Kicking Off Motherhood: Considering Return to Play Postpartum in the Footballer

Abstract

The longstanding belief that pregnancy marks the end of a footballer’s career is increasingly being challenged, with more players returning to professional, domestic, and international competition after childbirth. Pregnancy and childbirth involve unique physiological, musculoskeletal, and psychological adaptations that can influence postpartum health, wellbeing, and the return-to-play (RTP) process. This narrative review synthesizes current literature on postpartum RTP, with a focus on the specific needs of footballers. Key considerations include labor and delivery, postpartum health and wellbeing, general postpartum physical activity guidelines, broader return-to-sport principles, and football-specific factors. By supporting footballers to continue their careers through motherhood, we can enhance player retention and inspire future generations to engage in football across the lifespan.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-025-02248-9.

Key Points

Postpartum return-to-football protocols should be individualized and athlete-centered, emphasizing progressive RTP strategies to support recovery and optimize performance.

A comprehensive postpartum RTP approach should integrate biopsychosocial health considerations, with shared decision-making between the footballer and key stakeholders to ensure holistic support.

There is a need for evidence-informed postpartum RTP frameworks tailored to football, addressing current gaps in sport-specific guidance while prioritizing both athletic performance and long-term health.

Multidisciplinary teams (MDTs) are integral to postpartum RTP, providing coordinated care that supports musculoskeletal recovery, psychological readiness, and the physical demands of football.

Introduction

“There is a 4th trimester to pregnancy and we neglect it at our peril” said anthropologist Sheila Kitsinger in 1975 [1, 2]. Traditionally defined as the 6 weeks following childbirth [3], the postpartum period is now recognized as an extended period of physiological and psychological adaptation, with many individuals experiencing lingering effects that impact their return to sport. In 2018, the American College of Obstetricians and Gynecologists (ACOG) reframed the postpartum period as the “fourth trimester,” highlighting ongoing challenges such as sleep deprivation, hormonal shifts, psychological stress, and medical issues persisting from pregnancy [4]. ACOG’s position paper advocates for a transformational shift in the medical community’s understanding of postpartum recovery, to align with a more accurate reflection of the longer-term process requiring continued guidance and support.

The perspective that pregnancy marks the end of a footballer’s career is increasingly being challenged. Athletes such as Alex Morgan, Katrina Gorry, Melanie Leopolz, and Sydney Leroux have demonstrated that not only is postpartum return to elite competition possible but also offers opportunity for optimal performance. Although football-specific postpartum data remain limited, research from other elite sports indicate that returning to play at a high level is both safe and feasible [5].

This narrative review provides a structured synthesis and critical evaluation of postpartum return-to-play (RTP) considerations for footballers, beginning with an overview of postpartum recovery, followed by a discussion of current guidance for return to postpartum physical activity and sport as applied to the postpartum footballer. The review is grounded in original research with postpartum and athletic populations, alongside the practical experience of the author group working with perinatal football players who highlight key considerations that should inform structured RTP protocols, ensuring relevance across different levels of football participation while recognizing the individuality of each athlete’s postpartum experience.

Postpartum Recovery Considerations for the Footballer

Labor and Delivery

No birth experience is the same; however, the process of events characterizing labor and delivery are ultimately finite but have the potential to impact immediate postpartum recovery and, in some cases, well beyond [4]. Labor may commence naturally or with the aid of manual or chemical induction. The first of three stages of labor can develop slowly, over days, or quickly over the course of minutes to hours, with variation through each stage. The mode of delivery is also variable, determined by a combination of medical and personal factors. Although delivery mode does not in and of itself dictate return to sport parameters, different birth interventions do have implications for postpartum physical recovery and rehabilitation, which should be considered within the context of RTP planning. A player’s birth experience is crucial to acknowledge when approaching RTP as a continuum [6]. There are longstanding myths that labor and delivery outcomes in athletic individuals are discouraging; however, a systematic review of current evidence does not substantiate these concerns [7]. While the risk of having delivery complications is not increased, those who experience tearing, episiotomy, or a cesarean section may experience a delayed return to physical activity and sport, as additional time to heal will be required.

The mode of delivery, whether vaginal or cesarean, and any associated birth trauma (physical or otherwise), directly influence the return to activity. Women who undergo an uncomplicated cesarean section typically require a minimum of 4–8 weeks for initial recovery and healing from this major abdominal surgery. However, complete recovery extends beyond this period, as the uterine scar remains thickened, and the abdominal fascia regains only around 50% of its original tensile strength [8]. Even women who remained active throughout pregnancy may experience some level of deconditioning in the weeks following delivery and should resume low-impact activity in a graduated manner.

General Postpartum Physiological Adaptations

Regardless of athletic status, pregnancy and childbirth impose unique physiological, musculoskeletal, and psychological adaptations that have potential implications for pregnancy and postpartum health, function, and physical activity [9]. After delivery, the body undergoes a gradual process of recovery, with some changes reversing quickly and others persisting for an extended period. These adaptations impact several key systems:

Cardiovascular and Respiratory Function

Pregnancy induces significant cardiovascular adaptations, some of which rapidly reverse after delivery and others that persist. A longitudinal study found that ventricular blood volume, cardiac output, and systemic vascular resistance remain altered up to 1 year postpartum [10]. Similarly, a cross-sectional study identified that aortic diameter and compliance remain elevated in parous individuals, suggesting sustained vascular remodeling beyond the first postpartum year [11]. These persistent adaptations may confer a potential physiological advantage for postpartum footballers, particularly in aerobic capacity and endurance performance.

