Diastasis Recti And The Pressure To Love A Broken Body

When the best path to healing is surgery, you need support, not shame

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Photo by Arren Mills on Unsplash

I’ve had two kids and I’m approaching 40 with rapid speed. My partner and I are definitely not having anymore. I’m one of those annoying women who got back to pre-pregnancy weight very quickly after both babies. I’m an avid swimmer and triathlete. Still, I’ve decided to get an abdominoplasty, also known as a “tummy tuck.”

Why am I opting to get this invasive and expensive “cosmetic” procedure, especially if I am otherwise in shape and a healthy weight? The answer is simple: I have a severe case of diastasis recti, and it makes me miserable. It makes me even more miserable that this surgery will not be covered by insurance, despite the fact that for me, and many other women with this condition, surgery is the only way to fix this problem.

What Is Diastasis Recti (DR)?

First things first. I am not a medical doctor, so take what I say with that in mind. I’ve poured a lot of time into researching my condition and consulting with professionals, but I’m not offering medical advice here. These are just my experiences and opinions about what ought to be done to address DR more comprehensively, so other women can make informed decisions about their health.

DR happens when the linea alba — the ligament connecting your rectus abdominis (the “six pack” muscles in your stomach) is stretched beyond its normal length. The linea alba is typically very taut and acts as a sort of natural girdle for your midsection, running from sternum to pubic bone. In DR, however, the overstretched linea alba allows the right and left rectus abdominis to drift apart.

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From https://www.brillpt.com/blog/2018/12/20/diastasis-recti-how-do-you-know-if-you-have-it-and-what-can-you-do-about-it

DR is very common in women during and after pregnancy — those beautiful babies we produce do a number on our abdominal walls. Anyone can get DR (yes, men get it too), but pregnant women are especially prone to it. In fact, a majority of pregnant women will experience DR. For many of these women, the condition will naturally subside as the body returns to normal in the months after birth. However, for an estimated 35% of women, DR persists beyond the first postpartum months, and for many, it never heals.

You can think of it like a favorite pair of underwear. For a while, the elastic will remain taut and will bounce back to its original shape, but over time, it becomes so stretched that your undies simply won’t stay in place anymore. This is the condition of the linea alba in many women who have had children.

One of the tell-tale signs of having DR is the often maligned ‘mummy tummy’ — a perpetually pregnant look well after giving birth and despite not being pregnant. You can do a self test at home to determine if you have DR, but the best way to get a clear indication of the extent to which you have the condition involves seeing a medical professional that actually knows about DR.

In my case, if I am not holding my transverse abdominis and oblique muscles incredibly tight— if I relax even just for a second, I look 5 months pregnant. Even contracting those muscles with all my might leaves me with a bulge around my belly button, thanks to an umbilical hernia. It has been confirmed by several different medical doctors that my separation is at least 6 centimeters and runs all the way from sternum to pubis.

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Not engaging the transverse abdominis fully vs. engaging. It is definitely possible to train the muscles to pull in and look almost ‘normal’ but in a healthy abdomen, a lot of this work should be done below the conscious radar. In other words, you should not have to think about your muscles 24/7 to avoid having the preggo pooch, a sway back, and all that comes with it.

For reference, a healthy abdominal wall will have almost no separation between the rectus abdominis. In a healthy stomach, you can barely fit a finger in between the muscles. I can fit a whole fist in between mine. And it’s not just about the width of the separation. As you can see from this video, the depth of my DR is extensive as well.

Some people have DR just around the belly button, while others have it just above or below, or the full length of the torso like me. See below:

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Image from https://fit2b.us/how-to-check-for-diastasis-hd/

I cannot tell you the number of ‘well-meaning’ strangers who have commented on my stomach, asking when I was due, or saying how skinny I look for a pregnant lady. Comments like these are frustrating, to say the least, especially when you’ve worked nonstop for years to correct your DR.

What’s So Bad About A “Mummy Tummy”

Absolutely nothing. Love your body. Love your stretch marks. I support body positivity 100% and this includes respecting women who are happy to be larger than average or to have visible signs from bringing children into the world. Society definitely needs to quit fetishizing these celebrity moms who emerge just days after the bodily hell that is childbirth in high heels and bikinis, looking as though they have been training for a body building competition for months. Women, and mothers especially, are under impossible pressure to be everything to everyone, so who cares if you bounce back to pre-pregnancy shape, right away, or ever.

