Pregnancy and Early Motherhood After Anorexia
How does anorexia affect fertility, pregnancy, childbirth, and early motherhood?
Posted Dec 30, 2018
This is a guest post written by Karen Photiou, a medic and a mother of four children who is recovering from anorexia. (She also collaborated with me on a pair of posts about exercise and anorexia, starting here.) Her discussion here of the joys and the difficulties of pregnancy and early motherhood after anorexia complements my 2016 post ‘The forking paths of children and no children’, on how the decision about whether or not to have children relates to anorexia and recovery. In a sequel, 'Raising children after anorexia', she addresses questions about the later phases of raising healthy children (beyond the first year or so post-partum) when one has a history of anorexia – exploring both the worries that are common beforehand, and the realities as they unfold.
A common concern among women with anorexia surrounds the impact of past and present illness on fertility and future pregnancy, and the impact of pregnancy and childbirth on their own and their child’s health. Questions I have heard include:
- Have I damaged my fertility – will I be able to get pregnant?
- I haven’t had a period in over 10 years – does this mean they won’t start again?
- Will I be able to cope with weight gain and changes to my body during pregnancy?
- What if my body doesn’t return to the way it was before after pregnancy?
- What if the physical changes trigger a relapse?
- What’s the risk of me passing on my eating problems to my baby?
The desire to have children can be a huge motivator to recover and remain well. I had always wanted a family, but after developing anorexia at the age of 12 I worried I had caused irreparable damage that would preclude me from conceiving or carrying a pregnancy. Four children later, I am living testimony that this is not necessarily the case.
Although the outcome can be overwhelmingly positive, having a baby after anorexia is is not always easy. I was fortunate to have a very healthy first pregnancy, but ran into trouble with all other three at various points before and after their births. This isn’t something many women are comfortable talking about, so I would like to share what I have learned from the mistakes I made, and the things I did right. There are many tripping points along this journey – my hope in writing this is that if you know what to look out for, you’re less likely to fall flat on your face.
Contrary to common belief, the damage to the female reproductive system brought about by anorexia is fully reversible with proper weight restoration and adequate ongoing nutrition. Normal menstruation and ovulation can resume even after many years of amenorrhoea, with recalibration of hormonal systems necessary to sustain a healthy pregnancy. My period was absent for over 15 years prior to returning just before I conceived my first baby. The key here, however, is full weight restoration – not hovering around the lowest end of the ‘normal’ BMI range in a state of partial recovery.
Learning Point 1: Do not attempt to get pregnant through fertility treatment if you are unable to conceive because you are not fully weight restored
If you are suppressing your bodyweight, your fertility may be impaired – even if you are having periods. Interestingly, it has been reported by a private infertility clinic that 20% of women presenting who were unable to conceive met criteria for past or present disordered eating – none of whom had previously disclosed this to their endocrinology team (Freizinger et al., 2010). A certain percentage of body fat is necessary to sustain sufficient levels of oestrogen to allow menstruation and ovulation to take place, although the amount is highly variable from woman to woman. Eating behaviours are also important in sustaining hormonal balance: relative energy deficit at points over a 24-hour period can have a detrimental effect, which is why women with a 'normal' weight but highly disordered eating patterns (starving all day and only eating at night, for example) may experience amenorrhoea or fail to ovulate despite a calorie intake that is adequate overall.
If you are not having periods, you are not ovulating and are highly unlikely to become pregnant. Having a menstrual cycle does not, however, necessarily imply that ovulation has taken place: it is possible to menstruate but not ovulate and therefore be unable to conceive. Anovulatory cycles (menstrual cycles without ovulation) are common in women of low body weight and body fat percentage, and can be indistinguishable from the real thing. There is a spectrum from regular ovulatory cycles, to anovulatory cycles, to full-blown amenorrhoea, and women could theoretically progress along this spectrum as their body weight falls. Clues that ovulation has not occurred include things like irregular cycles, cycles longer than 35 days, or breakthrough or dysfunctional bleeding – but cycles could appear entirely normal. Presence of ovulation (or not) can be easily confirmed by a blood test for day 21 progesterone that can be carried out by a GP. This is explained clearly by the ever helpful Wikipedia.
If ovulation is not occurring it can be induced by drugs like clomiphene in women wishing to become pregnant. This is not, however, the panacea you may expect. If underweight women become pregnant through fertility medication there are associated adverse outcomes like miscarriage, prematurity, and low birth weight which is associated with risk of still-birth, low blood sugar levels, difficulty maintaining body temperature, and long-term growth problems (Kouba et al., 2005). Which is why, in the context of disordered eating, bodyweight restoration and adequate nutrition is imperative to allow natural resumption of ovulatory cycles in a body sufficiently nourished to sustain a healthy pregnancy.
