Maternal Sleeping Problems Before and After Childbirth - A Systematic Review

Figures & data

Figure 1 PRISMA flow diagram.

Table 1 Characteristics of the Studies Included in the Evaluation of Maternal Sleep Quality in the Perinatal Period

First Author’s Name	Sociodemographic Data: 1. Country 2. Maternal age 3. Sample size	Design: 1. Study design 2. Number of groups 3. Description of groups	Aim of the Study	Tools Used to Assess Sleep Quality	Main Results
Hsuan-Man Hung^Citation20	Eastern Taiwan Mean age: 31.5±4.3 Sample size: 202	Cross-sectional study Three groups (based on socioeconomic status): -Upper -Middle - Lower	Demographic and obstetric factors on the subjective sleep quality of postpartum women.	PSQS	Correlation for Postpartum sleep quality and: - Age (r=0.038) - Number of children (r=−0.012) - Daily household work (hours) (r=0.153, p<0.05) - Napping (hours/day) (r=−0.087) No significant associations were found between subjective sleep quality and number of births, feeding type, or type of delivery. Although dissatisfaction with the birth experience and daily housework are factors that affect sleep quality.
Jennifer J. Doering^Citation21	USA Mean age: 25.5±4.6 Sample size: 183	Cohort study One group: surveillance at 2 weeks postpartum, 4, 8, 12 and 24 weeks postpartum	To describe and explore patterns of postpartum sleep, fatigue, and depressive symptoms in low income urban women.	PSQS GSDS Actigraphy	Correlations between: Sleep disturbance and fatigue: 4 week 0.61***; 8 week 0.60***; Sleep disturbance and depressive symptoms: 4 week 0.39***; 8 week 0.30**; Sleep quality and depressive symptoms: 4 week 0.31***; 8 week 0.32***; Sleep quality and fatigue: 4 week 0.40***; 8 week 0.47***; Depressive symptoms and fatigue: 4 week 0.61***; 8 week 0.66***. ***p<0.001; **p<0.01 In this study, it was found that between 4 and 8 weeks, subjective time spent in bed at night decreased (from 8.0 ± 2.2 hours to 7.7 ± 2.2 hours), but sleep efficiency improved (from 5. 0 ± 1.5 hours to 5.4 ± 1.5). Sleep quality also improved during this period (p < 0.0001). According to the GSDS, sleep disturbances decreased from week 2 to week 12 (p < 0.0001). An objective sleep study showed that, on average, participants slept 5.5 hours a night at week 4 and 5.4 hours at week 12. Significant relationships were also identified between fatigue, sleep disturbance, sleep quality, and depressive symptoms.
Lisa M. Christian^Citation22	USA Mean age: African American Nulliparous 23.5±4.8 European American Nulliparous 23.3±3.5 African American Multiparousb24.8±4.2 European American Multiparous 25.8±3.9 Sample size: 133	Cohort study 4 groups: African American Nulliparous European American Nulliparous African American Multiparous European American Multiparous	To examine subjective sleep quality during each trimester of pregnancy and at 4–11 weeks postpartum women inclusive of nulliparous and multiparous African Americans and Whites.	PSQI	Total PSQI Score during 3rd trimester (T3) and postpartum period (PP) African American Nulliparous: T3 6.5±3.0; PP 7.4±2.8; European American Nulliparous: T3 6.6±2.8; PP 7.5±3.4; African American Multiparous: T3 7.6±3.7; PP 7.3±3.8; European American Multiparous: T3 6.6±3.9; PP 7.7±3.4. The study found no significant differences between African-American and Caucasian women on overall subjective sleep quality scores throughout the assessment period. However, 53–71% of respondents reported poor overall sleep quality (PSQI > 5). Studying parity, it was determined that any differences in indicators of subjective sleep quality were observed only during pregnancy, and were not noticed in the postpartum period.
Roshan Khadka^Citation23	Nepal Mean age: 30±3.9 Sample size: 380	Cross-sectional study One group	To identify the prevalence and determinants of postpartum poor maternal sleep and depression.	PSQI	Determinants of poor sleep quality among the mothers at 2–12 months postpartum: - Occupation in agriculture/ physical work OR 15.5 [95% CI 5.10–47.2] - Occupation in government/ private business OR 6.69 [95% CI 1.93–23.2] - Sex of infant – boy OR 2.37 [95% CI 1.29–4.33] - Place of delivery - home OR 2.17 [95% CI 1.20–3.93] - Complications after delivery OR 5.58 [95% CI 2.64–11.8] - Postpartum depression OR 2.86 [95% CI 1.49–5.49] The factors of poor sleep quality were: low level of education, involvement in agriculture/physical work low monthly family income, living in rural areas, age over 30 years, multiple children and male newborn (p<0.05).
Shih-Yi Wen^Citation24	Taiwan Mean age: 37.2±1.8 Sample size: 160	Cross-sectional study Two groups: - above 35 years of age - 20 to 34 years of age	To describe and compare sleep quality between women younger or older than 35 years of age at 3 months postpartum, and to examine the related factors.	PSQI	Logistic regression models for poor sleep quality: - Advanced age group OR 2.79 [95% CI 1.47–5.32] (p=0.002) - Sleeping in the same room as the infant OR 3.24 [95% CI 0.93–11.21] (p=0.06) - Sharing the bed with an infant OR 3.17 [95% CI 0.9–11.1] (p=0.07) - No exercise OR 2.25 [95% CI 1.14–4.45] (p=0.02) - Postpartum physical symptoms severity OR 1.23 [95% CI 1.09–1.38] (p=0.001) Poor sleep quality (PSQI>5) was noted among women older than 35 years of age - 66.25%, and the overall average score was 6.85±3.21. For women of the younger age group, the prevalence of poor subjective sleep quality was 41.25%, the average total score was 5.48±3.22, which was significantly different from those of the older group. Sleep efficiency and sleep disturbance were also worse in women in the older group. Better indicators of the subjective sleep quality were also observed among women who did not share a room or bed with their infants and who exercised during the last 2 weeks.
