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Women in Sport

Pregnancy

From grassroots to elite participation an additional consideration for many women is the impact of their menstrual cycle and/or pregnancy—pre-, during and post-partum—on their ability to participate in sport and physical activity.

Choosing to have children has significantly more impact on female than male elite athletes, and can lead not only to career disruption but also to reductions in income (sponsorship, match fees, etc.) and additional difficulties when returning to elite or professional sport commitments (such as a lack of child care).

For grass roots participation advice has often been difficult to find or contradictory. While the risks during pregnancy have often been considered the benefits were not necessarily understood.

Today, physical activity—including sport—for women before, during and after pregnancy is considered important for a healthy pregnancy and the long term health of mother and child. Meeting the normal physical activity guidelines of 150 minutes of moderate-vigorous physical activity per week is still recommended, through a variety of activities that best suit the individual. Surveys in Australia however, indicate that only a third of pregnant women met these guidelines, compared to 50% in the general female population.

Some sporting organisations, including Netball Australia and Basketball Australia, have developed specific guidelines for athletes competing in their sport.

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Additional resources

  • 2019 Canadian guideline for physical activity throughout pregnancy, Canadian Society for Exercise Physiology, (October 2018). New evidence-based guideline outlines the right amount of physical activity women should get throughout pregnancy to promote maternal, fetal, and neonatal health. Physical activity is now seen as a critical part of a healthy pregnancy. Following the guideline can reduce the risk of pregnancy-related illnesses such as depression by at least 25%, and the risk of developing gestational diabetes, high blood pressure and preeclampsia by 40%. Unless contraindicated pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week; however, being active in a variety of ways every day is encouraged.
  • Female Performance and Health Initiative (FPHI), Australian Institute of Sport, (accessed 18 December 2020). The AIS Female Performance & Health Initiative (FPHI) was established in October 2019, to improve female athlete specific knowledge and systems of support. The initiative will benefit Australian athletes, coaches, parents, sporting organisations and support staff in the sport sector and will raise awareness and understanding to key female athlete performance and health considerations, including but not limited to: the menstrual cycle and associated dysfunction including endometriosis and Polycystic ovary syndrome (PCOS); Medical conditions impacting female athletes; Pelvic floor health and incontinence; Breast health; Pregnancy and return to sport.
  • SmartHER: EIS prioritising female athlete health, Mark Jamieson, English Institute of Sport, (8 March 2019). The English Institute of Sport (EIS) has prioritised opening up conversations amongst athletes, coaches and staff in high performance sport around female athletes’ menstrual cycle and its possible effects, as well as offering expertise to help elite British female athletes be healthy, happy and deliver world class performances.
  • This Mum Moves is an initiative aimed at supporting pregnant women and new mums to be active. It looks to do this in two key ways: Providing healthcare professionals with the tools and training to knowledgeably and confidently discuss physical activity; and, providing women with further information on the benefits of being active, and activities to try. 
    • ukactive kicks off This Mum Moves project with first insights from mothers and healthcare professionals, ukactive, (25 April 2019). A survey of more than 400 healthcare professionals’ showed that 27% did not know whether pregnant women should continue to engage in 150 minutes of moderate-intensity physical activity every week, as recommended in specific guidance introduced by the Chief Medical Officer in 2017. This is in keeping with recommendations for the general adult population. However, 97% said they would be interested in further training to support their practice. The findings were consistent with existing literature in this area that shows there is a lack of knowledge and confidence in providing physical activity advice and guidance during pregnancy and the postnatal period.
