Describing Being a Single Parent of Multiples

Abstract

Objectives: To gather experiences from single parents of multiples, describe parenting and develop services for them. The literature review revealed a gap in this topic. There is a need to better understand such parenthood. This is part of a larger ICOMBO study based on international English data. Methods: As part of a study with quantitative and qualitative dimensions, this article focuses on two openended questions that describe being a single parent of multiples. The data were collected through questionnaires in seven countries between February and August 2016. Qualitative analysis was performed. Results: Being a single parent of multiples consists of four themes: "Moving forward", "Being surrounded by demands", "Diversity of relationships" and "The world is different". All of these are intertwined and interact. Conclusion: The decision to become a single parent is closely related to concern about the safety and future of the children, but some parents are single throughout the pregnancy and some consciously choose to be single parents from the outset. Diversity of relationships brings challenges. Daily life before and after divorce may be fragmented and needs to be put back together again. Despite this, the different and new situation also brings a feeling of security and more confidence in the future. Given the different backgrounds and life situations, being a single parent is individual, but there are also some universal elements such as life change, the workload involved in taking care of the children, lack of time for themselves. The social support systems and networks available to the participants varied greatly, which also affected their daily lives.

Headnote

Abstract

Objectives: To gather experiences from single parents of multiples, describe parenting and develop services for them. The literature review revealed a gap in this topic. There is a need to better understand such parenthood. This is part of a larger ICOMBO study based on international English data.

Methods: As part of a study with quantitative and qualitative dimensions, this article focuses on two openended questions that describe being a single parent of multiples. The data were collected through questionnaires in seven countries between February and August 2016. Qualitative analysis was performed.

Results: Being a single parent of multiples consists of four themes: "Moving forward", "Being surrounded by demands", "Diversity of relationships" and "The world is different". All of these are intertwined and interact.

Conclusion: The decision to become a single parent is closely related to concern about the safety and future of the children, but some parents are single throughout the pregnancy and some consciously choose to be single parents from the outset. Diversity of relationships brings challenges. Daily life before and after divorce may be fragmented and needs to be put back together again. Despite this, the different and new situation also brings a feeling of security and more confidence in the future. Given the different backgrounds and life situations, being a single parent is individual, but there are also some universal elements such as life change, the workload involved in taking care of the children, lack of time for themselves. The social support systems and networks available to the participants varied greatly, which also affected their daily lives.

Keywords: phenomenology, single parent, parenthood, family nursing, nurses/midwives/nursing

Introduction

Phenomenology is the philosophical name for the method of investigating or inquiring into the meaning of human beings' lived experiences. The main concepts in phenomenological research are the development of an understanding of meaning, the study of some human concern, lived experience, the lifeworld, and reduction (Cohen et al, 2000). The lifeworld, the world of everyday lived experience, is both the source and the object of phenomenological research. A researcher may search anywhere in the lifeworld for lived-experience material: through interview, observation, language, analysis, fictional accounts (van Manen, 1997; 2014).

Societies and families are changing across the world. A single parent is someone who has a child or children but no husband, wife, or partner who lives with them (Cambridge dictionary; 2019). The definition of a single-parent family includes those where the child/children live with a single parent, separated parents who share the care of their children, parents who look after the children in alternate weeks and mothers who are expecting their child/children alone. A singleparent family is one whose functioning is mainly dependent on one parent. Multiple-birth families are those that have twins, triplets or more (Finnish Multiple Births Association, 2019; ICOMBO, 2019). When we hear the term single parent, we tend to think of the negative aspects - the difficulty in coping, the impact on the children and how they may suffer as a result. But today, we are aware that it may also be a voluntary choice. Previous studies have found that parents of twins have difficulty in coping with more than one child of the same age (e.g. Anderson & Anderson, 1990; Beck, 2002; Garel & Blondel, 1992; Goshen-Gottstein, 1980; Heinonen, 2014; 2013). The mothers encountered problems with feeding (Harvey et al 2014; Heinonen, 2014; 2013; Leonard, 2000), getting the infants to sleep (Jahanafar, 2012; Heinonen, 2014; 2013; 2016;), and with individualisation and equal treatment (Robin et al, 1988; 1996). Parents were also worried about the lack of time for siblings (Harvey et al 2014; Heinonen, 2014). The mothers of twins showed significantly higher levels of parenting stress and depression than mothers of singletons, and were significantly more likely to find parenting difficult and significantly less likely to obtain pleasure from their child (Leonard, 1998; Olivennes et al, 2005).