To demonstrate the difference here, my first son was conceived when I was in a solid recovery. I had been weight-restored for a number of years, my period returned naturally, and we decided to try for a baby when I was quite young given my concerns about fertility, which fortunately proved unfounded. I had an uneventful pregnancy and delivered a healthy baby boy, Alex. After that remarkable success I didn’t do quite so well. During my second pregnancy I was overworked and overtired, juggling a toddler with postgraduate exams and long, irregular shifts as a doctor in the Emergency Department, and although I didn’t realise at the time, my eating was inconsistent and inadequate. Tom was born prematurely with severe growth restriction and spent eight weeks in intensive and special care. When two years later I went to my own GP as my periods hadn’t returned and I wanted to try for a third child, I was referred for infertility investigations and prescribed the ovulatory drug clomiphene. Three miscarriages later, Nick was born – induced at 36 weeks for growth restriction. And then, after five years and one serious relapse, along came Emma – a very much wanted, loved, and welcome surprise.
Which brings me to another point: the flipside to all this is unexpected pregnancy. People with a history of anorexia have a higher rate of unplanned pregnancies than the general population (Micali et al, 2014). This may be because women with irregular periods think they are unlikely to conceive and, because of this, take less care with birth control. Whatever the outcome, an unplanned pregnancy is highly stressful for both parties, and it is imperative to take reasonable measures to avoid it, and to seek good support if you find yourself in this situation.
So, do not attempt to conceive (naturally or otherwise) if you are underweight or know you are still engaging in eating-disordered behaviours. Be honest with yourself, make sure you have weight-restored and are able to nourish yourself consistently, and wait until you have been in a solid recovery for several months before subjecting yourself to the physical and psychological challenges of pregnancy.
Research has shown variable outcomes for women with anorexia who become pregnant (Ward et al., 2008). For some, the eating disorder continues unchanged during the pregnancy (Larsson et al., 2003), whereas for others, pregnancy can trigger a relapse into more severe illness (Kouba et al., 2005). There are, however, a number of reports that women often experience a remission of anorexic symptoms in pregnancy (Micali et al., 2007; Knoph et al., 2013). I most certainly did during my first pregnancy – nourishing my unborn baby was my priority, and I was prepared to accept any physical changes, including weight gain (permanent or otherwise), necessary to have a healthy baby. Pregnancy can, however, present a number of challenges to even a solid recovery. If you do run into trouble you will need support, quickly – but many women find it difficult to admit they are struggling and do not ask for help. Partly because a pregnant woman should put her unborn child first and nourish herself properly – and, of course, you want to do that – so admitting you are unable to can feel incredibly shameful.
Pregnancy after anorexia has been associated with adverse obstetric outcomes such as miscarriage, intrauterine growth restriction, low birth weight, and prematurity (Eik-Nes et al., 2018), especially if the mother’s BMI is less than 20 when she conceives (Kouba et al., 2005). Although this is association not causation, and the risk is reduced by adequate weight gain during pregnancy, these correlations highlight the importance of making sure you receive good antenatal care from a team fully informed about your history.
Learning point 2: Tell your GP, midwife, or obstetric team that you have a history of an eating disorder
Doctors and midwives are not mind-readers, and if you do not tell them about your anorexia they are unlikely to ask. Yes – ideally health professionals would spot the signs and ask the question…but this is the real world, and in a busy clinical setting this type of thing can easily go unnoticed. Interestingly, my husband is a GP and told me that doctors are automatically alerted to a high-risk pregnancy if a pregnant woman’s BMI is over 30, but there are no such alerts in place in the case of a low BMI. If your healthcare team do not know about your disordered eating, this may compromise the care you and your baby receive. You need to stand up and advocate for yourself. Equally, as a future mother, this is the first of many occasions on which you will need to fight for what is right for your child.
Omitting this important point from my medical history during my antenatal care was another of my mistakes. At the time, I thought I was recovered and bringing it up didn’t seem relevant but, if I’m being completely honest, the main reason I remained silent was shame and fear of judgement. You do not have to hide your eating disorder from health professionals who can help you and your baby if you allow them the opportunity to do so. Having a history of anorexia is not your fault, but it is your responsibility to manage the creation of a new life appropriately if you have the understanding and knowledge to allow you to do so.
