Postpartum Women’s Perceptions of Risk of Musculoskeletal Injuries in the Canadian Armed Forces: A Qualitative Research Study

Abstract

Musculoskeletal injuries (MSKi) are a major concern within military forces, significantly reducing productivity and military readiness. Within the Canadian Armed Forces (CAF), MSKi are the most common cause of delayed deployment of members. There is a lack of research specifically focused on the experiences of postpartum CAF members and their perceived risk of MSKi. Drawing on Giles et al.’s equity-centered 4 E’s injury prevention framework (education, engineering, enforcement, and equity), we highlight that individuals who experience pregnancy may perceive themselves to be at heightened risk of injury due to sex and gender-based inequities in their workplace. This qualitative research draws on data from focus groups with 32 individuals who experienced pregnancy while serving in the CAF. Using reflexive thematic analysis, we identified the following findings related to perceived increased risk of MSKi: (a) nature of relevant physiological and anatomical changes in pregnancy, (b) unreasonable pressures to return to work at peak physical readiness, and (c) perceived challenges associated with accessing resources and services to support physical recovery. There are opportunities to improve access to injury prevention resources and support for pregnant and postpartum CAF members to reduce rates of MSKi. Findings from this study may be additionally relevant to armed forces more broadly or other professions that require return to physical readiness.

Pregnancy and Musculoskeletal Injuries in the Canadian Armed Forces

Musculoskeletal injuries (MSKi) are a major concern within military forces, reducing productivity and military readiness. Within the Canadian Armed Forces (CAF), MSKi remains among the top cited reason for medical release and attrition (Serré, 2019). A Canadian study found that MSKi was the primary diagnosis for 40% of CAF members medically released from service (Serré, 2019). Given that 16.3% (Government of Canada, 2022) of the 103,873 CAF members (including Regular Forces and Reserves; Jackson & Lao, 2020) are women, understanding their perspectives of MSKi risk is crucial. MSKi can result from trauma or chronic overuse; for example, MSKi can occur from a single incident, such as tripping and falling, or by repetitive micro-traumas induced by activities such as running, marching, climbing stairs, and excessive lifting (Chassé et al., 2020). Researchers have explored many strategies to minimize MSKi within the military, and a systematic review exploring mitigation strategies among military personnel found that conditioning, modifying footwear, physical fitness, education and awareness, and leadership are the most common and effective prevention approaches (Wardle & Greeves, 2017). Despite these preventive methods, researchers have noted several risk factors that can increase an individual’s susceptibility to sustaining a MSKi (Barbeau et al., 2021; Chassé et al., 2020).

Risk Factors of MSKi

Of the many risk factors, low aerobic fitness has been identified as a leading risk factor for MSKi (McDonald et al., 2017). Other factors influencing the development of MSKi include older age, smoking status, extremes in body mass index (BMI), and a low physical activity level prior to joining the military (Barbeau et al., 2021; Chassé et al., 2020). Furthermore, researchers have indicated sex differences related to MSKi, noting that females are at a greater risk for sustaining injury (Chassé et al., 2020; Serré, 2019). Corroborating U.S. military data indicates a higher likelihood of females sustaining an MSKi compared to male counterparts (Roy et al., 2014). In a study analyzing medically released men and women from the CAF, MSKi releases were higher for women (43%) than for men (39%; Serré, 2019). Evidence suggests that sex differences in injury rates and types of injury are due to differences in physical, physiological, and musculoskeletal characteristics (Barbeau et al., 2021; Chassé et al., 2020; Roy et al., 2014). Furthermore, there are reproductive characteristics associated with MSKi (Puranda et al., 2023), and periods in which the risk of MSKi for female soldiers may be exacerbated, such as during pregnancy and postpartum.

