Self-objectification during the perinatal period: The role of body surveillance in maternal and infant wellbeing

Pregnancy represents a unique time during which women’s bodies undergo significant physical changes (e.g., expanding belly, larger breasts, weight gain) that can elicit increased objectification. Experiences of objectification set the stage for women to view themselves as sexual objects (i.e., self-objectification) and is associated with adverse mental health outcomes. Although women may experience heightened self-objectification and behavioral consequences (such as body surveillance) due to the objectification of pregnant bodies in Western cultures, there are remarkably few studies examining objectification theory among women during the perinatal period. The present study investigated the impact of body surveillance, a consequence of self-objectification, on maternal mental health, mother-infant bonding, and infant socioemotional outcomes in a sample of 159 women navigating pregnancy and postpartum. Utilizing a serial mediation model, we found that mothers who endorsed higher levels of body surveillance during pregnancy reported more depressive symptoms and body dissatisfaction, which were associated with greater impairments in mother-infant bonding following childbirth and more infant socioemotional dysfunction at 1-year postpartum. Maternal prenatal depressive symptoms emerged as a unique mechanism through which body surveillance predicted bonding impairments and subsequent infant outcomes. Results highlight the critical need for early intervention efforts that not only target general depression, but also promote body functionality and acceptance over the Western “thin ideal” of attractiveness among expecting mothers.


Introduction
Self-objecti cation-seeing the self as a sexual object-has been recognized as an important contributor to women's mental health since the phenomenon was formally introduced to the psychological literature in the form of objecti cation theory two and a half decades ago (Fredrickson & Roberts, 1997;Roberts et al., 2018). According to this framework, by living in a culture in which women are commonly reduced to their bodily appearance, women learn to view their bodies from a third person's perspective (i.e., selfobjectify, Fredrickson & Roberts, 1997)  Self-objecti cation and its behavioral consequences, such as body surveillance, set the stage for adverse mental health outcomes that disproportionately affect women (e.g., anxiety, depression, eating disorders;  Herba et al., 2016). The current study presents a novel conceptual framework in which self-objecti cation, as manifested by persistent body surveillance, is signi cantly linked to maternal mental health during pregnancy (i.e., body dissatisfaction, depression) and undermines infant socioemotional functioning through impaired mother-infant bonding following childbirth.
Despite growing evidence that body surveillance in mothers and associated mental health consequences (e.g., depression, body dissatisfaction) may negatively impact children, comparatively less is known about the impact of body surveillance on infant socioemotional functioning. Thus, we extend these considerations to examine whether body surveillance impacts not only maternal mental health, but also infants by undermining mother-infant bonding following childbirth. We posit that increased body surveillance, resulting from a culture that persistently objecti es women's bodies, is linked to maternal mental health concerns and the likelihood that mothers experience di culties bonding with their infants.

Body Surveillance and Body Dissatisfaction During Pregnancy
Research on body dissatisfaction during pregnancy has demonstrated mixed ndings (Coker &  physically capable of -nurturing and supporting a developing fetus (Rubin & Steinberg, 2011). This appreciation of body functionality, in turn, may buffer against distress related to the rapid physical changes that occur across pregnancy and postpartum (Clark et al., 2009). Alternatively, some pregnant women might be more susceptible to societal pressures around their bodies and continue to hold their bodies to unrealistic beauty standards, focusing more on body image than functionality (Johnson et al., 2004). For instance, some mothers may aspire to gain minimal gestational weight and to return to their pre-pregnancy gure, or "bounce back," quickly after childbirth (Watson et al., 2015). Perceived sociocultural pressure to remain thin is associated with maternal distress and body dissatisfaction during pregnancy and the postpartum (Dryer et al., 2020;Fuller-Tyszkiewicz et al., 2013;Kamysheva et al., 2008;Lovering et al., 2018). Further, gaining less than the recommended amount of weight during pregnancy is associated with higher risk of preterm birth and low birthweight (Han et al., 2011), which predict selfregulatory di culties as early as infancy (Arpi & Ferrari, 2013).

