The Legacy of Pregnancy: Elite Athletes and Women in Arduous Occupations

Advancing gender equity in sport: a scoping review of international sport federation policies for pregnant, postpartum and parenting elite athletes

OBJECTIVE

The aim was to synthesise international-level sport policies for pregnant, postpartum or parenting high-performance athletes in order to understand what policies currently exist and to identify policy gaps to be addressed.

DESIGN

Scoping review.

DATA SOURCES

Online databases (MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov) and Google up to 14 June 2024. Additionally, a targeted search of existing policies was conducted via the websites of International Federations (IFs) and continental sporting organisations (CSOs) in September 2023.

ELIGIBILITY CRITERIA

We included policies from IFs recognised by the International Olympic Committee, and CSOs associated with the IFs that specifically address pregnant, postpartum or parenting athletes. Policies were a written principle of action adopted by the IFs/CSOs that provided any form of support during pregnancy, post partum or for parents.

RESULTS

A total of 219 organisations (49 IFs; 170 CSOs) were identified and contacted, with 47/49 (96%) IFs and 15/170 (9%) CSOs responding. Sport policies related to pregnancy, postpartum or parenting athletes were identified from 20 IFs including (1) guidance on training/competition during and following pregnancy; (2) eligibility affected or training not advised; (3) protection from dismissal; (4) special rank, points or quota protection; (5) protections apply to adoption, surrogacy, miscarriage, stillbirth, egg freezing and/or fertility treatment; (6) duration of leave and if leave is paid and (7) breastfeeding support/space. No policies identified specific provisions for childcare support/space.

CONCLUSIONS

Less than half of all IFs have developed sport policies to support pregnant, postpartum and parenting athletes. Of the policies that do exist, most are limited in the extent to which they address the broad range of biopsychosocial supports that are necessary for facilitating optimal performance, enhancing long-term athlete health and addressing gender inequities that are deeply entrenched across all levels of sport. This review provides a critical piece of evidence needed to inform future policy development.

The Translation of Policy to Person: A Qualitative Analysis of Elite Athletes' Perceptions of Pregnancy in the United Kingdom

BACKGROUND

An increasing number of female athletes are navigating an athletic career alongside pregnancy. Limited qualitative research has investigated the experiences of elite athletes in the United Kingdom (UK). This study aimed to explore the experiences of elite athletes in the UK as they navigated pregnancy, employing a socio-ecological framework to inform future research and policy recommendations on sport participation during pregnancy.

METHODS

A descriptive qualitative study design, adopting a relativist ontology and constructivist epistemology, was implemented. Semi-structured online interviews were conducted with elite athletes ≥ 18 years old, who resided in the UK, and who trained and/or competed at the highest level of their sport prior to and/or during pregnancy. Interviews were recorded, transcribed and analysed using reflexive thematic analysis.

RESULTS

Eleven athletes (mean age 31 ± 3 years) from nine team and individual sports participated in the study. Four key themes were developed: (1) From the Podium to Parenthood: Institutional versus Individual Influence on Reproductive Planning; (2) Is My Career Over? Micro Level Support versus Macro Level Doubt and Worry; (3) Athlete to Mother: Internal Conflict to Community Role Model; (4) Navigating the Bump: Individual Drive to Tackle Systemic Gaps.

CONCLUSIONS

Findings highlight the complexity female athletes face when navigating pregnancy, motherhood and elite sport. There is a need for high-quality research focusing on preconception and pregnancy-specific training and nutrition modifications for elite athletes, particularly regarding nutrient intake and supplementation. Additionally, efforts to improve the translation of evidence-based research into practical applications remain essential.

Exploring pregnancy and postpartum experiences among geographically diverse elite athletes: A qualitative study

OBJECTIVES

Female athletes who experience childbirth during their athletic careers can expect to return to elite sports postpartum and perform at a comparable or improved level. However, mothering athletes often encounter significant barriers when re-entering elite sports. The aim of this study was to explore the experiences of a geographically diverse group of mothering athletes who returned to elite sports after childbirth.

DESIGN

Qualitative phenomenological research design using semi-structured interviews.

