How the UKSI Manages the Postpartum Return of British Athletes

This article was written by Rachel Woodland at the Leaders Performance Institute.

Given the recent increase in women choosing to not delay having a family, and the subsequent increase in athletes competing during and after pregnancy, sport systems need to adapt in support of this growing demographic.

Our [Leaders Performance Institute] recent Women’s High Performance Sport Community call featured the UK Sports Institute sharing how organisations can better support athletes returning to performance postpartum.

We were delighted to be joined by:

• Esme Matthew, the Head of Physiology at the UKSI
• Dr Kate Hutchings, a Sports Medicine Doctor working with the UKSI’s leading clinical services for all world-class-funded Olympic and Paralympic athletes
• Dr Richard Burden, who leads the Female Athlete Performance Programme at the UKSI

The conversation focused on the structures UKSI have put in place to support athletes, including the role multidisciplinary teams (MDTs) have, which practices are having a positive impact on athletes, and what was learnt in the most recent Games cycle.

Six core themes emerged around what is involved in guiding an athlete successfully through pregnancy and their postpartum return. We also discussed what can be done where resources are limited.

1. Preparation and planning are crucial

The timing of when an athlete chooses to inform their coach and support team of their pregnancy will vary, but having conversations as early as possible during pregnancy is essential to map out return-to-performance plans. It’s advised that athletes establish support networks and define expectations with their teams before delivery. This could include what they expect in terms of communication from their coach, when they’re hoping to train, and how they’d like to stay connected to their sport or team. The panel recommended putting this in contract form and falling back on the initial discussion when necessary.

In their experiences, Matthew and Hutchings have found that Performance Lifestyle Advisors play a pivotal role in helping athletes navigate logistics like childcare, breastfeeding, and travel. It might also be that the Performance Lifestyle Advisor is the team member the athlete lets know first of their  plans to have a child, and signposted the athlete to the resources offered by the Female Athlete Performance Programme.

Deciding what will be monitored before giving birth will help with this planning process and ensure shared expectations postpartum. The monitoring plan will also help shape MDT support. More on each to come.

2. Multidisciplinary support teams

It won’t surprise you to hear that effective return requires collaboration between many people, including but not limited to:

• Doctors (such as Hutchings)
• Physiologists (such as Matthew)
• Nutritionists
• Pelvic health physiotherapists
• Mental health professionals

That being said, the athlete must be central to all decisions, with support teams adapting to their evolving needs. It also won’t surprise you that no athlete return is the same as any other, even if it isn’t the athlete’s first child. Ultimately it comes down to who they trust to help them make decisions. Even if the goal is to have the athlete make final decisions, they’ll seek input and guidance along the way.

A key learning from more recent years has come from athletes wanting to test and push the boundaries of what’s possible when pregnant. For Matthew and Hutchings, the health and wellbeing of the athlete and baby are the first priority. But athletes are not used to that being a default mindset. It’s not that they don’t care about their own wellbeing or the wellbeing of their baby, but they are used to continuously thinking about how they are going to be better athletes. How can they return faster? How can they get themselves in the best possible shape pre-delivery so that their postpartum period is as easy as possible. Alongside this, MDTs will need to come together to help support an athlete through some really difficult questions. For example, ‘can I go on this training camp in warm weather?’, ‘can I still compete at this week of my pregnancy?’ or ‘can I still do  my sport?’ The reality is that you are not going to find an answer to these questions in a research article.

A further reality is that these questions will always be asked, and that a standard FAQ section won’t suffice. Instead, the duo recommend talking through the risk.

Typical questions:

• What’s the risk of falling?
• What’s the risk of impact?
• How far along in your pregnancy are you?
• What risk are you willing to take?

The aim is to have the athlete answer these question for themselves. The MDT needs to be able to provide guidelines for athletes to be able to consider that for themselves, given that some examples, such as ‘can I go on this training camp to Australia, where we know it’s going to be really hot?’ and ‘can I still do a competition while it’s still really hot if I feel OK?’ can’t be answered ahead of time. They have to be able to answer it on the day given how many factors might change. But we should be educating them in how to make that decision.

One way to approach this is to talk through the theory with the athlete. With the heat example, that’s explaining blood flow and where else blood will be directed beyond the placenta. If they understand the theory of it, it can make it easier for them to make decisions for themselves.

