External and internal influences on prepartum body image: a qualitative study

External and internal influences on prepartum body image: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article External and internal influences on prepartum body image: a qualitative study Alejandra Arellano, Ruth Roberts, Alejandra Perez, Elena Panagiotopoulou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5885905/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Research suggests that it is crucial to better understand prepartum body image experiences as they are associated with various maternal and infant outcomes. However, the available evidence is mixed. The lack of consensus reflects the complexity of this phenomenon and the need for greater emphasis on qualitative methods to better understand the range and nuances of such experiences. In line with evidence that body image is a multisensory construct, involving sensations that arise both within and outside the body, we set out to explore external and internal influences on pregnant women’s body image experiences, using a qualitative approach. Semi-structured interviews were conducted with first-time expectant mothers (N=10) during the third trimester of pregnancy. Thematic analysis revealed three themes: a sense of two bodies existing in one; conflicts and tensions due to internal and external changes; and the need for external support and reassurance. The implications of this research are important and potentially far-reaching, generating hypotheses and aiding the design of future studies, which can eventually help medical and mental health professionals in perinatal care better understand the complexity of prepartum body image experiences and support pregnant women. Various restrictions in response to the outbreak of COVID-19 were imposed when this study was conducted, offering a unique opportunity to consider the pandemic and associated restrictions as a contextual factor, which can also be informative to families facing restrictions due to other reasons, such as chronic illness or socio-political circumstances. Psychology Pregnancy body image body perception COVID-19 maternity services Statement of significance Problem or issue Empirical evidence on prepartum body image experiences is mixed, reflecting the complexity of this phenomenon and suggesting the need for greater emphasis on qualitative methods to better understand the range and nuances of such experiences. Also, no studies to date explore body image experiences during pregnancy with a focus on both the external and the internal environment to provide a more comprehensive understanding of this multifaceted phenomenon. What is already known It is known that prepartum body image experiences have an important role for various maternal and infant outcomes. However, there is a lack of consensus over how pregnant women experience their changing bodies. What this paper adds The implications of this research are important and potentially far-reaching, generating hypotheses and aiding the design of future studies, which can eventually help medical and mental health professionals better understand the complexity of prepartum body image experiences and support pregnant women. Specifically: Educating and supporting women to shift their focus from the appearance of the body to its temporal functionality could help improve body image satisfaction during pregnancy. Open communication with healthcare professionals, friends and family is highly valued by pregnant women as they also play a fundamental role in encouraging and reassuring them. Raising public awareness about the implications of social pressures on women's experiences and adjustment to pregnancy-related bodily changes could be very helpful. Various restrictions in response to the outbreak of COVID-19 were imposed when this study was conducted, hence offering a unique opportunity to consider the pandemic and associated restrictions as a contextual factor, which can also be informative to families facing restrictions due to other reasons, such as chronic illness or socio-political circumstances. Introduction Pregnancy entails a unique period during which women’s bodies undergo rapid and significant changes over a relatively short period of approximately forty weeks (Hosseini & Padhy, 2020 ; Grogan, 2016 ). Experiencing these natural bodily changes during pregnancy is quite complex as these are often in conflict with, and push women further away from, socio-cultural ideals of the female body, such as the unrealistic aspiration to a thin ideal (Watson et al., 2015 ; Hodkinson et al., 2014). These demands may influence how they experience their changing bodies during pregnancy, including their body image, which is universally understood as the subjective picture that individuals have of their own body, independent of how it actually looks (Hosseini & Padhy, 2020 ). Body image is not predominately visual but rather a multisensory construct and it therefore appears that both signals from outside and from within the body contribute to body image components (Badoud & Tsakiris, 2017 ). During pregnancy, the significant transformations in the appearance of the prepartum body result not only in women themselves noticing these changes but other people too. While positive feedback from other people, including the partner, can contribute positively and is highly valued (Watson et al., 2016 ), research suggests that negative feedback, such as commenting that they looked “small” or “compact” can lead to frustration and insecurity about whether the pregnancy is progressing healthily (Clark et al., 2009 ). Apart from external influences, internal signals, such as the baby’s kicking (Clark et al., 2009 ) and those arising from touch, (Watson et al., 2016 ), also contribute to body image components, helping pregnant women adapt to changes and maintain a positive experience of the body (Kirk & Preston, 2019 ). Understanding prepartum body image experiences is crucial as body image satisfaction during pregnancy has been found to be associated with better mother-infant relationship quality, lower depression and anxiety and higher levels of interoception, e.g. body listening and body trusting (Kirk & Preston, 2019 ). On the other hand, body dissatisfaction is linked to negative maternal and infant outcomes, such as maternal depression (Silveira et al., 2015 ), eating restraint, impaired maternal-foetal attachment (Fuller-Tyszkiewicz et al., 2013), smoking during pregnancy (Duncombe et al., 2008 ) and low rates of breastfeeding (Brown et al., 2015 ). Nevertheless, there is a lack of consensus over how pregnant women experience their changing bodies, thus, reflecting the complexity of this phenomenon. Some studies have found that women experience an improved body image and body satisfaction during pregnancy (Clark & Ogden, 1999 ; Loth, 2011), while others suggest that women experience a worsening in prepartum body satisfaction (Skouteris et al., 2005 ; Clark et al., 2009 ; Roomruangwong et al., 2017 ). Kirk and Preston ( 2019 ) suggest that an important limitation underlying body image research during pregnancy is that the measures used are not standardized or designed specifically for the pregnant population, while studies which have developed pregnancy body satisfaction scales have used suboptimal sample sizes. Moreover, several researchers advocate greater emphasis on qualitative methods to better understand the range and nuances of women's body image experiences during pregnancy (Watson et al., 2015 ; Clark et al., 2009 ). In summary, the existing literature suggests that body image during pregnancy is associated with various maternal and infant outcomes and it is, therefore, crucial to better understand prepartum body image experiences. The lack of consensus over how pregnant women experience their changing bodies reflects the complexity of this phenomenon and could be attributed to methodological limitations. Evidence suggests that each pregnancy is experienced uniquely, therefore, qualitative approaches could help better capture such experiences. To the best of our knowledge, there is no study to date exploring body image experiences during pregnancy with a focus on both the external and the internal environment to provide a more comprehensive understanding of this multifaceted phenomenon. This study also presented a unique opportunity to explore women’s prepartum body image experience whilst restrictions were in place in response to COVID-19. To this end, we set out to explore external and internal influences on pregnant women’s body image experience during COVID-19, using a qualitative approach. Consequently, we aimed to study how internal (e.g. perception of bodily signals and touch) and external (e.g. perception of appearance of the body and other people’s feedback) influences contribute to body image experiences during pregnancy. Participants, ethics, and method A qualitative exploratory design was employed to understand in depth participants’ experience of their body image from an internal and external perspective. Semi-structured interviews were conducted with a homogenous sample of first-time mothers during their third trimester of pregnancy. Their accounts were analysed using thematic analysis to consider common emerging themes (Frith & Gleeson, 2012 ). A total of ten participants took part in this study (N = 10). This sample size is considered appropriate for thematic analysis based on Braun and Clarke’s ( 2013 ) recommendation of six to ten participants being recruited for small projects. Participants were recruited through Facebook, using an informative poster, and had to fulfil a series of criteria, hence, a deliberate sampling strategy was used. Recruitment criteria included participants 1) being over the age of 18 years, 2) living in the United Kingdom 3) being currently in the third trimester of pregnancy and 4) completing their first pregnancy. The latter criterion of primiparity was based on previous research suggesting that women going through their first pregnancy may be more concerned with their body image than non-primiparous women (Johnson et al., 2004 ). The criterion of being in the last trimester was decided given that body changes would have been noticeably occurring in the last months, allowing the participant to relate and reflect on their impact (Fox & Yamaguchi, 1997 ). Two main instruments were used; a socio-demographic survey (see Appendix A) and an interview schedule (see Appendix B). The interview schedule was designed by the authors based on the study’s objectives and current literature. To ensure validity, the instrument was presented to two experts in the subject, who provided feedback. An initial pilot interview was held to test interview questions for their clarity and relevance and no difficulties in comprehension or with the content were found. The interview schedule consisted of 11 questions, including an initial warm-up question and a closing question designed to end the interview on a positive note. The main questions were divided into the external and internal influences of body image experiences, with the first four questions focusing on how participant, partner and others perceived participant’s pregnant body. The last five questions focused