METHODS

In-depth one-on-one interviews were conducted with nineteen mothering elite running athletes hailing from fourteen different countries. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

Findings were generated into five main themes: (1) Deciding to become a mother, (2) revealing pregnancy to stakeholders, (3) experience of pregnancy, (4) combining motherhood and elite running, and (5) improvement strategies to support athlete mothers. The findings revealed that participants experienced stress regarding their pregnancy announcements due to concerns about potential repercussions on their careers. These concerns included the impact on sponsorship deals, relationships with governing bodies, and interactions with their coaches. Participants felt their elite coaches and health practitioners had insufficient education to support them throughout their pregnancies and postpartum return to elite running. Finally, athletes express a sense of diminished pressure and increased motivation in races upon resuming their elite careers, attributing their improved athletic performance postpartum to their shift in focus from themselves to their child.

CONCLUSIONS

This study illuminates challenges and offers valuable insights to coaches, sponsors, health practitioners, exercise professionals, researchers, race organizers, and governing athletic bodies in better supporting mothering athletes.

Up for the tackle? The pelvic floor and rugby. A review

The pelvic floor and its associated disorders are a unique and often overlooked aspect of women's rugby. This review discusses relevant biopsychosocial considerations specific to the pelvic floor and rugby. Pelvic floor disorders can present at any time across the female lifespan but are more prevalent during pregnancy and postpartum. This is due to the substantial physiological and anatomical changes experienced during pregnancy and vaginal childbirth. Consequently, pelvic floor disorders can impact a player's ability to perform, maintain engagement with, or return to, rugby due to symptoms. Players need to be informed, supported, and guided through focused pelvic floor muscle training to condition the muscles and 'ready' them for the varied demands of rugby. Health and fitness professionals should understand the risk of pelvic floor disorders across the female lifespan and screen players for symptoms when supporting them to maintain or return to rugby. Rugby players who are symptomatic of pelvic floor disorders should be signposted to specialist services and/or resources to manage their symptoms. Once engaging in rugby training, ongoing evaluation of player load tolerance and implementation of individualized strategies to support managing rugby-related loads to the pelvic floor should be considered. Finally, surveillance and research focusing specifically on rugby players and pelvic floor function are needed.

Recommendations for postpartum athletes returning to sport: the past, present, and future

INTRODUCTION

There is a growing percentage of elite female athletes who choose to start a family during their athletic careers. Current guidelines to manage postpartum elite athletes returning to sport are weakly rooted in athlete-centered evidence and/or are restricted by small sample sizes. The purpose of this review was to collect and compare existing protocols and guidelines for elite athletes returning to sport following childbirth and to highlight the current culture surrounding postpartum athletes.

METHODS

Online databases including PubMed and BioMed Central were searched from September 2023 to May 2024. Studies of any design were included if they contained information on pregnancy and postpartum. Peer-reviewed research studies, systematic reviews, case reports, and data from organizational websites (American College of Obstetricians and Gynecologists, the World Health Organization, and the Official Olympics) were included.

RESULTS

Athlete-mothers face numerous challenges in their transition back to competitive sport following childbirth, including the societal expectations of a 'good' mother, potential loss of financial sponsorships, and limited guidance on postpartum training. Additionally, the healthcare community historically managed postpartum athletes in a reactionary manner by treating symptoms from pregnancy and childbirth as they arise. Recent literature is pointing toward adopting a preventive and proactive model of care to optimize an athlete's health prior to pregnancy and therefore support their safe return to sport postpartum.

CONCLUSION

Increased support for female participation in sports must also be met by increased support for pregnant and postpartum athletes. There is a continued need for research regarding return-to-sport guidelines for postpartum athletes, and their proper implementation.

Sprint interval training in the postpartum period maintains the enhanced cardiac output of pregnancy: A case study