Soledad Coo^Citation25	Australia Mean age: 31.08±3.82 Sample size: 29	Cohort study One group, surveillance at third trimester of pregnancy (Time 1), 15 days after childbirth (Time 2), 10–12 weeks postpartum (Time 3)	To examine association between measures of objective sleep (OS) and subjective sleep (SS) to postpartum mood in healthy women from the third trimester of pregnancy to 10 to 12 weeks postpartum.	Actigraphy for 7 days PSQI	Objective sleep (actigraphy) *P<0<01; **P<0.001 Efficiency: Time 1 77.43±8.0; Time 2 66.78±8.33*; Time 3 76.93±6.18**; Wake after sleep onset: Time 1 76.85±33.48; Time 2155.60±53.25*; Time 3 98.33±33.62**; Sleep disturbance: Time 1 36.65±11.52; Time 2 53.62±12.78*; Time 3 36.18±11.29**; Daily nap number: Time 1 1.89±1.22; Time 2 3.56±1.28*; Time 3 2.58±1.20**; Subjective sleep (PSQI) *P<0<01; **P<0.001 Sleep onset latency: Time 1 17.73±15.51; Time 2 10.12±9.61; Time 3 11.69±11.92*; Sleep efficiency: Time 1 81.68±10.91; Time 2 66.55±15.66**; Time 3 72.65±12.32** In this study, low mood was associated with daytime dysfunction in women in the third trimester of pregnancy and at 10–12 weeks postpartum and subjectively poor night sleep within 15 days after the birth of the child. An objectively bad night sleep also affected stress. These data indicate a stronger relationship between postpartum mood and subjective sleep perception than with objective sleep quality and duration in healthy women without depression.
Christopher Kalogeropoulos^Citation26	Canada Age of mothers: 25–35 years – 60.61% 35–44 years – 39.39% Sample size: 33 couples	Cross-sectional study Two groups: - mothers - fathers	To describe and compare sleep patterns and intraindividual night- to- night variability in mothers and fathers at 6 months postpartum using subjective and objective sleep measures.	Actigraphy Sleep diary	Subjective maternal sleep Nocturnal sleep duration (min) 437.67±45.81 Longest consecutive sleep duration (min) 240.86±65.40 Nocturnal awakenings 2.27±1.01 Objective maternal sleep Nocturnal sleep duration (min) 448.07±36.49 Longest consecutive sleep duration (min) 299.45±70.83 Nocturnal awakenings 2.46±0.99 It was found that the subjective duration of maternal night sleep (r=0.380, p=0.029) and the duration of continuous sleep (r=0.702, p<0.001), as well as a lower number of subjective night awakenings (r=−0.625, p <0.001) were associated with a longer night’s sleep of the child. No association was found between maternal sleep activity variables and employment status, education level, infant feeding method, sleep location, nighttime sleep duration, or infant nighttime awakenings.
Lucy S. King^Citation27	USA Mean age: 34.58±5.82 Sample size: 67	Cross-sectional One group: woman at 18 weeks postpartum.	The association of maternal sleep disturbance with both levels and trajectories of maternal sensitivity during interactions with their infants.	Actigraphy Consensus Sleep Diary	Correlations between: Objective WASO (wake time after sleep onset) and objective number of arousals (r = 0.75) Subjective WASO and subjective number of awakenings (r = 0.53) Subjective WASO and subjective total nighttime sleep time (r = −0.59) Subjective WASO and perceived sleep quality (r = −0.46) According to the results of this study, it was found that the poorer sleep continuity of mothers does not decrease the level of their general sensitivity to their babies. But during free play-interaction, there was a decrease in their level of sensitivity over time, which may indicate the importance of uninterrupted maternal sleep for sensitivity to infants.
Robyn Stremler^Citation28	Canada Mean age: not given Sample size: 217	Cohort study One group: surveillance at 6 and 12 weeks postpartum	To examine relationships between self-reported sleep quality, actigraphy data, and depressive symptoms in a sample of women at 6 and 12 weeks postpartum	Actigraphy GSDS	Sleep measures at 6 weeks postpartum: - Nocturnal sleep in minutes 391.9±68.6 - Longest stretch of nocturnal sleep in minutes 142.6±58.2 - Number of night awakenings 9.0±4.5 - Daytime sleep in minutes 38.8 ±52.7 - Mean GSDS score 48.49 ±16.3 - Perception that sleep is not a problem (%) 116 ±53,5 - Perception that sleep is a small problem (%) 76 ±35,0 - Perception that sleep is a big problem (%) 17 ±7,8 The average duration of nocturnal sleep of the studied women was 6.5 hours and the longest continuous period of sleep was slightly more than 2 hours. According to the GSDS scale, 38% of mothers had poor sleep. The results of logistic regression modeling showed that GSDS scores at 6 weeks postpartum were associated with high odds of having an EPDS score > 9 (OR = 3.56; 95% CI = 1.73–7.33) at 6 or 12 weeks postpartum. The study did not find a significant relationship between objective measures of sleep 6 weeks postpartum and symptoms of depression.