Pregnancy and MSKi

MSKi are a common occurrence during pregnancy (Cain et al., 2021). The anatomic and physiologic changes during pregnancy can impact the musculoskeletal system, leading to an increased risk for injury. For example, a woman’s center of gravity is shifted anteriorly during pregnancy due to the uterus displacing internal organs (Cain et al., 2021). Researchers noted this leads to variations in a woman’s biomechanics, causing anterior pelvic tilt, pain, and increased susceptibility to injuries and falls. Hormonal changes during pregnancy can also affect the musculoskeletal system. For example, relaxation of joints, predominantly the pelvic joints, to prepare for birth is common during pregnancy (Marnach et al., 2003). Pregnancy is also associated with changes in bone density due to a decrease in bone mineralization as the growing fetal skeleton requires a substantial transfer of calcium and these alterations can lead to an increased risk of MSKi, such as ligament injuries and insufficiency fractures (Marnach et al., 2003; Sanz-Salvador et al., 2015). Some of the musculoskeletal alterations associated with pregnancy persist during the postpartum period (Cain et al., 2021). During postpartum, women deal with pregnancy-related issues including gestational weight gain, hormonal changes, as well as the after-effects of birth, such as tearing of the pelvic floor muscles or recovering from a caesarian-section (Gutke et al., 2010). As such, women in the postpartum period often experience a number of musculoskeletal problems including pelvic girdle pain, lumbosacral back pain, diastasis recti abdominis, pubic symphysis separation, and poor control of abdominal muscles (Gluppe et al., 2018; Gutke et al., 2010; Sung et al., 2021; Wiezer et al., 2020). Pregnancy and postpartum can also have profound impacts on physical fitness levels, which can result in susceptibility to injuries (de la Motte et al., 2019).

Pregnancy and Fitness Levels

Despite the positive effects on maternal and fetal outcomes conferred by regular engagement in physical activity during pregnancy (Mottola et al., 2018), the physiological changes associated with pregnancy can impact physical fitness levels (Dipietro et al., 2019; Weina, 2006). Alongside the changes associated with the musculoskeletal system such as the relaxation of joints and changes in bone density, the physiological changes associated with pregnancy cause alterations in the cardiac, pulmonary, and renal systems (American College of Obstetricians and Gynecologists [ACOG], 2020; Sibai & Frangieh, 1995). As summarized by L’Heveder et al. (2022), past research has shown that the anatomic and functional alterations associated with the respiratory system can lead to decreased oxygen availability during aerobic exercise. These changes, as well as gestational weight gain, can impact both the duration and intensity of physical activity that can be undertaken during pregnancy (Weina, 2006). Researchers have indicated that women may experience a prolonged decrease in physical fitness levels beyond postpartum because these physiological changes can persist for more than 1 year after delivery (DeGroot et al., 2021). A study assessing the impact of pregnancy on physical fitness among U.S. soldiers found statistically significant effects of postpartum on test performance on the Army Physical Fitness Test (Weina, 2006). This study revealed that 6 months is not enough time for women to recover and return to the physical fitness level they had previously attained. The prolonged effects pregnancy can have on fitness levels have been examined in military populations, revealing that women perform worse on postpartum physical fitness tests (DeGroot et al., 2021; Miller et al., 2017; Rogers et al., 2020). In another study examining the experiences of postpartum women in the U.S. Air Force completing the fitness assessment, researchers found that women often experienced perinatal physiologic changes, including loss of muscle strength and postpartum joint pain (Armitage et al., 2014). The altered physical fitness levels associated with pregnancy and the postpartum period can put women at an increased risk of sustaining injuries. Within the literature, researchers have suggested several factors to help achieve postpartum physical fitness, including additional interventions to assist women in returning to pre-pregnancy fitness as well as social support, notably support from their command and family (DeGroot et al., 2021; Negron et al., 2012; Rogers et al., 2020). However, despite evidence that women in arduous occupations are at high risk of injury when returning to physical training in the postpartum period, there are no available guidelines on best management practices (Jackson et al., 2022). Due to increased risks and a need to address issues of equity, female members returning to service following pregnancy and postpartum periods need a supportive environment within the military culture.

Pregnancy and Military Culture

In an attempt to create an inclusive climate for pregnant CAF members, policies and protocols specific to managing pregnancy as well as maternal and parental leave have been created. The CAF manages pregnancy through a number of administrative and medical regulations described in the King’s Regulations and Orders (Government of Canada National Defence [GCND], 2017, 2018a). As discussed in these documents, a CAF member who is pregnant has restricted duties due to a number of factors, including the ergonomic and physiological changes associated with pregnancy, with the aim of minimizing activities that may be hazardous to the member or to the fetus (GCND, 2018a). However, researchers have noted that decisions around pregnancy or family planning for military women are challenging due to factors such as missing out on career advancement opportunities (Seymour et al., 2020). Witnesses from a House of Commons Standing Committee that focused on creating a culture of equality for women in the CAF described a male-dominated workplace where discrimination based on gender was common and specifically referenced a lack of support and services for military families (Vecchio, 2019). Studies looking at women’s experiences of pregnancy within the U.S. military have also described a culture that is not supportive of pregnant members (Armitage et al., 2014; Seymour et al., 2020). Seymour et al. (2020) found that those experiencing a pregnancy in the U.S. military felt reprimanded for becoming pregnant. Armitage et al. (2014) explained that participants felt pressure to perform the physical fitness tests at 6 months postpartum, irrespective of any pregnancy or delivery complications. Others expressed how they were reluctant to discuss physical training concerns with leadership. Furthermore, it was found that some women engaged in risky behaviors, such as extreme dieting, to prepare for their fitness assessment, which involves anthropometric measures, including weight. There are several reasons why many women are not yet fit enough to resume the level of training required to adequately prepare for physical testing upon their immediate return from maternity leave. Specific reasons may be pregnancy-related, or specific to family obligations, childcare needs, access to training opportunities, knowledge related to safe resumption of training. Regardless of the reasons, those who do return to training without proper supports in place, may put themselves at increased risk for injury.

