The relation between sleep quality during pregnancy and health-related quality of life—a systematic review

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Study characteristics and results regarding SQ and HRQoL. (a) Cross-sectional studies. (b) Longitudinal studies.

Study, year, reference + region	Participants (N = 7307)	HRQoL and sleep tools used	HRQoL subdomains used	Trimesters (weeks)	Participants	Key results
(A) Cross-sectional studies
Da Costa et al. (2010) [19] Canada	245	SF-36^c Prime-MD Patient Health Questionnaire (Dichotomous sleep outcome)	Physical functioning, role physical, bodily pain, general health, vitality, social functioning, mental health	3rd (28–40)	Pregnant women. No exclusion criteria	Sleep problems have a relation with poorer HRQoL in seven of eight domains during the third trimester (r < −0.23, p = <.001) (β < −0.17, p < .007). Related domains: Physical functioning, role physical, bodily pain, general health, vitality, social functioning, and mental health.
Rezaei et al. (2013) [27] Iran	100	WHOQoL-BREF^e PSQI^a (Continuous sleep outcome)	Physical health, psychological health, social relationships, environmental quality of life	2nd (15–25)	Pregnant women with insomnia or poor sleep quality before pregnancy. Exclusion: physical and psychiatric illnesses, drugs, alcohol, sleeping medication, and/or hormones. No traumatic event during the study, travel, and night shift.	There is a significant relationship between sleep quality score and general quality of life score and one (psychological health) of four domains (p < .04). Sleep disturbances have a significant effect on the overall QoL and two of four domains (p < .004). Related domains: Physical health and social relationships. Subjective sleep quality has a significant effect on overall QoL and four of four domains (p < .03). Related domains: Physical health, psychological health, social relationships, and environmental quality of life.
Effati et al. (2017) [28] Iran	364	WHOQoL-BREF^e PSQI^a (Continuous sleep outcome)	No information about domains of quality of life used, only total score	2nd and 3rd (>15)	Pregnant women. Exclusion: Night shifts, multiple pregnancy, fetal abnormalities, history of depression, previous mental health problems, problems during previous pregnancies, taking sleep medication, and big life events during the past 6 months before pregnancy.	There is a relationship between sleep quality and 2 subsets (sleep disturbance and daytime dysfunction) and quality of life. (r < −0.153, p < .001) (β < −0.23, p < .001). There is no significant difference in sleep quality among the trimesters.
Mourady et al. (2017) [29] Libanon	141	WHOQoL-BREF^e ISI^b (Continuous sleep outcome)	General health, physical health, psychological health, social relationships, environment	1st, 2nd and 3rd	Pregnant women (18+ years) Exclusion: chronic medical condition.	Higher Insomnia scores are significantly associated with quality of life and 5/5 domains (r < −0.264, p < .002). Related domains: General health, physical health, psychological health, social relationships, and environment. No significant difference in ISI score among the trimesters.
Sadaati et al. (2018) [30] Iran	364	WHOQoL-BREF^e PSQI^a (Continuous sleep outcome)	No information about domains of quality of life used, only total score	3rd (28–36)	Pregnant women (15–45 years) with preeclampsia or gestational diabetes. Exclusion: Fetal problems, multiple pregnancy, history of preterm birth, and history of mental disorder.	There is a significant relationship between sleep quality score and quality of life among high-risk pregnant women (r = 0.3, p < .0001) [β = −2.8 (−4.3 to −1.4), p < .001] in the 3rd trimester. Most subdomains of sleep quality including subjective sleep quality, sleep latency, sleep efficiency, sleep disturbances, and daytime dysfunction have also been associated with lower quality of life (r < 0.4, p < .015).
Zhang et al. (2019) [31] China	1120	SF-12^d PSQI^a (Continuous sleep outcome)	Physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health combined into 2 categories: PHQoL and MHQoL	3rd	Pregnant women (20+ years) Exclusion: Multiple pregnancy or mental illness.	The relations between sleep quality and physical HRQOL (PHQOL) (β = −0.235, p < .001) and mental HRQOL (MQOL) (β = −0.11, p < .001) are significant during the 3rd trimester. The effect of perceived stress on PHQOL and MHQOL was influenced partially through the indirect path of sleep quality. (β = −0.061/−0.029).
Davoud et al. (2020) [32] Iran	256	WHOQoL^e ISI^b (Continuous sleep outcome)	General health, physical health, psychological health, social relationships, environment	1st, 2nd, and 3rd	Pregnant women (18+ years). Exclusion: multiple pregnancy, fetal problems, night shift, history of clinical or psychological problems, bad life experiences previous or during pregnancy.	Higher insomnia scores have a significant negative relationship with general QoL and three of five domains of QoL (r < −0.281, p = <0.05). Related domains: General QoL, general health, and psychological health.
Kang et al. (2020) [33] USA	23	WHOQoL-BREF^e Actigraph (Continuous sleep outcome) Micro Motionlogger, AMI, Ardsley, NY	Physical health, psychological health, social health, environment, general health	3rd (24–28)	Pregnant women (18–40 years) with sleep problems, DSM-IV diagnose of major depressive disorder or anxiety disorder, and Hamilton Depression Rating Scale of ≥14. Exclusion: Active psychosis, suicidality, bipolar disorder, frequent migraines, high-risk pregnancy, shift work, alcohol or drug abuse.	Analyses were performed to examine the association between objective sleep and the various domains of QoL. No significant associations were observed. (Data not presented in the table/article).
Du et al. (2021) [34] China	4352	EQ-5D^f PSQI^a (Dichotomous sleep outcome)	No information about domains of quality of life used, only total score	1st (<14)	Pregnant women (18–45 years). Exclusion: mental cognitive disorders, pre pregnancy diabetes, pre-pregnancy hypertension, cardiovascular diseases, kidney diseases, and auto-immune diseases.	Women with a general HRQoL had a 3.98-fold (95% Cl: 2.97–5.34) risk of poor sleep quality compared to women with a good HRQoL during the first trimester
(B) Prospective studies
Tsai et al. (2016) [31] Taiwan	164	SF-12^d PSQI^a Actigraph (Continuous sleep outcome) Actiwatch-2, Respironics, Murrysville, PA^g	Mental and physical domain	1st, 2nd, and 3rd	Pregnant women (18+ years) Exclusion: Health complications at time of enrollment, multiple gestations, night shift workers, diagnosed depression or sleeping disorder	Subjective sleep quality is significantly associated with mental and physical HRQoL (β < −0.768, p < .01) during all three trimesters. 1st trimester subjective sleep predicts 2nd and 3rd trimester mental HRQoL and 2nd trimester physical HRQoL. (β < −0.85, p < .01). More daytime sleep was associated with better physical HRQOL in 1st trimester (β = 0.03, p = .04); sleep efficiency was associated with mental HRQOL in the 2nd trimester (β = 0.14, p = .04) and total nighttime sleep was associated with mental HRQOL in the 3rd trimester (β = 2.67, p < .01). 1st trimester total nighttime sleep is also associated with mental HRQOL in 2nd and 3rd trimester (β < 1.38, p < .02).

