Infant Behavior and Development 72 (2023) 101872

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Infant Behavior and Development

journal homepage: www.elsevier.com/locate/inbede

Possible contribution of better maternal psychological well-being

to the acquisition of sleeping through the night in infants during
the early postpartum period
Mayuko Kumagai a, Hitomi Shinohara b, Hideya Kodama a, *
a
Department of Maternity Nursing, Akita University Graduate School of Medicine and Faculty of Medicine, School of Health Science, Japan
b
Graduate School of Nursing, Hyogo University, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: The objective of this study was to elucidate whether better maternal psychological well-being
Infants contributes to the acquisition of “sleeping through the night” (STN) in infants during the early
Sleeping through the night postpartum period. Fifty-two primiparous mothers completed the General Health Questionnaire-
Psychological well-being
28 (GHQ-28) in the third trimester (prenatal) and when the conceptional ages of their babies
Postpartum mothers
Nocturnal sleep consolidation
reached 8–9 weeks (hereafter, 2 months), 12–13 weeks (3 months), and 16–17 weeks (4 months).
Co-sleeping at bedtime They also recorded babies’ nocturnal sleep patterns in a timetable for 5 consecutive days each
month postpartum. “Regular STN” was defined when the mean of longest nocturnal sleep dura­
tion for 5 consecutive days was > 8 h or between 6 and 8 h with < 1.0 nocturnal awakenings.
According to these criteria, a total of 14 infants (27 %) acquired regular STN at 4 months (referred
to as “STN infants”), with STN infants showing a marked increase in longest nocturnal sleep
duration and a decrease in nocturnal awakenings from 2 to 3 months of age. The mothers of STN
infants demonstrated steady reductions in postnatal GHQ-28 scores and had significantly lower
prenatal GHQ-28 scores compared with the mothers of non-STN infants (3.7 ± 3.0 vs. 6.4 ± 4.1,
p = 0.027). In random forest models for binomial classification, both prenatal and postnatal (at 4
months) GHQ-28 scores were identified as significant covariates for distinguishing STN infants,
and other important covariates, including weeks of delivery, stepfamily, birth weight of the in­
fant, and maternal co-sleeping at bedtime, were selected. Among these covariates, maternal co-
sleeping at bedtime had relatively stronger correlations with both STN infants (r = − 0.440)
and prenatal maternal GHQ-28 scores (r = 0.377). In conclusion, because prenatal maternal
psychological well-being was thought to predict the acquisition of STN in infants, infants born
from mothers with better psychological well-being appear to have some advantages in acquiring
STN. These cross-lagged correlations suggest that the pathway from mothers to infants may be
mediated by certain parenting behaviors, such as maternal co-sleeping at bedtime.

1. Introduction

Newborns frequently repeat sleep–wake cycles without distinguishing between day and night, and soon after childbirth, mothers
are required to cope with their babies’ feeding needs or crying signals throughout the night (McGuire, 2013; Sadeh et al., 2010). The

* Correspondence to: 1-1-1 Hondo, Akita-shi 010-8543, Japan.

E-mail address: kodamah@hs.akita-u.ac.jp (H. Kodama).

https://doi.org/10.1016/j.infbeh.2023.101872
Received 10 July 2022; Received in revised form 7 July 2023; Accepted 31 July 2023
Available online 3 August 2023
0163-6383/© 2023 Elsevier Inc. All rights reserved.
M. Kumagai et al. Infant Behavior and Development 72 (2023) 101872

