A cross-sectional, survey-based investigation was conducted among in Saudi Arabia from April to June 2023.

The survey targeted pregnant women living in all regions of Saudi Arabia, aged 18 years or older, irrespective of nationality (both Saudi and non-Saudi), and encompassing all pregnancy trimesters. Women under the age of 18 years old or those who refused to participate were excluded from the study.

Saudi Arabia is divided into 13 regions. Each region was assigned a team of data collectors to ensure representativeness and consistent inclusion across all regions. Based on the latest population census at the time of data collection, the estimated number of pregnant women annually ranged between 200,000 and 280,000. We used the number 240,000 as the total population estimate. The required sample size was estimated using a sample size calculator, assuming a 95% confidence level, a margin of error of $\pm$ 5%, a total population size of 240,000, and a supposed prevalence of 50%. The minimum required sample size was 385. However, to enhance accuracy, we conducted interviews with 651 participants. Interested participants were directed to an online survey platform to complete the survey until the total sample size was reached.

The survey instrument consisted of three sections: (1) demographic and clinical data; (2) the Body Image Questionnaire; and (3) the Rosenberg Self-esteem Scale (RSES).

(1) Demographic and clinical data included participants’ age group, nationality, residency, number of pregnancies, number of births, duration of marriage, educational level, employment status, family income, smoking habits, psychological disorders, medical history, and pregnancy trimester.

(2) The Body Image Questionnaire is a 19-item instrument designed to assess individuals’ perceptions and attitudes towards their bodies [29]. Each item on the questionnaire features two opposing descriptors, one positive and one negative, reflecting different aspects of body image. The scoring system for each item ranges from 1 to 5 and is structured to capture the respondent’s inclination towards the negative (1 = very much/often and 2 = fairly/fairly often), neutral (3 = in between/neither one), or positive (4 = fairly/fairly often and 5 = very much/often) end of the spectrum. For instance, the first item contrasts “bad health” with “healthy”, allowing respondents to rate their health perception on a scale from negative to positive. The total score is calculated by summing the scores of all items, thus ranging from 19 to 95, with a higher score indicating greater body satisfaction.

(3) The RSES is a 10-item tool designed and validated to measure an individual’s self-worth or self-esteem through a series of statements related to overall feelings of self-value and self-acceptance [30]. The ten items of the scale are answered on a Likert scale ranging from “strongly agree” to “strongly disagree”, where “strongly agree” is scored as 1, “agree” as 2, “disagree” as 3, and “strongly disagree” as 4. Items 2, 5, 6, 8, and 9 are reverse scored, meaning their scoring order is inverted. The total score is calculated by summing the points from all ten items, with the final scores maintained on a continuous scale (range: 10–40). A higher total score reflects higher self-esteem.

Both the Body Image Questionnare and the RSES are validated tools. They were both available in English and were translated by the researchers who were bilingiual. A bi-directoinal translation was done. Authors RAG and KAG translated the questionnaires from English to Arabic. Authors SSO and SJA then translated them back from Arabic to English to ensure consistency of meaning.

The survey was conducted online between 5 April 2023, to 13 June 2023. An initial phase involved pilot testing the survey questions to evaluate their clarity and acceptability among the targeted population. Following the final validation of the questionnaire, the authors assigned a team of data collectors to each region. Data collectors underwent training to effectively reach their target population, which consisted of pregnant women in the region. They were instructed in disseminating surveys through popular social media platforms such as WhatsApp, Twitter, and Facebook, focusing on the most active groups within each respective region. Furthermore, to improve participation rates and ensure data validity, strategies such as periodic survey response checks and data cleaning procedures were implemented. These measures aimed to identify and remove incomplete or inconsistent responses, thereby ensuring high-quality data. All respondents provided digital informed consent prior to participation. The questionnaire was administered anonymously, without collecting any identifying information. The respondents were informed that their participation was voluntary, with the option to withdraw at any time without any repercussions. Participants were assured of the confidentiality of their responses, with personal information used solely for research purposes. Confidentiality was maintained throughout the collection, processing, and storage of respondents’ data. Ethical approval was obtained from the King Abdulaziz University Ethics Committee (Reference No. 409-22).

