Insomnia, Short Sleep, And Snoring In Mid-To-Late Pregnancy: Disparities Related To Poverty, Race, And Obesity

Figures & data

Table 1 Sample Demographics And Pregnancy Characteristics (n=267)

	M±SD, Range		n, %
Age	29.76±4.72, 20–44	Employment
Gestational week	27.99±1.20, 25–37	Full-time	103/267; 52.1%
BMI, pre-pregnancy	27.59±7.20, 17.17–70.64	Part-time	49/267; 18.4%
BMI, at assessment	30.65±7.16, 19.13–70.67	Student	22/267; 8.2%
Exercise	3.06±1.90 days/week	Relationship
		Single	25/267; 9.4%
Prior Sleep Disorder Diagnosis	n, %	In relationship, unmarried	51/267; 19.1%
No diagnosis	249/267; 93.3%	Married	189/267; 70.8%
Insomnia	9/267; 3.4%	Separated or Divorced	2/267; 0.7%
Sleep apnea	8/267; 3.0%	Highest education
UARS	1/267; 0.4%	No HS diploma or GED	3/267; 1.1%
		Highschool or GED	87/267; 32.6%
		Trade, technical, vocational	15/267; 5.6%
Planned pregnancy	175/267; 65.5%	Associate degree	30/267; 11.2%
History of miscarriage	61/267; 22.8%	Bachelor’s degree	70/267; 26.2%
Prior parturition	171/267; 64.0%	Graduate or Professional Degree	52/267; 19.5%
Diabetes		Doctorate	10/267; 3.7%
Pre-pregnancy	0/267; 0.0%	Racial identity
Gestational	12/267; 4.5%	White	149/267; 55.8%
Pre-eclampsia		Black	73/267; 27.3%
Clinical signs, no diagnosis	9/267; 3.4%	Asian	11/267; 4.1%
Diagnosed	5/267; 1.9%	Middle Eastern	12/267; 4.5%
Hypertension		Hispanic or Latinx	10/267; 3.7%
Pre-pregnancy	5/267; 1.9%	Multiracial	11/267; 4.1%
Gestational	2/267; 0.7%	Other	1/267; 0.4%
Poverty (<$20K annual income)	45/261; 17.2%
Medicaid insurance	78/267; 29.2%

Abbreviations: BMI, body mass index (kg/m²), derived from electronic medical records; UARS, upper airway resistance syndrome; HS, High school; GED, General Education Development degree.

Table 2 Comparing Sleep Parameters Between Pregnant Women Above And Below The Poverty Line

	All Women n=267	Poverty n=45/261	Non-Poverty n=216/261
Medicaid insurance	78/267; 29.2%	40/45; 88.9%	36/216; 16.7%	χ^2=94.11***, RR=5.32
Black %	73/261; 27.9%	27/40; 67.5%	42/176; 23.9%	χ^2=28.55***, RR=2.82
BMI, pre-pregnancy
M±SD	27.59±7.20	28.39±7.57	27.36±7.15	t(218)=0.76, p=0.44
n; % ≥35	30/226; 13.3	8/35; 22.9%	21/185; 11.4%	χ^2=3.41, p=0.07
BMI, at assessment
M±SD	30.65±7.16	31.36±30.39	30.39±7.03	t(249)=0.79, p=0.43
n; % ≥35	56/257; 21.8	12/41; 29.3%	41/210; 19.5%	χ^2=1.96, p=0.38
ISI
M±SD	11.12±6.03	14.04±6.16	10.52±5.83	t(259)=3.65***, d=0.59
Traditional cutoffs n, %
0–7	85/267; 31.8%	8/45; 17.8%	76/216; 35.2%
8–14	112/267; 41.9%	16/45; 35.6%	92/216; 42.6%	ISI≥8: χ^2=5.17*, RR=1.27
15–28	70/267; 26.2%	21/45; 46.7%	48/216; 22.2%	ISI≥15: χ^2=11.44**, RR=2.10
Revised cutoffs n, %
≥10 (Epidemiological)	156/267; 58.4%	33/45; 73.3%	119/216; 55.1%	χ^2=5.10*, RR=1.33
≥11 (Clinical)	143/267; 53.6%	32/45; 71.1%	107/216; 49.5%	χ^2=6.96**, RR=1.44
PSQI
Total score M±SD	8.27±3.71	9.73±4.11	7.98±3.58	t(259)=2.91**, d=0.45
>5 (Traditional samples)	202/265; 76.2%	37/45; 82.2%	160/214; 74.8%	χ^2=1.14, p=0.29
>8 (Clinical samples)	117/265; 44.2%	30/45; 66.7%	83/214; 38.8%	χ^2=11.75**, RR=1.72
Sleep latency in minutes	32.61±25.99	43.56±29.28	30.37±24.90	t(258)=3.13**, d=0.49
Sleep duration
Hours per night	6.61±1.35	6.31±1.70	6.66±1.26	t(259)=−1.59, p=0.11
% <6 hrs/night	65/267; 24.3%	16/45; 35.6%	48/216; 22.2%	χ^2=3.58, p=0.06
Trouble sleep ≥ 3 days/week due to:
Cannot fall asleep within 30 mins	84/267; 31.5%%	23/45; 51.1%	58/216; 26.9%	χ^2=10.24**, RR=1.90
Nighttime or early morning waking	186/267; 69.7%	35/45; 77.8%	147/216; 68.1%	χ^2=1.67, p=0.20
Needing to use the bathroom	217/267; 81.3%	41/45; 91.1%	171/216; 79.2%	χ^2=3.48, p=0.06
Cannot breathe comfortably	44/267; 16.5%	12/45; 26.7%	31/216; 14.4%	χ^2=4.10*, RR=1.85
Cough or snore loudly	22/267; 8.2%	5/45; 11.1%	17/216; 7.9%	χ^2=0.51, p=0.48
Bad dreams	40/267; 15.0%	14/45; 31.1%	26/216; 12.0%	χ^2=10.44**, RR=2.59
Pain	57/267; 21.3%	15/45; 33.3%	41/216; 19.0%	χ^2=4.55*, RR=1.75
Sleep aid use within past month	34/267; 12.7%	8/45; 17.8%	37/216; 12.0%	χ^2=1.08, p=0.30
Snoring	81/265; 30.6%	15/45; 33.3%	63/214; 29.4%	χ^2=0.27, p=0.61
Stop breathing	13/265; 4.9%	6/45; 13.3%	7/214; 3.3%	χ^2=7.90*, RR=4.03
Woken up gasping for air	24/265; 9.1%	11/45; 24.4%	13/214; 6.1%	χ^2=14.92***, RR=4.00

