1. Breastfeeding and pelvic girdle pain: a follow-up study of 10 603 women 18 months after delivery Elisabeth K. Bjelland, PhD; Katrine M. Owe, PhD; Britt Stuge, PT PhD; Siri Vangen, MD PhD; Malin Eberhard-Gran, MD PhD

2. #BlueJC is on Twitter and LinkedIn. Join us!Twitter LinkedIn How does #BlueJC work? – Leung E, Tirlapur S, Siassakos D, Khan K. BJOG. 2013 May;120(6):657-60. http://bit.ly/10VaiRZhttp://bit.ly/10VaiRZ For further information: – Follow @BlueJCHost on Twitter@BlueJCHost – Explore our LinkedIn page and our blog: http://linkd.in/1Cuz8MZ &http://bluejournalclub.wordpress.com/ http://linkd.in/1Cuz8MZhttp://bluejournalclub.wordpress.com/ – See BJOG Journal Club: http://www.bjog.org/http://www.bjog.org/

3. Scenario A woman who is 32-week pregnant with her second child comes to see you because she is worried about persistent pelvic girdle pain afterbirth- she had pelvic pain for 20 months after an uncomplicated vaginal delivery of her first child 3 years ago. She is overweight (body mass index = 27Kg/m 2 ), has no other significant medical history and no complication during this pregnancy. How do you counsel this woman?

4. The Clinical Question It has been suggested that a woman’s hormonal state during breastfeeding negatively influences the recovery process of pelvic girdle pain Does breastfeeding have any impact on the recovery of pelvic girdle pain after birth?

5. Structured question (PICOD) Participants Women who had singleton deliveries in the Norwegian Mother and Child Cohort Study and reported pelvic girdle pain at 0–3 months postpartum Intervention Breastfeeding (coded as bottle-feeding, partial breastfeeding, and full breastfeeding). Duration of breastfeeding was coded as not breastfeeding at all and breastfeeding for 0-2, 3-5, 6-8, 9-11, or ≥12 months after delivery. Comparison Four self-administered questionnaires about pelvic pain at second and third trimesters of pregnancy, as well as 6 and 18 months after birth Outcomes Persistent pelvic pain at 18 months after birth, defined as having combined anterior and bilateral posterior pelvic pain. Study Design Population-based cohort study

6. Background How do you currently manage women with persistent pelvic pain after birth? What is the Norwegian Mother and Child Cohort Study (www.fhi.no/morogbarn)?www.fhi.no/morogbarn Were the analyses of the current study planned prospectively?

7. Figure 1. Flowchart of participants in the Norwegian Mother and Child Cohort Study (1999-2011). Q, questionnaire.

8. The severity of pelvic girdle pain at baseline was not associated with breastfeeding patterns. Figure 2. Breastfeeding patterns (full breastfeeding, partial breastfeeding, or bottle-feeding) with respect to the reported severity of pelvic girdle pain 0-3 months postpartum in the Norwegian Mother and Child Cohort Study (n=10 603). BF, breastfeeding.

9. Table 1. The associations of breastfeeding patterns and duration with persistence of pelvic girdle pain 18 months after delivery.

10. Summary of results Short duration of breastfeeding was associated with increased odds of persistent pelvic girdle pain – A significant association was only present in women with BMI ≥25 kg/m 2 Breastfeeding pattern was not associated with the severity of pelvic girdle pain 0-3 months postpartum Breastfeeding pattern was not associated with persistent pelvic girdle pain at 18 months after delivery

11. Results The majority of women in this study breast-fed for at least 3 months after birth. How does this breastfeeding rate compare to women in your daily practice? Women who did not breastfeed at all were not more likely to have persistent pelvic girdle pain. How does it affect your interpretation of this study? (See suggested reading)

12. Discussions What are the potential study designs that could further evaluate this clinical question? How do the results of this study change your understanding on persistent pelvic pain after birth?

13. Authors’ conclusions Long duration of breastfeeding was associated with a small beneficial effect on the recovery process of pelvic girdle pain in women with BMI ≥25 kg/m 2. This longitudinal study does not support discontinuation of breastfeeding to improve pelvic girdle pain. Among women with pelvic girdle pain, breastfeeding should be encouraged in accordance with the existing child-feeding recommendations.

14. Suggested reading Schünemann H, Hill S, Guyatt G, Akl EA, Ahmed F. The GRADE approach and Bradford Hill's criteria for causation. J Epidemiol Community Health. 2011 May;65(5):392-5. http://jech.bmj.com/content/65/5/392.long http://jech.bmj.com/content/65/5/392.long

15. Authors’ Affiliations Elisabeth K. Bjelland, PhD 1,2, Katrine M. Owe, PhD 3,2, Britt Stuge, PT PhD 4, Siri Vangen, MD PhD 3,5, Malin Eberhard-Gran, MD PhD 1,2 1 Health Services Research Unit, Akershus University Hospital, P.O. Box 1000, N-1478 Lørenskog, Norway; 2 Division of Mental Health, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway; 3 Norwegian Resource Centre for Women’s Health, Division of Women and Children, Oslo University Hospital Rikshospitalet, P.O. Box 4950 Nydalen, N-0424 Oslo, Norway; 4 Department of Orthopaedics, Oslo University Hospital Ullevål, P.O. Box 4950 Nydalen, N-0424 Oslo, Norway; 5 Division of Epidemiology, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway. E-mail to Corresponding Author: ElisabethKrefting.Bjelland@fhi.noElisabethKrefting.Bjelland@fhi.no None of the authors have reported conflict of interests.