Running is embraced globally as a pastime to keep fit and health, and yet there is little information for midwives to give to women runners. Running is, according to Audickas (2017), the most common participation sport in the UK, but there is very little evidence about the specific needs of women who run during pregnancy and who return to running in the postnatal period. Midwives have a responsibility to encourage woman to adopt healthy behaviours such as exercise during pregnancy and as they move into motherhood.
General recommendations for physical activity
The Department of Health's (2011a) ‘Start Active, Stay Active’ strategy recommends that adults should be active everyday and should complete at least 150 minutes of moderate intensity physical activity each week. Alternatively, similar health benefits can be achieved through 75 minutes of vigorous intensity activity or a combination of moderate and vigorous activity. Moderate intensity activity is an activity that results in faster breathing, whereas vigorous intensity activity can be described as activity that results in a faster heartbeat quickly and it is more difficult to have a conversation (Department of Health, 2011b).
Physical activity in pregnancy
Pregnancy is often seen as a teachable moment where a woman is often more willing to adopt risk-reducing behaviours that will benefit both her and her baby (Phelan, 2010). Evenson et al (2014) compared guidelines from around the world on physical activity during pregnancy and found that the variations reflect the lack of well-designed studies on vigorous intensity activity. Midwives should be advising pregnant women that 150 minutes of moderately intense activity per week is recommended (UK Chief Medical Officers, 2017a), which is the general advice for adults (UK Chief Medical Officers, 2017b). The UK Chief Medical Officers (2017b) suggest that the focus of the advice should be on recommendations for how to modify physical activity for women to remain comfortable as their pregnancy progresses, and adapting vigorous intensity activity such as running. Mottola and Artal (2016) propose following the FITT principle (Frequency, Intensity, Time or duration of an activity and the Type of exercise) as guidance for women who are exercising and that these factors will change as a pregnancy progresses. However, there is limited consensus on the optimal frequency, intensity or duration of physical activity for pregnant women. The Nuffield Department of Population Health found that there was no increased risk of preterm birth, small or large for gestational age babies or other newborn complications for pregnant women engaging regularly moderate intensity physical activity (UK Chief Medical Officers, 2017a).
Research has also shown that physical activity in pregnancy changes the metabolic responses in both the mother and fetus (Mottola and Artal, 2016), with decreases in plasma insulin levels, cortisol, glucagon and growth hormone concentrations. Exercise has been found to counteract the elevation of very-low-density-lipoprotein, low-density lipoprotein cholesterol and triglycerides observed in late pregnancy. Mottola et al (2013) suggest that physical activity during pregnancy may be an effective intervention in reducing the risk of developing pre-eclampsia and preterm birth. There are several other factors that may influence the maternal metabolic response, including the duration and intensity of physical activity, fitness level of the woman and nutritional intake.
Physiological adaptations become altered during pregnancy and as a result of aerobic conditioning. Aerobic exercise in non-pregnancy causes the resting heart rate to become lowered; however, during pregnancy this is reversed and the resting heart rate increases (Weissgerber et al, 2006). There is also some evidence that fetal heart modulation and improved autonomic control occurs in response to aerobic exercise (May et al, 2010). Aerobic exercise that continues throughout pregnancy has also been shown to have positive effects on the variability and adaptability of the fetal heart, both of which are both important for a healthy fetus (May et al, 2012). These cardiovascular responses in the fetus appear to be a result of a dose-response relationship between intensity and duration of maternal exercise (May et al 2012). Furthermore, there is some evidence to show that regular aerobic weight-bearing exercise, such as running, stimulates mid-pregnancy placenta growth and increases the surface area, which is advantageous for the fetus (Mottola and Artal, 2016).
There are also recommendations about different types of physical activity to avoid during pregnancy (Box 1) and key health messages about the benefits of physical activity for pregnant women of which midwives should be aware (UK Chief Medical Officers, 2017a) (Box 2). However, there are several contraindications to exercise in pregnancy, of which women should be made aware (Box 3). Women should be advised to stop exercising immediately and seek advice from their midwife or lead clinician if they experience any changes to fetal movements, vaginal bleeding, suspected amniotic fluid leakage, contractions that start to increase in frequency, chest pain, irregular heartbeat, shortness of breath, syncope or dizziness, calf pain or swelling in the calf.
Running and pregnancy
Running in pregnancy is not exclusive to the elite athlete. More women are participating regularly in running; however, there are no accurate figures specifically relating to the number of pregnant women who are taking part. With a growing interest in healthy lifestyles and fitness, running is accessible to many as it requires very little equipment. In fact, the demographic of runners has changed—more that 60% of marathon runners are women and in other running events, participation rates are higher for women than men. Therefore, it is important for midwives and other clinicians to recognise that more women are running before, during or after pregnancy (Blyholder et al, 2017; Kuhrt et al, 2018).
There are many physiological benefits for women who run, including stronger pelvic floor muscles, a lower resting heart rate, lower triglyceride levels, increased high-density lipoproteins and increased oxygen uptake. Runners also benefit from improved mental health, emotional and social support, and weight management (Hitchings and Latham, 2017).
Guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) and the American College of Obstetricians and Gynecologists (ACOG) (2015) have endorsed the recommendation that women who exercise regularly before pregnancy and have no contraindications can safely continue to participate in vigorous intensity activities such as running (UK Chief Medical Officers, 2017a). However, Ohlendorf et al (2018) found that women were often advised to stop running or reduce the amount of running they did during pregnancy, despite the evidence that physical activity is a healthy activity during pregnancy.