Longitudinal data from Clapp and Capeless (1991) provide further support for this concept. They compared maximal oxygen consumption (VO_2max) trajectories in recreational athletes who conceived versus those who did not [12]. Despite a reduced training volume during pregnancy, postpartum athletes exhibited an increase in VO_2max (+ 10%) that remained elevated at 12–20 weeks and persisted at 36–44 weeks postpartum. Thus, it is possible that pregnancy may induce lasting cardiovascular adaptations that enhance aerobic performance, provided training is maintained.

As the uterus involutes postpartum, pressure on the diaphragm and lungs is relieved, facilitating the return of respiratory function to preconception levels within weeks. Further research is needed to determine how these adaptations interact with varying training loads and whether maintenance of preconception training further optimizes postpartum performance.

Hormonal and Metabolic Function [6]

The postpartum period is a time of significant hormonal and metabolic recalibration [13]. The sharp decline in estrogen postpartum has been linked to changes in mood regulation, increased risk of postpartum depression, thermoregulation disturbances, and alterations in neuromuscular function [14]. Once breastfeeding is initiated, suckling stimulates the release of oxytocin and prolactin, which inhibit the release of gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) [15]. This suppression of LH and FSH levels can lead to temporary infertility while breastfeeding, although the effectiveness of this method of contraception can vary.

Metabolically, the postpartum period is characterized by shifts in insulin sensitivity and lipid metabolism, which can impact energy availability and exercise capacity. Insulin resistance, which increases during pregnancy, begins to normalize post-birth, but individual variability exists, particularly in those with a history of gestational diabetes [16, 17]. Understanding these hormonal and metabolic shifts is essential in optimizing RTP strategies, particularly in managing energy availability and monitoring load progression in footballers.

Musculoskeletal Function

The postpartum period is characterized by biomechanical and musculoskeletal adaptations that appear to influence movement efficiency, load transfer, and neuromuscular control, all of which have implications for returning to high-impact sport. Studies comparing postpartum individuals to nulliparous controls have demonstrated persistent alterations in gait mechanics, joint loading, and lumbopelvic motor control, which may contribute to compensatory movement patterns and potentially increased injury susceptibility [18]. Postpartum athletes experiencing residual changes in lower limb kinetics and kinematics, particularly in foot biomechanics and ground reaction forces, may impact acceleration, deceleration, and cutting maneuvers fundamental to football performance [19].

Breastfeeding and Nutritional Demands

The World Health Organization recommends exclusive breastfeeding for the first 6 months of life [20]. Decisions about infant feeding are multifactorial and may be influenced by factors such as pain, latch issues, milk production, sleep deprivation, or occupational demands [21]. At least 50% of postpartum mothers are breastfeeding at 6–8 weeks postpartum [22]. Lactation is a highly energetic process requiring 450–500 kcal/day [23] but has also been found to be linked to an antiinflammatory state and may be protective for lumbopelvic pain [24]. Lactation leads to changes in bone metabolism (demineralization), gut absorption of minerals, and kidney function (renal conservation) to support adequate calcium sequestering and other nutrients necessary for breast milk [15].

Historically, physical activity was perceived to negatively impact breastfeeding [25]. Lactating mothers are often concerned about the impact of exercise and weight loss while breastfeeding on the growth and development of the infant. Key concerns include a decrease in milk supply and or composition, especially with higher volumes of activity. However, data from acute and interventional studies demonstrate that participation in exercise up to vigorous intensities is not associated with a change in volume, energy density, or composition (protein, lipid, and lactose) of breast milk in women [26–28]. Evidence from randomized controlled trials of lactating women found no difference in the body weight or growth of infants of women who exercised compared with women who did not [26, 27]. A comprehensive review on this topic in 2025 indicated that physical activity does not influence breast milk volume or macronutrient composition or infant body weight or growth [29]. While excessive caloric restriction (< 1500 kcal/day) is associated with a decrease in breast milk volume, previous work has demonstrated that more moderate restriction is not. A small percentage of women may perceive a decrease in infant willingness to breastfeed immediately after maternal exercise [29]. However, a more appropriate indicator that breastfeeding and exercise are working well together is if baby’s growth and development is appropriate.

During lactation, breasts continue to require adequate support during exercise owing to their increased and variable size and mobility. Wearing a bra that provides support and minimizes excessive movement can help reduce discomfort, especially during higher-intensity or higher-impact activities. Education about nutritional requirements for postpartum athletes should ideally come from sports nutritionists and medical practitioners specializing in female athlete health. Sports dietitians and physiologists play a key role in ensuring adequate caloric intake, micronutrient balance, and hydration to optimize performance and recovery during lactation.

