Background: Low back and pelvic pain (LBPP) is an important issue related to mental health as well as to difficulty for daily life activity during early pregnancy and in the postpartum period. We examined the intensity of LBPP, difficulty for daily life activity and mental health and their associations from early pregnancy until 3 months postpartum in a prospective study. We also examined predictive factors for LBPP at 3 months postpartum. Methods: We recruited 55 pregnant women who responded to questionnaires in the first, second and third trimesters and at one week, one month and 3 months postpartum. We designed a self-administered questionnaire including a visual analog scale (VAS), pregnancy mobility index (PMI) of LBPP and Edinburgh postnatal depression scale (EPDS). Results: There were significant differences in the proportions of women with LBPP in the first trimester (63.6%), second trimester (78.2%) and third trimester (83.6%) and at one week postpartum (80.0%), one month postpartum (69.1%) and 3 months postpartum (56.4%). VAS score at 3 months postpartum was significantly correlated with VAS scores at the first trimester (r = 0.410, p = 0.002), second trimester (r = 0.298, p = 0.027) and one month postpartum (r = 0.476, p < 0.001). VAS score at 3 months postpartum was significantly correlated with PMI scores at the first trimester and one month postpartum. The presence of LBPP at 3 months postpartum was significantly associated with the proportion of women with LBPP at the first trimester. In multiparous women, predictive factor of LBPP at 3 months postpartum was a past history of LBPP in the previous pregnancy. Conclusion: The proportion of women with LBPP and the intensity of LBPP were increased at late pregnancy and gradually decreased until 3 months postpartum. LBPP at 3 months postpartum was associated with LBPP at the first trimester and a past history of LBPP in a previous pregnancy was an important factor for prediction of LBPP at 3 months postpartum. Provision of information regarding LBPP and confirmation of LBPP before pregnancy in addition to assessment of LBPP at early pregnancy are necessary for reduction of LBPP at 3 months postpartum.
Many studies have shown that pregnancy-related low back and pelvic pain (LBPP) occurs from the second or third trimester to postpartum [
Physical symptoms including pain are closely related to mental health during early pregnancy and the postpartum period. It has been reported that women who had experienced a greater number of physical health problems had an increased risk of depressive symptoms in early pregnancy [
Postpartum women have motions for infant rearing other than daily life motions, although the change in the shape of the body during pregnancy gradually returns to the shape before pregnancy. Mukkannavar et al. [
The study protocol was reviewed and approved by the Ethics Review Board of Tokushima University Hospital (approval no. 2201). The study was conducted from March 2015 to August 2017 in a birth center in Kagawa Prefecture in Japan. The number of hospital bed is 689 and the number of delivery is about 500 per year in the birth center. We distributed questionnaires regarding LBPP to 300 pregnant women at the first trimester who had undergone a prenatal health checkup at an obstetrics and gynecology clinic. Women with orthopedic disorders or neurological diseases that affected their activities regardless of pregnancy were excluded. Pregnant women having high risks such as twin pregnancy, severe infectious disease and mental disorders were also excluded. Participants were informed of the purposes and procedure of the study. We asked women who gave consent for research cooperation to respond to questionnaires at the first, second and third trimesters and at one week, one month and three months postpartum. The numbers of collected questionnaires were 231 in the first trimester (mean period: 14.8 weeks; 10 - 19 weeks), 171 in the second trimester (mean period: 25.8 weeks; 25 - 28 weeks), 151 in the third trimester (mean period: 35.7 weeks; 35 - 38 weeks), 89 at one week postpartum, 80 at one month postpartum and 55 at 3 months postpartum. Fifty-five pregnant women who responded to questionnaires in all six stages were used as subjects for this study (
We designed a self-administered questionnaire consisting of three parts that required about 20 minutes to complete. The contents of the questionnaire were shown in detail in our previous report [
Cochran’s Q test was used for comparison of changes in the proportions of women with LBPP in the 6 periods during pregnancy and in the postpartum period. Continuous VAS, PMI and EPDS scores in the 6 periods were compared by using Friedman test. The correlation of VAS score in one period with that in another period and the correlations of VAS score with PMI and EPDS score were analyzed by using Spearman’s correlation. We compared the number of women with LBPP in one period and the number of women with LBPP in another period by using the chi-square test and Fisher’s exact test. We classified the subjects by the VAS level at the first trimester into three groups; low group in which VAS level was less than the 25th percentile (n = 20), moderate group (n = 21), and high group in which VAS level was more than the 75th percentile (n = 14). Then, VAS, PMI, and EPDS scores between the three groups were compared by Median test. The proportions of women with menstrual pain, lumbar pain before pregnancy and a past history of LBPP in the previous pregnancy in the three groups of VAS at early pregnancy were compared by using Fisher’s exact test. We performed logistic regression analysis with LBPP at 3 months postpartum as dependent variables and age, BMI, body weight of newborn infant, menstrual pain, lumbar pain before pregnancy as in-dependent variables. In addition, in multiparous women, we performed logistic regression analysis with LBPP at 3 months postpartum as dependent variables and age, BMI, body weight of newborn infant, menstrual pain, lumbar pain before pregnancy and past history of LBPP in the previous pregnancy as independent variables. P values were two-tailed, and those less than 0.05 were considered to be statistically significant. Statistical analyses of the data were carried out using SPSS version 24 for Windows (IBM Corp., Aromonk, NY).
