BAOJ Gynaecology
Naseem Ahmed, et al. BAOJ Gynaec 2019, 2: 3
Research Article
Prevalence of Sleep Disturbances During Pregnancy – A Pilot Study
Naseem Ahmed1*, Aneeqa Khan2, Asra Waseem2, Tooba Khan2, Hussaina Shabbir2, Abdul Waqas2
1
Department of Pathology, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
2
Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
Abstract
Background
To determine the prevalence of sleep problems during pregnancy and
factors contributing to it.
Methods
A pilot study was conducted to determine the prevalence of sleep
disorders in pregnant women visiting gynecology and obstetrics
outpatient department, civil hospital, Karachi, Pakistan, ranging in
age from 18-37 years with sample size of 30. Willing participants were
included irrespective of gestational age. Relation of each contributing
factors with PSQI score was assessed by independent sample t test.
One-way ANOVA was applied to compare PSQI scores among 3
trimesters, correlation between sleep quality and other variables was
found through Pearson’s correlation, P value≤0.05 being considered
significant.
Results
30 women participated in the study among which 1(3.3%) was in her
first trimester, 5(16.7%) were in their second trimester and 24(80%)
were from third trimester. 16(53.3%) pregnant women being sorted
as having poor sleep quality (PSQI ≥5). Subjective sleep quality, sleep
latency, sleep duration, habitual sleep efficiency, sleep disturbances,
use of sleeping medication, daytime dysfunction as well as the global
PSQI score was not established as being significant with the three
trimesters (p >0.05). Furthermore, pain in lower back, frequent leg
cramps, night awakenings due to increased food cravings and a family
history of sleep disorders were discovered as significant contributing
factors (p≤0.05).
Conclusion
Disturbed sleep is a widespread problem encountered by pregnant
women in Pakistan. Pain in lower back, leg cramps, night time cravings
for food and a family history of sleep disorder are conspicuous
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contributory factors. Primary care providers should pay attention
towards carrying out preventive and conservative interventions
Key Words: Pregnant Women; Sleep Quality; Contributing Fac-
tors; One Way ANOVA, PSQI Score
Abbreviations
PSQI (Pittsburg Sleep Quality Index), BMI (body mass index)
Introduction
Despite being a natural phenomenon, pregnancy is associated with
major hormonal, psychological and physiological changes. Therefore,
it is no wonder that about two-third of pregnant women whine about
abnormal sleep patterns as quoted by a research in Tehran city, Iran.
[1]. National Sleep Foundation, a US based organization, showed by
a recent analysis that more than 79% of women experience changes
in sleep during pregnancy [2]. This problem conventionally worsens
linearly with every trimester [1]. The results of a research in USA
proved that a consequential sleep disorder in the first gestational
trimester was present in about quarter percent of women and it
increased up to 15% in the third trimester, meanwhile sleep duration
decreased progressively [3]. A study regarding inhabitants of China
*Corresponding Author: Naseem Ahmed, Department of Pathology,
Dow Medical College, Dow University of Health Sciences, Karachi,
Pakistan
Sub Date: April 20th, 2019, Acc Date: April 30th, 2019, Pub Date: May
03rd, 2019
Citation: Naseem Ahmed, Aneeqa Khan, Asra Waseem, Tooba Khan,
et al. (2019) Prevalence of Sleep Disturbances During Pregnancy – A Pilot
Study. BAOJ Gynaec 2: 019.
Copyright: © 2019 Naseem Ahmed, et al. This is an open access article
distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.
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Citation: Naseem Ahmed, Aneeqa Khan, Asra Waseem, Tooba Khan, et al. (2019) Prevalence of Sleep Disturbances During Pregnancy – A
Pilot Study. BAOJ Gynaec 2: 019.
revealed that 35.8% of women, who conceived suffered from sleep
disorders [4].
Variety of sleep disorders have been defined by Diagnostic and
Statistical Manual of Mental Disorders (4th edition) and as well as
by International Classification Of Sleep Disorder in Oxford book of
psychiatry. Among them; insomnia, snoring, restless leg syndrome are
outlined repeatedly by pregnant women in a prospective cohort study
carried out in Chicago [5]. Insomnia in pregnancy can be attributed
to physical illness (backache, nausea, hormonal changes, frequent
urination, and growth of fetus, inadequate respiration and increase in
their abdomen size as expounded in a Turkish survey [6]. Additionally,
modern data brought out a clear picture of sleep disturbances during