Abbreviations: PSQS, Postpartum Sleep Quality Scale; GSDS, General Sleep Disturbance Scale; PSQI, Pittsburgh Sleep Quality Index.

Table 2 Characteristics of the Studies Included in the Evaluation of Maternal Mood Disturbance in the Perinatal Period

First Author’s Name [Number in References]	Sociodemographic Data: 1. Country 2. Maternal age 3. Sample size	Design: 1. Study design 2. Number of groups 3. Description of groups	Aim of the Study	Tools Used to Assess Psycho – Emotional State	Main Results
Beth A. Lewis^Citation30	Upper Midwest of United States Mean age: not given Sample size: 122	Cohort study One group: surveillance at six weeks and at seven months postpartum	Examine the relationship between changes in self-reported sleep patterns (from six weeks to seven months postpartum) and depressive symptoms at seven months postpartum among women who were at high risk for postpartum depression.	PHQ-9	At 6 weeks postpartum period: 5.98±3.83 at 7 month postpartum period: 4.17±4.04 p < 0.001 According to linear regression analysis, greater increases in total PSQI scores from 6 weeks to 7 months postpartum predicted more severe depressive symptoms at 7 months postpartum. This was particularly the case for subscales of the PSQI, such as daytime dysfunction and sleep latency. To check for multicollinearity, variance inflation coefficients were calculated for each of the predictor variables in the regression analysis. They ranged from 1.002 to 1.056 for the predictors in the regression analysis, indicating low multicollinearity.
Soledad Coo^Citation25	Australia Mean age: 31.08±3.82 Sample size: 29	Cohort study One group, surveillance at third trimester of pregnancy (Time 1), 15 days after childbirth (Time 2), 10–12 weeks postpartum (Time 3)	To examine association between measures of objective sleep (OS) and subjective sleep (SS) to postpartum mood in healthy women from the third trimester of pregnancy from 10 to 12 weeks postpartum.	EPDS HADS DASS	EPDS - Time 1 5.56±4.07 - Time 2 6.96±3.93 - Time 3 6.19±4.94 DASS stress: - Time 1 9.56±6.87 - Time 2 8.67±6.56 - Time 3 9.63±8.82 HADS depression: - Time 1 3.00±2.62 - Time 2 4.58±3.69** (p<0.001) - Time 3 3.46±3.98 HADS anxiety: - Time 1 5.50±4.38 - Time 2 6.25±4.19 - Time 3 5.29±4.96 With the exception of HADS depression, the indicators of which significantly increased from the third trimester of pregnancy to the first 15 days after delivery, no statistically significant changes in stress, depression and anxiety indicators were observed. Despite the increase in depression at Time 2, scores on all mood scales corresponded to the normal range of distress. The mother’s subjective sleep disturbance also had a greater impact on her mood than objective indicators.
Michele L. Okun^Citation28	USA Mean age: 31.4±5.4 Sample size: 116	Cohort study Two groups: - Good sleepers (PSQI<5) - Poor sleepers (PSQI>5) Surveillance at 6 month postpartum	To evaluate the relationship between sleep quality and symptoms of depression and anxiety in women studied in pregnancy and postpartum.	PHQ-9 EPDSOASIS	OASIS: - Poor sleepers 4.67±3.75 - Good sleepers2.71±2.53 p=0.001 PHQ-9: - Poor sleepers 5.61±4.82 - Good sleepers 2.93±2.63 p<0.001 EPDS - Poor sleepers 6.5±5.07 - Good sleepers 3.4±3.36 p<0.001 According to the OASIS scale, only 10.3% of the respondents received a score of 8 or higher, which may indicate the presence of an anxiety disorder. Examining the indicators of the PHQ9 scale, 30.2% of the respondents had symptoms of mild depression, 4.3% - moderate, and 2.5% of women - symptoms of severe depression. Although only 9.5% of women scored 11 or more on the EPDS scale, indicating possible postpartum depression. After conducting multivariate linear regression analysis, it was determined that after 6 months, women with poor sleep quality had significantly higher postpartum PHQ9 scores (depression) (β = 0.191, p = 0.036), OASIS (anxiety) (β = 0.233, p = 0.012) and EPDS (postpartum depression and anxiety) scores (β = 0.369, p < 0.001).