Given the dearth of literature on pregnancy and the risk of MSKi among pregnant and postpartum female service members identified in the scoping review conducted by Barbeau et al. (2021), and the current lack of details about their specific experiences, this analysis examines the real-world experiences of members of this community.

Theoretical Framework

A commonly cited approach to injury prevention frameworks has been the 3 E’s of injury prevention. The 3 E’s include education (i.e., knowledge and skill translation), engineering (i.e., built and non-built environment and materials/equipment), and enforcement (i.e., adherence to safety protocols through policies and governing laws; Giles et al., 2020; Groeger, 2011). While the 3 E’s framework has been critiqued for various reasons, Giles et al. (2020) highlighted one central flaw: a lack of consideration of equity. Specifically, these researchers argued that the fundamental issue with the 3 E’s injury prevention framework is the “assumption that it is effective for everyone . . . [despite the fact that] injury continues to be disproportionately experienced by some people” (p. 1). Thus, they argued that equity must underpin this framework to prevent inequitable risks of experiencing injury for certain populations, which, in our case, is especially critical for pregnant, postpartum, and parenting CAF members.

Methods

A scoping review conducted by Barbeau et al. (2021) identified a gap in the literature in relation to the experiences of postpartum females in the military. As such, an exploratory qualitative research design was selected to learn more about the topic (Swedberg, 2020). As part of a broader research study that aimed to obtain pan-Canadian feedback on CAF members’ experiences in relation to MSKi (including risk profiles, socio-cultural factors, and perceived support or barriers), the work presented in this manuscript is related to focus group findings on the perceived impacts of pregnancy on MSKi risk. Herein, our focus was to highlight the experiences of pregnant and postpartum CAF members and their perception of the association between pregnancy and MSKi. The research was approved by the Department of National Defence (DND)/CAF Social Science Research Review Board (SSRRB) (#1929/20F), University of Ottawa Research Ethics Board (H-07-20-5967), and Carleton University Research Ethics Board (#114854). This exploratory, qualitative research approach included 18 focus groups (offered in French and English) conducted with 72 participants with varying selection criteria related to sex, pregnancy, MSKi injury, and the impact of MSKi on their duties. In this paper, we have focused on the perceived impacts of pregnancy on MSKi risk. As such, we have included the focus group data from the 32 individuals who experienced at least one pregnancy while serving in the CAF. Due to restrictions and guidelines implemented across Canada as a result of the ongoing coronavirus (COVID-19) pandemic, focus groups were conducted online via Microsoft Teams. Focus group sessions lasted between 75 and 160 min and were audio-recorded. Semi-structured questions were used to gain a deeper understanding of CAF member experiences related to MSKi, physical training, pregnancy, and perceived barriers related to career progression. Questions guiding the focus groups included but were not limited to the following: What do you think contributes to MSKi for members of the CAF? Do you think contributing factors differ for men and women? and During your pregnancy, were any modifications or accommodations made to your required work-related physical training?

Analysis

We used reflexive thematic analysis (RTA; Braun & Clarke, 2019). RTA is a process in which researchers explore participants’ experiences and perspectives to identify patterns of meaning and to develop themes within the data collected (Braun & Clarke, 2019). To engage in reflexivity, we reflected on our positionalities as they relate to this research. All authors on the paper are extremely physically active individuals who engage in a diversity of physical activity research. The first and last authors have experienced pregnancy and resulting MSKi. None of the authors are members of the CAF; however, the study design was developed in consultation with, and guidance from, CAF members throughout. To conduct an RTA of the data, we engaged in Braun and Clarke’s (2006) steps of thematic analysis while also engaging in reflexivity. This robust, systematic approach allows researchers to identify, analyze, and report patterns of meaning within and across the data. Thematic analysis enables researchers to describe, organize, and interpret qualitative data to better understand descriptions of participant experiences through identifying common themes and categories (Braun & Clarke, 2006; Crowe et al., 2015). First, the digitally recorded focus groups were transcribed verbatim and checked for accuracy. Next, data were uploaded and coded in NVivo(12), a qualitative software data analysis program. The data were reviewed and discussed, including making memos to document initial interpretations. Then, the three first authors developed a coding schedule based on our initial findings. We initially coded the interviews using open “parent” node categories, including “personal experience with MSKi” and “physical training,” before distilling connections within the data among these larger codes. Following the initial assignment of data to parent nodes, we developed further descriptive “child” node labels such as “impact on career” and “areas for enhancement.” We used these smaller nodes to break down the data and compare the interview excerpts. The three coders met to discuss and resolve any concerns and/or disagreements in the coding process. In the results presented below, we are not attempting to establish a causal relationship between MSKi and pregnancy/postpartum, but instead are focused on service women’s perceptions of the association and their actual experiences.

