This essay explores the ways in which eating disorders can affect a woman’s experiences and clinical management throughout pregnancy. Eating disorders in the antenatal period can have farreaching physiological and psychological consequences. Firstly, the classification of eating disorders used throughout the essay is elucidated, drawing on the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM). Secondly, the prevalence of eating disorders in pregnancy is examined. A third area of discussion is the potential physical harms associated with the condition, both in terms of maternal and fetal health. Due to word constraints, this includes a brief outline of the ways in which binge-eating disorders can create antenatal complexities, but is mainly focused on the effects of undernutrition on fetal development. Fourthly, the psychological difficulties experienced by women with eating disorders are discussed, along with the role of the midwife in providing sensitive and non-judgmental care. Relevant studies were found using the library tools WebCat and Delphis, and searches of the Cochrane Library database were conducted. Although the way a woman experiences an eating disorder (ED) will be highly individual, the DSM is used in psychiatric medicine to help define common features of each condition (APA, 2013). Midwives should act as ‘lifelong learners’ to familiarise themselves with the range of EDs so they can be alert and sensitive to the needs of the women they serve (Maclean, 2011, p.47). Anorexia nervosa (AN) is characterised by: refusing to keep body weight above what is considered to be a healthy body mass index (BMI) and a phobia of becoming “fat” or gaining weight (APA, 2013). Women with bulimia nervosa (BN) engage in binge eating behaviours followed by compensatory measures, either through self-induced vomiting, laxative or emetic usage, or excessive exercise (APA, 2013). ‘Other specified feeding and eating disorder’ (OSFED) is a further subtype of ED describing those who exhibit disordered behaviour but may not fall into any one category (APA, 2013). For example, a woman may meet all the criteria for anorexia nervosa with the exception of falling in the underweight category according to BMI. Finally, binge-eating disorder (BED) is characterised by eating abnormally large amounts of high calorie foods during episodes of loss of control, with no compensatory behaviours (APA, 2013). Sufferers often fall into the “overweight” or “obese” BMI classifications (APA, 2013). The manifestations of EDs are complex with a wide array of possible symptoms, and a low BMI should not be the only cause for concern. It is imperative that the midwife has an understanding of the spectrum of EDs to be alert to the fact that a woman in her care may have additional needs, and to be able to broach the subject with a woman if suspicions are raised (Tierney et al, 2013). Secondly, the prevalence of EDs in pregnancy is difficult to assess. In some cases, the clinical symptoms of a disorder can be masked by the pregnancy itself (Easter et al, 2013). For example, due to gestational weight gain, women with AN may no longer be “underweight” according to BMI, and excessive vomiting may be assumed to be pregnancy induced rather than as the result of BN (Torgersen et al, 2008). In other cases, the sensitive nature of EDs prevents pregnant women from disclosing their conditions (Watson et al, 2013; Micali and Treasure, 2009; Tierney et al, 2013; Tierney et al, 2011). Assessing the numbers of women affected in pregnancy is therefore problematic. Despite these challenges, some studies have attempted to obtain an estimate of those suffering with EDs throughout pregnancy. For example, Easter et al (2013) studied pregnant women attending their first ultrasound scan at King’s College Hospital, London. Self-report questionnaires were distributed to women within the study period and 94% were completed and returned. Data were collected and analysed for 739 women. Using the Eating Disorder Diagnostic Scale, a 22-item questionnaire surrounding eating habits and self-image (Stice et al, 2004), Easter et al found that 7.5% of women scored as having an eating disorder during pregnancy, and 9.2% as having some form in the 6-12 months prior to pregnancy. It must be borne in mind that the study was conducted in just one hospital and it is therefore difficult to assess the generalisability of this figure across the United Kingdom (UK). The literature would benefit from similar research in other areas of the UK to assess regional differences. However, the study also has several strengths. Firstly, ethical approval was gained which is especially critical when researching such an emotive topic (Ellis, 2010). Secondly, the sample is relatively large and the response rate extremely high, suggesting representative data. Thirdly, as highlighted, there is some evidence to suggest that women with EDs will downplay their condition for fear of judgment or social service involvement (Watson et al, 2013; Micali and Treasure, 2009; Tierney et al, 2013; Tierney et al, 2010). The self-report nature of the questionnaires may, consequently, underestimate eating disorders in the pregnant population. Therefore, if potentially conservative estimates place the incidence of EDs at more than one in every twenty pregnant women, midwives must be aware that this is a relatively common occurrence. Given this fact, it is imperative that midwives familiarise themselves with the sequelae and management of EDs. If undetected, potential physiological harms to the fetus are profound and life-long, and psychological damage to the mother may be severe. The possible physiological consequences of EDs throughout the antenatal period will be discussed first. The impacts of conditions such as BED are significant during pregnancy, as there is evidence to suggest that high calorie intake can lead to antenatal complexities such as maternal