Treading the tightrope between motherhood and an eating disorder: A qualitative study

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

Contents lists available at ScienceDirect

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 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 b

A R T I C L E I N F O

A B S T R A C T

Keywords: Breast-feeding Eating disorders Motherhood Pregnancy Qualitative research

Background: Pregnancy is a life event that involves a change in appearance, during which the eating behaviour and body of childbearing women is scrutinised by others. The impact this has on the thoughts and behaviours of individuals who have or have had an eating disorder has been little investigated. Objectives: A qualitative project to provide a deeper understanding of the views of women 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?  Women may have an eating disorder during pregnancy.  Having an eating disorder during pregnancy has potential risks for the woman and fetus.  In the postnatal period, eating disorders may be exacerbated.

* Corresponding author. Tel.: +44 0161 306 7651. E-mail address: [email protected] (S. Tierney). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.11.007

What this paper adds:  During pregnancy and in the early stages of motherhood, women can feel a conflict between heeding to the demands of an eating disorder and doing what they feel is best for their child.  This conflict can cause women to question their mothering skills and deplete their already diminished self-esteem.  An inability to relinquish extreme weight control practices relates to the functional qualities women attach to their eating disorder.

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 an eating disorder history may be seen by these mothers as an external marker of their success as a parent. 1. Background Over recent decades, eating disorders have entered the public’s consciousness. They are regularly discussed, and often trivialised, in the popular media, depicted as no more than dieting gone wrong or overzealous weight loss. Yet these conditions warrant serious consideration because they are potentially life-threatening and can persist for years, ruining individuals’ long-term health, their personal and their social functioning. Colton et al. (2004) wrote that eating disorders encompass behaviours such as fasting, bingeing and selfinduced vomiting, and psychological traits such as preoccupation with weight and shape, body image distortion and disturbed attitudes towards food. The most commonly discussed eating disorders are anorexia and bulimia nervosa, which are said to be united by a core psychopathology in which weight and shape are over-evaluated as a measure of self-worth (Fairburn and Harrison, 2003). The term ‘anorexia nervosa’, in itself, is misleading because it literally means nervous loss of appetite, whereas those with this condition do not lose their appetite, or at least not until starvation is advanced. Rather, they ignore their physical needs and suppress their intake, to maintain a subnormal weight, whilst at the same time tending to become increasingly preoccupied by thoughts of food and eating. Bulimia is characterised by strong, uncontrollable urges to binge, followed by compensatory behaviours, such as vomiting, laxative abuse and excessive exercise. Some individuals with anorexia may also engage in these more extreme forms of weight control; a distinction between restricting and binge-eating/purging anorexia was made for the first time in the mid 1990s (APA, 1994). However, the low weight of those classed as having binge-eating/purging anorexia means that a diagnosis of anorexia trumps that of bulimia. Aside from anorexia and bulimia, there is a third broad set of eating disorders classed as EDNOS (eating disorder not otherwise specified). This term encompasses a heterogeneous group of problems and is a label that can be applied to approximately half of eating disorder cases (Fairburn and Harrison, 2003). EDNOS incorporates people who have subclinical disorders (e.g. failing to fulfil one or more of the diagnostic criteria for anorexia or bulimia nervosa) (APA, 2000). It also applies to individuals who utilise other means of preventing weight gain (such as chewing and spitting out food) (Rock, 1999). In addition, binge eating disorder is currently listed under this umbrella term, which differs from bulimia because people do not purge after a binge, meaning that they tend to be overweight or obese. Eating difficulties described as EDNOS should not be regarded as less severe; such disorders can be equally as serious as fully diagnosed anorexia or bulimia (Walsh and Garner, 1997). It is typical for anorexia to develop at a younger age (early adolescence) to bulimia, the latter being rarer in those under 14, with onset tending to occur in older

adolescents and young adults (Lask and Bryant-Waugh, 1992). Both conditions are more common in females than males, with an estimated 5–10% of these eating disorders occurring among men (Button et al., 2008). Researchers have more recently started to examine the distribution of EDNOS, which it is suggested develops among adolescent and young women primarily (Fairburn and Harrison, 2003). Given that eating disorders generally affect females of childbearing age, such conditions are possible during pregnancy. For individuals with anorexia, fertility may be compromised because of low body weight. In contrast, those with bulimia appear to have fewer problems conceiving, even though they may have menstrual irregularities (Ward, 2008). In a large, UK-based community cohort study, over 4% of the 12, 254 pregnant women involved were reported to have a recent or past eating disorder, mainly of a bulimic type (Micali et al., 2007). Pregnancy can result in improved eating behaviours to avoid any adverse impact on the unborn child (Patel et al., 2002). However, some women continue having anxieties about their weight and still engage in practices such as dieting, laxative abuse, over-exercising and self-induced vomiting whilst pregnant (Micali et al., 2007). Experiencing an active eating disorder when pregnant has been associated with negative outcomes (Martos-Ordonez, 2005; Van der Spuy et al., 1988; Ward, 2008), including an increased risk of miscarriage, pre-eclampsia, low birth weight and congenital malformations. Pregnant women with an eating disorder are said to require greater time and attention at antenatal visits (NICE, 2004), to reduce potential risks to the fetus. Education about body changes and cravings, guidance about eating healthily and positive reinforcement of weight gain are all denoted as important for this population (Ward, 2008). Additional support from health professionals may also be needed during the postnatal period since women with an eating disorder are said to be at an increased risk of depression at this timepoint (Morgan et al., 2006). These women may experience an exacerbation of eating disorder pathology after giving birth (Welch et al., 1997), perhaps being tempted to use potentially dangerous behaviours to lose post-pregnancy weight (Ward, 2008) and/or because it can be hard to have regular eating patterns with an infant (Park et al., 2003). Most research looking at motherhood and eating disorders, to date, has been based on questionnaire data and has not explored in-depth the experiences of women who have such a condition and are also pregnant or have recently given birth. A review of the literature located two investigations broaching this topic using semi-structured interviews. One was conducted in America and involved six females with anorexia, who suggested that pregnancy enabled them to take better self-care and was a time when their body received positive attention, although there was a fear that they would never look the same again (Namir et al., 1986). The second used grounded theory to explore the experiences of 16 women in the UK, most of whom selfdefined as having bulimia (Stapleton, 2007). Interviewees in this study noted that it was easier not to be so critical about their weight when pregnant. However, once the

