Part 3 (1/2)

Data collected by Magann et al. (1996, 2002) on employment, exertion and outcome in Australian women suggest that women who were least active, in either employment or other physical activity, were at most risk of pre-birth admission to hospital and of PTD, and another study points to the benets of non-sedentary employment, together with leisure time physical activity, particularly in reducing risk of pre-eclampsia (Saftlas et al., 2004) (see also Chapter 5). Once again, the message in terms of 70 women's ability to respond appropriately in relation to their work practices is difcult to interpret. Clearly, some women are at risk, with those in the highest exposure category at risk of giving birth prematurely. The highest risk category means that they would have prolonged standing, considerable physical exertion and long working weeks. In these cases, women might be advised that continuing in employment might be putting themselves and their baby at risk.

A major consequence of research into outcomes has been the development and content of advice for pregnant women, at work and elsewhere, on activities to pursue, maintain or avoid. We address this topic at some length in Chapter 6 on exercise but in the context of this chapter on pregnancy and employment we open the discussion here by examining how prevailing discourses of responsibility present in research are translated into practice through advice.

Enacting responsibility: responding to advice The nature of advice provided is that women should avoid or maintain certain behaviours in relation to paid work, with standard advice to take more rest, to sit down regularly, to avoid heavy lifting and bending and to avoid working with chemicals, lead or x-rays. The prevailing biomedical discourse of pregnancy serves to locate advice as authoritative and rea.s.suring. However, advice about working is often contradictory or ambiguous, and though it stops short of dictating how women behave, it is often hectoring or patronising in style. As might be expected in the light of the extensive literature on the links between employment, aspects of job tasks and adverse pregnancy outcome, the advice is centred on the avoidance of risk and makes use of the literature we have discussed above. This has the effect of positioning work as one of the elemental forces' (Smith, 1992).

Paid work is presented as potentially dangerous for the baby and, in order to minimise the danger, the expectation is that women will manage to accommodate their need to work and simultaneously to extricate themselves from its risky components. Of course, this discourse of riskiness is also available to others in the workplace who may be able to use it to their advantage by pressuring women to behave in ways that might appear concordant with their own expectations but are in fact disadvantageous.

Representations of advice, however, fail to make connections between the discrete elements of research evidence that have emerged, for example that women may suffer stress at work, which is risky for the baby, but that it is others who are responsible for creating the stress, not the women themselves. Emphasis throughout is on how the woman can adjust her lifestyle and behaviour to reduce exposure to stress or other conditions that might be harmful.

71.The contradictory coverage of the risks a.s.sociated with working incidentally acts to separate public and private activity. As we have highlighted above, discussion of paid work rarely transfers into the private domain and domestic work in the home is largely ignored, with some exceptions.

Features on the demands of working and being responsible for home life are addressed occasionally, and indicate that women should avoid the double demands, though how this might be done is less well dened.

Specically, advice requires women to be proactive on their own behalf and that of their baby. As we have seen from the studies of women's experience at work, this is not always easily accomplished because of considerable opposition to providing exibility or even of conforming and responding to policy requirements. The difculty some women encounter is addressed in ways that make it sound as though it is merely a matter of being clear about needs and calling on legislation for back-up. As the various EOC surveys have shown, this is hardly helpful in many situations where pressure from others is signicantly greater than an individual might be in a position to confront.

A fascinating way in which women may respond to the demands to be proactive and to avoid risk is exemplied in our prospective study of women's changes in activity over the course of pregnancy (Clarke and Gross, 2004a; Clarke et al., 2005; Rousham et al., 2006). In this study, whose other ndings are discussed again in Chapter 6 on exercise activity, women's daily activity was measured through the use of activity monitors and through self-report. The ndings indicate that overall activity levels declined across the course of pregnancy. When this was broken down into the differing realms of activity, a similar pattern was demonstrated with mean self-reported total occupational activity levels decreasing over time.

Even prior to maternity leave, the mean number of hours worked per week decreased signicantly between 16 and 34 weeks of pregnancy. The women in our study were fortunate enough not to experience discrimination, and were generally treated well by their employers. Though, of course, as others have indicated, those who felt they might encounter difculty may have left work earlier, making the group of women involved in the study in some ways atypical in this regard. Most of the women reported that they had made adaptations to their work, nevertheless.

