Women's Football Hub

Author Carolyn Kent – Lecturer in Physiotherapy – University of Cumbria.

The 2023 FIFA Women’s World Cup (WWC) was a World Cup of firsts. It was the first WWC to be staged in 2 countries, the first senior tournament to be held in Oceania, first with 32 teams and 64 matches, highest fan attendance (1,978,274) and the first to break even financially generating $570 million in revenue¹ . It was also the first WWC where players who were also mothers were spotlighted, including Brazil defender Tamires and versatile USA player Julie Ertz.

What are the changes that a female athlete’s body will go through?

A female athlete will experience multiple changes once they become pregnant. Their cardio-vascular system will increase cardiac output by 30%, plasma volume increase by 40% and their heart rate will increase². Bone mineral density decreases by 3-6%,^3,4 biomechanical changes include an increase lumbar lordosis, center of mass shifts forward, trunk stability decreases, stride length reduces and step width and knee flexion increases⁵. Therefore, practitioners should be mindful of all these changes when prescribing exercise.

What are some of the risks and consequences to these changes?

70% of healthy pregnant women will complain of breathlessness⁶. 36% of pregnant women world-wide suffer anaemia⁷. Back pain is common during pregnancy with the global prevalence of back pain around 40%⁸.

What do female athlete’s need to be aware of if they are continuing to train?

Female athletes should be aware of taking on adequate nutrition/hydration, this is essential for weight gain, exercise and to prevent hypoglycaemia, and even prior to conception, an increased average intake of folate, iodine, and iron is recommended whereas, the consumption of alcohol, smoking, caffeine, and/or non-nutritive sweeteners should be avoided⁹.  Protection of bone density should be considered, transient osteoporosis of pregnancy (ToP) is a condition that is usually seen in the 3rd trimester and affects around 1 in every 250,000 women and it should be a consideration for any pregnant women complaining of hip pain during the third trimester, with MRI being the most sensitive method for diagnosis by detecting bone marrow oedema¹⁰.

What about exercise during pregnancy?

In 2019 the Canadian Physical Activity Guidelines for Physical Activity throughout pregnancy were released which advised the following:

Recommendation	Evidence quality
All women without contraindications should be physically active throughout pregnancy.	Strong recommendation, moderate-quality evidence.
Pregnant women should accumulate at least 150 min of moderate-intensity	Strong recommendation, moderate-quality evidence.
Physical activity should be accumulated over a minimum of 3 days per week. However, being active everyday is encouraged	Strong recommendation, moderate-quality evidence
Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial	Strong recommendation, high-quality evidence.
Pelvic floor muscle training (eg, Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction on the proper technique is recommended to obtain optimal benefits.	Weak recommendation, low-quality evidence.
Pregnant women who experience light-headedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position	Weak recommendation, very-low quality evidence

The guidelines stated that all pregnant women should participate in physical activity but gave a list of exceptions. These were broken down into absolute (should not exercise) and relative (should use caution) contraindications to physical activity throughout pregnancy.

Absolute Contraindications	Relative Contraindications
Ruptured membranes	Recurrent pregnancy loss.
Premature labour	Gestational hypertension.
Unexplained persistent vaginal bleeding	A history of spontaneous preterm birth.
Placenta praevia after 28 weeks’ gestation	Mild/moderate cardiovascular or respiratory disease.
Pre-eclampsia	Symptomatic anaemia.
Incompetent cervix	Malnutrition
Intrauterine growth restriction	Eating disorder
High-order multiple pregnancy (eg, triplets)	Twin pregnancy after the 28th week
Uncontrolled type I diabetes	Other significant medical conditions
Uncontrolled hypertension
Uncontrolled thyroid disease
Other serious cardiovascular, respiratory or systemic disorder.

If you are unsure whether or not you should exercise, you can use the get active questionnaire for pregnancy (UK version). This questionnaire can help you decide whether you should speak to a Doctor or healthcare professional before you begin or continue to be physically active.

But what about athletes?

Clearly the above guidelines on amount of exercise would be too conservative for some athletes and football players who have a history of high intensity and high volume training loads. In 2020, the World Health Organisation physical activity before pregnancy guidelines suggested that those who already engaged in high intensity physical activity before pregnancy could continue during pregnancy¹². High intensity interval training (HIIT) has been shown to have no adverse effects on mother or foetus at a volume and intensity of 10 x 1-min intervals at >90%HR_max¹³. With regards to weight lifting there is self reported evidence from recreational CrossFit^TM and weightlifters that showed most participants reported no complications during pregnancy or delivery while engaging in resistance exercise of >80% 1RM before and during pregnancy¹⁴.

When should players stop contact football?