However, if your body is causing you pain — physiological or psychological — you have every right to seek to change it for the better. There are so many messages out there urging us to love our maternal bodies that it can drown out the very legitimate voice inside your head that says, “but…I don’t and I don’t have to.” You are under no obligation to love a body that causes you grief. Since learning about my condition, I have been a part of many support groups for DR, and women from the every part of the body-spectrum complain about the condition and its deleterious effects on their lives.

There is not a conclusive body of research on the relationship between DR and other bodily functions. There’s not a lot of research on DR, generally. Many women — myself included — knew nothing about it before or during pregnancy, and only learned of it when it was clear something was not right. Women with DR have reported the following conditions: lower back pain, pelvic pain, urinary incontinence, organ prolapse, decreased core stability and/or exercise capacity, hernias, and gastrointestinal issues. There are studies that indicate many of these issues are either directly or indirectly caused by DR, though there are also studies that purportedly show no relation.

The most glaring omission in DR research, however, is the lack of concrete evidence regarding the proper way to ‘cure’ it. Many women turn to exercise programs, while others opt for surgery, but there are hardly any followup studies indicating the degree to which these interventions have permanently fixed the DR or any of the supposedly associated symptoms. The most conclusive evidence seems to be that in severe cases of DR, surgery is the only surefire way to close the gap entirely.

The Confusing Landscape Of ‘Curing’ DR

To reiterate, the lack of knowledge surrounding DR makes it really difficult to definitively determine how best to remedy it. Likewise, it is unclear whether there are ways to prevent it during pregnancy. I often wonder if I exacerbated the issue by continuing to lift heavy weights throughout my first pregnancy and then trying to get back to marathon swimming too quickly postpartum. There is some research indicating that certain exercises can indeed make DR worse. Simply being told what DR is during pregnancy would have been helpful to me, for sure. And if there are preventative measures that seem promising, including those among prenatal care would be a great start in addressing DR.

I didn’t learn about my DR until about 6 months after my first child was born. I had just completed a 6 mile ocean swim and was out jogging a few days later. A man on the street yelled out to me “pregnant women who jog are badass!” Aside from how inappropriate comments like these are, it was also the first day I had really thought about my belly in a long while. After all, I had been working out, was back to my pre-pregnancy weight, and felt strong. My back ached all the time, but I thought it was just residual healing from having such a huge baby. That day, I stopped, looked down, and realized I did look a little pregnant still. What gives, I wondered? I began to scour the internet, and quickly learned about DR.

It was suggested on many sites that I see a physical therapist (PT), so I did. He confirmed that I had a large separation, and asked if I had other issues. I told him my lower back was constantly hurting. He told me it was likely related to my lack of ability to recruit my transverse abdominis muscles and a weak pelvic floor. So, we set out on a rigorous program to correct all of this. After months of PT, I had definitely made some progress. (To any women reading this, if you have decent insurance, I highly recommend seeing a PT first thing after birth, even if you don’t think you have DR. Chances are, pregnancy and birth caused you to meet your deductible and out of pocket max, so PT will be completely free. Find a PT that specializes in pelvic floor issues and DR.)

PT helped, but it didn’t fix anything. What it taught me was to better control all the muscles that would make exercising less painful, and when needed, with much concentration, I could make my stomach mostly flat. A few months later, I completed a Half Ironman, and because it is nearly impossible to swim, bike, and run 70.3 miles while thinking about your pelvic floor the whole damn time, someone shouted out to me as I finished, “way to go momma!” My kid was nowhere in sight. This person saw my belly and thought I was one of those warriors who does Ironman races while pregnant. I sobbed off and on the rest of the day when I should have been celebrating my accomplishment.

I tried all the other programs — MUTU and Tupler are the big names out there. Katy Bowman has a great book too. She provides a biomechanical approach to DR. The problem I found with all these systems, however, besides paying for something that never really worked, is that they are all about restrictions. “Don’t do planks if you dome,” for example. Doming is what happens when you get this ridge in your belly as you put pressure on it (see my video above). It’s another classic sign of DR. I dome every time I do a plank. I cannot control it. To this day, I refuse to do them. There are a lot of exercises I refuse to do, for fear of making my DR worse. It hardly seems like “curing” DR if you are so dysfunctional that you cannot plank properly. Moreover, these programs tend to emphasize that fixing DR is a ‘whole life’ or ‘whole body’ solution, which sounds great at first. I’m all into holistic care, but when you get down to it, the resounding idea behind a lot of these programs is this: you must organize your life around your DR and every movement, everything you eat, even the breaths you take — they should all be in the service of engaging the muscles properly. Again, this does not seem like a return to normal functioning. Obsessing over your stomach is dysfunctional.