Beyond this, a couple of things to definitely avoid were shared too:

1. Anaerobic exercise.
2. No supine exercise later on in pregnancy.
3. No lying on your stomach during exercise.
4. Towards the end of pregnancy, although still up to the athlete, avoid any risk of falling. For example, avoiding contact sport.

The UKSI are also really clear with the athletes that they don’t provide any sort of obstetric support. So they’re not there to be midwives or health visitors.

Then there are additional considerations to think of for who might be part of the athlete’s support team. For example, Hutchings is working with a Paralympian and she had to leave a meeting because she was going to a session where her hearing dog was going to be trained to listen for a newborn baby’s cry. There are situations where the planning for post-natal is even more considered.

Involving a partner can also be an excellent addition to support teams. It gives them more information for when the athlete needs them to fight the traditional athlete mentality to push through. There can also be a discussion about how hard this transition might be and that the athlete is going to need support through their decision making. It can provide another check and challenge for them when questioning if they really need to push that hard today or offer observations such as ‘I can see you feel really tired. Why don’t you just have a day off?’ It’s not an athlete’s mindset. Their mindset is more likely ‘I feel a bit off, but I’m going to carry on anyway’. Matthew shared that, “having someone that’s there with them on a day-to-day that can really help with that has been really useful”.

It’s also important to train staff. Matthew added that ahead of the Paris cycle, the learning module for staff across the UKSI was rewritten. Para athlete support was interwoven across the module rather than being a separate section, as it had been previously.

On the call, we also spoke about any instances where an athlete might prefer to talk to Matthew or Hutchings about her pregnancy, rather than her MDT in her sport and her coach, and everything that goes with it. Both have found this to be quite rare. If it has happened it’s normally been where they are the only female support they have, or when the team haven’t known about the pregnancy yet. In response to this,  they’d focus on brining  everyone together to be aligned with the initial message to the athlete being a reminder that Matthew and Hutchings are there as an extra layer of support for both the athlete and their support team within the sport. This is usually followed up with an MDT webinar. This would cover what their training and pregnancy would look like. Talking through training plans postpartum with all of their support team with the athlete in the room. Typically this gels and brings everyone together.

Matthew and Hutchings were quick to point out that some of the best examples of support teams have been all male apart from themselves. They’ve been incredibly understanding, and couldn’t do enough for the athletes. It’s just trying to bring everyone together and get them on the same page.

The other time this can happen is before an athlete is pregnant, but they would like to talk about what training might look like during pregnancy or what return  timelines might look like for them in their sport, and they might not want to talk to the sport about it yet because they don’t feel comfortable.

So Matthew and Hutchings would always encourage them to tell their sport as early as possible, but it does at least give like a bit of a safety net for that.

3. Pelvic health as a game changer

When asked around practices that have a positive impact on athlete return postpartum, pelvic floor education and support before and after birth was repeatedly described as transformative for any female athlete, given its impact on incontinence and strength training.

From research around the Commonwealth Games in 2022 one in five athletes reported urinary incontinence. They were planning for adapting to this through kit changes or fluid restrictions. The stats for urinary incontinence postpartum, regardless of mode of delivery, is at one in three athletes; and faecal incontinence is one in 10. “It’s such an important area for us to get right and that’s why we always work very closely with pelvic health physios,” said Hutchings. “If you keep up and do all your pelvic floor exercises, if you’ve got good pelvic health antenatally, you reduce your risk of urinary incontinence by 40 per cent postpartum, regardless of the method  delivery.”

Athletes are encouraged to use tools like the NHS Squeezy app and see a pelvic health specialist pre- and postnatally if something bespoke is needed.

As a group we also discussed being careful with the interrelatedness of symptoms of pelvic floor weaknesses and REDs. With it being important to stay diligent around REDs given changes to nutritional needs, if breastfeeding; plus changes in bone density linked to giving birth. All with the added complexity that athletes remain on the register for drugs testing in their sports and will need to be sensible with supplements.

4) Individualised return plans

Given that no two athletes’ journeys are the same. Plans must be flexible and responsive to daily changes in health and energy. Monitoring will play an important role here, with the likes of readiness scores, subjective wellness, sub-max testing guiding training and return.

It’s important to have awareness about each athlete’s training environment. Especially as each athlete will stop full training at different stages antenatally for a variety of reasons. That could also impact when they reengage postpartum too. This awareness, allied to open communication, is even more important if they’re the only pregnant athlete in a squad or sport.

