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

The role of sleep protection in preventing and treating postpartum depression

Postpartum sleep disruption is a risk factor for postpartum depression (PPD) as well as a potential treatment target. In the first 6 months after delivery, when the risk of PPD is greatest, fragmented maternal sleep is most often related to necessary infant night feedings. Clinicians' conversations about planning for and navigating postpartum sleep should include questions about patient expectations, cultural traditions, and available support. For women at high risk of PPD, or with moderate to severe PPD or other symptoms of mental illness, protecting one 4-5 hour period of consolidated nighttime sleep may be necessary and effective. This can be achieved by having another adult step in for 1-2 infant night feedings or by employing other strategies. OBs can encourage high-risk patients to develop a postpartum plan for sleep protection by initiating this conversation during pregnancy.

Sleep duration and sleep loss during pregnancy: a longitudinal FinnBrain birth cohort study

PURPOSE

To investigate sleep duration and sleep loss during antenatal period and assess associative factors, including maternal characteristic and mood symptoms.

METHODS

A cohort of 3038 women was enrolled. Self-reported sleep duration and sleep loss, the latter being calculated from preferred sleep need and actual sleep duration, were measured in early, mid- and late pregnancy, and at delivery. The associations with age, BMI, parity, education, smoking, napping, and depressive and anxiety symptoms were evaluated.

RESULTS

Sleep duration was longest in early pregnancy and shortest at delivery (7.93 h-7.76 h, p < 0.001). The proportion of short sleepers (< 6 h) increased from 1.4% to 5.9% throughout the studied period (p < 0.001). Mean sleep loss remained stable in early- and mid-pregnancy, lowering in late pregnancy (p < 0.001) and increasing again until delivery (p = 0.003). The number of women with notable sleep loss (> 2 h) was similar during the first three measurement points (9.4%, 8.9% and 9.5%), but increased until delivery (14.1%, p < 0.001). Older, multiparous, and more-depressive women slept less (p < 0.001, p < 0.001, p = 0.017). Women with higher BMI were more likely to sleep < 6 h in late pregnancy (p = 0.012). Multiparous, more-depressive, and higher-BMI women reported more sleep loss (p < 0.001, p < 0.001, p = 0.049).

CONCLUSION

We confirmed earlier reported decrease in sleep duration at the end of pregnancy. As a novel finding, we showed a notable increase in sleep loss during the last month of pregnancy. Various factors were associated with both short sleep and sleep loss, especially multiparity, napping and depressive symptoms.

Longitudinal assessment of sleep and fatigue according to baby feeding method in postpartum women: a prospective observational study

BACKGROUND

Poor subjective sleep quality, depressive symptoms and fatigue occur frequently in postpartum. However, the dynamics of their respective associations from prepartum throughout the maternity period in function of baby feeding method have not been fully elucidated.

METHODS

Prospective, longitudinal study using validated questionnaires probing for sleep quality, insomnia, fatigue and depressive symptoms at 35-37 weeks of gestation and at 2, 8 and 12 weeks postpartum in the obstetric departments of two Flemish hospitals. Somers'd ordinal correlation was used for correlations between the results of questionnaires (ratio variables) and the feeding method variable (an ordinal variable); T tests (normal data) or Mann Whitney (non normal data) tests for equality of means; ordinal regression ('Proportional odds model') to investigate the predictive value of parameters at one moment on the feeding method choice at a later moment; logistic regression to investigate the predictive value of parameters on later change of feeding method.

RESULTS

188 women indicating a choice for either bottle or breastfeeding in prepartum (27-35 weeks' gestation) were included. Higher fatigue assessed through the Fatigue Severity Scale within late pregnancy was moderately associated with primary bottle feeding choice. Fatigue decreased at early and late postpartum in bottle feeding (-0.38 ± 1.04; p = .110 and - 0.31 ± 1.01; p = .642 respectively), but remained unchanged from late pregnancy through early and late postpartum in breastfeeding (0.04 ± 1.21; p = .110 and - 0.27 ± 0.96; p = .642 respectively), resulting in similar fatigue in both feeding methods in early through late postpartum. There were no differences in sleep quality or insomnia symptoms at all time points. Presence of postpartum depressive symptoms were associated with early switching to bottle feeding (Somers' d correlation 0.11 (p = .021).

CONCLUSIONS

Fatigue and depressive symptoms are inversely associated with breastfeeding initiation or maintenance and influence feeding method dynamics.

Sleep, circadian activity patterns and postpartum depression: A systematic review and meta-analysis of actigraphy studies

Transition to motherhood is a period full of challenges and demands. In this review, we focused on the associations of sleep and circadian activity patterns during and after pregnancy with postpartum mental health factors. A systematic review and meta-analysis were conducted (PROSPERO reference 316,505). A search for articles was performed using PsycARTICLES, PsycINFO, PubMed, MEDLINE, Scopus, Cochrane, DARE, hand search, and citation tracking. The search was meant to identify peer-reviewed, experimental and observational studies reporting on women over 18 years old that assessed sleep and circadian activity patterns during pregnancy or postpartum using actigraphy, and investigated postpartum mental health factors. Nineteen relevant publications were selected. Postpartum total sleep at night was the indicator that was most closely related to the psychological functioning of women after childbirth. The results of the systematic review indicated that postpartum total sleep at night was related to postpartum fatigue, and the results of the meta-analysis suggested that total sleep at night was most strongly linked with postpartum depression. More studies are needed to estimate the associations of sleep-wake rhythm during pregnancy and in the postpartum period with postpartum mental health factors.

Promoting sleep health during pregnancy for enhancing women's health: a longitudinal randomized controlled trial combining biological, physiological and psychological measures, Maternal Outcome after THERapy for Sleep (MOTHERS)

BACKGROUND

Sleep is vital for maintaining individuals' physical and mental health and is particularly challenged during pregnancy. More than 70% of women during the gestational period report insomnia symptoms. Sleep dysfunction in the peripartum increases the risk for a cascade of negative health outcomes during late pregnancy, birth, and postpartum. While psychological interventions are considered the first line treatment for sleep difficulties, they are still scarcely offered during pregnancy and there is a lack of longitudinal research combining psychological and physiological indices.

METHODS

The present protocol outlines a randomized controlled trial aimed at testing the long-term effectiveness of an automatized digitalized psychoeducational intervention for insomnia for expectant mothers complaining insomnia symptoms without comorbidity. Outcomes include physiological, hormonal, and subjective indices of maternal psychopathology, stress, and emotional processes, and sleep and wellbeing of the family system. The trial is part of a longitudinal study evaluating expectant mothers from early pregnancy (within the 15th gestational week) to 6-months postpartum through 6 observational phases: baseline (BSL), 6- and 12-weeks from BSL (FU1-FU2), 2-to-4 weeks after delivery (FU3), and 3- and 6-months after delivery (FU4-5). We plan to recruit 38 women without sleep difficulties (Group A) and 76 women with sleep difficulties (Group B). Group B will be randomly assigned to digital psychological control intervention (B1) or experimental psychoeducational intervention targeting insomnia (B2). At 3 time points, an ecological-momentary-assessment (EMA) design will be used to collect data on sleep and emotions (diaries), sleep-wake parameters (actigraphy) and stress reactivity (salivary cortisol). We will also test the DNA methylation of genes involved in the stress response as biomarkers of prenatal poor sleep. Information on partner's insomnia symptoms and new-borns' sleep will be collected at each stage.

DISCUSSION

The proposed protocol aims at testing an easily accessible evidence-based psychoeducational intervention for expectant mothers to help them improving sleep, health, and wellbeing in the peripartum. The results could improve the understanding and management of sleep difficulties and peripartum depression.

TRIAL REGISTRATION

The study protocol has been registered on 22 April 2024 with ClinicalTrials.gov Protocol Registration and Results System (PRS), ID: NCT06379074.

PROTOCOL VERSION

April 23, 2024.

The Association of Multidimensional Sleep Health With HbA1c and Depressive Symptoms in African American Adults With Type 2 Diabetes

OBJECTIVE

Sleep is important for diabetes-related health outcomes. Using a multidimensional sleep health framework, we examined the association of individual sleep health dimensions and a composite sleep health score with hemoglobin A1c (HbA1c) and depressive symptoms among African American adults with type 2 diabetes.

METHODS

Participants (N = 257; mean age = 62.5 years) were recruited through local churches. Wrist-worn actigraphy and sleep questionnaire data assessed multidimensional sleep health using the RuSATED framework (regularity, satisfaction, alertness, timing, efficiency, duration). Individual sleep dimensions were dichotomized into poor or good sleep health and summed into a composite score. HbA1c was assessed using the DCA Vantage™ Analyzer or A1CNow® Self Check. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Regression models examined the association of individual sleep dimensions and composite sleep health with HbA1c and depressive symptoms.