  • Physical activity during pregnancy 2011–12, Australian Institute of Health and Welfare, (2 May 2019). Currently, little is known about how much, and what types of, physical activity pregnant women undertake in Australia. This short report investigates the types and amount of physical activity undertaken by women during pregnancy, with comparisons made between pregnant and non-pregnant women of the same age, and against Australia’s Physical Activity and Sedentary Behaviour Guidelines for adults. The report found that only one third of pregnant women met the Australian physical activity guideline of at least 150 minutes per week of moderate to vigorous activity [compared to around 50% in the general female population as reported in other AIHW reports].
  • Benefits of Physical Activity during Pregnancy and Postpartum: An Umbrella Review, Dipietro, Loretta,Evenson, Kelly, Bloodgood, Boony, et al. for the 2018 Physical Activity Guidelines Committee, Medicine and Science in Sports and Exercise, Volume 51(6), pp.1292-1302, (June 2019). This study aimed to summarize the evidence from the 2018 Physical Activity Guidelines Advisory Committee Scientific Report, including new evidence from an updated search of the effects of physical activity on maternal health during pregnancy and postpartum. The reviewers concluded that the gestational period is an opportunity to promote positive health behaviors that can have both short- and long-term benefits for the mother. Given the low prevalence of physical activity in young women in general, and the high prevalence of obesity and cardio metabolic diseases among the U.S. population, the public health importance of increasing physical activity in women of childbearing age before, during, and after pregnancy is substantial.
  • Considerations for the Postpartum Runner, Kate Mihevc Edwards, Strength and Conditioning Journal, Volume 42(1), pp.45-52, (February 2020). According to Running USA, today there are over 35 million runners in the United States and greater than half are women. The psychological, physiological and biomechanical differences between male and female runners are well cited however, there is little guidance provided to healthcare providers including running and strength coaches about how to transition runners back to running postpartum. This article can serve as a reference for understanding the unique challenges female runners face postpartum and give clinicians the knowledge to manage the athlete’s expectations and training progression.
  • The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis, Kelly Lee McNulty, Kirsty Jayne Elliott-Sale, Eimear Dolan, et.al., Sports Medicine, Volume 50, pp.1813-1827, (2020). The results from this systematic review and meta-analysis indicate that exercise performance might be trivially reduced during the early follicular phase of the MC, compared to all other phases. Due to the trivial effect size, the large between-study variation and the number of poor-quality studies included in this review, general guidelines on exercise performance across the MC cannot be formed; rather, it is recommended that a personalised approach should be taken based on each individual's response to exercise performance across the MC.
  • The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis, Kirsty J. Elliott-Sale, Kelly L. McNulty, Paul Ansdell, et.al., Sports Medicine, Volume 50, pp.1785-1812, (2020). OCP use might result in slightly inferior exercise performance on average when compared to naturally menstruating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and variable across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle.
  • Elite athletes get pregnant, have healthy babies and return to sport early postpartum, Jorunn Sundgot-Borgen, Christine Sundgot-Borgen, Grethe Myklebust, Nina Sølvberg, Monica Klungland Torstveit, BMJ Open Sport & Exercise Medicine, Volume 5(1), (November 2019).  34 Norwegian elite athletes (33.1 years) and 34 active controls (31.5 years) were asked about training and competitive history, pregnancy-related issues, injuries, body dissatisfaction (BD), drive for thinness (DT), eating disorders (ED) and practical experiences, through a questionnaire and interview. The results showed that both elite athletes and active controls got pregnant easily, delivered healthy babies and decreased training during pregnancy and the first postpartum periods compared with prepregnancy. Most athletes and every third control returned to sport or exercise at week 0–6 postpartum. Athletes reported stress fractures and increased BD and DT, but decreased ED postpartum. However, since relatively few athletes were included these findings need further investigation.
  • Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant, Bo K, Aertal R, Barakat R, et.al., British Journal of Sports Medicine, Volume 50(10), pp.571-589, (2016). The IOC assembled an international expert committee to review the literature on physical activity and exercise (1) during pregnancy and (2) after childbirth, using rigorous systematic review and search criteria. Part 1 focuses on the effects of training during pregnancy and on the management of common pregnancy-related symptoms experienced by athletes.
  • Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2—the effect of exercise on the fetus, labour and birth, Bø K, Artal R, Barakat R, et al., British Journal of Sports Medicine, Volume 50(21), pp.1297-1305, (2016). This evidence statement, based on a systematic literature search, examines how strenuous exercise affects the fetus. It also addresses issues relating to birth, such as risk of preterm birth, prolonged labour and mode of delivery, including injuries to the pelvic floor muscles and the perineum.
  • Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3—exercise in the postpartum period, Bø K, Artal R, Barakat R IOC Medical Commission, et al., British Journal of Sports Medicine, Volume 51(21), pp.1516-1525, (2017). The aims of this paper are to present (1) the findings from a systematic review of the scientific literature on factors related to returning to exercise after childbirth in recreational and elite athletes, and (2) the prevalence, risk factors and evidence for prevention and treatment of common postpartum conditions that may affect sport performance and overall quality of life.
  • Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC expert group meeting, Lausanne. Part 4—Recommendations for future research, Bø K, Artal R, Barakat R, et al., British Journal of Sports Medicine, Volume 51(24), pp.1724-1726, (2017). In Part 4, we recommend future research based on Parts 1–3. The systematic reviews, on which the previous Parts were based, revealed many gaps in knowledge relating to strenuous exercise during pregnancy and in the postpartum period, in both regular recreational exercisers and elite athletes. Important research questions are listed below, in relation to the foci of Parts 1–3, under the following headings: exercise during pregnancy, exercise related to birth outcomes and exercise in the postpartum period.
  • Exercise and pregnancy in recreational and elite athletes: 2016/2017 evidence summary from the IOC expert group meeting, Lausanne. Part 5. Recommendations for health professionals and active women, Bø K, Artal R, Barakat R, et al., British Journal of Sports Medicine, Volume 52(17), pp.1080-1085, (2018). Summarises the recommendations for exercise during pregnancy and after childbirth in recreational exercisers and elite athletes experiencing healthy pregnancies. Part 5 also serves as a background for healthcare personnel to advise women who wish to stay active at a high level.
  • Exercise Benefits and Recommendations for the 6-Week Postpartum Period, Loewen, Brandon, Collum, Connor, Ryan, Greg A., Strength and Conditioning Journal, Volume 42(4), pp.12-21, (August 2020). The postpartum period is the stage after childbirth and is associated with many physical and psychological changes. Exercise has been shown to be beneficial for both the physical and psychological health of a new mother. Previous literature has examined the effect of both aerobic and resistance training in this period; however, there have been no clear guidelines and recommendations provided. Therefore, the purpose of this article is to review the benefits of exercise in the postpartum period, and to provide guidelines and a sample 6-week aerobic and resistance training program after exercise initiation after delivery and medical clearance.
  • From Childbirth to the Starting Blocks: Are We Providing the Best Care to Our Postpartum Athletes? Rita E. Deering, Shefali M. Christopher, Bryan C. Heiderscheit, Journal of Orthopaedic & Sports Physical Therapy, Volume 50(6), pp.281-345, (31 May 2020). There is minimal evidence to guide return to exercise after pregnancy and childbirth, and even less information on safe return to competitive sport. The International Olympic Committee has suggested a 3-phase approach to postpartum recovery in athletes. This Viewpoint expands on that 3-phase model and incorporates a multidisciplinary approach to ensure comprehensive care of postpartum athletes to facilitate safe return to sport with optimal health and performance outcomes. Adopting a multidisciplinary approach may also open new research avenues to ameliorate the dearth of knowledge regarding musculoskeletal recovery and facilitate the development of guidelines to inform clinicians and postpartum women about safe return to exercise, particularly, high-intensity or high-impact activities.
  • How the menstrual cycle and menstruation affect sporting performance: experiences and perceptions of elite female rugby players, Rebekka J Findlay, Eilidh H R Macrae, Ian Y Whyte, et.al., British Journal of Sports Medicine, Volume 54(18), pp.1108-1113, (2020). This study provides the first in-depth insight into athlete’s experiences of the menstrual cycle and perceived impact on training and competition. It highlights individual responses to menstrual ‘issues’ and emphasises the need for clinicians and support staff to undertake menstrual cycle profiling, monitoring and continue to develop awareness, openness, knowledge and understanding of the menstrual cycle.