All statistical analyses were performed using Statistical Package for Social Sciences (SPSS, IBM® Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0, Armonk, NY, USA) for Windows. Descriptive statistics, using frequency tables and percentages, were used to present the distributions of the categorical variables. For interval or continuous variables, and means and standard deviations (SDs) were used for statistical analysis and presentation. Cronbach’s alpha coefficient was calculated to analyze the reliability of the scales. Inferantial statistics were conducted to test the hypothesis that body satisfaction and self-esteem are correlated, as well as to examine their correlations with other demographic and clinical variables. Pearson’s correlation coefficient was used to measure the strength and direction of associations between two continuous variables. Independent t-test and one-way analysis of variance (ANOVA) were performed to compare the mean and variance of score variables across the categories of independent variables, as appropriate. Multivariate linear regression was used to analyze the independent factors associated with body image satisfaction score and self-esteem score. Results are presented as linear regression coefficient (B) with 95% confidence intervals (CI). A p-value 0.05 was considered statistically significant.

The survey included 651 complete participations, thereby surpassing the intended target sample size. The age distribution shows a predominant participation from the 20–30 years age group (52.8%), followed by the 31–40 years age group (35.5%), with a smaller representation from those under 20 and over 40. The majority of respondents were of Saudi nationality (91.2%), with a significant portion living in the Eastern (28.4%) and Central (25.3%) regions. Of the total participants, 82.1% had attained a university level of education or higher, 48.8% were housewives, 37% were employed, and 1% were retired. Regarding pregnancy history, a higher number of women reported having one pregnancy (33.2%), with a gradual decrease in the reported number of previous pregnancies. Notably, one-third of the participants reported having no children. All participants were married. The duration of the marriage was 0–5 years for 47% of participants, followed by 6–10 years (27.3%), whereas a minority were married for more than 20 years (4.6%). The distribution across pregnancy trimesters revealed a higher proportion in the 14–27 weeks range (37.6%), followed by 28–40 weeks (31.0%). The vast majority of participants were non-smokers (96%) and reported no psychological (91.4%) or medical (83.3%) comorbidities (Table 1).

Both scales used for this study showed a good reliability. The Cronbach’s alpha for the Body Image Questionnaire was 0.84, while that for the RSES was 0.77. These values indicate strong internal consistency of the tools and validate their adequacy for score calculation.

Partcipant’s body satisfaction scores ranged from 27 (the lowest) to 95 (the highest), with a mean $\pm$ SD of 67 $\pm$ 12.04 out of 95. Smokers exhibited significantly lower body satisfaction scores (p = 0.046), as did participants with psychological disorders (p 0.001), compared to their non-smoking counterparts. Additionally, the presence of a medical comorbidity was associated with lower body satisfaction (p 0.001) (Table 2).

Participants’ self-esteem scores ranged from 14 (the lowest) to 40 (the highest), with a mean $\pm$ SD of 30.8 $\pm$ 4.93 out of 40 for the total sample. Self-esteem scores varied significantly with the duration of marriage, with the highest scores (32.24 $\pm$ 6.13) observed between 16–20 years of mariage, while the lowest scores (30.08 $\pm$ 4.99) were found between 6–10 years of mariage (p = 0.046). There was a positive relationship between income and self-esteem (p = 0.033). Furthermore, self-esteem was higher during the early weeks of pregnancy (1–13 weeks, 31.54 $\pm$ 4.88) but decreased significantly between 28–40 weeks (30.38 $\pm$ 4.77) (p = 0.025). Smoking, psychological problems, and medical issues were associated with lower self-esteem, with p-values of 0.04, 0.001, and 0.003, respectively (Table 3).

In the analysis of correlations between body satisfaction and self-esteem, a significant positive relationship was identified, with a correlation coefficient (r) of 0.597 (p 0.001, N = 651), indicating a strong association at the 0.01 significance level (2-tailed). This finding underscores a substantial link between higher levels of body satisfaction and higher self-esteem among the participants.