RESULTS

Higher composite sleep health scores were associated with a lower likelihood of having greater than minimal depressive symptoms (PHQ-9 ≥ 5) (odds ratio [OR] = 0.578, 95% confidence interval [CI] = 0.461-0.725). Several individual sleep dimensions, including irregularity (OR = 1.013, CI = 1.005-1.021), poor satisfaction (OR = 3.130, CI = 2.095-4.678), and lower alertness (OR = 1.866, CI = 1.230-2.833) were associated with a greater likelihood of having depressive symptoms. Neither composite sleep health scores nor individual sleep dimensions were associated with HbA1c.

CONCLUSIONS

Better multidimensional sleep health is associated with lower depressive symptoms among African American adults with type 2 diabetes. Longitudinal research is needed to determine the causal association between multidimensional sleep health and depressive symptoms in this population.

TRIAL REGISTRY

ClinicalTrials.gov identifier NCT04282395.

The predictive effect of mid-pregnancy sleep disorders on perinatal depression within women with or without depression in early pregnancy: A prospective cohort study

BACKGROUND

To investigate the relationship between depression in early pregnancy and sleep quality in mid-pregnancy, and explore whether sleep disorders independently predicts depression across the perinatal period within women with or without depression in early pregnancy.

METHODS

Data were collected at 7 time points from 12 weeks of pregnancy to 6 weeks postpartum. Multiple logistic regression and survival analysis were used to explore the relationship between sleep quality in mid-pregnancy and perinatal depression within women with or without depression in early pregnancy.

RESULTS

390 women were included. Women with depression in early pregnancy were more likely to have sleep disorders and perinatal depression. Women with sleep disorders had a higher risk of perinatal depression compared to women without sleep disorders in mid-pregnancy. Stratified analysis based on whether depressed at 12 weeks of pregnancy found that among women without depression, those with sleep disorders in mid-pregnancy were more likely to have subsequent perinatal depression and appeared earlier; whereas, among women with depression, mid-pregnancy sleep disorders was not a predictor of subsequent perinatal depression.

LIMITATION

High rates of missed visits may lead to sample bias, with depression and sleep quality being assessed by self-report.

CONCLUSIONS

Women with depression in early pregnancy are more likely to have sleep disorders in mid-pregnancy. There is a strong correlation between sleep quality in mid-pregnancy and perinatal depression among women without depression in early pregnancy. Routine screening and intervention for sleep disorders should be a priority in perinatal care to reduce the incidence of perinatal depression.

Night-time sleep duration and postpartum weight retention in primiparous women

Objectives

Approximately 75% of women weigh more at 1-year postpartum than pre-pregnancy. More than 47% retain >10 lbs at 1-year postpartum, which is associated with adverse health outcomes for mother and child. Disturbed sleep may contribute to risk of postpartum weight retention (PWR) as short sleep duration is associated with increased risk of obesity. Thus, we investigated whether night-time sleep duration is associated with risk for excessive PWR. We also explored night-time sleep duration and change in postpartum waist circumference.

Methods

This is an ancillary analysis from a prospective cohort study. Participants were healthy primiparous adults with a singleton birth. Excessive PWR at 1-year postpartum was defined as ≥7% of pre-pregnancy weight. Log-binomial and linear regression assessed associations between night-time sleep duration at 6 months postpartum and PWR at 1-year postpartum. Linear regression assessed the association between night-time sleep duration and change in postpartum waist circumference.

Results

Mean age of participants (N = 467) was 29.51 (SD ± 4.78) years. Night-time sleep duration by actigraphy or self-report was not associated with risk for excessive PWR (risk ratio 0.96, [95%CI 0.87-1.06]; risk ratio 0.95 [95%CI 0.83-1.07], respectively) or change in waist circumference.

Conclusion

Night-time sleep duration at 6 months postpartum was not associated with PWR at 1-year postpartum. Mixed findings among our results and previous research could be due to our focus on night-time sleep, and differences in sleep measurement methods and timeframes across studies. More comprehensively assessing sleep, including multiple sleep dimensions, may help advance our understanding of potential links between sleep and PWR.

Trial Registration

The parent study, Motherhood and Pelvic Health (MAP Study), is registered at https://clinicaltrials.gov/ct2/show/NCT02512016, NCT02512016.

Quality of Life and Sexual Satisfaction in the Early Period of Motherhood-A Cross-Sectional Preliminary Study

The aim of the study was to assess the impact of breastfeeding-related fatigue and family support on the sexuality and quality of life of mothers during early motherhood. A cross-sectional preliminary study was conducted between 1 October 2021 and 15 May 2022 in 65 women being in early postpartum period. We used the authors' questionnaire developed for the purposes of the study; the Sexual Satisfaction Scale for Women-SSS-W; the Mell-Krat scale for women; and the General Health Questionnaire-GHQ28. A significant negative correlation was found between the age of the patients and the reduction in somatic symptoms (GHQ28 questionnaire) (r = -0.315, p = 0.011). Women working professionally achieved significantly higher results in the SSS-W contentment category (r = 0.313, p = 0.014). Frequent sexual activity reduced disorders in social functioning (the GHQ28 questionnaire) (r = -0.107, p = 0.283). Women who breastfed up to 5 times a day (p = 0.033) reached significantly higher SSS-W scores in terms of communication. The partner's help significantly contributed to higher sexual satisfaction in the aspect of compatibility (p = 0.004) and the overall level of satisfaction determined with the SSS-W questionnaire (p = 0.016). The presented study suggests that older mothers who are employed and supported by a partner have a higher level of contentment, sexual satisfaction and quality of life.

Decoding distress among pandemic pregnancies: Examining pregnancy distress and COVID-19 stress as concurrent predictors of current and anticipated postpartum sleep during the COVID-19 pandemic

OBJECTIVES

The goal of the present study was to examine pregnancy distress, COVID-19 stress, COVID-19 compliance, and life satisfaction as concurrent predictors of perceived current and anticipated postpartum sleep duration (SD) and quality among a U.S. sample of pregnant individuals.

METHODS

The sample comprised 544 pregnant individuals (62.3% non-Hispanic White; mean age = 28.0 and SD = 6.2), most of whom were in their third trimester (42.3%). Participants were recruited through an online panel (Qualtrics) between October and November 2020.

RESULTS

The primary analysis was based on a concurrent path model, which examined pregnancy distress, COVID-19 stress, COVID-19 compliance, and life satisfaction as predictors of current and anticipated postpartum SD and sleep quality, controlling for several demographic (eg, age and income), familial (eg, number of children and adults in the home), sleep-related (eg, chronotype and use of sleeping medication), and psychosocial functioning (eg, COVID-19 impact) variables. Results indicated that higher COVID-19 compliance was significantly associated with poorer current sleep quality. Furthermore, both pregnancy distress and COVID-19 stress predicted worse anticipated postpartum sleep quality (but not duration). Life satisfaction, however, was consistently significantly associated with current and anticipated postpartum SD and quality.

CONCLUSIONS

Findings are critical for understanding how various forms of stress correlate with sleep health behaviors during pregnancy, as well as expectations for postpartum sleep among a vulnerable population at risk for both psychological and sleep challenges during a period of unprecedented global stress.

Sleep Deficiency in Pregnancy

Sleep is a critical aspect of one's daily life for overall health, with a recommended 7 to 9 hours in adulthood (ages 26-64). Up to a third of women do not sleep sufficiently, and pregnant women are at an increased risk for sleep deficiency. Throughout pregnancy, sleep is affected in differing ways. For example, in the first trimester, hormones affect sleep cycles, but by the third trimester, physical complaints such as increasing frequent urination and fetal movement create frequent awakenings. Associations between sleep deficiency and gestational diabetes, hypertensive disorders, depression, and some evidence regarding preterm birth exist. A woman's labor course and perception of delivery are also negatively affected by short sleep duration.

Identification of postpartum symptom subgroups and associated long-term maternal depressive symptoms and well-being

Many postpartum women experience postpartum symptoms which often occur in clusters (i.e., three or more co-occurring symptoms that are related to each other). To date, research has focused on individual symptoms, which limits our understanding of how postpartum symptom clusters manifest and influence health. This secondary analysis used the Community and Child Health Network study data (N = 1784). No patient or public directly participated or contributed to the current analysis. Guided by the Symptom Management Theory, latent class analysis was performed to identify subgroups of postpartum women with different symptom experiences using observed variables at 6 months postpartum: anxiety (MINI-anxiety), general stress (PSS-10), posttraumatic stress (PCL-C), postpartum depression (EPDS), sleep disturbance (PSQI-sleep disturbance), and sleep duration (PSQI-sleep duration). Bivariate and multiple regression analyses were conducted to examine the association between subgroups and (a) individual characteristics and (b) long-term depressive symptoms (CES-D-9) and well-being at 18 and/or 24 months postpartum. Five subgroups were selected that had better-fit indices, entropy, and interpretability. Subgroups were labeled as (1) Minimum overall, (2) Mild-moderate overall, (3) Moderate-high sleep symptoms, (4) High psychological symptoms, and (5) High overall. After adjusting for covariates, postpartum women in Subgroups 4 and 5 had higher CES-D-9 scores at 18 and 24 months and lower well-being scores at 24 months. More postpartum women in Subgroups 4 and 5 experienced a history of depression or unemployment. Clinicians should provide targeted interventions for postpartum women in high-symptom subgroups.

