Pregnancy Back Pain: Its Prevalence, Pattern, and The Practice of Pregnancy Back Pain: Its Prevalence, Pattern, and The Practice of Ergonomic Behaviors Among Pregnant Women in Rural Sule Ergonomic Behaviors Among Pregnant Women in Rural Sule Tankarkar Local Government Area of Jigawa State Nigeria Tankarkar Local Government Area of Jigawa State Nigeria

Background: Studies on Back pain in pregnancy have reported rates ranging from 25% and 90%, with most studies estimating that 50% of pregnant women will suffer from back pain during the course of their pregnancy. Low back is the most common region affected followed by posterior pelvic region with upper back region being the region least affected. In Nigeria, relative to the minimum wage, back pain consumes a significantly high amount of money in accessing health care thereby incurring both direct and indirect cost. Therefore, this study explored pregnancy back pain and the practice of ergonomic behaviors among pregnant women. Methodology: Three hundred and eighty one pregnant women were recruited using Multi-stage sampling technique from eight Primary Health Care Centers of Sule Tankarkar local government. A questionnaire was used to obtain the required information. The data was analyzed using frequency and percentage to summarize the data and inferential statistic of chi square test to check association between categorical variables.

in their third trimester (54.6%). The prevalence of back pain was 57.2%, mostly in the low back region (36%). Majority of the participants (44.9%) did not practice any ergonomic behavior.
Conclusion: Low back pain is highly prevalent among pregnant women attending ante natal clinic in rural Jigawa State of Nigeria. Exercise during pregnancy, proper lifting techniques and ergonomics by experts could help pregnant women.
Keywords: back pain, ergonomic, pregnancy, postpartum BACKGROUND Back pain (BP) is a frequent phenomenon in pregnancy, which impacts the life of pregnant women 1 . It is estimated that about half of pregnant women will suffer from some kind of low back pain at some point during their pregnancies or postpartum period 2,3 . Factors like mechanical, hormonal and others like history of a pathology in the spine are thought to result in pregnancy back pain 2,4,5 .
Pregnancy low back pain mimics lumbar pain outside pregnancy, however one distinguishing feature is its appearance as pain over and around the lumbar spine, above the sacrum, which allows differentiating it from pelvic girdle pain (PGP) 1 as shown in Figure 1. Unlike PGP, LBP may and may not radiate to the foot but with presence of tenderness over paravertebral muscles 6 . Though, less disabling than PGP, Low back pain (LBP) aggravates with certain activities and posture, say prolong sitting and during postpartum period 6 .
Previous studies on Back pain in pregnancy have reported rates ranges from 25% and 90%, with most studies estimating that 50% of pregnant women will suffer from back pain 1 . Ayanniyi et al 3 , reported a prevalence of 52.5% of back pain in pregnancy with one third of them suffering from severe pain, which reduces their quality of life. The majority of women are affected in their first pregnancy 3,7 . Also, low back is the most common region affected followed by posterior pelvic region while upper back region being the least region affected 3 . During pregnancy, LBP seems to be the determinants of postpartum LBP 2 . previous pelvic trauma 4 , history of chronic back pain in a previous pregnancy 4,8,9 , previous pregnancy 10 , excessive body weight 11 and LBP during menstruation 7 were said to be important risk factors for pregnancy related back pain.
While it is difficult to eliminate back pain, the severity can be reduced in high risk women by encouraging prospective mothers to observe proper ergonomic behaviors 12 . Physical activity before pregnancy is correlated with a decrease risk of developing low back pain, which does not apply to PGP 6 . It is essential for women to learn appropriate lifting technique without stressing their backs. Also, they should be advised to use proper seats, cushions and beds, as well as proper transfer techniques in and out of bed, so that the body maintains a proper position and the spine is supported 13 .
Majority of pregnant women view pregnancy back pain as an unavoidable and usual sensation during pregnancy 1 , as only half seek advice from a health care professional and 70% of them will receive some kind of treatment 11 . Ayanniyi et al. reported that postural modification relieved the back pain in about 50% of pregnant women. Early identification and treatment, taking under consideration the individuality of every woman and pregnancy, provide the opportunity for the best possible outcome 1 . However, to our knowledge, there is a dearth of information about the prevalence of back pain and the level of adherence to the practice of ergonomics among pregnant women in rural area. Base on the fact that pain is the highest cause of economic burden to humans 14 , to the extent that the cost of low back pain management in developing countries like Nigeria may amount to 50% of the annual salary of the affected individuals 15 , this study explored pregnancy associated back pain and the practice of ergonomic behaviors among pregnant women in rural area of SuleTankarkar, local government, Jigawa state.

