International Journal of Nursing Studies 48 (2011) 1223–1233

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Treading the tightrope between motherhood and an eating disorder:

A qualitative study
S. Tierney a,*, J.R.E. Fox b,c, C. Butterfield a, E. Stringer d, C. Furber a
a
School of Nursing, Midwifery and Social Work, University Place, University of Manchester, Oxford Road, Manchester M13 9PL, UK
b
Division of Health Research, Lancaster University, Lancaster LA1 4YF, UK
c
Eating Disorders Unit, Russell House, Affinity Healthcare, Cheadle Royal Hospital, 100 Wilmslow Road, Cheadle, Cheshire SK8 3DG, UK
d
Pennine Acute Hospitals NHS Trust, Delaunys Road, Crumpsall, Manchester M8 5R, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Pregnancy is a life event that involves a change in appearance, during which
Breast-feeding the eating behaviour and body of childbearing women is scrutinised by others. The impact
Eating disorders this has on the thoughts and behaviours of individuals who have or have had an eating
Motherhood
disorder has been little investigated.
Pregnancy
Objectives: A qualitative project to provide a deeper understanding of the views of women
Qualitative research
with an eating disorder history about pregnancy and the early stages of motherhood.
Methods: Semi-structured interviews were conducted with eight women who were or had
recently been pregnant. All had an eating disorder history. It explored how becoming a
mother impacted on thoughts and practices relating to weight, using framework analysis.
Results: Interviews lasted approximately 80 min. The overriding concept identified
through analysis was the divided loyalties participants experienced between putting
their child first and disregarding the eating disorder. Interpretation of data resulted in the
identification by the research team of four main themes: fear of failure, transforming body
and eating, uncertainties about child’s shape and emotional regulation.
Conclusions: Three types of women were identified among interviewees; those that
seemed to be ‘cured’ of their eating disorder through motherhood, those that seemed able
to put their condition on hold during pregnancy and those that seemed unable to
relinquish dangerous behaviours. Issues relating to control, identity and perfectionism
may impede some women’s ability to enjoy pregnancy and motherhood if they have an
eating disorder history.
ß 2010 Elsevier Ltd. All rights reserved.

What is known about the topic? What this paper adds:

 Women may have an eating disorder during pregnancy.  During pregnancy and in the early stages of motherhood,
 Having an eating disorder during pregnancy has women can feel a conflict between heeding to the
potential risks for the woman and fetus. demands of an eating disorder and doing what they feel
 In the postnatal period, eating disorders may be is best for their child.
exacerbated.  This conflict can cause women to question their
mothering skills and deplete their already diminished
self-esteem.
 An inability to relinquish extreme weight control
* Corresponding author. Tel.: +44 0161 306 7651. practices relates to the functional qualities women
E-mail address: [email protected] (S. Tierney). attach to their eating disorder.

0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2010.11.007
1224 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233