Bone Health

Bone is a metabolically active tissue that undergoes continual remodeling through the processes of bone formation and resorption. During pregnancy, the maternal skeletal system serves as the primary source of calcium for the developing fetus [30]. Longitudinal studies have shown that maternal bone mineral density (BMD) decreases by approximately 6% from early to late pregnancy due to increased bone resorption [31], continuing until the resumption of menses [32, 33]. After cessation of breastfeeding, bone density is generally thought to recover within 6–12 months, with significant improvements often observed in the first 6 months post-weaning [34]. However, emerging data suggest that some women experience prolonged bone loss. A study tracking women from preconception to 9 months postpartum found that 26% of lactating individuals had not regained pre-pregnancy BMD at 19 months postpartum [33, 35–38].

To mitigate bone loss and support postpartum bone health, footballers should prioritize adequate calcium and vitamin D intake, along with progressive impact-loading exercises [39]. Weight-bearing and high-impact activities such as plyometric drills and resistance training are effective strategies to counteract lactation-associated bone demineralization [23, 40–42]. Increasing awareness about bone health should include both recommendations for dietary intake and exercise prescription. Coaches and trainers should be equipped with guidance on appropriate exercise modifications to promote safe postpartum RTP.

Postpartum Complications

Footballers and support staff need to be aware of the potential impact of postpartum complications on RTP. While a comprehensive overview is not possible, those not discussed remain important and include venous thromboembolism, peripartum psychosis, cardiac failure, post-spinal/anesthetic complications, retained products, and infection (sepsis). Below are conditions that may be experienced and can impact a players return to the pitch (Fig. 1).

Fig. 1.

Key considerations to optimise return to play postpartum

Miscarriage

The most common complication in early pregnancy is miscarriage, defined as the spontaneous loss of a fetus before 20 weeks’ gestation. The majority of miscarriages occur within the first 12 weeks [43], with estimates suggesting that 10–20% of clinically recognized pregnancies end in early pregnancy loss [44, 45]. Given that the physiological adaptations of pregnancy persist beyond pregnancy loss, particularly when miscarriage occurs in the later first trimester or early second trimester [46], attention to such adaptations post-loss, including the gradual involution of the uterus, ongoing hormonal fluctuations, and potential postpartum-like bleeding patterns, is needed [47, 48]. In addition, attention to the social and psychological adaptations for players post-loss is important [49, 50]. Ultimately, post-miscarriage care and support require a biopsychosocial approach.

Anemia

Anemia is caused by a combination of factors, including the high prevalence of untreated anemia during pregnancy and blood loss during and after delivery. The World Health Organization defines anemia as a hemoglobin concentration of < 11 g/dl at 1 week post-delivery, and < 12 g/dl in the first postpartum year [51]. This condition is highly prevalent postpartum, with up to 50% of individuals in developed and 80% in developing countries affected [52].

In addition to experiencing fatigue and altered cognition, a recent systematic review of literature demonstrated that mothers with low iron were 1.66 times more likely to experience depressive symptoms than postpartum women without anemia [53]. In addition, iron deficiency has been associated with altered neuromuscular function and diminished endurance, both of which are critical for high-performance athletes [54, 55].

It has been estimated that between 15–35% of female footballers experience iron deficiency [56]. Combined with the known reduction in iron status during pregnancy, an even greater proportion of pregnant footballers will experience anemia during and following pregnancy. Although the impact of iron supplementation on performance outcomes in pregnant and non-pregnant footballers is unknown, a recent meta-analysis demonstrated that in iron-deficient endurance footballers, supplemental iron improved iron status and aerobic capacity [55].

Low Energy Availability and Relative Energy Deficiency in Sport (REDs)

The postpartum period is characterized by significant metabolic shifts, including changes in energy availability, body composition, and nutritional demands. Weight fluctuation is common, with some individuals experiencing prolonged retention of gestational weight, while others undergo rapid postpartum weight loss due to increased energy expenditure, breastfeeding demands, or a return to physical activity. Both excessive postpartum weight retention and rapid weight loss can present challenges for athletes, particularly in sports that require high-intensity performance, speed, and endurance. However, overemphasizing weight loss in postpartum footballers has the strong potential to lead to chronic underfueling and is strongly discouraged [55, 57]. The signs and symptoms of REDs mirror those commonly experienced in the postpartum period: amenorrhea, fatigue, irritability, and sleep disturbance that can mask the development (or persistence) of REDs in the postpartum period. REDs and associated low energy availability can contribute to poor sports performance through several pathways, including hormone/endocrine, decreased neuromuscular performance, as well as a reduced intensity and/or volume of training [58]. Although REDs is poorly recognized in the postpartum period, as menstruation is a key feature and may not return during lactation, players who are breastfeeding may be at increased risk given the additional caloric demands of lactation and the masking effect of any associated ongoing amenorrhea, including bone stress injury. The primary goal of preventing and treating REDs is to maintain or restore appropriate energy balance (balancing energy intake and energy burned exercise) under the guidance of healthcare providers with specialist knowledge of REDs [59].

