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

Future Perspectives

Major gaps in our understanding exist because of the lack of studies investigating pregnancy, postpartum, and return to exercise in elite athletes and arduous occupations. It is important to acknowledge the similarities between the populations discussed in this article and use this collaborative approach to broaden the evidence base. Bø et al.[11] outlined important research questions that still need answering to advance the care of elite female athletes (spanning fertility; medical conditions, physiological and anatomical changes, exercise testing, athletic training, and exercise interventions) and recommended investigating the impact of strenuous exercise and the prevalence and risk factors associated with pregnancy complications. With reference to the postpartum period, they called for research to consider athletic training and exercise, breastfeeding, physiological and anatomical changes, and medical conditions. In addition to these recommendations, we suggest several other considerations to progress research and, thus, the care of elite female athletes and women in arduous occupations.

Point 1: A wider MDT should be used throughout pregnancy and after childbirth to maximize recovery. Seeking and reflecting upon qualitative data from elite female athletes who have previously trained and competed through and beyond pregnancy might help shape future MDT configurations as well as timelines of care.
Point 2: Pelvic health physiotherapists are well placed to evaluate specific pregnancy-related and postpartum concerns and to implement preventative strategies during, and even before, pregnancy. Further research is required to (i) assess the effectiveness of pelvic health physiotherapy interventions, such as pelvic floor muscle training during pregnancy; (ii) establish whether these interventions are required in the absence of dysfunction to improve overall performance outcomes after childbirth; and (iii) investigate whether implementation of interventions in asymptomatic women improves long-term health outcomes. A 5- to 10-year follow-up of women after these interventions would provide useful information on the long-term effectiveness of such interventions.
Point 3: Swift et al. [150] showed that "early pregnancy" is a period of significant and heterogeneous behavior change, which is prejudiced by women's lived experience and their perceptions of risk. As such, the time scale for pregnancy-based interventions needs to be established to maximize the advantages of an active pregnancy.
Point 4: The most effective exercise-based interventions for the active recovery phase of postpartum care needs to be investigated. We need to establish whether a combination of pelvic floor, abdominal, and general strengthening and conditioning exercises is more effective than each component in isolation.
Point 5: Six weeks postpartum is an arbitrary time point at which commencing exercise is often advised and many interventions start. For active women, where time to return to activity is often critical, research that investigates rehabilitation and exercise interventions from day 1 postpartum, rather than 6 wk, is needed. A similar approach is already adopted in the immediate postoperative period for many conditions.
Point 6: Observational studies of the interventions used by active women throughout pregnancy and postpartum would provide useful retrospective data for analysis to establish the most effective methods used to return to performance and competition. Furthermore, a repository of this case study-type information that is made accessible to researchers and medical professionals would improve the current state of the art.
Point 7: Continued surveillance of injuries and illness incurred in the first year after childbirth would provide useful information and direction for future intervention-based studies. Similarly, documentation of training, competition, and working days lost due to injury and illness during pregnancy and after childbirth may provide useful information of the significance of the injuries and illnesses experienced.
Point 8: Research is needed to demonstrate the effectiveness of an MDT approach with a structured exercise program to return women in arduous occupations to postpartum occupational fitness. Such studies should include an active recovery phase followed by a gradual increase in loading through both resistance and endurance training. Research should explore rehabilitative postpartum interventions with a focus on long-term health outcomes of UK servicewomen and incidences of illness and injury after return to work.
Point 9: Sociological implications of pregnancy and childbirth need to be assessed in active women. It is imperative that we improve our understanding of the impact of pregnancy and childbirth, including maternity pay, sponsorship, pressures to secure position on a team, and pressures to be fit and ready for major sporting events or deployment.
Point 10: Anecdotally, there are more mothers in elite para-sport than able-bodied sport, perhaps due, in part, to the longevity of their careers. It would be pertinent to scrutinize how para-athletes deal with their synchronous roles as mothers and Paralympians.