^aPSQI subsets: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication and daytime dysfunction.

^bISI subsets: sleep maintenance and early awakening, current sleep satisfaction, impact on daily functioning disturbances and the level of concern about current sleep difficulties.

^cSF-36 subsets: Physical functioning, role limitation due to physical health, bodily pain, general health, vitality, social functioning, role limitation due to emotional health and mental health.

^dSF-12 subsets: Individual’s physical and mental health, function, and well-being.

^eWHOQOL subsets: Physical health, psychological health, social relationships and environmental HRQoL.

^fEQ-5D subsets: Mobility, self-care, usual activities, pain/discomfort and anxiety/depression.

^gActiwatch-2, Respironics, Murrysville, PA subsets: total nighttime sleep and total daytime sleep; wake after sleep onset at night and sleep efficiency.

Figure 2. Risk of bias assessment for (a) cross-sectional and (b) longitudinal studies. +: low risk of bias; −: high risk of bias.

Table

Section and topic	Item #	Checklist item	Location where item is reported
Title
Title	1	Identify the report as a systematic review.	2
Abstract
Abstract	2	See the PRISMA 2020 for Abstracts checklist.	2
Introduction
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	3–4
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	4
Methods
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	5
Information sources	6	Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	4–5
Search strategy	7	Present the full search strategies for all databases, registers, and websites, including any filters and limits used.	4–5
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	5
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	5–6
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	5–6
	10b	List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	6
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	5–6
Effect measures	12	Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results.	6
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis [e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)].	6
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.	N/A
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	Table 1
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	5
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression).	5
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.	N/A
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	4–5
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	N/A
Results
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	5–6, Figure 1
	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	5, Figure 1
Study characteristics	17	Cite each included study and present its characteristics.	Table 1
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	6, Figure 2
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured Tables or plots.	Table 1
Results of syntheses	20a	For each synthesis, briefly summarize the characteristics and risk of bias among contributing studies.	6–10
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	N/A
	20c	Present results of all investigations of possible causes of heterogeneity among study results.	N/A
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.	N/A
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.	N/A
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	7, Figure 2
Discussion
Discussion	23a	Provide a general interpretation of the results in the context of other evidence.	10–13
	23b	Discuss any limitations of the evidence included in the review.	11–12
	23c	Discuss any limitations of the review processes used.	11–12
	23d	Discuss implications of the results for practice, policy, and future research.	12–13
Other information
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered.	4
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared.	4
	24c	Describe and explain any amendments to information provided at registration or in the protocol.	N/A
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.	13
Competing interests	26	Declare any competing interests of review authors.	13
Availability of data, code and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.	N/A

From Page et al. [50].

