Prevalence of lumbopelvic pain during pregnancy: A systematic review and meta‐analysis of cross‐sectional studies

Abstract

Introduction

Lumbopelvic pain (LPP) is common in pregnant women and has a significant negative effect on physical and psychological health. In this study, for the first time, we conduct a meta‐analysis to estimate the overall prevalence of LPP among pregnant women and clarify the reasons for the differences in the estimated results.

Material and methods

A systematic search of four databases (PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials) was conducted from inception until October 2022. Two reviewers conducted a methodological quality assessment. Random‐effects model analysis was used to estimate the pooled prevalence and the 95% confidence interval. Chi‐square tests and I ²‐values were used to assess the heterogeneity. Subgroup analysis (according to the participants’ continent, age, body mass index [BMI], gestational age and study risk of bias), sensitivity analysis and random‐effects meta‐regression were used to explore the the sources of heterogeneity.

Results

Of the 1661 unique citations, 38 studies (21 533 pregnant participants) were included in this systematic review and meta‐analysis. The overall pooled prevalence of LPP during pregnancy was 63% (95% CI: 0.57 to 0.69), with significant heterogeneity (I ² = 99.1%, P < 0.001). The prevalence differed by participants’ continents, 71% (North America), 74% (South America), 63% (Asia), 64% (Europe), 59% (Africa) and 45% (Oceania). The prevalence differed by BMI, 64% (BMI <25), 64% (25 ≤ BMI ≤ 28), and 71% (BMI >28). The prevalence differed by age, 72% (age <25 years), 58% (25 ≤ age ≤ 30 years), and 69% (age >30 years). The prevalence were the same differed by study risk of bias, 63% (both low and moderate risk of bias studies). The prevalence were similar by gestational age, 62% (second trimester) and 63% (third trimester).

Conclusions

Lumbopelvic pain during pregnancy is common; about three‐fifths of pregnant women experience LPP. More prevention and intervention research for lumbopelvic should be conducted in pregnant women with different clinical characteristics.

In this study, for the first time, we conduct a meta‐analysis to estimate the overall prevalence of lumbopelvic pain among pregnant women. Lumbopelvic pain during pregnancy is common; about three‐fifths of pregnant women experience lumbopelvic pain.

Abbreviations

BMI

body mass index

CI

confidence interval

LPP

lumbopelvic pain

Key message.

Lumbopelvic pain during pregnancy is common; 63% pregnant women experience LPP. Clinicians should pay more attention to exploring the characteristics of lumbopelvic pain during pregnancy to develop better treatment strategies.

1. INTRODUCTION

Lumbopelvic pain (LPP) during pregnancy is defined as pregnancy‐related low back, or pelvic girdle pain. ¹ LPP during pregnancy is a common and complex problem with both physical and psychological burdens. ² , ³ LPP has a serious negative effect on most women during pregnancy and is a leading cause of work absenteeism in pregnant women, ⁴ as well as having a significant impact on sleep and activities of daily life, increasing the risk of postpartum depression and anxiety. ³ Considering its adverse influence, it is necessary to increase awareness of LPP during pregnancy.

Previous research has shown that women with severe LPP during pregnancy have an extremely high risk of experiencing serious back pain during subsequent pregnancy and the postpartum period. ⁵ Women with LPP during pregnancy have a higher risk of reporting poor health and sick leave, making LPP during pregnancy a major public health issue which should not be ignored. ⁶ A recent systematic review found that a history of low back pain, pre‐pregnancy body mass index (BMI) >25, pelvic girdle pain, depression during pregnancy and heavy workload during pregnancy were significant risk factors for LPP. ⁷

