Running is a high-impact mode of exercise and a readily available and safe form of physical activity that most women can engage in during and after pregnancy.
1 , While the physical and psychological health benefits of running are well understood, 2 3 , many women are unsure about the suitability and safety of running during the 4 perinatal period. The literature indicates that most pregnant women reduce or stop participating in exercise due to concerns such as discomfort, fear of harm to the baby, and participation in fertility treatments. 5 6 , Our recent work specifically in runners (part A of this research) identifies similar concerns as well as highlighting pelvic floor dysfunction concerns. Furthermore, women who do want to continue to run during or after pregnancy often struggle to navigate how to engage with running, especially around work-related barriers. 7 Current recommendations informing pregnant and postpartum exercise advise 7 perinatal women to engage in at least 150 minutes of moderate-intensity exercise per week, including a combination of cardiovascular exercise and strength training. Existing guidance also advises pregnant and postpartum women to listen to their body and adapt exercise accordingly, 8–13 8 , outlining several cautions and contraindications to exercise. 9 While the United Kingdom (UK) Chief Medical Officer's guidance advises that postpartum women return to exercise using a graded approach, with particular focus on pelvic floor muscle training, 10–12 there is limited running-specific advice for 9 perinatal women. Consequently, often conflicting guidance is provided by medical and health practitioners or there is a reluctance to provide any type of exercise advice. 13
Research has shown that when women are advised about exercise either before or during their pregnancy, it can increase their odds of engaging with various modes of exercise during pregnancy by threefold.
In addition, running during pregnancy has been shown to be predictive of running engagement postpartum, 6 which could facilitate a reduction in pregnancy-associated increases in body mass and reduce the risk of future maternal obesity. 5 14 , This means that providing 15 perinatal women with exercise advice that enables them to continue high-impact exercise, such as running, could potentially have lifelong implications. However, there appear to be inconsistencies in the provision of pregnancy exercise advice 6 , and such inconsistencies may transfer over to postpartum high-impact exercise advice. Yet, this association in receiving advice across the 16 perinatal period has not been explored. This disparity in equitable service provision could affect engagement with running and potentially have negative impacts on maternal health, thus further investigation is warranted.
To overcome difficulties in accessing advice regarding postpartum high-impact exercise, internationally disseminated clinical guidelines on return-to-running postpartum were publicly released in 2019.
The clinical guidelines were freely accessible online and targeted at clinicians, fitness professionals, and postpartum women. Several key messages relating to postpartum recovery time and avenues to seek support were highlighted, with a view to change a woman's approach to return-to-running postpartum. A key component of behavior change is effective knowledge dissemination, 17 which needs to suit the preferences of the target population. This has been specifically identified as essential for the 18 perinatal population to maximize knowledge transfer, 16 , during a time when a wealth of information is being given to women. It is currently unknown whether the return-to-running clinical guidelines generated an awareness of key postpartum rehabilitation messages, led to women changing their approach to return-to-running, or whether the dissemination of the clinical guidelines was delivered via a suitable format. Understanding these aspects will inform the development and dissemination of future evidence-based guidelines. 17
The aim of this study was to explore the exercise and/or running-related advice that pregnant and postpartum women received and the impact that it had on their running habits. A secondary aim was to assess knowledge of return-to-running clinical guidelines and preferences for dissemination of running-related advice. It was hypothesized that: (i) women who received prenatal exercise advice would have increased odds of receiving postpartum running advice, (ii) women who received prenatal exercise and postpartum running advice or were aware of the return-to-running clinical guidelines would have increased odds of running during these periods, and (iii) women would prefer to receive running-related advice through websites.
Eight hundred and eighty-three women [age: 33.8 ± 3.7 years; years running: 10 [5-15] years; number of children 1 [1-2]; country of residence: UK 70% (n = 621); United States 17% (n = 147); Ireland 5% (n = 40); Canada 4% (n = 36); and other 4% (n = 26)] volunteered to complete an online survey related to their experiences of running during and after pregnancy. Participants were recruited via advertisement of the study on social media (Twitter, Instagram, and Facebook), with study inclusion criteria requiring respondents to be female, older than 18 years, within 2 years of childbirth, and have run at least once per week prior to pregnancy. All participants provided voluntary, informed consent at the beginning of the survey. The University's Ethics Committee granted ethical approval for the study (protocol number: Sta-2875) and data were anonymized and stored on a General Data Protection Regulation-compliant, online system, only accessible to the research team.
