Skip to main content

A scoping review of non-pharmacological perinatal interventions impacting maternal sleep and maternal mental health

Abstract

Background

A woman’s vulnerability to sleep disruption and mood disturbance is heightened during the perinatal period and there is a strong bidirectional relationship between them. Both sleep disruption and mood disturbance can result in significant adverse outcomes for women and their infant. Thus, supporting and improving sleep in the perinatal period is not only an important outcome in and of itself, but also a pathway through which future mental health outcomes may be altered.

Methods

Using scoping review methodology, we investigated the nature, extent and characteristics of intervention studies conducted during the perinatal period (pregnancy to one-year post-birth) that reported on both maternal sleep and maternal mental health. Numerical and descriptive results are presented on the types of studies, settings, sample characteristics, intervention design (including timeframes, facilitation and delivery), sleep and mood measures and findings.

Results

Thirty-seven perinatal interventions were identified and further described according to their primary focus (psychological (n = 9), educational (n = 15), lifestyle (n = 10), chronotherapeutic (n = 3)). Most studies were conducted in developed Western countries and published in the last 9 years. The majority of study samples were women with existing sleep or mental health problems, and participants were predominantly well-educated, not socio-economically disadvantaged, in stable relationships, primiparous and of White race/ethnicity. Interventions were generally delivered across a relatively short period of time, in either the second trimester of pregnancy or the early postnatal period and used the Pittsburgh Sleep Quality Index (PSQI) to measure sleep and the Edinburgh Postnatal Depression Scale (EPDS) to measure mood. Retention rates were high (mean 89%) and where reported, interventions were well accepted by women. Cognitive Behavioural Therapies (CBT) and educational interventions were largely delivered by trained personnel in person, whereas other interventions were often self-delivered after initial explanation.

Conclusions

Future perinatal interventions should consider spanning the perinatal period and using a stepped-care model. Women may be better supported by providing access to a range of information, services and treatment specific to their needs and maternal stage. The development of these interventions must involve and consider the needs of women experiencing disadvantage who are predominantly affected by poor sleep health and poor mental health.

Peer Review reports

Background

During the perinatal period, physiological changes (including hormonal changes), psychological adjustments, day to day demands of infant and self-care, and managing shifts in employment, finances and relationships all play a part in increasing a woman’s vulnerability to sleep disruption and mood disturbance (e.g., symptoms of depression and anxiety). One in five women will experience significant depressive symptoms during the perinatal period [1] and three in four women will experience insomnia symptoms [2], poor sleep quality [3] or disrupted sleep [4]. The strong bidirectional relationship between sleep and mood is well recognised. Women with greater levels of depressive symptoms report more sleep disruption [5], and women with poor sleep are more likely to experience depressive symptoms both antenatally [6, 7], and postnatally [8, 9].

The sequelae of poor sleep and mood across the perinatal period are significant. Accumulating evidence demonstrates associations between poor sleep and gestational diabetes [10], hypertension [11], pre-term birth [12] and type of birth (i.e., vaginal vs. caesarean) [13]. Studies have also shown that poor mood is associated with adverse obstetric and birth outcomes [14, 15], increased infant mortality and hospitalisation [16], decreases in the likelihood of breastfeeding initiation [17], early breastfeeding cessation [18] and disruptions in parent-baby interactions [19]. The deleterious effects of poor perinatal mental health persist beyond infancy, with children of depressed mothers having impaired or delayed developmental milestones [20] and a fivefold increase of experiencing depression themselves during adolescence [21]. Furthermore, the economic costs of perinatal mental health are significant. For example, a study assessing the costs and health-related quality of life losses over the lifetime of mothers and their children in the United Kingdom found that for all births in 2013, the costs of perinatal anxiety and depression amounted to £6.6 billion, with 60% of the costs relating to the negative impact on children [22].

The perinatal period represents a critical life stage where “there is no health without mental health” [23]. As such, the World Health Organization [24] has highlighted the urgent need for “evidence based, cost effective, and human rights oriented mental health and social care services in community-based settings for early identification and management of maternal mental disorders”. Addressing maternal mental health problems requires many approaches, and whilst pharmacotherapy is the most well studied, it is only indicated for moderate to severe illness. Less than 10% of women consider antidepressants their first choice of treatment [25] and report feeling anxious and regretful and poor adherence when continuing medications during the perinatal period [26, 27]. An international guideline review recommended the use of behavioural interventions before antidepressants as an initial therapy for mild to moderate depression [28].

A broad range of non-pharmacological interventions for improving maternal mental health are increasingly being researched and show promise in their efficacy, acceptability, and accessibility, and improving maternal wellbeing by addressing sleep difficulties is emerging as a viable treatment target. Furthermore, supporting and improving sleep in the perinatal period is not only an important outcome in and of itself, but also a pathway through which future mental health outcomes may be altered. Recent studies have shown that interventions aimed at improving perinatal sleep help reduce depressive symptoms [29, 30] and vice versa; interventions that reduce depressive symptoms assist in improving sleep [31, 32]. Previous reviews have described perinatal interventions that aim to improve sleep or improve mental health [33], or examine the relationship between sleep and mental health during either pregnancy or the postnatal period. To our knowledge, there has been no recently published review of perinatal interventions that influence both maternal sleep and maternal mental health outcomes. Given the bidirectional connections between sleep and mood, the present review is focused on intervention studies that report sleep and mood outcomes concurrently and that are delivered at any point throughout the perinatal period, pregnancy and one year postnatal inclusive.

Methods

To enable the synthesis of existing knowledge and identify the extent, range, and nature of evidence available on perinatal interventions that have measured the impact on both sleep and mood, a scoping review was conducted. Similar to systematic reviews, scoping reviews use the same systematic, rigorous approach to search databases and extract data [34], but because they are aimed at identifying knowledge gaps, setting research agendas, and/or guiding decision-making, they do not usually include a formal evaluation of the methodological quality of studies [35, 36]. The methodology outlined by Arksey and O’Malley [34], and expanded on by Levac et al. [37] and Tricco et al. [38] (including the PRISMA-ScR reporting guidelines [38]), was used to guide the study processes and reporting. This involved the following: (1) articulation of the research question (2) identification of relevant studies, (3) selection of relevant studies using an iterative team-based approach, (4) charting data, and (5) collating, summarising and reporting results. PROSPERO registration was not possible because it does not accept scoping reviews.

Identifying the research question

The intent of this review was to summarise current knowledge and identify evidence gaps in this subject area to inform policy and practice and provide recommendations for future research. The research question was defined as: ‘What is the nature, extent and characteristics of interventions developed for perinatal women that influence maternal sleep and maternal mental health?’ This will include identifying when, where and what type of studies have been conducted, describing the study methodologies (settings, sample characteristics, intervention length, facilitation and delivery measures of sleep, mood and acceptability), and summarising sleep and mood findings.

Inclusion/exclusion criteria

Full-text articles were eligible if published in peer-reviewed academic journals in the English language from 1st January 1975 to 1st April 2021. Randomised controlled trials (RCTs), randomised and non-randomised cross-over studies, and pre-post studies conducted in community, clinical, and mixed settings from any country were included provided they: a) included adequate details of an intervention (duration, methods, analysis techniques); b) the intervention covered any gestational week of pregnancy and/or postnatal week up to 12 months after birth; c) presented sufficient detail of pre- and post-intervention data (either between-group or within- group); d) defined the gestational or postnatal timeframe for intervention and data collection; and e) reported results of at least one circadian OR sleep metric AND at least one measure of mental health. Relevant sleep metrics were based on Buysse’s [39] model of sleep health and could include sleep quantity, quality, latency, continuity, daytime sleepiness and sleep timing. Objective or self-reported measures of sleep were included but measures of fatigue were excluded due to this construct being conceptually and psychometrically distinct from sleepiness [40]. Mental health measures included self-reported and clinician assessments of persistent poor mental or emotional health (such as symptoms of depression and anxiety) but excluded measures of stress (i.e., perceived level of stress, exposure to specific stressors). Pharmacological interventions were excluded as were reviews, meta-analyses, observational studies, case studies, protocols, editorials and conference abstracts. All studies were included irrespective of the sociodemographic or health profile of participants. When study criteria were not clear, authors of the original study were contacted.