Notes: Poverty = annual household income < $20,000. p represents statistical significance level of non-significant findings. Significant results are demarcated by *p<0.05, **p<0.01, ***p<0.001.

Abbreviations: BMI, body mass index (kg/m²), derived from electronic medical records; M, mean; SD, standard deviation; ISI, insomnia severity index; PSQI, Pittsburgh sleep quality index. t-statistic for comparison of independent groups; d, Cohen’s d. χ² represents chi-square; RR, rate ratio.

Table 3 Comparing Sleep Parameters Between Black And White Pregnant Women

	All Women n=267	Black n=73/222	White n=149/222
Poverty %	66/261; 25.3%	27/69; 39.1%	13/147; 8.8%	χ^2=28.55***, RR=4.44
Medicaid insurance	78/267; 29.2%	34/73; 46.6%	26/123; 17.4%	χ^2=21.07***, RR=2.69
BMI, pre-pregnancy
M±SD	27.59±7.20	29.59±8.66	27.09±6.57	t(191)=2.22*, d=0.33
n; % ≥35	30/226; 13.3	13/62; 21.0%	15/131; 11.5%	χ^2=3.07, p=0.08
BMI, at assessment
M±SD	30.65±7.16	32.55±8.90	30.18±6.19	t(213)=2.28*, d=0.31
n; % ≥35	56/257; 21.8	19/71; 26.8%	31/144; 21.5%	χ^2=0.73, p=0.39
ISI
M±SD	11.12±6.03	12.60±5.79	10.36±5.90	t(220)=2.68**, d=0.38
Traditional cutoffs n,%
0–7	85/267; 31.8%	13/73; 17.8%	59/149; 39.6%
8–14	112/267; 41.9%	36/73; 49.3%	57/149; 38.3%	ISI≥8: χ^2=10.62*, RR=1.29
15–28	70/267; 26.2%	24/73; 32.9%	33/149; 22.1%	ISI≥15: χ^2=2.96, p=0.09
Revised cutoffs n,%
≥10 (Epidemiological)	156/267; 58.4%	54/73; 74.0%	177/149; 51.7%	χ^2=10.07**, RR=1.43
≥11 (Clinical)	143/267; 53.6%	50/73; 68.5%	70/149; 47.0%	χ^2=9.13**, RR=1.46
PSQI
Total score M±SD	8.27±3.71	9.18±3.88	7.83±3.54	t(218)=2.57***, d=0.36
>5 (Traditional samples)	202/265; 76.2%	60/72; 83.3%	108/148; 73.0%	χ^2=2.88, p=0.09
>8 (Clinical samples)	117/265; 44.2%	46/72; 63.9%	54/148; 36.5%	χ^2=14.67***, RR=1.75
Sleep latency in minutes	32.61±25.99	38.84±29.34	29.32±22.40	t(219)=2.67**, d=0.36
Sleep duration
Hours per night	6.61±1.35	6.16±1.33	6.87±1.23	t(220)=−3.95***, d=0.55
% <6 hrs/night	65/267; 24.3%	28/73; 38.4%	26/149; 17.4%	χ^2=11.63**, RR=2.21
Trouble sleep ≥ 3 days/week due to:
Cannot fall asleep within 30 mins	84/267; 31.5%%	30/73; 41.1%	39/149; 26.2%	χ^2=5.09*, RR=1.57
Nighttime or early morning waking	186/267; 69.7%	58/73; 79.5%	102/149; 68.5%	χ^2=2.94, p=0.09
Needing to use the bathroom	217/267; 81.3%	61/73; 83.6%	122/149; 81.9%	χ^2=0.10, p=0.76
Cannot breathe comfortably	44/267; 16.5%	116/73; 21.9%	17/149; 11.4%	χ^2=4.28*, RR=1.92
Cough or snore loudly	22/267; 8.2%	6/73; 8.2%	14/149; 9.4%	χ^2=0.08, p=0.77
Bad dreams	40/267; 15.0%	14/73; 19.2%	18/149; 12.1%	χ^2=2.00, p=0.16
Pain	57/267; 21.3%	19/73; 26.0%	23/149; 15.4%	χ^2=3.58, p=0.60
Sleep aid use within past month	34/267; 12.7%	12/73; 16.4%	19/149; 12.8%	χ^2=0.55, p=0.46
Snoring	81/265; 30.6%	29/72; 40.3%	44/148; 29.7%	χ^2=2.43, p=0.12
Stop breathing	13/265; 4.9%	7/72; 9.7%	5/148; 3.4%	χ^2=3.78, p=0.05
Woken up gasping for air	24/265; 9.1%	10/72; 13.9%	8/148; 5.4%	χ^2=4.64*, RR=2.57