  • Postpartum exercise, Brad Roy, ACSM's Health & Fitness Journal, Volume 18(6), pp.3-4, (November/December 2014). There are numerous benefits to being physically active after pregnancy, including a reduction in fat mass, increased lean mass, improved lipid profiles, and enhanced mental outlook and acuity. All women are encouraged to begin exercising as soon as medically appropriate and to remain physically active throughout their lifetimes.
  • Pregnancy and Postpartum Training: Coaching Considerations, Wise, Stephanie L., Binkley, Jean L., Binkley, Helen M., Strength and Conditioning Journal, Volume 42(4), pp.93-104, (August 2020). Exercise is beneficial for women to continue during pregnancy and the postpartum period. However, many women do not meet the minimum guidelines set forth by the American College of Obstetricians and Gynecologists. Strength and conditioning coaches and personal trainers working specifically with athletes and nonathletes during childbearing years should continue to encourage their clientele to exercise. Educating them on altering their current exercise program and adapting it as they progress through their pregnancy into the postpartum period is important. General recommendations for exercise and certain modifications may be needed as many physical and physiological adaptations occur within the body during this time.
  • ‘Provide clarity and consistency’: the practicalities of following UK national policies and advice for exercise and sport during pregnancy and early motherhood, Eilidh H. R. Macrae, International Journal of Sport Policy and Politics, Volume 12(1), pp.147-161, (2020).  This qualitative study employed a social-ecological framework to investigate the experiences of new mothers based in the UK and the practicalities of engaging in regular exercise during pregnancy and the postpartum period. Three themes were generated as recommendations to the sector. The first theme was the importance of providing ‘trusted advice’ from reputable sources. The second theme was the need for provision of ‘safe, affordable sport and exercise options’. The final theme was the need for more ‘considered postpartum support’ for exercise, through further childcare options and a range of supportive environments for women to exercise within postpartum.
  • Spotlight on the fetus: how physical activity during pregnancy influences fetal health: a narrative review, Ilena Bauer, Julia Hartkopf, Stephanie Kullmann, et.al., BMJ Open Sport and Exercise Medicine, Volume 6(1), (2020). In the current review, we aimed to comprehensively assess the evidence of beneficial and harmful effects of maternal PA, including high-performance sports, on fetal development. The different mental and body-based relaxation techniques presented here are frequently performed during pregnancy. We found a considerable number of studies addressing these issues. In general, neither low key, moderate maternal PA nor relaxation techniques were observed to have a harmful effect on the developing child. However, we identified some forms of PA which could have at least a transient unfavourable effect. Notably, the literature currently available does not provide enough evidence to enable us to make a general conclusive statement on this subject. This is due to the lack of longitudinal studies on the metabolic and cognitive effects of regular PA during pregnancy and the wide diversity of methods used. In particular, the kind of PA investigated in each study differed from study to study.
  • Why can’t I exercise during pregnancy? Time to revisit medical ‘absolute’ and ‘relative’ contraindications: systematic review of evidence of harm and a call to action, Meah VL, Davies GA, Davenport MH, British Journal of Sports Medicine, (8 June 2020). We found that the majority of medical conditions listed as contraindications were based on expert opinion; there is minimal empirical evidence to demonstrate harm of exercise and benefit of activity restriction. We identified 11 complications (eg, gestational hypertension, twin pregnancy) previously classified as contraindications where women may in fact benefit from regular prenatal physical activity with or without modifications. However, the evidence suggests that severe cardiorespiratory disease, placental abruption, vasa previa, uncontrolled type 1 diabetes, intrauterine growth restriction, active preterm labour, severe pre-eclampsia and cervical insufficiency are associated with strong potential for maternal/fetal harm and warrant classification as absolute contraindications.

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