resulting sleep fragmentation can be a considerable stressor and may trigger symptoms of depression and anxiety in postpartum
mothers (Dennis & Ross, 2005; Goyal et al., 2009; Okun et al., 2018). However, infant sleep undergoes dramatic evolution and their
nocturnal sleep rapidly consolidates in the subsequent few months (de Weerd & van den Bossche, 2003; Sadeh et al., 2010). At around
4 months of age, some infants start to sleep from night until morning without disturbing their mothers, a state referred to as “sleeping
through the night” (STN) (Anders et al., 1992; Henderson et al., 2011). Many mothers may hope that their babies start STN as soon as
possible because it allows undisturbed nocturnal sleep. However, individual differences in sleep development are considerable, and
many infants continue to signal at night for a long period after birth (Burnham et al., 2002; Figueiredo et al., 2016). Therefore, only a
limited number of mothers can benefit from their babies’ STN in the early postpartum period, and sleep-related concerns are highly
prevalent during this period (Field, 2017; Simard et al., 2021).
Many researchers have long been investigating the causes and correlates of STN in early infant development (Adams et al., 2004;
Anuntaseree et al., 2008; Hysing et al., 2014; Touchette et al., 2005; Sadeh et al., 2016; Schwichtenberg & Goodlin-Jones, 2010). Ages
and weights are fundamental determinants regarding when infants start STN because having relatively more body weight frees the
infants metabolically from the need for nocturnal nutrition (Hysing et al., 2019). Videos of STN infants taken throughout the night
typically show the infant awakening several times but independently falling back asleep. Therefore, the difference between STN and
non-STN infants is whether they send signals when they awake rather than simply whether they awake during the night (Anders et al.,
1992; St James-Roberts et al., 2015). These observations mean that self-soothing ability could be a key factor in STN acquisition
(Williams et al., 2017). Some studies have suggested gender differences in this process, where compared with male infants, female
infants are more likely to acquire STN (Adams et al., 2004; Kaley et al., 2012; Sorondo & Reeb-Sutherland, 2015; Touchette et al.,
2005). Furthermore, the acquisition of STN is largely dependent on certain parenting behaviors. The involvement of parents during
sleep onset at bedtime (Adair et al., 1991; Philbrook & Teti, 2016), during breastfeeding (Figueiredo et al., 2017; Hysing et al., 2014;
Touchette et al., 2005), while co-sleeping in the parental bed (Hysing et al., 2014; Volkovich et al., 2015), while feeding after a
nocturnal awakening (Touchette et al., 2005), with shorter delays in response to infant signaling (Burnham et al., 2002), and with a
lower tolerance for crying (Sadeh et al., 2016) have been reported to interfere with STN acquisition. However, what types of infants
acquire regular STN early in life remains unclear, and previous studies have not investigated whether and how maternal psychological
status contributes to STN acquisition.
Maternal emotional distress, including depression, anxiety, and stress, is associated with infant sleep problems (Hiscock & Wake,
2001; Tikotzky et al., 2021). This link has been explained by the infant-driven model, in which infant sleep problems have an effect on
maternal symptoms (Lam et al., 2003; Ystrom et al., 2017), or the maternal-driven model, in which maternal symptoms predict the
emergence of infant sleep problems (Burdayron et al., 2021; Teti & Crosby, 2012); however, the two models likely coexist (Dias &
Figueiredo, 2021; Galbally et al., 2018). Concerning the maternal-driven model, the maternal emotional state may not necessarily
affect infant sleep directly because the pathway may be mediated through certain maternal parental behaviors (Teti & Crosby, 2012;
Warren et al., 2006). However, previous discussions have not reported any causal relationships between maternal mental health status
and STN acquisition in early infants, and the pathway from mothers to infants has not been fully explored. Therefore, the objective of
this study was to elucidate whether better maternal psychological well-being could contribute to the acquisition of STN in infants
during the early postpartum period. We specifically focused on the cross-lagged relationship of maternal prenatal mental status and
infant STN as a unidirectional relationship from mothers to infants (Dias & Figueiredo, 2021).

2. Methods

2.1. Participants

The study participants were pregnant women who had visited either the obstetrics outpatient clinic of our university hospital or a
private obstetric clinic in Akita city for a regular medical checkup from weeks 28 through 34 of gestation from August 2018 to
September 2020. Recruitment was performed by giving written and verbal explanations of the study objectives and an outline of the
research. The eligibility criteria were healthy nulliparous women who would be the primary parental caregiver after birth and whose
pregnancy course was uneventful. Since the presence of siblings was expected to affect maternal childcare practice, the participants
were selected from nulliparous women only. The exclusion criteria included medical complications, obstetric complications (e.g.,
preeclampsia, gestational diabetes, threatened premature labor, multiple pregnancies), suspected fetal abnormalities, history of
psychiatric disease, single mothers, extreme financial difficulty, and habitual smokers and drinkers. All participants completed a
questionnaire regarding their demographic characteristics, including age, weeks of pregnancy, working status, and the presence of a
stepfamily. Information on delivery outcomes was obtained from their clinical records. All participants in this study understood the
nature of the research and provided informed consent. This study was approved by our institutional ethics committee (March 13, 2018;
Approval no.: 3055). We certify that the study was performed in accordance with the ethical standards as laid down in the 1964
Declaration of Helsinki and its later amendments or comparable ethical standards and that all methods were performed in accordance
with the approved guidelines.

2.2. Maternal psychological well-being

The psychological well-being of the participants was assessed using the General Health Questionnaire-28 (GHQ-28) (Goldberg &
Hillier, 1979) at the time of recruitment (prenatal) and when the conceptional ages of the infants reached 8–9 weeks (hereafter, 2
months), 12–13 weeks (3 months), and 16–17 weeks (4 months). Data collection was conducted according to conceptional age, based

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M. Kumagai et al. Infant Behavior and Development 72 (2023) 101872

on evidence that the development of sleep structure in early infancy is dependent on age since the last menstrual cycle rather than since
birth (de Weerd & van den Bossche, 2003). For some infants, gestational age since the last menstrual cycle was corrected by at least two
ultrasound measurements of the crown–rump length during the first trimester. The GHQ-28 consists of 28 items, seven each for
assessing the following four domains: “somatic symptoms”, “anxiety/insomnia”, “social dysfunction”, and “severe depression”. The
participants were asked to answer how their health had been during the past week using a four-point Likert scale for each item (“better
than usual”, “same as usual”, “worse than usual”, and “much worse than usual”), with higher scores indicating worse psychological
well-being. This scale has two scoring systems, (0, 0, 1, 1) or (0, 1, 2, 3), in which the total score ranges from 0 to 28 or from 0 to 84. For
the purposes of this study, we adopted the former scoring system because the difference between the second and third responses was
thought to be substantial.

