Components of Care Expected from Midwives by Women with Twin Pregnancies After the Use of Assisted Reproductive Technology: A Cross-Sectional Study
1
Department of Nursing, Faculty of Medical Sciences, Shonan University of Medical Sciences, Yokohama 231-0862, Japan
2
Department of Nursing, Faculty of Medical Sciences, Teikyo University of Science, Tokyo 120-0045, Japan
3
Graduate School of Nursing Science, St. Luke’s International University, Tokyo 104-0044, Japan
*
Author to whom correspondence should be addressed.
Women 2025, 5(4), 46; https://doi.org/10.3390/women5040046
Submission received: 20 October 2025
/
Revised: 16 November 2025
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Accepted: 21 November 2025
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Published: 8 December 2025
Abstract
Use of assisted reproductive technology (ART) to bear children has in recent years become widespread in Japan. While midwives are required to understand the experiences of individual women and provide ongoing support for them, implementing respectful care that meets the needs of women using ART remains challenging. This study therefore aimed to explore the specific care components expected of midwives for women with twin pregnancies after ART. A cross-sectional questionnaire survey was conducted through Google Forms on 273 women with twin pregnancies, of whom 85 had conceived twins through ART. Women were recruited through national multiple birth support groups and midwifery centers providing postnatal care. Data were collected from July 2021 to December 2022, and care expectations were rated on a 5-point Likert scale. Factor analysis was performed to identify care components, and reliability was evaluated using Cronbach’s alpha. Among the participants, 41.2% were between 36 and 40 years of age. Seven primary care factors were identified: comprehensive parenting support for twins, addressing concerns regarding the sudden death of twins, interdisciplinary medical collaboration, connecting women with twin pregnancies, understanding post-delivery physical pain, providing continuity before and after delivery, and supporting the development and well-being of the twins. The findings emphasize the importance of understanding individual ART histories and providing tailored care to respond appropriately to women’s needs during pregnancy, childbirth, and the postpartum period. The identified components provide an empirical foundation for integrating these perspectives into routine midwifery care and educational programs for women with ART-conceived twin pregnancies.
1. Introduction
Assisted reproductive technology (ART) encompasses a range of medical procedures primarily used to treat infertility, including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART is thought to be a contributing factor to the increasing rates of twin births across the world [1]. In Japan, the total number of ART treatment cycles using ART reached 498,140 in 2021, 13.6% of which resulted in pregnancy [2]. According to national survey data in Japan [3], assisted reproductive technology (ART) is primarily used for infertility treatment, and a specific desire for twins or higher-order multiple pregnancies is rarely reported as a primary motivation. The rate of multiple pregnancies resulting from ART is 3.0% [2], which is higher than the overall rate of multiple pregnancies (1.7%, including ART) [4]. In this study, ART was defined as a generic term for specialized medical techniques, including IVF, embryo transfer, and ICSI, used in the diagnosis and treatment of infertility [5].
Following the use of ART, women face a higher risk of pregnancy-related complications, including preeclampsia [6], gestational diabetes mellitus [7], and hypertensive disorders of pregnancy [8], when compared to those with spontaneous pregnancies [6,7,8]. Women with multiple pregnancies are at a higher risk of complications, including preeclampsia [9] and gestational hypertension [10]. Even in cases of successful delivery, multiple births are associated with a high percentage of low birth weight infants [4]. Twin-to-twin transfusion syndrome (TTTS), a serious complication unique to monochorionic twin pregnancies, which occurs in approximately 10–15% of such pregnancies and is a major contributor to perinatal morbidity and mortality [11].
Furthermore, women undergoing fertility treatment are prone to depression [12,13], with risks heightened in those undergoing repeated treatment [14]. Approximately one-third of women with twin pregnancies experience depression [15], and this emotional vulnerability may persist into pregnancy and the postpartum period, even after successful delivery [16,17], potentially impairing mother–child bonding [18]. Women who conceive twins through ART have been reported to experience higher levels of maternal stress six months after birth than mothers of spontaneously conceived twins [19]. These findings suggest that women with ART-conceived twin pregnancies may carry a cumulative psychological burden, underscoring the need to clarify the components of midwifery care they expect.
Further, women who conceive twins through ART experience damaged self-esteem due to previous unsuccessful treatment cycles of ART treatment; the feelings of inadequacy and guilt may persist after delivery until the woman experiences the joy of motherhood and realizes that she has “become a mother” by attributing positive value to her past experiences [20,21]. Finally, mothers who have used ART are at risk of demonstrating a lack of affection for their newborns [22]. Midwives may need to carefully explain the benefits and risks of ART and provide ongoing care and support tailored to women’s individual experiences [21] and needs after using ART [23].
Despite previous research on issues associated with twin pregnancies following ART, a significant gap remains in understanding the specific care expectations of these mothers, particularly regarding receiving emotional support and tailored care from midwives. In a previous qualitative descriptive study, we explored the care that women who conceived twins using ART expect from midwives [24]. Based on the results of this study, we developed a questionnaire to measure these care expectations. In the present study conducted a questionnaire survey and performed a factor analysis to identify the care items that women with twin pregnancies expect from midwives. The results of this study are expected to contribute to improving the continuous midwifery care of midwives for women who have had a twin pregnancy using ART and to improve the health and quality of life of these mothers and their children.
Therefore, this study aimed to identify the components of midwifery care expected by women with ART-conceived twin pregnancies during pregnancy, childbirth, and the postpartum period.
2. Results
2.1. Respondents’ Demographics
Responses were obtained from 277 women with twin pregnancies. We excluded two participants who reported triplets and two who had non-responsive items, resulting in 273 participants (Table 1).