The etiology of LPP during pregnancy remains unclear; however, mechanical and hormonal factors have been suggested to play roles. ⁸ Regarding the biomechanical factors, evidence has shown that LPP during pregnancy is associated with altered kinetic parameters and motor control. ⁹ In addition, increasing body weight and width, particularly of the abdomen, can increase the force exerted on the back. ¹⁰ Body postural changes with increased lumbar lordosis to fight against increasing anterior abdominal weight, which, in combination with altered neuromuscular control, contribute to the development of joint, ligament and myofascial dysfunction. ¹ Hormonally, relaxin is thought to increase pelvic laxity, and a review assessing the relationship between hormone relaxation and LPP reported inconsistent results. ¹¹ Alterations in hormone levels weaken and stretch the muscles and ligaments attached to the chest and abdomen, resulting in pain in the low back and pelvic girdle. ¹²

Despite the association between LPP and pregnancy, there is currently no consensus regarding the prevalence of LPP during pregnancy. An increasing number of published studies on LPP during pregnancy have provided a comprehensive overview of its prevalence. Filling this knowledge gap is crucial for improvements in policy and practice. Therefore, the aim of this systematic review and meta‐analysis was to determine the best estimate of overall LPP prevalence during pregnancy and to clarify the reasons for the differences in estimates.

2. MATERIAL AND METHODS

This systematic review and meta‐analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA). All data were extracted from the published literature, and informed consent and ethical approval were therefore not required.

2.1. Search strategy and eligibility criteria

We searched four electronic databases (PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials) from their inception to October 12, 2022. A combination of medical subject headings and text words related to LPP, back pain, pelvic girdle pain, pregnancy and prevalence was used in the search strategy. The language of the literature search was limited to English. The reference lists of the final included studies were manually searched to identify eligible studies. The detailed search syntax for PubMed were displayed in Table S1.

All of the references were processed using EndNote X9 (Thomson Reuters). After duplicate removal, two reviewers screened all retrieved records, titles and abstracts to exclude irrelevant literature and then reviewed the full‐text articles according to the prespecified inclusion and exclusion criteria. We included studies meeting the following criteria: (1) publication language restricted to English; (2) study design type was cross‐sectional; (3) study population included women with LPP during pregnancy; and (4) reported LPP prevalence during pregnancy. The exclusion criteria were as follows: (1) studies written in languages other than English; (2) conference abstracts, anecdotal reports, reviews, protocols and letters; and (3) patients with specific back pain and/or pelvic girdle pain causes, such as compression fractures, tumors, infection and ankylosing spondylitis. All of the reviewers used the same EndNote file. Following completion of the literature retrieval, two reviewers screened the literature according to the inclusion and exclusion criteria. Disagreements regarding eligibility were discussed by the reviewers, and a third reviewer joined the discussion to reach an agreement, if necessary.

2.2. Data extraction and quality assessment

Two independent reviewers extracted relevant data using a prespecified data extraction form. The extracted information included author (year), country, age (years), BMI (kg/m²), gestational age (weeks), pain intensity (0–10, zero means no pain and 10 means the worst pain imaginable), sample size of pregnant women and sample size of LPP in pregnant women. This discrepancy was resolved by a third reviewer.

The methodological quality assessment tool, which was developed specifically for prevalence studies, was used by two reviewers. ¹³ This checklist contains 10 items used to assess external and internal validity, comprising study selection bias, non‐response bias, measurement bias and bias related to the analysis. The responses could indicate a low, moderate or high risk of bias for each item. The summary of overall risk of bias for the included studies was based on the number of high bias risk items: ≤2 was scored as low, ³ , ⁴ was scored as moderate and ≥5 was scored as high. ¹³

2.3. Statistical analysis

STATA/SE version 15.0 (Stata Corp, College Station, TX, USA) was used for all statistical analyses. The pooled prevalence of LPP during pregnancy was estimated using a 95% confidence interval (CI). The standard error of the pooled LPP prevalence was calculated from the reported prevalence and sample size, using the formula “square root of p × (1 − p)/n”. The meta‐analysis was conducted by package “metan” in STATA. Chi‐square tests and I ²‐values were used to assess the heterogeneity. We performed random‐effects model analysis to increase the robustness of the pooled results of the meta‐analysis. Sensitivity analysis was used to evaluate the stability of the pooled results and explore the possible sources of heterogeneity. We also performed subgroup and meta‐regression analyses to explore the sources of heterogeneity based on participants’ continent, age, BMI, gestational age and study risk of bias. ⁷ , ¹⁴ , ¹⁵ , ¹⁶ Meta‐regression analysis was carried out using package “metareg” in STATA. A P‐value of <0.05 was considered statistically significant for all tests.

