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Predictors of Mothers’ Postpartum Body Dissatisfaction
Dwenda Gjerdingen, MD, MS,
Department of Family Medicine & Community Health University of Minnesota
Patricia Fontaine, MD, MS,
Department of Family Medicine & Community Health University of Minnesota
Scott Crow, MD,
Department of Psychiatry University of Minnesota
Patricia McGovern, PhD, MPH,
School of Public Health University of Minnesota
Bruce Center, PhD, and
Department of Family Medicine & Community Health University of Minnesota
Michael Miner, PhD
Department of Family Medicine & Community Health University of Minnesota
Abstract
Purpose—To investigate changes in mothers’ body dissatisfaction from delivery to 9 months
postpartum, and the relationship of postpartum body dissatisfaction to weight, other health, and social
characteristics.
Methods—In this prospective longitudinal study, 506 mothers completed surveys at 0-1 and 9
months postpartum. Postpartum changes in body dissatisfaction and weight were evaluated by paired
t-tests, and predictors of postpartum body dissatisfaction were identified by stepwise multiple
regression analysis.
Results—Mothers’ body dissatisfaction increased significantly from 0-1 to 9 months postpartum
(mean scores of 15.2 and 18.2, respectively, p < .001). Although women lost an average of 10.1
pounds (sd = 16.3) or 4.6 kg. (sd = 7.4) between 0-1 and 9 months postpartum (p < .001), their weight
at 9 months postpartum remained an average of 5.4 pounds (sd = 15.6) or 2.5 kg (sd = 7.1) above
their pre-pregnancy weights (p < .001). Body dissatisfaction at 9 months postpartum was associated
with overeating or poor appetite, higher current weight, worse mental health (SF-36 Mental Health
scale), race other than black, bottle-feeding (vs. breastfeeding), being single (vs. married), and having
fewer children,.
Conclusions—Mothers’ body satisfaction worsened from 1 to 9 months postpartum, and 9-month
body dissatisfaction was associated with eating/appetite abnormalities, greater weight, worse mental
health, non-black race, non-breastfeeding status, and fewer immediate family relationships. Given
these relationships, it is important to educate women about expected postpartum weight and body
changes, and to find ways to enhance mothers’ postpartum self-esteem and body satisfaction.
Keywords
postpartum; body image; mental health; weight gain
Corresponding Author: Dwenda Gjerdingen, MD, MS 580 Rice St., St. Paul, MN 55103 Office: 651-227-6551; Fax: 651-227-1804
dgjerdin@umphysicians.umn.edu.
NIH Public Access
Author Manuscript
Women Health. Author manuscript; available in PMC 2010 September 1.
Published in final edited form as:
Women Health. 2009 September ; 49(6): 491–504. doi:10.1080/03630240903423998.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Pregnancy and childbirth are associated with dramatic changes in women's body shape and
size, and for many women, these changes are perceived negatively, resulting in body
dissatisfaction, or a negative body image (Jenkin & Tiggemann, 1997; Rallis, Skouteris,
Wetheim, & Paxton, 2007; Skouteris, Carr, Wetheim, Paxton, & Duncombe, 2005). “Body
image” has been defined as an individual's internal representation of his or her own outer
appearance, and “body dissatisfaction” as one facet of body image relating to dissatisfaction
with particular aspects of the body (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999).
One prospective study evaluated changes in mothers’ weight and body satisfaction from before
pregnancy to one month after delivery, and found that mothers were on average 4.88 kg. heavier
after delivery than before becoming pregnant, and they were less satisfied with their weight
and shape after delivery (Jenkin & Tiggemann, 1997). Similarly, another longitudinal study
found that women experienced greater levels of body dissatisfaction in the postpartum period
than during pre-pregnancy or late pregnancy (Rallis et al., 2007).
While a decline in body satisfaction is important in its own right, it is also important because
it may contribute to other problems. For example, women who are preoccupied or less satisfied
with their body shape are less likely to breastfeed (Barnes, Stein, Smith, & Pollock, 1997;
Foster, Slade, & Wilson, 1996; Walker & Freeland-Graves, 1998). Other studies have
demonstrated a relationship between postpartum body dissatisfaction or poor body image and
depressive symptoms or psychological distress (Abraham, Taylor, & Conti, 2001; Clark,
Skouteris, Wertheim, Milgrom, Paxton, 2009; Dipietro, Millet, Costigan, Gurewitsch, &
Caulfield, 2003; Duncombe, Wertheim, Skouteris, Paxton, & Kelly, 2008; Walker,
Timmerman, Kim, & Sterling, 2002; Walker et al., 2004). Depression could provoke body
dissatisfaction either through diminished self-esteem or overeating, weight retention, and
obesity, each of which have been linked to perinatal depression and/or anxiety (Carter, Baker,
& Brownell, 2000; Herring et al., 2008; Hurley, Caufield, Sacco, Costigan, & Dipietro,
2005; Laraia, Siega-Riz, Dole, & London, 2008). Alternatively, body dissatisfaction could
lower a mother's self-esteem and thereby contribute to depression.