Barber et al (1992) examined possible long-term influences of both divorce and living with a single mother on the development of adolescents' values and plans, as well as how divorce affects children both directly and indirectly through its impact on the mother's resources, attitudes and socialisation goals. Ellison & Hall (2003) determined the quality-of-life domains most affected by multiple births. These included social stigma, marital satisfaction, children's health, unmet family needs, parenting stress and maternal depression. Leonard & Denton (2006) presented guidelines to assist health professionals in helping families prepare for and successfully manage the demands of multiple pregnancy and the first five years after the births. They advised that multidisciplinary teams should have evidence-based guidelines and training to provide specialised and coordinated services for multiple-birth families. Copeland & Harbaugh (2010) compared the psychosocial factors, selfesteem, sense of mastery, life stress and social support among first-time married and single mothers in early parenthood. There were no statistical differences found between married and single mothers on social support and life stress. In their report on an Australian study, Neoh & Mellor (2010) concluded that shared parenting may not be a better arrangement for children than sole residence and access arrangements after parental separation. They found that parents in shared parenting families were more satisfied with their situation than were their children. Fathers in shared parenting families reported less stress than all other participant groups (even intact family members). The meta-analysis by Bauserman (2012) revealed that satisfaction with custody was greatest for both mothers and fathers when they had sole custody, less in joint custody, and least for non-custodial parents. Nielsen (2014) addressed the question of what type of parenting plan is most beneficial for the children after their parents separate, finding that, on the whole, the children in shared parenting families had better outcomes on measures of emotional, behavioural and psychological wellbeing, as well as better physical health and better relationships with their fathers and their mothers. Stavrova & Fetchenhauer (2015) explored the wellbeing of single and partnered parents as well as their childless peers in a crosscultural context. They demonstrate the importance of cultural norms in shaping the wellbeing of single and partnered parents and childless individuals. McArthur & Winkworth (2016) reported on the results of in-depth interviews with 20 sole parents with children aged under five who were not well connected to supportive services, finding that most participants were not satisfied with their informal networks. They conclude that there is a need for better understanding of the nature and extent of social networks so that practitioners and policymakers would be aware of the critical factors needed to increase service use for parents with limited resources. Tsai, Barr & Welch (2017) conducted an interpretative phenomenological study to explore the lived experiences of eight Burundian refugee single mothers in Australia. Their findings included the need to change parenting strategies when moving to a new country, and to provide education and support in parenting, as well as the importance of the role played by nurses in helping refugee single mothers. They recommend that further research needs to seek understanding of ethnic cultures and identify specific challenges and strategies to facilitate successful acculturation.

There is a need for better understanding of single-parent families and single parenthood with multiples in order to develop appropriate services for them. This need has been expressed by single parents of multiples, social and health care professionals and third sector providers (e.g. multiple-birth family organisations, family group providers). Single parents face many challenges and encounter varying attitudes from other people. There has been some research on single parents but very little on being a single parent of multiples. The aim of this study was to describe the life of single parents of multiples and find out what advice they would give others in the same situation based on their own experiences to help develop the services provided for multiple-birth families.

Methods

Study design: The whole study has both quantitative and qualitative components. This article focuses on two of the open-ended questions that describe being a single parent of multiples.

Setting, sample, data collection and analysis: This article is part of a larger study coordinated by the International Council of Multiple Birth Organisations (ICOMBO). The complete study involved 522 participants in 16 countries. The data were collected through questionnaires with structured and two open-ended questions. The participants submitted their answers through the websites of multiple-birth organisations. The data were analysed by qualitative data analysis. The results presented here concern the qualitative part of the research based on international data in English from the UK, USA, Canada, Australia, New Zealand, South Africa and Ecuador. Table 1 provides information on the participants in the whole study.