Identifying the relevant studies

The search strategy was co-designed in collaboration with a medical librarian using key search terms for sleep, mood and perinatal, including synonyms and medical subject headings (MeSH terms), and was conducted in the Cochrane Library, PubMed, Medline, psycINFO, Web of Science, CINAHL Complete, and Scopus databases. These databases were systematically searched using the Boolean string: “expect* mother*” OR maternal OR pregnan* OR postnatal OR perinatal OR postpartum OR antepartum OR antenatal AND sleep* OR circadian AND mental OR psycholog* OR psychiatric OR emotional AND intervention* OR treat* OR therap* OR pilot OR feasibility. Non-peer reviewed literature and manual searches of academic manuscript reference lists were also conducted to ensure that all possible interventions matching the inclusion criteria were identified.

Study selection

Endnote reference management software was used to import and manage references. The initial search produced 4696 articles, of which 3035 were duplicates, leaving 1661 for initial screening. Titles, abstracts and keywords of the 1661 identified articles were reviewed and 1477 records were excluded because studies had no intervention component; were not conducted in the perinatal period; the article was a review, case study, protocol or editorial; the study did not include mothers in the intervention; or had no sleep and psychological data (CL). Full text records of the remaining 184 articles were read independently and a further 146 articles were excluded based on the study inclusion/exclusion criteria (CL and TLS). If there was uncertainty about the inclusion of a study, at least two members of the extended research team discussed the study and reached consensus (BS, BB, KS). This resulted in 38 studies considered central to the topic and included in the review. It should be noted that one study reported sleep outcomes for only approximately one third of their sample [41]. Two additional articles used the same sample, but each manuscript reported different sleep and mood measures. Therefore, 38 articles are listed in Table 1 but only 37 study samples/interventions are described. Unless specifically referring to the 38 articles, the remainder of the review refers to the 37 studies/study samples/interventions. Fig. 1 outlines the study selection process.

Table 1 Study and sample characteristics
Fig. 1
figure 1

Flow diagram of the study selection process

Charting the data

A data extraction form was created jointly by CL and TLS in Excel and included the study characteristics and information outlined in Tables 1, 2, 3, 4, 5, 6, 7 and Figs. 2, 3, and 4. Figures 2, 3 and 4 illustrate the number of publications per year, intervention categories/timeframes and a timeline of intervention studies respectively. Table 1 describes the author(s), year of publication, country in which the research was conducted, intervention focus and participant demographics, including gestational/postnatal age at enrolment, maternal age, parity, education level, socioeconomic position, race/ethnicity and whether participants were required to meet physical, mental or sleep-related criteria. Tables 2 and 3 summarise the sample characteristics and the sleep and mental health measures respectively. Details on each study are summarised in Tables 4, 5, 6 and 7 (depending on the type of intervention) and include study design, method of intervention delivery, facilitator, length, data collection time points, number of participants (including breakdown of enrolled/completed, case/control and retention rates), recruitment sites/methods, and the sleep and mood variable(s) assessed. A summary of sleep and mood results are also included in these tables as a secondary outcome of the review.

Fig. 2
figure 2

Publications per year

Fig. 3
figure 3

Intervention categories and time periods

Fig. 4
figure 4

Timelines of perinatal intervention studies including recruitment and intervention phases

Table 2 Sample characteristics
Table 3 Sleep and mental health measures used
Table 4 Psychological interventions
Table 5 Educational interventions
Table 6 Lifestyle interventions
Table 7 Chronotherapeutic interventions

Results

Studies were conducted in the United States (n = 12), Australia (n = 7), China (n = 5), Taiwan (n = 5), Canada (n = 3), New Zealand (n = 2), Iran (n = 1), Sweden (n = 1), and Turkey (n = 1). Fig. 2 illustrates the recent growth in this field, with 86% of studies published in the past decade (n = 32).

Demographic characteristics

Twenty-eight of the eligible study samples reported a mean maternal age between 30 and 35 years, and seven studies reporting a mean maternal age between 25 and 30 years of age. Two studies did not report maternal age [53, 75]. Table 2 summarises the parity, education level, relationship status, socioeconomic position and race/ethnicity of the study samples. Based on information provided, participants in these studies were predominantly well-educated, not socio-economically disadvantaged, in stable relationships, primiparous and of White race/ethnicity.

Eligibility criteria

Over half of the studies screened potential participants to include women experiencing moderate or severe current or previous mental health concerns and/or moderate to severe sleep disruption (n = 19, 51%). Approximately one third of study samples had no restrictions on participants physical, mental and sleep health status (n = 11, 30%). Only one study assessed potential participants to ensure those who enrolled had no problems with their physical, mental and sleep health, whereas six samples screened participants to ensure good health in one or two of these domains.

Study design

Of the 37 interventions included in this review, 26 utilised a randomised controlled trial (RCT) study design, one study was a quasi-experimental controlled trial, and 10 studies were single arm pre-post comparisons. Across all 37 interventions, 4986 participants were enrolled, and 4422 women completed the interventions (sample size range = 10 to 802, median = 85). Sample sizes were smaller in single arm studies, (total 278 participants; range 10–85) whereas RCT study designs were generally larger (total of 4513 participants; range 26–802).

Retention

Retention rates were calculated using data from each manuscript. The mean retention rate across all studies was 89% (range = 55 to 100%), with similar rates for the different study designs (84% single arm, 89% case-control).

Sleep, mood and acceptability measures

Over half the studies (51%) used the Pittsburgh Sleep Quality Index (PSQI) as a sleep measure and over three-quarters of the studies (81%) used the Edinburgh Postnatal Depression Scale (EPDS) as a mental health measure. Table 3 presents the range of sleep and mental health measures used in the studies. Nine studies used objective sleep measures and only one study used clinical interview for their mental health assessment. Just over a quarter of the studies included one or more follow-up timepoints past intervention end and less than a third reported on intervention acceptability. Just over a third of interventions were online or self-delivered, with the remaining being delivered in person.

Intervention categories

After careful review, interventions were grouped into 4 general categories to enable further description: 1) psychological, 2) educational, 3) lifestyle and 4) chronotherapeutic. Psychological interventions (n = 9) were those based on a treatment or therapy aimed at changing cognitions, attitudes or emotions and founded on psychological theories. Educational interventions (n = 15) focused on providing participants with practical information and strategies to improve or support mood or sleep (maternal or infant). Lifestyle interventions (n = 10) used a range of methods to intervene, including exercise, massage, listening to music, and consuming various herbal teas. The final category of interventions, chronotherapeutic (n = 3), included studies based around changes to the timing of the circadian system or the timing of sleep. Interventions could incorporate components from more than one category, for example, a chronotherapeutic intervention could also include some educational material but was categorised as chronotherapeutic based on the key focus of the intervention.

Figure 3 illustrates the four identified categories (inner), the focus of the intervention (middle), and the intervention timeframe (outer). Twenty-one studies were conducted in the postnatal period (57%), 14 were conducted during pregnancy (38%) and only two studies spanned both pregnancy and the postnatal period (5%). The tendency for interventions to be delivered in the postnatal period was similar across all categories of intervention, except psychological interventions, where five studies (56%) were conducted in pregnancy and four studies (44%) in the postnatal period.

Figure 4 shows the timing of recruitment and intervention phases of each study. Amongst the 14 interventions commencing in pregnancy, only one study recruited solely in the first trimester, four recruited in the first and second trimesters, seven in the second and third trimesters and three in the third trimester. The intervention phase of these studies was conducted predominantly in the second trimester; with eight conducted exclusively in the second trimester, three spanned the second and third trimesters, two studies were conducted solely in the third trimester and one commenced in the third trimester and continued into the postnatal period. Seventeen of the 22 studies conducted in the postnatal period began recruitment within 3 months of birth. Three studies began recruitment at 3 months postnatal and the remaining two studies recruited between 6 and 7 months postnatal. Across all studies, the intervention length ranged from 5 days to 6 months (mean 6.5 weeks); 26 studies (70%) lasted 6 weeks or less, eight studies (22%) lasted between 8 and 12 weeks and three studies (8%) lasted 6 months or more.

Psychological interventions

The nine psychological interventions identified in this review centred around mindfulness (n = 4) [32, 50, 55, 64] and cognitive behavioural theory (CBT) (n = 5) [30, 31, 46, 65, 68]. Table 4 provides a summary of the interventions.

