1. Introduction
Weight stigma (WS), also called weight bias and weight discrimination, refers to the discrimination, stereotyping, and social exclusion based on one’s weight [
1]. It can be classified into three types: experienced WS, perceived WS (PWS), and internalized WS (or weight-related self-stigma). Experienced stigma occurs when someone has experienced bias directed at them. The person may be aware that this bias happened due to their weight and as a result develop a perceived WS. When the person accepts and endorses weight stigma and believes that negative weight-based bias applies to themselves, internalized WS happens [
2].
PWS has previously been used to refer to both experienced and perceived WS [
2]. Rarely are perceived and experienced WS expressly differentiated. PWS could refer to both perceived and experienced WS, although weight-related self-stigma is different from the other two categories of WS (PWS and experienced stigma), according to a recent systematic review and meta-analysis [
3]. In accordance with previous conclusions [
2,
3], we utilized PWS in our investigation to refer to both actual and perceived WS.
WS has become a serious public health issue. It has been reported that the prevalence of internalized WS and PWS in adults is as high as 44–57% (Saudi Arabia 46.4% [
4], United States 44% [
5] and 57% [
6]) or as low as 4.6–11% (Germany 7.3% [
7], United States 11% [
8], and the United Kingdom 4.6% [
9]). This suggests that WS is prevalent globally. More importantly, the prevalence is rapidly increasing. A longitudinal survey in 2008 showed that from 1995 to 2006, the rate of WS in the United States increased by 66%, and it increased more rapidly among women (55%) than in men (23%) [
10]. In a recent systematic review, psychological distress was recognized as a result of WS, including lowered self-esteem, anxiety, and depression [
11]. Moreover, the emotional toll of WS has been documented to lower adult quality of life [
12]. Behavioral effects are another consequence of WS. Adults who are subjected to WS, for instance, are less inclined to exercise, have lower levels of self-efficacy, and are more likely to binge eat [
13,
14]. Physiological effects of WS have also been confirmed, particularly regarding cortisol levels. In the presence of WS, the physiological stress response is triggered, resulting in the release of cortisol, which then contributes to fat storage and unhealthy eating behaviors [
15,
16].
Natural weight fluctuations, societal views of an “ideal” postpartum body image, and the pressure to quickly “bounce back” after birth to a pre-pregnancy body image make the postpartum period a particularly unique and vulnerable time [
17], and women are more susceptible to the effects of WS during this time. To make matters worse, the infant may also be impacted by maternal WS. WS may discourage women from breastfeeding [
18]. It is also possible to influence cortisol levels in the child by affecting the mother’s cortisol secretion, promoting the same cortisol-related effects on eating and weight in the child [
19].
To date, it appears that although postpartum women’s WS might be a common problem, it remains and underreported problem. Limited studies have examined the prevalence and average level of WS among postpartum women in the US. A US study of 358 postpartum women reported that almost one in five women (
n = 63) reported experiencing varying degrees of WS by providers in the medical setting [
18]. A prospective longitudinal study in the US involving 103 women showed that the mean Weight Bias Internalization Scale (WBIS) score for postpartum women was 26.86 ± 13.03 (Scores range from 11 to 77) [
20].
To improve Chinese women’s postpartum health and prevent the detrimental effects of WS, a detailed understanding of WS is required. According to cultural customs, to promote the health of mothers and babies after childbirth and during lactation, women in China have a “confinement in childbirth” during puerperium. This includes moving less, eating fewer fruits and vegetables, and drinking brown sugar water and a variety of nutritious soups [
21]. It is important that women have a large body for postpartum bodily functions such as breastfeeding, and body image is rarely considered [
22]. However, in recent years, the social trend of “thinness equals beauty” has become increasingly popular in China. Recent studies show that Chinese women have a very negative view of their body and a high level of endorsement of the thin ideal [
23]. Postpartum women in China, who are situated between the rapidly changing traditional and modernized worlds, may experience internal uncertainty and identity crises, which in turn may have a negative impact on them. Therefore, research is necessary to better understand the current status of weight stigma and associated factors among postpartum women in China.
The purpose of our study was three-fold: (1) investigate the prevalence of WS (including internalized WS and PWS) among postpartum women in China, (2) understand sociodemographic factors that put postpartum women at risk for WS, and (3) understand the relationship between psychological distress and WS among postpartum women in China.
2. Methods
2.1. Design and Participants
This is a cross-sectional study. A convenience sampling method was used to recruit participants from the waiting rooms of a maternal and child health hospital and four community health centers during postpartum visits from December 2021 to March 2022. Women who were met the inclusion criteria and willing to participate in this study completed the questionnaires in a demonstration room under the guidance of trained research staff. It took 10–15 min to complete a questionnaire, which was collected by the researcher on site.
For participants, the inclusion criteria were as follows: (1) ≥18 years; (2) within 12 months postpartum; (3) able to speak and read Chinese fluently and thus independently complete this survey; and (4) willing study participants. People with a history of significant mental or physical health disorders such as developmental delay, or cognitive disorders were excluded.
The planned sample size was determined based on the findings of comparable surveys conducted in other countries [
20]. With a confidence level (1 − α = 0.95), permissible error (
δ = 1.2) and response rate of the survey (95%), the required sample size was calculated to be 477 cases using PASS 11.0. A total of 530 postpartum women participated in the survey; 23 surveys were excluded due to incomplete questionnaires (more than 20% of the entire questionnaire incomplete) and missing important information such as height and weight. A total of 507 valid questionnaires were obtained.
