Postpartum recovery time

Having enough time to recover from childbirth was reported as essential to female athletes to avoid injury and regain fitness postpartum. Research suggests that female athletes who RTS too soon postpartum may be more prone to experience injury.10 53 54 Regardless, athletes in this review reported feeling pressured by their sport organisation to RTS sooner than preferred. Until recently, limited guidance existed to inform sport organisations how and when female athletes should RTS postpartum.55 Of the RTS frameworks that do exist, few acknowledge the postpartum period and typically focus on the management of musculoskeletal injuries, risk of reinjury and psychological readiness.10 56 As such, many sport organisations relied on the medical clearance at 6 weeks postpartum as the basis for their athletes to RTS postpartum.15 However, Goom et al (2019) highlights that 6 weeks is an arbitrary time for recovery, and that medical clearance does not account for other broader physiological and non-physiological factors (eg, fatigue, breastfeeding, hormonal changes, reduced exercise tolerance, readiness to return) that can contribute to an increased risk of injury postpartum.57 These broader factors combined with the limited knowledge of clinicians, trainers and coaches on how to treat and train postpartum athletes put these athletes at an increased risk of injury, especially if they RTS too soon.58 In 2022, Donnelly et al, published the 6 Rs framework providing a phased, whole systems, biopsychosocial approach. Specifically, this framework extends on existing RTS frameworks by utilising a ‘proactive rather than reactive approach’, recommends the involvement of a multidisciplinary team and provides a graduated, systematic, criterion-based approach to support the individualised, safe and effective RTS among postpartum athletes.59 This individualised approach is critical given the wide range of considerations that must be accounted for when athletes RTS postpartum (eg, type of birth, whether athletes trained during their pregnancy as research suggests athletes who train during their pregnancy can RTS postpartum more quickly than those who do not train during pregnancy).15 54

Time to manage motherhood and sport demands

Not having enough time to commit to both sport and family was commonly reported. A lack of time was mainly due to the competing demands of sport and motherhood (eg, time needed to look after child as well as train). Based on cultural and social norms of parenthood, women in general devote more time to the care of their child/children than men.60 Moreover, the time dedicated to taking care of children, especially prior to school years, is a major factor for determining whether women re-enter the workforce.61–63 To enable their RTS postpartum, female athletes in this review reported devising specific strategies to balance the demands of both family and sport. For instance, athletes expressed and stored breastmilk to enable partners to feed their child,43 45 as well as asked family or friends to look after their child while they trained.37 43 However, these strategies often required significant time to plan and implement and were highly influenced by the support available to the athletes (eg, whether family could assist with childcare).37 43

Sport organisation policies

The lack of sport organisation policy, specifically in relation to maternity leave, family travel and childcare, was identified as a barrier that reduced the ability of female athlete to RTS postpartum. Darroch et al (2019) suggests that the lack of maternity leave within female athlete contracts not only discriminates but forces athletes into a precarious financial situation to remain athletes postpartum particularly given their income is reduced and there is no guarantee for their return.14 Likewise, when sport organisations do not provide athletes family travel and childcare assistance, athletes were forced to pay for these expenses out of their own pocket, which they were not always able to afford. Despite female athletes playing at the pinnacle of their sport, many female athletes are considered low-income earners who earn considerably less than their male counterparts.64 65 As a result of their income, many female athletes were often forced to travel without family as well as rely on family for childcare support to enable them to train and compete. These arrangements, however, do not come without significant implications. For example, travelling without family caused many female athletes in this review to experience negative emotions such as guilt, selfishness and doubt about being a good mother.12 Similarly, over-relying on family for childcare caused some athletes to be subjected social judgements about their capabilities as mothers.37 Recently, policy issues such as maternity leave, family travel and childcare assistance have been placed on the agendas of sports organisations, thanks to the advocacy of elite athletes such as Allyson Felix.66 In a 2019 interview with TIME magazine, Felix spoke publicly about how her sponsor Nike failed to provide any equitable protections in her contract regarding injury or reduced performance postpartum.66 In response to public backlash regarding Felix’s article, organisations such as Nike have now amended their policies to include protections such as paid maternity leave, while other organisations like Athleta have gone on to introduce additional finance provisions such as funding for childcare and family travel.66 67 Regardless, polices like paid maternity leave, childcare, and family travel remain limited within female sport.5