Roshan Khadka^Citation23	Nepal Mean age: 30±3.9 Sample size: 380	Cross-sectional study One group: woman at 2–12 months postpartum	To identify the prevalence and determinants of postpartum poor maternal sleep and depression.	PHQ - 2	Determinants of depression quality among the mothers at 2–12 months postpartum: - Living in a nuclear family OR 48.5 [95% CI 15.3 to 154] - Living in rural areas OR 26.6 [95% CI 5.34 to 132] - Male infant OR 4.61 [95% CI 1.84 to 11.5] - No postnatal care visit OR 98.7 [95% CI 19.4 to 503], - Complications after delivery OR 21.9 [95% CI 7.30 to 65.9], - Early introduction of complementary foods before 6 months of age OR 4.71 [95% CI 1.88 to 11.8] - Poor sleep quality OR 3.20 [95% CI 1.34 to 7.61]. Women with postpartum depression were more likely to be engaged in agriculture/physical work, lived in a nuclear family and in rural areas, and gave birth to a male infant. They were also more likely to introduce complementary foods to their babies before 6 months of age, had postpartum medical complications in the mother or child, and did not have full access to postpartum care.
Kathryn Howard^Citation31	USA Mean age: 32.0±4.3 Sample size: 26	Cohort study One group: surveillance at 6 and 12 month postpartum	How modifiable maternal factors (body mass index (BMI), household income, fatigue, sleep, breastfeeding status, diet, and physical activity) relate to postpartum depression (PPD) at 6 and 12 months postpartum.	EPDS SEES BRUMS	Correlations between: - PPD and BMI at 6 month postpartum (r = 0.468, p = 0.021) - PPD and household income at 6 months (r = −0.391, p = 0.065) and at 12 months (r = −0.154, p = 0.556) - PPD and SEES at six months: (r = 0.642, p < 0.001); 12 months (r = 0.679, p = 0.003) - PPD and BRUMS at six months: (r = 0.701, p < 0.001); 12 months postpartum: (r = 0.680, p = 0.004) - PPD and PSQI at 12 month postpartum: (r = 0.752, p < 0.001) Regression analysis identified factors such as household income and fatigue as the strongest predictors of PPD at six months postpartum.
Hanshuang Zou^Citation32	China Age (years): - <25 (14.3%) - 26–35 (78.8%) - 36–45 (6.9%) Sample size: 293	Cross-sectional study Two divisions: - Two groups: - PPD - Non-PPD - Three groups - Low dietary inflammatory index (Q1, DII<33.3%) - Intermediate DII (Q2, 33.3%<DII<66.7) - High DII (Q3, DII>66.7%)	Evaluation of the dietary quality by assessing the DII (dietary inflammatory index) scores, exploring whether exclusive breastfeeding mothers’ diet contributes to an inflammatory environment in the body, which consequently affected the occurrence of depression	EPDS	Occupation level: - Employed: Non-PPD 36.1%, PPD 63.9%; - Unemployed: Non-PPD 47.1%, PPD 52.9%; p=0.069 (Chi-square test) Education levels: - Junior high school and below: Non-PPD 10%, PPD 90%; - Specialized degree: Non-PPD 33.3%, PPD 66.7%; - Bachelor’s degree: Non-PPD 46.0%, PPD 54.0%; - Postgraduate and above: Non-PPD 51.6%, PPD 48.4%; p=0.021 Number of children: - 1 child: Non-PPD 35.6%, PPD 64.4%; - 2 or more children: Non-PPD 46.9%; PPD 53.1%; p=0.054 When comparing sociodemographic factors between groups with and without postpartum depression it was found that women with a junior high school education or less, who had their first child, were the sole caregiver for the infant, and had low levels of social support, were more likely to suffer from PPD. Unemployed women and woman with better sleep quality, on the contrary, were less likely to suffer from depression. The use of an anti-inflammatory diet (DII < 2.89) is also a factor preventing the development of depression among exclusively breastfeeding women (OR = 0.47).