 The size and eating habits of the offspring of women with adolescents and young adults (Lask and Bryant-Waugh,
an eating disorder history may be seen by these mothers 1992). Both conditions are more common in females than
as an external marker of their success as a parent. males, with an estimated 5–10% of these eating disorders
occurring among men (Button et al., 2008). Researchers
1. Background have more recently started to examine the distribution of
EDNOS, which it is suggested develops among adolescent
Over recent decades, eating disorders have entered the and young women primarily (Fairburn and Harrison,
public’s consciousness. They are regularly discussed, and 2003).
often trivialised, in the popular media, depicted as no more Given that eating disorders generally affect females of
than dieting gone wrong or overzealous weight loss. Yet childbearing age, such conditions are possible during
these conditions warrant serious consideration because pregnancy. For individuals with anorexia, fertility may be
they are potentially life-threatening and can persist for compromised because of low body weight. In contrast,
years, ruining individuals’ long-term health, their personal those with bulimia appear to have fewer problems
and their social functioning. conceiving, even though they may have menstrual
Colton et al. (2004) wrote that eating disorders irregularities (Ward, 2008). In a large, UK-based commu-
encompass behaviours such as fasting, bingeing and self- nity cohort study, over 4% of the 12, 254 pregnant women
induced vomiting, and psychological traits such as pre- involved were reported to have a recent or past eating
occupation with weight and shape, body image distortion disorder, mainly of a bulimic type (Micali et al., 2007).
and disturbed attitudes towards food. The most commonly Pregnancy can result in improved eating behaviours to
discussed eating disorders are anorexia and bulimia avoid any adverse impact on the unborn child (Patel et al.,
nervosa, which are said to be united by a core psycho- 2002). However, some women continue having anxieties
pathology in which weight and shape are over-evaluated as about their weight and still engage in practices such as
a measure of self-worth (Fairburn and Harrison, 2003). dieting, laxative abuse, over-exercising and self-induced
The term ‘anorexia nervosa’, in itself, is misleading vomiting whilst pregnant (Micali et al., 2007). Experien-
because it literally means nervous loss of appetite, whereas cing an active eating disorder when pregnant has been
those with this condition do not lose their appetite, or at associated with negative outcomes (Martos-Ordonez,
least not until starvation is advanced. Rather, they ignore 2005; Van der Spuy et al., 1988; Ward, 2008), including
their physical needs and suppress their intake, to maintain a an increased risk of miscarriage, pre-eclampsia, low birth
subnormal weight, whilst at the same time tending to weight and congenital malformations.
become increasingly preoccupied by thoughts of food and Pregnant women with an eating disorder are said to
eating. Bulimia is characterised by strong, uncontrollable require greater time and attention at antenatal visits (NICE,
urges to binge, followed by compensatory behaviours, such 2004), to reduce potential risks to the fetus. Education
as vomiting, laxative abuse and excessive exercise. Some about body changes and cravings, guidance about eating
individuals with anorexia may also engage in these more healthily and positive reinforcement of weight gain are all
extreme forms of weight control; a distinction between denoted as important for this population (Ward, 2008).
restricting and binge-eating/purging anorexia was made for Additional support from health professionals may also be
the first time in the mid 1990s (APA, 1994). However, the needed during the postnatal period since women with an
low weight of those classed as having binge-eating/purging eating disorder are said to be at an increased risk of
anorexia means that a diagnosis of anorexia trumps that of depression at this timepoint (Morgan et al., 2006). These
bulimia. women may experience an exacerbation of eating disorder
Aside from anorexia and bulimia, there is a third broad pathology after giving birth (Welch et al., 1997), perhaps
set of eating disorders classed as EDNOS (eating disorder being tempted to use potentially dangerous behaviours to
not otherwise specified). This term encompasses a lose post-pregnancy weight (Ward, 2008) and/or because
heterogeneous group of problems and is a label that can it can be hard to have regular eating patterns with an infant
be applied to approximately half of eating disorder cases (Park et al., 2003).
(Fairburn and Harrison, 2003). EDNOS incorporates people Most research looking at motherhood and eating
who have subclinical disorders (e.g. failing to fulfil one or disorders, to date, has been based on questionnaire data
more of the diagnostic criteria for anorexia or bulimia and has not explored in-depth the experiences of women
nervosa) (APA, 2000). It also applies to individuals who who have such a condition and are also pregnant or have
utilise other means of preventing weight gain (such as recently given birth. A review of the literature located two
chewing and spitting out food) (Rock, 1999). In addition, investigations broaching this topic using semi-structured
binge eating disorder is currently listed under this interviews. One was conducted in America and involved
umbrella term, which differs from bulimia because people six females with anorexia, who suggested that pregnancy
do not purge after a binge, meaning that they tend to be enabled them to take better self-care and was a time when
overweight or obese. Eating difficulties described as their body received positive attention, although there was
EDNOS should not be regarded as less severe; such a fear that they would never look the same again (Namir
disorders can be equally as serious as fully diagnosed et al., 1986). The second used grounded theory to explore
anorexia or bulimia (Walsh and Garner, 1997). the experiences of 16 women in the UK, most of whom self-
It is typical for anorexia to develop at a younger age defined as having bulimia (Stapleton, 2007). Interviewees
(early adolescence) to bulimia, the latter being rarer in in this study noted that it was easier not to be so critical
those under 14, with onset tending to occur in older about their weight when pregnant. However, once the
 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233 1225

child was born some participants described being driven to understand and represent the experiences and actions of
return to their original body shape and were disheartened people as they encounter, engage, and live through
that this did not transpire as quickly as they wanted. These situations’’ (Elliott et al., 1999, p. 216). Approval for the
existing papers were employed as a building block for project was provided by a local NHS research ethics
research outlined below, expanding topics raised within committee. The research team consisted of one investi-
them (e.g. participants’ relationship with their partner and gator specialised in eating disorder research (ST), a clinical
women’s views of socialising with a young child), whilst psychologist who has conducted several studies on eating
also broaching new areas of investigation (e.g. emotions). disorders (JF), two midwifery lecturers with experience of
research focused on mental health and pregnancy (CF, CB),
2. Conceptual framework for the study and a midwife consultant (ES). They came together to
work on this project because it was felt that their diverse
The study was guided by the notion that eating disorders backgrounds would enhance the interpretation of data.
play a functional role in the lives of individuals diagnosed This group of investigators met on a regular basis
with such conditions. Triggers for onset may include (approximately every six weeks) during the research to
traumatic events (e.g. abuse in childhood, bullying, family think about data that was being collected, which enabled
conflict) (Dallos and Denford, 2008; Jeppson et al., 2003; their differing perspectives to inform the analysis and
Weaver et al., 2005), but this is not always the case. What is questioning in later interviews. Midwives within the
common in narratives from those with an eating disorder is group were able to talk about the clinical environment and
that management of food and weight are areas of life in policy associated with antenatal and post-natal care,
which individuals believe they can exhibit control (Button whilst the other researchers commented on eating
and Warren, 2001). Women have recounted the positive disorders more generally and how participants’ stories
benefits they derive from bulimic symptoms, which can related to existing literature in this field. Discussion from
make them feel different and special (Serpell et al., 1999), these differing perspectives led to group consensus on
with the binge–purge cycle experienced as empowering final themes.
because it enables people to eat what they want without
getting fat (Jeppson et al., 2003). Likewise, those with 3.2. Sample
anorexia have recounted feeling unique by engaging in food
restraint, seeing weight loss as a tangible sign of success The authors aimed to recruit women who had a
(Tierney and Fox, 2010). Individuals have depicted their diagnosed eating disorder or some form of eating
eating disorder as comforting, something they can rely on in disturbance that impacted on their physical and/or
times of difficulty (Arkell and Robinson, 2008), which can be psychosocial functioning. We felt it was important to
enacted without involvement from others (Jeppson et al., have a broad definition of eating disorder/disturbance
2003). Eating disorders have been said to arise among those because many people are estimated to live with problems
with inadequate identity formation, with a focus on weight that could be classed as EDNOS who do not receive
and associated behaviours distracting them from concerns professional support (Treasure et al., 2010). Hence, the
about a poor sense of self (Polivy and Herman, 2002). Given term ‘eating problem’ was used in information about the
the functional quality individuals have ascribed to an eating study given to women since it was anticipated that there
disorder, as outlined above, the authors wished to explore would be potential participants who did not consider
how this was affected prior to and after giving birth. themselves as having an eating disorder per se. It was
hoped that this would help to recruit individuals who had
2.1. Aims not necessarily received treatment but still had difficulties
with food/weight.
The study presented in this paper aimed to provide a Women were eligible to participate if:
deeper understanding of the views of women with an
eating disorder when pregnant and during the early years  16 weeks + pregnant or if they had their last child within
of their child’s life. Specific objectives included: the past two years (since the project’s focus was on the
early stages of a child’s life).
 To understand women’s experiences of pregnancy and  Over 16 years.
motherhood whilst also having or having had an eating  Conversant in English.
disorder, exploring how one might impact on the other.  Identified with risk factors associated with eating
 To understand these women’s perceptions of support disorders as measured by two screening questionnaires.
whilst pregnant and in the early months of a child’s life.
 To understand these women’s experiences of caring for a The initial intention was to recruit via a large acute
new infant. hospital trust in the north west of England. Between
January–July 2009, midwives were asked to give a letter
outlining the study and a brief screening questionnaire to
3. Method
all eligible women attending for antenatal care. Women
3.1. Design interested in taking part were invited to complete the
questionnaire and to return it to the research team in a
Qualitative research was undertaken to address the prepaid envelope. They were then contacted by one of the
aims listed above. This type of investigation strives ‘‘to investigators to arrange an interview, if identified as
1226 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233