Considering the factor analysis, of the 85 women who used ART, 35 (41.2%) were aged 36–40 years and 29 (34.1%) were aged 31–35 years. The most common occupation was company employment (n = 43 [50.6%]), followed by homemaker (n = 23 [27.1%]). Seventy-nine (92.9%) patients had undergone IVF, and 66 (77.6%) had undergone ICSI. The time between visit to the fertility clinic and conception was <2–3 years in 22 patients (25.9%) and <1–2 years in 21 patients (24.7%). Seven (8.2%) participants were pregnant with twins, and 78 (91.8%) were within three years postpartum after delivering twins (Table 1).
2.2. Analysis of Validity and Reliability
2.2.1. Assessment of Construct Validity
Seven factors were extracted from the factor analysis. The cumulative sum of the squares of the loadings after extraction was 61.859%, which was considered adequate to describe care for women with twin pregnancies using ART. The factor “2.11 Gradual introduction of family visits” was deleted because its factor loading was −0.24, and its absolute value was less than 0.3. Although Factors 5 and 7 had only two and one items, respectively, the sum of the squares of the factor loadings was 1.789 and 1.723, respectively. Hence, they were retained, as they were deemed to have sufficient explanatory power and appropriate care considerations for women with twin pregnancies using ART.
The remaining 27 items were subjected to an additional round of factor analysis with a Kaiser–Meyer–Olkin sample validity measure of 0.74 and Bartlett’s sphericity test of p < 0.001, which were sufficient to conduct the factor analysis. Seven factors were extracted, with a cumulative contribution of 63.803%. All IT correlation results for “2.2 Ensuring rest time after delivery” were low at 0.253. Nevertheless, this factor was expected to be a factor of care, considering the high physical burden on women who have twins using ART, and the fact that women tend to remain in a state of tension from preconception to childbirth. For the other items, the IT correlations ranged from 0.306 to 0.708 (p < 0.001), indicating a high degree of internal consistency.
The identified factors were “Factor 1: Care for comprehensive parenting support for twins,” “Factor 2: Care to address concerns regarding the sudden death of twins,” “Factor 3: Medical care based on interdisciplinary collaboration among medical professionals,” “Factor 4: Connecting women with twin pregnancies from the gestational period,” “Factor 5: Care to understand post-delivery physical pain,” “Factor 6: Providing continuity before and after delivery,” and “Factor 7: Supporting the development and well-being of the twins” (Table 2).
The sums of the squares of the factor loadings for each factor were as follows: Factor 1, 6.480; Factor 2, 4.873; Factor 3, 2.542; Factor 4, 2.960; Factor 5, 1.702; Factor 6, 1.884; and factor 7, 3.654 (Table 2). Regarding the correlation coefficients between the factors, correlations ranged from 0.124–0.749, with high correlations between Factors 1 and 7 (r = 0.749) and Factors 2 and 7 (r = 0.626; Table 3).
2.2.2. Examination of Reliability
The Cronbach’s alpha for all 27 items was 0.901, confirming the high reliability of the analysis. In particular, the Cronbach’s alphas for Factors 1, 2, 3, and 7 were α = 0.883, r = 0.857, r = 0.786, and r = 0.782, respectively, confirming sufficient reliability. Factors 4 (r = 0.656) and 5 (r = 0.648), although somewhat less reliable, were deemed acceptable and utilized in the exploratory phase of this study.
2.2.3. Examination of Content Validity
Although the themes and subthemes identified in the qualitative descriptive study did not individually correspond to the extracted care constructs, each factor was consistent with the relevant subthemes and was judged to appropriately reflect the care construct.
2.2.4. Evaluation of the Extent to Which Women with ART Twin Pregnancies Desire Care
For women with twin pregnancies using ART, the mean scores for the care items included in each factor were as follows (in descending order): 4.81 (SD = 0.39) for Factor 5, 4.67 (SD = 0.49) for Factor 4, 4.58 (SD = 0.68) for Factor 6, 4.49 (SD = 0.59) for Factor 1, 4.45 (SD = 0.61) for Factor 7, 4.45 (SD = 0.62) for Factor 2, and 4.24 (SD = 0.76) for Factor 3. The means of the care items included in each factor did not differ significantly relative to the experience with ART or fertility treatments (Table 4).
3. Discussion
This study identified the components of care expected from midwives by women with twin pregnancies receiving ART, reflecting their care needs. However, the similarity in the mean scores across factors, regardless of ART experience, suggests that these care components, although specific to post-ART twin pregnancies, are generally applicable to all twin pregnancies. For instance, the care item “1.1 Listen to my concerns about the risks of a twin pregnancy” was desired by both women who had experienced ART and women who did not. However, the experiences and feelings that led to “worried feelings” differed between women who experienced ART and those who conceived naturally. Women who have undergone ART may experience psychological difficulties in becoming mothers of twins [25]. Women who receive ART continue to express concerns about the sudden death of their child not only before birth but also 2–3 years after birth, owing to their experience of loss during the treatment [21]. ART resulted in 67,833 pregnancies and 23,336 miscarriages [2], suggesting that approximately one-third of women experience a miscarriage before achieving an ongoing pregnancy. Therefore, midwives must comprehend and demonstrate empathy toward women’s experiences through effective communication. It is crucial to acknowledge that women may experience multiple losses throughout their treatment journey, which is an integral part of their ART history, including failed embryo transfers, early miscarriages, and emotional distress related to fertility treatment. Previous research suggests that midwives can address the unique psychological needs of women arising from the ART experience by providing ongoing reassurance that their children are healthy and growing normally, thereby ensuring the comfort and security of motherhood in women [20,21].
