The Development and Implementation of a Prenatal Education Program for Expectant Parents of Multiples

ABSTRACT

Preparing expectant parents of multiples required a unique prenatal education program. A thorough explanation of the course layout, curriculum, and content the faculty developed for this unique 9-hour program is presented. The unique implications for parenting multiples was highlighted throughout the program, which included expectations for late pregnancy, preparation for labor and birth, assuring infant safety, learning how to provide infant care, identifying sources of support, breastfeeding information and support, potential for neonatal intensive care, postpartum depression, and providing a multiple parent’s personal perspective. All classes were interactive and used active learner-based teaching strategies.

Prenatal education was and continues to be a cornerstone of assuring adequate preparation for the transition to the parental role. With such a brief amount of time spent in the hospital after a vaginal birth or cesarean surgery and allowing for recovery from the birth process, the need for education prior to birth was clear. The prenatal education program in this article offered a comprehensive menu of classes in a variety of convenient locations and time frames on traditional topics of labor and childbirth, cesarean preparation, infant care, and breastfeeding. In addition, the program offered nontraditional courses on topics such as infant massage, dogs and babies, baby sign language, and hypnobirthing. During classes, the instructors noted that there seemed to be more expectant couples planning for birthing multiples (twins, triplets, etc.). These parents identified the need for more specific information tailored to their needs. A survey of the local hospitals’ websites revealed that there was no class available that was specific to preparation for multiple births. The national rate of multiple births in 2009 was 33.2 per 1,000 births and has remained steady since. Because the twin birth rate has risen 75% since 1980, a change attributed to the increase in fertility treatment (National Organization Mothers of Twins Club, 2014), two instructors proposed that they develop a course to prepare parents expecting multiples.

The national rate of multiple births in 2009 was 33.2 per 1,000 births and has remained steady since.

GENERAL LAYOUT, RESOURCES, AND FACULTY

The director of the parent education program at this large urban health-care setting with multiple suburban outpatient sites gave approval for the authors to develop the curriculum, find appropriate resources and instructors, and market the program. Discussion identified what topics all parents need, how the content would be tailored to expectant parents of multiples, and how much time each of these content areas would be allotted. The decision was made to develop this new class as a three-part series, one 3-hour session per week for 3 consecutive weeks. Offering it every 3 months satisfied the needs assessment.

The planning faculty included a certified childbirth educator who taught the perinatal material and a certified pediatric nurse practitioner who regularly taught infant care. A third instructor joined the team, an International Board Certified Lactation Consultant, neonatal intensive care unit (NICU) nurse, and coincidentally, a mother of twins who were breastfed. The best location for the class was determined to be at the hospital itself, rather than a suburban satellite, so that the tours of the Level 4 NICU and the inpatient setting would be accessible. The faculty identified that giving expectant parents the opportunity to see the actual locations for caregiving and potentially meet the NICU staff in person would be a comfort to them.

In preparation for developing the curriculum content, one of the instructors took the March of Dimes multiples-focused continuing education modules entitled Care of the Multiple Birth Family: Pregnancy and Birth and Care of the Multiple Birth Family: Postpartum Through Infancy (Bowers & Gromada, 2006). She also had professional experience working with mothers of multiples through years of teaching infant and parenting classes. The faculty then chose the InJoy DVD series More of Everything, which accompanied the text Preparing for Multiples, The Family Way (Carter, Green, & Amis, 2008), to be used as the curriculum resource and audiovisual support for the class. The first week’s class topics included labor and birth, cesarean surgery, and postpartum care. The second week focused on infant care and included a tour of the maternity services patient areas (labor and birth, postpartum, nursery). The third week’s class provided a tour of the NICU, content on infant feeding, and a personal perspective from a parent of multiples. In addition, the instructors searched Internet sites that would be reputable to recommend. Those websites are identified in Table 2. The curriculum for Weeks 1, 2, and 3 and the subtopics that are identified in Table 1 will be further explained.

TABLE 2. Handouts and Website Referrals.