having an eating difficulty via the screening question- of participants during and following pregnancy. The
naire. This questionnaire consisted of two short tools, interview schedule asked women about:
developed for use in general practice to detect eating
disorders: the SCOFF (Morgan et al., 1999) and the Eating  Experiences of their body.
disorder Screen for Primary care (ESP) (Cotton et al., 2003).  Views about healthcare received.
Women were asked to answer the former in terms of the  Thoughts about feeding their child.
three months prior to getting pregnant and the latter to  Accounts of eating and purging behaviours.
reflect their current situation. Answering ‘yes’ to two or  Opinions of support and others’ views of their eating/
more questions on either of these measures was sufficient weight control.
for someone to be included in the project. In total, 28
women attending clinic posted their details to the However, the semi-structured nature of data collection
research team, but only six met the cut-off score for meant that interviewees were able and encouraged to
one or both of the screening questionnaires. Discussion describe in their own words factors influencing their
with midwives assisting with recruitment implied that responses, allowing them to offer their own account of
they may have asked women to complete a pack even if their situation.
they did not have an eating problem, even though the
study information sheet made clear that potential 3.4. Data analysis
participants should only respond to the request for an
interview if they felt they had an eating problem. It was Interview transcripts were analysed using a framework
clear from questionnaire responses of those not identified approach (Ritchie et al., 2003), a systematic technique that
as having an eating disorder that they did not carry out involves five stages: (1) familiarisation with the data; (2)
behaviours associated with such conditions (e.g. restrict- development of a thematic framework; (3) indexing data;
ing/purging/eating in secret); they all said they were (4) devising thematic charts; (5) mapping and interpreting
satisfied with their eating patterns and that their weight data. Interview recordings were transcribed verbatim by the
did not influence how they felt about themselves. Three of first author. She checked transcription by listening back to
the six individuals who did meet the screening criteria the original recording. All members of the research team
could not be contacted; attempts were made to speak to read and reread transcripts. They then developed an initial
them via the mobile phone number they had supplied, set of codes, which they collapsed into an indexing scheme.
without success. Another person was not available for Three of the researchers worked together to chart data using
interview when she was contacted. this scheme, allowing for data reduction. Finally, the
Due to the lack of participants recruited from the research team met again to interpret data listed in the
hospital trust, information about the project was posted on charts, resulting in the themes described below.
an eating disorders organisation’s website (B-eat: www.b-
eat.co.uk/Home). B-eat has been used in the past to good 4. Results
effect by the researchers. It is a national organisation that
can be helpful in recruiting hard to reach individuals. Use All participants had experienced an eating disorder
of this website to publicise the study resulted in eight before becoming pregnant. Some had continued their
women contacting the research team and six further weight control behaviours when pregnant, whilst others
interviews being completed (two people could not be stopped during this period. In terms of eating disorder, two
contacted, despite several attempts). These individuals self-defined as being extremely restrictive in what they
were asked to complete the same screening questionnaire ate, one had been diagnosed with bulimia, four with a
referred to above. purging form of and one with restricting anorexia. Six
interviewees had been treated for their eating disorder,
3.3. Data collection one of whom no longer received such care at the point of
data collection. The majority of individuals had started
Between January–September 2009, semi-structured their disordered eating in their teens, although one person
interviews were carried out, which were taped with noted it was only following the birth of her second child
participants’ written consent. They lasted an average of that her anorexia developed. Three women said they had
80 min. Interviews were conducted face-to-face (n = 3) if a not planned their pregnancy. Most lived with a partner;
woman lived locally (<40 miles drive from the researchers’ only one was a single mother. Further details of
place of work) or by telephone (n = 5) if situated further participants can be found in Table 1.
away. Informed consent was obtained on the day for face- The overriding premise that authors identified through
to-face interviews or through the post if carried out over analysis was the divided loyalties interviewees experi-
the phone. In the case of telephone interviews, the enced between putting the child first and heeding to their
researcher reiterated the points listed on the consent eating disorder. This notion, which incorporates themes
form that the participant had signed to ensure they were described below, is depicted in Fig. 1.
still happy to be involved.
An interview schedule was developed at a meeting by 4.1.1. Theme 1 – fear of failure
the research team to reflect the differing backgrounds of all
authors. It aimed to address two agendas: clinical There was much discussion by interviewees about
midwifery practice and the emotional/social well-being getting things right in relation to their child. In order to
 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233 1227