Learning point 3: If you experience nausea and vomiting or loss of appetite in pregnancy, be aware this places you at greater risk of relapse and prioritise eating as much as you can physically tolerate
Common side-effects of pregnancy are nausea and vomiting, which is unpleasant for everyone but has far more significant implications in someone in recovery from anorexia than in the general population. Food aversions and cravings can also be difficult to manage. This comes down to luck – and my first pregnancy gave me a false sense of security. The first pregnancy was easy as I had very little morning sickness, my appetite was unaffected, and the main eating-related problem I experienced was an intense craving for Stilton and Camembert. My other pregnancies were not so straightforward. Other than morning (or all-day-long) sickness, my appetite was non-existent and I found it very difficult to eat as everything tasted, well …. meh. Getting into the habit of not eating much is not a good idea for someone with a history of anorexia – whatever the underlying reason. It is very easy to slip into the pattern of ‘matching down’ subsequent daily intake, and for eating more again to start feeling very difficult.
Pregnancy-induced nausea, vomiting, and appetite loss should be managed with a strict ‘food is medicine’ approach. It doesn’t matter if you don’t feel like eating – eating needs to happen to keep you and your baby safe. Find something you can tolerate (bland foods like pasta, rice, bread – whatever) and do not allow your intake to drop. And, if you really struggle, make yourself accountable to somebody who can help you to prioritise scheduling meals and eating as much as physically possible.
Learning point 4: Let go and relax into the weight gain
At the risk of stating the obvious, pregnancy is going to involve weight gain, which can be a huge concern for someone with a history of anorexia. Some women find they are comfortable with their pregnant bodies and love the changes that represent new life growing within them. Some experience a profound connection with their body and develop a new appreciation for its capabilities and functionality. Others, however, can find the weight gain that accompanies pregnancy psychologically difficult to cope with. Having your own and others’ attention focused on eating well during pregnancy, and being weighed and measured at antenatal appointments, can be challenging even for those who are stably recovered.
I personally loved watching my bumps grow and enjoyed seeing the physical changes that accompanied pregnancy. I wasn’t too keen on the hamster cheeks or the extra weight on my arms, but I took them as necessary parts of a process that was completely out of my hands, and allowed myself to let go and relax into it.
I was, however, entirely unprepared for my pregnant body suddenly being a form of public property upon which everyone I met felt entitled to pass comment: “Aren’t you neat!”, “Are you sure it’s not twins?”, “You must be due any day now”, or my personal favourite: “You don’t look pregnant from the back”. Nor was I prepared for my bump being touched by complete strangers. This level of scrutiny can be difficult to manage – but being prepared for it, having some stock answers up your sleeve, and doing your best not to dwell on insensitive comments can be helpful.
The time shortly after having a baby is a very high-risk period for relapse. The improvement in eating-disorder symptoms often experienced during pregnancy can lull women into a false sense of security that their anorexia has resolved – so they take their eye off the ball. A Norwegian study showed that 18 months after delivery, only 50% of mothers with anorexia remained in recovery, and at 36 months (i.e. with a three-year-old child to look after) 41% had relapsed (Knoph et al., 2013) .
However much we love and want them, life with a small baby is bone-shatteringly exhausting, unpredictable, and chaotic. New mothers find their self-confidence is tested to the extreme: most of us have no idea what we are doing, and the responsibility of caring for and keeping this tiny, helpless, and entirely dependent little being alive can, at times, be completely overwhelming. At this extremely vulnerable point it is all too easy to turn to previous maladaptive coping mechanisms in the attempt to numb the storm of emotions and restore some form of calm and order to life. Being tired and sleep-deprived does not lend itself to making wise decisions. And, at the risk of using the old ‘control’ chestnut, when the world feels huge and overwhelming and you are metaphorically drowning in a sea of emotion, micromanaging your food and focusing on the numbers on the scale moving satisfyingly downwards can be a welcome respite.
Having a baby is one of the most stressful times in a woman’s life – yet women are pressured into believing it is the most euphoric. In this context, women are often afraid to admit they are struggling, and the resurgence of eating-disorder symptoms, and other problems such as postnatal depression, tend to go quietly underground. After the immediate post-partum period the focus of healthcare professionals (and friends and family) shifts onto the baby – nobody is watching you, and nobody thinks to ask the questions, so it is very easy for relapse to slip under the radar.
Learning point 5: When you come home from hospital, take the chance to rest and enjoy your baby
Do not do any of the following:
- Get up at 6am the day after giving birth, get showered and dressed, do your hair, apply lipstick, and take your other children to school.
- Agree to edit and resubmit an academic paper for publication when you have a one-week-old baby.
