Abstract

The body image of pregnant women is an issue that should be further investigated by professionals in the area, especially in view of the fact that maternal and infant health has gained such prominence. The scope of this integrative review is to analyze the literature relating to body image and body dissatisfaction among pregnant women. Research was based on articles extracted from the Scopus, PubMed, BVS and PsycINFO databases, by cross-referencing “pregnancy” with the keywords “body image” and “body dissatisfaction.” Once the inclusion and exclusion criteria had been adopted, forty studies were analyzed. These produced inconclusive data about body dissatisfaction during pregnancy. Symptoms of depression, low self-esteem, an inadequate approach towards healthy eating and weight gain above recommended limits have been associated with a negative body image. The contradictory findings could be related to the different instruments used to measure body image. In view of the possible impact that a negative body image can have on maternal and infant health during pregnancy, it is recommended that further investigations are made, in particular related to the development of a specific tool to evaluate the body image of pregnant women.

Key words
Body image; Pregnancy; Adult; Health; Review

Introduction

Pregnancy is a deeply complex period in a woman's life, since it is considered to be a process when the transformations that occur during pregnancy will have a profound effect on the day-to-day life of the future mother¹1 Mann L, Kleinpaul JF, Mota CB, Santos, SG. Alterações biomecânicas durante o período gestacional: uma revisão. Motriz 2010; 16(3):730-741.. Pregnancy is a phase when complex physiological and psychological changes take place in a short space of time²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35.–⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361., which affect both the mental and physical health of the mother and influence the health of her baby²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35.,⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.–⁶6 Araújo DMR, Pereira NL, Kac G. Ansiedade na gestação, prematuridade e baixo peso ao nascer: uma revisão sistemática da literatura. Cad Saude Publica 2007; 23(4):747-756..

According to Skouteris et al.⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361. and Reis et al.⁷7 Reis DM, Pitta DR, Ferreira HMB, Jesus MCP, Moraes MEL, Soares MG. Educação em saúde como estratégia de promoção de saúde bucal em gestantes. Cien Saude Colet 2010; 15(1):269-276., since the attitudes of the mother will reflect on the development and on the post-partum life of a healthy baby, women in this condition are receptive to information which can be used to benefit their child. Thus, pregnancy represents a favorable phase for actions that promote health, due to the interest a pregnant woman has in adopting and/or changing her habits, since a woman at this particular stage in her life will face a series of issues that can encourage her to seek information and, as a result, adopt new and healthier habits⁸8 Codato LAB, Nakama L, Cordoni Júnior L, Higasi MS. Atenção odontológica à gestante: papel dos profissionais de saúde. Cien Saude Colet 2011; 16(4):2297-2301.. Thus, according to Skouteris et al.⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361., it is extremely important to evaluate a woman's body image during pregnancy, so as to improve the pre-natal assistance she is given while dealing with the body changes that typically occur during this period.

There has been a significant increase in the number of studies published in the international scientific literature⁹9 Bagheri M, Dorosty A, Sadrzadeh-Yeganeh H, Eshraghian M, Amiri E, Khamoush-Cheshm N. Pre-pregnancy body size dissatisfaction and excessive gestational weight gain. Matern Child Health J 2013; 17(4):699-707.–¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561., especially that dealing with a pregnant woman's body image. This is particularly true as a result of concerns related to the possible association that exists between the rapid body changes that occur and the reasons why women feel a profound dissatisfaction with their own bodies during this period. Body dissatisfaction is part of an attitudinal component of body image and refers to a negative evaluation of one's own body¹²12 Cash TF, Smolak L. Body image: a handbook of science, practice, and prevention. 2nd ed. New York: The Guilford Press; 2011.. In the case of pregnant women, a poor body image is often linked to an inadequate or restrictive diet¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.–¹⁵15 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 stud y . BMC Pregnancy Childbirth 2008; 22(8):1-9. and to pre and post-partum depression¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561.,¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63., which can have serious negative consequences both for the health and well-being of the mother as well as for the foetus¹⁷17 Fuller-Tyszkiewicz M, Skouteris H, Watson B, Hill B. Body image during pregnancy: an evaluation of the suitability of the body attitudes questionnaire. BMC Pregnancy Childbirth 2012; 12(1):91-101.,¹⁸18 Araujo DMR, Vilarim MM, Sabroza AR, Nardi AE. Depressão no período gestacional e baixo peso ao nascer: uma revisão sistemática da literatura. Cad Saude Publica 2010; 26(2):219-227..

In this sense, and in view of the relationship that can be established between pregnancy and between body dissatisfaction and maternal and infant health, it is clear that further research needs to be conducted on these issues, so as to broaden understanding of the subject and, as a result, improve the level of maternal health care provided. Thus, the aim of this study is to analyze bibliographic production related to body image and dissatisfaction among pregnant women by means of an integrative review of the literature.

Methods

An integrative review of the literature was conducted¹⁹19 Souza MT, Silva MD, Carvalho R, Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106. in order to produce a comprehensive overview of studies involving pregnancy, body image and dissatisfaction based on information obtained via the Scopus, PubMed, the Virtual Health Library (Biblioteca Virtual em Saúde) (BVS) and PsycINFO databases, during the months of September and October 2013. Thus, a search was performed using the following key words in English: “body image” and “pregnancy” and “body dissatisfaction” and “pregnancy,” since “body image” is a key word indexed under the Health Sciences Key Words (DeCS) system and “pregnancy” and “body dissatisfaction” are terms associated with the theme of this study. It should be stressed that an initial search was made using these terms in Portuguese. However, this only produced a limited number of references. So, for the purpose of this integrative review, it was decided to only cross-reference key words in English in all the databases used. Furthermore, in order to trace the greatest number of articles on the subject, no limits were set regarding dates of publication.

