Examination of a multi-factorial model of body-related experiences during pregnancy: The relationships among physical symptoms, sleep quality, depression, self-esteem, and negative body attitudes
Introduction
During pregnancy a woman's body and shape change substantially over a relatively short (40-week) period. It has been argued that such rapid changes may force a woman to re-examine her body image throughout the pregnancy (Abraham & Llewellyn-Jones, 2001). Given that optimal well-being during pregnancy is important both for the mother and the unborn child (Milgrom, Martin, & Negri, 1999), research identifying the factors that are associated with positive body image and general well-being during pregnancy is needed. The overall aim in the study described here, therefore, was to propose and explore such a model of a range of body-related experiences during pregnancy.
The proposed model, which stems from the theory that models of the development of body image need to be multi-factorial and cover bio-psycho-social and physical elements (see Cash & Pruzinsky, 2002; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999), posited that pregnancy-related physical symptoms would potentially affect well-being, including sleep quality and depressive symptoms, as well as several aspects of body image, and that any possible relationships between physical symptoms, or well-being, and body image would potentially be mediated by general self-esteem levels. In addition, a multidimensional conceptualization of body image was adopted, comprising four types of body attitudes: feeling fat, self-perception of one's attractiveness, perceived strength and fitness, and salience of weight and shape (Ben-Tovim & Walker, 1991). The development of our multi-factorial model was informed by the findings of past studies examining associations among the factors we focused on. Researchers have explored most of the variables we examined in isolation or combined in pairs, such as depression and sleep quality (Jomeen & Martin, 2007), physical symptoms and depression or self-esteem (Chou, Lin, Cooney, Walker, & Riggs, 2003; Koniak-Griffin, 1994; Wallace, Boyer, Dan, & Holm, 1986), or depression and the four different body attitudes outlined above (Skouteris, Carr, Wertheim, Paxton, & Duncombe, 2005). However, to our knowledge, these factors have not been explored in a comprehensive manner; the study described here was the first to explore the associations among these physical, psychological and physiological factors, adhering to a multi-factorial approach to body image. A theoretical model depicting the hypothesised associations was developed and is shown in Fig. 1.
Beginning from the far left hand side of the model, we proposed that physical symptoms would be related to body attitudes. Pregnancy-related physical symptoms are generally the direct consequence of rapid physiological changes necessary for the growth and development of the baby and these changes affect all major body systems during pregnancy (Callahan, Caughey, & Heffner, 2004). It has been argued that these symptoms (e.g., nausea, vomiting, heartburn, and haemorrhoids, see Wallace et al., 1986) affect women's everyday functioning significantly, including how she feels both physically and emotionally (Chou et al., 2003, Riley, 1995). Only two studies have explored the relationship between physical symptoms and maternal body attitudes. Whereas Price (1996) reported that higher body image concerns were related to more symptoms of nausea, fatigue, and vomiting, Chou et al. (2003) found that body dissatisfaction was related to the frequency with which these symptoms were experienced. Given that Price's study was based on four case studies and Chou et al. explored the occurrence of only three physical symptoms in 116 pregnant women, further systematic exploration of the relationship of physical symptoms and body attitudes during pregnancy is warranted.
Physical symptoms in pregnancy have been shown to be related to several other variables, such as lower self-esteem (Koniak-Griffin, 1994, Wallace et al., 1986) and greater depression levels (Koniak-Griffin, 1994), with relationships found between the number of nausea and vomiting (but not fatigue) symptoms experienced and the amount of depression reported (Chou et al., 2003). In addition to the links between physical symptoms and depression and self-esteem, we also proposed that depression and self-esteem would be associated with feeling fat, less attractive, and less strong and fit, and with greater salience of weight and shape. Depressive symptoms have been found to be associated with body image in non-pregnant female adolescents (Konstanski & Gullone, 1998; Rierdan & Koff, 1997; Stice & Whitenton, 2002) and during pregnancy, higher depressive symptoms earlier in pregnancy predict feeling less strong and fit, less attractive and fatter in late pregnancy (Skouteris et al., 2005). Similarly, research has shown that low self-esteem is related to body dissatisfaction in non-pregnant female adolescents (Konstanski & Gullone, 1998; Paxton, Eisenberg, & Neumark-Sztainer, 2006; Ricciardelli & McCabe, 2001; Tiggemann, 2005). The relationship between depressive symptoms and self-esteem has been described as bidirectional, with a stronger path from depression to self-esteem than from self-esteem to depression (Rosenberg, Schooler, & Schoenbach, 1989). Hence, we proposed that depressive symptoms and lower self-esteem would be linked to negative body attitudes either directly or via a path that links depression to self-esteem and then self-esteem to body attitudes. In addition, as any relationship found between pregnancy-related physical symptoms and dimensions of body image may be mediated by well-being (depression and self-esteem), these relationships were also explored.