Factor 1 is about how mothers expect comprehensive parenting support, such as “2.14 Ensuring a quality time with twins,” “2.10 Support to experience the joy of raising twins,” and “2.7 Assistance with breastfeeding twins” (Table 2). Women who became pregnant using ART considered childbirth their primary goal and were relatively less aware of the implications of childcare, often panicking about parenting twins after delivery [24]. However, 2–3 years after delivery, mothers viewed their twin pregnancies positively, ultimately developing their awareness as mothers of twins [21]. While experiencing anxiety regarding childbirth and the challenges of raising twins, mothers aspired to provide the best possible care for their twins [21]. Breastfeeding plays a crucial role in this transition as mothers develop their maternal identities and begin to view twin pregnancies and parenting more positively. Breastfeeding is a time for mothers to feel the joy of motherhood, as they experience a sense of oneness with their children. Often, the benefits of breastfeeding and disadvantages of formula feeding are not fully communicated to mothers [26]. Breastfeeding twins presents challenges in terms of feeding methods and time availability, and it is important to provide ongoing support to help overcome these challenges.
Factor 2 (“Care to address concerns regarding the sudden death of twins”) indicates that the respondents sympathized with and sought solutions to the anticipatory anxiety about the possible loss of a fetus or child, as reflected in items such as “1.1 Listening to my concerns about the risk of twin pregnancy” and “1.3 Sharing information about the risks of twin pregnancy.” According to the literature, women with twin pregnancies using ART not only experience anxiety about stillbirth or abnormalities in their twins, but also actively seek information to prepare for potential future abnormalities [24]. Additionally, the fear of sudden death in twins persists even after giving birth [21]. Therefore, it is important to provide information that affirms the normal growth of babies. For instance, many twins born using ART reach the same height as twins born to mothers with natural conceptions by the time they start school, and they also weigh more [27,28]. Hence, empathy based on an understanding of the ART history is essential. Additionally, women diagnosed with risks related to high-risk pregnancies are ruled by fear of the unknown [29], which may intensify their anxiety, especially if they do not fully comprehend the information provided. Therefore, providing easy-to-understand, individually tailored explanations of risk information [30] may reduce unnecessary anxiety [24].
Factor 7 (“Supporting the development and well-being of the twins”) indicates a mother’s desire to have confidence in the health and growth of her twins while building a deep bond with them, such as “2.8 Fostering a sense of unity with twins” and “2.5 Involvement to feel a sense of vitality in twins.” Given the high-risk nature of multiple births, pregnancy is a challenging period for mothers because of the uncertainty about the well-being of their babies. Hence, it is crucial to maintain open communication with mothers following childbirth by consistently reassuring them about the healthy development of twins.
Twins tend to have a low birth weight and are more likely to be admitted to the neonatal intensive care unit (NICU) [31]. In such cases, babies admitted to the NICU may have fewer opportunities for immediate Kangaroo Care or breastfeeding than those who are not admitted to the NICU. A newborn baby’s hospitalization requirement can directly affect the formation of the mother-infant bond [32]. Therefore, midwives must create opportunities for mothers to connect more deeply with their twins.
Factor 7 had the highest correlation among all factors, particularly with “Factor 1: Care for comprehensive parenting support for twins” and “Factor 2: Care to address concerns regarding the sudden death of twins.” These strong associations between Factor 7 and Factors 1 and 2 suggest that the care components associated with these factors may collectively contribute to alleviating maternal anxiety.
Taken together, these components of care indicate that midwives are expected to understand women’s individual process of ART and create opportunities to reassure mothers of their twins’ healthy development through empathic communication. Such care may help to reduce heightened anxiety about their twins’ health and promote enjoyable parenting. Building on the seven identified factors, it is feasible to develop a standardized educational program for midwives who provide care to women with ART-conceived twin pregnancies.
Although this study contributes substantially to the literature, it also has several limitations. The first is the transformation of the qualitative data. Whenever ethical considerations made it necessary to avoid directly expressing the items of care expected of women obtained in the qualitative descriptive study, we used euphemisms that may not have accurately captured the original needs of women who experienced ART. In addition, the psychological complexity of women’s experiences cannot be completely captured using a self-administered questionnaire. Women who conceive through ART often experience anticipatory anxiety. While they wish to alleviate their concerns about potential health risks to their child after birth, they may also experience conflicting emotions, feeling joy about their child’s health while simultaneously holding onto lingering anxiety [33]. In some cases, anxiety functions as a defense mechanism, creating resistance to a sense of complete security. This makes it challenging to capture ambivalent emotions accurately using questionnaires.
Second, there are limitations related to the target population. Given that postpartum women were the primary respondents, the questionnaire may not have fully captured care expectations specific to the pre-birth period. Post ART usage, women undergo a process of “re-telling” in which they reinterpret past anxieties and fears and find new meaning in their role as a mother after childbirth [22]. It is possible that the “re-telling” process results in a relative fading of memories about the anxieties they experienced before childbirth. Future research should administer the scale not only to women but also to partners or primary caregivers to capture family-level expectations, evaluate concordance or divergence in perceived needs, and inform family-centered midwifery and nursing practices.
Third, our exploratory factor analysis and subsequent comparisons did not take into account potentially influential individual or clinical characteristics, such as maternal age, type of ART procedure, pregnancy or childbirth complications, or time since delivery. These factors may shape women’s experiences and expectations of care; however, because women with ART-conceived twin pregnancies constitute a relatively small population, our sample was not sufficiently large to support stable multivariable modelling. Although the questionnaire was also administered to women with naturally conceived twin pregnancies, the exploratory factor analysis to identify care components focused on women who conceived twins using ART, and this study did not include comparative analyses with naturally conceived twin pregnancies. Consequently, our findings cannot fully disentangle which components of expected care are unique to ART-conceived twin pregnancies and which reflect care needs common to all twin pregnancies. Where sample size permits, future research would be expected to incorporate multivariable regression or other appropriate comparative analytical approaches to examine how individual characteristics and mode of conception are associated with specific components of expected midwifery care.
