Low back pain (LBP) is a common condition that is experienced by 50% of pregnant women both before and after delivery [1]. The incidence of post-partum back pain has been reported as from 5% to 40% and has a significant impact on women's dysfunction and their well-being [2].

LBP in pregnancy is a multifactorial condition involving components like mechanical, hormonal and psychological. The musculoskeletal system is subjected to a great deal of stress during pregnancy due to weight gain, changes in center of gravity, hormonal changes, etc. [3]. As a means of assisting the enlarging uterus, changes in fascia and muscles occur. Ligaments and bony parts of the spine and hip become weakened by hormonal changes, resulting in instability [4]. Estrogen, progesterone, and relaxin cause muscles and ligaments to relax, affecting the integrity of the spine. The majority of patients show a redistribution of the center of gravity making their spine curved abnormally at the thoracic and lumbar levels [5]

Cesarean section(C-section) is the most common surgical procedure in the world and in many parts of the world, it exceeds the 30% rate [6]. Advanced maternal age and better socio-economic situations have led to increased C-section rates [7]. Many studies have demonstrated that low back pain is linked with C-section. Women with backache after C-section cannot live a healthy life as they are unable to carry out their day-to-day activities [8]. There is some evidence that there is a higher incidence of post-partum backache with epidural anesthesia, and others that there is no significant difference [9].

Among the risk factors for post-partum low back pain are: age >30 years, lack of exercise, excess weight, pre-gestational weight, multiparity, poor posture, weak abdominal muscles, prolonged sitting/standing, smoking, and psychological conditions [10]. Yuan S et al. (2022) recently reported that previous LBP history, BMI and education levels were significant risk factors [11]. Persistent post-partum symptoms were found to be associated with multiparity and short inter-delivery interval [12].

According to recent research, 80% of the population will suffer from back pain at some point in their lives. The prevalence is 50-80% in pregnant and post-partum females, and about 20% of those females have persistent pain greater than 1 year after birth [13]. The symptoms include back stiffness, posture issues, muscle spasms and loss of range of motion (ROM) [14].

Treatment options involve physical therapy (as the foundation – teaching abdominal and back muscle strengthening and posture improvement), muscle relaxants and NSAIDs. Alternatives include cortisone injections, TENS, acupuncture and massage [15].

Post-partum women or mothers who have just had a baby are suddenly plagued with back pain. Since the impact of delivery mode on post-partum musculoskeletal health is still debatable and there are no recent data available from Pakistan, this study was done. The aim was to compare the incidence of low back pain in women after a vaginal delivery or cesarean section.

This comparative observational cross-sectional study was conducted at General Hospital Lahore from August 2022 to December 2022 to make a comparison between Low back pain in women who delivered vaginally and cesarean section. A total of 171 women were recruited using the non-probability convenience sampling. The sample size was calculated using the formula n = Z²(P)(1-P)/e² with Z=1.95, e=0.05, and P=0.87. The women were aged between 16-45 years, who had at least had one delivery, who had had a low back pain after delivery, and those who were more than 45 years old or had arthritis, tumor or disc prolapse were excluded. Demographic, obstetric, pain and functional data were collected by a modified self-constructed questionnaire which was pilot-tested with 20 women with a Cronbach's α=0.82. All the participants were asked to give written informed consent and ethical approval was obtained from the Ethical Review Committee of The School of Allied Health Sciences, Lahore (Approval No. 1177/SAHS). Data were analyzed using the SPSS 23 software package from IBM. Descriptive statistics (mean ± SD of age; frequencies and percentages of categorical variables) were computed. The Chi-square test was employed to determine associations between mode of birth and low back pain, and an independent t-test was used to compare the mean pain scores of the groups. A p value of < 0.05 was used to denote statistical significance.