Class #	Reference Shared
Week 1	Preparing for Multiples, the Family Way (Carter et al., 2008) Road Map of Labor (Simkin, 2003)
Week 2	“The Facts about Childhood Vaccines” Parent PACK newsletter,“Vaccine Education” (http://chop.edu) “Safe Sleep for your Baby” (http://www.nichd.nih.gov/sts/news/downloadable/Documents/SafeSleepInfographicHorizontal.pdf#search=sids%20prevention) “Shaken Baby Syndrome Prevention” (http://www.dontshake.org) “Stay Calm for Crying Out Loud” (http://www.dontshake.org) TIPP sheet from AAP “0–6 months” (AAP, 2014) Poison control handouts stickers, wallet cards, key tags (http://www.poison.org) “Child Safety” (http://www.ctsafekids.org) “Twins Magazine” (http://www.twinsmagazine.com) “Is Your Relationship Affecting Your Health?” (http://www.futureswithoutviolence.org) United Way info line 211 (http://www.211ct.org)
Week 3	What I wouldn’t have been able to do without . . .

Note. SIDS = sudden infant death syndrome; TIPP = The Injury Prevention Program; AAP = American Academy of Pediatrics.

TABLE 1. Preparing for Multiples Curriculum.

Class No. 1: Childbirth		Class No. 2: Baby Care		Class No. 3: Feeding/Home Care
Welcome	Introduction Needs assessment	Maternity tour	Individualized for clinical agency	NICU Tour	Physiologic needs requiring NICU admission NICU visitation/family-centered care Infant security
Late pregnancy	Late pregnancy characteristics and potential complications Directions for calling the provider Infant presentation and type of birth	Support	Social, professional, and community support Family adjustment	Infant feeding: breastfeeding	Benefits of breastfeeding Positional and latch-general and multiples-specific Pumping/milk storage
Labor and birth	Onset of labor/admission Stages/phases of labor Support measures/breathing Epidurals/spinals Pushing	Newborn appearance and behavior	Sleep patterns and soothing options Sleeping options Infant behavior	Infant feeding: breastmilk substitute feeding	Breastmilk substitute feeding preparation, schedule, and safety
Cesarean surgery	Preparation Procedure Birth	Infant care	Bathing, swaddling, diapering Recognizing illness Immunization recommendations	Postpartum emotional changes	Risk/recognition for blues, depression Follow-up
Immediate postpartum	Care of mother/baby Possible NICU transfer	Infant safety	Childproofing Sleep safety Car seat safety Pet safety	Parent’s perspective Home care/parental adjustment	Personal reflection on managing multiples and enjoying them
AV support	DVD More of Everything sections 1–6 (Carter et al., 2008)	AV support	DVD More of Everything sections 7–10 (Carter et al., 2008)		DVD More of Everything bonus chapter (Carter et al., 2008)
Evaluation	Mail-in survey	Evaluation	Mail-in survey	Evaluation	Mail-in survey

Note. NICU = neonatal intensive care unit; AV = audiovisual.

CURRICULUM DEVELOPMENT: WEEK 1

As shown in Table 1, the content for the first week of class was developed in preparation for the pilot series. At first glance, the amount of content seemed overwhelming for the 3-hour time frame. Six hours were typically spent in the Hartford Hospital prepared childbirth classes covering late pregnancy, labor/birth, and postpartum, without including the special considerations of multiple birth. However, doing a needs assessment of the group at the beginning of the class helped focus content for the session, allowing reviewing quickly the basic content that was not applicable or already known to the group. For example, if all the couples were already scheduled for cesarean surgeries, content specific to vaginal birth was skipped.

Late Pregnancy

Mothers readily discussed the differences in a twin pregnancy compared to their previous singleton pregnancies or those of friends. Increased fatigue and taking time off from work were universal concerns. A helpful handout about the Family and Medical Leave Act (2014) was referred to the group. Couples were also encouraged to involve their family and friends. Supportive family members were welcome to attend the three sessions, tours, and the expectant grandparents class.

Current evidence indicates 60% of twins and 90% of triplets are born prematurely (March of Dimes Foundation, 2014). Therefore, the warning signs of preterm labor were explained, and couples were encouraged to seek follow-up. Specific directions for accessing around-the-clock medical help were gone over in class, and couples walked through a “dry run” on the tour the following week.

Current evidence indicates 60% of twins and 90% of triplets are born prematurely

The babies themselves usually determine the mode of birth in full-term pregnancies. Mothers of multiples planning on a vaginal birth need the cooperation of the first baby in presenting head down (Barrett et al., 2013). Therefore, fetal presentation, implications for birth, and how their birth plan may be affected were discussed.

Labor and Birth

Whether a mother was planning a vaginal birth or not, she needed to be able to recognize the signs of early labor. At Hartford Hospital, all expectant mothers preregistered for their birth to expedite the process on the day of their admission. Mothers who had planned cesarean surgeries found this especially comforting in case they went into labor before their scheduled surgery date.