- Drive halfway across the country to sit a postgraduate exam the day after your premature baby is discharged from special care.
- Submit an entry for a competitive running race scheduled for when your baby is 5 months old, and use this as a reason/excuse/justification to get up at 5 a.m. every day to go for a 10K run.
- Refuse all offers of help as you are, obviously, superwoman.
My first son was born by caesarean section, leaving me little option other to lie on the sofa and spend a blissful few weeks cuddling, feeding, and getting to know my baby whilst eating unpasteurised cheese and watching hours of box-sets on the television (I’d highly recommend ‘Cold Feet’ for this).
I was fortunate enough to have very straightforward deliveries following my second and subsequent pregnancies and physically felt very well soon after the babies were born. In hindsight, I took this to mean I was fine to resume business as usual, and allowed it to contribute to a drive to prove (to whom, I have no idea) that having a baby was not going to reduce my productivity or compromise any of the ridiculous standards to which I held myself. This, sadly, did not end well. The time after having a baby is precious, so rest as much as possible, sleep, eat properly, and let your family and friends help you. Take the time to enjoy your baby. Don’t run yourself into the ground trying to show the world (and yourself) that you can keep doing it all. ‘Lower’ (or rather, change) your standards and show yourself a little compassion. Oh, and don’t drag your post-baby body to the gym.
Learning point 6: Don’t succumb to societal pressure to try to ‘get your body back’
After my babies were born I was amazed by how people seemed more inclined to focus on whether or not I had ‘got my figure back’ rather than being impressed I had managed to produce an entire human. Women are under immense social pressure to ping back into shape and their pre-pregnancy jeans – there is a ridiculous emphasis on the need to ‘lose the baby weight’, followed by validation, praise, and envy for having done so. Maternity leave can feel like a succession of endless coffee mornings with other mothers eating biscuits whilst simultaneously bemoaning their mummy-tummies…when you know you know exactly what to do to get rid of yours. And you know you have the ‘self-discipline’ to do so.
Remember that just as your body changes as you grow older, it will change after pregnancy. Try to be proud of what your body has done and is doing, not just what it looks like. And remember that starting to diet and exercise excessively immediately after giving birth is a perfect route back to old disordered behaviours.
After my first son was born, ‘getting my body back’ wasn’t even on my radar. I had no idea what to expect or what was realistic – my body had changed beyond recognition, I didn’t particularly like it, but any discomfort I felt was completely eclipsed by the joy and pride I had in being a new mother. Interestingly, with no conscious effort at all on my part, the weight I had gained during pregnancy gradually came off over the subsequent nine months and I was able to retrieve my pre-pregnancy jeans from the back of the wardrobe.
Once I realised this was possible, I would be lying if I said I didn’t try to expedite the process following my second and subsequent pregnancies. Which, again, was a huge mistake.
Learning point 7: Breastfeeding is wonderful, but is not a marker of your success as a mother, and if you want and are able to breastfeed your baby you need to eat more food
A history of anorexia does not mean you will be unable to breastfeed if you choose to do so. But, if this is what you want and are able to do, you need to remember that you need to eat more food to be able to sustain an adequate milk supply and prevent yourself from slipping into energy deficit. Breastfeeding places a huge caloric demand on the body, which was another thing I failed to anticipate. My third baby in particular fed vociferously and I found it difficult to increase my food intake to match… so I slipped unwittingly into energy deficit, and quietly slid back down the rabbit hole.
Learning point 8: You have needs and your needs matter
Another trap I fell into time and time again was mistakenly thinking I needed to deny my own needs in order to ‘be a good mother’ – for good mothers put the needs of their child before their own. Putting your baby first can be a convenient excuse for missing meals (the classic ‘too busy to eat’), or allowing them to slip later and later. Conditions for eating are highly unlikely to be perfect with a small baby around who could start to cry/poo/vomit at any second, and if you find it difficult to eat unless everything is just right…well, this is going to be a challenge. Ask for help if you anticipate finding this hard – but it is imperative to actively challenge this type of thought and to remember that eating needs to happen regardless of convenience, enjoyment, or anything else.
In this case, the airplane analogy of applying your own oxygen mask before attending to others is particularly relevant. You will be no use to anybody, including your child, if you do not prioritise feeding yourself and so slide back into an anorexic abyss. Plus, being a mother should not mean that you matter any less, to yourself or to anyone else.
(See the guest post by Emily's mother Sue for more on this in the context of supporting a child with an eating disorder.)