hypertension, gestational diabetes and fetal macrosomia (Linna et al, 2014; Micali and Treasure, 2009). Therefore, the clinical management for women with BED may include more frequent blood pressure checks and the recommendation for a glucose tolerance test (GTT) at 28 weeks to assess for disruption of glucose homeostasis (National Institute of Health and Care Excellence [NICE], 2010a; NICE, 2008; Micali and Treasure, 2009). On the other hand, the risks and management of AN or OSFED in pregnancy are more commonly associated with undernutrition and reduced fetal growth (Linna et al, 2014; Micali and Treasure, 2009). Nutrition has been shown to be crucial to both fetal development and the adult health of offspring. In his seminal work, Barker (1998) demonstrated a correlation between the experience of a fetus in utero and chronic disease later in life. By examining birth records and medical archives, he could show a statistically significant link between those born with low birth weights for their gestational age and those with chronic conditions such as coronary heart disease. Fetal development is reliant upon the right balance of nutrients and oxygen and if either of these is compromised, cell division is slowed (Barker, 1995). If division is depressed during what Barker terms one of the ‘critical periods’ of development, in which certain physiological structures are evolving, this can have long-term effects (Barker, 1998, p.115). For example, undernutrition later in pregnancy can slow down cell division in the kidneys, leading to permanently reduced numbers of kidney cells (Barker, 1998). This will have a direct impact upon renal function in adult life (Barker, 1998). It is easy to see how this would affect fetal development in mothers with active AN, BN or OSFED as the fetus is exposed to reduced or unpredictable nutritional intake. However, there is some suggestion that women with low pre-pregnancy weights also risk compromised fetal development. Jeric et al (2013) compared women who were “underweight” prior to pregnancy, with a BMI of less than 18.5 kg/m2, with a control group of “normal” weight women, whose BMIs were between 18.6-24.9 kg/m2. The mean birth weight of babies in the underweight group was found to be 167g lower than those in the control group, which may indicate risk of chronic disease later in life according to Barker’s theory. Underweight women who gained appropriate gestational weight tended to have heavier babies than underweight women who gained only small amounts of weight. On the surface, this may seem to support Barker, in that the nutrition a fetus is exposed to in utero affects development. However, Jeric et al (2013) also found that even if appropriate gestational weight was gained, babies born to underweight mothers were still more likely to be small for gestational age than those in the respective control sub-group. Therefore, whilst the effects of pre-pregnancy undernutrition could be mitigated to some extent by subsequent adequate nutrition, due to an existing deficit fetal development was likely to be compromised. The work of Barker (1998) and Jeric et al (2013) demonstrates the lifelong impact that maternal undernutrition can have on a fetus. Therefore, it is crucial that midwives be alert to the possibility of reduced fetal growth in previously underweight women, even if they are exhibiting no clinical symptoms of an ED during pregnancy and are gaining gestational weight appropriately. Antenatal risk assessments must take a holistic view of the woman to include pre-pregnancy factors which may cause complexities in pregnancy. Midwives have a dual responsibility when caring for pregnant women with eating disorders, to be clinically astute and refer any concerns to the wider obstetric team, but also to support women emotionally through changes in care pathways and management. For example, if a fetus is found to be small for gestational age on symphysis-fundal height measurement and this is subsequently confirmed by ultrasound scan, the mode and timing of delivery may be altered (Royal College of Obstetricians and Gynaecologists [RCOG], 2013). Continuous electronic fetal monitoring would be recommended in the case of spontaneous delivery, which would necessitate the mother to deliver on labour ward (RCOG, 2013). This may cause profound stress for a woman who has planned to birth in a low-risk environment, and feelings of guilt may ensue from feeling that her condition has impacted upon the fetus (Tierney et al, 2013). Her community midwife should support her by offering information and emotional encouragement. The Nursing and Midwifery Council (NMC) Code compels midwives to ‘encourage and empower people to share decisions about their treatment and care’ (NMC, 2015, p.5). By working in partnership with the woman in the antenatal period, a midwife can help her to devise an adjusted birth plan which will lead to maximum psychological fulfillment whilst managing risk in a safe environment. Finally, it is often stated in the literature that pregnancy is a time of remission for eating disorders (Zerwas et al, 2014; Easter et al, 2013; Watson et al, 2013; Micali and Treasure, 2009). Whilst large-scale, quantitative studies may demonstrate a reduction in exhibited disordered behaviours or compensatory measures, for midwives to interpret the findings in this simplistic manner is unhelpful as it overlooks women’s lived experiences. The majority of the research surrounding EDs in pregnancy is quantitative. Whilst this is extremely useful in outlining the scope and physiological impacts of the conditions, the literature would be complemented and enhanced by more qualitative studies. It also must be stated that a lacuna exists in the literature with respect to the impact of EDs in pregnancy on the wider family. Studies focusing on inter-relational aspects could only benefit women by generating greater empathy and support from health professionals