2.3. Sleep variables in infants

Participants recorded their infants’ sleep–wake behavior on a timetable for 5 consecutive days at 2, 3, and 4 months of age. They
recorded the sleep onset and offset times and nocturnal awakening periods of their infants in a timetable, where sleep durations were
marked with a (↔) in columns of 5-min intervals from 0 to 24 h. Meanwhile, the participants provided information on a timetable
about parental behaviors, including feeding methods, whether they co-slept with infants at bedtime, and whether they co-slept with
infants until morning. Later, from their timetables, nighttime sleep duration (total sleep time from 20:00 to 08:00 the next day) and
daytime sleep duration (total sleep time from 08:00 to 20:00) were considered indicators of circadian rhythm evolution. Then, longest
nocturnal sleep duration (most sustained nocturnal sleep after nocturnal sleep onset until morning the next day) and nocturnal
awakenings (number of awakening episodes during the nocturnal sleep period) were considered indicators of nocturnal sleep
consolidation. To determine these two variables, the start of nocturnal sleep was defined as the first onset of sleep after 18:00 that
continued for at least 30 min, and the end of nocturnal sleep was defined as arousal lasting more than 30 min in the morning. Finally,
these sleep variables in each postpartum month for each infant were determined by averaging the values for 5 days.
STN was defined as either > 6 or > 8 h of uninterrupted sleep without any parental intervention (Henderson et al., 2011). With
reference to this criterion, the infants were defined to acquire regular STN when the longest nocturnal sleep duration was > 8 h.
Additionally, borderline cases of infants whose longest nocturnal sleep duration was between 6 and 8 h were also defined as acquiring
regular STN when they had < 1.0 nocturnal awakening.

2.4. Statistical analysis

JMP (ver. 14; SAS Institute Inc., Cary, NC, USA) and IBM SPSS Statistics (ver. 22.0 Static Base and Advanced Statistics, IBM Japan,
Tokyo, Japan) were used for the basic statistical analysis. Means ± standard deviations (SDs) were used to express continuous vari­
ables. Because many variables were not normally deviated with a low sample size, nonparametric statistical methods were used to
examine group differences or correlations. The differences between nominal variables between groups were analyzed using the chi-
square test. One-way repeated-measures analysis of variance (ANOVA) was conducted to determine the overall difference in
maternal GHQ-28 scores or each sleep variable in infants by age. Greenhouse–Geisser adjustments were performed when the
assumption of sphericity was violated. If the ANOVA was significant, the Bonferroni multiple comparison procedure was used as a post
hoc test. A two-way repeated-measures ANOVA (group × months) was used to compare the infants’ sleep variables and maternal GHQ-
28 scores from 2 to 4 months. Random forest models for binomial classification were constructed to distinguish STN infants using
Minitab (R)19 statistical software (Kozo Keikaku Engineering Inc., Tokyo, Japan). The important variables for distinction were
identified and ranked according to the mean decrease Gini. The effectiveness of the models was assessed by the area under the curve of
the receiver operating characteristic (AUC-ROC). In these statistical analyses, p-values < 0.05 were considered significant.

3. Results

3.1. Study participants

A total of 60 participants were recruited in the third trimester (28–34 weeks of gestation), but four were excluded because of the
development of obstetric complications (premature labor [n = 2], intrauterine fetal death [n = 1], and low-birth-weight-infant < 2000
g [n = 1]) after recruitment. Furthermore, four participants were excluded because of the lack of infant sleep recordings for 1 month or
more. Finally, the study participants were 52 mothers with a mean age of 33.5 years (age range, 25–43 years). Among these mothers,
33 (63 %) were working, and 10 (19 %) lived with their stepfamily (= parents of mothers or their husbands). Fifty-one mothers (98 %)
had undergone full-term delivery, and one had preterm delivery at 36 weeks of gestation. All infants were born without neonatal
asphyxia or congenital malformations, and nine (17 %) were born by cesarean section. Three infants were born with a low birth weight
(2360–2464 g). Regarding feeding methods at 4 months, 24 infants were fed by breast milk only (labeled “exclusive breastfeeding”),
and the others were fed by a mixture of breast milk and formula. Among 24 mothers who breastfed exclusively, 23 (96 %) did so from 2
months postpartum. At 4 months postpartum, 34 mothers co-slept with infants at bedtime (labeled “maternal co-sleeping at bedtime”),
and 30 (88 %) had this habit from 2 months postpartum. Among 34 mothers who co-slept with infants at bedtime, 24 mothers co-slept
with their infants in the parental bed until morning (labeled “maternal co-sleeping while sleeping”), and 21 (91 %) had this habit from
2 months postpartum.
The participants’ mean (± SD) prenatal GHQ-28 score was 5.7 ± 4.0, and prenatal GHQ-28 scores were moderately correlated with

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M. Kumagai et al. Infant Behavior and Development 72 (2023) 101872

postnatal GHQ-28 scores, with Spearman’s coefficients of 0.634 at 2 months, 0.503 at 3 months, and 0.584 at 4 months.