3. RESULTS

3.1. Literature search and characteristics of the included studies

We collected 1661 unique citations from four electronic databases. After removing duplicates, the titles and abstracts of 1232 records were screened. Finally, 111 full‐text articles were assessed for eligibility, among which, 38 studies ⁵ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ were included in the meta‐analysis. A flow diagram of the study selection process is shown in Figure 1.

FIGURE 1.

Flow diagram for study selection.

Of these included studies, 12 studies ¹⁷ , ¹⁹ , ²¹ , ²⁵ , ²⁷ , ³¹ , ³² , ³⁷ , ³⁹ , ⁴² , ⁴³ , ⁵¹ were from Asia (Malaysia, Iran, Pakistan, India, Kuwait, Nepal and China), 15 studies ¹⁸ , ²² , ²⁸ , ²⁹ , ³³ , ³⁵ , ³⁶ , ³⁸ , ⁴⁰ , ⁴⁴ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵² from Europe (Turkey, Poland, Portugal, Sweden, Netherlands, Spain, UK and Norway), six studies ²⁰ , ²³ , ²⁴ , ³⁴ , ⁴¹ , ⁴⁵ from Africa (Malawi, Nigeria and Ethiopia), four studies ⁵ , ³⁰ , ⁴⁴ , ⁵³ from North America (USA), one study ²⁶ from South America (Brazil) and two studies ⁴⁶ , ⁵⁰ from Oceania (Australia). The present study is was a multicenter cross‐sectional study of four countries, USA, UK, Norway and Sweden. ⁴⁴ The publication dates of this study ranged from 1982 to 2022. A total of 21 included studies showed that the mean BMI ranged from 22 to 42 kg/m². A total of 27 included studies showed that the gestational age of the majority of participants was second or third trimester. The mean ages of the 37 included studies ranged from 23 to 32 years. The mean pain intensity in the 27 study participants was 4–6/10. The 38 studies included 21 533 pregnant participants and the prevalence of LPP during pregnancy ranged from 16.9% to 91.91%. The characteristics of all included studies are presented in Table 1.

TABLE 1.

Characteristics of included studies.