For more information, visit: http://www.prisma-statement.org/.

Table

Search #	Search terms	Field of search	Number of hits
1	Pregnan*	Title/Abstract	549,285
2	Gestation*	Title/Abstract	219,997
3	S1 OR S2		652,664
4	Sleep	Title/Abstract	179,180
5	Sleep deprivation	MeSH	10,035
6	Insomnia	Title/Abstract	23,404
7	S4 OR S5		180,147
8	S7 OR S6		190,926
9	Quality of life	Title/Abstract	298,430
10	Quality of life	MeSH	212,042
11	HRQOL	Title/Abstract	19,133
12	QOL	Title/Abstract	42,635
13	S9 OR S10		360,530
14	S13 OR S11		364,053
15	S14 OR S12		365,490
16	S3 AND S8		3791
17	S16 AND S15		152

Table

Search #	Search terms	Field of search	Number of hits
1	Pregnan*	Title OR Abstract	48,487
2	Gestation*	Title OR Abstract	13,905
3	S1 OR S2		55,998
4	Sleep	Title OR Abstract	70,491
5	Sleep deprivation	MeSH	3,720
6	Insomnia	Title OR Abstract	12,681
7	S4 OR S5		70,619
8	S7 OR S6		75,866
9	Quality of life	Title OR Abstract	78,983
10	Quality of life	MeSH	34,430
11	HRQOL	Title OR Abstract	5,001
12	QOL	Title OR Abstract	10,878
13	S9 OR S10		89,695
14	S13 OR S11		89,745
15	S14 OR S12		89,953
16	S3 AND S8		1241
17	S16 AND S15		49

Table

Search #	Search terms	Field of search	Number of hits
1	Pregnan*	Title OR Abstract	668,892
2	Gestation*	Title OR Abstract	302,462
3	S1 OR S2		804,763
4	Sleep	Title OR Abstract	267,609
5	Sleep deprivation	Emtree Submapping	16,889
6	Insomnia	Title OR Abstract	39,027
7	S4 OR S5		270,002
8	S7 OR S6		287,578
9	Quality of life	Title OR Abstract	479,983
10	Quality of life	Emtree submapping	509,013
11	HRQOL	Title OR Abstract	29,612
12	QOL	Title OR Abstract	79,992
13	S9 OR S10		630,987
14	S13 OR S11		631,747
15	S14 OR S12		637,208
16	S3 AND S8		6158
17	S16 AND S15		287

Table

Search #	Search terms	Field of search	C. reviews
1	Pregnan*	Title, Abstract, Keyword	1145
2	Gestation*	Title, Abstract, Keyword	438
3	S1 OR S2		1317
4	Sleep	Title, Abstract, Keyword	247
5	Sleep deprivation	Mesh	0
6	Insomnia	Title, Abstract, Keyword	85
7	S4 OR S5		247
8	S7 OR S6		303
9	Quality of life	Title, Abstract, Keyword	2429
10	Quality of life	Mesh	597
11	HRQOL	Title, Abstract, Keyword	72
12	QOL	Title, Abstract, Keyword	211
13	S9 OR S10		2429
14	S13 OR S11		2429
15	S14 OR S12		2433
16	S3 AND S8		27
17	S16 AND S15		4

Table

Study	Participants					Intervention					Outcome
	Trimester			Participants		Sleep measurement method used			Dichotomous/ continuous outcome		HRQOL questionnaire used			Results reported
	3rd	1st, 2nd, and 3rd	Other	Healthy in general	Other	PSQI	ISI	Other	Dicho	Contin	WHOQoL (or BREF)	SF-12 (or SF-36)	Other	p-Value	B-value	R-value	Other
Davoud et al. (2020)		X		x			X			X	X			X		X (Pearson)	F-value
Mourady et al. (2017)		X		x			X			X	X			X		X (Spearman)
Tsai et al. (2016)		X		x		X		Actigraph		X		X		X	X
Sadaati et al. (2018)	X				With high-risk pregnancy	X				X	X			X	X	X (Pearson)
Zhang et al. (2019)	X			x		X				X		X		X	X
Kang et al. (2020)	X				With sleeping problem and depression			Actigraph		X	X						No data
Da Costa et al. (2010)	X				All pregnancies			Prime-MD	X			X		X	X	X (Pearson)
Effati et al. (2017)			2nd and 3rd	x		X				X	X			X	X	X (Pearson/ Spearman)
Rezaei et al. (2013)			2nd		With sleeping problems prior to pregnancy	X				X	X			X (of Spearman/ Pearson)
Du et al. (2021)			1st	x		X			X				EQ-5D	X	X		Odds ratio

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