- Email: [email protected]
Body Image Attitudes During Pregnancy and the Postpartum Period
research and studies Body Image Attitudes During Pregnancy and the Postpartum Period VICTORIA R. STRANG, RN, MN, AND PATRICIA L. SULLIVAN, RN, PHD
Research was conducted to investigate postpartal women's attitudes toward their body image; these attitudes were then compared to their prepregnant and pregnant body image attitudes. A repeated measures design was used, with data collected at two and six weeks postpartum. Pregnant and prepregnant attitudes were collected retrospectively. A nonrandom, convenience sample of 63 multiparas and primiparas was used. The results indicated that the subjects had a slightly positive attitude toward their postpartum body image; multiparas felt more positive about their postpartum body image than did the primiparas; the women felt more positive about their prepregnant body image than about their postpartum body image; and the women felt more positive about their postpartum body image than about their pregnant body image.
form in our minds a s a tridimenThe idealized female body is sional unity involving physiologic, valued in our society.',' However, psychologic, and social factors.' the changes that occur to the body The image is the composite of due to pregnancy reflect that the woman is perhaps further from perceptions, attitudes, and feelings each individual has of his/her own the ideal body than s h e ever has been. After delivery, the woman's body as it exists in space.8 These components of body image have body still appears ~ r e g n a n tThis .~ been identified as two indepenis a very dissatisfying experience dent dimensions, body perception for many women.4 This dissatisand body a t t i t ~ d e . ~Body , ' ~ perfaction with the body has been ception refers to the direct mental identified a s one of the factors experience of the physical apwhich contribute to the critical nature of the postpartum p e r i ~ d . ~ ,pearance ~ of the body, which encompasses surface depth and postural mental pictures. The attituLITERATURE REVIEW dinal dimension encompasses a broad spectrum of feelings, attiBody image has been defined tudes, and emotional reactions toa s the picture or mental image we ward the body a n d represents the Submitted: September 1983. Accepted: individuals' valuation of their March 1984. bodies. 332
In studies of the attitudinal dimension of body image during the p re g n a n c y /p o s tp a rtu m period, women's dissatisfaction with their bodies seemed to increase as their p re g n a n c ie s progressed and peaked in the postpartum per i ~ d . ' , ~ .The '' women who were positive about themselves before pregnancy and who were happy with their pregnancies seemed positive about the changes that occurred in their bodies during their pregnancies and the postpartum p e r i ~ d . ' However, ~~'~ some studies did not explore the postpartum period.',':' Other studies investigating attitude toward body image in the postpartum period either presented insufficient data o r presented data only for the early segment of the postpartum July/August 1985 JOG"
period.4.11.12Also, the types of subjects were not congruent among the various studies. McConnell and Daston used only multiparas, Leifer and Harris used only primiparas, and Carty and Moore used both multiparas a n d primiparas, 1.4,10-12
RESEARCH QUESTIONS The following specific research questions were addressed: 1. What is the woman’s attitude toward her body image during the second and the sixth week of the postpartum period? 2. Does her attitude toward her body image change between two and six weeks postpartum? 3. 1s there a difference in attitude toward body image between primiparas and multiparas? 4. 1s there a difference among prepregnant attitude to body image, pregnant attitude to body image, and postpartal attitude to body image in postpartum women? A) Is there a difference between prepregnant attitude to body image and pregnant attitude to body image? B) Is there a difference between prepregnant attitude to body image and postpartal attitude to body image measured at two and six weeks? C) Is there a difference between pregnant attitude to body image and postpartal attitude t o body image measured at two and six weeks?
METHODS Design The research design was a repeated time measure design of the postpartal woman’s attitude toward body image at two and six weeks postpartum. The prepregnant and pregnant attitude to body
July/August 1985 JOCNN
image was collected retrospectively during the two-week postpartum home visit.
Sample
A group of 109 postpartal women who gave birth to healthy full-term infants at a large urban hospital in western Canada, between January 3, 1982, and February 1 , 1982, were approached to participate in the study. Criteria for inclusion in the study were that 1) the birth was a vaginal delivery, with no surgical procedure performed other than episiotomy; 2) the delivery was a single birth; 3) the mother and the infant had no diagnosed medical problems indicated on the hospital chart; 4) the mother and infant were discharged from the hospital together; 5) the mother and father of the infant were married and living together; 6) the mother spoke fluent English; and 7) the mother resided within the limits of the city chosen for the study. From this population of 109 women, 63 women-30 primiparas and 33 multiparas-consented to participate in the study. The subjects’ ages ranged from 20 to 37 years, inclusive. The mean age for the primiparas and multiparas was 25.2 and 27.8 years, respectively. The 58% of the population who chose to participate were similar to the 42% who chose not to participate, in that all met the criteria for inclusion. Many of the nonparticipating women indicated interest in the study, but wanted the investigator to come to their homes at three o r four weeks postpartum, rather than at two weeks. Other reasons for declining involvement were related to fatigue, infant concerns, being too busy, o r maternal illness. Instrument The Attitude to Body lmage Scale, a modified version of Jour-
ard’s Body Cathexis Scale, was used.I4The Attitude to Body Image Scale measured the degree and direction of feelings toward one’s body in the prepregnancy, pregnancy, and postpartal periods. The Attitude to Body lmage Scale consisted of a list of ten body parts: weight, bust, waist, hips, legs, feet, facial appearance, shoulder width, abdomen, and hair. The subjects indicated their attitude toward their bodies by rating each of the body parts on a Likert-type scale. On this scale, a rating of o n e represented strong positive feeling; two, positive feeling; three, slight positive feeling; four, no feeling one way or the other; five, slight negative feeling; six, negative feeling; and seven, strong negative feeling. To calculate the final body attitude score, the total score of all ten bodyparts was divided by ten. Therefore, the body attitude score could have ranged from one, indicating a strong positive feeling toward the body, to seven, indicating a strong negative feeling toward the body. Three experts in the field of maternal-child nursing, community health nursing, and statistics were asked, independently, to determine the content validity of the Attitude to Body lmage Scale. These experts were asked to indicate whether o r not the items on the Attitude to Body lmage Scale had been modified adequately to obtain data on body parts which were likely to change during pregnancy and the postpartum period. The test-retest method, with a four-week interval, was used to estimate the reliability of the Attitude to Body lmage Scale. On both testing occasions, 32 nonpregnant subjects were requested to respond to the instrument, indicating their current body image attitude and their attitude toward their body image of approximately
333
Table 1. Median and lnterquartile Range of Body Attitude Scores of Women at Two and Six Weeks Postpartum
Table 2. Frequency of Positive, Neutral, and Negative Body Attitude Scores at Two and Six Weeks Postpartum __~___-__. . - .