Most interestingly, given the advice to rest as much as possible but also to maintain activity, women undertook a neat s.h.i.+ft in their activity, whereby a signicant decrease in the mean total length of work breaks was observed, but the frequency of work breaks increased. In response to restrictions on the time available for breaks something women often reported the women managed their time differently in order to conform to the need to take more or at least adequate rest. The physical aspects of work, including working posture or stairs climbed, did not change signicantly (though most women's jobs were largely sedentary) since these 72 were mostly xed components. What women did report was that they changed the behaviour that was under their control, even if the activities did not form part of the women's daily routine, such as reducing lifting and carrying or bending: 89 per cent of the women reported not lifting although only 27 per cent had originally indicated that their job required them to lift heavy loads. However, this involved a subtle combination of behaviours in an attempt to minimise the impact on their role in paid employment and to undertake appropriate responses to the risks to maternal and foetal wellbeing. The adaptations were unlikely to impinge on productivity or performance and were under the women's individual control. This included the number of trips made around the ofce environment, recruiting others to do small tasks for them, such as taking things to other ofces when they are pa.s.sing and taking paper to the photocopier.

Such subtle changes may be a reection of how pregnancy may legitimate opportunities to relinquish roles or responsibilities that are considered irksome, boring or unnecessary. Alternatively, they may be represented as a woman's engagement with the perceived responsibilities of motherhood. The decision to maintain workplace activities, on the one hand, yet change the more exible elements of their job, on the other, may reect cultural att.i.tudes too. As other studies describing women's experiences at work have demonstrated, women have to conform to the role of responsible mother and as an individual with agency. By announcing that they have changed behaviour they are conforming to the explicit demands to minimise risks. At the same time they are maintaining agency through their judgement of the potential impact of their changes on their working day.

Concluding remarks In general terms, we can conclude from the available research that for most pregnant women work is not a source of serious problems, either in psychological terms or in terms of pregnancy outcome. Nevertheless, for some women, notably those in positions with less control and poorer working conditions or in smaller workplaces, the experience may not be as positive. As the case of pregnancy discrimination in the workplace demonstrates, pregnancy retains a potency that is perhaps unexpected in the early twenty-rst century. The issues raised by the negative treatment described appear to revisit a continuing ambiguity in societal or public beliefs about the divisions of labour and essential roles and about women and femininity.

These are very fundamental beliefs that cannot easily be dismissed by the presence of policies and laws designed to prevent their impact. Moreover, the protective framing of pregnancy legislation, together with the research striving to isolate the precise sources of harm, positions women and their babies as at the mercy of risks arising in the public world of work. The 73 treatment of women in the workplace is simultaneously accounting for and making women accountable to those risks. The construction of pregnancy as a risky endeavour emphasises the metaphors of containment which are inherent in the discussions that follow concerning diet and exercise.

The willingness of individuals to offer up their relinquis.h.i.+ng of activities identied as appropriate in the advice they receive suggests to us that it is possible to manage the demands created by the conicting and confusing evidence in a personally meaningful way. It is possible that where treatment at work is less positive, this controlled adjustment and accountability is more difcult to accomplish and, paradoxically, in being attempted may even reinforce att.i.tudes and beliefs about pregnancy in colleagues and employers. The pregnant woman in the workplace could be said, therefore, to provide a focus for all these beliefs that at other times remain unchallenged.

5.EATING FOR ONE OR EATING FOR TWO.

Diet and eating behaviour in pregnancy.

Changes in diet and eating behaviour are an essential part of the stereotypical image of pregnancy, but surprisingly little research has concentrated on what women actually eat and why. Pregnant women are typically depicted as being plagued by strange and irresistible cravings as well as having aversions to certain foods. Nausea, familiarly, though inaccurately, known as 'morning sickness', is seen to be characteristic of pregnancy and in popular culture is regularly depicted as the earliest somatic symptom.

The regularity of the reporting of somatic symptoms across the world suggests that these symptoms and dietary change in pregnancy are driven by physiological and endocrinal factors. Certainly research in this area routinely a.s.sumes that these are the only drivers but it is likely that other, psychological factors may be as important. In the case of eating behaviour, a combination of dietary beliefs, an a.s.sociation of symptoms with diet in the past, and past dietary behaviour may be used to guide behaviour and interpret experience. There are many traditional beliefs about what and how women should and should not eat during pregnancy, some of which appear to be common across cultures, for example that women should increase their food intake at least in the early stages, as summarised in the phrase eating for two'. Other dietary beliefs seem to be very culturally specic and derive from belief systems relating to the body and the development of the foetus, for example pica the craving for and eating of non-food substances such as earth and clay, as Walker et al. (1997) investigated in South Africa.