Findings: Being a single parent of multiples consists of four themes: "Moving forward", "Being surrounded by demands", "Diversity of relationships" and "The world is different". All these are intertwined and interact with each other. These findings are complemented with some of the quantitative results.

Ethics: The systematic literature review revealed a gap in this research topic. Respondents received information about the study and gave their informed consent to participate. They answered anonymously through the websites of multiple-birth organisations. Qualitative and quantitative analysis was performed. The participants were informed that the results would be presented later in a different context. Every phase of the research process involves ethical considerations.

Results

Being a single parent of multiples can be described as: 1) "Moving forward" (consisting of three themes: The life cycle of a single-parent family; Coping as a single parent; Protecting the child and childhood); 2) "Being surrounded by demands" (consisting of three themes: Being indispensable; Strengthening yourself; Survival strategies); 3) "Diversity of relationships" (consisting of three themes: A network taking you forward; Ensuring safety; Parenting alone); 4) "The world is different" (consisting of two themes: Our lovely home again; Life continues protectingly). (Figure 1.)

Being a singe parent of multiples

Moving forward

The life cycle of a single-parent family means moving forward, taking one day at a time and concentrating on the present. It is about appreciating life as it is at the moment; the parent is present and engaged, trying to enjoy their life now and valuing this moment. They also emphasise the future and are positive about it. They describe it like this:

Go with the flow means just breathe and carry on. Moving forward means a positive aspect.

Allowing yourself the chance to find easy solutions. The future may be even better and easier.

Believe in your ability to take care of your kids no matter what! That my [twins] will know who cares for them and takes care of them.

There were many descriptions and they talked about the importance of getting into a routine and trying to be as organised as possible in order to cope alone as a single parent. Being organised means being patient and understanding their own life situation and each individual - doing things in stages and establishing a routine that suits them and their children best, such as keeping meals simple, prioritising tasks and putting the babies to bed at the same time.

This also means that sometimes the world of a single parent is quite limited. They lack time and space of their own, which is a fundamental human need. They have to get used to living and making decisions alone without another parent to share the responsibilities. Only a few participants mentioned co-parenting, which is more than just seeing the children. The key thing is that the parent must put the children first, everything else can wait. They protect the child and childhood. It means spending time with and focusing on their children. They were happy with their twins and all their children. Some participants mention that their children also gave them motivation to leave and live.

The smiles and feelings of joy make it all worthwhile. I have goals & take one day at a time moving towards those goals.

When you think you can't do it, remember you actually are doing it right now and fake it till you make it. Also that you are important. If you don't take care of yourself you can't take care of those babies.

The biggest struggle I have is no me time away from the children. The only time I am away from them is when I am at work, so struggle with getting space and time to do things for me.

Multiples are amazing. They are also a form of torture designed to test your strength. My babies give me mine and I love them more than words can say. They gave me the motivation to leave. They deserve to be safe and happy. They literally saved my life.

Sometimes, being a single parent involves protecting their children from unpleasant experiences, especially when there are problems with the marital relationship. Better to be safe than unhappy and in fear and have [names of the twins] see [the other parent] as a role model as a liar, cheater and abuser.

It is important to engage with the children, give them your attention and interact with them because the relationship actually makes parenting meaningful and you can always look ahead to the future. It just emphasises what being a parent means, strengthening the parent in moments of weakness.

Being surrounded by demands

The single parent is surrounded by demands and one of the main and strongest bodily feelings is being indispensable. Parenting alone means being available all the time and the responsibility rests on your shoulders. It is there even when you are not with your children. It never leaves your mind. It was also often the case that they had various financial problems. Some recommended seeking advice about financial support available from the government.

They strengthen themselves. They gain strength from their children, inner strength from daily life. They discover how special it is to have twins and they love being such a mother. The joy comes from knowing they will always love you, you are doing a great job, you get all the cuddles and kisses. Single parenthood involves joys and worries. It is also important that parents let themselves express different kinds of feelings. There were other worries, such as the twins being premature or ill or conditions like colic. One mother wanted better preparation and parent education in professional antenatal care. Some parents also felt the lack of a male role model in daily life. They also felt in need of advice to help them concentrate on the essentials and to share the various responsibilities with the other parent after divorce. Despite their difficulties, they never give up. Survival strategies include accepting their own life and situation but also their own limitations.