But Remember

Research is constantly evolving so please ensure if you are working with a female athlete or you are a female athlete that you check the most recent recommendations and if necessary you see a qualified medical or healthcare professional.

References

1. FIFA [Internet]. fifa.com. Available from: https://inside.fifa.com/fifa-womens-world-cup-2023-tournament-recap#a-world-cup-of-firsts
2. ‌Morton A. Physiological Changes and Cardiovascular Investigations in Pregnancy. Heart Lung Circ. 2021 Jan;30(1):e6-e15. doi: 10.1016/j.hlc.2020.10.001. Epub 2020 Nov 4. PMID: 33158736.
3. Salari P, Abdollahi M. The influence of pregnancy and lactation on maternal bone health: a systematic review. J Family Reprod Health. 2014 Dec;8(4):135-48. PMID: 25530765; PMCID: PMC4266784
4. To WW, Wong MW, Leung TW. Relationship between bone mineral density changes in pregnancy and maternal and pregnancy characteristics: a longitudinal study. Acta Obstet Gynecol Scand. 2003 Sep;82(9):820-7. doi: 10.1034/j.1600-0412.2003.00227.x. PMID: 12911443.
5. Conder R, Zamani R, Akrami M. The Biomechanics of Pregnancy: A Systematic Review. J Funct Morphol Kinesiol. 2019 Dec 2;4(4):72. doi: 10.3390/jfmk4040072. PMID: 33467386; PMCID: PMC7739277.
6. LoMauro A, Aliverti A. Respiratory physiology of pregnancy: Physiology masterclass. Breathe (Sheff). 2015 Dec;11(4):297-301. doi: 10.1183/20734735.008615. PMID: 27066123; PMCID: PMC4818213.
7. Ataide R, Fielding K, Pasricha SR, Bennett C. Iron deficiency, pregnancy, and neonatal development. Int J Gynaecol Obstet. 2023 Aug;162 Suppl 2:14-22. doi: 10.1002/ijgo.14944. PMID: 37538017.
8. Salari N, Mohammadi A, Hemmati M, Hasheminezhad R, Kani S, Shohaimi S, Mohammadi M. The global prevalence of low back pain in pregnancy: a comprehensive systematic review and meta-analysis. BMC Pregnancy Childbirth. 2023 Dec 2;23(1):830. doi: 10.1186/s12884-023-06151-x. PMID: 38042815; PMCID: PMC10693090.
9. Silva MRG, Doñate BR, Carballo KNC. Nutritional Requirements for the Pregnant Exerciser and Athlete. In: Santos-Rocha R (eds), Exercise and Sporting Activity During Pregnancy. Springer, Cham. https://doi.org/10.1007/978-3-319-91032-1_11
10. Bhakta A. Transient osteoporosis in the third trimester of pregnancy: A case report. Case Rep Womens Health. 2022 Feb 14;34:e00400. doi: 10.1016/j.crwh.2022.e00400. PMID: 35242599; PMCID: PMC8857664.
11. Mottola MF, Davenport MH, Ruchat SM, Davies GA, Poitras VJ, Gray CE, Jaramillo Garcia A, Barrowman N, Adamo KB, Duggan M, Barakat R, Chilibeck P, Fleming K, Forte M, Korolnek J, Nagpal T, Slater LG, Stirling D, Zehr L. 2019 Canadian guideline for physical activity throughout pregnancy. Br J Sports Med. 2018 Nov;52(21):1339-1346. doi: 10.1136/bjsports-2018-100056. PMID: 30337460.
12. Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, Carty C, Chaput JP, Chastin S, Chou R, Dempsey PC, DiPietro L, Ekelund U, Firth J, Friedenreich CM, Garcia L, Gichu M, Jago R, Katzmarzyk PT, Lambert E, Leitzmann M, Milton K, Ortega FB, Ranasinghe C, Stamatakis E, Tiedemann A, Troiano RP, van der Ploeg HP, Wari V, Willumsen JF. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020 Dec;54(24):1451-1462. doi: 10.1136/bjsports-2020-102955. PMID: 33239350; PMCID: PMC7719906.
13. Wowdzia JB, Hazell TJ, Davenport MH. Glycemic response to acute high-intensity interval versus moderate-intensity continuous exercise during pregnancy. Physiol Rep. 2022 Sep;10(18):e15454. doi: 10.14814/phy2.15454. PMID: 36117457; PMCID: PMC9483614.
14. Prevett C, Kimber ML, Forner L, de Vivo M, Davenport MH. Impact of heavy resistance training on pregnancy and postpartum health outcomes. Int Urogynecol J. 2023 Feb;34(2):405-411. doi: 10.1007/s00192-022-05393-1. Epub 2022 Nov 4. PMID: 36331580.