE BUTTON 601 I felt like a milk factory. I was constantly breast-feeding, and I didn’t have time to even make a sandwich or anything. What I did was stuffed myself with like five double stuffed Oreo cookies and that’s why I put on a little bit of weight. Pausing Own Life As a result of the conditions in the lives of mothers of twins in Phase I, pausing own life occurred during Phase II. This phase consisted of three consequences: blurring of days, confining, and self-surrender. Blurring of days. Mothers vividly described the first 3 months’ caring for twins as the “blur period.” Night and day were intertwined. Day or night did not really make a difference. One day was the same as another day. As one mother of 5-month- old twins recalled, Every hour, every day, every night was the same. The cycle would start all over again. The twins would wake up and I would do it all over again. The feeding and changing: feeding and changing, all day and night. It was like a blur. Women repeatedly shared that the days flew by so fast, like a blur, that at the end of the day they would look back and have no idea what happened all day that they couldn’t take even 5 minutes to have something to eat. Confining. Another consequence of draining power was the mothers’ feeling secluded and lacking outside connection. Particularly when the twins were younger, the mothers felt they really could not go anywhere with them alone. They were tied down trying to go out around the twins’ feedings because it was difficult nursing both babies when they were out. Reflecting back on when her babies were first born, a mother of 1-year-old twins revealed, Even going to the mall I would panic. What if they are both hungry at the same time? With one even though I am nursing, you can slip into a ladies room and take care of it. With two babies though it’s just impossible, so I really didn’t go out much. Another reason for being confined to their homes was the mothers’ concern over the twins getting sick, especially if the twins had been premature. Self-surrender. The third consequence of draining power is a poignant one, self- surrender. One mother of 6-month-old twins summed this up best when she expressed, “Your life has to go on hold. You can’t be selfish and think about yourself. If you really want to give your babies the best, you have to self-surrender. It’s worth it in the end.” Another woman revealed that mothering twins involves complete self-sacrifice in all aspects of her life, even cutting her treasured long hair. I had very long hair, and it was one of the first things to go after the twins were born. It was so pretty and I was always acknowledged for my long hair, but there was just no time so I had to go short. It was the easiest. The easier the better it was. 602 QUALITATIVE HEALTH RESEARCH / May 2002 FIGURE 3: Mother of Twins’ Daily Worksheet Striving to Reset In striving to reset, the third phase of releasing the pause button, mothers of twins used five strategies: establishing a routine, shifting priorities, marshaling help, problem solving, and venturing out. The consequences in Phase II were conditions requiring strategies by the mothers in Phase III. Establishing a routine. The most critical and effective strategy for surviving life with twins during the first year was having a routine. Getting the twins on the same sleeping and/or feeding schedule was a process that required patience and perseverance. Mothers shared that with twins you do not have the luxury of feeding on demand that you do with only one infant. You would never get anything else accomplished, such as laundry or house cleaning, if twins were allowed to feed on demand. “People don’t realize that if you don’t have structure, you’ll never have any time. It’s just a different philosophy between one and having multiples but it works.” Planning and organization were lifelines for the mothers of twins. The follow- ing quote of a mother of 5-month-old twins captures this strategy:  Beck / RELEASING THE PAUSE BUTTON 603 I have this ritual of doing everything at night like organizing their bottles (usually I went through 16-20 bottles a day), making their meals, and setting their meals up so that when they are hungry I just go to the frig and get it and come back. A final illustration of this organization, which is key to the success of mothering multiples, is located in Figure 3. It is an example of a daily worksheet a woman cre- ated on her computer to help her keep track of her twins’ sleeping and eating schedules. Shifting Priorities. To cope, some things that before the birth of the twins had been priorities in their lives, such as house cleaning and cooking, had to be reprioritized. Priorities