The Scopus database was chosen because of its multi-disciplinary character. This was accessed by selecting the “all fields” option. In addition, in the “document type” section, it was decided to include only articles (“article”). The PubMed database was chosen because it is considered to be one of the most relevant sources of research material in the area of health today. The following filters were used in the advanced search phase: “all fields” and, under “article type,” only “journal article” was accessed. The Virtual Health Library (BVS) was chosen because of its nationwide coverage. In this case, the search was made by selecting “all indexes,” the “integrated method” and “all sources”: Medline, Lilacs, CENTRAL – Controlled Clinical Trials Registers database, IBECS (Spain) and Index Psi (Psychology). This filter was only limited to “document type,” since only “articles” were selected. And, finally, the PsycINFO was selected since it is considered to be one of the most important databases in the field of Psychology. An advanced search was made and it was decided to choose the following options: “any field” and, in the section “document type,” only “journal article” was selected.

Once the articles that met the above-mentioned criteria had been inserted, two documents for each database were created based on the search results – “body image” and “pregnancy” (Document 1) and “body dissatisfaction” and “pregnancy” (Document 2) – containing the titles and abstracts of all references found. The first phase of the exclusion criteria involved the identification and exclusion of articles that were duplicated on the different databases, in other words the same articles found on Scopus were eliminated from the other databases, and so on successively, so that none of the articles were duplicated on any of the other databases. A comparison was also made between Documents 1 and 2 on the same databases, until only one document from each site was left.

This process was continued during the second stage, which consisted of excluding all articles that did not include an abstract. Once this procedure had been completed, the next phase consisted in reading all titles and/or abstracts. This made it possible to exclude all articles where the main language used was not Portuguese, English or Spanish (stage 3). Also excluded were all articles that were not based on empirical methodology (stage 4) or where the methods used did not include tools that measured body image (stage 5).

The next two stages consisted in excluding all articles based on research study samplings. Thus, all articles were excluded that contained samplings from women who were not pregnant (stage 6) or where the sampling only included pregnant adolescents (stage 7).

Finally, the full texts of the remaining articles were accessed. In addition to their respective databases, the Capes Journal Portal was also used as a resource to access the full texts of these articles. However, all those that were not found in their entire form were excluded during the final phase (stage 8).

After applying the criteria as described above, to include or exclude articles, the full text of each article was read in detail. The analysis of this data made it possible to obtain the following information from the selected studies: 1) author and year of publication; 2) country of publication; 3) methodology used; 4) sampling characteristics; and 5) evaluation tools employed. Furthermore, concomitantly, analysis and interpretation was made of the results of each research study, which were then organized and debated according to three main topics: body satisfaction in pregnant women, body dissatisfaction in pregnant women and variables that influence a pregnant woman's perception of her body image.

Results

A total of 2,501 articles dealing with body image, body dissatisfaction and pregnancy were found on the databases accessed in accordance with the search strategy proposal. Table 1 shows the number of articles identified in each database by using the chosen combination of key words.

Exclusion criteria were established so as to delimit the number of articles identified that were suitable for the requirements established in this review. Thus, although a high number of publications were found, a total of only forty articles were analyzed in all. Table 2 and Figure 1 show details of the publications selected, bearing in mind the established exclusion criteria, for each database and according to the total number of articles found, respectively. It should be stressed that, although this search was conducted by using the word “pregnancy,” most of the articles that were excluded did not include samplings of pregnant women.

Based on the articles selected, which evaluated gestational body image and dissatisfaction, a list was made of the names of the authors, year of publication, country of publication, the research methodology used (transversal or longitudinal; quantitative or qualitative), the number of pregnant women evaluated (including, when possible, their gestational period) and the tools used to evaluate the variables of the study (Table 3). It should be said that the information related to the age of the pregnant women is not included in Table 3, since this was considered to be an exclusion criteria for the articles in question. Thus, these studies assessed adult pregnant women and the age of the participants varied between 18 and 49 years old.

With regards to the country and year of publication, the United States (n = 14), followed by Australia (n = 11) were the countries that led in terms of the number of studies made, while 2012 (n = 6) was the year during which the highest number of research studies were produced. As regards the characterization of these studies, most of these publications used quantitative procedures, in their approach; and with respect to their time frame, one-off (cross-sectional) evaluations were made. It should be said that one article used the cross-sectional methodology for the group of non-pregnant women and the longitudinal method for pregnant women¹⁷17 Fuller-Tyszkiewicz M, Skouteris H, Watson B, Hill B. Body image during pregnancy: an evaluation of the suitability of the body attitudes questionnaire. BMC Pregnancy Childbirth 2012; 12(1):91-101.. Thus, both methods were used in this research study.

In spite of the fact that not including pregnant women was one of the reasons why articles were excluded, some of these studies evaluated not only pregnant women at different gestational stages, but also during the pre-gestational and post-partum period. Most of the studies analyzed more than one gestational period, however the third trimester period was the one most frequently analyzed.

Discussion

Professionals in the area should give special attention to the gestational period, especially since promoting maternal and, consequently, fetal health care has become such an important issue. Even though pregnancy is a very special time for women and is a period when weight gain is ac-ceptable²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35., many become dissatisfied with their appearance and physical shape during pregnan-cy¹⁰10 Sui Z, Turnbull D, Dodd J. Effect of body image on gestational weight gain in overweight and obese women. Women Birth 2013; 26(4):267-272., which can have a negative impact on both mother and child¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561.,¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.–¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63.. Professionals who have a greater understanding of this issue can alert the women when a condition of risk becomes apparent. This shows the relevance of this study, which seeks to analyze available bibliographical material related to body image and dissatisfaction among pregnant women by means of an integrative review.