The final factor in the model is that of sleep quality. While an increased need for sleep has been reported in pregnant women (Viegas, Rodrigues, Silva, & Arboes, 2000), the quality of sleep also appears to be disturbed as early as the first trimester (Dzaja et al., 2005; Hedman, Pohjasvaara, Tolonen, Suhonen-Malm, & Myllyla, 2002). One study of 12 pregnant women listed several physical symptoms as self-reported reasons for disturbed sleep during late pregnancy (Hertz et al., 1992); however, the relationship between physical symptoms and sleep quality was not examined directly and therefore was explored in the study reported here. Sleep quality has also been associated with depressive symptoms such as increased irritability, fatigue, and loss of concentration (McVeigh, 1997). Hence, a path from physical symptoms to sleep quality and then to body attitudes via depression was also proposed. To our knowledge there have been no studies investigating the direct link between sleep quality and body attitudes, therefore a possible direct association between these variables was examined as well.
In addition to the variables discussed above, the relationship of pre-pregnancy (retrospective) and concurrent body attitudes (during pregnancy) was also assessed. Given that pre-pregnancy body attitudes have been shown to be associated with pregnancy body attitudes (Skouteris et al., 2005), we controlled for this relationship in relevant analyses. We also explored whether pre-pregnancy body attitudes would be related to physical symptoms during pregnancy (e.g., women who feel less strong/fit prior to pregnancy may experience more fatigue during pregnancy).
In summary, the overall aim in the current study, with women who were 15–25 weeks gestation, was to investigate pregnancy body experiences by exploring a model of factors potentially associated with pregnancy-related physical symptoms and predictive of four aspects of body image. This particular point in pregnancy was chosen because by this time (after the 13th week) the pregnancy has become well established (with threat of miscarriage subsiding), allowing the woman to have experienced a range of physical symptoms (Behrenz & Monga, 1999; Lacroix, Eason, & Melzack, 2000) and for the pregnant form to become evident (Price & Robinson, 2006).
From a methodological perspective, the few studies investigating physical symptoms during pregnancy have all measured pregnancy-related discomfort in terms of number and frequency of symptoms (Chou et al., 2003, Koniak-Griffin, 1994, Wallace et al., 1986). However, research in other health-related areas (e.g., cancer) suggests two other dimensions that can measure the subjective experience of physical symptoms, namely the severity of discomfort/distress caused by the symptoms (Hwang et al., 2004) and the effect of the symptom on the quality of life (Okamura, Yamawaki, Akechi, Taniguchi, & Uchitomi, 2005). Hence, in addition to frequency and number of physical symptoms, measures of the severity of discomfort caused by each symptom, as well as the effect each symptom was having on the participant's life were included in the assessment of pregnancy-related physical symptoms undertaken in the present study.
