Introduction
The postpartum transition reflects an intense period of recovery and adaptation. Although traditionally, starting a family has been seen as the end of a football career,1 2 with the appropriate support, players are consistently demonstrating that they can successfully return to high-performance football after childbirth.3–5 The Fédération Internationale de Football Association (FIFA; the global football governing body) updated their maternity regulations in 2024 to include a stipulation that ‘After maternity leave, the club must help the player get back into football, work with her on a postpartum plan and provide medical support’.6 Subsequently, the Fédération Internationale des Associations de Footballeurs Professionnels (FIFPro; the global players’ union) released guidance on key training considerations for return-to-football postpartum.7 Athletes have advocated for an evidence-informed, flexible and practical return-to-sport approach in the postpartum period to ensure they are prepared both mentally and physically.2 8 9 There is a clear and urgent need for football-specific guidance that explicates ‘how’ to implement and address the key considerations that are unique to the postpartum context, as established by FIFA, FIFPro and others.6 7 This gap between what is known based on established research and what is done in practice is referred to as the ‘know-do-gap’.10 There is tremendous potential for athlete-centred decision aids to fill this gap and improve participation and performance among footballers returning to play after childbirth. Thus, our aim was to develop a football-specific decision aid through the use of the knowledge-to-action (KTA) cycle to support players and their multidisciplinary teams (MDT)—such as coaches, medical staff and performance professionals—from low–to-high resource settings in football participation decisions after childbirth.11 12
Methods
The FIFA Stepping into Play Postpartum decision aid was developed using the KTA cycle as a comprehensive framework designed to guide the translation of research into practical interventions and real-world application.13 The KTA cycle is composed of two main components: knowledge creation, which involves identifying problems and synthesising knowledge, and knowledge in action, where the generated knowledge is translated into practical interventions. Separately, the intervention mapping and knowledge transfer scheme serves as an implementation science framework that offers a structured, theory-informed, step-by-step process to support the development, implementation and evaluation of the decision aid through five sequential phases. Phase 1: carrying out a narrative review of the literature on football participation postpartum, supported by published systematic reviews on physical activity following childbirth (knowledge creation); Phase 2: using systematic reviews of barriers to elite sport participation following childbirth to identify key considerations (knowledge creation); Phase 3: creating and refining the objective and approach of the decision aid (action); Phase 4: ascertaining the key health screening components for the decision aid (action) and Phase 5: administering a preliminary assessment of the usability and criterion validity of the decision aid. This scheme was integrated within the context of the KTA framework through the development process of the decision aid. The online supplement contains detailed information on the methods, results and practical guidance to support players’ return to football postpartum.
Phase 1: evaluation of the scientific literature
A search of academic literature was carried out in PubMed to identify papers up to February 2024 related to postpartum return-to-sport using the general search strategy of (postpartum OR postnatal) AND (rehabilitation OR recovery) AND (athlete* or sport*). Studies of any language or design were considered and discussed by the authors. The authors also conducted a narrative review of key considerations for football participation postpartum to inform the development of the decision aid.14 This narrative review critically evaluated original research covering postpartum return-to-football considerations.15
Phase 2: identifying barriers and enablers to sport participation following childbirth
As part of the Phase 1 search strategy, research investigating the barriers and enablers influencing postpartum sport participation in athletes was identified.
Phase 3: creating and refining the objective and approach of the decision aid
In February 2024, FIFA stakeholders and the working group (authors) met for 4 days in Zurich to establish the plan (objectives and methodology) for developing a decision aid. The group included experts with applied, clinical and research experience across multiple disciplines working with amateur and elite football players. The findings from Phases 1 and 2 were collated through a flexible, iterative process using informal interviews and reviewing existing literature. The findings from Phases 1 and 2 enabled the working group to identify the key screening domains to support the health of athletes after childbirth, which was later supported by an International Delphi.16 After a review and discussion of implementation science and knowledge translation literature to determine the most rigorous and suitable developmental frameworks, the working group discussed key moderating factors that would underpin progression and exit criteria for postpartum athletes.
Phase 4: ascertaining key screening components of the aid
The working group identified three core components based on data from Phases 2 and 3. First, all players must be screened for contraindications to exercise participation during the postpartum transitional period, in line with globally accepted guidance. Second, key biopsychosocial considerations must be included in the decision-making process to ensure athlete support is both targeted and individualised. Finally, the group identified specific tools via a narrative review to facilitate clear and comprehensive communication among the MDT. In the case that there were multiple, validated questionnaires that could be used, the most concise, sport-specific, postpartum validated and widely available tool was selected for integration within the decision aid.