gestation that bred untoward pregnancy sequels which included
preterm birth and intrauterine growth retardation [2]. Also there are
details of cognitive deficits and anxiety disorders in the offspring [7].
During pregnancy, sleep changes that occurred may not be reverted
to as it was before for years [8]. An analysis conducted in Lahore has
focused on restless leg syndrome among pregnant women, where the
prevalence was found to be 22.5% [9]. In Pakistan, few researchers
have investigated sleep disturbance during gestation.
With this pilot study we aimed at exploring the quality of sleep in one
of the biggest tertiary care teaching hospital in Pakistan. Our study
served three objectives, which included enumerating the commonness
of poor sleep quality during pregnancy, factors contributing to it and
relationship of perturbation of sleep and gestational trimester.
Material and Methods
Design and Sample
This is a cross-sectional study, conducted with stratified random
sampling technique. The research was conducted at the outpatient
department and ward of obstetrics and gynecology of Ruth KM Pfau
Civil hospital Karachi, Pakistan in the duration from 15th December
2018 to 15th January 2019. The sample size for this pilot study was
30. Recruited in this study were all the pregnant women attending
gynecology and obstetrics outpatient department, who agreed to
partake in the study and were mentally sound to give informed
consent. Pregnant women with any obstetric complication, any prior
diagnosed psychiatric illness or sleep disorder were not included.
Instruments
Our questionnaire inquired about the participant’s demographic
details, gestational age and personal characteristics. We utilized
the Pittsburgh sleep quality index (PSQI) questionnaire to assess
the participant’s sleep quality. PSQI evaluates the sleep quality over
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an interim of 1 month, which was concocted by Buysse et al at
Pittsburgh in USA [10]. It contains items, which are 19 in number,
generating a total of 7 components. We obtained a global score of all
the 7 components. The poorer the sleep quality, the more the score
increases. A global score more than 5 was labelled as poor sleep
quality. This cutoff point has good psychometric properties with a
diagnostic sensitivity of 89.6% and specificity of 86.5% in ascertaining
good and poor sleepers [10].
Pregnant women who were diagnosed as having poor sleep quality
were inquired further to reveal the contributing factors. Therefore, our
questionnaire also contains other relevant questions including whether
pain in lower back, frequent leg cramps, nausea, increased vomiting,
frequent fetal movements, night awakenings due to frequent urination
and food cravings during pregnancy have disturbed the participant’s
sleep. It also inquired about nasal stuffiness, shortness of breath when
lying supine, heart burn, increase in waistline during pregnancy, any
recent life stress, previous abortions, miscarriages and complications
in previous pregnancies, anemia or decreased Hemoglobin before or
during pregnancy and family history of any sleep disorder which may
contribute to sleep disturbance.
Participants were enrolled only after taking informed, verbal
consent. A face to face interview was conducted using a pre-coded
questionnaire. Translation of the questionnaire was done for the
participants’ feasibility. In order to remove interviewer bias, the
interviewers were given training on how to ask the questions.
Statistical Analysis
Data was analyzed using SPSS version 24. Frequencies and
percentages were computed for categorical responses. Among the
three trimesters, the disparity of sleep quality was revealed by using
one way ANOVA. Pearson coefficients were computed to outline the
bivariate associations. Independent sample t test was used to establish
statistically significant relation between the probable factors and PSQI
score. Overall, p value of less than or equal to 0.05 was considered
statistically consequential.
Results
General Characteristics
30 pregnant women, aged between 18 and 37 (mean 24.07 years),
visiting the gynecology and obstetrics outpatient department during
the study period enthusiastically participated in the survey of 30
participants, 1(3.3%) was in her first trimester, 5(16.7%) were in
their second trimester and 24(80%) were from third trimester. The
demographic details are summarized in Table 1.
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Citation: Naseem Ahmed, Aneeqa Khan, Asra Waseem, Tooba Khan, et al. (2019) Prevalence of Sleep Disturbances During Pregnancy – A Page 3 of 8
Pilot Study. BAOJ Gynaec 2: 019.