During pregnancy an increased cardiac output (Q ̇ $\dot{Q}$ ) and blood volume (BV) occur to support fetal growth. IncreasedQ ̇ $\dot{Q}$ and BV also occur during chronic endurance exercise training and benefit performance. We investigated if sprint interval training (SIT) undertaken early postpartum maintains the elevatedQ ̇ $\dot{Q}$ and BV of pregnancy and benefits performance. The participant, a competitive field hockey player and former cyclist, visited our laboratory at 2 weeks of gestation (baseline) and postpartum pre-, mid- and post-intervention (PPpre, PPmid and PPpost). Delivery was uncomplicated and she felt ready to start the SIT programme 5 weeks postpartum. Inert gas rebreathing was used to measure peak exerciseQ ̇ $\dot{Q}$ (Q ̇ $\dot{Q}$ peak);V ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ was measured with a metabolic cart; and postpartum haematological values were measured with carbon monoxide rebreathing. The 18 SIT sessions progressed from four to eight sprints at 130% ofV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ peak power output.Q ̇ $\dot{Q}$ peak increased from baseline at all postpartum time points (baseline 16.2 vs. 17.5, 16.8 and 17.2 L/min at PPpre, PPmid and PPpost, respectively). RelativeV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ remained below baseline values at all postpartum measurements (baseline 44.9 vs. 41.0, 42.3 and 42.5 mL/kg/min at PPpre, PPmid and PPpost, respectively) whereas absoluteV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ rapidly reached baseline values postpartum (baseline 3.19 vs. 3.12, 3.23 and 3.18 L/min at PPpre, PPmid and PPpost, respectively). Postpartum BV (5257, 4271 and 5214 mL at PPpre, PPmid and PPpost, respectively) and Hbmass (654, 525 and 641 g at PPpre, PPmid and PPpost, respectively) were similar between PPpre and PPpost but decreased alongsideQ ̇ $\dot{Q}$ peak at PPmid. Peak power was returned to pre-pregnancy values by intervention end (302 vs. 303 W, baseline vs. PPpost). These findings show that SIT undertaken early postpartum defends the elevatedQ ̇ $\dot{Q}$ peak of pregnancy and rapidly returns absoluteV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ and peak power to baseline levels.

Fatherhood and Elite Athletics: Sacrifice, Selfishness, and Gaining "Dad Strength"

This study contributes to a growing body of scholarly discussions around the many aspects and challenges of combining parenthood with elite-level sport, with a particular focus on the experiences of male elite athletes who are fathers. We used a caring masculinities theoretical framework, community-based participatory research, and semi-structured interviews to explore the experiences of 10 elite/international and world-class athletes (n = 9 fathers, n = 1 expectant father). Through reflexive thematic analysis, we identified three main themes: fatherhood can (1) improve and (2) impede elite athlete-fathers' athletic performance; and (3) athlete-fathers experience a trade-off between athletic performance and fatherhood responsibilities. Our findings underscore the ways in which male athletes' experiences with parenthood reflect the new era of involved fatherhood and are analogous to some of the identity tensions that have been reported with regard to the experiences of elite female athletes who are pregnant and/or mothers. Recognizing the impact of children on male athletes' athletic careers and the parallels between fatherhood, motherhood, and elite sport may lead to better support for athlete-fathers while also contributing to diminishing the expectation that women are primary caregivers to children.

Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement

Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications.A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement).118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care.Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.

Navigating the 'new normal': what guidelines exist for postpartum return to physical activity and sport? A scoping review

OBJECTIVE

Women are often advised to return to activity (RTA) as early as 6 weeks postpartum, despite undergoing significant physical, physiological and psychological changes. Our objective was to examine existing evidence and clinical practice guidelines to navigate a safe and successful RTA or return to sport (RTS) postpartum.

METHODS

We searched CINAHL, Embase, Medline, PsycINFO and SPORTDiscus and included any secondary studies with recommendations or guidelines for RTA or RTS postpartum. Grey literature and primary sources were excluded. Four reviewers independently screened titles and abstracts, followed by full-text review for eligibility, with conflicts resolved by a third-party reviewer. One reviewer extracted data, which was cross-referenced by another reviewer.

RESULTS

5851 studies were screened, and 33 were included in this scoping review. Most studies stated that RTS postpartum can begin once 'medically safe', around 6 weeks postpartum, but this term was generally left undefined. In addition, most studies recommended engaging in 150 min of moderate-vigorous physical activity per week after 6 weeks postpartum, but the type of exercise recommended was often non-specific.

CONCLUSION

A lack of consistent, evidence-based guidelines exist for RTA or RTS postpartum. Multiple evidence gaps require additional research to inform patient and activity specific guidelines for a safe and successful RTA or RTS postpartum.

