In everyday practice midwives will care for women from different career backgrounds. Do we always know the right advice to give? In this article about professional dancers Chloe Hillyar, PhD student at Queen’s University Belfast, discusses their particular needs during pregnancy.

  

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Many studies have documented the health benefits associated with exercise during pregnancy to help the general pregnant public understand how to participate in physical activity safely during their pregnancy. (Sports Medicine Australia, 2002, Bø, et al., 2016; Mills et al., 2020; De Vivo. & Mills. 2021;. Wedig, Duelge & Elmer, 2021; Wowdzia, 2021; Ribeiro, Andrade & Nunes, 2021; Jackson et al., 2022).

Physical Activity (PA) guidelines have been published (ACOG, NHS, APF) to help the general pregnant public understand how to participate in physical activity safely during their pregnancy. However, these guidelines are not suitable for birthing populations whose income derives from physical jobs that require frequent engagement in high-intensity training.

Professional freelance, female dancers meet many barriers during pregnancy. Due to their low income, it may not be financially viable to seek medical support from professionals that specialise in dance physiology. Often, dancers rely on the NHS for medical help in hope that their physician will have some knowledge of their unique physiology and understanding of their professional priorities. Furthermore, freelance dancers are not entitled to any maternity benefits from their employer. This means that if they become pregnant, they will often need to stop working without paid maternity leave or a job to come back to. Not only does this make pregnancy a particularly anxious and isolating period, but there are also long-lasting ramifications where post-partum recovery is concerned. The absence of paid maternity leave means that many dancers may feel pressured to regain their pre-pregnancy fitness as soon as possible to audition and compete for work.

When caring for a pregnant professional dancer, it is important to understand their professional priorities. This understanding will reassure the dancer that a return to the dance sector is possible postpartum. This article endeavours to provide an insight into the ‘dancer mentality’ along with some practical recommendations that I hope you will find useful.

When working with professional dancers, it is important to understand the type of person who pursues dance. Dancers possess a very specific set of principles that have allowed them to train for 10+ years, investing time, money, and energy with the knowledge that gainful employment is dubious and success might mean living at the poverty level (Krasnow, Kerr & Mainwaring, 1994). What this indicates is that dancers have very different priorities from those in mainstream careers. The potential loss of work and financial insecurity compounds the mental challenge dancers experience when grappling with the biomechanical changes that occur during pregnancy. Dancers often associate their identity with their bodies and may find the physical change of pregnancy difficult to process.

Dancers are notoriously motivated and used to working through discomfort (Quin et al, 2015). This means that dancers have a unique approach to pain management which cannot be ignored. Research suggests that dancers are more at risk of ignoring pain because dance culture is entrenched in the notion of ‘the show must go on’ (Anderson & Hanrahan, 2008). For pregnant dancers, the issue is this: without dance specific PA guidelines recognising what forms of discomfort are symptomatic of dance activity or of perinatal stress, puts the dancer at risk of mistaking contraindications for standard performance pains. Furthermore, dancers may see pain as benign, routine, or even expected as part of the dance career, rather than a precursor to injury. In some instances, pain has been reported as the measure of physical progression (Harrison and Ruddock-Hudson, 2017).

Motivation to avoid technique regression could stimulate exercise dependence (‘a condition that compels an individual to exercise despite contraindications’ Pierce & Daleng, 2002) to compensate for the progressive lack of movement inhibited by advancing gestation. For example, a study by Nordin-Bates, et al., (2017) evaluated that perfectionism and subsequent burnout are common in the performing arts domain because success is based on the achievement of near perfect or flawless performance (Hall & Hill, 2012). Exercise dependence and perfectionism may motivate dancers to exploit hormonal production benefits to their performance advantage in an attempt to satisfy their high standards of success.