Postpartum Insomnia and Poor Sleep Quality Are Longitudinally Predictive of Postpartum Mood Symptoms

OBJECTIVE

Insomnia and poor sleep quality are frequently reported by perinatal women. Both are noted to increase the risk of postpartum depression, with less known about their association with postpartum anxiety. This study sought to assess whether perinatal sleep disturbances predicted depression and anxiety symptoms across each month of the first 6 months postpartum in women with a history of depression.

METHODS

Pregnant women without active depression at enrollment ( N = 159), 18 to 45 years of age, were recruited. In late pregnancy and for up to 6 months postpartum, women completed monthly online questionnaires including the Insomnia Symptom Questionnaire, Pittsburgh Sleep Quality Index, Edinburgh Postnatal Depression Scale, and Generalized Anxiety Disorder-7. Repeated-measures multilevel models were used to predict depression and anxiety across the postpartum.

RESULTS

The prevalence of insomnia was 20.4%, and the prevalence of poor sleep quality was 67.8% across the first 6 months postpartum. Postpartum insomnia and poor sleep quality at the between-subject and within-subject levels tended to uniquely predict greater depressive and anxiety symptoms, even after controlling for demographic characteristics, prenatal insomnia, and prenatal poor sleep quality.

CONCLUSIONS

Most of the women in our sample had sleep disturbances across the perinatal period. Consistent with the extant literature, postpartum insomnia and poor sleep quality, but not prenatal measures of sleep, longitudinally predicted greater postpartum depression and anxiety symptoms. The chronic sleep deprivation of insomnia and the subjective experience of poor sleep quality are uniquely relevant risks of postpartum mood disorders. Evaluation and mitigation of perinatal sleep disturbance are ideal opportunities to reduce postpartum mood disorders and subsequent health outcomes.

Treating postpartum insomnia: a three arm randomised controlled trial of cognitive behavioural therapy and light dark therapy

BACKGROUND

Insomnia symptoms are common during the postpartum period, yet interventions remain scarce. This trial aimed to simultaneously examine the efficacy of cognitive behavioural therapy (CBT) and light dark therapy (LDT), targeting different mechanisms, against treatment-as-usual (TAU), in reducing maternal postpartum insomnia symptoms.

METHODS

This three-arm randomised controlled trial recruited from the general community in Australia. Nulliparous females 4-12 months postpartum with self-reported insomnia symptoms [Insomnia Severity Index (ISI) scores >7] were included; severe medical/psychiatric conditions were excluded. Participants were randomised 1:1:1 to CBT, LDT, or TAU stratified by ISI (< or ⩾14) and infant age (< or ⩾8 months). Participants and principal investigators were unblinded. Six-week interventions were delivered via digital materials and telephone. The primary outcome was insomnia symptoms (ISI), assessed pre-, midpoint-, post- (primary endpoint), and one-month post-intervention. Analyses were intention-to-treat using latent growth models.

RESULTS

114 participants (CBT = 39, LDT = 36, TAU = 39; Mage = 32.20 ± 4.62 years) were randomised. There were significantly greater reductions in ISI scores in CBT and LDT (effect sizes -2.01 and -1.52 respectively, p < 0.001) from baseline to post-intervention compared to TAU; improvements were maintained at follow-up. Similar effects were observed for self-reported sleep disturbance. There were greater reductions in fatigue in CBT (effect size = 0.85, p < 0.001) but not LDT (p = 0.11) compared to TAU. Changes in sleepiness, depression, and anxiety were non-significant compared to TAU (all p > 0.08). Four participants (11%) in the LDT group reported headaches, dizziness, or nausea; no others reported adverse events.

CONCLUSIONS

Therapist-assisted CBT and LDT were feasible during the first postpartum year; data at post-intervention and 1-month follow-up support their safety and efficacy in reducing postpartum insomnia symptoms.

Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes

STUDY OBJECTIVES

This study aimed to assess the effectiveness of cognitive behavioral therapy for insomnia (CBTI) during the postpartum period as part of a larger randomized controlled trial of CBTI on perinatal insomnia.

METHODS

A total of 179 women of 18-30 gestational weeks with insomnia disorder were randomly assigned to CBTI or an active control (CTRL) therapy. Participants were assessed between 18 and 32 weeks of pregnancy at baseline, after the intervention during pregnancy, and at 8, 18, and 30 weeks postpartum. The primary outcomes were Insomnia Severity Index (ISI) scores and total awake time, defined as minutes awake during the sleep opportunity period, assessed with actigraphy and sleep diaries. Included in the analyses were women who provided data for at least 1 of 3 postpartum assessments (68 in CBTI; 61 in CTRL).

RESULTS

Piecewise mixed-effects models revealed a main effect reflecting reduction in ISI scores from 8-18 weeks postpartum (P = .036) and a nonsignificant increase from 18-30 weeks; significant effects for group allocation were present only in week 30 (P = .042). CTRL participants reported significantly longer time awake, excluding time spent caring for the infant, at each postpartum assessment; time awake at night caring for the infant did not differ between groups. There was no significant group difference in the postpartum trajectory of actigraphy-measured total awake time, the two diary measures of time awake (P values > .05). CBTI participants with at least 50% reduction in ISI during pregnancy had consistently stable ISI scores (mean < 6) during the postpartum period; those in the CTRL group had variable ISI scores over time with large individual differences.

CONCLUSIONS

For women with insomnia disorder during pregnancy, CBTI initiated during pregnancy conferred postpartum benefits in terms of wakefulness after sleep onset (excluding time spent caring for the infant) and insomnia severity, though the latter emerged only later in the postpartum period. These findings underscore the importance of treating insomnia during pregnancy, a conclusion that is further supported by our finding that pregnant women who responded to insomnia treatment during pregnancy experienced better sleep in the postpartum period.

CLINICAL TRIAL REGISTRATION

Registry: Clinicaltrials.gov; Name: Treatment for Insomnia During Pregnancy; URL: https://www.clinicaltrials.gov/ct2/show/NCT01846585; Identifier: NCT01846585.

CITATION

Manber R, Bei B, Suh S, et al. Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes. J Clin Sleep Med. 2023;19(8):1411-1419.

Towards an objective measurement of sleep quality in non-human animals: using the horse as a model species for the creation of sleep quality indices

Sleep disturbance is observed across species, resulting in neurocognitive dysfunction, poor impulse control and poor regulation of negative emotion. Understanding animal sleep disturbance is thus important to understand how environmental factors influence animal sleep and day-to-day welfare. Self-reporting tools for sleep disturbance commonly used in human research to determine sleep quality cannot be transferred to non-verbal animal species research. Human research has, however, successfully used frequency of awakenings to create an objective measurement of sleep quality. The aim of this study was to use a novel sleep-quality scoring system for a non-human mammalian species. Five separate sleep quality indices calculations were developed, using frequency of awakenings, total sleep time and total time spent in different sleep states. These indices were applied to a pre-existing data set of equine sleep behaviour taken from a study investigating the effects of environmental change (lighting and bedding) on the duration of time in different sleep states. Significant treatment effects for index scores both differed and aligned with the original sleep quantity results, thus sleep quality may be a useful alternative measurement of sleep disturbance that could be used to investigate impactful (emotional, cognitive) effects on the animal.

Mental health and sleep quality of low-income mothers of one-year-olds during the COVID-19 pandemic

The COVID-19 pandemic and subsequent social restrictions created an unprecedented context for families raising young children. Although studies have documented detrimental effects of the pandemic on maternal well-being, less is known about how the pandemic specifically impacted low-income mothers. We examined depression, anxiety, and sleep quality among low-income mothers of one-year-olds during the early months of the pandemic using data from the Baby's First Years study. Focusing on the control group (n = 547), we compared mothers interviewed before March 14th, 2020 (n = 342) to mothers interviewed between March 14th and June 30th, 2020 (n = 205) to determine whether the pandemic was associated with differences in mental health and sleep quality. Mothers were recruited from four cities in the United States, and most of the sample identified as Hispanic (42.2%) or Black, non-Hispanic (38.6%). We found that mothers interviewed during the pandemic reported better mental health and sleep quality. While we cannot speak to longer-term impacts of the pandemic, it is possible low-income mothers experienced relief from daily stressors during the initial shelter-in-place orders, which may have led to improvements in well-being. These results have implications for understanding how complex life stressors influence mental health and sleep quality among low-income mothers raising young children.

Preventing recurrence of postpartum depression by regulating sleep

INTRODUCTION

Women are at a high risk of recurrence of depression in the postpartum period. Given the circumscribed duration of the risk period and knowledge of its triggers, postpartum depression should be easily preventable. However, prophylactic drug studies have reported contradictory findings partly due to the heterogeneity of the disorder. Currently, there are no studies on the efficacy of psychotherapy in the prevention of postpartum depression in women with major depressive or bipolar disorder.

