The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/ijmf20

The relation between sleep quality during

pregnancy and health-related quality of life—a
systematic review

Annemieke Emma Josina Peters, L. B. Verspeek, M. Nieuwenhuijze, M. W.

Harskamp-van Ginkel & R. M. Meertens

To cite this article: Annemieke Emma Josina Peters, L. B. Verspeek, M. Nieuwenhuijze, M.

W. Harskamp-van Ginkel & R. M. Meertens (2023) The relation between sleep quality during
pregnancy and health-related quality of life—a systematic review, The Journal of Maternal-Fetal
& Neonatal Medicine, 36:1, 2212829, DOI: 10.1080/14767058.2023.2212829

To link to this article: https://doi.org/10.1080/14767058.2023.2212829

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
2023, VOL. 36, NO. 1, 2212829
https://doi.org/10.1080/14767058.2023.2212829

REVIEW ARTICLE

The relation between sleep quality during pregnancy and health-related

quality of life—a systematic review
Annemieke Emma Josina Petersa, L. B. Verspeekb, M. Nieuwenhuijzec,d, M. W. Harskamp-van Ginkele and
R. M. Meertensa
a
Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, and Care and Public
Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands; bDepartment of Health Promotion, Maastricht
University, Maastricht, Netherlands; cResearch Centre for Midwifery Science Maastricht, Zuyd University, Maastricht, Netherlands;
d
Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands; eDepartment of Public and
Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, Netherlands

ABSTRACT ARTICLE HISTORY

Background: The majority of expectant mothers report sleep alterations during pregnancy and Received 28 January 2023
almost 40% report poor sleep quality. There is growing evidence that sleep quality (SQ) during Revised 25 April 2023
pregnancy influences maternal health. This review focuses on how SQ during pregnancy relates Accepted 5 May 2023
to maternal health-related quality of life (HRQoL). The review also aims to identify whether this
KEYWORDS
relation varies between pregnancy trimesters, and for different subdomains of HRQoL. Sleep; insomnia; pregnancy;
Methods: A systematic review was performed according to PRISMA guidelines and registered quality of life; primary care;
on Prospero in August 2021 with ID no: CRD42021264707. Pubmed, Psychinfo, Embase, systematic review
Cochrane, and trial registries were searched up to June 2021. Studies with any design that
investigated the relation between SQ and quality of life/HRQoL in pregnant women, published
in English, and peer-reviewed, were included. Two independent reviewers screened titles,
abstracts, and full texts, and extracted data from the included papers. The quality of the studies
was evaluated using the Newcastle-Ottawa Scale.
Results: Three hundred and thirteen papers were identified in the initial search, of which 10
met the inclusion criteria. Data included 7330 participants from six different countries. The stud-
ies had longitudinal (n ¼ 1) or cross-sectional designs (n ¼ 9). In nine studies SQ was reported
subjectively by self-report questionnaires. Actigraphic data was available from two studies.
HRQoL was assessed by validated questionnaires in all studies. Due to high levels of clinical and
methodological heterogeneity in included studies, a narrative synthesis was employed. Nine
studies found that poor sleep quality was related to a lower overall HRQoL during pregnancy.
Effect sizes were low to medium. This relation was reported most during the third trimester.
Especially sleep disturbances and subjective low SQ seemed to be related consistently to lower
HRQoL. Furthermore, an indication was found that SQ might have a relation with the mental
and physical domain of HRQoL. The social and environmental domain may also be associated
with overall SQ.
Conclusion: Despite the scarcity of studies available, this systematic review found evidence that
low SQ is related to low HRQoL during pregnancy. An indication was found that the relationship
between SQ and HRQoL during the second trimester might be less prominent.

Introduction sleep duration, an increase in sleep disturbances, and

The majority of expectant mothers report sleep altera-
tions during pregnancy [1–3]. and poor sleep quality
occurs in almost 40% of all pregnant women, peaking
in the third trimester, and persisting until about 50%
two years postpartum [4,5]. During pregnancy, poor
sleep quality is characterized by a decrease in mean
longer time to fall asleep. Gestational sleep disturban-
ces seem to increase the risk of multiple adverse mater-
nal/perinatal outcomes, including a higher chance of
depression, cesarean birth, preeclampsia, gestational
diabetes, preterm birth, lower birth weight, and off-
spring adiposity, and increased blood pressure [6,7].

CONTACT Annemieke Emma Josina Peters a.peters@maastrichtuniversity.nl Department of Health Promotion, Faculty of Health, Medicine & Life
Sciences, Maastricht University, Maastricht, 6200 MD, Netherlands.
ß 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the
posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
2 A. E. J. PETERS ET AL.

