At least once a week Lauren Askew is congratulated on her pregnancy – but she’s not pregnant.
‘It’s so embarrassing and upsetting,’ she says. ‘If it’s a stranger, I just go along with it because I can’t face saying anything.
‘But if it’s someone I’m going to see again, I have to say, ‘Actually, it’s a condition’.’
Lauren, 42, gave birth to twin boys in June 2021 and has severe diastasis recti – a condition where the abdominal muscles separate during pregnancy and do not return to their normal position.
While some degree of separation is normal in every pregnancy – as hormonal changes cause ligaments to relax – normally the muscles naturally come back together after birth.
But in one in three women, the muscles and connective tissues of the rectus abdominis – the ‘six pack’ muscles which run vertically down the front of your stomach – separate too far, so can’t return to their position.
The condition is usually caused by pregnancy, particularly if a woman has a large bump – such as Lauren’s twin pregnancy – or is very petite, overweight or quickly becomes pregnant again after a previous birth.
Genetics and pushing for long periods during labour are linked with the condition. It can also be triggered or worsened if a woman exercises intensely before recovering core strength in the weeks after birth – especially doing sit-ups or certain yoga positions which cause the abs to bulge.
Lauren, 42, gave birth to twin boys in June 2021 and has severe diastasis recti – a condition where the abdominal muscles separate during pregnancy and do not return to their normal position
In most moderate cases, if the muscles don’t come back together naturally, physiotherapy exercises in the first year after birth usually helps. Pictured: A woman with of diastasis recti
In rare cases, strenuous exercise that places strain on the abdominal muscles, such as weightlifting, can cause the condition in both men and women who have never given birth.
In around 5 per cent of mothers with the condition, the gap is so large and the tissues supporting the muscles are so weak that the stomach bulges out like a pregnancy bump.
Lauren estimates there is at least two inches of separation between her abdominal muscles – as a result she looks around six months’ pregnant.
With these severe cases, the damaged muscles are unable to properly support the spine and internal organs, meaning women may suffer from back pain, gut problems and urinary incontinence.
They may also develop hernias, where internal organs push out through the gap.
The lack of core support can even mean women can only roll sideways out of bed, as they are physically unable to sit up.
Although otherwise fit, Lauren struggles to bend down to put on her shoes. She also has chronic back pain and digestive issues such as pain and gas.
Women struggle not only with the physical symptoms, but also low body confidence and even depression, says Tina Mason, a specialist women’s health physiotherapist at the Women’s Health Brighton clinic.
A 2020 study in the journal BMC Women’s Health found it affected women in ‘a multitude of ways’, physically and psychologically.
‘Consider it like blowing up a balloon,’ says Tina Mason.
‘If you blow a balloon up a little and then release the air, it will return to its original shape.
‘But if you keep inflating it, there is a point at which the balloon has been stretched so far, it will never return to shape, even when you release all the air.’
Lauren, who lives in Portslade, East Sussex, says it’s had a ‘huge impact’ on her life. She’s needed days off from her work as a children’s speech therapist, and had counselling for low mood.
Although her husband Andrew, 43, has been supportive, she feels the condition has affected their intimacy.
‘It affects your confidence, your relationship – you feel rubbish all the time,’ she says. ‘I’m a sociable person but now I dread going out as I don’t feel there’s anything I can wear which will look good.’
While the rest of her body has returned to her pre-pregnancy size 10 to 12, she now wears size 14 to 16 leggings and baggy tops to cover her bump.
In most minor to moderate cases of diastasis recti, if the muscles don’t come back together naturally, targeted physiotherapy exercises in the first year after birth usually help. But surgery is the only option for severe cases.
Yet the abdominoplasty operation needed (commonly known as a ‘tummy tuck’) is not routinely available on the NHS, which classes it as cosmetic.
David Floyd, a consultant plastic surgeon in London, believes surgery for severe cases should be considered ‘functional’ instead.
He points to research that shows following the surgery, most patients see significant improvements in their overall health – in a Swedish study, published in the journal BJS Open, women followed for three years after surgery all experienced improvements in core stability, muscle strength and quality of life.
The physical and psychological benefits of surgery are ‘enormous’ says Mr Floyd. ‘Women get their core strength back, their back pain goes, they can sit up in bed, they can run around with their kids, [urine leakage] really improves.’
Local NHS guidelines in some areas say repair surgery should be offered if the gap is larger than an inch, causing ‘disabling or significant functional impairment’, the woman has had six months of physiotherapy and it is at least a year since birth. But patient groups and surgeons say most NHS commissioners do not follow these.
Yet while the NHS won’t provide abdominoplasty post-pregnancy, it does offer other cosmetic procedures – breast reduction or enlargement for cases where breast size causes back pain or psychological distress, for instance, or for prominent ears ‘causing significant distress’.
‘Women are expected to just live with this condition which causes real distress,’ says Tina Mason. ‘Of course, it is a choice to have a child but if a man suffered a knee injury after choosing to do sports, the NHS would treat that.’
She adds that most of her patients are young, fit women, who have lost their pregnancy weight and do their physiotherapy exercises – they’re doing everything they can to help themselves yet still look pregnant.
Tina Mason argues that the refusal to give them surgery is ‘short-sighted’ as some studies have found links between diastasis recti and conditions such as hernias and back problems, which the NHS does treat.
‘Ultimately the NHS will have to pay to sort out these knock-on conditions when it could have just dealt with the problem in the first place,’ she says.
Abdominoplasty costs £8,000 to £15,000 privately. It is a relatively straightforward two-hour procedure, although recovery is painful and slow.
Diastasis recti is not part of any routine postnatal check – Lauren first raised her concerns at her six-week GP check, only to be told it was ‘early days’ and should settle on its own. But three months after giving birth, with no improvement, she saw a specialist physiotherapist privately.
They diagnosed diastasis recti and gave her a programme of exercises. Yet despite working on these diligently, there’s been little change. Originally optimistic that exercise would work, she says: ‘I now know surgery is the only answer in my case, as the muscles on the sides of my abs are also very stretched.’
In August, Lauren saw a private plastic surgeon, but the surgery costs £10,000 and there is a waiting list: Lauren hopes to get a slot next year.
The physio who diagnosed Lauren was concerned she might have a hernia, so referred her back to her GP. But it took nearly three years of back and forth before she finally saw an NHS specialist this September, to learn she does have a hernia.
Although the NHS would repair this separately, Lauren wants to avoid two major procedures while caring for her twins, so is paying privately for both repairs to be done at the same time.
She and Andrew face getting into debt to cover the cost. Lauren is taking on extra shifts at work, and the couple plan to use credit cards and get financial help from Lauren’s parents.
‘It will be difficult but I am lucky that I am able to find a way to pay – a lot of women can’t,’ she says. ‘The condition can be very debilitating but with treatment women could return to health and to work.’
An NHS England spokesperson said: ‘Pelvic and abdominal physio is commonly the first-line treatment for conditions like diastasis recti, as it’s effective in many cases, but ICBs [local health authorities] can commission other procedures if needed by their patients locally.
‘Individual treatment plans should be decisions between clinicians and patients, taking into account the latest clinical guidance.’