on participant’s feelings arising from touch by others and self-touch, bodily signals, as well as functionality and fantasies related to the changing body. The data was collected within a time frame of four months, from February 2021 to June 2021, during which some restrictions in maternity services were in place. Participants who showed interest in the study were electronically provided with an information sheet containing details regarding the procedures and confidentiality policy. They were given the opportunity to ask questions and if they agreed to participate, they were sent the consent form via email. Once signed, a meeting time was agreed ensuring the participant’s convenience. Prior to the interview, they were asked to complete the demographic survey. Interviews were held through Zoom. The duration of the interviews varied from nineteen to thirty-four minutes and an encrypted digital dictaphone was used for their audio-recording. The verbatim transcription of the audio data was completed within twenty-four hours after the interviews occurred. After transcribing the audio, the recordings were deleted, and any personal information was replaced with pseudonymized information. The data was analysed using thematic analysis; “a method for identifying, analysing, and reporting patterns (themes) within data” (Braun & Clarke, 2006 , p. 79). To minimise researcher bias, the themes and selected quotations presented in the paper were initially developed by the lead author and were reviewed by the last author. Any discrepancies between the two researchers were discussed and resolved through consensus meetings. Results All participants of this study were married ( n = 2) or in committed relationships ( n = 8) and their age ranged from 29 to 38 years ( M = 33.5 years, SD = 3.14). All participants’ conception had been spontaneous, and the weeks of pregnancy at the time of the interview were between 30 and 36 weeks ( M = 33.6 weeks, SD = 1.91). Most participants had a White British ethnicity ( n = 6 ), and the rest were White European ( n = 2 ), White African ( n = 1 ) and Latino ( n = 1 ). Participants’ names shown below are pseudonyms (see Appendix C). The thematic analysis yielded three superordinate themes; “Two bodies in one”, “Balancing internal and external conflicts and tensions”, “Need for external support and reassurance” (see Table 1 ). Table 1 Themes and sub-themes Theme Subtheme 1. Two bodies in one 1.1. “There is a baby inside me” 1.2. My body’s temporal functionality 1.3. Self-touch: a way to communicate 2. Balancing internal and external conflicts and tensions 2.1. Body appearance vs. baby’s health 2.2. How I think I look vs. how others see me 2.3. Wanting to show my bump vs. feeling comfortable 2.4. Post-partum anxieties: being kind to myself vs. own and others’ expectations 3. Need for external support and reassurance 3.1. Touch as a way of sharing experience and responsibility with partner 3.2. Reassurance and empathy from the outside 3.1. Two bodies in one The first superordinate theme captured participants’ feeling of their body being shared, belonging both to them and to the baby. 3.1.1. “There is a baby inside me” The baby’s movements resulted in participants realising that “ There’s a baby inside… um, inside me” (Rose), making the experience feel more “ real, when the whole thing just feels a bit surreal […] I still like can’t believe like there’s a life inside” (Jill). This awareness of carrying a baby was associated with a sense of alertness and worry towards bodily signals, which were perceived as indicators of potential issues with the baby’s health. “You’re sort of worried about every little twinge because you think “oh, is that normal? Is that, is the baby okay?” […] I’m constantly sort of monitoring it [body].” (Elle) “Anything it’s like “oh, is it a cramp? Is it a contraction?”. […] in the beginning as well because […] your first trauma is having a miscarriage.” (Claire) 3.1.2. My body’s temporal functionality. Most participants described a sense of their body serving a function. Despite feeling that their bodies are being “taken over a bit” (Elle), they understood the changes are temporary and “ will eventually go away and there’s a good reason for it” (Lucy), therefore feeling “grateful” (Jane) and “proud” (Anne) of what their bodies can do. “It’s the means to getting something nice at the end, […] so it feels positive even though obviously I do feel quite monstruous at the minute.” (Lily) “I guess my body is just kind of like, a vessel for that [giving birth] to happen and then, when, when she’s out, I can then maybe kind of take ownership of my body again.” (Kate) 3.1.3. Self-touch: a way to communicate The experience of self-touching the bump appeared in all the participants’ accounts as an instinctive behaviour, “ you can’t help but touch it all the time.” (Anne). These moments of self-touch and feeling the baby’s movement were highly valued by most participants as opportunities to “communicate with the baby” (Anne), hoping that the baby can feel “that I’m touching him, I’m hugging him” (Jane). “I just absentmindedly rub it, just to kind of like reassure him that I’m still here […] when he’s having a kick or whatever I will kind of talk to him or just rub where he’s been kicking just to let him know that I’m responsive.” (Lucy) “When she’s moving, I feel like I wanna like put my hands there […] maybe she knows that then that’s my touch to kind of make her feel like she’s not alone […] I feel like I’m sort of protecting her a little bit […] creating that bond.” (Kate) 3.2. Balancing internal and external conflicts and tensions 3.2. Balancing internal and external conflicts and tensions The second superordinate theme captured the experience of trying to find a balance between external and internal pressures. 3.2.1. Body appearance vs. baby’s health Half of the participants described how people’s comments about their bump size led to worries regarding the baby’s health. “Lots of comments that I think people don’t realize can play on your mind […] “your bump looks really small” I guess I get worried about the health of the baby […] it just leaves this doubt in your mind that there is something not right.” (Rose) For Lily it was not only what other people commented, but also comparisons she made when seeing other women’s bump size which made her wonder “what does this mean for what size the baby is?”. Weight and bump growth were seen as “a sign that he’s growing and he’s healthy” (Claire), resulting in them prioritizing the desire to be healthy and have a healthy baby over their appearance. “I have been weighing myself but mainly because I want to […] make sure that I’m heathy […] I guess my mentality shifted […] “just focus on the baby, focus on her being healthy.” (Kate) “I just want there to be a healthy happy baby at the end […] I’m not worried about it, I don’t think about anything negative um, with my body.” (Elle) Anne conveyed how pregnant women might experience a tension between the importance given to their appearance and the desire for a healthy baby: “I think people are really quite careful with how they say it because things can come across the wrong way […] At the very beginning when people are saying “oh, you’re very small” you think maybe that’s a problem, um, but you also don’t want people to say, “you look really big” either, so it is quite hard to get it right.” (Anne) 3.2.2. How I think I look vs. how others see me Participants described how rapid changes in their bodies resulted in their minds having to also rapidly adapt. They explained there is a disconnection between how they perceived their own appearance and how others perceived it, “forgetting that I’m so noticeably pregnant now that people feel comfortable saying like “oh, you’re pregnant”” (Lily). “People are like “oh, do you want a seat?” […] I’m like “oh, I look pregnant!”, of course I look pregnant, I’m really big! (laughs) […] I’m still not used to it.” (Jill) “You get surprised that you look so obviously pregnant […] your body’s changing so quickly […] [you] haven’t had a chance to catch up with what you physically look like […] there is a slight disconnect between what you physically look like and what you think you look like.” (Kate) 3.2.3. Wanting to show my bump vs. feeling comfortable Given that this study occurred during lockdown, many participants mentioned not having bought maternity clothes as they did not have the need to dress-up for work or to socialise. Participants who had bought these clothes mentioned perceiving them as being “boring” (Lucy) and “not my personality” (Jane). Most participants mentioned that their priority regarding clothing was getting “ things that are comfy and just like easy to wear” (Claire), thus changing their style to “loose and comfy” (Elle ) , yet acknowledging this could be due to lockdown as “nobody is going out at the moment” (Elle). “I would normally wear dresses or skirts a lot, […] I haven’t as much during pregnancy, because they’re not very comfortable.” (Lucy) However, others expressed a preference for clothes that “ make me look pregnant” (Jill) and that “ I have got a bump” (Anne) rather than looking “huge” (Jane) or “fat” (Jill). 3.2.4. Post-partum anxieties: being kind to myself vs. own and others’ expectations Despite expressing worries and anxieties regarding wanting to go back to their pre-pregnancy appearance, “ wondering how quickly I can sort of bounce back” (Elle) and “ what clothes are gonna fit as you’re not really the same size as you were but you’re also not like your pregnant body” (Claire), participants also expressed a wish to be kind and accepting that their body would change, trying to avoid putting pressure on themselves either due to their own expectations or others’. “I’m trying really hard not to put pressure on myself about like just going back to being exactly the same as I was before because I know that’s just not gonna happen and my body’s gonna be different […] I wonder what other people will kind of expect afterwards in terms of how quickly I sort of jump back.” (Lily) “Make sure that I’m being kind to myself I think I just need to be really strong […] not put too much pressure […] I’ll have to be like mentally disciplined and not look at stupid crap on Instagram.” (Kate) 3.3. The need for external support and reassurance Participants expressed feelings that surged from others’ comments, attitudes and touch, and how when these were positive, they felt very supported and reassured. 