The concepts Quality of life (QOL) and Health- Search strategy

related QOL (HRQoL) are used interchangeably in the
The search was conducted in July 2021 using PubMed,
literature. QOL is defined by the World Health
PsycInfo, Embase, the Cochrane Central Register of
Organization (WHO) as “individuals’ perception of their
Controlled Trials (CENTRAL), and trial registries
position in life in the context of culture and value sys-
(https://clinicaltrials.gov and https://who.int/ictrp/en).
tems in which they live and in relation to their goals,
The databases have been systematically searched from
expectations, standards, and concerns” [8]. HRQoL is a
inception to June 2021. The database searches com-
multi-dimensional concept and is commonly divided
bined terms for pregnancy, sleep, and HRQoL con-
into different domains [9]. In recent years, the HRQoL
cepts using the PICOS (participants, interest,
has become increasingly important as a concept in
comparison, outcome, and study design) strategy [21].
the public health sector, such as prenatal care to
The search terms used are found in Appendix 2.
detect unmet needs during pregnancy [10,11]. Due to
Studies were included if (1) the population researched
its interchangeable use, this review will refer to QOL
were pregnant women, (2) measured SQ either object-
and HRQoL as HRQoL.
ive (e.g. polysomnography, actigraphy) or subjective
Poor sleep quality is found to be related to lower
(e.g. Pittsburgh Sleep Quality Index (PSQI) [22] or the
HRQoL in various populations, such as in the general
Insomnia Severity Index Scale (ISI) [23] which is also
population [12,13], postpartum women [14], and
often used as a measure of sleep quality [24]), (3)
patients with Obstructive Sleep Apnea [15], cancer,
compared women with or without sleeping problems,
diabetes, depression, Parkinson and chronic kidney
(4) had an outcome of either QOL or HRQoL, and (5)
diseases [16]. Previous articles also suggested a pos-
were published as an original study (in journals, “in
sible relationship between sleep quality (SQ) and
press” or in a trial registry). There were no restrictions
HRQoL during pregnancy [17,18]. However, to date, no
on sample size, study design, or measurement tools.
systematic review is available.
For example, sleep quality could be measured object-
In 2010, Da Costa et al. [19] concluded that the
ively as well as subjectively, to give a complete as pos-
HRQoL of pregnant women were comparable to
sible answer to the research question.
patients with chronic disorders. However, frequently
Reference lists were screened to identify additional
pregnant women are told a decrease in sleep is a col-
articles.
lateral of pregnancy and therefore it is a natural and
in principle healthy state which does not need atten-
tion. Consequently, it is interesting to see whether SQ Study selection
has a similar impact on the HRQoL during pregnancy
Relevant records were identified through database
as in other populations and therefore may no longer
searches. After removing duplicates, a two-step
be considered “just” collateral.
screening process was conducted. In the first step
By clarifying the relation between SQ and the
titles and abstracts were reviewed by two independ-
HRQoL further, we can better identify which aspects
ent reviewers (MP, LV). In case of disagreement,
of sleep lead to poor perceived health and possibly
papers were included. The second step included full-
expand knowledge on how to improve HRQoL during
text screening. Disagreement was resolved by discus-
pregnancy. The aim of this review is to evaluate how
sion or a third reviewer (RM). Reference screening was
sleep during pregnancy relates to HRQoL and whether
performed afterward.
this relation varies during different trimesters and/or
on different subdomains of HRQoL.
Quality appraisal, data extraction, and analyses
Methods Data extraction was completed independently by both
reviewers in Microsoft Excel and compared. Extracted
Study protocol
data included author name, publication year, study
This review was registered in August 2021 with the design, country, sample size, trimester(s) observed,
International Prospective Register of Systematic available data on sleep, HRQoL outcomes including
Reviews (PROSPERO; Registration no. CRD42021264707) subdomains, the relation of SQ and HRQoL, and meth-
and was conducted following the Preferred Reporting ods of measurement.
Items for Systematic Reviews and Meta-Analyses The Newcastle-Ottawa Scale (NOS, see Appendix 3)
(PRISMA) [20]. The checklist can be found in was used to evaluate the quality of the included
Appendix 1. papers (with modifications to match the needs of this

review). Two independent reviewers assessed the risk
of bias (MP, LV). Disagreements were resolved by dis-
cussion with a third reviewer (RM). Cross-sectional
studies with a score of 7 were considered high qual-
ity [25]. Longitudinal studies with a score of 2 in the
selection category, 2 in comparability, and 2 in the
outcome domain were considered fair quality [26].
Options to perform meta-analyses were explored.
Results
Studies included
Figure 1 shows that the initial search identified 531
relevant records, of which 313 remained after the
Figure 1. PRISMA flow diagram.
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3
duplicate screening. After exclusion based on title and
abstract, 19 full-text papers were screened, which led
to 10 studies to be included in this review. Reference
screening did not yield any extra eligible studies.
Study characteristics
Data across studies involved 7330 subjects ranging
from 23 to 4352 participants per study (Table 1).
Studies were published in English between 2010 and
2021. Seven studies included healthy pregnant women
[19,28,29,31,32,34,35], one included women with prior
sleeping disorders [27], one included women with
ongoing mood disorders [33], and one study included
women with high-risk pregnancies [30]. Eight studies