Survey Design and Development
Participants responded to an initial series of demographic question items including age, number of children, country of residence, whether they ran during pregnancy, the date that they gave birth, and whether they had returned to any level of running postpartum, as well as how many weeks postpartum they were when they first ran. Then items relating to being given any prenatal exercise guidance (“yes” or “no”) were provided and those who selected “yes” to receiving prenatal exercise guidance had to specify what prenatal exercise guidance they received from a list of 5 options [“pelvic floor exercise,” “physical activity (eg, 150 minutes of moderate-intensity activity per week),” “strengthening exercises (excluding pelvic floor),” “understanding signs and symptoms of when to scale back exercise during pregnancy (eg, dizziness, abdominal cramping, and spotting/fluid loss),” and “other”]. If “other” was selected, participants were asked to specify what other advice they had received. Finally, participants were asked whether they had ever been provided with specific return-to-running guidance following childbirth (“yes, to follow the Couch to 5K,” “yes, but not the Couch to 5K”, and “no”). If “yes, but not the Couch to 5K” was selected, participants were then asked to specify who provided their return-to-running guidance from 6 possible options (“GP,” “pelvic health physiotherapist,” “MSK/sport physiotherapist,” “nurse/midwife,” “running coach/personal trainer,” and “other”). The National Health Service (NHS) “Couch to 5K” is a structured, graded return-to-running program,
suggested as beneficial in the return-to-running clinical guidelines. 19 Again, those who selected “other” were then asked to specify the source of the advice in a free-response text box. Any type of postpartum advice outlined above is referred to herein as broadly sourced postpartum running advice. 17
Awareness of the recently published return-to-running clinical guidelines
was then established with participants answering “yes” or “no” to the question “Are you aware of return to running guidelines recently published by Goom, Donnelly and Brockwell?”. If participants answered “yes,” they were then asked whether reading the clinical guidelines resulted in participants either: (1) seeing a pelvic health physiotherapist or (2) changing their approach to return-to-running (“yes” or “no”). Participants were also asked what key messages they took from the guidelines and selected any of the 5 options that applied (“recovery following childbirth extends beyond the traditional concept of the 6-week postnatal check,” “it is generally recommended to wait at least 12 weeks prior to returning to high-impact activity such as running,” “symptoms of pelvic floor dysfunction may be common, but are not normal and are an indication that my body is not ready for this level of exercise yet,” “an evaluation with a pelvic health physiotherapist from 6 weeks following childbirth can be useful to identify any areas requiring targeted rehabilitation in order to safeguard a return-to-running,” and “there are additional factors to consider in determining readiness to return-to-running, eg, weight, sleep, energy levels, and psychological well-being”). Finally, participants were asked how they would like to receive return-to-running guidance and selected all that applied in an 8-option list [“Infographics,” “websites,” “GP,” “pelvic health physiotherapist,” “nurse/midwife,” “short videos,” “educational leaflets/handouts,” “other (please specify)”]. Those who answered “other (please specify)” were then provided with a free-text response box to expand. 17 Data Preparation and Analysis
The survey originally yielded 1462 responses; however, some participants failed to provide consent (n = 52) and 527 respondents either did not meet the inclusion criteria or did not complete the required questions. Participants were only included in the analysis if they gave an answer for all of the closed-ended questions analyzed in part A and part B of this study (n = 883), such that survey completeness was 62.6%. There were no duplicate responses, checked using IP address and age to account for the possibility that multiple respondents had the same IP address. The number of total responses for each question differed from the overall number of survey respondents because some questions were only displayed if specific conditions were met. All responses were forced.
Descriptive data (frequencies and proportions) were computed for each question. Chi-square analysis and odds ratios (ORs; 95% confidence intervals [CIs]) were used to ascertain whether there was an association between receiving prenatal exercise advice and receiving broadly sourced postpartum running advice, as well as receiving prenatal exercise advice and continuing to run through pregnancy. A binary logistic regression was used to determine whether there was an association between having returned to running postpartum (“yes” or “no”) and the following independent variables: (1) receiving any broadly sourced postpartum running advice (Couch to 5K or other sources) and (2) being aware of the return-to-running clinical guidelines.