Based on these findings, it may be seen that research has been conducted in an attempt to evaluate body image and associate this with a series of variables during this specific period in a woman's life, such as: depression²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35.,⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561.,¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.,¹⁴14 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? J Health Psychol 2008; 13(4):503-515.,¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63.,²⁰20 Haedt A, Keel P. Maternal attachment, depression, and body dissatisfaction in pregnant women. J Reprod Infant Psychol 2007; 25(4):285-295., self-esteem⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,²¹21 Edwards CH, Cole OJ, Oyemade UJ, Knight EM, Johnson AA, Westney OE, Laryea H, West W, Jones S, Westney LS. Maternal stress and pregnancy outcomes in a prenatal clinic population. J Nutr 1994; 124(Supl. 6):1006-1021.–²³23 Oyemade UJ, Cole OJ, Johnson AA, Knight EM, Westney OE, Laryea H, et al. Prenatal substance abuse and pregnancy outcomes among African American women. J Nutr 1994; 124(Supl. 6):994-999., eating habits¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.,¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63.,²⁴24 Clark M, Ogden J. The impact of pregnancy on eating behaviour and aspects of weight concern. Int J Obes 1999; 23(1):18-24.–²⁶26 Rocco PL, Orbitello B, Perini L, Pera V, Ciano RP, Balestrieri M. Effects of pregnancy on eating attitudes and disorders: a prospective study. J Psychosom Res 2005; 59(3):175-179., physical activity²⁷27 Boscaglia N, Skouteris H, Wertheim EH. Changes in body image satisfaction during pregnancy: a comparison of high exercising and low exercising women. Aust N Z J Obstet Gynaecol 2003; 43(1):41-45.,²⁸28 Goodwin A, Astbury J, McMeeken J. Body image and psychological well-being in pregnancy: a comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynaecol 2000; 40(4):442-447., ethnicity²⁹29 Brooten D, Youngblut JM, Golembeski S, Magnus MH, Hannan J. Perceived weight gain, risk, and nutrition in pregnancy in five racial groups. J Am Acad Nurse Pract 2012; 24(1):32-42., Body Mass Index (BMI)¹⁰10 Sui Z, Turnbull D, Dodd J. Effect of body image on gestational weight gain in overweight and obese women. Women Birth 2013; 26(4):267-272.,¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.,³⁰30 Davies K, Wardle J. Body image and dieting in pregnancy. J Psychosom Res 1994; 38(8):787-799.–³²32 Hauff LE, Demerath EW. Body image concerns and reduced breastfeeding duration in primiparous overweight and obese women. Am J Hum Biol 2012; 24(3):339-349., weight gain outside recommended intervals⁹9 Bagheri M, Dorosty A, Sadrzadeh-Yeganeh H, Eshraghian M, Amiri E, Khamoush-Cheshm N. Pre-pregnancy body size dissatisfaction and excessive gestational weight gain. Matern Child Health J 2013; 17(4):699-707.,¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.,¹⁵15 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 stud y . BMC Pregnancy Childbirth 2008; 22(8):1-9.,³³33 Mehta UJ, Siega-Riz AM, Herring AH. Effect of body image on pregnancy weight gain. Matern Child Health J 2011; 15:(3)324-332.,³⁵35 Rauff EL, Downs DS. Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Ann Behav Med 2011; 42(3):381-390.,⁴⁶46 Pauls RN, Occhino JA, Dryfhout V, Karram MM. Effects of pregnancy on pelvic foor dysfunction and body image: a prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19(11):1495-1501., among others. In addition, this reproductive stage has also been investigated by using cross-sectional methods²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35.,⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,⁹9 Bagheri M, Dorosty A, Sadrzadeh-Yeganeh H, Eshraghian M, Amiri E, Khamoush-Cheshm N. Pre-pregnancy body size dissatisfaction and excessive gestational weight gain. Matern Child Health J 2013; 17(4):699-707.,¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.,¹⁵15 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 stud y . BMC Pregnancy Childbirth 2008; 22(8):1-9.,²⁰20 Haedt A, Keel P. Maternal attachment, depression, and body dissatisfaction in pregnant women. J Reprod Infant Psychol 2007; 25(4):285-295.,²²22 Kazmierczak M, Goodwin R. Pregnancy and body image in Poland: gender roles and self-esteem during the third trimester. J Reprod Infant Psychol 2011; 29(4):334-342.,²⁴24 Clark M, Ogden J. The impact of pregnancy on eating behaviour and aspects of weight concern. Int J Obes 1999; 23(1):18-24.,²⁵25 Lai BP, Tang CS, Tse WK. Prevalence and psychosocial correlates of disordered eating among Chinese pregnant women in Hong Kong. Eat Disord 2005; 13(2):171-186.,²⁹29 Brooten D, Youngblut JM, Golembeski S, Magnus MH, Hannan J. Perceived weight gain, risk, and nutrition in pregnancy in five racial groups. J Am Acad Nurse Pract 2012; 24(1):32-42.–³¹31 Fox P, Yamaguchi C. Body image change in pregnancy: a comparison of normal weight and overweight primigrávidas. Birth 1997; 24(1):35-40.,³⁶36 Sacomori C, Cardoso FL, Vanderlinde C. Pelvic floor muscle strength and body self-perception among Brazilian pregnant women. Physiotherapy 2010; 96(4):337-343.,³⁷37 Chang SR, Kenney NJ, Chao YM. Transformation in self-identity amongst Taiwanese women in late pregnancy: a qualitative study. Int J Nurs Stud 2010; 47(1):60-66.,³⁹39 Chang SR, Chao YM, Kenney NJ. I am a woman and I'm pregnant: body image of women in Taiwan during the third trimester of pregnancy. Birth 2006; 33(2):147-153.