In the multivariate linear regression, the Body Image Questionnaire score exhibited independent and negative associations with the presence of psychological disorders (B = –7.50; 95% CI: –10.76, –4.23; p 0.001) and medical comorbidity (B = –4.36; 95% CI: –6.81, –1.91; p = 0.001). Conversely, smoking showed no significance (B = –2.90; 95% CI: –7.50, 1.78; p = 0.227) (Table 4).

Regarding self-esteem, the multivariate model 1 revealed that the RSES was positively associated with education level (B = 0.57; 95% CI: 0.02, 1.12; p = 0.043), whereas it was negatively associated with psychological (B = –2.51; 95% CI: –3.86, –1.16; p 0.001) and medical conditions (B = –1.09; 95% CI: –2.12, –0.07; p = 0.037) independently. Conversely, the model indicated no independent effect of the duration of marriage (p = 0.254), smoking (p = 0.284), family income (p = 0.076), or pregnancy trimester (p = 0.065) on self-esteem. However, this model accounted for only 6% of the variance in self-esteem (R square = 0.060). By incorporating body satisfaction into the model, only Body Image Questionnaire score remained independently associated with self-esteem (B = 0.24; 95% CI: 0.21, 0.26; p 0.001), explaining 37% of the variance (R square = 0.370) (Table 4).

Pregnancy triggers physical changes and weight gain that may negatively impact women’s self-esteem and body image, leading to prevalent body dissatisfaction and an increased risk of impaired mental and physical well-being. The societal pressures surrounding beauty and body weight exacerbate these challenges, though positive body image can be nurtured by balancing maternal roles and embracing physical changes, thereby improving self-esteem. This nationwide, population-based survey explored the dynamic interplay between BIP and self-esteem during pregnancy, within the previously unexplored context of Saudi Arabia. The participants’ demographics revealed a majority in the 20–30 age group, predominantly consisting of Saudi nationals with a high education level. Key findings include a strong positive correlation between body satisfaction and self-esteem, as well as noteworthy associations of psychological disorders, medical comorbidities, and smoking with both constructs. Notably, body satisfaction and self-esteem were independently affected by these factors, with self-esteem additionally associated to education level. This study provides critical insights into the complex interplay between body satisfaction, self-esteem, and various life factors during pregnancy, thereby contributing valuable information within the cultural context of Saudi Arabia.

Overall, the relationship with body image in Saudi society, among both men and women, is transitioning from a conservative, modesty-based perspective to a more body-centered model. This transition is accompanied by an increasing social stigma concerning weight and beauty standards. Additionally, this transition leads to notable intergenerational differences regarding BIP and the influence of related societal pressures [31]. Recent data among young Saudi university females (mean age = 20 years) showed that the “internalization of Western values” is associated with greater body image concerns, as well as related eating disorders and psychological comorbidity [32]. Other recent data among middle-aged Saudi women demonstrate a significant decrease in body image satisfaction with age and educational level, correlating with perceived stress [33]. This suggests that educational level influences body awareness by enhancing the perception of age-related body changes among the new generation of Saudi women.

However, during pregnancy, issues related to body image may be mitigated by local cultural and religious values, including the emphasis on privacy, collective decision-making for maternal and fetal health, the importance of motherhood, and breastfeeding practices [34]. In other words, cultural factors may protect against body dissatisfaction during pregnancy, promoting acceptance and appreciation of the body’s functionality and changes throughout pregnancy [1, 23].

The influence of these cultural aspects might explain the relatively high body satisfaction scores, with a mean score of 67, representing 70.5% of the maximal score. For instance, in Turkey, Uçar et al. [35] developed and implemented the Body Image Concerns during Pregnancy Scale, revealing a total mean (SD) score of approximately 57 out of 115 (50% of the maximum score), indicating relatively lower scores in comparison to the findings of the present study. However, comparing these scores with those of other studies poses difficulties because of the lack of a defined cutoff point for dissatisfaction in the Body Image Questionnaire, as well as the variety of assessment tools used in the literature. Therefore, the majority of the studies in the literature adopted a comparative approach, typically contrasting scores with those of pre-pregnancy periods or nonpregnant women from the same cultural context. For example, a Norwegian study revealed that only 44% and 42.7% of pregnant women expressed satisfaction with their body weight and shape, respectively, representing a 10% decline from satisfaction rates observed before pregnancy [36]. Conversely, a study from the USA, which employed a modified version of the Body Shape Satisfaction Scale, reported a mean score of 32.6 out of 50 among pregnant women, which was significantly higher than the score of nonpregnant women (mean = 29.6) [37].

