Susie Orbach, PhD
Holli Rubin Psychotherapist specializing in body image
Body image concerns are widespread. The conjunction of body image distress and disturbances in eating have either been seen as rather trivial or as medical psychiatric issues. This has meant that they have rarely been in focus in considering health policies for expectant mothers.
Women’s concerns are anything but trivial. They are making women feel deeply uneasy in their bodies. They are disturbing women’s eating patterns. They are impacting on how women relate to their physical needs in pregnancy and post-partum, interrupting the focus on bonding with baby in the crucial early months when attachment behaviours are being established (Easter et al., 2013; Orbach, 2003).
Becoming ‘an ordinary devoted mother’ (Winnicott, 1960) is not as natural a process in our times as we might wish.
The first few months of life are critical in establishing the foundations for well-being in the mother-infant couple and for the building of security and resilience in the baby. From Bowlby’s work on Attachment (1969) to neuro-scientific studies showing the effects of brain development, motor development and the uptake of specific hormones as soothers for babies, the picture is clear. Becoming ‘an ordinary devoted mother’ (Winnicott, 1960) is not as natural a process in our times as we might wish. Women’s relationship to their bodies, including their feeding of themselves, combined with the avalanche of often contradictory information telling them how to settle and feed their babies, meets messages from the media which represent pregnancy and post pregnancy as an opportunity to target them about their size as though the most important thing about giving birth is the retrieval of the pre-pregnant body (Orbach, 2009).
Media images that laud celebrity mothers who achieve a state of emaciation six weeks after delivery are switching the focus of the post-partum period away from mother and baby getting to know each other and finding a rhythm together. Instead, there is a cultural insinuation that a mother’s job is to present herself physically as though nothing as life-changing or body-changing as having a baby has occurred. This critical moment in which new life and the new mother weave together a delicate and precious bond needs supporting in order to ensure the best possibilities for both.
Images and experience of pregnancy
Pregnancy is a time of hope, joy and promise. Many women enjoy being pregnant. They revel in their growing roundness and feel good both on the outside as well as the inside. Hormonal changes are having a positive effect.
For others, discomfort about bodily changes causes worry and creates a background of anxiety about how large they are and whether they will ever get their bodies back. They feel out of control. For still others, the difficulties are far more serious. There is considerable despair about how they look (Lemberg & Phillips, 1989). They are discontented and focused on feeling fat. They feel exempted from the hype and excitement around being pregnant. The lack of a ‘blooming pregnancy’ contributes to a sense of guilt and confusion. They aren’t able to surrender to their body’s changes. The midwife encounters all of these concerns.
If a woman has always managed her body by strict guidelines regarding food and exercise regimes, she is now confronted by a body which seems to have a mind of its own. It is in rebellion. The pregnant body is felt as alien rather than natural and its changing can alarm her. Her diet is disrupted and she becomes anxious.
If she has always over-eaten, then she will not necessarily know how to eat appropriately in pregnancy. She may misinterpret bodily signals and ‘over’ eat to quell morning sickness, distancing herself further from her bodily needs. Her emotional need to eat will provide the rationale for eating for more than two (Park et al., 2003).
For those who have long lost touch with hunger mechanisms, the solution may be continuing to eat without regard to physiological cues or nutritional common sense (Stein et al., 1994; Fairburn et al., 1993)
All of this is exacerbated by societal and media pressures which implicitly encourage women to restrict their eating so as to have less to lose after baby is born while at the same time encouraging them to indulge themselves during pregnancy. These contradictory messages cause considerable confusion.
From pregnancy to becoming a mother
Pregnancy is different from mothering. In a first time pregnancy, the focus is all on the woman. As soon as the baby arrives, the focus switches to the baby. Considerable hormonal shifts intensify after birth just as the woman’s attention is directed to establishing routines, being responsive to her baby, managing her own milk supply, finding time to sleep, to relate to her partner, to become a parent. It is an exhausting and exhilarating time for most women. For a percentage, the hormonal fluctuations create a post-partum depression which is debilitating and deeply dismaying and health and family visitors have been trained to pick this up early so as to intervene as soon as possible to minimize the risk to mothers and babies.