Table 1. Study characteristics and results regarding SQ and HRQoL. (a) Cross-sectional studies. (b) Longitudinal studies.
Study, year, reference
þ region
(A) Cross-sectional studies
Da Costa et al. (2010) [19]
Canada
Rezaei et al. (2013) [27]
Iran
Effati et al. (2017) [28]
Iran
Mourady et al. (2017) [29]
Libanon
4
HRQoL and sleep
Participants (N ¼ 7307) tools used HRQoL subdomains used Trimesters (weeks) Participants Key results
245 SF-36c Physical functioning, role 3rd (28–40) Pregnant women. Sleep problems have a relation with
Prime-MD Patient physical, bodily pain, No exclusion criteria poorer HRQoL in seven of eight
Health general health, vitality, domains during the third trimester
Questionnaire social functioning, mental (r < 0.23, p ¼ <.001) (b < 0.17,
(Dichotomous sleep health p < .007). Related domains:
A. E. J. PETERS ET AL.
outcome) Physical functioning, role physical,
bodily pain, general health,
vitality, social functioning, and
mental health.
100 WHOQoL-BREFe Physical health, psychological 2nd (15–25) Pregnant women with insomnia or There is a significant relationship
PSQIa (Continuous health, social relationships, poor sleep quality before between sleep quality score and
sleep outcome) environmental quality of pregnancy. general quality of life score and
life Exclusion: physical and psychiatric one (psychological health) of four
illnesses, drugs, alcohol, sleeping domains (p < .04). Sleep
medication, and/or hormones. No disturbances have a significant
traumatic event during the study, effect on the overall QoL and two
travel, and night shift. of four domains (p < .004).
Related domains: Physical health
and social relationships. Subjective
sleep quality has a significant
effect on overall QoL and four of
four domains (p < .03). Related
domains: Physical health,
psychological health, social
relationships, and environmental
quality of life.
364 WHOQoL-BREFe No information about 2nd and 3rd Pregnant women. There is a relationship between sleep
PSQIa (Continuous domains of quality of life (>15) Exclusion: Night shifts, multiple quality and 2 subsets (sleep
sleep outcome) used, only total score pregnancy, fetal abnormalities, disturbance and daytime
history of depression, previous dysfunction) and quality of life.
mental health problems, problems (r < 0.153, p < .001) (b < 0.23,
during previous pregnancies, p < .001). There is no significant
taking sleep medication, and big difference in sleep quality among
life events during the past the trimesters.
6 months before pregnancy.
141 WHOQoL-BREFe General health, physical 1st, 2nd and 3rd Pregnant women (18þ years) Higher Insomnia scores are
ISIb (Continuous sleep health, psychological Exclusion: chronic medical condition. significantly associated with
outcome) health, social relationships, quality of life and 5/5 domains
environment (r < 0.264, p < .002). Related
domains: General health, physical
health, psychological health, social
relationships, and environment.
No significant difference in ISI
score among the trimesters.
(continued)
Table 1. Continued.
Study, year, reference
þ region Participants (N ¼ 7307)
Sadaati et al. (2018) [30]
Iran
Zhang et al. (2019) [31]
China
Davoud et al. (2020) [32]
Iran
Kang et al. (2020) [33]
USA
Du et al. (2021) [34]
China
HRQoL and sleep
tools used HRQoL subdomains used Trimesters (weeks) Participants Key results
364 WHOQoL-BREFe No information about 3rd (28–36) Pregnant women (15–45 years) with There is a significant relationship
PSQIa (Continuous domains of quality of life preeclampsia or gestational between sleep quality score and
sleep outcome) used, only total score diabetes. quality of life among high-risk
Exclusion: Fetal problems, multiple pregnant women (r ¼ 0.3,
pregnancy, history of preterm p < .0001) [b ¼ 2.8 (4.3 to
birth, and history of mental 1.4), p < .001] in the 3rd
disorder. trimester. Most subdomains of
sleep quality including subjective
sleep quality, sleep latency, sleep
efficiency, sleep disturbances, and
daytime dysfunction have also
been associated with lower quality
of life (r < 0.4, p < .015).
1120 SF-12d Physical functioning, role 3rd Pregnant women (20þ years) The relations between sleep quality
PSQIa (Continuous physical, bodily pain, Exclusion: Multiple pregnancy or and physical HRQOL (PHQOL)
sleep outcome) general health, vitality, mental illness. (b ¼ 0.235, p < .001) and mental
social functioning, role HRQOL (MQOL) (b ¼ 0.11,
emotional and mental p < .001) are significant during the
health combined into 2 3rd trimester. The effect of
categories: PHQoL and perceived stress on PHQOL and
MHQoL MHQOL was influenced partially
through the indirect path of sleep
quality. (b ¼ 0.061/0.029).
256 WHOQoLe General health, physical 1st, 2nd, and 3rd Pregnant women (18þ years). Higher insomnia scores have a
ISIb (Continuous sleep health, psychological Exclusion: multiple pregnancy, fetal significant negative relationship
outcome) health, social relationships, problems, night shift, history of with general QoL and three of five
environment clinical or psychological problems, domains of QoL (r < 0.281,
bad life experiences previous or p ¼ <0.05). Related domains:
during pregnancy. General QoL, general health, and
psychological health.
23 WHOQoL-BREFe Physical health, psychological 3rd (24–28) Pregnant women (18–40 years) with Analyses were performed to examine
Actigraph (Continuous health, social health, sleep problems, DSM-IV diagnose the association between objective
sleep outcome) environment, general of major depressive disorder or sleep and the various domains of
Micro Motionlogger, health anxiety disorder, and Hamilton QoL. No significant associations
AMI, Ardsley, NY Depression Rating Scale of 14. were observed. (Data not
Exclusion: Active psychosis, presented in the table/article).
suicidality, bipolar disorder,
frequent migraines, high-risk
pregnancy, shift work, alcohol or
drug abuse.
4352 EQ-5Df No information about 1st (<14) Pregnant women (18–45 years). Women with a general HRQoL had a
PSQIa (Dichotomous domains of quality of life Exclusion: mental cognitive disorders, 3.98-fold (95% Cl: 2.97–5.34) risk
sleep outcome) used, only total score pre pregnancy diabetes, pre- of poor sleep quality compared to
pregnancy hypertension, women with a good HRQoL
cardiovascular diseases, kidney during the first trimester
diseases, and auto-immune
diseases.
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
(continued)
5
 6
A. E. J. PETERS ET AL.