Time since birth was controlled for via entry as a continuous covariate. The exponent of the regression model estimates was used to calculate OR. A Mann-Whitney 17 U test compared the time to first run postpartum in those who were aware and those who were not aware of the return-to-running clinical guidelines. Chi-square analyses were performed in Microsoft Excel (16.21.1) and all other statistical analysis was undertaken in SPSS Statistics (Version 26, IBM, Armonk, New York). Statistical significance was accepted at α level .05. RESULTS
Prenatal and Postpartum Exercise Advice
Only 37% of participants (n = 330) reported receiving prenatal exercise advice, with the most common advice being about pelvic floor exercises (
Figure 1). Examples of responses from participants who answered “other” (n = 23) included advice to reduce running or weights, modify exercise, monitor heart rate, undertake core strengthening, and exercise if you feel it is OK, as well as advice that it is safe to run. There was no association between receiving prenatal advice and continuing to run during pregnancy (OR: 1.17, 95% CI: 0.89-1.54, P = .258). Figure 1.:
The proportion (%) of respondents reporting to receive each type of prenatal exercise advice (n = 330). The number of responses (n) for each reason is shown at the end of the bars. As participants could select multiple options, the total number of responses does not equal 100%.
Note: Selections are abbreviated in the figure. Full descriptions of selections as they appeared in the survey include: (i) pelvic floor exercises; (ii) physical activity (eg, 150 minutes of moderate-intensity activity per week); (iii) strengthening exercises (excluding pelvic floor); (iv) understanding signs and symptoms of when to scale back exercise during pregnancy (eg, dizziness, abdominal cramping, and spotting/fluid loss); and (v) other.
There was an association between receiving prenatal exercise advice and receiving broadly sourced postpartum running advice, with those who had received prenatal exercise advice being more likely to receive postpartum running advice (OR: 1.78, 95% CI: 1.33-2.38,
P < .001). Of the 31% (n = 278) who had received postpartum exercise guidance, 47% (n = 130) were advised to follow the Couch to 5K and 53% (n = 148) were provided with general advice. Of those provided with general advice, most (64%; n = 95) women received postpartum guidance from a pelvic health physiotherapist ( Figure 2A). One-fifth (19%; n = 28) received advice from “other” sources. Examples of these included other forms of physiotherapists, social media, own research, friends, ReCORE, Buggyfit, and information leaflets. Figure 2.:
The proportion (%) of respondents for (A) how they received return-to-running guidance (if it was not the Couch to 5K; n = 148) and (B) their preferred way of receiving return-to-running guidance in the future (n = 883). The number of responses (n) for each reason is shown at the end of the bars. As participants could select multiple options, the total number of responses does not equal 100%.
Note: Selections are abbreviated in the figure. Full descriptions of selections as they appeared in the survey include (A): (i) pelvic health physiotherapist; (ii) running coach/personal trainer; (iii) other; (iv) MSK/sport physiotherapist; (v) GP; and (vi) nurse/midwife and (B): (i) websites; (ii) pelvic health physiotherapist; (iii) infographics; (iv) nurse/midwife; (v) educational leaflets/handouts; (vi) GP; (vii) short videos; and (viii) other. GP indicates general practitioner; MSK, musculoskeletal. Awareness of Return-to-Running Postpartum Guidelines
Over one-third (35%; n = 310) of study respondents were aware of the recent return-to-running clinical guidelines, with the majority of these (94%; n = 290) finding the clinical guidelines useful. Nearly three-quarters of respondents (74%; n = 230) who were aware of the clinical guidelines changed how they approached return-to-running and 45% (n = 138) went to see a pelvic health physiotherapist. Having returned to any level of running postpartum was associated with having received postpartum running-related guidance (OR: 2.192, 95% CI: 1.450-3.316, β= 0.785;
P < .001) and not associated with being aware of the return-to-running clinical guidelines (OR: 0.689, 95% CI: 0.476-0.997, β= −0.373; P = .048). Additionally, those who were aware of the return-to-running clinical guidelines took longer to return-to-running than those who were not aware [14 (10-20) vs 10 (6-16.5) weeks, respectively, U = 34 889, P < .001].