shifted to making the care of the twins number one. The house isn’t as clean as I would like it to be but you know what? All that other stuff is unimportant. It’s not as high of a priority. Dinner, many a night during the first few months after the twins were born, consisted of scrambled eggs, peanut but- ter and jelly, or carry out. Marshaling help. Mothering twins through their first year of life required help from a multitude of persons: family, friends, and health care professionals. Some women described this strategy as mobilizing a team, especially through the first few months. Critical to the success of this strategy was the mother’s learning to accept help when it was offered and to ask for it when it was not offered. Women repeat- edly shared that a supportive husband was essential to the mother’s survival. Recalling her first year as a mother of twins, one woman affirmed, “With twins it’s got to be two—you and your husband—everyday. You have to be a team or you can forget it.” Out of all the health care professionals these women were in contact with over the first year, the one who stood out for the mothers was the registered nurse who was in charge of the Parents of Multiples Group. She regularly telephoned the women to check in with them and see if they needed anything. As one mom put it, “Without fail, she calls me. I needed someone to just be able to listen to me and she is that one. She’s my lifeline.” Problem solving. Even for multiparas, who had other children before the birth of the twins, parenting multiple infants required creativity and problem solving. “Experimenting,” “tailoring,” “discovering,” “figuring it out,” and “trying what- ever works” were some terms used by women to describe their problem-solving activities. Discovering little things that were going to help a woman survive the day were all added to a mother’s repertoire. For instance, a mother of 4-month-old twins recounted how she solved a problem with breast-feeding: My biggest problem trying to breast-feed the twins at the same time was keeping my son awake. I couldn’t get up and walk him around because my daughter was feeding on the other breast. So what I would do is just keep a wet face cloth close by and I would just wipe his brow or if I had to I would lift his T-shirt and wipe his tummy with that and it would usually keep him awake. Venturing out. To maintain their sanity, to quiet fussing twins, and to break up the long days, mothers began the formidable task of taking the twins outside the 604 QUALITATIVE HEALTH RESEARCH / May 2002 home. A couple of women took their twins out by themselves soon after the babies were born, but by far the majority of mothers waited until the infants were around 3 months old to venture out alone with them. Some women took their twins out only if they had another adult to accompany them. The earliest time that a mom ventured out alone with her twins was at 1 week. No matter if a woman was taking her twins out alone or with someone along to help, the outing took a tremendous amount of preparation. For example, if a woman was going to venture out with her twins the next day, she spent a portion of the eve- ning before preparing and getting organized. I try to organize the night before for things. I will pack their bag and I will get help from my husband. I will ask him to put their stroller in the car and to do this stuff because we are going out tomorrow. For many women, their first attempt at adventuring out by themselves was to the Parents of Multiples Group. One mother of 6-month-old twins recalled, The first time I took the twins out by myself was when they were 3 months old. I decided to go to the multiples group. That morning I actually prayed for the strength to get there; struggling, one was screaming and I’m trying to get the other baby ready, I thought, “How am I going to do this?” Trying to maneuver the twins’ strollers around stores made the women sensi- tive to the trials of handicapped persons. One mother of 17-month-old twins recounted, “I appreciate now the people that are disabled because of what they have to go through because the twin strollers are pretty monstrous and it’s hard to get through some places.” Resuming Own Life Resuming own life was the fourth and final phase in the substantive theory of releasing the pause button. This fourth phase consisted of the following two conse- quences of the strategies women used in the previous phase: becoming manageable and reaping the blessings. Becoming manageable. Three months after the birth of the twins emerged as the cutting point when mothers began to hold their heads above water or, as one woman expressed it, “to surface.” Cutting points are very important in grounded theory generation because these critical junctures indicate where the difference occurs, which has distinguishing effects (Glaser, 1992). As the twins slept through the night and achieved some developmental mile- stones like feeding themselves, mothers began to recapture some of that vanishing time for themselves to recuperate. As one mother of 3-month-old twins shared, It is very, very manageable now. I would say that all my days are full but they are no longer hectic. They are not out of control. It’s just full and it’s a good full and cer- tainly there are days when I am just so tired it’s hard to even realize what I am doing during the day.  