In additional to mothers’ psychological distress and breastfeeding status, other factors that have
been found to be associated with perinatal body/shape dissatisfaction or poor body image
include: prior body image (Rallis et al., 2007), race (Walker et al., 2002), gestational weight
gain (Rallis et al., 2007), postpartum weight (Jenkin & Tiggemann, 1997), postpartum weight
gain among bottle-feeding mothers (Walker & Freeland-Graves, 1998), dieting behaviors
(Rallis et al., 2007), perceived socio-cultural pressure (Skouteris et al., 2005), and perception
of teasing (Skouteris et al. 2005).
Noteworthy among body dissatisfaction-related factors are those related to weight. Excessive
gestational weight gain, defined as over 35 pounds for normal weight women, over 25 pounds
for overweight women, and over 20 pounds for the obese (Institute of Medicine, 2009), may
be associated with long-term weight retention (Gunderson et al., 2004; Linne, Dye, Barkeling,
& Rossner, 2004) or obesity (Gunderson et al., 2004; Rossner, 1997; Rossner & Ohlin,
1995), which could in turn lead to body dissatisfaction. However, it is not clear which weight
characteristic (e.g., prenatal weight, postpartum weight, or pre-pregnancy to postpartum weight
gain/retention) is most important in predicting body dissatisfaction. Also unknown is the
contribution of certain social variables (some discretionary), such as employment status,
marital status, number of children, or baby's gender to postpartum body dissatisfaction. Further,
given the relationship between postpartum body image concerns, mood disorders, and eating
disorders suggested by other researchers (Astrachan-Fletcher, Veldhuis, Lively, Fowler, &
Marcks, 2008), it is important to consider the relationship of abnormal appetite or eating to
postpartum body dissatisfaction.
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Taken together, these studies show preliminary evidence of a decline in body satisfaction after
delivery, and a relationship between postpartum body dissatisfaction and breastfeeding,
depressive symptoms, eating disorders, and postpartum weight and weight retention. However,
the relative importance of each of these factors, particularly the weight variables, and the
significance of certain social factors such as close relationships or employment status remain
unknown. Therefore, this study sought to help fill these gaps by investigating the relationship
of postpartum body dissatisfaction to current postpartum weight, weight retention, certain
social characteristics (e.g., marital status, number of children, employment status), other
demographic and health characteristics, and several of the above-listed previously identified
correlates (e.g., breastfeeding status, mental health, and poor appetite or overeating).
Methods
Setting and Participants
This analysis was conducted from surveys administered from October, 2005 through June,
2007, for a randomized, controlled trial (RCT) that tested the impact of stepped collaborative
care on postpartum depression outcomes (Gjerdingen, Crow, McGovern, Miner, & Center,
2009). All 506 trial participants were included in this study. The University of Minnesota's
Institutional Review Board approved the study prior to its initiation.
Mothers’ eligibility criteria for the RCT included: English literate, ≥12 years of age and mother
of 0-1 month old infant who received care at one of 7 participating Minneapolis/St. Paul
metropolitan area clinics: 4 were urban university-affiliated family medicine residency clinics,
and 3 were suburban, private pediatric clinics. As each woman registered her infant for an
initial visit, research assistants (RAs) informed mothers of the study and gave them enrollment
packets (consisting of a brief description of the study, a self-administered questionnaire that
screened for eligibility, consent form, and initial survey). Although RAs attempted to approach
as many mothers as possible, some mothers were missed due to RAs’ multiple, often competing
responsibilities (e.g., RAs also registered infants and made follow-up appointments). Eligible,
willing mothers completed their informed consent and initial survey at this time, and were
mailed a follow-up survey at 9 months postpartum.
Of approximately 1988 mothers encountered during the enrollment phase of the study, an
estimated 1556 were eligible (most of the 432 non-eligible women were not English literate).
Of the 1556 eligible women, 506 (33%) women participated, and 1050 did not participate for
various reasons: 170 were known refusals, 65 completed the enrollment form but not the first
survey, and 815 were either not offered the enrollment packet for reasons described above, or
ignored it, due to tacit refusal or preoccupation with infant care or form completion.