Although the adoption of stereotypical beliefs may limit women's choices, it also sanctions behaviour that is otherwise not regarded as acceptable in young women, for example satisfying 'cravings' allows high calorie eating patterns. Many young women restrict their caloric intake in pursuit of the current ideal feminine body shape in the developed world and concern is often expressed in the popular press in the developed world about children and young girls as young as seven years old restricting their food intake. It has been estimated that on any given day approximately 45 per cent of American women are on a diet. Eating disorders, princ.i.p.ally anorexia and bulimia nervosa, are largely afictions of women (Andersen, 75 1995) and women of all ages express dissatisfaction with their body (Stevens and Tiggemann, 1998). Estimates of the prevalence of eating disorders in women of childbearing age have been found to be between 1 and 2 per cent (Fairburn and Beglin, 1990).

Further pressures on pregnant women come from external sources. As we have shown in Chapter 4, and as David-Floyd (1994) points out, the pregnant body can be seen as inappropriate. In Chapter 7, we see how pregnant celebrities are currently usually depicted in the media as remaining slim during pregnancy and rapidly regaining their pre-pregnancy shape.

Therefore, for many women, pregnancy, with its accompanying change in body size and shape, may be seen as a personal challenge.

To add to these pressures, pregnant women are often the target of food scares in the media. In some instances this is because a link has been posited, by epidemiologists or basic scientists, between particular foodstuffs and foetal wellbeing (for example, there were reports in 2002 on the possible risks of drinking too much coffee and the dangers of mercury in tuna sh). In other cases, targeting arises because pregnant women are generally regarded as a vulnerable group, alongside older people and the very young. So if a foodstuff is discovered, or thought, to pose some health risk, then vulnerable groups are advised to avoid it. This was the case in the UK when there were reports on the risks of Salmonella in chicken eggs, which originally appeared in the 1980s and reoccurred in the late 1990s.

How women respond to these scares is less frequently reported.

And it is not just the potential risk of poor foetal outcome; the diet of women during pregnancy has a signicant impact on their long-term health. The most rapid rise in obesity and overweight in women occurs during the peak childbearing years (Department of Health, 2002) and obesity is a major factor in ante- and perinatal maternal deaths (Lewis and Drife, 2004). Importantly, for long-term health, 1420 per cent of women are 5kg or more heavier 618 months post partum, compared to their pre-pregnancy weight (Keppel and Taffel, 1993; Ohlin and Rossner, 1990). As has been regularly doc.u.mented, obesity and overweight are increasingly important health problems and are a.s.sociated with a number of diseases including hypertension, type II diabetes, cardiovascular disease and some types of cancer (NIH, 1998).

Despite the known impact of diet on the health of women, it has taken the results of long-term studies of its impact on the health of offspring into adulthood to prompt the interest of mainstream medical researchers in maternal nutrition during pregnancy, outside underdeveloped countries where even basic nutrition is problematic. Poor maternal nutrition has long been linked to foetal and child ill-health. This effect is due not only to insufcient energy intake overall but also to the incorrect balance of food types and nutrients, leading to restricted intrauterine growth, low birthweight, prematurity and other perinatal morbidity (Kramer, 1993). More 76 recent research suggests that several diseases of later life also originate from impaired intrauterine growth and development, leading to permanent effects on structure, physiology and metabolism (G.o.dfrey and Barker, 2000; Mathews et al., 1999). This is known as thefoetal origins' or Barker hypothesis, named after David Barker who studied the records of 16,000 men and women born in Hertfords.h.i.+re, England from 1911 to 1930 and whose records can be traced to the present day. The birth records on which these studies were based came to light as a result of the Medical Research Council's systematic search of the archives and records ofces of Britain.

The Hertfords.h.i.+re records were maintained by health visitors and include measurements of growth in infancy as well as birthweight. Death rates from coronary heart disease fell two-fold between those at the lower and upper ends of the birthweight distribution. Barker concluded: 'The fetal origins hypothesis states that fetal under nutrition in middle to late gestation, which leads to disproportionate fetal growth, programmes later coronary heart disease' (Barker, 1995: 171). Similar results have been reported in other European countries, India and the US. More recently, excessive maternal weight gain has also been related to perinatal problems in babies (Kabiru and Raynor, 2004) and to childhood obesity (Whitaker, 2004). Higher levels of obesity and of infant mortality and morbidity (a.s.sociated with poor maternal nutrition) are seen in more disadvantaged groups in the UK (Department of Health, 2002; Macfarlane et al., 2000). This work prompted an ongoing large-scale survey of the lifestyle and dietary behaviour of 20- to 34-year-old women in Southampton in southern England.

Three thousand of the 12,500 women surveyed became pregnant during the course of the study, and their dietary behaviour is being closely monitored.