CBT interventions

Characteristics

Of the five CBT interventions, three occurred during pregnancy [30, 46, 68] and two during the postnatal period [31, 65] and ranged from five to 10 weeks in duration. Three studies used CBT for insomnia (CBTi) and included information about maternal and infant sleep [30, 65, 68], while two further studies used generic CBT and focussed on maternal mental health [31, 46]. One study did not report who facilitated the intervention or how it was delivered [31], while four studies were facilitated by a trained CBT therapist or clinical psychologist, with three conducting face-to-face individual or group sessions [30, 65, 68] and one using online delivery [46]. Improving both sleep and mood were the focus of three studies [30, 31, 68], while one study concentrated on mood as a primary outcome and sleep as a secondary outcome [65] and another study did the reverse [46]. All CBT interventions recruited women experiencing either moderate to severe depressive symptoms (n = 2) [31, 46], moderate or severe insomnia (n = 2) [30, 68] or both (n = 1) [65]. Three studies reported on acceptability measures: one study reported 95% of participants found the intervention important and helpful [46]; another that 77% of participants felt “satisfied” or “very satisfied” with the care provided [31]; and a further study reported 54% of participants enjoyed the group environment and 62% enjoyed the education component [68].

Measures and findings

In general, the CBTi interventions reported improvements in both sleep and mood, with group improvements or group differences in both sleep quality and insomnia symptoms [30, 65, 68]. One of these studies reported on sleep diary and actigraphy (a validated and objective motion-based measure of sleep) results, finding sleep efficiency was improved, however they noted mixed results for other dimensions of sleep [68]. Mental health measures were improved in all CBTi studies (depression symptoms in two studies [30, 65] and depression and anxiety symptoms in the other study [68]). The two CBT studies that utilised RCT methodology largely reported improvements in mental health measures when comparing the intervention and control groups [31, 46], however one study found improvements in two measures of mental health (MADRS and GAD) but not the third (EPDS) [46]. One CBT study found improvements in self-reported sleep quality [31], but the other did not find differences between groups for insomnia symptoms [46]. There was no follow-up past the intervention end for any of the CBT intervention studies.

Mindfulness interventions

Characteristics

All four mindfulness interventions [32, 50, 55, 64] were self-delivered or administered using apps or recordings after participants were provided with instructions. Two interventions were delivered during pregnancy [50, 64] and two during the postnatal period [32, 55] and they ranged in length from two to 8 weeks duration. Three of the four studies involved women with moderate to severe depressive symptoms [32, 50, 64]; the fourth had no eligibility criteria [55]. Improving sleep and mood concurrently were the focus of three studies [32, 50, 55], while the fourth study focussed on mood as a primary outcome and sleep as a secondary outcome [64]. Three studies reported on acceptability, with two studies noting that 67 and 69% of the sample were “very” or “extremely” satisfied [32, 50], while the other study reported that 96% of participant’s had a “somewhat” or “very positive” experience [55].

Measures and findings

Overall, participants in mindfulness interventions reported improvements in both sleep and mood. Two single-arm mindfulness studies reported within-group improvements immediately post intervention for both sleep quality and mental health measures (depression symptoms) [32, 50]. Another single-arm study reported a decrease in depressive symptoms and improvements in both sleep quality and duration (but not sleep efficiency or latency) [55]. Only one mindfulness intervention had follow-up time points after the intervention end and was also the only study that used an RCT [64]. This study reported between group differences on depressive and anxiety symptoms but not on sleep quality measures. It also found within group differences in depressive symptoms immediately post intervention and in late pregnancy, but not at 6 weeks postnatal, and within group differences in anxiety symptoms immediately post intervention and at both follow-up time points.

Educational interventions

The 14 educational interventions identified in this review focussed on either maternal health (n = 5) [29, 57, 60, 73, 74], infant health (n = 5) [41, 47, 48, 59, 61] or a combination of both (n = 4) [49, 62, 63, 69, 70] (70 & 71 used the same sample). Table 5 provides a summary of the interventions.

Maternal health interventions

Characteristics

Five maternal health interventions [29, 57, 60, 73, 74] ranged from 4 to 24 weeks in duration. Four occurred during pregnancy and one during the postnatal period [57]. Four of the five studies used an RCT design, and all had similar session schedules: 1–2-hours in duration, weekly or fortnightly, over a time period of 4–12 weeks, the shortest consisting of four sessions over 4 weeks and the longest consisting of eight sessions over 12 weeks. The fifth study was a single arm pilot which ran 1–2-hour education sessions in the first, second and third trimesters of pregnancy (three sessions over 24 weeks) [29]. All five of these interventions utilised face-to-face delivery; three studies provided individual education sessions [29, 57, 74], one study used group education sessions [73] and one utilised both modes [60]. Four interventions were considered ‘individualised’, ‘tailored’ or ‘interactive’, catering to the sleep and health needs of the participant [29, 60, 73, 74]. The facilitators of the education sessions varied and included; a sleep scientist (n = 1) [29], registered nurse/midwife (n = 3) [57, 73, 74] and an allied health professional (n = 1) [60]. Two studies recruited women with either current or previous mental health symptoms [29, 74], one study included women with current mental health symptoms as well as an obstetric complication [73], and two studies had no eligibility criteria [57, 60]. The content of the interventions ranged widely. One study focussed on improving sleep [29], two centred on obstetric issues and mental health concerns [73, 74] and two had a broader lifestyle and health focus (e.g., nutrition, exercise, sleep, stress) [57, 60].

Measures and findings

Improving both sleep and mood were primary outcomes for four studies, and one study concentrated on reducing weight gain as a primary outcome and sleep and mood as secondary outcomes [60]. Significant results were found for all primary outcomes, but no change was seen for any secondary measures in these studies. The three studies measuring sleep quality and the two studies reporting on insomnia symptoms found improvements within or between groups [29, 57, 60], particularly for sleep quality, but not across all follow-up time points [29] or all dimensions of sleep [29, 57]. Two of the three studies investigating sleep duration found that intervention groups slept longer [73, 74] however the one study examining daytime sleepiness found no difference between intervention and control groups [29]. Depressive symptoms improved in three out of the six studies [29, 73, 74], but not at follow-up for one [29]. One study that examined overall psychological health found that the intervention group remained stable while the control group deteriorated [57]. The two studies examining anxiety symptoms found no difference between groups [29, 60].

Only one study reported on acceptability measures, with 86% of participants reporting the intervention was ‘definitely’ a positive experience and 93% reporting they would ‘definitely’ recommend the study to others [29]. This was also the only study to have follow-up measures past the conclusion of the intervention.

Infant sleep interventions

Characteristics

Five studies were classified as infant sleep interventions [41, 47, 48, 59, 61], ranging from 2 to 26 weeks in duration. Four of the interventions were similar, in that they were conducted solely during the postnatal period. Only one intervention spanned late pregnancy through until 4 months postnatal [47]. All studies had relatively large cohorts with between 72 and 802 enrolments and high retention rates (> 82%). Only one study had health requirements for eligibility (good mental, physical and sleep health) [59], while the remaining studies had no mental, physical and sleep health criteria.

Four of the five studies were similar in their aims and delivery style: all aimed to provide information about infant sleep and/or establish infant sleep management plans via an initial face-to-face individual session, with subsequent weekly or fortnightly follow-up sessions (either face-to-face or telephone) over a 2–8-week period [41, 48, 59, 61]. These four interventions were delivered by health professionals (midwife, paediatrician or maternal health nurse). All but one of these interventions (which did not provide information) [59], reported that the sessions were either ‘individualised’ or ‘tailored’ to the mother’s (and in one case, mother and father’s [61]) concerns about their infant’s sleep.

The fifth study varied from those above, and was a longer 6-month RCT intervention with four arms covering a more holistic range of material, primarily infant sleep, with additional support on breastfeeding, nutrition and exercise (supplementary to normal infant care from an infant health nurse) [47]. This intervention combined group and individual sessions, included partners and was facilitated by a researcher with infant sleep training and a lactation consultant.

