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Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study
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Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research - Quantitative
Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study Marjon De Roosea,* , Dimitri Beeckmana , Katrijn Eggermonta , Elke Vanhouchea , Ann Van Heckea,b , Sofie Verhaeghea a b
University Centre for Nursing & Midwifery, Department of Public Health, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium Nursing Science, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 May 2017 Received in revised form 23 August 2017 Accepted 1 September 2017 Available online xxx
Problem: To date, it is unclear which factors are associated with parenting stress. Background: There are no studies investigating the association between parenting stress and coping strategies such as coparenting and social support, while simultaneously considering demographic and obstetric factors, in mothers of singletons and twins. Aim: To investigate if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, and the availability of and satisfaction with social support in mothers of singletons and twins until one year postpartum. Methods: A cross-sectional study was conducted. A total of 151 singleton mothers and 101 twin mothers were included. Results: Both singleton and twin mothers experiencing lower parenting stress levels indicated a better coparenting relationship quality (b = 0.253, p < 0.01; b = 0.341, p = 0.001). Elevated parenting stress levels positively influenced the level of satisfaction with social support in only mothers of twins (b = 0.273, p < 0.01). The availability of social support, personal, and obstetric characteristics were not associated with the level of parenting stress in neither singleton nor twin mothers. Conclusion: Coparenting seems to be a significant coping strategy reducing the level of parenting stress in singleton and twin mothers, irrespective of their personal and obstetric characteristics. Large-scale longitudinal research is needed to identify predictors of parenting stress, which may help to develop parenting stress reducing interventions. The acknowledgement and support of an adequate coparenting relationship quality by health care professionals might be an important factor to include in such interventions. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Parenting stress Social support Coparenting Singletons Twins
Statement of significance
Problem or issue To date, it is unclear which factors are associated with parenting stress. What is already known Social support and coparenting have been identified as two coping strategies to prevent or mitigate the level of parenting stress and its adverse consequences. Besides
these coping strategies, there is limited research suggesting that there might be other factors influencing the level of parenting stress, including demographic, prenatal, obstetric, and postpartum factors. However, it still remains unclear which of these factors are associated with parenting stress. What this paper adds This study is the first examining if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, the availability of and satisfaction with social support in mothers of singletons and mothers of twins until one year postpartum.
* Corresponding author. E-mail address: [email protected] (M. De Roose). http://dx.doi.org/10.1016/j.wombi.2017.09.003 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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1. Introduction There is a growing body of knowledge recognising the considerable adverse effects of parenting stress on the mother, her partner, and the child. Parenting stress is defined as “an imbalance between the perceived demands of parenting and the perceived available resources”.1 Higher parenting stress levels are associated with a higher risk for developing postpartum depression, lower levels of marital satisfaction, negative parent-child interactions, and even the development of behavioural problems and psychopathology in children.2 Previous research established that some parents are at higher risk for developing parenting stress, including mothers who gave birth to twins.3,4 These higher parenting stress levels can be explained by greater functional, financial and/or medical demands faced by mothers of twins during pregnancy and postpartum.3 Social support and coparenting have been identified as two considerable coping strategies to prevent or mitigate the level of parenting stress and its adverse consequences.4,5 Social support is defined as “having one’s need met through the presence of and interaction with others, such as spouses or partners, family members, or friends”.6 Social support can be emotional, informational, and instrumental.6 In general, literature indicates that women perceive their partner and own mother as the most important sources of support.4,7 In addition, a higher perception of own mother’s support has found to be associated with better wellbeing and mental health in mothers,4,7 and a better marital relationship.4,7 In contrast, lack of support from family members, friends, and colleagues might contribute to the development of postpartum stress and depression.8 In addition to social support, several studies identified coparenting as another significant element in coping with parenting stress.4,8 Coparenting is defined as “the way parents support and coordinate with each other in their roles as parents”.9 The definition refers to two people who are collectively raising a child, regardless of whether or not they are both biological parents or have ever been romantically involved.10 Literature indicates that good coparenting leads to less parenting stress, while insufficient coparenting causes more parenting stress.11 Better coparenting has also been linked with higher relationship quality between parents.12 Besides these coping strategies, there is limited research suggesting that there might be other factors influencing the level of parenting stress, including prenatal, obstetric, and postpartum factors.13 However, it remains unclear which of these factors are associated with parenting stress. Also the association between demographic factors and parenting stress show inconsistencies in literature.13 A search of the literature revealed no studies investigating the association between parenting stress and both the coping strategies coparenting and social support, while simultaneously considering demographic and obstetric factors. Moreover, there are no studies examining the associated factors of parenting stress in mothers of singletons and mothers of twins. The objective of this study is to investigate if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, the availability of social support, and the level of satisfaction with social support in mothers of singletons and mothers of twins until one year postpartum. 2. Methods 2.1. Design and setting A cross-sectional study was conducted in one university hospital, and one regional, none-university hospital in Flanders (Northern region of Belgium). In addition, the Flemish agency ‘Kind
en Gezin’ [Child and Family] being active in the ‘Public Health, Welfare and Family’ policy area, and organizing and delivering primary health care, distributed the questionnaires among eligible participants in their caseload. 2.2. Sample Participants were included if they had given birth to a singleton or twins after 33 weeks of pregnancy, and if they spoke and understood Dutch. Participants were excluded if their last born child(ren) was/were (1) older than one year, and/or (2) admitted to neonatology at the moment of data collection. Since the population was difficult to reach due to the specificity of the inclusion criteria, a mix of convenience and snowball sampling was used to recruit mothers. The final sample consisted of 252 participants, including 151 mothers of singletons and 101 mothers of twins. 2.3. Data collection Participants were recruited between January and May, 2016. Participants had to complete a questionnaire, which included an informed consent explaining both the context and the aim of the study. 2.4. Instruments The questionnaire was based on three existing validated instruments (Parental Stress Scale, Coparenting Relationship Scale, and Social Support Questionnaire) for measuring respectively the level of parenting stress, the level of coparenting, the availability of and the level of satisfaction with social support. Two professional translators having no background knowledge about the topic independently translated each original instrument to Dutch. The translated instruments were compared, discussed, and the most adequate translation was selected. The translated instrument was reviewed by a panel of four experts (with expertise in mother and child care or methodology) and six non-professionals (mothers who met the inclusion criteria) during individual face-to-face discussions. The panel evaluated the translated instruments in terms of clarity and face validity, involving two rounds. Several alterations were made to adapt the questionnaire to the Flemish context. The same translators assessed the linguistic conformity of each item in the Dutch-language questionnaire compared with the original English instrument. The feedback was integrated in the final version of the questionnaire. The Parental Stress Scale (PSS)14 was developed to measure the level of parenting stress experienced by parents taking into account the positive and negative aspects of parenting. The original questionnaire consists of 18 items rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A higher total score is indicative of higher parenting stress levels.14 The original PSS demonstrated satisfactory levels of internal consistency (0.83), and test-retest reliability (0.81), as well as good convergent and discriminant validity.15 The final scale in our study comprised of 19 items rated on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). To become specific answers, the panel decided to omit the original rating option ‘undecided’ and to replace it by two new rating options being ‘rather disagree’ and ‘rather agree’. One item of the original PSS was extracted, and included as a separate question. The panel added two items to the final PSS. Cronbach’s alpha for this final scale was 0.87. The Coparenting Relationship Scale (CRS)5 is a 35-item selfreport scale measuring the quality of coparenting in a family, which is in this article referred to as ‘the level of coparenting’. The higher the total score, the higher the level of coparenting and thus the better the coparenting relationship quality. The first part of the