Table 1 Those who had a partner talked about support they

Background details on participants at the time of interview.
received from this individual, both emotional (e.g. some-
Participant Pregnant or post pregnancy Number of Age one to turn to when they felt down) and practical (e.g.
children cooking meals, doing the shopping), but they were not
I1 Pregnant (37 weeks) First pregnancy 17 necessarily open about their eating behaviours with this
I2 Pregnant (20 weeks) First pregnancy 26 person. For example, whilst pregnant, participant 5 went
I3 Post pregnancy (12 months) 3 37 upstairs and turned on the taps so she could make herself
I4 Post pregnancy (24 months) 1 33
sick without her husband hearing and participant 4 was
I5 Post pregnancy (8 months) 1 34
I6 Post pregnancy (12 months) 2 29 secretive about how much she was exercising. Both
I7 Pregnant (18 weeks) 1 29 women concealed such activities because they felt they
I8 Post pregnancy (2 months) 1 30 were letting down their spouse.
I, interviewee. Interviewees suggested they avoided socialising with
other mothers because they felt uncomfortable discussing
achieve this aim, they read a range of literature or sought weight gain/loss and in case their child was unsettled; they
advice from websites. Breast-feeding was an area in which worried that if they were unable to provide succour others
maternal skills could be undermined. Only one person would interpret this as evidence of poor mothering:
described this in positive terms; participant 6 breast-fed
both her children until they were aged one, which she I5: ‘‘. . .he wasn’t a nightmare baby but they cry a lot
defined as a ‘‘triumph’’ for her body. Most interviewees don’t they the first few months. . .I don’t like it if he
talked about wanting to breast-feed because they had been starts to cry in front of other people because I always
encouraged by midwives to do so. However, they generally think he’s a problem and he’s not, he’s a baby, but I just
experienced difficulties, having to stop because their feel on edge and that sends me on edge...’’
offspring was not gaining adequate weight. This could As this theme has highlighted, most participants were
make them feel as though they were not providing the best concerned about being judged negatively by others and
start for their child: placed a great emphasis on external markers of their
mothering skills. Interviewees often focused on pointers
I7: ‘‘I really, really wanted to be able to eat more in
they perceived as contrary to their endeavours to self-
order to produce better milk and I couldn’t do it and I
present as competent mothers (e.g. being unable to breast-
felt that I’d failed him. I can remember crying when I
feed). Perfectionism has been associated with eating
was buying the formula for the first time and I
disorder predisposition and onset (Polivy and Herman,
couldn’t. . .be around when he was given the formula
2002), which could explain participants’ unwillingness to
because it upset me. . .I didn’t want anyone else to know
disclosure their difficulties because they did not want to be
he was getting the formula. There was only me and my
regarded as unable to cope. Individuals with an eating
husband that knew we were giving it to him.’’
disorder are generally secretive about their problem
Only one person was glad when advised to switch to (Pettersen et al., 2008; Tierney, 2004), concerned about
formula by health professionals because it meant her others’ reaction. Interviewees were anxious about society’s
daughter was no longer dependent on her body: lack of understanding of behaviours (e.g. bingeing/
purging) they perceived as a necessary coping mechanism.
I8: ‘‘I’m free now aren’t I really. I’ve not got that physical This fear of being criticised was discussed by the following
attachment to [daughter]. We’re two separate entities. participant:
My responsibility to her is in a different way now, it’s
not in that physical, nutritional type.’’
I7: ‘‘I think people who haven’t experienced it can be
very judgemental of someone who’s pregnant and can’t
Can impede their goal of being a eat properly. I took part in an article for [newspaper]
perfect mother last year about eating disorders in pregnancy and
although I had a lot of very positive feedback and
supportive comments from my family and friends, over
the internet there were a lot of really nasty comments
about it posted on the website ‘these selfish women,
Betraying Putting
the eating Divided loyalties their child they shouldn’t have children’, things like that. . . if you
disorder first
haven’t got that experience then it seems, it just seems
like you are putting your appearance above your child’s
health and that’s how it must seem to people I think.’’

Fear of
Uncertainties 4.1.2. Theme 2 – transforming body and eating behaviours
about child’s
failure Transforming shape Emotional
body and eating regulation Upon hearing they were pregnant, a number of
interviewees expressed their concerns about what this
Fig. 1. The overriding concept derived from data analysis was that of the
conflict interviewees expressed between motherhood and their eating meant in terms of their eating and body shape, as
disorder. participant 2 expressed:
1228 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233

