Sleep-wake timing and chronotype in perinatal periods: longitudinal changes and associations with insomnia symptoms, sleep-related impairment, and mood from pregnancy to 2 years postpartum.

Across the perinatal transition, existing research focuses mainly on significant changes in sleep duration and quality, neglecting sleep timing. This study investigated change trajectories of sleep timing and chronotype from late pregnancy to 2 years postpartum and examined longitudinal associations of chronotype with symptoms of insomnia, daytime sleep-related impairment, and mood. Data were from a two-arm randomised controlled trial testing parent-focused wellbeing interventions. Participants were a community sample of nullipara without severe sleep/mental health conditions. Participants self-reported bedtime, rise-time, chronotype, insomnia symptoms, sleep-related impairment, depression, and anxiety at seven time points: gestation Weeks 30 and 35, and postpartum Months 1.5, 3, 6, 12 and 24. Trajectories were estimated using mixed-effects models with continuous time, quadratic splines, and a knot at childbirth, controlling for age and group allocation. A total of 163 participants (mean [SD] age 33.35 [3.42] years) took part. Bedtime and rise-times delayed during late pregnancy (~8 and ~20 min, respectively) but became progressively earlier (~20 and ~60 min, respectively) over the 2 postpartum years. Chronotype became more eveningness in late pregnancy, and more morningness after childbirth, however changes were small. Controlling for sleep duration and efficiency, greater morningness was associated with significantly less symptoms of insomnia and sleep-related impairment over time (all p < 0.001); longitudinal associations between chronotype and symptoms of depression and anxiety were non-significant (all p > 0.65). Sleep-wake timing and chronotype became progressively earlier from pregnancy to 2 years postpartum. Morningness chronotype may be sleep-protective during the transition from pregnancy to parenthood. Mechanisms underlying these associations require further research.

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.

Does breastfeeding influence sleep? A longitudinal study across the first two postpartum years.

BACKGROUND: The association between breastfeeding and sleep of the gestational parent is poorly understood. This longitudinal study investigated how breastfeeding is associated with total nighttime sleep duration and sleep efficiency (percentage of total sleep time in bed) in nulliparous participants over the first two postpartum years. METHODS: Nulliparous participants (N = 155, Mage  = 33.45, SDage  = 3.50) self-reported patterns of breastfeeding via telephone interviews and sleep via self-report at 1.5, 3, 6, 12 and 24 months postpartum. Data were analyzed using mixed-effects models, with breastfeeding variables as predictors and sleep variables as outcomes, controlling for relevant covariates. RESULTS: Neither the presence of breastfeeding nor the percentage of human milk in infants' total diets was significantly associated with participants' sleep duration or sleep quality (P-values > 0.08). This finding held after controlling for the number of nighttime feeds (P-values > 0.11). However, greater numbers of nighttime feeds, regardless of feeding content, were strongly associated with shorter sleep duration and poor sleep efficiency (P-values < 0.05). On average, with each additional nighttime feed, nocturnal sleep duration decreased by 6.6-8.4 minutes, and sleep efficiency decreased by 2.88%-3.02%. CONCLUSIONS: Data from this study showed that breastfeeding per se was not associated with shorter or poor nocturnal sleep, but the number of nighttime feeds was. Sharing nighttime infant care amongst different carers in the household could help reduce postpartum sleep disturbance and ameliorate its negative impact on wellbeing.

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.

A scalable cognitive behavioural program to promote healthy sleep during pregnancy and postpartum periods: protocol of a randomised controlled trial (the SEED project).

BACKGROUND: Poor sleep, including symptoms of insomnia are common during pregnancy and postpartum periods. Poor sleep during the perinatal period is linked to impaired daytime functioning, mood disturbance, and risk for chronic insomnia. Cognitive behavioural therapy (CBT) is consistently shown to be efficacious in treating insomnia, but it is largely inaccessible to new mothers, and surprisingly, not part of current perinatal care. This study aims to evaluate the feasibility and efficacy of a scalable CBT-based intervention for better sleep quality. METHODS: In this single-blind randomised controlled trial, eligible nulliparous women are randomised in a 1:1 ratio to either the intervention (CBT) or active control (healthy diet) condition. The interventions are provided from the third trimester till 6 months postpartum. The primary outcome is maternal sleep quality and secondary outcomes are maternal sleep-related impairment, mood, health-related quality of life, relationship satisfaction, and mother-infant-relationship, all assessed using validated instruments at 30- (baseline) and 35 weeks gestation (pregnancy endpoint), and 1.5, 3, and 6 months (postpartum endpoint) after childbirth, with follow-up assessments conducted at 1-year and 2-year postpartum. DISCUSSION: This study has the potential to address the need for an evidence-based, non-pharmacological sleep intervention tailored for the pregnancy and postpartum periods. The intervention is designed to maximise reach and minimise cost, with the potential to scale up and incorporate in routine perinatal care. With outcomes measured at 8 time points, from the third trimester of pregnancy to 2-year postpartum, this study has the potential to examine both short- and long-term impact on maternal sleep and wellbeing. TRIAL REGISTRATION: ACTRN12616001462471 ; retrospectively registered on 19/10/2016.