Body image, an important factor in weight control, encompasses one’s perception of body size and the emotional response or attitude toward that perception [6–8]. Body image is often assessed using attitudinal questionnaires such as the Body Cathexis Scale [9], the Body Shape Questionnaire [10] or by exploring percept evaluations using figure rating exercises. For the figure rating exercises, participants are shown a series of numbered silhouettes ranging from very thin to extremely obese. Participants are asked to select which figure they currently most resemble. This is known as body image_current. To further explore dimensions of body image, participants are often asked to select which figure they would like to resemble. This is known as body image_ideal. The calculated difference between body image_current and body image_ideal is called body image discrepancy or body image dissatisfaction (BID = body image_current − body image_ideal). Several instruments have been developed to facilitate this line of study. The most widely used instrument is the Stunkard Figure Rating Scale, which consists of 9 silhouettes (see Fig. 7.2a) [11]. The Stunkard scale was introduced in the early 1980s as an easy-to-administer self-assessment of body image and has been strengthened by subsequent work, which established BMI norms for adults and children [12]. Several additional figure rating scales have been developed and adapted to be appropriate for diverse populations [8, 13, 14]. Highlighted at the bottom of Fig. 7.2b is the scale developed by Pulvers et al., who sought to develop an instrument more relatable to a range of cultures with detailed figures, but not specific to any one culture [13]. Scales are currently being developed that better depict body proportions for African-Americans and allow participants to desire change of specific body parts (i.e., chest, hips) vs. change of the entire body. From these figure rating exercises, many conclusions have been drawn about body image among African-American and White women. Research has shown that both African-American and White women report some body image dissatisfaction [15–18]. However, White women typically report greater body image dissatisfaction than African-American women, while African-American women generally report body image ideals larger than that of White women [19, 20]. There are a range of proposed factors that may influence body image differences across race/ethnic groups.

Body image is a part of a woman’s psyche that begins to develop at a young age and continues through the life course. However, body image is not a static concept and may change with the different phases of life that a woman may experience. One such time to consider is the pregnancy phase, which is a very important phase in a woman’s life, with implications for both her own well-being and that of her developing fetus. During pregnancy, women experience substantial and sometimes dramatic changes in their body shape, sensations, muscle tone, and weight, over a relatively short period of time, resulting in significant alterations of body image [31]. It is important to understand women’s adaptation to their changing bodies during pregnancy because body image dissatisfaction has been shown to be associated with depression, anxiety [32, 33], and unhealthy dieting and eating behaviors [34], which all have serious implications for the health and well-being of the mother and developing fetus [35, 36]. In addition, body image influences the ability of a woman to develop a positive maternal identity, which has a great impact on her ability to accept the maternal role postpartum. Nevertheless, there is a paucity of evidence in this area with almost all of the studies having been conducted in very small samples containing only nonminority participants or no report of race. A summary of studies evaluating body image during pregnancy is presented in Table 7.1.

The current Institute of Medicine [IOM] guidelines recommend that women with normal prepregnancy weight (body mass index [BMI] <25) gain 25–35 lb whereas overweight (25< BMI <30) or obese (BMI ≥30) women are advised to gain 15–25 lb and 11–20 lb, respectively [37]. However, currently, fewer than one third of pregnant women achieve guideline-recommended gains, with the majority gaining above IOM recommended levels [38]. Excessive gestational weight gain is on the rise, with more than 40 % of normal-weight women and 60 % of overweight women exceeding the gestational weight gain recommendations [38]. There are significant racial differences in gestational weight gain with White women more likely than their African-American counterparts to gain in excess of recommended levels [39–41]. However, African-American women are more likely to enter pregnancy overweight or obese compared to their White peers [42]. As mentioned earlier, a significant amount of research indicates that the idealized image of female beauty in western societies is thin [43]. During the course of pregnancy, with the increase in weight, breast size, and thickening of the waist, women depart from this cultural ideal of beauty. A woman’s assessment of her body image when nonpregnant is based on her current perceived body image in comparison to her ideal body image. Thus, it can be expected that if the ideal remains stable during pregnancy, there would be an increase in body image dissatisfaction as pregnancy progresses [31].

The body changes that occur during pregnancy are somewhat expected, but there are some inconsistencies in the literature on whether a woman adapts positively to these changes or becomes dissatisfied or concerned about them [44–51]. In addition, it is evident that women have conflicting feelings about the changes in their bodies. Although for the most part, women have a positive perception of themselves during pregnancy, a considerable proportion report feeling unattractive [44]. A qualitative study by Chang et al. [50] reported that over 50 % of the women interviewed expressed dissatisfaction with their overall appearance. Some women talked about loss of the self/body and expressed concern about regaining their prepregnancy feminine self after the birth of baby. However, some women responded positively to their changed bodies. For others, the response was either negative or conflicted and their reactions to changing breasts covered the spectrum. Almost half of the women expressed concern and most expressed strong negative reactions to striae gravidarum (stretch marks). In this study, the reactions of significant others played a crucial role in a woman’s adaptation to her pregnant body. As such, Chang et al. concluded that even during pregnancy, women are relying on ideas of men’s standards of attractiveness and media representations to assess the changes they are experiencing during pregnancy. In a cross-sectional study [44] of 891 women, more than half of the study population felt less attractive than usual and 60 % reported being less interested in sex.