Baseline characteristics of the subjects are shown in
The proportions of women who complained of LBPP were 63.6% at the first trimester, 78.2% at the second trimester, 83.6% at the third trimester, 80.0% at one week postpartum, 69.1% at one month postpartum and 56.4% at 3 months postpartum. There was a significant difference in the proportion of women with
Age (years) | 32.3 ± 4.9 | |
---|---|---|
Parity | Primiparous | 23 (41.8) |
Multiparous | 32 (58.2) | |
Working (first trimester) | Yes | 44 (80.0) |
No | 11 (20.0) | |
Presence of LBPP before pregnancy | Yes | 25 (45.5) |
No | 30 (54.5) | |
Past history of LBPP in previous pregnancy (n = 32) | Yes | 19 (59.4) |
No | 13 (40.6) |
The numbers in parenthesis indicate the proportion. Age is shown as mean ± standard deviation. LBPP: low back and pelvic pain.
LBPP among the 6 stages (p = 0.001) (
As shown in
PMI scores in the 6 stages are shown in
1st trimester | 2nd trimester | 3rd trimester | 1 week postpartum | 1 month postpartum | 3 months postpartum | p-value | |
---|---|---|---|---|---|---|---|
Gestational week | 14.8 (10 - 19) | 25.8 (25 - 28) | 35.7 (35 - 38) | ||||
Proportion of women with LBPP (%) | 63.6 | 78.2 | 83.6 | 80.0 | 69.1 | 56.4 | 0.001 |
VAS score | 1.7 (0.0 - 4.9) | 2.6 (0.6 - 5.6) | 4.1 (2.7 - 6.1) | 2.8 (1.1 - 5.1) | 2.2 (0.0 - 4.2) | 1.1 (0.0 - 3.3) | <0.001 |
PMI | 2.0 (0.0 - 8.0) | 9.0 (0.0 - 14.0) | 16.0 (8.0 - 26.0) | 9.0 (1.0 - 22.0) | 1.0 (0.0 - 6.0) | 0.0 (0.0 - 2.0) | <0.001 |
EPDS | 5.0 (4.0 - 8.0) | 4.0 (2.0 - 7.0) | 4.0 (2.0 - 7.0) | 6.0 (1.0 - 10.0) | 5.0 (3.0 - 10.0) | 3.0 (1.0 - 6.0) | 0.001 |
Gestational week is shown as mean (range). VAS, PMI and EPDS score are shown as medians. The numbers in parenthesis indicate the 25 - 75 percentiles. VAS: visual analog scale, PMI: Pregnancy Mobility Index, EPDS: Edinburgh Postnatal Depression Scale.
Stage | VAS at 3 months postpartum | |
---|---|---|
VAS | 1st trimester | 0.410** |
2nd trimester | 0.298* | |
3rd trimester | 0.146 | |
1 week postpartum | −0.028 | |
1 month postpartum | 0.476** | |
PMI | 1st trimester | 0.428** |
2nd trimester | 0.198 | |
3rd trimester | 0.084 | |
1 week postpartum | 0.099 | |
1 month postpartum | 0.353** | |
3 months postpartum | 0.766** | |
EPDS | 1st trimester | −0.027 |
2nd trimester | −0.146 | |
3rd trimester | −0.132 | |
1 week postpartum | −0.222 | |
1 month postpartum | −0.219 | |
3 months postpartum | −0.179 |
*p < 0.05, **p < 0.01. VAS: Visual Analog Scale, PMI: Pregnancy Mobility Index. EPDS: Edinburgh Postnatal Depression Scale.