If I sound critical of non-surgical attempts to correct DR it is because I am. I tried them all, religiously, and today, my gap is just as big as it ever was. It was not all for nothing, however. My core is in many ways stronger than it ever has been because I have learned so much about my inner vs. outer obliques, how to engage my transverse abdominis during exercise, and how important posture is. These programs help tremendously in regards to gaining some function. They are full of great information that is likely useful even if you end up having surgery, because knowing how to properly engage your core is beneficial as you begin to heal and exercise again. I strongly encourage women to try non-surgical means to fix DR before going in for a major costly surgery. Just know that most of these programs are not free either.

When I started sharing my DR journey on Instagram, influencers began contacting me, wanting to share their success stories with me. I was naïve at first and engaged with them, only to find out they were hoping to sell me some new system or a special belly brace. I thought about all the women out there with DR, desperately looking for a solution, vulnerable and unsure. How many of them would fall prey to this marketing, only to be disappointed still, after months or years of trying everything, and having spent tons of money?

So that brings us to the surgical option. DR can be surgically corrected by sewing the rectus abdominus back together. This is called muscle repair. This can be done by a general surgeon, but the predominant way the correction occurs is via plastic surgery. One reason for this is because many times, in repairing the abdominal wall, there will be extra skin left over and it will need to be removed if the patient wants optimal results — hence the name “tummy tuck.” The belly button will often be affected as well and will need to be reconstructed. If there are hernias present, they can be repaired as well — again, something a general surgeon could do, but often, plastic surgeons are the ones to do it since they are doing the rest of the procedure. Plus, if you get a hernia repaired, but continue to have severe abdominal separation, the hernia is far more likely to return. Plastic surgeons can also perform liposuction around the areas being repaired, and many women go all in for a “mommy makeover,” which often includes breast augmentation.

In short, repairing DR surgically is pricey. The national average cost of a non-complicated abdominoplasty is around 6,300 dollars, which does not include anesthesia and facility fees, and of course, this number rises dramatically if you tack on other “mommy makeover” items. Insurance — in the U.S. at least — will almost certainly not cover it, because it is considered “cosmetic.”

Like with any surgery, there are risks. One of those risks is failure, but with a board certified plastic surgeon who has a good track record, this outcome is unlikely. As this study indicates, there is a fairly high percentage of cases where patients request revisions or have minor complications, but despite these issues, the repair itself was successful and the patients were satisfied. In fact, there are plenty of studies showing that surgically repairing DR is correlated with decreased back pain and increased urinary continence, along with the obvious benefits for so many women of not looking perpetually five months pregnant.

Why I Am Opting For Surgery

As with many deliberative processes, you must perform a cost/benefit analysis. It’s true that the programs out there are less expensive than surgery, but at some point, I realized I was exerting too much mental and physical effort for the small gains I was making. After talking to so many women who have similar body types to me and have had amazing success, I realized that the several thousand dollars it would cost, plus the several weeks of recovery were worth it. I don’t want to spend the rest of my life like this, or worse, become even more dysfunctional as I age, which seems to be a risk, though I have found no studies confirming this.

Furthermore, if you dig deep enough, you will find that many of these influencers and program directors that sport flat and toned post-baby abs have had surgery themselves! To be fair, many of them are transparent about this fact, but then it makes you wonder why they are selling programs that did not work for them. Also, how many of these program directors are flat-out lying about not having surgery?

In considering options as to how best to remedy your DR, you have to remember basic anatomy and physiology. Like the underwear example I shared above, sometimes our ligaments just cannot bounce back. Sometimes they completely tear, as in the case of the commonly torn ACL in the knee. When that ligament is damaged, hardly anyone thinks twice about getting it surgically fixed. So why is there so much resistance to the idea of surgically correcting DR?

The answer to this question is probably complex and a combination of factors. Again, all surgery is dangerous, so there’s that. It’s expensive. Ok, but so are diamond engagement rings and people find ways to finance those. What really seems to drive the anti-surgery attitude about correcting DR is the stench of “cosmetic” that is attached to the procedure. To be sure, some people are absolutely unashamed to get every cosmetic surgical procedure under the sun performed, but in the complex world of moms trying to make peace with their postpartum bodies, there is a definite tension.

