Sleep quality in women with and without postpartum depression

Sleep, daily activity rhythms and postpartum mood: A longitudinal study across the perinatal period

Women with a diagnosis of bipolar and major depressive disorders are at higher risk to develop postpartum depression. The primary objective of this longitudinal study was to determine whether daily activity rhythms and sleep parameters differ between women with and without a history of a mood disorder across the perinatal period. A secondary objective was to determine whether changes in these parameters were associated with postpartum mood. In total, 33 women were included in this study, 15 of which had a history of a mood disorder (high-risk group) and 18 who did not (low-risk group). Sleep and daily rhythms were assessed subjectively and objectively during the third trimester (≥26 weeks gestation) and again at 6-12 weeks postpartum. Mood was also assessed at both time points. Women in the high-risk group showed greater subjective daily rhythms and sleep disturbances across the perinatal period. Objective sleep efficiency was worse in the high-risk group in the postpartum period. Changes in both subjective daily rhythms and objective sleep efficiency were predictive of changes in depressive symptoms across the perinatal period. These findings encourage the development of preventative therapeutics to ensure circadian rhythm and sleep stability throughout the perinatal period.

Effects of a single night of postpartum sleep on childless women's daytime functioning

STUDY OBJECTIVES

The maternal postpartum period is characterized by sleep fragmentation, which is associated with daytime impairment, mental health disturbances, and changes in melatonin patterns. In addition to sleep fragmentation, women undergo a complex set of physiological and environmental changes upon entering the postpartum period, confounding our understanding of effects of postpartum sleep disturbance. The primary study aim was to understand the basic impact of a single night of postpartum-like sleep fragmentation on sleep architecture, nocturnal melatonin levels, mood, daytime sleepiness, and neurobehavioral performance.

MEASUREMENTS AND RESULTS

For one week prior to entry into the laboratory, eleven healthy nulliparous women kept a stable sleep-wake schedule (verified via actigraphy). Participants contributed three consecutive nights of laboratory overnight polysomnography: (1) a habituation/sleep disorder screening night; (2) a baseline night; and (3) a sleep fragmentation night, when participants were awakened three times for ~30min each. Self-reported sleep quality and mood (Profile of Mood States survey) both decreased significantly after sleep fragmentation compared to baseline measurements. Unexpectedly, daytime sleepiness (Multiple Sleep Latency Test) decreased significantly after sleep fragmentation. Experimental fragmentation had no significant effect on time spent in nocturnal sleep stages, urinary 6-sulfatoxymelatonin concentration, or psychomotor vigilance test performance. Participants continued to provide actigraphy data, and daily PVTs and self-reported sleep quality assessments at home for one week following sleep fragmentation; these assessments did not differ from baseline values.

CONCLUSIONS

While there were no changes in measured physiological components of a single night of postpartum-like experimental sleep fragmentation, there were decreases in self-reported measures of mood and sleep quality. Future research should examine the effects of multiple nights of modeling postpartum-like sleep fragmentation on objective measures of sleep and daytime functioning.

Sleep Moderates and Mediates the Relationship Between Acculturation and Depressive Symptoms in Pregnant Mexican-American Women

OBJECTIVE

Greater acculturation is associated with adverse perinatal outcomes in Mexican-American women, but the mechanisms by which acculturation influences perinatal outcomes are unclear. Pregnant acculturated Mexican-American women are more likely to engage in unhealthy prenatal behaviors relative to those less acculturated, including poor sleep. As sleep disruptions are associated with acculturation and negative perinatal outcomes, particularly maternal depression, alterations in sleep may adversely affect pregnant Mexican-American women.

METHODS

Sixty pregnant women of Mexican descent completed surveys about sleep, acculturation, depressive symptoms and potential protective factor of social support.

RESULTS

Acculturation, but not social support, significantly predicted increased sleep disruptions as well as overall feeling less refreshed upon waking across pregnancy. Moderation analysis indicated that more acculturated women who took longer to fall asleep reported increased depressive symptoms. Feeling refreshed upon waking also mediated the relationship between increased acculturation and elevated maternal depressive symptoms.

CONCLUSIONS

Acculturation and altered sleep contribute to greater risk in Mexican-American women for maternal depressive symptoms in the perinatal period. These findings have implications for prevention and treatment of maternal mental health disorders, which may adversely affect perinatal outcomes in the vulnerable Mexican-American population.

Sleep and postpartum depression

PURPOSE OF REVIEW

The perinatal period introduces a myriad of changes. One important but often overlooked change is the increased risk for sleep disturbance. Although casually regarded as a consequence of pregnancy or postpartum, there is emerging evidence to suggest that women with significant sleep disturbance, characterized by insomnia symptoms and/or poor sleep quality, are more likely to report an increase in depressive symptomatology or develop postpartum depression (PPD). Significant consequences may arise as a result including issues with maternal-infant bonding, effective care for the infant and behavioral or emotional difficulties in the infant. This review discusses the relevant literature as to how disturbed sleep during pregnancy as well as in the postpartum may increase the risk for PPD.