Seyhan Çankaya^Citation33	Turkey Mean age: 27.3±5.2 Sample size: 245	Cohort study One group: surveillance at 3rd trimester of pregnancy and at 6–8 weeks postpartum	To determine the psychosocial risk factors that may increase the risk of developing postpartum depression (PPD) symptoms in the antenatal period and at 6–8 weeks postpartum.	PSS HADS EPDS	Comparison of different characteristics of woman with and without PPD: - Trouble in marriage p=0.002 - Husband wanting the pregnancy p=0.036 - Being subjected to violence from the husband or another male in the family p=0.012 - Being subjected to emotional abuse p=0.007 - Experiencing a sad event in the family during pregnancy p=0.006 Among the 245 surveyed women, 18% received an EPDS score above 13, which indicated the presence of symptoms of postpartum depression. Levels of anxiety and depression on the HADS-A and HADS-D scales were also significantly higher in women with PPD. Psychosocial health, perceived stress, and other psychosocial risk factors during pregnancy were also identified as important factors in postpartum depression.
Danielle Clout^Citation34	Australia Mean age: 31.8±4.37 Sample size: 105	Cohort study One group: surveillance at 3rd trimester of pregnancy and at 4–6 months postpartum	To evaluate the relationship between sociodemographic, pregnancy, obstetric, and postnatal variables and postpartum depression, anxiety and stress levels in new mothers	DASS EPDS	*P<0.05; **P<0.01 Correlations between depression (DASS) and: - Anxiety r=0.62** - PPD (EPDS) r=0.73* - Stress r=0.70** - Caesarean section r=0.22* - Childˈs current health r=0.214* - Childˈs sleep problems r=−0.035** - Maternal sleep quality r=0.29* Correlations between anxiety (DASS) and: - Stress r=0.66** - PPD (EPDS) r=0.66* - Childˈs current health r=0.26** - Maternal sleep quality r=0.2* Correlations between PPD (EPDS) and: - Pregnancy intention r=0.22* - Gestation at birth r=−0.26 - Childˈs current health r=0.32** - Childˈs sleep problems r=−0.4* - Maternal sleep quality r=0.38** - Stressful life events r=0.24* Among those interviewed, only 14.3% of the women reported symptoms of anxiety and stress without comorbid depression. Further analysis revealed that maternal depression, anxiety, and stress were closely interrelated and correlated with sleep and maternal and child health problems.
Ying Liu^Citation35	China Mean age: not given Sample size: 1204	Cross-sectional study One group	To evaluate the relationship between sociodemographic, perinatal variables, and PPA and PPD symptoms of parturients at 6 weeks postpartum.	SAS EPDS	Factors associated with PPA symptoms: - Low monthly income <5000 RMB OR 2.13 [95% CI 1.26 to 3.59] - Low support from the family OR 4.37 [95% CI 3.07 to 7.37] - Unplanned pregnancy OR 2.00 [95% CI 1.36 to 2.94] - Unsatisfactory labour experience OR 6.26 [95% CI 3.27 to 10.51] - Severe fatigue OR 26.85 [95% CI 8.69 to 83.0] - Having PPD symptoms OR 13.41 [95% CI 9.35 to 19.22] Factors associated with PPD symptoms: - Low support from family OR 5.46 [95% CI 3.65 to 8.15] - Low support from colleagues or friends OR 5.64 [95% CI 3.74 to 8.52] - Unsatisfactory labour experience OR 2.54 [95% CI 1.53 to 4.24] - Maternal separation OR 1.88 [95% CI 1.33 to 2.64] - Severe fatigue OR 35.97 [95% CI 11.56 to 111.30] - Breastfeeding difficulties OR 2.07 [95% CI 1.57 to 2.73]