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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original CRS consists of 30 items with 6 subscales: Coparenting Agreement, Closeness, Support, Undermining, Endorse Partner Parenting, and Division of Labour. The second part comprises 5 items, assessing the seventh subscale ‘Exposure to Conflict’.5 The CRS is theory-based and demonstrated excellent internal consistency (Cronbach’s alphas 0.91–0.94), stability (regression coefficients 0.74–0.71), and good convergent- and discriminative validity.5 During the translation process, the panel decided to omit four original items in the first part because the meaning of their Dutch-language translation overlapped. The final scale comprised 32 items, and responses were marked on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), and from 1 (never) to 5 (very often) in the first and second part respectively. In the present study, Cronbach’s alphas were 0.92 for the first part and 0.78 for the second part. Mothers, who were a single parent, were not required to complete this scale. The six-item short form of the Social Support Questionnaire (SSQ6)16 was used to quantify the availability of and satisfaction with social support of an individual.16,17 The SSQ6 is psychometrically sound and an acceptable substitute of the original twentyseven-item SSQ.16 Comparable to the original SSQ, the SSQ6 consists of six items, each one describing a circumstance in which especially emotional social support might be important to people.16,18 For each item, the subjects have to (a) list the people whom they can count on for help or support in a given circumstance (i.e. N score) and (b) indicate how satisfied they are with the overall (emotional) support they have (i.e. S score).18 Taking into account the length of the questionnaire, the participants had the possibility to list a maximum of two individuals per item in the translated SSQ6, instead of nine in the original SSQ. Each individual must be identified through their initials and relationships with the participant.17,18 Responses are marked on a 6-point rating scale from 1 (very dissatisfied) to 6 (very satisfied). The mean S score was calculated by dividing the sum of the S score for each individual whom mothers can count on for help or support for each given circumstance by the total number of individuals mothers could count on for all given circumstances (NValid). The higher the total N and S score, the more people mothers can count on for help and support, and the higher the measured level of satisfaction with the received (emotional) social support respectively. The original SSQ6 demonstrated good internal consistency (Cronbach’s alpha 0.97), and stability (test-retest reliability 0.90–0.93).16 The internal consistency of the final SSQ6 in our study showed a Cronbach’s alpha of 0.84. The questionnaire also included a demographic data sheet, which comprised personal and obstetric characteristics. Personal characteristics included age (in years), educational level (secondary education or lower vs. higher education), and working situation (working vs. not working due to maternity leave or being unemployed). Obstetric characteristics were having other children in family or not, type of pregnancy (spontaneous conception vs. fertility treatment), mode of birth (vaginal vs. caesarean section), entry to a neonatology unit or not before the moment of data collection, presence of maternal and/or neonatal complications before/during/after childbirth or not (e.g. retained placenta, clavicle fracture), and having a premature (defined as ‘born between 33 and 37 weeks of pregnancy’) born child or not. 2.5. Procedure One researcher (E.V.) invited eligible mothers to participate during their hospital stay at maternity ward. Primary healthcare providers of the agency ‘Kind en Gezin’ also invited eligible mothers to participate during house visits. Participants mainly completed the survey at 6 months postpartum (M = 5.94, SD =
3
3.60). After giving informed consent, participants were given/sent either a paper-based or a digital questionnaire in order to positively influence the response rate. Paper questionnaires were dispatched in a sealed envelope. TeleForm Software was used for data capture and entry of the digital questionnaires. 2.6. Statistics Results with a p-value of 0.05 were considered statistically significant. For normally distributed continuous variables, mean values (M) with standard deviation (SD) are presented. Differences between the level of parenting stress, and personal and obstetric characteristics in mothers of singletons and twins were examined using independent sample t-tests. Simple linear regression analysis was performed to investigate associations between the level of parenting stress, and personal and obstetric characteristics, the level of coparenting, the availability of and the level of satisfaction with social support in mothers of singletons and mothers of twins. Independent variables with a relationship to the level of parenting stress on univariate analysis (p 0.10) were then entered in a multiple linear regression model.19 A multicollinearity test was performed, and was diagnosed if the independent variables had a Tolerance value lower than 0.4.19 However, no multicollinearity was found. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 22.0 (Armonk, NY: IBM Corp 2013). 3. Results 3.1. Demographic characteristics of the study sample A total of 35 paper questionnaires, and 217 digital questionnaires were returned. Table 1 provides an overview of the personal and obstetric characteristics of singleton mothers (SM) and twin mothers (TM). The majority of the participants were between 26 and 35 years old (SM: 74.8% vs. TM: 78.2%). About 73% of the singleton mothers and 68% of the twin mothers held a diploma of higher education. Most singleton (53.0%) and twin mothers (56.4%) were employed. More than half of the participants in each group recently gave birth to their first child (SM: 58.9% vs. TM: 52.5%). Singleton mothers mainly delivered at term (83.3%), while 75.2% of the twin mothers gave birth before 37 weeks of pregnancy. Before data collection, 62.6% of the newborn twins were admitted to neonatology, compared to 11.9% of the singletons. Particularly singleton mothers were highly likely to have conceived spontaneously (SM: 92.1% vs. TM: 59.4%), to have had a vaginal birth (SM: 82.1% vs. TM: 50.5%), and more likely to have experienced no maternal or neonatal complications before, during or after childbirth compared to mothers of twins (SM: 76.7% vs. TM: 66.3%). 3.2. Associated factors of parenting stress in mothers of singletons, and mothers of twins Univariate linear regression analysis (Table 2) showed elevated levels of parenting stress in mothers of singletons who were highly educated (p < 0.05), and who were more satisfied with the received social support (p < 0.01). Lower levels of parenting stress were seen in singleton mothers having a better coparenting relationship (p < 0.01). Independent sample t-test showed significant higher parenting stress levels among higher educated mothers of singletons (M = 41.53, SD = 10.85) compared to singleton mothers having a lower educational standard (M = 37.36, SD = 9.73). Since ‘maternal age’, and ‘having other children in family’ had a p-value 0.10, these variables were also entered in the multiple regression model of singleton mothers. In mothers of twins, higher parenting stress levels were found in those being
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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Table 1 Personal and obstetric characteristics of mothers of singletons (n = 151) and twins (n = 101). Mothers of singletons
Mothers of twins
N valid
Valid %
N valid
Valid %
Personal characteristics Age (years) (n = 252) 18–25 26–35 36–45
31 113 7
20.5 74.8 4.7
8 79 14
7.9 78.2 13.9
Educational level (n = 251) Secondary education or lower Higher education
41 109
27.3 72.7
32 69
31.7 68.3
Working situation (n = 240) Working Not working (i.e. unemployed or maternity leave)
80 71 1 66
53.0 47.0 0.7 43.7
57 44 7 37
56.4 43.6 6.9 36.6
Obstetric characteristics Other children in family (n = 252) Yes No
62 89
41.1 58.9
48 53
47.5 52.5
Type of pregnancy (n = 252) Spontaneous conception Fertility treatment
139 12
92.1 7.9
60 41
59.4 40.6
Mode of birth (n = 252) Vaginal Caesarean section
124 27
82.1 17.9
51 50
50.5 49.5
Child admitted to neonatology (n = 250) Yes No
18 133
11.9 88.1
62 37
62.6 37.4
Complications (n = 251) Yes No
35 115
23.3 76.7
34 67
33.7 66.3
Prematurity (33–37 weeks) (n = 251) Yes No
25 125
16.7 83.3
76 25
75.2 24.8
more satisfied with social support (p < 0.001). Twin mothers experiencing less parenting stress indicated a higher level of coparenting (p < 0.01). The level of parenting stress was inversely correlated with type of pregnancy (p = 0.045); twin mothers who became pregnant after fertility treatment experienced more parenting stress (M = 47.63, SD = 13.07) compared to those who conceived spontaneously (M = 42.38, SD = 12.42, p < 0.05). A multiple linear regression analysis (Table 3) was performed to explore the simultaneous associations of all independent variables with the level of parenting stress. 3.2.1. Mothers of singletons Although univariate regression analysis showed higher parenting stress levels in mothers of singletons having a higher educational level, and those being more satisfied with the received social support, the latter associations remained not significant (p = 0.25; p = 0.27). The negative association with the level of coparenting was significant when the other variables were controlled for (Beta b = 0.25, p < 0.01). 3.2.2. Mothers of twins In mothers of twins, the level of parenting stress remained significantly negatively associated with the level of coparenting (b = 0.34, p = 0.001), and positively associated with the level of satisfaction with the received social support (b = 0.27, p < 0.01).