TABLE 1. DEMOGRAPHIC DETAILS OF PREGNANT WOMEN (N=30) Sleep Quality

VARIABLE N(%)
Global PSQI, individual component scores and their relations with
Pre pregnancy BMI
three trimesters quantified using one-way ANOVA are tabulated in
Underweight (BMI<19) 6 (20) Table 2. The mean score of global PSQI eventuated to be 6.43 ± 2.431,
Normal weight (19 25) 15 (50) with 16(53.3%) pregnant women being sorted as having poor sleep
Overweight (25 < BMI 6 (20) quality (PSQI > 5), illustrated in Fig 1. The only participant in her
Obesity (BMI > 30) 3 (10) first trimester scored less than 5. Besides, the women having poor
OCCUPATIONAL STATUS sleep in second and third trimester were 3(60%) and 13(54.16%)
respectively. However, no significant differences of global PSQI score
House wife 30 (100)
and it’s 7 components (subjective sleep quality, sleep latency, sleep
Part time job 0 (0.0) duration, habitual sleep efficiency, sleep disturbances, use of sleeping
Full time job 0 (0.0) medication, daytime dysfunction) were established with the three
GESTATIONAL AGE trimesters (p >0.05).
First trimester 1 (3.3)
Second trimester 55 (16.7)
Third trimester 24 (80.0)
SOCIOECONOMIC STATUS
Upper class 0 (0.0)
Middle class 23 (76.7)
Lower class 7 (23.3)
TYPE OF FAMILY
Joint 28 (93.3)
Nuclear 2 (16.7)
Fig. 1. Prevalence of sleep disturbances during pregnancy

TABLE 2. DISPARITY AMONG THREE TRIMESTERS AND THE PSQI SCORE

COMPONENTS AND GLOBAL SCORE GESTATIONAL AGE F P
Mean score First trimester Second Third
trimester trimester
(n=30) (n=1)
(n=5) (n=24)
Global score 6.43 2.431 3.00 6.40 1 6.58 5 1.047 0.365
Subjective sleep quality 1.40 0.770 0.00 1.40 1.46 1.818 0.182
Sleep latency 1.67 0.994 0.00 1.80 1.71 1.524 0.236
Sleep duration 0.43 1.00 0.20 0.46 0.938 0.404
Habitual sleep efficiency 0.10 0.00 0.00 0.13 0.386 0.684
Sleep disturbances 1.60 1.00 2.00 1.54 2.813 0.078
Use of sleeping medication 0.03 0.00 0.00 0.04 0.117 0.890
Day time dysfunction 1.20 1.00 1.00 1.25 0.180 0.836

In contrast to the second trimester, third trimester scores for all the
PSQI components were higher with the exception of sleep latency and
sleep disturbances. In contradistinction with the first trimester, the
scores of all the components with the exception of sleep duration were
reportedly higher in the third trimester.
Bivariate Associations
In order to point out the correlates of sleep quality in pregnant women,
Pearson coefficients were reckoned as shown in Table 3. Though
gestational age was positively correlated with poor sleep quality yet the

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Citation: Naseem Ahmed, Aneeqa Khan, Asra Waseem, Tooba Khan, et al. (2019) Prevalence of Sleep Disturbances During Pregnancy – A Page 4 of 8
Pilot Study. BAOJ Gynaec 2: 019.

result wasn’t significant enough to warrant a direct relation between Factors Contributing To Poor Sleep Quality
the two (p >0.05). Meanwhile, maternal age and BMI were not found
to be important determinants of poor sleep quality in this pilot study. Independent samples t test was used purposefully to reveal the
possible contributing factors of poor sleep quality, the results of which
TABLE 3. Correlation coefficients between quality of sleep and other are summarized in Table 4. In this pilot study, pain in lower back,
variables
frequent leg cramps, night awakenings due to increased food cravings
Variable r P and a family history of sleep disorders were entrenched as noteworthy
Maternal age -0.086 0.653 contributing factors (p≤0.05). The number of participants answering
Pre pregnancy BMI -0.170 0.369 in approval and disapproval for individual contributing factors, asked
Gestational age 0.133 0.483 in this survey is illustrated in Fig 2.