Abbreviations: PHQ-9, Patient Health Questionnaire-9; EPDS, Edinburgh Postnatal Depression Scale; HADS, Hamilton Depression Scale; DASS, Depression, Anxiety, and Stress Scales; OASIS, Overall Anxiety Severity and Impairment Scale; PHQ-2, Patient Health Questionnaire-2; SEES, Subjective Exercise Experience Scale; BRUMS, The Brunel Mood Scale; PSS, Perceived Stress Scale; SAS, Self-Rating Anxiety Scale; PPD, postpartum depression; PPA, postpartum anxiety.

Table 3 Characteristics of the Studies Included in the Evaluation of Sleep Interventions in Women’s Sleep Disturbance in the Perinatal Period

First Author’s Name	Sociodemographic Data: 1. Country 2. Maternal age 3. Sample size	Design: 1. Study design 2. Number of groups 3. Description of groups	Aim of the Study	Tools used to Assess Sleep Quality and Psycho – Emotional State	Main Results
Shao-Min Chang^Citation36	Taiwan Age: 24–43 Sample size: 73	Randomized control trial Two groups: - Experimental - Control	Evaluate the effects of single-ingredient chamomile tea on sleep quality, fatigue, and depression in postpartum women.	PSQS EPDS	2 weeks after starting chamomile tea, significant differences were found between the study group and controls on the PSQS ”sleep inefficiency associated with physical symptoms” scale (t = −2482, P = 0.015) and EPDS (t = −2.372, P = 0.020). However, in the long term, the consumption of chamomile tea did not show a significant difference in the indicators between the groups. Yet, 40% of women from the research group noted that drinking German chamomile tea effectively promotes sleep quality, and 37% - emotional stability and relaxation.
Fatemeh Effati-Daryani^Citation37	East Azerbaijan Age: 18–40 Sample size: 141	Randomized control trial Three groups: - Intervention with lavender cream and foot bath - Intervention with lavender cream - Placebo cream	Effectiveness of Lavender cream and footbath on sleep quality and fatigue in pregnancy and postpartum.	PSQI MAF	At the beginning of the study, the mean total PSQI was 9.7+2.7, and the fatigue index (MAF) was 25.9±7.1. When comparing the groups after the start of the intervention, women receiving lavender and foot baths had significantly better sleep quality scores at 6 months postpartum than women in the control group (6.6 vs 8.9; mean difference: −2.3 [95% CI −3.6 to −0.9]. Also, a significant difference in sleep quality at 6 weeks postpartum could be observed between the lavender and placebo groups (5.7 vs 8.9; mean difference: −3.0 [95% CI −4.4 to −1.7]. Significant differences were found between the control group and both intervention groups in fatigue scores (mean difference: −6.2 [95% CI: −9.8 to −2.5] for the lavender group and foot baths, and mean difference: −5.8 [95% CI: −9.4 – −2.2] for lavender group).
Mei-Ling Chen^Citation38	Eastern Taiwan Mean age: 33 Sample size: 60	Randomized control trial Two groups: - experimental - control	Explore the effect of a bergamot essential oil aromatherapy intervention on depressive mood and sleep quality in postpartum women.	PSQS EPDS	According to the results of the regression analysis, there was no significant difference between the sleep quality indicators of women who received aromatherapy with bergamot essential oil and the control group (p > 0.05). However, the interaction effect between groups on the depression scale showed a significant difference (p < 0.001).
Yi-Li Ko^Citation8	Northern Taiwan Mean age: 34.63 ±3,58 Sample size: 30	Quasi-experimental study One group: before and post intervention comparison	Effects of auricular acupressure therapy on women with postpartum insomnia.	Chinese PSQI	At baseline, about 60% of women expressed dissatisfaction with the quality of sleep, 33% noted prolonged falling asleep (>30 minutes), and only 23.3% of women had high sleep efficiency ≥85%. Acupressure point massage of the auricle (Shenmen point) significantly reduced both the overall average score of the PSQI scale (t = 6, 6, p = 0.000), as well as the indicators of individual components of the PSQI scale: subjective perception of sleep quality, sleep latency, sleep duration, and sleep disturbance (p < 0.05).
Chiu-Ling Yang^Citation10	Southern Taiwan Mean age: 31.89±4.03 - experimental, 32.45±4.12 – control. Sample size: 140	Randomized control trial Two groups: - experimental - control	Determine whether the aerobic gymnastic exercise improves stress, fatigue, sleep quality and depression in postpartum women	PSQS EPDS PSS PFS	There is a significant difference among the experimental group between baseline values and values 4 weeks after the intervention (Pre-test 1) on PSQS Factor 1 and EPDS (p<0.05) and between baseline values and values after 12 weeks (Pre-test 2) on PSS, PFS, PSQS Factor 1 and EPDS indicators (p<0.05). In general, using paired t-tests, a significant improvement in stress, fatigue and sleep quality indicators was noted after using daily gymnastic exercises for 12 weeks.