Results

We identified three interrelated themes related to perceived risk of MSKi: (a) nature of relevant physiological and anatomical changes in pregnancy, (b) unreasonable pressures to return to work at peak physical readiness, and (c) lack of access to appropriate resources and services to support physical recovery.

Physiological and Anatomical Changes in Pregnancy Increase Risk of MSKi Postpartum

The vast majority of participants highlighted the physical impacts of pregnancy on their bodies and the ways in which CAF physical training and testing contributed to, or exacerbated, injuries. A participant explained the ways in which she felt she was at a greater risk of injury:

I have to lift all of this weight. I’m like, somebody’s going to catch my uterus as I walk out because seriously this is going to fall out. So, you know, or my bladder, whichever one, take your pick. But when I did talk to my gyno [gynecologist], she was like, you can’t do that [exercise] . . . Just the strain of pulling 225 pounds on your core, like you may as well kiss your uterus goodbye. (Participant (P)25/Focus Group (FG) Category (CAT) 3, Officer)

In addition to the physiological changes described by this individual, other participants echoed similar sentiments about the impacts of pregnancy on their body and specific risks associated with heavy lifting. Interestingly, one CAF member explained how relaxin, a hormone that relaxes ligaments specific to the female reproductive system and pregnancy, increased her risk of injury. She explained,

I sprained my ankle running right after my middle child and the physio suggested that it was the breastfeeding had contributed because of relaxin, and so when I was running, I was more susceptible to rolling my ankle and whatever else. (P9/FG CAT 1, Officer)

Many CAF members highlighted the challenges with returning to physical training and duties post-pregnancy. Their commentaries highlighted how injuries often occurred upon the return to work, one individual explained:

As far as tendon issues and all that kind of stuff, I wish I had known [post-pregnancy] that because maybe I wouldn’t have been so foolish as to try to lift a 40-pound sandbag and swing it up onto my shoulder as I’m walking forward. I noticed after I came back [from maternity leave] that it really frigged me up. And to this day, I actually have to go for surgery on my shoulder because of it. So maybe also recognizing how long it takes to get the body back in shape would go a long way in not having lower back problems and hips too. (P13/FG CAT 1, Officer)

Frustrated members explained the heightened risk of injury due to physical fitness testing expectations upon their return from parental leave. A participant explained the risks of long-term bodily harm and career loss:

So, my doctor said to me that I’ve got a really strong pelvic floor. But they said it doesn’t matter because it’ll continue to degrade and every time you do it, you will do permanent damage . . . I can deadlift and I can squat like high amounts of weight because I’m able to control the muscles properly. But because the time limit on the PT test . . . You lose your form and you’re just slinging things up to make this deadline and now causing yourself permanent damage. And I know for me, . . . I’m facing essentially like a medical release from the military that affects absolutely nothing else in my job except for that FORCE ¹ test. And that is frustrating. (P26/FG CAT 3, Officer)

The majority of participants detailed concerns and injuries that they connected to their postpartum bodies. Similar to the aforementioned experiences, another participant described the numerous injuries she faced, she stated:

I ended up with diastasis recti, so the splitting of the abdominal muscles and had a big impact with chronic back problems that I had again. Having a rucksack and such because that core strength doesn’t have the same structural capacity that it did before I had my three kids. I’ve blown out a knee, had hip problems and wrist problems as well from all that hyper mobility, not working to my advantage. And then when you’re adding all that heavy weight and lifting equipment, you tear and sprain things. Sometimes I feel like I’ve lived in the physio clinic for the last 10 years it seems to go from having one thing to the next. (P1/FG CAT 1, Officer)

This participant detailed the long-term impacts of her injuries and the ongoing attention required to deal with these physical ailments. Focus group participants discussed injuries as commonplace in the CAF, such experiences were noted as being rooted in the physical requirements for some duties and the training required, while others highlighted the pressure to be in peak physical readiness.