As shown in
VAS at the first trimester | p-value | ||||
---|---|---|---|---|---|
Low | Moderate | High | |||
n = 20 | n = 21 | n = 14 | |||
VAS score | 1st trimester | 0.0 | 1.9 | 6.4 | <0.001 |
Age (years) | 33.5 | 32.2 | 30.7 | 0.406 | |
Parity | Primiparous | 8 | 12 | 3 | 0.100 |
Multiparous | 12 | 9 | 11 | ||
Menstrual pain | Yes | 13 | 16 | 13 | 0.207 |
No | 7 | 5 | 1 | ||
Presence of LBPP before pregnancy | Yes | 6 | 9 | 10 | 0.059 |
No | 14 | 12 | 4 | ||
Past history of LBPP in previous pregnancy (n = 32) | Yes | 3 | 6 | 10 | 0.004 |
No | 9 | 3 | 1 | ||
VAS score | 2nd trimester | 0.7 | 2.2 | 4.9 | 0.034 |
3rd trimester | 3.5 | 3.7 | 5.1 | 0.151 | |
one week postpartum | 1.3 | 2.8 | 5.1 | 0.020 | |
one month postpartum | 0.0 | 3.0 | 3.2 | 0.005 | |
three months postpartum | 0.0 | 2.7 | 1.6 | 0.005 | |
PMI | 1st trimester | 0.0 | 6.0 | 7.5 | <0.001 |
2nd trimester | 2.0 | 11.0 | 13.0 | 0.093 | |
3rd trimester | 15.0 | 14.0 | 18.5 | 0.706 | |
one week postpartum | 6.0 | 13.0 | 9.5 | 0.120 | |
one month postpartum | 0.0 | 2.0 | 4.5 | 0.042 | |
three months postpartum | 0.0 | 2.0 | 0.0 | 0.019 | |
EPDS | 1st trimester | 5.0 | 5.0 | 8.0 | 0.373 |
2nd trimester | 3.0 | 4.0 | 5.5 | 0.495 | |
3rd trimester | 5.0 | 4.0 | 5.0 | 0.436 | |
one week postpartum | 6.5 | 6.0 | 6.0 | 0.985 | |
one month postpartum | 8.0 | 5.0 | 3.0 | 0.373 | |
three months postpartum | 2.0 | 3.0 | 4.0 | 0.959 |
VAS, PMI and EPDS score are shown as medians. VAS: Visual Analog Scale, PMI: Pregnancy Mobility Index, EPDS: Edinburgh Postnatal Depression Scale.
1 week postpartum (p = 0.020) and at 1 month postpartum (p = 0.005). A moderate VAS score was significantly associated with a high VAS score at 3 months postpartum (p = 0.005). A high VAS score at early pregnancy was significantly associated with high PMI scores at the first trimester (p < 0.001) and 1 month postpartum (p = 0.042) but not with high PMI score at the second trimester, third trimester or 1 week postpartum. The VAS score at early pregnancy was not associated with EPDS levels during pregnancy and puerperium.
As can be seen in
There was a large proportion of women with LBPP in the third trimester and 56.4% of the women had LBPP at 3 months postpartum. Olsson et al. [
LBPP of 3 months postpartum | p-value | |||
---|---|---|---|---|
yes | no | |||
LBPP of 1st trimester | yes | 27 | 8 | <0.001 |
no | 4 | 16 | ||
LBPP of 2nd trimester | yes | 28 | 15 | 0.016 |
no | 3 | 9 | ||
LBPP of 3rd trimester | yes | 27 | 19 | 0.335 |
no | 4 | 5 | ||
LBPP of 1 week postpartum | yes | 28 | 16 | 0.033 |
no | 3 | 8 | ||
LBPP of 1 month postpartum | yes | 27 | 11 | 0.001 |
no | 4 | 13 |
All women | (n = 55) | ||
---|---|---|---|
odds ratio | 95% CI | p-value | |
Age | 1.02 | 0.90 - 1.14 | 0.751 |
Body mass index | 1.02 | 0.87 - 1.20 | 0.773 |
Body weight of newborn infant | 1.00 | 0.99 - 1.00 | 0.958 |
Menstrual pain | 0.99 | 0.26 - 3.73 | 0.990 |
Presence of LBPP before pregnacy | 2.33 | 0.71 - 7.63 | 0.160 |
Multiparous women | (n = 32) | ||
odds ratio | 95% CI | p-value | |
Age | 1.11 | 0.78 - 1.57 | 0.557 |
Body mass index | 1.04 | 0.86 - 1.25 | 0.658 |
Body weight of newborn infant | 1.00 | 0.99 - 1.00 | 0.403 |
Menstrual pain | 1.20 | 0.15 - 9.53 | 0.862 |
Presence of LBPP before pregnacy | 1.26 | 0.16 - 9.69 | 0.821 |
Past history of LBPP in previous pregnancy | 7.68 | 1.15 - 50.98 | 0.035 |
CI: Confidence interval, LBPP: Low back and pelvic pain.