Study, first author (year)	Country	Age (years)	BMI (kg/m2)	Pain intensity (0–10)	Gestational age (weeks)	Sample size of LPP in pregnancy	Sample size of pregnancy	Prevalence of LPP in pregnancy
Aabroo (2020)	Pakistan	27.4 ± 3.89	27.3 ± 3.89	NR	NR	313	400	78.25%
Acharya (2019)	Nepal	25 ± 4	25 ± 4	6 ± 2	24 ± 10	437	1284	34.03%
Al‐Sayegh (2012)	Kuwait	29.6 ± 5.2	29.7 ± 5.0	5.1 ± 2.3	second trimester (majority)	255	280	91.07%
Ansari (2010)	Iran	27.14 ± 5.46	NR	Moderate‐severe	NR	59	103	57.28%
Berber (2020)	Turkey	28.09 ± 5.58	NR	4.75 ± 1.93	32.54 ± 7.12	297	400	74.25%
Bryndal (2020)	Poland	28.6 ± 4.4	27.4 ± 3.8	NR	37.6 ± 5.0	822	1510	54.44%
Ceprnja (2021)	Australia	31.6 ± 0.4	27.8 (27.6, 28.1)	2.3 ± 2.8	29.1 (28.5, 29.6)	344	780	44.10%
Chang (2011)	China	32.5 ± 3.88	26.3 ± 2.93	4.3 ± 1.73	36.4 ± 1.28	140	187	74.87%
Fruscalzo (2021)	Germany	30.43 ± 4.94	41.62	6	39.71	128	229	55.90%
Gashaw (2020)	Ethiopia	27 ± 4.6	NR	NR	third trimester (majority)	103	424	24.29%
Gutke (2018)	USA	31 (30, 32)	30 (29, 31)	5 (3;7)	34 (33.6, 33.9)	184	214	85.98%
	UK	30 (29, 31)	29 (28, 29)	7 (5;8)	34 (34.1, 34.5)	184	220	83.64%
	Norway	32 (31, 32)	27 (26, 27)	5 (3;7)	34 (33.7, 34.2)	154	220	70.00%
	Sweden	31 (30, 31)	28 (28, 29)	5 (3;7)	34 (33.8, 34.3)	177	215	82.33%
Hameed (2022)	USA	30.55 ± 6.16	27.38 ± 6.06	Mild–moderate	20.2 ± 10.4	536	851	63%
Kovacs (2012)	Spain	32	26.8	4	35	822	1152	71.35%
Manyozo (2019)	Malawi	25.83 ± 5.91	NR	NR	NR	249	404	61.63%
Mazicioglu (2006)	Turkey	27.1 ± 9.9	NR	4.18 ± 1.85	third trimester (majority)	734	1357	54.09%
Mogren (2005)	Sweden	29.99 ± 4.8	28–30	5.8 ± 2.2	22.1 ± 7.9	639	891	71.72%
Mohseni‐Bandpei (2009)	Iran	25.98 ± 5.08	26.41 ± 4.58	5.12 ± 2.13	22.98 ± 9.31	427	1062	40.21%
Mota (2015)	Portugal	29.7 ± 4.5	29.2 ± 5.0	NR	third trimester (majority)	71	105	67.62%
Mousavi (2007)	Netherlands	25.4 ± 5.0	25.65	5.6 ± 2.0	30	161	325	49.54%
Nazari (2020)	Iran	25.49 ± 0.51	28.15 ± 4.89	NR	third trimester (majority)	350	550	63.64%
Ng (2017)	Malaysia	29 (26, 32)	23.3 (20.1, 27.3)	4–5	third trimester (majority)	303	358	84.64%
Nwuga (1982)	Nigeria	24.2 ± 2.3	NR	Very mild–mild	NR	89	99	89.90%
Omoke (2021)	Nigeria	29.33 ± 4.8	NR	4.3 ± 1.36	NR	138	478	28.87%
Onyemaechi (2021)	Nigeria	29.6 ± 5.4	NR	NR	27.2 ± 6.9	180	317	56.78%
Rodrigues (2011)	Brazil	25	22.7	NR	23.31	49	66	74.24%
Röst (2004)	Netherlands	31.9 ± 4.0	NR	5.2	26.3 ± 7.0	666	870	76.55%
Saxena (2019)	India	24.24 ± 3.20	NR	4–7	34 (majority)	162	201	80.60%
Sencan (2018)	Turkey	26.5 ± 5.5	26.1 ± 3.9	3.70 ± 1.60	third trimester (majority)	809	1500	53.93%
Shad (2018)	Pakistan	20–40	NR	4	third trimester	343	554	61.91%
Shafi (2021)	Pakistan	26–27	NR	NR	32–33	108	160	67.50%
Shahzad (2021)	Pakistan	26.47 ± 4.8	NR	5.2 ± 1.9	3rd trimester (majority)	169	1000	16.90%
Skaggs (2007)	USA	22.7 ± 4.5	NR	NR	26	401	599	66.94%
Starzec (2019)	Poland	29.85 ± 3.84	21.66 ± 3	4.87 ± 1.73	26.89 ± 5.67	79	189	41.80%
	Norway	32.23 ± 3.55	22.64 ± 2.74	4.88 ± 2.41	26.6 ± 6.38	42	75	56.00%
Sturesson (1997)	Sweden	NR	NR	3.7 ± 2.1	12–40	171	338	50.59%
Usman (2017)	Nigeria	28.4 ± 5.86	NR	Moderate	NR	284	309	91.91%
Virgara (2018)	Australia	24.5 ± 5.4	26.4 ± 6.19	NR	NR	48	96	50.00%
Walczak (2021)	Poland	17–40	14–47	4.11 ± 2.71	NR	160	211	75.83%
Wang (2004)	USA	31.5 ± 4.8	NR	4.56 ± 2.6	third trimester (majority)	645	950	67.89%