Early and active labor, transition, and pushing were discussed. Simkin’s Road Map of Labor, by Childbirth Graphics, was a helpful handout (Simkin, 2003). Appropriate support measures and the various breathing techniques were taught. Mothers planning a vaginal birth were encouraged to have an epidural put in place during active labor, even if they did not plan any pain medication (Bowers & Gromada, 2006). If needed, epidural placement would facilitate an emergency cesarean for either twin without resorting to general anesthesia. One of the births included in the More of Everything DVD illustrated this scenario.

Epidural and spinal methods of analgesia were contrasted in terms of placement, medication administration, and sensation. Epidural analgesia was a popular choice for vaginal births, and spinal anesthesia was common for cesarean surgeries.

At Hartford Hospital, mothers birthing multiples were moved to an operative room setting for pushing and birth. Couples were alerted to the “crowd” that would be on hand. An obstetrical birth team, anesthesiologist, sonographer, and neonatal caregivers for each baby would all be available for any unexpected occurrences.

Cesarean Surgeries

Planned cesarean surgeries are a reality for many mothers birthing multiples (Barrett et al., 2013). Preparations done at home prior to the admission process on the day of birth were discussed in detail. The surgical procedure itself was explained step-by-step. Special attention was given to the role of the support person during birth, with specific suggestions for comforting the mother. The Connecticut Children’s Medical Center NICU was on site at Hartford Hospital, and pediatricians or NICU staff would be present at the birth to evaluate the babies. Mothers especially appreciated that there would be opportunities to bond with the babies before leaving the recovery room. Three of the four births in the DVD More of Everything were cesareans and positively illustrated this content.

Immediate Postpartum

Assessments of mother and babies made during the immediate postpartum period were explained. Pain control options were also reviewed. Initiation of breastfeeding in the recovery room was promoted and laid the foundation for the third class in which newborn feeding was discussed.

The increased rate of prematurity in multiples increased the possibility of a NICU admission. Mothers always had contact with their babies before their NICU transfer. The babies were also photographed, so mothers could have a photo until they could go to the NICU themselves. In addition, families were given a phone contact to speak to NICU staff directly. It was explained that a NICU team member would visit the parents with the plan of care and that they would be involved in their infants’ care. Around-the-clock visiting hours in the NICU facilitated bonding and breastfeeding. The NICU transfer procedure was illustrated in one of the births in the DVD More of Everything.

As the couples bonded with each other, they also bonded with the couples in the DVD. They looked forward to finding out what happened to them when they went home with their babies. This anticipation provided a natural bridge to the following two classes.

CURRICULUM DEVELOPMENT: WEEK 2

Maternity Tour

After introductions and needs assessment were completed, the group headed out on the maternity tour. If modified bed rest was in place or transport chairs required, those accommodations were made. The length of the tour was limited to 30 or 40 min so as not to keep the expectant mothers on their feet too long. Topics covered during the walking tour were preregistration and instructions for complimentary parking with ticket validation. Directions for entrance points at various times of day and night were also discussed. The tour included the private triage rooms and typical admission procedures, electronic fetal monitors, bathroom facilities, and provisions. Before proceeding to the cesarean area, around-the-clock anesthesia coverage was discussed. The fact that all multiples would be birthed in the operating room (OR) for the safety of the mother and babies was reinforced. Labor rooms were shown with attention to nursing support, a review of how many support people would be allowed, and the timing of the transfer to the OR for surgery. The set up for two or more infants in the OR and the neonatal coverage that would be present at birth was also discussed. The recovery area was shown before proceeding to the postpartum area, where infant security measures and visiting policies were explained. Topics addressed included admission to the room, rooming-in of infants with mother and a support person, and the nursing and lactation support available. Usual routines such as infant clothing and linens provided, length of stay, daily visits by providers, pediatric coverage, and agency-specific infant security measures were discussed. The highlight of the tour usually included showing an infant to the group (after obtaining parental consent) and noting security tags and umbilical clamp, in addition to the typical “oohs” and “ahhs” after seeing an actual newborn.