Unreasonable Pressures to Return to Work at Peak Physical Readiness

Women in our study detailed the pressure to return to work post-pregnancy, and to be prepared to pass physical tests such as the FORCE evaluation and the combat test for infantry members, immediately upon return. This expectation was coupled with the pressure female CAF members felt to perform competitively with male counterparts, which, for many participants, resulted in overtraining, leading to injury. In a discussion about post-pregnancy return, one participant described the pressures she experienced:

You know, as women in the military, we do feel that need to go above and beyond, like men can just do their regular everyday thing. But women, if you want to survive and get acknowledged and go anywhere with the military, you have to go above and beyond. You cannot do the status quo . . . You have to go that extra mile or ten push-ups or whatever it is given the situation . . . But just that’s the institutionalization part of it all. It’s just the way you feel in that environment. (P12/FG CAT 1, Non-commissioned member (NCM))

Pressure to outperform male CAF members was further problematized by pregnancy and the postpartum period. One female member detailed the pressure to overtrain in the CAF. Following her pregnancy and return to work, she was admittedly “guilty of this, trying to do too much, too soon, too fast” (P8/FG CAT 1, Officer), and explained that this did indeed lead to health issues and injuries.

In addition to the pressures to perform competitively with male CAF members, female members described their struggle to reach a level of physical fitness upon their return to work, to pass physical testing that is mandatory for career progression. Many participants noted the lack of appropriate support to prepare for fitness evaluations during parental leave. A participant explained,

There really is a struggle for women having to come back after a year of, you know, parental, maternity leave and then having to do the test right away because either they’re ready for a posting, a course, or promotion. And you have to have that done. So trying to help women while on maternity leave is a real struggle and it’s inconsistent on the bases. (P6/FG CAT 1, NCM)

Another CAF member highlighted the unrealistic expectations of physical fitness levels after returning to work:

Oh, one huge thing I found is depending on when you take your parental leave, when you come back, you are expected to be ready to do your FORCE test. And like I said, depending on when it falls in the process, you’re expected to be able to do your FORCE test right away for your promotion and stuff, so I think it’s a huge thing, and yes, you were off for a year, but you’re not off. You’re taking care of a baby. And to be expected to be like physically fit, some people can’t do it right away . . . I don’t think it’s fair in that way. (P17/FG CAT 1, NCM)

Participant concerns focused on the expectations to successfully complete evaluations immediately upon return from maternity leave. In addition to risks of injury, a participant spoke about the implications of such demands on the career progression for women. Many participants voiced that completing FORCE evaluations are important for career advancements and employability in the CAF:

. . . the challenge with career progression for women and having children is that they say the policy protects you in the sense that you shouldn’t be penalized for going on maternity leave. But I’ve seen it multiple times where you don’t have a valid PT test . . . I mean, a lot of times when you are getting pregnant, you don’t necessarily think, you know, it’s not like something that you can plan for. And so I’ve seen multiple situations where career managers are saying while they can’t get, they can’t be promoted until they come back and do their PT test because they didn’t have it done for the last fiscal year when they weren’t pregnant. (P27/FG CAT 3, Officer)

Like other CAF members, a participant described the pressure to complete fitness testing when returning from parental leave, however, she described it as an unspoken expectation:

However, after the fact [returning from maternity leave], I did not take the proper time to recover and no one ever sat me down and said, “Hey, X, get yourself back together because you need to do a PT test as soon as you come back to work.” But in my head, I knew that that was the expectation.” (P6/FG CAT 1, NCM)

Indeed, several CAF members felt that fitness testing and training were risky for specific groups such as women, specifically post-pregnancy, and individuals with smaller stature. However, some felt that testing in its current form was appropriately challenging and that all members of the CAF should be able to engage in these fitness activities and achieve a standard. During a discussion around fitness testing, one participant spoke more broadly:

I mean, the test is a bit harder for shorter and lighter individuals, but being based on task base, it is still fair. It is harder, but it is fair. And the reason behind the test, you know, the sandbags are still going to need to be lifted. So, someone needs to do it. It’s just that, you know, of course, the heavier you are, the taller you are, it’s easier. That’s it. Fair is not equal. Equal is not fair. But that’s where we are. (P2/FG CAT 1, Officer)

This sentiment aligns with the universality of service or “solider first” principle within the CAF, which holds that members must at all times and under any circumstances be liable to perform general military, common defense, and security duties, including any duties outside of their occupation specification (GCND, 2018b) which is, as noted by one of the participants, equal but not equitable, particularly considering return to duties after parental leave.