Exploring the stress of olympic postponement due to COVID-19 on elite/international and world-class parenting and pregnant runners

The primary objective of this community-based participatory research is to explore the impacts of COVID-19 and the delayed Tokyo 2020 Olympic Games on world-class and elite/international-class parenting and pregnant athletes. Participants in this study include 11 female and 10 male parenting and/or pregnant middle and distance runners. Combined, the participants have competed at 26 Olympic Games and 31 World Championships. Drawing on the general concepts of stressors and psychological resilience, we use thematic analysis to develop four themes to understand the stressors for world-class and elite/international-class parenting and pregnant athletes due to COVID-19 and the delayed Tokyo 2020 Olympic Games: (1) lack of childcare support, (2) family planning, and (3) needing to stay away from sources of COVID-including their children. Despite the stressors identified in the aforementioned themes, we identified a fourth theme: (4) participants demonstrated adaptability to stress in spite of-or due to-their athlete-parent identities.

Effect of Pregnancy in 42 Elite to World-Class Runners on Training and Performance Outcomes

PURPOSE

The International Olympic Committee expert group on pregnancy has identified a paucity of information regarding training and performance in truly elite athletes. Thus, the purpose of this study was to quantify elite runners' training volume throughout pregnancy and postpartum competition performance outcomes.

METHODS

Forty-two elite (>50% competed at the World Championships/Olympic) middle-/long-distance runners' training before, during, and after pregnancy (quality/quantity/type) data (retrospective questionnaire) and competition data (published online) were collected.

RESULTS

Running volume decreased significantly ( P < 0.01) from the first trimester (63 ± 34 km·wk -1 ) to the third trimester (30 ± 30 km·wk -1 ). Participants returned to activity/exercise at ~6 wk postpartum and to 80% of prepregnancy training volumes by 3 months. Participants who intended to return to equivalent performance levels postpregnancy, there was no statistical decrease in performance in the 1 to 3 yr postpregnancy compared with prepregnancy, and ~56% improved performances postpregnancy.

CONCLUSIONS

This study features the largest cohort of elite runners training and competition outcomes assessed throughout pregnancy, with training volumes being approximately two to four times greater than current guidelines. For the first time, performance was directly assessed (due to the quantifiable nature of elite running), and study participants who intended to return to high-level competition did so at a statistically similar level of performance in the 1- to 3-yr period postpregnancy. Taken together, this article provides much needed insights into current training practices and performance of elite pregnant runners, which should help to inform future training guidelines as well as sport policy and sponsor expectations around return to training timelines and performance.

Sport and exercise recommendations for pregnant athletes: a systematic scoping review

Objectives

To analyse the available evidence and identify gaps in current knowledge regarding physical activity volume and intensity and their effects on pregnancy outcomes in female athletes.

Design

Scoping review.

Data sources

A structured literature search of three electronic databases (Embase, PubMed and Web of Science) was conducted on 25 February 2022, and a rerun search was conducted on 8 September 2022.

Eligibility criteria

Studies were eligible if they contained information on the relevant population (ie, elite or competitive amateur female athletes), intervention/exposure (ie, minimum of 10 hours of sport per week) and fetal and maternal outcomes. Eligible comparators included female recreational athletes and pregnant non-exercisers.

Risk of bias

The risk of bias was evaluated with the National Institutes of Health (National Heart, Lung and Blood Institute) quality assessment tool.

Results

The results revealed a discrepancy between the number of original research papers and the number of reviews and recommendations derived from them. The identified studies focused primarily on pregnant recreational athletes. Sixteen clinical studies met the inclusion criteria. No adverse effects on maternal or fetal outcomes were reported. Only during performance tests involving acute intensive exercise with the mother exercising at more than 90% of her maximal heart rate did some fetuses experience decelerations in heart rate.

Summary/conclusion

A lack of high-quality studies and direct evidence on pregnant elite and competitive amateur female athletes is evident. Further prospective observational cohort studies are needed using new monitoring methods (eg, non-invasive, wireless monitoring systems) aiming to gain a broader understanding of the stress tolerance of pregnant athletes and fetuses during exercise. Following that, interventional studies with stress tests in laboratory settings should be conducted. Therefore, technology plays a decisive role in gaining new knowledge and providing evidence-based recommendations on this topic.

PROSPERO registration number

CRD42022309541.