Running is seen by many women as a part of their identity, but also provides many physical and mental health benefits (Ohlendorf et al, 2018). Little (2017) recognised that one benefits of running was mental relaxation. Running gave women ‘me time’ and this was noted by some as being more important than the actual running itself (Little, 2017). There was also a suggestion that women who run had a heightened awareness of the physical changes occurring in their body during and after pregnancy and would make adjustments to their exercise regime if they felt any discomfort during exercise, or they felt they were putting themselves or their fetus at risk (Ohlendorf et al, 2018).
However, the UK Chief Medical Officers (2017b) suggest that women should be advised to modify their physical activity as there is insufficient evidence to support a recommendation for vigorous intensity activity during pregnancy. Ohlendorf et al (2018) found that women in their study would often withhold information about their running activities, particularly if they perceived the advice given by health professionals to be incorrect or old-fashioned. Increasingly women are turning to social media sites for information and support to self-manage their health during pregnancy (Little, 2017; Ohlendorf et al, 2018). Several initiatives set up in the UK by women to support like-minded women who run. Run Mummy Run and This Mum Runs (Box 4) have launched social media pages and both have seen these networks grow into large online running communities dedicated to supporting mothers who run. These support networks bring women together from all backgrounds via social media to enjoy the social and emotional wellbeing benefits that running offers.
Hadfield (2014) offers several recommendations to women runners who are pregnant: re-framing training goals to adapt to the pregnancy by running regularly rather than increasing distance; focusing on the quality of the run; using a treadmill, which gives a more safe and consistent terrain and therefore decreases the risk of falls; adjusting goals to reflect the change in role as a mother; and enabling the physiological changes in the body to return to normal after pregnancy before returning to maximum-effort running.
Postnatal advice
Midwives need to be aware that there is no specific information for women runners about the postpartum period and when to return to their pre-pregnancy running schedule. However, women should be advised to return gradually. General advice includes pelvic floor exercises to prevent incontinence issues. Up to 40% of women may experience some degree of urinary incontinence during the postpartum period; however, most can be resolved with simple pelvic floor exercises. In addition, women runners can experience aching in the pelvic area. Blyholder et al (2017) reported that 1 in 3 women experienced musculoskeletal pain on returning to running, with the majority of pain in the lumbopelvic area. This can often be attributed to the action that the hormone relaxin has on the joints and ligaments during pregnancy, so women should be advised to build up their return to running gradually.
Women may experience some degree of diastasis recti (a gap between the longitudinal abdominal muscles) and this can lead to abdominal and pelvic issues. A midwife should refer women with this condition to an obstetric physiotherapist for specific advise.
Women runners are usually aware of the benefits of supportive and correctly fitting footwear that helps to reduce the risk of injury and muscle pain, but it may come as a surprise to find that their running shoes are no longer comfortable or fitting correctly after having a baby. This is thought to be from the action of relaxin causing a change to the arches of the feet triggering the feet to flatten and widen, so women runners should seek advice from a reputable running shoe provider, where they can receive a gait analysis and have their running shoes fitted correctly to provide proper support (Bachelor, 2017).
Support networks for women runners
Physical activity and other healthy behaviours have the potential can change patterns of disease such as obesity, diabetes, heart disease and cancer and to deliver improvements in morbidity and mortality. It is well documented that physical activity decreases abdominal fat and plays a role in long-term weight maintenance and cardiovascular fitness (Townsend and Scriven, 2014).
The Royal College of General Practitioners (RCGP) (2018) has recently partnered with Parkrun UK (Box 4) to promote health and wellbeing for their staff and patients, an international network of free weekly timed 5 km runs with over 1650 events in 20 countries worldwide (Parkrun, 2018a; Parkrun,2018b). This partnership supports a UK-wide move to increase social prescribing activities as an alternative to medical treatment, which will benefit the long-term health of individuals and ease some of the pressures on general practices. Many Parkruns are buggy friendly, enabling women to continue to run with their families, and are led by volunteers to promote physical activity in a supportive community event (Stevinson et al, 2015). Research has explored the benefits of mass participation community running events and women's running networks in reducing physical inactivity and boosting self-esteem and physical and mental fitness (Wiltshire et al, 2018).
A more specific running-based initiative set up by England Athletics is called RunTogether (Box 4). It is also based online and signposts people who want to start running, or those who already run, to local groups in their area, in order to build community networks, and provide an opportunity to keep physically active. RunTogether has set up other initiatives such as #RunAndTalk where running groups help with motivation, mental health and wellbeing. RunTogether's aim is to provide a fun, friendly and inclusive environment for everyone in England; RunWales/Rhedeg Cymru is a similar organisation based in Wales. Furthermore, Sport England funded by the National Lottery set up the ‘This Girl Can’ initiative in 2015 (Box 4). The use of online marketing campaigns showing women from all backgrounds, abilities, shapes and sizes celebrating their achievements has persuaded more than 3 million women to become more active.
Conclusion
Women choosing to run during pregnancy is a result of the popularity of running generally and it is important that health professionals feel confident to give women the best advice based on the most up-to-date evidence available. Midwives are best placed to care and advise women to meet their individual circumstances through the trusting relationships they build. Midwives and other health professionals can signpost women in their care towards the growing number of support networks available. Physical activity should generally be encouraged during pregnancy for the many benefits that it provides, but there are some occasions where women should be advised to either refrain from exercise or modify their running patterns. There does however, remain a gap in clinicians' knowledge of guidance specifically for pregnant women who run, which warrants further detailed research.
