The Legacy of Pregnancy

Elite Athletes and Women in Arduous Occupations

Thea Jackson; Emma L. Bostock; Amal Hassan; Julie P. Greeves; Craig Sale; Kirsty J. Elliott-Sale


Exerc Sport Sci Rev. 2022;50(1):14-24. 

In This Article

Abstract and Introduction


Best-practice guidance and management of pregnant and postpartum elite athletes and women in arduous occupations is limited by the lack of high-quality evidence available within these populations. We have summarized the adaptations and implications of pregnancy and childbirth, proposed a novel integrative concept to address these changes, and made recommendations to progress research in this area.


Motherhood has been considered incompatible with an athletic career; traditionally, sportswomen have been encouraged to end their careers to have children,[1] although there are now increasing numbers of elite female athletes conceiving, giving birth, and successfully returning to sport.[2] Similarly, there are many women employed in arduous occupations, such as servicewomen (11% of the UK Regular Forces are female),[3] police officers (31% of police officers in England and Wales are female),[4] firefighters (7% of all firefighters employed by Fire and Rescue Authorities England are female),[5] and manual laborers (15% of construction jobs are held by women),[6] who have returned to their physically demanding occupations after childbirth. Women in elite sport and arduous occupations must adapt training, competition, and occupational activities during and after pregnancy to minimize adverse effects on maternal and fetal health outcomes and reduce their risk of injury.

Elite female athletes face many challenges when considering having a baby, planning a pregnancy within an Olympic/Paralympic cycle, time away from training and competition, profound pregnancy- and postpartum-related physiological and anatomical changes, and returning to previous levels of performance within a limited time frame.[7] In 2016, the International Olympic Committee produced a five-part series providing expert opinion on these matters and highlights the need for more high-quality evidence investigating the impact of high-intensity exercise on pregnancy, childbirth, and the return to competitive sport in elite athletes.[8–12] Subsequent evidence has shown that postpartum elite athletes are still unsatisfied with the training and exercise advice given to them,[13] which may present practical challenges when rehabilitating in preparation for returning to sport.

Since 2016, servicewomen have been fully integrated into all UK Armed Forces roles, including ground close combat, and are required to be physically and mentally fit and ready for intense physical training and deployment. Upon declaring pregnancy, servicewomen are medically downgraded, meaning they are not deployable for the duration of their pregnancy. UK servicewomen can return to physically and mentally demanding roles as early as 2 wk postpartum. As of October 1, 2020, 99% of servicewomen who went on maternity leave returned to work within 27 to 40 wk after giving birth.[3] Recent data suggest that postpartum UK servicewomen are at greater risk of illness and injury in the year after giving birth compared with prepregnancy.[14] The number of working days lost due to illness and injury per week was twofold higher postpartum than prepregnancy.[14] Postnatal depression and gynecological disorders were the most common causes of workdays lost due to illness.[14] Similarly, several studies have shown that U.S. military servicewomen are returning to work unprepared for the demands of their role because of reduced physical fitness compared with prepregnancy, and with symptoms of depression and anxiety.[15,16]

Little is known about pregnancy and postpartum fitness in other arduous occupations, including police officers, firefighters, and manual laborers. The characteristics of these occupations require women to be able to perform physically strenuous activities, such as sustained heavy lifting and running. There is a dearth of evidence regarding the implications of pregnancy on the risk of injury and illness when returning to work, although physically strenuous jobs are a risk factor for pelvic floor dysfunction in the general female population.[17] At 12 months postpartum, women with physically strenuous occupations experience more symptoms of pelvic organ prolapse (POP) compared with women who did not participate in heavy lifting and spent <50% of their day seated.[18] Moreover, reduced abdominal muscle function (19) and incomplete recovery of the structural integrity of the linea alba observed after childbirth[20] (decreased strength,[21,22] increased fatigability,[22] and decreased steadiness of muscle contraction)[22] expose high-functioning postpartum women to increased injury risk, especially those who return to occupations that demand repetitive, sustained, or strenuous physical activity.[19] Despite evidence to suggest that women in arduous occupations are at an increased risk of pelvic floor dysfunction and musculoskeletal injury postpartum, there are no data or guidelines on the most appropriate management of pregnant or postpartum women in arduous and manual occupations.

The aim of this opinion article is to detail the changes that occur because of pregnancy, provide opinion on the current management of pregnancy in elite athletes and women employed in arduous occupations, propose a novel integrative concept to improve the legacy of pregnancy in these groups, and recommend future high-quality, impactful studies.