The impact of pregnancy and birth on the body is immense, yet we rarely discuss the ways it impacts women’s lives, says Emily Writes.
Before writing this piece on pregnancy and postpartum body changes I ran a short survey that I shared in a small Facebook group. Within half a day I had more than 100 responses. By the end of the day, 260.
I asked people who had been pregnant how their body had changed through the process and after birth. Those who answered were mostly pragmatic about how their body had changed – and for most, it had changed a lot:
I have no feeling around my C-section scar. More spider veins. Boobs are bigger, but flatter. Weak abdominal muscles, despite targeted weight training…so my stomach pooches out more. Skin is drier. More fine wrinkles. Stretch marks. My periods are heavier but shorter. My joints tend to get sore more easily.
I am a fairly fit and skinny person, but the excess skin I now have around my tummy makes me sad every day. It will never go away. Neither will the tear in my abdominal muscles, regardless of how much yoga I do. Giving birth vaginally to a breech baby was also fairly damaging, and carrying them caused my uterus to flop onto my bowel, so sex is now painful in certain positions. Really puts a dampener on your marriage.
Change in how my stomach sits, have an overhang now after C-section and surgeries. I had an obstetric fistula which has resulted in bladder damage and painful periods.
I gained 25kg during first pregnancy then lost 35kg the year after. Fell pregnant again and gained another 20kg, then lost it. And now having gone back to work, I’ve gained it all back and then some! So my poor body has been constantly changing over the last seven years.
My boobs are saggier and have lost their density on the top. My labia are longer. My cervix is lower. I have grey hair now.
Boobs saggier, anus higher up (hard to explain but that’s the best I can do), saggy skin on stomach, deeper voice, weaker core, much more prone to nerve pain in lower back, less comfortable during periods, and much worse ovulation pain mid cycle.
My back is weak, my pelvic floor destroyed, my teeth have degraded, I’m exhausted and my joints hurt, especially my pelvis.
It’s like a list of car crash injuries. And it seems unlikely that someone recovering from a car crash would be expected to lose weight immediately, get on some dick and/or love their stretch marks. Yet the prevailing focus on postpartum bodies is squarely on weight loss or “loving your body” or having penetrative sex.
What lies in between? Where did this focus come from and how can we turn the tide? What even is body image when your body feels broken?
Meredith Nash is a senior lecturer in sociology at the University of Tasmania, and deputy director of its Institute for the Study of Social Change. She studies body image in women during and after pregnancy.
Body image is a profound theme in women’s experiences of reproduction, she says – particularly for first-time mothers. She explains that the drive to drop as much weight as possible, as fast as possible, can “take hold in a way that can be very unexpected for women”. As to why, anyone who’s been through the up-ending experience of having a baby will understand the logic, at least to some degree: “[Weight loss] can be a simplistic way to take back control of your life when it has changed so much.”
Nash started her research more than a decade ago, when the narrative about postpartum bodies was just emerging: think celebrity “bump watches” and magazines asking “who bounced back faster?” She’s now a mother to a four month-old.
The focus on weight loss has grown over time, at the expense of any proper conversation about birth injury, ongoing health issues and body changes after pregnancy, she says. The psychological damage to women can be immense.
“It’s a huge emotional labour, and that’s on top of the physical stuff women go through when they have kids.”
The reality is that weight gain and loss is a small part of most postpartum experiences.
Caitlin Day is a physiotherapist on the pre and postnatal wards at Auckland City Hospital. At Greenlane Clinical Centre she treats patients for pelvic floor dysfunction including prolapse, incontinence, bladder urgency, constipation, faecal incontinence, and sexual pain.
She also has a private clinic where she treats pregnant women for back and pelvic pain, rib pain and carpal tunnel syndrome; and postnatal women for pelvic floor dysfunction from childbirth, diastasis (separation) of their abdominal muscles, and “aches and pains from mothering”.
On top of that, she’s a mum to a 16 month-old.
She reels off the statistics: one in three women who have had a baby leak urine. Around 50% of women who deliver a baby vaginally have a prolapse whether they know it or not. (A prolapse is where the vaginal walls have been stretched, allowing one or more of the pelvic organs to bulge down into the vaginal area.)
One in eight women who have had a baby have faecal incontinence or difficulties controlling their gas. Around 85% of women who resume sex by 12 months postpartum (including those who had a C-section) experience pain during vaginal penetration after birth.
“Pregnancy itself causes huge stretching of the pelvic floor, abdominal muscles and chest area from the increasing size of the baby, but also the pregnancy hormones, making us more stretchy,” Day says.
“A vaginal birth causes the pelvic floor muscles to stretch 2.5 times their resting length – no other muscle in the body can do that without completely failing. More stretch is caused by bigger babies, forceps, suction or pushing for a really long time. So it’s no wonder pelvic floor issues are so common.”
But common does not mean normal – or untreatable.
“Women who have leakage are eight times more likely to report a cure or improvement of symptoms if they perform pelvic floor exercises with a physio when compared to women who don’t do them. This includes behavioural changes like addressing how you are exercising, if you are coughing a lot, how you are lifting your baby, constipation – all of these things can make urinary leakage worse. Pelvic floor exercises can help too.
“However, 30% of all women are doing their pelvic floor squeezes incorrectly, and the only way to know if you are doing it right, is to see a pelvic floor physio.”
Leakage and prolapse can be further improved by a vaginal pessary, “a little soft removable device that you insert into the vagina that holds everything up – kind of like a bra for your vag. It can be fitted by some pelvic floor physios, or a gynaecologist”. Surgery by a gynaecologist is also an option.
If there are options for women, why do so many struggle to get help? Nash suggests the transition in healthcare from pregnancy to postpartum can be jarring.