–⁴²42 Earle S. “Bumps and Boobs”: fatness and women's experiences of pregnancy. Womens Stud Int Forum 2003; 26(3):245-252.,⁴⁴44 Kendall A, Olson CM, Frongillo EA Jr. Evaluation of psychosocial measures for understanding weight-related behaviors in pregnant women. Ann Behav Med 2001; 23(1):50-58.,⁴⁵45 Foster SF, Slade P, Wilson K. Body image, maternal fetal attachment, and breast feeding. J Psychosom Res 1996; 41(2):181-184.,⁴⁷47 Ruggieri V, Milizia M, Romano MF. Effects of body image on tactile sensitivity to a tickle: a study of pregnancy. Percept Mot Skills 1979; 49(2):555-563. as well as longitudinal methods³3 Nash M. Weighty matters: Negotiating ‘fatness’ and ‘in -betweenness’ in early pregnancy. Feminism Psychology 2012; 22(3):307-323.,⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,¹⁰10 Sui Z, Turnbull D, Dodd J. Effect of body image on gestational weight gain in overweight and obese women. Women Birth 2013; 26(4):267-272.,¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561.,¹⁴14 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? J Health Psychol 2008; 13(4):503-515.,¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63.,²¹21 Edwards CH, Cole OJ, Oyemade UJ, Knight EM, Johnson AA, Westney OE, Laryea H, West W, Jones S, Westney LS. Maternal stress and pregnancy outcomes in a prenatal clinic population. J Nutr 1994; 124(Supl. 6):1006-1021.,²³23 Oyemade UJ, Cole OJ, Johnson AA, Knight EM, Westney OE, Laryea H, et al. Prenatal substance abuse and pregnancy outcomes among African American women. J Nutr 1994; 124(Supl. 6):994-999.,²⁶26 Rocco PL, Orbitello B, Perini L, Pera V, Ciano RP, Balestrieri M. Effects of pregnancy on eating attitudes and disorders: a prospective study. J Psychosom Res 2005; 59(3):175-179.–²⁸28 Goodwin A, Astbury J, McMeeken J. Body image and psychological well-being in pregnancy: a comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynaecol 2000; 40(4):442-447.,³²32 Hauff LE, Demerath EW. Body image concerns and reduced breastfeeding duration in primiparous overweight and obese women. Am J Hum Biol 2012; 24(3):339-349.–³⁵35 Rauff EL, Downs DS. Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Ann Behav Med 2011; 42(3):381-390.,³⁸38 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. My baby body: A qualitative insight into women's body-related experiences and mood during pregnancy and the postpartum. J Reprod Infant Psychol 2009; 27(4):330-345.,⁴³43 Schmied V, Lupton D. The externality of the inside: body images of pregnancy. Nurs Inq 2001; 8(1):32-40.,⁴⁶46 Pauls RN, Occhino JA, Dryfhout V, Karram MM. Effects of pregnancy on pelvic foor dysfunction and body image: a prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19(11):1495-1501., mixed¹⁷17 Fuller-Tyszkiewicz M, Skouteris H, Watson B, Hill B. Body image during pregnancy: an evaluation of the suitability of the body attitudes questionnaire. BMC Pregnancy Childbirth 2012; 12(1):91-101., qualitative²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35.,³3 Nash M. Weighty matters: Negotiating ‘fatness’ and ‘in -betweenness’ in early pregnancy. Feminism Psychology 2012; 22(3):307-323.,²⁶26 Rocco PL, Orbitello B, Perini L, Pera V, Ciano RP, Balestrieri M. Effects of pregnancy on eating attitudes and disorders: a prospective study. J Psychosom Res 2005; 59(3):175-179.,³⁷37 Chang SR, Kenney NJ, Chao YM. Transformation in self-identity amongst Taiwanese women in late pregnancy: a qualitative study. Int J Nurs Stud 2010; 47(1):60-66.,³⁹39 Chang SR, Chao YM, Kenney NJ. I am a woman and I'm pregnant: body image of women in Taiwan during the third trimester of pregnancy. Birth 2006; 33(2):147-153.,⁴⁰40 Johnson S, Burrows A, Williamson I. ‘Does my bump look big in this?’ The meaning of bodily changes for first-time mothers-to-be. J Health Psychol 2004; 9(3):361-374.,⁴²42 Earle S. “Bumps and Boobs”: fatness and women's experiences of pregnancy. Womens Stud Int Forum 2003; 26(3):245-252.,⁴³43 Schmied V, Lupton D. The externality of the inside: body images of pregnancy. Nurs Inq 2001; 8(1):32-40., quantitative⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,⁹9 Bagheri M, Dorosty A, Sadrzadeh-Yeganeh H, Eshraghian M, Amiri E, Khamoush-Cheshm N. Pre-pregnancy body size dissatisfaction and excessive gestational weight gain. Matern Child Health J 2013; 17(4):699-707.–¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561.,¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319.–¹⁷17 Fuller-Tyszkiewicz M, Skouteris H, Watson B, Hill B. Body image during pregnancy: an evaluation of the suitability of the body attitudes questionnaire. BMC Pregnancy Childbirth 2012; 12(1):91-101.,²⁰20 Haedt A, Keel P. Maternal attachment, depression, and body dissatisfaction in pregnant women. J Reprod Infant Psychol 2007; 25(4):285-295.–²⁵25 Lai BP, Tang CS, Tse WK. Prevalence and psychosocial correlates of disordered eating among Chinese pregnant women in Hong Kong. Eat Disord 2005; 13(2):171-186.,²⁷27 Boscaglia N, Skouteris H, Wertheim EH. Changes in body image satisfaction during pregnancy: a comparison of high exercising and low exercising women. Aust N Z J Obstet Gynaecol 2003; 43(1):41-45.–³⁰30 Davies K, Wardle J. Body image and dieting in pregnancy. J Psychosom Res 1994; 38(8):787-799.,³²32 Hauff LE, Demerath EW. Body image concerns and reduced breastfeeding duration in primiparous overweight and obese women. Am J Hum Biol 2012; 24(3):339-349.–³⁶36 Sacomori C, Cardoso FL, Vanderlinde C. Pelvic floor muscle strength and body self-perception among Brazilian pregnant women. Physiotherapy 2010; 96(4):337-343.,³⁸38 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. My baby body: A qualitative insight into women's body-related experiences and mood during pregnancy and the postpartum. J Reprod Infant Psychol 2009; 27(4):330-345.,⁴¹41 Huang HC, Wang SY, Chen CH. Body image, maternal-fetal attachment, and choice of infant feeding method: a study in Taiwan. Birth 2004; 31(3):183-188.,⁴⁴44 Kendall A, Olson CM, Frongillo EA Jr. Evaluation of psychosocial measures for understanding weight-related behaviors in pregnant women. Ann Behav Med 2001; 23(1):50-58.–⁴⁷47 Ruggieri V, Milizia M, Romano MF. Effects of body image on tactile sensitivity to a tickle: a study of pregnancy. Percept Mot Skills 1979; 49(2):555-563. and qualitative-quantitative approaches³¹31 Fox P, Yamaguchi C. Body image change in pregnancy: a comparison of normal weight and overweight primigrávidas. Birth 1997; 24(1):35-40., comprising the pre-gestational periods; the first, second and third trimesters; and post-partum.