An example of where dancers may be at risk of maladaptive activity for technique progression, could manifest as the potential exploitation of relaxin. The hormone ‘relaxin’ is released during pregnancy for purposes of preparing the pelvis for the birth of the baby (Quin et al, 2015). Its role is to increase the size and pliability of ligaments, tendons and cartilage. The hormone is not localized and will affect the entire body, the effect of which will result in feeling more flexible. Genres of dance, such as ballet and contemporary, place value in flexibility and encourage practitioners to maintain a high degree of flexibility. Dancers who are used to pushing their bodies might enjoy and exploit their increased range of motion. However, if the joints are overextended during pregnancy then the damage could be permanent. This not only puts the dancer at more risk to other joint and muscular related injuries, but it could also harm career longevity.

There is also something to be said about the conflict dancers may experience during pregnancy in relation to the ideal body composition. The aesthetic of pregnancy is not synonymous with the “ideal dancer body” and literature suggests that dancers equate their expectations of physical training with the need for the ideal body (Pierce & Daleng, 2002). Therefore, dancers experiencing pregnancy may try to control the inevitable weight gain through exercise in fear of being deselected for work. Furthermore, it is important to bear in mind the high prevalence of eating disorders among dancers (Wellard, Pickard & Bailey, 2007). Encouraging a conversation around how to incorporate a healthy and satiating diet into the dancer’s lifestyle during pregnancy might provide reassurance and comfort to a dancer who many have anxiety around food.

Existing literature exploring High Intensity PA guidance

Dance encompasses a specialist range of movements that are high in intensity and virtuosic in style. The lack of evidence-based PA guidelines for dancers has meant that the dance sector loses many talented mature women to motherhood since a dancer’s performative years coincide with their childbearing years. Put simply, the physical demands of each dance context vary considerably and warrants individual research attention to provide dedicated guidelines for dancers who wish to continue working throughout their pregnancies.

Whilst no recommendations exist regarding upper limitations for dancers in training, UK Sport have recently developed guidance on how to best support an athlete’s pregnancy from a qualitative study that employed semi-structured interviews with five Paralympic and five Olympic athletes. Whilst these guidelines are limited in providing specific physiological recommendations, it is encouraging that leading sport organisations are investing in these studies.

Similarly, existing literature documenting the effects of high intensity training on pregnant elite athletes has shown no association with an increased odds of adverse pregnancy outcomes (Wowdzia et al., 2022). These studies are encouraging for professional dancers who are not too far removed from the realm of sport.

In 2016, due to the lack of evidenced based research on the impacts of high-intensity PA during pregnancy, the International Olympic Committee (ICO) produced a five-part series providing an expert opinion on the matter. Whilst enfranchising many activities, the ICO cautioned against participating in sports that have the potential to ‘bump the bump’. The ICO also acknowledged that the physically elite are more likely to maintain a more strenuous training regime and could be more at risk of pelvic floor dysfunctions (Erdener & Budgett, 2016). The ICO called for more research that could inform guidelines for elite athletes who often met and exceed general exercise recommendations (Bø et al., 2016).

In the years following, few studies have been conducted despite the numerous calls for such investigations. The American College of Obstetricians and Gynaecologists produced a committee opinion, replacing the one published in Dec 2015, stating that athletes engaging in vigorous-intensity exercise in the third trimester appear to be safe doing so in uncomplicated pregnancies (ACOG, 2020). They also called for further research on the effects of vigorous-intensity exercise in first and second trimesters, particularly in intensities exceeding 90% of Vo2 max (ACOG, 2020). Equally,  a more recent study recognised that exercise can help prevent important pregnancy related disorders such as gestational diabetes mellitus, gestational hypertension and preeclampsia (Ribeiro, Andrade and Nunes, 2021). Nearly twenty years prior, Kardel found that high-level training in pregnant athletes can sustain initial fitness levels and aid a quicker return to sport post-birth (Kardel, 2005). Wowdzia et al., declared that most evidence-based PA guidelines are not suitable for pregnant elite athletes: “current guidelines are limited to moderate intensities of short durations that do not account for high levels of preconception training an elite athlete may be attempting to maintain during gestation” (Wowdzia et al., 2022)

Most recently, Jackson et al., released an opinion article in 2022 detailing the morphological changes that occur throughout gestation in correlation to scientific opinions held on prenatal management in elite athletes. However, the article was inconclusive insofar as PA recommendations go for the physically elite and added their voice to others calling for evidence-based guidelines for pregnant athletes.

