INTRODUCTION

In the seminal work by Schilder (1935), the concept of body image (BI) was introduced as one’s mental representation of self, including one’s perception of their appearance¹. This is based on one’s self-impression, originating from central consciousness, which is influenced by personality, experiences, memory, association, and self-esteem¹. Throughout one’s lifetime, these influential factors tend to fluctuate, resulting in higher levels of body-distortion amongst women, than in men². Pregnancy has been described as an experience that is subject to body-distortion, potentially altering one’s perception of their naturally-deviating body¹.

As pregnancy brings physical changes with it, some women enjoy looking pregnant or having an increased breast size³. However, a substantial number of women have a lack of appreciation for their changing bodily measurements, spotty skin, and hair thinning. It was further declared that while some women are fascinated by their changing appearance when looking in the mirror, others feel horrified by these changes as they feel that they are now less feminine. Despite these varying perspectives, changes in BI are an inevitable part of pregnancies³.

Moreover, pregnancy symptoms such as nausea, vomiting and cravings inevitably alter one’s dietary intake in pregnancy, making women more prone to weight fluctuations and therefore BI issues⁴. While pregnancy contributes to an optimal time during which most women consider lifestyle adjustments including healthy eating, others do not hold back on their cravings⁵. This in turn contributes to some women reporting a lack of control over their appearance during pregnancy⁵. While some women have reported feeling unsure and confused about the effects of exercise during pregnancy and the implications this had on their BI⁴, others have asserted that their main aim of exercising during pregnancy was due to its role in weight control and improved mental well-being⁶.

Furthermore, pregnant women have also reported a low sexual desire which has also been associated with a negative perception of their body and anxiety about their partner’s thoughts regarding their changing body during this time^3,7. Indeed, it was revealed that 10% of women (n=57/570) stop sexual activity during pregnancy⁷. Other contributing factors to this altered rate of sexual activity during pregnancy include maternal age, parity, psychological and socio-cultural factors⁷.

Indeed, social constructs and stereotypes create a discrepancy between the ideal female body and the natural pregnant body. Social pressures and constant surveillance amongst women are already significant, regardless of pregnancy, encouraging self-evaluation and uncertainty⁶. This is especially so in Western cultures where, due to being an accessible and obvious feature of judgement, appearance is a daily preoccupation and a social pressure in itself⁶. This explains the societal attention and society’s entitlement to comment freely on one’s pregnant body when a woman is visibly pregnant^6,8.

Similarly, exposure to mass media is unavoidable and this in turn influences pregnant women’s BI perceptions. Exposure to magazines and celebrity gossip appear to create two opposing emotions in women, involving comparison⁸. From one end, women felt satisfied knowing that despite their lower financial status, their lives were superior and less materialistic. Others felt occasionally disappointed and confused by the difference between their own pregnancy experience and the perfect picture painted by media⁸. Fortunately, women reported being aware of media’s unrealistic and glamourized portrayals of celebrities and pregnant women, the economic aim and the disappointing focus on the ideal pregnant body, consisting of a petite shape, an accessory-like pregnant belly, and skinny arms and legs^8,9.

The current study expands upon existing literature with the aim of exploring pregnant women’s views of self during their first pregnancy, via three main objectives: 1) To explore women’s feelings and thoughts about their pregnant bodies, 2) To understand if and how lifestyle adjustments’ influence women’s BI in pregnancy, and 3) To explore social and media influences on pregnant women’s BI.

METHODS

A qualitative research design was used in this study, which allowed the researchers to collect rich data from the participants¹⁰. A purposive sample of eight women was selected via intermediaries for participation in this study. Participants were primigravid women of Maltese nationality, at thirty weeks of gestation onwards, who were currently experiencing a singleton pregnancy and were admitted at a local general hospital in Malta.

A self-designed semi-structured interview schedule was specifically designed by the researchers for the purpose of the study. This was then submitted and approved for use by the Faculty Research Ethics Committee (FREC) and by the University Research Ethics Committee - Data Protection (UREC-DP). The interview schedule provided guiding questions and additional probes, which encouraged participants to contribute towards a rich conversation. The interview schedule was designed in both Maltese and English, allowing participants to choose their preferred language to speak in, given that Malta is a bilingual country. The interview scheduled was piloted before use in the actual study. Participants were asked to participate in a virtual interview given that the study was conducted during the COVID-19 pandemic to ensure safety for both the participants and the researchers. Audio-recording was carried out with participants’ consent and participants’ names were pseudonymized for confidentiality purposes.

The data generated in this study were then transcribed verbatim and analyzed using the six-step linear method of thematic analysis of Braun and Clarke¹¹. The first step required the researcher to familiarize herself with the data collected, reading it multiple times. Next, initial codes from the data were generated, highlighting the interesting points. Thirdly, common concepts were listed and grouped into themes, which were further selectively reviewed as step four. The fifth step required the definition and naming of the themes, before finally creating an analysis report of the fully identified themes created¹¹.

Methodological rigor was given significant importance throughout the research process. This was ensured by maintaining a continuous discussion amongst the researchers on evolving themes throughout the research process, increasing credibility. Secondly, research needed to be dependable, meaning that its findings are stable over varying times and conditions, and would repeat themselves if replicated. To ensure credibility and dependability, member checking was carried out by the researchers. This was done by double-checking the data transcribed with the audio recordings, and by confirming the audio-recording via email with the participants themselves after the interview.