Lack of Access to Appropriate Resources and Services to Support Physical Recovery

The vast majority of participants advocated for increased services and resources, including a straightforward continuum of care, for women pre- and post-pregnancy. Generally, female CAF members suggested increased specialization in women’s health among CAF medical personnel, One CAF member asserted,

I think that’s one of the core issues here, there’s not much specialization in women’s health. And there’s not great education on it either. I didn’t know anything about pelvic floor health until I got pregnant and I started looking into, you know, what does pregnancy do to my body type thing? (P26/FG CAT 3, Officer)

Participants reported a lack of appropriate pre- and post-natal resources as well as a general lack of knowledge of women’s health needs to adequately support women in the CAF. A CAF member stated,

I had given birth just over 2 years ago, and I explicitly asked for support and training to see a specialist in terms of pelvic floor and was denied that service. I was told that that specialty doesn’t exist in the CAF. So no, go to physio. (P24/FG CAT 3, Officer)

Another participant described her experiences of referral to pelvic floor physio, which seemed to differ depending on the base in which they were stationed. She also highlighted her confusing experience with CAF medical and fitness staff:

I was offered pelvic floor physio. I asked for it. And [name of base] has a really good setup . . . when I asked for physical help from PSP [Personal Support Programs] for other exercises on top of what I’m doing specifically for those movements, because they’re not necessarily the same movement that we do in daily life. I kind of got a lot of deer in the headlights. They were afraid to touch me because the pelvic floor issue like, well, we don’t know. (P26/FG CAT 3, Officer)

Several participants did report positive experiences engaging in return to work or rehabilitation programs postpartum, though most detailed that it was both difficult to find as well as access this type of care in the CAF. One participant highlighted unexpected pelvic floor challenges following pregnancy and the lengthy and unclear process involved in getting connected with appropriate care, based on her experience, she recommended:

It would be great if it was an automatic like, “hey, you’re coming back to work like here, like go see this doctor or physio or whatever, and they’re going to help work with you to make sure everything’s in order.” Because I find personally, the mentality or the expectation is just you’re going to go back and do what you used to do. But there’s a way, there’s a proper way to actually prepare your body that I don’t think is genuinely understood. (P11/FG CAT 1, Officer)

Herein, participants highlighted the challenges they experienced receiving consistent support from CAF medical and fitness staff upon their return to work. Many of the participants noted that the availability of services is geographically/base specific and in need of improved accessibility nationwide. One participant specifically described the barriers to accessing physical activity as a new mother, and how these obstacles set women up for failure as they re-engage in physical activity following their pregnancy:

You know, the other contributor [to injury risk] is access to a [base] gym while you’re on parental leave. You can’t take your children in there because they’re a liability. So, you’re on leave and you’re trying to stay fit and being a good soldier, sailor, aviator, but yet you can’t get to the gym or you have to get a babysitter so you can go to the gym. . . . Like, we need to get ourselves better sorted out in that area. . . . Women here in [city name] are actually buying memberships at a Goodlife Fitness and at different gyms because they actually come with daycares for one, or you can take your baby there or they offer a variety of classes that is much more conducive to real life hours that you can attend. But there’s no reimbursement for such things. (P6/FG CAT 1, NCM)

Indeed, some women had positive experiences being referred to health services and resources but noticed a lack of internal knowledge, care, and specialization in women’s health among CAF health professionals. Postpartum care, including rehabilitation and postpartum-specific training, is available for CAF members on some bases, but only if they know to specifically ask for these services. Participants suggested the implementation of standardized processes for return from maternity leave to connect women to appropriate postpartum services. One participant recommended,

So one thing I think we can do to improve, sort of the medical side of things and then returning to work would be to ask if there’s a way to standardize across the CAF the way that the medical system is applied to individuals . . . And then we get the same treatment to every individual . . . For example, pelvic floor physio is not something I had ever heard of until maybe a year ago when one of my friends who was also pregnant in the CAF in B.C. had mentioned it to me and I mentioned it to other people as well. And it’s been extremely helpful. But you have to know to ask for it. They don’t offer it. So it’s just one small thing that I think that everybody could benefit from it, but certainly those returning to work from pregnancy. (P16/FG CAT 1, Officer)

This quote highlights the importance of access and awareness related to strengthening support for CAF members and leadership to support post-pregnancy individuals with services such as pelvic floor strengthening. Another participant in this focus group pointed out the challenges in accessing gyms:

I think it would be valuable to have options on bases [for physical activity with baby] because it is a requirement of our job that we be physically fit . . . I am doing it because I personally want to be fit, but also I am mandated to be physically fit . . . (P9/FG CAT 1, Officer)

Generally, the focus group participants problematized the inconsistent fitness support during maternity leave, and advocated for a graduated process of restoring peak fitness levels and testing when returning to work. A graduated fitness testing process would reduce the risk of injuries to work toward equitable advancement of women in the CAF.