Section snippets
Participants
A total of 215 Australian women participated in this study (of 282 women recruited, 67 (23.7%) did not return their questionnaires), with an age range of 18–42 years (M = 31.73 years, SD = 4.54). At time of participation, participants were 15–25 weeks gestation (M = 18.55 weeks, SD = 1.28). Forty-two percent (n = 90) of the women were primaparous and 37.7% (n = 81) had one child. Most women were married (75.3%; n = 161) or living with a de facto partner (18%; n = 39); 74% (n = 159) were university or technical
Frequency of physical symptoms in the current sample
Fatigue (94.9%), increased urination (88.3%), nausea (85.6%), and tender breasts (81.4%) were the four most commonly reported symptoms in the current sample; these were followed by headache, vaginal discharge, and flatulence occurring in 74.8–76.3% of women. Between 61.4 and 67% of women reported constipation, appetite increase, insomnia, shortness of breath, and backache, followed by heartburn, dizziness, congestion, vomiting and bleeding gums (44.2–53%), pelvic pressure, leg cramps, appetite
Discussion
In this study pregnant women reported experiencing a large range of unpleasant physical symptoms. The main aims of the study were to explore the relationships that these body experiences had with various indices of well-being and body image, and to examine a multi-factorial model of these variables. It was found that the experience of more frequent and distressing physical symptoms was associated with poorer sleep quality, greater depressive symptoms, and lower self-esteem. In relation to body
Acknowledgements
An Australian Research Council Discovery Grant (DP0557181) awarded to EW, SJ, HS, and JM, funded the research reported here. We thank the Australian Research Council for their financial support. We also extend our thanks and appreciation to the women who participated in this research. We are grateful to Leanne Kelly for her assistance with data collection and data analyses, Carmela Germano for data entry and Sonia Zammit and Abigail Clark for assistance with recruitment.
References (53)
- et al.
The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research
Journal of Psychiatric Research
(1989) - et al.
Body image and dieting in pregnancy
Journal of Psychosomatic Research
(1994) - et al.
Women's sleep in health and disease
Journal of Psychiatric Research
(2005) - et al.
Effects of pregnancy on mother's sleep
Sleep Medicine
(2002) - et al.
Pregnancy outcomes among active and sedentary primaparous women
Journal of Obstetric, Gynecologic & Neonatal Nursing
(1996) - et al.
Nausea and vomiting during pregnancy: A prospective study of its frequency, intensity, and patterns of change
American Journal of Obstetrics and Gynecology
(2000) - et al.
A prospective study of factors that lead to body image dissatisfaction during pregnancy
Body Image
(2005) Body dissatisfaction and adolescent self-esteem: Prospective findings
Body Image
(2005)- et al.
Aerobic exercise, maternal self-esteem, and physical discomforts during pregnancy
Journal of Nurse-Midwifery
(1986) - et al.
Eating disorders: The facts
(2001)
Screening depressed patients in family practice: A rapid technique
Postgraduate Medicine
Short form of depression cross validation
Psychological Reports
Fatigue in pregnancy: A comparative study
American Journal of Perinatology
The development of the Ben-Tovim Walker Attitudes Questionnaire (BAQ), a new measure of women's attitudes towards their own bodies
Psychological Medicine
A quantitative study of body-related attitudes in patients with anorexia and bulimia nervosa
Psychological Medicine
Blueprints: Obstetrics & gynecology
Psychosocial factors related to nausea, vomiting, and fatigue in early pregnancy
Journal of Nursing Scholarship
Factors related to depression and eating disorders: Self-esteem, body image, and attractiveness
Psychological Reports
Causes and consequences of low self-esteem in children and adolescents
Sleep in normal late pregnancy
Sleep
Screening for depression in pregnancy: Characteristics of the Beck Depression Inventory
Obstetrics & Gynecology
Prediction of survival for advance cancer patients by recursive partitioning analysis: Role of Karnofsky performance status, quality of life, and symptom distress
Cancer Investigation
Replicability and stability of the multidimensional model of the Edinburgh Postnatal Depression Scale in late pregnancy
Journal of Psychiatric and Mental Health Nursing
Aerobic exercise, psychological well-being, and physical discomforts during adolescent pregnancy
Research in Nursing and Health
Adolescent body image dissatisfaction: Relationships with self-esteem, anxiety and depression controlling for body mass
Journal of Child Psychology and Psychiatry and Allied Disciplines
Cited by (71)
Mirror, mirror on my phone: Drivers and consequences of selfie editing
2021, Journal of Business ResearchSleeping disorders in pregnancy and post-partum (review)
2019, Annales Medico-Psychologiques