The influence of cultural aspects may also account for the lack of a significant age effect on body satisfaction and self-esteem among our participants. Although there was a trend towards higher self-esteem with age, it could possibly reflecting the aforementioned intergenerational effect. Another plausible explanation for the lack of a clear generational effect is the nature of the sample, which primarily consists of women of childbearing age. This inherent characteristic of the sample limits the range and impact of age disparities. Conversely, cultural norms and distinct perception of body image during pregnancy may restrict Saudi women’s engagement in physical activity and their adherence to healthy behaviors, as suggested by findings from a recent clinic-based study [38]. Subsequently, low physical activity and unhealthy behaviors can exacerbate gestational weight gain and physical discomfort, further affecting body image and quality of life [39].

Among the factors explored in the present study, we found that smoking was associated with lower body satisfaction scores, whereas psychological and medical comorbidities exhibited an independent negative correlation with body satisfaction. While a negative body image is highly associated with psychiatric comorbidity [21, 40], it is important to interpret our findings with caution due to the self-reported and imprecise nature of the assessment, which relies on a simple, generic self-reported item for each factor. This method, despite its simplicity, lacks precision and is prone to information bias, hindering the determination of its clinical applicability.

In contrast, a study from Turkey showed that a more negative body image was associated with low-income status, intended pregnancy, and a negative attitude towards weight gain from the husband, whereas engagement in physical exercise was associated with higher body satisfaction [41]. One of the modern factors that impact body image during pregnancy is the extent of social media use. A study conducted in Lebanon found that increased social media usage correlated with more negative BIP and conflicted attitudes towards pregnancy body. Paradoxically, it was also found to improve healthy eating habits [42]. The role of self-comparison is key in explaining such correlations [43]. Another significant factor associated with image perception during pregnancy is breastfeeding expectations, since body image dissatisfaction during pregnancy was associated with shorter breastfeeding duration [44]. This would be particularly relevant in the Saudi population, where breastfeeding is a culturally promoted practice.

The health burden associated with body dissatisfaction during pregnancy is well recognized, given its widespread prevalence [17, 18, 19, 20]. It is closely linked to low self-esteem, inadequate health behaviors [45], and various psychiatric morbidity [21, 40].

However, the independent impact of pregnancy on body image satisfaction remains debatable due to inconsistent findings from comparative analyses between pregnant and non-pregnant women. These studies demonstrate a mixed impact, with some indicating negative effects while others suggesting positive effects. This is probably related to the confounding effect of various extrinsic and intrinsic factors, often unexplored, beyond pregnancy-related body changes [28]. Such evidence should be carefully considered in the critical review and interpretation of studies examining this construct, including the present study, especially concerning effective exploration of key moderator variables. Additionally, the variability of instruments used and the extreme diversity of cultural and environmental factors challenge the ability to drawing direct comparisons between studies [28]. Therefore, when examining the trends in the literature, it is important to recognize a growing interest in exploring both negative and positive aspects of body image during pregnancy [28].

Moreover, when addressing body image during pregnancy, healthcare professionals must make a careful distinction between subjective appearance concerns and actual physical impairments, even though there may be a correlation between both [46]. The presence of physical impairements may further confound the association between medical morbidity and body image and self-esteem, as observed in the present study. While this distinction may seem straighforward in theory, identifying it in clinical settings can pose challenes. However, it is crucial for healthcare professionals to make this differentiation in order to develop effective counseling messages and interventions. These interventions should aim to foster acceptance, appreciate bodily functionality, and encourage a positive body perception, while addressing any debilitating physical symptoms. This also underscores the importance of carefully handling body- and weight-focused messages, as they have the potential to negatively impact body perception or may be irrelevant to the specific situation of the patient [37].