AREAS COVERED

This review evaluates the results of controlled medication and psychotherapeutic studies in the prevention of depression in women with major depressive disorder or bipolar disorder; it further suggests that the management of sleep loss/insomnia may be an effective strategy in the prevention of postpartum depression.

EXPERT OPINION

A thorough understanding of the clinical course of the antecedent mood disorder and historical treatment response is necessary before the implementation of strategies for the prevention of postpartum depression. Targeting disturbed and/or insufficient sleep - a common and early transdiagnostic symptom of peripartum psychiatric disorders - may be a more effective intervention for the prevention of postpartum depression and psychiatric comorbidities in some individuals than the traditional approach of antidepressant use.

Preconception sleep quality moderates the association between preconception hair cortisol levels and mental health in pregnant women

BACKGROUND

Poor sleep quality may elevate cortisol levels and affect prenatal mental health through altered HPA axis functioning. This study aims to examine whether subjective sleep quality during preconception moderates the association between preconception hair cortisol levels and mental health from preconception to pregnancy trimesters.

METHODS

Women from a prospective cohort study completed the Pittsburgh Sleep Quality Index (PSQI), the Edinburgh Postnatal Depression Scale (EPDS), and the State-Trait Anxiety Inventory (STAI) questionnaires during preconception (T0) and at each pregnancy trimesters (T1, T2, and T3). We analyzed 266 of these women who conceived and had fully completed measures at preconception for hair cortisol, sleep quality and either EPDS or STAI-state. Changes in EPDS and STAI-state scores were derived (i.e., T1-T0, T2-T0, T3-T0). Johnson-Neyman technique identified PSQI scores with significant moderation of cortisol on mental health.

RESULTS

After adjusting for potential covariates, there was a significant positive correlation between preconception hair cortisol levels and depressive symptom at the second trimester (r_s (144) = 0.22, p = 0.008), but not the first and third trimesters (all p_s > 0.05). The positive association between preconception hair cortisol and change in depressive symptoms between third trimester and preconception was significant only among women with poor preconception sleep quality (PSQI ≥ 7).

LIMITATIONS

Sleep quality and prenatal mood were derived from self-reported questionnaires, which may be more susceptible to bias.

CONCLUSIONS

The positive association between preconception hair cortisol and change in prenatal depressive symptoms is significant among women who reported poor sleep quality during preconception. Improving preconception sleep quality can potentially mitigate the association between preconception hair cortisol and depressive symptoms during pregnancy.

Systematic review of the associations between prenatal sleep behaviours and components of energy balance for regulating weight gain

This systematic review aimed to examine the magnitude and direction of the associations between prenatal sleep behaviours (i.e. nighttime sleep duration, sleep quality, night awakenings and daytime nap duration) and eating behaviours, physical activity and gestational weight gain. A systematic search was conducted using Medline/PubMed, PsychINFO, CINAHL Complete, ProQuest Dissertations and Thesis A&I, and Web of Science to identify studies with at least one sleep measure, and either eating behaviours, physical activity and/or gestational weight gain. In summary, 11 studies met the review criteria and generated 11 total effect size across 10,900 participants. The majority of the studies were conducted after 2010, which highlights the infancy of this research. Overall, the strengths of the effect size were small: sleep-gestational weight gain (effect size = 0.29), sleep-eating behaviours (effect size = 0.13) and sleep-physical activity (effect size = 0.13). The only effect size that emerged as significant was for the pooled sleep behaviours-physical activity association; good sleep behaviours were positively associated with higher levels of physical activity. These findings summarize and provide insight on how sleep behaviours are related to prenatal gestational weight gain, eating behaviours and physical activity by identifying the strength and direction of the associations that have been previously unknown. Results support the rationale for future longitudinal and randomized control trials to examine the effects of sleep behaviours on gestational weight gain, eating behaviours and physical activity over the course of pregnancy.

ABM Clinical Protocol #37: Physiological Infant Care-Managing Nighttime Breastfeeding in Young Infants

A central goal of the Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The ABM empowers health professionals to provide safe, inclusive, patient-centered, and evidence-based care. Pregnant and lactating people identify with a broad spectrum of genders, pronouns, and terms for feeding and parenting. There are two reasons ABM's use of gender-inclusive language may be transitional or inconsistent across protocols. First, gender-inclusive language is nuanced and evolving across languages, cultures, and countries. Second, foundational research has not adequately described the experiences of gender-diverse individuals. Therefore, ABM advocates for, and will strive to use language that is as inclusive and accurate as possible within this framework. For more explanation, please read ABM Position Statements on Infant Feeding and Lactation-Related Language and Gender (https://doi.org/10.1089/bfm.2021.29188.abm) and Breastfeeding As a Basic Human Right (https://doi.org/10.1089/bfm.2022.29216.abm).

Association between sleep disorders during pregnancy and risk of postpartum depression: a systematic review and meta-analysis

Sleep disorders are common among pregnant females. However, its association with postpartum depression (PPD) is unknown. We aimed to assess if sleep disorders during pregnancy increase the risk of PPD by a systematic review. The databases of PubMed, CENTRAL, ScienceDirect, Embase, and Google Scholar were searched for studies reporting the association between any type of sleep disorder during pregnancy and the risk of PPD. Effect sizes were pooled in a random-effects model. Sixteen studies with data of 12,614 women were included. Meta-analysis indicated that sleep disorders during pregnancy resulted in a statistically significant increased risk of PPD (OR: 2.36 95% CI: 1.72, 2.32). The overall result had high heterogeneity (I² = 84%). Sub-group analysis based on study location (Asian vs Western), sample size (> 500 vs < 500), depression scale, and PPD assessment time did not change the results. However, we found that only poor sleep quality but not insomnia was associated with PPD. The risk was also increased only with sleep disorders measured in the 3rd trimester but not for the 1st and 2nd trimesters. Evidence suggests that sleep disorders during pregnancy may increase risk of PPD. The risk is high for sleep disorders occurring in the 3rd trimester. Based on these findings, there is a need for thorough screening and subsequent corrective measures to ensure adequate and quality sleep among pregnant females.

Actigraphic Wake after Sleep Onset and Symptom Severity Correspond with Rumination in Trauma-Exposed Individuals

Rumination and worry are forms of repetitive negative thinking (RNT) commonly associated with internalizing psychopathologies, although less is known about RNT in trauma-exposed individuals with internalizing psychopathologies. Separate lines of research show RNT also plays a role in problematic sleep, which is frequently experienced after trauma exposure. To address gaps in the literature, the current study examines the impact of sleep and symptoms on RNT in trauma-exposed participants. A transdiagnostic sample of 46 unmedicated treatment-seeking trauma-exposed participants completed standard measures of rumination and worry, as well as clinical measures that assessed posttraumatic stress, depression, and anxiety severity. Actigraphic sleep variables were sleep duration, wake after sleep onset (WASO), and sleep efficiency. Sleep and clinical measures were submitted to multiple regression analyses with rumination and worry as dependent variables. The regression results showed that rumination was significantly explained by WASO and posttraumatic stress symptom (PTSS) severity, and the omnibus test was significant. Depression, anxiety, and other estimates of sleep were not significant. No significant results emerged for worry. Preliminary findings suggest that PTSS and WASO, an index of fragmented sleep, may contribute to rumination, but not worry, in trauma-exposed individuals. Longitudinal studies are needed to determine potential causal relationships.

Relationships between postpartum depression, sleep, and infant feeding in the early postpartum: An exploratory analysis

Introduction

The study objectives were to determine the relationships between postpartum depression and maternal and infant sleep parameters and to examine the impact of infant feeding method on infant and maternal sleep and postpartum depression symptomatology.

Methods

Participants were 61 new mothers aged 18 to 45 years old, and their full-term, normal birth-weight, singleton infants. Participants were recruited from a large teaching hospital in northeast England. Data collection took place in participants' homes. The study used a prospective longitudinal design, with data collected at six, 12 and 18 weeks postpartum. We collected data on total sleep time, longest sleep period, wake after sleep onset, and night waking for mothers and infants objectively from actigraphic records and subjectively from maternal sleep logs. Participants reported on sleep disturbances using the General Sleep Disturbances Scale, on maternal sleepiness, and on depression symptomatology using the Edinburgh Postnatal Depression Scale.

Results

Scores on the Edinburgh Postnatal Depression Scale and General Sleep Disturbances Scale were consistently correlated with each other (6 weeks r = 0.452, p < 0.01; 12 weeks r = 0.317, p < 0.05; 18 weeks r = 0.493, p < 0.01), and did not correlate with objective measures or subjective reports of maternal or infant sleep. Edinburgh Postnatal Depression Scale scores at six, 12 and 18 weeks were predicted by General Sleep Disturbances Scale, prior Edinburgh Postnatal Depression Scale score, or both, but not by sleep parameters. With regard to infant feeding method, EPDS score was not higher among exclusively breastfeeding than among exclusively formula-feeding participants at any time point (6 weeks  t = 0.306, p = 0.762; 12 weeks  t = 0.343, p = 0.733; 18 weeks  t = 0.426; p = 0.673). Different pathways emerged to predict Edinburgh Postnatal Depression Scale score for exclusively breastfeeding and exclusively formula-feeding women.