The distribution of post-pregnancy pain, mode of anesthesia and occupation among women who had normal vaginal delivery (NVD) and C-section is shown in Table 1. There was a higher proportion of recurrent pain (73) in the NVD group compared to C-section (34) and persistent pain was similarly distributed between the NVD (34) and C-section (30) groups. Local anesthesia was the most common anesthetic in both NVD (76) and C-section (35) whilst general anesthesia was only used in C-section (29). Interestingly, all women in the NVD group were not under general anesthetic, and all women in the C-section group were not under no anesthetic. There was no difference in the number of employed women in NVD (34) and C-section (24) while there was a higher number of unemployed women in NVD (73) and C-section (40). The results of this study indicate that there are disparities in pain experience and anesthetic use between NVD and C-section and factors that could be considered as socioeconomic issues related to childbirth experience.

Table 1: Post-Pregnancy Pain and Anaesthesia Patterns among NVD and C-Section Deliveries

The maternal age, parity and gestational age at delivery were compared and contrasted among the women who had normal vaginal delivery (NVD, n=107) and C-section (n=64) as shown in Table 2. The results indicate that this difference in the proportion of pre-term deliveries (<37 weeks) was approaching significance (p=0.11) for C-sections. The mean gestational age was significantly greater for NVD (40±1.5) than for C-section (39±1.5, p<0.0001). There was a significant difference in maternal age, with the C-section mothers being older than the NVD mothers (31.6±4.8 years vs 27.4±4.6 years, respectively, p<0.0001). In addition, median parity was significantly greater for the NVD group (2, IQR 1-3) than in the C-section group (1, IQR 1-2, p<0.0001). The results indicate that there are significant differences in demographic and obstetric data for NVD and C-section deliveries.

Table 2: "Demographic and Obstetric Differences Between NVD and C-Section Deliveries

Table 3 compares the post-partum outcomes of the C-section (n=64) and the normal vaginal delivery (NVD, n=107) groups and highlights some of the differences between the two groups. The mean back pain score for the C-section women was 5.25±2.3, compared to 3.5±2 for the NVD women (t-test=5.05, p<0.00001). Chi-square analysis revealed significantly more moderate (31% vs 25%) and severe PPLBP (16% vs 8%) among women who delivered by cesarean section (C-section); and significantly more mild pain among women who had NVD (66% vs 36%) (χ²=11.83, p=0.0003). Moreover, severe anxiety was found in 39% of the C-section women compared to 9% of the NVD women (χ²=56.4, p<0.00001). Interestingly, 15% of NVD women said they were not feeling anxious compared to 3% of the non-NVD women. The results indicate that there is a relationship between C-section delivery and risk of PPLBP and anxiety.

Table 3: Postpartum Morbidity: Low Back Pain and Anxiety in C-Section and NVD Deliveries"

