Breastfeeding and Multiple Birth Loss

I am a multiple birth loss mother. During my second trimester, one of my twins had died. This was a time of uncertainty and emotional distress. I remember feeling like I was the only one this had ever happened to. I felt alone in my grief. I felt like no one understood my pain. I remember the drastic status change from mother of twins to mother of surviving twin. At the time when my surviving twin was born, I had an almost 2-year-old child. I had already experienced breastfeeding a singleton infant. This enhanced my ability to make some observations about breastfeeding after a multiple birth loss. Clearly, every child is different and every experience of breastfeeding will be unique. Yet, the difference in this situation lies in the emotional aftermath of the death of the multiple. I was simultaneously grieving for the loss of an infant while establishing a breastfeeding relationship with my surviving baby. I faced cremation arrangements while I coped with a premature infant with health issues. My experiences with breastfeeding were shaped by my special circumstance of having a surviving twin. My surviving twin was premature and needed NICU care. The extended hospital stay left me with the challenge of establishing breastfeeding while separated from my baby. His prematurity was a factor in his ability to position at the breast and suckle. Some of my breastfeeding experiences were bittersweet. I was happy to be able to establish breastfeeding but I longed to have the opportunity to breastfeed multiples. I was filled with joy to bond with my baby through breastfeeding, yet terrified that he would also die. I felt I needed to breastfeed my surviving twin so that he would reap the established benefits of being breastfed and have a better chance for survival.

Multiple birth loss is medically and emotionally complicated. The circumstances surrounding multiple birth loss are varied. Multiple birth loss mothers often experience delivery via c-section. Many surviving multiples are delivered pre-term; require NICU care and extended hospitalization. Other possible infant medical conditions are dysfunctional suckle, jaundice, anemia, respiratory distress syndrome and sepsis. The wide-ranging medical complications that might accompany a multiple birth loss situation are distinctive breastfeeding situations. Additionally, bereavement issues may be associated with special breastfeeding support needs. Possibilities include the management of depression through medications, loss of maternal appetite, low milk production and insufficient milk supply.

“Although twin birth constitute only approximately 2% of all births…twins account for…approximately 12% of all infant deaths.” This astounding percentage fails to account for stillbirths in a multiple birth along with the rate of demise in higher order multiples. “The twin stillbirth rate is about three times higher that of a singleton.” Another consideration is that medical technology has increased the rate of twins and higher order multiples pregnancies. “Since 1980, the twin birth rate has risen 49 percent and the triplet and other higher order multiple birth rate has risen 423 percent.” It is important to note that, “Estimates suggest up to 15% of multiples grow up as singleton survivors.”

The emotional complications of loss in a multiple birth loss have been expressed as “grieving and loving at the same time”. Limbo and Wheeler note the turmoil, tensions and vulnerability of grieving for the loss of a twin or higher multiple while parenting the survivor(s). They describe the conflict of emotions as “reminders of love and death [that] occur simultaneously every day, almost every minute.”5 Needless to say, this is a stressful time for multiple birth loss parents. This stress may impact the initiation and success of the breastfeeding experience.

Low milk production may occur after a mother has experienced significant stress. Kathryn Dewey notes, “women and infants whose experience is at the high end of the range for stress may be at greater risk for adverse outcomes.” Her research indicates “acute physical and mental stress can impair the milk ejection reflex by affecting the release of oxytocin during a feed. If this occurs repeatedly, it could reduce milk production…”7 She suggests “Mothers who experience high levels of stress should receive additional lactation guidance during the first week or two postpartum.”7 Support and assistance to the mother by healthcare providers are variables that influence a mother’s decision to initiate and continue breastfeeding.8 “Social support is especially important in the period immediately following any life stress.”