In order to better understand these findings, it was decided to discuss these results in accordance with their proximity to specific issues. Thus, three categories were created: Body Satisfaction among pregnant women; Body Dissatisfaction among pregnant women, and Variables that Influence Body Image among pregnant women.

Body Satisfaction among pregnant women

Several studies were conducted to compare the level of body satisfaction among pregnant and non-pregnant women, though these produced different results. Davies and Wardle³⁰30 Davies K, Wardle J. Body image and dieting in pregnancy. J Psychosom Res 1994; 38(8):787-799. found that pregnant women showed a lower score as regards wanting to lose weight, both by restricting their diet and in the efforts they made to lose weight. Clark and Ogden²⁴24 Clark M, Ogden J. The impact of pregnancy on eating behaviour and aspects of weight concern. Int J Obes 1999; 23(1):18-24. found that pregnant women were less dissatisfied with the bodies when compared to non-pregnant women, and suggest that pregnancy legitimizes an increase in food consumption as well as eliminates any prior intention a woman may have had to eat less. Loth et al.³⁴34 Loth KA, Bauer KW, Wall M, Berge J, Neumark-Sztainer D. Body satisfaction during pregnancy. Body Image 2011; 8(3):297-300. have recently established that, in spite of gaining weight, body satisfaction was higher among pregnant than among non-pregnant women, which corroborates previous findings. These factors indicate that pregnant women are less concerned about their weight during pregnancy, even when their body size increases.

Other studies have found that weight and body shape dissatisfaction remains stable or is temporarily reduced during pregnancy⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,²⁶26 Rocco PL, Orbitello B, Perini L, Pera V, Ciano RP, Balestrieri M. Effects of pregnancy on eating attitudes and disorders: a prospective study. J Psychosom Res 2005; 59(3):175-179.,⁴¹41 Huang HC, Wang SY, Chen CH. Body image, maternal-fetal attachment, and choice of infant feeding method: a study in Taiwan. Birth 2004; 31(3):183-188., in spite of the fact that women gain weight and are, therefore, far from their social ideal of slimness⁴⁸48 Dittmar H. How do “body perfect” ideals in the media have a negative impact on body image and behaviors? Factors and processes related to self and identity. J Soc Clin Psychol 2009; 28(1):1-8.,⁴⁹49 López-Guimerà G, Levine MP, Sánchez-Carracedo D, Fauquet J. Influence of mass media on body image and eating disordered attitudes and behaviors in females: a review of effects and processes. Media Psychol 2010, 13(4):387-416.. Duncombe et al.¹⁴14 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? J Health Psychol 2008; 13(4):503-515. found that a woman's body image appears to remain stable during their entire pregnancy, such that women who began by worrying about their bodies continued to do so over the whole gestational period. In a study conducted in Poland, Kazmierczak and Goodwin²²22 Kazmierczak M, Goodwin R. Pregnancy and body image in Poland: gender roles and self-esteem during the third trimester. J Reprod Infant Psychol 2011; 29(4):334-342. found that pregnant women generally had a good body image, which is positively associated with self-esteem. According to investigations conducted by Clark et al.²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35., Clark et al.³⁸38 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. My baby body: A qualitative insight into women's body-related experiences and mood during pregnancy and the postpartum. J Reprod Infant Psychol 2009; 27(4):330-345. and Boscaglia et al.²⁷27 Boscaglia N, Skouteris H, Wertheim EH. Changes in body image satisfaction during pregnancy: a comparison of high exercising and low exercising women. Aust N Z J Obstet Gynaecol 2003; 43(1):41-45., most Australian women adapted well to the changes in their bodies during pregnancy, while the relevance of their own weight and body shape were reduced during the final months of pregnancy. Based on these findings, it is possible to affirm that pregnancy is a unique period in a woman's life when weight gain is regarded as acceptable²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35..