I2: ‘‘I’m really excited but at the same time I’m really exercising rigorously; everything she ate was low fat and
scared that I’m going to be awful. . .I don’t want to class small portions. Others also struggled to eat adequate
myself as having an eating disorder but at the same amounts to put on sufficient weight, but there were a
time I know that I have disordered thinking and. . .I’m group of interviewees who altered their eating behaviours
worried that might get in the way of being able to cope for the good of their child. A craving for fish and dairy
with being a mum.’’ products caused participant 8 to eat these foods when
pregnant, even though she had refused to consume them
Interviewees 2, 3 and 4 hated their shape whilst
for five years. She recalled how doing this got easier the
pregnant because they were the heaviest they had ever
bigger she became during the pregnancy. Likewise,
been. Conversely, although interviewees 5 and 8 disliked
participant 1 described making an effort to have regular
the first trimester because they worried they would be
meals, which she hoped to continue once her child was
seen as getting fat, they were content when it became
born. She was prompted to change her eating after advice
visibly obvious they were pregnant. These interviewees
from a midwife:
seemed able to cope with their abdomen changing because
they could link it to their growing baby, but worried about I1: ‘‘I do eat a lot more than before I was pregnant. . .I’d
arms and legs becoming larger, unable to attribute this never have any breakfast, never used to really eat
directly to pregnancy. Participant 5 did not like her dress dinner. It was always my main meal in the evening. I
sizes increasing but said she loved her bump because it never used to pick during the day. I just used to live off
was solid and round. Similarly, participant 6 defined her one meal. . .I saw the midwife about eight weeks ago
stomach as ‘‘beautiful. . .nice and smooth’’, recalling that she now and she’d said she’d found something in my urine
was the happiest she had ever been with her body during that had shown that my body was eating my fat as
her first pregnancy, valuing its productiveness. energy because I wasn’t putting any fat on.’’
Most interviewees talked about closely monitoring
changes to their body during pregnancy, by weighing This theme implies that individuals’ sense of self was
themselves on a regular basis. A sense of despondency and strongly related to their appearance, which is something
disgust could transpire if they had gained, whilst weight they tried to control in terms of weight. They did not wish
loss brought a sense of relief. One woman (participant 7) to be regarded as excessive in their appetite or shape, being
who was pregnant when interviewed said she had recently relieved when others were aware that they were pregnant
thrown away her scales because she could cope with her rather than this being regarded as a lapse in somatic
body size changing but became downhearted when she control. Again, external markers of change (e.g. numbers
saw the numbers on the scales go up. This sentiment was on the scales, dress size) could cause disquiet, although
echoed by participant 3. She was attending a specialist interviewees tried to normalise these transformations by
eating disorders service during her third pregnancy and comparing themselves with other pregnant women. Some
recounted how her dietician outlined the weight she participants seemed able to turn off concerns about food,
should gain at each stage. She added: in the short-term at least, putting their child’s needs before
their own, although for some a restrictive pattern of intake
I3: ‘‘. . .immediately you’ve got to be careful because if
continued. In this sense individuals were torn between
you’re told there’s a certain amount you should put on,
their performance as someone with an eating disorder and
to put on more than that, well that’s just an absolute no
their wish to be seen as a caring mother. Hence, friction
no. . .part of it was just wanting to prove them wrong,
arose between two opposing cultural norms of the female
that you didn’t have to gain that much. . .’’
form: the slender ideal held up as the only acceptable body
One way a few interviewees tried to contextualise their shape and the expectation that women will put their child
expanding form was to monitor the weight changes of first by embracing weight gain during pregnancy. If
other pregnant women, via the internet. They reported individuals are over-invested in being a perfect mother,
logging on to parenting sites and observing what people any lapse they perceive from this position may prompt
were writing about their weight during and after them to return to a familiar role in which they have
pregnancy, using this as a yardstick to ensure they were succeeded previously, namely as someone with an eating
not gaining more than others. Women who were pregnant disorder.
when interviewed were anxious about how and whether
they would be able to lose their baby fat, whilst those who 4.1.3. Theme 3 – uncertainties about child’s shape
had given birth said they were too busy being a new
mother to be overly concerned about their shape. Interviewees mentioned not wishing sons or daughters
Interviewees talked about their food intake being to become obese, but at the same time not wanting them to
monitored during pregnancy. For example, participant 2 be obsessed with food. Consequently, they disguised their
said she felt ‘‘on show’’ at work because she was consuming own anxieties relating to eating and body image and made
more than usual and participant 3 described being an effort to eat as a family, even though this could raise
scrutinised by professionals who threatened her with their stress levels significantly. For example, participant 4
hospitalisation if she failed to gain weight. Participant 4 described pacing and being jumpy before a family meal.
noted her husband observed more closely her intake when She tried to rein in any disordered eating in her son’s
she was carrying his son. She admitted that her eating presence, such as cutting food into minute pieces, but
during pregnancy ‘‘wasn’t great’’, especially since she was worried he had picked up on her discomfort since he now
 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233 1229