Table 4. Factors contributing to poor sleep quality

Contributing factors Mean difference t-test significance
Pain in lower back 2.50 2.4666 0.027*
Leg cramps 3.300 4.095 0.001*
Nausea and increased vomiting 1.945 1.715 0.108
Frequent fetal movements 1.945 1.715 0.108
Night awakenings due to food cravings 3.698 5.981 0.000*
Night awakenings to frequent urination -0.744 -0.506 0.620
Nasal stuffiness -1.718 -1.219 0.243
Heart burn -0.619 -0.536 0.600
Shortness of breath on lying supine -0.919 -0.698 0.497
Recent life stress/emotional upset -1.255 -1.044 0.314
Increase in waist line -2.214 -1.345 0.200
Anemia or decreased Hemoglobin 1.255 1.044 0.314
Previous abortions or miscarriages 1.375 1.254 0.231
Family history of sleep disorders 3.357 2.236 0.042*
Complications in previous pregnancy -0.711 -0.535 0.602

Fig. 2. Possible factors contributing to poor sleep quality

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Citation: Naseem Ahmed, Aneeqa Khan, Asra Waseem, Tooba Khan, et al. (2019) Prevalence of Sleep Disturbances During Pregnancy – A
Pilot Study. BAOJ Gynaec 2: 019.
Discussion
Pregnant women face marked deterioration in sleep quality during
pregnancy [11-20].This may even lead to undesirable outcomes. Poor
sleep quality can result in pre-term birth, gestational hypertension and
cesarean section deliveries [21,22]. It can also influence birth type, birth
weight, labor length and Apgar score inimically [23]. Pathogenesis of
adverse pregnancy outcomes is directly related to inflammation [24-
27]. Raised levels of inflammatory markers (IL-6, TNF alpha, and
CRP) were found to be associated with sleep disordered breathing and
short sleep duration [28-31]. Sleep disorders increase inflammatory
and oxidative stress which damages the endothelium and deranges
metabolism resulting in hypertension or diabetes mellitus type 2 [32-
35]. Besides that pregnant women also go through excruciating labour
pain due to lack of sufficient sleep [36, 37].
The prevalence of sleep problems in our pilot study came out to
be 53.3%. Among which the three trimesters proportioned out to
be 0.00%, 54.16% and 60% in order. Mindell JA et al reported that
third trimester has increased incidence of poor sleep quality and
our results are fully assertive to their study [17]. Schweiger MS et
al and Suzuki Set al have mentioned in their publications that sleep
quality declines during the first trimester and returns back to normal
in second trimester, although 19% of participants still continue to
experience perturbed sleep [18,19]. In contrast to their findings, this
pilot study reveals that the global scores of PSQI and its components
with the exception of sleep duration are interestingly higher in second
trimester as compared to the first, yet the findings seen were from a
small sample size; therefore, the interpretation is, at best, preliminary.
Future studies in Pakistan should bring into account problems
including insomnia [38], narcolepsy, sleep disordered breathing
[39], restless leg syndrome [40] etc. which are frequently prevalent in
pregnancy [5].
Yang Y et al reported that maternal age and gestational age is
positively correlated with poor sleep quality [8]. Moreover, Hedman
C et al and Hutchinson BL et al outlined BMI as an important factor
contributing to poor sleep [41,42]. Nevertheless, in this pilot study
only gestational age was positively correlated but the result wasn’t
significant enough to merit discussion. On the contrary, no substantial
relation was established between maternal age and BMI in this survey.
Study conducted by Okun ML et al discovered that third trimester
had remarkable deteriorations in sleep quality when contrasted with
first and second trimester [43]. The results of this pilot study are
consistent with their findings. Poorer global sleep quality, subjective
sleep quality, daytime dysfunction and habitual sleep efficiency were
observed in third trimester as indicated by higher scores in table 2.
However, neither the global score nor the individual components were
significantly correlated with the three trimesters (P>0.05). Thus future
researches are still needed to explicate the divergence in sleep quality
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among the three trimesters meticulously.
Several researchers have outlined backache, urinary frequency,
spontaneous awakenings, fetal movements, increase in the abdomen
size, leg discomfort and heart burn as conspicuous factors contributing
to poor sleep [6,12,13,15,18,44-45]. This pilot study has also addressed
such relevant factors. As a result, among 16 participants, identified
