INTRODUCTION
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 , 2 3 , 4 perinatal period.5 6 , 7 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.8–13 8 , 9 10–12 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.6 5 14 , 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 advice6 , 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 2019.17 18 perinatal population to maximize knowledge transfer,16 , 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.
METHODS
Participants
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
A 25-item online survey was designed and developed by a team of pelvic health physiotherapists and human movement experts. Face validity and readability of the survey were established via pilot testing with a small group (n = 3) of postpartum runners. Following usability testing, the survey was refined and published on a University Qualtrics account (Qualtrics, Provo, Utah). The final version included 24 closed-ended questions and 1 open-ended question, with the opportunity to expand on certain selected responses with a free-response text box for 5 of the close-ended items. Participants accessed the survey via a software-generated, bespoke survey address from June 2020 to September 2020. No incentives were offered for participating in this study and items could not be randomized due to the ordered nature of questions that were asked. Some question items were only available to participants depending on the response provided to the previous question(s), such that the number of items (18-24) and screens (9-10) varied between participants. JavaScript was used to ensure completion of items and facilitate changes to and reviewing of answers throughout the survey with a back button.
Survey Items
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,19 17
Awareness of the recently published return-to-running clinical guidelines17
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.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 , 21 Figure 1 ), which is recommended in most countries' prenatal and postpartum guidance.13 , 22 perinatal population,5 , 23 24 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.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.26 perinatal women. However, there is a shortage of pelvic health physiotherapists to serve the demands of the perinatal population in the UK.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,6 7 , 16 , 27
Positively, of the 35% of women who were aware of the return-to-running postpartum clinical guidelines,17 17 perinatal populations and is also similar to individuals involved in the management of sport-related injuries, such as concussion.28–30 16 , 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.31 32 33 5 34 5 , 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.
CONCLUSION
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.
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