A prospective study of factors that lead to body dissatisfaction during pregnancy

Abstract

This study examined changes in body image and predictors of body dissatisfaction during pregnancy. It was expected that higher levels of depression, social comparison tendencies, teasing, societal pressure to be thin and public self-consciousness would predict body dissatisfaction prospectively. Healthy pregnant women (n = 128) completed questionnaires on three occasions during their pregnancies reporting on a total of four time points: 3 months prior to pregnancy (retrospectively reported), in the early to mid-second trimester, the late-second/early-third trimester, and the latter part of the third trimester. For the most part women reported adapting to the changes that occurred in their body; however, women were most likely to experience higher levels of body dissatisfaction in early to mid-second trimester. Findings related to predictors of body dissatisfaction revealed that both social and psychological factors contributed to body image changes in pregnancy. Implications of the findings are discussed.

Introduction

Pregnancy is an ideal time to examine body image prospectively given that pregnant women experience rapid physical changes over a relatively short (40-week) period. The term body image refers to the internal representation an individual has of his or her own outer appearance (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). It is generally agreed that body image encompasses a range of behavioural, perceptual, cognitive, and affective phenomena (Pruzinsky, 1990). Body dissatisfaction is one facet of body image relating to the degree of dissatisfaction with particular aspects of the body (Thompson et al., 1999).

During pregnancy, women are likely to re-evaluate their body image over time as their size increases and body shape changes. This potentially allows for a more powerful test of the factors leading to body dissatisfaction than at other times in women's lives, when body shape remains relatively stable. Moreover, body dissatisfaction during pregnancy is of particular importance because it can potentially lead to unhealthy eating and weight loss behaviours (Fairburn & Welch, 1990), which in turn can have serious implications for both mother and child health (Franko & Walton, 1993). To date, the factors that might lead to body dissatisfaction during pregnancy have not been explored systematically. The overall goal of the research described here, therefore, was to address this issue.

Several researchers have suggested that body image standards may be relaxed during pregnancy (Davies & Wardle, 1994; Fairburn, Stein, & Jones, 1992; Richardson, 1990) since women see the changes that they are going through as “transient and unique to the childbearing endeavour” (Richardson, 1990, p. 105). Pregnancy has been argued to be the one time in a woman's life when it is socially acceptable to be large because the reproductive role is valued more highly than physical appearance (Usher, 1989). However, other research reveals that pregnancy is not always a time of positive adjustment to the changes in physical appearance. Leifer (1977) found that body image changes in pregnancy evoked negative feelings, irrespective of how satisfied women were with their body prior to pregnancy. Similarly, Fairburn and Welch (1990) found that 40% of the pregnant women in their sample expressed fear of weight gain in pregnancy and 72% expressed a fear that they would not be able to return to their pre-pregnancy body weight.

In terms of changes in body image as women progress through pregnancy, findings have been inconsistent. Three studies from the 1970s and early 1980s (Leifer, 1977, Moore, 1978; Strang & Sullivan, 1985) found that body dissatisfaction increased over the course of pregnancy. More recent studies, however, have not replicated this pattern. Goodwin, Astbury, and McMeekan (2000) found that, while there were no significant changes in body dissatisfaction as pregnancy progressed from early to middle pregnancy, body dissatisfaction was greater at early pregnancy compared to pre-pregnancy. In contrast, Boscaglia, Skouteris, and Wertheim (2003) found that the pregnant women in their study did not become more negative in the evaluations of their bodies from pre-pregnancy to 15–22 weeks gestation; women either became significantly more positive (high exercise group) or remained relatively stable (low exercise group).

From this literature conclusions about changes in body image across the course of pregnancy are difficult to make (see Tiggemann, 2004; Wertheim, Paxton, & Blaney, 2004a). The disparate findings may reflect differing research methods, making direct comparisons difficult; for example, approaches have been cross-sectional (Davies & Wardle, 1994), retrospective (Fairburn & Welch, 1990; Strang & Sullivan, 1985), part retrospective through pregnancy and part prospective (Richardson, 1990), prospective but with a small sample size (Leifer, 1977), or prospective to middle pregnancy only (Boscaglia et al., 2003, Goodwin et al., 2000). It is clear that a prospective study across pregnancy is needed to clarify the nature of changes in body image during this time. To this end, the study reported here had two aims. The first aim was to examine body image changes in women as they progressed through pregnancy. Two key aspects of body image were examined: (1) body dissatisfaction as assessed by attitudes and (2) discrepancies between current and ideal shape as measured by figural stimuli.