In this observational comparative study, 171 women were studied to compare the occurrence of post-partum low back pain between women who gave birth vaginally and women who had cesarean section. Results of this study revealed that low back pain is prevalent in both groups, with no significant difference between the two groups (p> 0.05). However, women who had cesarean section had significantly higher mean pain scores (5.25 ± 2.3) than women who had vaginal delivery (3.5 ± 2). There were also more women in the cesarean group that experienced moderate and severe pain. Moreover, the post-partum anxiety was significantly higher in cesarean section group (39% severe vs 9% in vaginal delivery, p < 0.00001). Recently published studies have found that low back pain is prevalent among women after cesarean delivery, which is consistent with the findings of this study. Sharma et al. (2025) shown that musculoskeletal complaints are a common occurrence in women after cesarean delivery, with low back pain being the most common (81.2%) [16]. Similarly, Ali et al. (2025) found the prevalence of low back pain was also high among mothers who had cesarean births at 56.67% compared to 33.33% among those who had vaginal births [17]. As the severity of pain is found to be significantly higher among cesarean section women as compared to normal women's, our findings are in line with the recent findings. A cross-sectional study evaluating associations of low back pain intensity and core muscle strength in postpartum women was conducted in 2025 and showed that low back pain intensity was significantly greater in the cesarean delivery group (p = 0.000), and the core muscle strength was significantly lower in the cesarean delivery group than in the vaginal delivery group (p = 0.009) [18]. C-section may cause a change in the biomechanics of the lumbopelvic complex, causing compensation of the lumbar spine, which leads to an overload of the spine in that region. Ali et al. (2025) reported that moderate-severity low back pain mothers who had delivered children underwent significant changes in both their contractile and viscous properties, with muscle tone being lowered and the viscosity being raised, respectively, in the paravertebral muscles in the lumbar region [17]. The significantly increased anxiety in the cesarean section group (39% severe anxiety vs 9% in vaginal delivery) is an important finding that was not reported in the search results, despite the fact that this specific comparison was not included in our study. Barega et al. (2025) pointed out, however, that low back pain post-delivery may result in emotional issues, such as an increase in stress, anxiety, and even postpartum depression, and can impede a mother's ability to participate in bonding with her newborn [19]. Excess weight gain in pregnancy was also present in our study and was reflected in the role of BMI in the post-partum low back pain. Barega et al. (2025) identified body mass index over 30 kg/m² as a significant risk factor for postpartum low back pain [AOR = 3.01 (1.92–5.43), p = 0.013] [19]. Concerning functional impairment, our study revealed that 59.9% of women were somewhat unable to stand, 55.2% found walking difficult and 75% found moving a chair difficult. Yogeswari et al. found that low back pain and functional limitations are common in postnatal women after cesarean section and psoas major exercise was a significant factor in decreasing low back pain and functional status (p < 0.001) [20]. Given that 64.5% of women in our study were given local anesthesia (spinal/epidural), there is an interest in back pain due to anesthesia. Barega et al. (2025) reported that the use of spinal anesthesia during cesarean section, factors like immobilization of the spine, repeated dural puncture, increased length of surgery, high body mass index, and muscle relaxation were associated with the occurrence of post-spinal low back pain in 13%–44.9% of cases [19]. There are a number of limitations to our study. The main problem with the cross-sectional design is that it does not allow for causal inferences. Secondly, the convenience sampling method does not allow generalizing the findings. Thirdly, questionnaires are prone to recall bias. Finally, there was no adjustment for pre-pregnancy back pain. Fifthly, we were not able to follow participants over time.

This study found no statistically significant difference in the rate of pain in post-partum women based on mode of delivery (p > 0.05) and that low back pain is common in women during the first six months after giving birth. Women who delivered by cesarean section reported a significantly higher level of pain severity (5.25 ± 2.3 vs 3.5 ± 2) and a significantly higher rate of severe anxiety (39% vs 9%) after delivery. Thus, cesarean section does not appear to be a risk factor for post-partum low back pain, but it is a risk factor for greater low back pain and psychological distress and the need is great for providing specific physical and emotional support to all women after childbirth.

