Pregnancy Loss - The Value of Physical Activity

Danielle Girard, PhD and Tegan Hartmann, PhD

What is pregnancy loss, and what consequences can this have?

Pregnancy loss (miscarriage; an unexpected loss of a foetus before viability) is a common occurrence, affecting approximately 15% of all confirmed pregnancies, with an estimated 44 pregnancy losses reported globally each minute.

Commonly experienced as a silent trauma, pregnancy loss frequently goes unnoticed by both society and the medical community, due largely to experiences of stigma related to feelings of shame and personal failure by those who encounter it. Women and their significant others are left to cope with the intense grief and devastation that accompanies a loss, with limited to nil support and acknowledgement. Reports indicate that the care provided by health providers in the period following a loss is seen as being substandard, with a lack of sensitivity, empathy, follow-up care, and the unrealistic expectation that parents, in particular women, should recover quickly from their experiences of grief.

Such circumstances lead to increased risks of developing a mental illness, which is further amplified by other factors such as difficulty with conception, mode of conception, previous history of loss, previous or current mental illnesses, nullipara (no current children), lower levels of education, and lower socioeconomic status. Notably, the risks of mental illness are further heightened in those who experience recurrent miscarriage (two or more pregnancy losses).

Physical and mental impacts of pregnancy loss

Adverse physical and mental health outcomes are prevalent, with the distress, grief and trauma that accompanies a loss predisposing women to psychological conditions, including depression and anxiety. Reports suggest that more than half of women who experience a loss will experience symptoms of depression, a quarter will experience moderate to severe anxiety, which is sometimes accompanied by thoughts of self-harm. Such psychological symptoms often persist for extended periods of time. Women frequently disclose feelings of hopelessness, detachment, shame, shock, anger, self-blame and guilt as a result of a loss. Importantly, both parents, not just the person carrying the pregnancy but also their partner, experience negative emotions (sadness, helplessness and anger) and other negative health-related consequences as a result of a loss. For example, one in 14 partners met the criteria for post-traumatic stress (PTS) in the month following a loss, with one in 25 continuing to experience PTS at 9 months.

Physiologically, during early-stage pregnancy, women experience elevated cardiac, metabolic, and hormonal adjustments, and despite the compromised viability of the pregnancy, women who experience a loss will encounter these physiological changes.

Benefits of physical activity and exercise for women following a loss

Exercise is known to elicit multiple physical and mental health benefits, including improved cardiovascular function, favourable metabolic changes, weight management, and improved psychological benefits associated with body image, perceived health status, and reduced symptoms of depression.

The mood-regulating effects of exercise are well established and have been suggested to improve physiological parameters that increase the risk or severity of psychological morbidity. Exercise has proven benefits in managing depressive symptoms, with the effects reported as being similar to pharmacological treatments in certain settings. Exercise has also been shown to improve emotional well-being and reduce symptoms of anxiety in the post-partum period.

Research indicates that exercise can lead to favourable outcomes on fertility. For example, moderate intensity physical activity is associated with improved fertility for all women, and vigorous intensity exercise is associated with improved fertility for women classified as overweight or obese. Walking for greater than ten minutes has been found to improve fecundability (the probability that a couple will achieve a pregnancy in a given menstrual cycle) in women classified as overweight or obese with a history of pregnancy loss. As such, engaging in exercise post pregnancy loss may be a suitable way for women to reduce the risk of being diagnosed with a mental illness, reduce symptoms of depression, while also improving their physical wellbeing. However, despite these encouraging health related benefits, women who have previously experienced a loss are less likely to exercise than their peers who have not experienced a pregnancy loss.

At present, existing physical activity and exercise-based guidelines provide key information on appropriately working with women across several pregnancy-related phases, including pre-pregnancy, during pregnancy and post-pregnancy. Unfortunately, there is a lack of reference to those who experience a pregnancy loss within these guidelines. Given the prevalence and significance of pregnancy loss on women’s physical and mental health and well-being, this lack of acknowledgement within guidelines is an area of priority that must be addressed. As such, pregnancy loss must be considered and incorporated into future research and guidelines for exercise and physical activity to adequately support this subgroup of women.

Key research findings for the role of physical activity and exercise for women following a loss

Our brief review, published in Exercise and Sport Sciences Reviews (ESSR), draws together research around pregnancy loss, mental illness, exercise-related benefits for regulating mood, preventing mental illness and the usefulness of exercise in aiding future pregnancy.

A summary of key findings includes:

• As little as 15 minutes of exercise can effectively regulate mood and positively regulate emotions after experiencing a stressful event.