The second aim of this study was to determine which distal and proximal factors earlier in pregnancy predict body dissatisfaction during late pregnancy. Researchers in the body image and eating disorders fields are in agreement that any complete model of the development of body image disturbance and consequent behaviours needs to be multi-factorial and cover bio-psycho-social elements (Pruzinsky & Cash, 2002; Thompson et al., 1999; Wertheim et al., 2004a, Wertheim et al., 2004b). Many multifactorial studies have been conducted in the general (non-pregnancy related) body image research field reporting the effects of different variables on body dissatisfaction; these studies appear to be consistent in terms of the impact of factors such as global psychopathology, perception of family influences, teasing history, and social comparisons (Schutz, Paxton, & Wertheim, 2002; Wertheim et al., 2004a, Wertheim et al., 2004b). Hence, we focused on identifying social and psychological factors that might lead to body dissatisfaction during pregnancy in particular.

Depressive symptoms and affect have been found to be associated with greater body dissatisfaction (Koff, Rierdan, & Stubbs, 1990; Kostanski & Gullone, 1998; Rierdan & Koff, 1997; Stice & Whitenton, 2002). Measures of depression are particularly important to assess during pregnancy since they have been found to predict adverse pregnancy outcomes (Paarlberg et al., 1995, Rutter and Quine, 1990; Stanton, Lobel, Sears, & DeLuca, 2002). Whether depressed affect predicts body dissatisfaction in pregnant women was investigated here.

In terms of individual psychological characteristics, empirical evidence suggests that body comparison tendencies contribute to the development of body dissatisfaction (Stice & Agras, 1998; Thompson et al., 1999; Wertheim, Paxton, Schutz, & Muir, 1997; Wertheim et al., 2004a, Wertheim et al., 2004b). Body comparison is defined as the ‘tendency to compare one's body with others’ and is based on social comparison theory (SCT: Festinger, 1954). Recent findings have shown that appearance comparisons in young women statistically predict body dissatisfaction (Van den Berg, Thompson, Brandon, & Coovert, 2002). Based on these findings, we reasoned that women who report most often comparing themselves to others earlier on in their pregnancy would be at greater risk of increased body dissatisfaction later in pregnancy. An additional dispositional variable to be considered was Public Self-Consciousness (PSC; Fenigstein, Scheier, & Buss, 1975), which involves the tendency to be conscious of whether one is being judged by others when in public. PSC has been found to be associated with eating problems (Striegel-Moore, Silberstein, & Rodin, 1993) and may enhance any concerns about one's body by increasing body salience (Schutz et al., 2002). Whether this continues to be the case prospectively during pregnancy was a research question addressed here.

Empirical evidence also suggests that two social environmental factors are associated with body dissatisfaction in non-pregnant groups – teasing (Cattarin & Thompson, 1994; Fabian & Thompson, 1989; Jackson, Grilo, & Masheb, 2000; Levine, Smolak, & Hayden, 1994; Schwartz, Phares, Tantleff-Dunn, & Thompson, 1999; Thompson, Coovert, Richards, Johnson, & Cattarin, 1995) and social pressures to lose weight (Fabian & Thompson, 1989; Green & Pritchard, 2003; Levine et al., 1994; Paxton, Schutz, Wertheim, & Muir, 1999; Twamley & Davis, 1999; Wertheim et al., 1997). Whether these two factors also influence pregnant women's body satisfaction was explored here.

In summary, there were two main aims of this study. The first aim was to examine body image changes in women as they progress from early or mid-second trimester to the third trimester of their pregnancy. It was expected that if women see pregnancy as a special time in which normal standards are relaxed, increases in body dissatisfaction (e.g., feeling fat or unattractive) may not occur as a response to increases in body size over the course of pregnancy, and ideal body size may increase in parallel to increases in body size. Alternatively, if pregnancy is not a time of positive adjustment to the changes in physical appearance, it is expected that body dissatisfaction will increase throughout the course of pregnancy as will the discrepancy between current and ideal shape/size.

The second aim was to determine which distal and proximal factors during early or mid-second trimester of pregnancy predict body dissatisfaction during late pregnancy. Firstly, a stability model of body image was proposed, in which pre-pregnancy levels of feeling fat; salience of weight and shape; perceived attractiveness; and strength and fitness ratings would strongly predict the concomitant body image measures in late pregnancy. Several further predictions were made in accordance with the proposed model of predictors of body dissatisfaction and findings of past research. It was expected that higher levels of depression, social comparisons with others, perceived societal pressure to be thin, and public self-consciousness during early/mid-second trimester, as well as greater perceived levels of teasing during late-second/early-third trimester, would predict four aspects of body image (feeling fat, greater salience of weight and shape, feeling less attractive and feeling less strong and fit) during late pregnancy. In each case, pre-pregnancy body size and the relevant body image variable assessed in relation to pre-pregnancy were controlled for. In addition to examining the individual contributions of each of the predictors, their combined contribution was examined (in a regression) to determine whether the potential risk factors each contributed unique variance in the prediction of body image and thus offered a more powerful predictive model.