Measures and findings

Two of the five infant sleep education interventions identified maternal sleep and mood as primary outcomes [47, 59], while another study also had maternal mood as a primary outcome, with maternal sleep as a secondary outcome [41]. The two remaining studies assessed infant sleep (n = 2) as primary outcomes with maternal mood and sleep as secondary outcomes [48, 61]. Three of the five studies had follow-up periods past the intervention end date [41, 47, 48]. Three of the five studies reported improvements in maternal sleep quality (either pre-post or between groups) immediately post intervention [41, 59, 61] and one study saw improvements at the 2-month follow-up but not immediately [48]. Maternal sleep duration results were mixed, with two studies reporting improvements (one immediately [41] and one at follow-up [48]), while two studies saw no difference or improvement [47, 61]. Four of the five studies saw improvements in maternal mood immediately post intervention [41, 48, 59, 61], however, the two studies that included follow-up at 2-months post intervention had conflicting findings on the longevity of these improvements [41, 48].

Four of the five studies measured acceptability. Helpfulness was rated in two studies; one intervention was rated by 75% of women as helpful [61] and another had ratings of 73–100% for the helpfulness of individual strategies [59] (e.g., ‘putting infant in bed, awake but drowsy’). The remaining two studies rated satisfaction and usefulness on visual analogue scales (8.2 and 8.4 (out of 9) [41], the other 7.7 and 7.3 (out of 10) respectively [48]).

Combined maternal and infant sleep interventions

Characteristics

Although there were four interventions that encompassed both maternal and infant sleep, two were very similar, being a pilot [62] and RCT [63] of the same TIPS (Tips for Infant and Parents Sleep) program. This intervention was similar to the infant interventions describe above, in that a nurse guided an initial face-to-face individual session, with subsequent weekly follow-up telephone calls over a 4- to 5-week period that were ‘individualised’ to the mother’s concerns. Another maternal/infant intervention was a 5-day intensive residential program, with a range of medical clinicians providing multidisciplinary assistance and support to mother and baby (two manuscripts providing different data on the same intervention) [69, 70]. The last maternal/infant sleep intervention was an RCT study, providing sleep information and strategies to women and their partners over two 1.5 hr. face-to-face group sessions in late pregnancy [49]. It had three follow-up data time points in the postnatal period and was facilitated by a sleep psychologist.

Measures and findings

While the TIPS pilot study found sleep duration and self-reported sleep problems were significantly different between groups (but not sleep quality, 24 hr. TST, and sleep disruptions), the full TIPS RCT did not. Mood related measures did not differ in either the pilot or full RCT. Acceptability and usability measures were well described with only one woman in the pilot [62] and eight women in the RCT indicating that would not re-participate [63]. The residential program intervention found improvements to mood outcomes and most sleep related measures (except duration) but did not report on follow-up data or program acceptability [69, 70]. The joint mother and partner RCT study focussed on sleep as a primary outcome and found differences in sleep quality and insomnia symptoms at some but not all time points [49]. No differences were seen for daytime sleepiness. Depression and anxiety symptoms were secondary outcomes, and no differences were seen on either measure. No acceptability measures were reported.

Lifestyle interventions

Eleven studies were classified as lifestyle interventions, including; drinking herbal tea (n = 3) [42, 43, 71], listening to music (n = 1) [53], massage (n = 2) [44, 56] and incorporating exercise/movement (n = 5) [45, 52, 54, 67, 72]. Table 6 provides a summary of the interventions.

Herbal tea interventions

Characteristics

The three herbal tea interventions were largely similar in design; all were RCTs requiring women to drink one cup of tea a day for 2–3 weeks and all were aimed at women experiencing poor sleep health in the early postnatal period [42, 43, 71].

Measures and findings

All three studies used the PSQS to assess sleep and the EPDS to evaluate mood (both primary measures) with measures completed immediately post intervention and an additional follow-up timepoint 2–3 weeks past the intervention end. Both the chamomile and magnolia tea interventions found the intervention group to have improved physical sleep related symptoms immediately post intervention, though not at follow-up, and fewer depressive symptoms at both post intervention time points compared to controls [42, 71]. The lavender tea intervention did not find a between group difference in sleep and although depressive symptoms were better immediately post intervention, this difference was also apparent at baseline and did not extend through to the follow-up timepoint [43]. Study samples for the three studies ranged between 80 and 112 participants and retention rates were above 90%, however none of the studies reported on intervention acceptability.

Music interventions

Characteristics

One RCT intervention explored listening to music as a strategy for improving sleep and mood [53]. This intervention was aimed at women in their second trimester experiencing poor sleep. Like the tea drinking interventions, music was self-guided over 2 weeks, with women required to listen to one of five pre-recorded CDs for a minimum of 30-minutes at bedtime.

Measures and findings

Both the intervention and control groups reported better sleep quality, with the intervention group having greater improvement compared to controls. Within and between group differences were found for anxiety symptoms at intervention end. Participant retention was 95% and there were no follow-up time points past intervention end or acceptability information.

Massage interventions

Characteristics

Two interventions utilised massage, with very different study designs. One intervention investigated the effect of ten 20-minute massages over 5 weeks for women in their second trimester, delivered by trained massage therapists [44]. The second intervention was conducted in the second half of the first postnatal year, with 123 mothers massaging their infants nightly over 2 weeks [56]. The only physical, mental or sleep health eligibility criteria was for the infant massage intervention which required mothers to be physically healthy.

Measures and findings

Even though the recipients of the massage were different, maternal sleep and mood were primary measures in both studies. Within and/or between group sleep and mood results were varied. The maternal massage study found sleep disturbance improved for the intervention group from baseline to intervention end but there was no difference for other sleep metrics [44]. This study found improvements in immediate (beginning to end of massage) depressive and anxiety symptoms and longer-term improvements (baseline to intervention end) on the PAAS Pregnancy subscale, but not on the other PAAS subscales or on the CES-D. The infant massage study found mothers in the intervention group had greater improvement in sleep quality, fewer night wakings and fewer mothers were designated as poor sleepers post intervention [56]. However, there was no difference between groups for daytime sleepiness symptoms, bedtime, sleep latency, sleep duration or the time spent awake at night. Similarly, there were mixed findings for mood, with no difference between groups for depressive or anxiety symptoms, but a significant improvement in mood from baseline to weeks one and two. This study also reported that between 83% (week one) and 91% (weeks two) of mothers were ‘somewhat satisfied’ or ‘very satisfied’ with the routine and 69% of mothers were ‘very likely’ to continue the recommended routine in the future.

Exercise/movement interventions

Characteristics

Five studies were movement or exercise-based interventions [45, 52, 54, 67, 72]. Four studies used RCT and one study employed a quasi-experimental [54] study design, with relatively large cohorts (62–140 enrolments) and high retention rates (> 82%). The sole intervention occurring in pregnancy was a weekly 20-minute tai chi/yoga group session, delivered face-to-face by a qualified yoga instructor over 3 months [45]. The four postnatal interventions were similar in design to each other, in that they involved self-delivered (after instruction) moderate to high intensity aerobic exercises involving either walking [54], gymnastic exercises [72] or home exercise equipment (stationary bicycle or treadmill) [52, 67]. Three of the four aerobic interventions lasted 3 months [54, 67, 72] with only one of these studies providing contact and support to participants throughout, via access to an online forum [67]. The fourth aerobic intervention lasted 6 months and was the only study in this category that provided 11 individualised support phone calls and also covered additional health information (stress reduction, nutrition and sleep) [52]. Three studies recruited women with either current or previous poor mental health [45, 52, 67] and one study recruited women with poor sleep [54]. The remaining study had no mental, physical and sleep health criteria [72].

Measures and findings

Three exercise interventions identified maternal sleep and mood as primary outcomes [45, 54, 72], while another study also had maternal mood as a primary outcome, with maternal sleep as a secondary outcome [52]. The remaining study assessed feasibility as its primary outcomes with maternal mood and sleep as secondary outcomes [67]. While three of the five studies had mid-intervention data collection time points, none of the five studies had follow-up periods past the intervention end date [54, 67, 72].

Only one study (the face-to-face yoga/tai chi intervention) observed between group differences on both sleep and mood [45]. The 6-month study, with support phone calls, found mixed findings for mood measures, with participants reporting fewer depressive symptoms post intervention on the EPDS and PHQ, but not when assessed using clinical interview (DSM-IV) [52]. There were also no changes in sleep in this study. The three remaining self-delivered studies had either no improvements in mood or sleep measures [67], reported significant differences in both the intervention and control groups [72] or reported a group difference on one sleep measure (fewer physical symptoms related to sleep inefficiency) mid intervention but not at intervention end [54].