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

child was born some participants described being driven to return to their original body shape and were disheartened that this did not transpire as quickly as they wanted. These existing papers were employed as a building block for research outlined below, expanding topics raised within them (e.g. participants’ relationship with their partner and women’s views of socialising with a young child), whilst also broaching new areas of investigation (e.g. emotions). 2. Conceptual framework for the study The study was guided by the notion that eating disorders play a functional role in the lives of individuals diagnosed with such conditions. Triggers for onset may include traumatic events (e.g. abuse in childhood, bullying, family conflict) (Dallos and Denford, 2008; Jeppson et al., 2003; Weaver et al., 2005), but this is not always the case. What is common in narratives from those with an eating disorder is that management of food and weight are areas of life in which individuals believe they can exhibit control (Button and Warren, 2001). Women have recounted the positive benefits they derive from bulimic symptoms, which can make them feel different and special (Serpell et al., 1999), with the binge–purge cycle experienced as empowering because it enables people to eat what they want without getting fat (Jeppson et al., 2003). Likewise, those with anorexia have recounted feeling unique by engaging in food restraint, seeing weight loss as a tangible sign of success (Tierney and Fox, 2010). Individuals have depicted their eating disorder as comforting, something they can rely on in times of difficulty (Arkell and Robinson, 2008), which can be enacted without involvement from others (Jeppson et al., 2003). Eating disorders have been said to arise among those with inadequate identity formation, with a focus on weight and associated behaviours distracting them from concerns about a poor sense of self (Polivy and Herman, 2002). Given the functional quality individuals have ascribed to an eating disorder, as outlined above, the authors wished to explore how this was affected prior to and after giving birth. 2.1. Aims The study presented in this paper aimed to provide a deeper understanding of the views of women with an eating disorder when pregnant and during the early years of their child’s life. Specific objectives included:  To understand women’s experiences of pregnancy and motherhood whilst also having or having had an eating disorder, exploring how one might impact on the other.  To understand these women’s perceptions of support whilst pregnant and in the early months of a child’s life.  To understand these women’s experiences of caring for a new infant. 3. Method 3.1. Design Qualitative research was undertaken to address the aims listed above. This type of investigation strives ‘‘to

1225

understand and represent the experiences and actions of people as they encounter, engage, and live through situations’’ (Elliott et al., 1999, p. 216). Approval for the project was provided by a local NHS research ethics committee. The research team consisted of one investigator specialised in eating disorder research (ST), a clinical psychologist who has conducted several studies on eating disorders (JF), two midwifery lecturers with experience of research focused on mental health and pregnancy (CF, CB), and a midwife consultant (ES). They came together to work on this project because it was felt that their diverse backgrounds would enhance the interpretation of data. This group of investigators met on a regular basis (approximately every six weeks) during the research to think about data that was being collected, which enabled their differing perspectives to inform the analysis and questioning in later interviews. Midwives within the group were able to talk about the clinical environment and policy associated with antenatal and post-natal care, whilst the other researchers commented on eating disorders more generally and how participants’ stories related to existing literature in this field. Discussion from these differing perspectives led to group consensus on final themes. 3.2. Sample The authors aimed to recruit women who had a diagnosed eating disorder or some form of eating disturbance that impacted on their physical and/or psychosocial functioning. We felt it was important to have a broad definition of eating disorder/disturbance because many people are estimated to live with problems that could be classed as EDNOS who do not receive professional support (Treasure et al., 2010). Hence, the term ‘eating problem’ was used in information about the study given to women since it was anticipated that there would be potential participants who did not consider themselves as having an eating disorder per se. It was hoped that this would help to recruit individuals who had not necessarily received treatment but still had difficulties with food/weight. Women were eligible to participate if:  16 weeks + pregnant or if they had their last child within the past two years (since the project’s focus was on the early stages of a child’s life).  Over 16 years.  Conversant in English.  Identified with risk factors associated with eating disorders as measured by two screening questionnaires. The initial intention was to recruit via a large acute 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 all eligible women attending for antenatal care. Women interested in taking part were invited to complete the questionnaire and to return it to the research team in a prepaid envelope. They were then contacted by one of the 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 questionnaire. This questionnaire consisted of two short tools, developed for use in general practice to detect eating disorders: the SCOFF (Morgan et al., 1999) and the Eating disorder Screen for Primary care (ESP) (Cotton et al., 2003). Women were asked to answer the former in terms of the three months prior to getting pregnant and the latter to reflect their current situation. Answering ‘yes’ to two or more questions on either of these measures was sufficient for someone to be included in the project. In total, 28 women attending clinic posted their details to the research team, but only six met the cut-off score for one or both of the screening questionnaires. Discussion with midwives assisting with recruitment implied that they may have asked women to complete a pack even if they did not have an eating problem, even though the study information sheet made clear that potential participants should only respond to the request for an interview if they felt they had an eating problem. It was clear from questionnaire responses of those not identified as having an eating disorder that they did not carry out behaviours associated with such conditions (e.g. restricting/purging/eating in secret); they all said they were satisfied with their eating patterns and that their weight did not influence how they felt about themselves. Three of the six individuals who did meet the screening criteria could not be contacted; attempts were made to speak to them via the mobile phone number they had supplied, without success. Another person was not available for interview when she was contacted. Due to the lack of participants recruited from the hospital trust, information about the project was posted on an eating disorders organisation’s website (B-eat: www.beat.co.uk/Home). B-eat has been used in the past to good effect by the researchers. It is a national organisation that can be helpful in recruiting hard to reach individuals. Use of this website to publicise the study resulted in eight women contacting the research team and six further interviews being completed (two people could not be contacted, despite several attempts). These individuals were asked to complete the same screening questionnaire referred to above. 3.3. Data collection Between January–September 2009, semi-structured interviews were carried out, which were taped with participants’ written consent. They lasted an average of 80 min. Interviews were conducted face-to-face (n = 3) if a woman lived locally (<40 miles drive from the researchers’ place of work) or by telephone (n = 5) if situated further away. Informed consent was obtained on the day for faceto-face interviews or through the post if carried out over the phone. In the case of telephone interviews, the researcher reiterated the points listed on the consent form that the participant had signed to ensure they were still happy to be involved. An interview schedule was developed at a meeting by the research team to reflect the differing backgrounds of all authors. It aimed to address two agendas: clinical midwifery practice and the emotional/social well-being

of participants during and following pregnancy. The interview schedule asked women about:     

Experiences of their body. Views about healthcare received. Thoughts about feeding their child. Accounts of eating and purging behaviours. Opinions of support and others’ views of their eating/ weight control.