The key messages that females took from the clinical guidelines in descending order were: recovery following childbirth extends beyond the traditional concept of the 6-week postpartum check (86%; n = 266); it is generally recommended to wait at least 12 weeks prior to returning to high-impact activity such as running (85%; n = 262); there are additional factors to consider in determining readiness to return-to-running (eg, weight, sleep, energy levels, and psychological well-being; 77%; n = 237); an evaluation with a pelvic health physiotherapist from 6 weeks following childbirth can be useful to identify any areas requiring targeted rehabilitation in order to safeguard a return-to-running (76%; n = 235); and symptoms of pelvic floor dysfunction may be common, but are not normal and are an indication that my body is not ready for this level of exercise yet (73%; n = 227). The most popular preferred dissemination route for return-to-running information was through websites (62%; n = 547) and pelvic health physiotherapists (62%; n = 545), with less than half (41%; n = 358) of respondents wanting such information from their general practitioner (GP) (
Figure 2B). Some examples of sources suggested by respondents who selected “other” (4%; n = 35) included general antenatal packs, apps, or “anyway” possible. DISCUSSION
The aim of this study was to explore the exercise and running-related advice that pregnant and postpartum women received and the impact that it had on their running habits. Only one-third of women received prenatal exercise guidance, broadly sourced postpartum running-related guidance, or were aware of the return-to-running postpartum clinical guidance. Women who received prenatal exercise guidance had greater odds of receiving postpartum running guidance. However, contrasting findings were observed regarding guidance received and, exercise and running habits. Specifically, receiving exercise guidance during pregnancy was not associated with continuing to run through pregnancy, while receiving broadly sourced postpartum running-related guidance was associated with returning to running. Contrary to our hypothesis, being aware of the return-to-running postpartum clinical guidelines was associated with reduced odds of returning to running and led to a delay in the time taken to return-to-running postpartum. Websites and pelvic health physiotherapists were the preferred dissemination routes for postpartum women.
Interestingly, our findings show that only one-third of females received prenatal exercise guidance, which is considerably less than previous reports of 53% and 72% of women receiving prenatal exercise advice.
20 , This may reflect differences in country-related health care provision, with previous observations reported from Australian- and Canadian-based studies compared with the majority of respondents in the current study being based in the UK. Of those who received prenatal advice, the most common form of advice was to engage with pelvic floor exercises ( 21 Figure 1), which is recommended in most countries' prenatal and postpartum guidance. 13 , Given the high prevalence of stress urinary incontinence within the 22 perinatal population, 5 , such advice is warranted as there is strong evidence that pelvic floor exercises decrease the risk of developing stress urinary incontinence as well as effectively treat it. 23 Physical activity and exercise that align with the current, pregnancy-related guidance from the UK Chief Medical Officer 24 was the second most common recommendation ( 8 Figure 1). While this advice was not specific to the current study cohort's needs, it shows that consistent exercise advice is being provided to pregnant women. However, two-thirds of females did not have access to pregnancy exercise advice, which appears to reflect an issue specific to UK-based health provision, given the high percentage of respondents from the UK. Further research is required to determine whether this is a widespread global issue.
In support of our first hypothesis, receiving prenatal exercise-related guidance was found to increase the odds of receiving postpartum running guidance. There are likely to be several factors that may influence whether guidance is received. One factor is lower socioeconomic status, which has been associated with reduced access to education in relation to maternal obesity among similar
perinatal populations. It is possible that access to all forms of 25 perinatal knowledge dissemination may be impacted in lower socioeconomic backgrounds and should be a priority to investigate further. Another possible factor is geographical health care provision and promoted initiatives within such provision. Specifically, staffing levels within a perinatal multidisciplinary team need to be able to meet the demands of the service and any unmet need will have associated implications for the service users. Interestingly, GPs and nurses/midwives were not the main source of advice for postpartum running, with pelvic health physiotherapists identified as the main source of running advice for 26 perinatal women. However, there is a shortage of pelvic health physiotherapists to serve the demands of the perinatal population in the UK. Therefore, utilizing a multidisciplinary team to support 26 perinatal care appears to be necessary to enable equitable, tailored perinatal exercise guidance to be provided. In addition, further exploration to understand the knowledge and provision of perinatal exercise advice by the wider multidisciplinary team is necessary to identify training needs and streamline services.