3.3.1. Touch as a way of sharing experience and responsibility with partner All participants mentioned that their partner’s touch was a positive experience, felt as “caring” (Jill) and “loving” (Vania) and one of the few opportunities for them to “really get involved” (Claire) and “ get some of that sort of connection that you’re feeling as well.” (Anne), especially under the context of lockdown, where partners were not allowed “ to go to the midwife appointments” (Lucy). Hence, the partner’s touch and experience of the baby’s movements resulted in a feeling of shared responsibility. “ It’s a sense of like shared responsibility when he’s touching the bump because I feel like pregnancy is quite lonely […] it feels like you’re sharing a part of the pregnancy.” (Rose) “It’s nice to sort of do that [feel the bump] together and for him to feel that he’s part of that.” (Lily) 3.3.2. Reassurance and empathy from the outside All participants expressed that their partner’s supportive attitude was fundamental for them, being “complimentary” (Kate) “a lot more kind” (Jill), “very accepting” and “protective” (Lucy). Partners were viewed as someone who, regarding their physical appearance, “isn’t gonna put pressure on me” (Lily), and who reassured them by reminding them of the functionality behind their bodily changes, saying “you’re not fat, you’re pregnant” […] “I don’t see what you see, I just see that there’s a little person growing there and that’s incredible”.” (Jill) Furthermore, participants discussed the importance of the midwives’ feedback as a trustworthy source of reassurance for their constant doubts regarding the baby’s health, helping them feel “ really relieved, knowing that the baby is growing normally” (Vania), hence being able to put [the worry] to bed ” (Lily). Similarly, participants communicated the importance of family and friends offering “reassurance” (Jane). “It says I should’ve only gained like nine and a half kilos, and I’ve gained like thirteen and a half and I’m just like “what is this rubbish!?” […] I speak to my friends and they’re like “no, we’re the exact same.”” (Kate) Finally, some participants described that they “felt quite supported by people” (Jill) who were showed “compassion or a smile […] empathy” (Jill), helping them “ feel like you can be openly excited about it and like other people are excited for you” (Lily). Discussion The thematic analysis of ten interviews resulted in three superordinate themes. The first theme that emerged was the sense of two bodies in one, which came along with a feeling of losing ownership, as well as an appreciation of their bodies’ functionality. The second theme was the challenge of balancing internal and external pressures. Finally, the third theme that emerged was the need for external support and reassurance, especially from the partner, followed by the midwives, friends and family. The recognition of the baby’s presence inside pregnant women’s own body arose from internal bodily signals, such as baby’s movement, in line with Clark et al. ( 2009 ) and Johnson et al. ( 2004 ). This resulted in participants paying more attention and monitoring their pregnancy and baby’s development, making the experience feel more real. This sense of ‘two bodies in one’ led to a feeling of losing ownership over their body and instead sharing it with their baby. The feeling of losing control of the pregnant body has been noted by Hodgkinson et al. ( 2014 ), whilst sharing the body with the baby was also noted by Schmied and Lupton ( 2001 ), who found that many participants perceived the baby as part of themselves, co-existing harmoniously with their bodily rhythms and patterns. In an attempt to adapt to this new, shared body, expectant mothers were found to make sense of their bodily changes by considering their temporary functionality for the baby’s development, in line with Meireles et al. ( 2022 ). This enabled them not only to accept their body changes but, in fact, feel proud of their body’s capacity to change for their baby. One explanation for this could be that, in taking a new social role, expectant mothers are more protected from the pressures of achieving an ideal body shape or size (Loth et al., 2011 ). However, participants expressed their struggles of balancing external and internal pressures. One such tension is between the importance given to their physical appearance and the desire for a healthy baby, with the current study showing that others’ comments about bump size, which may be aimed at complimenting women on their appearance, could lead to worry about the baby’s development. Similarly, the present research, in line with Watson et al. ( 2016 ), illustrated how others’ comments resulted in participants realising that there was a disconnection between how they thought they looked and how others perceived them due to rapidly occurring bodily changes and them coursing their third trimester, thus being largest in size. When choosing clothes, feeling comfortable appeared to be a priority for the participants of this study, especially during lockdown with less opportunities to socialise, however, some of them highlighted that they wanted to look pregnant and not just “huge”, in line with research suggesting that women strongly believed that “pregnancy is socially acceptable but being fat is not” (see Hodgkinson et al., 2014 ). This was also emphasized by Sohn and Bye ( 2015 ) in a study where pregnant women expressed feeling more secure wearing fitted clothes that showed their bump, hence not being mistakenly seen as fat. The current findings also illustrated anxieties about the appearance of the postpartum body and the tension between accepting their bodies as they are and managing own and others’ expectations, also imposed through social media platforms, like Instagram. Zeeni et al. ( 2023 ) found that social media were associated with increased appearance comparison and body image dissatisfaction in pregnant women, yet our findings suggest that potential deleterious effects of social media also extend to anxieties about bouncing back after birth. Overall, participants of this study found themselves balancing external and internal pressures and trying to protect their relationship with their body and well-being in the face of socially constructed ideals and expectations. Finally, the findings illustrated the importance of external sources of reassurance and support. Participants experienced their partner’s touch of the bump and praising comments as very positive and reassuring, also helping them feel that they share the experience and responsibility with them. While this finding in relation to partner’s touch has not been reported before in previous research (and will be discussed further below), the significance of praising comments is consistent with Watson et al. ( 2016 ) and Chang et al. ( 2006 ), who concluded that partners’ positive feedback was a very helpful experience that provided reassurance about body change and reinforced body satisfaction. Furthermore, this theme illustrated how feedback from midwives was reassuring enough to stop worries about the baby’s health, in line with previous research by Watson et al., ( 2016 ). Participants of the current study described how friends’ and family’s praising comments, as well as other people’s compassionate and empathic looks and attitudes were also perceived as a source of support. Clark et al. ( 2009 ) suggested an increased social connectedness during pregnancy, where being pregnant led to being seen as more approachable and receiving positive comments, which seemed to contribute to women feeling positively about their bodies. The importance of perceived social support as a protective factor for parents’ emotional wellbeing has also been identified in the literature in the context of the COVID-19 pandemic (Perez et al., 2021 ). It is important to note that this research was conducted whilst various restrictions were in place in response to the COVID-19 pandemic, hence this being a contextual factor that should be taken into consideration in the interpretation of the findings. For instance, participants’ desire to constantly feel their bump by touching it or having their partner touch their belly, may be related to the sudden loss of physical contact due to lockdown, which has been found to be a challenge for expectant parents (Perez et al., 2021 ). The importance of sharing the experience of pregnancy with their partner could be related to restrictions in maternity services, not allowing partners attend scans and appointments. Likewise, prioritizing baby’s health over own physical appearance might have been particularly important due to fears of becoming ill with COVID-19 and the uncertainty in medical advice and appointments (Perez et al., 2021 ), and facilitated by having more limited opportunities for socialisation. The latter was also associated with a preference for clothes that are comfortable and easy to wear. Nevertheless, what is very interesting is that the current findings were largely in line with the literature from the pre-COVID-19 era, suggesting that prepartum experiences of body image are complex but relatively stable over time. This study possessed several strengths but also limitations. This was the first study to conduct an in-depth exploration of first-time expectant mothers’ experiences of body image in the last trimester, considering both the external and the internal environment. Moreover, the pandemic presented a unique opportunity to consider the impact of the restrictions imposed in response to COVID-19. Conducting in-depth interviews and using thematic analysis supported the inductive and data-led approach, allowing participants to explore and discuss their experiences in their own terms. The homogeneity and small sample size are also an advantage for a study using thematic analysis (Braun & Clark, 2013). Despite the fact that this study was conducted during the COVID-19 era, it is generally informative to families and expectant parents facing restrictions due to other reasons, such as chronic illness or socio-political circumstances. However, the inherent subjectivity of interpretation when using thematic analysis and the small sample required for in-depth analysis results in difficulties replicating and generalizing the findings. Additionally, all participants identified as women and most of them were either of a White British or White European ethnicity, as well as in committed relationships, therefore, the findings cannot be generalised to women of other ethnicities, not involved in relationships or involved in different types of relationships, as well as transgender individuals. Further research could also focus on the body image experience of women from different cultural backgrounds, where the western thin ideal is not so deeply rooted, as well as explore the experience of bodily changes longitudinally, starting from pregnancy through to birth and the postpartum era. The implications of this research are important and potentially far-reaching, generating hypotheses and aiding the design of future studies, which can eventually help medical and mental health professionals in perinatal care better understand the complexity of prepartum body image experiences and support pregnant women. To begin with, educating and supporting women in shifting their focus from the pressure of maintaining a particular physical appearance to the importance of the temporal functionality of their body could help improve body image satisfaction during pregnancy. Moreover, the partner appears to be one of the most important sources of support and reassurance, therefore raising their awareness about their role and involving them as much as possible seems crucial. Apart from the partners, open communication with healthcare professionals (e.g. midwives), friends and family is highly valued by pregnant women as they also play a fundamental role in encouraging and reassuring them. However, the dissolution of social boundaries during pregnancy, such as others commenting on and having expectations about appearance of the prepartum body is not always experienced as something positive but can rather create pressure in women. Interestingly, the decreased social pressures associated with COVID-19 restrictions, as well as increased uncertainty about health, appeared to lessen preoccupation with physical appearance in the prepartum era. While there are no 'concrete' solutions and different people experience their pregnancy and pregnant bodies differently, raising public awareness about the implications of social pressures on women's experiences and adjustment to pregnancy-related changes could help identify how we can better support women during pregnancy. Declarations "Ethics statement: Approval was granted in February 2020 by the Ethics Committee of the Research Department of Clinical, Educational and Health Psychology, University College London (11781/002)." References Badoud D, Tsakiris M (2017) From the body’s viscera to the body’s image: Is there a link between interoception and body image concerns? Neurosci Biobehavioral Reviews 77:237–246 Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Res Psychol 3:77–101 Braun V, Clarke V (2013) Successful qualitative research: A practical guide for beginners. 