Two of the five studies measured acceptability, with one study reporting specific health and wellbeing benefits (i.e., reducing muscular pain) for between 36 and 50% of participants [72]. The other study had a key focus on feasibility and acceptability and reported comprehensively on these topics [67] and whilst exact percentages were not reported, it was stated that ‘almost all women’ liked the convenience, accessibility and flexibility of the program and that ‘a majority’ of women suggested it had a positive effect on exercise engagement.

Chronotherapeutic interventions

Two studies used bright light therapy (BLT) [51, 66] and one study trialled sleep restriction in either the first or second half of the night [58]. Table 7 provides a summary of the interventions.

Bright light therapy interventions

Characteristics, measures and finding

The two BLT studies required women, who were early in the postnatal period, to wear light therapy glasses (visors) daily for 30–60 minutes within the first hour of waking. One of the BLT interventions also included a brief discussion of sleep hygiene principles prior to using the glasses [51]. This 2-week intervention, that utilised an RCT design, found no difference for either sleep or mood post intervention. This small study (n = 10) found improvements in depressive symptoms and sleep efficiency, but no improvement in other aspects of sleep. It also found a significant correlation between the phase angle difference (PAD) of melatonin and sleep onset and percent change in SIGH-SAD score (lengthening of the PAD was associated with greater improvement on SIGH-SAD). One study discussed acceptability, reporting high adherence rates to the treatment protocol and that the device was well tolerated by participants [66].

Early-night and late-night wake therapy intervention

Characteristics, measures and finding

Recruitment for this study spanned the entire perinatal period except for the 6 weeks prior to birth [58]. It involved a single-arm cross-over trial of one night of early-night wake therapy (EWT, sleep between 3:00–7:00 am) versus late-night wake therapy (LWT, sleep between 9:00 pm–01:00 am) in physically healthy women. EWT showed greater improvement in mood in depressed pregnant women compared to postnatal women; LWT showed greater improvement in mood for depressed postpartum women compared to pregnant women. Results also showed that improved mood in pregnant women after EWT was associated with smaller PAD i.e., less time between melatonin onset and sleep onset. Improved mood in postpartum women after LWT was associated with increased total sleep time. This study did not report on intervention acceptability.

Discussion

This scoping review identified and summarised the range and nature of 37 perinatal interventions that aimed to influence sleep and mood outcomes. The studies were grouped into either psychological, educational, lifestyle or chronotherapeutic categories depending on the intervention’s key focus and ranged from those grounded in sleep and circadian science to those based on complementary and alternative therapies. Our literature search showed that this field is rapidly growing, indicated by the number of studies published in the last 5 years, most frequently in developed Western countries (USA, Australia, New Zealand and Canada).

Most interventions started within 3 months of birth and were delivered across a relatively short period of time. The short delivery timeframe is likely to be advantageous from a participant burden perspective and assist with engagement and retention. However, retention rates did not appear to be lower for longer interventions. On the contrary, most studies that provided data showed high retention rates, despite occurring during a challenging and busy life stage. These high retention rates suggest that women are interested in, and are open to, support during the perinatal period, particularly in relation to sleep and mental health.

For some women, mental health concerns that commence in pregnancy are chronic and remain years later [29]. However, there is reliable evidence that intervening in sleep and mental health early in pregnancy [76], may prevent the onset of difficulties later in pregnancy and postnatally. However, only four of the 37 interventions in the review recruited women in their first trimester of pregnancy highlighting a gap in early and preventive perinatal interventions. Additionally, only two interventions spanned both pregnancy and the postnatal period and, as far as we are aware, there are no perinatal health interventions with a sleep or mental health focus that cover pre-conception to pregnancy even though women have voiced a strong desire for information at this time [77]. Future interventions may better support women by spanning a longer period and broadening their focus as factors that influence both sleep health and mental health change across this timeframe. For example, shifting from solely focusing on maternal sleep during pregnancy to also including information and strategies to support infant sleep.

Over half of the studies were conducted with women with existing sleep or mental health problems, and the sleep health and mental health of study samples were described for many of the studies, which is expected given the focus of the interventions. In contrast, there was often limited information provided on other demographic characteristics of the study samples, particularly the socioeconomic position and race/ethnicity of women. Only two interventions were specifically designed for, or trialled with, women from minority or disadvantaged groups [45, 51] (i.e., women from indigenous or minority ethnic groups, women experiencing socio-economic disadvantage, women with low education/literacy levels or teenage mothers). Interventions that meet the needs and priorities of these women are vital given women who experience disadvantage are disproportionately affected by poor mental and sleep health [78,79,80].

None of the studies reviewed explicitly stated that the interventions were designed in collaboration with women, although it is possible that this did occur but was not acknowledged. To ensure the content and focus of the information and intervention is appropriate, culturally based information is incorporated [81, 82], and suitable methods and modes of delivery are considered, interventions need to be co-designed with perinatal women, their family members, and relevant clinical, health and community stakeholders. In Aotearoa New Zealand, for example, perinatal sleep and mood interventions must be developed by or in collaboration with Māori and Pacific women, family and whānau, and Māori and Pacific health providers. This approach has been shown to be effective in the design and development of other public health interventions in minority populations [83, 84].

It is also important to note that all studies in this review were person-centric and focused on changing a woman’s thoughts or behaviour (or infant’s behaviour). Intervention at an individual level has an important role, but the structural and social determinants of mental health and sleep health, such as racism, socioeconomic deprivation, poor housing, limited education, violence, and chronic life stress are also critically important in the perinatal period [85] and must be addressed through policy and action by government and associated agencies, and community engagement [86]. Thus, alongside the development and application of perinatal interventions there must be a broader range of work to reduce the social drivers of sleep health and mental health inequities for women.

Women with existing sleep or mental health problems may also experience multiple comorbid issues including, for example, other health conditions, alcohol and substance abuse, and dietary concerns. Furthermore, in many countries, Aotearoa New Zealand included, health services that can provide support for sleep or mental health concerns and deliver interventions are very limited [87] and are often only able to engage with women who are experiencing the most severe difficulties. Findings from the review indicate that interventions can be delivered using a range of methods from online delivery with no or minimal personal contact through to live-in residential programmes. Given the restrictions created through the COVID-19 pandemic, the continued use of online information and virtual visits in delivering such interventions is important to explore, but access and effectiveness for all women must also be considered. While the reviewed interventions hold promise, barriers to accessibility and help-seeking must be taken into account and interventions may need to incorporate self-recognition of issues, encouragement to seek help and pathways to care.

Although there was some overlap between the methods used and focus of interventions, such as education in conjunction with psychological therapy, there is potential for greater integration. Together these findings suggest the following: there is space for prevention therapies to work alongside intervention models of care; that sleep and mood interventions could be integrated into routine perinatal care and support for other issues that perinatal women may be facing; and that interventions should be provided within a stepped care model and span a broader range of methods depending on the woman’s health concerns (mild vs severe symptoms, comorbid vs singular issues) or ability to participate in different formats (online vs in person delivery). For example, empirical, high quality, easily accessible information about sleep and mental health could be provided to all women via websites, apps or written material that also address a range of perinatal topics. Women that begin or continue to experience difficulties with sleep and/or their mental health need to be able to access further support in a timely manner. This might involve women being able to enrol or engage with an intervention directly and/or assessment by an informed health care provider and referral to appropriate services. Depending on the issues women face and the degree of severity, intervention options may need to be both specific (i.e., a course of bright light therapy) or broad (i.e., further education in conjunction with CBTi and admission to residential care). Proximity to care, availability of technology and therapy preference are also important options to consider when women are choosing perinatal care that is right for them.

A clear finding from the review was the lack of follow-up timepoints to determine if any improvements in either sleep or mental health persisted over longer periods of time. Those that did collect follow up data show mixed findings (long term improvement in five studies, short term but no long-term improvement in six studies, no short term or long-term improvement in eight studies, and no short-term improvement but long-term change in two studies). A recently published study found that CBTi delivered in a community sample over multiple time points during pregnancy and postpartum was associated with improved insomnia severity and sleep disturbance in late pregnancy and at 24 months postpartum, but not at 12 months postpartum [88], suggesting that within the immediate postpartum timeframe making measurable changes to sleep may be difficult to achieve but that there are long term benefits to supporting sleep at this time.