Learning point 9: You do not need to do this perfectly
Motherhood is not another thing in which you need to try to achieve perfection. New mothers are bombarded with messages about how to care for their babies, with a never-ending stream of conflicting advice about routines, feeding practices, sleeping patterns, etc. Some of us experience a powerful instinctive drive to rebel against our own parental role models, or worry about repeating destructive patterns from our childhoods. The main thing I have learned after having four children is to recognise all this as bullshit, let it go, muddle through as best you can, and follow your instincts – you will know better than anyone what is right for you and your baby. And if you’re struggling, talk to someone – ask for help. Failing (refusing?) to do that was my major downfall. Motherhood was another thing I wanted to do perfectly – and how can you do that if you admit (or don’t admit) you can’t even feed yourself properly? Drop the façade and allow yourself to be vulnerable with people who care about you. I cannot emphasise how important this is.
This also means letting go of any misplaced guilt you may have if you have already made some of the mistakes I did, or suffered any of the complications discussed. We are all muddling along doing the best we can with the tools we have. Being ill is not your fault. I am writing this not to apportion blame or invite further harsh and unfair self-judgement, but rather to help other women avoid making the mistakes I did. My four children are, through luck more than judgement, growing into healthy, happy, and well-balanced young people. And it’s important to realise that, as parents, we will never get everything right.
Relapse during or after pregnancy doesn’t always happen through initiating obviously risky behaviours such as trying to ‘lose the baby weight’, or sinking into a dramatic post-partum depression. The return of anorexia could simply be, as it was for me, more of an insidious slide into comfortable, familiar patterns in a subconscious misguided attempt to restore order to an unfamiliar and unremitting chaos. The point may not be to raise a cry for help or signal you are unable to cope – in my case, it was more to demonstrate I was so supremely competent that my ability to manage motherhood was reliant on nothing, requiring neither food nor rest. Fortunately, I have learned a lot.
The main point I want to get across is the importance of honesty, openness, and support at this vulnerable time. Having a baby is a wonderful, magical experience, but it is difficult too. I kept my anorexia shrouded in secrecy from everyone, including my husband and health professionals; I didn’t tell anyone or allow anyone to help me because I was ashamed and afraid of being judged. One reason I am prepared to speak out about this now is I have realised how sadly misplaced these fears were. I don’t want other women to feel they need to don their protective armour and pretend to the world that everything is ‘fine’. It may be fine, in which case, great. But, if it’s not – well, this is not just about you any more.
Eik‐Nes, T. T., Horn, J., Strohmaier, S., Holmen, T. L., Micali, N., & Bjørnelv, S. (2018). Impact of eating disorders on obstetric outcomes in a large clinical sample: A comparison with the HUNT study. International Journal of Eating Disorders, 51(10), 1134-1143. Paywall-protected journal record here.
Freizinger, M., Franko, D. L., Dacey, M., Okun, B., & Domar, A. D. (2010). The prevalence of eating disorders in infertile women. Fertility and Sterility, 93(1), 72-78. Full-text PDF here.
Knoph, C., Von Holle, A., Zerwas, S., Torgersen, L., Tambs, K., Stoltenberg, C., ... & Reichborn‐Kjennerud, T. (2013). Course and predictors of maternal eating disorders in the postpartum period. International Journal of Eating Disorders, 46(4), 355-368. Open-access full text here.
Kouba, S., Hällström, T., Lindholm, C., & Hirschberg, A. L. (2005). Pregnancy and neonatal outcomes in women with eating disorders. Obstetrics & Gynecology, 105(2), 255-260. Open-access full text here.
Larsson, G., & Andersson‐Ellström, A. (2003). Experiences of pregnancy‐related body shape changes and of breast‐feeding in women with a history of eating disorders. European Eating Disorders Review, 11(2), 116-124. Paywall-protected journal record here.
Micali, N., dos‐Santos‐Silva, I., De Stavola, B., Steenweg‐de Graaf, J., Jaddoe, V., Hofman, A., ... & Tiemeier, H. (2014). Fertility treatment, twin births, and unplanned pregnancies in women with eating disorders: findings from a population‐based birth cohort. BJOG: An International Journal of Obstetrics & Gynaecology, 121(4), 408-416. Open-access full text here.
Micali, N., Treasure, J., & Simonoff, E. (2007). Eating disorders symptoms in pregnancy: a longitudinal study of women with recent and past eating disorders and obesity. Journal of Psychosomatic Research, 63(3), 297-303. Full-text PDF here.
Ward, V. B. (2008). Eating disorders in pregnancy. BMJ, 336(7635), 93-96. Open-access full text here.