I saw a post once that said “Your kids don’t need a perfect mom. They need a happy one.” The person who posted it meant it to convey they idea that you don’t need to get surgical procedures to “fix” your “mom bod” because your kids will love you no matter what you look like. This seems obviously true, but it misses the point that you deserve to love your body too. If your body is damaged, causing you pain, or making it impossible to do the things you love to do, then you deserve to get it fixed. DR surgery is not just about looks.

Even if DR surgery is about looks, desiring not to look pregnant should not be shamed. Regaining functionality in your core and having the psychological wellbeing that comes with not fearing someone will ask you if you are pregnant if you relax even just a bit — that is hugely beneficial. And yet, society frowns on this surgery as vain, and just another part of the trend to abuse plastic surgery. In turn, insurance companies almost always refuse to cover it. Compare this point with the fact that when women who survive breast cancer and undergo mastectomies seek reconstructive surgery, it is almost always covered. Don’t get me wrong: it absolutely should be covered. Why? Because feeling whole and looking like yourself is integral to your psychological wellbeing, always, but especially if you have survived cancer. But let’s face it: fake boobs don’t do anything, aside from look nice. It’s not like the breast augmentation is allowing the heart to properly pump blood. It’s just cosmetic. It’s covered because breasts are seen by insurance companies as necessary. A functioning core with no torn ligaments, on the other hand, is not. No, bringing a child into the world is not the same thing as surviving cancer, but it is taxing on the body and can be downright traumatic. DR is a complication of pregnancy — an injury related to carrying and birthing a human being. It is a medical condition and should be treated as such.

The fact that insurance companies do not see it this way is not only sexist, but it reveals the irony of the anti-surgery movement surrounding DR. We are supposed to love our “birth battle scars” and not fixate on our looks. Then why do we need to pay monthly fees and buy belly binders to lose the mommy pooch? Should I desire to feel like myself again after having a baby? Or does that make me selfish? There are influencers and entrepreneurs out there capitalizing on these insecurities women have and sending mixed messages, or worse, providing medically false information, such as the idea that you can fix severe DR with a few quick exercises. To repeat: if you stretch the linea alba enough, no amount of belly breathing, pelvic tilts, or kale-eating is going to magically fix that injury. And you should be wary of anyone who is willing to take your money that is not qualified and able to perform a physical examination of you and assess your individual medical needs.

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One example of the misleading claims made by programs out there. You cannot “seal” your rectus abdominis back together with exercise. It’s a ligament that is damaged, not muscles.

At the end of the day, if you support women having whatever body they want to have, you must support their choice to strive to attain a semblance of pre-pregnancy functionality and aesthetics just as much as you support their choice to love their stretch-marks, scars, and extra skin.

My Decision Should Be One Any Woman Can Make

As I’ve said, I tried ALL the programs. I did not make this decision lightly. I’m not looking forward to the grueling recovery from surgery. It means I won’t be able to pick up my kids for weeks and I will not be doing any triathlons any time soon. But I will also likely come out on the other side with a truly functional core, less back pain, and no more psychological turmoil that comes with the dreaded “when are you due?” questions I get so often.

Thanks to some amazing women who have been open about their surgical journeys on IG, I don’t feel ashamed about making this decision. Moreover, online support groups, in particular, one started by Rhiana Stranges, with over 3,000 members, have been integral to my decision-making process. Many of these women have become advocates for raising awareness about DR surgery, such as Renee Shocket. Renee helped fuse her advocacy efforts by collaborating with Dr. Rady Rahban and his podcast, “Plastic Surgery Uncensored,” in which Rhiana and Renee spoke about various topics related to Diastasis Recti. Renee also has an Instagram account as well as a Facebook group devoted to raising awareness about DR. (You should check out her before and after images if you want to see what super severe DR can look like and how transformative surgery can be.)

I also realize my privilege in having the means to afford this surgery (well, it’s going on a credit card, but still), which is why I have written this article. Like many of the advocates I’ve met, I want to see a world where all women have access to DR-comprehensive care. This might mean closing the gap as much as possible through exercises, and that might be enough for many women. All of these exercise programs, however, should cost women nothing. No one should be profiting off helping women regain functionality after having babies. This should just be part of the overall comprehensive care women receive during and after pregnancy. In severe cases of DR, surgery should not only be explored, but it should be covered.

Of course, there will still be moms who fall between the cracks, given the failures of the U.S. healthcare system generally. The fact that women go through pregnancy and childbirth without insurance coverage is a travesty in itself. There is no simple answer to those major flaws in our system. But in properly addressing DR and recognizing that it is a medical condition that should be remedied, we can at least stop failing women in one concrete way.