Measures
Survey measures included the following:
1. Body dissatisfaction (0-1 and 9 month surveys), defined as dissatisfaction with
particular aspects of the body (Thompson et al., 1999), was assessed by sum score of
the 8-item Body Shape Questionnaire, Alternate Form 8B (Evans & Dolan, 1993;
www.psyctc.org/tools/bsq/). Responses are given on a 6-point scale (possible score
range 8-48), with a higher body shape score representing a greater number of body
concerns relating to physical appearance, or more body dissatisfaction. This 8-item
survey, derived from the 34 item Body Shape Questionnaire, has been previously
tested on 342 adult women attending a London family planning and well woman clinic
(mean age 27 years, 60% never married, mean body mass index of 22.4). In that study,
the mean score was 20.4 (sd = 8.1), Cronbach's alpha = .87, and the scale correlated
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significantly with body mass index, anxiety, and depression measures (Evans &
Dolan, 1993).
2. Demographic information (all from 0-1 month survey except marital status, taken
from 9 month survey): age, education, marital status, annual family income, race,
health insurance, number of children, and baby's gender.
3. Employment status (9 month survey): this question asked whether the woman was
employed, currently working at a job, or on leave.
4. General Health (9 month survey): consisted of the widely used single-item rating of
health from the SF-36, “In general, would you say your health is: poor, fair, good,
very good, or excellent?” (range 1-5; Ware, Snow, Kosinski, & Gandek, 1993).
5. Depressive symptoms (0-1 and 9 month surveys): Patient Health Questionnaire, 9-
item depression module (PHQ-9; possible range of total score 0-27; Kroenke, Spitzer,
& Williams, 2001).
6. Mental health (9 month survey): 5-item SF-36 Mental Health scale, which consists
of items relating to both positive and negative mental states (i.e., nervous, down in
the dumps, calm and peaceful, down-hearted and blue, happy person; range 5-30;
Ware et al., 1993).
7. Poor appetite or overeating (9 month survey): this PHQ-9 item asks “How often over
the past 2 weeks have you been bothered by a poor appetite or overeating?” (range
0-3; 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every
day). Mean scores in primary care populations have ranged from approximately 0.4
to 1.0 (Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006).
8. Breastfeeding status (9 month survey): currently breastfeeding (yes/no)
9. Mother's weight: included self-reported current weights (0-1 and 9 month surveys),
and recalled pre-pregnancy weight (0-1 month survey). In a previous study, self-
reported weight correlated well with measured weight, with only small errors which
increase somewhat in overweight groups (Rowland, 1990). In another study of
overweight and obese women, participants underestimated their weight by an average
of 0.8 kg (Rossouw, Senekal, & Stander, 2000).
Statistical Analysis
We performed paired t-tests to compare participants’ body image scores at 0-1 and 9 months
postpartum. We also used paired t-tests to determine significant maternal weight changes from
pre-pregnancy to 0-1 month and 9 months postpartum.
We conducted a stepwise multiple regression analysis to explore the relationship between
mothers’ postpartum body dissatisfaction and variables previously shown to be related to body
dissatisfaction (e.g., mental health, not breastfeeding, postpartum weight and weight retention),
as well as other important demographic and social variables not previously associated with
body dissatisfaction (e.g., marital status, number of children, and employment status). New
variables that were significant at p < .05 were allowed to enter the equation and were removed
if p became greater than .10 (no variables were removed from the equation). We selected the
model with the highest variance (R square), and goodness of fit was determined by whether
the proportion of variance accounted for by the model was significant (p < .05). We did not
examine interactions. The dependent variable was the 9-month body dissatisfaction score, and
the independent variables were: mother's age, education, marital status, family income, race
(black vs. other), health insurance (medical assistance vs. other or no insurance), number of
children, baby's gender, breastfeeding status (any vs. none), currently working at a job, PHQ-9
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depressive symptom score, mental health score (SF-36), general health, poor appetite or
overeating, pre-pregnancy weight, 9 month postpartum weight, and weight change from pre-
pregnancy to 9 months postpartum.
We also evaluated the potential impact of our stepped collaborative care intervention
(consisting of a multidisciplinary treatment team, including care manager) on body
dissatisfaction for the 39 depressed women who were in the RCT component of the study by
performing a one-way analysis of variance, with body dissatisfaction as the dependent variable
and treatment group as the independent variable.
