Severe Eating Disorders During Pregnancy and Early Motherhood

A Swedish study identifies distinct characteristics in 5 groups.

Pregnancy and early motherhood are times of increased risk for women with eating disorders. For example, women who experience persistent eating disorder symptoms during pregnancy and the early postpartum period tend to have greater depression and anxiety. Postpartum depression also seems to occur more often in women who currently have or have had an eating disorder in the past (Psychol Med. 2007. 37:1109).

A better understanding of the trajectories or paths women with eating disorders experience during pregnancy and the early postpartum period may help combat the risks of relapse and worsening symptoms. In the first study of the psychological processes that women with eating disorders experience during pre-pregnancy, pregnancy, and early motherhood, Dr. Bente Sommerfeldt of the Institute for Eating Disorders, University of Oslo, Sweden, and fellow researchers traced the common traits, factors, or processes that women link to worsening symptoms and relapse, as well as improvement and recovery during pregnancy and early motherhood (Front Psychiatry. 2024.10.3389/fsyt.2023.1323779).

Dr. Sommerfeldt and colleagues designed a longitudinal in-depth study of a non-clinical sample of 24 women with histories of severe eating disorders during pregnancy and the 6 months after birth. Severity was defined by persistent and long-lasting symptoms, and a treatment history lasting more than 7 years. The women were interviewed twice: once during pregnancy, and then 4 to 6 months after delivery.

Five types of mothers and their trajectories were identified: (1) the “mastering mother,” whose eating disorder was absent during pregnancy and the postpartum period; (2 ) the “inadequate mother,” whose eating disorder worsened before and during pregnancy, and continued during early motherhood; (3) the “overwhelmed mother,” whose eating disorder worsened during pregnancy and early motherhood; (4) the “depressed mother,” whose eating disorder stopped during pregnancy but worsened after birth; and (5) the “succeeding mother,” whose eating disorder worsened during pregnancy but improved in early motherhood.

Characteristics of the mastering mother

Three women were categorized as mastering pregnancy and early motherhood. All had low body mass indexes before pregnancy, and a strong awareness of their food intake and the importance of exercise. All had anorexia nervosa (AN), were goal oriented, and wanted to become pregnant and in fact had planned their pregnancies. They had another quality in common: they had good support at home, and viewed their pregnancy as a family project. All delivered close to their proposed delivery dates, giving them a sense of safety and control. After birth, they mastered breastfeeding, and lost extra weight right away. A common expression was that pregnancy and being a mother meant they no longer needed their eating disorder.

The succeeding mother: improvement after birth

Four women fit into this category. Their eating disorders worsened during pregnancy but subsided early in the postpartum period. Birth and early motherhood were important turning points for these mothers. Before becoming pregnant, they had a history of AN and low self-esteem, and struggled with perfectionism as well. They were rigid and perfectionist before pregnancy, and feared not succeeding in being thin and healthy after their child was born. Although they wanted to control all aspects of their pregnancy, nothing went as planned. It was helpful if they had a small stomach and gained less weight than they feared.

The authors noted that these mothers felt good when they lost weight and their body weight returned to pre-pregnancy levels. Breastfeeding led to healthier eating patterns, and the mothers expressed that they no longer needed their eating disorder to feel special.

The inadequate mother: a feeling of not being good enough

Seven of the mothers reported that their eating disorder symptoms returned or worsened before they became pregnant, and continued to worsen during pregnancy and early motherhood. All had severe AN, and several had histories of anxiety during childhood. They also reported becoming pregnant while they had a general feeling of insecurity. Six had become pregnant through in-vitro fertilization (IVF), and they viewed their inability to become pregnant without IVF as a loss of control. All felt their pregnancy was overwhelming and as something that brought them guilt and self-contempt. They were also obsessed with what others thought of them and feared doing something wrong that could harm the baby. These mothers felt detached from their bodies and their babies, and this feeling of inadequacy continued into feeling unable to cope as a mother. They used excessive exercise to take attention away from their baby and hoped that by focusing on their body shape, appearance, and weight, they might feel better about themselves.

These women also had difficulty breastfeeding. Breastfeeding became a way to lose weight or to eat “normal” amounts of food. Ironically, the inadequate mothers’ strict routines and rules gave them a feeling of safety.

The depressed mother: eating disorders that worsened after birth

Ten of the women were second or third-time mothers, and all were diagnosed with postpartum depression. However, during pregnancy, the depressed mothers put their symptoms on hold by learning how to deal with their bodies, weight, and changes in shape after their babies were born. All had histories of bulimia nervosa, and also reported growing up with mothers who binged and purged and worried about weight gain throughout their pregnancies.

Depressed mothers tended to have rapid body changes as their pregnancies progressed and felt detached from their bodies. Delivery became a trigger for symptoms because nothing went as they had planned, and all the women had complications.

Several symptoms worsened during the postpartum period. All were diagnosed with postpartum depression, and they were unable to accomplish their original plans for healthy eating and exercise —this made them feel like failures. Some protective factors included the fact that they had been able to “get their body back” between prior pregnancies. Planning ways to achieve this protected them from disordered eating during pregnancy.

The overwhelmed mother: chaos, shame, and guilt during pregnancy and early motherhood

The typical overwhelmed mother felt chaos during pregnancy and early motherhood, as well as a self-affirmation of herself as a “bad person.” The women in this category had a history of intense self-hatred that they linked to traumas in early childhood. To them, their eating disorder was a way to deal with chaos earlier in life, and all were bulimic. They also typically experienced pregnancy as a threat to the degree of control they felt they had over their lives. Using their eating disorder gave them a way to disconnect from being pregnant. This led to purging and overeating. Early in motherhood, they expressed a fear of harming their baby. Three mothers delivered later than expected, leading to a larger body, and to a feeling of loss of control during the birth.

Hatred of their bodies triggered yet more eating disorder pathology. This group expressed feeling like aliens, and were angry with the baby for “destroying” their body. This disgust with themselves made it difficult to form a healthy relationship with their babies. Breastfeeding also seemed overwhelming, and within a short time they stopped breastfeeding. After a few months, the mothers began feeding their babies with a bottle, and their partners took responsibility for feedings. Good support from their partners became a protective factor in early motherhood.

The authors pointed out that pregnancy and the postpartum period are especially vulnerable times for women’s mental wellbeing. In the case of the depressed mothers, women could put their eating disorder on hold during the pregnancy, but it grew worse during birth and into early motherhood.

According to the authors, women in the inadequate mother category need support to feel well, to be reassured that their babies are doing well, and to cope with emotional experiences during this time. Those in the depressed mother category may need routines they can stick to. Additional help that emphasizes building self-compassion and reduces shame would be helpful for mothers in the overwhelmed category.

Finally, Dr. Sommerfeldt noted that their trajectories are not mutually exclusive, and that the women had several elements in common during pregnancy and early motherhood, including low self-esteem, feeling shame, and finding it difficult to regulate emotions.