rejected food. A number of interviewees disclosed strug- 2003) and allowing them to cope with what may be
gling with feeding their child solids. Participant 5 recalled perceived as dangerous/unwelcome states, such as anger
how difficult this was because it called for her to handle (Fox and Power, 2009) or shame (Goss and Gilbert, 2002).
‘‘real food’’. As a consequence, she left this to her husband, a Hence, a binge may help individuals dissociate from
setup echoed in other interviews. painful feelings, whilst restricting intake inhibits the
Participants 3 and 4 noted their child was small, which activation of an emotion (Waller et al., 2007) as attention
they welcomed on some level, although this raised is focused on not eating. Women interviewed had
concerns about what others would think: struggled with negative feelings, such as depression and
anxiety during their life, with a couple admitting to suicide
I3: ‘‘. . .she’s very small and the anorexic part of me likes attempts in the past. Low mood continued for some during
that. She’s not skinny, she’s just very small. . .but on the
pregnancy and/or after giving birth, which individuals
other hand because she’s small I’m constantly trying to blamed on their hormones and concerns about whether
pack food into her. I think the health visitors are aware
they were equipped to be a good enough mother.
of me having an eating disorder, sometimes I feel Exercise was a common means of regulating negative
people are constantly checking up on me, ‘am I starving
emotions for study participants, most of whom recalled
her?’ this sort of thing, which it’s the opposite.’’ having to amend activity levels when pregnant because
The son of participant 4 had to consume extra calories they felt too tired or were worried about harming their
because of a medical condition. She had reconciled herself child. Participant 4 tried to keep running but mid
to his diagnosis but admitted worrying about him pregnancy had stomach pains and stopped for a couple
becoming too large. She compared her son to other of weeks. However, concerns about her weight became too
children his age and was pleased he had ‘‘twig legs’’. much so she recommenced, taking up swimming as well to
Voicing these views to practitioners resulted in social make up for her short break. She described the ‘‘buzz’’ she
services becoming involved in supervising her son’s care. got from running and recalled thinking immediately after
Only one person defined her child as ‘‘big’’; participant 5 giving birth, ‘‘well I’ve had the baby. . .how quickly can I get
noted her son was larger than his peers but this did not back to. . .doing my exercises. . .?’’ Likewise, participant 8
cause her concern. She added that her thoughts on this recounted returning to the gym 10 days after having her
would have been different had he been female because all daughter. She curtailed her exercise whilst pregnant
the baby girls she knew were ‘‘small and cute’’. Others also (although she did walk several miles each day) but had
referred to their child’s gender. Participant 3 was glad her to rationalise with herself to be able to do so:
most recent offspring had been female because she was a
I8: ‘‘I’d stopped like proper exercising, weights and
single parent and therefore felt less of a need for a male role
biking and stuff like that at about six months and then I
model. Conversely, others were happy they had boys,
thought OK we’ll just see this as a little retirement. You
believing their son was unlikely to be affected by an eating
can start it all up again once the baby’s here. And I just
disorder.
let go fullstop then. I just thought OK just monitor your
The preceding description of data implies that women
weight, make sure you don’t put too much on and just
with an eating disorder may see their child’s shape as an
be relaxed about it all. You can work at making it all
external marker of their success as a parent. Recent social
better once [daughter] turns up.’’
messages about obesity in childhood could increase
anxieties about an offspring’s weight and the need to As well as exercise, a number of interviewees talked
monitor this closely. As noted above, a desire for control about inducing vomiting whilst pregnant to regulate
and striving for perfection have been associated with emotions. They felt some guilt about how it might affect
eating disorder onset and could extend to food consumed the child but also depicted this behaviour as compulsive,
by children; some women with an eating disorder may see adding that it brought them relief. Participant 7, in
their child’s body as an extension of their own, viewing any particular, noted how hard it was to refrain from doing
changes in their offspring and his/her eating behaviours as so in pregnancy because negative feelings (e.g. of greed and
indicative of their own self-control, potentially projecting being weak) encountered after eating were so powerful
their condition onto the youngster as a consequence. It has and only abated once she had been sick.
been noted that as a child of someone with an eating Self-harm was performed by a few interviewees as an
disorder develops, feeding difficulties may arise (Stice outlet for their emotions. Participant 5 did not do this during
et al., 1999). In addition, these youngsters are reported to pregnancy but had since giving birth, especially when
hold overvalued ideas about weight/shape in their self- finding it hard adapting to motherhood; she enjoyed being
evaluation and appear more likely to engage in restrictive needed by her child, now he was nearly one, but had said to
practices (Stein et al., 2006). her psychologist, when her son was a few weeks old, ‘‘I love
him, but I don’t want him’’, believing she was not capable of
4.1.4. Theme 4 – emotional regulation caring for him because she struggled to understand what he
needed when he cried. Participant 4 described cutting her
Much has been written in recent years about emotions abdomen on several occasions whilst pregnant:
and eating disorders, with a whole journal edition devoted
to this topic (Fox, 2009). It is argued that eating disorders I4: ‘‘I think it was because my stomach was getting
serve a purpose by enabling individuals to suppress much bigger. . .I mean obviously I was growing because
unwanted emotions (Geller et al., 2000; Waller et al., of the baby but when I look back I didn’t have a huge
1230 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233