previous studies. Also, 38% of the women had LBPP continuously from early pregnancy until 3 months postpartum. The subjects who had LBPP at early pregnancy were interested in LBPP and they might be included in the higher proportion of women who had LBPP continuously.
Thorell et al. [
It has been reported that PMI was highest in late pregnancy and that PMI in women with low back pain was significantly higher than PMI in women without low back pain at early pregnancy, late pregnancy and 1 year postpartum [
Mori et al. [
Women who had a high intensity of LBPP at early pregnancy showed high intensity of LBPP until 1 month postpartum and had difficulty of daily life activity at 1 month postpartum. Morino et al. [
We showed that moderate VAS, but not high VAS, at early pregnancy was related to high intensity of LBPP and high PMI at 3 months postpartum. Many women spend much of their time resting until their 1 month postpartum checkup, but their physical burden increases in daily activity thereafter since the scope of activity increases after 1 month postpartum. Also, the physical burden of nursing, due to the increase in body weight of the infant, increases in postpartum women. Thus, LBPP in women whose VAS levels were moderate at early pregnancy might worsen since they did not initially feel severe pain. Also, no significant difference in the third trimester is due to high levels of VAS and PMI in the third trimester. A high VAS level at early pregnancy was not associated with EPDS score at any of the stages. Chang et al. [
Gutke et al. [
The predictive factor for LBPP at 3 months postpartum was a past history of LBPP before pregnancy in multiparous women. The result was in line with the result of previous study [
Care for LBPP at early pregnancy may result in improvement of postpartum LBPP. In Japan, health guidance for LBPP has been mainly done after the second trimester, in which the posture of pregnant women has changed. The results of the present study indicate that it is necessary to provide information about LBPP and assess LBPP at early pregnancy rather than at the second trimester. It is particularly important to provide information on LBPP at the stage of early pregnancy to women for whom there is a risk of LBPP occurring.
This study was a prospective study on LBPP from early pregnancy until 3 months postpartum. The study showed that assessment of LBPP at early pregnancy is important for preventing LBPP at 3 months postpartum and we have proposed the appropriate content of health guidance and the appropriate timing for such health guidance for pregnant women. However, this study has several limitations. First, compliance of response was low. Many of the women who dropped out were those at 1 week postpartum. The recovery rate might have been low because postmpartum women were busy for nursing. Second, the sample size was relatively small. Generalization of the results in our study may have a limitation. A significant association of LBPP with mental health may not have been found because of the small sample size.
In conclusion, the proportion of women with LBPP and the intensity of LBPP were increased at late pregnancy and gradually decreased until 3 months postpartum. LBPP at 3 months postpartum was associated with LBPP at the first trimester and a past history of LBPP in a previous pregnancy was an important factor for prediction of LBPP at 3 months postpartum. Provision of information regarding LBPP and confirmation of LBPP before pregnancy in addition to assessment of LBPP at early pregnancy are necessary for reduction of LBPP at 3 months postpartum.
The authors are grateful to doctors, midwives and medical assistants in Shikoku Medical Center for Children and Adults for supporting this research. We also thank the women who participated in this study.
The study protocol was reviewed and approved by the Ethics Review Board of Tokushima University Hospital (approval no. 2201). This study was reviewed by the Ethics Review Board of a birth center in Kagawa Prefecture in Japan.
The authors declare no conflicts of interest regarding the publication of this paper.
Uemura, Y., Yasui, T., Horike, K., Maeda, K., Uemura, H., Haku, M., Sakae, R. and Matsumura, K. (2018) Possible Predictive Factors for Low Back and Pelvic Pain at Three Months Postpartum Assessed in a Prospective Study from Early Pregnancy until the Postpartum Period. Open Journal of Nursing, 8, 552-566. https://doi.org/10.4236/ojn.2018.88041