The above illustrates that not only is PA safe during pregnancy, but necessary for exercise continuity postpartum. However, there is a paucity of literature on the physiological needs of pregnant dancers, though it seems intuitive there should be a relationship. Current research supports exercise during pregnancy, especially for those who have already been exercising (ACSM, 2005 cited in Sanders, 2008).

 

Recommendations

The structural and cultural atmosphere of the dance world is currently not conducive for pregnancy and dancers might need to rely heavily on their midwifery team for guidance and support. The below sets out some practical recommendations I hope you may find useful:

1. Establishing a dialogue about the dancer’s professional ambitions and commitments after birth (i.e., post-birth performances, current rehearsing/performing schedules, future auditions) will help establish a safe pre/postnatal training regime that will aid their professional return.
2. Signposting freelance dancers to their maternity entitlements from the Government (i.e., maternity allowance, universal credit, etc.) would be a good way of ensuring the dancer knows where to seek financial support should they need it.
3. Understanding any particular physiological features that could be exacerbated during pregnancy. For example, my PhD research has recorded an anecdotal experience from a dancer who was pre-disposed to frequent patella dislocation due to her hypermobility. Similarly, most dancers do not seek medical attention for their injuries. Asking questions about any pre-existing and/or ongoing injuries they routinely work through when dancing will help inform what PA should be prescribed.
4. Understanding how the woman appraises pain. Pain is a routine part of a dancer’s daily schedule. During pregnancy, they’ll need to fight through their professional requirement to power through the pain. Many dancers categorise pain into either ‘good’ or ‘bad’ (Harrison & Ruddock-Hudson, 2017). This means that there are instances where pain is perceived positively. The risk is this: the simplification of pain by dancers reduces the significance of its presence and ignores the seriousness of its warning. If dancers apply this attitude to pregnancy pains, they could be at risk of ignoring something more serious in relation to their pregnancy. A conversation about the different types of pregnancy pains one might experience, and how to identify them, will help the dancer recognise when they need to seek medical assistance.
5. Communicating the different types of hormonal production that will occur during pregnancy and explaining how that might impact their physicality when dancing. Despite the dearth in literature translating prenatal biomechanical processes to the dancing body, the One Dance UK Factsheet might be a good resource until more research is published (or until I publish my thesis!).
6. A long-term goal is the inclusion of dance medicine training within medical and midwifery training. Midwives with a thorough understanding and sensitivity to dancers’ unique needs would be invaluable to the freelance dance community.

The above indicates a layered and complex position for dancers when experiencing pregnancy. As their midwives, your support and understanding of their professional priorities and prospects will be an invaluable source of reassurance and comfort for them during their pregnancy.

I always welcome new knowledge and perspectives and would greatly value a conversation with anyone who finds this topic interesting. If you would like to get in touch to hear about how you may get involved in the study, please email me: [email protected]

 

References

American College of Gynaecologists and Obstetricians (ACOG). (2020) ACOG Committee Opinion Number 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstet Gynecol, 135, 178-188.

Anderson, R., Hanrahan, S. (2008). “Dancing in pain: pain appraisal and coping in dancers.” Journal of Dance Medicine & Science 12: 9-16.

Bø, K., et al. (2016). “Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1-exercise in women planning pregnancy and those who are pregnant.” Br J Sports Med 50(10): 571-589.

