REVIEW PAPER

The influence of pregnant’s body image on the decision to breastfeed: A systematic review

A influência da imagem corporal da grávida na sua decisão em amamentar: uma revisão sistemática da literatura

Márcio Moniz Tavares ¹

Ana Paula Santos ¹

Sandra Silva ²

José Mendes ³

(1) Universidade dos Açores, Escola Superior de Saúde (ESS-UAC), Açores, Portugal
(2) Unidade de Saúde da Ilha de São Miguel (USISM), Açores, Portugal
(3) INTELECTO – Psicologia & Investigação, Açores, Portugal

Received: 23/09/2022; Reviewed: 01/02/2022; Accepted: 16/02/2023.

https://doi.org/10.31211/rpics.2023.9.1.281

Introduction

The experience of being pregnant can evoke conflicting emotions in women, ranging from fear of the unknown to joy or sadness at the prospect of having a child. Nevertheless, concerns about body image during this stage of life appear to be increasingly prevalent (Güney & Uçar, 2018; Swanson et al., 2017).

Body image has gained greater attention in recent years, with societal ideals of perfection perpetuated by media new trends, which promote certain body types and shapes as desirable, and influences people's perception of their own bodies (Loth et al., 2011; Martins & Petroski, 2015; Carter & Vartanian, 2022). In the same direction, recent studies have focused on the influence of social media on body image (Marques et al., 2022; Manning & Mulgrew, 2022; McComb & Mills, 2022). Body image is a multidimensional concept (Cash & Smolak, 2012) that encompasses a person's mental image of themself, including their body size and shape (appearance schemes) and related attitudes, feelings, and experiences (Cash & Labarge, 1996; Moss et al., 2014; Mendes et al., 2019).

It is not surprising that women considering how to feed their babies also contemplate the potential impact on their bodies, body image, and personal well-being (Güney & Uçar, 2018; Schalla et al., 2017). Expectations of rapid weight loss in the postpartum period, the desire for a body free of marks, and the need for control can increase stress for women already adjusting to the challenges of motherhood. However, the perception that breastfeeding, particularly extended breastfeeding, may contribute to the recovery of pre-pregnancy body image, can also influence the decision to breastfeed (Gillen et al., 2021). In fact, research has shown that individuals who place a high value on their appearance schemas tend to engage in behaviors that maintain or improve their appearance, which can lead to higher levels of social anxiety, eating disorders, and susceptibility to negative psychological states (Cash et al., 2004; Mancini, 2017).

According to Brown et al. (2015), dissatisfaction with body image during pregnancy can negatively impact both mother and baby by engaging in unhealthy behaviors, such as the increased use of formula. These authors also note that psychosocial factors, such as shame related to its practice in public and concerns about changes in breast shape, can affect breastfeeding.

Breastfeeding has been extensively researched and documented as a crucial factor in improving maternal and child health for several decades. The European Parliament and the European Union Council (2015) have advocated for the protection, promotion, and support of breastfeeding as a public health priority. This Commission considers breastfeeding as the natural and expected way to feed infants and young children, exclusively for the first six months of life, with complementary foods introduced thereafter. It is also argued that this practice not only contributes to optimal growth, optimal development, and health but also provides adequate nutrition. The WHO (https://www.who.int/health-topics/breastfeeding) stresses that low rates of breastfeeding and its premature cessation have significant adverse implications for the health and social structures of women, children, families, communities, and the environment. These implications include underweight, inadequate intake of vitamins or minerals, overweight, cancer, diabetes, and heart disease, among others. Consequently, health service expenditure increases, health inequalities are exacerbated, and ecological concerns arise.

Despite the well-documented benefits of breastfeeding, its practice remains a challenge for many women. Research suggests that perceived negative impacts on body image may discourage some women from initiating or continuing breastfeeding (Newby & Davies, 2016). Consequently, formula feeding may be chosen as an alternative, despite its known drawbacks.

Research Methodology

A systematic literature review was conducted based on instructions from the manual The Joanna Briggs Institute (2014). The research question was formulated using a modified Person/Population, Intervention/Exposure, Comparison/Context, and Outcome/Results (PICO) strategy to investigate the influence of body image on women's decision to breastfeed during pregnancy: What is the impact of body image (I) on women's (P) decision to breastfeed (O) during pregnancy (C)?

