Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: A randomized controlled trial

During pregnancy, many women experience pelvic and low back pain that can significantly affect their quality of life and ability to work. This pain, known as pelvic girdle and low back pain, affects between 5% and 76% of pregnant women, depending on the diagnostic criteria used. The condition is characterized by pain between the posterior iliac crest and the gluteal fold, especially near the sacroiliac joints or in the lumbar region above the sacrum. In addition to physical discomfort, this condition represents an important economic burden, mainly due to indirect costs related to work absence and reduced productivity.

The traditionally recommended treatment includes stabilization exercises, general guidance, and limited pain medication, with acetaminophen as the first choice. However, between 50% and 75% of women with this problem receive little or no intervention from healthcare professionals.

This study, called TAPP (Trial of Acupuncture for Pelvic and low back Pain in Pregnancy), was a pragmatic randomized controlled trial conducted between 2012 and 2014 at five maternity hospitals in the Paris region of France. The main objective was to evaluate not only whether acupuncture is effective for treating pelvic and low back pain during pregnancy, but also whether it represents an economically advantageous option compared with standard care. Investigators recruited 199 pregnant women between 16 and 34 weeks of gestation who had low back pain for at least two weeks, with intensity greater than 4 on a 0–10 scale, and at least one positive provocation test. Participants were randomly assigned to two groups: 96 received standard care plus acupuncture, while 103 received standard care alone.

The acupuncture protocol consisted of five sessions delivered by an experienced acupuncturist-midwife, with two sessions in the first week followed by three weekly sessions. Acupuncture points were selected based on the location of pain and the traditional Chinese medicine diagnosis, with needles retained for 30 minutes per session. Standard care in both groups included a maternity belt, lifestyle recommendations, and exercises explained by the midwife responsible for the study. Pain medication, rest, and sick leave were prescribed per usual practice by the responsible physicians or midwives.

The study followed participants from enrollment to delivery, using daily and weekly self-assessment questionnaires to measure pain intensity and disability.

Results showed significant benefits of acupuncture compared with standard care alone. The percentage of days with pain intensity of 4 or less on the 0–10 scale was greater in the acupuncture group (61%) than in the control group (48%), a statistically significant difference. In terms of functional disability, measured by the Oswestry Disability Index, the acupuncture group had a lower mean score (33 points) compared with the control group (38 points), indicating less limitation in daily activities. The mean pain reduction between treatment start and five weeks later was 2.3 points in the acupuncture group versus 1.4 points in the control group.

As for acupuncture-specific adverse effects, these occurred in 33% of patients and mainly included bruising at the needle sites, fatigue, dizziness, and headache, all considered mild and transient.

From an economic standpoint, the results were particularly notable. When all societal costs were considered, including healthcare expenses, work absences, and productivity loss, the acupuncture group had lower total costs (€2,635) than the control group (€2,947), a difference of €312 per patient. This savings was mainly due to lower indirect costs related to absenteeism and presenteeism at work. When only direct healthcare costs were analyzed, acupuncture represented an additional cost of just €22 per additional day with controlled pain.

This means that acupuncture was considered a dominant strategy from the societal perspective — that is, more effective and less costly than standard care alone.

For patients with pelvic and low back pain during pregnancy, these results suggest that acupuncture may be a valuable therapeutic option when added to conventional care. The technique was able to provide significant pain relief and improvement in functional capacity, allowing women to maintain better quality of life during pregnancy. For health professionals, the study provides robust evidence that acupuncture can be safely integrated into routine obstetric care. For health system managers and policy makers, the economic findings are especially relevant, as they demonstrate that initial investment in acupuncture can result in significant savings when total societal costs are considered, including benefits related to maintaining work productivity.

The study has some important limitations that should be considered when interpreting the results. The absence of a sham-acupuncture control group prevents complete evaluation of the placebo effect, which may be substantial during pregnancy. In addition, recruitment was based on pregnant women who voluntarily expressed interest in participating, which may have introduced a selection bias favoring acupuncture. The study was also stopped before reaching the planned number of participants due to lack of funding, although this did not compromise the ability to detect significant differences between groups.

Missing data, more frequent in the control group, required complex statistical imputation methods, which may have influenced the results. Finally, the relatively short follow-up, limited to the pregnancy period, does not allow assessment of whether benefits persist after delivery.

Despite these limitations, this is the first study to comprehensively evaluate both efficacy and cost-effectiveness of acupuncture for pelvic and low back pain in pregnancy. The results suggest that acupuncture represents a valuable addition to the therapeutic arsenal available for pregnant women, offering not only symptom relief but also economic advantages when considered from a broader societal perspective. Future studies could explore optimized treatment protocols, evaluate long-term benefits, and investigate practical implementation of this therapy in different health systems.