3.2. Maternal GHQ-28 scores, infants’ sleep variables, and number of infants acquiring regular STN during the early postnatal period

Table 1 shows maternal GHQ-28 scores, infants’ sleep variables, and the number of infants acquiring regular STN at 2–4 months of
age. During this period, maternal GHQ-28 scores showed a significant overall decrease (p < 0.001), and a multiple comparison
procedure showed a significant decrease from 2 to 3 months (p = 0.001). As for infants’ sleep variables, overall changes during this
period were significant for all variables (p < 0.001), and a multiple comparison procedure showed significant changes from 2 to 3
months; both nocturnal sleep duration and longest nocturnal sleep duration were increased (p = 0.001 and p < 0.001), and both
diurnal sleep duration and number of awakenings at night were decreased (p < 0.001 and p < 0.001). However, from 3 to 4 months of
age, these changes were not significant for all variables, and the values of two variables (longest nocturnal sleep duration and number
of awakenings) were almost constant during this period. According to the criteria mentioned above, two (4 %), 10 (19 %), and 14 (27
%) infants were defined as acquiring regular STN at each postnatal month.

3.3. Correlation of maternal GHQ-28 scores with infants’ sleep variables at each postnatal month

Table 2 shows Spearman’s coefficients between maternal GHQ-28 scores and infants’ sleep variables at each postnatal month. The
values at 2 or 3 months were extremely low, indicating that GHQ-28 scores and infants’ sleep variables were almost irrelevant during
these months. However, maternal GHQ-28 scores at 4 months were mildly correlated with nocturnal sleep duration (r = − 0.208) or
nocturnal awakenings (r = 0.217), and moderately correlated with longest nocturnal sleep duration (r = − 0.372). Therefore, during
the early postpartum period, significant relationships between maternal GHQ-28 scores and infants’ sleep variables were found to be
detectable at 4 months postpartum.
These findings suggest that relationships between maternal psychological well-being and infant sleep during the early postpartum
months should be preferably evaluated at 4 months because infants’ sleep variables become relatively stable. Before 4 months (at 2 or 3
months), when infants undergo rapid nocturnal sleep evolution, the relationships concerning these two sleep variables (longest
nocturnal sleep duration and nocturnal awakenings) were less detectable because they demonstrated large intra-individual variability.
Therefore, we focused on data from 4 months.

3.4. Comparison of maternal characteristics, delivery outcome, and childcare factors between STN and non-STN infants

A total of 14 infants were defined as acquiring regular STN at 4 months of age and thus referred to as “STN infants”; the other infants
were referred to as “non-STN infants”. Among these infants, 10 were classified as STN infants because their longest nocturnal sleep
duration was > 8 h, and 4 were classified as STN infants because their longest nocturnal sleep duration was between 6 and 8 h with
quite low nocturnal awakenings (< 1.0). Two STN infants at 3 months were not classified as STN infants at 4 months of age.
Maternal characteristics, delivery outcomes, and childcare factors were then compared between STN and non-STN infants
(Table 3). The presence of a stepfamily was significantly lower among STN than non-STN infants (p = 0.008). Prenatal GHQ-28 scores
for the mothers of STN infants were significantly lower than those for the mothers of non-STN infants (p = 0.027). The birth weight of
STN infants tended to be higher than that of non-STN infants (p = 0.089), and non-STN infants tended to have a higher incidence of
being breastfed exclusively than did STN infants (p = 0.117). The incidences of mothers who co-slept with their infant at bedtime
(maternal co-sleeping at bedtime) and who co-slept with their infant until morning in the parental bed (maternal co-sleeping while
sleeping) were significantly lower among STN than among non-STN infants (p = 0.002 and p = 0.026, respectively).

Table 1
Maternal GHQ-28 scores, infants’ sleep variables, and number of infants acquiring regular STN at 2–4 months of age (n = 52).
2 monthsa 3 monthsa 4 monthsa ANOVAb Multiple comparisonc

F p 2 vs. 3 months 2 vs. 4 months 3 vs. 4 months

Maternal GHQ-28 score 6.5 ± 4.1 4.9 ± 3.9 4.3 ± 4.5 10.54 < 0.001** 0.001** < 0.001** 0.288
Infants’ sleep variables
Nocturnal sleep duration (min) 495 ± 73 524 ± 56 530 ± 60 13.89 < 0.001** 0.001** < 0.001** 0.139
Daytime sleep duration (min) 257 ± 82 225 ± 69 200 ± 57 27.21 < 0.001** < 0.001** < 0.001** 0.753
Longest nocturnal sleep duration 289 ± 81 364 ± 115 367 ± 106 27.21 < 0.001** < 0.001** < 0.001** 0.753
(min)
Number of awakenings at night 2.2 ± 0.9 1.6 ± 0.9 1.7 ± 0.9 23.26 < 0.001** < 0.001** < 0.001** 0.299
Number of infants acquiring regular 2 (4 %) 10 (19 %) 14 (27 %)
STN

STN, sleeping through the night; GHQ-28, General Health Questionnaire-28; ANOVA, analysis of variance.
a
Values are mean ± standard deviation or number (percentage).
b
One-way repeated-measures ANOVA. **p < 0.01.
c
Bonferroni multiple comparison procedure. **p < 0.01.

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Table 2
Spearman’s coefficients between maternal GHQ-28 scores and infants’ sleep variables at each postnatal month (n = 52).
2 months 3 months 4 months

Nocturnal sleep duration − 0.194 − 0.165 − 0.208

Daytime sleep duration 0.150 0.030 − 0.067
Longest nocturnal sleep duration − 0.098 − 0.031 − 0.372**
Nocturnal awakenings − 0.007 0.001 0.217

GHQ-28, General Health Questionnaire-28.