We computed Cronbach's internal consistency on the Body Shape Questionnaire and evaluated
stability of this scale over time with Pearson's Correlation Coefficient on the 0-1 month and
9-month Body Shape Questionnaire total score. Cronbach's alpha for the Body Shape
Questionnaire was 0.88 at 0-1 month, and 0.89 at 9 months postpartum. The stability of the
Body Shape Questionnaire score from 0-1 month to 9 months postpartum was r = .56, indicating
that this measure of body dissatisfaction was fairly stable over time.
Results
Participants
Five hundred six women completed the initial survey, and 472 completed the 9 month survey.
Participants’ demographic characteristics (Table 1) revealed a somewhat diverse sample, with
approximately two-thirds of women being married, employed and white, and nearly one-third
on medical assistance. Although we do not have information about the characteristics of eligible
non-participants, we do know that the 34 drop-outs (women who did not complete the final
survey) were on average younger, less educated, had more children, and were more likely to
be single, compared to women who completed the study (Gjerdingen et al., 2009). The 0-1
month survey was completed at an average of 16.8 days (sd = 10.1) postpartum, and the 9-
month survey at an average of 38.7 weeks (sd = 1.7) postpartum.
Change in Weight
Mean self-reported weights at three time intervals were: 150.1 pounds (sd = 35.4) or 68.2 kg.
(sd = 16.1) at pre-pregnancy, 166.1 pounds (sd = 37.3) or 75.5 kg. (sd = 17.0) at 0-1 months
postpartum, and 155.9 pounds (sd = 37.4) or 70.9 kg. (sd = 17.0) at 9 months postpartum (Table
1). Participants lost an average of 10.1 pounds (sd = 16.3) or 4.6 kg (sd = 7.4) from 0-1 months
to 9 months postpartum (p < .001), and remained an average 5.4 pounds (sd = 15.6) or 2.5 kg.
(7.1) heavier at 9 months postpartum, compared to pre-pregnancy (p < .001).
Change in Body Dissatisfaction
On average, mothers’ body dissatisfaction increased significantly from 0-1 to 9 months
postpartum. On a scale for which larger numbers reflect greater body dissatisfaction, the mean
Body Shape score increased by 3.0 points, from 15.2 (sd = 7.0) at 0-1 month to 18.2 (sd = 8.5;
p < .001) at 9 months postpartum (Table 2).
Characteristics Related to Body Dissatisfaction
Body dissatisfaction at 9 months postpartum was significantly associated with overeating or
poor appetite, higher current weight, worse mental health (SF-36 mental health scale), being
single (vs. married), race other than black, bottle feeding (vs. breastfeeding), and having fewer
children (Table 3). Variables that were not significantly related to body dissatisfaction
included: mother's age, education, income, health insurance, currently working at a job, PHQ-9
depressive symptom score, general health, pre-pregnancy weight, weight gain from pre-
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pregnancy to 9 months postpartum, and baby's gender. In addition, body dissatisfaction was
not influenced by our stepped care intervention.
Discussion
Postpartum Body Dissatisfaction
In this sample of postpartum women, body dissatisfaction increased from 0-1 to 9 months
postpartum. This is in line with Rallis et al.'s (2007) finding that women's body dissatisfaction
is greatest at 6 months postpartum, and with other research indicating that body image becomes
increasingly negative during pregnancy and reaches its nadir during the postpartum period
(Drake, 1988; Moore, 1978).
To put the current findings in context, the mean responses to items such as “feeling ashamed
of your body” and “avoiding wearing clothes which make you particularly aware of the shape
of your body” increased from a score of “rarely” to “sometimes.” Thus the absolute body
dissatisfaction scores indicated a relatively low level of concern. In addition, the mean total
score of 18.2 at 9 months postpartum indicated greater body satisfaction in our sample,
compared to Evans & Dolan's (1993) sample of mostly single young adult women (average
age of 27 years), whose mean score was 20.4. Despite this, the lower body dissatisfaction scores
were significantly associated with poorer mental health, highlighting the importance of body
satisfaction to women.
Relationship of Postpartum Body Dissatisfaction to Weight and Mental Health
We found that at 9 months postpartum mothers weighed an average of 5.4 pounds or 2.5
kilograms more than before pregnancy. This postpartum weight retention is in line with a
historical upward trend. In 1995, the mean 12 month postpartum weight retention in a cohort
of 1423 Swedish women was 0.5 kg, (Rossner, 1997; Rossner & Ohlin, 1995) while in 2003
a mean 12 month weight retention of 1.51 kg. was reported in a prospective study of 540 women
in upstate New York (Olson & Strawderman, 2003).
Mothers’ body dissatisfaction at 9 months postpartum was associated with greater current
weight, but not with pre-pregnancy (baseline) weight or 9 month postpartum weight retention.