Support and Resources for the New Family

Returning to the classroom, participants took a short break, and the group was surveyed for questions from the tour. The content on how to care for more than one baby at a time was next addressed. The first topic was where to find reliable information, resources, and sources of support. Discussion included identifying friends, family, and social networks they could recruit. “It takes a village” and “Line up your team” were mantras often repeated for the purposes of soliciting help with groceries, meals, and yard work so that parents would be freed up for baby care of the multiples. Although parents often found people willing to help with holding and feeding babies, what was needed more often was help with household chores instead, so they would be able to spend time with their babies in between napping. If anyone in the group had children, sibling adjustment was discussed, relevant to the developmental stage of the sibling. Local classes for cardiopulmonary resuscitation, referral to reputable websites, and books were available for loan. Discussion also included interview questions for choosing a pediatric health-care provider. Dependent on where the families were in this process, and what their knowledge was regarding the variety of providers available, a good discussion within the group usually ensued. In addition, immunization schedules were discussed and questions and concerns addressed.

Newborn Appearance and Behavior

Newborn appearance and behavior was explained and reinforced with audiovisual support. Crying as early communication and potential interventions to soothe crying babies as demonstrated by Dr. Karp’s methods (Karp, 2014) and soothing measures for parents were discussed (Lyons, 2007; Vaziri, 2010). The potential for shaken baby syndrome, identifying a safety plan, and how parents could best use their resource network were also discussed.

One of the biggest adjustments new parents face amidst so much role transition is the impact taking care of babies has on their sleep pattern (Weissbluth, 2009). A written handout prepared by a certified pediatric nurse practitioner (CPNP) covered how to provide a safe sleeping environment while following current recommendations for sudden infant death syndrome (SIDS) prevention, co-bedding, and co-sleeping. Normal infant sleep patterns, development, and preventing sleep problems were also addressed.

Infant Care

After another short break, expectant parents began practicing infant care techniques such as swaddling, bathing, shampooing, diapering, and taking a temperature on infant manikins. Parents expressed much concern about the ability to perform these tasks with a real baby, but they were encouraged when the instructors reassured them that they would practice under the guidance of nursing staff in the hospital postpartum and they could ask for more teaching, so they would feel confident upon discharge. Appreciating that the manikins were not quite the same as a real baby, parents understood that they were the best option for the first practice in class and were a good start before working with their own infants in the hospital.

Infant Safety

The final topic of the night was infant safety. The American Academy of Pediatrics (AAP, 2014) TIPP Sheet was reviewed with the participants. In addition, the prenatal home survey, room-by-room childproofing, and adjustment to pets in the home were discussed. Parents who had dogs or cats often referred to them as their “first babies,” so canine and feline rivalry was discussed, along with health and supervision issues with animals. Car seat safety was also discussed, and parents were given resources for assistance with installation. The DVD reinforced the content about how parents should organize themselves, what baby equipment they would need, and how much to prepare ahead. By the end of Week 2, parents had a good start on understanding what taking care of their babies would involve, so that progressing on to the Week 3 focus on infant feeding and the potential problems multiples may face was a natural next step.

CURRICULUM DEVELOPMENT: WEEK 3

Neonatal Intensive Care Unit Tour

After a brief introduction of the instructors and their expertise and teaching styles and a needs assessment of the attendants, the group headed to the NICU for a tour, which included location of facility; identification of staff; usual practices such as scrubbing, signing in, infant security, parent visitation and involvement; and an explanation of some of the support a premature baby might need. In addition, visualization of premature infants and support, and communication with a parent who was with their baby in the NICU, dependent on availability, were typical components of the tour.

Hartford Hospital, where most of the attendants planned to give birth, was designated as a World Health Organization (WHO) “baby-friendly” institution and therefore strongly promoted breastfeeding (Saadeh & Akré, 1996). The NICU was housed in the same building as the mothers’ postpartum unit but was also a free-standing children’s hospital. The NICU had a very strong lactation program as well, so the focus and recommendation for feeding infants was geared toward breastfeeding as the best evidence-based option for nutrition for all infants, especially premature ones. Often, however, preterm infants required transitional feedings to accomplish the eventual goal of exclusive breastfeeding, so this content was included as well (Academy of Breastfeeding Medicine [ABM], 2011; Nyqvist et al., 2012).