The researchers, whose studies indicate that pregnancy has a positive effect on body image, appreciate that less pressure appears to have been brought to bear on these women to attain the perfect body during this phase⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,³⁰30 Davies K, Wardle J. Body image and dieting in pregnancy. J Psychosom Res 1994; 38(8):787-799.,³⁸38 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. My baby body: A qualitative insight into women's body-related experiences and mood during pregnancy and the postpartum. J Reprod Infant Psychol 2009; 27(4):330-345.. Pregnancy seems to enable women to develop an innermost sense that an increase in body weight and in the shape of their bodies is something that can be tolerated by most, and is something that some women even appreciate⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,³⁰30 Davies K, Wardle J. Body image and dieting in pregnancy. J Psychosom Res 1994; 38(8):787-799.. According to Clark and Ogden²⁴24 Clark M, Ogden J. The impact of pregnancy on eating behaviour and aspects of weight concern. Int J Obes 1999; 23(1):18-24., they develop a more positive body image and their desire to lose weight is reduced. In addition, it is suggested that pregnancy appears to go hand-in-hand with a feeling of being free of dietary habits and the usual restraints that are common to Western society today⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,²⁴24 Clark M, Ogden J. The impact of pregnancy on eating behaviour and aspects of weight concern. Int J Obes 1999; 23(1):18-24.,⁵⁰50 Murnen SK. Gender and body images. In: Cash T, Smolak L, editors. Body image: a handbook of science, practice, and prevention. 2nd ed. New York: The Guilford Press; 2011. p. 173-179. Thus, it may well be that women have a tendency at this time to prioritize their own health and that of their unborn child, rather than aesthetics²⁶26 Rocco PL, Orbitello B, Perini L, Pera V, Ciano RP, Balestrieri M. Effects of pregnancy on eating attitudes and disorders: a prospective study. J Psychosom Res 2005; 59(3):175-179.,³⁹39 Chang SR, Chao YM, Kenney NJ. I am a woman and I'm pregnant: body image of women in Taiwan during the third trimester of pregnancy. Birth 2006; 33(2):147-153..

Using a qualitative approach, Nash³3 Nash M. Weighty matters: Negotiating ‘fatness’ and ‘in -betweenness’ in early pregnancy. Feminism Psychology 2012; 22(3):307-323. noted that some pregnant women feel they have the freedom to be “fat” for the first time in their lives. On the other hand, others saw weight gain as “frightening,” especially because of the social stigma attached to body weight. This duality was also noted in the study conducted by Chang et al.³⁹39 Chang SR, Chao YM, Kenney NJ. I am a woman and I'm pregnant: body image of women in Taiwan during the third trimester of pregnancy. Birth 2006; 33(2):147-153. who highlighted two main concerns that prospective mothers have during the final three months of their pregnancy: “My body: where is it heading?” which reflects the standards of beauty used by non-pregnant adults of the female sex to evaluate their pregnant bodies and their hope of recovering their pre-gestational figures after childbirth; and 2) “My body: my baby's body,” which reflects how women regard the changes that occur in their bodies as being a sign of good health, that their baby is developing and as a confirmation of their adequacy as mothers. In other words, there is a visible conflict between what is seen as being good for the pregnant woman as a female and what is good for her child, or for the woman as an a mother.

Body dissatisfaction among pregnant women

The prevalence of body dissatisfaction during pregnancy is not a consensus in the literature. The oldest study found during this review, which was conducted in Italy, investigated the body image of pregnant and non-pregnant women⁴⁴44 Kendall A, Olson CM, Frongillo EA Jr. Evaluation of psychosocial measures for understanding weight-related behaviors in pregnant women. Ann Behav Med 2001; 23(1):50-58.. It should be said that the authors used the term “body schema” to refer to body image, unlike other studies found in this review. These findings indicate that pregnant women gave a lower rating when evaluating their own body images in comparison to non-pregnant women. According to Scagliusi and Lourenço⁵¹51 Scagliusi FB, Lourenço BH. A ditadura da beleza e suas consequências no discurso nutricional. In: Alvarenga M, Scagliusi FB, Philippi ST, organizadoras. Nutrição e transtornos alimentares: avaliação e tratamento. Barueri: Manole; 2011. p. 59-83., between 1970 and 1990, the desire to have an athletic body was combined with the ideal of having a slim figure at a time when supermodels represented the height of beauty. It is worth noting that during this period pregnant women were likely to be influenced by the image of an ideal body, which would probably have provoked the initial interest of the researchers.

The study by Earle⁴²42 Earle S. “Bumps and Boobs”: fatness and women's experiences of pregnancy. Womens Stud Int Forum 2003; 26(3):245-252. indicated that, during pregnancy, women expressed three main concerns in relation to their size and body shape, which are as follows: how they would look when their pregnancy began to show, where the changes in their bodies would occur, and how easy it would be to recuperate their pre-gestational body shape.

Thus, pregnant women are worried about questions related to their body image and weight during the whole process of pregnancy. In view of these concerns, Lai et al.²⁵25 Lai BP, Tang CS, Tse WK. Prevalence and psychosocial correlates of disordered eating among Chinese pregnant women in Hong Kong. Eat Disord 2005; 13(2):171-186. point to the fact that pregnancy can be seen as a vulnerable period for issues involving diet, because of increased pressure to conform to feminine values. In this study conducted in China, the authors show that body dissatisfaction was related to a poor maternal-fetal relationship. In addition, 9.8 % of the participants of the survey stated they ate less during pregnancy, which was linked to health risks for the mother and her baby.

In a research study conducted in England, all the pregnant mothers said they had become less satisfied with their bodies during the course of their pregnancy⁴⁰40 Johnson S, Burrows A, Williamson I. ‘Does my bump look big in this?’ The meaning of bodily changes for first-time mothers-to-be. J Health Psychol 2004; 9(3):361-374.. Brooten et al.²⁹29 Brooten D, Youngblut JM, Golembeski S, Magnus MH, Hannan J. Perceived weight gain, risk, and nutrition in pregnancy in five racial groups. J Am Acad Nurse Pract 2012; 24(1):32-42., when comparing different American ethnic groups, found that, irrespective of their ethnicity, all the pregnant women desired to have a smaller body size. In studies undertaken by Sui et al.¹⁰10 Sui Z, Turnbull D, Dodd J. Effect of body image on gestational weight gain in overweight and obese women. Women Birth 2013; 26(4):267-272. and Hauff and Demerath³²32 Hauff LE, Demerath EW. Body image concerns and reduced breastfeeding duration in primiparous overweight and obese women. Am J Hum Biol 2012; 24(3):339-349., body dissatisfaction was associated with the nutritional condition of the pregnant women. In the first case, the authors found a high level of body dissatisfaction (45 %), which was more apparent in women who had a high BMI and greater frequency of childbirth. In the second case, overweight/obese women were significantly more concerned about their body shape and weight and were less confident and less comfortable with their bodies compared to women with more slender figures.