An important task of early parenting is establishing the baby’s emotional safety. Infant researchers Beebe (2011) and Tronick (2007) demonstrate the significance of the early communication between mother and baby. They show the importance of feeding, of play, teasing, tenderness and engagement between mother and baby and how these are the building blocks of attachment and psychological well-being. Primary in this emotional interchange is the feeding relationship which along with holding, hugging, smiling, bathing and helping the baby to sleep, builds the psychic structure and internal security of the baby. It is how the baby comes to know herself (Gerhardt, 2004).
When a mother responds to her baby today in a way similar to the way she did yesterday and the day before, the baby senses that her or his needs for hunger, for soothing, for sleeping, for recognition are being met. The personal rhythm of each mother-baby couple shapes the baby’s experience of what is to come. If the mother is reasonably consistent, the baby will experience consistency of care as an emotional baseline. If the mother is inconsistent, the baby will find her or himself alive to a kind of jagged or varying baseline to which they will adapt and which will become their idiom, their way of being in a close relationship.
Breastfeeding, weaning and establishing eating habits for a new person pose challenges. Once the baby is born, his or her growth occurs outside the woman. Every woman has to learn how to feed their baby. The ‘breast is best’ message does not mean that breastfeeding is straightforward for every woman. Breastfeeding may require the help of the health visitor, grandmother or older sister. It is not ‘the most natural thing’ for every woman, so if there are initial difficulties and mothers are not taught properly and patiently, they may become disheartened, stressed and feel guilty. Troublingly, this will loop back into negative feelings they may have about their body image which means that without intervention, their own embodiment, that’s to say, the body experience that they bring to mothering, will encode within it a sense of failure (Orbach, 2009).
Mothers with body image and eating problems
Understanding how a woman’s body image may be affecting her well-being and functioning is important for health professionals responsible for caring for her at this precious and vulnerable time. This issue is often missed or minimized because of society’s normalization of pathological attitudes to food and the body.
What is neglected, as a result, is the intergenerational transmission of body and eating problems (The BODI Group, 2014). We have tended to see such problems as coming from external forces such as the media and the style industries – which they do – but we have underestimated the ways in which cultural influences come to life in the individual woman and are integrated into her sense of self. It is her attitude towards bodies, and her own bodily sense which she will pass on. As she absorbs the cultural messaging about thinness and fatness, she makes the culturally praised values her own but the means to implement those values may clash with her ability to moderate her own appetite in a healthy way. The way she eats, her attitudes towards health, food and hunger, as well as the emotional reasons why she may eat or not eat, are all passed on wordlessly to her baby. The positive and the negative. She will not want to pass on the negative and yet inevitably, without intervention, she will.
Every mother wishes to do right by her baby. For those who begin this journey already struggling with more serious eating problems and body image disturbance, the challenge to feed and nurture will be considerable and yet it may be wrapped in shame and hidden from view. The shame coupled with the wish to give the baby a good start, without actually knowing what that might be, can make this an especially tense time for mothers (Easter et al., 2013).
With appropriate training, pregnancy and post-partum provide a unique opportunity for health and family visitors to help women transform their body image and eating problems. In so doing, they enable both an existing population to get through their issues while inoculating the next generation against identical issues.
Building baby’s secure body image
A critical but until recently overlooked aspect of child development in the very early months is around the baby’s comprehension of its own body image. Body image does not happen at 5 or 10 or 15 years. Body image evolves as the baby grows into a child and an adolescent, but the basic sense of one’s body is structured into the individual very early on (Orbach, 2009). This comes from how the mother relates to the baby’s evolving needs for food, sleep, soothing and the like, but it also emerges out of the way in which the mother brings her own body to her baby. What does this mean?
The awareness that a woman has of her own bodily needs, her personal comfort or discomfort about feeding, her ease or uneasiness about living in a post-partum body, is an important aspect of the body to body relationship between a mother and her infant.