Body Attitude Scores ~
Postpartum Time Body Attitude Scores
2 Weeks (N = 63)
6 Weeks (N = 61)
Median lnterquartile range
3.4 3-4
3.5 2.5-4
Postpartum Time
Positive
Neutral
Negative
N
(1-3.9)
(4-4.9)
(5-7)
Two weeks Six weeks
63 61
45 43
16 17
2 1
~
___-_I
_
_
--
one year ago. The Spearman r for the present measurement was 0.71 (N = 30), and for the retrospective measurement, 0.89 (N = 24). The internal consistency of the scale, using Cronbach’s alpha, at the first testing occasion was 0.85 for the present measurement and 0.76 for the retrospective measurement. At the second testing occasion, the alpha was 0.88 for the present and 0.90 for the retrospective measurements. RESULTS The results for the first question indicated that the subjects had a slightly positive feeling toward their body image at two and six weeks postpartum (Table 1). To determine the frequency of the scores as they occurred in the various segments of the scale, the scores from the Attitude to Body Image Scale were grouped into three categories: positive (scores ranging from 1-3.9), neutral (scores ranging from 4-4.9), and negative (scores ranging from 57). The majority of subjects (71.4%) in this study had a positive attitude toward their bodies in the postpartum period (Table 2). With such a large number of subjects’ scores occurring in the positive category, that category was further divided into three subgroups: strongly positive (scores ranging from 1-1.9), moderately positive (scores ranging from 2-2.9), and slightly positive (scores ranging from 3-3.9). The
334
majority of subjects in the “positive” category indicated only a slightly positive postpartum attitude toward body image (Table 3). In relation to the second research question, no significant difference was found between the postpartal women’s body image attitude scores at two weeks and at six weeks, using the Wilcoxon Matched-Pair Signed Ranks Test. The third question was analyzed by using the Median Test with the postpartum mean scores (scores resulting from the mean calculation of the two postpartum attitude scores for each subject). A significant difference ( P < 0.03) was evident in attitude toward body image between primiparas and multiparas in the postpartum period. As indicated by the medians of the scores, the multiparas had a more positive attitude toward their body image than did the primiparas. In the analysis of the three subquestions that were part of the fourth question, the Wilcoxon Test was used (Table 4). The subjects felt more negative about their bodies during the last three months of -
pregnancy than they did before the onset of their pregnancy ( P < O.Ol), and more negative about their bodies in the postpartum period than they did before the onset of pregnancy ( P < 0.04). On the other hand, the subjects felt more positive about their body in the postpartum period than they did during the last three months of their pregnancy (P < 0.04).