Despite previous work identifying an association between receiving exercise-related guidance and exercising during pregnancy,
there was no association between receiving prenatal exercise-related guidance and continuing to run during pregnancy. This is in contrast with receiving broadly sourced postpartum running guidance increasing the odds of return-to-running, meaning our second hypothesis was only partially supported. It is conceivable that this is due to the type of advice (eg, general exercise vs running specific) being provided. During pregnancy women predominantly received general pelvic floor exercise and physical activity advice and only a few received running-specific advice (“other” category). Conversely, postpartum women were provided with running- advice, but sought this from physiotherapists and running coaches/personal trainers rather than GPs and midwives. Thus, guidance was provided from outside standard health care models, where midwives are the standard point of contact and the 6- to 8-week postpartum check with the GP is considered to be the cornerstone of postpartum recovery. It is evident that supporting women to remain active during pregnancy needs to go beyond providing women with standardized medical information relating to exercise. Instead, guidance should consider the individual constraints and needs of pregnant women (eg, lifestyle). 6 7 , 16 , Therefore, it is important that women are provided with tailored exercise guidance during pregnancy, which aligns with their preferred exercise habits, in a similar manner to that which was found during postpartum with women receiving broadly sourced running advice. Furthermore, given the range of sources providing advice identified in our study, it is critical that consistent UK governmental or other country-specific guidance on general pregnancy and postpartum activity is being provided by health care practitioners and those in community-based settings. 27
Positively, of the 35% of women who were aware of the return-to-running postpartum clinical guidelines,
94% found them useful. This indicates that the format and content was helpful to postpartum women and provides a suggested template for future revisions, while also advocating the need for such guidance. The key messages taken from the return-to-running guidance by postpartum respondents indicate they had greater awareness of appropriate factors they should consider when returning to running. Alongside the return-to-running clinical guidelines, 17 marginally more females stated they would prefer to receive advice on return-to-running through websites than any other source. This indicates that ease of access is a priority for women, which supports previous work in 17 perinatal populations and is also similar to individuals involved in the management of sport-related injuries, such as concussion. Further, internet-based e-technologies can facilitate interventions aimed at changing behavior in the postpartum population, but there is a need to individualize the support provided. 28–30 16 , While broad return-to-running clinical guidelines provide a framework to support postpartum women, it is pertinent to suggest that interventions aimed at returning women to running should meet their individual needs. Pelvic health physiotherapists were also identified as a preferred source for postpartum women to receive advice and demonstrated the ability to meet this need, as a similar proportion of women who wanted to receive advice from them did receive such advice. It is imperative that return-to-running behavior change is facilitated by aligning knowledge dissemination with preferred dissemination routes. Consequently, appropriate signposting to online resources and pelvic health physiotherapists, as service provision allows, from those involved in standard postpartum care (eg, GPs and midwives) should be in place to ensure women receive adequate exercise guidance that meets their individual needs. 29
In contrast to our second hypothesis, women who were aware of the return-to-running clinical guidelines had decreased odds of returning. In part, this may be explained by the fact that women who were aware of the return-to-running clinical guidelines took, on average, 4 weeks longer to undertake their first postpartum run than women who were not aware (14 vs 10 weeks, respectively). Delaying the time to return-to-running could be viewed negatively, as enhanced rehabilitation for musculoskeletal injuries typically shortens recovery.