Phase 5: preliminary assessment of usability and criterion- and content-validity
In Phase 5, the authors explored the usability of the decision aid components, as well as a preliminary assessment of their usability, criterion- and content-validity. The decision aid was pilot tested with five individuals (sports medicine physician, physiotherapist and coaches) working in elite-level football in diverse geographic regions to obtain feedback on the content validity, usability, appropriateness, clarity, length and format for use with amateur and professional football players. Their qualitative feedback was incorporated prior to conducting a broader consultation.
A wider consultation on the decision aid was conducted through an electronic survey (Research Electronic Data Capture (REDCap)). Participants in this consultation were first provided with an explanation of the Stepping into Play Postpartum decision aid and a case example demonstrating its application by a postpartum football player. Subsequently, respondents provided feedback on the decision aid’s usability and its structural elements, specifically the seven-stage training protocol and its corresponding progression and regression system, and the Postpartum Medical and Performance Debrief Form (ie, were they user-friendly, did they translate well to the football environment). Criterion validity was assessed, through a case study, to confirm that the decision aid’s recommendations accurately aligned with appropriate actions and produced the intended results. The case study illustrated a scenario from which the respondents had to choose the correct course of action from four options at each step of the decision aid (eg, player must cease training and exercising, and speak to her healthcare provider; player can continue training and exercising but needs to discuss with her healthcare provider; player can continue training and exercising but needs to discuss with her MDT; and finally, no additional action needed, and therefore she can progress to the next part of the decision aid). Demographic data were analysed as mean and SD or the frequency and percentage (IBM SPSS Statistics V.29). An analysis of open-ended responses was carried out using an inductive approach to thematic coding to identify patterns within the data following the framework of Braun and Clarke.14 Multiple researchers carried out coding independently, with discrepancies resolved through discussion and consensus. This feedback was incorporated into the decision aid.
Equity, diversity and inclusion
Four women from Brazil, Canada and the UK, who were strategically chosen by FIFA to champion the knowledge translation process, made up the author group and represented researchers, physiotherapists and a physical performance coach working with footballers. A strong effort was made to survey a diverse range of individuals from low-to-middle income countries, across amateur to elite levels, from a variety of cultures.
Patient and public involvement
Key stakeholders and end users were engaged through the decision-aid development process. Football players, coaches, medical and organisational staff were involved in developing the aid and assessing its validity and usability.
Results
Phase 1: evaluation of the scientific literature
Four frameworks centred on postpartum return-to-sport were identified and considered in the development of the decision aid.17–21 The 6Rs framework outlined key principles to support athletes to gradually and safely return to sport after childbirth, but lacked personalisation in the return-to-sport journey (eg, modifications based on medical conditions or social factors). The three remaining frameworks (across four publications) covered personalised step-by-step progression on return-to-running or sport postpartum and outlined key biopsychosocial considerations. However, this existing guidance was primarily focused on return-to-running and did not cover the full spectrum of team sport participation. A comprehensive, football-specific framework to guide postpartum players to return to football was not identified; thus, the developed decision aid builds on the postpartum frameworks that do currently exist.
Phase 2: identifying barriers and enablers to sport participation in pregnancy
Although 22 primary research studies were identified that examined factors influencing postpartum sport participation in athletes, none were specific to football. To prevent redundancy and use existing evidence efficiently, the working group opted to use a scoping review on barriers and enablers as the primary information source for the decision aid that had been published within the last 12 months, rather than conducting a new, updated scoping review.8 Key barriers and enablers identified by this review included the need to foster supportive environments by providing flexible training and support to the athlete, and to provide clear, evidence-based information to athletes, coaches, support staff and organisational staff. The authors identified the implementation of the new FIFA maternity regulations for female football players as a key football-specific enabler of football participation in the postpartum period.6
Phase 3: creating and refining the objective and approach of the decision aid
Based on extensive empirical evidence supporting the health and performance benefits of sport participation in the postpartum period, footballers should be empowered to continue training.22 Their participation should only be ceased if they choose to or if they screen positive for contraindications (at which point their participation can often be modified).3 16 22–29 Thus, this decision aid: (1) prioritises the athlete’s voice in all decisions, (2) supports the maintenance of safe participation for players, (3) facilitates the resumption of participation in team training when and where possible, (4) considers postpartum symptoms and dysfunction, (5) reflects that football participation requires cognitive stimulus and (6) uses currently available questionnaires validated for the postpartum period whenever possible to enhance global internal methodological rigour.
