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ORIGINAL ARTICLE

Pelvic girdle pain in pregnancy: The impact on function

HILDE STENDAL ROBINSON1, ANNE ESKILD2, ELI HEIBERG2 &

MALIN EBERHARD-GRAN2

1Section for Health Science, University of Oslo, P.O. Box 1153, Blindern, N-0318 Oslo, Norway,

2Division of Epidemiology,

Norwegian Institute of Public Health, P.O. Box 4404, Nydalen, N-0403 Oslo, Norway

Abstract

Background . The aim of this study was to determine the prevalence of self-reported pelvic girdle pain in pregnancy and studythe impact on function, the use of crutches, and waking up at night, according to location of pain. Methods. A population-based questionnaire study was performed among all women 18 Á /40 years in two communities in Norway in 1998 Á /99. Atotal of 1,817 women with a prior delivery constituted the study sample. Pelvic girdle pain was grouped into five categories:pain in anterior pelvis, in posterior pelvis, in anterior and unilateral posterior pelvis, in anterior and bilateral posterior pelvis(a complete pelvic girdle syndrome), and pelvic pain with no information on location. Results. A total of 46% (843/1,817)reported pelvic girdle pain in pregnancy at one location or more. Nineteen percent reported pain in anterior pelvis only,14% in posterior pelvis only, 4% in anterior and unilateral posterior pelvis, and 5% reported a complete pelvic girdlesyndrome. A total of 7% of all pregnant women used crutches during pregnancy and 15% reported waking up at nightfrequently due to pelvic girdle pain. A complete pelvic girdle syndrome, as compared to pain in the anterior pelvis only, wasstrongly associated with the use of crutches (adjusted odds ratio (OR) 4.3; 95% confidence interval (CI) 2.5 Á /7.4) and withwaking up at night due to pain (OR 4.6; 95% CI 2.7 Á /7.2). Conclusion. Pain related to the pelvic joints is common amongpregnant women in Norway and may cause serious functional problems.

Key words: pelvic girdle pain, pelvic pain, pregnancy, prevalence

Abbreviations: PGP: pelvic girdle pain, SD: standard deviation, OR: odds ratio, CI: confidence interval

Introduction

Pelvic girdle pain (PGP) is considered as a specific

form of low back pain, related to onset during

pregnancy or the immediate postpartum period

(1 Á /9). The pain occurs separately or in conjunction

with low back pain. It is related to nonoptimal

stability of the pelvic girdle joints, thus leaving out

gynecological and urological disorders, as well as

pain originating from the intestines and tissuessurrounding the pelvis. Hence, pain in symphysis

pubis, and/or uni- or bilateral pain in the sacroiliac

joints are designated as PGP. A European committee

on diagnoses and treatment guidelines for PGP has

recently made a consensus attempt to provide

recommendations on the diagnosis and treatment

of PGP (9). According to this consensus, the pain or

functional disturbances must be reproducible by

specific clinical tests.

Several terms other than PGP have been used in

the literature: pelvic pain, posterior pelvic pain,

pelvic girdle relaxation, and pelvic joint pain

(2,6,9). The prevalence of PGP is reported to be

between 4 and 75% (1,2,4,10 Á /15). The large

variation in the prevalence estimates most likely

reflects a varying understanding of the conditionand differences in the selection of study populations.

The European committee of guidelines suggests that

the point prevalence of women suffering from PGP is

approximately 20% (9). In a clinical study the

prevalence of a complete pelvic girdle syndrome

(pain in the anterior as well as in both posterior

pelvic joints) was estimated to be 6% in pregnancy

Correspondence: Hilde Stendal Robinson, Section for Health Science, University of Oslo, P.O.Box 1153, Blindern, NO-0318 Oslo, Norway. E-mail:

[email protected]

Acta Obstetricia et Gynecologica. 2006; 85: 160 Á /164

(Received 26 May 2005; accepted 22 August 2005)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2006 Taylor & Francis

DOI: 10.1080/00016340500410024

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week 33 (6). PGP is reported to affect activities of

daily living, and especially activities that involve

weight bearing, and the endurance capacity for

standing, walking, and sitting is diminished (9).