In Counseling Grieving Families, Diane Herthforth offers practical breastfeeding suggestions for families that are bereaved. This Lactation Consultant Series addresses lactation and singleton infant loss, however, some suggestions might be applicable to some multiple birth situations. Particularly, the special support needs of grieving families and the importance of sensitivity. “When a baby or young child who has been breastfeed dies, the LC can remind the mother of the loving concerns she showed her baby through breastfeeding, something only she could give, and a memory she can cherish.” Bereaved multiple birth mothers report that acknowledgment and understanding are helpful, while unacknowledged grief and insensitive comments are least helpful.4

Beth Pector, MD in Protocol for Management of Perinatal Multiple Birth Loss offers suggestions for the support of breastfeeding after a multiple birth loss. She recommends involving lactation consultants and grief counselors. She notes that, “Giving up on breastfeeding too early because of prematurity, infant feeding difficulties, medical complications or difficulty initiating lactation introduces yet another loss to the mother. Multiple birth mothers may face obstacles to breastfeeding with “healthy babies at home and a moribund infant in the NICU”. In multiple birth loss situations modification of NICU policies is suggested to facilitate the breastfeeding relationship. “Bereaved mothers may find it emotionally difficult to breastfeed their survivors.”11 Pector remarks that breastfeeding might “create acute sadness when a mother who had planned to nurse all her babies is confronted again with the reality that one is missing.” “Nursing promotes bonding, but feeding surviving co-multiples in the same location where their deceased were held may remind mothers of their loss.”

Multiple birth loss mothers simultaneously grieve the loss of an infant(s) while establishing a breastfeeding relationship with the survivor(s). Breastfeeding a surviving multiple(s) may be rewarding, empowering, and healing for the bereaved mother. Some multiple birth loss mothers may indicate feelings of stress. Dewey suggested “additional lactation guidance” when high levels of stress are experienced.7 Herthforth noted the special support needs and sensitivity of grieving families. Sensitivity and support are helpful to multiple birth loss mothers. Swanson found that “insensitive comments” are perceived as least helpful to multiple birth loss mothers.4 This finding can be applied as well to the breastfeeding experiences of multiple birth loss mothers. Beth Pector suggested involving lactation counselors and grief counselors. She noted preserving breastfeeding might avoid “another loss to the mother”.10 At the same time, she mentions the possibility that breastfeeding may serve as a reminder of the loss. Some women indicate grieving influences their decisions about breastfeeding or their breastfeeding experience. Some mothers find the breastfeeding experience both reminds them of their loss while providing a way to mourn.

Multiple birth loss is a distinctive breastfeeding situation. Special counseling considerations for breastfeeding management in a multiple birth loss situation need to developed and practiced. Careful consideration needs to be taken to avoid breastfeeding suggestions that might lead to frustrations and discouragement. It is important to bear in mind the possible impact of grief on the breastfeeding experience. Thoughtfulness needs to be given to the possible stress of the situation. Multiple birth loss mothers may require extra support and sensitivity when provided suggestions related to pumping or NICU feedings. It is imperative they receive accurate breastfeeding information. Multiple birth loss mothers breastfeeding experiences are best supported through empowerment, encouragement, and support.

Junelle Medler

1 CDC. MMWR Weekly. Feb 14, 1997; 46(6): 121-125.

2 Bryan, E. & Higgins, R. Introduction. Twin Res. June 2002; 5(3): 146-148.

3 HHS News. National Vital Statistics Reports. March 28, 2000; 48(3).

4 Swanson, PB. Pearsall-Jones, JG. Hay DA. How mothers cope with the death of a twin or higher multiple. Twin Res. June 2002, 5(3): 156-64.

5 Limbo, R. & Wheeler, S. When A Baby Dies: A Handbook For Healing and Helping. La Crosse, Wisconsin: RTS Bereavement Services; 1995. 55-60.

6 Ruvalcaba, RHA. Stress-induced cessation of lactation. West J Med. 1987; 146:228-30.

7 Dewey, Kathryn G. Maternal and Fetal Stress Are Associated with Impaired Lactogenesis in Humans. J Nutrition. Nov 2001; 131(11): 3012S-5S.

8 Riordan, J. & Auerbach, K. Breastfeeding and Human Lactation. Boston, MA: Jones & Bartlett; 2000, 664.

9 Herforth, Diane. Counseling Grieving Families. Lactation Consultant Series. Unit 12. New Jersey: Avery Publishing Group Inc.

10 Pector, MD, Elizabeth A. Protocol for Management of Perinatal Multiple Birth Loss. 2000.

11 Pector, MD, Elizabeth A. & Smith-Levitin, Michelle. Mourning and Psychological Issues in Multiple Birth Loss. Senim Neonatal 2002; 7:247-256.

12 Pector, MD, Elizabeth A. and Smith-Levitin, MD, Michelle. Bereavement in Multiple Birth. Part 1: general considerations. The Female Patient. Nov 2001; 25:31-35.