Stereotypes

Underpinned by traditional gendered ideologies and trivialised perceptions of women and mothers in sport, female athletes in this review both perceived and were subject to stereotypes that influenced their decision/s to RTS postpartum. Stereotypes specifically perceived by female athletes focused primarily on traditional gendered ideologies such as ‘ethic of care’ and ‘good mother identity’ and how such ideologies do not align with their sport. As a result of these ideologies, athletes perceived negative emotions regarding their RTS postpartum such as guilt. Markedly, these same ideologies were also perceived by friends and family which exacerbated the negative emotions felt by athletes. Comparatively, stereotypes from sport organisation personnel, such as coaches, reflected trivialised perceptions of women and mothers in sport. For example, one perception is that female athletes are incapable of returning to the same level of sport postpartum.41 Research suggests that any stereotype can threaten the career, performance and motivation of female athletes to ‘persevere’ with sport.68 To negate stereotypes, female athletes modified their perceptions by justifying the positive attributes and benefits of sport to self and child; for instance, allowing athlete to role model dedication, hard work and a healthy lifestyle to their child, as well as provide their child new experiences.11–13 41 43 One’s ability to modify their perceptions in the face of adversity aligns to that of self-efficacy.69 Research regarding interventions to improve self-efficacy amid injured athletes has been shown to improve athlete retention and RTS, thus too could be beneficial for postpartum athletes to enable their RTS postpartum.70

Social support

Given the lack of policy to support female athlete to RTS postpartum, athletes relied heavily on social networks (ie, family, friends, coaches and teammates) for emotional, financial and practical types of support. This support was essential for female athletes to be able to RTS postpartum. For example, to afford themselves both time and space to RTS postpartum athletes relied heavily on family for childcare. Research shows that family support is imperative for both the physical and mental health of mothers; yet not all women have access to or are able to draw on family for support.71 Barkin et al (2014) and Darvill et al (2010) found that mothers experience difficulties obtaining help if family do not live close by.72 73 Similar findings were also found in this review with athletes who did not have family nearby, reporting being forced to RTS later than preferred.41 However, in cases where family support was not available, athletes acknowledged seeking the support of close friends.13 Notably, coaches and teammates also provided athletes with support; however, this support reflected coaches being understanding of athlete circumstances and catering to the athletes needs such as being flexible with training, and teammates providing athletes with advice about sport and motherhood such as when to express/feed their child before training. Though this type of support from coaches and teammates is beneficial, it does not fully accommodate the practical and emotional needs of female athlete to RTS postpartum.

Strengths and limitations

This scoping review used rigorous and transparent methods throughout the entire process including the use of PRISMA-ScR guidelines to guide data collection, cross-checking data with two researchers and summarising findings using an established framework (ie, the socioecological model). Nevertheless, there are limitations to consider when interpreting the findings of this review. Only studies reporting the barriers and enablers of athletes who successfully returned to sport postpartum were included in this review. These barriers and enablers may differ from athletes who did not RTS postpartum. As such, this review may not have identified all barriers and/or enablers that influence athletes RTS postpartum. Despite an extensive review of the literature, the exclusion of non-English language studies may have also led to additional barriers and enablers not being identified. Some studies included in this review also assessed athletes who had given birth before becoming an ‘elite’ athlete, thus their identity as a mother may be more established. It is not known if this would have a greater or lesser impact on barriers and enablers experienced. While not limitations of this review, but rather limitations of the current body of evidence, the following factors should still be considered when interpreting the findings of this review. No study explicitly defined the ‘postpartum period’. This resulted in significant variability in the timeframe in which athletes’ barriers and enablers were examined. Additionally, the ‘athlete’ was inconsistently defined across studies. For instance, the two McGannon et al, studies defined their ‘athletes' as ‘recreational athletes’, who were competing at an international level,11 44 while other studies defined their ‘athletes’ as ‘elite athletes’ if they were competing at an international level.15 48 Moreover, few studies in this review specified when athletes returned to sport postpartum or what level of sport they returned to. Without this information, a standardised account of barriers and enablers cannot be determined to guide policy development. Lastly, five studies in this review comprised of athletes competing at different levels of sport (eg, local, national, international), but then did not separate the athletes based on the level of sport athletes were competing at for analysis. This meant we were unable to differentiate the barriers and enablers experienced by athletes competing at the different levels of sport within these studies. Therefore, barriers and enablers identified in this review may not be relevant to all athletes.

Based on these limitations we recommended future research: (1) explicitly define the postpartum period, such as the 12-month timeframe suggested by Bø et al 10; (2) follow standardised definitions and classifications of ‘athletes’, such as those recently established by McKay et al in their Participant Classification Framework74; (3) report when (weeks post birth) athletes returned to sport postpartum and what level of sport the athletes returned to; (4) separate athletes based on level of sport for analysis to enable greater exploration of the barriers and enablers experienced by athletes who compete at different levels to help establish policies of relevance; as well as consider the limitations of this review when examining barriers and enablers influencing female athlete RTS postpartum.