Note: Data were presented as mean (standard difference) or median (95% CI) or range.

Abbreviations: BMI, body mass index; LPP, lumbopelvic pain; NR, not reported.

3.2. Prevalence of LPP during pregnancy and subgroup analysis

The overall pooled prevalence of LPP during pregnancy was 63% (95% CI: 0.57 to 0.69) with significant heterogeneity (I ² = 99.1%, P < 0.001) (Figure 2).

FIGURE 2.

Forest plot for prevalence of lumbopelvic pain during pregnancy.

As shown in Figure 3, we performed a subgroup analysis based on the different participant continents. The prevalence of LPP during pregnancy was 63% (95% CI: 0.47 to 0.78) in Asia, 64% (95% CI: 0.59 to 0.70) in Europe, 59% (95% CI: 0.33 to 0.84) in Africa, 71% (95% CI: 0.62 to 0.79) in North America, 74% (95% CI: 0.64 to 0.85) in South America and 45% (95% CI: 0.41 to 0.49) in Oceania. Significant heterogeneity was observed in most subgroups, including those from Asia (I ² = 99.5%, P < 0.001), Europe (I ² = 97.1%, P < 0.001), Africa (I ² = 99.5%, P < 0.001), North America (I ² = 95.5%, P < 0.001) and Oceania (I ² = 16%, P = 0.275).

FIGURE 3.

Forest plot for prevalence of lumbopelvic pain during pregnancy stratified by participants’ continents.

As shown in Figure 4, we performed subgroup analysis based on the mean age of the participants. The prevalence of LPP during pregnancy was 72% (95% CI: 0.59 to 0.86) in participants aged <25, 58% (95% CI: 0.49 to 0.68) in participants aged between 25 and 30, and 69% (95% CI: 0.63 to 0.76) in participants aged >30 years. Significant heterogeneity existed in all subgroups: age <25 years (I ² = 95.6%, P < 0.001), 25–30 years (I ² = 99.4%, P < 0.001) and >30 years (I ² = 97.1%, P < 0.001).

FIGURE 4.

Forest plot for prevalence of lumbopelvic pain during pregnancy stratified by participants’ age.

As shown in Figure 5, we performed a subgroup analysis based on the participants’ BMI. The prevalence of LPP during pregnancy was 64% (95% CI: 0.41 to 0.88) in participants with BMI <25, 64% (95% CI: 0.56 to 0.71) in participants with BMI between 25 and 28, and was 71% (95% CI: 0.42 to 1.01) in participants with BMI >28. Significant heterogeneity existed in all subgroups: BMI <25 (I ² = 97.5%, P < 0.001), 25 ≤ BMI ≤28 (I ² = 98.8%, P < 0.001) and BMI >28 (I ² = 98.2%, P < 0.001).

FIGURE 5.

Forest plot for prevalence of lumbopelvic pain during pregnancy stratified by participants’ BMI.

As shown in Figure 6, we performed a subgroup analysis based on participants’ gestational period. The second trimester was defined as 13–27 gestation weeks and the third trimester as 28–40 gestation weeks. The prevalence of LPP during pregnancy was 62% (95% CI: 0.49 to 0.74) in second trimester participants and 63% (95% CI: 0.55 to 0.71) in third trimester participants. Significant heterogeneity was observed in both subgroups: second trimester (I ² = 99.2%, P < 0.001) and third trimester (I ² = 99.1%, P < 0.001).