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J Health Psychol 9(3):361–374 Kirk E, Preston C (2019) Development and validation of the Body Understanding Measure for Pregnancy Scale (BUMPS) and its role in antenatal attachment. Psychol Assess 31(9):1092–1106 Loth KA, Bauer KW, Wall M, Berge J, Neumark-Sztainer D (2011) Body satisfaction during pregnancy. Body Image 8:297–300 Meireles JFF, Neves CM, Amaral ACS, Morgado FFDR, Ferreira MEC (2022) Body appreciation, depressive symptoms, and self-esteem in pregnant and postpartum Brazilian women. Front Global Women's Health 3:834040 Perez A, Panagiotopoulou E, Curtis P, Roberts R (2021) Barriers and facilitators to mood and confidence in pregnancy and early parenthood during COVID-19 in the UK: mixed-methods synthesis survey. BJPsych open, 7(4) Roomruangwong C, Kanchanatawan B, Sirivichayakul S, Maes M (2017) High incidence of body image dissatisfaction in pregnancy and the postnatal period: Associations with depression, anxiety, body mass index and weight gain during pregnancy. Sex reproductive healthcare: official J Swed Association Midwives 13:103–109 Schmied V, Lupton D (2001) The externality of the inside: body images of pregnancy. Nurs Inq 8(1):32–40 Silveira ML, Ertel KA, Dole N, Chasan-Taber L (2015) The role of body image in prenatal and postpartum depression: A critical review of the literature. Archives Women’s Mental Health 18:409–421 Skouteris H, Carr R, Wertheim EH, Paxton SJ (2005) Duncombe D. A prospective study of factors that lead to body dissatisfaction during pregnancy. Body Image 2:347–361 Sohn M, Bye E (2015) Pregnancy and body image: analysis of clothing functions of maternity wear. Cloth Textiles Res J 33(1):64–78 Watson B, Fuller-Tyszkiewicz M, Broadbent J, Skouteris H (2015) The meaning of body image experiences during the perinatal period: A systematic review of the qualitative literature. Body image. 14:102–113 Watson B, Broadbent J, Skouteris H, Fuller-Tyszkiewicz M (2016) A qualitative exploration of body image experiences of women progressing through pregnancy. Women Birth 29(1):72–79 Zeeni N, Abi Kharma J, Mattar L (2023) Social media use impacts body image and eating behavior in pregnant women. Curr Psychol 42:4948–4955 Additional Declarations The authors declare no competing interests. Supplementary Files Appendixs.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5885905","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":405984395,"identity":"f949a4e8-2725-4d8d-8411-a50a3828caae","order_by":0,"name":"Alejandra Arellano","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Alejandra","middleName":"","lastName":"Arellano","suffix":""},{"id":405984396,"identity":"53949c84-0f99-43d3-9280-0aa38ec66e2f","order_by":1,"name":"Ruth Roberts","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"Roberts","suffix":""},{"id":405984397,"identity":"8d7b522b-7360-4518-8bbd-81b166df2c68","order_by":2,"name":"Alejandra Perez","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Alejandra","middleName":"","lastName":"Perez","suffix":""},{"id":405984398,"identity":"4b259cfc-9f15-4707-9a74-dd9f559fcdf6","order_by":3,"name":"Elena Panagiotopoulou","email":"data:image/png;base64,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","orcid":"","institution":"University College London","correspondingAuthor":true,"prefix":"","firstName":"Elena","middleName":"","lastName":"Panagiotopoulou","suffix":""}],"badges":[],"createdAt":"2025-01-23 07:10:27","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5885905/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5885905/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74984134,"identity":"c983a383-5aa2-4377-b555-e18772210028","added_by":"auto","created_at":"2025-01-29 05:39:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":668492,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5885905/v1/992ec742-6683-42b6-ad74-20beab79bc1b.pdf"},{"id":74984132,"identity":"17d5516a-76fb-4c27-ab6d-31579977c1ea","added_by":"auto","created_at":"2025-01-29 05:38:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21264,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixs.docx","url":"https://assets-eu.researchsquare.com/files/rs-5885905/v1/861408244e187dbe1e4de58c.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eExternal and internal influences on prepartum body image: a qualitative study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Statement of significance","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1431%;\"\u003e\n \u003cp\u003e\u003cem\u003eProblem or issue\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8569%;\"\u003e\n \u003cp\u003eEmpirical evidence on prepartum body image experiences is mixed, reflecting the complexity of this phenomenon and suggesting the need for greater emphasis on qualitative methods to better understand the range and nuances of such experiences. Also, no studies to date explore body image experiences during pregnancy with a focus on both the external and the internal environment to provide a more comprehensive understanding of this multifaceted phenomenon.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1431%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;What is already known\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8569%;\"\u003e\n \u003cp\u003eIt is known that prepartum body image experiences have an important role for various maternal and infant outcomes. However, there is a lack of consensus over how pregnant women experience their changing bodies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1431%;\"\u003e\n \u003cp\u003e\u003cem\u003eWhat this paper adds\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8569%;\"\u003e\n \u003cp\u003eThe implications of this research are important and potentially far-reaching, generating hypotheses and aiding the design of future studies, which can eventually help medical and mental health professionals better understand the complexity of prepartum body image experiences and support pregnant women. Specifically:\u003c/p\u003e\n \u003cp\u003eEducating and supporting women to shift their focus\u0026nbsp;from the appearance of the body to its temporal functionality could help improve body image satisfaction during pregnancy.\u003c/p\u003e\n \u003cp\u003eOpen communication with healthcare professionals, friends and family is highly valued by pregnant women as they also play a fundamental role in encouraging and reassuring them.\u003c/p\u003e\n \u003cp\u003eRaising public awareness about the implications of social pressures on women\u0026apos;s experiences and adjustment to pregnancy-related bodily changes could be very helpful.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVarious restrictions in response to the outbreak of COVID-19 were imposed when this study was conducted, hence offering a unique opportunity to consider the pandemic and associated restrictions as a contextual factor, which can also be informative to families facing restrictions due to other reasons, such as chronic illness or socio-political circumstances.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"},{"header":"Introduction","content":"\u003cp\u003ePregnancy entails a unique period during which women\u0026rsquo;s bodies undergo rapid and significant changes over a relatively short period of approximately forty weeks (Hosseini \u0026amp; Padhy, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Grogan, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Experiencing these natural bodily changes during pregnancy is quite complex as these are often in conflict with, and push women further away from, socio-cultural ideals of the female body, such as the unrealistic aspiration to a thin ideal (Watson et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Hodkinson et al., 2014). These demands may influence how they experience their changing bodies during pregnancy, including their body image, which is universally understood as the subjective picture that individuals have of their own body, independent of how it actually looks (Hosseini \u0026amp; Padhy, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Body image is not predominately visual but rather a multisensory construct and it therefore appears that both signals from outside and from within the body contribute to body image components (Badoud \u0026amp; Tsakiris, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). During pregnancy, the significant transformations in the appearance of the prepartum body result not only in women themselves noticing these changes but other people too. While positive feedback from other people, including the partner, can contribute positively and is highly valued (Watson et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), research suggests that negative feedback, such as commenting that they looked \u0026ldquo;small\u0026rdquo; or \u0026ldquo;compact\u0026rdquo; can lead to frustration and insecurity about whether the pregnancy is progressing healthily (Clark et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Apart from external influences, internal signals, such as the baby\u0026rsquo;s kicking (Clark et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) and those arising from touch, (Watson et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), also contribute to body image components, helping pregnant women adapt to changes and maintain a positive experience of the body (Kirk \u0026amp; Preston, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnderstanding prepartum body image experiences is crucial as body image satisfaction during pregnancy has been found to be associated with better mother-infant relationship quality, lower depression and anxiety and higher levels of interoception, e.g. body listening and body trusting (Kirk \u0026amp; Preston, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). On the other hand, body dissatisfaction is linked to negative maternal and infant outcomes, such as maternal depression (Silveira