In this regard, several authors have proposed new scales to assess body image during pregnancy, aiming to by capture a multitude of dimensions that interfere with body image dissatisfaction specifically during pregnancy [47]. For instance, Watson et al. [48] developed the BIP Scale (BIPS), a 36-item tool capturing 7 dimensions of BIP in the specific context of pregnancy. The multidimensional framework of the BIPS enables the distinction between subjective attitudes towards aesthetic bodily features and functional attributes such as physical strength. It also explores unique dimensions such as “prioritizing physical appearance over bodily function” and “appearance-related behavioral avoidance”. Furthermore, a thorough examination of personal experiences is essential to fully understand what influences pregnant women’s feelings towards their changing bodies and the significant consequences of their bodily experiences. Research in this field should advance towards refined and individualized approaches to assessing and managing body image concerns. This enatils avoiding the pitfalls of standardization, which can that contribute to body dissatisfaction through adherence to beauty standards.

Similar to BIP, self-esteem is consistently reported to be impacted during pregnancy, with studies indicating positive correlations between the two constructs [2, 22, 25, 41, 49]. However, there is almost unanimous use of the RSES, facilitating more consistent comparisons across studies, cultural contexts, and between pregnant and non-pregnant women within the same region or country.

The present study found a mean self-esteem score of 30.8 out of 40, with a relatively small variance (SD = 4.93). This value can be considered high, as it is 5.8 points above the theoretical arithmetic mean (estimated at 25 considering scoring range: 10–40). In comparison to local figures among married Saudi women in Riyadh, the mean self-esteem score was estimated as 21.50 (SD = 4.01) out of 30 (scoring range: 0–30), irrespective of pregnancy status. This score is 6.5 points above the theoretical arithmetic mean [50]. These comparable figures suggest that self-esteem among Saudi women may not be greatly impacted during pregnancy. The same study from Riyadh showed that self-esteem among married women increased with age [50]. This finding is consistent with our analysis, which indicates increasing scores with marriage duration. Another study involving 5587 Saudi women employed as faculty or administrative staff in governmental universities showed that approximately 50% of the participants had medium self-esteem, while the 50% others had high self-esteem. None of the participants had low self-esteem (score 20) [51]. This is consistent to our findings showing a significant increase in self-esteem scores with educational level, demonstrating the role of academic achievement in building self-esteem.

Internationally, a study from Iran using the same scale found a relatively higher mean score of 25.58 (SD = 5.97) out of 30, which is 10 points higher than the arithmetic mean of 15 [49]. In Turkey, Cevik et al. [41] found significantly lower self-esteem scores, as indicated by the adjusted scores (0.9 $\pm$ 1.0; range: 0–6), which correlated positively with body image and negatively with depression symptoms. A study from Brazil categorized self-esteem score into 3 levels: high ($>$30), medium (20–30), and low (20). The majority of participants (81.1%) had medium levels of self-esteem, and 17.4% had high levels. Authors demonstrated a significant association between self-esteem and anxiety [52].

Women’s self-esteem in the Saudi society is both multifaceted and dynamic, often subject to misinterpretations or limited understanding. In the ongoing debates surrounding women’s rights in Saudi Arabia, the dimension of self-esteem is frequently scrutinized beyond the confines of the Saudi cultural framework, putting it into conflict with the religious values or societal gender norms. It is therefore crucial to understand the relevance of cultural factors in shaping the self-esteem of Saudi women. A study among Saudi nursing students showed no gender-based differences in self-esteem, while self-esteem increased with the progression of college year [53]. Other data among adolescents in Kuweit, who share similar cultural and geographic backgrounds with Saudi Arabia, indicate that adherence to religious values is significantly associated with higher self-esteem and lower anxiety among both genders [54]. A more recent study involving 5587 Saudi women employed as faculty or administrative staff in governmental universities showed that self-esteem was high and independently associated with empowerment [51]. These observations indicate absence of conflict between women’s self-esteem with societal values, while emphasizing its strong interaction with personal, social, and professional achievements. This aligns with our findings showing an independent association of self-esteem with educational level, which is probably indicative of the aforementioned social and professional achievements. This highlights the risk of low self-esteem among socially disadvantaged women, calling for targeted supportive measures.