FIGURE 6.

Forest plot for prevalence of lumbopelvic pain during pregnancy stratified by participants’ gestational age.

As shown in Figure 7, we performed subgroup analysis based on the risk of bias in the included studies. The prevalence of LPP during pregnancy was 63% (95% CI: 0.55 to 0.71) in both low risk of bias studies and moderate risk of bias studies. Significant heterogeneity was observed in both subgroups: low risk of bias (I ² = 99.3%, P < 0.001) and moderate risk of bias (I ² = 96.4%, P < 0.001).

FIGURE 7.

Forest plot for prevalence of lumbopelvic pain during pregnancy stratified by risk of bias.

3.3. Sensitivity analysis and meta‐regression analysis

We performed a sensitivity analysis by excluding eligible studies individually to explore the stability of the pooled results. The sensitivity analysis revealed that none of the unique studies influenced the pooled estimates. A meta‐regression analysis was performed to explore the sources of heterogeneity in the prevalence of LPP during pregnancy. Multivariate meta‐regression results demonstrated that the sample region, age, BMI, gestation period and study risk of bias were unlikely to contribute to the high heterogeneity (all P > 0.05) (Table S2).

3.4. Methodological quality assessments

A methodological quality assessment of the included studies showed that all had a low or moderate risk of bias. This is for the general risk of bias assessment, as there were high risks in Table S3. Details of the quality evaluation of each study are given in Table S3.

4. DISCUSSION

To the best of our knowledge, this is the first systematic review and meta‐analysis to determine the best estimates of LPP prevalence during pregnancy. The pooled prevalence of LPP during pregnancy was 63%. As the heterogeneity in the prevalence estimates was relatively high (I ² = 99.1%), the pooled results should be interpreted with caution.

A previous narrative review reported that pregnancy‐related pelvic girdle and low back pain were widespread in approximately 45% of all pregnant women. ³ This meta‐analysis pooled the prevalence of LPP during pregnancy, which was slightly higher than that reported in a previous narrative review, ³ possibly due to the increasing incidence of LPP during pregnancy. A recently published meta‐analysis demonstrated that the pooled prevalence of low back pain was 40.8% by week among healthy workers across all professional groups. ⁵⁴ Thus, there is a higher incidence of LPP in pregnant patients than that in the general population. Due to the structural, physiological, physical and psychosocial factors of pregnant women, it is easy to determine that the prevalence of LPP during pregnancy is higher than that of the general population.

We identified five possible sources of heterogeneity a priori: participant location, continent, age, BMI, gestational age and study risk of bias. When stratified by participant location, the prevalence of LPP during pregnancy was slightly higher in North and South America than in Asia, Europe, Africa or Oceania. However, only four studies were from North America and one from South America; this is insufficient to explain the prevalence of LPP during pregnancy, with significant differences among participants on different continents, given the limited number of included studies in North America and South America. When stratified by BMI, the prevalence of LPP during pregnancy was higher in participants with BMI >28 than in those with BMI <28. In contrast to our findings, a previous study showed that women with higher BMI had a higher prevalence of pelvic girdle pain syndrome during pregnancy. ⁵⁵ A cohort study showed that higher BMI is associated with pelvic girdle pain during pregnancy. ⁵⁶ The reason for this inconsistency may be that there were only two studies with participants with a BMI >28, so subgroup analysis stratified by BMI revealed no significant impact of BMI on the prevalence of LPP during pregnancy. Additionally, multivariate logistic regression analysis demonstrated that BMI was not significantly associated with low back pain during pregnancy. ⁵⁷ We should not over‐explain the results of the subgroup analysis. When stratified by age, the prevalence of LPP during pregnancy was slightly higher in participants aged >30 years and <25 years, than in those aged between 25 and 30 years. In contrast to our findings, a longitudinal cohort study found that young pregnant women had more back pain than older pregnant women. ⁵⁸ The reasons for this may be the limited amount of participants with age >30 and the fact that most participants were primipara, who are more prone to LPP than menstruating women. A prospective cohort study ⁵⁹ of pregnant women demonstrated that the prevalence and severity of LPP increased over the course of pregnancy, which is comparable to our results. It has been reported that the prevalence of low back pain among the different trimesters is inconsistent and is more prevalent in the third trimester. ⁵⁷ Multivariate logistic regression analysis demonstrated that maternal age and gestational age were significantly related to low back pain. ⁵⁷ In contrast, another study concluded that low back pain was more frequent in the second trimester of pregnancy. ⁶⁰ Based on our findings, the pooled prevalence rates of LPP during pregnancy in the second and third trimesters were similar. When stratified by the study risk of bias, the prevalence of LPP during pregnancy was the same in both the low‐ and moderate‐risk bias subgroups. A previous review reported that the average visual analog score for pain ranged from 50 to 60 mm on a 100‐mm scale, ³ which was similar to our findings.

