We all know lots about obesity, but we don’t learn much about anorexia in midwifery training.

Midwives are busy people. The work is a privilege, but that doesn’t stop the fact we have mighty workloads on challenging shift patterns, caring for difficult demographics, and all while documenting clinical chaos in legalese! Sometimes it can feel like we're drowning in information, and we have limited time to spend learning about the conditions that crop up infrequently.

I’ve definitely been guilty of not suspecting anorexia in a lady with hyperemesis. I’ll call her Paris, and she attended looking like The Girl With The Dragon Tattoo, cropped hair, leather jacket and many piercings.  She was horribly nauseous but surprisingly lippy. She was good fun to look after. But I didn’t suspect anorexia, and only had it drawn to my attention when I pulled Paris’s prior notes.

Anorexia is on the rise. 1.6 million people in the UK have eating disorders and we know that 1/5 of these will die prematurely, often through killing themselves. 4% of childbearing age women will suffer from anorexia.

Anorexic women are high risk in pregnancy. They can have:

• Unplanned pregnancies
• Social problems and a history of abuse
• Nutrient deficiencies
• A harder time giving up smoking
• Hyperemesis (or they can use sickness to cover up their eating disorder)
• Depression, especially postnatally
• Have mixed feelings about pregnancy and motherhood
• Miscarriage, bleeding, small for gestational age or IUGR babies, and increased risk of caesarean birth

Maternity care for mental illness always suffers from a lack of attention and resources.

But midwives can make a massive difference to women with anorexia. Anorexic mums can worry terribly about how they’ll adjust to parenthood, and need a ‘professional friend’ to support them .

There are also long term issues for their babies. We know from studies on famine that undernourished, stressed mothers can pass on effects like increased anxiety, and lower cognitive function, to the next two generations.

 

Midwives can make a massive difference to generations, just by getting care right for one anorexic mum.

Midwives are often in a good place to pick up on these issues for the first time. Young women who have anorexia can often avoid healthcare, for fear of having the illness discovered.

Paris had a BMI of about 17.5, but for 12 hours or so she had all of us believing that she had no history of eating disorders. She was confident, and easy to chat to, and until I read she had been hospitalised for an eating disorder before, I’d never have believed it.

So what are the important things to remember when looking after someone with anorexia?

We need to consider:

• Making sure it’s as easy as possible for women to disclose an eating disorder by building a good relationship with them
• Asking the mental health screening questions sensitively
• Referring women to psychiatric services, so they can get the help they need, which might include cognitive behavioural and self help strategies

• Thinking through whether women should get the full whack of 5mg (5000mcg) folic acid in early pregnancy, to prevent problems like spina bifida. The normal dose is 400 mcg, and the higher dose  is usually reserved for women who have medical conditions like epilepsy, the treatment of which can cause poor folic acid absorption
• Supplements for micronutrients
• Asking the medical team about more frequent growth scans
• Making a birth plan that reduces anxiety

And postnatally:

• Support breastfeeding - there’s not that much evidence about  maternal nutrition affecting breast milk. Women in famine zones can breastfeed well, it’s likely not a problem
• Some studies say anorexic women tend to breastfeed for longer, some say shorter; reassurance is key because they are sometimes distressed by normal hungry baby cries!
• There’s the highest chance of depression and relapse postnatally, so midwives need to be on the ball and get in touch with psychiatric services if necessary
• Watch carefully, and also assess whether mum is bonding with baby well (because of the possible depression)

The good news is during pregnancy between 30-70% of women with anorexia go into remission. This is usually because they feel able to ‘eat for the baby’.

Paris fell into this category once her hyperemesis was over and done with. She had a history of preterm labour and had to be admitted from 28 weeks with a 3cm open cervix. We kept a close eye on her, and she gained weight nicely, though she declined to give up smoking.

She seemed well adjusted, but unfortunately did go on to have her baby at 32 weeks. She then came in and out of the hospital so she could look after her 2 year old as well as her premature baby in neonatal, and last I heard, she want home happily without relapse.

 

Women with anorexia are often so undernourished they stop having periods, so are considered infertile. That might be why there’s so little guidance for anorexia in pregnancy.

But the research I'm reading suggests anorexic women are more likely to have unplanned pregnancies. So even though anorexics don’t get pregnant all that often, once they are pregnant their care can fall through the net, especially if they haven’t been diagnosed.

And until recently, maternal suicide was a leading cause of maternal death, it’s important to have good links with psychiatric services and have a good idea of what to do if a woman with a small BMI, who seems worried about becoming a mum, and anxious about food comes to your booking clinic.

I hope you found that info useful! I’d love to hear from you - have you looked after an anorexic client in pregnancy? I’d love to hear your tips for supporting these women. Midwives learn from story telling, and your thoughts might be just what someone needs to hear to give someone excellent care.

I hope whatever you're up to at the moment in practice, studying to be a midwife, or as part of your application it's going well and you stay inspired in this kind of highly valued maternity care. I hope you also have time to have fun in your own life and take care of you and your family, because we all know that supporting maternal mental health can be tough on us as well.

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