Across all interventions, a majority reported improved sleep and mood and the primary study outcomes tended to be significantly changed by the intervention. Although this sounds encouraging, it also highlights a possible bias in the publishing of studies with positive effects for sleep and mood and in the participating women who enrol in studies focused on these health outcomes.

As is the norm for scoping reviews, it was not the purpose of the present review to assess the quality or efficacy of studies or to comment on whether one category or type of intervention may be more or less effective. However, there is certainly a need for future research that evaluates the efficacy, acceptability and cost effectiveness of different types of interventions. In doing so, the clinical implications of results must also be considered. This may prove challenging, as the present review found limited and varied use of clinically significant outcome measures, such as clinically validated thresholds for sleep and mental health scales. Consideration must also be given to the rigour of measures employed in assessing intervention efficacy. Only one study in the present review utilised structured diagnostic interviews to determine the presence of mental health disorders and only nine studies employed objective measures of sleep, with the large majority relying on self-report measures. Furthermore, only 12 studies in this review reported on acceptability. It is recommended that studies seek acceptability feedback from participants to allow future perinatal interventions to be tailored and further refined to women’s needs.

Limitations of the review include limiting the review to studies published only in the English language, after 1975. The review used online databases only, but these are considered to contain most of the peer-reviewed health-related research. Accordingly, it is possible that some studies were not identified using the search strategies outlined in this paper. Exclusion of studies that did not fit the methodological criteria or were outside the designated perinatal timeframe was undertaken by one author, but the remaining 184 full text articles were considered independently for inclusion by two authors. Although important, interventions exploring infant sleep and infant health outcomes were outside the scope of this research and not included as part of this review.

Conclusions

In summary, there is a rapidly growing body of literature on sleep and mood focused interventions during the perinatal period which indicates the importance of this field. The high prevalence of sleep and mood disturbances in the perinatal period can have severe and extended repercussions for mothers, children, families and communities and perinatal sleep complaints and mental health problems remain widely under-recognised, under-researched and under-treated. Due to the strong bi-directional relationship between sleep and mood, treating or preventing issues in one area has great potential to treat or prevent concerns in the other. Sleep is also a less stigmatised pathway through which mental health concerns can be addressed. We recommend that future interventions consider supporting perinatal women over an extended period of time using a stepped-care model, such that basic sleep and mood information is readily available to all women as part of routine perinatal care which could prevent problems occurring or issues escalating, and that as required, women can access an integrated range of therapies that are specific to their needs. The development of these perinatal interventions must involve and consider the needs of women from minority groups or women experiencing disadvantage who are disproportionately affected by poor sleep health and poor mental health in the perinatal period.

Availability of data and materials

The data that support the findings of this study are available from author, T.L. Signal.

References

  1. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. J Women's Health. 2003;12(4):373–80.

    Article  Google Scholar 

  2. Sivertsen B, Hysing M, Dørheim SK, Eberhard-Gran M. Trajectories of maternal sleep problems before and after childbirth: a longitudinal population-based study. BMC Pregnancy Childbirth. 2015;15(1):129.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Yang Y, Li W, Ma T-J, Zhang L, Hall BJ, Ungvari GS, et al. Prevalence of poor sleep quality in perinatal and postnatal women: a comprehensive meta-analysis of observational studies. Front Psychiatry. 2020;11:161.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Summary of findings of the 2007 Sleep in America Poll [http://sleepfoundation.org/media-center/press-release/sleep-america-poll-summary-findings].

  5. Goyal D, Gay CL, Lee KA. Patterns of sleep disruption and depressive symptoms in new mothers. J Perinat Neonat Nurs. 2007;21(2):123–9.

    Article  Google Scholar 

  6. Dørheim SK, Bjorvatn B, Eberhard-Gran M. Insomnia and depressive symptoms in late pregnancy: a population-based study. Behav Sleep Med. 2012;10(3):152–66.

    Article  PubMed  Google Scholar 

  7. Skouteris H, Germano C, Wertheim EH, Paxton SJ, Milgrom J. Sleep quality and depression during pregnancy: a prospective study. J Sleep Res. 2008;17(2):217–20.

    Article  PubMed  Google Scholar 

  8. Bhati S, Richards K. A systematic review of the relationship between postpartum sleep disturbance and postpartum depression. J Obstet Gynecol Neonatal Nurs. 2015;44(3):350–7.

    Article  PubMed  Google Scholar 

  9. Dørheim SK, Bondevik GT, Eberhard-Gran M, Bjorvatn B. Sleep and depression in postpartum women: a population-based study. Sleep. 2009;32(7):847–55.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Qiu C, Enquobahrie D, Frederick IO, Abetew D, Williams MA. Glucose intolerance and gestational diabetes risk in relation to sleep duration and snoring during pregnancy: a pilot study. BMC Womens Health. 2010;10:17.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  11. Williams MA, Miller RS, Qiu C, Cripe SM, Gelaye B, Enquobahrie D. Associations of early pregnancy sleep duration with trimester-specific blood pressures and hypertensive disorders in pregnancy. Sleep. 2010;33(10):1363–71.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Micheli K, Komninos I, Bagkeris E, Roumeliotaki T, Koutis A, Kogevinas M, et al. Sleep patterns in late pregnancy and risk of preterm birth and fetal growth restriction. Epidemiology. 2011;22(5):738–44.

    Article  PubMed  Google Scholar 

  13. Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstet Gynecol. 2004;191(6):2041–6.

    Article  PubMed  Google Scholar 

  14. August EM, Salihu HM, Biroscak BJ, Rahman S, Bruder K, Whiteman VE. Systematic review on sleep disorders and obstetric outcomes: scope of current knowledge. Am J Perinatol. 2013;30(4):323–34.

    Article  PubMed  Google Scholar 

  15. Jarde A, Morais M, Kingston D, Giallo R, MacQueen GM, Giglia L, et al. Neonatal outcomes in women with untreated antenatal depression compared with women without depression: a systematic review and meta-analysis. JAMA Psychiatry. 2016;73(8):826–37.

    Article  PubMed  Google Scholar 

  16. Jacques N, de Mola CL, Joseph G, Mesenburg MA, da Silveira MF. Prenatal and postnatal maternal depression and infant hospitalization and mortality in the first year of life: a systematic review and meta-analysis. J Affect Disord. 2019;243:201–8.

    Article  PubMed  Google Scholar 

  17. Grigoriadis S, VonderPorten EH, Mamisashvili L, Tomlinson G, Dennis CL, Koren G, et al. The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. J Clin Psychiatry. 2013;74(4):321–41.

    Article  Google Scholar 

  18. Cato K, Sylvén SM, Lindbäck J, Skalkidou A, Rubertsson C. Risk factors for exclusive breastfeeding lasting less than two months-Identifying women in need of targeted breastfeeding support. PloS one. 2017;12(6):e0179402.

  19. Hairston I, Solnik-Menilo T, Deviri D, Handelzalts J. Maternal depressed mood moderates the impact of infant sleep on mother–infant bonding. Arch Women's Mental Health. 2016;19(6):1029–39.

    Article  Google Scholar 

  20. Tuovinen S, Lahti-Pulkkinen M, Girchenko P, Lipsanen J, Lahti J, Heinonen K, et al. Maternal depressive symptoms during and after pregnancy and child developmental milestones. Depress Anxiety. 2018;35(8):732–41.

    Article  PubMed  Google Scholar 

  21. Murray L, Arteche A, Fearon P, Halligan S, Goodyer I, Cooper P. Maternal postnatal depression and the development of depression in offspring up to 16 years of age. J Am Acad Child Adolesc Psychiatry. 2011;50(5):460–70.

    Article  PubMed  Google Scholar 

  22. Bauer A, Knapp M, Parsonage M. Lifetime costs of perinatal anxiety and depression. J Affect Disord. 2016;192:83–90.

    Article  PubMed  Google Scholar 

  23. Sattler MC, Jelsma JGM, Bogaerts A, Simmons D, Desoye G, Corcoy R, et al. Correlates of poor mental health in early pregnancy in obese European women. BMC Pregnancy Childbirth. 2017;17:1.

    Article  Google Scholar 

  24. Maternal mental health and child health and development in low and middle income countries [https://apps.who.int/iris/rest/bitstreams/52277/retrieve].