LPP in pregnant women is a serious public health problem. Indeed, an investigation reported that the prevalence of sick leave was 56% in employed pregnant women in the first 32 weeks of gestation, and more than 25% of pregnant women reported long‐term sick leave (>20 days). ⁶¹ Pregnancy‐related low back pain was the most frequently reported reason. ⁶¹ In terms of the main reason for this, a previous review ⁶² summarized the risk factors evaluated in various studies on pregnancy‐related low back pain and pelvic girdle pain as follows: physical factors (age, weight, height, BMI, parity, oral contraceptives, smoking, and social conditions), psychological factors (stress level, work satisfaction, and strenuous work), during pregnancy/labor (higher fetal weight, prolonged second stage of labor, traumatic delivery, and excessive hip abduction), and others (previous low back pain, low back pain during menstruation, and trauma to the back). The results of different studies vary owing to different subjective and objective factors. Moreover, a systematic review found that participants with pregnancy‐related pelvic girdle pain had increased motion in their pelvic joints compared with healthy pregnant women. ⁶³ Increased motion in the pelvic joints diminishes the efficiency of load transmission and increases shear forces across the joints, resulting in pelvic girdle pain in pregnant women. ⁶³ Additionally, there is an increase in the sagittal moment due to the enlarged fetus and uterus, resulting in hyperlordosis. ⁶⁴ One study found that pregnant women with pelvic girdle pain had lower back flexor endurance values than those without pain. ⁶⁵ A case–control study showed that pregnant women adapted to their patterns of lumbar motion and erector spinae activity during flexion and extension. ⁶⁶ These biomechanisms act against the increase in abdominal mass and ligamentous laxity, which are associated with the genesis of pregnancy‐related back pain. ⁶⁶ Brown et al. found that higher pain intensity during the third trimester of pregnancy was associated with an increased incidence of cesarean section, assisted delivery and longer duration of labor. ⁶⁷ Women with diastasis recti abdominis tend to have weaker abdominal muscles and a higher prevalence of abdominal pain. ⁶⁸ Furthermore, a high proportion of pelvic floor muscle dysfunction was present among women with LPP. ⁶⁹ Pilot data suggested that the gluteus media were strongly associated with the presence of low back pain during pregnancy. ⁷⁰ In pregnant women of a later gestational age, disorders of static alternations in sacroiliac and pelvic alignment may occur, resulting in strain symptoms in the lumbopelvic region. ⁷¹ The presence of back pain during a previous pregnancy or during the last pregnancy has a significant relationship with pregnancy‐related LPP. ⁷² A cohort study showed that a history of low back or pelvic girdle pain, younger maternal age, higher BMI, smoking before and during pregnancy, multiparity and sports performance during pregnancy were associated with pelvic girdle pain during pregnancy. ⁵⁶

In this study, we prespecified five variables to perform a subgroup analysis and meta‐regression, although it was difficult to identify the source of heterogeneity. Participants’ characteristic variables in the included literature may have large variations within the study. Only variables at the study level can be aggregated for analysis; therefore, representing the true conditions of the study is difficult. Subgroup analysis revealed that continence, age, BMI, gestational age and risk of bias in the included studies were not significant moderators and did not explain the heterogeneity in the prevalence of LPP during pregnancy. Multivariate meta‐regression results demonstrated that the high heterogeneity did not vary with the participants’ continent, age, BMI, gestational age or risk of bias of the included studies. The reason may simply be the underlying distribution in that particular study, country or region, without any independent covariates explaining it.