In addition, longitudinal or mixed-method designs that incorporate in-depth interviews or other qualitative approaches would also be useful for exploring women’s experiences and expectations in greater depth and for complementing the quantitative findings. On this basis, midwifery education programs grounded in the identified components can be developed and evaluated, which may help establish a model of care for women with twin pregnancies using ART.
4. Materials and Methods
4.1. Research Design
This study employed a cross-sectional survey design prepared using Google Forms (Google LLC, Mountain View, CA, USA). This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. The STROBE checklist was used to ensure the comprehensive and transparent reporting of the study design, data collection, and analysis and the completed checklist is provided in the Supplementary Materials. This cross-sectional, web-based survey captured women’s care expectations at a single time point. The analyses were designed to be descriptive and associative, rather than causal, in examining the components of care expected of midwives by women with ART-conceived twin pregnancies.
4.2. Participants
Survey participants were women who were either pregnant with twins or had given birth to twins within the previous three years. Women up to three years postpartum were included because previous studies have shown that women vividly recalled events and recounted their unsatisfactory experiences during infertility treatment, even two to three years after childbirth [21]. To reach women with twin pregnancies living throughout Japan, participants were recruited through national multiple birth circles and midwifery centers that provide postnatal care. The sample size was determined pragmatically by recruiting as many eligible women as possible through these channels during the study period.
4.3. Ethical Considerations
This study was approved by the university’s Ethics Committee for Human Subjects (approval no. 2122-2). The participants provided consent to participate in this study through an online survey. The purpose, significance, research methods, and ethical considerations of this study were described in the request form to the potential research participants. Research cooperation was voluntary; anonymity was guaranteed; and personal information was strictly protected. The participants were informed that the study results would be published, and their consent was obtained.
4.4. Data Collection
4.4.1. Research Procedures
Of the 143 support circles affiliated with the Japan Multiple Birth Support Association, administrators and cooperating postpartum care facilities were first mailed letters requesting participation in this study. Administrators who agreed to participate received a request form for potential research participants. The form explained the purpose, objectives, methods, and ethical considerations of this study and included a QR code linked to a web-based questionnaire created using Google Forms. Cooperating administrators distributed the form to eligible women in their circles or facilities. In total, 67 support circles participated in this study. These 67 circles were overseen by 12 administrators, some of whom managed multiple circles and therefore distributed invitations collectively. Additionally, using a key-informant approach, directors or senior midwives at five cooperating midwifery centers distributed the same request form with the QR code to eligible women receiving services. Data were collected during an 18-month period, from July 2021 to December 2022.
4.4.2. Baseline Characteristics
The participants’ basic attributes, including age, occupation, and family members, were assessed. Regarding the circumstances leading up to conception, the respondents were asked whether they had undergone fertility treatments, including ovulation induction, artificial insemination, IVF, or ICSI. They were also asked about the number of times they underwent these methods and the treatment duration. To evaluate their pregnancy status, the respondents were asked whether the twins were identical or fraternal and if they were hospitalized for management.
4.4.3. Items Related to the Care Expected from Midwives
Items related to women’s care expectations were developed from a previous qualitative descriptive study of women who conceived twins through ART, which identified four main themes with associated subthemes of expected midwifery care [24]. In addition, we drew on qualitative findings regarding the pregnancy and parenting experiences of women with ART-conceived twin pregnancies [20,21]. Based on these findings, we generated an item pool and developed a questionnaire to measure women’s expectations of midwifery care, and constructed items in three domains: ‘care desired from midwives and nurses during pregnancy’, ‘care desired from midwives and nurses after delivery until discharge’, and ‘care desired regarding information sharing among facilities (hospitals, community health centers, and so on) that support pregnancy, delivery, and child care’. The final instrument comprised 28 items: eight for care during pregnancy, 14 for post-delivery care until discharge, and six for information sharing and continuity of care (Table 5). Respondents rated each item on a 5-point Likert scale ranging from 1 (‘undesirable’) to 5 (‘desirable’). The item pool was drafted by the authors and refined through iterative discussions to ensure content validity. We have also added a table summarizing the correspondence between the qualitative themes/subthemes and the 28 questionnaire items to make the derivation process more transparent.
4.5. Data Analysis
4.5.1. Calculation of Descriptive Statistics
Descriptive statistics were calculated for the respondents’ attributes and their pregnancy-related characteristics up to and during pregnancy by dividing the participants into three groups: “no experience with infertility treatment”, “experience with infertility treatment but no experience with ART”, and “experience with infertility treatment and ART”.
4.5.2. Procedures for Assessment of Construct Validity
To confirm the validity of the care items, we restricted all analyses to women who conceived twins through ART. First, suitability of the data for factor analysis was examined using the Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlett’s test of sphericity. An exploratory factor analysis of 28 items assessing women’s expectations of midwifery care was then conducted using maximum likelihood extraction and promax rotation with Kaiser’s normalization. The number of factors was assumed to have an initial eigenvalue greater than or equal to one, and the possibility of reducing the number of items was examined. Items with factor loadings less than 0.3 or the inter-item correlations less than 0.3 were considered candidates for deletion. Even if each factor contained only one item, we decided to adopt it if it was considered appropriate for the care of women with twin pregnancies using ART. The inter-factor correlations were subsequently checked. Three researchers examined the validity of the constructs.
4.5.3. Procedures for Examination of Reliability
Cronbach’s alpha was calculated for all items to ensure internal consistency.