**p < 0.01.

Table 3
Comparison of maternal characteristics, delivery outcomes, and childcare factors between STN and non-STN infants.
STN infants Non-STN infants p-valuea
n = 14 n = 38

Maternal characteristics
Age (years) 34.2 ± 3.9 33.2 ± 5.2 0.469
Working status 10 (71 %) 23 (61 %) 0.464
Stepfamily 0 (0 %) 10 (26 %) 0.008**
GHQ-28 3.7 ± 3.0 6.4 ± 4.1 0.027*
Delivery outcome
Gestational age (weeks) 39.0 ± 1.2 39.1 ± 1.3 0.648
Cesarean section (number, %) 3 (21 %) 6 (16 %) 0.639
Male infants (number, %) 5 (36 %) 18 (47 %) 0.450
Birth weight of infants (g) 3113 ± 310 2942 ± 306 0.089
Childcare factors
Exclusive breastfeeding 4 (29 %) 20 (52 %) 0.117
Maternal co-sleeping while sleeping 3 (21 %) 21 (55 %) 0.026*
Maternal co-sleeping at bedtime 4 (28 %) 29 (76 %) 0.002**

Values are presented as mean ± standard deviation or number (percentage).

a
Group differences were examined by the Wilcoxon signed-rank test or chi-square test. *p < 0.05, ** p < 0.01.
STN, sleeping through the night; GHQ-28, General Health Questionnaire-28.

3.5. Comparison of sleep variables between STN and non-STN infants

The distributions of sleep variables from 2 m to 4 months of age in STN and non-STN infants are shown in Fig. 1, and the statistical
differences between the two groups are shown in Table 2. Regarding variables related to the evolution of circadian rhythms, a sig­
nificant month-dependent increase in nighttime sleep duration (p < 0.001) and a significant decrease in daytime sleep duration (p <
0.001) were observed during this period. The group and group × month differences were significant for nighttime sleep duration in
STN infants (p = 0.036 and p = 0.038, respectively), but not for daytime sleep duration. Regarding variables related to nocturnal sleep
consolidation, a significant month-dependent increase in the longest nocturnal sleep duration and a significant decrease in nocturnal
awakenings were observed during this period (p < 0.001), and the changes in these variables were more evident among STN than
among non-STN infants. The group and group × months differences between the two groups were significant for the longest nocturnal
sleep duration (p < 0.001 and p < 0.001, respectively) and nocturnal awakenings (p < 0.001 and p = 0.003, respectively).

3.6. Comparison of GHQ-28 scores between mothers of STN and non-STN infants

The distributions of GHQ-28 scores from the prenatal to early postpartum periods among the mothers of STN and non-STN infants
are shown in Fig. 2, and statistical differences in postpartum scores are shown in Table 2. A significant month-dependent reduction in
maternal GHQ-28 scores was seen during the postpartum period (p < 0.001). The scores of the mothers of STN infants increased from
the prenatal period to 2 months postpartum, and then decreased at about 4 months, but no such steady month-to-month reduction in
postnatal scores was evident for the mothers of non-STN infants. A significant group × month difference in changes in postnatal GHQ-
28 scores was seen between the two groups (p = 0.025).

3.7. Variables identified for distinguishing STN infants

Table 5 presents Spearman’s coefficients between STN infants, maternal GHQ-28 scores (prenatal, at 4 months postnatal), and
possible covariates, including maternal characteristics, delivery outcome, and childcare factors (see Table 1). STN infants were
moderately correlated with prenatal and postnatal (at 4 months) maternal GHQ-28 scores (r = − 0.311 and r = − 0.363), and
childcare factors, including maternal co-sleeping at bedtime (r = − 0.440) and maternal co-sleeping while sleeping (r = − 0.301).
Prenatal and postnatal maternal GHQ-28 scores were moderately or mildly correlated with maternal co-sleeping at bedtime (r = 0.377
and r = − 0.267) and maternal co-sleeping while sleeping (r = 0.473 and r = 0.381). Several multicollinearities were observed

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Fig. 1. Distributions of sleep variables from age 2–4 months in STN and non-STN infants (statistical differences are shown in Table 2). P-values
indicate differences of group × month by two-way repeated-measures analysis of variance (see Table 4). STN, sleeping through the night.

Table 4
Statistical differences of infants’ sleep variables and maternal GHQ-28 scores from 2–4 months postpartum between STN and non-STN infants and
their mothers.
n 2 monthsa 3 monthsa 4 monthsa Monthb Groupb Group × Monthb

