OBGYN.net: The Universe of Women's Health

Horse Riding During Pregnancy

By MS Rogers, FRCOG, FRCS, MD. Professor O&G
Chinese University of Hong Kong, and N Rodgers, District Commissioner for Equitation, Hong Kong Jockey Club.*

Address for Correspondence:

Prof. MS Rogers
Department of Obstetrics & Gynaecology
The Chinese University, Hong Kong
1/EF, Prince of Wales Hospital
Shatin, New Territories
Hong Kong, SARTel: (852) 26322805
Fax: (852)26360008
Email: msrogers@cuhk.edu.hk  

Abstract

Objective: To determine the risks of continuing to engage in equestrian activities when pregnant.

Methods: An internet search including an Ovid search of Medline and Pre-Medline from 1966 to the present.

Results: 137 hits using the terms 'equestrian' or 'horse riding' but no return when the term 'pregnancy' was added. A review of the reported risks of injury during equestrian events is presented and recommendations for pregnant women made based on this information.

Conclusions: Provided the pregnant woman is aware of the risks involved, the decision to continue riding or handling horses remains hers alone. However, from the equestrian establishment’s point of view, pregnant women should be discouraged from show jumping or cross country eventing.

Introduction.

We are, each in our individual roles, frequently asked to give advice on the advisability of stopping horse riding during pregnancy.  Until a few years ago the advice offered was that the risks of injury during horse riding were too high to justify continuing.  Recently, one of the riding instructors attended for antenatal care and posed the same question, whilst stressing that stopping riding would adversely affect the business she and her husband had started.  Having reminded her of the risks of trauma due to falling and other horse related incidents, the final decision was left to her; given that there is little or no evidence that the action of horse riding per se carries any other risks. She subsequently continued riding and teaching (though not eventing) throughout this, and her next pregnancy, with spontaneous and relatively short labour at term, followed by normal vaginal delivery on both occasions. This may have provided an inappropriate example to other women riders in Hong Kong . The Hong Kong Jockey Club therefore commissioned a formal report on the risks of riding during pregnancy so that suitable advice can be provided, and regulations amended if necessary.

Methods.

An Ovid search of Medline and Pre-Medline from 1966 to the present detected 137 references using the terms ‘horse riding’ or ‘equestrian.’  Adding the term ‘pregnancy’ however resulted in a failure to detect a single reference.

Current Advice During Pregnancy: Clearly, if a pregnancy is complicated by bleeding, membrane rupture, pregnancy induced hypertension or growth restriction, or if there is a past history of pre-term labour, consulting an obstetrician or midwife is advisable, and they will almost certainly advise against continuing to ride. However, given the absolute dearth of scientific information in the medical literature on this subject, these professionals cannot offer any more than subjective opinion for the woman with a normal pregnancy who wishes to continue riding.

Womens’ own views on continuing riding vary considerably, depending to some extent on whether they ride themselves or are making recommendations to others. There are several interesting anecdotal reports and opinions that have been posted on the internet from women who have decided to continue or to stop riding whilst pregnant.[1][2] Women in favour of continuing to ride tend to be over-represented in these bulletin boards, but a number also express more conservative opinions. Only one woman relates a negative incident where premature labour followed a fall from her horse.  The remainder had uneventful pregnancies and (easy) normal deliveries, although a number had had to stop horse riding in the third trimester of pregnancy because of discomfort or difficulty mounting and/or dismounting, or simply the removal of much of the pleasure they previously associated with riding.3

In order for women and clinicians to make rational decisions about continuing equestrian activities, it is therefore necessary to establish what are the real risks associated with horse riding outside of pregnancy, and to extrapolate these to the pregnant state.

Epidemiology: Horse riding is undoubtedly a hazardous pastime, with a number of studies documenting high rates of injury and death among horse riders in general.  In New Zealand the frequency of injury is compatible with that associated with playing rugby.[3]  The rate of hospitalizations is around 24/100,000 population/per year with a mortality rate of 0.2/100,000 population/per year.  In Germany , one quarter of all lethal sports injuries are caused by horse riding.[4]  Analysis of sports associated mortality in England and Wales found that horse riding was the most hazardous activity with 98 deaths, followed by air sports (92 deaths), motor sports (86 deaths) and mountaineering (74 deaths): 19 of the horse riding deaths occurred in children.[5] Injuries commonly affect young women riders (85% of all hospitalizations for horse riding accidents), although this may only reflect a preponderance of young women amongst the riding community.[6] Equestrian injuries which require clinical treatment are often serious in nature resulting in long-term disabilities and handicaps.[7]