Don't sweat the small stuff. If you worry about everything, it 's hopeless.

You don't have to be perfect, the kids just want you. It's OK to cry and be angry. Being a human being, not just a breastfeeding robot.

Enjoy parenting, don't try to be perfect. You can't be mum and dad, so don't try to overcompensate.

Women should stop fighting for full custody of their multiples and start fighting to make the fathers take more than financial responsibility but also physical responsibility of raising their multiples.

I make all the decisions and carry all the load of responsibility. It would be nice to share the family moments with a partner though, do at times wish they had a good male role model at hand.

As you can imagine caring for two babies alone with colic was extremely tiring and difficult. As colic is so common and not to mention unpleasant for the baby I think there should be a more immediate and pro active approach towards it by health professionals to educate parents antenatally in preparation. I was at a loss for so long not really knowing what was wrong with them ... It was added stress which could have been sorted out sooner had I been educated better.

Diversity of relationships

In a single-parent family, the social network, including close family members, friends, peer support and professionals, helps them keep going. It means getting encouragement and a variety of help and support. The networks of the participants varied greatly. Several mothers noticed kindnesses and support extended to married parents, but the needs of single parents often weren't addressed. Club events tended to be geared to couples and single parents felt excluded. Some of them mentioned practical help, guidance programmes and multiple-birth organisations. There were also situations where they were without help even from professionals.

My local multiple birth association was and is very supportive, organising events and assistance for all families specific to their needs. This includes, advice sessions, free music classes, coffee groups, children playgroups, and providing support for parents to obtain counseling if needed.

Friends visiting to care for girls while I had a 2hr sleep. Family stayed for first weeks to help while I recovered from a difficult birth. Dropped off meals from local multiple birth group.

It was very hard physically for first two years. Once they are walking well, life gets a lot easier. I was able to cope for first two years but it would have been a more pleasant ride with some part time help and even a health visitor visiting once a month to make helpful suggestions with development and different phases that changed so fast.

I feel alone due to being the only person in my social group with twins and single parent. I would have loved and would still love a single parent support group.

I had to pay for everything, which means I had to work even more. Such a vicious circle!! Then I felt judged by the public health nurses, as I was not coping well.

They also used online support and some had their own online support groups, such as single-bychoice mothers. Several respondents talked about how helpful it was for them to network with other single parents of multiples - either on line or in their community. Single parents also compare their situation with that of different families and stress the importance of their own attitude. Another aspect was the inner strength they gained from religious faith. Single-bychoice mothers built their own community to get support and share their experiences. One mother found that her own positive attitude to being alone helped alleviate stress in her children. Sometimes mothers encountered negative attitudes from professionals.

That I needed to lean on God to help me through, he's not going to work magic, and won't take all the bad away, but he knows we can do it with His help and His guidance.

It has been a wonderful experience - I have friends and family support and my twins are thriving. The only downside is the loneliness and need for adult company - social media helps but it would be great if we could have more in-person support and get togetherness.

I don't think being a single parent is any more difficult then having a partner who works long hours. If you stay calm, they are less likely to get stressed.

Single mothers by choice do have an exceptional online community globally and I think this puts us in an advantageous positon when we are seeking support. We are also often highly motivated to have children and I have found we seem to have high levels of resilience as a result. Saying that: I found the lack of government support appalling... the hospital/birth experience was particularly bad. Hospitals seem to assume the mother has a partner there to do all the care for them...

There were many experiences of communication problems with the single parent not getting support from their ex-spouse, experiences of the other parent being irresponsible and making it impossible for them to continue together, causing suffering and fear. It means being a responsible parent and making the decision that is best for them and their children. I have been struggling financially since he doesn't pay child support. Parenting alone means that the parent who is taking care of the children sees the impact of divorce on them, such as changes in the twins' relationship.

One advantage may be that I would talk to my [twins] more and perhaps this has helped their speech development.