Population and Research Design
This was a cross-sectional survey among all consenting pregnant women from primary healthcare centers (PHC) in SuleTankarkar, local government, Jigawa state.

Sample Size Determination and Sampling technique
To achieve a power of 95% CI at significance level of 0.05 and prevalence of 34.4% from a previous study, 345 sample was determined using n =Z 2 pq/d 2 16 Where n=the desired sample size Z= standard normal deviation set at 1.96 that corresponds to the 95% confidence interval. Assuming 10% loss rate, 345+10% (wastage factor and non-response rate) =380 were proposed to participate.

Sampling Technique
Multi-stage sampling technique was used, there are 16 PHCs in suletankarkar local government. 50% of the PHCs 8 were randomly selected for the study. The sample size was divided equally amongst the 8 PHCs (76 participant each). Participants were recruited using systemic sampling.

Exclusion Criteria
• Pregnant women with history of back pain before pregnancy.
• Pregnant women with history of back trauma.

Instrument
The instrument for this study was a researcher-administered close-ended questionnaire, which was designed to obtain information on subjects' demographic status, back pain and ergonomic practice. The questionnaire was a modified version of the questionnaire by Ayanniyi et al. 3 and Manyozo et al. 18 and an ergonomic practice component by Ephraim-Emmanuel, et al. 19 . The modified version of the questionnaire (APPENDIX I) was assessed by experts in physiotherapy to ensure its face and content validity. A pilot study gave its test-retest reliability to be r = 0.72. It has three sections A, B and C. Section A collected information on demography such age, body mass index, trimester, educational status, gravidity and parity, section B collected details of low back pain; its prevalence, body part affected, nature of the pain, the effect of low back pain on activities of daily living while section C enquires about ergonomic practice component. The practice component had ten questions on a yes or no basis, where 0 was awarded to "no" and 1 was awarded to "yes" option. A score of 0 was recognized as no practice of ergonomic behavior, 1-3 was categorized as poor practice, 4-6 as fair, and above 7 as good practice. With respect to the location of pain in section B, it was categorized into three groups' i.e Low Back Pain (LBP), High back pain (HBP) and Posterior pelvic pain (PPP).

Ethical consideration
The study was approved by Jigawa state research ethics committee with reference number JHREC/2020/002. An informed consent was sought before commencement of data collection.

Analysis of Data
Data was analyzed using SPSS 20.0 version software using a descriptive statistic of frequency and percentage to summarize the data and inferential statistic of chi square test to check association between categorical variables. Probability level was set at 0.05.

RESULTS
Three hundred and eighty one individuals were interviewed using the questionnaire and all were included in the analysis. Table 1 shows the demographic details of the participants. Majority of the participants are within the age range of 15-19 (34.9%), multigravidas (72.4%), multiparous (70.3%) in their third trimester (54.6%) with no formal education (76.1%), with normal body mass index (BMI) (84%) and no history of any medical comorbidity (74.5%). Incidence of low back pain in the previous pregnancy was 72.9%.
More than half (57.2%) of the participants experienced low back pain in their current pregnancy ( Figure 1 ). The part of the back mostly affected is low back (36%) followed by combined low back and pelvic girdle pain (Figure 2 ). The back pain experienced by the participants is mild to moderate in severity and, intermittent (69%) in occurrence. It is most often provoked by sitting in the table (25.2%) and worsen with coughing (32%) ( Table 2 ).
The pain disturbed the sleeping of one-tenth (11.3%) of the participants while in almost a quarter the pain interfered with their activities of daily living. Most of the participants had difficulty in lifting heavy objects (42.3%), doing heavy work (39.9%), sitting for long (37.5%) and it hindered participation in exercises (35.4%) ( Table 3 ).
Only one-tenth (11.3%) of the participants possess good ergonomic behaviors while 44.9% did not practice any ergonomic behavior (Figure 3 ). Table 4 showed a significant association between the practice of ergonomic behaviors and prevalence of back pain among the participants (p<0.05).
There was significant association between the prevalence of low back pain and age, gravidity, parity, level of education, BMI and back pain in the previous pregnancy (P<0.05) ( Tables 4 and 5 ). However, there was no significant association between the prevalence of low back pain and the trimester of pregnancy (P>0.05).

