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A Systematic Review of the Relationship Between Postpartum Sleep

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Article  in  Journal of Obstetric Gynecologic & Neonatal Nursing · March 2015

DOI: 10.1111/1552-6909.12562

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JOGNN REVIEW

A Systematic Review of the

Relationship Between Postpartum Sleep
Disturbance and Postpartum Depression
Sue Bhati and Kathy Richards

Correspondence
Sue Bhati, Northern
Virginia Community
College, 6699 Springfield
Center Drive, Room 326 I,
Springfield, VA 22150.
sbhati@nvcc.edu
Keywords
postpartum sleep and
postpartum depression
postpartum sleep
disturbances
effect size
systematic review
ABSTRACT
Objective: To examine the relationship between postpartum sleep disturbance and postpartum depression and describe
the characteristics and demographics of the samples.
Data Sources: Electronic databases Medline, PubMed, Cochrane, EPOC, CINAHL, ProQuest, and Psych INFO. In
addition, hand searches of bibliographies supplemented the electronic search.
Study Selection: English language primary studies on the relationship between postpartum sleep disturbance and
postpartum depression were included. Thirteen observational studies met the inclusion criteria.
Data Extraction: Data that specified the relationship between sleep disturbance and postpartum depression were
extracted from the studies. The data were organized per author, year, participants, setting, country, demographics,
design, sample size, outcomes, evidence, and effect size.
Data Synthesis: The effect size indicating the relationship between sleep disturbance and postpartum depression
across the studies ranged between 0.4 and 1.7. There was evidence of a strong relationship between sleep disturbance
and postpartum depression; however, the participants in the 13 studies were predominantly educated, middle class,
older than age 30 years, and White. Likewise, the definition and measurement of postpartum sleep varied across the
studies, which increased the possibility of bias.
Conclusions: Further research within the postpartum period involving underserved, younger women and samples with
more diversity in race and ethnicity are needed.
JOGNN, 44, 350-357; 2015. DOI: 10.1111/1552-6909.12562
Accepted January 2015

Sue Bhati, PhD, FNP-BC,

ike nutrition and exercise, sleep is a de- later, are more likely to experience sleep distur-
NP-C, MSN, RN, is a
professor at Northern
Virginia Community
L terminant of health and illness (Institute of
Medicine, 2006). An adequate night of sleep for
bance than all other women.

College, Springfield, VA
and a family nurse
practitioner at My Urgent
Care, Alexandria, VA.
Kathy Richards, PhD,
FAAN, RN, is a professor
and assistant dean of
Doctoral Programs and
Research Development,
School of Nursing, College
of Health and Human
Services, George Mason
University, Fairfax, VA.
The authors report no con-
flict of interest or relevant
financial relationships.
a healthy adult is falling asleep within 5 to 10
minutes after the light is turned off, sleeping at
least 7 hours, and spending less than 10% of the
night awake, (Lee, 1998, 2007). Nocturnal sleep
when longer or shorter than 7 to 8 hours is sig-
nificantly associated with cardiovascular disease,
metabolic syndrome, automobile and workplace
accidents, learning struggles, memory deficits,
fibromyalgia, and increased mortality (Holshoe,
2009; Krueger & Friedman, 2009). In addition,
there is a sleep disparity between the sexes,
with women having shorter sleep durations (Baker,
Wolfson, & Lee, 2007; Chang, Pien, Duntley, & Ma-
cones, 2010; Lee, & Caughey, 2006; Moore, Adler,
& Williams, 2002; Soares & Murray, 2006). Women
in the postpartum period, defined as the interval
between the birth of the infant and 6 to 8 weeks
Postpartum sleep disturbance is a combination of
sleep deprivation and sleep fragmentation (Lee,
1998). Sleep deprivation is sleep loss, and sleep
fragmentation is frequent awakenings after sleep
onset (Lee, 2007). Among postpartum women,
primiparous women experience the greatest in-
cidence of sleep disturbance (Kennedy, Gay,
Gardner, & Lee, 2007). Postpartum sleep dis-
turbance begins after birth and may persist for
6 to 12 months until the infant sleeps through
the night (Dennis & Ross, 2005; Hiscock et al.,
2007). Kennedy et al. (2007) explored sleep in a
purposive sample of 20 postpartum women. The
women described their sleep loss as extreme, re-
sulting in exhaustion and impatience with their
partners. In addition, the women lost the ability
to concentrate and lowered their expectations of