However, it could be argued that this is a positive step forward due to resources such as the return-to-running clinical guidelines offering greater awareness and knowledge of postpartum recovery, informed by return-to-running criteria. Previous work has shown longer musculoskeletal injury rehabilitation times occur when using individualized, criteria-based rehabilitation, in addition to a reduction in future injury risk. 31 Further, greater sports injury knowledge has been argued to lead to higher reported injury rates rather than a reduction in injury rates. 32 Specifically in our study, the majority of women recognized that they had changed their approach to running and nearly half visited a pelvic health physiotherapist. This means that increased awareness of postpartum recovery, particularly the key message to wait 12 weeks on average, before return-to-running, in combination with changing reported behavior appears to have delayed the return-to-running. This approach to return-to-running reduces the odds of returning to pre-pregnancy running levels, 33 which potentially reflects a more cautious approach involving graded exposure and greater awareness of postpartum symptoms. Such an approach aligns with sports injury return-to-play models, whereby active recoveries that gradually increase load are recommended. 5 Application of similar principles to postpartum recovery is encouraged to support women to lead active lifestyles following childbirth. 34 5 , Consequently, providing women with key postpartum rehabilitation messages through open access and easily interpretable documentation appears to facilitate behavior change and should be considered by future initiatives. 17
A strength of this study was that a large cohort was used, but due to the retrospective nature of the study recall bias may be present, particularly for pregnancy-related responses. Another limitation was that all exercise-related advice during pregnancy was considered rather than specific running-related advice, as currently there are no recommended guidelines relating to running during pregnancy. However, women were able to indicate whether they received running advice by choosing “other” and specifying the advice provided. Future research exploring prenatal running-related guidance specifically may offer further insights. Factors such as socioeconomic status and type of medical provision (eg, private or public) were not directly assessed in the current study and warrant further investigation. Lastly, data were collected during the global COVID-19 pandemic and therefore it is possible that restrictions and lockdowns, particularly in the UK, may have affected some of the participants' experiences or access to information.
In summary, only one-third of postpartum women received pregnancy exercise-related guidance. Those who received such guidance were more likely to also receive postpartum running-related guidance. This indicates that demographic factors may influence access to
perinatal exercise knowledge and highlight the need for further investigation. To positively influence running habits, guidance needs to be individualized and specific to the needs and interests of perinatal women rather than broad and only pertaining to general activity guidance. This was evidenced by a lack of association between maintaining running habits during pregnancy and receiving general exercise guidance, compared with a positive association between returning to running and receiving postpartum running-related guidance. Internet-based, open-access clinical guidelines appeared to be effective at stimulating behavior change and women returning to running after an appropriate rehabilitation period. Ensuring a multidisciplinary team supports postpartum women to return-to-running is important, particularly with pelvic health physiotherapists being one of the preferred avenues of dissemination for running-related advice. ACKNOWLEDGMENTS
The authors would like to thank all mothers who completed this survey and Ms Olivia Mannall for her initial contribution to the article.
1. Keyes LE, Hackett PH, Luks AM. Outdoor activity and high altitude exposure during pregnancy: a survey of 459 pregnancies. Wilderness Environ Med. 2016;27(2):227–235. doi:10.1016/j.wem.2016.02.010.
2. Kuhrt K, Harmon M, Hezelgrave NL, Seed PT, Shennan AH. Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy. BMJ Open Sport Exerc Med. 2018;4(1):e000296. doi:10.1136/bmjsem-2017-000296.
3. Pedisic Z, Shrestha N, Kovalchik S, et al. Is running associated with a lower risk of all-cause, cardiovascular and cancer mortality, and is the more the better? A systematic review and meta-analysis. Br J Sports Med. 2020;54(15):898–905. doi:10.1136/bjsports-2018-100493.
4. Nascimento SL, Surita FG, Cecatti JG. Physical exercise during pregnancy: a systematic review. Curr Opin Obstet Gynecol. 2012;24(6):387–394. doi:10.1097/GCO.0b013e328359f131.
5. Moore IS, James ML, Brockwell E, Perkins J, Jones A, Donnelly GM. Multidisciplinary, biopsychosocial factors contributing to return-to-running and running-related stress urinary incontinence in postpartum females. Br J Sports Med. 2021. doi:10.1136/bjsports-2021-104168.
6. Nascimento SL, Surita FG, Godoy AC, Kasawara KT, Morais SS. Physical activity patterns and factors related to exercise during pregnancy: a cross sectional study. PLoS One. 2015;10(6):e0128953. doi:10.1371/journal.pone.0128953.
7. Connelly M, Brown H, van der Pligt P, Teychenne M. Modifiable barriers to leisure-time physical activity during pregnancy: a qualitative study investigating first time mother's views and experiences. BMC Pregnancy Childbirth. 2015;15(1):100. doi:10.1186/s12884-015-0529-9.
10. Mottola MF, Davenport MH, Ruchat S-M, et al. 2019 Canadian guideline for physical activity throughout pregnancy. Br J Sports Med. 2018;52(21):1339–1346. doi:10.1136/bjsports-2018-100056.
12. Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstet Gynecol. 2020;135(4):e178–e188. doi:10.1097/aog.0000000000003772.