Previous investigators have shown that women want to return to a normal weight after
childbirth (Fairburn & Welch, 1990; Walker & Freeland-Graves, 1998), so it is possible that
this expectation contributed to an increase in body dissatisfaction ratings at the later postpartum
interval. The significant relationship found here between body dissatisfaction and 9 month
postpartum weight suggests that the postpartum period, often characterized by greater weight
and slow return to former body shape, may predispose women to a poorer body image in a
culture that often equates beauty with thinness.
This cultural “thinness” mindset could unfortunately have negative repercussions on a mother's
mental health. Similar to previous studies that documented an association between perinatal
depressive symptoms and body image or shape concerns (Abraham et al., 2001; Dipietro et al.,
2003; Walker et al., 2002), our study also showed a significant relationship between body
dissatisfaction and poorer mental health. It is interesting to note that our global measure of
mental health, the SF-36 Mental Health Scale, was a better predictor of body dissatisfaction
than was our measure of depressive symptoms, the PHQ-9. While we do not know the direction
of causation between poor mental health and body dissatisfaction, it is possible that this
relationship is bi-directional: that is, poor mental health may contribute to body dissatisfaction,
and body dissatisfaction could also predispose to mental health declines. Further, the
combination of body dissatisfaction and poor mental health may heighten the risk for
postpartum eating disorders, as suggested by other investigators (Astrachan-Fletcher et al.,
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2008), as well as our own findings of a significant association between body dissatisfaction
and poor appetite or overeating.
Relationship of Postpartum Body Dissatisfaction to Demographic Characteristics
Our finding that black women had greater body satisfaction is also supported in previous
research. In an ethnically diverse low income sample of women at 6 weeks postpartum, 76 of
whom were Anglo/White, 72 African American, and 135 Hispanic, the Anglo mothers had the
highest number of negative body image components and the African-American women had
the least (Walker et al., 2002). Similarly, in a study of 114 female college students, African-
American Women had both higher levels of self-esteem and a more positive body image than
did white women (Molloy & Herzberger, 1998).
Prior research on the relationship between body image and marital status is mixed: some studies
showed no association between body image and marital status (Friedman, Dixon, Brownell,
Whisman, & Wilfley, 1999; Khorshid, Eser, Denat, & Cinar, 2007), and others, like ours,
showed a positive association (Manos, Sebastian, Bueno, Mateos, & De la Torre, 2005). Less
evidence exists from prior work about the link between mothers’ body image and number of
children; however, it is possible that these close social relationships could positively affect a
mother's body image and self esteem.
Relationship of Body Satisfaction to Breastfeeding
Mothers’ postpartum body satisfaction was also associated with breastfeeding. This is
consistent with three previous studies that showed a relationship between intent to breastfeed
and positive body image (Barnes, Stein, Smith, & Pollock, 1997; Foster et al., 1996; Huang,
Wang, & Chen, 2004). In a study of 195 Taiwanese women, those who intended to breastfeed
rated their pre-pregnancy body image more positively than those who planned to bottle-feed
(Huang et al., 2004). A study of 38 British women showed that women intending to bottle-feed
had a higher level of body shape concerns (Foster et al., 1996). Similarly, in the large (n =
12,000) Avon Longitudinal Study of Pregnancy and Childhood, women who were preoccupied
with their body shape and those who expressed controlling, less child-centered responses to
managing an infant were less likely to express intentions to breastfeed (Barnes et al., 1997).
In contrast, in a survey of 207 women at approximately 4 months postpartum no significant
differences in body image scores or in postpartum weight retention were observed between
breast- and bottle-feeding mothers (Walker & Freeland-Graves, 1998). Thus, most of the
current evidence points to a positive relationship between breastfeeding (or intent to breastfeed)
and mother's body image.
Strengths and Weaknesses
Strengths of this study included its primary care-based sample, prospective longitudinal design,
use of a previously tested body shape (dissatisfaction) survey, and the evaluation of women's
body dissatisfaction at a time when their bodies were undergoing dramatic changes, that is,
after childbirth. The study also had several limitations, including possible social acceptability
bias in the self-reported data on weight and body dissatisfaction, and potential participation
bias and non-representativeness of the study sample, resulting from our exclusion of non-
English literate women, our relatively low participation rate (due to women either refusing to
participate or not being approached –we often could not differentiate between the two), and
study dropouts (who were younger, less educated, and more often single). In addition, study
follow-up was limited to 9 months postpartum, making it difficult to know whether body
satisfaction improves beyond 9 months, as occurred in the Rallis et al. (2007) study.