350 
C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org
Bhati, S., and Richards, K.
motherhood to include a poor quality of life with
sleep disturbances and fatigue.
Although postpartum sleep disturbance is not a
disease, it is associated with a poor quality of
life, a decrease in daytime attentiveness (Rych-
novsky & Hunter, 2009), and a lack of general
wellness (Letourneau et al., 2012; Moline, Broch,
Zak, & Gross, 2003) that affects the postpartum
woman, her infant, and her family (Letourneau
et al., 2012). More importantly, postpartum sleep
disturbance may be a risk factor for postpartum
depression (Dorheim, Bondevik, Eberhard-Grad,
& Bjorvatn, 2009; Lumley & Austin, 2001). Post-
partum depression carries serious implications for
the postpartum woman’s health and the health
of her infant (Corwin & Pajer, 2008; Letourneau
et al., 2012).
Minor depression does not meet full criteria
for a major depression disorder but includes
two symptoms of depression that are present
for 2 weeks (American Psychiatric Association
[APA], 2013). However, postpartum depression
is classified as a major depression episode in
the Diagnostic and Statistical Manual of Mental
Disorders (DSM) (APA, 2013). The criteria for a
diagnosis of major depression are three of the
following consistent symptoms for a period of
2 weeks or more: a depressed mood, insomnia
or hypersomnia, impaired concentration, loss of
pleasure, worthlessness or guilt, anxiety, fatigue,
irritability, and recurrent thoughts of suicide or
death (APA, 2013; Daley, MacArthur, & Winter,
2007). Perinatal mood disorders are one of
the most common complications of childbirth
(Letourneau et al., 2012). Approximately, 10%
to 17% of new mothers experience diagnosable
postpartum depression (Centers for Disease Con-
trol and Prevention [CDC], 2012; Letourneau et al.,
2012; Ross, Murray, & Steiner, 2005; Ugarriza,
2002; Wolfson, Crowley, Anwer, & Bassett, 2003).
Biological and psychosocial factors may con-
tribute to postpartum depression. Biological fac-
tors include the circadian rhythm disturbance
(sleep disturbance) due to infant nighttime feed-
ing and extensive hormonal shifts after giving
birth (Lee, 1998). Shifts in estrogen, progesterone,
prolactin, thyroid, cortisol, and hemoglobin are
known to affect mood disorders (Lee, Zafke, &
McEnany, 2000b; Okun et al., 2011; Ross et al.,
2005). Supplementation with estradiol showed im-
provement in postpartum depression (Ahokas,
Kaukoranta, Wahlbeck, & Aito, 2001). Additionally,
hypothyroidism and anemia must be ruled out be-
JOGNN 2015; Vol. 44, Issue 3
REVIEW
Sleep may be one of the few modifiable risk factors for
postpartum depression but evidence for the strength of this
relationship is lacking.
fore initiating therapy for postpartum depression
(Corwin, Murray-Kolb, & Beard, 2003; Horowitz &
Goodman, 2005). Psychosocial factors include
prenatal depression, stress related to child care,
infant temperament, infant gender, infant health
problems, low self-esteem, and poor social sup-
port (Corwin & Pajer, 2008; Dennis & Chung-
Lee, 2006; Friedman, Resnick, & Rosenthal, 2009;
Glavin & Leahy-Warren, 2013; Lee & Gay, 2004).
In qualitative studies with postpartum depressed
mothers, the mothers spoke of being unable to
care for themselves and their infants, having harm-
ful thoughts and feelings toward their infants, and
little to no interest in them (Amankwaa, 2003;
Barr & Beck, 2008; Beck, 1992; Chan, Levy,
Chung, & Lee, 2002; Hall, 2006; Lauer-Williams,
2001; Meighan, Davis, Thomas, & Droppleman,
1999; Ugarriza, 2002). Despite the large body
of literature on sleep and mood disorders,
the association between sleep disturbance and
postpartum depression remains ambiguous. Post-
partum depression is multifactorial in nature, and
postpartum depression and sleep disturbances
have many similar symptoms.
Sleep may be one of the few modifiable risk fac-
tors for postpartum depression, but evidence for
the strength of this relationship is lacking. The pur-
pose of this systematic review was to examine the
strength of the relationship between sleep distur-
bance and postpartum depression in postpartum
women.
Methods
Literature Search Strategy
A systematic review was conducted following the
Preferred Reporting Items for Systematic Reviews
and Meta-Analysis (PRISMA) guidelines (Moher,
Liberati, Tetzlaff, & Altman, 2009). We searched
for published, peer reviewed English language
primary research articles using the electronic
databases Medline, PubMed, Cochrane, EPOC,
CINAHL, ProQuest, and Psych INFO. Inclusion cri-
teria for relevant articles were as follows: quan-
titative research studies (including systematic
reviews) on the relationship between sleep
disturbance and depression in postpartum
women and published in peer reviewed journals
351
REVIEW A Systematic Review of the Relationship Between Postpartum Sleep Disturbance and Postpartum Depression