4.5.4. Procedures for Examination of Content Validity
To confirm the relevance of the factors extracted by factor analysis to the four themes and their corresponding subthemes identified in the qualitative descriptive study, we checked for differences by matching the question items included in each factor with care items designed based on the subthemes.
4.5.5. One-Way Analysis of Variance (ANOVA) of the Strength of Desire for Care Among Women with Twin Pregnancies After Using ART
To assess desire for care, descriptive statistics were calculated for the mean scores of all items belonging to the factor. A one-way ANOVA was conducted with the three groups of infertility treatment and ART experience as the independent variables, and the mean scores of the items belonging to each factor as the dependent variables. The statistical software IBM SPSS Statistics Package for the Social Sciences (SPSS) for Windows Ver. 27 (IBM Corp., Armonk, NY, USA) was used for the analysis.
5. Conclusions
This study identified distinct components of midwifery care expected by women with ART-conceived twin pregnancies, reflecting needs shared with twin pregnancies generally and shaped by ART-specific experiences. These findings highlight the importance of understanding individual ART histories in order to respond appropriately to women’s needs during pregnancy, childbirth, and the postpartum period. The identified components provide an empirical foundation for integrating these perspectives into routine midwifery care and educational programs and for extending support to women’s partners and family members, thereby promoting family-centered, continuous care for ART-conceived twin pregnancies.
Supplementary Materials
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/women5040046/s1, Table S1: STROBE statement—Checklist for items that should be included in reports of cross-sectional studies.
Author Contributions
K.A.: conceptualization, methodology, data curation, data analysis, and writing—original draft preparation. M.F.: Conceptualization, methodology, investigation, validation, review, and editing. Y.Y.: conceptualization, methodology, validation, review, and editing. All authors have read and agreed to the published version of the manuscript.
Funding
This study was supported by a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science, KAKENHI [Grant Number 21K10860].
Institutional Review Board Statement
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee for Human Subjects of Wayo Women’s University (Approval No. 2122-2). This cross-sectional study was conducted in accordance with the STROBE guidelines for observational studies, and the completed STROBE checklist is provided as Supplementary Table S1. The ethical procedures followed the institutional requirements and the Declaration of Helsinki.
Informed Consent Statement
Informed consent was obtained electronically from all participants prior to survey initiation. Members of the public, patients, or advocacy groups were not involved in the design, conduct, reporting, or analysis of this study. The Japan Multiple Birth Support Association and collaborating midwifery centers assisted with participant outreach.
Data Availability Statement
Data are not available due to ethical restrictions. No generative artificial intelligence tools were used for data collection, statistical analysis, or generation of scientific content or conclusions. After drafting, an AI-assisted language tool was used solely for English grammar and style editing, all of which were verified and approved by the authors, who take full responsibility for the content. The data supporting the findings of this study are not publicly available due to ethical restrictions.
Acknowledgments
We would like to express our sincere gratitude to all the participants who generously shared their time and experience in this study. We also appreciate the support of the Japan Multiple Birth Support Association and midwifery centers that facilitated participant recruitment.
Conflicts of Interest
The authors declare no conflicts of interest.
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Table 1.
Participant Attributes.
| Never Had Fertility Treatment (n = 124) | Experienced Fertility Treatment, No Experience with ART (n = 64) | Experienced Fertility Treatment and ART (n = 85) | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Age | ||||||
| 20–25 years old | 4 | 3.2 | 0 | 0.0 | 1 | 1.2 |
| 26–30 years old | 28 | 22.6 | 15 | 23.4 | 6 | 7.1 |
| 31–35 years old | 50 | 40.3 | 28 | 43.8 | 29 | 34.1 |
| 36–40 years old | 33 | 26.6 | 11 | 17.2 | 35 | 41.2 |
| 41 years old and over | 9 | 7.3 | 10 | 15.6 | 14 | 16.5 |
| Occupation | ||||||
| Company employee | 60 | 48.4 | 26 | 40.6 | 43 | 50.6 |
| Civil servant | 12 | 9.7 | 10 | 15.6 | 6 | 7.1 |
| Self-employed/liberal | 1 | 0.8 | 1 | 1.6 | 6 | 7.1 |
| Housewife | 35 | 28.2 | 18 | 28.1 | 23 | 27.1 |
| Part-time job | 15 | 12.1 | 7 | 10.9 | 4 | 4.7 |
| Other | 1 | 0.8 | 2 | 3.1 | 3 | 3.5 |
| Experienced ovulation induction | – | – | 55 | 85.9 | 67 | 78.8 |
| Experienced artificial insemination | – | – | 26 | 40.6 | 62 | 72.9 |
| Experienced IVF | – | – | – | – | 79 | 92.9 |
| Experienced ICSI | – | – | – | – | 66 | 77.6 |
| Time from fertility clinic visit to conception of twins * | ||||||
| Less than 6 months | – | – | 22 | 34.4 | 4 | 4.7 |
| Less than 1 year | – | – | 32 | 50 | 19 | 22.4 |
| Between 1 and 2 years | – | – | 4 | 6.3 | 21 | 24.7 |
| Between 2 and 3 years | – | – | 5 | 7.8 | 22 | 25.9 |
| More than 3 years | – | – | 1 | 1.6 | 19 | 22.4 |
| Pregnant at the time of response | 6 | 4.8 | 11 | 17.2 | 7 | 8.2 |
| First-time mother | 52 | 41.9 | 44 | 68.8 | 70 | 82.4 |
| Zygosity of twins | ||||||
| Monozygotic | 61 | 49.2 | 13 | 20.3 | 26 | 30.6 |
| Dizygotic | 57 | 46.0 | 50 | 78.1 | 56 | 65.9 |
| Unknown | 4 | 3.2 | 1 | 1.6 | 3 | 3.5 |
| Managed hospitalization during pregnancy | ||||||
| Did not (did not plan to) have a managed hospitalization | 36 | 29.0 | 37 | 57.8 | 32 | 37.6 |
| Had a managed hospitalization | 87 | 70.2 | 26 | 40.6 | 51 | 60.0 |
| Plans to have a managed hospitalization in the future | 1 | 0.8 | 1 | 1.6 | 2 | 2.4 |
* This item was asked only of participants who had undergone fertility treatment.