Notes: Poverty = annual household income < $20,000. p represents statistical significance level of non-significant findings. Significant results are demarcated by *p<0.05, **p<0.01, ***p<0.001.

Abbreviations: BMI, body mass index (kg/m2), derived from electronic medical records; M, mean; SD, standard deviation; ISI, insomnia severity index; PSQI, Pittsburgh sleep quality index. t-statistic for comparison of independent groups. d, Cohen’s d. χ² represents chi-square; RR, rate ratio.

Table 4 Comparing Sleep Parameters Between Women Pre-Pregnancy BMI ≥ 35 Vs BMI < 35

	All Women n=267	BMI ≥ 35 n=30/226	BMI < 35 n=196/226
ISI
M±SD	11.12±6.03	13.50±6.11	10.60±6.01	t(224)=2.46*, d=0.46
Traditional cutoffs n, %
0–7	85/267; 31.8%	8/30; 26.7%	68/196; 34.7%
8–14	112/267; 41.9%	8/30; 26.7%	82/196; 41.8%	ISI≥8: χ^2=0.75, p=0.39
15–28	70/267; 26.2%	14/30; 46.7%	46/196; 23.5%	ISI≥15: χ^2=7.18**, RR=1.99
Revised cutoffs n, %
≥10 (Epidemiological)	156/267; 58.4%	21/30; 70.0%	105/196; 53.6%	χ^2=2.85, p=0.09
≥11 (Clinical)	143/267; 53.6%	20/30; 66.7%	96/196; 49.0%	χ^2=3.26, p=0.07
PSQI
Total score M±SD	8.27±3.71	10.87±4.32	7.94±3.63	t(222)=4.00***, d=0.73
>5 (Traditional samples)	202/265; 76.2%	24/30; 80.0%	145/194; 74.7%	χ^2=0.39, p=0.53
>8 (Clinical samples)	117/265; 44.2%	21/30; 70.0%	81/194; 41.8%	χ^2=8.36**, RR=1.67
Sleep latency in minutes	32.61±25.99	41.83±28.45	30.90±24.91	t(223)=2.20*, d=0.41
Sleep duration
Hours per night	6.61±1.35	5.93±1.55	6.71±1.29	t(224)=–2.99**, d=0.55
% <6 hrs/night	65/267; 24.3%	14/30; 46.7%	42/196; 21.4%	χ^2=8.89**, RR=2.18
Trouble sleep ≥ 3 days/week due to:
Cannot fall asleep within 30 mins	84/267; 31.5%%	13/30; 43.3%	58/196; 29.6%	χ^2=2.28, p=0.13
Nighttime or early morning waking	186/267; 69.7%	27/30; 90.0%	133/196; 67.9%	χ^2=6.17*, RR=1.33
Needing to use the bathroom	217/267; 81.3%	29/30; 96.7%	156/196; 79.6%	χ^2=5.11*, RR=1.21
Cannot breathe comfortably	44/267; 16.5%	8/30; 26.7%	32/196; 16.3%	χ^2=1.91, p=0.17
Cough or snore loudly	22/267; 8.2%	2/30; 6.7%	17/196; 8.7%	χ^2=0.14, p=0.71
Bad dreams	40/267; 15.0%	7/30; 23.3%	28/196; 14.3%	χ^2=1.63, p=0.20
Pain	57/267; 21.3%	7/30; 23.3%	41/196; 20.9%	χ^2=0.09, p=0.76
Sleep aid use within past month	34/267; 12.7%	8/30; 26.7%	22/196; 11.2%	χ^2=5.39*, RR=2.38
Snoring	81/265; 30.6%	17/30; 56.7%	56/195; 28.7%	χ^2=9.27**, RR=1.98
Stop breathing	13/265; 4.9%	4/30; 13.3%	8/195; 4.1%	χ^2=4.39*, RR=3.24
Woken up gasping for air	24/265; 9.1%	2/30; 6.7%	16/195; 8.2%	χ^2=0.08, p=0.77