However, the semi-structured nature of data collection meant that interviewees were able and encouraged to describe in their own words factors influencing their responses, allowing them to offer their own account of their situation. 3.4. Data analysis Interview transcripts were analysed using a framework approach (Ritchie et al., 2003), a systematic technique that involves five stages: (1) familiarisation with the data; (2) development of a thematic framework; (3) indexing data; (4) devising thematic charts; (5) mapping and interpreting data. Interview recordings were transcribed verbatim by the first author. She checked transcription by listening back to the original recording. All members of the research team read and reread transcripts. They then developed an initial set of codes, which they collapsed into an indexing scheme. Three of the researchers worked together to chart data using this scheme, allowing for data reduction. Finally, the research team met again to interpret data listed in the charts, resulting in the themes described below. 4. Results All participants had experienced an eating disorder before becoming pregnant. Some had continued their weight control behaviours when pregnant, whilst others stopped during this period. In terms of eating disorder, two self-defined as being extremely restrictive in what they ate, one had been diagnosed with bulimia, four with a purging form of and one with restricting anorexia. Six interviewees had been treated for their eating disorder, one of whom no longer received such care at the point of data collection. The majority of individuals had started their disordered eating in their teens, although one person noted it was only following the birth of her second child that her anorexia developed. Three women said they had not planned their pregnancy. Most lived with a partner; only one was a single mother. Further details of participants can be found in Table 1. The overriding premise that authors identified through analysis was the divided loyalties interviewees experienced between putting the child first and heeding to their eating disorder. This notion, which incorporates themes described below, is depicted in Fig. 1. 4.1.1. Theme 1 – fear of failure There was much discussion by interviewees about getting things right in relation to their child. In order to

S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233 Table 1 Background details on participants at the time of interview. Participant

Pregnant or post pregnancy

Number of children

Age

I1 I2 I3 I4 I5 I6 I7 I8

Pregnant (37 weeks) Pregnant (20 weeks) Post pregnancy (12 months) Post pregnancy (24 months) Post pregnancy (8 months) Post pregnancy (12 months) Pregnant (18 weeks) Post pregnancy (2 months)

First pregnancy First pregnancy 3 1 1 2 1 1

17 26 37 33 34 29 29 30

I, interviewee.

achieve this aim, they read a range of literature or sought advice from websites. Breast-feeding was an area in which maternal skills could be undermined. Only one person described this in positive terms; participant 6 breast-fed both her children until they were aged one, which she defined as a ‘‘triumph’’ for her body. Most interviewees talked about wanting to breast-feed because they had been encouraged by midwives to do so. However, they generally experienced difficulties, having to stop because their offspring was not gaining adequate weight. This could make them feel as though they were not providing the best start for their child: I7: ‘‘I really, really wanted to be able to eat more in order to produce better milk and I couldn’t do it and I felt that I’d failed him. I can remember crying when I was buying the formula for the first time and I couldn’t. . .be around when he was given the formula because it upset me. . .I didn’t want anyone else to know he was getting the formula. There was only me and my husband that knew we were giving it to him.’’ Only one person was glad when advised to switch to formula by health professionals because it meant her daughter was no longer dependent on her body: I8: ‘‘I’m free now aren’t I really. I’ve not got that physical attachment to [daughter]. We’re two separate entities. My responsibility to her is in a different way now, it’s not in that physical, nutritional type.’’

Can impede their goal of being a perfect mother

Betraying the eating disorder

Putting their child first

Divided loyalties

Fear of failure

Transforming body and eating

Uncertainties about child’s shape

1227

Those who had a partner talked about support they received from this individual, both emotional (e.g. someone to turn to when they felt down) and practical (e.g. cooking meals, doing the shopping), but they were not necessarily open about their eating behaviours with this person. For example, whilst pregnant, participant 5 went upstairs and turned on the taps so she could make herself sick without her husband hearing and participant 4 was secretive about how much she was exercising. Both women concealed such activities because they felt they were letting down their spouse. Interviewees suggested they avoided socialising with other mothers because they felt uncomfortable discussing weight gain/loss and in case their child was unsettled; they worried that if they were unable to provide succour others would interpret this as evidence of poor mothering: I5: ‘‘. . .he wasn’t a nightmare baby but they cry a lot don’t they the first few months. . .I don’t like it if he starts to cry in front of other people because I always think he’s a problem and he’s not, he’s a baby, but I just feel on edge and that sends me on edge...’’ As this theme has highlighted, most participants were concerned about being judged negatively by others and placed a great emphasis on external markers of their mothering skills. Interviewees often focused on pointers they perceived as contrary to their endeavours to selfpresent as competent mothers (e.g. being unable to breastfeed). Perfectionism has been associated with eating disorder predisposition and onset (Polivy and Herman, 2002), which could explain participants’ unwillingness to disclosure their difficulties because they did not want to be regarded as unable to cope. Individuals with an eating disorder are generally secretive about their problem (Pettersen et al., 2008; Tierney, 2004), concerned about others’ reaction. Interviewees were anxious about society’s lack of understanding of behaviours (e.g. bingeing/ purging) they perceived as a necessary coping mechanism. This fear of being criticised was discussed by the following participant: I7: ‘‘I think people who haven’t experienced it can be very judgemental of someone who’s pregnant and can’t eat properly. I took part in an article for [newspaper] 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, they shouldn’t have children’, things like that. . . if you 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.’’ 4.1.2. Theme 2 – transforming body and eating behaviours

Emotional regulation

Fig. 1. The overriding concept derived from data analysis was that of the conflict interviewees expressed between motherhood and their eating disorder.