et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), eating restraint, impaired maternal-foetal attachment (Fuller-Tyszkiewicz et al., 2013), smoking during pregnancy (Duncombe et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) and low rates of breastfeeding (Brown et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Nevertheless, there is a lack of consensus over how pregnant women experience their changing bodies, thus, reflecting the complexity of this phenomenon. Some studies have found that women experience an improved body image and body satisfaction during pregnancy (Clark \u0026amp; Ogden, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Loth, 2011), while others suggest that women experience a worsening in prepartum body satisfaction (Skouteris et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Clark et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Roomruangwong et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Kirk and Preston (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) suggest that an important limitation underlying body image research during pregnancy is that the measures used are not standardized or designed specifically for the pregnant population, while studies which have developed pregnancy body satisfaction scales have used suboptimal sample sizes. Moreover, several researchers advocate greater emphasis on qualitative methods to better understand the range and nuances of women's body image experiences during pregnancy (Watson et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Clark et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, the existing literature suggests that body image during pregnancy is associated with various maternal and infant outcomes and it is, therefore, crucial to better understand prepartum body image experiences. The lack of consensus over how pregnant women experience their changing bodies reflects the complexity of this phenomenon and could be attributed to methodological limitations. Evidence suggests that each pregnancy is experienced uniquely, therefore, qualitative approaches could help better capture such experiences. To the best of our knowledge, there is no study to date exploring body image experiences during pregnancy with a focus on both the external and the internal environment to provide a more comprehensive understanding of this multifaceted phenomenon. This study also presented a unique opportunity to explore women\u0026rsquo;s prepartum body image experience whilst restrictions were in place in response to COVID-19. To this end, we set out to explore external and internal influences on pregnant women\u0026rsquo;s body image experience during COVID-19, using a qualitative approach. Consequently, we aimed to study how internal (e.g. perception of bodily signals and touch) and external (e.g. perception of appearance of the body and other people\u0026rsquo;s feedback) influences contribute to body image experiences during pregnancy.\u003c/p\u003e"},{"header":"Participants, ethics, and method","content":"\u003cp\u003eA qualitative exploratory design was employed to understand in depth participants\u0026rsquo; experience of their body image from an internal and external perspective. Semi-structured interviews were conducted with a homogenous sample of first-time mothers during their third trimester of pregnancy. Their accounts were analysed using thematic analysis to consider common emerging themes (Frith \u0026amp; Gleeson, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA total of ten participants took part in this study (N\u0026thinsp;=\u0026thinsp;10). This sample size is considered appropriate for thematic analysis based on Braun and Clarke\u0026rsquo;s (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) recommendation of six to ten participants being recruited for small projects. Participants were recruited through Facebook, using an informative poster, and had to fulfil a series of criteria, hence, a deliberate sampling strategy was used. Recruitment criteria included participants 1) being over the age of 18 years, 2) living in the United Kingdom 3) being currently in the third trimester of pregnancy and 4) completing their first pregnancy. The latter criterion of primiparity was based on previous research suggesting that women going through their first pregnancy may be more concerned with their body image than non-primiparous women (Johnson et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). The criterion of being in the last trimester was decided given that body changes would have been noticeably occurring in the last months, allowing the participant to relate and reflect on their impact (Fox \u0026amp; Yamaguchi, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1997\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTwo main instruments were used; a socio-demographic survey (see Appendix A) and an interview schedule (see Appendix B). The interview schedule was designed by the authors based on the study\u0026rsquo;s objectives and current literature. To ensure validity, the instrument was presented to two experts in the subject, who provided feedback. An initial pilot interview was held to test interview questions for their clarity and relevance and no difficulties in comprehension or with the content were found. The interview schedule consisted of 11 questions, including an initial warm-up question and a closing question designed to end the interview on a positive note. The main questions were divided into the external and internal influences of body image experiences, with the first four questions focusing on how participant, partner and others perceived participant\u0026rsquo;s pregnant body. The last five questions focused on participant\u0026rsquo;s feelings arising from touch by others and self-touch, bodily signals, as well as functionality and fantasies related to the changing body.\u003c/p\u003e \u003cp\u003eThe data was collected within a time frame of four months, from February 2021 to June 2021, during which some restrictions in maternity services were in place. Participants who showed interest in the study were electronically provided with an information sheet containing details regarding the procedures and confidentiality policy. They were given the opportunity to ask questions and if they agreed to participate, they were sent the consent form via email. Once signed, a meeting time was agreed ensuring the participant\u0026rsquo;s convenience. Prior to the interview, they were asked to complete the demographic survey. Interviews were held through Zoom.\u003c/p\u003e \u003cp\u003eThe duration of the interviews varied from nineteen to thirty-four minutes and an encrypted digital dictaphone was used for their audio-recording. The verbatim transcription of the audio data was completed within twenty-four hours after the interviews occurred. After transcribing the audio, the recordings were deleted, and any personal information was replaced with pseudonymized information.\u003c/p\u003e \u003cp\u003eThe data was analysed using thematic analysis; \u0026ldquo;a method for identifying, analysing, and reporting patterns (themes) within data\u0026rdquo; (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2006\u003c/span\u003e, p. 79). To minimise researcher bias, the themes and selected quotations presented in the paper were initially developed by the lead author and were reviewed by the last author. Any discrepancies between the two researchers were discussed and resolved through consensus meetings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll participants of this study were married (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2) or in committed relationships (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8) and their age ranged from 29 to 38 years (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33.5 years, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.14). All participants\u0026rsquo; conception had been spontaneous, and the weeks of pregnancy at the time of the interview were between 30 and 36 weeks (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33.6 weeks, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.91). Most participants had a White British ethnicity (\u003cem\u003en\u0026thinsp;=\u0026thinsp;6\u003c/em\u003e), and the rest were White European (\u003cem\u003en\u0026thinsp;=\u0026thinsp;2\u003c/em\u003e), White African (\u003cem\u003en\u0026thinsp;=\u0026thinsp;1\u003c/em\u003e) and Latino (\u003cem\u003en\u0026thinsp;=\u0026thinsp;1\u003c/em\u003e). Participants\u0026rsquo; names shown below are pseudonyms (see Appendix C).\u003c/p\u003e \u003cp\u003eThe thematic analysis yielded three superordinate themes; \u0026ldquo;Two bodies in one\u0026rdquo;, \u0026ldquo;Balancing internal and external conflicts and tensions\u0026rdquo;, \u0026ldquo;Need for external support and reassurance\u0026rdquo; (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eThemes and sub-themes\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1. Two bodies in one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1. \u0026ldquo;There is a baby inside me\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2. My body\u0026rsquo;s temporal functionality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3. Self-touch: a way to communicate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e2. Balancing internal and external conflicts and tensions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1. Body appearance vs. baby\u0026rsquo;s health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2. How I think I look vs. how others see me\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3. Wanting to show my bump vs. feeling comfortable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4. Post-partum anxieties: being kind to myself vs. own and others\u0026rsquo; expectations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3. Need for external support and reassurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1. Touch as a way of sharing experience and responsibility with partner\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2. Reassurance and empathy from the outside\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3.1. Two bodies in one\u003c/h3\u003e\n\u003cp\u003eThe first superordinate theme captured participants\u0026rsquo; feeling of their body being shared, belonging both to them and to the baby.\u003c/p\u003e\n\u003ch3\u003e3.1.1. “There is a baby inside me”\u003c/h3\u003e\n\u003cp\u003eThe baby\u0026rsquo;s movements resulted in participants realising that \u0026ldquo;\u003cem\u003eThere\u0026rsquo;s a baby inside\u0026hellip; um, inside me\u0026rdquo;\u003c/em\u003e (Rose), making the experience feel more \u0026ldquo;\u003cem\u003ereal, when the whole thing just feels a bit surreal [\u0026hellip;] I still like can\u0026rsquo;t believe like there\u0026rsquo;s a life inside\u0026rdquo;\u003c/em\u003e (Jill). This awareness of carrying a baby was associated with a sense of alertness and worry towards bodily signals, which were perceived as indicators of potential issues with the baby\u0026rsquo;s health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You\u0026rsquo;re sort of worried about every little twinge because you think \u0026ldquo;oh, is that normal? Is that, is the baby okay?