Type of injury: Equestrian activities can result in a wide range of injuries varying in severity from very minor to fatal. Most injuries result from falls (80%) and are to the head, upper limbs and chest. Head injuries outnumber spinal injuries by five to one, and in contrast to other sports, there are more lumbar and thoracic than cervical injuries.[8] The most common location of horse-related injuries is the upper limb (24% to 61%) with lower limb injuries coming second in frequency (36% to 40%). 20% of horse-related injuries are to the head and face.[9] In studies from Australia and the United States , the majority of deaths are related to head injuries (78% and 60%), followed by chest injuries (9%). A recent study in the United Kingdom has shown a changing pattern of injuries to horse riders, with an increase in the incidence and severity of upper limb injuries and a decline in head injuries, associated with greater use of protective headgear.4 Abdominal and pelvic injuries are relatively rare. Moss and colleagues reported rates of 1.2% and 5% respectively, but most only involved soft tissue.4 Flynn[10] however, reported two cases of disruption of the symphysis pubis whilst horse riding.

Type of riding: The overall frequency of injury is comparable in hacking, jumping and cross-country riding, but the injuries are more severe in the latter. Jumping is the most frequent activity associated with severe injury, and cross country event riders should be considered an even higher risk subset with especially high injury rates due to frequent falls.

Experience: There are mixed reports regarding the effect of experience on the severity of injuries. Silver & Parry[11] performed a retrospective study of riders sustaining serious spinal injuries admitted to Stoke Mandeville Hospital and compared them to riders sustaining minor but significant injuries. “It was found that 70% of the 20 accidents could be thought attributable to the behaviour of the horse at the time, and seven of these were in the spinal injuries group. Rider error was a significant contribution in seven cases, and in two instances the rider was under instruction at the time. There was also inadequate experience of the rider in seven cases, of which five were thought to show inadequate supervision.”  In contrast the injury rates during cross country eventing are not reduced by experience; rather the highest rates are found among the riders competing at the highest levels.[12] Similarly, a Canadian study of injuries during professional rodeo showed that inexperienced riders had a lower rate of severe injury compared with experienced competitors. Inexperienced riders also had a lower rate of injury overall to most body parts, except the upper limb (arm, hand, and wrist).[13] Kriss & Kriss,[14] reviewing equestrian injuries admitted to the University of Kentucky Medical Center summarise the situation: “Risk of serious injury appears to be a function of cumulative exposure to horses, not level of expertise. Experience is not protective; helmets are.”

Stables and horse handling: Injuries are not all sustained by riding. Riders may underestimate the risk of severe injury from hoof kicks, particularly while handling the horse. A horse’s kick can transfer a force of more than 10,000 Newtons to the body, causing skull fractures or severe trauma to the viscera.[15]  Iba and colleagues investigated the patterns of 637 horse-related injuries in 581 thoroughbred stable and stud-workers in Japan . As with horse-riding injuries the upper half of the body was more frequently involved than the lower half. Kicks accounted for 39% of all injuries, including 11 serious and one lethal visceral injury.[16]

Fitness: Meyers and Sterling [17] have recently published a study comparing the physical, hematological, and exercise response of female equestrian athletes to those of athletes engaging in other sports. Percent body fat (24.5+/-6.0%), was higher, and mean VO2max (33.9+/-4.5 ml/kg/min), treadmill time (10:06+/-:36 min:sec), VEmax (90.3+/-16.0 l/min), observed peak power (5.3+/-0.9 w/kg), total work output (315.9+/-48.1 j/kg), fatigue index (66.9+/-7.9%), and handgrip strength (27.8+/-6.6 kg) were all lower amongst the equestrian group. They concluded that “the lack of adequate physical conditioning of the equestrian may be a contributing factor in the growing number of injuries” and that “equestrian athletes need to supplement conventional sport activity with traditional aerobic and anaerobic training regimens”.

Discussion.

Most sports are safe during the first 2 trimesters as long as there is no risk of impact or trauma. Horse riding however, poses risks both from falls and from kicks, and there are also theoretical risks from recurrent impact during riding in women prone to pre-term labour. It is apparent both from personal experience, and from the experience of others, that in a healthy uncomplicated pregnancy, horse riding per se does not cause any obstetric problems unless an accident occurs. Some horses are safer than others but no horse should be considered safe: all horses are potentially lethal animals. Prevention of accidents and injuries is dependent upon using knowledge obtained from studying activities involving horses.  Provided the pregnant woman is aware of the risks involved, the decision to continue riding or handling horses remains hers alone. However, from the equestrian establishment’s point of view, pregnant women should be discouraged from show jumping or cross country events.