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Conclusions
This study showed a significant increase in mothers’ postpartum body dissatisfaction over 9
months, and a relationship between body dissatisfaction and higher postpartum weight. Further,
findings suggest that breastfeeding and close social relationships (e.g., spouse and children)
may positively affect mothers’ body satisfaction, although the direction of causation remains
unknown. Given the many ways in which body image, weight gain, and mental health are
intertwined, along with current trends toward increasing obesity and postpartum weight
retention, it is important to educate women about the expected course of postpartum weight
loss and body changes, and to find ways to enhance mother's body image and self esteem after
delivery.
Acknowledgments
This study was funded by the National Institute of Mental Health. None of the authors has a conflict of interest.
References
Abraham S, Taylor A, Conti J. Postnatal depression, eating, exercise, and vomiting before and during
pregnancy. International Journal of Eating Disorders 2001;29:482–487. [PubMed: 11285587]
Astrachan-Fletcher E, Veldhuis C, Lively N, Fowler C, Marcks B. The reciprocal effects of eating
disorders and the postpartum period: A review of the literature and recommendations for clinical care.
Journal of Women's Health 2008;17:227–239.
Barnes J, Stein A, Smith T, Pollock JI. Extreme attitudes to body shape, social and psychological factors
and a reluctance to breast feed. ALSPAC study team. Avon longitudinal study of pregnancy and
childhood. Journal of the Royal Society of Medicine 1997;90:551–559. [PubMed: 9488013]
Carter AS, Baker CW, Brownell KD. Body mass index, eating attitudes, and symptoms of depression
and anxiety in pregnancy and the postpartum period. Psychosomatic Medicine 2000;62:264–270.
[PubMed: 10772407]
Clark A, Skouteris H, Wertheim EH, Milgrom J, Paxton SJ. The relationship between depression and
body dissatisfaction across pregnancy and the postpartum: A prospective study. Journal of Health
Psychology 2009;14(1):27–35. [PubMed: 19129334]
Dipietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain
attitudes and behaviors during pregnancy. Journal of the American Dietetic Association
2003;103:1314–1319. [PubMed: 14520249]
Drake ML, Verhulst D, Fawcett J, Barger DF. Spouses’ body image changes during and after pregnancy:
A replication in Canada. Image: Journal of Nursing Scholarship 1988;20:88–92.
Duncombe D, Wertheim EH, Skouteris H, Paxton SJ, Kelly L. How well do women adapt to changes in
their body size and shape across the course of pregnancy? Journal of Health Psychology 2008;13:503–
515. [PubMed: 18420758]
Evans C, Dolan B. Body shape questionnaire: Derivation of shortened “alternate forms.”. International
Journal of Eating Disorders 1993;13:315–321. [PubMed: 8477304]
Fairburn CG, Welch SL. The impact of pregnancy on eating habits and attitudes to shape and weight.
International Journal of Eating Disorders 1990;9:153–160.
Foster SF, Slade P, Wilson K. Body image, maternal fetal attachment, and breast feeding. Journal of
Psychosomatic Research 1996;41:181–184. [PubMed: 8887831]
Friedman MA, Dixon AE, Brownell KD, Whisman MA, Wilfley DE. Marital status, marital satisfaction,
and body image dissatisfaction. International Journal of Eating Disorders 1999;26(1):81–85.
[PubMed: 10349587]
Gjerdingen D, Crow S, McGovern P, Miner M, Center C. Postpartum depression screening at well-child
visits: Validity of the two-question screen and PHQ-9. Annals of Family Medicine 2009;7(1):63–70.
[PubMed: 19139451]
Gunderson EP, Murtaugh MA, Lewis CE, Quesenberry CP, West DS, Sidney S. Excess gains in weight
and waist circumference associated with childbearing: The coronary artery risk development in young
Gjerdingen et al. Page 8
Women Health. Author manuscript; available in PMC 2010 September 1.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
adults study (CARDIA). International Journal of Obesity Related Metabolic Disorders 2004;28:525–
535.
Herring SJ, Oken E, Haines J, Rich-Edwards JW, Rifas-Shiman SL, Kleinman KP, Gillman MW.
Misperceived pre-pregnancy body weight status predicts excessive gestational weight gain: findings
from a US cohort study. BMC Pregnancy and Childbirth 2008;8:54. [PubMed: 19102729]
Herring SJ, Rich-Edwards JW, Oken E, Rifas-Shiman SL, Kleinman KP, Gillman MW. Association of
postpartum depression with weight retention 1 year after childbirth. Obesity 2008;16(6):1296–1301.