Table 1. Continued.
Study, year, reference HRQoL and sleep
þ region Participants (N ¼ 7307) tools used HRQoL subdomains used Trimesters (weeks) Participants Key results
(B) Prospective studies
Tsai et al. (2016) [31] 164 SF-12d Mental and physical domain 1st, 2nd, and 3rd Pregnant women (18þ years) Subjective sleep quality is
Taiwan PSQIa Exclusion: Health complications at significantly associated with
Actigraph (Continuous time of enrollment, multiple mental and physical HRQoL
sleep outcome) gestations, night shift workers, (b < 0.768, p < .01) during all
Actiwatch-2, diagnosed depression or sleeping three trimesters. 1st trimester
Respironics, disorder subjective sleep predicts 2nd and
Murrysville, PAg 3rd trimester mental HRQoL and
2nd trimester physical HRQoL.
(b < 0.85, p < .01).
More daytime sleep was associated
with better physical HRQOL in 1st
trimester (b ¼ 0.03, p ¼ .04); sleep
efficiency was associated with
mental HRQOL in the 2nd
trimester (b ¼ 0.14, p ¼ .04) and
total nighttime sleep was
associated with mental HRQOL in
the 3rd trimester (b ¼ 2.67,
p < .01). 1st trimester total
nighttime sleep is also associated
with mental HRQOL in 2nd and
3rd trimester (b < 1.38, p < .02).
a
PSQI subsets: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication and daytime dysfunction.
b
ISI subsets: sleep maintenance and early awakening, current sleep satisfaction, impact on daily functioning disturbances and the level of concern about current sleep difficulties.
c
SF-36 subsets: Physical functioning, role limitation due to physical health, bodily pain, general health, vitality, social functioning, role limitation due to emotional health and mental health.
d
SF-12 subsets: Individual’s physical and mental health, function, and well-being.
e
WHOQOL subsets: Physical health, psychological health, social relationships and environmental HRQoL.
f
EQ-5D subsets: Mobility, self-care, usual activities, pain/discomfort and anxiety/depression.
g
Actiwatch-2, Respironics, Murrysville, PA subsets: total nighttime sleep and total daytime sleep; wake after sleep onset at night and sleep efficiency.