Upon hearing they were pregnant, a number of interviewees expressed their concerns about what this meant in terms of their eating and body shape, as 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 scared that I’m going to be awful. . .I don’t want to class myself as having an eating disorder but at the same time I know that I have disordered thinking and. . .I’m worried that might get in the way of being able to cope with being a mum.’’ Interviewees 2, 3 and 4 hated their shape whilst pregnant because they were the heaviest they had ever been. Conversely, although interviewees 5 and 8 disliked the first trimester because they worried they would be seen as getting fat, they were content when it became visibly obvious they were pregnant. These interviewees seemed able to cope with their abdomen changing because they could link it to their growing baby, but worried about arms and legs becoming larger, unable to attribute this directly to pregnancy. Participant 5 did not like her dress sizes increasing but said she loved her bump because it was solid and round. Similarly, participant 6 defined her stomach as ‘‘beautiful. . .nice and smooth’’, recalling that she was the happiest she had ever been with her body during her first pregnancy, valuing its productiveness. Most interviewees talked about closely monitoring changes to their body during pregnancy, by weighing themselves on a regular basis. A sense of despondency and disgust could transpire if they had gained, whilst weight loss brought a sense of relief. One woman (participant 7) who was pregnant when interviewed said she had recently thrown away her scales because she could cope with her body size changing but became downhearted when she saw the numbers on the scales go up. This sentiment was echoed by participant 3. She was attending a specialist eating disorders service during her third pregnancy and recounted how her dietician outlined the weight she should gain at each stage. She added: I3: ‘‘. . .immediately you’ve got to be careful because if you’re told there’s a certain amount you should put on, to put on more than that, well that’s just an absolute no no. . .part of it was just wanting to prove them wrong, that you didn’t have to gain that much. . .’’ One way a few interviewees tried to contextualise their expanding form was to monitor the weight changes of other pregnant women, via the internet. They reported logging on to parenting sites and observing what people were writing about their weight during and after pregnancy, using this as a yardstick to ensure they were not gaining more than others. Women who were pregnant when interviewed were anxious about how and whether they would be able to lose their baby fat, whilst those who had given birth said they were too busy being a new mother to be overly concerned about their shape. Interviewees talked about their food intake being monitored during pregnancy. For example, participant 2 said she felt ‘‘on show’’ at work because she was consuming more than usual and participant 3 described being scrutinised by professionals who threatened her with hospitalisation if she failed to gain weight. Participant 4 noted her husband observed more closely her intake when she was carrying his son. She admitted that her eating during pregnancy ‘‘wasn’t great’’, especially since she was

exercising rigorously; everything she ate was low fat and small portions. Others also struggled to eat adequate amounts to put on sufficient weight, but there were a group of interviewees who altered their eating behaviours for the good of their child. A craving for fish and dairy products caused participant 8 to eat these foods when pregnant, even though she had refused to consume them for five years. She recalled how doing this got easier the bigger she became during the pregnancy. Likewise, participant 1 described making an effort to have regular meals, which she hoped to continue once her child was born. She was prompted to change her eating after advice from a midwife: I1: ‘‘I do eat a lot more than before I was pregnant. . .I’d never have any breakfast, never used to really eat dinner. It was always my main meal in the evening. I never used to pick during the day. I just used to live off one meal. . .I saw the midwife about eight weeks ago now and she’d said she’d found something in my urine that had shown that my body was eating my fat as energy because I wasn’t putting any fat on.’’ This theme implies that individuals’ sense of self was strongly related to their appearance, which is something they tried to control in terms of weight. They did not wish to be regarded as excessive in their appetite or shape, being relieved when others were aware that they were pregnant rather than this being regarded as a lapse in somatic control. Again, external markers of change (e.g. numbers on the scales, dress size) could cause disquiet, although interviewees tried to normalise these transformations by comparing themselves with other pregnant women. Some participants seemed able to turn off concerns about food, in the short-term at least, putting their child’s needs before their own, although for some a restrictive pattern of intake continued. In this sense individuals were torn between their performance as someone with an eating disorder and their wish to be seen as a caring mother. Hence, friction arose between two opposing cultural norms of the female form: the slender ideal held up as the only acceptable body shape and the expectation that women will put their child first by embracing weight gain during pregnancy. If individuals are over-invested in being a perfect mother, any lapse they perceive from this position may prompt them to return to a familiar role in which they have succeeded previously, namely as someone with an eating disorder. 4.1.3. Theme 3 – uncertainties about child’s shape Interviewees mentioned not wishing sons or daughters to become obese, but at the same time not wanting them to be obsessed with food. Consequently, they disguised their own anxieties relating to eating and body image and made an effort to eat as a family, even though this could raise their stress levels significantly. For example, participant 4 described pacing and being jumpy before a family meal. She tried to rein in any disordered eating in her son’s presence, such as cutting food into minute pieces, but worried he had picked up on her discomfort since he now

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

rejected food. A number of interviewees disclosed struggling with feeding their child solids. Participant 5 recalled how difficult this was because it called for her to handle ‘‘real food’’. As a consequence, she left this to her husband, a setup echoed in other interviews. Participants 3 and 4 noted their child was small, which they welcomed on some level, although this raised concerns about what others would think: I3: ‘‘. . .she’s very small and the anorexic part of me likes that. She’s not skinny, she’s just very small. . .but on the other hand because she’s small I’m constantly trying to pack food into her. I think the health visitors are aware of me having an eating disorder, sometimes I feel people are constantly checking up on me, ‘am I starving her?’ this sort of thing, which it’s the opposite.’’ The son of participant 4 had to consume extra calories because of a medical condition. She had reconciled herself to his diagnosis but admitted worrying about him becoming too large. She compared her son to other children his age and was pleased he had ‘‘twig legs’’. Voicing these views to practitioners resulted in social services becoming involved in supervising her son’s care. Only one person defined her child as ‘‘big’’; participant 5 noted her son was larger than his peers but this did not cause her concern. She added that her thoughts on this would have been different had he been female because all the baby girls she knew were ‘‘small and cute’’. Others also referred to their child’s gender. Participant 3 was glad her most recent offspring had been female because she was a single parent and therefore felt less of a need for a male role model. Conversely, others were happy they had boys, believing their son was unlikely to be affected by an eating disorder. The preceding description of data implies that women with an eating disorder may see their child’s shape as an external marker of their success as a parent. Recent social messages about obesity in childhood could increase anxieties about an offspring’s weight and the need to monitor this closely. As noted above, a desire for control and striving for perfection have been associated with eating disorder onset and could extend to food consumed by children; some women with an eating disorder may see their child’s body as an extension of their own, viewing any changes in their offspring and his/her eating behaviours as indicative of their own self-control, potentially projecting their condition onto the youngster as a consequence. It has been noted that as a child of someone with an eating disorder develops, feeding difficulties may arise (Stice et al., 1999). In addition, these youngsters are reported to hold overvalued ideas about weight/shape in their selfevaluation and appear more likely to engage in restrictive practices (Stein et al., 2006). 4.1.4. Theme 4 – emotional regulation Much has been written in recent years about emotions and eating disorders, with a whole journal edition devoted to this topic (Fox, 2009). It is argued that eating disorders serve a purpose by enabling individuals to suppress unwanted emotions (Geller et al., 2000; Waller et al.,