Data Collection and Processing

A literature search was carried out from January 1 to 31, 2022, using Medical Subject Heading (MeSH) descriptors. The descriptors were organized using Boolean operators (AND and OR) to create the search expression: ((Body image) OR (Body identity) OR (Body Representation) OR (Body Interaction)) AND ((Pregnancy) OR (Gestation)) AND ((Breast*) OR (Lactation)).

Inclusion and exclusion criteria were defined at the start and are listed in Table 2.

Search Strategy

Searches were conducted on the following databases: B-On, Scopus, Web of Science, and Ebsco (Cinahl, Medline, Nursing & Allied Health Collection, MedicLatina, and Cochrane Clinical Answers) to find primary studies between 2010 and 2022 that met defined criteria. Initially, we defined a five-year period of time; however, because only two articles met the criteria, we expanded the search period. The search was restricted to publications in English, Portuguese, and Spanish.

Selection and Critical Evaluation Process

The identification of relevant studies involved three reviewers who independently examined the titles and abstracts of studies, extracted data from eligible studies, and evaluated their quality using the forms provided by the Johanna Briggs Institute (JBI, https://jbi.global/critical-appraisal-tools). A total of 77 studies were initially identified, out of which ten were excluded due to being duplicates across multiple databases. Of the remaining 67 articles, 54 were excluded based on the analysis of their title and abstract. The remaining 13 articles were screened in detail and assessed against pre-established inclusion and exclusion criteria, resulting in the exclusion of nine studies. Finally, four studies were selected for the review.

To provide a clear overview of the study selection process, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram (Page et al., 2021), as shown in Figure 1. The PRISMA flowchart was followed closely throughout the study selection process. To ensure consistency, critical appraisal, data extraction, and synthesis were conducted independently by three reviewers, with a fourth reviewer consulted to resolve any disagreements. We used an online tool called Convidence (https://www.covidence.org/) to streamline the review process. This tool allowed for efficient collaboration and management of the study selection and data extraction process. The tool also facilitated the identification of potential conflicts or discrepancies among reviewers, allowing for timely resolution.

Figure 1

Articles Identification and Inclusion Process - PRISMA Diagram Flow

Outcomes

Table 3 presents an overview of the key features of the four studies included in this review. The studies are all situated within the quantitative paradigm, comprising two cross-sectional studies, one non-experimental, descriptive, and comparative, and one correlational study. The studies originate from diverse geographical locations, including two from Europe (Slovakia and the United Kingdom), one from the United States of America, and another from Nigeria. The studies examined various participant groups, with three studies focusing on pregnant women, one of which included follow-up data collection six months post-delivery and one study examining retrospectively women who had been mothers between two months and six months. The sample sizes in the studies ranged from 66 to 200 participants. Following the selection of the studies, they were rigorously evaluated for reliability, methodological quality, and relevance to ascertain their level of evidence. In accordance with the JBI norms and postulates (https://bit.ly/OvidDatabaseGuide), three studies were classified as level IV evidence, and one was classified as level VI evidence.

The analysis of the selected articles revealed that body image was identified as a factor influencing the decision to breastfeed and its duration in three studies. However, one study indicated that body image did not predict the practice of breastfeeding. Instead, this study found that the intention to breastfeed was a significant predictor.

Discussion

The period of pregnancy and postpartum brings about significant and varied bodily changes in women, which occur rapidly and may deviate from the idealized conception of their bodies. Although, in most cases, it seems that women adapt positively to these changes, some may develop a negative relationship with their bodies due to the physical changes that occur during pregnancy and post-breastfeeding.

Exclusive breastfeeding for the first six months of life is recommended by international organizations, such as UNICEF, the World Health Organization, and the European Community. Despite these recommendations, the Azores, a group of Portuguese islands located in the Atlantic Ocean, and the location of the authors who conducted this review, face unique challenges in promoting and supporting breastfeeding. The prevalence of exclusive breastfeeding in the Azores is low, with rates falling below acceptable levels. The prevalence of breastfeeding in the first hour of life is only 69.5%, further decreasing to 9.0% for exclusively breastfeeding during hospitalization, which persists at two and three months (Santos et al., 2021).