Discussion

Postpartum depression may be associated with disturbed sleep due to negative perception of sleep among depressed women, rather than disrupted sleep causing postpartum depression. With regard to infant feeding method, exclusively breastfeeding women are not more likely to suffer from postpartum depression, and different pathways may predict development of postpartum depression symptoms in exclusively breastfeeding and exclusively formula feeding women.

Improving perinatal sleep via a scalable cognitive behavioural intervention: findings from a randomised controlled trial from pregnancy to 2 years postpartum

BACKGROUND

Sleep disturbance is common in gestational parents during pregnancy and postpartum periods. This study evaluated the feasibility and efficacy of a scalable cognitive behavioural therapy (CBT) sleep intervention tailored for these periods.

METHODS

This is a two-arm, parallel-group, single-blind, superiority randomised controlled trial. Nulliparous females without severe medical/psychiatric conditions were randomised 1:1 to CBT or attention- and time-matched control. All participants received a 1 h telephone session and automated multimedia emails from the third trimester until 6 months postpartum. Outcomes were assessed with validated instruments at gestation weeks 30 (baseline) and 35 (pregnancy endpoint), and postpartum months 1.5, 3, 6 (postpartum endpoint), 12 and 24.

RESULTS

In total, 163 eligible participants (age M ± s.d. = 33.35 ± 3.42) were randomised. The CBT intervention was well accepted, with no reported adverse effect. Intention-to-treat analyses showed that compared to control, receiving CBT was associated with lower insomnia severity and sleep disturbance (two primary outcomes), and lower sleep-related impairment at the pregnancy endpoint (p values ⩽ 0.001), as well as at 24 months postpartum (p ranges 0.012-0.052). Group differences across the first postpartum year were non-significant. Participants with elevated insomnia symptoms at baseline benefitted substantially more from CBT (v. control), including having significantly lower insomnia symptoms throughout the first postpartum year. Group differences in symptoms of depression or anxiety were non-significant.

CONCLUSIONS

A scalable CBT sleep intervention is efficacious in buffering against sleep disturbance during pregnancy and benefitted sleep at 2-year postpartum, especially for individuals with insomnia symptoms during pregnancy. The intervention holds promise for implementation into routine perinatal care.

The relationship between perinatal circadian rhythm and postnatal depression: an overview, hypothesis, and recommendations for practice

Postnatal depression (PND) is an important public health problem with far-reaching consequences for mothers, families, and society. Current treatment approaches tend to focus on the depressive symptoms of the mother. We propose the need for a shift in the conceptualisation of PND and its management, by focusing on circadian rhythm as an early manifestation of mother-infant synchrony. We have reviewed the relevant interdisciplinary literature to formulate a hypothesis and suggest recommendations for practice. We hypothesise that, after a mother’s circadian rhythm becomes ‘desynchronised’ immediately following birth, persistence of this disruption is implicated in the development of PND. This has important implications for novel treatment strategies in the critical and vulnerable postnatal period, for example the use of outdoor-based interventions and light.

Use of Child Care Attenuates the Link Between Decreased Maternal Sleep and Increased Depressive Symptoms

OBJECTIVE

Sleep disruption is common among postpartum women and is linked with depression. Child care may alleviate parenting stress and protect new mothers against symptoms of depression.

METHODS

Mothers from the NURTURE study, a birth cohort of 666 women of full-term infants, completed questionnaires during home visits when their infants were 3, 6, 9, and 12 months old. The Edinburgh Postnatal Depression Scale and the Perceived Stress Scale were used to measure depressive symptoms and stress, respectively. Mothers reported total nightly sleep duration for themselves and their infants, child care arrangements, marital status, and income. We used mixed-effects models adjusting for income, marital status, and child age to examine the indirect effect of infants' sleep on maternal mental health through mothers' sleep and assessed whether patterns differed depending on child care.

RESULTS

Decreased maternal sleep mediated the association between infant sleep and maternal mental health. When infants slept 1 hour less than usual, mothers slept 7 fewer minutes (B = 0.19, 95% confidence interval [CI], 0.01 to 0.27) and reported more depressive symptoms (B = -0.27, 95% CI, -0.43 to -0.11) and stress (B = -0.33, 95% CI -0.58 to -0.09). Child care moderated the indirect effect; decreased maternal sleep was not associated with increased depressive symptoms (and was not a mediator) when mothers had child care (indirect effect = -0.001, 95% CI, -0.03 to 0.03).

CONCLUSION

Use of infant child care reduced the link between maternal sleep and depressive symptoms. Regular access to child care may be a method to mitigate feelings of depression for new mothers.

Sleep Deficiency in Pregnancy

Sleep is a critical aspect of one's daily life for overall health, with a recommended 7 to 9 hours in adulthood (ages 26-64). Up to a third of women do not sleep sufficiently, and pregnant women are at an increased risk for sleep deficiency. Throughout pregnancy, sleep is affected in differing ways. For example, in the first trimester, hormones affect sleep cycles, but by the third trimester, physical complaints such as increasing frequent urination and fetal movement create frequent awakenings. Associations between sleep deficiency and gestational diabetes, hypertensive disorders, depression, and some evidence regarding preterm birth exist. A woman's labor course and perception of delivery are also negatively affected by short sleep duration.

Trajectories and Depressive Symptoms During the Perinatal Period: A Longitudinal Population-Based Study in China

Most women in the perinatal period face sleep issues, which can affect their mental health. Only a few studies have focused on sleep trajectories and depressive symptoms of women during the perinatal period in China. This study aims to explore the development trajectory of sleep quality by classifying pregnant women according to the changes in their sleep quality during pregnancy and postpartum and investigate the correlation between different sleep quality trajectory groups and depressive symptoms. The Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality, and the Edinburgh Postnatal Depression Scale (EPDS) was used to assess the symptoms of depression. Participants (n = 412) completed the assessment of sleep quality, depressive symptoms, and some sociodemographic and obstetric data at 36 weeks of gestation, 1 week after delivery, and 6 weeks after delivery. The group-based trajectory model (GBTM) was used to complete the trajectory classification, and logistic regression was used to analyze the predictive factors of postpartum depressive symptoms. Four different sleep quality trajectories were determined: "stable-good," "worsening," "improving," and "stable-poor" groups. The results demonstrate that poor sleep trajectories, social support and parenting experience during the perinatal period are related to postpartum depression. Screening for prenatal sleep problems is crucial for identifying the onset of perinatal depressive symptoms.

Effects of family relationship and social support on the mental health of Chinese postpartum women

Background

Numerous studies suggest that interpersonal relationships and social support influence the development of postpartum depression and sleep quality for women. However, the effect of support from the husband or the mother-in-law has not been thoroughly validated. The current study examined the relative contribution of marital satisfaction, perceived caring of the mother-in-law, and social support on postpartum depression and sleep quality simultaneously in a path model.

Methods

A cross-sectional study was conducted from March to June 2017 in Hebei, China, using a self-report questionnaire. A total of 817 women participated at 6 weeks postpartum. Sociodemographics and information about marital satisfaction, perceived caring of the mother-in-law, social support, postpartum depression, and sleep were collected. Path analysis was used to analyze the cross-sectional data.

Results

The final model had a highly satisfactory fit. Marital satisfaction and perceived caring of mother-in-law had both direct and indirect effects on postpartum depression through social support, but these two variables had only an indirect effect on sleep quality through social support and postpartum depression. Sleep quality is a consequence of postpartum depression at 6 weeks after delivery. The prevalence of minor and major postpartum depressive symptoms at 6 weeks postpartum was 41.49 and 23.13%, respectively. A total of 371 (45.41%) women experienced sleep disturbance at 6 weeks postpartum.

Conclusions

These findings suggest that interpersonal relationships with family members play important roles in postpartum depression and sleep quality through social support in Chinese women. Improving the relationship between new mothers and their husbands or mothers-in-law and then enhancing social support might reduce postpartum depression and sleep disturbance.

Sleep deprivation and fatigue in early postpartum and their association with postpartum depression in primiparas intending to establish breastfeeding

Objective: To examine the association of objective sleep and fatigue in the early postpartum period with postpartum depression in Japanese primiparas intending to establish breastfeeding.

Materials and Methods: The participants were 34 primiparas who were in the postnatal ward after vaginal delivery and responsively breastfeeding their rooming-in baby. Actigraphy data for objective sleep were collected for three consecutive days starting from the first day postpartum. Fatigue and postpartum depression were assessed using the Postpartum Fatigue Scale and Edinburgh Postnatal Depression Scale, respectively, on numerous days between the first day postpartum and the one-month checkup. Breastfeeding and rooming-in data were also collected.