Body Surveillance and Depression During Pregnancy
Body surveillance is associated with higher levels of depressive symptoms during the perinatal period Rubin & Steinberg, 2011). These associations are alarming given that pregnant women are already at increased risk for depression during the perinatal period, with one in ve women endorsing depressive symptoms across pregnancy and postpartum (Underwood et al., 2016;Woolhouse et al., 2015). In the United States, over half of women with perinatal depression go undetected, undiagnosed, and untreated for this condition (Cox et al., 2016). This represents a signi cant public health burden given that antenatal depression contributes to the proliferation of a range of mental health concerns in both parents and children (Hentges et Goodman & Gotlib, 1999;Szekely et al., 2021). Indeed, perinatal depression predicts socioemotional di culties (e.g., crying for long periods of time) as early as infancy (Field, 2017;Porter et al., 2019). Mother-infant bonding (i.e., the emotional tie between mother and infant; Bicking Kinsey & Hupcey, 2013), is a salient mechanism through which depression can undermine child functioning (Lefkovics et al., 2014;Slomian et al., 2019). In particular, bonding during the rst 6 months postpartum is critical to infant socioemotional development, as infants largely depend on their caregivers to regulate their emotions (Rosenblum et al., 2009), and early mother-infant bonding impairments predict infant socioemotional di culties as early as 6-months postpartum . Women who report higher levels of depression during and after pregnancy tend to demonstrate greater impairments in mother-infant bonding (Moehler et al., 2006;Nonnenmacher et al., 2016;O'Higgins et al., 2013), and research suggests that negative cognitions associated with perinatal depression may undermine maternal motivation to bond with the infant following childbirth (Muzik & Borovska, 2011).
Although maternal depression is a robust predictor of bonding impairments and associated infant maladjustment, researchers also posit that body dissatisfaction during pregnancy impacts mothers' developing bonds with their infants and, subsequently, child socioemotional functioning (Bergmeier et al., 2020). Indeed, the physical changes that occur over the course of pregnancy-and how these changes are perceived and experienced-represent one of the rst ways in which mothers interact with their babies. Women who embrace the bodily changes associated with pregnancy may be more likely to engage emotionally with their babies prior to childbirth, whereas women who feel negatively about these changes and experience greater body dissatisfaction may face more bonding di culties (Kirk & Preston, 2019). Further, some women may experience a loss of agency and control over their own bodies during pregnancy (Kinloch & Jaworska, 2021). This perceived loss of control, which is associated with maternal distress (Hodgkinson et al., 2014), might also interfere with antenatal attachment.

The Present Study
Objecti cation theory would suggest that women may be at heightened risk for self-objecti cation during pregnancy, which can compromise their mental health, and past research suggests a robust link between maternal mental health and bonding di culties. Taken together, this work suggests that elevations in self-objecti cation and its correlates (e.g., body surveillance, body dissatisfaction, depression) during pregnancy might ultimately undermine healthy infant socioemotional development. Building on recent work applying objecti cation theory to motherhood (e.g., Beech et al., 2020), we present a novel conceptual framework (see Fig. 1) in which mothers who report greater body surveillance during pregnancy-a marker of self-objecti cation-experience higher levels of prenatal depressive symptoms and body dissatisfaction that, in turn, uniquely predict greater mother-infant bonding impairments following childbirth, thereby undermining infant socioemotional functioning at age 1. An integration of research and theory in the areas of objecti cation and maternal-infant health has the potential to impact both maternal and infant wellbeing by identifying largely overlooked intervention targets during pregnancy (i.e., body surveillance and body dissatisfaction) that arise as a consequence of living in a culture of persistent objecti cation.

Participants and Procedures
The present study is part of a multi-method, longitudinal study examining how couples navigate the transition from pregnancy to postpartum; thus, participants also completed other procedures beyond the scope of the present study. All participants identi ed as cisgender upon study entry. Most women were in the second (38.4%) or third (58.5%) trimester of pregnancy. On average, there was one child living at home during pregnancy (SD = 1.18); more than half of women (57.9%) had no children and were experiencing the transition into parenthood for the rst time. The majority of women were married (84.9%). Annual household income ranged from less than $9,999 to more than $90,000, with a median household income of $60,000 to $69,999. Nearly half (47.8%) reported earning $50,000 to 59,999 or less which converges with federal guidelines for de ning low-income status (Roberts et al., 2012). Re ecting the Midwestern region where the study was conducted, women were primarily White (89.3%), and 9.4% identi ed as Hispanic or Latina. On average, women were 28.67 years of age (SD = 4.27), and most women were employed at least 16 hours per week (74.2%). Modal education was a bachelor's degree (46.5%). During follow-up assessments, it was determined that one infant was diagnosed with trisomy 21, and one mother experienced a miscarriage. As such, those families were excluded from analyses to focus on women with typically developing infants (50% male) for a nal sample of 157 perinatal women.
There were four waves of data collection spanning February 2016 to April 2019. To address the aims of the present study, we assessed body surveillance, body dissatisfaction, and depressive symptoms using self-report questionnaires administered to mothers during the appointment. We assessed mother-infant bonding at 1-month postpartum (M = 1.12 months, SD = 0.29) and 6-months postpartum (M = 6.32 months, SD = 0.36) using a self-report questionnaire. Additionally, when the infant turned 1year of age (M = 12.80 months, SD = 0.76), both parents reported on infant socioemotional dysfunction. All procedures were approved by the University of Nebraska-Lincoln Institutional Review Board.