bump. . .but at the time it seemed massive. So I was, I conflict between doing the best for their child and heeding
suppose, I wasn’t thinking of the baby, I was just seeing to the demands of their eating disorder. The results
my stomach was fat so I was trying to get the fat out. . .’’ revealed three categories of women: group A seemed
unable to cease their dangerous behaviours during
As this quote implies, a heightened emotional state
pregnancy (participants 3, 4, 5, 7); group B appeared able
could make it hard to put the child’s needs first. Participant
to put these on hold, but could be vulnerable to relapsing
4 recalled struggling to look at the screen when she went
after giving birth (participants 2 and 8); and group C, who
for a scan because she knew she was engaging in harmful
relinquished their weight control during pregnancy and
behaviours (e.g. slimming pills, self-harm). This inter-
saw this as a long rather than a short-term break from such
viewee described the numbness she experienced when she
practices (participants 1 and 6). Differences between these
first saw her son. Similarly, participant 3 felt pressurised by
groups appeared to be on a continuum, as displayed in
professionals to have skin to skin contact with her baby.
Fig. 2.
She did not have the confidence to voice her discomfort
Of the groups described above, A and B appeared to be
and was concerned about being regarded as a bad mother if
over-reliant on external markers that they were good
she did so.
mothers and over-sensitive to being negatively perceived,
Despite the emotional difficulties some individuals
which impeded them from opening up about their
associated with pregnancy, becoming a mother was
difficulties to close others. Feeling unable to live up to
depicted as life changing by all those who had given birth
self-imposed expectations of being a ‘perfect mum’, they
when interviewed. Participant 6 credited her children as
were tempted back into eating disorder behaviours.
being the catalyst for her eating disorder ceasing because
Although providing a sense of relief, this led to feelings
she no longer had time to dwell on what she was
of guilt and could augment their sense of incompetence.
consuming. Similarly, participant 8 said she had to put
Nevertheless, they drew solace whilst engaging in such
her concerns to one side and focus on her new child.
behaviour because it gave them some semblance of
Nevertheless, she was clear that she did not want to
command over their body. As mentioned above, a desire
surrender her sense of self to this role and expressed how
for control has been denoted as contributing to eating
joyful she had been when glimpses of her former identity,
disorder onset (Shapiro et al., 1993). Pregnancy can
prior to becoming a mother, emerged:
therefore be a challenge because there are numerous
I8: ‘‘I want to be consumed by [daughter] to a certain factors that are outside a mother’s influence. She may feel
degree but I still want a bit of me too. . . I remember she has limited control over her eating and over emotions
going to the gym for the first time, I was still breast- encountered throughout pregnancy. In addition, she has to
feeding her and I started crying just because I thought witness her body changing in ways that are threatening to
I’m still there. I felt like I’d lost me. It was really weird, it her previous identity as someone with an eating disorder.
was surreal.’’ Other research has noted that women may be concerned
about losing their eating disorder during pregnancy. For
The identity referred to by this interviewee related to example, in a study by Namir and colleagues (1986, p. 842),
her eating disorder persona, since she was keen to return to one interviewee stated, ‘‘I’m afraid I won’t be able to be
a life dominated by somatic control. Abandoning familiar anorectic again.’’ A strong bond with their eating disorder
yet potentially dangerous coping strategies appeared to be persona may make it more difficult for women to shift their
tolerated by this individual and some other participants by self-perception towards a new identity as a mother.
seeing it as a temporary state of being; whether this left What distinguished interviewees in B from those in A
them vulnerable to relapse and an escalation of disordered was the former’s ability to rationalise with themselves that
eating behaviours needs to be explored further through they had to halt their harmful behaviours, temporarily at
longitudinal research. least, for their child’s sake. Other studies have noted how
pregnant women with an eating disorder may make an
5. Discussion effort to eat more regularly and add previously restricted
foods to their diet, with the thought of their child
This study of women’s views suggested that in most prompting them to take better self-care (Namir et al.,
cases pregnancy and motherhood resulted in a sense of 1986). Pregnancy could be seen as a period of reprieve from

Set A Set B Set C

(wholly attached to their eating (intermittent rejection of their (motherhood replaces their eating
disorder) eating disorder) disorder)
Maternal skills Rely on external markers Rely on internal markers

Coping Dysfunctional practices Healthy methods

Identity Absorbed by the eating disorder Absorbed by motherhood

Attachment Focus on the eating disorder Focus on child

Body Seen as defective Seen as productive

Fig. 2. A continuum of attitudes and behaviours between identified sets of participants.