Based on our pooled results and to improve the understanding of LPP prevalence during pregnancy, the following issues were addressed. The prevalence of LPP during pregnancy appeared to be higher in South America, North America and Europe than in Asia, Africa and Oceania. Therefore, during pregnancy preventing and treating strategies of LPP should be prioritized for women in South America, North America and Europe. We should pay more attention to pregnant women aged <25 years or >30 years, as they seem to have a higher probability of developing low back pain during pregnancy. Pregnancy at an appropriate age (such as 25–30 years old) could be an effective choice for reducing LPP during pregnancy risk. Women with low or high BMI (BMI <25 or >30) are also at higher risk of developing low back pain during pregnancy, so we recommend that pregnant women should maintain a reasonable BMI range. Education on low back pain should be provided before or in the early stages of pregnancy, eg reducing poor sitting posture, prolonged standing and rest, correcting poor lifestyle or work habits, and learning to handle low back pain during pregnancy. Women who have low back pain before pregnancy should undergo exercise training before becoming pregnant. The risk factors related to low back pain during pregnancy should also be explored to provide guidance for clinical practice. More research should be conducted on the prevention and intervention of LPP in the pregnant women with different clinical characteristics.

This systematic review and meta‐analysis had several limitations. The stratified pooled prevalence estimates may be influenced by some unextracted data, which might have an impact on the estimates, such as interference with treatment, numbers of fetuses and previous LPP history. Secondly, some studies did not provide a clear and detailed definition of low back pain and/or pelvic girdle pain, and a subgroup analysis of unique low back pain and pelvic girdle pain could not be performed. Third, the number of included studies on different continents varied significantly, and further studies should be conducted in other countries. Fourth, cross‐sectional studies, and hence their meta‐analyses, can be imprecise, as they only represent a snapshot of time. Finally, only cross‐sectional studies published in English were included in our meta‐analysis so some studies may have been missed. However, we believe that missing studies did not significantly affect the findings, as a large number of studies were included. Finally, although subgroup, sensitivity and meta‐regression analyses were performed, the reasons for the high heterogeneity could not be identified.

5. CONCLUSION

LPP during pregnancy is common; about three‐fifths of pregnant women experience LPP. More attention should be paid to pregnant women in South America, North America and Europe. The clinicians should pay more attention to exploring the characteristics of LPP during pregnancy to develop better treatment strategies. More prevention and intervention research for lumbopelvic pain should be conducted in pregnant women with different clinical characteristics. The contributors to high heterogeneity were explored, and further research is required.

AUTHOR CONTRIBUTIONS

Hong Shanshan and Chen Liying contributed equally to this work and share first authorship. Hong Shanshan and Chen Liying designed the research, Zhuang Huihong and Wang Yanting conducted the research, Lin Tiantian and Jin Tong collected data, and Zhuang Huihong and Lin Tiantian assessed the risk of bias. Qin Jiawei and Jin Tong participated in data analysis and interpretation and wrote the paper. All authors contributed to the article and approved the submitted version.

CONFLICT OF INTEREST STATEMENT

The authors have stated explicitly that there are no conflicts of interest in connection with this article.

Supporting information

Table S1

Table S2

Table S3

Shanshan H, Liying C, Huihong Z, et al. Prevalence of lumbopelvic pain during pregnancy: A systematic review and meta‐analysis of cross‐sectional studies. Acta Obstet Gynecol Scand. 2024;103:225‐240. doi: 10.1111/aogs.14714