1. Salari N, Mohammadi A, Hemmati M, Hasheminezhad R, Kani S, Shohaimi S, Mohammadi M. The global prevalence of low back pain in pregnancy: a comprehensive systematic review and meta-analysis. BMC pregnancy and childbirth. 2023 Dec 2;23(1):830.
2. Asif A, Amjad F, Dastgir H, Asif W, Adil A, Afzal M. Prevalence of neck and low back pain in women during post-partum period: neck and back pain during post-partum. The Healer Journal of Physiotherapy and Rehabilitation Sciences. 2022;2(4):271-8.
3. Yoseph ET, Taiwo R, Kiapour A, Touponse G, Massaad E, Theologitis M, Wu JY, Williamson T, Zygourakis CC. Pregnancy-related spinal biomechanics: a review of low back pain and degenerative spine disease. Bioengineering. 2025 Aug 10;12(8):858.
4. Daneau C, Nougarou F, Abboud J, Ruchat SM, Descarreaux M. Changes in pregnancy-related hormones, neuromechanical adaptations and clinical pain status throughout pregnancy: A prospective cohort study. Plos one. 2025 Feb 21;20(2):e0314158.
5. Fiat F, Merghes PE, Scurtu AD, Almajan Guta B, Dehelean CA, Varan N, Bernad E. The main changes in pregnancy—therapeutic approach to musculoskeletal pain. Medicina. 2022 Aug 17;58(8):1115.
6. Idris IM, Menghisteab S. Cesarean section delivery rates, determinants, and indications: a retrospective study in Dekemhare Hospital. Global Reproductive Health. 2022 Apr 1;7(1):e56.
7. Nessa Z. Impact of Age and Socio-Economic Factors in doing EmergencyCaesarean Section—A Cross-Sectional Study. The Planet. 2023;7(02):35-9.
8. Nawshin N, Sanam S. The impact of low back pain on functional status of postpartum women: survey in Bangladesh. Nurs Prim Care. 2023;8(5):1-8.
9. Timerga S, Walle G, Mebratu W, Befkadu A. Assessment of the Association Between Neuraxial Anesthesia and Back Pain After Delivery: A Systematic Review and Meta‐Analysis. Anesthesiology Research and Practice. 2025;2025(1):2105413.
10. Miladi S, Makhlouf Y, Boussaa H, Abdelghani KB, Fazaa A, Laatar A. Prevalence and associated factors for persistent low back pain in the postpartum period. La Tunisie Medicale. 2023 Sep 5;101(9):688.
11. Yuan S, Wang H, Zhou J. Prevalence and risk factors of low back and pelvic pain in women with rectus abdominis diastasis: a multicenter retrospective cohort study. The Korean journal of pain. 2022 Jan 1;35(1):86-96.
12. Kessous R, Sheiner E. Is there an association between short interval from previous cesarean section and adverse obstetric and prinatal outcome?. The Journal of Maternal-Fetal & Neonatal Medicine. 2013 Jul 1;26(10):1003-6.
13. Zhou L, Li J, Zhou Y, Liang Y, Ma Q, Yang L, Pang Y, Fang Y, Guo Y. Pain management for postpartum pain: a narrative review. Journal of Pain Research. 2025 Dec 31:5617-26.
14. Sertpoyraz FM. Understanding and Addressing Musculoskeletal Challenges in Pregnancy. InManaging Maternal Chronic Diseases for a Healthy Pregnancy 2026 Feb 12 (pp. 201-218). Cham: Springer Nature Switzerland.
15. Kaur R, Shahid A. Effectiveness of Core Stability Exercises on Low Back Pain among Postpartum Women: A Systematic Review.
16. Sharma P, Dave J, Sharma R. Common Musculoskeletal Complaints Arising among Women after Caesarean Section Delivery. Journal of Clinical & Diagnostic Research. 2025 Sep 2;19.
17. Ali MG, Mohammed AA, Ragab WM, Zakaria HM, Alwhaibi RM, Ibrahim ZM, Mamoon RS. Do lumbar paravertebral muscle properties show changes in mothers with moderate-severity low back pain following a cesarean birth? A case–control study. Journal of Clinical Medicine. 2025 Jan 23;14(3):719.
18. Ali MG, Yousef AM, Sarhan MA, Alwhaibi RM, Zakaria HM, Mohammed AA, Ragab WM, Mamoon RS, Auais M. Testing the association between low back pain intensity and core muscle strength in postpartum women with different delivery modes: an analytical cross-sectional study. Journal of Clinical Medicine. 2025 Sep 16;14(18):6505.
19. Barega MT, Hemba Y, Redela A, Girma T, Milkiyas Wonte M, Dimma A, Assen S, Eanga S. Incidence, risk factors, and quality of life of low back pain after cesarean delivery and vaginal delivery at Dilla University General Hospital: a prospective cohort study. Frontiers in medicine. 2025 May 21; 12:1495335.
20. Yogeswari M, Revwathy S, Swathi J, Sivakumar VP, Vidyagajalakshmi M, Balaji P. Evaluation of the Functional Status of Post Caesarean Women with Low Back Pain Using Psoas Major Exercise: A Randomized Clinical Trial. International Journal of Health Sciences.;8(3):392-8.