Eating Disorders and Pregnancy

By: Jennifer L. Gaudiani, MD, CEDS

Monday, February 15, 2016

I’ve gotten a few requests from folks to discuss key questions about eating disorders and child-bearing. I’ll use excerpts from a chapter I just wrote in Encyclopedia of Feeding and Eating Disorders for Springer Reference. I think the key questions are: do women with eating disorders seek more fertility help? What are pregnancy outcomes in women who have had an eating disorder? How does childbearing affect mortality rates in those with a history of anorexia nervosa (AN)? And finally, how does pregnancy itself affect eating disorders?

To get and stay pregnant, an immense number of things must “go right,” among them a reasonable nutritional status and adequate body weight for ovulation to occur. Even some modern day healthy bodies in women without eating disorders may simply be too underweight, from Mother Nature’s perspective, to conceive a baby. Purging, and the psychological stressors that drive purging, may also impede fertility. A large study showed that 16-20% of women attending fertility clinics had eating disorders. This is a way higher number than the population prevalence of eating disorders. Relative to women with no psychiatric disorder, women with bulimia nervosa in particular had more than double the rates of having undergone fertility treatment. Another study showed that 7.2% of eating disordered patients who had previously received residential treatment sought infertility treatment, compared with 4.5% of those without an eating disorder.

Intrauterine growth retardation (IUGR, or small babies at birth) is a well-established risk in babies of women with eating disorders, related to inadequate pre- and during-pregnancy nutrition. Many studies have confirmed that pregnancy and childbirth rates are lower in those with current or former eating disorders than in controls. In one study, those with a history of AN had a pregnancy rate less than half that of controls. The highest rates of miscarriage were in those with binge eating disorder (BED), with 47% of pregnancies ending in miscarriage, compared with 17% miscarriage rates in those without eating disorders.

A large Swedish study found a strong connection between death rates and childbearing. Presumably arising from the fact that women who truly recovered to the point where they chose a partner, were able to become pregnant, and were able to carry the pregnancy to term, a woman with a history of AN who bears a child has a decreased death rate of more than 60%.

The Norwegian Mother and Child Cohort Study was the first large population study on the effect on eating disorders during pregnancy and after. The study identified that women with eating disorders worry more about size and shape during pregnancy and have higher rates of postpartum depression. Confirming prior research, they found that eating disorder symptoms may go away during pregnancy, but symptoms can recur after birth. With a three year old child to care for, up to 40% of women with AN and 70% of those with BN had relapsed.

The message I think is this: eating disorders are serious, life-threatening diseases that have a real impact on every aspect of one’s life, including in this case fertility and childbearing. Not everyone wants to have a baby, and infertility is a challenge that women of every age and health status can struggle with, but in my experience as a mama and a physician, babies and children need parents who are as healthy, energetic, grounded, and mindful as possible. If you want to get pregnant but aren’t yet in full recovery from ED…my recommendation is to wait and keep working on you. If you have a history of ED and you’re now in the joyful place of being pregnant, prepare for ridiculous commentary on your body (You’re huge! You’re tiny! Oi.), with gentle reminders to folks not to discuss shape and size with you, and advocate for yourself in the doctor’s office. Ask not to see your weight when you go for checkups, and not to have weight discussed unless it’s significantly abnormal. And as ever: be kind to yourself, be patient, practice self-care, and check in with your support people throughout.

References:

  1. Knoph C., Von Holle A., Zerwas S., Torgersen L., Tambs K., Stoltenberg C., Bulik C.M., Reichborn-Kjennerud T. (2013) Course and predictors of maternal eating disoders in the postpartum period. International Journal of Eating Disorders, 46, 355-368. 
  2. Linna M.S., Raevuori A., Haukka J., Suvisaari J.M., Suokas J.T., Gissler M. (2013) Reproductive health outcomes in eating disorders. International Journal of Eating Disorders, 46, 826-833. 
  3. Micali N., dos-Santos-Silva I., De Stavola B., Steenweg-deGraaf J., Jaddoe V., Hofman A., Verhulst F.C., Steegers E.A.P., Tiemeier H. (2014) Fertility treatment, twin births, and unplanned pregnancies in women with eating disorders: findings from a population-based birth cohort. British Journal of Obstetrics and Gynaecology, 121, 408-16. 
  4. Papadopoulos F.C., Karamanis G., Brandt L., Ekbom A., Ekselius L. (2013) Childbearing and mortality among women with anorexia nervosa. International Journal of Eating Disorders, 46, 164-170.