RECENT FINDINGS

Symptoms of insomnia and poor sleep quality are independently associated with greater depressive symptoms across pregnancy and throughout postpartum. Likewise, both can negatively impact the ability to mother effectively.

SUMMARY

The presence of insomnia or sleep disturbance during the perinatal period is a risk factor for depressive symptoms. Women with depression are at an increased risk of developing sleep disturbance thereby increasing depressive symptomatology. This bidirectional and additive relationship needs more clinical attention as both sleep disturbance and depression are noted risk factors for adverse pregnancy outcomes.

Sleep Trajectories of Women Undergoing Elective Cesarean Section: Effects on Body Weight and Psychological Well-Being

BACKGROUND

After cesarean section (CS), women may be at great risk for sleep disturbance, but little is known about temporal changes in their sleep patterns and characteristics. We had two aims: 1) to identify distinct classes of sleep-disturbance trajectories in women considering elective CS from third-trimester pregnancy to 6 months post-CS and 2) to examine associations of sleep trajectories with body mass index (BMI), depressive symptoms, and fatigue scores.

METHODS

We analyzed data from a prospective cohort study of 139 Taiwanese pregnant women who elected CS. Sleep components were assessed using the Pittsburgh Sleep Quality Index in third-trimester pregnancy, 1 day, 1 week, 1 month, and 6 months post-CS. Data were collected on depressive symptoms, fatigue symptoms, and BMI. Sleep-quality trajectories were identified by group-based trajectory modeling.

RESULTS

We identified three distinct trajectories: stable poor sleep (50 women, 36.0%), progressively worse sleep (67 women, 48.2%), and persistently poor sleep (22 women, 15.8%). Poor sleep was significantly associated with pre-pregnancy BMI and more baseline (third-trimester pregnancy) depressive and fatigue symptoms. At 6 months post-CS, women classified as progressively worse or persistently poor sleepers showed a trend toward higher BMI (p<0.03), more depressive symptoms (p<0.001), and higher fatigue scores (p<0.001) than those with stable poor sleep.

CONCLUSIONS

Women had three distinct sleep-disturbance trajectories before and after elective CS. These poor-sleep courses were associated with BMI and psychological well-being. Our findings suggest a need to continuously assess sleep quality among women considering elective CS and up to 6 months post-CS.

The relationship between sleep and postpartum mental disorders: A systematic review

BACKGROUND

Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders.

METHODS

Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included.

RESULTS

There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak.

LIMITATIONS

Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis.

CONCLUSIONS

Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.

Lavender Fragrance Essential Oil and the Quality of Sleep in Postpartum Women

Background:

Objectives:

Patients and Methods:

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A systematic review of the relationship between postpartum sleep disturbance and postpartum depression

OBJECTIVE

To examine the relationship between postpartum sleep disturbance and postpartum depression and describe the characteristics and demographics of the samples.

DATA SOURCES

Electronic databases Medline, PubMed, Cochrane, EPOC, CINAHL, ProQuest, and Psych INFO. In addition, hand searches of bibliographies supplemented the electronic search.

STUDY SELECTION

English language primary studies on the relationship between postpartum sleep disturbance and postpartum depression were included. Thirteen observational studies met the inclusion criteria.

DATA EXTRACTION

Data that specified the relationship between sleep disturbance and postpartum depression were extracted from the studies. The data were organized per author, year, participants, setting, country, demographics, design, sample size, outcomes, evidence, and effect size.

DATA SYNTHESIS

The effect size indicating the relationship between sleep disturbance and postpartum depression across the studies ranged between 0.4 and 1.7. There was evidence of a strong relationship between sleep disturbance and postpartum depression; however, the participants in the 13 studies were predominantly educated, middle class, older than age 30 years, and White. Likewise, the definition and measurement of postpartum sleep varied across the studies, which increased the possibility of bias.

CONCLUSIONS

Further research within the postpartum period involving underserved, younger women and samples with more diversity in race and ethnicity are needed.

Meta-analysis of the role of delivery mode in postpartum depression (Iran 1997-2011)

BACKGROUND

Postpartum period is the riskiest time for mood disorders and psychosis. Postpartum depression is the most important mood disorder after delivery, which can be accompanied by mother-child and family relationship disorders. Meta-analysis with the integration of research results demonstrates to investigate the association between the mode of delivery and postpartum depression.

MATERIALS AND METHODS

This meta-analysis uses the Rosenthal and Robin approach. For this purpose, 18 studies which were acceptable in terms of methodology were selected and meta-analysis was conducted on them. Research instrument was a checklist of meta-analysis. After summarizing the results of the studies, effect sizes were calculated manually and combined based on meta-analysis method.