Table 2.
Factor Analysis and Descriptive Statistics of Desired Items of Care for Women Pregnant with Twins After Using ART.
Table 2.
Factor Analysis and Descriptive Statistics of Desired Items of Care for Women Pregnant with Twins After Using ART.
| Factor Name | Item | Factor Loadings | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | M | SD | ||
| Factor 1: Care for comprehensive parenting support for twins | 2.14. Ensuring quality time with twins | 0.945 | −0.061 | 0.041 | −0.096 | 0.007 | −0.086 | −0.105 | 4.67 | 0.70 |
| 2.10. Support to experience the joy of raising twins | 0.915 | −0.108 | −0.042 | 0.154 | −0.074 | −0.054 | −0.047 | 4.62 | 0.74 | |
| 2.13. Involvement while understanding my feeling of wanting to do the best for the twins | 0.765 | 0.071 | 0.086 | −0.122 | 0.010 | −0.179 | 0.206 | 4.48 | 0.78 | |
| 2.12. Understanding the loneliness of raising twins | 0.758 | 0.055 | −0.123 | −0.040 | 0.029 | −0.050 | 0.090 | 4.60 | 0.76 | |
| 2.9. Support to instill confidence in the mother’s role | 0.714 | −0.193 | 0.074 | −0.036 | −0.073 | −0.023 | 0.355 | 4.46 | 0.78 | |
| 2.3. Easing tension | 0.603 | 0.066 | −0.070 | −0.112 | 0.077 | 0.143 | 0.066 | 4.61 | 0.67 | |
| 3.6. For the midwife (nurse) who was in charge during my hospitalization to continue to be involved after childbirth | 0.470 | −0.119 | 0.157 | −0.064 | 0.036 | 0.389 | −0.037 | 3.98 | 1.14 | |
| 2.7. Assistance with breastfeeding twins | 0.368 | −0.027 | 0.103 | 0.202 | 0.096 | −0.127 | 0.150 | 4.52 | 0.78 | |
| Factor 2: Care to address concerns regarding the sudden death of twins | 1.1. Listening to my concerns about the risk of twin pregnancy | −0.192 | 0.877 | 0.003 | 0.034 | 0.076 | −0.138 | −0.063 | 4.33 | 0.88 |
| 1.3. Sharing information about the risks of twin pregnancy | 0.039 | 0.846 | 0.151 | −0.179 | −0.100 | 0.041 | −0.110 | 4.68 | 0.64 | |
| 1.2. Helping me positively accept my twin pregnancy | 0.212 | 0.710 | −0.008 | −0.117 | −0.106 | −0.038 | 0.089 | 4.31 | 1.11 | |
| 1.5. Explanation to ease my anxiety about twin pregnancy | −0.146 | 0.704 | −0.058 | 0.094 | 0.107 | 0.114 | 0.147 | 4.58 | 0.73 | |
| 1.4. Ensuring a sense of security after conceiving twins | 0.405 | 0.591 | −0.190 | 0.195 | −0.112 | 0.144 | −0.144 | 4.56 | 0.81 | |
| 1.6. Providing information about what could happen to me during a twin delivery | −0.135 | 0.520 | 0.142 | −0.001 | 0.021 | 0.067 | 0.002 | 4.74 | 0.49 | |
| 2.6. Taking the time to listen to my feelings about safe delivery after giving birth | 0.196 | 0.371 | 0.078 | 0.323 | −0.028 | −0.136 | 0.284 | 3.96 | 1.10 | |
| Factor 3: Medical care based on interdisciplinary collaboration among medical professionals | 3.2. Sharing my pregnancy, childbirth, and related information with facilities even after discharge | −0.029 | −0.064 | 0.870 | 0.045 | −0.106 | 0.164 | 0.111 | 4.08 | 0.94 |
| 3.1. After pregnancy is confirmed (including information from before pregnancy), sharing my information with facilities and the hospital where I will give birth | −0.056 | 0.427 | 0.734 | −0.057 | 0.095 | −0.078 | 0.011 | 4.26 | 0.93 | |
| 3.4. Sharing information about me and my child with the hospital where I gave birth and administrative agencies such as the local health center | 0.129 | −0.042 | 0.538 | 0.071 | 0.026 | 0.291 | −0.130 | 4.36 | 0.86 | |
| Factor 4: Connecting women with twin pregnancies from the gestational period | 1.8. Encouraging interaction with other mothers of twins during pregnancy | −0.183 | −0.013 | −0.083 | 1.060 | −0.061 | 0.045 | 0.071 | 4.51 | 0.80 |
| 3.5. Providing information about local childcare support services | 0.041 | −0.071 | 0.243 | 0.484 | 0.035 | −0.083 | −0.069 | 4.82 | 0.41 | |
| 1.7. Supporting women to visualize life with twins | 0.280 | 0.016 | 0.062 | 0.392 | 0.141 | 0.179 | −0.101 | 4.67 | 0.64 | |
| Factor 5: Care to understand post-delivery physical pain | 2.2. Ensuring rest time after delivery | 0.097 | 0.004 | 0.009 | 0.029 | 0.998 | −0.101 | −0.078 | 4.88 | 0.36 |
| 2.1. Care to alleviate pain | −0.110 | −0.026 | −0.068 | −0.071 | 0.528 | 0.156 | 0.402 | 4.74 | 0.54 | |
| Factor 6: Providing continuity before and after delivery | 3.3. Sharing information about me and my child with the ward where I was hospitalized during pregnancy and the ward after delivery | −0.214 | 0.059 | 0.188 | 0.032 | −0.025 | 0.818 | 0.129 | 4.58 | 0.68 |
| Factor 7: Supporting the development and well-being of the twins | 2.8. Fostering a sense of unity with twins | 0.334 | −0.163 | 0.181 | 0.135 | −0.018 | −0.060 | 0.589 | 4.32 | 0.80 |
| 2.4. Recognition and empathetic interaction regarding my efforts until childbirth | 0.239 | 0.184 | −0.079 | −0.101 | −0.006 | 0.161 | 0.572 | 4.52 | 0.72 | |
| 2.5. Involvement to feel a sense of vitality in twins | 0.381 | 0.105 | −0.146 | −0.042 | 0.131 | 0.132 | 0.466 | 4.53 | 0.68 | |
| Factor loadings sum of squares after rotation | 6.480 | 4.873 | 2.542 | 2.960 | 1.702 | 1.884 | 3.654 | 4.50 | 0.41 | |
Note. Maximum likelihood method, promax rotation; n = 85.