[PubMed: 18369338]
Huang HC, Wang SY, Chen CH. Body image, maternal-fetal attachment, and choice of infant feeding
method: A study in Taiwan. Birth 2004;31:183–188. [PubMed: 15330880]
Huang FY, Chung H, Kroenke K, Delucchi KL, Spitzer RL. Using the Patient Health Questionnaire-9 to
measure depression among racially and ethnically diverse primary care patients. Journal of General
Internal Medicine 2006;21:547–552. [PubMed: 16808734]
Hurley KM, Caufield LE, Sacco LM, Costigan KA, Dipietro JA. Psychosocial influences in dietary
patterns during pregnancy. Journal of the American Dietetic Association 2005;105:963–966.
[PubMed: 15942549]
Institute of Medicine (U.S.). Weight Gain during Pregnancy: Reexamining the Guidelines. National
Academies Press; Washington, D.C.: Committee to Reexamine IOM Pregnancy Weight Guidelines..
(20009)
Jenkin W, Tiggemann M. Psychological effects of weight retained after pregnancy. Women Health
1997;25:89–98. [PubMed: 9253140]
Khorshid L, Eser I, Denat Y, Cinar S. An investigation into the body image of women. International
Journal of Human Sciences 2007;4(2) online.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. Journal
of General Internal Medicine 2001;16:606–613. [PubMed: 11556941]
Laraia BA, Siega-Riz AM, Dole N, London E. Pregravid weight is associated with prior dietary restraint
and psychosocial factors during pregnancy. Obesity 2008;17:550–558. [PubMed: 19131943]
Linne Y, Dye L, Barkeling B, Rossner S. Long-term weight development in women: A 15-year follow-
up of the effects of pregnancy. Obesity Research 2004;12:1166–1178. [PubMed: 15292482]
Manos D, Sebastian J, Bueno MJ, Mateos N, De la Torre A. Body image in relation to self-esteem in a
sample of Spanish women with early-stage breast cancer. PsicoOncologia 2005;2(1):103–116.
Molloy BL, Herzberger SD. Body image and self-esteem: A comparison of African American and
Caucasian women. Sex Roles: a Journal of Research 1998;38:631–643.
Moore DS. The body image in pregnancy. Journal of Nurse Midwifery 1978;22:17–27. [PubMed:
246461]
Olson CM, Strawderman MS. Modifiable behavioral factors in a biopsychosocial model predict
inadequate and excessive gestational weight gain. Journal of the American Dietetic Association
2003;103:48–54. [PubMed: 12525793]
Rallis S, Skouteris H, Wertheim EH, Paxton SJ. Predictors of body image during the first year postpartum:
A prospective study. Women Health 2007;45:87–104. [PubMed: 17613464]
Rossner S, Ohlin A. Pregnancy as a risk factor for obesity: Lessons from the Stockholm pregnancy and
weight development study. Obesity Research 1995;3(Suppl 2):267s–275s. [PubMed: 8581786]
Rossner S. Weight gain in pregnancy. Human Reproduction 1997;12(Suppl):110–115. 1. [PubMed:
9403327]
Rossouw K, Senekal M, Stander I. The accuracy of self-reported weight by overweight and obese women
in an outpatient setting. Public Health Nutrition 2000;4(1):19–26. [PubMed: 11255492]
Rowland ML. Self-reported weight and height. American Journal of Clinical Nutrition 1990;52:1125–
1133. [PubMed: 2239790]
Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to
body dissatisfaction during pregnancy. Body Image 2005;2:347–361. [PubMed: 18089200]
Thompson, JK.; Heinberg, LJ.; Altabe, M.; Tantleff-Dunn, S. An introduction to the concept of body
image disturbance: History, definitions, and descriptions.. In: J. Thompson, L.; Heinberg, M.; Altabe,
Gjerdingen et al. Page 9
Women Health. Author manuscript; available in PMC 2010 September 1.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
M.; S. Tantleff-Dunn, S., editors. Exacting beauty: Theory, assessment, and treatment of body image
disturbance. American Psychological Association; Washington: 1999. p. 3-15.
Walker LO, Freeland-Graves J. Lifestyle factors related to postpartum weight gain and body image in
bottle- and breastfeeding women. Journal of Obstetetric, Gynecologic, and Neonatal Nursing
1998;27:151–160.