# of records identified through # of additional records = 3

electronic search = 113

# of records after inclusion criteria applied

and duplicates removed = 33

# of records screened = 33 # of records excluded

=20

# of full-text articles # of full-text articles

assessed for eligibility=
13
# of studies included in
qualitative synthesis = 0
# of studies included in
quantitative systematic
review =13
excluded, =20
Reasons for exclusion:
case reports (1),
depression in
pregnancy (2), sleep
and depression in
adoptive parents (1),
infant sleep and
postpartum depression
(5), sleep deprivation to
treat depression in
postpartum (2),
postpartum fatigue,
obesity, and infant
temperament (5),
postpartum outcomes
(2), and postpartum
psychosis (2).

Figure 1. Literature search.

between the years 1990 and 2014 (Figure 1). The

search terms postpartum sleep and postpartum
depression yielded 113 articles. Further search
terms limited to postpartum sleep disturbances,
postpartum sleep deprivation, and postpartum
depression reduced the list to 33 articles. After
a full text review of each article, 13 studies met
inclusion criteria for this systematic review.
Data Extraction
Data specifying the relationship between sleep
disturbance and postpartum depression were ex-
tracted. All the articles were independently re-
viewed and organized using the matrix method
of organizing literature (Garrard, 2011) per author,
year, participants, setting, country, demograph-
ics, design, sample size, outcomes, evidence,
and effect size (see Table 1 supplied as sup-
plemental information to the online version of this
article at http://jognn.awhonn.org). No systematic
reviews met the inclusion criteria for the relation-
ship between sleep disturbance and postpartum
depression.
Risk of Bias
The evidence was graded according to the
Grading, Recommendations, Assessment, De-
velopment, and Evaluation (GRADE) approach
(Balshem et al., 2011; Guyatt, Oxman, Sultan,
Glasziou, & Coello-Alonso, 2011). This approach
is used by the Cochrane collaboration to spec-
ify evidence quality as high, moderate, low, and
very low (Balshem et al., 2011; Guyatt et al.,
2011). Based on this methodology, randomized
controlled trials are usually graded as high and
observational studies are usually graded as low.
Observational studies can be upgraded based on
one or more of the following three criteria: large ef-
fect sizes, dose-response gradients, and control
of confounders (Balshem et al., 2011).
Magnitude of the Relationship
Effect size is an indicator for the strength of a rela-
tionship (Polit & Beck, 2012) and can be small
(.2–.4), medium (.5–.7), large (.8–1), and very
large (1.1–2) (Cohen, 1988). To evaluate the