DISCUSSION
Out of the three hundred and eighty-one pregnant women that participated in this study. The incidence of back pain in our population was 57.2%. This result was in consistent with the earlier study by Ayanniyi et al. 3 which reported that back pain is one of the common complaint of women during pregnancy. Others have also reported that at least half of pregnant women will experience a form of back pain to some degree during pregnancy 6,20,21 .
Pregnant women with LBP had the highest frequency (36%) which was higher than the two other groups combined (i.e HBP+PPP). This was consistent with the outcome in Ayanniyi et al., 3 but in contrast to Colliton 22 who found PPP is approximately four times as prevalent as low back pain during pregnancy and Noren et al., 23 who stated that PPP constituted half or more of women with back pain during pregnancy.
The variation in prevalence of pain location based on back sub-region might be influenced by the way data was collected. Data on LBP is commonly collected using questionnaires 2,24 . Although, for optimum distinguishing of LBP from PGP, a pictorial demonstration should be shown to the pregnant women for identification 25 . Unfortunately, we were not able to clinically examine all the women. However, we based our classification and recording on a verbal explanation of the various back sub regions by the research assistants to the participants and the participants described the location where they were experiencing the pain back to the research assistant for documentation.
Although, higher education level has been found to be associated with severity of pain symptoms in pregnancy 26 . Most of the pregnant women in this study reported a moderate pain intensity while more than three quarter had no formal education. The reduction in their pain severity could be explained by socio-cultural attribute of people of Northern part of Nigeria to pain. Pain tolerance has also been shown to be strongly associated with ethnic differences in one of the earlier study in another developing country 27 .
Less than one-quarter of the women reported that they had to limit their daily activities especially activities that has to do with lifting heavy object, sitting for long, and participation in any form of exercise. These rates are lower than those seen in the study by Shijagurumayum et al. 28 .
A very low percentage (11.3%) of the participants in this study possess a good practice of ergonomics in form of maintaining good posture during activities of daily livings and proper lifting techniques. However, the result of chi-square statistics run in this study showed that, pregnant women practicing ergonomic behaviors were the majority of the participants with back pain. This might be due to the fact that, they might not have started observing the ergonomic behaviors until after they started experiencing the back pain and sought medical advice from their health care provider who advise them on proper sitting and posture. Another reason might be because they wrongly observe the behaviors not as prescribed by their health care provider as this study failed to use pictures to explore the way they practice the ergonomics behaviors.
Younger age was shown to be a risk factor for back pain in this study. This could be linked to the fact that the body of the younger ones is trying to adjust to the new normal unlike the older ones. It could also be due to fact that the elder ones may not report the back pain compared to the younger ones as they may think back pain is normal in pregnancy. Likewise, the trimester of the participants was a determinant of back pain during the pregnancy and this might be true because of the increase in stretching of core stability muscles, change in spinal curvature among other factors caused by the growing fetus.
Due to the fact that, most of the participants had low levels of education, oral administration of the questionnaire was utilized to obtain data.

LIMITATIONS
This was a facility based study and as such, the prevalence reported may not be generalized. It only included those who attended antenatal clinics in that area. The study also recruited participants from a rural setting only, therefore, results may not reflect the urban situation for pregnant women as they may be characteristically very different.
Another possible limitation is that the questionnaires were administrated by a research assistant as opposed to self-administration. Likewise, the study failed to use pictorial demonstration while asking the questions on location on the pain and the practice of ergonomic behaviors.

CONCLUSIONS
Low back pain is highly prevalent among pregnant women attending ante natal clinic in rural Jigawa State of Nigeria. Many pregnant women suffer considerable pain and discomfort during pregnancy. Their experiences result into reduced activity engagement, exercise participation and self-productivity. Given the prevalence and the clinical importance of LBP in pregnancy, health workers should be proactive in engaging these pregnant women on health education that will be beneficial during pregnancy back care education inclusive. Further studies should consider a wider variety of population and settings to study the varied LBP experience in pregnant women and the role of ergonomic education towards LBP during pregnancy in the rural area.  .............................