RESULTS

The findings showed that the amount of effect size (in term of Cohen d) of delivery mode on postpartum depression was 0/30 (P < 0.001).

CONCLUSION

Delivery mode on maternal mental health is assessed medium. Meta analysis also indicates moderator variables role, and researcher must focus in these variables.

A study of marital satisfaction among non-depressed and depressed mothers after childbirth in Jahrom, Iran, 2014

Introduction:

Birth is one of the most wonderful events in nature and pregnancy and delivery are major developments for most married women. Similar to the pregnancy period, the period of time following delivery is accompanied by certain mental and physical changes in women. During this time, mothers experience a full range of mental disorders, varying from minor to psychotic. The objective of this study was to examine marital satisfaction among non-depressed and depressed mothers who visited primary health centers in Jahrom after childbirth in 2014.

Method and Material:

This is a descriptive cross-sectional study. The study population consisted of 80 mothers, who were in the 6 to 12 weeks of delivery and had visited primary health centers in Jahrom from April to July, 2014.To select the participants, the researcher looked thorough the files at each center and chose the mothers who were qualified for the study based on convenience sampling. The criteria for participation were: being aged from 20 to 40; being in the 6-12 weeks since delivery; having a healthy newborn; willingness to participate in the study. The participants were divided into the two groups of mothers suffering from postpartum depression (40 women) and mothers not affected by postpartum depression (40 women) on basis of questionnaire. The study follows the ethics in a scientific study. The researcher personally visited the primary health centers and explained the objectives of the study to the participants. Subsequently, the participants were asked to complete a demographic questionnaire, Enrich Marital Satisfaction Scale, and Edinburgh Postpartum Depression Scale. The participants were allowed one hour to complete the questionnaires.

Result:

The results showed that the average age of depressed and non-depressed women was respectively 28.1±5 and 29.4±5.5. Regarding the sex of the newborns, 53% of the depressed women had a son and 46.7% had a daughter. In the non-depressed group, 43.3% of the mothers had a son and 56.7% had a daughter. 56.7% of the depressed mothers were first-time mothers; however, 43.3% of the non-depressed mothers had experienced childbirth for the first time.

Most of the women in both groups had a high-school diploma—53% of the depressed mothers and 51% of the non-depressed. 66.7% of the depressed mothers had had natural childbirths; 60% of the non-depressed mothers had had Cesareans. There was not a statistically meaningful difference between the two groups in terms of the demographic variables. The average depression score of the depressed group was 13.7 with a standard deviation of 3.2; the average depression score of the non-depressed group was 5.8 with a standard deviation of 2. There was a statistically significant difference between the two groups in terms of marital satisfaction.

Conclusion:

Postpartum depression is a major and common health problem, affects many women after childbirth and inflicts not only direct costs on the health care system, but causes extensive indirect losses due to mothers’ inability to function.

Though this condition is prevalent among new mothers, not many researchers have addressed it in small towns and investigated its relationship with marital satisfaction. In addition, most women suffering from postpartum depression know very little about the disorder. Accordingly, it is vital to educate women and conduct more studies on the issue.

Cultural differences in perinatal experiences for women with low socioeconomic status

In this study, similarities and differences in perinatal experiences between women with low socioeconomic status (SES) by race, ethnicity, and nativity were explored. The objective was to better understand the sociocultural and environmental contexts ofperinatal experiences and potential implications for screening and assessment among women with low SES. A purposive stratified sample of 32 women who were likely to be screened for perinatal depression participated in four focus groups organized by African American, white, Hmong, or Latina race or ethnicity. A descriptive study design was used to collect and evaluate focus-group data using qualitative content analysis. Women understood their perinatal experiences through the stressors in their environment. The stressors of insufficient socioeconomic resources and interpersonal support were relatively consistent across the focus groups. However, women's understanding of these stressors and their meaning differed between groups. Racially and ethnically diverse women with low SES experienced a complex interaction of sociocultural and environmental factors in the perinatal period. The findings highlight the need for health and social work practitioners to conduct depression screenings in conjunction with a com- prehensive psychosocial assessment, informed by cultural competence.

Dispelling myths to support breastfeeding in women with postpartum depression

Increasing attention is being paid to the possible connection between infant feeding practices and postpartum depression. Nurses caring for women and their families in the postpartum period might wonder how to best support the breastfeeding relationship if a woman has a history of depression. Using evidence from the scientific literature, this article dispels some myths regarding breastfeeding and depression, and provides suggested dialogue nurses can use when counseling women about depression and breastfeeding.