4. Discussion This study is the first examining if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, the availability of social support, and the level of satisfaction with social support in mothers of singletons and mothers of twins until one year postpartum. The level of coparenting was found to be significantly associated with parenting stress in both mothers of singletons and mothers of twins. Moreover, the level of satisfaction with social support was positively associated with parenting stress in only mothers of twins. None of the personal characteristics (i.e. maternal age, educational level, working status) were significantly associated with the level of parenting stress, which might be explained by an overrepresentation of highly educated and working mothers of mainly the same age category (26–35 years old) in this sample. Although other research reported the same results,20,21 the largescale longitudinal study of Matvienko-Sikar et al.13 found lower stress levels in mothers being at work, indicating that working status might influence the level of parenting stress. Regarding the obstetric characteristics, parenting stress was found to be correlated with only type of pregnancy (i.e. spontaneous conception or fertility treatment) in mothers of twins in the univariate regression analysis. In spite of this, we did not find any obstetric factor being significantly associated with the
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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Table 2 Results for univariate linear regression analysis with the level of parenting stress as the outcome. Level of parenting stress in mothers of singletons
Mean (SD)a
t (df)a
Beta (t)b
95% CIb
p
0.099
39.00 (10.04) 45.04 (13.05)
1.275 (97)
0.128 ( 1.275)
15.450 to 3.362
0.205
0.174 (2.103) 0.250 to 8.089
0.037*
45.30 (12.50) 43.00 (13.76)
0.828 (97)
0.084 (0.828)
3.209 to 7.806
0.410
0.48 (142)
0.040 ( 0.476)
4.461 to 2.728
0.635
44.95 (13.20) 44.07 (12.64)
0.335 (97)
0.034 (0.738)
4.322 to 6.077
0.738
42.60 (11.56) 39.17 (10.14)
1.88 (142)
0.156 ( 1.880)
7.034 to 0.176
0.062
45.02 (13.05) 44.13 (12.86)
0.340 (97)
0.035 (0.734)
6.060 to 4.287
0.734
40.86 (10.77) 37.17 (11.39)
1.13 (142)
0.095 (1.133)
2.751 to 10.145
0.259
42.38 (12.42) 47.63 (13.07)
2.029 (97)
0.202 ( 2.029)
40.75 (11.08) 39.65 (9.77)
0.47 (142)
0.039 (0.468)
3.550 to 5.751
0.641
44.44 (11.08) 44.67 (14.63)
0.089 (89.45)
0.009 ( 0.090)
5.404 to 4.937
0.929
43.17 (10.65) 40.18 (10.84)
1.09 (142)
0.091 (1.094)
2.406 to 8.374
0.276
44.53 (13.38) 44.49 (12.46)
0.017 (95)
0.002 (0.017)
5.434 to 5.527
0.987
40.91 (11.52) 40.50 (10.69)
0.19 (141)
0.016 (0.190)
3.822 to 4.636
0.849
43.94 (11.51) 44.86 (13.61)
0.335 (97)
0.034 ( 0.335)
6.405 to 4.556
0.739
34.42 (12.43) 40.95 (10.52)
1.04 (141)
0.087 ( 1.043)
7.336 to 2.270
0.299
43.85 (13.03) 46.64 (12.49)
0.934 (97)
0.094 ( 0.934)
8.712 to 3.135
0.352
Level of coparenting
0.311 ( 3.832)
0.269 to 0.086
<0.01**
0.470 ( 5.114)
0.447 to 0.197
Availability of social support (N score)
0.110 ( 1.251)
1.705 to 0.384
0.213
0.058 (0.566)
0.931 to 1.675
0.572
Level of satisfaction with social support (S score)
0.226 (2.698)
1.267 to 8.223
0.008**
0.405 (4.312)
5.644 to 15.272
<0.001***
Personal characteristics Age of mother 18–25 years 26–45 yearsc
Educational level Higher education Secondary school or lowerc
Working situation mother Working Not workingc
Obstetric characteristics Other children in family No Yes
c
Type of pregnancy Spontaneous conception c
Fertility treatment
Mode of birth Vaginal Caesarean section
c
Admission to neonatology Yes Noc
Complications Yes Noc
Prematurity (33–37 weeks) Yes Noc
a b c
t (df)
37.59 (9.59) 41.30 (11.03)
b
b
Level of parenting stress in mothers of twins p
Mean (SD)a
a
Beta (t)
95% CI
1.66 (142)
0.138 (-1.663)
8.139 to 0.703
41.53 (10.85) 37.36 (9.73)
2.10 (141)
40.16 (11.24) 41.03 (10.38)
10.395 to 0.115
0.045*
<0.01**
Independent sample t-test. univariate linear regression analysis. Reference category, *p < 0.05 (two-tailed), **p < 0.01 (two-tailed), ***p < 0.001 (two-tailed), p < 0.10 (i.e. include in multiple linear regression analysis).
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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Table 3 Results for multiple linear regression analysis with the level of parenting stress as the outcome Level of parenting stress in mothers of singletonsb Collinearity Level of parenting stress in mothers of twinsc Statistics Beta (t) 95% CI p Tolerance Beta (t) 95% CI p Personal characteristics Age of mother 18–25 years 26–45 yearsa Educational level Higher education Secondary school or lowera Obstetric characteristics Other children in family No Yesa
0.113 ( 1.226)
0.105 (1.168)
0.037 ( 0.423)
7.606 to 1.786
0.222
0.782
1.680 to 6.525
0.245
0.820
4.442 to 2.878
0.673
0.881
Type of pregnancy Spontaneous conception Fertility treatmenta Level of coparenting Level of satisfaction with social support (S score) a b c
0.253 ( 2.805) 0.099 (1.108)
0.242 to
0.042
1.596 to 5.658
0.006** 0.818 0.270
0.835
Collinearity statistics Tolerance
0.131 ( 1.473)
7.966 to 1.182
0.144
0.341 ( 3.497)
0.365 to
0.001*** 0.820
0.273 (2.822)
0.101
2.075 to 11.951
0.006**
0.981
0.832
Reference category, *p < 0.05 (two-tailed), **p < 0.01 (two-tailed), ***p = 0.001 (two-tailed). Model summary for mothers of singletons: Adjusted R Square = 0.107, F = 4.210, p = 0.001. Model summary for mothers of twins: Adjusted R Square = 0.277, F = 12.901, p < 0.001.
