Low back pain during pregnancy is one of the most common musculoskeletal complaints experienced by women worldwide, particularly during the third trimester. Based on a global meta-analysis of 28 studies with a total of 12,908 respondents, the prevalence of lower back pain during pregnancy was 40.5%, with a peak of 47.8% in the third trimester ( Omoke et al., 2021). This condition not only causes physical discomfort but also reduces the quality of life of pregnant women, limits their daily activities, and increases the risk of medical intervention during labor. Amidst the development of non-pharmacological approaches in nursing practice, music therapy and hypnobirthing are gaining attention as safe, effective, and evidence-based alternative interventions. However, there is limited integration of these approaches in maternal health care policies globally, which calls for rigorous ( Purnamasari, 2021).

Pregnant women experience discomfort during the adaptation process due to physical and psychological changes. Physiological changes in pregnant women throughout pregnancy can have harmful effects. Low back pain (LBP) during pregnancy is a significant global health issue, ranking as the highest cause of disability worldwide over the past three decades. According to the 2021 Global Burden of Disease study, over 628 million people worldwide experience LBP, with the highest prevalence occurring in women of reproductive age, especially during pregnancy (Li et al., 2024). Although the global prevalence rate has decreased in relative terms, the absolute number of sufferers has increased significantly because of population growth and increased life expectancy. The World Health Organization (WHO) and several international studies have shown that more than 50% of pregnant women experience LBP, especially in the third trimester, which interferes with daily activities and potentially worsens psychological conditions during pregnancy ( Chen et al., 2021).

Back pain during pregnancy can be caused by weight gain, changing posture, hormone fluctuations, shifting the center of gravity, muscle separation, the natural elasticity of ligaments to prepare for labor, and stress. Lower back discomfort in pregnant women is frequently caused by mechanical instability of the lumbar spine and pelvis. The lumbar joints, ligaments, and muscles are overstressed as a result of compensatory lumber lordosis ( Atis & Rathfisch, 2018). Pregnancy hormone changes cause the ligaments connecting the pelvic bones to the spine to relax and the joints to become less rigid. This results in pain when bending, lifting, walking, standing, and sitting for extended periods of time ( Amayri et al., 2023).

This phenomenon not only limits the physical activities of pregnant women but also affects their quality of life and psychological state to a large extent. There is an increasing need for safe, sustainable, and non-pharmacological approaches to pain management ( Manyozo et al., 2019). This condition impacts individuals and adds to the burden of the global health system, given the importance of supporting healthy pregnancies as an essential component of human development. In the academic realm, various non-pharmacological intervention approaches, including music therapy and hypnobirthing, have been developed as part of the integration of health technology, culture-based interventions, and psychological approaches to pain mitigation during pregnancy. This development calls for more profound research to empirically and contextually assess the effectiveness of these approaches ( Salamah, 2019).

National data from the Indonesian Ministry of Health and other regional studies indicate a substantial prevalence of lower back pain (LBP) among pregnant women in Indonesia, particularly the third trimester. A regional survey indicated that over 60% of pregnant women in South Sumatra experienced back discomfort that impacted their daily activities and sleep quality ( Ismawati, 2022). Research in several government hospitals shows that most pain complaints are not managed through evidence-based intervention methods, and pharmacological interventions are often avoided due to risks to the fetus. Despite policies on maternal and child health, interventions for low back pain during pregnancy have not been prioritized in the primary healthcare system. This gap highlights the need for in-depth studies on alternative therapies that are highly effective, safe, and widely applicable. In addition, community-based approaches and health system support need to be designed based on robust and contextualized research results, making this research important not only for theory development but also for the reformulation of maternal care policies at the national level ( Bloom & Reenen, 2021).

In the third trimester, nursing care for pregnant women with back pain complaints and acute pain problems can be provided through non-pharmacological pain management interventions with distraction and diversion through classical music therapy and hypnobirthing relaxation techniques. Non-pharmacological pain management methods, such as deep breathing exercises, are frequently employed in hospitals ( Hu et al., 2020). Typically, doctors use medications to relieve pain. Although much research has been conducted on the influence of music on physical and emotional well-being, there is still a lack of research specifically exploring the effects of traditional Indonesian music. Hypnobirthing and music therapy have emerged as promising complementary therapies for managing pain and anxiety during pregnancy and labor. However, empirical evidence comparing their effectiveness, both individually and in combination, in reducing LBP during late pregnancy remains limited (Thakare et al., 2022).