Longitudinal change in sleep and daytime sleepiness in postpartum women

Sleep disruption strongly influences daytime functioning; resultant sleepiness is recognised as a contributing risk-factor for individuals performing critical and dangerous tasks. While the relationship between sleep and sleepiness has been heavily investigated in the vulnerable sub-populations of shift workers and patients with sleep disorders, postpartum women have been comparatively overlooked. Thirty-three healthy, postpartum women recorded every episode of sleep and wake each day during postpartum weeks 6, 12 and 18. Although repeated measures analysis revealed there was no significant difference in the amount of nocturnal sleep and frequency of night-time wakings, there was a significant reduction in sleep disruption, due to fewer minutes of wake after sleep onset. Subjective sleepiness was measured each day using the Karolinska Sleepiness Scale; at the two earlier time points this was significantly correlated with sleep quality but not to sleep quantity. Epworth Sleepiness Scores significantly reduced over time; however, during week 18 over 50% of participants were still experiencing excessive daytime sleepiness (Epworth Sleepiness Score ≥12). Results have implications for health care providers and policy makers. Health care providers designing interventions to address sleepiness in new mothers should take into account the dynamic changes to sleep and sleepiness during this initial postpartum period. Policy makers developing regulations for parental leave entitlements should take into consideration the high prevalence of excessive daytime sleepiness experienced by new mothers, ensuring enough opportunity for daytime sleepiness to diminish to a manageable level prior to reengagement in the workforce.

Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression

BACKGROUND

This prospective cohort study explored the effects of prenatal and postpartum depression on breastfeeding and the effect of breastfeeding on postpartum depression.

METHOD

The Edinburgh Postpartum Depression Scale (EPDS) was administered to 145 women at the first, second and third trimester, and at the neonatal period and 3 months postpartum. Self-report exclusive breastfeeding since birth was collected at birth and at 3, 6 and 12 months postpartum. Data analyses were performed using repeated-measures ANOVAs and logistic and multiple linear regressions.

RESULTS

Depression scores at the third trimester, but not at 3 months postpartum, were the best predictors of exclusive breastfeeding duration (β = -0.30, t = -2.08, p < 0.05). A significant decrease in depression scores was seen from childbirth to 3 months postpartum in women who maintained exclusive breastfeeding for ⩾3 months (F 1,65 = 3.73, p < 0.10, η p 2 = 0.05).

CONCLUSIONS

These findings suggest that screening for depression symptoms during pregnancy can help to identify women at risk for early cessation of exclusive breastfeeding, and that exclusive breastfeeding may help to reduce symptoms of depression from childbirth to 3 months postpartum.

Insomnia treatment in the third trimester of pregnancy reduces postpartum depression symptoms: a randomized clinical trial

Mental health is an important medical issue in perinatal care, and there is increasing evidence that insomnia during pregnancy is associated with postpartum depression (PPD). Therefore, the present study evaluated the effect of insomnia treatment during the third trimester of pregnancy on PPD symptoms. Fifty-four pregnant women with insomnia were randomly assigned to trazodone, diphenhydramine, or placebo treatment. Sleep quality was measured by actigraphy at baseline, and after 2 and 6 weeks of treatment. In addition, depression was assessed 2 and 6 weeks after delivery. Trazodone and diphenhydramine improved sleep profile compared to placebo after 6 weeks of treatment. Further, depressive symptoms were reduced 2 and 6 weeks after delivery in trazodone and diphenhydramine groups compared to placebo. No differences in depressive symptoms were observed between the trazodone and diphenhydramine groups. These findings indicate that insomnia treatment with trazodone or diphenhydramine during the third trimester of pregnancy may prevent PPD.

Poor sleep maintenance and subjective sleep quality are associated with postpartum maternal depression symptom severity

Women are at increased risk of developing mood disorders during the postpartum period, and poor postpartum sleep may be a modifiable risk factor for the development of depression. This longitudinal study investigated the relationship between sleep variables and postpartum depression symptoms using wrist actigraphy and self-report surveys. Twenty-five healthy primiparous women were recruited from their outpatient obstetricians' offices from July 2009 through March 2010. Subjects wore wrist actigraphs for 1 week during the third trimester of pregnancy and again during the 2nd, 6th, 10th, and 14th weeks postpartum while completing sleep logs and sleep surveys. Subjective assessments of mood were collected at the end of each actigraph week. Subjective sleep assessments were strongly predictive of depression severity scores as measured by the Edinburgh Postnatal Depression Scale (EPDS) across all weeks (p < 0.001). Actigraphic measures of sleep maintenance, such as sleep fragmentation, sleep efficiency, and wake time after sleep onset, were also significantly correlated with EPDS scores postpartum. However, there was no relationship between nocturnal sleep duration and EPDS scores. This study provides additional evidence that poor sleep maintenance as measured by wrist actigraphy, rather than lesser amounts of sleep, is associated with EPDS scores during the postpartum period and that subjective assessments of sleep may be more accurate predictors of postpartum depression symptoms than wrist actigraphy. It also supports the hypothesis that disrupted sleep may contribute to the development and extent of postpartum depression symptoms.

