Outlook: Newsletter of the Society of Behavorial Medicine

Winter 2025

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Maternal Morbidity and Mortality: The Overlooked Role of Sleep

Marie A. Hayes, PhD, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina - Sleep SIG

The United States continues to face a maternal health crisis. It ranks poorest in maternal morbidity and mortality outcomes among developed countries and statistics are even worse for birthing people of color, particularly Black pregnant and postpartum people.1 Researchers, clinicians and medical organizations are working to improve these outcomes through universal screening and improved access to treatment for mental health and substance use disorders, anti-racism policies and practices, and publication of practice guidelines. Despite these efforts, rates of perinatal mood and anxiety disorders continue to increase, worsening more rapidly from 2015-2020 as compared to 2008-2015,2 with postpartum depression diagnoses specifically increasing from 9.4% in 2010 to 19% in 2021.3 This may reflect improved screening, access to care or reduced stigma around seeking mental health treatment among perinatal people, but overall, the understanding of, and support provided to, pregnant and postpartum people in America remains egregiously lacking. One largely overlooked target is sleep.

Up to 80% of birthing people experience disrupted sleep during pregnancy, with prevalence increasing as pregnancy progresses.4 Disruption results from multifactorial changes: hormonal shifts, a growing fetus and uterus constricting bladder space, reduced airway patency, and general physical discomfort. Disrupted sleep has long been accepted as the rule for perinatal people rather than the exception. Is it possible that the pervasiveness of disrupted sleep, coupled with chronic under-diagnosis and treatment of sleep disorders, has led to a normalization that perpetuates poor maternal health outcomes? Consider the critical role sleep plays in mental health symptomatology. Often a bidirectional relationship, disturbed sleep can contribute to the onset or exacerbation of depressive disorders, bipolar disorders, anxiety disorders and psychotic symptoms including hallucinations and paranoia.5 Treating insomnia has been shown to improve other mental health symptoms, and vice versa. Women experiencing impaired or fragmented sleep are at risk for cardiovascular disease,6 worse cognitive functioning,7 mental health disorders8 and poor maternal and fetal outcomes.9 Birthing people with pre-existing mental10,11 and physical health conditions, like hypertension and obesity,12 may be particularly vulnerable to developing perinatal sleep disorders. Non-Hispanic Black pregnant people experience more frequent and more severe sleep disturbances compared to White pregnant people; sleep may even be a mechanism by which black women experience worse birth outcomes including higher rates of maternal morbidity and mortality compared to non-Black patients.13 Sleep disruptions also are cited as a driver of substance use, and often co-occur with initiation, maintenance and return to substance use.14 Given that the leading causes of maternal morbidity and mortality include perinatal mood and anxiety disorders (PMADS), substance use disorders, and cardiac and coronary conditions, sleep researchers and clinicians must do more to understand the critical role of sleep and its influence on maternal health outcomes, and develop interventions accordingly.15

Importantly, disordered sleep during pregnancy and postpartum, and attempts to self-manage symptoms, may impact more than just the birthing. For example, a key driver of cannabis use by pregnant people is to manage pregnancy symptoms, including disrupted sleep.16 Use of cannabis in pregnancy has been linked to poorer maternal and birth outcomes, as well as worse adolescent behavioral outcomes and is the largest risk factor for early cannabis use initiation in the exposed offspring.17–19 The gold standard of insomnia treatment, Cognitive Behavioral Therapy for Insomnia (CBT-I), has already been adapted for and tested among pregnant people, demonstrating improvement in symptoms that extends into the postpartum period.20 Despite this, access to CBT-I remains limited and many birthing people may instead turn to cannabis, which may be more widely-available than CBT-I.

As we, as a society, continue to grapple with poor maternal health outcomes, it is imperative to include sleep researchers, clinicians and policy makers in conversations exploring avenues for intervention. Understanding how to improve sleep during pregnancy and postpartum can help not only birthing people, but also their families and future generations to come.