Notes: p represents statistical significance level of non-significant findings. Significant results are demarcated by * p<0.05. ** p<0.01. ***p<0.001.

Abbreviations: BMI, body mass index (kg/m²), derived from electronic medical records; M, mean; SD, standard deviation; ISI, insomnia severity index; PSQI, Pittsburgh sleep quality index. t-statistic for comparison of independent groups; d, Cohen’s d. χ² represents chi-square; RR, rate ratio.

Table 5 Regressing Sleep Parameters On BMI, Race, And Poverty Status

Outcome	Predictors
Linear Regression Models		b	β	p
ISI
F(3,183)=5.14, p<0.01	Poverty	2.84	0.18	0.03
	Black	1.32	0.10	0.20
	BMI ≥ 35	1.91	0.11	0.12
PSQI
F(3,181)=6.17, p<0.01	Poverty	1.16	0.12	0.15
	Black	0.56	0.07	0.39
	BMI ≥ 35	2.58	0.24	<0.01
Sleep Duration
F(3,183)=5.64, p<0.01	Poverty	−0.13	−0.04	0.64
	Black	−0.51	−0.18	0.02
	BMI ≥ 35	−0.68	−0.19	0.01
Logistic Regression Models		b	OR (95% CI)	p
Sleep Onset Insomnia
χ^2=7.67, p=0.05	Poverty	1.03	2.81 (1.16, 6.78)	0.02
	Black	0.05	–	0.90
	BMI ≥ 35	0.25	–	0.61
Sleep Maintenance Insomnia
χ^2=7.64, p=0.08	Poverty	0.18	–	0.74
	Black	0.49	–	0.26
	BMI ≥ 35	1.12	–	0.08
Breathing-related sleep disturbance
χ^2=9.72, p=0.02	Poverty	1.62	5.06 (1.99, 12.86)	<0.01
	Black	0.58	–	0.40
	BMI ≥ 35	−0.07	–	0.91
Nightmare-related sleep disturbance
χ^2=9.79, p=0.02	Poverty	1.31	3.72 (1.34, 10.31)	0.01
	Black	0.25	–	0.61
	BMI ≥ 35	0.04	–	0.92
Pain-related sleep disturbance
χ^2=6.32, p=0.10	Poverty	0.80	–	0.10
	Black	0.45	–	0.30
	BMI ≥ 35	−0.27	–	0.63
Snoring
χ^2=7.93, p<0.05	Poverty	−0.28	–	0.55
	Black	0.53	–	0.15
	BMI ≥ 35	0.97	2.64 (1.14, 6.15)	0.02
Sleep aid use
χ^2=5.27, p=0.15	Poverty	−0.11	–	0.84
	Black	0.49	–	0.30
	BMI ≥ 35	0.97	2.64 (1.01, 6.91)	<0.05

Notes: Poverty = annual household income < $20,000. Sleep duration, sleep onset insomnia, sleep maintenance insomnia, nightmare-related sleep disturbance, pain-related sleep disturbance, and sleep aid use were all derived and dichotomized based on responses to individual items on the PSQI. Subjects who endorsed trouble sleeping ≥ 3 days/week due to these issues were categorized as positive cases, whereas subjects who experienced these symptoms <3 days/week were categorized as negative cases. F-statistic represents overall linear regression model fit. χ² represents overall logistic regression model fit. b = unstandardized regression coefficients. β = standardized regression coefficient for linear model predictors. p = statistical significance.

Abbreviations: BMI, body mass index (kg/m²), derived from electronic medical records. BMI ≥ 35 represents class II–III obesity; ISI, insomnia severity index; PSQI, Pittsburgh sleep quality index; OR, odds-ratio; 95% CI, 95% confidence interval.