Beck / RELEASING THE PAUSE BUTTON 605 As the first birthday of the twins neared, mothers shared, “I became a normal person again” and “Now I feel like I have a social life again and my husband and I have time together and that kind of thing now as the twins get older.” These two examples illustrate this consequence. Looking back over the first year of their twins’ lives, a typical comment made by mothers was, “To me it’s amazing when I think back that I did nurse them. Because when you are in the midst of doing it, it seems like you’re never going to get your freedom back, but you do!” Reaping the blessings. As the pause button in mothers’ lives began to be released, these women began to reap the blessings of having given birth to twins. As the twins approached their first birthdays, they began to interact with each other and the fun really started. A mother of 11-month-old twins admitted, I love to watch the twins, and I wish I were a twin myself. They would make me jeal- ous because they always have a playmate. They are so funny together. They have a total blast. One will crawl around the corner and kind of peek around. They play hide and seek. They crawl after each other. When her twins were 6 months old, one mother realized, Now I am reaping a lot of the blessings of the twins giggling and interacting. They are each so different. They are so much fun now. Where in the beginning I kept say- ing to my friend, “Where is the blessing? I’m waiting for the blessing.” DISCUSSION The fruitfulness of the present grounded theory is in the discovery of the process that mothers of twins used to resume their lives. Mothers of multiples attempted to cope with the problem of life on hold through the four-phase process of releasing the pause button. Only bits and pieces of these four phases are spattered in the find- ings of previous research. The grounded theory of releasing the pause button paints a more complete, holistic picture of the first year of mothers’ lives with twins. The conditions occurring in the first phase, draining power, confirm findings of previous research on mothering twins (Chang, 1990; Goshen-Gottstein, 1980; Holditch-Davis & Roberts, 1999; Neifert & Thorpe, 1990; Robin et al., 1988). Neifert and Thorpe (1990) and Williams and Medalie (1994), for instance, warned that although the rest of the world is proclaiming how lucky the parents should feel, total exhaustion is robbing the parents of their rightful joy. Robin et al. (1996) coined the term triadic relationship to capture the difficulties operating at feeding time between a mother and her twins. This triadic relationship confronting mothers of twins involves how to manage time to satisfy two babies with different needs at the same time. Frustration and guilt can result for some mothers. Holditch-Davis and Roberts (1999) reported that mothers felt guilty that their infants had to “wait in line” to feed. In their study of twins, Anderson and Anderson (1990) found that mothers strove to achieve “maternal justice,” which is the need to give each twin fair and equal attention. 606 QUALITATIVE HEALTH RESEARCH / May 2002 Vanishing time was another of the conditions in Phase I previously noted in the literature. Williams and Medalie (1994) identified loss of control over time and lack of time for oneself and one’s partner as two sources of stress. Theroux (1989) described the increased time requirement feeding twins demanded. Time commit- ment is further increased when the twins are poor feeders or are premature. Cou- ples in Holditch-Davis and Roberts’s (1999) study frequently expressed concern over lack of time. These parents shared that when you have only one baby and there are two parents, you are off at least some of the time, but with multiples you never are off. In comparing the literature with the findings of Phase II, pausing own life, two of the three consequences have not been addressed as such in the research literature, namely, blurring of days and self-surrender. The third consequence, confining, has been previously