were cross-sectional [19,27–33] and two were labeled
as longitudinal study [34,35]. One study, however,
labeled as a longitudinal, which included cross-sec-
tional data pertaining to our research question has
been treated as so [34].
Three studies focused on the entire pregnancy
[29,32,35], one study on the second and third trimes-
ters [28], one on only the first- [34], one on the
second- [27], and four on the third trimester
[19,30,31,33].
SQ was measured subjectively in nine studies, of
which one also included actigraphic data [35]. One
study used only actigraphic data [33]. The PSQI was
used in six studies [27,28,30,31,34,35], two studies
used the ISI [29,32] and one study [19] used the
prime-MD patient health questionnaire (PHQ) [36].
When measuring HRQoL, six studies [27–30,32,33]
used the WHO’s Quality of Life Scale (WHOQoL) ques-
tionnaire [37], or its shorter validated version [38], one
study [19] used the Medical Outcomes Study Short
Form 36 survey (SF-36) [39], two [31,35] its shorter ver-
sion, the SF 12v2 [40] and one study [34] used
EuroQol (EQ-5D) [41].
Quality assessment
Quality assessment is found in Figure 2. After discus-
sion, agreement was met for the 10th article which
was considered to be of unsatisfactory quality [33].
One study was found to be of satisfactory quality [27],
four of good quality [29–31,35], and four of very good
quality [19,28,32,34].
The relation between SQ and the overall HRQoL
All studies reported on the relationship between SQ
and HRQoL. Nine studies found a lower SQ [19,24–
32,34,35] to be related to a lower overall HRQoL. Only
Figure 2. Risk of bias assessment for (a) cross-sectional and (b) longitudinal studies. þ: low risk of bias; : high risk of bias.
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 7
one study found no association between overall
HRQoL and objective sleep measures [33].
Five studies reported effect sizes on this relation.
Two articles [29,32] reported a medium effect size
[42,43] over the entire pregnancy. One study reported
a low effect size for the second and third trimesters
[28]. In the third trimester, two studies reported
medium effect sizes [19,30].
The relation of sleep components and HRQoL
Four studies [27,28,30,35] explored the relation of
HRQoL with various components of sleep. Sleep distur-
bances [27,28,30] and lower subjective SQ [27,30,35]
were found to be associated with lower HRQoL in
three of four studies. Two studies reported a higher
daytime dysfunction [28,30] and lower sleep efficiency
[30,35] to be related to a lower HRQoL. No relation
was found for sleep latency.
The study using wrist actigraphy found daytime
sleep duration to be associated with higher scores of
HRQoL on the physical subdomain during the first tri-
mester [35]. Shorter total nighttime sleep duration was
also found to be related to lower mental HRQoL sub-
domain scores during the third trimester in this study.
No relation was found between the total nighttime
sleep duration and overall HRQoL [27,28,30].
The relation of overall SQ and domains of HRQoL
Seven studies reported on the relation of overall SQ
with specific domains of HRQoL. Two studies meas-
ured HRQoL as only a physical and mental domain
[31,35], and five included more domains (e.g. mental,
physical, emotional, social, and environmental)
[19,27,29,32,33].
Poor SQ was associated with both the mental and
physical domains in the studies which investigated
8 A. E. J. PETERS ET AL.
only two domains [31,35]. Tsai et al. [35] furthermore
observed that the relation of SQ and the physical
domain was strongest in the first trimester, weakening
with progressing pregnancy; the relation of SQ and
the mental component was found to be strongest in
the first and third trimesters.
Rezaei et al. [27] and Kang et al. [33] reported on
four HRQoL domains (physical, psychological, social,
and environmental). Kang et al. [33] report no associ-
ation between sleep and these domains. Rezaei et al.
[27] found low SQ to be related to low scores in the
psychological domain only.
Two articles reported on five domains of HRQoL
(general, physical, psychological, social, and environ-
mental health) [29,32]. Mourady et al. [29] found SQ to
be associated with all. Davoud et al. [32] found only a
relation of SQ with three domains, namely general
health, physical health, and psychological health.
Da Costa et al. [19] report a significant relationship
between lower SQ and lower scores in the domains of
physical functioning, role physical, bodily pain, general
health, vitality, social function, and mental health (psy-
chological health). The domain of role emotion how-
ever did not have a relation with SQ.
Longitudinal effects of SQ on the HRQoL during
pregnancy
Only one study described the longitudinal effects of
SQ in the first trimester on the HRQoL of the second
and third trimesters [35]. Lower SQ in the first trimes-
ter predicted lower physical HRQoL in the second tri-
mester (b ¼ 0.87), and a lower mental HRQoL in both
second and third trimesters (b ¼ 0.85). Higher total
nighttime sleep duration in the first trimester pre-
dicted better mental HRQoL in the second and third
trimesters (b > 1.38) but did not have a significant
relation with physical HRQoL. Other sleep compo-
nents, such as sleep latency, sleep efficiency, and total
daytime sleep duration in the first trimester did not
predict HRQoL in later trimesters.
Possibility of further analyses
To investigate the possibility of a meta-analysis a
“Table of study characteristics illustrating similarity of
PICO elements” [44] was constructed (see Appendix 4).
Because of high clinical and methodological diversity
[45] and as some scholars argue against doing meta-
analysis on observational data anyway [46], we
decided not to execute a meta-analysis.
Summary of findings
Nine studies show a relation between overall SQ and
HRQoL during pregnancy (effect sizes: low to
medium). One study reports no association between
SQ and HRQoL.
Studies tended to show associations between sleep
disturbances and HRQoL (3/4), and subjective SQ and
HRQoL (3/4). Two studies did and two didn’t find a
relation between higher daytime dysfunction and
sleep efficiency with lower HRQOL (2/4). No study
found a relationship between sleep latency and
HRQoL (0/4). One study, with actigraphic data found
less daytime sleep and low total nighttime sleep dur-
ation to be associated with lower HRQoL. Three ques-
tionnaire studies, however, found no relation between
total nighttime sleep duration and HRQoL.
The mental (psychological) and physical domains of
HRQoL were found to be related to overall SQ scores
in respectively 6/7 and 5/7 studies. The social and
environmental domains of HRQoL were found to be
associated with overall SQ scores in 2/5 studies.
One study found overall lower SQ and total night-
time sleep duration in the first trimester to be related
to HRQoL in further trimesters.
Discussion
The objective of this review was to evaluate the rela-
tionship between SQ and HRQoL during pregnancy.
Our review suggests a relationship between poor SQ
with lower HRQoL during pregnancy, backed up by
all studies included, except for one. This difference
in outcome may be due to a lack of power related
to the small number of pregnant women
included (n ¼ 23).
Effect sizes of SQ on HRQoL were considered low
to medium. The studies which focused on all three tri-
mesters or on only the third trimester found medium
effects; the study that focused on the second and
third trimesters combined found a low effect size,
which might suggest a less prominent effect of SQ on
the HRQoL during the second trimester, as is also sug-
gested by the longitudinal study included in this
review.
Subjective SQ and sleep disturbances seem associ-
ated with lower HRQoL in most studies. There also
seems to be some evidence for daytime dysfunction
and worsened sleep efficiency to be related to HRQoL
in a negative way, but the findings were not
consistent.
Our findings build further on the studies of Sut
et al. [17] and Lagadec et al. [18]. Sut et al. [17] found