My [twins] have got louder and more demanding and need more of my time since becoming a single parent as they compete more with each other for their parent's attention.

The world is different

Despite the divorce and the fact that life is hard after the separation, having a happy home again gives them a lot of strength and positive feelings. Support is also needed for mothers single by choice to promote the wellbeing of the children. The home is a secure and safe place where they can be themselves. They are positive about their lives and situation.

And I agree: a supported mother (single mothers by choice) can create a happier and more stable home and happier and stable children.

... that not having the other parent in the household was a positive for the children - much less stress and more harmony in the household.

Look at the positives in life, two amazing healthy [twins], and how special it is to have identical twins... - so many special moments that are absolutely priceless.

Focus on the strengths or positive aspects that are unique to single parent homes such as working together as a team and achieving our goals no matter what. People feel sorry for you as a single parent of multiples, but are also amazed that you are a single parent of multiples and wonder how you cope!

Very often, single parents felt free and that it was easier to go on with life and protect the children. Fundamentally, it's about what kind of home and environment their children will grow up in. The decision to be a single parent meant having a new perspective and new light in their lives. The children would have a better life. Sometimes, the choice to be a single parent had already been made before the children were born. They were happy with the decision and didn't complain even though life was sometimes hard.

I chose to have my (twins) via IVF as a single as i didnt want the opportunity to have children pass me by. Despite our very stressful & emotional first few months, being a mum is the greatest decision I've ever made.

Discussion

This study reveals that, before the divorce, many mothers' resources were consumed by unresolved conflict between the parents. For the mothers, getting out of the relationship means breathing freely again, reorganisating their life, concentrating on essentials, being a parent to the children and supporting their growth and development. Insecurity causes emotional stress, exacerbated by exposure to (the threat of) violence, money worries, and anxieties about the children and the spouse, too. This study also indicates that, even though the decision to separate may be hard, many single parents felt that life was easier and lighter than before.

Some participants mention the differences in being a single parent. Regarding appointments with professionals and events targeted at families, e.g. events providing support for parenting and those organised by the multiplebirth association, it was assumed that there were two parents. In such cases, a single parent may have felt she was not treated equally or that the information provided was not applicable to her life situation. Moreover, it was difficult for some mothers, as single parents, to go to events aimed at families. This does not mean that they were treated badly, but rather that they felt they did not belong to the group or were different or that the people around them had doubts about the family because it lacked the other parent.

Despite the difficulty of the divorce and the fact that life is hard after the separation, having a happy home again gives them a lot of strength and positive feelings. This is something that social and health care professionals should emphasise. At first the basic needs of the family and children should be met. Professionals, or volunteers from the multiple-birth organisation, should not only look to the future, but also encourage parents to appreciate the present moment in their lives and believe that they can cope despite the problems they are currently facing. Professionals can use a mind map, at the centre of which is the family surrounded by positive things. Another mind map could show the things that need to be solved and with which they need help.

Stavrova & Fetchenhauer (2015) examined the effect of social norms and expectations regarding childbearing practices on parents' wellbeing in 43 European countries. They found that the negative effect of single parenthood on life satisfaction and emotions was restricted to collectivist countries and countries with a strong norm of two-parent families. In countries with a high prevalence of two-parent families and a widespread belief that growing up in singleparent families makes children unhappy, parents raising children alone were indeed unhappy. In such countries, single parenthood was associated with a lower life satisfaction, less positive and more negative emotions. In countries with a strong norm of two-parent families, single parents might be subject to disapproval or rejection. In individualist countries, in which childbearing in single-parent families represented a socially acceptable practice, single parents did not report a lower level of wellbeing than partnered parents; they were freed from the moral obligation to provide their children with a traditional family, and the psychological burden of single parents was alleviated.