Results: The mean total sleep time was 252.0 ± 73.1 min/day. Mean breastfeeding frequency was 12.4 ± 3.2 times/day and mean total breastfeeding time was 247.4 ± 101.8 min/day. Among the participants, 67.6% were exclusively breastfeeding on the discharge day. Fatigue scores were significantly higher during the hospital stay, compared with one month postpartum. Multiple regression analysis showed that sleep frequency on the third day postpartum and mean total breastfeeding time and fatigue on the fifth day postpartum were factors affecting the Edinburgh Postnatal Depression Scale score.

Conclusion: The association between postpartum depression among breastfeeding primiparas in the early postpartum period and objective sleep, fatigue, and total breastfeeding time per day was suggested. An environment wherein breastfeeding mothers can rest and sleep without hesitation will be beneficial. Moreover, the importance of sleep during pregnancy and the early postpartum period must be highlighted. Midwifery and/or nursing care starting while the mother is in a postnatal hospital stay can play a key role in preventing postpartum depression.

Differentiating perinatal Insomnia Disorder and sleep disruption: a longitudinal study from pregnancy to 2 years postpartum

STUDY OBJECTIVES

Insomnia Disorder diagnoses require persistent sleep complaints despite "adequate sleep opportunity." Significant Perinatal Sleep Disruption makes this diagnosis challenging. This longitudinal study distinguished between Insomnia Disorder and Perinatal Sleep Disruption and their sleep and mental health correlates.

METHODS

One hundred sixty-three nulliparous females (age M ± SD = 33.35 ± 3.42) participating in a randomized controlled trial repeated the Insomnia Disorder module of the Duke Structured Interview for Sleep Disorders and Patient-Reported Outcome Measurement Information System measures for sleep and mental health at 30- and 35-weeks' gestation, and 1.5, 3, 6, 12, and 24 months postpartum (944 interviews, 1009 questionnaires completed). We compared clinical features when Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Insomnia Disorder criteria (without the Duration criterion) were: (1) met (Insomnia Disorder), (2) not met only because of the sleep opportunity criteria (Perinatal Sleep Disruption), and (3) not met due to other criteria (Low Complaint).

RESULTS

Proportions of Insomnia Disorder were 16.0% and 19.8% during early and late third trimester, and ranged 5.3%-11.7% postpartum. If the sleep opportunity criteria were not considered, rates of Insomnia would be 2-4 times higher (21.4%-40.4%) across time-points. Mixed-effects models adjusting for covariates showed that compared to Low Complaint, both Insomnia Disorder and Perinatal Sleep Disruption scored significantly higher on insomnia and sleep disturbance scales, sleep effort, and sleep-related impairments (p values < .01), but depression and anxiety were comparable (p values > .12).

CONCLUSION

Assessing sleep complaints without considering sleep opportunities can result in over-diagnosis of Insomnia Disorder in the perinatal periods. Insomnia Disorder and Perinatal Sleep Disruption were both associated with adverse sleep and mood outcomes, and need to be carefully differentiated and appropriately addressed. Clinical Trial Registration: The SEED Project (Sleep, Eat, Emotions, and Development): A randomized controlled pilot study of a perinatal sleep intervention on sleep and wellbeing in mothers and infants. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371634, Australian New Zealand Clinical Trials Registry: ACTRN12616001462471.

Preventing postpartum insomnia by targeting maternal versus infant sleep: a protocol for a randomized controlled trial (the Study for Mother-Infant Sleep “SMILE”)

Symptoms of insomnia are common during the perinatal periods and are linked to adverse parent/infant outcomes. Theories on insomnia development (e.g. 3P model) suggest that significant sleep disruption (e.g. nighttime infant care) can precipitate, while unhelpful sleep-related cognitions/behaviors can perpetuate parental insomnia symptoms. This study aims to examine how two interventions, one addressing infant sleep as the precipitator, the other targeting maternal sleep-related cognitions/behaviors as the perpetuator, might prevent postpartum insomnia. Participants are 114 nulliparous females 26 to 32 weeks gestation, with self-reported insomnia symptoms (Insomnia Severity Index scores ≥ 8). Participants are randomized to one of three conditions and receive: (1) a “responsive bassinet” used until 6 months postpartum, designed to boost/consolidate infant sleep and target infant sleep as a precipitator of insomnia, (2) therapist-assisted cognitive behavioral therapy for insomnia, addressing unhelpful sleep-related cognitions/behaviors as perpetuators of insomnia, or (3) a sleep hygiene booklet (control condition). The primary outcome is maternal insomnia symptoms. Secondary outcomes include maternal sleep duration/quality, mental health (e.g. depression, anxiety), and wellbeing-related variables (e.g. sleep-related impairment). Outcomes are assessed using validated instruments at 26–32 and 35–36 weeks’ gestation, and 2, 6, and 12 months postpartum. This study adopts an early-intervention approach and longitudinally compares two distinct approaches to prevent postpartum insomnia in an at-risk population. If interventions are efficacious, findings will demonstrate how interventions targeting different mechanisms mitigate insomnia symptoms in perinatal populations. This will provide empirical evidence for future development of multi-component sleep intervention to improve mother-infant wellbeing.

Clinical Trial Registration: The Study for Mother-Infant Sleep (The SMILE Project): reducing postpartum insomnia using an infant sleep intervention and a maternal sleep intervention in first-time mothers. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377927, Australian New Zealand Clinical Trials Registry: ACTRN12619001166167.

Infant sleep and temperament characteristics in association with maternal postpartum depression

OBJECTIVE

Aim of this study was to examine the association between infant temperament and sleep characteristics and postpartum depressive symptoms among mothers.

STUDY DESIGN

Research data were collected at the baseline (2nd -4th days postpartum) and the follow-up (6-8 weeks postpartum), Slovak version of the (EPDS) was used, along with questions focused on perceived sleeping problems of an infant, and temperament Linear regression models were employed.

SETTING

Two public hospital sites in Slovakia.

PARTICIPANTS

204 women participated in both time points (mean age 30.9 ± 4.8, age range: 20-44; 78.9% vaginal births; 56.9% primiparas).

RESULTS

Significant differences in the EPDS scores were found according to infant sleeping problems (p ≤ 0.05) and duration of infant night sleep (p ≤ 0.01). Both night sleep and day sleep duration were significant predictors for the level of postpartum depression symptoms at the 6-8 weeks follow-up in the linear regression model after adjusting for confounding variables (β= -0.13; 95%CI: -3.04;-0.01; β= -0.15; 95%CI: -3.02;-0.28, total explained variance 39.0%). Infant temperament characteristics have not been found significant predictors of postpartum depression symptoms in this study.

KEY CONCLUSIONS

Significant differences in depression levels were found among postpartum women according to perceived sleeping problems of infant, and the duration of infant night sleep. It is important to focus more attention on the role of infant sleeping problems as a possible risk factor for the increased occurrence of postpartum depressive symptoms.

Cognitive Behavioural Therapy and Light Dark Therapy for Maternal Postpartum Insomnia Symptoms: Protocol of a Parallel-Group Randomised Controlled Efficacy Trial

Background: Symptoms of insomnia are common in new mothers and have been associated with a range of negative maternal and child outcomes. Despite this, interventions to improve maternal postpartum sleep remain scarce. Cognitive Behavioural Therapy (CBT) and Light Dark Therapy (LDT) represent two promising interventions for insomnia symptoms and associated daytime consequences such as fatigue. This randomised controlled trial examines whether CBT and LDT improve maternal insomnia symptoms as the primary outcome and maternal sleep disturbance, mood, fatigue, and sleepiness as secondary outcomes. This protocol paper outlines the development, design, and implementation of the trial. Methods: Participants are an Australian community-sample of 90 first-time mothers who are 4-12 months postpartum with self-reported symptoms of insomnia (Insomnia Severity Index scores ≥ 8). Exclusion criteria include current severe sleep/psychiatric disorders, unsettled infant sleep behaviour, sleep-affecting medication use, and photosensitivity. Eligible women are randomised into a CBT (strategies targeting sleep, worries, fatigue, and relaxation), LDT, or a treatment-as-usual control condition. Interventions are therapist-assisted and personalised through two telephone calls and include a series of automated intervention emails delivered over 6 weeks. Primary and secondary outcomes are assessed at four time points: baseline, intervention mid-point, post-intervention, and 1-month post-intervention. Discussion: If found effective, these interventions could represent efficacious, safe, and inexpensive treatments for improving postpartum insomnia and mitigate its negative impact on maternal well-being. Interventions tested are highly scalable and can be integrated into postpartum care and made available to the broader community. ANZCTR trial registration: Accessible at: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618000842268.

Comparison of longitudinal diary and actigraphy-assessed sleep in pregnant women

STUDY OBJECTIVES

Various methods are employed to assess sleep in pregnant women, including self-report, sleep diary, and actigraphy. Unfortunately, the data are often contradictory, and interpretations are often inconsistent. The current aims are to compare subjective and objective sleep data in pregnant women collected longitudinally in early pregnancy.

METHODS

In this secondary analysis of 104 pregnant women, sleep was collected via diary and actigraphy for 14 days during three separate occasions (10-12 weeks; 14-16 weeks; and 18-20 weeks). Sleep variables included wake after sleep onset (WASO), sleep efficiency (SE), bedtime/lights out, sleep onset latency (SL), and total sleep duration (TST). Repeated measures ANOVAs compared each sleep variable across Time and by Method of data collection, while controlling for parity and daytime naps.