reported. Leonard (1998), for instance, described the social isola- tion of mothers of multiples. Holditch-Davis and Roberts (1999) also reported par- ents’ feeling tied down and confined. These parents shared that with just one baby it is manageable to run into the grocery store or do other errands, but not so with mul- tiples. Williams and Medalie (1994) identified loss of control regarding mobility as one source of stress for parents of twins. When stroller access, for example, is not available at a certain destination, a minimum of two adults might be needed to carry the twins. The strategies involved in Phase III, striving to reset, confirm those reported in previous literature. If the mothers who participated in this grounded theory study had to prioritize these strategies, establishing a routine would be considered the cornerstone of survival with twins during the first year of life. As pointed out by Neifert and Thorpe (1990), mothers need reassurance that some of their compro- mises to establish a schedule do not detract from the overall quality of their mother- ing. Women also need to hear explicit permission that it is acceptable to lower their usual household standards when they use shifting priorities as one of their survival strategies (Neifert & Thorpe, 1990). Problem solving as a strategy identified in Phase III confirmed findings from Kaplan’s (1998) research on coping processes used by mothers of multiples. Planful problem solving was the coping method used most often by the mothers in her study. Planful problem solving was defined as “a problem-focused effort which is deliberately aimed at changing both the situation and solving the problem in an analytic manner” (p. 78). Gromada and Spangler (1998) offered some creative solutions for helping time- deprived mothers of twins who cannot manage to find even a few precious minutes to fix a meal for themselves. They suggested that the mother sit in a comfortable chair or sofa next to a table or shelves stocked with nutritious finger foods and bev- erages. Moilanen and Ebeling (1998) found that in Finland, some parents solved the problem of their twins’ having to share the attention from their parents by dividing the twins, whereby the “mother’s child” and “father’s child” can develop. When considering the strategy of marshalling help, the benefits of multiples support groups have been repeatedly highlighted in the literature (William & Medalie, 1994). Gromada and Spangler (1998) recommendeded involving mothers of multiples prenatally with these support groups. Chang (1990) stressed that moth- ers of multiples need much more than physical assistance. Perhaps most needed is a sympathetic ear from a mother of multiples who has been or is going through it her- self. Twin clubs or support groups can make a significant contribution. Spillman  Beck / RELEASING THE PAUSE BUTTON 607 (1999) confirmed that the value of membership in a multiples support group could not be overstated. Even though venturing out was an effective strategy used by mothers of twins, it did have a downside. Walton, Collins, and Linney (1994), for example, described how the preparation of two infants for an office visit to the pediatrician can be a logistical nightmare. This grounded theory study confirmed the findings reported by Gromada and Spangler (1998) regarding the stress that mothers of multiples experienced as a result of the constant unsolicited attention that going out in public with twins attracted. Reaping the blessings, one of the components of the fourth phase of resuming own life, was reported by Holditch-Davis and Roberts (1999). They addressed the positive outcomes of multiple births in one of their themes that focused on the specialness of multiples. Health care providers dealing with mothers of multiples need to be educated about the difference in the multiple-birth experience so that they can provide realis- tic and knowledgeable guidance. Leonard (1998) warned that the constant demands of being a mother of multiples can mean that the self is lost. Depression can overtake a mother’s life. Three mothers (19%) in this study experienced postpartum depression at some point during the first year of their twins’ lives. This percentage rate in mothers of multiples is higher than the general postpartum depression rate of 13% (O’Hara & Swain, 1996). Clinicians can use this four-phase process of releasing the pause button to locate where in this process mothers of multiples are. Specific nursing interventions can be designed to target different phases of this substantive theory. The most vulnerable time for mothers of twins is the first 3 months after delivery. Robin et al. (1998) sup- ported this 