The present study found hardly any mention of joint parenthood, and in some cases it would not have been possible for safety reasons. Some of the participants felt lonely and sought togetherness. Neoh & Mellor (24) found no significant differences between children in the different family configurations, suggesting that shared parenting is not necessarily associated with better outcomes for the child. They also found that parents in shared families were more satisfied with their situation than were their children, fathers particularly so. Fathers in shared parenting families reported less stress than all other participant groups (even intact family members). So, in this respect, shared parenting appears to be better for fathers, but not for the children or mothers. Although joint parenthood is not always possible, some participants in the current study said that, after the divorce, mothers should concentrate more on trying to cooperate with the other parent and talk about how to share the various responsibilities. Nielsen (2014) found that, overall, the children in shared parenting families had better outcomes on measures of emotional, behavioural and psychological wellbeing, as well as better physical health and better relationships with their fathers and their mothers, benefits that remained even when there were high levels of parental conflict. Neoh & Mellor (2010) found that parents in all groups underestimated the emotional problems reported by children, while in separated families, they overestimated the children's desire for the parents to reunite.

In the present study, mothers encouraged each other to take all the help they could get. They wanted more financial help from the government and bemoaned the high cost of childcare. They also commented on how hard it was to find assistance or help because of the range of services they needed - social security office, social worker, psychologist, lawyer, etc. They also wanted online support because of long distances, the difficulty in going out with the children and/or finding babysitters. But what they needed most was social contact, people who would listen to them with understanding, giving their time and support. Copeland & Harbaugh (2010) recommend that professionals develop parenting programmes and use other innovative solutions to provide social support, such as internet and technology-based interventions. It is important to provide interventions specific to single mothers that focus on improving their selfesteem and sense of mastery related to parenting. McArthur & Winkworth (2016) analysed three different kinds of support: practical or concrete support (e.g. giving her a lift, helping her with a big chore, looking after her belongings or children for a while), emotional support (e.g. comforting her when she is upset, being with her in a stressful situation and listening to her talk about her feelings) and advice and information (e.g. giving her information on how to do something, helping her make a big decision, teaching her how to do something new with regard to things such as the baby's sleeping, eating, or the children's behaviour) (McArthur & Winkworth, 2016). Heinonen (2016) shows that multiple-birth families need various forms of support, such as social support that can further be divided into emotional, practical, informative and peer support. Family care workers have the opportunity to observe multiple-birth family life in real contexts and to guide and support them. This is important because professionals who help them in the family homes can share their needs with other professionals. Family care nursing with multiple-birth families could be developed in cooperation with hospital staff and the staff of maternity and child health clinics, involving home visits together with public health nurses (Heinonen, 2016). The findings of Copeland & Harbaugh (2010) support the theoretical assertion that personal psychological resources are most indicative of successful parenting. Accordingly, it is important that healthcare professionals focus their assessments on the mother's personal resources after birth and in early parenthood.

In the current study, some participants mention their strong religious faith, although there was little mention of the church. The church also helped single parents of multiples. Religious faith is something that is present and strengthens you in your own space, i.e. home, in which case there is not always a need to go somewhere else. In the study by McArthur & Winkworth (2016), there were some participants involved in religious-based organisations. They experienced not receiving much in the way of social support or connections there, but it was important to them either because of what it provided for their children or in terms of their faith and sense of meaning. Many sole parents experience multiple barriers to their participation in playgroups, such as lack of transport, the costs involved or not having friends or contacts in playgroups.

Even when mothers identified some support from family and friends and part of the service system, there was not a strong sense of community support or belonging, but rather a sense of this parenting experience being, in varying degrees, an individual, lonely one. The capacity of these parents' social networks to be a bridge to other resources is very limited.

In the present study, there were mentions of loneliness and wishing for close family members and friends. With regard to mothers from other cultures, Tsai, Barr & Welch (2017) stress that being a new immigrant is challenging and requires adaptation, and that there is no understanding of the experiences of single refugee mothers, which they explore. Mothering in a new country was a difficult process and the single refugee mothers in this kind of context decided to embrace both new and original cultures. Learning socially acceptable child disciplinary strategies in a new country was not easy for the participants and was at the same time potentially detrimental to the family dynamics. There was also an increasing fear of losing their children to the foreign culture (2017).