Another notable aspect of the Saudi context (and the Muslim societies in general) is the triangular relationship between self-esteem, body image, and religious values. This offers an additional perspective on the social significance of body image. Studies conducted among women who wear the hijab (the modest clothing worn by Muslim women) have demonstrated that modern Muslims view this garment as a source of autonomy and self-esteem, rather than a factor impeding their empowerment [55]. Understanding this context is essential to understanding the dynamics of self-esteem during pregnancy and its association with body image.

The present study showed a relatively strong (r = 0.6) positive relationship between self-esteem and body image satisfaction. However, the abrupt physical changes and discomfort during pregnancy may impact self-esteem through mechanisms beyond body appearance. This suggests the importance of considering critical dimensions of physical and functional well-being, which have not been explored in the present study. An interesting qualitative study conducted in 1995 elucidated the meaning of being healthy from the perspective of Saudi women. The thematic analysis identified nine primary themes, including role performance, life harmony, spiritual expression, and productivity. When compared to middle-aged Western women, these components were either undervalued or missing in the concept of health. Conversely, body image was ranked seventh in importance in studies on Western women, whereas it did not appear at all in the health construct of Saudi women [56]. That being said, the observed positive relationship between self-esteem and body satisfaction may be confounded by difficulty for the women of performing their role and the disruption of their life harmony due to the excess body weight, rather than being an inference of bodily aesthetics. On the other hand, it is important to note that the conception of well-being in Saudi society has evolved since 1995, with an increased emphasis on the role of body image in self-esteem. This evolution likely contributes to the correlation between self-esteem and body image satisfaction observed in the current study. Therefore, it is crucial to contextualize these findings with the women’s bodily expectations before drawing definitive conclusions.

Another unexplored factor that could influence self-esteem during pregnancy is the level of social support received. Both emotional support and practical aid has been demonstrated to be strongly associated with self-esteem among Saudi married women, surpassing the impact of physical activity [50]. The role of family support during pregnancy is primordial for Saudi women [34]. Furthermore, relationship satisfaction, which is another unexplored determinant of self-esteem, merits investigation in the Saudi context due to its unique cultural implications for couple and family dynamics, and also given the significant role of body image within this factor [57]. A large 5-wave longitudinal study (n = 84,711) from Norway showed a strong association between the level of self-esteem and relationship satisfaction, highlighting how transitioning to motherhood affects both constructs [25].

Interestingly, a previous longitudinal study found that the most substantial declines in self-esteem (and relationship satisfaction) occur after the birth of the first child, with subsequent pregnancies having a more gradual effect [25]. Similarly, an Iranian study showed that self-esteem was negatively correlated with the number of pregnancies [49], while our study showed no such effect. Conversely, our study showed variations in across several sociodemographic factors, alongside smoking status and pregnancy trimester. However, not all of these factors remained significant in the adjusted models. Similarly, the literature identifies a diverse range of factors influencing self-esteem, such as education level, partner’s age, pregnancy planning, abortion history, maternal age, duration of marriage, family income, and smoking, among others [2, 41, 49, 58]. This underscores the multifaceted relationship of self-esteem and pregnancy, emphasizing the need to accurately measure these factors to understand the contribution of body image satisfaction. Importantly, the observed influence of socioeconomic factors on body image satisfaction and self-esteem in this study warrants further exploration due to its potential implications for health inequities.

The reliability of this study is enhanced by its control over several potential confounding variables, such as sociodemographic factors, smoking status, and the number of pregnancies, thereby minimizing the likelihood of spurious results. Additionally, its nationwide scope strengthens its representativeness of the Saudi population and culturally similar populations. However, the study has limitations, including the omission of culturally relevant factors such as family and partner support, the influence of social media, and breastfeeding expectations. The reliance on self-reported, generic assessments for psychological and medical comorbidities introduces information bias and may lead to inaccurate classification, as not all comorbidities equally affect the constructs studied. Furthermore, future research could benefit from measuring weight and body mass index (BMI) before conception and across trimesters, to better understand the dynamics between body image, self-esteem, and body weight. Lastly, the cross-sectional nature of this study limits the ability to infer causality from the observation associations.