Discussion

To our knowledge, we have undertaken the first qualitative study examining postpartum CAF members’ perceptions of the association between pregnancy and MSKi risk. Drawing on the themes generated, (a) physiological and anatomical changes in pregnancy, (b) pressures to return to work at peak fitness levels, and (c) perceived challenges associated with accessing appropriate resources and services, we will contextualize our findings in the relevant and existing literature and demonstrate how our findings advance research in this field and further make the case of the need to address issues of equity in injury prevention.

Participants shared their experiences of physiological and anatomical changes to their bodies during pregnancy that they felt increased their risk of MSKi. Our findings align with those of Armitage et al. (2014), who reported that their participants felt pressure to perform physical fitness tests in the postpartum period in the U.S. Air Force. The authors cautioned that women who return to training at an intensity and volume too quickly may be at increased risk of injury. The insights gleaned from female CAF participants expand on the aforementioned literature by pointing to specific ways in which they are at a disadvantage when returning post-pregnancy. The participants noted a lack of access to workout facilities (e.g., hours that not conducive to lifestyle with young child, no childcare provided), which inhibits their ability to handle heavy lifting and equipment (e.g., sandbags) required for testing. Moreover, participants noted the lack of CAF-centric support/resources to recover physically from pregnancy and challenges of returning after parental leave to complete mandatory testing.

Research conducted by Weina (2006) in the United States revealed that physical testing at 6 months postpartum does not provide adequate time to recover from childbirth nor return to pre-pregnancy fitness levels. The participants in our study typically returned to the CAF 12 months postpartum and found that the prolonged effects of pregnancy and maternity leave made it challenging to be physically prepared for mandatory fitness testing at that time point. MSKi issues identified by the participants in this study include, but are not limited to, pelvic floor issues, diastasis recti abdominis, and poor control of abdominal muscles. These findings align with findings from various research studies with similar populations (Gluppe et al., 2018; Gutke et al., 2010; Sung et al., 2021; Wiezer et al., 2020). While stating the obvious, we highlight the point that these same issues are not experienced by those who do not give birth; this is, hence, a distinct case of inequity.

Participants in this study identified that the current CAF fitness culture leads to expectations for physical readiness upon return from parental leave. While physical fitness is a requirement of their job, CAF members note the limited support to prepare them to be physically ready. As such, many participants highlighted the ways in which they were not physically prepared for mandatory testing upon return from maternity leaves. Our findings support work by Armitage et al. (2014), who argued that U.S. military culture creates pressure for individuals to perform physical fitness tests despite not being prepared, which puts them at increased risk for injury. If we consider this through an equity lens, gender influences the likelihood and severity of MSKi. As one participant highlighted, “fair is not equal. Equal is not fair.” Mandatory fitness testing of postpartum individuals, without proper support and preparation, places them at greater risk of injury.

While there have been attempts to create a supportive environment for pregnant and parenting CAF members (GCND, 2017, 2018a), our findings reveal opportunities for enhancing resources related to physical training. Postnatal services to support post-pregnancy physical readiness have been identified as an important strategy to prevent MSKi risk in the CAF. Other researchers have recommended that additional interventions be enacted to assist women in returning to pre-pregnancy fitness (DeGroot et al., 2021; Rogers et al., 2020). The participants in our study highlighted opportunities for the CAF to reduce the risk of injury for postpartum individuals—and how this issue can also impact retention of females in the CAF. Recommendations included tailoring support to postpartum bodies, lives, and demanding schedules. It was also revealed that services vary by geographic location and base; participants suggested streamlining and improving access to services such as pelvic floor physiotherapy, postnatal yoga, and strength and conditioning for postpartum individuals.

We initially anticipated that personal protective equipment (PPE) would be identified as a contributing factor to MSKi for pregnant CAF members; however, CAF members’ duties are restricted due to the ergonomic and physiological changes associated with pregnancy to minimize activities that may be hazardous to the member or to the fetus (GCND, 2018a). Although participants did discuss limited access to quality maternity uniforms to accommodate changing body sizes and noted this was an equity issue, they did not connect this to MSKi. It is crucial to note that PPE was indeed identified as a contributing factor to MSKi risk for females and individuals of smaller stature, but participants did not discuss this in relation to the timepoints of pregnancy and postpartum.