1229

2003) and allowing them to cope with what may be perceived as dangerous/unwelcome states, such as anger (Fox and Power, 2009) or shame (Goss and Gilbert, 2002). Hence, a binge may help individuals dissociate from painful feelings, whilst restricting intake inhibits the activation of an emotion (Waller et al., 2007) as attention is focused on not eating. Women interviewed had struggled with negative feelings, such as depression and anxiety during their life, with a couple admitting to suicide attempts in the past. Low mood continued for some during pregnancy and/or after giving birth, which individuals blamed on their hormones and concerns about whether they were equipped to be a good enough mother. Exercise was a common means of regulating negative emotions for study participants, most of whom recalled having to amend activity levels when pregnant because they felt too tired or were worried about harming their child. Participant 4 tried to keep running but mid pregnancy had stomach pains and stopped for a couple of weeks. However, concerns about her weight became too much so she recommenced, taking up swimming as well to make up for her short break. She described the ‘‘buzz’’ she got from running and recalled thinking immediately after giving birth, ‘‘well I’ve had the baby. . .how quickly can I get back to. . .doing my exercises. . .?’’ Likewise, participant 8 recounted returning to the gym 10 days after having her daughter. She curtailed her exercise whilst pregnant (although she did walk several miles each day) but had to rationalise with herself to be able to do so: I8: ‘‘I’d stopped like proper exercising, weights and biking and stuff like that at about six months and then I thought OK we’ll just see this as a little retirement. You can start it all up again once the baby’s here. And I just let go fullstop then. I just thought OK just monitor your weight, make sure you don’t put too much on and just be relaxed about it all. You can work at making it all better once [daughter] turns up.’’ As well as exercise, a number of interviewees talked about inducing vomiting whilst pregnant to regulate emotions. They felt some guilt about how it might affect the child but also depicted this behaviour as compulsive, adding that it brought them relief. Participant 7, in particular, noted how hard it was to refrain from doing so in pregnancy because negative feelings (e.g. of greed and being weak) encountered after eating were so powerful and only abated once she had been sick. Self-harm was performed by a few interviewees as an outlet for their emotions. Participant 5 did not do this during pregnancy but had since giving birth, especially when finding it hard adapting to motherhood; she enjoyed being needed by her child, now he was nearly one, but had said to 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 caring for him because she struggled to understand what he needed when he cried. Participant 4 described cutting her abdomen on several occasions whilst pregnant: I4: ‘‘I think it was because my stomach was getting much bigger. . .I mean obviously I was growing because of the baby but when I look back I didn’t have a huge

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

1230

conflict between doing the best for their child and heeding to the demands of their eating disorder. The results revealed three categories of women: group A seemed unable to cease their dangerous behaviours during pregnancy (participants 3, 4, 5, 7); group B appeared able to put these on hold, but could be vulnerable to relapsing after giving birth (participants 2 and 8); and group C, who relinquished their weight control during pregnancy and saw this as a long rather than a short-term break from such practices (participants 1 and 6). Differences between these groups appeared to be on a continuum, as displayed in Fig. 2. Of the groups described above, A and B appeared to be over-reliant on external markers that they were good mothers and over-sensitive to being negatively perceived, which impeded them from opening up about their difficulties to close others. Feeling unable to live up to self-imposed expectations of being a ‘perfect mum’, they were tempted back into eating disorder behaviours. Although providing a sense of relief, this led to feelings of guilt and could augment their sense of incompetence. Nevertheless, they drew solace whilst engaging in such behaviour because it gave them some semblance of command over their body. As mentioned above, a desire for control has been denoted as contributing to eating disorder onset (Shapiro et al., 1993). Pregnancy can therefore be a challenge because there are numerous factors that are outside a mother’s influence. She may feel she has limited control over her eating and over emotions encountered throughout pregnancy. In addition, she has to witness her body changing in ways that are threatening to her previous identity as someone with an eating disorder. Other research has noted that women may be concerned about losing their eating disorder during pregnancy. For example, in a study by Namir and colleagues (1986, p. 842), one interviewee stated, ‘‘I’m afraid I won’t be able to be anorectic again.’’ A strong bond with their eating disorder persona may make it more difficult for women to shift their self-perception towards a new identity as a mother. What distinguished interviewees in B from those in A was the former’s ability to rationalise with themselves that they had to halt their harmful behaviours, temporarily at least, for their child’s sake. Other studies have noted how pregnant women with an eating disorder may make an effort to eat more regularly and add previously restricted foods to their diet, with the thought of their child prompting them to take better self-care (Namir et al., 1986). Pregnancy could be seen as a period of reprieve from

bump. . .but at the time it seemed massive. So I was, I suppose, I wasn’t thinking of the baby, I was just seeing my stomach was fat so I was trying to get the fat out. . .’’ As this quote implies, a heightened emotional state could make it hard to put the child’s needs first. Participant 4 recalled struggling to look at the screen when she went for a scan because she knew she was engaging in harmful behaviours (e.g. slimming pills, self-harm). This interviewee described the numbness she experienced when she first saw her son. Similarly, participant 3 felt pressurised by professionals to have skin to skin contact with her baby. She did not have the confidence to voice her discomfort and was concerned about being regarded as a bad mother if she did so. Despite the emotional difficulties some individuals associated with pregnancy, becoming a mother was depicted as life changing by all those who had given birth when interviewed. Participant 6 credited her children as being the catalyst for her eating disorder ceasing because she no longer had time to dwell on what she was consuming. Similarly, participant 8 said she had to put her concerns to one side and focus on her new child. Nevertheless, she was clear that she did not want to surrender her sense of self to this role and expressed how joyful she had been when glimpses of her former identity, prior to becoming a mother, emerged: I8: ‘‘I want to be consumed by [daughter] to a certain degree but I still want a bit of me too. . . I remember going to the gym for the first time, I was still breastfeeding her and I started crying just because I thought I’m still there. I felt like I’d lost me. It was really weird, it was surreal.’’ The identity referred to by this interviewee related to her eating disorder persona, since she was keen to return to a life dominated by somatic control. Abandoning familiar yet potentially dangerous coping strategies appeared to be tolerated by this individual and some other participants by seeing it as a temporary state of being; whether this left them vulnerable to relapse and an escalation of disordered eating behaviours needs to be explored further through longitudinal research. 5. Discussion This study of women’s views suggested that in most cases pregnancy and motherhood resulted in a sense of Set A