DISCUSSION The finding that the majority of the subjects seemed to feel slightly positive about their bodies during the postpartum period is different from other studies. The majority of the women in Leifer’s study had low (negative) body satisfaction in the postpartum p e r i ~ d . ~ Other studies have indicated that one of the postpartum woman’s main concerns is the “return of her figure to normal.”’”’“ RUSsell indicated that the woman’s concern about her body and loss of figure is one of the factors that can contribute to the critical nature of the puerperium.‘ If women were so concerned about their
~~
Table 3. Frequency of the Positive Categories of Body Attitude Scores at Two and Six Weeks Postpartum
Positive Bodv Attitude Scores Strongly Positive
Postpartum Time
N
(’ -l .9)
Two weeks Six weeks
45 43
6 3
Moderately Positive
(2-2.9) 10 15
Slightly Positive
(3-3.9) 29 25
,~~
~
_
_
~
~
July/August 1985 JOG“
sonal need.’” The multiparas were more concerned about having enough physical rest and sleep. Mercer indicated that multiparas Direction of Attitude Change Wilcoxon were greatly concerned about their ability to relate to an inNegative 1517* creasing number of relationships Negative 1274‘ and about being able to care adPositive 1155 5 t ____ equately for another child.” The multipara’s priorities may shift to being more concerned about having enough energy to meet the demands of the family than about of figure to normal” and to link it how the body is changing and to body image attitude would seem how it looks. an important area for further reThe comparison between the search. prepregnant and the pregnant The finding that multiparas felt body attitude scores indicated that more positive about their postparthe subjects felt more negative tal body image than did the pritoward their body image during miparas can be interpreted in sevtheir pregnancy than they did beeral ways. First, the entire expefore the onset o f pregnancy. This rience of pregnancy, labor and finding compares favorably with delivery, and postpartum adjustother research in the area.’ I ’ I I ment was a new o n e for th e priPregnancy, particularly in the mipara. Therefore, the primipara last three months, does not repmay think it is reasonable to exresent a body state of smallness pect a quick return of her body to is rather distant from the ideal and its former state. The fact that the female figure so valued in society.’ body was not like it was before This discrepancy between the act h e onset of pregnancy, and that tual pregnant body and the ideal it did not seem to be changing to female body could account for the a more desirable state, could cremore negative attitude toward ate the more negative feelings body image during pregnancy, identified in this study. The mulwhich the subjects in this study tipara, on th e other hand, has had indicated. previous experience with th e Another factor that could exbodily changes that occur in pregplain the negative attitude toward nancy, delivery, and postpartum. the body in the last trimester of The multipara knows what to expregnancy is the fact that the enpect and, therefore, is not so disof the body, and parlarged size turbed by the seeming lack of, o r ticularly the enlarged abdomen, slow progress in postpartal bodily could be physically uncomfortachanges. This attitude was reble. Pregnant women in Carty’s flected in the more positive feelstudy talked about feeling uncomings toward body image during fortable and unwieldy.” t h e postpartum period. The finding that the subjects A second interpretation of this felt significantly more negative finding is that multiparas were just about their bodies in the postparnot as concerned about their bodtum period than they did before ies in t he postpartum period as the onset of their pregnancies were t h e primiparas. Grubb stated could be explained by the fact that the multiparas in her study, that th e body is still recovering although very concerned about their lack of time for themselves, from the recent experience with were less concerned about their pregnancy. The body is still alappearance than any other pertered dramatically from how it
Table 4. The Wilcoxon Matched-Pairs Analysis of the Comparison of Body Image Attitude at the Prepregnant, Pregnant, and the Postpartal Periods
-
-~
Period
Prepregnancy to pregnancy Prepregnancy to postpartum Pregnancy to postpartum
N
60 59 61
‘Pi001 t Pi004
bodies and the return of their figures to normal postpartum, they might have a rather negative attitude or feeling toward their bodies. However, in this study, when the specific attitude o r feeling toward the body was measured, the majority of the women (71.4% at two weeks and 70.5% at six weeks) indicated a positive feeling toward their bodies during the postpartum period. Only 25.4% at two weeks, and 27.9% at six weeks, indicated a neutral attitude of having no feeling o n e way o r the other toward their body image; 3.2% at two weeks and 1.6% at six weeks indicated a negative attitude toward their body image. The incongruency between the slightly positive body image attitudes found in this study and concern about “return of figure to normal” expressed in other work suggests that the meaning of the phrase “return of figure to normal” is unclear. Postpartal women may not be so concerned about t h e actual physical appearance of the body. Perhaps, the high degree of concern toward the body stems from how the body itself is being experienced subjectively. The body’s ability to function could be the component of the body the women were concerned about when they checked the “return of figure to normal.” The concern was not so much the degree of dissatisfaction with the actual shape and size of t h e body as the wording “return of figure to normal” might imply. Therefore, to identify what is meant by “return
July/August 1985 JOGNN
________
‘
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appeared and felt before the pregnancy. Also, the fact that the prepregnant data were collected retrospectively at the two-week, postpartum home visit could have influenced how the subject indicated s h e felt about her body before pregnancy. In the reality of experiencing her body at two weeks postpartum and being asked t o reflect back to how s h e felt about her prepregnant body, t h e subject might indicate a more positive rating of her prepregnant attitude than s h e would have had she answered the Attitude to Body lmage Scale at the actual time before pregnancy. The last comparison, between the pregnant period and t h e postpartum period, indicated that the subjects felt more positive about their body image in the postpartum period than they did during the last three months of their pregnancy. This finding is different from other research in the area. Both Leifer and Carty stated that the subjects in their studies were more dissatisfied with their bodies in the postpartum period than they were during their pregnancies.“ I ’ The findings in this study are more congruent with Harris’s findings that subjects showed t h e most body distortion in the ninth month of pregnancy and their postpartum scores of body distortion fell significantly.13A similarity exists between the reduced number of unusual body experiences in the postpartum period, which was Harris’s measure of body image, and the more positive postpartum body attitude scores of this study. NURSING IMPLICATIONS Nurses can help pregnant and postpartum women with their selfperceptions and in how they integrate their changing bodies into their daily lives. The nurse can help primiparas, specifically, t o