level of parenting stress in singleton and twin mothers in the final model. Other research, however, identified other obstetric factors including vaginal birth as predictors of parenting stress.20 Since research is lacking, and findings are inconsistent, further research is needed to investigate the role of both personal and obstetric factors in the development of parenting stress. Findings resulting from those studies will provide a means to help identify risk profiles of women who are more prone to parenting stress. The present study observed a negative association between the level of parenting stress and the level of coparenting, which is in line with several other studies.3 Coparenting seems to be a significant coping strategy reducing the level of parenting stress in both mothers of singletons and twins, irrespective of their personal and obstetric characteristics. Besides the level of coparenting, we investigated the association with the coping strategy ‘social support’. The multiple linear regression model showed that not the availability, but the degree of satisfaction with (emotional) social support was significantly positively associated with the level of parenting stress in only mothers of twins until one year postpartum. In other words, mothers of singletons experiencing higher parenting stress levels are likely to be more satisfied with the social support they receive compared to those experiencing lower parenting stress levels. Although most studies report a negative association between parenting stress and satisfaction with social support,22 the latter result can be explained. In keeping with existing literature,4,7 the majority of both mothers of singletons (87.4%) and twins (96.0%) indicated their partner as the most important person providing emotional social support to them. Furthermore, additional analysis showed a significant negative correlation between the level of coparenting and the level of satisfaction with social support in both groups. Consequently, it is possible that, in couples having a lower coparenting relationship quality, mothers might experience inadequate emotional support of their partner which may result in a higher appreciation of emotional support received from others (i.e. own mother, friends, siblings . . . ) and vice versa. The aforementioned findings might imply important consequences for the future organization of midwifery practice,
particularly for independent midwives working in primary health care. Several organizations stress the valuable role midwives have in improving perinatal mental health in mothers.23–25 The growing significance of this role will be inevitable, especially because the annual incidence rates of maternal psychological illnesses continue to rise.26 This might be explained by several changes in society and the current health care landscape, including a worldwide shortened length of postnatal hospital stay.27 Since midwives have a considerable role in performing the necessary screening/ detection of mental health problems,24,28 and providing integrated and coordinated care,24 they can be the key figure in performing interventions in low-risk situations in order to maintain and enhance women’s mental health during the postpartum period.29 In this respect, a future development of (couple-based) interventions aimed at preventing and/or mitigating parenting stress is needed in order to reduce the substantial adverse consequences of parenting stress for both the mother, her partner, and child(ren). According to the present study, it is likely that acknowledging and supporting a good coparenting relationship in couples by health care professionals will be an important factor to include in such interventions. There are several limitations that challenge both the validity and generalizability of this study. First, owing to the crosssectional design, only associations and no causations can be inferred. Second, recruitment was performed using a mix of convenience and snowball sampling which could induce selection bias and response bias. Due to the sampling method, nonresponders could not be identified. Consequently, we were unable to determine the response rate. Previous limitations might impede the external validity of the results. Third, it is also important to consider possible bias caused by unequal numbers in the subgroups (e.g. overrepresentation of highly educated mothers). Fourth, we lacked information on partners’ characteristics and health status,13,20 on child factors (e.g. problem behaviours, health status),20,21 and on contextual factors (e.g. household income, family conflict and cohesion).13,21 These factors may not only influence the level of parenting stress, but also the level of coparenting, and social support of the mother.13,30 Moreover, the
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inclusion of the partner in research investigating the associated factors of parenting stress is also relevant because those factors seem to differ between genders.13 Future researchers should perform large-scale longitudinal studies that also include the aforementioned factors in an integrated manner in order to identify them as potential predictors of parenting stress, which may help to develop parenting stress reducing interventions. This paper presents an integrated model that might provide further insights in the complex mechanisms influencing the level of parenting stress. The results might also contribute to the identification of risk profiles, and factors that are relevant to include in stress-reducing interventions. This study includes the use of validated instruments to compose the questionnaire in which a panel of experts and non-professionals evaluated the translated instruments on the comprehensibility, clarity, and face validity. In addition, the internal consistency of the instruments was high. The questionnaire was anonymous, which could minimize social desirability bias. 5. Conclusion In conclusion, the level of coparenting was found to be significantly negatively associated with parenting stress in both mothers of singletons and twins until one year postpartum, irrespective of the personal and obstetric characteristics. The level of satisfaction with social support was positively associated with parenting stress in only mothers of twins. Large-scale longitudinal studies including a range of personal and obstetric characteristics are needed to identify predictors of parenting stress, which may help to develop parenting stress reducing interventions. Acknowledging and supporting an adequate coparenting relationship quality by health care professionals is likely to be an important factor to include in such interventions. Midwives might be the key figure in performing parenting stress reducing interventions in order to maintain and enhance women’s mental health during the postpartum period. Ethical statement This study was approved by the Ethical Committee of Ghent University Hospital on the 23th of October, 2014. The approval number is EC/2014/0942. Funding This study was funded by the Research Foundation – Flanders (FWO) (grant number G058113N). Conflicts of interest None to declare. Acknowledgements The authors would like to thank the hospitals involved, and all women for their willingness to participate. References 1. Venkatesh KK. The relationship between parental stress and postpartum depression among adolescent mothers enrolled in a randomized controlled prevention trial. Matern Child Health J 2014;18(6):1532–9.
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2. Fink G. In: Fink G, editor. Stress consequences: mental, neuropsychological and socioeconomic. Elsevier; 2010. 3. Kehoe A, Dempster M, McManus J, Lewis S. Stress and coping in parents of newly born twins. J Psychosom Obstet Gynaecol 2016;37(3):110–8. 4. Noy A, Taubman-Ben-Ari O, Kuint J. Well-being and personal growth in mothers of full-term and pre-term singletons and twins. Stress Health 2015;31:365–72. 5. Feinberg ME, Brown LD, Kan ML. A multi-domain self-report measure of coparenting. Parent Sci Pract 2012;12(1):1–21. 6. Lutz K, Burnson C, Hane A, Samuelson A, Maleck S, Poehlman J. Parenting stress, social support, and mother-child interactions in families of multiple and singleton preterm toddlers. Fam Relat 2012;61(4):642–56. 7. Hung C, Lin CJ, Stocker J, Yu CY. Predictors of postpartum stress. J Clin Nurs 2011;20:666–74. 8. Dennis C, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev 2013(2). 9. Feinberg ME, Jones DE, Hostetler ML, Roettger ME, Paul IM, Ehrenthal DB. Couple-focused prevention at the transition to parenthood, a randomized trial: effects on coparenting, parenting, family violence, and parent and child adjustment. Prev Sci 2016;17(6):751–64. 10. Van Egeren L, Hawkins D. Coming to terms with coparenting: implications of definition and measurement. J Adult Dev 2004;11(3):165–78. 11. Solmeyer AR, Feinberg ME. Mother and father adjustment during early parenthood: the roles of infant temperament and coparenting relationship quality. Infant Behav Dev 2011;34(4):504–14. 12. Feinberg ME, Jones DE, Goslin MC. Effects of family foundations on parents and children: 3.5 years after baseline. J Fam Psychol 2010;24(5):532–42. 