that the SQ and HRQoL of pregnant women were
worse than those of non-pregnant healthy controls.
Lagadec et al. [18] did a systematic review of the
determinants of HRQoL in pregnant women and con-
cluded that sleep difficulties are one of these
determinants.
To our knowledge, however, this is the only system-
atic review aimed to explore the relationship between
SQ and HRQoL during pregnancy. The strength of this
systematic review includes the use of multiple data-
bases including trial registries and the use of two
independent reviewers for screening and data
extraction.
Findings from the present systematic review should
however be considered in the light of several limita-
tions. First, our search has only identified 10 studies,
which limits the validity and generalizability of our
conclusions. Second, the heterogeneity among studies
and insufficient availability of data prevented execut-
ing a meta-analysis. Third, the included studies primar-
ily consisted of cross-sectional designs, which limit the
interpretation of causality. Only one study included
examined the cross-sectional and longitudinal associ-
ation between SQ and HRQoL in pregnant women.
Fourth, some studies used HRQoL questionnaires con-
taining direct questions about SQ, which directly affect
the score of some subdomains. It was not clear
whether these studies corrected this influence when
discussing their results on the relation between SQ
and HRQoL. However, these direct questions, such as
“How satisfied are you with your sleep?” are not
expected to explain all of the relations found between
SQ and HRQoL. Lastly, the small number of included
studies prevented us from testing for publication bias.
This review provides yet another argument to
underline the importance of good sleep in pregnant
women; adding to the previously published articles
(see Introduction) about the relation of poor gesta-
tional sleep with the risk of adverse maternal/perinatal
outcomes, such as depression, preeclampsia, preterm
birth and offspring adiposity [6,7]. A low HRQoL is
found to be related to low birth weight and preterm
birth and is, therefore, an important factor, by itself,
for optimizing maternal and neonatal health [47,48].
The WHO even considers optimizing HRQoL the num-
ber one priority of care during pregnancy [49]. So,
despite the limited number of studies, this systematic
review contributes to the general body of knowledge
on HRQoL and sleep during pregnancy and may con-
tribute to reaching the goal of the WHO’s main prior-
ity of care during pregnancy. If HRQoL is indeed
affected by SQ during pregnancy, sleep information
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 9
should be considered as important as prenatal infor-
mation given about prenatal supplements and food
restrictions. Furthermore, screening to prevent the
chronic aspect of sleep problems during and after
pregnancy is to be considered [7]. Future studies
should examine the effectiveness of evidence-based
interventions to improve sleep during pregnancy and
thus maybe prevent low quality of life and/or mater-
nal and neonatal health issues. Furthermore, we rec-
ommend that future studies should try to combine
both subjective and objective sleep measures. In case
the used HRQoL scale also contains a sleep quality
item, we recommend also analyzing the relation
between SQ and HRQoL without this item.
By clarifying the relation between SQ and the
HRQoL further, we can better identify which aspects
of sleep quality lead to poor perceived health during
pregnancy and expand knowledge on what aspects of
sleep during pregnancy should be improved espe-
cially. This may also be helpful in guiding future inter-
ventions to improve maternal well-being and give
children the best start in life.
Conclusion
This review shows evidence of a relation between SQ
and HRQoL during pregnancy in all trimesters, with
most evidence found for the third trimester. The only
longitudinal study in this review also indicates a longi-
tudinal relation of sleep with the HRQoL during preg-
nancy, where SQ and sleep duration during the first
trimester seem to be related to the HRQoL in the later
trimesters. This review thus provides more evidence
for the importance of good sleep during pregnancy.
Future research should focus on developing evidence-
based interventions to improve sleep during preg-
nancy and evaluate their effect on child and maternal
health, including quality of life.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
Funding
The author(s) reported there is no funding associated with
the work featured in this article.
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12 A. E. J. PETERS ET AL.

Appendix 1. PRISMA 2020 checklist

Location where
Section and topic Item # Checklist item item is reported
Title
Title 1 Identify the report as a systematic review. 2
Abstract
Abstract 2 See the PRISMA 2020 for Abstracts checklist. 2
Introduction
Rationale 3 Describe the rationale for the review in the context of existing knowledge. 3–4
Objectives 4 Provide an explicit statement of the objective(s) or question(s) the review 4
addresses.
Methods
Eligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies 5
were grouped for the syntheses.
Information sources 6 Specify all databases, registers, websites, organizations, reference lists, and 4–5
other sources searched or consulted to identify studies. Specify the date
when each source was last searched or consulted.
Search strategy 7 Present the full search strategies for all databases, registers, and websites, 4–5
including any filters and limits used.
Selection process 8 Specify the methods used to decide whether a study met the inclusion 5
criteria of the review, including how many reviewers screened each
record and each report retrieved, whether they worked independently,
and if applicable, details of automation tools used in the process.
Data collection process 9 Specify the methods used to collect data from reports, including how many 5–6
reviewers collected data from each report, whether they worked
independently, any processes for obtaining or confirming data from study
investigators, and if applicable, details of automation tools used in the
process.
Data items 10a List and define all outcomes for which data were sought. Specify whether 5–6
all results that were compatible with each outcome domain in each
study were sought (e.g. for all measures, time points, analyses), and if
not, the methods used to decide which results to collect.
10b List and define all other variables for which data were sought (e.g. 6
participant and intervention characteristics, funding sources). Describe
any assumptions made about any missing or unclear information.
Study risk of bias assessment 11 Specify the methods used to assess risk of bias in the included studies, 5–6
including details of the tool(s) used, how many reviewers assessed each
study and whether they worked independently, and if applicable, details
of automation tools used in the process.
Effect measures 12 Specify for each outcome the effect measure(s) (e.g. risk ratio, mean 6
difference) used in the synthesis or presentation of results.
Synthesis methods 13a Describe the processes used to decide which studies were eligible for each 6
synthesis [e.g. tabulating the study intervention characteristics and
comparing against the planned groups for each synthesis (item #5)].
13b Describe any methods required to prepare the data for presentation or N/A
synthesis, such as handling of missing summary statistics, or data
conversions.
13c Describe any methods used to tabulate or visually display results of Table 1
individual studies and syntheses.
13d Describe any methods used to synthesize results and provide a rationale for 5
the choice(s). If meta-analysis was performed, describe the model(s),
method(s) to identify the presence and extent of statistical heterogeneity,
and software package(s) used.
13e Describe any methods used to explore possible causes of heterogeneity 5
among study results (e.g. subgroup analysis, meta-regression).
13f Describe any sensitivity analyses conducted to assess robustness of the N/A
synthesized results.
Reporting bias assessment 14 Describe any methods used to assess risk of bias due to missing results in a 4–5
synthesis (arising from reporting biases).
Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body N/A
of evidence for an outcome.
Results
Study selection 16a Describe the results of the search and selection process, from the number 5–6, Figure 1
of records identified in the search to the number of studies included in
the review, ideally using a flow diagram.
16b Cite studies that might appear to meet the inclusion criteria, but which 5, Figure 1
were excluded, and explain why they were excluded.
(continued)
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 13