Scar Complications

Scars resulting from childbirth primarily include perineal scars from episiotomies or spontaneous tearing, and abdominal wall scars from cesarean sections. Studies have reported surgical site infection rates following cesarean sections ranging from 3.87% to 11.91%, with a pooled global incidence of 5.63% (95% confidence interval (CI): 5.18–6.11%). Regional variations are notable, with the highest rates observed in Africa (11.91%) and the lowest in North America (3.87%). Signs such as increasing pain, redness, discharge, separation, dehiscence, or fever should be promptly assessed to prevent complications [60]. For abdominal scars, mobility strategies can enhance abdominal wall strength and reduce pain [61]. However, it is important to recognize the return of tissue integrity in the postpartum period. The abdominal fascia regains only 51–59% of its original tensile strength by 6 weeks post-cesarean and 73–93% by 6–7 months postpartum [8]. For footballers, impaired tissue mobility due to scar tissue can impair movement strategies and associated performance, thus it should be addressed within the context of RTP planning.

Pelvic and Abdominal Health

Pregnancy, birth, and participation in high-impact activity are all independent risk factors for pelvic floor dysfunction (PFD). PFD during the postpartum period can occur following both vaginal and cesarean birth [62], with increased severity linked to several birth interventions such as prolonged second stage of labor, perineal trauma, and operative vaginal delivery (forceps-assisted birth). These factors may contribute to neuromuscular impairment of the pelvic floor, altered proprioception, and decreased load transfer capabilities, increasing susceptibility to symptoms during high-intensity sport [63]. This condition is particularly relevant for footballers owing to the sport’s repetitive load-bearing activities, high-intensity movement patterns, and the associated increases in intra-abdominal pressure (IAP) [64], all of which can place significant strain on the pelvic floor muscles and connective tissues, potentially exacerbating underlying pelvic floor dysfunction, particularly in those with a history of childbirth-related pelvic floor trauma [65].

Pelvic and abdominal health represent important domains for consideration for all postpartum footballers as both are relevant to both vaginal and cesarean birth [62]. From the perspective of pelvic floor dysfunction (PFD), which includes a spectrum of symptoms and conditions but most commonly stress urinary incontinence and pelvic organ prolapse, specific interventions used in vaginal birth, such as prolonged second stage of labor, perineal trauma, and operative vaginal delivery (forceps-assisted birth), do increase risk [66]. From the perspective of abdominal wall concerns, namely diastasis rectus abdominis, cesarean birth translates to higher risk. Given the repetitive load-bearing activities, high-intensity movement patterns, and the associated increases in intra-abdominal pressure, ensuring optimal pelvic and abdominal healthcare provision is needed [64, 67]. Fortunately, there is strong support for the conservative care of PFD that includes individualized pelvic floor muscle training (PFMT) among other conservative care strategies such as lifestyle interventions and bowel management that are typically best guided by a physiotherapist with specialized training in pelvic health [68]. It is important to note that the symptoms associated with PFD (urinary leakage, feelings of vaginal heaviness, or pelvic pressure) are key barriers to new mothers engaging in postpartum physical activity and exercise. Addressing these concerns from a biopsychosocial perspective is important to encourage new mothers to resume their physical activity after giving birth [69].

Stress Urinary Incontinence (SUI)

SUI impacts one of every three women across the lifespan, but SUI prevalence is disproportionately higher in athletes participating in high-impact sports, with incidence rates reported between 28% and 80% depending on sport type, training intensity, and postpartum status [70, 71]. Emerging evidence suggests that prolonged second-stage labor, levator ani trauma, and pudendal nerve stretch injuries during vaginal delivery may contribute to postnatal urinary incontinence, with symptoms persisting in up to 40% of women at 1-year postpartum [72–75]. Coaches and clinicians should engage in screening for PFD and integrate pelvic health specialists into RTP protocols where possible [76, 77].

Pelvic Organ Prolapse (POP)

The prevalence of symptomatic POP in the general population is 11% (4–12%) [78, 79]. The etiology of POP is multifactorial. It can be congenital and associated with connective tissue disorders, or acquired, related to pelvic floor muscle weakness, pregnancy, childbirth, ageing, menopause, and factors associated with chronically raised IAP [80, 81]. Given the high levels of intra-abdominal loading inherent to football (e.g., sprinting, cutting, jumping, and impact forces), postpartum footballers may experience a heightened risk of symptom exacerbation. Further, chronic constipation, straining behaviors, and use of forceps in vaginal birth are all established risk factors for the development of POP [68]. Screening for PFD will flag POP symptoms, and such individuals should engage with a pelvic health specialist for support and care. Improved biopsychosocial profiling of women with POP symptoms is needed as many factors, including sleep, pain, central sensitization, mood, fear of movement, and general health perception, factor into one’s function, performance, and outcomes [82].

Diastasis Rectus Abdominis (DRA)

Diastasis rectus abdominis (DRA) refers to the natural separation and thinning of the linea alba, an adaptive response of the abdominal wall tissues to accommodate fetal growth during the later stages of pregnancy [83]. After pregnancy, DRA may be considered pathological if the inter-rectus distance (IRD) remains excessive or leads to functional impairments, affecting daily activities, physical participation, or overall quality of life. [84, 85]. It has been found that 23–32% of women have persistent DRA at 1 year postpartum [86, 87].