F p F p F p

Infants’ sleep variables

Nighttime sleep duration
STN infants 14 503 ± 68 554 ± 41 565 ± 46 17.95 < 0.001** 4.65 0.036* 3.39 0.038*
Non-STN infants 38 492 ± 60 513 ± 57 518 ± 59
Daytime sleep duration
STN infants 14 233 ± 68 223 ± 45 181 ± 35 15.61 < 0.001** 1.21 0.302 1.36 0.248
Non-STN infants 38 265 ± 73 226 ± 77 207 ± 62
Longest nocturnal sleep duration
STN infants 14 332 ± 65 474 ± 87 495 ± 61 51.04 < 0.001** 34.95 < 0.001** 14.49 < 0.001**
Non-STN infants 38 273 ± 81 323 ± 97 319 ± 78
Nocturnal awakenings
STN infants 14 1.69 ± 0.77 0.80 ± 0.60 0.67 ± 0.19 32.65 < 0.001** 22.59 < 0.001** 6.10 0.003**
Non-STN infants 38 2.39 ± 0.93 1.91 ± 0.85 2.06 ± 0.81
Maternal GHQ-28 score
STN infants 14 6.07 ± 5.05 4.14 ± 3.78 1.93 ± 2.84 16.21 < 0.001** 1.87 0.178 3.85 0.025*
Non-STN infants 38 6.63 ± 3.76 5.16 ± 4.00 5.11 ± 4.77

STN, sleeping through the night; GHQ, General Health Questionnaire-28.

a
Values are presented as mean ± standard deviation.
b
Two-way repeated-measures analysis of variance, *p < 0.05, **p < 0.01

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Fig. 2. Distributions of GHQ-28 scores from the prenatal to postnatal period in the mothers of STN and non-STN infants (statistical differences for
postnatal values are shown in Table 2). P-values indicate differences of group × month (from 2 m to 4 months postpartum) by two-way repeated-
measures analysis of variance (see Table 4). STN, sleeping through the night; GHQ-28, General Health Questionnaire-28.

between possible covariates, including maternal age, gestational age, exclusive breastfeeding, maternal co-sleeping at bedtime, and
maternal co-sleeping while sleeping.
For the purpose of identifying variables associated with distinguishing STN infants, we constructed random forest models for
binomial classification. The tested variables included maternal characteristics (age, working status, stepfamily), delivery outcomes
(weeks of delivery, cesarean section, birth weight of infant, male sex), childcare factors (exclusive breastfeeding, maternal co-sleeping
at bedtime), and maternal GHQ-28 scores. Regarding childcare factors, maternal co-sleeping while sleeping was not included because
of its high collinearity with maternal co-sleeping at bedtime. Fig. 3A shows important variables selected by a cross-sectional model
using GHQ-28 scores at 4 months. The model identified a total of five variables as important covariates, with maternal co-sleeping at
bedtime being the most important and GHQ-28 scores at 4 months being the third most important (AUC-ROC [95% confidence interval
(CI)] = 0.690 [0.542− 0.837]). Fig. 3B shows important variables selected by the cross-lagged model using prenatal GHQ-28 scores.
The model identified a total of five variables as important covariates, with the prenatal GHQ-28 scores being the fifth most important
(AUC-ROC [95 % CI] = 0.624 [0.473− 0.775]). Among the covariates other than GHQ-28 scores (weeks of delivery, stepfamily, birth
weight of infants, maternal co-sleeping at bedtime), maternal co-sleeping at bedtime had relatively stronger correlations with both
STN infants (r = − 0.440) and prenatal or postnatal maternal GHQ-28 scores (r = 0.377 or r = 0.473, respectively).

4. Discussion

Previous studies have reported that 50 % of infants first slept through the night by age 8 weeks and 75 % by age 12 weeks based on
information obtained through parental interviews (Adams et al., 2004). However, according to our relatively strict criteria for regular
STN based on a maternal infant sleep diary, only 26 % of infants actually acquired STN at age 4 months. This wide difference might be
partly attributable to cultural differences in parental behaviors between Asian and Western countries, where bed-sharing is common or
uncommon (Ball, 2003). Nocturnal sleep among infants became consolidated within the first few months, and rapid consolidation was
found to occur from 2 to 3 months in many infants. The levels of consolidation during this period differed markedly between STN and
non-STN infants. The increase in the longest nocturnal sleep duration and the decrease in nocturnal awakenings from 2 to 3 months
were marked in the STN infants, whereas the changes in these variables during this period were relatively small in the non-STN infants.
During this period, the evolution of circadian rhythms simultaneously occurred in infant sleep, which was indicated by a decrease in
daytime and an increase in nighttime sleep duration (Rivkees, 2003). However, when these variables were compared between STN and
non-STN infants, no difference in daytime sleep duration was observed. Therefore, the evolution of circadian sleep–wake rhythms,
especially as indicated by the reduction of daytime sleep duration, was not closely related to the acquisition of STN.
According to the profile of GHQ-28 scores from the prenatal to postnatal periods, psychological well-being in the mothers of STN
infants was a slightly compromised after birth. Since all our participants were first-time mothers, their first full-scale childcare
experience might have been a considerable stressor. However, their postnatal GHQ-28 scores showed a steady month-to-month
reduction, which was not observed in the mothers of non-STN infants, and the interaction effect with the mothers of non-STN in­
fants was significant. Therefore, the acquisition of STN in their infants was associated with the steady postpartum improvement of their
mothers’ psychological well-being. Furthermore, significant decreases in GHQ-28 scores among mothers of STN infants were also
evident in the prenatal GHQ-28 scores. In accordance with the previous finding that prenatal emotional status is a strong predictor of
postnatal emotional status (Ogbo et al., 2018; Pampaka et al., 2019), a moderate correlation was found between prenatal and postnatal
GHQ-28 scores. Therefore, it is likely that the poor mental health status of many postnatal mothers continued before childbirth. So, we