Walker L, Timmerman GM, Kim M, Sterling B. Relationships between body image and depressive
symptoms during postpartum in ethnically diverse, low income women. Women Health
2002;36:101–121. [PubMed: 12539795]
Walker LO, Freeland-Graves JH, Milani T, Hanss-Nuss H, George G, Sterling BS, Kim M, Timmerman
GM, Wilkinson S, Arheart KL, Stuifbergen A. Weight and behavioral and psychosocial factors
among ethnically diverse, low-income women after childbirth: I. methods and context. Women
Health 2004;40:1–17. [PubMed: 15778135]
Ware, JE.; Snow, KK.; Kosinski, M.; Gandek, B. SF-36 Health Survey: Manual and Interpretation Guide.
The Health Institute, New England Medical Center; Boston: 1993.
Gjerdingen et al. Page 10
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Table 1
Participants’ Characteristics* in Frequencies (%) or Means (sd), n = 506
Characteristic Number (%) or Mean (sd)
Race/Ethnicity, # (%)
White 339 (67.0%)
Black or African American 89 (17.6%)
Asian 34 (6.7%)
Other 44 (8.7%)
Total Annual Family Income, # (%)
≥ $80,000 178 (36.5%)
$20,000 - $79,999 177 (36.3%)
< $20,000 133 (27.3%)
Education, # (%)
≥ 4-year degree 263 (52.2%)
High School Diploma or some Post-High School 160 (31.8%)
< High School Diploma 81 (16.1%)
Health Insurance, # (%)
Private Insurance 257 (55.3%)
Medical Assistance 142 (30.5%)
None 6 (1.3%)
Mother's age in years, mean, s.d. 29.1 (6.2)
Married (9 month survey), # (%) 328 (65.2%)
Employed: working or on leave (9 month survey), # (%) 322 (63.6%)
Having only one child, # (%) 207 (41.7%)
Breastfeeding (9 month survey), # (%) 155 (32.9%)
Weight, pounds or kilograms (s.d.)
Baseline (pre-pregnancy) 150.1 (35.4) lb.
68.2 (16.1) kg.
0-1 month postpartum 166.1 (37.3) lb.
75.5 (17.0) kg.
9 months postpartum 155.9 (37.4) lb.
70.9 9 (17.0) kg.
PHQ-9 (9 mo.), mean (sd) 3.7 (4.5)
Possible range: 0-27; higher score – more depressive symptoms
Mental Health Score (9 mo.) mean (sd) 24.3 (4.0)
Possible range: 5-30; higher score – better mental health
General Health Score (9 mo.), mean (sd) 3.6 (0.9)
Possible range: 1-5; higher score – better general health
Poor appetite or overeating, (9 mo.), mean (sd) 0.5 (0.8)
Possible range: 0-3; higher score – greater difficulty
*Characteristics were measured at 0-1 month postpartum, unless otherwise stated.
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Table 2
Body Shape Questionnaire:* Item Means (sd) at 0-1 and 9 Months Postpartum (n=506)
Questions 0-1 Month
Mean (sd) 9 Month
Mean (sd)
1. Have you worried about your flesh being not firm enough? 2.4 (1.4) 2.7 (1.5)
2. Has eating even a small amount of food made you feel fat? 1.5 (0.9) 1.8 (1.3)
3. Have you avoided wearing clothes which make you particularly aware of the shape of your body? 2.4 (1.5) 2.7 (1.5)
4. Have you felt ashamed of your body? 2.0 (1.3) 2.5 (1.5)
5. Has worry about your shape made you diet? 1.7 (1.2) 2.3 (1.5)
6. Have you felt happiest about your shape when your stomach has been empty (e.g., in the morning)? 1.7 (1.2) 2.2 (1.5)
7. Have you felt that it is not fair that other women are thinner than you? 1.7 (1.1) 2.0 (1.4)
8. Have you worried about your flesh being dimply? 1.9 (1.2) 2.2 (1.4)
Total Score 15.2 (7.0) 18.2 (8.6)
*Body Shape Questionnaire (Evans & Dolan, 1993). Items were scored on a 1-6 scale, with 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = very
often, and 6 = always.
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Table 3
Factors Associated with Women's Body Dissatisfaction (High Body Shape Questionnaire Score) at 9 Months
Postpartum, as Determined by Stepwise Regression Analysis (n = 386)
Independent Variables Beta SE t P Value
Poor appetite or overeating 3.017 .544 5.547 <.001
Current weight .052 .010 5.387 <.001
Mental health −.491 .110 −4.456 <.001
Married −1.984 .548 −3.622 <.001
Black race −4.235 1.218 −3.477 .001
Breastfeeding at 9 months −2.049 .782 −2.619 .009
Number of children −.954 .385 −2.481 .014
R Square .359 <.001
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