Premature discontinuation of breastfeeding can result from a variety of factors, including physical challenges such as pain, fatigue, and difficulty in attaching the baby to the breast, as well as social and psychological factors (Brown et al., 2015; Santos et al., 2021). Among these, psychosocial factors such as the mother's knowledge about breast milk, her self-confidence, and her decision to breastfeed during pregnancy can significantly impact the duration of breastfeeding (Mancini, 2017) (E3, Table 3). In fact, Mancini's (2017) study found that the intention to breastfeed during pregnancy was the strongest predictor of actual breastfeeding behavior. The study tested several hypotheses regarding the relationship between breastfeeding and body image and eating attitudes, using the Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS) and the Eating Attitudes Test-26 (EAT-26). Contrary to the hypotheses, the results indicated that body image and eating attitudes did not predict the practice of breastfeeding. In fact, mothers who breastfed had higher scores on the subscales of the MBSRQ-AS and lower scores on the EAT-26 than those who did not breastfeed (Mancini, 2017). However, it is important to acknowledge the study's limitations, including potential issues with group homogeneity and the retrospective design. Additionally, the measures used in the study were not specifically designed for pregnant, postpartum, or breastfeeding women.

The decision to breastfeed is influenced by various factors, one of which is a woman's perception of her body. During a healthy pregnancy, weight gain and changes in body image, including those of the breast, are natural occurrences. However, while some women may accept or overlook these changes, others may experience stress that negatively affects their body image, which can lead to reluctance to breastfeed (Brown et al., 2015; Mrosková et al., 2018).

Research on the influence of maternal weight during pregnancy and specific concerns related to breast appearance/shape and the postpartum period on infant nutrition was scarce until 2015 (Brown et al., 2015). The study by Brown et al. (2015) study found that women with higher concerns about body image were more likely to use formula and had a shorter predicted or effective duration of breastfeeding (E2, Table 3). Notably, these concerns were not limited to overweight women, as the actual body mass index was not related to the onset and duration of breastfeeding. This research considered three distinct aspects of body image during pregnancy: i) concerns about body image during pregnancy, ii) prospective concerns about postpartum appearance, and iii) eating behavior. The authors argued that the results of their study were consequential as a caution to those who work with women during pregnancy and the postpartum period to the importance of considering the global issue of maternal body image and its impact on the duration of breastfeeding. The three behaviors considered in the study were predictive of breastfeeding intention, initiation, and duration of breastfeeding. Women who had higher concerns about each aspect were found to be more likely to use intentional and real formula following birth and were less likely to plan or actually breastfeed at two, six, twelve, and twenty-six weeks. Body image was predictive of the duration of breastfeeding regardless of the broader maternal context, including demographic factors, type of birth, and weight (Brown et al., 2015). The authors found that high concerns related to these three aspects were associated with a shorter duration of breastfeeding, both predicted (intention) and actual (Brown et al., 2015). Thus, the study suggests that mothers who were more concerned about their body image were more likely to use the formula from birth or to breastfeed for a shorter period. Overall, these findings suggest that perceptions about breastfeeding rather than actual negative experiences with it contribute to reduced breastfeeding intention and duration. Negative experiences such as shame about breastfeeding in public, breast exposure, or a desire to regain control over the body, sexualization of the breast, and conflicts with a partner who does not support breastfeeding, which had been identified in previous studies (Espada, 2012; Powell-Yost, 2020), do not appear to be the primary factors influencing breastfeeding practices.

Similarly, among mothers who stopped breastfeeding before six months, those who were more concerned about body image were more likely to report having stopped because of shame (Brown et al., 2015) or the perceived impact on the shape of their breasts regarding the effect breastfeeding might have on beauty and attraction (Chiejina & Odira, 2012). The relationship between body image concerns and breastfeeding practices was not explained by maternal weight, although higher residual weight gain at six months was associated with a shorter duration of breastfeeding.

The results of studies E1 and E2 (Table 3) suggest that mothers who are negatively affected by changes in their body during pregnancy may be less likely to plan or initiate breastfeeding, potentially due to underlying issues such as embarrassment or the perceived impact of breastfeeding their appearance (Brown et al., 2015; Chiejina & Odira, 2012). Chiejina and Odira (2012) also found a significant relationship between the age and occupation of pregnant women and their body image regarding the decision to breastfeed (E1, Table 3).