352 JOGNN, 44, 350-357; 2015. DOI: 10.1111/1552-6909.12562 http://jognn.awhonn.org

Bhati, S., and Richards, K.
magnitude of the relationship between sleep dis-
turbance and postpartum depression, we calcu-
lated effect sizes for nine studies from available
data. Dorheim et al. (2009) also reported the ef-
fect sizes for sleep disturbance and postpartum
depression in their study.
Results
Characteristics of the Studies
The common purpose among the studies was
to examine or describe postpartum sleep distur-
bances and the relationship to postpartum de-
pression and/or depression symptoms. All the
studies contained in this review are described
in Table 1, which is supplied as supplemen-
tal information to the online version of this arti-
cle at http://jognn.awhonn.org. The women were
recruited from hospitals, child birth classes,
obstetricians’ offices, and women’s clinics. At
recruitment, the women were in the third trimester
of pregnancy, postpartum, and one day to 8
months after delivery. Some of the women were in
the third trimester of pregnancy for baseline data
collection, and a few researchers compared sleep
during pregnancy with postpartum sleep distur-
bance and depression. However, we examined
only postpartum sleep disturbance and postpar-
tum depression.
Of the 13 studies in our review, four were published
during 1998 to 2003, and the remaining nine were
published between 2007 and 2013. Nine studies
were conducted in the United States, two in Aus-
tralia, and one each in Norway and Taiwan. A total
of 3,793 postpartum women participated in the in-
cluded studies, with sample sizes ranging from
22 to 2,870. The participants were between age
18 and 47 years (M = 32.41, SD = 4.71). The ma-
jority of the women (90%) were White, married or
partnered, middle class, and or socially advan-
taged. The women were primiparous (52%) and
multiparous (48%).
Design
The design of a majority of the studies (11) was
prospective longitudinal observational. Of the re-
maining two studies, one was a case control and
the other was a survey. A majority (11) of the
researchers indicated that they determined the
sample size based on standard power = .80,
α = .05, and a small to medium effect size.
Measures
Sleep measures. Sleep disturbance was mea-
sured with subjective and objective instruments.
JOGNN 2015; Vol. 44, Issue 3
REVIEW
The purpose of this systematic review was to examine the
strength of the relationship between sleep disturbance and
postpartum depression in postpartum women.
In four studies, only subjective measures of sleep
were used (Dorheim et al., 2009; Goyal, Gay, &
Lee, 2007, 2009; Huang, Carter, & Guo, 2004).
The remaining studies contained subjective and
objective measures.
The timing and measurement of sleep with objec-
tive measures (actigraphy, polysomnography, or
electroencephalography) varied among the stud-
ies. In three studies, the authors measured sleep
for 48 hours, whereas in four they measured
it for 7 days, and in two they measured it for
7 days at each time point. Some researchers mea-
sured sleep from Day 1 whereas others began 2 to
4 weeks later and long after the postpartum
period. No rationale was provided regarding
the specific durations or timing of actigraphy,
polysomnography, or electroencephalography.
Depression measures. In the majority of the stud-
ies (11), researchers measured depression with
subjective measures. Objective measures such
as structured clinical interviews and the Research
Diagnostic Criteria (Spitzer, Endicott, & Robbins,
1978) were used in two studies (Posmontier, 2008;
Tsai & Thomas, 2012) in addition to the self-report
measures.
Data Analysis and Findings From the
Studies
Dorheim et al. (2009) reported a large, very large,
and medium effect size of the relationship be-
tween sleep disturbance and postpartum depres-
sion. The odds ratios more than two (Dorheim
et al., 2009) and more than four (Huang et al.,
2004) were reported in two studies. In four stud-
ies, the researchers reported sleep disturbance,
which explained 35%, 46%, 37%, and 41% of
the variance in depression, respectively (Bei, Mil-
gron, Ericksen, & Tindler, 2010; Calcagni, Bei,
Milgrom, & Trinder, 2012; Goyal et al., 2007,
2009). In two studies researchers used univari-
ate ANOVA to analyze the differences between
depression scores, subjective sleep, and objec-
tive sleep across Times 1 through 4, p = .001. In
three studies, researchers (Park, Meltzer-Brody, &
Stickgold, 2013; Wolfson et al., 2003) found that
subjective sleep was significantly associated with
depression, p = .05. The η2 was not reported.
In one study, Tsai and Thomas (2012) reported
353
REVIEW A Systematic Review of the Relationship Between Postpartum Sleep Disturbance and Postpartum Depression

that sleep disturbance correlated with increased
depression scores r = .51. Bei et al. (2010) and
Park et al. (2013) found that subjective perception
of sleep disturbance but not objective sleep was
associated with increased depression p = < .001.
In two studies, the researchers found poor sleep
quality predicted postpartum depression p = .05
(Okun et al., 2011; Posmontier, 2008).
tion, the inconsistent timing of the measurement
of sleep involved the risk of bias. Sleep was mea-
sured at 48 hours, 7 days, or months after the post-
partum period ended. Further, selection bias was
increased in the individual studies and across the
studies by the selection of a predominantly White,
middle to high-income population.