Set B

Set C

(wholly attached to their eating disorder)

(intermittent rejection of their eating disorder)

(motherhood replaces their eating 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

social norms placed on women in terms of shape (Stapleton, 2007), but it brings new expectations in terms of health behaviours to benefit a child and can be a stressful life event. Consequently, individuals may be tempted to turn to their disordered eating as a familiar route for managing anxieties, but at the same time feel it is contraindicated because they are responsible for the child’s welfare. This may lead to questions about ownership of their body, heightening concerns with their physique, as they are caught between the competing demands of the child and the eating disorder. It is unsurprising, given such pressures, that disordered thinking about weight and food, even if eased during pregnancy, often resumes after giving birth (Namir et al., 1986). Most interviewees in group A were detached from their child whilst in-utero, possibly to enable them to persist with their disordered eating practices (including excessive exercise, purging and self-harm); becoming too attached at this stage would make such behaviours difficult to maintain but without a replacement for regulating emotions their internal struggles may have been unbearable. Difficulties transpired when a woman was suddenly presented with a new child with whom she felt little rapport. Research has suggested that not all mothers bond immediately with their child (Robson and Kumar, 1980; Kumar, 1997), but it may be regarded by those with an eating disorder as evidence of their inability to mother. Likewise, breast-feeding was an area in which interviewees’ sense of competence could be undermined. Others have listed feeding problems among this group (Koubaa et al., 2008; Stein et al., 1999; Waugh and Bulik, 1999). For example, in a study comparing women with and without an eating disorder history, the former were more likely to stop breast-feeding prematurely (Larrson and AnderssonEllstron, 2003). It has been noted that as well as knowledge, successful breast-feeding calls for self-confidence and belief in the potential of one’s body (Larrson and Andersson-Ellstron, 2003). Poor self-image among those with an eating disorder may impede this activity and could reinforce existing views of their body as defective rather than productive. Interviewee 6, from group C, was the only person to be positive about breast-feeding, seeing it as a sign of her body’s creative capacity. The two women in group C seemed able to subsume their previous eating disorder identity with one of being a mother. This allowed them to put their child’s needs before that of their previous status as someone with an eating disorder. They took pride in their altered identity and appeared to grow in selfconfidence and self-love. Nevertheless, they may be prone to perfectionist tendencies; as suggested above, this has been proposed as a key trait among those with an eating disorder (Bardone-Cone et al., 2007). Perfectionism and being self-critical in eating disorders have been theoretically linked to the need to defend against a pervasive negative self-worth (Goss and Gilbert, 2002). 5.1. Implications for practice Motherhood is said to be an optimum time to intervene in cases of eating disorders, when individuals may be more willing to make changes to their weight-control practices

1231

for the sake of their child (Koubaa et al., 2008). Signs midwives are advised to look for to indicate such conditions include (a) lack of weight gain in two consecutive appointments in the second trimester, (b) an eating disorder history, (c) hyperemesis gravidarum (Franko and Spurrell, 2000). However, an ability to act may be hindered by the lack of local facilities for people with an eating disorder. In addition, even if professional support is accessed, difficulties may still arise due to problems with childcare provision or after-hours appointments for women who work (Stapleton, 2007). A range of suggestions have been given for how professionals could assist pregnant women with an eating disorder, including psychoeducation about physical and psychological consequences of their behaviours and nutritional requirements (Little and Lowkes, 2000). It may also be useful during antenatal appointments to raise awareness that a failure to bond immediately with a baby is not uncommon, otherwise this may be used as a reason to be self-critical. Women with an eating disorder should receive extra support after giving birth due to their increased risk of postnatal depression (Ward, 2008). Help at this point may be beneficial for the child’s immediate and long-term wellbeing, since youngsters of these mothers are reported to be susceptible to developing eating issues themselves (Park et al., 2003; Stein et al., 2006). Mothers with an eating disorder may need practical assistance with preparing meals and eating with children, which have been reported in this and in other papers as causing difficulties (Fahy and Treasure, 1989; Stein and Fairburn, 1989). Data from those interviewed implied that women with an eating disorder can be anxious about their offspring’s food intake. Other authors have noted that mothers with such a condition underestimate their child’s nutritional needs (Hodes et al., 1997) and make fewer positive comments at mealtimes than control women (Park et al., 2003; Waugh and Bulik, 1999). 5.2. Areas for future research Those with an eating disorder history may be more vulnerable to feeling inadequate as a mother, and, as a consequence, turn to what they consider to be a necessary coping mechanism, whereby they focus on their weight and nutritional intake. The types of core beliefs that have been found to be important in eating disorders are socially orientated ones, such as expectation of abandonment, mistrust/abuse, feeling defective and/or shame (Cooper et al., 1998; Meyer and Waller, 1999). Results implied that for certain women these core beliefs are more engrained and may mean someone feels she will be a poor mother from the outset. Additional investigation could be made of the perceptions of motherhood among women with and without an eating disorder, looking at how they measure their abilities in this sphere and where their ideas about this concept derive. For example, do those with an eating disorder focus more on external markers of their mothering skills because they are unable to accept/trust their own judgment on this matter? For some interviewees, pregnancy 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. Factors predicting whether someone improves or relapses could be explored in further research. Ideas relating to drivers towards eating disorder behaviours during and after pregnancy, based on interview data, are illustrated in Fig. 2. Investigators could examine what enables women who make positive changes to their harmful weightcontrol practices during pregnancy to maintain a healthier lifestyle following their child’s birth. Finally, partners played a role in supporting interviewees. Other studies have talked about women with an eating disorder drawing on a spouse to help them rationalise concerns about weight gain (Namir et al., 1986). Needs of these fathers requires further exploration, as they may feel torn between wanting the best for the child and not wanting their partner to feel anguished. 5.3. Limitations Engaging in potentially harmful eating behaviours whilst pregnant may be regarded as a tangible reason for rejection by others, which could explain recruitment difficulties. Yet even though only a small group of women was interviewed, information provided was rich in detail. Participants represented a range of characteristics and experiences, and their responses have been linked to the wider literature, in line with theoretical generalisability associated with qualitative research. Women who did not meet the screening questionnaires cut-off were sent a letter explaining that the researchers were not interviewing everyone because the aim was to include individuals who varied in age and stage in pregnancy. Given the responses of those who were not eligible (none of whom ticked any of the risk factors related to an eating disorder on the two questionnaires), these women did not appear to have eating issues. However, they were told that they could discuss any concerns or queries derived from the invitation to participate with the lead researcher or a member of their healthcare team. They were also informed that any data collected on them as part of the initial screening would be destroyed. Methodological rigour was aimed for by following guidelines outlined for qualitative research by Elliott and colleagues (1999). For example, prior to commencing data collection, to bracket out preconceptions, the first author recorded factors she thought would arise during interviews, based on the existing literature. Trustworthiness was aimed for by recording and transcribing interviews and using open coding initially, based on interviewees’ words. In addition, a systematic approach to analysis was used (Ritchie et al., 2003), which allowed researchers to share and explore together charted data. Findings are elucidated by presenting primary data (i.e. direct quotations), providing some insight into what was said by participants. 6. Conclusion When women with an eating disorder become pregnant they enter a situation in which competing demands can dominate life. Most interviewees walked a tightrope