Timing and variability of postpartum sleep in relation to daytime performance

Postpartum women have highly disturbed sleep, also known as sleep fragmentation. Fragmentation extends their total sleep period, also disrupting sleep timing. A stable and earlier sleep period among non-postpartum populations is related to better performance, physical health, and mental health. However, sleep timing has not been examined among postpartum women who are also vulnerable to daytime impairment. The study objective was to examine how the timing and regularity of sleep during the early postpartum period are related to daytime functioning across postpartum weeks 2-13. In this field-based study, 71 primiparous women wore an actigraph, a small wrist-worn device that monitors sleep and sleep timing, for the 12-week study period. Mothers self-administered a 5-min psychomotor vigilance test (PVT) each morning to evaluate the number of >500ms response lapses. They also completed a Morningness-Eveningness scale at the beginning of the study to identify chronotype. After controlling for maternal age, earlier sleep timing was associated with significantly fewer PVT lapses at postpartum weeks 9,12; a more stable sleep midpoint was associated with significantly fewer PVT lapses at postpartum weeks 2,5-13. Earlier sleep midpoints were related to more stable sleep midpoints at postpartum week 2 and a morning-type chronotype. An earlier sleep midpoint was also associated with a reduced slope of worsening PVT lapses across weeks. Across the first 12 postpartum weeks, women with earlier or more stable sleep periods had less daytime impairment than women with later or more variable sleep midpoints. Postpartum women with earlier sleep midpoints also showed less severe decrements in performance across time, which has been attributed to cumulative impacts of sleep disturbance. These data suggest that the sleep period, in addition to sleep duration and fragmentation, should be more closely examined, particularly among vulnerable women, as it may affect the neurobehavioral performance of new mothers.

Breastfeeding and postpartum depression: state of the art review

OBJECTIVE

To review the literature on the association between breastfeeding and postpartum depression.

SOURCES

A review of literature found on MEDLINE/PubMed database.

SUMMARY OF FINDINGS

The literature consistently shows that breastfeeding provides a wide range of benefits for both the child and the mother. The psychological benefits for the mother are still in need of further research. Some studies point out that pregnancy depression is one of the factors that may contribute to breastfeeding failure. Others studies also suggest an association between breastfeeding and postpartum depression; the direction of this association is still unclear. Breastfeeding can promote hormonal processes that protect mothers against postpartum depression by attenuating cortisol response to stress. It can also reduce the risk of postpartum depression, by helping the regulation of sleep and wake patterns for mother and child, improving mother's self-efficacy and her emotional involvement with the child, reducing the child's temperamental difficulties, and promoting a better interaction between mother and child.

CONCLUSIONS

Studies demonstrate that breastfeeding can protect mothers from postpartum depression, and are starting to clarify which biological and psychological processes may explain this protection. However, there are still equivocal results in the literature that may be explained by the methodological limitations presented by some studies.

Postpartum mothers' napping and improved cognitive growth fostering of infants: results from a pilot study

Little is known about how maternal sleep disturbances in the postpartum period affect mother-infant interaction. The study was designed to assess if less maternal sleep disturbance and less fatigue were associated with more positive mother-child interaction, independent of maternal depression symptoms. Twenty-three mothers completed 1 week of actigraphy and self-report measures of fatigue and depression symptoms. To determine the quality of mother-infant interaction, mothers and infants were then observed in a structured, video-recorded teaching episode. Greater maternal napping frequency was associated with better cognitive growth fostering of the infant (r s = .44, p < .05), a subscale of the interaction assessment. Maternal napping, not the quality or quantity of nocturnal sleep, appears to be associated with improvements in mother-infant interactions.

Guided imagery: an innovative approach to improving maternal sleep quality

Mothers of preterm infants are at risk for poor sleep quality, which may adversely affect their health, maternal-infant attachment, and infant caretaking activities. This study examined the relationship of an 8-week relaxation guided imagery intervention on sleep quality and the association between sleep quality and maternal distress (perceived stress, depressive symptoms, and state anxiety) in 20 mothers of hospitalized preterm infants. Mothers received a CD (compact disc) with three 20-minutes recordings and were asked to listen to at least 1 recording daily for 8 weeks. This analysis used self-report data gathered at baseline and 8 weeks. Pearson correlations were used to examine the relationships between mean cumulative relaxation guided imagery use and measures of maternal distress and sleep quality scores at 8 weeks. Complete data on 19 mothers were available for analysis. At 8 weeks, higher mean relaxation guided imagery use was inversely correlated with sleep quality scores (r = -0.30); sleep quality scores were positively correlated with stress (r = 0.42), depressive symptoms (r = 0.34), and anxiety (r = 0.39) scores. In mothers of preterm infants, sleep quality was negatively affected by mental distress and may be improved by a guided imagery intervention.