The urgency of this research is highlighted by two main aspects: its contribution to the development of maternity nursing science and its potential implementation in primary health care systems. From an academic perspective, this study enables the renewal of intervention models in nursing based on cultural integration and relaxation psychology. From a practical point of view, the findings of this study can help create standard procedures for music therapy and hypnobirthing that can be used in health centers, especially in cities such as Palembang ( Sr et al., 2021). In addition, this study contributes to national efforts to reduce the use of pharmacological interventions during pregnancy, which, in the long run, impacts maternal and fetal safety and health system efficiency. This study aimed to evaluate the effectiveness of hypnobirthing, music therapy, and their combination in reducing lower back pain among third-trimester pregnant women.

The research phase began with the approval of the ethics committee and research permit in July 2024. Researchers began to identify respondents based on the following inclusion criteria: pregnant women in the third trimester, experiencing mild to severe lower back pain, and primigravida. After the respondents were collected, lower back pain was measured using a visual analogue scale (VAS) questionnaire on 200 respondents of pregnant women in the third trimester in the working areas of the Pembina Health Center, Nagaswidak Health center, Taman Bacaan Health Center and Pembina Health Center. Data analysis was performed as follows:

Based on Table 1, a total of 200 respondents were involved in this study. The majority of respondents were in the age range of 21-25 years (56%), indicating that most mothers were at the optimal reproductive age. The highest gestational age was in the range of 28-31 weeks (70.5%), indicating that the respondents were in the third trimester phase, which generally experiences an increase in the number of pregnancies.

Based on Table 2, the average pain level before music therapy was 5,96 (SD = 1,958), and the average pain level after music therapy was 4,48 (SD =1,644). The average pain level before Hypnobirthing was 6,50 (SD = 1,619, the average pain level after music therapy was 4,50 (SD =1,619), and the average pain level before Hypnobirthing with music therapy was 5,50 (SD = 1,669. The average pain level after music therapy was 3,52 (SD =1,644), and the average pain level in the control group was 5,22 (SD = 1,075. The average pain level after control group was 4,56 (SD =1,280).

Based on Table 3, the average pain score before the combined therapy (hypnobirthing and music therapy) was 5,50 (SD = 1,669), indicating moderate to severe pain levels. After the combined intervention, the average pain score decreased to 3,52 (SD = 1,644), showing a significant reduction to mild pain levels. The mean difference in pain scores (pre-vs. post-test) was 1,803 (SD = 2,157), demonstrating a substantial reduction in pain following the combined therapy. The paired t-test statistic (t(49) = 22,496) was highly significant (p 0.000). This confirms that the observed reduction in pain scores was not due to chance but was likely caused by the combined effect of hypnobirthing and music therapy.

Based on Table 4, the ANOVA test revealed a statistically significant difference in the effectiveness of the interventions (F = 20.521, p: 0,000) This indicating that at least one group differed significantly in terms of pain reduction.

Based on Table 5, the average pain score before the combined therapy (hypnobirthing and music therapy) was 5,50 (SD = 1,669), indicating moderate to severe pain levels. After the combined intervention, the average pain score decreased to 3,52 (SD = 1,644), showing a significant reduction to mild pain levels. The mean difference in pain scores (pre-test vs. post-test) was 1,803 (SD = 2,157), demonstrating a substantial reduction in pain following the combined therapy. The paired t-test statistic (t(49) = 22,496) was highly significant with p: 0.000. This confirms that the observed reduction in pain scores was not due to chance but was likely caused by the combined effect of hypnobirthing and music therapy.