between responding to the eating disorder and putting their child first, whilst a couple described turning their back on their condition. Practitioners should bear in mind that a positive investment may be placed in motherhood when a woman with an eating disorder becomes pregnant; the child may be regarded as someone who will love her for who she is, not judging her shortfalls. This could account for an improvement of the eating disorder, but an overwhelming sense of responsibility may result in an escalation of or return to symptoms. Having a stronger identity as a mother may contribute to a ceasing of eating disorder behaviours, although individuals may return to such activities when self-doubt about parenting skills transpires. Believing things are out of their control and feeling unable to live up to their ideal as a mother, as well as concerns about their weight, could drive these women into disordered eating patterns. A vulnerability to depression during and after pregnancy may also be a trigger for a resumption of such practices. Professionals need to identify and support these women during and post pregnancy to prevent them from endangering themselves and the fetus, and from increasing their child’s likelihood of potentially harmful weight control in the future. Conflict of interest: None. Funding: Work described in this paper was funded by the School of Nursing, Midwifery and Social Work, University of Manchester. Ethical approval: South Manchester Local Research Ethics Committee. References APA (American Psychiatric Association), 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. APA, Washington, DC. APA (American Psychiatric Association), 2000. Practice guidelines for the treatment of eating disorders (revised). American Journal of Psychiatry 157 (suppl.), 1–39. Arkell, J., Robinson, P., 2008. A pilot case series using qualitative and quantitative methods: biological, psychological and social outcome of severe and enduring eating disorder (anorexia nervosa). International Journal of Eating Disorders 41, 650–656. Bardone-Cone, A.M., Wonderlich, S.A., Frost, R.O., Bulik, C.M., Mitchell, J.E., Uppala, S., Simonich, H., 2007. Perfectionism and eating disorders: current status and future directions. Clinical Psychology Review 27, 384–405. Button, E.J., Warren, R.L., 2001. Living with anorexia nervosa: the experience of a cohort of sufferers from anorexia nervosa 7.5 years after initial presentation to a specialized eating disorders service. European Eating Disorders Review 9, 74–96. Button, E., Aldridge, S., Palmer, R., 2008. Males assessed by a specialized adult eating disorders service: patterns over time and comparisons with females. International Journal of Eating Disorders 41, 758–761. Colton, P., Olmsted, M., Daneman, D., Rydall, A., Rodin, G., 2004. Disturbed eating behavior and eating disorders in preteen and early teenage girls with type 1 diabetes: a case-controlled study. Diabetes Care 27, 1654–1659. Cooper, M.J., Todd, G., Wells, A., 1998. Content, origins and consequences of dysfunctional beliefs in anorexia nervosa and bulimia nervosa. Journal of Cognitive Psychotherapy: An International Quarterly 12, 213–230. Cotton, M.A., Ball, C., Robinson, P., 2003. Four simple questions can help screen for eating disorders. Journal of General Internal Medicine 18, 55–56. Dallos, R., Denford, S., 2008. A qualitative exploration of relationship and attachment themes in families with an eating disorder. Clinical Child Psychology and Psychiatry 13, 305–322.

S. Tierney et al. / International Journal of Nursing Studies 48 (2011) 1223–1233 Elliott, R., Fischer, C.T., Rennie, D.L., 1999. Evolving guidelines for publication of qualitative research studies in psychology and related fields. British Journal of Clinical Psychology 38, 215–229. Fahy, T., Treasure, T., 1989. Children of mothers with bulimia nervosa. British Medical Journal 299, 1031. Fairburn, C.G., Harrison, P.J., 2003. Eating disorders. Lancet 361, 407–416. Fox, J.R.E., 2009. Eating disorders and emotions. Clinical Psychology and Psychotherapy 16, 237–239. Fox, J.R.E., Power, M.J., 2009. Eating disorders and multi-level models of emotion: an integrated model. Clinical Psychology and Psychotherapy 16, 240–267. Franko, D.L., Spurrell, E.B., 2000. Detection and management of eating disorders during pregnancy. Obstetrics and Gynecology 95, 942– 946. Geller, J., Cockell, S.J., Hewitt, P.L., Goldner, E.M., Flett, G.L., 2000. Inhibited expression of negative emotions and interpersonal orientation in anorexia nervosa. International Journal of Eating Disorders 28, 8–19. Goss, K., Gilbert, P., 2002. Eating disorders, shame and pride: a cognitivebehavioural functional analysis. In: Gilbert, P., Miles, J. (Eds.), Body Shame: Conceptualisation, Research and Treatment. Brunner-Routledge, Hove, New York. Hodes, M., Timimi, S., Robinson, P., 1997. Children of mothers with eating disorders: a preliminary study. European Eating Disorders Review 5, 11–24. Jeppson, J.E., Richards, P.S., Hardman, R.K., Granley, H.M., 2003. Binge and purge processes in bulimia nervosa: a qualitative investigation. Eating Disorders 11, 115–128. Koubaa, S., Hallstrom, T., Hirschberg, A.L., 2008. Early maternal adjustment in women with eating disorders. International Journal of Eating Disorders 41, 405–410. Kumar, R.C., 1997. ‘Anybody’s child’: severe disorders of mother-to-infant bonding. British Journal of Psychiatry 171, 175–181. Larrson, G., Andersson-Ellstron, A., 2003. Experiences of pregnancyrelated body shape changes and of breast-feeding in women with a history of eating disorders. European Eating Disorders Review 11, 116–124. Lask, B., Bryant-Waugh, R., 1992. Early onset anorexia nervosa and related eating disorders. Journal of Child Psychology and Psychiatry 33, 281– 300. Little, L., Lowkes, E., 2000. Critical issues in the care of pregnant women with eating disorders and the impact on their children. Journal of Midwifery and Women’s Health 45, 301–307. Martos-Ordonez, C., 2005. Pregnancy in women with eating disorders: a review. British Journal of Midwifery 13, 446–448. Meyer, C., Waller, G., 1999. The impact of emotion upon eating behaviour: the role of subliminal visual processing of threat cues. International Journal of Eating 25, 319–326. Micali, N., Treasure, J., Simonoff, E., 2007. Eating disorders symptoms in pregnancy: a longitudinal study of women with recent and past eating disorders and obesity. Journal of Psychosomatic Research 63, 297–303. Morgan, J.F., Reid, F., Lacey, J.H., 1999. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. British Medical Journal 319, 1467–1468. Morgan, J.F., Lacey, J.H., Chung, E., 2006. Risk of postnatal depression, miscarriage and preterm birth in bulimia nervosa: retrospective controlled study. Psychosomatic Medicine 68, 487–492. Namir, S., Melman, K.N., Yager, J., 1986. Pregnancy in restricter-type anorexia nervosa: a study of six women. International Journal of Eating Disorders 5, 837–845. NICE (National Institute for Health Clinical Excellence), 2004. Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders: A National Clinical Practice Guideline. National Institute for Health and Clinical Excellence, London. Park, R.J., Senior, R., Stein, A., 2003. The offspring of mothers with eating disorders. European Child and Adolescent Psychiatry 12 (suppl. 1), 110–119.