Continued.
Location where
Section and topic Item # Checklist item item is reported
Study characteristics 17 Cite each included study and present its characteristics. Table 1
Risk of bias in studies 18 Present assessments of risk of bias for each included study. 6, Figure 2
Results of individual studies 19 For all outcomes, present, for each study: (a) summary statistics for each Table 1
group (where appropriate) and (b) an effect estimate and its precision
(e.g. confidence/credible interval), ideally using structured Tables or plots.
Results of syntheses 20a For each synthesis, briefly summarize the characteristics and risk of bias 6–10
among contributing studies.
20b Present results of all statistical syntheses conducted. If meta-analysis was N/A
done, present for each the summary estimate and its precision (e.g.
confidence/credible interval) and measures of statistical heterogeneity. If
comparing groups, describe the direction of the effect.
20c Present results of all investigations of possible causes of heterogeneity N/A
among study results.
20d Present results of all sensitivity analyses conducted to assess the robustness N/A
of the synthesized results.
Reporting biases 21 Present assessments of risk of bias due to missing results (arising from N/A
reporting biases) for each synthesis assessed.
Certainty of evidence 22 Present assessments of certainty (or confidence) in the body of evidence for 7, Figure 2
each outcome assessed.
Discussion
Discussion 23a Provide a general interpretation of the results in the context of other 10–13
evidence.
23b Discuss any limitations of the evidence included in the review. 11–12
23c Discuss any limitations of the review processes used. 11–12
23d Discuss implications of the results for practice, policy, and future research. 12–13
Other information
Registration and protocol 24a Provide registration information for the review, including register name and 4
registration number, or state that the review was not registered.
24b Indicate where the review protocol can be accessed, or state that a protocol 4
was not prepared.
24c Describe and explain any amendments to information provided at N/A
registration or in the protocol.
Support 25 Describe sources of financial or non-financial support for the review, and 13
the role of the funders or sponsors in the review.
Competing interests 26 Declare any competing interests of review authors. 13
Availability of data, code and other materials 27 Report which of the following are publicly available and where they can be N/A
found: template data collection forms; data extracted from included
studies; data used for all analyses; analytic code; any other materials
used in the review.
From Page et al. [50].
For more information, visit: http://www.prisma-statement.org/.
14 A. E. J. PETERS ET AL.

Appendix 2. Search strategies Embase

Pubmed

Search # Search terms Field of search Number of hits Search # Search terms Field of search Number of hits
1 Pregnan Title/Abstract 549,285 1 Pregnan Title OR Abstract 668,892
2 Gestation Title/Abstract 219,997 2 Gestation Title OR Abstract 302,462
3 S1 OR S2 652,664 3 S1 OR S2 804,763
4 Sleep Title/Abstract 179,180 4 Sleep Title OR Abstract 267,609
5 Sleep deprivation MeSH 10,035 5 Sleep deprivation Emtree Submapping 16,889
6 Insomnia Title/Abstract 23,404 6 Insomnia Title OR Abstract 39,027
7 S4 OR S5 180,147 7 S4 OR S5 270,002
8 S7 OR S6 190,926 8 S7 OR S6 287,578
9 Quality of life Title/Abstract 298,430 9 Quality of life Title OR Abstract 479,983
10 Quality of life MeSH 212,042 10 Quality of life Emtree submapping 509,013
11 HRQOL Title/Abstract 19,133 11 HRQOL Title OR Abstract 29,612
12 QOL Title/Abstract 42,635 12 QOL Title OR Abstract 79,992
13 S9 OR S10 360,530 13 S9 OR S10 630,987
14 S13 OR S11 364,053 14 S13 OR S11 631,747
15 S14 OR S12 365,490 15 S14 OR S12 637,208
16 S3 AND S8 3791 16 S3 AND S8 6158
17 S16 AND S15 152 17 S16 AND S15 287

PsychInfo Cochrane

Search # Search terms Field of search Number of hits Search # Search terms Field of search C. reviews
1 Pregnan Title OR Abstract 48,487 1 Pregnan Title, Abstract, Keyword 1145
2 Gestation Title OR Abstract 13,905 2 Gestation Title, Abstract, Keyword 438
3 S1 OR S2 55,998 3 S1 OR S2 1317
4 Sleep Title OR Abstract 70,491 4 Sleep Title, Abstract, Keyword 247
5 Sleep deprivation MeSH 3,720 5 Sleep deprivation Mesh 0
6 Insomnia Title OR Abstract 12,681 6 Insomnia Title, Abstract, Keyword 85
7 S4 OR S5 70,619 7 S4 OR S5 247
8 S7 OR S6 75,866 8 S7 OR S6 303
9 Quality of life Title OR Abstract 78,983 9 Quality of life Title, Abstract, Keyword 2429
10 Quality of life MeSH 34,430 10 Quality of life Mesh 597
11 HRQOL Title OR Abstract 5,001 11 HRQOL Title, Abstract, Keyword 72
12 QOL Title OR Abstract 10,878 12 QOL Title, Abstract, Keyword 211
13 S9 OR S10 89,695 13 S9 OR S10 2429
14 S13 OR S11 89,745 14 S13 OR S11 2429
15 S14 OR S12 89,953 15 S14 OR S12 2433
16 S3 AND S8 1241 16 S3 AND S8 27
17 S16 AND S15 49 17 S16 AND S15 4
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 15

Appendix 3. Quality assessment scales

Newcastle-Ottawa Scale adapted for cross-sectional studies
Selection:

1. Representativeness of the sample:

a. Truly representative of the average in the target population.  (all subjects or random sampling)
b. Somewhat representative of the average in the target group.  (non-random sampling)
c. Selected group of users/convenience sample.
d. No description of the derivation of the included subjects.
2. Sample size:
a. Justified and satisfactory (including sample size calculation)
b. Not justified)
c. No information provided
3. Non-respondents:
a. Proportion of target sample recruited attains pre-specified target or basic summary of non-respondent characteristics
in sampling frame recorded
b. Unsatisfactory recruitment rate, no summary data on non-respondents)
c. No information provided
4. Ascertainment of the exposure (risk factor):
a. Clinic registers/hospital records only/Validated Questionnaires
b. Parental or personal recall and vaccine/hospital records/validated Questionnaires
c. Parental/personal recall only

Comparability: (Maximum 2 stars)

1. Comparability of subjects in different outcome groups on the basis of design or analysis) Confounding factors controlled
a. Data/results adjusted for relevant predictors/risk factors/confounders e.g. age, sex, time since vaccination, etc.)
b. Data/results not adjusted for all relevant confounders/risk factors/information not provided.

Outcome:

1. Assessment of outcome:
a. Independent blind assessment using objective validated methods.
b. Unblinded assessment using objective validated methods.
c. Used nonstandard or non-validated laboratory methods with gold standard.
d. No description/nonstandard laboratory methods used.
2. Statistical test:
a. Statistical test used to analyze the data clearly described, appropriate, and measures of association presented includ-
ing confidence intervals and probability level (p-value).
b. Statistical test not appropriate, not described, or incomplete.

Cross-sectional Studies:
Very Good Studies: 9–10 points
Good Studies: 7–8 points
Satisfactory Studies: 5–6 points
Unsatisfactory Studies: 0–4 points

This scale has been adapted from the Newcastle-Ottawa Quality Assessment Scale for longitudinal studies to provide qual-
ity assessment of cross sectional studies.

Newcastle-Ottawa Scale adapted for longitudinal studies

Note: A study can be awarded a maximum of one star for each numbered item within the Selection and Outcome categories.
A maximum of two stars can be given for Comparability

Selection

1. Representativeness of the exposed longitudinal

a. Truly representative of the average _______________ (describe) in the community w

b. Somewhat representative of the average ______________ in the community w

c. Selected group of users, e.g. nurses, volunteers
d. No description of the derivation of the longitudinal
16 A. E. J. PETERS ET AL.

2. Selection of the non-exposed longitudinal

a. Drawn from the same community as the exposed longitudinal w
b. Drawn from a different source
c. No description of the derivation of the non-exposed longitudinal/no exposed longitudinal present
3. Ascertainment of exposure
a. Secure record (e.g. surgical records) w
b. Structured interview/validated questionnaire w
c. Written self-report
d. No description
4. Demonstration that outcome of interest was not present at start of study; Sleep problems not present before pregnancy
a. Yes w
b. No

Comparability

1. Comparability of longitudinals on the basis of the design or analysis

a. Study controls for pregnancy related symptoms (select the most important factor) w
b. Study controls for any additional factor w (This criteria could be modified to indicate specific control for a second
important factor.)

Outcome
1. Assessment of outcome
a. Independent blind assessment w
b. Record linkage/validated questionnaire w
c. Self-report
d. No description
2. Was follow-up long enough for outcomes to occur
a. Yes (select an adequate follow up period for outcome of interest) w
b. No
3. Adequacy of follow up of longitudinals
a. Complete follow up—all subjects accounted for w
b. Subjects lost to follow up unlikely to introduce bias—small number lost—>20% follow up, or description provided
of those lost) w
c. Follow up rate <80% and no description of those lost
d. No statement

Thresholds for converting the Newcastle-Ottawa scales to AHRQ standards (good, fair, and poor):
Good quality: 3 or 4 stars in selection domain AND 1 or 2 stars in comparability domain AND 2 or 3 stars in outcome/expo-
sure domain
Fair quality: 2 stars in selection domain AND 2 stars in comparability domain AND 2 or 3 stars in outcome/exposure
domain
Poor quality: 0 or 1 star in selection domain OR 0 stars in comparability domain OR 0 or 1 stars in outcome/exposure
domain
Appendix 4. Table of study characteristics illustrating similarity of PICO elements across studies

Participants Intervention Outcome

Sleep Dichotomous/ HRQOL
measurement continuous questionnaire Results
Trimester Participants method used outcome used reported
1st, 2nd, Healthy WHOQoL SF-12
Study 3rd and 3rd Other in general Other PSQI ISI Other Dicho Contin (or BREF) (or SF-36) Other p-Value B-value R-value Other
Davoud et al. (2020) X x X X X X X (Pearson) F-value
Mourady et al. (2017) X x X X X X X (Spearman)
Tsai et al. (2016) X x X Actigraph X X X X
Sadaati et al. (2018) X With high-risk X X X X X X (Pearson)
pregnancy
Zhang et al. (2019) X x X X X X X
Kang et al. (2020) X With sleeping Actigraph X X No data
problem
and depression
Da Costa et al. (2010) X All pregnancies Prime-MD X X X X X (Pearson)
Effati et al. (2017) 2nd and 3rd x X X X X X X (Pearson/
Spearman)
Rezaei et al. (2013) 2nd With sleeping X X X X (of Spearman/
problems Pearson)
prior to pregnancy
Du et al. (2021) 1st x X X EQ-5D X X Odds ratio
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17