In addition, as well as being linked to BMI, a greater concern with their body image was associated with shorter lactation periods³²32 Hauff LE, Demerath EW. Body image concerns and reduced breastfeeding duration in primiparous overweight and obese women. Am J Hum Biol 2012; 24(3):339-349.. This last finding is also corroborated by the investigation conducted by Foster et al.⁴⁵45 Foster SF, Slade P, Wilson K. Body image, maternal fetal attachment, and breast feeding. J Psychosom Res 1996; 41(2):181-184., where body dissatisfaction and a low level of maternal-fetal attachment can help explain the reason why some women decide to bottle-feed their babies. It should be underlined that body dissatisfaction is also related to depression¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561.,¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63. and excessive weight gain⁹9 Bagheri M, Dorosty A, Sadrzadeh-Yeganeh H, Eshraghian M, Amiri E, Khamoush-Cheshm N. Pre-pregnancy body size dissatisfaction and excessive gestational weight gain. Matern Child Health J 2013; 17(4):699-707.,¹⁵15 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 stud y . BMC Pregnancy Childbirth 2008; 22(8):1-9.,³³33 Mehta UJ, Siega-Riz AM, Herring AH. Effect of body image on pregnancy weight gain. Matern Child Health J 2011; 15:(3)324-332.,³⁵35 Rauff EL, Downs DS. Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Ann Behav Med 2011; 42(3):381-390..

Variables that influence body image in pregnant women

Depression is frequently associated with body dissatisfaction⁴4 Skouteris H, Carr R, Wertheim EH, Paxton SJ, Duncombe D. A prospective study of factors that lead to body image dissatisfaction during pregnancy. Body Image 2005; 2(4):347-361.,⁵5 Kamysheva E, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. Examination of a multi-factorial model of body-related experiences during pregnancy: the relationships among physical symptoms sleep quality, depression, self-esteem, and negative body attitudes. Body Image 2008; 5(2):152-163.,³⁸38 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. My baby body: A qualitative insight into women's body-related experiences and mood during pregnancy and the postpartum. J Reprod Infant Psychol 2009; 27(4):330-345. and can have serious implications for the health and well-being of pregnant women. Recently, Sweeney and Fingerhut¹¹11 Sweeney AC, Fingerhut R. Examining relationships between body dissatisfaction, maladaptive perfectionism, and postpartum depression symptoms. J Obstet Gynecol Neonatal Nurs 2013; 42(5):551-561. showed that body dissatisfaction during the last three months of pregnancy represents a risk factor for post-partum depression. Downs et al.¹⁶16 Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum depression: prospective influences of depressive symptoms, body image satisfaction, and exercise behavior. Ann Behav Med 2008; 36(1):54-63. corroborates these findings by establishing that: 1) symptoms of depression, body image dissatisfaction and poor eating habits are linked to the first, second and third trimesters of pregnancy and during the post-partum period; 2) body dissatisfaction as being the main cause of post-partum depression. These points suggest that symptoms of depression and body dissatisfaction are important psychological factors that require intervention so as to improve pregnancy for women and their psychological health in the post-partum period.

Emphasis should be given to the relationship that some researchers have established between body dissatisfaction and weight gain that go beyond gestational guidelines. Bagheri et al.⁹9 Bagheri M, Dorosty A, Sadrzadeh-Yeganeh H, Eshraghian M, Amiri E, Khamoush-Cheshm N. Pre-pregnancy body size dissatisfaction and excessive gestational weight gain. Matern Child Health J 2013; 17(4):699-707. and Mehta et al.³³33 Mehta UJ, Siega-Riz AM, Herring AH. Effect of body image on pregnancy weight gain. Matern Child Health J 2011; 15:(3)324-332. found that pregnant women who would like to have a more slender body had a greater tendency to put on excessive weight during their pregnancy compared with women who were initially satisfied with their body image. Herring et al.¹⁵15 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 stud y . BMC Pregnancy Childbirth 2008; 22(8):1-9. also highlight that not having a true perception of their pre-pregnancy body weight was associated with excessive gestational weight gain among women of normal weight and those who are overweight/obese, and that there was a greater possibility of those who underestimated their overweight/obesity to gain excessive weight during pregnancy. When assessing socio-demographic issues, Rauff and Downs³⁵35 Rauff EL, Downs DS. Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Ann Behav Med 2011; 42(3):381-390. showed that pregnant women who are dissatisfied with their bodies, and who have lower levels of education and family income, were more at risk of gaining weight outside the recommended intervals. Thus, being able to identify situations that can lead to weight gains outside recommended guidelines, can help to reduce health problems associated with pregnancy³³33 Mehta UJ, Siega-Riz AM, Herring AH. Effect of body image on pregnancy weight gain. Matern Child Health J 2011; 15:(3)324-332.,³⁵35 Rauff EL, Downs DS. Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Ann Behav Med 2011; 42(3):381-390..

Another variable that has been examined in these studies with pregnant women is the practice of physical activities. This practice can positively influence a pregnant woman's body image, as well as prevent excessive weight gain. Goodwin et al.²⁸28 Goodwin A, Astbury J, McMeeken J. Body image and psychological well-being in pregnancy: a comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynaecol 2000; 40(4):442-447. state that women who decide to exercise during pregnancy usually felt more positive about their body image and had a greater sense of psychological well-being when compared with pregnant women who were physically inactive. Furthermore, Boscaglia et al.²⁷27 Boscaglia N, Skouteris H, Wertheim EH. Changes in body image satisfaction during pregnancy: a comparison of high exercising and low exercising women. Aust N Z J Obstet Gynaecol 2003; 43(1):41-45. underline that greater levels of physical activity are related to a pregnant woman's body satisfaction. However, it may be that women who take exercise during pregnancy react more favorably to the changes in their bodies than those who are sedentary.