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understand that their bodies, which have changed so dramatically during their pregnancies, can only gradually return to their former prepregnant state. Women need to understand that they might feel more negative about their bodies a s they progress through their pregnancies because of its altered appearance, increased size, and general discomfort. The nurse can help postpartal women understand that, although they might feel more positive about their bodies in th e postpartum period than during their pregnancies, they might feel considerably more negative about their postpartal bodies than they did before the onset of their pregnancies. The nurse can help the woman gain insight into her own specific situation by giving her information about her changing body. If the woman gains insight into her particular situation, the woman’s ability t o cope with that situation will improve.22 Second, the findings of this study have implications for how t h e nature of th e postpartum period is interpreted. Dissatisfaction with the body has been identified a s a contributing factor to the critical nature of the postpartum p e r i ~ d . ~Also, . ~ certain nursing studies indicated that th e most frequently expressed concern of postpartum women was th e “return of th e figure to normal.” However, based on th e findings of this study, these assumptions and findings need t o be reexamined, 15.16.19 This study provides nurses with information to help them understand how women feel about the alterations they experience in their bodies during pregnancy and t h e postpartum period. Only after nurses have a better understanding about how women feel about their changing bodies during and after pregnancy will they be able
t o provide new and prospective mothers with more information about their feelings toward their bodies in the postpartum period. CONCLUSION T h e results gained from the specific investigation of the dimension of pregnant and postpartum body attitudes add to the growing body of knowledge about how women react to their changing bodies during pregnancy and t h e postpartum period. As the amount of information in this area increases and new insights are gained, nurses will be able to incorporate this new knowledge with greater confidence in their practice. This research-based approach to nursing practice should facilitate a more empathetic and informative nursing service to prospective and new mothers. REFERENCES 1. Moore DS. The body image in pregnancy. J Nurse-Midwif 1978;21(4):17-26. 2. Weinberg JS. Body image disturbance as a factor in the crisis situation of pregnancy. JOGNN 1978;7(2): 18-2 1. 3. Becker C. The postpartum period-what is reality? Can Nurse 1980;76(12):24-7. 4. Leifer M. Psychological changes accompanying pregnancy and motherhood. Genet Psycho1 Mono 1977;95:55-96. 5. Russell CS. Transition to parenthood: problems and gratifications. J Marriage Fam 1974;36(5):294301. 6. Mercer RT. The nurse and maternal tasks of early postpartum. Am J Matern-Child Nurs 1981;6(5): 34 1-5. 7. Schilder P. The image and appearance of the human body. New York: International Press, 1950. 8. Shontz FC. Perceptual and cognitive aspects of body experience. New York: Academic Press, 1969. 9. Traub AC, Orbach J. Psychophysical studies of body image 1. The adjustable body-distorting mirror. Arch Gen Psych 1964;11:53-4. 10. Fawcett JM, Frye S. An exploratory
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study of body image dimensionality. Nurs Res 1980;29(5):324-7. 11. Carty EA. My, you’re getting big. Can Nurse 1970;66(8):40-3. 12. McConnell OL, Daston PG. Body image changes in pregnancy. J Project Techn 1961;25( 12):45 1-6. 13. Harris R. Cultural differences in body perception during pregnancy. Br J Med Psychol 1979;52: 347-52. 14. Jourard SM, Secord PF. Bodycathexis a n d t h e ideal female figure, .I Abnorm Soc Psychol 1955;50:243-6. 15. Gruis M. Beyond maternity: postpartum concerns of mothers. Am J Matern Child Nurs 1977;2(3): 182-8. 16. Harrison MJ, Hicks SA. Postpartum concerns of mothers a n d their sources of help. Can J Public Health 1983;74(5):325-8.
17. Bull MJ. Changes in concerns of first-time mothers after o n e week a t home. JOGNN 1981;10(5):3914. 18. Moss JR. Concern of multiparas o n t h e third day postpartum. JOGNN 1981;10(6):421-4. 19. Pate ME. A study of concerns of mothers during t h e puerperium and their sources of help: a replication. Unpublished master’s thesis, University of Washington, Seattle, 1979. 20. Grubb C. Perceptions of time by multiparous women in relation t o themselves and others during t h e first postpartal month. MaternChild Nurs J 1980;9(4):225-331. 21. Mercer R. She’s a multip-she knows t h e ropes. Am J MaternChild Nurs 1979;4(5):301-4. 22. Caplan G. Principles of preventive
psychiatry. New Books, Inc., 1964.
York:
Basic
Address for correspondence: Victoria Strang, RN, M N , Faculty of Nursing, T h e University of Alberta, Clinical Sciences Building, Edmonton, Alberta, Canada T6G263. Victoria Strang is an assistant professor at the University of Alberta, Faculty of Nursing, in Edmonton, Alberta, Canada. Ms. Strang is a member of the Canadian Nurses Association and the Canadian Public Health Association. Patricia Sullivan is an associate professor at Dalhousie University, Faculty of Nursing, in Halifax, Nova Scotia, Canada. Dr. Sullivan is a member of the Canadian Nurses Association and the Canadian Association of Untversity Schools of Nursing.
letters (Continued from page 3 70)
warfarin.” It is ultimately the patient who makes the decision to use an alternative drug and still nurse her baby. I personally would put up with an injectable medication and its regimen in order to breastfeed. Nursing care would not call for an “advise against” this choice, but would require contin-
uous support along with filling the client’s need to know and understand her treatment. What a doctor o r nurse feel a r e t h e best managements might not be in the best interest of th e patient. If a mother-to-be is told, at t h e onset of her prenatal care, that breastfeeding is out, s h e may never discover that sh e could have
nursed using an alternative drug. By giving out factual information and referring her to specialists on breastfeeding, such a s La Leche League, International, s h e can make the decision that is best for her.
JOMARIEF. KELLY, R N Galveston, Texas
~~
SYMPOSIUM SCHEDULED
Rush-Presbyterian-St. Luke’s Medical Center and Rush University will offer a symposium entitled “The Blue Ribbon Baby: Quality Care from Conception Through Birth” on October 3 and 4, 1985. Conference cosponsors are the Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Obstetric/Genecological Nursing, Rush-Presbyterian-St. Luke’s Medical Center, Chicago. The registration fee for nurses is $125, and 16 credit hours will be offered. The symposium will take place at the Hyatt Oakbrook in Oakbrook, Illinois. For additional information, contact Barbara Trejo, Meeting Planner, at (312) 942-7119.