Leonard & Denton (2006) point out that multiple births are associated with substantial medical, healthcare, psycho-social, developmental, educational and economic consequences for families and society. They state that twins and higher-order multiple-birth children and their families have unique needs, which are still not widely understood or sufficiently addressed by healthcare and other professionals. They identify four interrelated principles of good practice: the involvement of a range of disciplines, the family and the multiple-birth community; the provision of specialised care; coordinated services; and the building of family competency including the capacity to make informed decisions. Multiplebirth parents need more advice and different kinds of support and understanding from professionals to promote their children's health, growth and development, but also to take care of themselves and their own health and wellbeing (Heinonen, 2016).

Limitations

The literature review revealed a gap in this research area, with only a few studies being found, thus justifying the current study. The participants themselves and professionals have also expressed a wish for more research that could lead to the provision of better help for single parents of multiples. The ethical guidelines were followed during the research process, but there were no positive statements from the ethics committees in the various countries in the whole study which was organised by ICOMBO. The respondents were sent information about the study and gave their informed consent before taking part. The data for this study had been collected in different countries by survey. Despite their different backgrounds (divorced, single by choice, etc.), all the participants in this study fall into the category of single parents, and the aim was not to compare different countries, but to describe the participants' lives. The responses to the openended questions included good descriptions of the experiences, but also very short comments or "none". Conducting interviews could lead to greater understanding of culturally sensitive aspects. It would also be better to have further contact with the participants to ask them more about their experiences in order to gain deeper insights. After the results were ready, two single parents of multiples said that the description of being a single parent corresponded to how they themselves experienced it. It would be better to ask more participants for their opinion. This field is relatively unexplored, especially with regard to the category of single by choice.

Conclusion

As a group, single parents are vulnerable; most of them are pregnant or in the postnatal period and breastfeeding more than one child. The need for protection and possible support is essential for all single parents.

Different kinds of families and ways of supporting them should be better addressed in the context of different societies and cultures. There are many dimensions to being a single parent of multiples and to continuing their life.

Attention should be given to the background situation - whether they were single before the birth of the children, are divorced or single by choice. The relationship between the parents could contribute positively to the family situation. Parents also need the support of their local parents of multiples group. It is also important to develop peer and family groups and other methods such as online support to respond to their needs. Their needs should be taken into account in trying to provide them with the right kind of help. Single parents are not alone: there are a lot of other single parents and peer support is available, even from those in other countries. We need to help such parents to get together to have other people listening and sharing their lives.

Single parents are survivors. They have got used to or experienced different circumstances in their daily lives. They look to the future - to give their children a better life even as a single parent. They have to be and stay strong enough; everything depends on them. The possibility of co-parenting may exist, but not always. These parents need to know that there are people who care and appreciate them for all the work they do. There is a need for special training for different types of nurses (e.g. registered nurses, public heath nurses, midwives), but also for students.

A useful topic for further research would be to explore the experiences of family members and professionals in order to gain more understanding of what it is like to be a single mother of multiples. Intervention and action research would be also very interesting.

Acknowledgements: I thank all the participants for sharing their experiences in this large international study. I thank the Chair of ICOMBO, Monica Rankin, J. Susan Griffith, MD, the Executive Director of the Finnish Multiple Births Association, Ulla Kumpula, and all the ICOMBO members for this collaboration. I would also like to thank William Ansell, BA, for helping with the language revision of the manuscript.

References

References

Anderson A. & Anderson B. (1990). Toward a substantive theory of mother-twin attachment. American Journal of Maternal and Child Nursing, 15(3): 373-377.

Barber BB., Eccles L. & Jacquelynn, S. (1992). Longterm influence of divorce and single parenting on adolescent family- and work-related values, behaviors, and aspirations. Psychological Bulletin, 111(1): 108-126.

Bauserman R. (2012). A Meta-analysis of Parental Satisfaction, Adjustment, and Conflict in Joint Custody and Sole Custody Following Divorce. Journal of Divorce & Remarriage, 53(6): 464488.

Beck CT. (2002) Mothering Multiples. A metasynthesis of qualitative research. The American Journal of Maternal and Child Nursing, 27: 214-222.

Cambridge dictionary. (2019)<https://dictionary.cambridge.org/dictionary/english /single>- parent. 27.6.2019.