Insomnia and depressive symptoms in late pregnancy: a population-based study

A population-based questionnaire study of 2,816 women was conducted in week 32 of pregnancy to estimate the prevalence of and risk factors for insomnia and depressive symptoms. The Bergen Insomnia Scale (BIS) measured insomnia. The Edinburgh Postnatal Depression Scale (EPDS) measured depressive symptoms. The prevalence of insomnia (DSM-IV-TR criteria) was 61.9%, and mean BIS score 17.5 (SD = 10.5), significantly higher than among the general population. The prevalence of depressive symptoms (EPDS ≥ 10) was 14.6%. Depressive symptoms were strongly associated with insomnia during late pregnancy, especially with sleep durations <5 or >10 hours, sleep efficiency <75%, daytime impairment, and long sleep onset latency. Pelvic girdle pain and lower back pain was associated with insomnia, but not with depressive symptoms.

Parental sleep experiences on the pediatric oncology ward

PURPOSE

Parents of pediatric oncology patients are encouraged to sleep on the ward with their child to provide additional care throughout the night. The purpose of this study was to provide the first prevalence estimates of self-reported sleep quantity and quality among parents accommodated on the pediatric oncology ward, compared to parents of age-matched controls.

METHODS

Parents of children receiving in-patient cancer treatment and parents of healthy, age-matched children completed a self-report questionnaire, including validated measures of parental sleep and psychological distress, demographic, and clinical characteristics.

RESULTS

In total, 114 parents participated (52 parents of children with cancer; 62 control parents; over all response rate 70 %). Parents on the pediatric oncology ward reported sleeping 5.7 h (SD = 1.8) on average, in comparison to control parents who reported sleeping 7.0 h at home (SD = 1.4; t = 4.3, p < 0.001). Parents reported waking an average of 4.6 times (SD = 0.3) per night on the ward, compared to control parents who reported 2.0 (SD = 0.2) nighttime awakenings (t = 7.69, p < 0.001). Parents of children with cancer were significantly more likely to report that they had slept "badly" (67.3 versus 21.0 %; χ(2) = 21.9, p < 0.001). Significant predictors of sleep duration included anxiety (p = 0.013) and caffeine consumption (p = 0.017). Parents who slept on the ward attributed poor sleep to feelings of anxiety, environmental noise, and child-related factors.

CONCLUSIONS

Parents who sleep on the pediatric oncology ward experience poor sleep outcomes, including inadequate duration and frequent interruptions. The detrimental effects of sleep deprivation on parents' ability to cope during this challenging time require further investigation and intervention.

Does activity matter: an exploratory study among mothers with preterm infants?

The purpose of this study was to describe the daytime activity levels and their association with sleep, fatigue, depressive symptoms, and quality of life. Wrist actigraphy and questionnaires were used to examine 51 mothers with a preterm infant during their second week postpartum. Circadian activity rhythms (CAR) were less synchronized in these mothers; they experienced sleep disturbances, fatigue, depressive symptoms, and poor health-related quality of life (H-QOL). Compared to high-activity mothers, mothers with low activity levels slept less during nighttime but napped more during daytime, and reported more postpartum depressive symptoms. Further research is needed to examine the effect of low activity level and sleep loss on postpartum depression, and to develop interventions for improving rest/activity patterns for new mothers.

Stress and health-related well-being among mothers with a low birth weight infant: the role of sleep

This U.S.A.-based study examined the quantitative and qualitative characteristics of sleep, as well as the role of sleep, in the association of stress with depression, fatigue, and health-related quality of life (H-QOL) among mothers with a low-birth-weight, preterm infant in the neonatal intensive care unit at early postpartum. Fifty-five first-time mothers kept a sleep diary and filled out a battery of questionnaires. The wrist actigraphy method was also applied to collect information on maternal sleep. We tested a path model, with sleep disturbance and depression mediating the effect of stress on health-related well-being. Results showed that the majority of the study participants were stressed, depressed, fatigued, and at risk for poor physical and mental health. Poor sleep quality as perceived by mothers was significantly associated with their stress, fatigue, and poor mental and physical H-QOL. A cascading effect was found in the path model where maternal stress contributed to poor sleep quality and depression, which in turn contributed to poor mental H-QOL. In addition, poor sleep quality was associated with fatigue, which in turn contributed to poor physical and mental H-QOL. The underlying neurobiological mechanisms through which sleep affects the stress-health relation are discussed. The implications of sleep for intervention and prevention are also addressed.

Interaction of maternal age and mode of delivery in the development of postpartum depression in Yerevan, Armenia

BACKGROUND

To investigate determinants of development of postpartum depression among women in Yerevan, Armenia.

METHOD

A case-control study of all reproductive age (18-45) women having 1-3 months old children registered in 7 Primary Health Care (PHC) facilities, in Yerevan. We used Edinburgh Postnatal Depression Scale (EPDS) and a structured questionnaire to assess possible postpartum depression status of mothers and exposure status through telephone interviews.

