Non-pharmacological Interventions for Improving Sleep Quality During Pregnancy: A Systematic Review and Meta-Analysis

Abstract

Objective To investigate the effect of non-pharmacological interventions to improve sleep quality during pregnancy.

Data sources A search was made in the NCBI/PubMed, ClinicalTrials.gov, Embase, BVS, and Web of Science databases. There were no limitations regarding language, sample size, and type of non-pharmacological intervention. We have included prospective clinical trials between July 2014 and July 2019.

Selection of studies This study was registered in the Prospective International Registration of Systematic Reviews (PROSPERO) database was performed. Publication bias was also assessed with funnel plots. the primary outcome was the total score in the Pittsburgh Sleep Quality Index (PSQI) before and after intervention. Risk of bias and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were used for assessing methodological quality. From the 28 retrieved studies, we have selected 8 for qualitative analysis and 6 for meta-analysis.

Data collection Two independent reviewers performed the study selection. In the case of disagreement, a third senior reviewer was consulted. The study was initially assessed based on the title, followed by abstract. Lastly, the full text was assessed to be included.

Data Synthesis A significant improvement on the sleep quality (PSQI score) was observed when all interventions were grouped (MD = -3.03, 95%CI -4.15 to -1.92, n = 623, i² = 84%, p < 0.001). Analysis by subgroup (music listening: MD = -1.96, 95% CI -3.27 to -0.65, n = 207, i² = 67%, p = 0.003 and other interventions: MD = -3.66, 95% CI -4.93 to -2.40, n = 416, i2 = 80%, p < 0.001) showed an improvement, with high heterogeneity. Risk of bias has shown performance and detection bias for almost studies, and GRADE evidence was very low for all analyzed variables.

Conclusion Non-pharmacological interventions—listening to music, physical exercise, relaxation exercises, lettuce seed, sleep hygiene, and acupressure—are effective for improving sleep quality during pregnancy.

Resumo

Objetivo Investigar o efeito de intervenções não-farmacológicas para melhorar a qualidade do sono durante a gravidez.

Fontes dos dados Uma busca foi feita nas bases de dados NBCI/PubMed, ClinicalTrials.gov, Embase, BVS, e Web of Science. Não houve limitações quanto ao idioma, tamanho da amostra e tipo de intervenção não-farmacológica. Incluímos estudos clínicos prospectivos entre julho de 2014 e julho de 2019.

Seleção dos estudos Foi realizado um registro no banco de dados Prospective International Registration of Systematic Reviews (PROSPERO). O viés de publicação foi avaliado com gráficos de funil. O desfecho primário foi a pontuação total do Pittsburgh Sleep Quality Index (PSQI) antes e depois da intervenção. O risco de viés e os critérios Grading of Recommendations Assessment, Development, and Evaluation (GRADE) foram usados para avaliar a qualidade metodológica. Dos 28 estudos encontrados, selecionamos 8 para análise qualitativa e 6 para a metanálise.

Coleta de dados Dois revisores independentes realizaram a seleção dos estudos. Em caso de discordância, um terceiro revisor foi consultado. Inicialmente o estudo foi avaliado com base no título e resumo. Para a inclusão, foi avaliado o texto completo.

Síntese dos dados Uma melhora significativa na qualidade do sono (PSQI score) foi observada quando todas as intervenções foram agrupadas (MD = -3.03, 95% CI -4.15 a -1.92, n = 623, i² = 84%, p < 0.001). A análise por subgrupo (escutar música: MD = -1.96, 95% CI -3.27 a -0.65, n = 207, i² = 67%, p = 0.003 e outras intervenções: MD = -3.66, 95% CI -4.93 a -2.40, n = 416, i2 = 80%, p < 0.001) também mostrou uma melhora da qualidade do sono, porém com alta heterogeneidade. A análise do risco de viés mostrou que quase todos os estudos avaliados apresentaram viés de desempenho e detecção, e o nível de evidência GRADE foi muito baixo para todas as variáveis analisadas.

Conclusão Intervenções não-farmacológicas - ouvir música, exercícios físicos, exercícios de relaxamento, sementes de alface, higiene do sono e acupressão - são eficazes para melhorar a qualidade do sono durante a gravidez.

Keywords

sleep quality - non-pharmacological interventions - pregnant women - systematic review - meta-analysis

Palavras-chave

qualidade do sono - intervenções não-farmacológicas - gestantes - revisão sistemática - metanálise