\u0026rdquo; [\u0026hellip;] I\u0026rsquo;m constantly sort of monitoring it [body].\u0026rdquo;\u003c/em\u003e (Elle)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Anything it\u0026rsquo;s like \u0026ldquo;oh, is it a cramp? Is it a contraction?\u0026rdquo;. [\u0026hellip;] in the beginning as well because [\u0026hellip;] your first trauma is having a miscarriage.\u0026rdquo;\u003c/em\u003e (Claire)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e3.1.2. My body\u0026rsquo;s temporal functionality.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost participants described a sense of their body serving a function. Despite feeling that their bodies are being \u003cem\u003e\u0026ldquo;taken over a bit\u0026rdquo;\u003c/em\u003e (Elle), they understood the changes are temporary and \u0026ldquo;\u003cem\u003ewill eventually go away and there\u0026rsquo;s a good reason for it\u0026rdquo;\u003c/em\u003e (Lucy), therefore feeling \u003cem\u003e\u0026ldquo;grateful\u0026rdquo;\u003c/em\u003e (Jane) and \u003cem\u003e\u0026ldquo;proud\u0026rdquo;\u003c/em\u003e (Anne) of what their bodies can do.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s the means to getting something nice at the end, [\u0026hellip;] so it feels positive even though obviously I do feel quite monstruous at the minute.\u0026rdquo;\u003c/em\u003e (Lily)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I guess my body is just kind of like, a vessel for that [giving birth] to happen and then, when, when she\u0026rsquo;s out, I can then maybe kind of take ownership of my body again.\u0026rdquo;\u003c/em\u003e (Kate)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e3.1.3. Self-touch: a way to communicate\u003c/h3\u003e\n\u003cp\u003eThe experience of self-touching the bump appeared in all the participants\u0026rsquo; accounts as an instinctive behaviour, \u0026ldquo;\u003cem\u003eyou can\u0026rsquo;t help but touch it all the time.\u0026rdquo;\u003c/em\u003e (Anne). These moments of self-touch and feeling the baby\u0026rsquo;s movement were highly valued by most participants as opportunities to \u003cem\u003e\u0026ldquo;communicate with the baby\u0026rdquo;\u003c/em\u003e (Anne), hoping that the baby can feel \u003cem\u003e\u0026ldquo;that I\u0026rsquo;m touching him, I\u0026rsquo;m hugging him\u0026rdquo;\u003c/em\u003e (Jane).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I just absentmindedly rub it, just to kind of like reassure him that I\u0026rsquo;m still here [\u0026hellip;] when he\u0026rsquo;s having a kick or whatever I will kind of talk to him or just rub where he\u0026rsquo;s been kicking just to let him know that I\u0026rsquo;m responsive.\u0026rdquo;\u003c/em\u003e (Lucy)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When she\u0026rsquo;s moving, I feel like I wanna like put my hands there [\u0026hellip;] maybe she knows that then that\u0026rsquo;s my touch to kind of make her feel like she\u0026rsquo;s not alone [\u0026hellip;] I feel like I\u0026rsquo;m sort of protecting her a little bit [\u0026hellip;] creating that bond.\u0026rdquo;\u003c/em\u003e (Kate)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e3.2. Balancing internal and external conflicts and tensions\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e3.2. Balancing internal and external conflicts and tensions\u003c/div\u003e \u003cp\u003eThe second superordinate theme captured the experience of trying to find a balance between external and internal pressures.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2.1. Body appearance vs. baby\u0026rsquo;s health\u003c/h2\u003e \u003cp\u003eHalf of the participants described how people\u0026rsquo;s comments about their bump size led to worries regarding the baby\u0026rsquo;s health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Lots of comments that I think people don\u0026rsquo;t realize can play on your mind [\u0026hellip;] \u0026ldquo;your bump looks really small\u0026rdquo; I guess I get worried about the health of the baby [\u0026hellip;] it just leaves this doubt in your mind that there is something not right.\u0026rdquo;\u003c/em\u003e (Rose)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor Lily it was not only what other people commented, but also comparisons she made when seeing other women\u0026rsquo;s bump size which made her wonder \u003cem\u003e\u0026ldquo;what does this mean for what size the baby is?\u0026rdquo;.\u003c/em\u003e Weight and bump growth were seen as \u003cem\u003e\u0026ldquo;a sign that he\u0026rsquo;s growing and he\u0026rsquo;s healthy\u0026rdquo;\u003c/em\u003e (Claire), resulting in them prioritizing the desire to be healthy and have a healthy baby over their appearance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have been weighing myself but mainly because I want to [\u0026hellip;] make sure that I\u0026rsquo;m heathy [\u0026hellip;] I guess my mentality shifted [\u0026hellip;] \u0026ldquo;just focus on the baby, focus on her being healthy.\u0026rdquo;\u003c/em\u003e (Kate)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I just want there to be a healthy happy baby at the end [\u0026hellip;] I\u0026rsquo;m not worried about it, I don\u0026rsquo;t think about anything negative um, with my body.\u0026rdquo;\u003c/em\u003e (Elle)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnne conveyed how pregnant women might experience a tension between the importance given to their appearance and the desire for a healthy baby:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think people are really quite careful with how they say it because things can come across the wrong way [\u0026hellip;] At the very beginning when people are saying \u0026ldquo;oh, you\u0026rsquo;re very small\u0026rdquo; you think maybe that\u0026rsquo;s a problem, um, but you also don\u0026rsquo;t want people to say, \u0026ldquo;you look really big\u0026rdquo; either, so it is quite hard to get it right.\u0026rdquo;\u003c/em\u003e (Anne)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e3.2.2. How I think I look vs. how others see me\u003c/h3\u003e\n\u003cp\u003eParticipants described how rapid changes in their bodies resulted in their minds having to also rapidly adapt. They explained there is a disconnection between how they perceived their own appearance and how others perceived it, \u003cem\u003e\u0026ldquo;forgetting that I\u0026rsquo;m so noticeably pregnant now that people feel comfortable saying like \u0026ldquo;oh, you\u0026rsquo;re pregnant\u0026rdquo;\u0026rdquo;\u003c/em\u003e (Lily).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;People are like \u0026ldquo;oh, do you want a seat?\u0026rdquo; [\u0026hellip;] I\u0026rsquo;m like \u0026ldquo;oh, I look pregnant!\u0026rdquo;, of course I look pregnant, I\u0026rsquo;m really big! (laughs) [\u0026hellip;] I\u0026rsquo;m still not used to it.\u0026rdquo;\u003c/em\u003e (Jill)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You get surprised that you look so obviously pregnant [\u0026hellip;] your body\u0026rsquo;s changing so quickly [\u0026hellip;] [you] haven\u0026rsquo;t had a chance to catch up with what you physically look like [\u0026hellip;] there is a slight disconnect between what you physically look like and what you think you look like.\u0026rdquo;\u003c/em\u003e (Kate)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e3.2.3. Wanting to show my bump vs. feeling comfortable\u003c/h3\u003e\n\u003cp\u003eGiven that this study occurred during lockdown, many participants mentioned not having bought maternity clothes as they did not have the need to dress-up for work or to socialise. Participants who had bought these clothes mentioned perceiving them as being \u003cem\u003e\u0026ldquo;boring\u0026rdquo;\u003c/em\u003e (Lucy) and \u003cem\u003e\u0026ldquo;not my personality\u0026rdquo;\u003c/em\u003e (Jane). Most participants mentioned that their priority regarding clothing was getting \u0026ldquo;\u003cem\u003ethings that are comfy and just like easy to wear\u0026rdquo;\u003c/em\u003e (Claire), thus changing their style to \u003cem\u003e\u0026ldquo;loose and comfy\u0026rdquo;\u003c/em\u003e (Elle\u003cem\u003e)\u003c/em\u003e, yet acknowledging this could be due to lockdown as \u003cem\u003e\u0026ldquo;nobody is going out at the moment\u0026rdquo;\u003c/em\u003e (Elle).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would normally wear dresses or skirts a lot, [\u0026hellip;] I haven\u0026rsquo;t as much during pregnancy, because they\u0026rsquo;re not very comfortable.\u0026rdquo;\u003c/em\u003e (Lucy)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, others expressed a preference for clothes that \u0026ldquo;\u003cem\u003emake me look pregnant\u0026rdquo;\u003c/em\u003e (Jill) and that \u003cem\u003e\u0026ldquo; I have got a bump\u0026rdquo;\u003c/em\u003e (Anne) rather than looking \u003cem\u003e\u0026ldquo;huge\u0026rdquo;\u003c/em\u003e (Jane) or \u003cem\u003e\u0026ldquo;fat\u0026rdquo;\u003c/em\u003e (Jill).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2.4. Post-partum anxieties: being kind to myself vs. own and others\u0026rsquo; expectations\u003c/h2\u003e \u003cp\u003eDespite expressing worries and anxieties regarding wanting to go back to their pre-pregnancy appearance, \u0026ldquo;\u003cem\u003ewondering how quickly I can sort of bounce back\u0026rdquo;\u003c/em\u003e (Elle) and \u0026ldquo;\u003cem\u003ewhat clothes are gonna fit as you\u0026rsquo;re not really the same size as you were but you\u0026rsquo;re also not like your pregnant body\u0026rdquo;\u003c/em\u003e (Claire), participants also expressed a wish to be kind and accepting that their body would change, trying to avoid putting pressure on themselves either due to their own expectations or others\u0026rsquo;.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;m trying really hard not to put pressure on myself about like just going back to being exactly the same as I was before because I know that\u0026rsquo;s just not gonna happen and my body\u0026rsquo;s gonna be different [\u0026hellip;] I wonder what other people will kind of expect afterwards in terms of how quickly I sort of jump back.\u0026rdquo;\u003c/em\u003e (Lily)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Make sure that I\u0026rsquo;m being kind to myself I think I just need to be really strong [\u0026hellip;] not put too much pressure [\u0026hellip;] I\u0026rsquo;ll have to be like mentally disciplined and not look at stupid crap on Instagram.\u0026rdquo;\u003c/em\u003e (Kate)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. The need for external support and reassurance\u003c/h2\u003e \u003cp\u003e Participants expressed feelings that surged from others\u0026rsquo; comments, attitudes and touch, and how when these were positive, they felt very supported and reassured.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3.1. Touch as a way of sharing experience and responsibility with partner\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll participants mentioned that their partner\u0026rsquo;s touch was a positive experience, felt as \u003cem\u003e\u0026ldquo;caring\u0026rdquo;\u003c/em\u003e (Jill) and \u003cem\u003e\u0026ldquo;loving\u0026rdquo;\u003c/em\u003e (Vania) and one of the few opportunities for them to \u003cem\u003e\u0026ldquo;really get involved\u0026rdquo;\u003c/em\u003e (Claire) and \u0026ldquo;\u003cem\u003eget some of that sort of connection that you\u0026rsquo;re feeling as well.