RESULTS

The study had a 96.7% response rate for 63 cases and 272 controls. The prevalence of possible postpartum depression was 14.4%. The risk of possible postpartum depression associated with age less than 25 years at childbirth was increased only among women who delivered their child through C-section (OR=7.8; 95% CI: 1.5-40.7). Meanwhile, this risk was much lower among women who delivered through vaginal delivery (OR=0.9; 95% CI: 0.4-1.8).

LIMITATIONS

EPDS had not been translated and validated in Armenia. Study population included only women having 1-3 months old children.

CONCLUSION

The study suggested that the effect of younger age at last childbirth on the risk of possible postpartum depression development was higher for women who gave birth through C-section compared to those with vaginal delivery. Despite the stressful and crisis conditions existing in Armenia over the past 2 decades the prevalence of possible postpartum depression does not differ much from that in other societies.

Wrist actigraphy

To record sleep, actigraph devices are worn on the wrist and record movements that can be used to estimate sleep parameters with specialized algorithms in computer software programs. With the recent establishment of a Current Procedural Terminology code for wrist actigraphy, this technology is being used increasingly in clinical settings as actigraphy has the advantage of providing objective information on sleep habits in the patient's natural sleep environment. Actigraphy has been well validated for the estimation of nighttime sleep parameters across age groups, but the validity of the estimation of sleep-onset latency and daytime sleeping is limited. Clinical guidelines and research suggest that wrist actigraphy is particularly useful in the documentation of sleep patterns prior to a multiple sleep latency test, in the evaluation of circadian rhythm sleep disorders, to evaluate treatment outcomes, and as an adjunct to home monitoring of sleep-disordered breathing. Actigraphy has also been well studied in the evaluation of sleep in the context of depression and dementia. Although actigraphy should not be viewed as a substitute for clinical interviews, sleep diaries, or overnight polysomnography when indicated, it can provide useful information about sleep in the natural sleep environment and/or when extended monitoring is clinically indicated.

Normative longitudinal maternal sleep: the first 4 postpartum months

OBJECTIVE

To describe the normative course of maternal sleep during the first 4 months postpartum.

STUDY DESIGN

Sleep was objectively measured using continuous wrist actigraphy. This was a longitudinal, field-based assessment of nocturnal sleep during postpartum weeks 2 through 16. Fifty mothers participated during postpartum weeks 2 through 13; 24 participated during postpartum weeks 9 through 16.

RESULTS

Maternal nocturnal sleep time was 7.2 (SD ± 0.95) hours and did not change significantly across postpartum weeks 2 through 16. Maternal sleep efficiency did improve across weeks 2 (79.7%; SD ± 5.5) through 16 (90.2%; SD ± 3.5) as a function of decreased sleep fragmentation across weeks 2 (21.7; SD ± 5.2) through 16 (12.8; SD ± 3.3).

CONCLUSION

Though postpartum mothers' total sleep time was higher than expected during the initial postpartum months, this sleep was highly fragmented (similar to fragmenting sleep disorders) and inefficient. This profile of disturbed sleep should be considered in intervention designs and family leave policies.

Mother-Infant Activity Synchrony as a Correlate of the Emergence of Circadian Rhythm

Objective: Entrainment to the day—night cycle is critical for infant sleep and social development. Synchronization of infant circadian systems with the social 24-hr day may require maternal activity signals as an entraining cue. This descriptive and exploratory research examines the activity level and circadian pattern in mothers and infants. Method: Twenty-two healthy mothers and their infants (postnatal age 49.8 ± 17.1 days) wore actigraph monitors for seven days. Daytime (06:00—21:59) and nighttime (22:00—05:59) activity levels and circadian parameters of rest—activity patterns (i.e., mesor, amplitude, acrophase, and 24-hr cosinor fit) were calculated. Results: Mothers and infants were significantly more active during the day than at night. The goodness-of-fit index for the model (R2) indicates that circadian rhythm accounted for a mean of 29 ± 10% and 12 ± 8% of the variability in maternal and infant activity, respectively. Acrophase of activity occurred at 15:46 ± 1:07 for the mothers and 15:20 ± 1:21 for the infants. The mean within-dyad correlation of activity counts was r = .46 ± .11, and the within-dyad correlation was associated with the amplitude (r = .66, p < .01) and 24-hr cosinor fit of infant activity (r = .67, p < .01). Conclusions: Our findings suggest maternal rhythms as a possible exogenous influence on shaping an infant’s emerging rhythms and synchronizing them with the external light—dark cycle. Strong pattern synchrony between maternal and infant activity may support infant circadian entrainment and enhance a regular 24-hr sleep—wake schedule during the early postnatal weeks.