“When your body is on display as a pregnant person it’s in a positive way. Everybody wants to engage with your belly and talk to it and touch it because the foetus slash baby is this very public figure.
“After the baby has come, it’s different. Having a pelvic floor check is not part and parcel of the process after birth. If you’re in pelvic pain it’s really up to women to deal with that themselves and the whole postpartum experience is cast aside. In terms of the after-effects on your body, if it’s not related to breastfeeding nobody really wants to know. And that’s really difficult. Women feel really alone in these issues and it can be really scary to have everything change so much with your body so quickly and then to face coping with that on your own.”
Net result? “I think women suffer pelvic pain and painful sex and they’ll suffer through that for years.”
Many of the postpartum body stories Meredith Nash collected focus on what she calls “dealing with a leaky body”. “Post birth you’re bleeding for up to six weeks, and then you have breast milk leaking at all times. [It’s about] just having this body that you can’t rely on in a way that you could before you were pregnant.”
There’s no escape from your body – you’re stuck. If your birth involved an episiotomy or tearing you must manage stitches. Likewise, after a caesarean section you have wounds – internal and external – that must heal.
Midwives recommend getting a referral to a pelvic health physio for concerns following any type of birth. “They can provide guidance for exercise and activity level, and the correct way to perform daily activities like lifting,” says midwife Kylie Gilbert. “The physio can also help with ensuring the correct way to do pelvic floor exercise which will help with healing.”
Penetrative sex is often the last thing on a new mother’s mind but Gilbert says pain during intercourse after eight weeks (but not before a birthing parent is ready) could be a sign something isn’t right.
“I usually advise that if it’s still uncomfortable after three or four times to see their GP for assessment and referral to a gynaecologist. And to do this sooner rather than later as waiting lists are long. Don’t be embarrassed – this is their job.”
Can we change the narrative so women are able to get support for postpartum body injury or health issues rather than being stuck with the immense focus on weight loss?
Nash doesn’t feel hopeful. She worries that the time for pushing back has been lost. The postpartum weight loss industry is now too ingrained, too strong, it’s making too much money.
“I think the sad part is that … people don’t even question it anymore. I think there was a time when there was space to provide a critique of these new cultural norms, whereas now it has kind of become accepted that women will lose their baby weight and their bodies have to be managed in line with how we expect women to manage their bodies.
“We’ve kind of forgotten how to be critical of it, because it has become so normalised.”
The emerging body positivity movement isn’t necessarily an answer either, she says. It can be conflicting and confusing for mothers already being forced to focus so much on their bodies.
“The trope of ‘my stretch marks are my battle scars’; ‘ my postpartum body is beautiful’ is something I have trouble with, simply because I think there is a place where women can feel sad about losing their bodies.”
In her thesis Nash shares comments by participant “Zoe” who feels “really upset” about her body post birth. And it’s not the stretch marks.
“…although Zoe seemed to be in awe of the important reproductive work her body had performed, when she said, ‘I suppose I should be grateful for [my body]’, she seemed to imply that giving up control of her body or having a changed appearance was acceptable given the functional purpose of a maternal body.
“…it is possible that Zoe thought that demonstrating ‘pride’ in her postnatal body was the ‘correct’ reaction to perform for me as a researcher because, in Australian culture, ‘good’ mothers are represented as being focused on their children and not themselves.”
When you’re losing basic functionality new stretch marks can seem like the very least of your problems. Not loving your body can feel like you’re in the wrong too, Nash says.
“And that makes me angry. Being upset about your stretch marks – women are doing exactly what they’ve been told to do by the culture they live. So to tell women to love their stretch marks, that is totally counter-intuitive to what culture is telling them about their bodies. ‘Am I a bad woman because I don’t love my stretch marks?’”
There should be a space to feel the loss or the transition, Nash says.
“There’s this expectation that women will just love their bodies how they are in this new way and that’s another kind of cultural norm that never gets spoken about, because it’s framed positively. It’s OK to mourn the loss of your body [the way it was] before you had a baby … it’s a transition you need to move through slowly. I wish there was more acceptance of that. I wish we moved slower in that way.”
Meanwhile, Day says she would love everyone to be told how the pregnant body changes, the risks of both a C-section and a vaginal birth, and how to tell when things aren’t right after delivery.
“I also would love all women to have a mummy ‘Warrant of Fitness’: a postnatal assessment by a pelvic floor physio at six weeks after birth. France gives all their women 10 free government-funded pelvic floor physio appointments after they have a baby. We don’t do that in New Zealand, so women usually have to seek help themselves. But mostly, I would love women to know that there is help out there if you are concerned about your body or how it is functioning. It’s free through your DHB – just get a referral from your GP or midwife, or you can seek help from a private pelvic floor physiotherapist, no referral needed.”
Nash agrees. The key, she says, is giving women better access to kind, sensitive, evidence-based postpartum care, leading to comprehensive, considered care for new parents. She’d like to see “more patience, more resources”.
“And for women? My wish for them is to not place too many expectations on themselves.”
Expectation isn’t just in the hands of post-birth parents though – all of society needs to consider the role played in placing pressure on new parents to return to a body state exactly as it was before (or better).
Perhaps nuance is the answer – a space where women are not expected to perform joy in their changed bodies for the benefit of others, to give cutesy nicknames like “tiger stripes” to stretch marks, to be “good” women reacting the right way to their bodies. A space where new mothers are able to feel all of their feelings without judgement or pressure – and to feel confident and supported in rejecting the expectation that their bodies are public property before, during, or after birth.
Without these spaces – for grief, growth and transition – healthy conversations that change cultural narratives on postpartum bodies seems impossible.
This content was created in paid partnership with Women’s Health Action. Learn more about our partnerships here.