Yu-Hsiang Liu^Citation35	Taiwan Mean age: - experimental group 32.22 ±3.43 - control 32.96 ±3.32 Sample size: 88	Randomized control trial Two groups: - experimental - control	Evaluate the effects of a walking exercise in relieving sleep quality, fatigue, and depression in new mothers during the postpartum period.	PSQS EPDS PFS	A two-way repeated-measures analysis of variance determined that the interaction of experimental group and duration of the study on the PSQS factor 2 “physical symptoms related to sleep inefficiency” was significant (F = 7.253, p = 0.009) at 4 weeks post-intervention. No significant interaction was found among the indicators of the EPDS and PFS scales in the experimental group.
Hongling Liu^Citation9	China Mean age: - intervention group 26.89 ±4.12 - control 27.31 ±4.56 Sample size: 260	Randomized control trial Two groups: - intervention group - control	Prevention of the pathogenesis of postpartum depression in primiparous women using cognitive behavior intervention.	PSQI HAMA HAMD EPDS	Participants receiving cognitive behavioral therapy had significantly lower HAMA (Hamilton Anxiety Scale), HAMD (Hamilton Depression Scale), EPDS, and PSQI scores compared to baseline scores (p = 0.034, p = 0.038, p = 0.004, p = 0.014, respectively). The number of women with postpartum depression after 6 weeks of intervention was significantly lower in the experimental group (11.5%) than in the control group (24.3%).
Jennifer N. Felder^Citation39	USA Mean age: - Control 33.21±3.98 - Digital CBT-I 33.9±3.38 Sample size: 208	Randomized control trial Two groups: - Usual treatment (control) - Digital CBT-I (Cognitive behavior therapy for insomnia)	To evaluate the effects of digital cognitive behavior therapy for insomnia (dCBT-I) delivered during pregnancy on subjective sleep outcomes, depressive symptoms, and anxiety symptoms through 6 months postpartum.	PSQI EPDS GAD-7	A decrease in ISI was found in the digital CBT-I group compared to the control group, but not at a significant level (p = 0.08). At the same time, women from the experimental group noted higher rates of insomnia remission 6 months after childbirth (approximately 53% vs 35%, p = 0.02). PSQI scores did not differ between the two groups at 3 or 6 months postpartum. The likelihood ratio test of two differences in changes from baseline was statistically significant for the EPDS scale (p = 0.002) at 3 and 6 months postpartum. Differences between anxiety scores between groups were significant only in the period of 3 months postpartum (p = 0.001).
Mozhgan Rouzafzoon^Citation40	Iran Mean age: 29.6 Sample size: 82	Randomized control trial Two groups: - intervention group - control	Effects of preventive behavioral sleep intervention (BSI) on infant sleep patterns, maternal sleep quality, and depression.	PSQI EPDS	The quality of maternal sleep in the group receiving the infant behavioral sleep intervention changed from 10.9±2.9 to 8.9±3.1 (p = 0.040). Depression scores also improved: from 9.02±4.65 to 7.22±4.29 (p = 0.045). Regarding the analysis of sleep itself, 88% of women considered ”maintaining a consistent sleep pattern for babies” to be the most difficult task, and ”consistent sleep routine” of women - The second most difficult (66%).
Asmaa A. El Sehmawy^Citation41	Egypt Age (years): - 18–25 (56–58%) - >25 (42–44%) Sample size: 400	Randomized control trial Two groups: - KMC group - Conventional care group (control)	Evaluation of the effect of skin-to-skin contact [Kangaroo mother care (KMC)] on the postpartum psychiatric disorders in mothers and its effectiveness on their full-term neonate.	PSQI EPDS PASS PBQ	The prevalence of mild depression among mothers who used Kangaroo mother care was 8.5%, compared to 23.5% in mothers who received standard care - [RR=0.62 (0.51–0.74)]. The prevalence of mild to moderate anxiety also differed: 10% in the KMC group versus 25.5% in the control group [RR = 0.63 (0.52–0.76)]. Also, mothers from the KMC group expressed less excessive concern for the child, less specific fears, and social and acute anxiety according to the PASS scale and had significantly better sleep indicators on all PSQI subscales (p<0.001)
Liora Kempler^Citation42	Australia Mean age: 33.3±4.0 Sample size: 215	Randomized control trial Two groups: - intervention - control	Efficacies of prenatal brief, group sleep psychoeducation in improving postpartum maternal sleep, and depression.	PSQI ISI MAF ESS EPDS DASS	A decrease in sleep quality was observed in both groups at 6 weeks postpartum (control group: mean difference −1.82; p < 0.001; intervention group: mean difference = −1.81; 95% CI [−2.64 to −0, 98]; p < 0.001). At 4 months postpartum, the intervention group reported improved sleep quality compared to the control group (mean difference = 1.27; 95% CI [0.12 to 2.41]; p = 0.03), but at 10 months the differences between groups were not observed. No significant effect of the intervention was found on general symptoms of postpartum insomnia, depression, anxiety, and stress.