This is important for thinking about athletes feeling disconnected, and how we can continue to keep them in the same spaces as other athletes, but with a different programme, for example in the gym, or continuing to attend squad meetings, even if they’re not training at the same capacity.

As mentioned earlier, having some really clear markers as part of an athlete’s individualised plan is also helpful. This would include discussing what you would like to measure postpartum before you get there. This can useful for the coach too. Matthew and Hutchings also always work hard on helping the athlete connect with detraining while accepting that some of the markers that they would keep track of normally are going to go down. There are also conversations about things like blood volume and endurance levels. For example, some endurance athletes will panic about losing fitness and when these conversations happen, Matthew and Hutchings talk about the physiological principles that sit around pregnancy that actually support a maintenance of economy and supporting systems. So having those markers lets the athlete and MDT talk through the pregnancy, what are you expecting to see, and managing those expectations and then, postpartum, what would you look to be monitoring when you come back and when would you look to do that?

An example where this work well, is in rowing and Jack Brown’s work with Olympic double sculls bronze medallist Mathilda Hodgkins-Byrne. They included clear physiological markers and sub-max testing to guide return. Together they put some good markers in place around sub-max testing to look at economy. They had some clear markers in the sand that the sport wanted the athlete to meet but did some nice monitoring around that. This included morning monitoring, which is quite tricky to get done when the athlete is having to get up and look after her child. Her first thought is to talk about what can work and potential practical solutions that you can look at. It could be that starting with just a readiness score for training for the day can be tracked and then over time you can start to build others back in. For example, resting heart rate in the morning when that feels really important, say, six months postpartum.

We discussed options to support training, including blood flow restriction. However, there are other things that can be done that are just really sound training principles around muscle hypertrophy postpartum that could be harder to implement than previously; therefore focus could be on those first. It could be as basic as doing good training and recovery. It can be quite difficult for athletes to do the training postpartum when they’ve got so much going on, like getting to training, being able to take the time out to do it, finding childcare, sorting all of their nutrition. So that’s a really big focus for the UKSI postpartum, the planning and organisation. With nutrition, this might be have you got something in the car that you can eat on the way home? Because once you get home the baby is back to you and you’re in full-on Mum mode.

Further, if an athlete or coach wants to use methods such as BFR because they want to accelerate their return, it’s known that from a pelvic floor point of view the UKSI doesn’t get people running much before 12 weeks anyway. Thus, you could accelerate other areas such as muscle development, but it’s the pelvic floor that you want to engage. And that takes time.

5) Mental health and identity

Both Matthew and Hutchings advocate for mental health support, and work with a psychologist for pregnant and postpartum athletes. The change they face is vast, likely moving from a very regimented and structured training life to one full of unpredictability and many unknowns and firsts. There can be a struggle with the dual identity of being a new mother and an elite performer. As Hutchings said: “I think that’s really important for us to recognise and have those conversations and then feeling comfortable to say to their team. Actually, I don’t feel all right today or I’m a bit tearful, I’m struggling or I don’t feel like I fit in.”

It’s important for the MDT to recognise that an athlete might feel disconnected as they return to their sporting environment. They might be the first (or only current) athlete to be pregnant.

6) Peer support and mentorship

A simple support mechanism has been the creation of a WhatsApp group for pregnant and postpartum athletes to foster peer mentorship and shared learning. This informal network has been highly valued for emotional support and practical advice.

What about those with fewer resources?

Smaller sports often lack in-house expertise. UKSI fills this gap by offering bespoke support and education.

Practitioners are encouraged to upskill using resources like:

IOC Pregnancy Guidelines
6R Framework (Gráinne Donnelly)
Greg Whyte’s Bump It Up

How might you take advantage of the UKSI’s experiences in athlete return postpartum?

• If you’re in the GB Paralympic and Olympic system your sport can utilise the UKSI Female Athlete Performance Team through Dr Kate Hutchings.
• If you have research and innovation questions, and you’re in a position to do so, (Paralympic, Olympic or professional sport), you could work with the Centre of Excellence for Women in Sport, which the UKSI collaborate with alongside Manchester Metropolitan University through Dr Richard Burden.

The Women’s High Performance Sport Community Group is an action orientated space for those working in high performance sport that are passionate about growing women’s sport and access for women in sport to learn, build relationships, solve shared problems and share those learnings with the wider performance community.

Join the Group by visiting the Leaders Performance Institute website.