Efforts within the CAF to address issues of gender inequity have been attempted through the adoption of a Gender-Based Analysis Plus (GBA+) framework. The goals of this framework have been identified as improving and developing programs for diverse users, ensuring that benefits and/or risks do not unequally affect members, and promoting equality, diversity, and inclusiveness by addressing gaps (Johnstone & Momani, 2019). Johnstone and Momani (2022) emphasized the value in using a GBA+ framework in a “male-dominated institution” (p. 267). Although it is too early to measure the degree of success with regard to the implementation of this framework, there has been mixed feedback surrounding this implementation as researchers have reported a perceived lack of support from the top, according to DND and CAF members (Johnstone & Momani, 2022). In line with this work, the 4 E’s framework of injury prevention may be a useful approach when considering and addressing the risk of MSKi for pregnant and postpartum members of the armed forces.

Similar to Giles et al.’s (2020) proposed 4 E’s framework, our recommendations underpin equity as a central component to addressing MSKi prevention for pregnant and postpartum individuals. As such, our recommendations highlight the need to focus on education (i.e., training support staff), engineering (i.e., ensure materials/equipment are effective for diverse bodies), and enforcement (i.e., review of global armed forces to create equitable protocols and testing through policies and governing laws) with a key understanding of how addressing the issue of equity may reduce disproportionate injury experiences.

Based on our findings and guidance from the participants themselves, we recommend three key actions to advance MSKi prevention for females in the CAF: (a) create a task force including key stakeholders (e.g., female CAF members who have experienced pregnancy, diverse CAF members, obstetrician and gynecologists, CAF medical personnel, occupational health specialists, exercise physiologists) to develop strategies to implement practical changes in CAF policies and practices to better support female CAF members upon return to work from maternity leave; (b) improve and subsidize CAF member access to injury prevention resources—physical training from qualified professionals (i.e., certified exercise physiologists, kinesiologists), gyms (that offer childcare), and pre/postnatal yoga classes; and (c) examine best practices related to preventive strategies and rehabilitation plans to reduce the risk of MSKi in the post-pregnancy period. This includes CAF-specific research on best strategies to reduce exacerbation of injury and ensure adequate training progression with medical support postpartum and upon return to work after parental leave. A longitudinal study to evaluate the outcomes of the application of an injury prevention training model during critical periods in the reproductive health cycle is also recommended. While it is likely that military personnel may have insights into some of the diverse pregnancy and postpartum practices globally, we would highlight that there may be an opportunity for a systematic policy review across global armed forces, including the CAF. Such a review may provide key insights for policymakers, advocates, and decision-makers to collectively compare, and contrast policies related to pregnancy and postpartum with an overall goal of developing a model for best practices.

It is important to note several limitations of this study. The identity system of ranks in the CAF denotes an individual’s position in a hierarchical structure (GCND, 2021). As such, we made many efforts to form groups where rank would not be a constraint to open discussions, but, in some instances, we did not have the numbers to do so. As such, lower ranking individuals may have felt uncomfortable sharing their experiences based on perceived and real power dynamics. All of the focus groups were conducted during periods of “lockdowns” in various parts of Canada; given the heavy burden of childcare responsibilities on women (Johnston et al., 2020), this may have limited the number of participants who had the capacity to take part in the study. Furthermore, the COVID-19 context may have exacerbated the challenging experiences of postpartum individuals. Nevertheless, there was a wide range of ages among participants with some individuals who were postpartum and others whose children were much older, therefore we recognize that experiences vary based on the practices/policies in place at the time of their pregnancies. Despite these limitations, this research provides insights into the experiences of pregnancy, postpartum, and return to work after parental leave and perceived risk of MSKi.

In summary, participants identified a number of factors they perceive lead to increased risk and susceptibility of MSKi in the CAF for pregnant and postpartum individuals. While pregnancy and parenting are “not incompatible” with a career in the CAF, there is room to enhance services and supports to individuals to reduce risk of MSKi, particularly in the name of equity. As these results indicate, pregnant/postpartum individuals need nuanced and tailored support, resources, policies, and procedures to reduce the risk of MSKi. Efforts to improve resources and supports for this population will address identified issues of inequities, in that females who have biological children face unique uncertainties in their careers due to the prenatal, antenatal, and postpartum periods that may increase their susceptibility to MSKi. Careful consideration of these recommendations and addressing these issues may be a step toward decreasing rates of MSKi, addressing equity issues, and improving retention of females in the CAF or other armed forces around the world.