\u0026rdquo;\u003c/em\u003e (Anne), especially under the context of lockdown, where partners were not allowed \u0026ldquo;\u003cem\u003eto go to the midwife appointments\u0026rdquo;\u003c/em\u003e (Lucy).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHence, the partner\u0026rsquo;s touch and experience of the baby\u0026rsquo;s movements resulted in a feeling of shared responsibility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt\u0026rsquo;s a sense of like shared responsibility when he\u0026rsquo;s touching the bump because I feel like pregnancy is quite lonely [\u0026hellip;] it feels like you\u0026rsquo;re sharing a part of the pregnancy.\u0026rdquo;\u003c/em\u003e (Rose)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s nice to sort of do that [feel the bump] together and for him to feel that he\u0026rsquo;s part of that.\u0026rdquo;\u003c/em\u003e (Lily)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3.2. Reassurance and empathy from the outside\u003c/h2\u003e \u003cp\u003eAll participants expressed that their partner\u0026rsquo;s supportive attitude was fundamental for them, being \u003cem\u003e\u0026ldquo;complimentary\u0026rdquo;\u003c/em\u003e (Kate) \u003cem\u003e\u0026ldquo;a lot more kind\u0026rdquo;\u003c/em\u003e (Jill), \u003cem\u003e\u0026ldquo;very accepting\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;protective\u0026rdquo;\u003c/em\u003e (Lucy). Partners were viewed as someone who, regarding their physical appearance, \u003cem\u003e\u0026ldquo;isn\u0026rsquo;t gonna put pressure on me\u0026rdquo;\u003c/em\u003e (Lily), and who reassured them by reminding them of the functionality behind their bodily changes, saying \u003cem\u003e\u0026ldquo;you\u0026rsquo;re not fat, you\u0026rsquo;re pregnant\u0026rdquo; [\u0026hellip;] \u0026ldquo;I don\u0026rsquo;t see what you see, I just see that there\u0026rsquo;s a little person growing there and that\u0026rsquo;s incredible\u0026rdquo;.\u0026rdquo;\u003c/em\u003e (Jill)\u003c/p\u003e \u003cp\u003eFurthermore, participants discussed the importance of the midwives\u0026rsquo; feedback as a trustworthy source of reassurance for their constant doubts regarding the baby\u0026rsquo;s health, helping them feel \u0026ldquo;\u003cem\u003ereally relieved, knowing that the baby is growing normally\u0026rdquo;\u003c/em\u003e (Vania), hence being able \u003cem\u003eto put\u003c/em\u003e [the worry] \u003cem\u003eto bed\u003c/em\u003e\u0026rdquo; (Lily).\u003c/p\u003e \u003cp\u003eSimilarly, participants communicated the importance of family and friends offering \u003cem\u003e\u0026ldquo;reassurance\u0026rdquo;\u003c/em\u003e (Jane).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It says I should\u0026rsquo;ve only gained like nine and a half kilos, and I\u0026rsquo;ve gained like thirteen and a half and I\u0026rsquo;m just like \u0026ldquo;what is this rubbish!?\u0026rdquo; [\u0026hellip;] I speak to my friends and they\u0026rsquo;re like \u0026ldquo;no, we\u0026rsquo;re the exact same.\u0026rdquo;\u0026rdquo;\u003c/em\u003e (Kate)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFinally, some participants described that they \u003cem\u003e\u0026ldquo;felt quite supported by people\u0026rdquo;\u003c/em\u003e (Jill) who were showed \u003cem\u003e\u0026ldquo;compassion or a smile [\u0026hellip;] empathy\u0026rdquo;\u003c/em\u003e (Jill), helping them \u0026ldquo;\u003cem\u003efeel like you can be openly excited about it and like other people are excited for you\u0026rdquo;\u003c/em\u003e (Lily).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe thematic analysis of ten interviews resulted in three superordinate themes. The first theme that emerged was the sense of two bodies in one, which came along with a feeling of losing ownership, as well as an appreciation of their bodies\u0026rsquo; functionality. The second theme was the challenge of balancing internal and external pressures. Finally, the third theme that emerged was the need for external support and reassurance, especially from the partner, followed by the midwives, friends and family.\u003c/p\u003e \u003cp\u003eThe recognition of the baby\u0026rsquo;s presence inside pregnant women\u0026rsquo;s own body arose from internal bodily signals, such as baby\u0026rsquo;s movement, in line with Clark et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) and Johnson et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). This resulted in participants paying more attention and monitoring their pregnancy and baby\u0026rsquo;s development, making the experience feel more real. This sense of \u0026lsquo;two bodies in one\u0026rsquo; led to a feeling of losing ownership over their body and instead sharing it with their baby. The feeling of losing control of the pregnant body has been noted by Hodgkinson et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), whilst sharing the body with the baby was also noted by Schmied and Lupton (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), who found that many participants perceived the baby as part of themselves, co-existing harmoniously with their bodily rhythms and patterns. In an attempt to adapt to this new, shared body, expectant mothers were found to make sense of their bodily changes by considering their temporary functionality for the baby\u0026rsquo;s development, in line with Meireles et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This enabled them not only to accept their body changes but, in fact, feel proud of their body\u0026rsquo;s capacity to change for their baby. One explanation for this could be that, in taking a new social role, expectant mothers are more protected from the pressures of achieving an ideal body shape or size (Loth et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, participants expressed their struggles of balancing external and internal pressures. One such tension is between the importance given to their physical appearance and the desire for a healthy baby, with the current study showing that others\u0026rsquo; comments about bump size, which may be aimed at complimenting women on their appearance, could lead to worry about the baby\u0026rsquo;s development. Similarly, the present research, in line with Watson et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), illustrated how others\u0026rsquo; comments resulted in participants realising that there was a disconnection between how they thought they looked and how others perceived them due to rapidly occurring bodily changes and them coursing their third trimester, thus being largest in size. When choosing clothes, feeling comfortable appeared to be a priority for the participants of this study, especially during lockdown with less opportunities to socialise, however, some of them highlighted that they wanted to look pregnant and not just \u0026ldquo;huge\u0026rdquo;, in line with research suggesting that women strongly believed that \u0026ldquo;pregnancy is socially acceptable but being fat is not\u0026rdquo; (see Hodgkinson et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). This was also emphasized by Sohn and Bye (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) in a study where pregnant women expressed feeling more secure wearing fitted clothes that showed their bump, hence not being mistakenly seen as fat. The current findings also illustrated anxieties about the appearance of the postpartum body and the tension between accepting their bodies as they are and managing own and others\u0026rsquo; expectations, also imposed through social media platforms, like Instagram. Zeeni et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that social media were associated with increased appearance comparison and body image dissatisfaction in pregnant women, yet our findings suggest that potential deleterious effects of social media also extend to anxieties about bouncing back after birth. Overall, participants of this study found themselves balancing external and internal pressures and trying to protect their relationship with their body and well-being in the face of socially constructed ideals and expectations.\u003c/p\u003e \u003cp\u003eFinally, the findings illustrated the importance of external sources of reassurance and support. Participants experienced their partner\u0026rsquo;s touch of the bump and praising comments as very positive and reassuring, also helping them feel that they share the experience and responsibility with them. While this finding in relation to partner\u0026rsquo;s touch has not been reported before in previous research (and will be discussed further below), the significance of praising comments is consistent with Watson et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and Chang et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), who concluded that partners\u0026rsquo; positive feedback was a very helpful experience that provided reassurance about body change and reinforced body satisfaction. Furthermore, this theme illustrated how feedback from midwives was reassuring enough to stop worries about the baby\u0026rsquo;s health, in line with previous research by Watson et al., (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Participants of the current study described how friends\u0026rsquo; and family\u0026rsquo;s praising comments, as well as other people\u0026rsquo;s compassionate and empathic looks and attitudes were also perceived as a source of support. Clark et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) suggested an increased social connectedness during pregnancy, where being pregnant led to being seen as more approachable and receiving positive comments, which seemed to contribute to women feeling positively about their bodies. The importance of perceived social support as a protective factor for parents\u0026rsquo; emotional wellbeing has also been identified in the literature in the context of the COVID-19 pandemic (Perez et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is important to note that this research was conducted whilst various restrictions were in place in response to the COVID-19 pandemic, hence this being a contextual factor that should be taken into consideration in the interpretation of the findings. For instance, participants\u0026rsquo; desire to constantly feel their bump by touching it or having their partner touch their belly, may be related to the sudden loss of physical contact due to lockdown, which has been found to be a challenge for expectant parents (Perez et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The importance of sharing the experience of pregnancy with their partner could be related to restrictions in maternity services, not allowing partners attend scans and appointments. Likewise, prioritizing baby\u0026rsquo;s health over own physical appearance might have been particularly important due to fears of becoming ill with COVID-19 and the uncertainty in medical advice and appointments (Perez et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and facilitated by having more limited opportunities for socialisation. The latter was also associated with a preference for clothes that are comfortable and easy to wear. Nevertheless, what is very interesting is that the current findings were largely in line with the literature from the pre-COVID-19 era, suggesting that prepartum experiences of body image are complex but relatively stable over time.