Infant Feeding: Breastfeeding

The majority of the time in class was spent on breastfeeding, the method of feeding recommended by the WHO, the AAP (2012; Eidelman, 2012), and the ABM (2009). Multiples are often at higher risk for being born preterm, which puts sustained breastfeeding at risk (Meier, Furman, & Degenhardt, 2007). Because breastfeeding is often the method of feeding that creates the greatest challenges for postpartum parents of multiples, the provision of breastfeeding prenatal education has been shown to promote breastfeeding self-efficacy after birth (McQueen, Dennis, Stremler, & Norman, 2011). Content of the class included the benefits of breastfeeding for mother and baby, promotion of breastfeeding, avoidance of separation by promoting rooming-in, and what to do if separation was medically indicated. There was discussion on why breastfeeding or providing breastmilk was promoted for the premature infant and the supports available to overcome the challenges that may arise. In addition, the instructor explained the potential need for pumping and supplementation, how the typical infants progressed to oral feedings if supplementation occurred, and the methods of supplementation available. Lastly, family support for breastfeeding, how to achieve an effective and pain-free latch, and the position for simultaneous feeding with twins were discussed and demonstrated using dolls and breast models. Parents typically express extreme anxiety about knowing whether their baby is getting enough milk, so the process of lactogenesis, expectations for output, appropriate infant weights, and provider follow-up were presented. Postdischarge availability of lactation support, both in the hospital and in the community, was discussed as well. If mothers were returning to work, breast pumps and effective pumping techniques were discussed, as well as the state’s legal requirements for employers to support breastfeeding.

Infant Feeding: Breastmilk Substitutes

The equipment required, types of breastmilk substitutes (ready to feed, concentrate, and powder), and preparation techniques, as well as instructions for the care and cleaning of the equipment, were presented. How to administer bottle feeding to their babies, timing, burping, positioning, and maintaining infant safety by not propping bottles were discussed. Parents usually wanted to know what types of bottles they should buy and how many, which led to product discussion within the group. Discussion usually involved returning to work for both breastfeeding and non-breastfeeding mothers and the implications for how to plan feedings accordingly.

Postpartum Blues/Depression

Women with multiples pregnancies demonstrate an increased risk for the hormonal imbalance and emotional response to pregnancy and birth. Mothers with a history of anxiety and/or depression may be predisposed to postpartum depression, or at least postpartum blues. Parents who have to care for multiples get less sleep and have more demands on their time, which further increase this risk (Ross, McQueen, Vigod, & Dennis, 2011). Therefore, the instructors taught the rationale for identifying significant symptoms, the differences between baby blues and postpartum depression, and the necessary step of identifying a safety plan if the mother or her support person identifies an issue. In addition, one instructor had some personal experience with postpartum depression, and she shared that with the attendants as a way for them to identify symptoms and potential resources for them to access.

Personal Reflection

Expectant parents were always happy to know that at least one of the instructors herself had a twin birth. Even though those children were born 20 years ago, it gave expectant parents hope that they could do it, and they appreciated the personal perspective on the immense amount of work involved in caring for multiples. Throughout the class, personal stories were shared regarding simultaneous breastfeeding, tracking feedings and output, and buying certain equipment. As a summary, the instructor shared a list she had created, entitled, “I don’t know what I would have done without . . . .” This list was updated to reflect the availability of new equipment and services. For example, the cell phone now replaces the cordless phone that was so important 20 years ago, and the tracking notebook used to keep track of questions, feedings, and output is replaced by an “app” on a smart phone. However, some things still hold true 20 years later: a breastfeeding twin pillow for simultaneous feeding; a strong evidence-based health-care provider who is supportive of breastfeeding, with resources for that follow up; having a sense of humor; partner, family or friend support; the ability to take pictures quickly and easily; and a carriage system for getting outside on walks. In addition, no parent of multiples would be able to keep going without smiles from their babies as rewards for all the work parents do, extra cheers from everyone they meet, excellent daycare, a good breast pump, and lastly, a remote control for the TV while feeding for what seems like hours on end. Various personal stories were shared throughout the recitation of this list as a way to provide humor to the class and help them appreciate what lay ahead.

Throughout the class, personal stories were shared regarding simultaneous breastfeeding, tracking feedings and output, and buying certain equipment

SUMMARY AND QUESTIONS AND ANSWERS

Questions usually helped the entire group, so they were encouraged. With such a large amount of content to cover in 3 hours, it is likely that there were additional questions that didn’t get addressed. The instructor closed by reinforcing the three goals she wanted the students to attain through the course. First, breastfeeding was the preferred method of feeding for all infants. Second, breastfeeding wasn’t supposed to hurt, but there may be challenges to it (having more than one baby or a premature birth, for example). Third, there was help for mothers to overcome these challenges, provided by the nursing and lactation staff in the hospital and resources after discharge. Deciding how they want to feed their baby is one of the first parenting decisions a new mother and father make. The information participants received through this program enabled them to make an informed decision, create a plan, have resources identified and put into place prior to birth, and then feel more prepared in the process.

