Chronic low back pain (CLBP) is one of the most prevalent musculoskeletal disorders affecting women during the postpartum period and may continue for months or even years after childbirth. It significantly interferes with physical activity, childcare responsibilities, occupational performance, sleep quality, and overall quality of life. The etiology of postpartum chronic low back pain is multifactorial and includes pregnancy-related hormonal influences causing ligamentous laxity, progressive weight gain, altered posture with increased lumbar lordosis, stretching and weakening of abdominal and pelvic floor muscles, and repetitive mechanical strain during pregnancy and child-rearing activities. Multiparous women may be particularly vulnerable because repeated pregnancies can result in cumulative stress on the spine, pelvis, and supporting musculature. Cesarean delivery may represent an additional contributing factor to persistent low back pain. Surgical incision through the abdominal wall, fascial disruption, scar tissue formation, postoperative pain, reduced early mobility, core muscle weakness, and adhesions may alter biomechanics of the trunk and pelvis, thereby increasing the likelihood of chronic lumbar discomfort. Repeated cesarean sections may further intensify these effects due to recurrent tissue trauma and prolonged recovery periods. Although postpartum back pain has been widely reported, limited studies have specifically examined the long-term association between previous cesarean delivery and chronic low back pain among multiparous women, particularly in hospital-based populations from developing countries. Understanding this relationship is clinically important for patient counseling, delivery planning, postpartum rehabilitation, and prevention of long-term disability. Therefore, the present study was conducted to evaluate the association between cesarean delivery history and chronic low back pain in multiparous women attending a tertiary care hospital.
Low back pain is frequently reported during pregnancy and postpartum periods. Mechanical strain, ligament laxity, altered posture, and abdominal muscle weakness are recognized causes. While many women improve within weeks of childbirth, a subgroup develops persistent chronic pain affecting quality of life, childcare ability, sleep, and daily function.
Cesarean delivery involves incision through abdominal wall layers and may lead to scar fibrosis, weakened core musculature, altered gait mechanics, delayed mobilization, and chronic pelvic-lumbar dysfunction. Repeated cesarean deliveries may intensify these changes. However, limited Indian hospital-based studies have examined this issue in multiparous women.
Hence, this study was undertaken.
To determine the association between history of cesarean delivery and chronic low back pain in multiparous women attending a tertiary care hospital. A hospital-based cross-sectional observational study was conducted in the Departments of Orthopedics and Obstetrics & Gynecology of a tertiary care teaching hospital from January 2013 to December 2014. A total of 320 multiparous women aged 25–45 years were enrolled and divided into: • Group A: Women with history of one or more cesarean deliveries (n = 170) • Group B: Women with history of only vaginal deliveries (n = 150) Inclusion Criteria • Multiparous women (≥2 deliveries) • Age 25–45 years • Last childbirth at least 1 year prior Exclusion Criteria • Previous spinal trauma • Congenital spinal deformity • Known prolapsed disc disease • Rheumatoid arthritis • Recent pregnancy (<1 year) • Malignancy • Renal or neurological disease causing referred pain Data Collection Detailed history was recorded regarding: • Age • Body mass index (BMI) • Occupation • Number of pregnancies • Mode of previous deliveries • Number of cesarean sections • Duration of low back pain • Pain intensity by Visual Analog Scale (VAS) • Functional disability using Oswestry Disability Index (ODI) Definition of Chronic Low Back Pain Pain localized between lower rib margin and gluteal folds persisting for more than 3 months. Statistical Analysis Data were analyzed using SPSS version 20. Chi-square test, independent t-test, and logistic regression were applied. p <0.05 was considered statistically significant.
Table 1: Demographic Profile
|
Variable |
Cesarean Group (n=170) |
Vaginal Group (n=150) |
p-value |
|
Mean age (years) |
34.8 ± 5.2 |
35.1 ± 5.0 |
0.61 |
|
BMI (kg/m²) |
27.3 ± 3.8 |
26.7 ± 3.4 |
0.19 |
|
Mean parity |
2.9 ± 0.8 |
3.0 ± 0.9 |
0.34 |
|
Homemakers |
102 (60.0%) |
88 (58.7%) |
0.82 |
|
Working women |
68 (40.0%) |
62 (41.3%) |
0.82 |
Both groups were comparable regarding age, BMI, parity, and occupation.
Table 2: Prevalence of Chronic Low Back Pain
|
Outcome |
Cesarean Group |
Vaginal Group |
p-value |
|
Chronic low back pain present |
94 (55.3%) |
49 (32.7%) |
<0.001 |
|
No chronic pain |
76 (44.7%) |
101 (67.3%) |
<0.001 |
Women with prior cesarean delivery had significantly higher prevalence of CLBP.
Table 3: Severity of Pain
|
Parameter |
Cesarean Group |
Vaginal Group |
p-value |
|
Mean VAS score |
6.0 ± 1.7 |
4.2 ± 1.5 |
<0.001 |
|
Pain duration (months) |
14.8 ± 6.4 |
9.6 ± 4.1 |
<0.001 |
Pain severity and duration were significantly higher in cesarean group.
Table 4: Functional Disability (ODI Score)
|
Disability Category |
Cesarean Group |
Vaginal Group |
|
Minimal |
38 (22.4%) |
71 (47.3%) |
|
Moderate |
82 (48.2%) |
58 (38.7%) |
|
Severe |
50 (29.4%) |
21 (14.0%) |
Cesarean group showed greater disability.
Table 5: Effect of Number of Cesarean Deliveries
|
Number of Cesarean Sections |
Women with CLBP (%) |
|
One CS |
39/84 (46.4%) |
|
Two CS |
35/55 (63.6%) |
|
Three or more CS |
20/31 (64.5%) |
Increasing number of cesarean deliveries was associated with rising prevalence of CLBP.
Table 6: Multivariate Logistic Regression
|
Variable |
Adjusted OR |
95% CI |
p-value |
|
History of cesarean delivery |
2.42 |
1.51–3.88 |
<0.001 |
|
BMI >28 kg/m² |
1.89 |
1.13–3.11 |
0.01 |
|
Parity >3 |
1.74 |
1.02–2.95 |
0.04 |
|
Sedentary lifestyle |
1.62 |
1.01–2.60 |
0.03 |
Prior cesarean delivery remained an independent predictor of chronic low back pain.
History of cesarean delivery is significantly associated with chronic low back pain among multiparous women. Women with multiple cesarean sections had higher pain severity and disability. Early physiotherapy, postpartum core strengthening, weight control, and musculoskeletal follow-up may reduce long-term morbidity. Limitations • Single-center study • Cross-sectional design • Recall bias possible • MRI/radiological correlation not performed Recommendations • Encourage postpartum rehabilitation programs • Counsel women after repeat cesarean section • Promote exercise and weight reduction • Conduct multicenter prospective studies
Norén L, Ostgaard HC. Reduction of postpartum back pain by exercise. Spine. 2001;26:179-84.
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