Measures During Pregnancy
Body Surveillance. The Body Surveillance subscale of the Objecti ed Body Consciousness Scale (OBCS, (McKinley & Hyde, 1996) was used to assess body surveillance, an important manifestation of selfobjecti cation. During pregnancy, mothers rated the degree to which they persistently monitored their bodily appearance on a scale from one (strongly disagree) to six (strongly agree), with a not applicable option (coded as missing) for items that did not apply. The Body Surveillance subscale contains 8 items, including "During the day, I think about how I look many times" and "I rarely worry about how I look to other people" (reverse coded). Items were averaged with higher scores indicating more body surveillance (Cronbach's α = .85).
Depression. Maternal depressive symptoms were assessed using the General Depression subscale of the Inventory of Depression and Anxiety Symptoms (IDAS-II; Watson et al., 2012). The IDAS-II is a 99-item self-report questionnaire designed to assess general and speci c symptom dimensions of depression and related anxiety disorders. Participants rated their feelings and experiences during the past two weeks on a scale from 1 (not at all) to 5 (extremely). The general depression subscale consists of 20 items (e.g., "I felt inadequate," "I felt discouraged about things"), with possible scores ranging from 20 to 100 (Cronbach's α = 0.84).
Body Dissatisfaction. The Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013Forbush et al., , 2014) was used to assess body dissatisfaction reported by mothers during pregnancy. The EPSI is a factor analytically derived scale of eating disorder (ED) symptoms. The Body Dissatisfaction subscale consists of 7 items (e.g., "I did not like how clothes t the shape of my body," "I wished the shape of my body was different") and captures the higher-order, shared dimension among ED symptoms. Participants rated how frequently each statement applied to them during the past month on a scale from 0 (never) to 4 (very often). Items responses were summed, with possible scores ranging from 0 to 28 (Cronbach's α = 0.88).

Measures At 1-And 6-months Postpartum
Impaired Mother-Infant Bonding. Postpartum mother-infant bonding was assessed using the Postpartum Bonding Questionnaire (PBQ; Brockington et al. 2001). The PBQ is a 25-item, factor-analytically derived, parent-report measure of a parent's feelings or attitudes toward their baby. The PBQ assesses impaired bonding, rejection and anger, anxiety about care, and risk of abuse, represented as four subscales that can be summed for a total score. Participants rated their agreement with a series of statements on a 6point Likert scale. Positive responses (e.g., "I feel close to my baby") were scored from 0 (always) to 5 (never), while negative responses (e.g., "My baby irritates me") were scored from 0 (never) to 5 (always). Items were summed to generate a total score, with low scores denoting good bonding and high scores indicating impaired bonding. Scores at 1-and 6-months postpartum were internally consistent (Cronbach's α = 0.88 at 1 month and Cronbach's α = 0.86 at 6 months). Scores at each time point were highly correlated (r = .76, p < .001) and were thus aggregated to provide a robust measure of mother-infant impaired bonding during the rst 6 months postpartum.

Measures At 1-year Postpartum
Infant Socioemotional Dysfunction. The Ages and Stages Questionnaire: Social-Emotional, Second Edition (ASQ:SE-2; (Squires et al., 2015) was used to assess socioemotional dysfunction when the infant turned one year of age. Participants reported how frequently their infant had engaged in a series of behaviors (e.g., "Smiles at you and family members?", "Cries for long periods of time?") using the following scale: often or always (score = 1), sometimes (score = 5), and rarely or never (score = 10). They were also asked to indicate if this is a concern (score = 5). Items were aggregated to obtain an overall score ranging from 0 to 345 (reverse coding items that represent competencies), with higher scores indicating greater infant socioemotional dysfunction. The correlation between maternal and paternal reports was signi cant (r = .33, p < .001). Therefore, scores were aggregated to obtain a score of infant socioemotional dysfunction based on multiple parental reports to produce a less biased and more reliable estimate (Lengua et al., 2008). The ASQ:SE-2 has demonstrated good reliability and validity, and there was adequate internal consistency in the present sample (Cronbach's α = .71).