regarding the social and emotional strains of pregnancy among those with EDs. The few available qualitative studies highlight that although pregnancy is ostensibly a time of remission for the clinical symptoms of EDs, it can be a period of psychological turmoil for women. A review of seven qualitative studies was conducted by Tierney et al (2013) which draws out common themes of women’s experiences. One recurring concern of women was the ‘constant struggle’ between strongly disliking gestational weight gain and yet wanting to nourish the fetus (Tierney et al, 2013, p.546). Women reported feeling a profound loss of control over their bodies and worried that they would not regain this control in the postpartum period. In an original study by Tierney et al (2011), it was found that, as the above quantitative studies have suggested, some women saw pregnancy as an opportunity to relinquish some control over their strict weight or exercise management and as a window for remission. However, on further examination, some participants saw this as only a temporary postponement of risky behaviours, with the intention to return to pre-pregnancy habits postnatally. This correlates with the findings of quantitative studies which have found that women with eating disorders gain gestational weight more rapidly than those without such conditions, but also lose weight much more quickly after birth (Zerwas et al, 2014; Micali and Treasure, 2009). Therefore, although an ED may not be “active” during the antenatal period, it is the role of the midwife to create an environment of openness and trust in which a woman feels she can discuss psychological challenges. Additionally, it is imperative that midwives and other health professionals treat the issue of gestational weight gain with sensitivity and understanding. The qualitative studies highlight that throwaway, or even well-meaning remarks can have a devastating effect on a pregnant woman with an active or past eating disorder. A participant in one study described abject panic when the specialist dietician she was consulting throughout the antenatal period outlined how much weight she should be gaining at each stage of pregnancy (Tierney et al, 2011). Whilst the comments were intended to encourage weight gain, the message was perceived in such a way that to put on more than this amount of weight would have been extremely damaging to the woman’s self-perception (Tierney et al, 2011). NICE (2010b) guidelines for weight management in pregnancy state that women’s weight and height should be measured at the first antenatal appointment to calculate BMI, and no subsequent weights should be taken throughout pregnancy unless clinically indicated. It is stressed that ‘no evidence-based UK guidelines on recommended weight gain ranges during pregnancy’ exist (NICE, 2010b). Despite this, the antenatal framework of the local trust includes routine weighing for women at 28 and 36 weeks with boxes in the maternal hand-held notes highlighting appropriate and inappropriate weight gain (Anonymised, 2014a and 2014b). Countries which do utilise evidence-based guidelines for weight gain ranges have different categories based on booking weight. For example, in the United States of America the Institute of Medicine (IoM) recommends that “normal” weight women should gain between 25-35 lbs (11.3-15.9 kgs) during pregnancy, whereas “underweight” women should gain 28-40 lbs (12.7-18.1 kgs) (IoM, 2009). However, the local trust guidelines make no such distinction, basing optimum weight gain on those in the “normal” weight category. Given that women with EDs may use information on weight gain as a yardstick with which to compare themselves against other women, by applying “normal” weight gain to those who are at a pre-pregnancy nutritional deficit, women may try to limit their dietary intake or continue compensatory measures in order to be situated within these parameters (Tierney et al, 2013). Alternatively, women may feel a great amount of anxiety and psychological conflict if they do manage to control their eating disordered behaviours and find themselves gaining more weight than the antenatal booklets “allow”. Therefore, midwives and health professionals must be mindful of not allowing their focus on clinical tasks to impede their sense of perspective and tact. If measuring weight is deemed clinically necessary, midwives should obtain consent and respect a woman’s right to decline if she chooses (NMC, 2015). In conclusion, pregnancy can be a frightening experience for women who have maintained strict control over their body shape, in some cases for many years. Midwives have several roles when caring for women with eating disorders. Firstly, they must familiarise themselves with what constitutes an eating disorder in order to broach the subject if the woman does not herself disclose a condition. This is necessary in order to ensure that appropriate help and care is provided. Secondly, relevant skills such as blood pressure checks, glucose tolerance tests, abdominal examinations and symphysis-fundal height measurements must be maintained so maternal and fetal well-being can be assessed throughout pregnancy. Finally, the midwife must treat the women in her care with sensitivity and lack of judgment in order to create an open atmosphere so that concerns can be discussed and overcome. References American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders (4th edition). Washington, DC: American Psychiatric Association. American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders (5th Edition). Arlington, Virginia: American Psychiatric Publishing. Anonymised Trust Guideline. 2014a. Antenatal risk assessment/Frequency for midwifery led care: Guideline. National Health Service Foundation Trust. Anonymised Trust Guideline. 2014b. Antenatal care records. National Health Service Foundation Trust. 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