13. Matvienko-Sikar K, Murphy G, Murphy M. The role of prenatal, obstetric, and post-partum factors in the parenting stress of mothers and fathers of 9-month old infants. J Psychosom Obstet Gynecol 2017;1–9. 14. Berry J, Jones WH. The parental stress scale: initial psychometric evidence. J Soc Pers Relat 1995;12:463–72. 15. Lessenberry BM, Rehfeldt RA. Evaluating stress levels of parents of children with disabilities. J Except Child 2004;70(2):231–44. 16. Sarason IG, Sarason BR, Shearin EN, Pierce GR. A brief measure of social support: practical and theoretical implications. J Soc Pers Relationsh 1987;4:497–510. 17. Culum I. BioPsychoSocial assessment tools for the elderly — assessment summary sheet. 2009https://instruct.uwo.ca/kinesiology/9641/Assessments/Social/SSQ. html2016. 18. Sarason IG, Levine HM, Basham RB, Sarason BR. Assessing social support: the social support questionnaire. J Pers Soc Psychol 1983;44:127–39. 19. Chan YH. Biostatistics 201: linear regression analysis. Singapore Med J 2004;45 (2):55–61. 20. Saisto T, Salmela-Aro K, Nurmi JE, Halmesmaki E. Longitudinal study on the predictors of parental stress in mothers and fathers of toddlers. J Psychosom Obstet Gynecol 2008;29:213–22. 21. Zaidman-Zait A, Mirenda P, Duku E, Vaillancourt T, Smith IM, Szatmari P, Bryson S, Fombonne E, Volden J, Waddell C, Zwaigenbaum L, Georgiades S, Bennett T, Elsabaggh M, Thompson A. Impact of personal and social resources on parenting stress in mothers of children with autism spectrum disorder. Autism 2017;21(2):155–66. 22. Solem MB, Christophersen KA, Martinussen M. Predicting parenting stress: children’s behavioural problems and parents’ coping. Inf Child Dev 2010;20:162–80. 23. NICE Clinical Guidelines, No. 192. Antenatal and postnatal mental health: clinical management and service guidance: updated edition. Leicester (UK): British Psychological Society; 2014. 24. The Royal College of Midwives, Maternal Mental Health Alliance. Specialist mental health midwives. 2013https://www.rcm.org.uk/sites/default/files/ MMHA%20SMHMs%20Nov%2013.pdf. 25. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynaecol 2015;125(5):1268–71. 26. Armed Forces Health Surveillance Center. Incident rates rising for post-partum depression among women, risk factor for suicide. ScienceDaily 2013www. sciencedaily.com/releases/2013/10/131002131400.htm. 27. Bowers J, Cheyne H. Reducing the length of postnatal hospital stay: implications for cost and quality of care. BMC Health Serv Res 2016;16 (16):1–12. 28. Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Fen Cheung N, Delage Silva DRA, Downe S, Powell Kennedy H, Malata A, McCormick F, Wick L, Declercq E. Midwifery and quality care: findings form a new evidenceinformed framework for maternal and newborn care. Lancet 2014;384:1129– 45. 29. Song JE, Kim T, Ahn JA. A systematic review of psychosocial interventions for women with postpartum stress. J Obstet Gynecol Neonatal Nurs 2015;44 (2):183–92. 30. Viana AG, Welsh JA. Correlates and predictors of parenting stress among internationally adopting mothers: a longitudinal investigation. Int J Behav Dev 2010;34(4):363–73.
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Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research - Quantitative
Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study Marjon De Roosea,* , Dimitri Beeckmana , Katrijn Eggermonta , Elke Vanhouchea , Ann Van Heckea,b , Sofie Verhaeghea a b
University Centre for Nursing & Midwifery, Department of Public Health, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium Nursing Science, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 May 2017 Received in revised form 23 August 2017 Accepted 1 September 2017 Available online xxx
Problem: To date, it is unclear which factors are associated with parenting stress. Background: There are no studies investigating the association between parenting stress and coping strategies such as coparenting and social support, while simultaneously considering demographic and obstetric factors, in mothers of singletons and twins. Aim: To investigate if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, and the availability of and satisfaction with social support in mothers of singletons and twins until one year postpartum. Methods: A cross-sectional study was conducted. A total of 151 singleton mothers and 101 twin mothers were included. Results: Both singleton and twin mothers experiencing lower parenting stress levels indicated a better coparenting relationship quality (b = 0.253, p < 0.01; b = 0.341, p = 0.001). Elevated parenting stress levels positively influenced the level of satisfaction with social support in only mothers of twins (b = 0.273, p < 0.01). The availability of social support, personal, and obstetric characteristics were not associated with the level of parenting stress in neither singleton nor twin mothers. Conclusion: Coparenting seems to be a significant coping strategy reducing the level of parenting stress in singleton and twin mothers, irrespective of their personal and obstetric characteristics. Large-scale longitudinal research is needed to identify predictors of parenting stress, which may help to develop parenting stress reducing interventions. The acknowledgement and support of an adequate coparenting relationship quality by health care professionals might be an important factor to include in such interventions. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Parenting stress Social support Coparenting Singletons Twins
Statement of significance
Problem or issue To date, it is unclear which factors are associated with parenting stress. What is already known Social support and coparenting have been identified as two coping strategies to prevent or mitigate the level of parenting stress and its adverse consequences. Besides
these coping strategies, there is limited research suggesting that there might be other factors influencing the level of parenting stress, including demographic, prenatal, obstetric, and postpartum factors. However, it still remains unclear which of these factors are associated with parenting stress. What this paper adds This study is the first examining if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, the availability of and satisfaction with social support in mothers of singletons and mothers of twins until one year postpartum.
* Corresponding author. E-mail address: [email protected] (M. De Roose). http://dx.doi.org/10.1016/j.wombi.2017.09.003 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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1. Introduction There is a growing body of knowledge recognising the considerable adverse effects of parenting stress on the mother, her partner, and the child. Parenting stress is defined as “an imbalance between the perceived demands of parenting and the perceived available resources”.1 Higher parenting stress levels are associated with a higher risk for developing postpartum depression, lower levels of marital satisfaction, negative parent-child interactions, and even the development of behavioural problems and psychopathology in children.2 Previous research established that some parents are at higher risk for developing parenting stress, including mothers who gave birth to twins.3,4 These higher parenting stress levels can be explained by greater functional, financial and/or medical demands faced by mothers of twins during pregnancy and postpartum.3 Social support and coparenting have been identified as two considerable coping strategies to prevent or mitigate the level of parenting stress and its adverse consequences.4,5 Social support is defined as “having one’s need met through the presence of and interaction with others, such as spouses or partners, family members, or friends”.6 Social support can be emotional, informational, and instrumental.6 In general, literature indicates that women perceive their partner and own mother as the most important sources of support.4,7 In addition, a higher perception of own mother’s support has found to be associated with better wellbeing and mental health in mothers,4,7 and a better marital relationship.4,7 In contrast, lack of support from family members, friends, and colleagues might contribute to the development of postpartum stress and depression.8 In addition to social support, several studies identified coparenting as another significant element in coping with parenting stress.4,8 Coparenting is defined as “the way parents support and coordinate with each other in their roles as parents”.9 The definition refers to two people who are collectively raising a child, regardless of whether or not they are both biological parents or have ever been romantically involved.10 Literature indicates that good coparenting leads to less parenting stress, while insufficient coparenting causes more parenting stress.11 Better coparenting has also been linked with higher relationship quality between parents.12 Besides these coping strategies, there is limited research suggesting that there might be other factors influencing the level of parenting stress, including prenatal, obstetric, and postpartum factors.13 However, it remains unclear which of these factors are associated with parenting stress. Also the association between demographic factors and parenting stress show inconsistencies in literature.13 A search of the literature revealed no studies investigating the association between parenting stress and both the coping strategies coparenting and social support, while simultaneously considering demographic and obstetric factors. Moreover, there are no studies examining the associated factors of parenting stress in mothers of singletons and mothers of twins. The objective of this study is to investigate if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, the availability of social support, and the level of satisfaction with social support in mothers of singletons and mothers of twins until one year postpartum. 2. Methods 2.1. Design and setting A cross-sectional study was conducted in one university hospital, and one regional, none-university hospital in Flanders (Northern region of Belgium). In addition, the Flemish agency ‘Kind