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Table 5
Spearman’s coefficients between STN infants, maternal GHQ-28 scores, and possible covariates, including maternal characteristics, delivery outcome, and childcare factors (n = 52).
STN infant Prenatal GHQ-28 at 4 Maternal Working Stepfamily Gestational Cesarean Birth weight Male Exclusive Co-sleeping at Co-sleeping
GHQ-28 months age status age section of infants infants breastfeeding bedtime while sleeping

STN infant 1.000 − 0.311* − 0.363** 0.103 0.100 − 0.296 − 0.065 0.066 0.240 − 0.104 − 0.214 − 0.440** − 0.301*
Prenatal GHQ-28 − 0.311* 1.000 0.584** − 0.150 0.103 0.106 − 0.162 0.019 − 0.027 0.144 − 0.136 0.377** 0.267
GHQ-28 at 4 − 0.363** 0.584** 1.000 − 0.098 − 0.174 0.105 − 0.161 − 0.129 0.017 − 0.145 − 0.042 0.473** 0.381**
months
Maternal age 0.103 − 0.150 − 0.098 1.000 0.065 0.117 − 0.123 0.263 0.059 0.075 − 0.300* − 0.318* − 0.202
Working status 0.100 0.103 − 0.174 0.065 1.000 − 0.136 0.063 0.031 0.009 − 0.048 − 0.259 − 0.161 − 0.099
Stepfamily − 0.296 0.106 0.105 0.117 − 0.136 1.000 − 0.109 0.035 − 0.158 0.057 0.038 0.168 0.038
Gestational age − 0.065 − 0.162 − 0.161 − 0.123 0.063 − 0.109 1.000 − 0.373** 0.234 0.198 0.360** − 0.105 − 0.168
Cesarean section 0.066 0.019 − 0.129 0.263 0.031 0.035 − 0.373** 1.000 − 0.078 0.104 − 0.322* − 0.075 − 0.016
8

Birth weight of 0.240 − 0.027 0.017 0.059 0.009 − 0.158 0.234 − 0.078 1.000 − 0.190 0.167 − 0.140 − 0.175
infants
Male infants − 0.104 0.144 − 0.145 0.075 − 0.048 0.057 0.198 0.104 − 0.190 1.000 0.108 0.033 0.030
Exclusive − 0.214 − 0.136 − 0.042 − 0.300* − 0.259 0.038 0.360** − 0.322* 0.167 0.108 1.000 0.302* 0.149
breastfeeding
Co-sleeping at − 0.440** 0.377** 0.473** − 0.318* − 0.161 0.168 − 0.105 − 0.075 − 0.140 0.033 0.302* 1.000 0.703**
bedtime
Co-sleeping while − 0.301* 0.267 0.381** − 0.202 − 0.099 0.038 − 0.168 − 0.016 − 0.175 0.030 0.149 0.703** 1.000
sleeping

STN, sleeping through the night; GHQ-28, General Health Questionnaire-28.

Infant Behavior and Development 72 (2023) 101872

**p < 0.01.
*
p < 0.05.
M. Kumagai et al. Infant Behavior and Development 72 (2023) 101872

Fig. 3. Important variables selected by random forest models for binomial classification to identify STN infants. A: Cross-sectional model using
GHQ-28 scores at 4 months. B: Cross-lagged model using prenatal GHQ-28 scores. STN, sleeping through the night; GHQ, General Health Ques­
tionnaire-28.