Not unlike pelvic organ prolapse, DRA can be associated with fear of movement and other psychological factors and thus must be approached from a biopsychosocial perspective [88]. There is no conclusive answer to questions regarding which specific exercise protocol is most beneficial nor which dosing parameters are recommended. Interventions need to be individualized at the discretion of clinicians and coaches, which generally involves a physiotherapist, ideally one who has additional training in the specifications of pelvic floor and abdominal wall function [83]. There is currently very low-quality scientific evidence to recommend specific exercise programs in the treatment of DRA postpartum [89]. However, developing control and strength through the core and developing trunk rotation strength has been recommended [83, 89]. Movement strategies [90] that optimize the foundational function of the pelvic floor and deep core system, such as to optimize intra-abdominal pressure management and load transfer while not potentially straining the abdominal wall tissue, are recommended [83].

Lumbopelvic Pain (LPP)

LPP in pregnancy and through the first postpartum year is common [91–94]. Once again, approaching footballer’s health, wellbeing, and performance from a biopsychosocial perspective has been advocated. Despite this, there remains an ongoing tendency in the sports world to consider musculoskeletal (MSK) pain from a structural and mechanical perspective. The tendency to mechanize MSK pain and thus clinical decision-making is often misguided by out-of-date notions regarding the factors that are driving a pain experience. Athletic pain has traditionally been attributed to tissue damage, such as acute trauma or overuse injuries. While biomechanical factors can contribute to nociceptive input in some cases, they do not fully account for pain experiences in athletes, including postpartum footballers [92–95]. In the absence of acute injury, contemporary treatment approaches for lumbopelvic pain prioritize enhancing movement freedom, flexibility, strength, and variability to promote comfort and resilience [91, 92].

Pregnancy-related lumbopelvic pain (PPGP) is increasingly recognized as a manifestation of tissue sensitivity rather than structural instability or damage [91, 92]. Addressing underlying beliefs and fears surrounding movement, alongside modifiable systemic factors such as inflammation, actually represents the primary up-to-date care approach for postpartum lumbopelvic pain. [93]. A psychologically informed approach incorporating education, counseling, novel movement strategies, restorative exercise, and other supportive interventions can help foster trust in the body while mitigating dependence and disability [91–93, 96–107].

For postpartum footballers, the physiological status of a system that is not fully recovered and energy typically being in a deficit has implications for tissue sensitivity and, potentially, performance and injury risk [93]. Movements that support more optimized sensorimotor patterning and protect energy requirements are important in reducing LPP. In addition, empowering people with a menu of self-management options to drive more optimal physiology and to feel safe and strong in their body are key (e.g., optimal sleep hygiene, wearing an external compression garment) [91]. Consultation with a physiotherapist or other psychologically informed provider who has an up-to-date understanding of pain science would be optimal if possible, for any footballers with pregnancy-related LPP.

Sleep Disturbance

While most individuals experience poor sleep quality in pregnancy [108], it is even more prevalent during the early postpartum period [109] but improves in most women after 6 months post-birth. Disruptions in infant sleep and feeding schedules, postpartum pain and complications, and hormonal fluctuations following pregnancy are all significant contributors to reduced sleep quality and duration in the early postpartum period. [110]. Sleep is essential for physiological and psychological repair and recovery from daily stressors. It is primarily during sleep that restoration of the body occurs, including muscle repair, energy replenishment, and endocrine regulation. Sleep is also essential for cognitive function, memory consolidation, and mood regulation. More recent work has demonstrated that adequate sleep is essential to maintain a healthy immune system by reducing inflammation and infections during deep sleep.

Given the key functions of sleep, it is a cornerstone to player health, wellbeing, and performance. The increased training load, both physiologically and cognitively, mean that footballers likely require more sleep as well as intentional recovery strategies to support optimal recovery, especially during a heavy training or competition schedule. Footballers commonly report poorer sleep quality and duration than the general population [111]. However, with the increased demand for physiological and psychological recovery, footballers experiencing insufficient and broken sleep are likely to experience impaired health and performance. Thus, more attention to sleep as well as other intentional recovery strategies and mitigating energy expenditure in the face of compromised sleep and recovery are needed.

Mental Health

The sudden drop in estrogen, progesterone, and testosterone levels following delivery can lead to a range of physical and emotional symptoms. These symptoms are commonly referred to as the “baby blues” and can include mood swings, irritability, and feelings of sadness or anxiety. In some cases, these symptoms can progress to postpartum depression [112]. Postpartum depression is a common condition that can have significant consequences for both the mother and child’s health and development. Current estimates indicate that approximately 13% of pregnant and postpartum women experience depression, while anxiety affects up to 39%; however, both conditions are widely recognized as being underdiagnosed and undertreated during the perinatal period [113–116]. The consequences of untreated perinatal mental health disorders can be severe, with nearly 20% of women with postpartum depression reporting thoughts of self-harm, suicide being the leading cause of maternal death in the UK within the first year after childbirth [117]. Even in cases where there is no clinical depression, depressive symptoms can still compromise caregiving practices and maternal–infant bonding, potentially leading to delays in cognitive, social, and emotional development in children. Standard treatments for postpartum depression include medication and psychotherapy. Exercise and physical activity have long been established as a key care strategy for depression; however, it is only recently that it has been looked at in perinatal populations and has been shown to improve mild-to-moderate depressive symptoms and increase the likelihood of resolving mild-to-moderate postpartum depression [118]. All women experiencing poor mental health should speak to their healthcare provider to discuss treatment options [118, 119]. The additional impact of being a footballer in the postpartum period has not been examined but has the potential to carry additional risks for mental health challenges.