RESULTS

Significant differences were noted for only the method of data collection for sleep component studied for WASO, F (1, 98) = 147.20, p < 0.001; SE, F (1, 98) = 129.41, p < 0.001); bedtime/lights out, F (1, 103) = 5.33, p < 0.05); and sleep duration, F (1, 104) = 182.75, p < 0.001). Significant variation was not seen in any variable across time-period.

CONCLUSIONS

There are substantial discrepancies between diary- and actigraphy-assessed sleep measures in pregnant women which is in alignment with previous literature. These data highlight that these methodologies assess different constructs. We contend that these data may be useful as a reference to compare high-risk women or those with sleep disorders. Using a multi-modal approach to identify sleep disturbance in pregnancy is likely a more clinically useful option.

Relationship of Depression, Anxiety and Stress Levels with Religious Coping Strategies Among Turkish Pregnant Women During the COVID-19 Pandemic

The aim of this study was to investigate the depression, anxiety, stress levels, and religious coping strategies of Turkish pregnant women during the COVID-19 pandemic. Of the pregnant women involved in this study (N = 327), 74.6% were concerned about their health, whereas 85.9% had concerns about the health of the fetus during the COVID-19 pandemic. It was found that 19.9% had extremely severe depression, 97.9% had extremely severe anxiety, and 52.3% had severe stress symptoms. Religious coping scores of the pregnant women included in the study were found to be high. There was a weak positive correlation between positive religious coping and depression and a very weak negative correlation between negative religious coping and depression.

Sleep Health Characteristics among Adults Who Attempted Weight Loss in the Past Year: NHANES 2017-2018

Background: The purpose of this study was to characterize sleep health in adults who attempted weight loss in the prior year. Methods: We analyzed data from the National Health and Nutrition Examination Survey 2017–2018 exam cycle. We included 4837 US adults who did (n = 1919) or did not (n = 2918) attempt weight loss in the past year. Participants self-reported their sleep regularity, satisfaction, sleepiness, timing, and duration, which we defined as “good” based on the prior literature. We characterized sleep health by weight loss attempts status, current BMI and weight change among participants who attempted weight loss. Results: On average, participants reported good sleep health in 3.21 ± 1.14 out of the five sleep domains. A total of 13% of participants had good sleep health in all five domains. The prevalence of sleep regularity (52%) was lowest, and the prevalence of infrequent sleepiness was highest (72%), relative to other sleep domains. In models adjusting for BMI, sleep health was similar in participants who did and did not attempt weight loss. Among adults who attempted weight loss, good sleep health was inversely associated with current BMI and self-reported weight change. Discussion: This study’s findings highlight the importance of considering sleep health when engaging with adults attempting weight loss.

Sleep, biological rhythms and anxiety in the perinatal period: a systematic review protocol

INTRODUCTION

Pregnancy and new parenthood is an exciting time, but also a stressful life event that can predispose to mental health challenges. Perinatal anxiety is one such challenge, and is an important contributor to parental distress and other negative outcomes. Sleep and biological rhythms are often disrupted in the perinatal period. These disruptions have been associated with postpartum depression, and in some cases with perinatal anxiety. However, the literature concerning the association with perinatal anxiety is inconsistent and may be methodologically limited. To our knowledge, there has been no comprehensive review published characterising the relationships between sleep, biological rhythms, and perinatal anxiety and related disorders to date. In this systematic review, we will summarise the current state of the literature concerning these relationships, allowing us to highlight gaps and potentially inform clinical understanding of perinatal anxiety, sleep and biological rhythms.

METHODS AND ANALYSIS

Primary research articles will be eligible for inclusion if they assess perinatal anxiety or related disorders using validated criteria (self-report or diagnostic), assess sleep and biological rhythms in the perinatal period, include >4 participants and meet other inclusion/exclusion criteria. We will conduct comprehensive searches of MEDLINE, PsycINFO, Embase and CINAHL, with coverage spanning from database conception to search date (August 1, 2021). Key search concepts include (1) the perinatal period, (2) sleep/biological rhythms and (3) anxiety. Risk of bias will be evaluated using the Cochrane Risk of Bias Tool. Data will be narratively synthesised, with quantitative synthesis included if possible. When relevant, strength of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation criteria, and potential publication bias will be assessed.

ETHICS AND DISSEMINATION

Research ethics approval is not required. Study results will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results will be disseminated to relevant stakeholders as conference presentation(s) and submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

200166.

The Relationship Between a Baby's Age and Sleepiness in a Sample of Mothers

One question of great practical importance for the parents, and especially the mother, after the birth of a baby, refers to how long the time during which they have to go with less and more fragmented sleep actually lasts. Most of the studies only explore this issue up to 6 months of the newborn's life, and less is known about the sleep problems the mothers may have after this initial period. The objective of this study is to examine the relationship between the sleep disruption and daytime sleepiness of mothers with infants until 2 years old compared to a group of women currently not at care of babies. To this end, a sample of 113 women, 67 currently bringing up a baby of under 2 years old, and the remainder without a baby at their care under 6 years old, reported sleep duration, sleep interruptions, sleep quality, and responded to questionnaires of sleep quality and daytime sleepiness. The relationship between the age of the children and the comparison between the groups was used to highlight the sleep problems of the mothers taking care of the infant. The results showed that there was a positive relationship between the age of the infant and the duration of the sleep of the mothers and that the duration of sleep for them was similar to those of the women in the control group about 6 months after the infant was born. However, fragmentation of sleep, daytime sleepiness, and sleep problems were still higher than in the control group for mothers with children between 6 and 12 months old.

Sleep HAPi: A Feasibility and Descriptive Analysis of an Early and Longitudinal Sleep Education Intervention for Pregnant Women

Background: Poor sleep and prior depression are key predictors of perinatal depression, with research suggesting depressive symptoms may emerge in early pregnancy. Sleep is a potentially modifiable risk factor for depression. This pilot study examined the feasibility and acceptability of a six-month sleep education intervention designed to optimize sleep and minimize depressive symptoms throughout pregnancy. Sleep measures and depressive symptoms are described from 12 weeks gestation to 12 weeks postpartum.Participants: A community sample of nulliparous pregnant women with a history of depression were recruited prior to 14 weeks gestation.Methods: An individualized sleep education program was developed and participants engaged in three trimester specific sleep education sessions. Feasibility and acceptability were determined via recruitment and retention rates and participant feedback. Depressive symptoms and sleep were measured at five time points throughout the study.Results: 22 women enrolled in the study and 15 completed the intervention. Participants reported the intervention as highly acceptable. There was minimal change in all dimensions of sleep across pregnancy, but sleep measures were significantly worse at six weeks postpartum and improved by 12 weeks postpartum. Depressive symptoms were significantly lower at the conclusion of the intervention and 12 weeks postpartum compared to trimester 1.Conclusions: This sleep education program appears feasible, acceptable and may be effective in minimizing depressive symptoms in pregnant women with a history of depression. Trials with larger and more diverse samples are warranted and further studies to ascertain efficacy should be undertaken with a control group.

Effects of saffron on sleep quality in healthy adults with self-reported poor sleep: a randomized, double-blind, placebo-controlled trial

STUDY OBJECTIVES

Herbal medicines are frequently used by adults with sleep difficulties. However, evidence of their efficacy is limited. Therefore, the goal of this study was to examine the sleep-enhancing effects of a standardized saffron extract (affron).

METHODS

This was a 28-day, parallel-group, double-blind, randomized controlled trial. Sixty-three healthy adults aged 18-70 with self-reported sleep problems were recruited and randomized to receive either saffron extract (affron; 14 mg twice daily) or a placebo. Outcome measures included the Insomnia Severity Index (ISI; primary outcome measure) collected at baseline and days 7, 14, 21, and 28 and the Restorative Sleep Questionnaire (RSQ) and the Pittsburgh Sleep Diary (PSD) collected on days -1, 0, 3, 7, 14, 27, and 28.

RESULTS

Based on data collected from 55 participants, saffron was associated with greater improvements in ISI total score (P = .017), RSQ total score (P = .029), and PSD sleep quality ratings (P = .014) than the placebo. Saffron intake was well tolerated with no reported adverse effects.

CONCLUSIONS

Saffron intake was associated with improvements in sleep quality in adults with self-reported sleep complaints. Further studies using larger samples sizes, treatment periods, objective outcome measures, and volunteers with varying demographic and psychographic characteristics are required to replicate and extend these findings.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Effects of Saffron on Sleep Quality in Healthy Adults with Self-Reported Unsatisfactory Sleep; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377781; Identifier: ACTRN12619000863134.

