Supporting reproductive health in female athletes: A mixed-methods exploration of supplementation practices and perceptions

An increasing number of female athletes continue their sporting careers through pregnancy to postpartum (1) . However, pregnancy increases nutritional demands, often requiring supplementation to maintain adequate micronutrient status (2) . Although limited, emerging evidence highlights the challenges female athletes face during pregnancy planning and pregnancy, particularly in relation to supplementation (3) . The aims of this study were to: (1) Explore patterns of pregnancy supplement use among female athletes, including the frequency, types, and timing of supplements used, as well as reasons for use; (2) Explore athletes’ perceptions of supplementation in the context of nutrition and reproductive health. A mixed-methods design was utilised. Participants were recruited via researcher networks and social media. Female athletes who had been pregnant within the past eight years completed an online cross-sectional Pregnancy and Nutrition (PAN) survey on supplementation during and after pregnancy. Descriptive statistics were summarised using SPSS. Semi-structured, one-to-one online interviews with female athletes of reproductive age explored perceptions and experiences of reproductive health and supplementation. Interviews were audio-recorded, transcribed verbatim, and analysed using Reflexive Thematic Analysis informed by a relativist ontology and constructivist epistemology. Ethical approval was granted by King’s College London Research Ethics Board (LRU/DP-23/24-41676, LRS-24/25-48790). 287 athletes (mean age 35 ± 3.8 years) were included from the survey. Supplements were most commonly used for health reasons (including pregnancy (n = 98; 34.1%), postpartum (n = 92; 32.1%), and general health (n = 108; 37.6%)), rather than for performance (n = 39; 13.9%). Pregnancy-related supplements only (n = 133; 50.0%) were more common than both pregnancy- and sport-specific supplements (n = 25; 36.1%) or sport-specific supplements only (n = 37; 13.9%). Folic acid and iron (as single supplements) were more frequently reported during pregnancy (n = 234; 81.5% and n = 148, 51.6%, respectively) than preconception (n = 139; 48.4% and n = 49; 17.1%). Vitamin D supplementation remained relatively consistent through preconception (n = 111, 38.7%), pregnancy (n = 166; 57.8%), and postpartum (n = 112; 39.02%). Sixteen female athletes (mean age 26.3 ±4.7 years) participated in the interviews to date. Participants described supplements as largely irrelevant until pregnancy, despite acknowledging the importance of micronutrients. Many reported gaps in reproductive health nutrition knowledge, and highlighted inequities in sport, with women’s health needs often dismissed. Online misinformation contributed to conflicted trust in guidance. Female athletes continue to face challenges in accessing support on reproductive health and nutrition. Tailored education and systematic monitoring of key nutrients, specifically folic acid, iron and vitamin D, should be implemented. Further mixed-methods research should examine the prevalence of nutrient deficiencies and barriers to supplementation across reproductive stages. Addressing these gaps is a critical step toward supporting athletes in balancing motherhood with sport and protecting long-term maternal and child health.