EVALUATION OF THE PILOT SERIES

Once the first pilot series was presented, feedback from the attendees was solicited for validation of content and suggestions for improvement. For example, reference lists were developed and shared with the participants. A primary concern of the participants was establishing healthy sleep habits for multiples and ideas for parents coping with sleep deprivation. An entire unit was developed to address these concerns and to reinforce safe sleeping habits. Verbal feedback was requested and written evaluation cards were completed after each session. The curriculum has since continued to evolve to meet the changing needs of the participants based on their ongoing evaluations. Some expectant parents were very well-educated health-care consumers who had already done a lot of research. That meant the typical parenting questions on feeding and bathing a baby were necessary, but not the primary focus of the class anymore. Although immediate postpartum infant care was covered, adjusting the content to understanding infant sleep and how to promote it, and to get sleep as parents with twins or triplets, was information all the parents wanted. A list of handouts that were developed in response to the parents’ feedback is presented in Table 2.

LEARNER-BASED TEACHING STYLE

There were consistent approaches to teaching that all instructors found helpful to employ as they taught the classes. At the beginning of each class, the participants were asked to explain their goals for attending this portion of the program and to share any thoughts or feelings with the instructors and group members. This needs assessment disclosed what they wanted to learn, as well as attitudes and expectations they may have already had, and built a sense of camaraderie with the fellow expectant parents. The format of each class was best when one break was given each hour to promote comfort, restroom breaks, and a refreshed ability to learn. Lastly, all classes had an informal feel that encouraged questions and sharing.

Besides the class textbook and audiovisual needs, props required were two dolls per family for practice, and props and supplies for demonstration of childbirth, infant care, and feeding. In addition, monitors to show the PowerPoint slides and DVDs and a whiteboard with markers for teaching purposes were readily available in the education classroom. Water and snack crackers were available for participants, but expectant parents were welcome to bring more substantial snacks or drinks for the 3-hour session.

COST AND MARKETING

The class was marketed through the hospital call center, hospital website, and especially through referrals from the high-risk perinatal provider office and area obstetric offices. This usually accomplished a planned attendance of three to seven expectant couples if the class was offered four times per year. The cost for the 3-week series was originally $125.00 and could be prorated for couples interested only in certain classes. The cost analysis determined the class to be cost effective if three couples attended. Since the program began, participants have come from three neighboring states based on word-of-mouth referrals. There was discussion of having online course components, but it was decided to start with real-time attendance because it would promote more supportive relationships within the group. The instructors found that families frequently made voluntary contact outside of class and continued their mutually supportive network after the classes ended, as they then had children roughly the same age. Two improvements were made based on the feedback: Handouts were developed, and more social support icebreakers were conducted in the first class to build mutual support.

CONCLUSION

This course has been well attended and has received strong evaluations since its inception. It has therefore remained a mainstay of the prenatal education program. After the pilot class series, instructors discussed the curriculum and made revisions to it based on feedback from the participant evaluations. The director of the prenatal education program continually monitors the evaluation feedback as well. Expectant parents voluntarily communicated back to the faculty on the outcomes of their births. Positive responses from the evaluations typically included feedback that parents appreciated not having to assemble piecemeal their information from singleton birth classes, and they appreciated having time with other expectant multiple parents. In addition, they usually cited excellent instructor feedback, which has reinforced the instructors’ vision and beliefs as they continue to develop the program.

Attendance by expectant parents who traveled 3 hours sparked an interest in disseminating the curriculum in the literature so more programs such as this could be developed and made available. Future challenges include continued marketing to improve attendance among all potential parents of multiples, advertising the availability of scholarships for parents who can’t afford the cost, and potentially promoting more Internet-based education and support options, such as use of social media and website applications.

ACKNOWLEDGMENTS

The authors acknowledge Hartford Hospital and Amy Schroeder, RNC, former director, and Cheri Cronin, RN, current director of prenatal education at Hartford Hospital, for their support in the development of this program. The authors also acknowledge University of Connecticut School of Nursing’s Center for Nursing Scholarship for its assistance in the development of this manuscript.

Biographies

JOAN ESPER KUHNLY has recently completed her doctor of nursing practice degree and is a full-time faculty with University of Connecticut School of Nursing. She teaches parenting classes and conducts her breastfeeding research on late preterm infants at Hartford Hospital.

MARION JULIANO has many years of experience teaching in the perinatal field and has retired from teaching baccalaureate nursing students and expectant parents.

PATRICIA SWIDER McLARNEY, originally certified as a pediatric nurse practitioner, has switched careers and is now working as a child life specialist at Connecticut Children’s Medical Center.