13. Evenson KR, Mottola MF, Owe KM, Rousham EK, Brown WJ. Summary of international guidelines for physical activity after pregnancy. Obstet Gynecol Surv. 2014;69(7):407–414. doi:10.1097/OGX.0000000000000077.
14. Rooney BL, Schauberger CW. Excess pregnancy weight gain and long-term obesity: one decade later. Obstet Gynecol. 2002;100(2):245–252. doi:10.1016/s0029-7844(02)02125-7.
15. (NICE) NIoCE. Overview. Weight management before, during and after pregnancy. 2010.
. Published July 28, 2010.
16. Salmon VE, Rodgers LR, Rouse P, et al. Moving through motherhood: involving the public in research to inform physical activity promotion throughout pregnancy and beyond. Int J Environ Res Public Health. 2021;18(9):4482. doi:10.3390/ijerph18094482.
17. Goom T, Donnelly GM, Brockwell E. Returning to running postnatal–guidelines for medical, health and fitness professionals managing this population.
. Published 2019. Accessed June 7, 2021.
18. NICE. Behaviour Change: The Principles for Effective Interventions. London, England: National Institute for Health and Care Excellence; 2007.
20. Hayman M, Reaburn P, Alley S, Cannon S, Short C. What exercise advice are women receiving from their healthcare practitioners during pregnancy? Women Birth. 2020;33(4):e357–e362. doi:10.1016/j.wombi.2019.07.302.
21. Santo EC, Forbes PW, Oken E, Belfort MB. Determinants of physical activity frequency and provider advice during pregnancy. BMC Pregnancy Childbirth. 2017;17(1):286. doi:10.1186/s12884-017-1460-z.
22. Evenson KR, Barakat R, Brown WJ, et al. Guidelines for physical activity during pregnancy: comparisons from around the world. Am J Lifestyle Med. 2014;8(2):102–221. doi:10.1177/1559827613498204.
23. Hansen BB, Svare J, Viktrup L, Jørgensen T, Lose G. Urinary incontinence during pregnancy and 1 year after delivery in primiparous women compared with a control group of nulliparous women. Neurourol Urodyn. 2012;31(4):475–480. doi:10.1002/nau.21221.
24. Mørkved S, Bø K. Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med. 2014;48(4):299–310.
25. Okesene-Gafa KAM, Li M, McKinlay CJD, et al. Effect of antenatal dietary interventions in maternal obesity on pregnancy weight-gain and birthweight: Healthy Mums and Babies (HUMBA) randomized trial. Am J Obstet Gynecol. 2019;221(2):152.e1–152.e13. doi:10.1016/j.ajog.2019.03.003.
27. Wagnild JM, Pollard TM. “sit yourself down”: women's experiences of negotiating physical activity during pregnancy. Qual Health Res. 2020;30(7):1072–1082. doi:10.1177/1049732320909103.
28. Mathema P, Evans D, Moore IS, Ranson C, Martin R. Concussed or not? An assessment of concussion experience and knowledge within elite and semi-professional Rugby Union. Clin J Sport Med. 2015;26(4):320–325. doi:10.1097/JSM.0000000000000256.
29. Almohanna AA, Win KT, Meedya S. Effectiveness of Internet-based electronic technology interventions on breastfeeding outcomes: systematic review. J Med Internet Res. 2020;22(5):e17361. doi:10.2196/17361.
30. Watterson JL, Walsh J, Madeka I. Using mHealth to improve usage of antenatal care, postnatal care, and immunization: a systematic review of the literature. Biomed Res Int. 2015;2015:153402. doi:10.1155/2015/153402.
31. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2013;47(15):953–959. doi:10.1136/bjsports-2013-092165.
32. Mendiguchia J, Martinez-Ruiz E, Edouard P, et al. A multifactorial, criteria-based progressive algorithm for hamstring injury treatment. Med Sci Sports Exerc. 2017;49(7):1482–1492. doi:10.1249/mss.0000000000001241.
33. Bitchell CL, Mathema P, Moore IS. Four-year match injury surveillance in male Welsh professional Rugby Union teams. Phys Ther Sport. 2020;42:26–32. doi:10.1016/j.ptsp.2019.12.001.
34. Ardern CL, Glasgow P, Schneiders A, et al. 2016 consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016;50(14):853. doi:10.1136/bjsports-2016-096278.