Table 3.
Correlation Coefficients Between Factors of Care Desired by Women Pregnant with Twins After ART (n = 85).
Table 3.
Correlation Coefficients Between Factors of Care Desired by Women Pregnant with Twins After ART (n = 85).
| Factor 1: Care for Comprehensive Parenting Support for Twins | Factor 2: Care to Address Concerns Regarding the Sudden Death of Twins | Factor 3: Medical Care Based on Interdisciplinary Collaboration Among Medical Professionals | Factor 4: Connecting Women with Twin Pregnancies from the Gestational Period | Factor 5: Care to Understand Post-Delivery Physical Pain | Factor 6: Providing Continuity Before and After Delivery | |
|---|---|---|---|---|---|---|
| Factor 1: Care for comprehensive parenting support for twins | ||||||
| Factor 2: Care to address concerns regarding the sudden death of twins | 0.538 ** | |||||
| Factor 3: Medical care based on interdisciplinary collaboration among medical professionals | 0.430 ** | 0.372 ** | ||||
| Factor 4: Connecting women with twin pregnancies from the gestational period | 0.394 ** | 0.452 ** | 0.370 ** | |||
| Factor 5: Care to understand post-delivery physical pain | 0.338 ** | 0.175 | 0.124 | 0.188 | ||
| Factor 6: Providing continuity before and after delivery | 0.250 * | 0.312 ** | 0.372 ** | 0.296 ** | 0.249 * | |
| Factor 7: Supporting the development and well-being of the twins | 0.749 ** | 0.626 ** | 0.341 ** | 0.326 ** | 0.405 ** | 0.283 ** |
Note. ** p < 0.001, * p < 0.05.
Table 4.
One-way ANOVA of Care Items Included in Each Factor of Care Desired by Pregnant Women.
| Factor | Pregnancy-Related Characteristics | n | M | SD | F | p |
|---|---|---|---|---|---|---|
| Factor 1: Care for comprehensive parenting support for twins | Never had fertility treatment | 124 | 4.47 | 0.44 | 0.115 | 0.891 |
| Experienced fertility treatment No experience with ART | 64 | 4.45 | 0.48 | |||
| Experienced infertility treatment and ART | 85 | 4.49 | 0.59 | |||
| Factor 2: Care to address concerns regarding the sudden death of twins | Never had fertility treatment | 124 | 4.50 | 0.51 | 0.159 | 0.853 |
| Experienced fertility treatment No experience with ART | 64 | 4.47 | 0.52 | |||
| Experienced infertility treatment and ART | 85 | 4.45 | 0.62 | |||
| Factor 3: Medical care based on interdisciplinary collaboration among medical professionals | Never had fertility treatment | 124 | 4.05 | 0.85 | 1.336 | 0.265 |
| Experienced fertility treatment No experience with ART | 64 | 4.18 | 0.85 | |||
| Experienced infertility treatment and ART | 85 | 4.24 | 0.76 | |||
| Factor 4: Connecting women with twin pregnancies from the gestational period | Never had fertility treatment | 124 | 4.63 | 0.48 | 0.402 | 0.669 |
| Experienced fertility treatment No experience with ART | 64 | 4.70 | 0.42 | |||
| Experienced infertility treatment and ART | 85 | 4.67 | 0.49 | |||
| Factor 5: Care to understand post-delivery physical pain | Never had fertility treatment | 124 | 4.81 | 0.32 | 0.502 | 0.606 |
| Experienced fertility treatment No experience with ART | 64 | 4.76 | 0.43 | |||
| Experienced infertility treatment and ART | 85 | 4.81 | 0.39 | |||
| Factor 6: Providing continuity before and after delivery | Never had fertility treatment | 124 | 4.35 | 0.85 | 1.995 | 0.138 |
| Experienced fertility treatment No experience with ART | 64 | 4.41 | 0.85 | |||
| Experienced infertility treatment and ART | 85 | 4.58 | 0.68 | |||
| Factor 7: Supporting the development and well-being of the twins | Never had fertility treatment | 124 | 4.42 | 0.68 | 0.571 | 0.566 |
| Experienced fertility treatment No experience with ART | 64 | 4.34 | 0.69 | |||
| Experienced infertility treatment and ART | 85 | 4.45 | 0.61 |
Table 5.