further focused on this cross-lagged association because it may imply a contribution of better maternal psychological well-being to the
early acquisition of STN in infants due to a unidirectional relationship from mothers to infants (Dias & Figueiredo, 2021).
Our random forest model for distinguishing STN infants using cross-sectional postnatal GHQ-28 scores identified a total of five
variables, with GHQ-28 scores being the third most important covariate. Subsequently, we reconstructed this model using cross-lagged
prenatal GHQ-28 scores and confirmed that GHQ-28 scores were still an important covariate for distinction. Other important cova­
riates were selected by the model, including weeks of delivery, stepfamily, birth weight of the infant, and maternal co-sleeping at
bedtime. Among these covariates, maternal co-sleeping at bedtime and low infant birth weight have often been listed as inhibitors of
STN acquisition (Adams et al., 2004; Schwichtenberg et al., 2010). “Weeks of delivery” was newly added to this list because we
collected data according to the infants’ conceptional ages rather than the age from delivery. Among infants with the same conceptional
age, those born in earlier gestational weeks might have an advantage in acquiring STN because a longer time has elapsed since de­
livery. Stepfamily was also newly added to the list because in a stepfamily, it is more common for someone in the family to be involved
in the baby’s bedtime (Adair et al., 1991). Among these covariates, maternal co-sleeping at bedtime had relatively stronger corre­
lations with both STN infants and prenatal or postnatal maternal GHQ-28 scores. Therefore, it is conceivable that this covariate could
mediate the pathway between mothers and infants although there is a need for discussion about the direction of the pathway.
Because the association of STN infants with postnatal maternal GHQ-28 scores may be largely dependent on the improvement of the
mother’s mental state due to the acquisition of STN in infants, it is difficult to argue whether the mother’s improved mental state could
contribute to the acquisition of STN in their infants. Therefore, our final discussion focuses on the possible mechanism of the pathway
from prenatal maternal mental status to infants’ STN acquisition because it could indicate a unidirectional relationship from mothers
to infants (Dias & Figueiredo, 2021). Regarding the possible direct pathway, according to fetal programming theory, pregnant women
with severe stress deliver infants who are relatively sensitive to external stimuli (Lewis et al., 2014). In fact, poor prenatal mental
health status of mothers has been reported to predict irritable temperaments in their offspring during early infancy (Austin et al., 2005;
Davis et al., 2007; de Vente et al., 2020; Kim et al., 2020). Therefore, conversely, pregnant women with better psychological well-being
would deliver infants with less-irritable temperaments, which might lead to higher self-soothing ability. However, another possibility
is that this pathway could be mediated by a certain covariate, such as maternal co-sleeping at bedtime. Prenatal maternal GHQ-28
scores and maternal co-sleeping at bedtime showed a moderate positive correlation. Thus, many of the prenatal mothers with poor
mental health status likely struggled with their mental health after delivery, and were more willing to co-sleep at bedtime, possibly
because they were more worried about nocturnal infant sleep. Furthermore, maternal co-sleeping at bedtime showed a moderate
negative correlation with STN in infants. Although the data in the correlation table (Table 5) were measured at 4 months, the majority
of mothers who co-slept with infants at bedtime at 4 months had such a habit from 2 or 3 months postpartum. Therefore, there must
have been sufficient time for this habit to contribute to STN acquisition in infants. Similarly, Sadeh et al. (2016) suggested the
involvement of another parenting behavior: a lower parental tolerance for crying. Women with more anxiety might be more sensitive
to the crying of their babies after birth, and this behavior could interfere with the acquisition of STN. Identifying the pathway from a
prenatal mental state to STN acquisition in infants should be explored further to assess clinical validity.
This study had several strengths. First, data on prenatal and postnatal maternal mental health were collected longitudinally, and
their cross-sectional and cross-lagged associations with STN infants were simultaneously examined. Especially, data on associations of

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prenatal maternal mental health with STN infants and postnatal covariables appear rare. Second, STN infants were carefully classified
according to detailed sleep diaries for 5 consecutive days. Third, a random forest model based on machine learning was used to detect
significant covariates. Conventional logistic models can capture only linear relationships and are limited when considerable multi­
collinearity exists between possible covariates. A random forest model is effective even if possible covariates are not related to linear
relationships and have multicollinearity between them; therefore, we considered it to be more suitable for our analysis. On the other
hand, several limitations of this study warrant discussion. First, the small sample size may have hampered the accuracy of the statistical
analysis. We might have identified the involvement of some variables that were not significant at a borderline level if a larger sample
size had been available. Second, the sleep variables in infants were determined based on maternal reports, but it is difficult to confirm
that all mothers described the sleep patterns of their babies accurately. There is a concern that inaccurate diary entries by some of the
mothers might have been reflected in the results. Third, assessing maternal mental status based on GHQ-28 scores may not be optimal.
More conclusive findings might be obtained using some quantitative scales specific for symptoms of anxiety or depression. Fourth, the
degree to which a husband or someone in the family is involved in parental behaviors could affect the mental state of the mother, and
thus may be a significant confounder. Although we confirmed that all mothers were the primary parental caregivers in this study, there
might have been a situation in which the father was more actively involved in co-sleeping at bedtime than the mother. However, we
did not evaluate such a situation quantitatively. Fifth, data from 4 mothers were excluded prior to analysis because of incomplete
infant sleep reports. If the mentally compromised mothers had provided such incomplete reports and were systematically excluded,
this could have led to bias in the resulting data set. Sixth, because birth weight was a fairly important variable for distinguishing STN
infants, current infant weight may be a more notable variable for distinction. However, we did not collect sufficient data on the current
weight of the infants. Finally, common childcare methods are highly dependent on the environment and social and cultural back­
grounds. For this reason, our results may not be representative of different areas or countries.
In conclusion, the consolidation of nocturnal sleep progressed rapidly from 2 to 3 months of age in infants who acquired regular
STN, and was associated with the steady postnatal improvement of psychological well-being in their mothers. On the other hand,
prenatal maternal psychological well-being was thought to predict the acquisition of STN in infants, indicating that infants born from
mothers with better psychological well-being appear to have some advantages in acquiring STN. Because of relatively strong corre­
lations of maternal co-sleeping at bedtime with both STN infants and prenatal maternal psychological well-being, this covariate may
mediate the pathway from mothers to infants. Although many researchers have been investigating whether postpartum interventions
can facilitate the early acquisition of regular STN in infants, our results indicate that maintaining good maternal mental health during
the perinatal period could contribute to the early acquisition of STN in infants.

Funding

This study was supported by a Grant-in-Aid for Scientific Research (19K19636) from the Japan Society for the Promotion of
Science.

CRediT authorship contribution statement

HK and HS conceived the idea of the study. MK and HS performed an investigation and data sampling. HK and MK conducted
statistical analyses and interpretation of the results. MK drafted the original manuscript. HK reviewed and edited the manuscript. All
authors approved the final version of the manuscript to be published.

Declaration of Competing Interest

We declare no conflict of interest.

Data Availability

Data will be made available on request.

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