Pain when turning in bed may also be a sign of

PGP (16). There are few systematic studies on the

impact of PGP on daily functioning.The aim of this study was to estimate the

prevalence of PGP according to pain location. An

additional aim was to study the impact on function,

the use of crutches, and waking up at night,

according to location of pain.

Material and methods

Study design

The study was a population-based questionnaire

study. Information on PGP was retrospective.

Study population and recruitment

The study population included all women 18 Á /40

years old (n0/4,303) in two municipalities (Nes and

Sørum) in Norway. The two communities are

situated approximately 60 km northeast of Oslo,

the capital of Norway. The study population was

identified through the Norwegian Central Person

Registry.

Postal questionnaires were mailed to the home

addresses of all women between 18 and 40 years

(n0/4,303) in 1998 Á /99. Of the 4,303 womenidentified, 182 had moved and did not receive the

questionnaire. Of the remaining 4,121, 2,993 (73%)

returned the questionnaire. Women with a prior

delivery, and thus at risk of having had PGP,

constituted the study sample (n0/1,817). The

mean age of the women when answering the ques-

tionnaire was 33.2 years (range 18 Á /45; SD 4.9).

Seventeen percent of these women had their last

delivery before 1990, whereas 83% had a delivery

between 1990 and 1999. A total of 416 women were

in the postpartum period when answering the ques-

tionnaire. The study and the questionnaire were

primarily designed to study mental health issues

during the reproductive period. However, other

questions, such as PGP, were also addressed (17).

Variables

Pelvic g irdle pain (PGP). The location of PGP was

classified on the basis of the following questions:

‘‘Did you have pain in the pelvic girdle during your

last pregnancy?’’ (coded: ‘‘yes’’ or ‘‘no’’), and ‘‘If you

had pain in the pelvic girdle during your last

pregnancy, where was the pain located?’’ One or

more locations could be given and the answering

alternatives were: ‘‘frontal part of the pelvis’’/‘‘left

side of the rear part of the pelvis’’/‘‘right side of the

rear part of the pelvis’’. Based on the answers, PGP

was classified into five groups: 1. pain in anterior

pelvis, 2. pain in the posterior pelvis (uni- or

bilateral), 3. pain in anterior pelvis and unilateralposterior pelvis, 4. pain in anterior pelvis and

bilateral posterior pelvis (a complete pelvic girdle

syndrome), 5. pelvic pain, but no information on

location. This classification of pain location is in

agreement with results from prior research (6).

The impact of pain location on functional pro-

blems such as the use of crutches and waking up at

night because of PGP was addressed by the ques-

tions: ‘‘Did you use crutches because of pelvic girdle

pain?’’ (yes/no) and ‘‘Did you wake up during night

because of pelvic girdle pain?’’ (never/sometimes/

frequently). In the multivariate analyses this variable

was coded never, sometimes, or frequently. Thewomen answering the questionnaire in the postpar-

tum period also reported on sick leave. The ques-

tions were: ‘‘Were you on sick leave during your last

pregnancy?’’ (yes/no) and ‘‘What was the reason?’’

(open answer alternatives).

Other variables. When studying the impact of pain

location on function, the following other variables

were included in the multivariate analysis as possible

confounding factors: parity (coded: para 1 or para /

1), age at delivery (coded: B/30 or ]/30 years),

period of delivery (coded: delivery before 1990/

delivery 1991 Á /97/delivery 1998 Á /99), prepregnancy

low back pain (coded: yes/no).

Statistical methods

Statistical analysis of the data was performed using

the SPSS statistical package version 11.0. Odds

ratios (OR) with 95% confidence intervals (CI) of

using crutches and waking up at night due to PGP

for the different pain locations were estimated in

univariate and multivariate logistic regression mod-

els. Pain in the anterior pelvis only was used as thereference variable.

Results

Prevalence of self-reported pelvic girdle pain

A total of 834 out of 1,817 women (46%) reported

PGP in one or more location during last pregnancy.