Strength of the Evidence

Discussion
Findings from the studies contained in this review
To quantify the strength of the relationship between
revealed a consistent and significant relationship
sleep disturbance and postpartum depression we
between sleep disturbance and postpartum de-
calculated effect sizes from available data. With
pression. Similarly, except for one study with a
the exception of one study (Dorheim et al., 2009),
small effect size (0.4), the effect sizes ranged from
researchers associated with the remaining studies
moderate to large and very large (0.6–1.7), indi-
did not report their effect sizes. Based on means
cating a strong relationship between sleep distur-
and standard deviations and/or R2 our calcu-
bance and postpartum depression. Nonetheless,
lated effect sizes for subjective sleep disturbance
because one of the symptoms of depression is
and postpartum depression were as follows: small
sleep disturbance (APA, 2013; Soares & Murray,
(Huang et al., 2004), medium (Calcagni et al.,
2006), other possible biological and psychoso-
2012), large (Goyal et al., 2007; Tsai & Thomas,
cial factors must be considered to better under-
2012), and very large (Bei et al., 2010; Goyal et al.,
stand the relationship between sleep disturbance
2009; Wolfson et al., 2003). Our calculated effect
and postpartum depression. Future investigators
sizes for objective sleep disturbance and postpar-
should consider these mediating and moderat-
tum depression were medium (Goyal et al., 2009;
ing factors and screen for depression pre and
Lee, Zafke, & McEnany, 2000a; Posmontier, 2008).
postnatally.
Further, Dorheim et al. (2009) reported medium,
large, and very large effect sizes. We could not
Consistent with the findings of Hunter and Rych-
calculate effect sizes for three studies due to in-
novsky, and Yount (2009), we found small sam-
sufficient data provided. Additionally, with the ex-
ple sizes, a variety of study designs, and various
ception of one study (Dorheim et al., 2009), the
definitions of the postpartum period. Postpartum
authors did not specify which variables were con-
sleep disturbance and postpartum depression re-
trolled, only that they controlled for all extraneous
search are challenging to conduct because of
variables.
the inconvenience for this already overburdened
population. Postpartum women are in transition
The findings from all 13 studies revealed a con-
and learning their new mothering roles. These
sistent strong relationship between sleep distur-
circumstances may in part account for the vari-
bance and postpartum depression. Additionally,
ability in the measurement of postpartum sleep.
the effect sizes for the strength of the relation-
However, the large and very large effect sizes
ship between sleep disturbance and postpartum
for the relationship between sleep disturbance
depression ranged from small, medium, large, to
and postpartum depression suggest a strong
very large. Only one study had a small effect size
relationship.
(.4). Using the GRADE approach, the studies were
upgraded to high because a majority of them con-
The principal findings of this review were
sisted of large or very large effect sizes, and/or ex-
as follows: (a) postpartum sleep disturbances
traneous variables were controlled. As such, the
are associated with postpartum depression,
evidence was rated as strong.
(b) associated factors for this risk are not known
or understood, (c) perception of inadequate sleep
Risk of Bias in Individual Studies and is associated with sleep disturbance and post-
Across Studies partum depression, (d) studies focused on pri-
The studies were assessed for measurement and mary prevention strategies to increase sleep
observation bias. In four studies only subjective and the causality between sleep disturbance
measures were used. Therefore, in these studies and postpartum depression are lacking, and
the risk for recall bias was increased. In addi- (e) qualitative studies on the lived experience of