Postpartum Health and Physical Activity Guidelines

Historically, postpartum health focused on breastfeeding (nourishing the infant), on avoiding maternal illicit drug use (keeping the infant safe), and on screening for postpartum depression [120]. Physical activity guidelines around the world encourage a physically active lifestyle in the postpartum period [121]. The 2025 Canadian Guideline for Physical Activity, Sedentary Behaviour and Sleep throughout the First Year Postpartum provides evidence-based recommendations emphasizing that progression toward the goal of 120 min of moderate-to-vigorous physical activity (MVPA) across 4 or more days of the week that should be individualized, gradual, and symptom-based [122]. This guideline recommends incorporating a variety of aerobic and resistance training activities and highlights the importance of daily PFMT. Postpartum women are encouraged to initiate early mobilization with light intensity physical activity and progress to MVPA once surgical incisions or perineal tears have sufficiently healed. The seven associated systematic reviews and meta-analyses underpinning the development of these recommendations demonstrate clinically meaningful improvements in depression and anxiety, urinary incontinence and prolapse, musculoskeletal pain, diabetes, and maternal body composition [89, 123–128]. These health benefits were achieved without increasing the risk of injury or impacting breastmilk quality or quantity [29]. In addition, this guideline provides evidence-based guidance that engaging in physical activity postpartum supports better quality sleep, which can subsequently improve maternal health (e.g., reduced risk of depression). Supporting mothers physically, emotionally, and socially to be able to be physically active and have better quality sleep is the responsibility of all.

The 2025 Canadian guideline no longer recommends routine medical clearance prior to initiating postpartum physical activity [122]. However, identifying the small number of women with medical conditions (i.e., contraindications to exercise) that may require medical guidance is essential. As part of the guideline-development process, a group of international experts developed a postpartum-specific exercise prescreening tool, the Get Active Questionnaire for Postpartum [123]. This document can be self-completed by postpartum women, allowing for the removal of a key barrier to returning to exercise.

Return to Football Postpartum

Returning to football postpartum is a multifaceted process that extends beyond standard rehabilitation frameworks. Unlike musculoskeletal injuries, postpartum recovery involves systemic physiological, musculoskeletal, and psychological adaptations, each of which influences the timeline, safety, and success of RTP. The process must be flexible and athlete-centered, accounting for the physiological, physical, and psychosocial considerations presented above (Fig. 2).

Fig. 2.

Supporting return to football postpartum

Over the last 5 years there has been increasing recognition of the need to follow a gradual, stepwise return to physical activity that is individualized, based on the players’ physical and mental health and wellbeing [122, 129–132]. Progression should be based on the presence of physical symptoms and psychological recovery. Women are encouraged to prioritize sleep and intentional recovery strategies as well as nutrition ahead of overall load exposure to ensure adequate recovery and energy balance. Recent studies have found that early ambulation following cesarean section delivery is associated with reduced postoperative complications; thus, promoting gentle walking early after delivery is encouraged [133]. However, athletes commonly return to sport in the very early postpartum period, often well before the 6-week postpartum checkup [134]. Revisioning how footballers return to activity following childbirth is critically needed to take into account the myriad of physiological changes and challenges commonly experienced. However, each woman’s recovery timeline can vary depending on factors such as the type of delivery, complications during pregnancy or delivery, and overall physical and mental health. A player-centered approach to return to sport should incorporate key considerations, including type of delivery (vaginal versus cesarean, tears, episiotomy), position and performance demands, core and pelvic floor strength and function (e.g., urinary incontinence, diastasis recti abdominis), current symptoms (musculoskeletal pain, depression, anemia), and breastfeeding [134, 135].

This section outlines evidence-based strategies for postpartum return to physical activity, phased load progression, and injury risk reduction. The applicability of existing RTP frameworks from musculoskeletal injury rehabilitation, highlighting the role of individualized screening, progressive RTP frameworks, and multidisciplinary team (MDT) support, is reviewed. In addition, social and structural factors, such as maternity policies, childcare responsibilities, and cultural perceptions of motherhood in elite sport, to ensure sustainable career progression are considered. By integrating football-specific rehabilitation strategies with postpartum recovery principles, this section provides a foundation for structured RTP protocols that prioritize athlete health, performance longevity, and injury prevention.

Guidelines for Return to Physical Activity and Sport Postpartum: Existing Frameworks and How They Apply to the Postpartum Footballer

In 2019, the release of the Return to Running Postpartum Guideline revolutionized how we viewed return to exercise in the postpartum period by outlining the first evidence-based framework that emphasized recovery and rehabilitation following pregnancy and birth [136]. This and other newly developed frameworks for postpartum return to running emphasize the requirement that footballers reach specific healing and functional milestones prior to resuming high-impact/intensity exercise, while considering common postpartum complaints, including musculoskeletal pain and urinary incontinence [129, 132, 136, 137].