 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233 1231

social norms placed on women in terms of shape for the sake of their child (Koubaa et al., 2008). Signs
(Stapleton, 2007), but it brings new expectations in terms midwives are advised to look for to indicate such
of health behaviours to benefit a child and can be a conditions include (a) lack of weight gain in two
stressful life event. Consequently, individuals may be consecutive appointments in the second trimester, (b)
tempted to turn to their disordered eating as a familiar an eating disorder history, (c) hyperemesis gravidarum
route for managing anxieties, but at the same time feel it is (Franko and Spurrell, 2000). However, an ability to act may
contraindicated because they are responsible for the be hindered by the lack of local facilities for people with an
child’s welfare. This may lead to questions about owner- eating disorder. In addition, even if professional support is
ship of their body, heightening concerns with their accessed, difficulties may still arise due to problems with
physique, as they are caught between the competing childcare provision or after-hours appointments for
demands of the child and the eating disorder. It is women who work (Stapleton, 2007).
unsurprising, given such pressures, that disordered think- A range of suggestions have been given for how
ing about weight and food, even if eased during pregnancy, professionals could assist pregnant women with an eating
often resumes after giving birth (Namir et al., 1986). disorder, including psychoeducation about physical and
Most interviewees in group A were detached from their psychological consequences of their behaviours and
child whilst in-utero, possibly to enable them to persist nutritional requirements (Little and Lowkes, 2000). It
with their disordered eating practices (including excessive may also be useful during antenatal appointments to raise
exercise, purging and self-harm); becoming too attached at awareness that a failure to bond immediately with a baby
this stage would make such behaviours difficult to is not uncommon, otherwise this may be used as a reason
maintain but without a replacement for regulating to be self-critical.
emotions their internal struggles may have been unbear- Women with an eating disorder should receive extra
able. Difficulties transpired when a woman was suddenly support after giving birth due to their increased risk of
presented with a new child with whom she felt little postnatal depression (Ward, 2008). Help at this point may
rapport. Research has suggested that not all mothers bond be beneficial for the child’s immediate and long-term well-
immediately with their child (Robson and Kumar, 1980; being, since youngsters of these mothers are reported to be
Kumar, 1997), but it may be regarded by those with an susceptible to developing eating issues themselves (Park
eating disorder as evidence of their inability to mother. et al., 2003; Stein et al., 2006). Mothers with an eating
Likewise, breast-feeding was an area in which intervie- disorder may need practical assistance with preparing
wees’ sense of competence could be undermined. Others meals and eating with children, which have been reported
have listed feeding problems among this group (Koubaa in this and in other papers as causing difficulties (Fahy and
et al., 2008; Stein et al., 1999; Waugh and Bulik, 1999). For Treasure, 1989; Stein and Fairburn, 1989). Data from those
example, in a study comparing women with and without interviewed implied that women with an eating disorder
an eating disorder history, the former were more likely to can be anxious about their offspring’s food intake. Other
stop breast-feeding prematurely (Larrson and Andersson- authors have noted that mothers with such a condition
Ellstron, 2003). It has been noted that as well as knowl- underestimate their child’s nutritional needs (Hodes et al.,
edge, successful breast-feeding calls for self-confidence 1997) and make fewer positive comments at mealtimes
and belief in the potential of one’s body (Larrson and than control women (Park et al., 2003; Waugh and Bulik,
Andersson-Ellstron, 2003). Poor self-image among those 1999).
with an eating disorder may impede this activity and could
reinforce existing views of their body as defective rather 5.2. Areas for future research
than productive. Interviewee 6, from group C, was the only
person to be positive about breast-feeding, seeing it as a Those with an eating disorder history may be more
sign of her body’s creative capacity. The two women in vulnerable to feeling inadequate as a mother, and, as a
group C seemed able to subsume their previous eating consequence, turn to what they consider to be a necessary
disorder identity with one of being a mother. This allowed coping mechanism, whereby they focus on their weight
them to put their child’s needs before that of their previous and nutritional intake. The types of core beliefs that have
status as someone with an eating disorder. They took pride been found to be important in eating disorders are socially
in their altered identity and appeared to grow in self- orientated ones, such as expectation of abandonment,
confidence and self-love. Nevertheless, they may be prone mistrust/abuse, feeling defective and/or shame (Cooper
to perfectionist tendencies; as suggested above, this has et al., 1998; Meyer and Waller, 1999). Results implied that
been proposed as a key trait among those with an eating for certain women these core beliefs are more engrained
disorder (Bardone-Cone et al., 2007). Perfectionism and and may mean someone feels she will be a poor mother
being self-critical in eating disorders have been theoreti- from the outset. Additional investigation could be made of
cally linked to the need to defend against a pervasive the perceptions of motherhood among women with and
negative self-worth (Goss and Gilbert, 2002). without an eating disorder, looking at how they measure
their abilities in this sphere and where their ideas about
5.1. Implications for practice this concept derive. For example, do those with an eating
disorder focus more on external markers of their mother-
Motherhood is said to be an optimum time to intervene ing skills because they are unable to accept/trust their own
in cases of eating disorders, when individuals may be more judgment on this matter? For some interviewees, preg-
willing to make changes to their weight-control practices nancy prompted them to amend disordered eating
1232 S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233

behaviours, whilst others appeared to spiral downwards. between responding to the eating disorder and putting
Factors predicting whether someone improves or relapses their child first, whilst a couple described turning their
could be explored in further research. Ideas relating to back on their condition. Practitioners should bear in mind
drivers towards eating disorder behaviours during and that a positive investment may be placed in motherhood
after pregnancy, based on interview data, are illustrated in when a woman with an eating disorder becomes pregnant;
Fig. 2. Investigators could examine what enables women the child may be regarded as someone who will love her for
who make positive changes to their harmful weight- who she is, not judging her shortfalls. This could account
control practices during pregnancy to maintain a healthier for an improvement of the eating disorder, but an
lifestyle following their child’s birth. overwhelming sense of responsibility may result in an
Finally, partners played a role in supporting inter- escalation of or return to symptoms. Having a stronger
viewees. Other studies have talked about women with an identity as a mother may contribute to a ceasing of eating
eating disorder drawing on a spouse to help them disorder behaviours, although individuals may return to
rationalise concerns about weight gain (Namir et al., such activities when self-doubt about parenting skills
1986). Needs of these fathers requires further exploration, transpires. Believing things are out of their control and
as they may feel torn between wanting the best for the feeling unable to live up to their ideal as a mother, as well
child and not wanting their partner to feel anguished. as concerns about their weight, could drive these women
into disordered eating patterns. A vulnerability to depres-
5.3. Limitations sion during and after pregnancy may also be a trigger for a
resumption of such practices. Professionals need to
Engaging in potentially harmful eating behaviours identify and support these women during and post
whilst pregnant may be regarded as a tangible reason pregnancy to prevent them from endangering themselves
for rejection by others, which could explain recruitment and the fetus, and from increasing their child’s likelihood
difficulties. Yet even though only a small group of women of potentially harmful weight control in the future.
was interviewed, information provided was rich in detail.
Participants represented a range of characteristics and Conflict of interest: None.
experiences, and their responses have been linked to the
wider literature, in line with theoretical generalisability Funding: Work described in this paper was funded by the
associated with qualitative research. Women who did not School of Nursing, Midwifery and Social Work, University of
meet the screening questionnaires cut-off were sent a Manchester.
letter explaining that the researchers were not interview-
ing everyone because the aim was to include individuals Ethical approval: South Manchester Local Research Ethics
who varied in age and stage in pregnancy. Given the Committee.
responses of those who were not eligible (none of whom
ticked any of the risk factors related to an eating disorder References
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