  25. Goodman JH. Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009;36(1):60–9.

    Article  PubMed  Google Scholar 

  26. Bonari L, Koren G, Einarson TR, Jasper JD, Taddio A, Einarson A. Use of antidepressants by pregnant women: evaluation of perception of risk, efficacy of evidence based counseling and determinants of decision making. Arch Women’s Ment Health. 2005;8(4):214–20.

    Article  CAS  Google Scholar 

  27. Boath E, Bradley E, Henshaw C. Women's views of antidepressants in the treatment of postnatal depression. J Psychosom Obstet Gynaecol. 2004;25(3–4):221–33.

    Article  CAS  PubMed  Google Scholar 

  28. Molenaar NM, Kamperman AM, Boyce P, Bergink V. Guidelines on treatment of perinatal depression with antidepressants: an international review. Aust N Z J Psychiatry. 2018;52(4):320–7.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Ladyman C, Signal TL, Sweeney B, Gander P, Huthwaite M, Paine SJ. A pilot longitudinal sleep education intervention from early pregnancy and its effect on optimizing sleep and minimizing depressive symptoms. Sleep Health. 2020;6:778–86.

    Article  PubMed  Google Scholar 

  30. Manber R, Bei B, Simpson N, Asarnow L, Rangel E, Sit A, et al. Cognitive behavioral therapy for prenatal insomnia. Obstet Gynecol. 2019;133(5):911–9.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Liu H, Yang Y. Effects of a psychological nursing intervention on prevention of anxiety and depression in the postpartum period: a randomized controlled trial. Ann Gen Pyschiatry. 2021;20:2.

    Article  Google Scholar 

  32. Avalos LA, Aghaee S, Kurtovich E, Quesenberry C Jr, Nkemere L, McGinnis MK, et al. A mobile health mindfulness intervention for women with moderate to moderately severe postpartum depressive symptoms: feasibility study. JMIR Mental Health. 2020;7(11):e17405.

    Article  PubMed  PubMed Central  Google Scholar 

  33. O'Connor E, Senger CA, Henninger ML, Coppola E, Gaynes BN. Interventions to prevent perinatal depression: evidence report and systematic review for the US preventive services task force. JAMA. 2019;321(6):588–601.

    Article  PubMed  Google Scholar 

  34. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

    Article  Google Scholar 

  35. Colquhoun HL, Levac D, O'Brien KK, Straus S, Tricco AC, Perrier L, et al. Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. 2014;67(12):1291–4.

    Article  PubMed  Google Scholar 

  36. Peters M, Godfrey C, McInerney P, Soares C, Khalil H, Parker D. The Joanna Briggs institute reviewers’ manual 2015: methodology for JBI scoping reviews. Adelaide: The Joanna Briggs Institute; 2015.

    Google Scholar 

  37. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69–77.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

    Article  PubMed  Google Scholar 

  39. Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014;37(1):9–17.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Shen J, Barbera J, Shapiro CM. Distinguishing sleepiness and fatigue: focus on definition and measurement. Sleep Med Rev. 2006;10(1):63–76.

    Article  PubMed  Google Scholar 

  41. Hiscock H, Wake M. Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ (Clinical research ed). 2002;324(7345):1062–5.

    Article  CAS  Google Scholar 

  42. Chang SM, Chen CH. Effects of an intervention with drinking chamomile tea on sleep quality and depression in sleep disturbed postnatal women: a randomized controlled trial. J Adv Nurs. 2015;72(2):306–15.

    Article  PubMed  Google Scholar 

  43. Chen S-L, Chen C-H. Effects of lavender tea on fatigue, depression, and maternal-infant attachment in sleep-disturbed postnatal women. Worldviews Evid-Based Nurs. 2015;12(6):370–9.

    Article  PubMed  Google Scholar 

  44. Field T, Hernandez-Reif M, Hart S, Theakston H, Schanberg S, Kuhn C. Pregnant women benefit from massage therapy. J Psychosom Obstet Gynaecol. 1999;20(1):31–8.

    Article  CAS  PubMed  Google Scholar 

  45. Field T, Diego M, Delgado J, Medina L. Tai chi/yoga reduces prenatal depression, anxiety and sleep disturbances. Complement Ther Clin Pract. 2013;19:6–10.

    Article  PubMed  Google Scholar 

  46. Forsell E, Bendix M, Holländare F, Szymanska von Schultz B, Nasiell J, Blomdahl-Wetterholm M, et al. Internet delivered cognitive behavior therapy for antenatal depression: a randomised controlled trial. J Affect Disord. 2017;221:56–64.

    Article  PubMed  Google Scholar 

  47. Galland BC, Sayers R, Cameron S, Gray AR. Heath A-LM, Lawrence J, Newlands a, Taylor B, Taylor RW: anticipatory guidance to prevent infant sleep problems within a randomised controlled trial: infant, maternal and partner outcomes at 6 months of age. BMJ Open. 2017;7:e014908.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Hiscock H, Bayer J, Gold L, Hampton A, Ukoumunne OC, Wake M. Improving infant sleep and maternal mental health: a cluster randomised trial. Arch Dis Child. 2007;92(11):952.

    Article  PubMed  Google Scholar 

  49. Kempler L, Sharpe LA, Marshall NS, Bartlett DJ. A brief sleep focused psychoeducation program for sleep-related outcomes in new mothers: a randomized controlled trial. Sleep. 2020;43(11):zsaa101.

    Article  PubMed  Google Scholar 

  50. Kubo A. mHealth mindfulness intervention for women with moderate-to-moderately-severe antenatal depressive symptoms: a pilot study within an integrated health care system. Mindfulness. 2021;12:1387–97.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Lee S-Y, Aycock DM, Moloney MF. Bright light therapy to promote sleep in mothers of low-birth-weight infants: a pilot study. Biol Res Nurs. 2013;15(4):398–406.

    Article  PubMed  Google Scholar 

  52. Lewis BA, Gjerdingen DK, Avery MD, Sirard JR, Guo H, Schuver K, et al. A randomized trial examining a physical activity intervention for the prevention of postpartum depression: the healthy mom trial. Ment Health Phys Act. 2014;7(1):42–9.

    Article  Google Scholar 

  53. Liu Y-H, Lee CS, Yu C-H, Chen C-H. Effects of music listening on stress, anxiety, and sleep quality for sleep-disturbed pregnant women. Women & Health. 2016;56(3):296–311.

    Article  Google Scholar 

  54. Liu Y-H, Chang C-F, Hung H-M, Chen C-H. Outcomes of a walking exercise intervention in postpartum women with disordered sleep. J Obstet Gynaecol Res. 2021;47:1380–7.

    Article  PubMed  Google Scholar 

  55. Mendelson T, McAfee C, Damian AJ, Brar A, Donohue P, Sibinga E. A mindfulness intervention to reduce maternal distress in neonatal intensive care: a mixed methods pilot study. Arch Women's Ment Health. 2018;21(6):791–9.

    Article  Google Scholar 

  56. Mindell JA, Lee CI, Leichman ES, Rotella KN. Massage-based bedtime routine: impact on sleep and mood in infants and mothers. Sleep Med. 2018;41:51–7.

    Article  PubMed  Google Scholar 

  57. Ozcan S, Eryilmaz G. Using levine’s conservation model in postpartum care: a randomized controlled trial. Health Care Women Int. 2020;42:794–814.

    Article  PubMed  Google Scholar 

  58. Parry BL, Meliska CJ, Lopez AM, Sorenson DL, Martinez LF, Orff HJ, et al. Early versus late wake therapy improves mood more in antepartum versus postpartum depression by differentially altering melatonin-sleep timing disturbances. J Affect Disord. 2019;245:608–16.

    Article  PubMed  Google Scholar 

  59. Rouzafzoon M, Farnam F, Khakbazan Z. The effects of infant behavioural sleep interventions on maternal sleep and mood, and infant sleep: a randomised controlled trial. J Sleep Res. 2021;30(5):e13344.

  60. Skouteris H, McPhie S, Hill B, McCabe M, Milgrom J, Kent B, et al. Health coaching to prevent excessive gestational weight gain: a randomized-controlled trial. Br J Health Psychol. 2016;21(1):31–51.