If the mother has a stable body image, she will weather the challenges which mothering an infant provokes.
Is she able to see her baby as a separate but dependent being who expresses different bodily needs than she has herself? Does she see her baby as an extension of her own body that she likes or dislikes and so on (Orbach, 2009)? Does she allow her baby to relish her or his appetites or does she try to shut them down as she may try to do with her own? Does she feed the baby up to give herself a good feeling? Does she offer food when other forms of soothing or relating would more accurately meet baby’s squalling?
All such questions beset new mothers and are part of the discovery of parenting and the magical power that is vested in the relationship for the mother. But in so far as the mother has a troubled relationship to her own body, this will be reflected in aspects of this very intimate time together.
The body that mother brings to her baby will form the template for the baby’s sense of its body. If she has a stable body image, she will weather the challenges which mothering an infant provokes. In turn, she will pass on a confident body to her baby which will protect the developing child from the many exhortations to have a certain kind of body which now accompany childhood. If she feels insecure in her body and relates to it chaotically, bingeing for several days and restrictive eating for others, for example, the baby will sense the tension in her body as he or she unconsciously begins the process of developing their own body signature.
Save lives by saving money: The economic case for early intervention
Evidence-based and well implemented preventive services and early intervention in the foundation years are likely to do more to reduce problems than reactive services which have to respond to entrenched patterns of behaviour. They deliver economic and social benefits. Such services also have an important role in making sure all children reach school ready to learn and able to achieve to the best of their abilities.
A review (Wave Trust, 2013) conducted on a wide range of published UK and international studies into the economic case for investment in the early years came to the consensus that returns on investment on well-designed early years’ interventions significantly exceed both their costs and stock market returns. Early intervention saves money by saving lives.
The Early Intervention literature makes a persuasive case for support to new mothers. The need to provide help in relationship to women’s body, food and self-esteem issues is crucial if we are to inoculate the next generation from even more severe body image and eating difficulties, including anorexia, bulimia, compulsive eating and obesity. A population living with body anxiety and its physical manifestations is fast becoming the norm. We have the tools to intervene early on to minimize the effects of a commercial culture which is now affecting children as young as five and continues throughout life. By supporting mothers as they feed their babies and feed their selves, we ensure that this foundational aspect of parenting is wholesome, relaxed and secure.
What midwives, health and family visitors, and early years’ professionals need to understand...
• How body image and eating problems affect women
• The significance of the early feeding relationship to mental health and prevention of obesity, bulimia, compulsive eating and anorexia
• The impact of mothers’ entrenched eating difficulties on their infant’s development as well as on the relationship with their infant
• The intergenerational transmission of eating anxieties
• How food deprivation or over-eating during pregnancy and post- partum impacts on how mothers bond
• Mother and baby attunement
• Ethnic and class issues affecting the attachment and feeding relationship
• How to refer when there is concern.
And what they need to do…..
• Help mothers to identify their own needs for food and nutrition
• Teach mothers to recognise infants’ and children’s need for food, cues which indicate hunger and satiety, and to separate those from needs and cues for comfort, soothing, stimulation and recognition
• Attend to the feelings which interrupt women feeding their babies and themselves healthily post-partum
• Examine their personal attitudes towards body size and weight and how these may influence interactions with mothers.
It may seem difficult to include the subject of body image in an already heavy clinical caseload. However, midwives, health and family visitors and early years professionals can make a valuable contribution by making small but thoughtful changes in how they discuss body and nutrition issues with the women in their care.
• Eating problems of all kinds are on the rise. The most visible and obvious is obesity which is straining the resources of the NHS in the UK. The most hidden is the chaotic eating which doesn’t show but which involves individuals who intermittently restrict and binge while obsessing about their bodies, rarely feeling safe around food.