Phase 4: identifying key screening components of the decision aid
A flow chart of the FIFA Stepping into Play Postpartum decision aid is illustrated in figure 1. In 2025, an international consensus study used the Delphi method to create a prescreening tool for exercise after childbirth.16 This tool identified contraindications to exercise, along with other biopsychosocial factors that could be barriers to a person’s participation in postpartum physical activity. In these cases, the study recommended that additional screening and treatment may be necessary. This Delphi study developed a screening tool for postpartum contraindications that was designed to be self-completed by postpartum women and people—The Get Active Questionnaire for Postpartum.30
Figure 1
Flow diagram of the FIFA Stepping into Play Postpartum decision aid. FIFA, Fédération Internationale de Football Association; MDT, multidisciplinary team.
Key biopsychosocial barriers identified by the Delphi study included mental health, pelvic floor and abdominal wall function, musculoskeletal pain, wound healing, relative energy deficiency in sport, poor sleep, fear of movement, lactation status, social/emotional support and eating disorders. Barriers that could be identified by a yes/no response were assessed by checkboxes in the decision aid. In contrast, three key health domains that feature prominently within both postpartum and athletic populations were identified—mental health, fear of movement and pelvic health—which are not optimally identified with a yes/no response but can be assessed using psychometrically sound self-report questionnaires. The Edinburgh Postnatal Depression Scale (EPDS) is widely recognised as one of the most reliable tools to identify potential depressive symptoms in the postpartum period. With only 10 questions, validation in several populations, and an embedded anxiety questionnaire, the EPDS was selected to assess mental health.31 32 Two questionnaires, the Fear Avoidance Belief Questionnaire (FABQ) and the Tampa Kinesiophobia scale, were considered to assess fear of movement; however, the FABQ has been specifically validated for use in the perinatal lumbopelvic pain, and for this reason, was chosen for use in the decision aid. The FABQ33 was considered to most optimally fit the purpose of the decision aid, and the physical activity-specific subscale (questions 2–5) was included. The working group considered several questionnaires to assess pelvic floor dysfunction (PFD). Tools endorsed by the International Continence Society were initially discussed due to their strong psychometric properties. However, using these would have required integrating multiple tools into the decision aid to capture the numerous symptom domains of PFD, which would detract from its usability. Additionally, many existing tools were deemed unsuitable as they either focused on only one aspect of PFD, assessed severity or examined quality of life. Therefore, the PFD Sentinel, a newly developed tool specific to the female athletic population, was selected as the most appropriate measure.32 It is succinct (five symptoms checklist), comprehensive and identifies a breadth of pelvic floor symptoms. While the PFD Sentinel is not psychometrically34 tested to the degree of more established tools, it was developed through an International Delphi consensus process and pairs with a series of physical tests aimed to determine readiness of load and impact movements such as running.19 For these reasons, the PFD Sentinel was considered to best fit the purpose of the Stepping into Play decision aid. If a player has a positive screen on any of the mental health problems, fear of movement or PFD, they are directed to speak to their healthcare provider (eg, pelvic health physiotherapist) as treatment can aid more optimal participation and performance (see the online supplement for more details).34
An initial version of the decision aid was developed with four objectives: (1) general information about the player; (2) screening for health conditions where medical guidance is needed; (3) screening for biopsychosocial considerations to football participation and (4) guidance on football participation following childbirth. After completing Objective 1, the player should move to Objective 2 (see figure 2). Objective 2 is the part of the decision aid where a player may be told that continuing to play is not advisable due to the identification of a contraindication to postpartum exercise. Objective 3 (see figure 3) allows for the identification of biopsychosocial factors to football participation and prompts for further conversations with the players’ healthcare provider to ascertain support options, and subsequently all players move to Objective 4 (see figure 4), which provides practical guidance and suggestions on how players can step into play, through the stepwise scheme of progression and regression (figure 5; online supplementa Table 1) to facilitate transparent communication, a separate onwards communication tool was developed for the MDT to use when discussing decisions with the athlete (figure 6). Detailed instructions for both the decision aid and this standalone communication tool can be found in the online supplement.
Figure 2
The Fédération Internationale de Football Association Stepping into Play Postpartum Decision Aid page 1.
Figure 3
The Fédération Internationale de Football Association Stepping into Play Postpartum Decision Aid page 2.
Figure 4
The Fédération Internationale de Football Association Stepping into Play Postpartum Decision Aid page 3.
Figure 5
Seven-stage training framework for postpartum. FIFA, Fédération Internationale de Football Association.
Figure 6
Onward communication (adapted from Football Australia). FIFA, Fédération Internationale de Football Association.