Mapping of questionnaire items to qualitative themes and subthemes.
| Category in This Study | Item Code & Content | Theme (Qualitative Study) | Subtheme (Qualitative Study) |
|---|---|---|---|
| Care desired from midwives and nurses during pregnancy | 1.1 Listening to my concerns about the risk of twin pregnancy | Helping women come to terms with high-risk ART pregnancies | Accounting for women’s concerns about high-risk pregnancy; providing responses that do not provoke worry |
| 1.2 Helping me positively accept my twin pregnancy | Helping women come to terms with high-risk ART pregnancies | Helping women accept their twin pregnancy under unwanted circumstances | |
| 1.3 Sharing information about the risks of twin pregnancy | Helping women come to terms with high-risk ART pregnancies | Sharing information about risks associated with twin pregnancy | |
| 1.4 Ensuring a sense of security after conceiving twins | Fostering self-identification as a mother | Promoting reassurance by relieving tension | |
| 1.5 Explanation to ease my anxiety about twin pregnancy | Helping women come to terms with high-risk ART pregnancies | Providing responses that do not provoke worry | |
| 1.6 Providing information about what could happen to me during a twin delivery | Helping women come to terms with high-risk ART pregnancies | Sharing information about risks due to twin pregnancy | |
| 1.7 Supporting women to visualize life with twins | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Helping women visualize life after childbirth | |
| 1.8 Encouraging interaction with other mothers of twins during pregnancy | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Connecting women with other mothers of twins | |
| Care desired from midwives and nurses after delivery until discharge | 2.1 Care to alleviate pain | Fostering self-identification as a mother | Promoting reassurance by relieving tension |
| 2.2 Ensuring rest time after delivery | Fostering self-identification as a mother | Promoting reassurance by relieving tension | |
| 2.3 Easing tension | Fostering self-identification as a mother | Promoting reassurance by relieving tension | |
| 2.4 Recognition and empathetic interaction regarding my efforts until childbirth | Respectful care recognizing the journey of ART-induced twin pregnancy | Non-application/appropriate use of fertility treatment history; acknowledging women’s efforts | |
| 2.5 Involvement to feel a sense of vitality in twins | Fostering self-identification as a mother | Drawing attention to the children’s vitality by promoting connection with the babies | |
| 2.6 Taking the time to listen to my feelings about safe delivery after giving birth | Fostering self-identification as a mother | Recognizing lingering psychological discomfort from ART experiences; promoting reassurance | |
| 2.7 Assistance with breastfeeding twins | Fostering self-identification as a mother | Supporting the acquisition of maternal roles | |
| 2.8 Fostering a sense of unity with twins | Fostering self-identification as a mother | Promoting connection with the babies | |
| 2.9 Support to instill confidence in the mother’s role | Fostering self-identification as a mother | Supporting the acquisition of maternal roles | |
| 2.10 Support to experience the joy of raising twins | Fostering self-identification as a mother | Promoting positive motherhood experiences | |
| 2.12 Understanding the loneliness of raising twins | Fostering self-identification as a mother | Recognizing emotional strain and need for support | |
| 2.13 Involvement while understanding my feeling of wanting to do the best for the twins | Respectful care recognizing the journey of ART-induced twin pregnancy & Fostering self-identification as a mother | Acknowledging strong commitment shaped by ART; supporting mothers’ efforts | |
| 2.14 Ensuring quality time with twins | Fostering self-identification as a mother | Drawing attention to children’s vitality; ensuring bonding opportunities | |
| Care desired regarding information sharing among facilities (hospitals, community health centers, and so on) that support pregnancy, delivery, and child care | 3.1 After pregnancy is confirmed (including information from before pregnancy), sharing my information with facilities and the hospital where I will give birth | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Coordination and cooperation with fertility clinics and childbirth facilities |
| 3.2 Sharing my pregnancy, childbirth, and related information with facilities even after discharge | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Coordination and cooperation from postnatal ward to community health center | |
| 3.3 Sharing information about me and my child with the ward where I was hospitalized during pregnancy and the ward after delivery | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Coordination and cooperation from prenatal admission ward to the postnatal ward | |
| 3.4 Sharing information about me and my child with the hospital where I gave birth and administrative agencies such as the local health center | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Coordination and cooperation between hospital and community health center | |
| 3.5 Providing information about local childcare support services | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Helping women visualize life after childbirth; connecting to support resources | |
| 3.6 For the midwife (nurse) who was in charge during my hospitalization to continue to be involved after childbirth | Providing continued support informed by the characteristics of women who undergo ART, from fertility treatment to parenting stages | Addressing interruption of continuous midwife support |
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MDPI and ACS Style
Aizawa, K.; Fujii, M.; Yonekura, Y. Components of Care Expected from Midwives by Women with Twin Pregnancies After the Use of Assisted Reproductive Technology: A Cross-Sectional Study. Women 2025, 5, 46. https://doi.org/10.3390/women5040046
AMA Style
Aizawa K, Fujii M, Yonekura Y. Components of Care Expected from Midwives by Women with Twin Pregnancies After the Use of Assisted Reproductive Technology: A Cross-Sectional Study. Women. 2025; 5(4):46. https://doi.org/10.3390/women5040046
Chicago/Turabian StyleAizawa, Keiko, Mihoko Fujii, and Yuki Yonekura. 2025. "Components of Care Expected from Midwives by Women with Twin Pregnancies After the Use of Assisted Reproductive Technology: A Cross-Sectional Study" Women 5, no. 4: 46. https://doi.org/10.3390/women5040046
APA StyleAizawa, K., Fujii, M., & Yonekura, Y. (2025). Components of Care Expected from Midwives by Women with Twin Pregnancies After the Use of Assisted Reproductive Technology: A Cross-Sectional Study. Women, 5(4), 46. https://doi.org/10.3390/women5040046
