Background & Aims

Background: Chronic pelvic pain is a common condition affecting between 4% and 10% of women of reproductive age, equivalent to approximately 5 million women worldwide. The determinants of the condition’s development are not clearly defined, likely representing a complex interaction of various factors. However, literature has consistently demonstrated a significant association between the disease and prior exposure to abdominal surgeries. Cesarean section stands out due to its frequency, particularly in certain countries such as Brazil, and its global prevalence. Objectives: Our aims were to infer the cumulative incidence of chronic pelvic pain in women 12-24 months postpartum, identify factors associated with its occurrence, and investigate the potential cause-and-effect relationship of cesarean section in the process.

Methods

Methods: A cross-sectional study nested in the Brazilian Ribeirão Preto and São Luís Birth Cohort Studies (BRISA) cohort was conducted in two Brazilian municipalities in 2010-2011. A convenience sample of 2,847 pregnant women at 22-25 weeks of gestation was included. Among 2,750 women interviewed during prenatal, 2,160 women without pelvic pain before pregnancy and birth were included. Agglomerative clustering identified homogeneous subgroups, and a Random Forest classifier determined feature importance. Multinomial logit regression models were constructed to assess variable associations with the outcome, using augmented backward elimination. To test the causal assumption (cesarean section as exposure and pelvic pain as outcome), a counterfactual approach was employed. Common causes were identified through a directed acyclic graph, and causal effects were estimated using backdoor propensity score-based inverse weighting. Assumption validity was tested through robustness checks.

Results

Results: The cumulative incidence of pelvic pain was 12.7% in 24 months postpartum. Two distinct clusters were identified, with one characterized by more symptoms of depression, anxiety, and a less supportive network, leading to earlier pelvic pain development. Cesarean section was strongly associated with chronic pelvic pain in both clusters (OR=1.72|2.08, p<.001|p=.003). Perception of discrimination (OR=1.52|1.84, p<.030|p=.002) and geographic region (OR=1.53|1.54, p<.035|p=.048) were also positively associated with increased risk. Conversely, delivery satisfaction (OR=0.53, p<.006) and breastfeeding (OR=0.61, p<.018) appeared to be associated with a lower risk, even that in specific subgroups. Causal estimation indicated a 5.8% increased probability of developing chronic pelvic pain after cesarean section compared to other deliveries.

Conclusions

Conclusions: The cumulative incidence of pelvic pain postpartum is high and directly associated with the mode of delivery, with cesarean section increasing this risk. Perception of discrimination and local geographic factors independently contribute to an increased risk, while delivery satisfaction and breastfeeding seem to have a protective effect. Our data support a significant causal effect of cesarean section on the development of postpartum pelvic pain.

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Presenting Author

Omero Benedicto Poli-Neto

Poster Authors

Omero Poli-Neto

PhD

Ribeirao Preto Medical School of University of Sao Paulo

Lead Author

Lia Shimamura

Lead Author

Heloisa Bettiol

Lead Author

Antonio Silva

Lead Author

Antonio Nogueira

Lead Author

Marco Barbieri

Lead Author

Julio Rosa-e-Silva

Lead Author

Topics

  • Epidemiology