Such surveys and monitoring research will add considerably to our knowledge of what women eat during pregnancy and how their diet changes. However, we still know little about what prompts women to change their diets during pregnancy and what external pressures, personal beliefs and habits underlie the dietary choices they make: for example, whether women who eat healthily prior to pregnancy make more changes than those who do not. In this chapter we consider the research on various aspects of dietary behaviour during pregnancy and reect on research perspectives. On the one hand these perspectives take pregnancy out of the context of women's lives and, except in the extreme case of eating disorders, disregard previous eating behaviours. On the other hand they fail to take account of the inuence of women's culturally embedded beliefs about pregnancy as a different and specic physical experience.

Dietary beliefs and dietary change There seems to be general agreement among those with expertise in nutrition and women themselves that diet should change during pregnancy.

77.At the very least, the extra demands on the body call for increased calorie consumption of about an extra 200 calories a day. Beyond this consensus, however, there seems to be wide variation about what exactly is an appropriate diet during pregnancy, with competing information from the media, health professionals and pregnancy manuals and from family and friends. Beliefs about changing one's diet during pregnancy may be a.s.sociated with the wellbeing of the mother, with the wellbeing of the baby or with a desirable weight gain. Such beliefs may be rooted in the woman's own past eating behaviour, in antenatal health education or may have been transmitted from generation to generation within a particular culture or subculture.

One of the rst questions we should ask is whether women do deliberately change their diet during pregnancy for either their own or their child's wellbeing. The answer, from our own and others' work, suggests that they do, and that the changes seem rather more motivated by concern for their child than themselves.

Two early studies of US women looked at how they reported changing their diet (Norman and Adams, 1970; Orr and Simmons, 1979). In Norman and Adams' (1970) study, approximately two-thirds of the women reported adjusting their diet. Such adjustments included adding, reducing or eliminating foods. Greater intakes of dairy products together with fruit and vegetables have generally been reported as usual dietary additions.

High sugar foods such as desserts, chocolates and biscuits were the items most commonly reported to be reduced or eliminated, as were foods with a high salt or fat content. Orr and Simmons (1979) found that most of the women they studied believed diet to be important for both mother and baby, though a substantial number did not recognise its importance for mothers. However, they did report that they were prompted to change their diet on the basis of advice from health professionals, who may have placed more explicit emphasis on change.

Most studies rely on women's reports of how they change their diets rather than measuring actual food intake. In a study we carried out we examined the eating patterns of a demographically mixed sample of 102 women during their rst or second pregnancy by exploring specic changes that they made to their diet, as well as how somatic symptoms a.s.sociated with pregnancy, such as nausea, affect food choice, and how dietary beliefs inuenced women's food choice (Pattison and Bhagrath, 2003, 2004). We found that 79 per cent of women reported that they should increase consumption of certain foods and 82 per cent reported trying to avoid certain foods. The foods increased were fruit, vegetables and dairy products whereas the foods avoided were foods high in sugar and fat and those that health professionals and other advisors had suggested were dangerous, such as soft cheeses. However, when we measured the actual frequency of consumption, no signicant difference was found between when women 78 last consumed the food they felt they should increase or avoid and their current reported intake, suggesting that other factors are at play.

In a study in the US, Pope et al. (1997) studied dietary changes in pregnant adolescents. Their results indicated that the pregnant girls' diets were more nutrient dense than a matched sample of non-pregnant girls.

Since becoming pregnant, a majority reported that they had increased the amount of food eaten, specically milk/dairy products, vegetables, fresh fruit/unsweetened juices, breads/cereals and chocolate. Health professionals' inuence was cited for increased intake of vitamin supplements and milk, but not for changes in food intake. The major motivations for increasing food intake during pregnancy seemed to be food cravings, increased appet.i.te, improved taste of food and concern for the baby.

So there is evidence that women report changing their diets in such a way as to increase their caloric intake, and specically increasing certain foodstuffs and reducing intake of others. However, what they actually eat is not simply motivated by dietary advice from midwives or nutritionists. One interpretation of our own ndings is that the women in our sample knew what foods their midwives would recommend them to eat, but that somatic symptoms such as nausea, or other beliefs about diet, affected their food choices as well as presumably personal preferences. Traditional beliefs may signicantly inuence dietary patterns and many are not consistent with recommended guidelines for nutrition during pregnancy. Examples of these include eating for two, not mixing certain foods, taking vitamins to overcome an inadequate diet and eating only a few selected foods.

The impact these traditional beliefs have on dietary behaviour in developed countries may be limited because of increasing access to resources, for example formal education, the internet and pregnancy magazines as well as positive media attention promoting healthy eating and regular contact with health professionals, which would subsequently encourage a different att.i.tude towards diet to be established. In our own work in a UK population, belief in traditional eating patterns varied with educational level so that more highly educated women were less likely to endorse such beliefs and less likely to report suffering cravings (Pattison and Bhagrath, 2003).