De Vivo, M. & Mills, H. (2021) Laying the Foundation for Pregnancy Physical Activity Profiling: A Framework for Providing Tailored Physical Activity Advice and Guidance to Pregnant Women. Int J Environ Res Public Health, 18.

Erdener, U. and R. Budgett (2016). “Exercise and pregnancy: focus on advice for the competitive and elite athlete.” Br J Sports Med 50(10): 567.

Hall H. K., Hill A. P. & Appleton P. R. (2012) Perfectionism: a foundation for sporting excellence or an uneasy pathway toward purgatory? In: Roberts GC, Treasure D (eds): Advances in Motivation in Sport and Exercise. Champaign, IL: Human Kinetics, pp. 129-168.

Harrison, C. and M. Ruddock-Hudson (2017). “Perceptions of Pain, Injury, and Transition-Retirement: The Experiences of Professional Dancers.” J Dance Med Sci 21(2): 43-52.

Kardel, K. R. (2005). “Effects of intense training during and after pregnancy in top-level athletes.” Scand J Med Sci Sports 15(2): 79-86.

Krasnow, D., Kerr, G., Mainwaring, L. (1994) Psychology of Dealing with the Injured Dancer. Medical Problems of Performing Artists, 7-9.

Jackson, T., Bostock, E. L., Hassan, A., Greeves, J. P., Sale, C. & Elliott-Sale, K. J. (2022) The Legacy of Pregnancy: Elite Athletes and Women in Arduous Occupations. Exerc Sport Sci Rev, 50, 14-24.

McCoid, F., Harris, S. & Rafiefar, R. (2013) Pregnancy and the Dancer [Online]. One Dance UK. Available: https://www.onedanceuk.org/wp-content/uploads/2017/11/DUK-Info-Sheet-19-Pregnancy-information-for-dancers.pdf

Mills, H., Atkinson, L., Olander, E., Smith, D., Hayes, L., Currie, S., Newham, J., Foster, C. & De Vivo, M. (2020) Bump start needed: linking guidelines, policy and practice in promoting physical activity during and beyond pregnancy. Br J Sports Med, 54, 764-765.

Nordin-Bates, S. M., et al. (2017). “Perfectionism, Burnout, and Motivation in Dance: A Replication and Test of the 2×2 Model of Perfectionism.” J Dance Med Sci 21(3): 115-122.

Pierce, E. F. & Daleng, M. L. (2002). “Exercise Dependence in Elite Female Dancers.” Journal of Dance Medicine & Science 6: 4-6.

Quin, E., Tomlinson, C. & Rafferty, S. (2015) Safe Dance Practice. Human Kinetics, United Kingdom.

Ribeiro, M. M., et al. (2021). “Physical exercise in pregnancy: benefits, risks and prescription.” J Perinat Med.

Sanders, S. G. (2008). “Dancing Through Pregnancy Activity Guidelines for Professional and Recreational Dancers.” Journal of Dance Medicine & Science 12: 17-21.

Sports Medicine Australia. (2002) Statement: The benefits and risks of exercise during pregnancy. J Sci Med Sports. 5(1):11–19.

Wedig, I. J., Duelge, T. A. & Elmer, S. J. (2021) Infographic. Stay physically active during COVID-19 with exercise as medicine. Br J Sports Med, 55, 346-347.

Wellard, I., Pickard, A. & Bailey, R. (2007) ‘A shock of electricity just sort of goes through my body’: physical activity and embodied reflexive practices in young female ballet dancers. Gender and Education, 19, 79-91.

Wowdzia J. B., Mchugh, T. L., Thornton, J., Sivak, A., Mottola, M. F. & Davenport, M. H. (2021) Elite Athletes and Pregnancy Outcomes: A Systematic Review and Meta-analysis. Med Sci Sports Exerc, 53, 534-542.

 

Chloe Hillyar

May 2022

PhD Student, School of Arts, English and Languages

Queen’s University Belfast