354 JOGNN, 44, 350-357; 2015. DOI: 10.1111/1552-6909.12562 http://jognn.awhonn.org

Bhati, S., and Richards, K.
postpartum sleep disturbances and postpartum
depression are lacking.
Strengths and Limitations of This
Review Method
A strength of our review was that we used the
GRADE approach to minimize the risk of bias and
enhance the clarity of the findings. A statistician
and a research analyst reviewed the calculated
effect sizes. Limitations of our review were that the
first author reviewed the articles independently,
only studies published in English were included,
and we did not include any unpublished gray
literature.
Strengths and Limitations of the
Evidence From the Review
The primary strength of evidence from this review
was a consistent strong positive association be-
tween sleep disturbance and postpartum depres-
sion. The 13 studies included in our review had
several strengths. Researchers used prospective
longitudinal designs in nine studies, which re-
duced recall bias. All the researchers used valid
and reliable tools for measuring sleep disturbance
and postpartum depression. All the researchers
used methods for control of potential confounding
factors, which allowed for more accurate interpre-
tation of the results. Additionally, eight of the stud-
ies had adequate to large sample sizes lending
power to the findings.
The limitation of the evidence is that most re-
searchers did not specify which confounding fac-
tors were controlled, and five used small sample
sizes ranging from 22 to 38. In addition, across
the studies, the definition of the length of postpar-
tum was loose with postpartum defined as any-
time from Day 1 to 6 months after birth. There-
fore, the measurement of postpartum sleep lacked
precision, and data frequently were collected af-
ter the 6- to 8-week postpartum mark (Dorheim
et al., 2009; Goyal et al., 2007, 2009; Park et al.,
2013; Posmontier, 2008; Tsai & Thomas, 2012).
Two sets of authors measured postpartum sleep
the first day while the women were still hospi-
talized (Bei et al., 2010; Calcagni et al., 2012).
Several other researchers collected sleep data at
the third trimester of pregnancy and at several
points between 1 to 24 weeks postdelivery (Goyal
et al., 2007, 2009; Park et al., 2013; Wolfson et al.,
2003). Similarly, a majority of the researchers used
actigraphy at varied times for a period of 48 hours
to 7 days although the postpartum period is 6
JOGNN 2015; Vol. 44, Issue 3
REVIEW
There is a strong relationship between sleep disturbance and
postpartum depression. However, associated factors for this
risk are not known or understood.
to 8 weeks. The above-mentioned limitations in-
creased recall and observational bias across the
studies.
Applicability and Implications From the
Findings
Although a majority of the studies were conducted
in the United States, four occurred in other coun-
tries. However, a majority (90%) of the partici-
pants were White women belonging to middle and
higher socioeconomic groups. Research is lack-
ing on the relationship between postpartum sleep
and depression symptoms in disadvantaged pop-
ulations and in women of diverse racial and ethnic
backgrounds. In addition, the mean age of the par-
ticipants was 32.4 years. Also lacking is research
on the effect of sleep disturbances and postpar-
tum depression in younger mothers between ages
18 and 25. Therefore, the applicability of these
findings is limited to White, educated, postpar-
tum woman older than age 30. Nurses and other
health care professionals can use this evidence
in clinical settings to counsel women during preg-
nancy about the importance of sleep and the rela-
tionship between sleep disturbance to postpartum
depression.
Recommendations for Future Research
From the Findings
Future researchers should consider mediating
and moderating factors and screen for depres-
sion pre- and postnatally to better understand
this relationship. Investigators should design stud-
ies within the standardized definition of postpar-
tum, that is, the first 6 to 8 weeks after birth
and measure sleep for that entire duration in
order to better understand the nature of sleep
disturbance, postpartum depression, and the
contextual factors surrounding this relationship.
Researchers should also use samples of dis-
advantaged, younger, postpartum women and
women with diverse racial and ethnic back-
grounds.
Conclusion
Strategies to improve sleep in any postpar-
tum setting may lead to improved mental and
physical well-being and enhanced enjoyment of
355
REVIEW A Systematic Review of the Relationship Between Postpartum Sleep Disturbance and Postpartum Depression
motherhood (Hunter, Rychnovsky, & Yount, 2009).
Research findings from the 13 studies contained
in this review suggest a consistent significant re-
lationship between sleep disturbance and post-
partum depression. Based on this evidence,
counselling postpartum women about the impor-
tance of adequate sleep and the association of
sleep disturbance to postpartum depression may
be a valuable preventive measure in increasing
wellness and decreasing the risk of postpartum
depression.
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Supporting Information
Additional supporting information may be found in
the online version of this article at the publisher’s
web-site:
Table 1: Summary of the Evidence on the Rela-
tionship Between Sleep and Depression in Post-
partum Women
357