2.2. Variables and Measures
2.2.1. Sociodemographic Factors, and Anthropometric Information
An author-designed questionnaire was prepared to collect the participants’ sociodemographic and anthropometric data. Specifically, the sociodemographic questions include age, ethnicity, educational levels, profession, income, and living conditions (living alone, living with spouse/children, living with parents/grandparents, and other). Anthropometric questions include weight (kg) and height (cm). A portable height and weight meter was used to gauge the participants’ height and weight. Body mass index (BMI; kg/m
2) was calculated based on height and weight, and participants’ weight status was then classified with Chinese classification as underweight (BMI < 18.5 kg/m
2), normal weight (18.5 ≤ BMI < 24.0 kg/m
2), overweight (24.0 ≤ BMI < 28.0 kg/m
2), or obese (BMI ≥28 kg/m
2) [
24].
2.2.2. Perceived WS Questionnaire (PWS)
The PWS is a self-reported questionnaire that tracks perceptions of experiences with weight-based stigmatization. The scale uses 10 dichotomous items with a total score of 10. Items are scored as “yes” or “no”, with a score of 1 for “yes” and a score of 0 for “no”. Participants answered either yes or no on whether they had the described experience and feelings within the last week. A higher total score on the PWS indicates a higher level of perceived WS. The Chinese version of the PWS has been validated with Chinese university students and its internal consistency is acceptable (Cronbach’s alpha = 0.84) [
25]. In the present study, PWS also showed good internal consistency with Cronbach α equaling 0.80.
2.2.3. Weight Bias Internalization Scale (WBIS)
The WBIS consists of 11 items with a Likert scale rating of 1 (strongly disagree) to 5 (strongly agree). After reverse coding two item scores (items 1 and 9), the sum of the 11 item scores—which can reach a maximum of 55—represents the degree of internalized weight bias; a higher score denotes a higher level of internalization. “I hate my overweight” is an example item for the WBIS. The English version of the WBIS has shown good internal consistency (Cronbach’s α = 0.90) [
26]. The original English version of the WBIS was translated into Chinese and now uses “weight” to replace “overweight”. For example, the sample item above is “I hate my weight” in the Chinese WBIS. The Chinese version showed good internal consistency in a study examining the psychometric properties of the WBIS using samples of Chinese children and adolescents [
27]. In the present study, WBIS showed good internal consistency with Cronbach α equaling 0.90. For WBIS scores, there are no specified thresholds. The mean in this study was 25.50 ± 9.26, and we utilized that as our cutoff point and considered those who scored more than that to have a high level of weight biased internalization.
2.2.4. Depression Anxiety Stress Scale-21 (DASS-21)
The 21-item DASS-21 was used to measure maternal psychological status. Depression (7 items), anxiety (7 items), and stress (7 items) are three distinct types of psychological distress assessed by the DASS-21 [
27]. The scale uses a four-point Likert scale to evaluate each item (0 being not at all, and 3 being very much). The sum of the item scores multiplied by two can be used to generate the three subscale scores, with larger scores denoting higher degrees of psychological distress. Depression cutoffs are 10–13 (mild), 14–20 (moderate), 21–27 (severe), and over 28 (extremely severe); anxiety cutoffs are 8–9 (mild), 10–14 (moderate), 15–19 (severe), and over 20 (extremely severe); and stress cutoffs are 15–18 (mild), 19–25 (moderate), 26–33 (severe), and over 34 (extremely severe) [
28]. The DASS-21’s psychometric properties have been extensively researched and found to be robust [
29]. The Chinese version of the DASS has good internal consistency indices (Cronbach’s alpha) of 0.83, 0.80, and 0.82 for the depression, anxiety, and stress subscales, respectively, and 0.92 for the total DASS total [
30].
2.3. Statistical Analysis
SPSS 26.0 software (IBM SPSS Inc., Chicago, IL, USA) was used to analyze the data. Categorical variables in socio-demography, psychological distress, PWS, and internalized WS were summarized as frequency counts (percentages), where continuous variables were summarized as means, standard deviations, and ranges. According to the Kolmogorov–Smirnov criteria, the total scores of the PWS and WBIS were not normally distributed. Therefore, the Mann–Whitney U non-parametric test (for 2-level variables, such as marital status) or the Kruskal–Wallis non-parametric test (for variables with 3 or more levels, such as occupation) was used to determine the association between postpartum women’s sociodemographic characteristics and WS (including internalized WS and PWS). Then, Spearman’s analysis was used to examine the correlation between PWS, internalized WS, and psychological distress. Variables that were statistically significant in the bivariate analysis were included in the multivariate analysis. Multiple linear regression (with input regression variable selection) was used to explore the major factors affecting perceived and internalized WS among postpartum women. Level of significance was set at p < 0.05 (two-tailed).
2.4. Ethical Considerations
Prior to recruitment, ethical approval for this study was obtained from the Ethics Committee of the School of Nursing, Central South University (Approval no. E2021108). Before the investigation, participants were informed about this study, the voluntary and anonymous nature of participation, and that the study would not cause harm to participants. Verbal and written consent was obtained. All collected data was kept confidential, and only researchers had access to the database’s encrypted data.
5. Conclusions
Our study suggests a high prevalence of WS (including internalized WS and PWS) among postpartum women in China. Additionally, almost four-fifths of postpartum women in this study experienced moderate-to-high internalized WS. High internalized WS was associated with living alone, higher BMI, higher PWS, and anxiety. In addition, high perceived WS was associated with having a low income, an occupation as a worker or farmer, stress, depression, and high WBI. In the future, we need to conduct longitudinal studies to explore the causal relationships of these associated factors. Additionally, we need to develop targeted intervention programs to provide comprehensive interventions for the postpartum population in China to reduce the prevalence of WS and its negative impact on maternal outcomes.