The marketing around pregnancy can feel like a minefield for some people, as it involves navigating the forbidden food list and living with the fear and anxiety of making sure the baby is growing properly. When a pregnant person also has an eating disorder, it can add a layer of complication not only to navigating foods, body changes and emotions, but also to the mixed messages pregnant people can be presented with.
The 2019 NHS health survey found that 16% of the adult population (those aged 16 years or over) screened positive for a possible eating disorder (NHS Digital, 2020). Through my campaign work, it has been clear that because of stigma and shame, many people do not seek support or receive a diagnosis. With these staggering statistics, there is no doubt that midwives will have already come into contact with someone affected by an eating disorder and will do in the future.
While being able to have children was a huge motivator to recover from anorexia as a child, at the age of 31 years when I found myself unexpectantly pregnant, I was not set up to deal with what was about to happen, the bodily changes, the heightened emotions and the uncertainty of it all. These feelings are not unique to those with eating disorders, but research has shown that pregnancy can have a huge impact on those with an eating disorder. A recent study showed that there is a 67% rate of relapse during pregnancy and a 50% chance of relapse after birth (Makino et al, 2020).
Dr Agnes Ayton, chair of the Faculty of Eating Disorders at the Royal College of Psychiatrists, said to me that ‘eating disorders are potentially life-threatening but treatable mental illnesses, so it's important that pregnant women can get help as soon as possible’. She described pregnancy as ‘a time of heightened risk for women with eating disorders because of both the physical and psychological changes involved’. She also emphasised the importance of proper training for health professionals, including midwives, health visitors and perinatal mental health staff, who should talk ‘openly about the risk of relapse’ and prepare women for the bodily changes that pregnancy causes. Dr Ayton said that health services need to provide closer monitoring and be able to develop a ‘relapse prevention plan’ and refer to specialist services when needed. She described information sharing between services as ‘essential for delivering the best multidisciplinary care possible to support the health of the mother and baby.’
There is much that can to be done to ensure that mothers and babies receive the right support, but while those changes are ongoing, there are things that a midwife can do to help those who have an eating disorder (whether diagnosed or not).
Supporting those affected by eating disorders
Asking someone how they are feeling about their body and how they are navigating the body changes can help support them. When weighing someone, it can be helpful to suggest blind weigh-ins and avoid announcing body mass index to the room. It is important to be mindful of saying things like ‘you need to put on X weight, but not too much.’
It is also important to remember that telling a pregnant person that they are doing it for the baby will likely not help shift their way of thinking, and can make them feel guilty. If it were that simple, they would likely already be making those changes. Instead, a midwife can work with them on their motivations and check in with them on how they feel.
It is not helpful to judge the tone of voice or behaviours a person uses to explain what they are going through or whether they need support. I often present things very factually and I am articulate in how I do it. I do not show a huge amount of emotion, but that does not mean that I am not struggling; this will be the same for others too.
Share affrmations that they can learn about their bodies and motherhood. A friend of mine who is a midwife shared some of these with me, and having this list helped in those moments when I was finding things harder to navigate.
Six months into a pregnancy, start talking to the pregnant person about how they will manage after birth. For me, I know the fear of what would happen in my recovery after the baby was born was causing a huge amount of fear and anxiety as to whether I would be able to keep pushing for total recovery. Relapse rates around eating disorders are high when someone has a baby (Makino et al, 2020) and for so many people, they will have been telling themselves the narrative that they can lose weight when the baby comes. Be aware of this and start these conversations early.
It is important to be aware of the patient's history as well. For someone who has had an eating disorder or exercise addiction, it is inappropriate to advise them to exercise more to manage feelings of anxiety. Instead, help them to stay focused on reasons for getting well
Encourage them to open up about how they are feeling, both to you and to those around them. Help them to identify who that might be but also how they might do it.
I would also recommend that midwives be direct. You do not have to be an expert to talk about eating disorders, so please ask. Ask if they are eating enough or directly about rumination at night. Ask about their energy, and whether they are thinking about food a lot.
Living with an eating disorder is tough, there is no denying that. When we have a pregnancy in the mix, it can feel harder to navigate, but the right support, timely conversations and bringing these issues into the light will allow a person to feel safer, to share those anxieties and help them to feel valid. Please do not shy away from these conversations, even if they feel hard, as they could save a person's life.