Publication History

Received: 30 November 2021

Accepted: 17 February 2022

Article published online:
23 May 2022

• References

• 1 Facco FL. Sleep-disordered breathing and pregnancy. Semin Perinatol 2011; 35 (06) 335-339 DOI: 10.1053/j.semperi.2011.05.018.
• 2 Pien GW, Schwab RJ. Sleep disorders during pregnancy. Sleep 2004; 27 (07) 1405-1417 DOI: 10.1093/sleep/27.7.1405.
• 3 Hutchison BL, Stone PR, McCowan LM, Stewart AW, Thompson JM, Mitchell EA. A postal survey of maternal sleep in late pregnancy. BMC Pregnancy Childbirth 2012; 12: 144 DOI: 10.1186/1471-2393-12-144.
• 4 Naud K, Ouellet A, Brown C, Pasquier JC, Moutquin JM. Is sleep disturbed in pregnancy?. J Obstet Gynaecol Can 2010; 32 (01) 28-34 DOI: 10.1016/S1701-2163(16)34400-0.
• 5 Ko SH, Chang SC, Chen CH. A comparative study of sleep quality between pregnant and nonpregnant Taiwanese women. J Nurs Scholarsh 2010; 42 (01) 23-30 DOI: 10.1111/j.1547-5069.2009.01326.x.
• 6 Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstet Gynecol 2004; 191 (06) 2041-2046 DOI: 10.1016/j.ajog.2004.05.086.
• 7 Naghi I, Keypour F, Ahari SB, Tavalai SA, Khak M. Sleep disturbance in late pregnancy and type and duration of labour. J Obstet Gynaecol 2011; 31 (06) 489-491 DOI: 10.3109/01443615.2011.579196.
• 8 Zafarghandi N, Hadavand S, Davati A, Mohseni SM, Kimiaiimoghadam F, Torkestani F. The effects of sleep quality and duration in late pregnancy on labor and fetal outcome. J Matern Fetal Neonatal Med 2012; 25 (05) 535-537 DOI: 10.3109/14767058.2011.600370.
• 9 Sut HK, Asci O, Topac N. Sleep quality and health-related quality of life in pregnancy. J Perinat Neonatal Nurs 2016; 34 (04) 302-309 DOI: 10.1097/JPN.0000000000000181.
• 10 Facco FL, Grobman WA, Reid KJ, Parker CB, Hunter SM, Silver RM. et al. Objectively measured short sleep duration and later sleep midpoint in pregnancy are associated with a higher risk of gestational diabetes. Am J Obstet Gynecol 2017; 217 (04) 447.e1-447.e13 DOI: 10.1016/j.ajog.2017.05.066.
• 11 Sharma SK, Nehra A, Sinha S, Soneja M, Sunesh K, Sreenivas V. et al. Sleep disorders in pregnancy and their association with pregnancy outcomes: a prospective observational study. Sleep Breath 2016; 20 (01) 87-93 DOI: 10.1007/s11325-015-1188-9.
• 12 Sahota PK, Jain SS, Dhand R. Sleep disorders in pregnancy. Curr Opin Pulm Med 2003; 9 (06) 477-483 DOI: 10.1097/00063198-200311000-00005.
• 13 Wu M, Li X, Feng B, Wu H, Qiu C, Zhang W. Poor sleep quality of third-trimester pregnancy is a risk factor for postpartum depression. Med Sci Monit 2014; 20: 2740-2745 DOI: 10.12659/MSM.891222.
• 14 Takzare N, Hosseini MJ, Bakhtiarian A, Takzare A, Habibi P. The teratogenic effects of flurazepam intake during organogenesis of the rat fetus. Toxicol Mech Methods 2008; 18 (09) 711-716 DOI: 10.1080/15376510801897739.
• 15 Wang LH, Lin HC, Lin CC, Chen YH, Lin HC. Increased risk of adverse pregnancy outcomes in women receiving zolpidem during pregnancy. Clin Pharmacol Ther 2010; 88 (03) 369-374 DOI: 10.1038/clpt.2010.97.
• 16 Buysse DJ, Reynolds III CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989; 28 (02) 193-213 DOI: 10.1016/0165-1781(89)90047-4.
• 17 Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD. et al; Cochrane Bias Methods Group, Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928 DOI: 10.1136/bmj.d5928.
• 18 Neri I, Bruno R, Dante G, Facchinetti F. Acupressure on self-reported sleep quality during pregnancy. J Acupunct Meridian Stud 2016; 9 (01) 11-15 DOI: 10.1016/j.jams.2015.11.036.
• 19 Kocsis I, Szilágyi T, Turos J, Bakó A, Frigy A. Effect of a gymnastics program on sleep characteristics in pregnant women. Taiwan J Obstet Gynecol 2017; 56 (02) 204-209 DOI: 10.1016/j.tjog.2017.02.001.
• 20 Shobeiri F, Khaledi S, Masoumi SZ, Roshanaei G. The effect of music therapy counseling on sleep quality in pregnant women. Int J Med Res Health Sci. 2016; 5 (9S): 408-416
• 21 Liu YH, Lee CS, Yu CH, Chen CH. Effects of music listening on stress, anxiety, and sleep quality for sleep-disturbed pregnant women. Women Health 2016; 56 (03) 296-311 DOI: 10.1080/03630242.2015.1088116.