References:

  1. Munira Z. Gunja, Evan D. Gumas, Relebohile Masitha, Laurie C. Zephyrin. Insights into the U.S. Maternal Mortality Crisis: An International Comparison. The Commonwealth Fund. Preprint posted online June 4, 2024. doi:DOI:%2010.26099/cthn-st75
  2. Zivin K, Pangori A, Zhang X, et al. Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008–20. Health Aff (Millwood). 2024;43(4):496-503. doi:10.1377/hlthaff.2023.01437
  3. Khadka N, Fassett MJ, Oyelese Y, et al. Trends in Postpartum Depression by Race, Ethnicity, and Prepregnancy Body Mass Index. JAMA Netw Open. 2024;7(11):e2446486. doi:10.1001/jamanetworkopen.2024.46486
  4. Hashmi AM, Bhatia SK, Bhatia SK, Khawaja IS. Insomnia during pregnancy: Diagnosis and Rational Interventions. Pak J Med Sci. 2016;32(4):1030-1037. doi:10.12669/pjms.324.10421
  5. Freeman D, Sheaves B, Goodwin GM, et al. The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis. Lancet Psychiatry. 2017;4(10):749-758. doi:10.1016/S2215-0366(17)30328-0
  6. Yeghiazarians Y, Jneid H, Tietjens JR, et al. Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2021;144(3):e56-e67. doi:10.1161/CIR.0000000000000988
  7. Wołyńczyk-Gmaj D, Majewska A, Bramorska A, et al. Cognitive Function Decline in the Third Trimester of Pregnancy Is Associated with Sleep Fragmentation. J Clin Med. 2022;11(19):5607. doi:10.3390/jcm11195607
  8. Swanson LM, Kalmbach DA, Raglan GB, O’Brien LM. Perinatal Insomnia and Mental Health: A Review of Recent Literature. Curr Psychiatry Rep. 2020;22(12):73. doi:10.1007/s11920-020-01198-5
  9. Xu T, Feng Y, Peng H, Guo D, Li T. Obstructive sleep apnea and the risk of perinatal outcomes: a meta-analysis of cohort studies. Sci Rep. 2014;4:6982. doi:10.1038/srep06982
  10. Nacar G, Taşhan ST. Relationship between sleep characteristics and depressive symptoms in last trimester of pregnancy. Afr Health Sci. 2019;19(4):2934-2944. doi:10.4314/ahs.v19i4.14
  11. Sanchez SE, Friedman LE, Rondon MB, Drake CL, Williams MA, Gelaye B. Association of stress-related sleep disturbance with psychiatric symptoms among pregnant women. Sleep Med. 2020;70:27-32. doi:10.1016/j.sleep.2020.02.007
  12. Dominguez JE, Habib AS. Obstructive sleep apnea in pregnant women. Int Anesthesiol Clin. 2022;60(2):59-65. doi:10.1097/AIA.0000000000000360
  13. White KM, Dunietz GL, Pitts DS, Kalmbach DA, Lucchini M, O’Brien LM. Burden of sleep disturbance in non-Hispanic Black pregnant women. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med. 2022;18(5):1319-1325. doi:10.5664/jcsm.985
  14. Roehrs TA, Roth T. Sleep Disturbance in Substance Use Disorders. Psychiatr Clin North Am. 2015;38(4):793-803. doi:10.1016/j.psc.2015.07.008
  15. Trost S, J Beauregard, Njie F. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. Published online 2022. Accessed November 14, 2025. https://www.cdc.gov/maternal-mortality/php/data-research/mmrc/index.html
  16. Besse M, Parikh K, Mark K. Reported Reasons for Cannabis Use Before and After Pregnancy Recognition. J Addict Med. 2023;17(5):563-567. doi:10.1097/ADM.0000000000001178
  17. Ryan SA, Ammerman SD, O’Connor ME, et al. Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes. Pediatrics. 2018;142(3):e20181889. doi:10.1542/peds.2018-1889
  18. Huizink AC. Prenatal cannabis exposure and infant outcomes: Overview of studies. Prog Neuropsychopharmacol Biol Psychiatry. 2014;52:45-52. doi:10.1016/j.pnpbp.2013.09.014
  19. Miller AP, Baranger DAA, Paul SE, et al. Characteristics Associated With Cannabis Use Initiation by Late Childhood and Early Adolescence in the Adolescent Brain Cognitive Development (ABCD) Study. JAMA Pediatr. 2023;177(8):861-863. doi:10.1001/jamapediatrics.2023.1801
  20. Manber R, Bei B, Suh S, et al. Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes. J Clin Sleep Med. 2023;19(8):1411-1419. doi:10.5664/jcsm.10572