Data Analytic Plan
We tested a series of mediation models in Mplus 8.0. (Muthén & Muthén, 2010). Missing data were addressed with full information maximum likelihood estimation (covariance coverage ranged from .74 to 1.00), which retains all participants and is preferred over more traditional approaches for handling missing data that introduce bias (e.g., pairwise deletion; Enders, 2010). A series of demographic characteristics (e.g., maternal age, relationship duration, rst-time parenthood status, minority racial/ethnic identity, and low-income status) were screened for potential inclusion as control variables. First-time parenthood status was associated with mother-infant bonding and was therefore included as a control. We also controlled for week of pregnancy when the initial assessment occurred to account for differing time intervals between the pregnancy and follow-up assessments across participants.
Mediation models were just-identi ed. To test for mediation, a nonparametric resampling method (biascorrected bootstrap) with 10,000 resamples was performed to derive the 95% con dence intervals for indirect effects (Preacher et al., 2007). Bias-corrected bootstrapped con dence intervals were used to determine signi cance of effects given they are robust to violations of univariate and multivariate normality. Data management and analysis procedures for this project were registered (https://osf.io/hprk8), and we made no deviations from that plan. Because we had prior knowledge of data from this longitudinal study, we did not preregister study hypotheses.

Results
Descriptive statistics and correlations are reported in Table 1. As expected for a community sample, levels of body surveillance, general depression, and body dissatisfaction in mothers during pregnancy were relatively low, as were impairments in bonding during the rst 6 months postpartum and infant socioemotional dysfunction at 1-year postpartum. There was a large correlation between body surveillance and body dissatisfaction during pregnancy (r = .54, p < .001), as well as a moderate correlation between body surveillance and general depression (r = .30, p < .001). Body surveillance in mothers was signi cantly correlated with impaired bonding during the rst 6 months postpartum (r = .16, p < .05). There was a moderate correlation between general depression and body dissatisfaction during pregnancy (r = .34, p < .001). Small but signi cant correlations between general depression and impaired bonding (r = .26, p < .001) and between body dissatisfaction and impaired bonding (r = .23, p < .01) emerged. Last, impaired bonding was associated with greater infant socioemotional di culties (r = .21, p < .01).

Mediation Model With General Depression As Critical Mediator
First, we tested a serial mediation model with body surveillance → general depression → impaired mother-infant bonding → infant socioemotional dysfunction. Full model results are reported in Table 2 and Fig. 2a

Mediation Model With Body Dissatisfaction As Critical Mediator
Next, we tested a serial mediation model with body surveillance → body dissatisfaction → impaired mother-infant bonding → infant socioemotional dysfunction. Full model results are reported in Table 2 and Fig. 2b

Integrated Model With Depression And Body Dissatisfaction As Parallel Mediators
Finally, we tested an integrated model with general depression and body dissatisfaction as parallel mediators in a larger serial mediation model. We covaried the residuals of general depression and body dissatisfaction as they are both dimensions of maternal mental health. Full model results are reported in Notably, when controlling for depression, body dissatisfaction was no longer a signi cant mechanism through which body surveillance impacted mother-infant bonding and infant socioemotional dysfunction.

Discussion
Living in a culture of persistent objecti cation, women may self-objectify and experience societal pressure to modify their bodies to achieve the thin ideal. During pregnancy, a period in which the body undergoes rapid changes to support fetal development, women who have internalized these messages and engage in more body surveillance may be at increased risk for negative mental health consequences, theory in the areas of objecti cation and maternal-infant health, we found support for a novel conceptual framework in which self-objecti cation during pregnancy, as manifested by body surveillance, contributes to impaired mother-infant bonding and infant socioemotional functioning at 1-year postpartum through maternal mental health di culties during pregnancy (i.e., body dissatisfaction and depression).
Speci cally, we found that mothers who endorsed higher levels of body surveillance also reported higher levels of depressive symptoms and body dissatisfaction during pregnancy. In turn, depressive symptoms and body dissatisfaction were associated with greater mother-infant bonding impairments during the 6 months following childbirth, which contributed to subsequent infant socioemotional dysfunction at 1year postpartum (i.e., di culties self-soothing, feeding, and sleeping).
When examining maternal depressive symptoms and body dissatisfaction during pregnancy as parallel mechanisms, results suggested that maternal depressive symptoms uniquely contribute to bonding impairments and subsequent maladjustment. Thus, maternal prenatal depression, which was moderately correlated with body dissatisfaction, might be a particularly salient pathway through which body surveillance undermines bonding and infant development. A potential explanation for this nding is that body dissatisfaction during pregnancy could be a prodromal symptom of an underlying mood disorder (Chan et