References

Benjamin, Deenika R., Helena C. Frawley, Nora Shields, Alexander T. M. van de Water, and Nicholas F. Taylor. 2019. “Relationship between Diastasis of the Rectus Abdominis Muscle (DRAM) and Musculoskeletal Dysfunctions, Pain and Quality of Life: A Systematic Review.” Physiotherapy 105 (1): 24–34.

Bowman, Julie. 2016. Diastasis Recti: The Whole-Body Solution to Abdominal Weakness and Separation. Propriometrics Press.

Doubkova, Lucie, Ross Andel, Ingrid Palascakova-Springrova, Pavel Kolar, Jiri Kriz, and Alena Kobesova. 2018. “Diastasis of Rectus Abdominis Muscles in Low Back Pain Patients.” Journal of Back and Musculoskeletal Rehabilitation 31 (1): 107–12.

Fiori, Federico, Francesco Ferrara, Davide Gobatti, Daniele Gentile, and Marco Stella. 2020. “Surgical Treatment of Diastasis Recti: The Importance of an Overall View of the Problem.” Hernia: The Journal of Hernias and Abdominal Wall Surgery, June. https://doi.org/10.1007/s10029-020-02252-0.

Mommers, Elwin H. H., Jeroen E. H. Ponten, Aminah K. Al Omar, Tammo S. de Vries Reilingh, Nicole D. Bouvy, and Simon W. Nienhuijs. 2017. “The General Surgeon’s Perspective of Rectus Diastasis. A Systematic Review of Treatment Options.” Surgical Endoscopy 31 (12): 4934–49.

Mota, Patrícia, Augusto Gil Pascoal, Cristiana Vaz, Filipa João, António Veloso, and Kari Bø. 2018. “Diastasis Recti During Pregnancy and Postpartum.” In Women’s Health and Biomechanics: Where Medicine and Engineering Meet, edited by Sofia Brandão, Thuane Da Roza, Isabel Ramos, and Teresa Mascarenhas, 121–32. Cham: Springer International Publishing.

Petronella, Pasquale, Adelmo Gubitosi, Fulvio Freda, Chiara Freda, and Alessandro Esposito. 2017. “Benefits of Abdominoplasty Associated with the Repair of Abdominal Hernias.” World Journal of Surgical Research 6 (3). http://www.npplweb.com/wjsr/content/6/3.

Sperstad, Jorun Bakken, Merete Kolberg Tennfjord, Gunvor Hilde, Marie Ellström-Engh, and Kari Bø. 2016. “Diastasis Recti Abdominis during Pregnancy and 12 Months after Childbirth: Prevalence, Risk Factors and Report of Lumbopelvic Pain.” British Journal of Sports Medicine 50 (17): 1092–96.

Swedenhammar, E., K. Strigård, P. Emanuelsson, U. Gunnarsson, and B. Stark. 2020. “Long-Term Follow-up after Surgical Repair of Abdominal Rectus Diastasis: A Prospective Randomized Study.” Scandinavian Journal of Surgery: SJS: Official Organ for the Finnish Surgical Society and the Scandinavian Surgical Society, April, 1457496920913677.

Taylor, D. Alastair, Steven L. Merten, Gavin D. Sandercoe, Dilip Gahankari, Scott B. Ingram, Nicholas J. Moncrieff, Kevin Ho, Graham D. Sellars, and Mark R. Magnusson. 2018. “Abdominoplasty Improves Low Back Pain and Urinary Incontinence.” Plastic and Reconstructive Surgery 141 (3): 637–45.

Téllez, Ester Cerezo, Esther Delgado Pérez, and María Blanco Morales. 2018. “C0102 Diastasis Recti Changes during Abdomini Wall Work in Low Back Pain Subject at Long Postpartum. a Case Report.” British Journal of Sports Medicine 52 (Suppl 2): A25–A25.

Plastic Surgery Uncensored: https://podcasts.apple.com/us/podcast/plastic-surgery-uncensored/id1462543521

Self Test: https://www.youtube.com/watch?v=YiEFYh0ulTk

Stats about the costs of plastic surgery: https://www.plasticsurgery.org/documents/News/Statistics/2018/cosmetic-procedures-average-cost-2018.pdf

Constant collisions between the personal and political. Professor. Adoptee. Advocate. Activist. I write about dogs a lot. michelemerritt.com

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