July/August 1985 JOGNN
337
Research was conducted to investigate postpartal women's attitudes toward their body image; these attitudes were then compared to their prepregnant and pregnant body image attitudes. A repeated measures design was used, with data collected at two and six weeks postpartum. Pregnant and prepregnant attitudes were collected retrospectively. A nonrandom, convenience sample of 63 multiparas and primiparas was used. The results indicated that the subjects had a slightly positive attitude toward their postpartum body image; multiparas felt more positive about their postpartum body image than did the primiparas; the women felt more positive about their prepregnant body image than about their postpartum body image; and the women felt more positive about their postpartum body image than about their pregnant body image.
form in our minds a s a tridimenThe idealized female body is sional unity involving physiologic, valued in our society.',' However, psychologic, and social factors.' the changes that occur to the body The image is the composite of due to pregnancy reflect that the woman is perhaps further from perceptions, attitudes, and feelings each individual has of his/her own the ideal body than s h e ever has been. After delivery, the woman's body as it exists in space.8 These components of body image have body still appears ~ r e g n a n tThis .~ been identified as two indepenis a very dissatisfying experience dent dimensions, body perception for many women.4 This dissatisand body a t t i t ~ d e . ~Body , ' ~ perfaction with the body has been ception refers to the direct mental identified a s one of the factors experience of the physical apwhich contribute to the critical nature of the postpartum p e r i ~ d . ~ ,pearance ~ of the body, which encompasses surface depth and postural mental pictures. The attituLITERATURE REVIEW dinal dimension encompasses a broad spectrum of feelings, attiBody image has been defined tudes, and emotional reactions toa s the picture or mental image we ward the body a n d represents the Submitted: September 1983. Accepted: individuals' valuation of their March 1984. bodies. 332
In studies of the attitudinal dimension of body image during the p re g n a n c y /p o s tp a rtu m period, women's dissatisfaction with their bodies seemed to increase as their p re g n a n c ie s progressed and peaked in the postpartum per i ~ d . ' , ~ .The '' women who were positive about themselves before pregnancy and who were happy with their pregnancies seemed positive about the changes that occurred in their bodies during their pregnancies and the postpartum p e r i ~ d . ' However, ~~'~ some studies did not explore the postpartum period.',':' Other studies investigating attitude toward body image in the postpartum period either presented insufficient data o r presented data only for the early segment of the postpartum July/August 1985 JOG"
period.4.11.12Also, the types of subjects were not congruent among the various studies. McConnell and Daston used only multiparas, Leifer and Harris used only primiparas, and Carty and Moore used both multiparas a n d primiparas, 1.4,10-12
RESEARCH QUESTIONS The following specific research questions were addressed: 1. What is the woman’s attitude toward her body image during the second and the sixth week of the postpartum period? 2. Does her attitude toward her body image change between two and six weeks postpartum? 3. 1s there a difference in attitude toward body image between primiparas and multiparas? 4. 1s there a difference among prepregnant attitude to body image, pregnant attitude to body image, and postpartal attitude to body image in postpartum women? A) Is there a difference between prepregnant attitude to body image and pregnant attitude to body image? B) Is there a difference between prepregnant attitude to body image and postpartal attitude to body image measured at two and six weeks? C) Is there a difference between pregnant attitude to body image and postpartal attitude t o body image measured at two and six weeks?
METHODS Design The research design was a repeated time measure design of the postpartal woman’s attitude toward body image at two and six weeks postpartum. The prepregnant and pregnant attitude to body
July/August 1985 JOCNN
image was collected retrospectively during the two-week postpartum home visit.
Sample
A group of 109 postpartal women who gave birth to healthy full-term infants at a large urban hospital in western Canada, between January 3, 1982, and February 1 , 1982, were approached to participate in the study. Criteria for inclusion in the study were that 1) the birth was a vaginal delivery, with no surgical procedure performed other than episiotomy; 2) the delivery was a single birth; 3) the mother and the infant had no diagnosed medical problems indicated on the hospital chart; 4) the mother and infant were discharged from the hospital together; 5) the mother and father of the infant were married and living together; 6) the mother spoke fluent English; and 7) the mother resided within the limits of the city chosen for the study. From this population of 109 women, 63 women-30 primiparas and 33 multiparas-consented to participate in the study. The subjects’ ages ranged from 20 to 37 years, inclusive. The mean age for the primiparas and multiparas was 25.2 and 27.8 years, respectively. The 58% of the population who chose to participate were similar to the 42% who chose not to participate, in that all met the criteria for inclusion. Many of the nonparticipating women indicated interest in the study, but wanted the investigator to come to their homes at three o r four weeks postpartum, rather than at two weeks. Other reasons for declining involvement were related to fatigue, infant concerns, being too busy, o r maternal illness. Instrument The Attitude to Body lmage Scale, a modified version of Jour-
ard’s Body Cathexis Scale, was used.I4The Attitude to Body Image Scale measured the degree and direction of feelings toward one’s body in the prepregnancy, pregnancy, and postpartal periods. The Attitude to Body lmage Scale consisted of a list of ten body parts: weight, bust, waist, hips, legs, feet, facial appearance, shoulder width, abdomen, and hair. The subjects indicated their attitude toward their bodies by rating each of the body parts on a Likert-type scale. On this scale, a rating of o n e represented strong positive feeling; two, positive feeling; three, slight positive feeling; four, no feeling one way or the other; five, slight negative feeling; six, negative feeling; and seven, strong negative feeling. To calculate the final body attitude score, the total score of all ten bodyparts was divided by ten. Therefore, the body attitude score could have ranged from one, indicating a strong positive feeling toward the body, to seven, indicating a strong negative feeling toward the body. Three experts in the field of maternal-child nursing, community health nursing, and statistics were asked, independently, to determine the content validity of the Attitude to Body lmage Scale. These experts were asked to indicate whether o r not the items on the Attitude to Body lmage Scale had been modified adequately to obtain data on body parts which were likely to change during pregnancy and the postpartum period. The test-retest method, with a four-week interval, was used to estimate the reliability of the Attitude to Body lmage Scale. On both testing occasions, 32 nonpregnant subjects were requested to respond to the instrument, indicating their current body image attitude and their attitude toward their body image of approximately
333
Table 1. Median and lnterquartile Range of Body Attitude Scores of Women at Two and Six Weeks Postpartum
Table 2. Frequency of Positive, Neutral, and Negative Body Attitude Scores at Two and Six Weeks Postpartum __~___-__. . - .