In study E4 (Table 3), Mrosková et al. (2018) identified a high intention among pregnant women to breastfeed in general but found that women with more than one child expressed less intention to breastfeed than those with only one child. The authors also found that women living in urban areas had a greater intention to breastfeed, while those who smoked during pregnancy had a lower intention to breastfeed than non-smokers. In what is the focus of this review, the authors concluded that women who had a positive perception of their body image had a greater intention to breastfeed. Furthermore, the higher the level of education, the greater the intention to breastfeed, and the partner's attitudes strongly influenced the intention to breastfeed (Mrosková et al., 2018).

Additionally, education is an important factor influencing the decision to breastfeed and the practice of breastfeeding. In a study carried out in the Azores with a sample of 1105 mothers, Santos et al. (2021) found that education was statistically significant not only for the decision to breastfeed but also for the practice of breastfeeding in the first hour of life, exclusive until two and three months of life and not exclusive breastfeeding up to 12 months of life. Although this is not an aspect related to body image and the decision to breastfeed, it seems that women with higher levels of education understand better the importance of breastfeeding and, for that reason, decide to practice it, regardless of their appearance scheme.

In the same study, Santos et al. (2021) found that 79.6% of partners support mothers in their decision to breastfeed, and 22% were the main source of support in this practice. However, other studies suggest the influence of partners on the body image and food concerns of women in the postpartum period, and the practice of exclusive breastfeeding is also significant (Rodgers et al., 2022). Regarding the role of the partner, a systematic literature review conducted by Chang et al. (2020) pointed out their crucial impact on the practice of breastfeeding. The study found that if women were supported in their decision to give up breastfeeding, they made the decision faster, especially when facing difficulties related to body image.

Thus, it seems useful to include partners in consultations to analyze women's attitudes toward body perception and to support women in addressing issues related to body image dissatisfaction (Chang et al., 2020; Mrosková et al., 2018; Santos et al., 2021).

Conclusion

This literature review has highlighted that women's perception of their body image can influence the decision to breastfeed during pregnancy. Women with a more positive perception of their body image are more likely to decide to breastfeed during pregnancy, while those with a less positive perception of body image may be more likely to decide not to start breastfeeding. Therefore, body image issues seem to be of considerable relevance to breastfeeding and should be a concern of healthcare professionals who work on pregnancy surveillance. These professionals must provide appropriate information and strategies that will foster breastfeeding practice and raise awareness of the importance of breastfeeding, while demystifying the issues of breastfeeding's influence on the woman's body and clarifying its benefits with pregnant women and their partners. Likewise, the normalization of breastfeeding should begin early, from childhood, to overcome issues related to the sexualization of the breast.

Involving the partner in pregnancy surveillance consultations is also important as they can be a strong ally in the decision-making processes.

Nursing assumes a leading role in this regard due to the knowledge and skills it can transmit in the context of monitoring women in pregnancy surveillance consultations. However, combining mental health knowledge (e.g., health psychology) is also essential for effective intervention. From a scientific standpoint, it is not enough to demonstrate the influence of body image on the decision to breastfeed. It is also important to understand healthcare professionals can improve their activity with these women and define appropriate interventions for this aim.

Despite limitations in this review, such as the limited scientific evidence on the relationship between body image and breastfeeding, future studies are needed to determine the influence of body image on the decision to breastfeed. It is suggested to carry out stronger research to determine if body image can be understood as a predictor of this practice and to explore the planning and evaluation of the effectiveness of health literacy programs in stimulating breastfeeding.

Conflict of interest | Conflito de interesses: none | nenhum.
Funding sources | Fontes de financiamento: This work did not receive any financial contribution or scholarship | nenhum.
Contributions | Contributos: MT: Literature review; Data collection, input, and analysis; Writing of the manuscript. APS: Contribution to the writing of the manuscript; Treatment and discussion of data; Revision of the final draft of the manuscript. SS: Contribution to the writing of the manuscript; Treatment and discussion of data; Revision of final draft of the manuscript. JM: Literature review; Data collection, input, and analysis; Revision of the manuscript.

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