Limitations And Future Research Directions
It is important to acknowledge that the sample was comprised of women in committed relationships with men; participants also primarily identi ed as White and were from middle-class backgrounds, thereby limiting the generalizability of the results. There is a need for research examining objecti cation theory among more diverse populations (e.g., among sexual, gender, and racial minorities). For example, people of color, as well as sexual and gender minorities, experience unique forms of objecti cation, such as racialized sexual objecti cation and body policing (Flores et al., 2018). These additional forms of objecti cation may place pregnant people at even greater risk for self-objecti cation and related adverse mental health outcomes. There is also increasing recognition that researchers and clinicians alike must There were also limitations to our measurement approach. First, while the present work examined body surveillance as a manifestation of self-objecti cation and downstream consequences identi ed by objecti cation theory (e.g., body dissatisfaction, depression, Roberts et al., 2018) as well as novel consequences (e.g., infant outcomes), some aspects of the objecti cation model remain untested in pregnant women. We did not measure speci c types of objecti cation that pregnant women may experience, such as objecti cation directed at their size and shape (e.g., because their bodies no longer conform to feminine ideals of thinness) or involving denial of autonomy and subjectivity (e.g., because their bodies become public property). Relatedly, we only included one indicator of self-objecti cation. Second, our measure of body dissatisfaction was not speci cally designed for pregnancy and therefore may not capture speci c appearance-related concerns associated with pregnancy (e.g., stretch marks, having a prototypical "baby bump"). Future research should consider newly developed measures, such as the Body Understanding Measure for Pregnancy Scale (BUMPs; Kirk & Preston, 2019) or the Body Experience during Pregnancy Scale (BEPS; Talmon & Ginzburg, 2018), that measure other facets of the body experience during pregnancy (e.g., body agency, estrangement, and visibility; satisfaction with appearing pregnant; weight gain concerns; physical burdens of pregnancy). Third, all data were collected using self-report questionnaires, raising the possibility of shared method bias. Although most objecti cation research has relied on self-report measures, there is increasing evidence that innovative approaches, such as eye tracking technology, can be utilized to assess the objectifying gaze, which may Broader dissemination of campaigns of this nature has the potential to promote maternal well-being. Finally, emerging evidence suggests that social media can be leveraged for the delivery of brief interventions to improve maternal body image and wellbeing (Wallis et al., 2021).
Unfortunately, societal change is slow, and objecti cation continues to manifest in ways that justify the patriarchy despite collective advances (Roberts et al., 2018). Therefore, beyond broad prevention efforts, there is also a need for targeted interventions informed by careful screening. Providers who interact regularly with pregnant women (e.g., obstetricians, nurses, midwives) could screen for elevations in body surveillance and associated body dissatisfaction and, when indicated, deliver brief interventions to disrupt self-objecti cation by promoting embodiment, which emphasizes positive self-talk, body functionality and agency, and experiencing the body from a subjective position rather than viewing themselves as sexual objects (Piran, 2017). It is critical that providers avoid protective paternalism and benevolent sexism discourses (e.g., restricting women's behaviors during pregnancy to protect the fetus;

Conclusion
The present study demonstrated that body surveillance during pregnancy impacts infant socioemotional functioning at 1-year postpartum through increased prenatal depressive symptoms and body dissatisfaction and impaired mother-bonding during the 6 months following childbirth. Further, results suggested that maternal depressive symptoms may uniquely contribute to bonding impairments and subsequent child outcomes. This work expands on the limited body of research applying objecti cation theory to the experience of pregnancy and childbirth and supports a novel conceptual framework within which maternal self-objecti cation, manifested as body surveillance during pregnancy, impacts infant development as early as 1-year postpartum. Results highlight the potential utility of prenatal interventions guided by objecti cation theory to reduce the consequences of sexual objecti cation on mothers and their children.