Body Attitude Scores ~
Postpartum Time Body Attitude Scores
2 Weeks (N = 63)
6 Weeks (N = 61)
Median lnterquartile range
3.4 3-4
3.5 2.5-4
Postpartum Time
Positive
Neutral
Negative
N
(1-3.9)
(4-4.9)
(5-7)
Two weeks Six weeks
63 61
45 43
16 17
2 1
~
___-_I
_
_
--
one year ago. The Spearman r for the present measurement was 0.71 (N = 30), and for the retrospective measurement, 0.89 (N = 24). The internal consistency of the scale, using Cronbach’s alpha, at the first testing occasion was 0.85 for the present measurement and 0.76 for the retrospective measurement. At the second testing occasion, the alpha was 0.88 for the present and 0.90 for the retrospective measurements. RESULTS The results for the first question indicated that the subjects had a slightly positive feeling toward their body image at two and six weeks postpartum (Table 1). To determine the frequency of the scores as they occurred in the various segments of the scale, the scores from the Attitude to Body Image Scale were grouped into three categories: positive (scores ranging from 1-3.9), neutral (scores ranging from 4-4.9), and negative (scores ranging from 57). The majority of subjects (71.4%) in this study had a positive attitude toward their bodies in the postpartum period (Table 2). With such a large number of subjects’ scores occurring in the positive category, that category was further divided into three subgroups: strongly positive (scores ranging from 1-1.9), moderately positive (scores ranging from 2-2.9), and slightly positive (scores ranging from 3-3.9). The
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majority of subjects in the “positive” category indicated only a slightly positive postpartum attitude toward body image (Table 3). In relation to the second research question, no significant difference was found between the postpartal women’s body image attitude scores at two weeks and at six weeks, using the Wilcoxon Matched-Pair Signed Ranks Test. The third question was analyzed by using the Median Test with the postpartum mean scores (scores resulting from the mean calculation of the two postpartum attitude scores for each subject). A significant difference ( P < 0.03) was evident in attitude toward body image between primiparas and multiparas in the postpartum period. As indicated by the medians of the scores, the multiparas had a more positive attitude toward their body image than did the primiparas. In the analysis of the three subquestions that were part of the fourth question, the Wilcoxon Test was used (Table 4). The subjects felt more negative about their bodies during the last three months of -
pregnancy than they did before the onset of their pregnancy ( P < O.Ol), and more negative about their bodies in the postpartum period than they did before the onset of pregnancy ( P < 0.04). On the other hand, the subjects felt more positive about their body in the postpartum period than they did during the last three months of their pregnancy (P < 0.04).
DISCUSSION The finding that the majority of the subjects seemed to feel slightly positive about their bodies during the postpartum period is different from other studies. The majority of the women in Leifer’s study had low (negative) body satisfaction in the postpartum p e r i ~ d . ~ Other studies have indicated that one of the postpartum woman’s main concerns is the “return of her figure to normal.”’”’“ RUSsell indicated that the woman’s concern about her body and loss of figure is one of the factors that can contribute to the critical nature of the puerperium.‘ If women were so concerned about their
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Table 3. Frequency of the Positive Categories of Body Attitude Scores at Two and Six Weeks Postpartum
Positive Bodv Attitude Scores Strongly Positive
Postpartum Time
N
(’ -l .9)
Two weeks Six weeks
45 43
6 3
Moderately Positive
(2-2.9) 10 15
Slightly Positive
(3-3.9) 29 25
,~~
~
_
_
~
~
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sonal need.’” The multiparas were more concerned about having enough physical rest and sleep. Mercer indicated that multiparas Direction of Attitude Change Wilcoxon were greatly concerned about their ability to relate to an inNegative 1517* creasing number of relationships Negative 1274‘ and about being able to care adPositive 1155 5 t ____ equately for another child.” The multipara’s priorities may shift to being more concerned about having enough energy to meet the demands of the family than about of figure to normal” and to link it how the body is changing and to body image attitude would seem how it looks. an important area for further reThe comparison between the search. prepregnant and the pregnant The finding that multiparas felt body attitude scores indicated that more positive about their postparthe subjects felt more negative tal body image than did the pritoward their body image during miparas can be interpreted in sevtheir pregnancy than they did beeral ways. First, the entire expefore the onset o f pregnancy. This rience of pregnancy, labor and finding compares favorably with delivery, and postpartum adjustother research in the area.’ I ’ I I ment was a new o n e for th e priPregnancy, particularly in the mipara. Therefore, the primipara last three months, does not repmay think it is reasonable to exresent a body state of smallness pect a quick return of her body to is rather distant from the ideal and its former state. The fact that the female figure so valued in society.’ body was not like it was before This discrepancy between the act h e onset of pregnancy, and that tual pregnant body and the ideal it did not seem to be changing to female body could account for the a more desirable state, could cremore negative attitude toward ate the more negative feelings body image during pregnancy, identified in this study. The mulwhich the subjects in this study tipara, on th e other hand, has had indicated. previous experience with th e Another factor that could exbodily changes that occur in pregplain the negative attitude toward nancy, delivery, and postpartum. the body in the last trimester of The multipara knows what to expregnancy is the fact that the enpect and, therefore, is not so disof the body, and parlarged size turbed by the seeming lack of, o r ticularly the enlarged abdomen, slow progress in postpartal bodily could be physically uncomfortachanges. This attitude was reble. Pregnant women in Carty’s flected in the more positive feelstudy talked about feeling uncomings toward body image during fortable and unwieldy.” t h e postpartum period. The finding that the subjects A second interpretation of this felt significantly more negative finding is that multiparas were just about their bodies in the postparnot as concerned about their bodtum period than they did before ies in t he postpartum period as the onset of their pregnancies were t h e primiparas. Grubb stated could be explained by the fact that the multiparas in her study, that th e body is still recovering although very concerned about their lack of time for themselves, from the recent experience with were less concerned about their pregnancy. The body is still alappearance than any other pertered dramatically from how it
Table 4. The Wilcoxon Matched-Pairs Analysis of the Comparison of Body Image Attitude at the Prepregnant, Pregnant, and the Postpartal Periods
-
-~
Period
Prepregnancy to pregnancy Prepregnancy to postpartum Pregnancy to postpartum
N
60 59 61
‘Pi001 t Pi004
bodies and the return of their figures to normal postpartum, they might have a rather negative attitude or feeling toward their bodies. However, in this study, when the specific attitude o r feeling toward the body was measured, the majority of the women (71.4% at two weeks and 70.5% at six weeks) indicated a positive feeling toward their bodies during the postpartum period. Only 25.4% at two weeks, and 27.9% at six weeks, indicated a neutral attitude of having no feeling o n e way o r the other toward their body image; 3.2% at two weeks and 1.6% at six weeks indicated a negative attitude toward their body image. The incongruency between the slightly positive body image attitudes found in this study and concern about “return of figure to normal” expressed in other work suggests that the meaning of the phrase “return of figure to normal” is unclear. Postpartal women may not be so concerned about t h e actual physical appearance of the body. Perhaps, the high degree of concern toward the body stems from how the body itself is being experienced subjectively. The body’s ability to function could be the component of the body the women were concerned about when they checked the “return of figure to normal.” The concern was not so much the degree of dissatisfaction with the actual shape and size of t h e body as the wording “return of figure to normal” might imply. Therefore, to identify what is meant by “return
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appeared and felt before the pregnancy. Also, the fact that the prepregnant data were collected retrospectively at the two-week, postpartum home visit could have influenced how the subject indicated s h e felt about her body before pregnancy. In the reality of experiencing her body at two weeks postpartum and being asked t o reflect back to how s h e felt about her prepregnant body, t h e subject might indicate a more positive rating of her prepregnant attitude than s h e would have had she answered the Attitude to Body lmage Scale at the actual time before pregnancy. The last comparison, between the pregnant period and t h e postpartum period, indicated that the subjects felt more positive about their body image in the postpartum period than they did during the last three months of their pregnancy. This finding is different from other research in the area. Both Leifer and Carty stated that the subjects in their studies were more dissatisfied with their bodies in the postpartum period than they were during their pregnancies.“ I ’ The findings in this study are more congruent with Harris’s findings that subjects showed t h e most body distortion in the ninth month of pregnancy and their postpartum scores of body distortion fell significantly.13A similarity exists between the reduced number of unusual body experiences in the postpartum period, which was Harris’s measure of body image, and the more positive postpartum body attitude scores of this study. NURSING IMPLICATIONS Nurses can help pregnant and postpartum women with their selfperceptions and in how they integrate their changing bodies into their daily lives. The nurse can help primiparas, specifically, t o
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understand that their bodies, which have changed so dramatically during their pregnancies, can only gradually return to their former prepregnant state. Women need to understand that they might feel more negative about their bodies a s they progress through their pregnancies because of its altered appearance, increased size, and general discomfort. The nurse can help postpartal women understand that, although they might feel more positive about their bodies in th e postpartum period than during their pregnancies, they might feel considerably more negative about their postpartal bodies than they did before the onset of their pregnancies. The nurse can help the woman gain insight into her own specific situation by giving her information about her changing body. If the woman gains insight into her particular situation, the woman’s ability t o cope with that situation will improve.22 Second, the findings of this study have implications for how t h e nature of th e postpartum period is interpreted. Dissatisfaction with the body has been identified a s a contributing factor to the critical nature of the postpartum p e r i ~ d . ~Also, . ~ certain nursing studies indicated that th e most frequently expressed concern of postpartum women was th e “return of th e figure to normal.” However, based on th e findings of this study, these assumptions and findings need t o be reexamined, 15.16.19 This study provides nurses with information to help them understand how women feel about the alterations they experience in their bodies during pregnancy and t h e postpartum period. Only after nurses have a better understanding about how women feel about their changing bodies during and after pregnancy will they be able