A recent consensus statement of clinical and exercise professionals’ opinions on designing a postpartum return-to-running training program utilized a Delphi method to identify key progression and milestones while returning to running [138]. The return-to-running guidance strongly advocates an individualized approach that balances the need for adequate tissue healing and recovery, with the runner’s desire to return to activity. Although practical football-specific guidance has not yet been developed, the initial phases of return-to-football can utilize this guidance followed by adaptation to be specific to football.

The results of the Delphi Consensus Statement further emphasized that the “how” to return to running is more important than the “when.” The consensus statement recommended that the recovery period after birth be person-specific and criteria-based. Initiation of a return-to-running protocol should begin slowly with a walk–run protocol—the programming of which should be guided by symptoms (measures of wellness, significant leaking of urine, pain, among others). Decisions on progression versus regression through return to running should be based on physiological and biopsychosocial factors (e.g., sleep, mental health, lactation, pelvic floor and musculoskeletal symptoms), with adjustments to training volume made as necessary. Similar to any return-to-activity protocol, it was also recommended that the duration of exercise be progressed before intensity. For all runners (including football players), screening for pelvic floor and musculoskeletal imbalances and dysfunction is strongly encouraged to reduce the risk of injury and other symptoms. Football-specific considerations are currently being developed to aid in return to football. Until they are available, return-to-sport protocols provide an evidence-based approach to initiate this process [131, 132, 138, 139]

Return to Football Postpartum: Current Evidence and the Application to Football

Returning to football postpartum requires an athlete to regain the high-intensity, multidirectional movement patterns, anaerobic power, and neuromuscular control essential for match play. Football is characterized by repeated sprint ability, rapid acceleration and deceleration, agility-based directional changes, and sustained aerobic capacity, placing significant demands on the musculoskeletal, cardiovascular, and metabolic systems [140]. In addition, positional demands vary, with midfielders covering the greatest total distance, wingers performing the highest number of sprints, and goalkeepers requiring explosive force generation and landing mechanics [141]. Given that elite footballers sustain high training and match intensities, RTP framework should incorporate progressive exposure to football-specific loading, high-impact activities, and competitive match scenarios to mitigate injury risk and optimize performance.

The International Federation of Professional Footballers (FIFPro) recently published a guide to returning to play postpartum [142]. They presented professional players’ postpartum RTP case studies, alongside guidance related to timelines; associated support represents an important first step to establishing needed guidance that is scalable. Current cases of postpartum return to football are necessarily managed on an individual basis, with success hinging on several environmental (e.g., level of professionalization; regulatory standards; available resource, including access to specialist MDT members) and individual factors [142]. Little is known about current postpartum RTP and performance practices in football—either at the grassroots or the elite level, with case studies lacking.

Progressive RTP Protocols and Decision-Making Frameworks

The 2016 Consensus Statement on Return to Sport [139], which has formed the foundation of generic postpartum-specific return-to-sport frameworks, including the “6 Rs” (ready, review, restore, recondition, return, refine), recommends that return to sport should be viewed as a continuum comprising return to participation, return to sport, and return to performance [132]. It advocates for objective markers to guide progression, accounting for the biopsychosocial health of the athlete, and emphasizes a shared decision-making process involving key stakeholders (e.g., medical staff, performance specialists, and coaches), with the footballer’s needs at the center.

Postpartum recovery presents a unique challenge distinct from traditional injury rehabilitation models. However, established RTP frameworks—such as those used in musculoskeletal injury rehabilitation—do offer valuable insight into phased return to training and competition. While injury-based RTP protocols typically focus on restoring pre-injury function, postpartum RTP must consider additional variables, including hormonal fluctuations, tissue healing, and psychological readiness.

A football-specific RTP framework should integrate sport- and position-specific demands, individual rehabilitation needs, and the necessary timeline to restore physical, technical, and psychological readiness, ultimately reducing injury risk and optimizing long-term performance. However, RTP decision-making is not always straightforward. Tabener et al. (2020) described the decision to return a player to competition as a “risk management exercise” in which players may return before reaching pre-injury competition [143]. As in musculoskeletal injury rehabilitation, postpartum RTP is unlikely to follow a linear trajectory, and progression must be tailored to the individual. Given this complexity, decision-making frameworks such as the Strategic Assessment of Risk and Risk Tolerance (StARRT) model [144] can help structure RTP assessments by weighing biopsychosocial factors, sport-specific load exposure, and contextual considerations. For example, in a professional football setting, a player’s physical readiness might be prioritized differently depending on whether they are preparing for a major tournament or a standard season match. Ultimately, the optimal RTP outcome is determined by a reasoned, athlete-centered decision-making process [145]. Postpartum RTP should align with expert consensus and evidence-based sports medicine principles, incorporating a phased, criteria-based progression that prioritizes objective markers over arbitrary timelines [131].

Exercise pre-screening for contraindications should be conducted using the Get Active Questionnaire for Postpartum. Regular reassessment of postpartum-specific and sport-related metrics throughout the RTP continuum is essential. These should include markers of pelvic floor dysfunction, sleep, and mental health parameters, including fear of movement, energy availability, lactation-related nutrition needs, and childcare responsibilities. This whole-athlete evaluation should inform progression, regression, or training modifications, using both objective biomechanical/physiological markers and subjective self-reported indicators. In the absence of football-specific epidemiological data on postpartum injuries, pre-pregnancy performance benchmarks and positional requirements should be factored into RTP assessments.

