Background: Pregnancy and the postpartum period present significant challenges for women with eating disorders (EDs), with high prevalence rates observed among pregnant mothers and in the postpartum phase. Systematic descriptions are necessary to understand the complexity of these women's experiences from pregnancy through birth and into early motherhood. Thus, this research project explores how changes in body, food, and weight are experienced by pregnant and new mothers with a history of EDs. It seeks to identify the courses and experiences associated with ED pathology during pregnancy, childbirth, and the postpartum period, as well as to explore how these experiences may worsen or improve to provide personalised support.
Method: This longitudinal, prospective qualitative study involves a sample of 24 women with a history of severe EDs, assessed during pregnancy and six months postpartum. The Eating Disorder Examination Questionnaire (EDE-Q) and the Eating Disorder Examination (EDE) were employed to evaluate current diagnoses at both time points. Ideal types, Grounded Theory, and Interpretative Phenomenological Analysis were utilised to refine user experiences and develop perceived models based on these experiences. The study protocol received approval from the Norwegian Regional Ethics Committee (REK) (project ID 92655/2020).
Findings: The findings illustrate that ED pathology in women can be either triggered or worsened by experiences during pregnancy and the postpartum period. All three sub-studies conceptualise how various risks and protective factors may influence the course of pregnancy and early motherhood.
In Paper I, 23 of the 24 participants reported a worsening or relapse of their EDs during pregnancy, both in their first pregnancy and in subsequent pregnancies. Seven personal characteristics were associated with these deteriorations, including chaos and impulsivity, rigidity, perfectionism, insecurity, shame, fear of motherhood, and loss of identity. Perceived triggers included loss of control, unpredictability, competition, changes in appearance, shame, nausea, ambivalence, and identity loss.
In Paper II, seven of the 24 participants underwent in vitro fertilisation (IVF) and experienced a relapse of their eating disorder during the process. Core phenomena, such as anxiety, fear, shame, guilt, sexual maladjustment, and non-disclosure, were notably similar among the seven women.
In Paper III, all 24 women were followed from pregnancy to postpartum. Five perceived trajectories illustrate ED pathology throughout pregnancy and early motherhood. These trajectories were categorised according to the women's experiences: a trajectory in which eating disorder pathology is absent (mastering mother), one in which the disorder worsens during pregnancy but reduces in early motherhood (succeeding mother), a trajectory where pathology worsens before, during, and after pregnancy (inadequate mother), one where pathology is put on hold during pregnancy but worsens postpartum (depressed mother), and a trajectory where the disorder worsens during pregnancy and continues into early motherhood (overwhelmed mother).
Discussion: These findings enhance the understanding of EDs during the perinatal phase and underscore the vulnerabilities faced by women with EDs during pregnancy and early motherhood. The study posits that ED behaviours may serve as mechanisms for controlling and regulating emotional and psychological changes experienced during this period. For many women, pregnancy is perceived as a loss of control, with bodily changes and unpredictability potentially triggering confusion and anxiety. Feelings of loss of identity, shame, and guilt associated with fears of harm, as well as diminished joy and connection with the baby, may exacerbate EDs. Women undergoing fertility treatment often report significant deterioration due to feelings of shame and guilt. Additionally, performance anxiety and fear of motherhood-related expectations may serve as further triggers. Conversely, some women find that their new roles as mothers, alongside coping with their infants, facilitate recovery or improvement.
Women associate varying combinations of precursors, triggers, and protective factors with their improvement, worsening, or relapse during the transition to motherhood. Personality traits appear to interact with perceived triggers and protective factors, influencing the course of EDs. The findings are discussed in relation to existing literature on self-esteem, body image, identity, and emotional regulation, highlighting how ED pathology functions as a means of managing affect and self-identity through the body. Understanding factors that contribute to worsening or relapse is crucial for tailoring effective interventions. Healthcare professionals should remain vigilant and intervene when they suspect a woman with a history of EDs who may be at risk of relapse or in need of support for improvement. Further research should focus on trajectories from pregnancy to early motherhood to enhance the recognition of EDs and improve the design of interventions.