t o provide new and prospective mothers with more information about their feelings toward their bodies in the postpartum period. CONCLUSION T h e results gained from the specific investigation of the dimension of pregnant and postpartum body attitudes add to the growing body of knowledge about how women react to their changing bodies during pregnancy and t h e postpartum period. As the amount of information in this area increases and new insights are gained, nurses will be able to incorporate this new knowledge with greater confidence in their practice. This research-based approach to nursing practice should facilitate a more empathetic and informative nursing service to prospective and new mothers. REFERENCES 1. Moore DS. The body image in pregnancy. J Nurse-Midwif 1978;21(4):17-26. 2. Weinberg JS. Body image disturbance as a factor in the crisis situation of pregnancy. JOGNN 1978;7(2): 18-2 1. 3. Becker C. The postpartum period-what is reality? Can Nurse 1980;76(12):24-7. 4. Leifer M. Psychological changes accompanying pregnancy and motherhood. Genet Psycho1 Mono 1977;95:55-96. 5. Russell CS. Transition to parenthood: problems and gratifications. J Marriage Fam 1974;36(5):294301. 6. Mercer RT. The nurse and maternal tasks of early postpartum. Am J Matern-Child Nurs 1981;6(5): 34 1-5. 7. Schilder P. The image and appearance of the human body. New York: International Press, 1950. 8. Shontz FC. Perceptual and cognitive aspects of body experience. New York: Academic Press, 1969. 9. Traub AC, Orbach J. Psychophysical studies of body image 1. The adjustable body-distorting mirror. Arch Gen Psych 1964;11:53-4. 10. Fawcett JM, Frye S. An exploratory
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study of body image dimensionality. Nurs Res 1980;29(5):324-7. 11. Carty EA. My, you’re getting big. Can Nurse 1970;66(8):40-3. 12. McConnell OL, Daston PG. Body image changes in pregnancy. J Project Techn 1961;25( 12):45 1-6. 13. Harris R. Cultural differences in body perception during pregnancy. Br J Med Psychol 1979;52: 347-52. 14. Jourard SM, Secord PF. Bodycathexis a n d t h e ideal female figure, .I Abnorm Soc Psychol 1955;50:243-6. 15. Gruis M. Beyond maternity: postpartum concerns of mothers. Am J Matern Child Nurs 1977;2(3): 182-8. 16. Harrison MJ, Hicks SA. Postpartum concerns of mothers a n d their sources of help. Can J Public Health 1983;74(5):325-8.
17. Bull MJ. Changes in concerns of first-time mothers after o n e week a t home. JOGNN 1981;10(5):3914. 18. Moss JR. Concern of multiparas o n t h e third day postpartum. JOGNN 1981;10(6):421-4. 19. Pate ME. A study of concerns of mothers during t h e puerperium and their sources of help: a replication. Unpublished master’s thesis, University of Washington, Seattle, 1979. 20. Grubb C. Perceptions of time by multiparous women in relation t o themselves and others during t h e first postpartal month. MaternChild Nurs J 1980;9(4):225-331. 21. Mercer R. She’s a multip-she knows t h e ropes. Am J MaternChild Nurs 1979;4(5):301-4. 22. Caplan G. Principles of preventive
psychiatry. New Books, Inc., 1964.
York:
Basic
Address for correspondence: Victoria Strang, RN, M N , Faculty of Nursing, T h e University of Alberta, Clinical Sciences Building, Edmonton, Alberta, Canada T6G263. Victoria Strang is an assistant professor at the University of Alberta, Faculty of Nursing, in Edmonton, Alberta, Canada. Ms. Strang is a member of the Canadian Nurses Association and the Canadian Public Health Association. Patricia Sullivan is an associate professor at Dalhousie University, Faculty of Nursing, in Halifax, Nova Scotia, Canada. Dr. Sullivan is a member of the Canadian Nurses Association and the Canadian Association of Untversity Schools of Nursing.
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warfarin.” It is ultimately the patient who makes the decision to use an alternative drug and still nurse her baby. I personally would put up with an injectable medication and its regimen in order to breastfeed. Nursing care would not call for an “advise against” this choice, but would require contin-
uous support along with filling the client’s need to know and understand her treatment. What a doctor o r nurse feel a r e t h e best managements might not be in the best interest of th e patient. If a mother-to-be is told, at t h e onset of her prenatal care, that breastfeeding is out, s h e may never discover that sh e could have
nursed using an alternative drug. By giving out factual information and referring her to specialists on breastfeeding, such a s La Leche League, International, s h e can make the decision that is best for her.
JOMARIEF. KELLY, R N Galveston, Texas
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SYMPOSIUM SCHEDULED
Rush-Presbyterian-St. Luke’s Medical Center and Rush University will offer a symposium entitled “The Blue Ribbon Baby: Quality Care from Conception Through Birth” on October 3 and 4, 1985. Conference cosponsors are the Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Department of Obstetric/Genecological Nursing, Rush-Presbyterian-St. Luke’s Medical Center, Chicago. The registration fee for nurses is $125, and 16 credit hours will be offered. The symposium will take place at the Hyatt Oakbrook in Oakbrook, Illinois. For additional information, contact Barbara Trejo, Meeting Planner, at (312) 942-7119.
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