• 30 minutes of low to moderate intensity exercise improves mood in those who have a pre-existing mental illness.

• Regular engagement in exercise can prevent and manage mental illnesses by improving the severity of symptoms.

• The relationship between exercise and mental health is generally dose-dependent, meaning that with higher levels of physical activity and exercise, there is a lower risk of experiencing depression.

• Exercise is associated with improved fertility, whereby overweight and/or obese women who have a history of loss have an enhanced likelihood of conceiving when they engage in walking for greater than 10 minutes during a single session.

• Women who have experienced a loss may be hesitant to exercise, however there are numerous physical and mental benefits to engaging in some form of physical activity post-loss.

Given the positive physical and mental outcomes, and the potential role of physical activity and exercise on fertility, coupled with reduced participation in exercise following a loss, those in the fields of Sport and Exercise (academics and practitioners) must be aware of these factors.

The image emphasises the benefits of regular exercise, highlighting its protective role against depression and its positive impact on fertility, particularly in women with a history of pregnancy loss.

Key considerations to help support women in engaging in physical activity during pregnancy loss

Exercise, sport and physical activity professionals have the unique opportunity to utilise their expertise to support women with physical activity and exercise following a loss. Here are some ways that we can do this:

• If someone discloses to you that they’ve experienced a pregnancy loss, offer your support by acknowledging their loss, validating their feelings, and taking the time to hear their story. A simple “I’m sorry for your loss” goes a long way in validating and acknowledging people’s feelings of grief and loss.

• Become informed on how to best communicate with someone who has experienced a pregnancy loss. You can do this by having a look at suggestions about what to say and what not to say.

• To help decrease the stigma and isolation associated with pregnancy loss, if you have experienced a miscarriage, share your lived experience.

• If prescribing physical activity and exercise to women who have experienced a loss, the goal is to first support women in their return to physical activity with a longer-term intent for meeting global physical activity guidelines.

• Use a trauma-informed approach when working with women who have experienced a prior pregnancy loss.

• Consider the varied experiences of women, for example, the timing of the loss (0-20 weeks), methods used to manage the loss, physical and mental consequences and other unique pregnancy loss-related factors.

• More research needs to be conducted to understand and support the role of physical activity and exercise for women following a loss. To do this, pregnancy loss must be considered as a part of the broader pregnancy continuum.

• Don’t forget about the negative impacts on significant others (parents, family, friends) within the woman's immediate support network

Where to go for more information on how to best support women following a loss

There are many reputable places that you can go to learn more about pregnancy loss and how best to support women in such circumstances. There are a few places that we recommend you check out first.

o   PANDA

o   PINK Elephants

o   Miscarriage Association 

Conclusion

Exercise has the potential to improve mood regulation, prevent mental illness and aid in the success of future pregnancy. As little as 15 minutes may be sufficient to support the emotional and physical well-being of women following the loss; however, research needs to be conducted to support this. Pregnancy loss must be recognised and acknowledged as a key part of the broader pregnancy continuum. In addition we must continue to progress our knowledge and support of women in the field of exercise, sport and physical activity, as it shapes the narrative of the health, wellbeing and fecundity of women. Overall, exercise appears to be a promising strategy for women who face mental health challenges following a loss.

For more information about the potential utility of exercise during pregnancy loss, please read our brief review as published in Exercise and Sport Sciences Reviews (ESSR).

Dr Danielle Girard

Email: Danielle.Girard@unisa.edu.au

Dani is a Senior Lecturer and Program Director of the Clinical Exercise Physiology degree within the Allied Health & Human Performance Unit at the University of South Australia. She is an Accredited Exercise Physiologist with Exercise & Sports Science Australia and currently serves as Vice President of the Council of Heads of Exercise, Sport and Movement Sciences (CHESMS), Australia. Her research focusses on exercise-based interventions for the prevention and management of cancer, mental illness and cardiovascular disease, with a particular emphasis on women’s health conditions such as pregnancy loss, endometriosis and polycystic ovary syndrome (PCOS).

Dr Tegan Hartmann

Email: thartmann@csu.edu.au

Tegan is a Senior Lecturer in Exercise Science at Charles Sturt University. Her research is focussed on women’s health, particularly examining the links between physical activity, mental wellbeing and complex health conditions. She is passionate about addressing conditions such as endometriosis, pregnancy loss and other under-researched areas that significantly impact women’s quality of life. Through her work, she advocates for greater awareness, education and strategies to support women across the lifespan. Dr Hartmann also mentors students and early career researchers, encouraging innovation, compassion and evidence-based practice in the exercise sciences.

Blog editor: Dr Tess Flood

Blog administrator: Dr Jacky Forsyth