RESULTS

The participants’ age ranged from 23 and 37 years, with a mean age of 31 years. The gestational age during which the mothers were interviewed ranged from 33+1 to 40 weeks. All mothers were Caucasian in ethnicity, and were in a stable, romantic relationship at the time of interview. The mothers’ education level ranged from secondary to tertiary, and all women were employed. Additionally, none of the participants disclosed any previous or existing mental illness (Table 1). From thematic analysis, six main themes emerged (Table 2).

DISCUSSION

Pregnancy is a time of many changes. Overall, the study’s participants viewed their pregnancy experience as predominantly positive, with some negative aspects which impacted on the perception of their BI. This was consistent with findings from a systematic review¹², with both highlighting a lack of control women felt they had over their body throughout their pregnancy.

Some participants described their pregnancy as ‘lonely’, ‘difficult’ and ‘overwhelming’ at times, mainly due to the COVID-19 pandemic and its restrictions. In line with this, an Italy-based study reported higher rates of anxiety and psychological disturbances brought about by social isolation and decreased family interactions during pregnancy¹³. These feelings might have further contributed to negative feelings about women’s BI in this study.

Pregnancy brought about a spectrum of different perceptions of BI, ranging from body satisfaction to dissatisfaction. Participants’ perception of their pregnant appearance in the current study varied with some feeling just as attractive and others feeling less attractive than before their pregnancy, with the latter case leading to feelings of disappointment. Similar to other literature, participating women also highlighted the importance of their partner’s support and opinions of their counterparts’ attractiveness^3,6,8. Most women were particularly satisfied with their increased breast size and a growing belly. Interestingly, the former feature was commented on by small-chested women, which was also the case in other studies⁶. Several participants also stated their disappointment when their belly did not show, hindering them from looking officially pregnant^6,8.

Some participants in the current study did not feel as excited when looking at themselves in the mirror, reporting that they felt overwhelmed with their changed BI. Pregnancy changes that appeared to dissatisfy women were acne and hair thinning, while stretch marks were not as concerning to women in the current study, when compared to other studies³. A sense of loss of identity linked to pregnancy changes identified in the findings was also consistent^6,8. Ultimately, women accepted their changing bodies, prioritizing their baby’s health over aesthetics⁸.

Pregnancy lifestyle adjustments and their impact on BI also varied. Some participants maintained a healthy diet while others indulged in their cravings, similar to other findings^4,5. In the current study, the latter led to weight gain which affected women’s BI. Additionally, a decrease or complete cessation of exercise in pregnancy, mainly due to fatigue and nausea was reported⁶. When it came to sexual intercourse during pregnancy, a reduced frequency of sexual encounters was reported, consistent to other international research^7,14,15. Interestingly, women’s confusion and fear about whether any physical activity is beneficial or harmful in pregnancy, may imply a lack of information giving in this regard, which has implications for midwives in particular.

Increased societal attention with increased gestation was reported by the women in this study and others⁶, resulting in different reactions. While some felt self-conscious, others wanted to show it off in order to let society know they were pregnant. The latter was consistent with other studies especially since this would help with speculations regarding women’s weight gain^6,8,12. A society’s need to advise women on how to look and feel, as well as the need to ‘give their two cents’, was in line with the current findings. Additionally, participants from this study suggested that some women can be negatively impacted by certain comments made about their size⁶.

What separates this current study from other international research, is Malta’s unique characteristics, especially regarding its small population and the impact of a face-to-face community. This small community notion states that a small Mediterranean population emphasizes social pressures that encourage feelings of self-evaluation¹⁶. This was evident in the current study and participating women highlighted the need for society to be less intrusive. Upward and downward social comparison¹⁷ was also brought up by participants, where women compared themselves to their friends, feeling either better or worse about themselves, and their BI during pregnancy. The general pressure of females and their bodies regardless of pregnancy was also brought up in this current study and in others^6,8.

When it came to media’s influence over BI in pregnancy, participants were aware of the unrealistic portrayals of pregnant women on media and their drive for economic gain, which enforces glamourization and sexualization of women, including pregnant women⁸. This consistent need of ‘sexualizing the body’ (Roberta) that was commented on by participants, was addressed in the Sexual Objectification Theory⁹. This notion created feelings of disgust and disappointment as found in the current study. Upward and downward comparisons to the media were described by the study’s participants as well as other studies^6,17. Some found themselves upward comparing themselves to media, despite knowing about media’s unrealistic portrayals. On the other hand, some downward compared themselves as relatively superior to celebrities’ lack of freedom.

Ultimately, despite the challenges that pregnancy brings along with it, all women managed to bond with their unborn baby and prioritized the baby’s well-being over theirs⁶. Women in the present study, additionally expressed excitement to meet their baby, adding that they will miss their pregnancy, irrespective of its impact on their BI.

CONCLUSIONS

Overall, women viewed themselves as less attractive during pregnancy, and a desire to gain control of the inevitably changing body was emphasized. However, acceptance of their naturally-deviating body and support from their partners was exhibited by all participants. A growing abdomen was generally perceived in a positive light amongst the study participants. The majority of women managed to adjust their daily activities to pregnancy, with some struggling to maintain exercise, sexual activity and a healthy weight. With increased attention from society, women seemed to be impacted both positively and negatively. Unsolicited comments were experienced by most, who emphasized a small society’s potential impact on one’s well-being. Several women compared themselves to others in society, highlighting the social pressures put on pregnant women. Moreover, all women were aware of the influence of media and their inaccurate depictions of the pregnant female form, with some women’s BI being somewhat impacted. Despite this, all women concluded that despite pregnancy’s impact on BI, women appreciated their pregnancy and their body’s ability to change, whilst they looked forward to meeting their baby.