en Gezin’ [Child and Family] being active in the ‘Public Health, Welfare and Family’ policy area, and organizing and delivering primary health care, distributed the questionnaires among eligible participants in their caseload. 2.2. Sample Participants were included if they had given birth to a singleton or twins after 33 weeks of pregnancy, and if they spoke and understood Dutch. Participants were excluded if their last born child(ren) was/were (1) older than one year, and/or (2) admitted to neonatology at the moment of data collection. Since the population was difficult to reach due to the specificity of the inclusion criteria, a mix of convenience and snowball sampling was used to recruit mothers. The final sample consisted of 252 participants, including 151 mothers of singletons and 101 mothers of twins. 2.3. Data collection Participants were recruited between January and May, 2016. Participants had to complete a questionnaire, which included an informed consent explaining both the context and the aim of the study. 2.4. Instruments The questionnaire was based on three existing validated instruments (Parental Stress Scale, Coparenting Relationship Scale, and Social Support Questionnaire) for measuring respectively the level of parenting stress, the level of coparenting, the availability of and the level of satisfaction with social support. Two professional translators having no background knowledge about the topic independently translated each original instrument to Dutch. The translated instruments were compared, discussed, and the most adequate translation was selected. The translated instrument was reviewed by a panel of four experts (with expertise in mother and child care or methodology) and six non-professionals (mothers who met the inclusion criteria) during individual face-to-face discussions. The panel evaluated the translated instruments in terms of clarity and face validity, involving two rounds. Several alterations were made to adapt the questionnaire to the Flemish context. The same translators assessed the linguistic conformity of each item in the Dutch-language questionnaire compared with the original English instrument. The feedback was integrated in the final version of the questionnaire. The Parental Stress Scale (PSS)14 was developed to measure the level of parenting stress experienced by parents taking into account the positive and negative aspects of parenting. The original questionnaire consists of 18 items rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A higher total score is indicative of higher parenting stress levels.14 The original PSS demonstrated satisfactory levels of internal consistency (0.83), and test-retest reliability (0.81), as well as good convergent and discriminant validity.15 The final scale in our study comprised of 19 items rated on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). To become specific answers, the panel decided to omit the original rating option ‘undecided’ and to replace it by two new rating options being ‘rather disagree’ and ‘rather agree’. One item of the original PSS was extracted, and included as a separate question. The panel added two items to the final PSS. Cronbach’s alpha for this final scale was 0.87. The Coparenting Relationship Scale (CRS)5 is a 35-item selfreport scale measuring the quality of coparenting in a family, which is in this article referred to as ‘the level of coparenting’. The higher the total score, the higher the level of coparenting and thus the better the coparenting relationship quality. The first part of the
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original CRS consists of 30 items with 6 subscales: Coparenting Agreement, Closeness, Support, Undermining, Endorse Partner Parenting, and Division of Labour. The second part comprises 5 items, assessing the seventh subscale ‘Exposure to Conflict’.5 The CRS is theory-based and demonstrated excellent internal consistency (Cronbach’s alphas 0.91–0.94), stability (regression coefficients 0.74–0.71), and good convergent- and discriminative validity.5 During the translation process, the panel decided to omit four original items in the first part because the meaning of their Dutch-language translation overlapped. The final scale comprised 32 items, and responses were marked on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), and from 1 (never) to 5 (very often) in the first and second part respectively. In the present study, Cronbach’s alphas were 0.92 for the first part and 0.78 for the second part. Mothers, who were a single parent, were not required to complete this scale. The six-item short form of the Social Support Questionnaire (SSQ6)16 was used to quantify the availability of and satisfaction with social support of an individual.16,17 The SSQ6 is psychometrically sound and an acceptable substitute of the original twentyseven-item SSQ.16 Comparable to the original SSQ, the SSQ6 consists of six items, each one describing a circumstance in which especially emotional social support might be important to people.16,18 For each item, the subjects have to (a) list the people whom they can count on for help or support in a given circumstance (i.e. N score) and (b) indicate how satisfied they are with the overall (emotional) support they have (i.e. S score).18 Taking into account the length of the questionnaire, the participants had the possibility to list a maximum of two individuals per item in the translated SSQ6, instead of nine in the original SSQ. Each individual must be identified through their initials and relationships with the participant.17,18 Responses are marked on a 6-point rating scale from 1 (very dissatisfied) to 6 (very satisfied). The mean S score was calculated by dividing the sum of the S score for each individual whom mothers can count on for help or support for each given circumstance by the total number of individuals mothers could count on for all given circumstances (NValid). The higher the total N and S score, the more people mothers can count on for help and support, and the higher the measured level of satisfaction with the received (emotional) social support respectively. The original SSQ6 demonstrated good internal consistency (Cronbach’s alpha 0.97), and stability (test-retest reliability 0.90–0.93).16 The internal consistency of the final SSQ6 in our study showed a Cronbach’s alpha of 0.84. The questionnaire also included a demographic data sheet, which comprised personal and obstetric characteristics. Personal characteristics included age (in years), educational level (secondary education or lower vs. higher education), and working situation (working vs. not working due to maternity leave or being unemployed). Obstetric characteristics were having other children in family or not, type of pregnancy (spontaneous conception vs. fertility treatment), mode of birth (vaginal vs. caesarean section), entry to a neonatology unit or not before the moment of data collection, presence of maternal and/or neonatal complications before/during/after childbirth or not (e.g. retained placenta, clavicle fracture), and having a premature (defined as ‘born between 33 and 37 weeks of pregnancy’) born child or not. 2.5. Procedure One researcher (E.V.) invited eligible mothers to participate during their hospital stay at maternity ward. Primary healthcare providers of the agency ‘Kind en Gezin’ also invited eligible mothers to participate during house visits. Participants mainly completed the survey at 6 months postpartum (M = 5.94, SD =
3