Abbreviations: PSQS, Postpartum Sleep Quality Scale; EPDS, Edinburgh Postnatal Depression Scale; PSQI, Pittsburgh Sleep Quality Index; MAF, Multidimensional assessment of fatigue; PSS, Perceived Stress Scale; PFS, Postpartum Fatigue Scale; HAMA, Hamilton Anxiety Rating Scale; HAMD, Hamilton Depression Rating Scale; GAD-7, Generalised Anxiety Disorder Assessment; PASS, Perinatal Anxiety Screening Scale; PBQ, Postpartum Bonding Questionnaire; ISI, Insomnia Severity Index; ESS, Epworth Sleepiness Scale; DASS, Depression, Anxiety, and Stress Scales.

Table 4 Characteristics of the Studies Included in the Analysis on the Relationship Between Maternal Sleep Quality and Breastfeeding

First Author’s Name	Sociodemographic Data: 1. Country 2. Maternal age 3. Sample size	Design: 1. Study design 2. Number of groups 3. Description of groups	Aim of the Study	Tools Used to Assess Sleep Quality	Main Results
Yi-Li Ko^Citation8	Northern Taiwan Mean age: 34.63 ±3.58 Sample size: 30	Quasi-experimental study One group: before and post intervention comparison	Effects of auricular acupressure therapy on women with postpartum insomnia.	Chinese PSQI	PSQI scores in woman with different modes of breastfeeding: - Breastfeeding 5.33±2.54 - Mixed feeding 5.72±2.32 PSQI scores in woman with different numbers of milking per night: - No 5.83±3.59 - 1–2 times 5.45±2.0 - >2 times 6.0±4.24 According to the basic demographic indicators of the mothers, before the intervention, 40% of them breastfed only and 60% gave mixed feeding. The majority (73.3%) squeezed milk more than 2 times during the night.
Els Tobback^Citation17	Belgium Mean age: 30.4±4.51 Sample size: 105	Cross-sectional study Two groups: - Breastfeeding mothers - Bottle-feeding mothers	To investigate whether perceived sleep and fatigue differ between breast- and bottle-feeding women during the postpartum period.	PSQI	Global PSQI score: - Breastfeeding mothers 7.3±3.01 - Bottle-feeding mothers 7.6±3.42 Subjective sleep quality: - Breastfeeding mothers 1.2±0.7 - Bottle-feeding mothers 1.6±0.81 Habitual sleep efficiency: - Breastfeeding mothers 2.2±0.97 - Bottle-feeding mothers 1.5±1.3 In this study, breastfeeding women had better subjective sleep quality scores but lower habitual sleep efficiency. There was no significant difference in total PSQI scores between the two groups.
Aslihan Aksu^Citation18	Turkey Mean age: 25.4±5.1 Sample size: 128	Cohort study One group: primiparous women after vaginal delivery at 2 weeks postpartum	Relationship between sleep quality and breastfeeding self-efficacy of the mothers in the postpartum period.	PSQS BSES-SF	Mean PSQS score 33.57±11.26 Breastfeeding self-efficacy increased as maternal quality of sleep increased.

Abbreviations: PSQI, Pittsburgh Sleep Quality Index; PSQS, Postpartum Sleep Quality Scale; BSES-SF, The Breastfeeding Self-Efficacy Scale-Short Form.

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