Cohen M.Z., Kahn D. & Steeves R. (2000). Hermeneutic Phenomenological Research: A Practical Guide for Nurse Researchers. Thousand Oaks, SAGE Publications, California.

Copeland DB. & Harbaugh BL. (2010). Psychosocial differences related to parenting infants among single and married mothers. Issues in Comprehensive Pediatric Nursing, 33, 129-148.

Ellison MA. & Hall JE. (2003). Social stigma and compounded losses: quality-of-life issues for multiple-birth families. Fertility and Sterility, 80(2): 405-414.

Finnish Multiple Births Association. (2019). Retrieved from <http://www.suomenmonikkoperheet.fi/monikkotiet oa/> 22.6.2019.

Garel M. & Blondel B. (1992). Assessment at 1 year of the psychological consequences of having triplets. Human Reproduction, 7(5): 729-732.

Goshen-Gottstein ER. (1980). The mothering of twins, triplets and quadruplets. Psychiatry, 43: 189-204.

Harvey ME., Athi R. & Denny E. (2014). Exploratory study on meeting the health and social care needs of mothering with twins. Community Practitioner, 87(2): 28-31.

Heinonen K. (2004). Dimensions and possibilities in multiple birth parenthood. University of Kuopio. Abstract in English. Kopijyvä. Kuopio. Finland

Heinonen K. (2013). The lifeworld of multiple-birth families from being on guard to strengthening parenthood. Phenomenological-hermeneutic study. Publications of the University of Eastern Finland. Dissertation in Health Sciences. Abstract in English.

Heinonen K. (2016). Supporting Multiple Birth Families at Home. International Journal of Caring Science, 9(2): 422-431.

ICOMBO (2019). International Council of Multiplebirth Organisations. Retrieved from http://icombo.org/. 20.6.2019.

Jahanafar S. (2012). Twins co-bedding at home. Parents' perspective, sleeping pattern and developmental millstone. Medical Journal, 13(1): 13-18.

Leonard LG. (1998). Depression and Anxiety Disorders During Multiple Pregnancy and Parenthood. Journal of Obstetric, Gynecologic & Neonatal Nursing, 27(3): 329-337.

Leonard LG. (2000). Breastfeeding Triplets. The at home experience. Public Health Nursing, 17(3): 211-221.

Leonard LG. & Denton J. (2006). Preparation for parenting multiple birth children. Early Human Development, 82(6): 371-8.

van Manen M. (1997). Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. 2nd Edition, Althouse Press, London.

van Manen M. (2014) Phenomenology of Practice: Meaning-Giving Methods in Phenomenological Research and Writing. Left Coast Press, Walnut Creek, California.

McArthur M. & Winkworth G. (2016). What do we know about the social networks of single parents who do not use supportive services? Child & Family Social Work, 22: 638-647.

Neoh J. & Mellor D. (2010). Shared Parenting: Adding Children's Voices and Their Measures of Adjustment to the Evaluation. Journal of Child Custody, 7(3): 155-175.

Nielsen L. (2014). Shared Physical Custody: Summary of 40 Studies on Outcomes for Children. Journal of Divorce & Remarriage, 55: 613-635.

Olivennes F., Golombok S. & Ramogida C. (2005). Behavioral and cognitive development as well as family functioning of twins conceived by assisted reproduction: findingsn from a large population study. Fertility and Sterility, 84(3): 725-733.

Robin M., Josse D. & Tourette C. (1988). Mothertwin interaction during early childhood. Acta Geneticae Medicae et Gemellologiae, 37(2): 151159.

Robin M., Corroyer D. & Casati I. (1996). Childcare patterns of mothers of twins during the first year. Journal of Child Psychology and Psychiatry, 37(4): 435-460.

Stavrova O. & Fetchenhauer D. (2015). Single Parents, Unhappy Parents? Parenthood, Partnership, and the Cultural Normative Context. Journal of Cross-Cultural Psychology, 46: 134149.

Tsai LP., Barr JA. & Welch A. (2017). Single mothering as experienced by Burundian refugees in Australia: a qualitative inquiry. BMC Nursing, 16(70): 1-7.