Phase 5: preliminary assessment of usability and criterion-related validity
32 respondents from 12 countries provided feedback on the decision aid (see table 1). Respondents were 37.9±7.1 years of age, primarily female (84%) with experience at the amateur (31%), semiprofessional (16%) or professional level (53%). Respondents included athletes (37%), healthcare providers (34%), coaches (12%) and support staff (16%). Respondents indicated the decision aid was easy to follow (93%). Based on feedback from respondents who reported the decision aid was difficult to follow (n=4), a flow chart was created, which provides specific, response-based actions for the user to follow (see figure 1). Respondents indicated that the decision aid (97%), seven-stage approach (100%) and the Postpartum Medical and Performance Debrief Form (100%) would be useful to guide a postpartum player and their MDT working in amateur to professional level football.
Table 1
Participant demographics (n=32)
Using a standard case study of a fictitious player, the criterion-related validity of the decision aid was assessed. Overall, 93% appropriately completed objective 2 (contraindications). In objective 3 (biopsychosocial considerations), the appropriate action for mental health (93%), fear of movement (97%), pelvic floor health (93%) and additional biopsychosocial considerations (100%) was identified. Thematic analysis of respondent feedback identified several necessary changes: the flow chart needed to be easier to follow, the language needed simplification (eg, aiming for a Grade 8–10 reading level and reducing medical terminology), and the directions based on player responses required greater clarity. The decision aid was updated to reflect all of these suggestions. Overall, 93% of the time, the observed responses led to the correct actions as laid out by the decision aid. The FIFA Stepping into Play decision aid requires implementation and associated testing to complete the final steps of the KTA cycle—monitoring knowledge use and evaluating outcomes—across player levels (amateur vs professional), and across international borders.
Discussion
Extensive research has demonstrated the health benefits and necessary considerations to optimise postpartum return-to-sport. Building on this body of literature, the aim of this manuscript was to present the development of evidence-informed, practical guidance to enable postpartum players and their MDT to establish a clear return-to-football roadmap. Based on the preliminary results of our usability, and validity assessments described herein, the FIFA Stepping into Play decision aid is expected to translate into improved participation and performance for postpartum footballers across amateur to elite levels. The ongoing evaluation of the implementation of the decision aid (final stage of the KTA framework) as required by the KTA framework is essential for further refinement and continued evaluation of the tools to ensure their use and applicability across cultures and competition levels.
Strengths and limitations
A key strength was the integration of implementation science frameworks, which ensured the final product was not only effective but also practical and scalable in real-world settings. The project was strengthened by international collaboration and incorporated diverse global perspectives from experts in a variety of roles within football (athlete, coach, physician and physiotherapist). This collaborative approach ensured the tool was culturally relevant and widely applicable. Several limitations of the process should be acknowledged. First, the surveys and preliminary validation were carried out with a small respondent group, primarily based in Europe, working in high performance football. In order to refine the decision aid, the authors recognise that work is still required to identify its use across cultures and more diverse populations (eg, amateur football). While the scoping review included the search of one database and potentially missed additional information, this step was supplemental to the narrative review, which included an examination of grey literature. At present, there is limited empirical evidence specific to postpartum football players. The authors also acknowledge that while the decision aid was designed specifically for football players, and even takes into account position-specific adaptations, the decision aid may not fully capture the needs of football players postpartum. Although integrated psychometrically sound questionnaires were integrated, some complex biopsychosocial considerations (eg, sleep and low energy availability) are nuanced and may benefit from assessment beyond a yes/no check box. Since nuanced, validated tools are not available for these constructs for postpartum athletic populations, the decision aid is designed to evolve over time to reflect these advances, adhering to the principles of the KTA cycle. As future research evolves, so too should the decision aid. Finally, online supplemental table 1 provides practical advice on modalities and training adaptations for the seven stages of football participation after birth. However, the suggested adaptations are not the only options for exercises or adaptations. The progressions can be used by players and their MDT as a guide with a view to adapt to suit each athlete to their individual needs. From the perspective of using the KTA action cycle, monitoring knowledge use, evaluating outcomes and sustaining knowledge use are the final aspects of the action cycle. These are the steps that will form essential future research.
Clinical implications
This decision aid has been created to help guide postpartum football participation decisions for players ranging from amateur to elite levels in both low to high resource settings. It can be used by athletes themselves as well as their MDTs to facilitate informed, collaborative decision-making. Additionally, the inclusion of a Postpartum Medical and Performance Debrief Form provides a structured way to document decisions transparently, fostering accountability and an opportunity for reflection throughout the return-to-football process.
Conclusion
The development of a postpartum return-to-football decision aid represents an essential step towards making high-quality decisions to support players from the amateur to professional level following childbirth. While principles for navigating the return-to-football process in the postpartum period are established, there has been a significant lack of guidance on how to practically operationalise these principles in practice. The FIFA Stepping into Play decision aid and framework successfully bridge this gap, offering female footballers and their support teams a practical, clear mechanism to manage the transition through and beyond the postpartum period.