1233

Patel, P., Wheatcroft, R., Park, R.J., Stein, A., 2002. The children of mothers with eating disorders. Clinical Child and Family Psychology Review 5, 1–19. Pettersen, G., Rosenvinge, J.H., Ytterhus, B., 2008. The ‘double life’ of bulimia: patients’ experiences in daily life interactions. Eating Disorders 16, 204–211. Polivy, J., Herman, C.P., 2002. Causes of eating disorders. Annual Review of Psychology 53, 187–213. Ritchie, J., Spencer, L., O’Connor, W., 2003. Carrying out qualitative analysis. In: Ritchie, J., Lewis, J. (Eds.), Qualitative Research Practice: A Guide for Social Science Students and Researchers. Sage, London, Thousand oaks; New Delhi. Robson, K.S., Kumar, R., 1980. Delayed onset of maternal affection after childbirth. British Journal of Psychiatry 136, 347–353. Rock, C.L., 1999. Nutritional and medical assessment and management of eating disorders. Nutrition in Clinical Care 2, 332–343. Serpell, L., Treasure, J., Teasdale, J., Sullivan, V., 1999. Anorexia nervosa: friend or foe? International Journal of Eating Disorders 25, 177–186. Shapiro, D.H., Blinder, B.J., Hagman, J., Pituck, S., 1993. A psychological ‘sense-of-control’ profile of patients with anorexia nervosa and bulimia nervosa. Psychological Reports 73, 531–541. Stapleton, H., 2007. ‘‘I´m not pregnant, I’m fat.’’ The experiences of some eating disordered childbearing women and mothers. School of Nursing and Midwifery, University of Sheffield, GRiP (Getting Research into Practice) Report. Stein, A., Fairburn, C.G., 1989. Children of mothers with bulimia nervosa. British Medical Journal 299, 777–778. Stein, A., Woolley, H., McPherson, K., 1999. Conflict between mothers with eating disorders and their infants during mealtimes. British Journal of Psychiatry 175, 455–461. Stein, A., Woolley, H., Cooper, S., Winterbottom, J., Fairburn, C.G., CortinaBorja, M., 2006. Eating habits and attitudes among 10-year-old children of mothers with eating disorders: a longitudinal study. British Journal of Psychiatry 189, 324–329. Stice, E., Agras, S.W., Hammer, L.D., 1999. Risk factors for the emergence of childhood eating disturbance: a 5 year prospective study. International Journal of Eating Disorders 25, 375–387. Tierney, S., 2004. The effectiveness of psychosocial interventions for adolescents with anorexia nervosa. PhD thesis, University of Exeter. Tierney, S., Fox, J., 2010. Living with the ‘anorexic voice’: a thematic analysis. Psychology and Psychotherapy: Theory, Research and Practice 83, 243–254. Treasure, J., Claudino, A.M., Zucker, N., 2010. Eating disorders. Lancet 375, 583–593. Van der Spuy, Z.M., Steer, P.J., McCusker, M., Steele, S.J., Jacobs, H.S., 1988. Outcome of pregnancy in underweight women after spontaneous and induced ovulation. British Medical Journal 296, 962–965. Waller, G., Babbs, M., Milligan, R.J., Meyer, C., Ohanian, V., Leung, N., 2003. Anger and core beliefs in the eating disorders. International Journal of Eating Disorders 15, 317–331. Waller, G., Kennerley, H., Ohanian, V., 2007. Schema focused cognitivebehaviour therapy with easting disorders. In: Riso, L.P., du Poit, P.T., Young, J.E. (Eds.), Cognitive Schemas and Core Beliefs in Psychiatric Disorders: A Scientist-Practitioner Guide. American Psychiatric Association, New York. Walsh, B.T., Garner, D.M., 1997. Diagnostic issues. In: Garner, D.M., Garfinkel, P.E. (Eds.), Handbook of Treatment for Eating Disorders. 2nd ed. The Guildford Press, New York, London. Ward, V.B., 2008. Eating disorders in pregnancy. British Medical Journal 336, 93–96. Waugh, E., Bulik, C.M., 1999. Offspring of women with eating disorders. International Journal of Eating Disorders 25, 123–133. Weaver, K., Wuest, J., Ciliska, D., 2005. Understanding women’s journey of recovering from anorexia nervosa. Qualitative Health Research 15, 188–206. Welch, S.L., Doll, H.A., Fairburn, C.G., 1997. Life events and the onset of bulimia nervosa: a controlled study. Psychological Medicine 27, 515– 522.