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

Pregnancy and Postpartum Adaptations and Implications

Pregnancy and childbirth cause unique physiological, musculoskeletal, and psychological adaptations that have potential implications for pregnancy and postpartum health, function, and physical activity (Table). Many of these adaptations resolve naturally after childbirth, as physiological homeostasis is restored, but some adaptations can persist and affect maternal health, posing significant challenge on physical activity participation. It is understood now that the effects of pregnancy and childbirth can extend beyond 12 months postpartum.[130] The long-term health implications of returning to high-impact and intense physical activity too soon after childbirth are unknown.[10]

In the absence of contraindications, exercise can be beneficial during pregnancy,[131] including fewer newborn complications and improved maternal health outcomes.[132] The American College of Obstetricians and Gynecologists committee proposed that the type and volume of training modality should be considered between trimesters because of the normal anatomical and physiological changes (Table) that occur.[133] Observational studies have shown that both elite athletes and physically active controls reduced their training volume between the first, second, and third trimesters, and none participated in high-intensity training in the final trimester.[13] Although elite athletes and women in arduous roles are more likely than the general population to be physically active throughout pregnancy, they still undergo significant anatomical and physiological changes. Emerging evidence suggests that physically demanding occupations (heavy lifting, prolonged standing, prolonged walking, and prolonged bending) during pregnancy are associated with increased risk of adverse pregnancy outcomes including preterm delivery, low birth weight, small for gestational weight, and preeclampsia.[134] Furthermore, the changes that occur during pregnancy may affect exercise capacity;[8] however, the full extent of these implications on exercise performance is not fully understood (for a review on the state of the art, see).[135] The time taken to recover from pregnancy and childbirth can vary, dependent on gestational complications, mode of delivery (vaginal, instrumental, or cesarean section), pelvic floor dysfunction, pain, and depression. After an uncomplicated pregnancy, it is possible for women to return to low-impact physical activity in less than 12 wk after childbirth,[136] and elite athletes have returned to physical activity less than 6 wk postpartum.[13,137,138] Women who return to high-impact physical activity in the early postpartum period risk becoming injured without adequate rehabilitation and recovery after childbirth.[13,137,139,140]

Twelve weeks or more are required for the musculoskeletal soft tissues to heal after an injury, which is accounted for by the time taken to progress through the defined stages of inflammation, proliferation, and remodelling.[141] Recent self-published guidelines for returning to running after childbirth suggest that symptomatic women or asymptomatic women who are without the guidance of a health care professional may benefit from waiting until 12 wk postpartum to resume high-impact activities.[142] Without adequate healing and rehabilitation of the pelvic floor[143] and abdominal muscles,[19–22] women are at risk of dysfunction, which may present with (symptomatic) or without (asymptomatic) physical symptoms. If asymptomatic, it is unknown whether pelvic floor dysfunction, such as POP, could worsen because of lack of detection and intervention and become a barrier to returning to physical activity, competition, or occupational performance. Moreover, it is important to understand that the degree to which symptoms relate to function can vary between individuals, and symptomatic women will be better placed to seek help to manage these symptoms.

Women may return to work or training/competition prematurely after pregnancy because of external pressure regardless of physical health or symptoms. Elite athletes are forced to consider the timing of major sporting events including the Olympic/Paralympic cycle. Taking time away from sport to have a baby may impact on ranking, team selection, or qualification to major sporting events. In addition to considering qualification or selection, elite athletes face financial worries, because paid maternity leave is uncommon. Most sports do not offer financial protection for pregnant athletes, and often, funding is withheld. Women in arduous occupations also face financial pressures as maternity pay decreases over time; for example, UK servicewomen are entitled to 26 wk' full pay, 13 wk of additional maternity leave paid at the statutory pay rate, followed by 13 wk of unpaid leave. The reductions in paid maternity leave coincide with when UK servicewomen typically return to work after childbirth.[3] Moreover, women in elite sport are faced with social and psychological challenges driven by cultural beliefs and traditions regarding their responsibility to prioritize their role as a new mother over their career as an athlete. Elite female athletes often strive to meet the expectation that they can "do it all" but may experience psychological distress when they do not feel they meet the expectation of being a mother and able to perform at the highest level.[7]