3.60). After giving informed consent, participants were given/sent either a paper-based or a digital questionnaire in order to positively influence the response rate. Paper questionnaires were dispatched in a sealed envelope. TeleForm Software was used for data capture and entry of the digital questionnaires. 2.6. Statistics Results with a p-value of 0.05 were considered statistically significant. For normally distributed continuous variables, mean values (M) with standard deviation (SD) are presented. Differences between the level of parenting stress, and personal and obstetric characteristics in mothers of singletons and twins were examined using independent sample t-tests. Simple linear regression analysis was performed to investigate associations between the level of parenting stress, and personal and obstetric characteristics, the level of coparenting, the availability of and the level of satisfaction with social support in mothers of singletons and mothers of twins. Independent variables with a relationship to the level of parenting stress on univariate analysis (p 0.10) were then entered in a multiple linear regression model.19 A multicollinearity test was performed, and was diagnosed if the independent variables had a Tolerance value lower than 0.4.19 However, no multicollinearity was found. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 22.0 (Armonk, NY: IBM Corp 2013). 3. Results 3.1. Demographic characteristics of the study sample A total of 35 paper questionnaires, and 217 digital questionnaires were returned. Table 1 provides an overview of the personal and obstetric characteristics of singleton mothers (SM) and twin mothers (TM). The majority of the participants were between 26 and 35 years old (SM: 74.8% vs. TM: 78.2%). About 73% of the singleton mothers and 68% of the twin mothers held a diploma of higher education. Most singleton (53.0%) and twin mothers (56.4%) were employed. More than half of the participants in each group recently gave birth to their first child (SM: 58.9% vs. TM: 52.5%). Singleton mothers mainly delivered at term (83.3%), while 75.2% of the twin mothers gave birth before 37 weeks of pregnancy. Before data collection, 62.6% of the newborn twins were admitted to neonatology, compared to 11.9% of the singletons. Particularly singleton mothers were highly likely to have conceived spontaneously (SM: 92.1% vs. TM: 59.4%), to have had a vaginal birth (SM: 82.1% vs. TM: 50.5%), and more likely to have experienced no maternal or neonatal complications before, during or after childbirth compared to mothers of twins (SM: 76.7% vs. TM: 66.3%). 3.2. Associated factors of parenting stress in mothers of singletons, and mothers of twins Univariate linear regression analysis (Table 2) showed elevated levels of parenting stress in mothers of singletons who were highly educated (p < 0.05), and who were more satisfied with the received social support (p < 0.01). Lower levels of parenting stress were seen in singleton mothers having a better coparenting relationship (p < 0.01). Independent sample t-test showed significant higher parenting stress levels among higher educated mothers of singletons (M = 41.53, SD = 10.85) compared to singleton mothers having a lower educational standard (M = 37.36, SD = 9.73). Since ‘maternal age’, and ‘having other children in family’ had a p-value 0.10, these variables were also entered in the multiple regression model of singleton mothers. In mothers of twins, higher parenting stress levels were found in those being
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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Table 1 Personal and obstetric characteristics of mothers of singletons (n = 151) and twins (n = 101). Mothers of singletons
Mothers of twins
N valid
Valid %
N valid
Valid %
Personal characteristics Age (years) (n = 252) 18–25 26–35 36–45
31 113 7
20.5 74.8 4.7
8 79 14
7.9 78.2 13.9
Educational level (n = 251) Secondary education or lower Higher education
41 109
27.3 72.7
32 69
31.7 68.3
Working situation (n = 240) Working Not working (i.e. unemployed or maternity leave)
80 71 1 66
53.0 47.0 0.7 43.7
57 44 7 37
56.4 43.6 6.9 36.6
Obstetric characteristics Other children in family (n = 252) Yes No
62 89
41.1 58.9
48 53
47.5 52.5
Type of pregnancy (n = 252) Spontaneous conception Fertility treatment
139 12
92.1 7.9
60 41
59.4 40.6
Mode of birth (n = 252) Vaginal Caesarean section
124 27
82.1 17.9
51 50
50.5 49.5
Child admitted to neonatology (n = 250) Yes No
18 133
11.9 88.1
62 37
62.6 37.4
Complications (n = 251) Yes No
35 115
23.3 76.7
34 67
33.7 66.3
Prematurity (33–37 weeks) (n = 251) Yes No
25 125
16.7 83.3
76 25
75.2 24.8
more satisfied with social support (p < 0.001). Twin mothers experiencing less parenting stress indicated a higher level of coparenting (p < 0.01). The level of parenting stress was inversely correlated with type of pregnancy (p = 0.045); twin mothers who became pregnant after fertility treatment experienced more parenting stress (M = 47.63, SD = 13.07) compared to those who conceived spontaneously (M = 42.38, SD = 12.42, p < 0.05). A multiple linear regression analysis (Table 3) was performed to explore the simultaneous associations of all independent variables with the level of parenting stress. 3.2.1. Mothers of singletons Although univariate regression analysis showed higher parenting stress levels in mothers of singletons having a higher educational level, and those being more satisfied with the received social support, the latter associations remained not significant (p = 0.25; p = 0.27). The negative association with the level of coparenting was significant when the other variables were controlled for (Beta b = 0.25, p < 0.01). 3.2.2. Mothers of twins In mothers of twins, the level of parenting stress remained significantly negatively associated with the level of coparenting (b = 0.34, p = 0.001), and positively associated with the level of satisfaction with the received social support (b = 0.27, p < 0.01).
4. Discussion This study is the first examining if parenting stress is associated with personal, and obstetric characteristics, the level of coparenting, the availability of social support, and the level of satisfaction with social support in mothers of singletons and mothers of twins until one year postpartum. The level of coparenting was found to be significantly associated with parenting stress in both mothers of singletons and mothers of twins. Moreover, the level of satisfaction with social support was positively associated with parenting stress in only mothers of twins. None of the personal characteristics (i.e. maternal age, educational level, working status) were significantly associated with the level of parenting stress, which might be explained by an overrepresentation of highly educated and working mothers of mainly the same age category (26–35 years old) in this sample. Although other research reported the same results,20,21 the largescale longitudinal study of Matvienko-Sikar et al.13 found lower stress levels in mothers being at work, indicating that working status might influence the level of parenting stress. Regarding the obstetric characteristics, parenting stress was found to be correlated with only type of pregnancy (i.e. spontaneous conception or fertility treatment) in mothers of twins in the univariate regression analysis. In spite of this, we did not find any obstetric factor being significantly associated with the
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Table 2 Results for univariate linear regression analysis with the level of parenting stress as the outcome. Level of parenting stress in mothers of singletons
Mean (SD)a
t (df)a
Beta (t)b
95% CIb
p
0.099
39.00 (10.04) 45.04 (13.05)
1.275 (97)
0.128 ( 1.275)
15.450 to 3.362
0.205
0.174 (2.103) 0.250 to 8.089
0.037*
45.30 (12.50) 43.00 (13.76)
0.828 (97)
0.084 (0.828)
3.209 to 7.806
0.410
0.48 (142)
0.040 ( 0.476)
4.461 to 2.728
0.635
44.95 (13.20) 44.07 (12.64)
0.335 (97)
0.034 (0.738)
4.322 to 6.077
0.738
42.60 (11.56) 39.17 (10.14)
1.88 (142)
0.156 ( 1.880)
7.034 to 0.176
0.062
45.02 (13.05) 44.13 (12.86)
0.340 (97)
0.035 (0.734)
6.060 to 4.287
0.734
40.86 (10.77) 37.17 (11.39)
1.13 (142)
0.095 (1.133)
2.751 to 10.145
0.259
42.38 (12.42) 47.63 (13.07)
2.029 (97)
0.202 ( 2.029)
40.75 (11.08) 39.65 (9.77)
0.47 (142)
0.039 (0.468)
3.550 to 5.751
0.641
44.44 (11.08) 44.67 (14.63)
0.089 (89.45)
0.009 ( 0.090)
5.404 to 4.937
0.929
43.17 (10.65) 40.18 (10.84)
1.09 (142)
0.091 (1.094)
2.406 to 8.374
0.276
44.53 (13.38) 44.49 (12.46)
0.017 (95)
0.002 (0.017)
5.434 to 5.527
0.987
40.91 (11.52) 40.50 (10.69)
0.19 (141)
0.016 (0.190)
3.822 to 4.636
0.849
43.94 (11.51) 44.86 (13.61)
0.335 (97)
0.034 ( 0.335)
6.405 to 4.556
0.739
34.42 (12.43) 40.95 (10.52)
1.04 (141)
0.087 ( 1.043)
7.336 to 2.270
0.299
43.85 (13.03) 46.64 (12.49)
0.934 (97)
0.094 ( 0.934)
8.712 to 3.135
0.352
Level of coparenting
0.311 ( 3.832)
0.269 to 0.086
<0.01**
0.470 ( 5.114)
0.447 to 0.197
Availability of social support (N score)
0.110 ( 1.251)
1.705 to 0.384
0.213
0.058 (0.566)
0.931 to 1.675
0.572
Level of satisfaction with social support (S score)
0.226 (2.698)
1.267 to 8.223
0.008**
0.405 (4.312)
5.644 to 15.272
<0.001***
Personal characteristics Age of mother 18–25 years 26–45 yearsc
Educational level Higher education Secondary school or lowerc
Working situation mother Working Not workingc
Obstetric characteristics Other children in family No Yes
c
Type of pregnancy Spontaneous conception c
Fertility treatment
Mode of birth Vaginal Caesarean section
c
Admission to neonatology Yes Noc
Complications Yes Noc
Prematurity (33–37 weeks) Yes Noc
a b c
t (df)
37.59 (9.59) 41.30 (11.03)
b
b
Level of parenting stress in mothers of twins p
Mean (SD)a
a
Beta (t)
95% CI
1.66 (142)
0.138 (-1.663)
8.139 to 0.703
41.53 (10.85) 37.36 (9.73)
2.10 (141)
40.16 (11.24) 41.03 (10.38)
10.395 to 0.115
0.045*
<0.01**
Independent sample t-test. univariate linear regression analysis. Reference category, *p < 0.05 (two-tailed), **p < 0.01 (two-tailed), ***p < 0.001 (two-tailed), p < 0.10 (i.e. include in multiple linear regression analysis).