3-month cutoff point with regard to child care routines. Research focus- ing on interventions for mothers of twins is beginning to be cited in the literature. Hattori and Hattori (1999), for example, reported success with testing an interven- tion of breast-feeding support to help mothers of twins overcome the many obsta- cles in breast-feeding they face. Phone lines with health care providers can become lifelines for mothers of multiples before they begin to venture out with their twins. Intensive interventions such as support groups for parents of multiples need to be in place to support women during this vulnerable period. REFERENCES Anderson, A., & Anderson, B. (1990). Toward a substantive theory of mother-twin attachment. Maternal Child Nursing, 15, 373-377. Blumer, H. (1969). Symbolic interactionism: Perspectives and method. Englewood Cliffs, NJ: Prentice Hall. Bowers, N. (1998). The multiple birth explosion: Implications for nursing practice. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27, 302-310. Chang, C. (1990). Raising twin babies and problems in the family. Acta Geneticae Medicae Gemellologiae, 39, 501-505. Charon, J. (1995). Symbolic interactionism: An introduction, an interpretation, an integration. Englewood Cliffs, NJ: Prentice Hall. DeLisi, T. (1999). The rising number of multiple births. Journal of Newborn Nursing, 1, 17-19. Glaser, B. (1978). Theoretical sensitivity. Mill Valley, CA: Sociology Press. Glaser, B. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. New York: Aldine. 608 QUALITATIVE HEALTH RESEARCH / May 2002 Goshen-Gottstein, E. R. (1980). The mothering of twins, triplets, and quadruplets. Psychiatry, 43, 189-204. Gromada, K. K., & Spangler, A. K. (1998). Breastfeeding twins and higher-order multiples. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 441-449. Hattori, R., & Hattori, H. (1999). Breastfeeding twins: Guidelines for success. Birth: Issues in Perinatal Care and Education, 26, 37-42. Holditch-Davis, D., & Roberts, D. (1999). Early parental interactions with and perceptions of multiple- birth infants. Journal of Advanced Nursing, 30, 200-210. Hutchinson, S. (1993). Grounded theory: The method. In P. Munhall & C. Oiler (Eds.), Nursing Research: A Qualitative Perspective (pp. 180-212). New York: National League for Nursing Press. Kaplan, S. M. (1998). Coping processes used by mothers of triplets. Unpublished Doctoral Dissertation. Nor- folk, VA: Old Dominion University. Leonard, L. (1998). Depression and anxiety disorder during multiple pregnancy and parenthood. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27, 329-337. Mead, G. (1934). Mind, self, and society. Chicago: University of Chicago Press. Moilanen, I., & Ebeling, H. (1998). To be born as a twin—risks and sequelae. International Journal of Cir- cumpolar Health, 57, 138-147. Neifert, M., & Thorpe, J. (1990). Twins: Family adjustment, parenting, and infant feeding in the fourth tri- mester. Clinical Obstetrics and Gynecology, 33, 102-113. O’Hara, M., & Swain, A. (1996). Rates and risk of postpartum depression-a meta-analysis. International Review of Psychiatry, 8, 37-45. Robin, M., Corroyer, D., & Casati, I. (1996). Childcare patterns of mothers of twins during the first year. Journal of Child Psychology and Psychiatry, 37, 453-460. Robin, M., Josse, D., & Tourette, C. (1988). Mother-twin interaction during early childhood. Acta Geneticae Medicae Gemellologiae, 37, 151-159. Robin, M., Maner-Idrissi, G., & Corroyer, D. (1998). Mothers’ representations of their 13-month-old twins and child-raising attitudes. Infant Mental Health Journal, 19, 1-19. Spillman, J. A. (1999). Antenatal and postnatal influences on family relationships. In A. C. Sandbank (Ed.), Twin and triplet psychology: A professional guide to working with multiples (pp. 19-35). London: Routledge. Theroux, R. (1989). Multiple birth: A unique parenting experience. Journal of Perinatal and Neonatal Nursing, 3, 35-45. Thorpe, K., Golding, J., MacGillivray, I., & Greenwood, R. (1991). Comparison of prevalence of depres- sion in mothers of twins and mothers of singletons. British Medical Journal, 302, 875-878. Tough, S. C., Greene, C. A., Svenson, L. W., & Belik, J. (2000). Effects of in vitro fertilization on low birth weight, preterm delivery, and multiple births. Journal of Pediatrics, 136, 618-622. Walton, J., Collins, J., & Linney, J. (1994). Working together to meet the needs of multiple-birth families. Health Visitor, 67, 342-343. Williams, R. L., & Medalie, J. H. (1994). Twins: Double pleasure or double trouble? American Family Physi- cian, 49, 869-873. Cheryl Tatano Beck, D.N.Sc., C.N.M., F.A.A.N., is a professor of nursing at the University of Connecticut.