as poor sleepers, 75% complained of having pain in lower back,
62.5% had frequent leg cramps, 43.75% woke up at night due to food
cravings and 12.5% had a family history of sleep disorders. The above
mentioned complains of participants had a statistically consequential
relation with Poor Sleep Quality score (p≤0.05). Other participants
also complained of nausea and vomiting, frequent fetal movements,
night awakenings due to frequent urination etc. which might have
contributed to poor sleep quality. However, no statistically significant
relation was established with PSQI score.
Limitations and Future Recommendations
The pivotal strength of this study lies in its disclosure of widespread
presence of sleep deprivation throughout pregnancy and responsible
etiologies that can be managed by adequate counseling during prenatal
visits. However, they were some limitations. We didn’t find any such
questionnaire that could have been implicated in the gestational period
alone. Several hormonal changes occur during this period including
a surge in estrogen level which decreases REM sleep duration and
exogenously administered progesterone which results in lengthening
of non REM sleep [38]. Therefore, we suggest that there is a dire need
of devising such a questionnaire. Furthermore, multiparous women
having children less than 1 to 2 years felt confused in analyzing
their sleep adequately because some of them scheduled their sleep
according to their responsibilities towards their family which may
have fabricated the results to some extent. This issue has also been
highlighted by previous researchers, who found it difficult to interpret
the results because of factors in the milieu (for instance, a crying baby)
[38]. Thus, future researchers are still needed to address this issue.
The prevalence of sleep disorders in this pilot study numbered 53.3%.
This is sufficient enough to deduce that it is a common problem during
pregnancy in Pakistan. Therefore, we advise that medical personnel
should heedfully address sleep problems and deliver sufficient guidance
during antenatal checkups. Conservative interventions are frequently
effective as shown in several studies. This includes improving sleep
hygiene, avoiding caffeine, practicing yoga and meditation techniques,
sound proofing of bedroom, limiting liquid diet after evening to
reduce nocturnal urinary frequency, application of liniments and heat
pads and managing low back pain with massage, local heat and pillow
support [46,47].Techniques to control stimulus, such as getting out
of bed in the event of prolonged awakenings and going to bed only
when sleepy, using the bed only for sleep are try worthy [48]. When
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Citation: Naseem Ahmed, Aneeqa Khan, Asra Waseem, Tooba Khan, et al. (2019) Prevalence of Sleep Disturbances During Pregnancy – A
Pilot Study. BAOJ Gynaec 2: 019.
these conservative measures are unable to work, the pharmacologic
agents of choice are diphenhydramine or zolpredem, both of which
are category B agents in pregnancy [49]. The authors also recommend
that future researches should take into account the individual sleep
disorders and their relationship with the three trimesters.
Conclusion
In conclusion, the present study demonstrated that in the course of
pregnancy the prevalence of sleep problem turned out to be 53.3% in
Pakistan. This issue should be addressed by the health care providers
for the wellbeing of both mother and her child. Current study appears
to relate pain in lower back, leg cramps, food cravings during night
and family history of sleep disorders more strongly with poor sleep.
These factors should be assimilated into a supportive template of
sleep related antenatal care. In this study neither the PSQI score nor
the sleep components significantly related with the three trimesters.
Nevertheless, third trimester had higher scores indicating decline in
sleep quality. In addition to this, maternal age, gestational age and
pre-pregnancy BMI didn’t establish any noteworthy relation with
worsening sleep quality. Hence, the empirical evidence is still scarce
and further studies are needed to reach definite conclusions.
Acknowledgement
The authors would like to acknowledge and thank Dr Nusrat Shah,
who provided us acquaintance in this research by allowing us to
conduct the study in her department of gynecology and obstetrics
and all the participants for giving their precious time to the study.
Furthermore, we would like to thank the Mr. Muhammad Arif&
Ms. Batool of Research Department of DUHS for their guidance and
support throughout the study.
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