• Many factors contribute to the current epidemic. Often overlooked is the role of inter-generational transmission of eating problems and the psychological meaning of eating and body difficulties. This is especially powerful between mothers and daughters but it extends to the whole family. We see obesogenic families and families who are vulnerable to eating problems and we see families in which food restraining, fad dieting and extreme exercise are the manifestation of disturbed appetites and fear of food.
• Psychologists, neuroscientists, infant researchers, and public health professionals agree that conception to age two is a vitally important time in human development. It lays down patterns for life. It is also a time when attention targeted to parents and babies reaps huge dividends for society.
• Early attachment between mothers and babies creates the foundation for mental health, resilience and flexibility in children. Mothers who are preoccupied with eating and body image problems can inadvertently behave so as to shape bonding and attachment patterns in damaging ways.
• Midwives and health and family visitors are crucial in the transmission of public health to mothers and new babies. They are vested with ensuring the mental and physical health of mother and baby.
• Midwives and health and family visitors receive scant training on the effect of eating problems on the mother’s relationship with her infant, the feeding relationship and its impact on the baby’s developing body. Training is required not only to alert them to cases where feeding difficulties are already evident, but to provide an understanding of the role of mothers’ eating habits and attitudes to food, nutrition and shape, and the consequent impact on infant emotional and nutritional development.
• Early intervention reaches two populations in one go. Pregnancy and post-partum are times when mothers are most receptive to ‘getting things right’. Reaching all mothers as a matter of course will help them reflect on their attitudes and support them not to pass on negative habits to their babies.
Allen, G. (2011) Early intervention: Smart investment, massive savings. London, Cabinet Office. Available at: https://www.gov.uk/government/publications/early-intervention-smart-investment-massive-savings <accessed 26 Jan, 2018>
Beebe, B., Steele, M., Jaffe, J., Buck, K.A., Chen, H. et al. (2011) Maternal anxiety symptoms and mother–infant self and interactive contingency. Infant Mental Health Journal, 32(2),174-206.
Bowlby, J. (1969) Attachment and Loss: Vol. 1, Attachment. New York, Basic Books.
Easter, A., Naumann, U., Northstone, K., Schmidt, U., Treasure, J. et al. (2013) A longitudinal investigation of nutrition and dietary patterns in children of mothers with eating disorders. Journal of Pediatrics, 163(1), 173-178.
Fairburn, C.G., Jones, R., Stein, A. (1993) Eating habits and attitudes during pregnancy. Psychosomatic Medicine, 54, 665-672.
Gerhardt, S. (2004) Why Love Matters: How affection shapes a baby’s brain. London, Routledge.
Lemberg, R., Phillips, J., (1989) The impact of pregnancy on anorexia nervosa and bulimia. International Journal of Eating Disorders, 8(3), 285-295.
Orbach, S. (2003) There is no such thing as a body. British Journal of Psychotherapy, 20(1), 3-16.
Orbach, S. (2010) Bodies. London, Profile Books.
Park, R.J., Senior, R., Stein, A. (2003) The offspring of mothers with eating disorders. European Child and Adolescent Psychiatry (Suppl. 1), 12, 110-119.
Stein, A., Woolley, H., Cooper, S.D., Fairburn, C.G. (1994) An observational study of mothers with eating disorders and their infants. Journal of Child Psychology and Psychiatry, 35(4),733-748.
The BODI Group (2014) The acquisition of a body: Establishing a new paradigm and introducing a clinical tool to explore the intergenerational transmission of embodiment. Ch. 21 in: Petrucelli, J. (Ed.) Body-States: Interpersonal and Relational Perspectives on the Treatment of Eating Disorders. London, Routledge.
Tronick, E. (2007) The Neurobehavioural and Social Emotional Development of Infants and Children. New York, W.W. Norton.
WAVE Trust (2013) Conception to age 2 – The age of opportunity. Available at: http://www.wavetrust.org/sites/default/files/reports/conception-to-age-2-full-report_0.pdf <accessed 26 Jan, 2018>
Winnicott, D.W. (1960) Maturational Processes and the Facilitating Environment. London, Hogarth Press.