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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Table 3 Results for multiple linear regression analysis with the level of parenting stress as the outcome Level of parenting stress in mothers of singletonsb Collinearity Level of parenting stress in mothers of twinsc Statistics Beta (t) 95% CI p Tolerance Beta (t) 95% CI p Personal characteristics Age of mother 18–25 years 26–45 yearsa Educational level Higher education Secondary school or lowera Obstetric characteristics Other children in family No Yesa
0.113 ( 1.226)
0.105 (1.168)
0.037 ( 0.423)
7.606 to 1.786
0.222
0.782
1.680 to 6.525
0.245
0.820
4.442 to 2.878
0.673
0.881
Type of pregnancy Spontaneous conception Fertility treatmenta Level of coparenting Level of satisfaction with social support (S score) a b c
0.253 ( 2.805) 0.099 (1.108)
0.242 to
0.042
1.596 to 5.658
0.006** 0.818 0.270
0.835
Collinearity statistics Tolerance
0.131 ( 1.473)
7.966 to 1.182
0.144
0.341 ( 3.497)
0.365 to
0.001*** 0.820
0.273 (2.822)
0.101
2.075 to 11.951
0.006**
0.981
0.832
Reference category, *p < 0.05 (two-tailed), **p < 0.01 (two-tailed), ***p = 0.001 (two-tailed). Model summary for mothers of singletons: Adjusted R Square = 0.107, F = 4.210, p = 0.001. Model summary for mothers of twins: Adjusted R Square = 0.277, F = 12.901, p < 0.001.
level of parenting stress in singleton and twin mothers in the final model. Other research, however, identified other obstetric factors including vaginal birth as predictors of parenting stress.20 Since research is lacking, and findings are inconsistent, further research is needed to investigate the role of both personal and obstetric factors in the development of parenting stress. Findings resulting from those studies will provide a means to help identify risk profiles of women who are more prone to parenting stress. The present study observed a negative association between the level of parenting stress and the level of coparenting, which is in line with several other studies.3 Coparenting seems to be a significant coping strategy reducing the level of parenting stress in both mothers of singletons and twins, irrespective of their personal and obstetric characteristics. Besides the level of coparenting, we investigated the association with the coping strategy ‘social support’. The multiple linear regression model showed that not the availability, but the degree of satisfaction with (emotional) social support was significantly positively associated with the level of parenting stress in only mothers of twins until one year postpartum. In other words, mothers of singletons experiencing higher parenting stress levels are likely to be more satisfied with the social support they receive compared to those experiencing lower parenting stress levels. Although most studies report a negative association between parenting stress and satisfaction with social support,22 the latter result can be explained. In keeping with existing literature,4,7 the majority of both mothers of singletons (87.4%) and twins (96.0%) indicated their partner as the most important person providing emotional social support to them. Furthermore, additional analysis showed a significant negative correlation between the level of coparenting and the level of satisfaction with social support in both groups. Consequently, it is possible that, in couples having a lower coparenting relationship quality, mothers might experience inadequate emotional support of their partner which may result in a higher appreciation of emotional support received from others (i.e. own mother, friends, siblings . . . ) and vice versa. The aforementioned findings might imply important consequences for the future organization of midwifery practice,
particularly for independent midwives working in primary health care. Several organizations stress the valuable role midwives have in improving perinatal mental health in mothers.23–25 The growing significance of this role will be inevitable, especially because the annual incidence rates of maternal psychological illnesses continue to rise.26 This might be explained by several changes in society and the current health care landscape, including a worldwide shortened length of postnatal hospital stay.27 Since midwives have a considerable role in performing the necessary screening/ detection of mental health problems,24,28 and providing integrated and coordinated care,24 they can be the key figure in performing interventions in low-risk situations in order to maintain and enhance women’s mental health during the postpartum period.29 In this respect, a future development of (couple-based) interventions aimed at preventing and/or mitigating parenting stress is needed in order to reduce the substantial adverse consequences of parenting stress for both the mother, her partner, and child(ren). According to the present study, it is likely that acknowledging and supporting a good coparenting relationship in couples by health care professionals will be an important factor to include in such interventions. There are several limitations that challenge both the validity and generalizability of this study. First, owing to the crosssectional design, only associations and no causations can be inferred. Second, recruitment was performed using a mix of convenience and snowball sampling which could induce selection bias and response bias. Due to the sampling method, nonresponders could not be identified. Consequently, we were unable to determine the response rate. Previous limitations might impede the external validity of the results. Third, it is also important to consider possible bias caused by unequal numbers in the subgroups (e.g. overrepresentation of highly educated mothers). Fourth, we lacked information on partners’ characteristics and health status,13,20 on child factors (e.g. problem behaviours, health status),20,21 and on contextual factors (e.g. household income, family conflict and cohesion).13,21 These factors may not only influence the level of parenting stress, but also the level of coparenting, and social support of the mother.13,30 Moreover, the
Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003
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inclusion of the partner in research investigating the associated factors of parenting stress is also relevant because those factors seem to differ between genders.13 Future researchers should perform large-scale longitudinal studies that also include the aforementioned factors in an integrated manner in order to identify them as potential predictors of parenting stress, which may help to develop parenting stress reducing interventions. This paper presents an integrated model that might provide further insights in the complex mechanisms influencing the level of parenting stress. The results might also contribute to the identification of risk profiles, and factors that are relevant to include in stress-reducing interventions. This study includes the use of validated instruments to compose the questionnaire in which a panel of experts and non-professionals evaluated the translated instruments on the comprehensibility, clarity, and face validity. In addition, the internal consistency of the instruments was high. The questionnaire was anonymous, which could minimize social desirability bias. 5. Conclusion In conclusion, the level of coparenting was found to be significantly negatively associated with parenting stress in both mothers of singletons and twins until one year postpartum, irrespective of the personal and obstetric characteristics. The level of satisfaction with social support was positively associated with parenting stress in only mothers of twins. Large-scale longitudinal studies including a range of personal and obstetric characteristics are needed to identify predictors of parenting stress, which may help to develop parenting stress reducing interventions. Acknowledging and supporting an adequate coparenting relationship quality by health care professionals is likely to be an important factor to include in such interventions. Midwives might be the key figure in performing parenting stress reducing interventions in order to maintain and enhance women’s mental health during the postpartum period. Ethical statement This study was approved by the Ethical Committee of Ghent University Hospital on the 23th of October, 2014. The approval number is EC/2014/0942. Funding This study was funded by the Research Foundation – Flanders (FWO) (grant number G058113N). Conflicts of interest None to declare. Acknowledgements The authors would like to thank the hospitals involved, and all women for their willingness to participate. References 1. Venkatesh KK. The relationship between parental stress and postpartum depression among adolescent mothers enrolled in a randomized controlled prevention trial. Matern Child Health J 2014;18(6):1532–9.
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Please cite this article in press as: M. De Roose, et al., Level of parenting stress in mothers of singletons and mothers of twins until one year postpartum: A cross-sectional study, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.09.003