• 22 Rodriguez-Blanque R, Sánchez-García JC, Sánchez-López AM, Mur-Villar N, Aguilar-Cordero MJ. The influence of physical activity in water on sleep quality in pregnant women: A randomised trial. Women Birth 2018; 31 (01) e51-e58 DOI: 10.1016/j.wombi.2017.06.018.
• 23 Özkan SA, Rathfisch G. The effect of relaxation exercises on sleep quality in pregnant women in the third trimester: A randomized controlled trial. Complement Ther Clin Pract 2018; 32: 79-84 DOI: 10.1016/j.ctcp.2018.05.008.
• 24 Pour ZS, Hosseinkhani A, Asadi N, Shahraki HR, Vafaei H, Kasraeian M. et al. Double-blind randomized placebo-controlled trial on efficacy and safety of Lactuca sativa L. seeds on pregnancy-related insomnia. J Ethnopharmacol 2018; 227: 176-180 DOI: 10.1016/j.jep.2018.08.001.
• 25 Sönmez A, Aksoy Derya Y. Effects of sleep hygiene training given to pregnant women with restless leg syndrome on their sleep quality. Sleep Breath 2018; 22 (02) 527-535 DOI: 10.1007/s11325-018-1619-5.
• 26 Okun ML, Coussons-Read ME. Sleep disruption during pregnancy: how does it influence serum cytokines?. J Reprod Immunol 2007; 73 (02) 158-165 DOI: 10.1016/j.jri.2006.06.006.
• 27 Mellor R, Chua SC, Boyce P. Antenatal depression: an artefact of sleep disturbance?. Arch Women Ment Health 2014; 17 (04) 291-302 DOI: 10.1007/s00737-014-0427-6.
• 28 Sedov ID, Cameron EE, Madigan S, Tomfohr-Madsen LM. Sleep quality during pregnancy: A meta-analysis. Sleep Med Rev 2018; 38: 168-176 DOI: 10.1016/j.smrv.2017.06.005.
• 29 Tomfohr LM, Buliga E, Letourneau NL, Campbell TS, Giesbrecht GF. Trajectories of sleep quality and associations with mood during the perinatal period. Sleep (Basel) 2015; 38 (08) 1237-1245 DOI: 10.5665/sleep.4900.
• 30 Okun ML, Luther JF, Wisniewski SR, Sit D, Prairie BA, Wisner KL. Disturbed sleep, a novel risk factor for preterm birth?. J Womens Health (Larchmt) 2012; 21 (01) 54-60 DOI: 10.1089/jwh.2010.2670.
• 31 Blair LM, Porter K, Leblebicioglu B, Christian LM. Poor sleep quality and associated inflammation predict preterm birth: heightened risk among African Americans. Sleep (Basel) 2015; 38 (08) 1259-1267 DOI: 10.5665/sleep.4904.
• 32 Wilson DL, Fung A, Walker SP, Barnes M. Subjective reports versus objective measurement of sleep latency and sleep duration in pregnancy. Behav Sleep Med 2013; 11 (03) 207-221 DOI: 10.1080/15402002.2012.670674.
• 33 Tsai SY, Kuo LT, Lai YH, Lee CN. Factors associated with sleep quality in pregnant women: a prospective observational study. Nurs Res 2011; 60 (06) 405-412 DOI: 10.1097/NNR.0b013e3182346249.
• 34 Park EM, Meltzer-Brody S, Stickgold R. Poor sleep maintenance and subjective sleep quality are associated with postpartum maternal depression symptom severity. Arch Women Ment Health 2013; 16 (06) 539-547 DOI: 10.1007/s00737-013-0356-9.
• 35 Volkovich E, Tikotzky L, Manber R. Objective and subjective sleep during pregnancy: links with depressive and anxiety symptoms. Arch Women Ment Health 2016; 19 (01) 173-181 DOI: 10.1007/s00737-015-0554-8.
• 36 Coo S, Milgrom J, Trinder J. Mood and objective and subjective measures of sleep during late pregnancy and the postpartum period. Behav Sleep Med 2014; 12 (04) 317-330 DOI: 10.1080/15402002.2013.801348.
• 37 Alves DA, Carvalho LB, Morais JF, Prado GF. Restless legs syndrome during pregnancy in Brazilian women. Sleep Med 2010; 11 (10) 1049-1054 DOI: 10.1016/j.sleep.2010.06.006.
• 38 Broberg L, Backhausen M, Damm P, Bech P, Tabor A, Hegaard HK. Effect of supervised exercise in groups on psychological well-being among pregnant women at risk of depression (the EWE Study): study protocol for a randomized controlled trial. Trials 2017; 18 (01) 210 DOI: 10.1186/s13063-017-1938-z.
• 39 Harano S, Oshida T, Kaneita Y, Yokoyama E, Tamaki T, Takemura S. et al. Prevalence of restless legs syndrome with pregnancy and the relationship with sleep disorders in the Japanese large population. Sleep Biol Rhythms 2008; 6 (02) 102-109 DOI: 10.1111/j.1479-8425.2008.00343.x.
• 40 Panvatvanich S, Lolekha P. Restless legs syndrome in pregnant Thai women: prevalence, predictive factors, and natural course. J Clin Neurol 2019; 15 (01) 97-101 DOI: 10.3988/jcn.2019.15.1.97.