The findings demonstrate that both hypnobirthing and music therapy are effective in reducing LBP during the third trimester of pregnancy. The superior effectiveness of the combined intervention suggests potential synergistic benefits when these approaches are used concurrently. These results align with previous studies, highlighting the efficacy of relaxation-based therapies in managing prenatal discomfort. Integrating these non-invasive, low-cost interventions into antenatal care protocols may enhance maternal comfort, reduce dependence on pharmacological pain relief, and support holistic prenatal care. Saad and Jariyah (2022) found that hypnobirthing works through the cognitive-emotional pathway by reducing anxiety and activating positive suggestion mechanisms. Therefore, when these two approaches are combined, the result is not simply a summation of effects but a synergy that strengthens the body’s adaptive response to pain. This aligns with the biopsychosocial approach to pain management, which emphasizes the importance of integrating biological, psychological, and sociocultural interventions ( Maidawilis et al., 2023).

Comparison between the three intervention groups showed that the combination of hypnobirthing and music therapy provided the best results in reducing lower back pain, followed by single hypnobirthing and single music therapy. This finding indicates that integrating non-pharmacological methods with different but complementary approaches can strengthen the effect of interventions on pain. This combination of methods addresses pain perception from two directions: cognitive-affective through hypnobirthing and sensory-emotional through music ( Asmara et al., 2017).

In terms of implementation, these results show that combined interventions have enormous potential for application in midwifery practice in Indonesia, especially in non-invasive antenatal care. The application of a multimodal approach that combines cultural and psychological aspects provides a more holistic therapeutic response and empowers patients. This effectiveness is the basis for developing an integrated intervention model in the management of musculoskeletal pain in pregnancy ( Hall et al., 2016).

Nursing care for pregnant women with back pain and acute pain issues may include non-pharmacological pain management therapies, such as distraction and diversion through classical music therapy and hypnobirthing relaxation techniques. Non-pharmacological pain management techniques, such as deep breathing exercises, are commonly used in hospitals. Medications are generally employed exclusively for pain relief ( Cheung et al., 2023). Despite extensive research on the impact of music on physical and emotional health, there remains a deficiency of studies explicitly examining the effects of traditional Indonesian music, such as Gending Sriwijaya, on lower back pain in pregnant women ( Santiváñez-Acosta et al., 2020).

This synergy amplifies the release of endorphins and oxytocin, inhibits cortisol production, and decreases the perception of the threat often associated with pregnancy pain. These combined effects create optimal physical and psychological conditions for a sustained reduction in pain. In other words, the combination of interventions provides a layered stimulus that supports the mother’s self-regulation capacity for pain ( Sr et al., 2021).

Furthermore, the combined intervention of hypnobirthing and therapeutic music works through physiological pathways and creates profound psychospiritual effects on pregnant women. In hypnobirthing, pregnant women are directed to enter a deeper state of relaxed awareness through positive affirmation and visualization techniques ( Sr et al., 2021). This process maximizes the emotional and cognitive resonance effects when paired with traditional music, such as Gending Sriwijaya. Traditional music has a stable and harmonious rhythmic and melodic structure, which is known to facilitate light trance states that are ideal for the reception of positive suggestions during hypnobirthing sessions.

Hypnobirthing and music therapy significantly reduced pregnancy-related lower back pain, with their combination yielding the most pronounced benefits. These non-pharmacological interventions should be considered for routine use in third-trimester prenatal care to improve maternal wellbeing. All interventions were effective, and a combined approach may offer better benefits or be a promising holistic approach.

This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). The approval is based on 7 (seven) WHO 2011 Standard and guidance part III ( WHO, 2011), Namely Ethical basis for decision-making will reference to the fulfilment of 2016 CIOMS guideline ( CIOMS, 2016). The respondents were third-trimester pregnant women who experienced mild to severe lower back pain. Prior to participation, all eligible pregnant women were informed about the study objectives, procedures, potential risks, and benefits. Written informed consent was obtained from all participants before data collection began. The consent process emphasized voluntary participation, the right to withdraw at any stage without any consequences, and assurance of confidentiality. No parental or guardian consent was required since all participants were adults above the age of 18 years. All collected data were anonymized to ensure participant privacy and confidentiality, and after being explained, the respondents are asked to sign the availability of being a respondent on the consent sheet provided. Zenodo. Questionnaire and research tools. https://doi.org/10.5281/zenodo.16881327 ( Murbiah, 2025a).