However, in this sample educational level was confounded with socioeconomic status, as it is in many studies.

In a sample of 6,125 non-pregnant women from the Southampton study, mentioned above, Robinson et al. (2004) examined the inuence of socio-demographic and anthropometric factors on the quality of the diets of young women in the UK. They found that educational attainment was the most important factor related to the quality of the diet consumed. In all, 55 per cent of women with no educational qualications had scores in the lowest quarter of the distribution, compared to only 3 per cent of those who had a degree. Smoking, watching television, lack of strenuous exercise and living with children were also a.s.sociated with lower diet scores. After 79 taking these factors into account, no other factor including social cla.s.s, the deprivation score of the neighbourhood or receipt of benets added more than 1 per cent to the variance in the diet score. The signicance of these ndings is that they suggest that poor diets in general in this group are not simply a result of the level of deprivation, but reect a more general pattern of health behaviour that is linked to poor access to information sources through education.

Some support for this thesis comes from our study (Pattison and Bhagrath, 2004) where women who reported making changes to their diet were also more likely to have made additional changes to their lifestyle.

Although there was no variation on alcohol intake (all women who previously drank alcohol reported cutting down or abstaining from alcohol consumption during pregnancy), more educated and younger women were more likely to have attended antenatal cla.s.ses and changed their exercise levels. In our study, women who increased exercise and women who decreased exercise were cla.s.sied together as having made a change. As we shall show in the next chapter, exercise seems to be an area where pregnant women respond in different ways.

In considering how women respond to pregnancy we should not forget that people's belief systems are complex and they can simultaneously hold beliefs which are conicting and contradictory. A study carried out by Carruth and Skinner (1991) found that a substantial proportion of clients of the 1,771 pract.i.tioners they surveyed had beliefs about physiological needs during pregnancy, practices related to a healthy baby and alcohol and caffeine consumption that were not signicantly different from those endorsed by the American Dietetic a.s.sociation. However, they also held beliefs, particularly about cravings, which showed strong regional differences, and which represent traditional views not supported by dieticians (e.g. eating for two, eating only a few selected foods, restricting salt intake, taking vitamins to overcome an inadequate diet and deciding that pregnancy is a good time to lose weight). This study was performed in the US.

However, few similar studies have been done elsewhere to a.s.sess whether similar beliefs exist and if so to what extent. Nevertheless, as we discuss below, advice given by midwives and in publications for pregnant women is often vague, recommending ahealthy diet' and being open to interpretation within the woman's own belief system. Many traditional beliefs about diet in pregnancy revolve around cravings, aversions and somatic symptoms of pregnancy, particularly nausea and vomiting, and we will now consider these in more detail.

Cravings, aversions and somatic symptoms Many women report cravings and aversions towards particular foods during pregnancy; the reported occurrence in the literature ranges from 66 80.to 85 per cent. Cravings and aversions are undoubtedly at least partially interrelated with beliefs as the behaviour of consuming or avoiding particular foods during pregnancy may be directly related to cultural or social values. For example, there is a strong belief system within certain cultures to support pica, which is the consumption of non-food substances such as clay and earth. Food cravings may also be experienced as a somatic symptom though these are also likely to be inuenced by cultural beliefs (Bayley et al., 2002).

The medical model of pregnancy suggests that all experience of pregnancy is related to physiological and endocrinal change, thus much early research on cravings and aversions a.s.sumed that the root of these desires is a mechanism to protect the foetus. Therefore, cravings are seen as a way of making up for dietary inadequacies and aversions, and nausea and vomiting are seen as a way of protecting the foetus from noxious substances.

Traditional beliefs about food restrictions have also been investigated in this way. Fessler (2002), for example, suggests that maternal immunosuppression, which is necessary for tolerance of the foetus, results in vulnerability to pathogens. Symptoms could be abehavioural prophylaxis'

against infection, with nausea and aversions leading to the avoidance of foods likely to carry pathogens, and cravings leading to foods which boost the immune system. A similar conclusion is reached in a review by Flaxman and Sherman (2000) of morning sickness and pregnancy outcome. This was particularly a.s.sumed in the case of pica, the most extreme and unusual of cravings. These a.s.sumptions are also found in the explanations women themselves give for what they are experiencing. Several studies carried out in the US by Carruth and Skinner on pregnant adolescents identied beliefs which gave aphysiological basis' for cravings. For example should give in to my cravings or I will harm my baby' and 'foods that make me feel sick must be bad for my baby' (Pope et al. 1992).