Associations between Suboptimal Sleep and Smoking, Poor Nutrition, Harmful Alcohol Consumption and Inadequate Physical Activity ('SNAP Risks'): A Comparison of People with and without a Mental Health Condition in an Australian Community Survey

Introduction: People with a mental health condition experience disproportionate morbidity and mortality compared to the general population. This inequity has been largely attributed to a higher prevalence of chronic disease risk behaviours including smoking, poor nutrition, harmful alcohol consumption and inadequate physical activity (‘SNAP risks’). Suboptimal sleep is highly prevalent among people with a mental health condition and, as an identified risk behaviour for several chronic diseases, has been implicated as an additional contributor to this health inequity. Research involving people without a mental health condition suggests associations between poor sleep and each SNAP risk; however, interactions with mental health status have not been reported in an Australian population. This study explored associations between suboptimal sleep and all four SNAP risks, and assessed whether they vary by mental health status. Materials and Methods: A descriptive study (n = 1265) was undertaken using self-report data from a cross-sectional telephone survey of Australian adults. Based on national guidelines and recommendations that indicate when someone might be at risk of adverse health effects, SNAP risks and sleep variables were reduced to two levels: ‘at risk’ or ‘not at risk’; and ‘appropriate’ or ‘suboptimal’, respectively. Chi square tests and multivariable logistic regression models explored associations between suboptimal sleep, SNAP risks and mental health status. Results: Fifteen per cent (n = 184) of participants identified as having a mental health condition in the past 12 months. Being at risk of adverse health effects due to smoking had the strongest association with several measures of suboptimal sleep (ps < 0.05). Two-way interactions revealed that being at risk of adverse health effects due to alcohol use and physical inactivity resulted in a significantly greater likelihood of suboptimal sleep duration (OR 3.06, 95% CI 1.41 to 6.64; OR 3.06, 95% CI 1.41 to 6.69) and nap duration (OR 7.96, 95% CI 1.90 to 33.22), respectively, for people with a mental health condition compared to those without. Conclusions: The findings suggest associations between suboptimal sleep and smoking, risky alcohol consumption and physical inactivity, with the latter two perhaps being stronger among people with a mental health condition compared to those without such a condition. Poor sleep should be considered in interventions to address smoking, alcohol and physical activity; and vice versa. This study lends further support for the value of multirisk lifestyle interventions to promote physical and mental health for people with mental health conditions.

A mixed methods study of perinatal sleep and breastfeeding outcomes in women at risk for postpartum depression

INTRODUCTION

Pregnant and postpartum women experience significant sleep disruption, but the role of perinatal sleep disturbances in breastfeeding is understudied.

METHODS

In this observational cohort study, we used mixed methods to examine associations between perinatal sleep and breastfeeding. Forty-eight women (mean age 28.2 ± 4.9 years) who were euthymic at enrollment but had a history of major depression (n = 43) or bipolar disorder (n = 5) had sleep recorded with wrist actigraphy. We determined feeding status through daily diaries and used semi-structured interviews to identify themes regarding participants' experiences, breastfeeding decisions, and behaviors. To examine whether sleep disturbance during pregnancy predicted breastfeeding (BF) rates, we defined "lower sleep efficiency" (LSE) and "higher sleep efficiency" (HSE) groups based on the median split of actigraphic SE at 33 weeks' gestation (cutoff SE = 84.9%) and classified mothers as No-BF, Mixed-BF (BF + formula), and Exclusive-BF at 2 weeks postpartum.

RESULTS

Percentages of women who did any breastfeeding were: Week 2 = 72.3%, Week 6 = 62.5%, Week 16 = 50%. LSE mothers were less likely than HSE mothers to initiate breastfeeding (percent No-BF: LSE = 45.8%, HSE = 16.7%, P < .05). Average actigraphic sleep onset, sleep offset, time in bed, sleep duration, and SE did not differ based on breastfeeding status at any time point. Qualitative themes included insufficient preparation for the demands of breastfeeding, interrupted and nonrestorative sleep, and unrelenting daytime tiredness.

CONCLUSIONS

In our sample, preserved actigraphic SE during pregnancy was associated with initiation and continuation of breastfeeding. Future work should examine whether improving sleep in pregnancy improves mothers' feeding experiences.

Religiosity/Spirituality and Mental Health and Quality of Life of Early Pregnant Women

The present study aims to investigate how religious/spiritual (R/S) beliefs are associated with depressive, anxious and stress symptoms and quality of life (QOL) of 160 Brazilian women in early pregnancy. In this cross-sectional study, religiosity/spirituality (DUREL, Daily Spiritual Experiences, Brief-RCOPE), mental health (DASS-21) and quality of life (WHOQOL-Bref) were assessed. Negative R/S coping was associated with higher levels of depressive, anxious and stress symptoms and worse physical and psychological QOL. On the other hand, positive R/S coping, intrinsic religiosity, and spirituality were associated with better psychological QOL, while only spirituality was associated with better social QOL.

Investigating the link between sleep and postpartum depression in fathers utilizing subjective and objective sleep measures

Background

While fathers are at risk of developing poorer sleep and depressive symptoms in the postpartum period, they represent an understudied population in the literature. The present study aimed to explore the association between sleep and postpartum depressive symptoms in fathers using subjective and objective sleep measures.

Methods

Fifty-four fathers reporting no history of depression took part in this cross-sectional study. At 6 months postpartum, paternal sleep was assessed for 2 weeks utilizing a self-report daily sleep diary, a self-report perceived sleep quality rating, and actigraphy. In the same period, depressive symptoms in fathers were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D).

Results

Regression analyses showed that paternal subjective sleep variables captured by the sleep diary (total nocturnal sleep time and number of night awakenings) were not related to postpartum depressive symptoms. However, self-reported perceived sleep quality was significantly associated with postpartum depressive symptom severity in fathers independently of demographic variables related to depression. Alternatively, the objective sleep variables (total nocturnal sleep time, number of night awakenings, sleep efficiency, and wake after sleep onset), measured by actigraphy, did not demonstrate a significant relationship with paternal depression scores.

Conclusions

These findings highlight the importance of perceived sleep quality, along with better understanding its association with postpartum depressive symptoms. Implementing a multi-measure approach enabled us to expand our knowledge about how different facets of sleep relate to postpartum depression, specifically in fathers. The results have important implications for the development of clinical interventions targeting paternal sleep and mood in the postpartum period.

Sleep disorders during pregnancy and postpartum depression: A systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is one of the most important mental disorders in recent years. However, the effects of prenatal sleep disorders on the development of PPD among pregnant women have not been elucidated. This review aims to provide a summary of the literature evaluating the relation between sleep disorders during pregnancy and PPD.

METHOD

A systematic literature search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and Embase up to September 2020. All observational studies (cross-sectional, case-control, and cohort) and studies that assessed the association between sleep disorders during pregnancy and PPD were included. Total sample of 36,873 women from 13 studies was entered to meta-analysis. An aggregate effect size estimate (odds ratio) was generated using the comprehensive meta-analysis software. A random effects model was set a priori. Heterogeneity and publication bias were examined using the standard meta-analytic approaches.

RESULT

We found maternal sleep disorder increased odds of PPD (point estimate, 3.300; 95% confidence interval [CI], 2.136-5.098; p < .001; n = 13). However, there was significant heterogeneity (Q, 131.250; df, 12; p < .001; I² , 90.857%). The estimated effect size was significant for all categorical studies. According to meta-regression, no moderating factor (age and publication year) significantly mediated the estimated effect size.

CONCLUSION

We found a significant relationship between sleep disturbances during pregnancy and PPD. Women with sleep disorders are at an increased risk of developing PPD, which warrants screening pregnant mothers for sleep disturbances. Also, we found that the increasing age in pregnancy was associated with increased risk of PPD.

Determinants of postpartum sleep duration and sleep efficiency in minority women

STUDY OBJECTIVES

To examine demographic, psychosocial, and behavioral determinants of postpartum sleep duration and sleep efficiency among a cohort of black and Latina women.

METHODS

Data were from 148 women (67% black, 32% Latina) at 5 months postpartum, recruited from an academic medical center in Philadelphia. Relevant demographic, psychosocial and behavioral predictors were assessed via questionnaire. Nocturnal sleep was objectively measured for 1 week using wrist actigraphy. Sleep duration was examined as a continuous variable and in categories (<7 versus ≥7 h per night); sleep efficiency was examined as a continuous variable. Independent multiple linear regression models were built to evaluate significant determinants of sleep.

RESULTS

Adjusted models revealed that breastfeeding, having a bedtime after midnight, and being employed were associated with shorter sleep duration (-25-33 min, all p < 0.05). Multiparity, being unmarried, being employed, breastfeeding, having a bedtime after midnight, bedsharing, and responding to infant awakenings by getting up immediately rather than waiting a few minutes to see if the infant fell back asleep, were all significant determinants of sleeping <7 h per night (OR varying: 2.29-4.59, all p < 0.05). Bedsharing was the only variable identified from the multiple regression model that associated with poorer sleep efficiency (-3.8%, p < 0.05).

CONCLUSIONS

Findings may inform interventions for improving postpartum sleep in socioeconomically disadvantaged, racial/ethnic minority postpartum women.