    Article  PubMed  Google Scholar 

  61. Smart J, Hiscock H. Early infant crying and sleeping problems: a pilot study of impact on parental well-being and parent-endorsed strategies for management. J Paediatr Child Health. 2007;43(4):284–90.

    Article  PubMed  Google Scholar 

  62. Stremler R, Hodnett E, Lee K, MacMillan S, Mill C, Ongcangco L, Willan A. A behavioral-educational intervention to promote maternal and infant sleep: a pilot randomized, controlled trial. Sleep. 2006;29(12):1609–15.

    Article  PubMed  Google Scholar 

  63. Stremler R, Hodnett E, Kenton L, Lee K, Weiss S, et al. Effect of behavioural-educational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial. BMJ. 2013;346:f1164.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Sun Y, Li Y, Wang J, Chen Q, Bazzano AN, Cao F. Effectiveness of smartphone-based mindfulness training on maternal perinatal depression: randomized Controlled Trial. J Med Internet Res. 2021;23(1):e23410.

  65. Swanson LM, Flynn H, Adams-Mundy JD, Armitage R, Arnedt JT. An open pilot of cognitive-behavioral therapy for insomnia in women with postpartum depression. Behav Sleep Med. 2013;11(4):297–307.

    Article  PubMed  Google Scholar 

  66. Swanson LM, Burgess HJ, Zollars J, Todd Arnedt J. An open-label pilot study of a home wearable light therapy device for postpartum depression. Arch Women's Ment Health. 2018;21(5):583.

    Article  Google Scholar 

  67. Teychenne M, Abbott G, Stephens LD, Opie RS, Olander EK, Brennan L, et al. Mums on the move: a pilot randomised controlled trial of a home-based physical activity intervention for mothers at risk of postnatal depression. Midwifery. 2020;93:102898.

    Article  PubMed  Google Scholar 

  68. Tomfohr-Madsen LM, Clayborne ZM, Rouleau CR, Campbell TS. Sleeping for two: an open-pilot study of cognitive behavioral therapy for insomnia in pregnancy. Behav Sleep Med. 2017;15(5):377–93.

    Article  PubMed  Google Scholar 

  69. Wilson N, Wynter K, Anderson C, Rajaratnam SMW, Fisher J, Bei B. Postpartum fatigue, daytime sleepiness, and psychomotor vigilance are modifiable through a brief residential early parenting program. Sleep Med. 2019;59:33–41.

    Article  PubMed  Google Scholar 

  70. Wilson N, Wynter K, Anderson C, Rajaratnam SMW, Fisher J, Bei B. More than depression: a multi-dimensional assessment of postpartum distress symptoms before and after a residential early parenting program. BMC Psychiatry. 2019;19(1):1–11.

    Article  Google Scholar 

  71. Xue L, Zhang J, Shen H, Ai L, Wu R. A randomized controlled pilot study of the effectiveness of magnolia tea on alleviating depression in postnatal women. Food Sci Nutr. 2020;8(3):1554–61.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Yang C-L, Chen C-H. Effectiveness of aerobic gymnastic exercise on stress, fatigue, and sleep quality during postpartum: a pilot randomized controlled trial. Int J Nurs Stud. 2018;77:1–7.

    Article  PubMed  Google Scholar 

  73. Zhao Y, Munro-Kramer ML, Shi S, Wang J, Luo J. A randomized controlled trial: effects of a prenatal depression intervention on perinatal outcomes among Chinese high-risk pregnant women with medically defined complications. Arch Women’s Ment Health. 2017;20(2):333.

    Article  Google Scholar 

  74. Zhao Y, Lin Q, Wang J, Bao J. Effects of prenatal individualized mixed management on breastfeeding and maternal health at three days postpartum: a randomized controlled trial. Early Hum Dev. 2020;141:104944.

    Article  PubMed  Google Scholar 

  75. Parry BL, Meliska CJ, Lopez AM, Sorenson DL, Martinez LF, Orff HJ, Hauger RL, Kripke DF: Early versus late wake therapy improves mood more in antepartum versus postpartum depression by differentially altering melatonin-sleep timing disturbances. 2019.

  76. Ladyman C, Signal TL, Sweeney B, Jefferies M, Gander P, Paine S-J, et al. Multiple dimensions of sleep are consistently associated with chronically elevated depressive symptoms from late pregnancy to 3 years postnatal in indigenous and non-indigenous New Zealand women. Aust N Z J Psychiatry. 2020;55(7):687–98.

    Article  PubMed  Google Scholar 

  77. Kamali S, Ahmadian L, Khajouei R, Bahaadinbeigy K. Health information needs of pregnant women: information sources, motives and barriers. Health Info Libr J. 2018;35(1):24–37.

    Article  PubMed  Google Scholar 

  78. Watson H, Harrop D, Walton E, Young A, Soltani H. A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. PLoS One. 2019;14(1):e0210587.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Signal TL, Paine SJ, Sweeney B, Muller D, Priston M, Lee K, et al. The prevalence of symptoms of depression and anxiety, and the level of life stress and worry in New Zealand Māori and non-Māori women in late pregnancy. Aust N Z J Psychiatry. 2017;51(2):168–76.

    Article  PubMed  Google Scholar 

  80. Signal TL, Paine SJ, Sweeney B, Priston M, Muller D, Smith A, et al. Prevalence of abnormal sleep duration and excessive daytime sleepiness in pregnancy and the role of socio-demographic factors: comparing pregnant women with women in the general population. Sleep Med. 2014;15(12):1477–83.

    Article  PubMed  Google Scholar 

  81. Baddock SA, Tipene-Leach D, Williams SM, Tangiora A, Jones R, Iosua E, et al. Wahakura versus bassinet for safe infant sleep: a randomized trial. Pediatrics. 2017;139(2):e20160162.

    Article  PubMed  Google Scholar 

  82. James R, Hesketh MA, Benally TR, Johnson SS, Tanner LR, Means SV. Assessing social determinants of health in a prenatal and perinatal cultural intervention for American Indians and Alaska natives. Int J Environ Res Public Health. 2021;18(21):11079.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Pulu V, Tiatia-Sheath I, Borman B, Firestone R. Investigating principles that underlie frameworks for Pacific health research using a co-design approach: learnings from a Tongan community based project. Pacific Health Dialog. 2021;21(7):399–406.

    Article  Google Scholar 

  84. Firestone R, Faeamani G, Okiakama E, Funaki T, Henry A, Prapaveissis D, et al. Pasifika prediabetes youth empowerment programme: evaluating a co-designed community-based intervention from a participants’ perspective. Kōtuitui. 2021;16(1):210–24.

    Google Scholar 

  85. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Cornwall A. Unpacking ‘participation’: models, meanings and practices. Commun Dev J. 2008;43(3):269–83.

    Article  Google Scholar 

  87. Sambrook Smith M, Lawrence V, Sadler E, Easter A. Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK. BMJ Open. 2019;9(1):e024803.

    Article  PubMed  PubMed Central  Google Scholar 

  88. Bei B, Pinnington DM, Quin N, Shen L, Blumfield M, Wiley JF, et al. Improving perinatal sleep via a scalable cognitive behavioural intervention: Findings from a randomised controlled trial from pregnancy to 2 years postpartum. Psychol Med. 2021;7:1–11.

    Article  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge the involvement of Professor Jane Fisher as a member of the research team and Ms. Bice Awan and Ms. Meisha Nicholson as study advisors. Thank you also to Mr. James Duncan for his assistance with the literature search.

Funding

This work was supported by the New Zealand Health Research Council (HRC grant number 20/937).

Author information

Authors and Affiliations

Authors

Contributions

TLS conceptualised the study idea. CL and TLS developed the study design, screened articles, performed data assessment, analyses and interpretation, and drafted the manuscript. BS, BB and KS contributed to study design, data interpretation and revised the manuscript. All authors revised the manuscript, contributed to the editorial preparation of this paper, and have read and approved the final version of the manuscript.

Corresponding author

Correspondence to T. Leigh Signal.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The author(s) declare there are no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ladyman, C., Sweeney, B., Sharkey, K. et al. A scoping review of non-pharmacological perinatal interventions impacting maternal sleep and maternal mental health. BMC Pregnancy Childbirth 22, 659 (2022). https://doi.org/10.1186/s12884-022-04844-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12884-022-04844-3

Keywords