Nineteen percent of all the women (337/1,817)

reported pain in anterior pelvis only, 14% reported

uni- or bilateral pain in posterior pelvis, 4% reported

Pelvic girdle pain in pregnancy 161

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Sick leave

A total of 67% (280/416) of all postpartum women

were sick listed during pregnancy. Of these, 41%

(116/280) reported to have been sick listed because

of PGP. The prevalence of sick leave varied accord-

ing to pelvic pain locations and is presented in Table

III. Among women with a complete pelvic girdlesyndrome, 85% were sick listed due to pelvic pain.

Discussion

In the present study including 1,817 mothers, 46%

reported having had PGP during their last preg-

nancy. Seven percent of all pregnant women used

crutches during pregnancy and 15% reported wak-

ing up at night often due to PGP. Five percent (97/

1,817) of the women reported a complete pelvic

girdle syndrome. Women with a complete pelvic

girdle syndrome had a strongly increased risk of using crutches and waking up at night due to pain as

compared to women with pain in the anterior pelvis

only.

In this study, the prevalence of PGP was based on

self-reported, retrospective information obtained by

questionnaires. Recall bias may be associated with

long time since delivery. The social and medical

acceptance of PGP has increased in Norway during

the last 15 Á /20 years (2,18,19) and there has been an

increased focus on PGP in pregnancy. This may have

influenced the reporting of PGP in this study. The

classification of PGP in our study has not been

validated according to clinical examination. The

sensitivity and the specificity of our questions to

the suggested clinical diagnosis of PGP are therefore

not known. However, one former study has shown

good agreement between self-reported pain location

and PGP diagnosed by clinical examination (6).

PGP is a relatively new designation and diagnostic

criteria and clinical signs have just recently been

suggested (9).

In the present study, 5% of the women reported

having had pain in both anterior and bilateral

posterior pelvis during pregnancy. To our knowl-

edge, one study only has previously reported pre-valence estimates according to pain location (6). The

number of affected pelvic joints has been associated

with long persistence of PGP after delivery (6).

Presence of PGP has also been associated with

decreased ability to do housework (2). No prior

study has investigated the use of crutches and waking

up at night due to PGP according to pain location.

We find that women affected in both anterior and

bilateral posterior pelvis had markedly more such

functional problems than women affected in either

anterior or posterior pelvis only. Hence, this study

has contributed with questions that may identify the

severity of the condition.

The observation that 7% of all pregnant women

used crutches because of self-reported PGP demon-

strates that this condition causes severe functional

disability for many pregnant women. In this group,

false classification of PGP is unlikely since women

with gynecological, urological, and lumbar pain are

not likely to use crutches. The women who used

crutches represent the most severely affected group;

however, as many as 46% may have symptoms

compatible with PGP during pregnancy. Lack of

sleep may also affect daytime functioning, behavior,

and quality of life and has been associated with anincreased risk of accidents (20). Hence, when 15%

of all pregnant women reported lack of sleep due to

PGP, it is clear that PGP may have severe con-

sequences. Almost a third of all postpartum women

were sick listed due to PGP during pregnancy. This

confirms earlier findings that PGP and low back pain

account for most of the sick leave among pregnant

women in Scandinavian countries (4,15,16,21).

Hence, PGP has a great economic and social impact.

This study confirms that pain related to the pelvic

girdle is common in pregnant Norwegian women

and causes severe functional disability. Despite this,uniform classification is lacking and knowledge on

consequences is scarce. Thus, systematic research on

this condition should be encouraged.

Acknowledgements

We thank the health care providers for distributing

the questionnaires. We also thank Dr Unni-Berit

Schjervheim for practical help and support

during the data collection and Professor Anne Marit

Table III. Proportion of women on sick leave during pregnancy,

according to pelvic pain location, among 416 Norwegian post-

partum women

Location of pelvic girdle pain

Number of women on sick

leave due to PGP (%)

No reported pelvic girdle pain

(n0/211)

11 (5)

Pain in the anterior pelvis

(n0/98)

42 (43)

Pain in the posterior pelvis

(n0/34)

18 (52)

Pain in anterior and unilateral

posterior pelvis (n0/25)

13 (52)

Pain in anterior and bilateral

posterior pelvis (n0/34)

29 (85)

Pelvic pain, location not reported

(n0/11)

3 (27)

Pelvic girdle pain in pregnancy 163

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Mengshoel and Research Fellow in physiotherapy

Britt Stuge, for valuable advice.

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