Development of a universal psycho-educational intervention to prevent common postpartum mental disorders in primiparous women: a multiple method approach

BACKGROUND

Prevention of postnatal mental disorders in women is an important component of comprehensive health service delivery because of the substantial potential benefits for population health. However, diverse approaches to prevention of postnatal depression have had limited success, possibly because anxiety and adjustment disorders are also problematic, mental health problems are multifactorially determined, and because relationships amongst psychosocial risk factors are complex and difficult to modify. The aim of this paper is to describe the development of a novel psycho-educational intervention to prevent postnatal mental disorders in mothers of firstborn infants.

METHODS

Data from a variety of sources were synthesised: a literature review summarised epidemiological evidence about neglected modifiable risk factors; clinical research evidence identified successful psychosocial treatments for postnatal mental health problems; consultations with clinicians, health professionals, policy makers and consumers informed the proposed program and psychological and health promotion theories underpinned the proposed mechanisms of effect. The intervention was pilot-tested with small groups of mothers and fathers and their first newborn infants.

RESULTS

What Were We Thinking! is a psycho-educational intervention, designed for universal implementation, that addresses heightened learning needs of parents of first newborns. It re-conceptualises mental health problems in mothers of infants as reflecting unmet needs for adaptations in the intimate partner relationship after the birth of a baby, and skills to promote settled infant behaviour. It addresses these two risk factors in half-day seminars, facilitated by trained maternal and child health nurses using non-psychiatric language, in groups of up to five couples and their four-week old infants in primary care. It is designed to promote confidence and reduce mental disorders by providing skills in sustainable sleep and settling strategies, and the re-negotiation of the unpaid household workload in non-confrontational ways. Materials include a Facilitators' Handbook, creatively designed worksheets for use in seminars, and a book for couples to take home for reference. A website provides an alternative means of access to the intervention.

CONCLUSIONS

What Were We Thinking! is a postnatal mental health intervention which has the potential to contribute to psychologically-informed routine primary postnatal health care and prevent common mental disorders in women.

Subjective perception of sleep, but not its objective quality, is associated with immediate postpartum mood disturbances in healthy women

STUDY OBJECTIVES

This study investigated whether there was a relationship between disrupted sleep and postpartum mood disturbances in women during the week after delivery.

DESIGN

Sleep and mood were measured during the third trimester (Time-1) and one week postpartum (Time-2) in a 2-stage longitudinal design.

SETTING

Participants were recruited from an antenatal clinic in a regional Melbourne hospital.

PARTICIPANTS

Forty-four healthy women at low risk for postpartum depression.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Objective sleep was measured by actigraphy and subjective sleep by the Pittsburgh Sleep Quality Index; mood was assessed by the Depression Anxiety Stress Scale, the Hospital Anxiety Depression Scale, and the Positive and Negative Affect Schedule. Sleep and mood questionnaires were administered at Time-1 and Time-2. Wrist actigraphy was collected for one week at both times. After delivery, both objective and subjective nighttime sleep significantly worsened with decreased total sleep time and sleep efficiency, while daytime napping behavior significantly increased. On average, mood improved across all scales after delivery, although 45.95% of the sample experienced deterioration of mood. Regression analyses showed little relationship between Time-1 and Time-2 objective nighttime sleep, and postpartum mood. Variables that related to both Time-1 and Time-2 subjective perception of sleep, including subjective nighttime sleep, sleep-related daytime dysfunction, and daytime napping behavior, were significant predictors of postpartum mood.

CONCLUSIONS

The perception of poor sleep, and the conscious awareness of its impact during wake-time, might share a stronger relationship with the occurrence of immediate postpartum mood disturbances than actual sleep quality and quantity.

Impaired sleep and well-being in mothers with low-birth-weight infants

OBJECTIVE

To explore relationships between impaired sleep and well-being in mothers with low-birth-weight infants in the neonatal intensive care unit.

DESIGN

Cross-sectional descriptive exploratory design.

SETTING

Neonatal intensive care unit in metropolitan Atlanta, GA.

PARTICIPANTS

Twenty second-week postpartum, first-time mothers who had a low-birth-weight infant hospitalized in the neonatal intensive care unit.

METHODS

Self-report data were collected for sleep, fatigue, depression, and well-being. Total sleep time, wake after sleep onset, circadian activity rhythms, and light exposure were measured using a wrist actigraph.

RESULTS

Mothers reported clinically significant sleep disturbance and fatigue severity. Actigraphy showed the average nighttime total sleep time was less than 7 hours with 19%+/-2.2% wake after sleep onset, and the total daytime sleep was more than an hour. Mothers also experienced moderate depressive symptoms. Maternal well-being as measured by the Medical Outcomes Short Form-36, version 2 was approximately 1 SD below the mean scores of age-matched women in the general U.S. population.

CONCLUSION

Mothers of hospitalized low-birth-weight infants are vulnerable. The presence of sleep disturbances and negative physical and mental health indicators warrants further study. Intervention is needed to promote sleep for new mothers during postpartum recovery, especially mothers who are dealing with a medically ill infant.