\u003c/p\u003e \u003cp\u003eThis study possessed several strengths but also limitations. This was the first study to conduct an in-depth exploration of first-time expectant mothers\u0026rsquo; experiences of body image in the last trimester, considering both the external and the internal environment. Moreover, the pandemic presented a unique opportunity to consider the impact of the restrictions imposed in response to COVID-19. Conducting in-depth interviews and using thematic analysis supported the inductive and data-led approach, allowing participants to explore and discuss their experiences in their own terms. The homogeneity and small sample size are also an advantage for a study using thematic analysis (Braun \u0026amp; Clark, 2013). Despite the fact that this study was conducted during the COVID-19 era, it is generally informative to families and expectant parents facing restrictions due to other reasons, such as chronic illness or socio-political circumstances. However, the inherent subjectivity of interpretation when using thematic analysis and the small sample required for in-depth analysis results in difficulties replicating and generalizing the findings. Additionally, all participants identified as women and most of them were either of a White British or White European ethnicity, as well as in committed relationships, therefore, the findings cannot be generalised to women of other ethnicities, not involved in relationships or involved in different types of relationships, as well as transgender individuals. Further research could also focus on the body image experience of women from different cultural backgrounds, where the western thin ideal is not so deeply rooted, as well as explore the experience of bodily changes longitudinally, starting from pregnancy through to birth and the postpartum era.\u003c/p\u003e \u003cp\u003eThe implications of this research are important and potentially far-reaching, generating hypotheses and aiding the design of future studies, which can eventually help medical and mental health professionals in perinatal care better understand the complexity of prepartum body image experiences and support pregnant women. To begin with, educating and supporting women in shifting their focus from the pressure of maintaining a particular physical appearance to the importance of the temporal functionality of their body could help improve body image satisfaction during pregnancy. Moreover, the partner appears to be one of the most important sources of support and reassurance, therefore raising their awareness about their role and involving them as much as possible seems crucial. Apart from the partners, open communication with healthcare professionals (e.g. midwives), friends and family is highly valued by pregnant women as they also play a fundamental role in encouraging and reassuring them. However, the dissolution of social boundaries during pregnancy, such as others commenting on and having expectations about appearance of the prepartum body is not always experienced as something positive but can rather create pressure in women. Interestingly, the decreased social pressures associated with COVID-19 restrictions, as well as increased uncertainty about health, appeared to lessen preoccupation with physical appearance in the prepartum era. While there are no 'concrete' solutions and different people experience their pregnancy and pregnant bodies differently, raising public awareness about the implications of social pressures on women's experiences and adjustment to pregnancy-related changes could help identify how we can better support women during pregnancy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\"Ethics statement: Approval was granted in February 2020 by the Ethics Committee of the Research Department of Clinical, Educational and Health Psychology, University College London (11781/002).\"\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBadoud D, Tsakiris M (2017) From the body\u0026rsquo;s viscera to the body\u0026rsquo;s image: Is there a link between interoception and body image concerns? Neurosci Biobehavioral Reviews 77:237\u0026ndash;246\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Res Psychol 3:77\u0026ndash;101\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V (2013) Successful qualitative research: A practical guide for beginners. Sage\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown A, Rance J, Warren L (2015) Body image concerns during pregnancy are associated with a shorter breast feeding duration. Mid-wifery 31:80\u0026ndash;89\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang SR, Chao YMY, Kenney NJ (2006) I am a woman and I\u0026rsquo;m pregnant: Body image of women in Taiwan during the third trimester of pregnancy. Birth 33:147\u0026ndash;153\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark M, Ogden J (1999) The impact of pregnancy on eating behaviour and aspects of weight concern. Int J Obes 23:18\u0026ndash;24\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J (2009) The relationship between depression and body dissatisfaction across pregnancy and the postpartum: A prospective study. J Health Psychol 14:27\u0026ndash;35\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuncombe D, Wertheim EH, Skouteris H, Paxton SJ, Kelly L (2008) How Well Do Women Adapt to Changes in Their Body Size and Shape across the Course of Pregnancy? J Health Psychol 13(4):503\u0026ndash;515\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFox P, Yamaguchi C (1997) Body Image Change in Pregnancy: A Comparison of Normal Weight and Overweight Primigravidas. Birth 24:35\u0026ndash;40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrith H, Gleeson K (2012) Qualitative Data Collection: Asking the Right Questions. In: Harper D, Thompson AR (eds) Qualitative research methods in mental health and psychotherapy: A guide for students and practitioners. Wiley-Blackwell, pp 69\u0026ndash;82\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFuller-Tyszkiewicz M, Skouteris H, Watson BE, Hill B Body dissatisfaction during pregnancy: A systematic review of cross-sectional and prospective correlates. J Health Psychol 2013 18(11), 1411\u0026ndash;1421\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrogan S (2016) Body image: Understanding body dissatisfaction in men, women and children. Routledge\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodgkinson EL, Smith DM, Wittkowski A (2014) Women\u0026rsquo;s experiences of their pregnancy and postpartum body image: a systematic review and meta-synthesis. BMC Pregnancy Childbirth 14(1):1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosseini SA, Padhy RK (2020) Body Image Distortion. StatPearls [Internet]. StatPearls Publishing\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson S, Burrows A, Williamson I (2004) Does My Bump Look Big in This?\u0026rsquo; the Meaning of Bodily Changes for First-time Mothers-to-be. J Health Psychol 9(3):361\u0026ndash;374\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirk E, Preston C (2019) Development and validation of the Body Understanding Measure for Pregnancy Scale (BUMPS) and its role in antenatal attachment. 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A prospective study of factors that lead to body dissatisfaction during pregnancy. Body Image 2:347\u0026ndash;361\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSohn M, Bye E (2015) Pregnancy and body image: analysis of clothing functions of maternity wear. Cloth Textiles Res J 33(1):64\u0026ndash;78\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatson B, Fuller-Tyszkiewicz M, Broadbent J, Skouteris H (2015) The meaning of body image experiences during the perinatal period: A systematic review of the qualitative literature. Body image. 14:102\u0026ndash;113\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatson B, Broadbent J, Skouteris H, Fuller-Tyszkiewicz M (2016) A qualitative exploration of body image experiences of women progressing through pregnancy. Women Birth 29(1):72\u0026ndash;79\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeeni N, Abi Kharma J, Mattar L (2023) Social media use impacts body image and eating behavior in pregnant women. Curr Psychol 42:4948\u0026ndash;4955\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University College London","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, body image, body perception, COVID-19, maternity services","lastPublishedDoi":"10.21203/rs.3.rs-5885905/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5885905/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eResearch suggests that it is crucial to better understand prepartum body image experiences as they are associated with various maternal and infant outcomes. However, the available evidence is mixed. The lack of consensus reflects the complexity of this phenomenon and the need for greater emphasis on qualitative methods to better understand the range and nuances of such experiences. In line with evidence that body image is a multisensory construct, involving sensations that arise both within and outside the body, we set out to explore external and internal influences on pregnant women’s body image experiences, using a qualitative approach. Semi-structured interviews were conducted with first-time expectant mothers (N=10) during the third trimester of pregnancy. Thematic analysis revealed three themes: a sense of two bodies existing in one; conflicts and tensions due to internal and external changes; and the need for external support and reassurance. The implications of this research are important and potentially far-reaching, generating hypotheses and aiding the design of future studies, which can eventually help medical and mental health professionals in perinatal care better understand the complexity of prepartum body image experiences and support pregnant women. Various restrictions in response to the outbreak of COVID-19 were imposed when this study was conducted, offering a unique opportunity to consider the pandemic and associated restrictions as a contextual factor, which can also be informative to families facing restrictions due to other reasons, such as chronic illness or socio-political circumstances.\u003c/p\u003e","manuscriptTitle":"External and internal influences on prepartum body image: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-29 05:30:55","doi":"10.21203/rs.3.rs-5885905/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d6d1fca-b3da-4b8b-a528-33975c17d5e5","owner":[],"postedDate":"January 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":43289800,"name":"Psychology"}],"tags":[],"updatedAt":"2025-01-29T05:30:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-29 05:30:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5885905","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5885905","identity":"rs-5885905","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}