Concerns regarding load exposure or musculoskeletal symptoms should be raised early and monitored proactively, without creating unnecessary fear. Collaborative MDT conversations between medical, coaching, and performance staff can prevent reactive decision-making and ensure that returning players are appropriately supported throughout the postpartum RTP journey.

Injury Risk Reduction in Postpartum Footballers

There is an absence of postpartum-specific injury epidemiology in football, and as such, it is recommended that pre-pregnancy and position-specific performance metrics be used as a baseline for assessing player readiness. Open communication between players and staff is critical to managing concerns regarding load exposure, markers of recovery and readiness, or musculoskeletal symptoms, preventing fear-based decision-making.

From the player’s perspective, fear of losing their position on a team or not being able to qualify for major competition may drive many athletes to return to sport too soon, risking injury as a result [146]. As per the StARRT model, informed, shared decision-making may still support taking such risks. Postpartum elite athletes have strongly identified the need for flexible return to sport timelines to allow them to gradually ease back into their training and competition schedules [147]. Not only can this approach help reduce the risk of injury, but it is also more likely to ensure that the footballer is physically and emotionally ready to return to sport.

Multidisciplinary Support, Psychological Readiness, and Social Support for the Postpartum Footballer

A comprehensive support system is essential for postpartum footballers navigating the complexities of recovery and RTP. This includes education, structured resources, and tailored guidance from coaches, trainers, and medical professionals, all working collaboratively to develop an individualized, flexible RTP plan. Elite footballers have identified significant gaps in awareness and access to key healthcare specialists, including pelvic health physiotherapists, lactation consultants, and sports psychologists, to support their transition back to sport [147]. These barriers to specialist care are likely to be more pronounced at lower levels of play, where fewer integrated multidisciplinary resources exist.

Where possible, footballer-centered RTP protocols should be developed in collaboration with key stakeholders while prioritizing medical confidentiality and player autonomy. With the player’s consent, early and ongoing communication between primary healthcare providers (e.g., obstetricians, midwives, general practitioners), sports medicine, and performance teams is crucial. Effective MDT cohesion and preparedness ensure seamless support as players progress through the RTP continuum. Initially, medical and rehabilitation professionals such as pelvic health physiotherapists and nutritionists play a central role, whereas in later phases, collaboration with performance staff, including athletic trainers and strength and conditioning coaches, becomes increasingly relevant.

Beyond medical and performance considerations, psychosocial factors play a critical role in postpartum RTP. A lack of financial, emotional, and logistical support can significantly hinder a successful return to competition. Athletes have reported that access to flexible training schedules, childcare support, and financial security are crucial to managing the dual demands of motherhood and professional sport [147]. Addressing these structural challenges can foster an environment where footballers feel empowered to return at a pace that aligns with their physical recovery and personal circumstances.

Conclusions

Over the past several decades, our understanding of physical activity and exercise during and following pregnancy has evolved significantly. Historically, pregnancy was often perceived as a barrier to continued athletic participation, but advancements in research have provided greater clarity on the physiological, psychological, and social factors influencing postpartum RTP. In practice, postpartum RTP protocols should align with expert consensus and evidence-based sports medicine principles. These include the use of objective markers to guide phase progression, integration of biopsychosocial health considerations, maintaining an athlete-centered approach, and establishing a shared decision-making process that includes key stakeholders. By providing the necessary support for footballers to continue their careers through motherhood, the football community can contribute to the long-term retention of players in the sport and foster an environment that empowers future generations to engage in football throughout their lifespan.

Supplementary Information

Below is the link to the electronic supplementary material.

Declarations

Funding

This article is published in a supplement issue that was supported by Fédération Internationale de Football Association (FIFA). All authors received consulting fees for time spent working on this manuscript. Although members of FIFA reviewed the final manuscript, as a funding body, they had no influence over the content or findings of the review. M.H.D. is supported by the Christenson Professorship in Active Healthy Living.

Conflict of Interests

The authors declare the following competing interests: A.H. is employed by Harlequins FC Women’s Rugby Team (UK) and received consulting fees from Kynisca Innovation Hub (KIH) as an expert medical consultant. KIH was not involved in this review, did not provide financial or material support, and does not directly benefit from its findings; E.B. is employed by PhysioMUM and consults with football teams across the UK; M.H.D. has received grant funding from NSERC, SSHRC, CIHR, and the Women and Children’s Health Research Institute that funded studies that have been cited within this manuscript related to athlete health during and following pregnancy; S.D. is employed by The World of My Baby, consults Urospot, and is a Director at the College of Physiotherapists of Ontario; M.D. has no competing interests to declare.

Availability of Data and Material

Not applicable as no datasets were generated or analyzed during the current study.

Author Contributions

All authors contributed significantly to the conception, design, and writing of the manuscript. All authors contributed to the conception of the review. A.H. and M.H.D.—led the drafting of the manuscript and coordinated revisions; S.D. and E.B.—provided expertise and contributed to the sections on pelvic health and pain. M.D.—provided expertise in review of both general postpartum and football-specific considerations. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work in ensuring its accuracy and integrity.