In the only Brazilian study found, Sacomori et al.³⁶36 Sacomori C, Cardoso FL, Vanderlinde C. Pelvic floor muscle strength and body self-perception among Brazilian pregnant women. Physiotherapy 2010; 96(4):337-343. set out to examine the relationship that exists between the muscle power of the pelvic foor and variables of body image self-perception among pregnant women. Their findings showed that women who were experiencing their first pregnancy were more satisfied with their bodies. In addition, the multipara participants expressed a greater desire to be slimmer when compared with the women who are pregnant for the first time. As regards the strength of the pelvic floor, the analysis found no differences between the two groups.

Figures obtained in the investigations conducted by DiPietro et al.¹³13 DiPietro JA, Millet S, Costigan KA, Gurewitsch E, Caulfield LE. Psychosocial influences on weight gain attitudes and behaviors during pregnancy. J Am Diet Assoc 2003; 103(10):1314-1319. are worrying: 21 % of North Americans represented in this survey had practiced at least one way to lose weight during pregnancy. Those that mentioned having adopted more than one of these habits felt more anxious, depressed, irritable and highly stressed, as well as having a higher level of dissatisfaction with their body image. Added to which, even pregnant women who had gained weight within the recommended limits showed a negative attitude towards weight gain. In order to treat pregnant women, maintaining an adequate BMI reflects not only on the health of the mother, but also of the fetus.

Further recommendations

Lastly, two aspects need to be stressed in relation to the articles used in this survey: the tools used in research studies and the broad range of the sample size. As regards assessing body image, there are currently many ways to interpret, research and evaluate this. Depending on the size of the construct that one wishes to investigate, it is usual to employ a series of figures, interviews, questionnaires and perception tests¹²12 Cash TF, Smolak L. Body image: a handbook of science, practice, and prevention. 2nd ed. New York: The Guilford Press; 2011.,⁵²52 Fortes LS, Amaral ACS, Almeida SS, Ferreira MEC. Efeitos de diversos fatores sobre o comportamento alimentar de adolescentes. Cien Saude Colet 2013; 18(11):3301-3310.. However, Conti et al.⁵³53 Conti MA, Ferreira MEC, Amaral ACS, Hearst N, Cordás TA, Scagliusi FB. Equivalência Semântica da versão em português do “Body Change Inventory”. Cien Saude Colet 2012; 17(9):2457-2469. point to the importance of trans-cultural creation and adaptation of tools, bearing in mind the Brazilian reality, so as to guarantee that the information collected expresses that which one wishes to measure.

Possibly, the controversies encountered in the literature stem from the fact that they use tools adapted for other social groups such as, for example, young adults; or even those that do not feature the documented psychometric properties of a sample of pregnant women. Thus, it is necessary to emphasize that, in most cases, these scales may not reflect the specific concerns at this particular time in a woman's life.

In respect to this, Fuller-Tyszkiewicz et al.¹⁷17 Fuller-Tyszkiewicz M, Skouteris H, Watson B, Hill B. Body image during pregnancy: an evaluation of the suitability of the body attitudes questionnaire. BMC Pregnancy Childbirth 2012; 12(1):91-101. also add that those conducting such an investigation should be cautious when evaluating body dissatisfaction among pregnant women until an adequate measure has been established for use with this sector of the population. Due to the possible existence of body dissatisfaction during pregnancy and because this can be linked to inadequate behavioral patterns and, consequently, generate a negative impact on both the mother and child²2 Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. The relationship between depression and body dissatisfaction across pregnancy and the postpartum: a prospective study. J Health Psychol 2009; 14(1):27-35., developing an appropriate tool to evaluate body image during the perinatal period is clearly justified.

As regards the size of the sample, these investigations were based on samples varying between 6⁴⁰40 Johnson S, Burrows A, Williamson I. ‘Does my bump look big in this?’ The meaning of bodily changes for first-time mothers-to-be. J Health Psychol 2004; 9(3):361-374. and 1,597¹⁵15 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 stud y . BMC Pregnancy Childbirth 2008; 22(8):1-9., with an average of 205 pregnant women. Possibly, the fact of the adoption of qualitative and quantitative methodologies may explain why the first one involved smaller samples in comparison with the second. In addition, the cross-sectional or longitudinal surveys may also be one of the reasons that restricted this sample. Adding together the intrinsic characteristics of the longitudinal studies, in the case of pregnancy, abortion may be a factor that excludes a pregnant woman from this sample and, thereby, reduces the sample size.

It may be concluded that studies were conducted, mainly on an international level, to investigate body image in pregnant women. These findings highlight the controversy and inconclusiveness found in such studies related to body dissatisfaction in pregnant women. Some studies show an improvement in the matter of body dissatisfaction among pregnant women. On the other hand, dissatisfaction with body form and weight among pregnant women was also underlined in other research studies. Furthermore, it should be emphasized that research studies have shown a relationship between a negative body image and other variables, such as depression, self-esteem, eating habits and weight gain outside recommended limits.

It is therefore suggested that, in order to gain a better understanding of the particular concerns of a woman during this stage in her life, specific tools should be created/validated to be used in the case of pregnant women. It might then be possible for future research studies to provide greater knowledge about body image and related contributing factors, which will in turn benefit professionals working directly with groups of pregnant women (doctors, nurses, physical therapists, nutritionists, psychologists) and, particularly the pregnant women themselves, to ensure they receive the necessary healthcare while dealing with the changes that occur in their bodies, which are necessarily associated with pregnancy. This will have a positive effect on both maternal and infant well-being and health.

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