Introduction
Sleep disturbance is a change of sleeping habits in quality and/ or quantity of sleep [
1]. It encompasses disorders of initiating and maintaining sleep, excessive daytime sleepiness, and, disorders of sleep-wake cycle [
2,
3]. Sleep disturbance is a critical public health concern that affects the overall productivity of the country by decreasing an individual’s ability to comprehend and accomplish their day-to-day lives, disrupt school or work performance, and diminishing mental and physical health [
4,
5].
During pregnancy, the inconsistent sleep awake cycle in an indicator of sleep disturbance [
6‐
9] they have increased, normal and decreased sleep pattern in their total sleep time in the first trimester, second and third trimester of pregnancy respectively [
3,
9,
10]. Sleep disturbance is highly predominant during pregnancy and are commonly overlooked as a potential cause of maternal and fetal morbidity [
3,
11]. Women’s sleep-awake cycle is frequently disturbed during their pregnancy and it can diminishes the usual health functioning [
9,
12] and increases pregnancy related psychiatric comorbidities including anxiety and depression [
11,
13]. As the gestational age of pregnancy increases, the more likely women to have frequent awakenings and inadequate sleep habits [
14,
15].
Sleep disturbance causes maternal and fetal mental impairment [
16], preterm birth [
17], low birth weight [
11,
18], increase the risk of developing gestational diabetes mellitus [
19‐
21] and the offspring predisposed to developmental delay and learning disabilities [
22].
Sleep disturbance among pregnant women can be due to the hormonal and mental changes that the body undergoes during pregnancy time [
23]. This may be due to mechanical and physical changes which leads the women to experience discomforts including leg cramps, urinary incontinence, and shortness of breath, and intense backaches [
24]. Marked increment in the level of estrogen and progesterone because of the pregnancy influences a diverse range of both physiological and psychological processes, including sleep and mood disturbance [
25] estrogen and oxytocin causes difficulty in breathing and sleep fragmentation [
26].
Previous studies have identified multiple factors influence sleep disturbance among pregnant women such as unplanned pregnancy, third trimester anxiety depression and stress.
In Ethiopia, several individual studies have been conducted on the prevalence and factors of sleep disturbance among pregnant women. However, the findings are inconsistently reported from 30.8 to 68.4% and are not systematically reviewed. Therefore, the purpose of this systematic review and meta-analysis was to determine the pooled prevalence of sleep disturbance and its associated factors among Ethiopian pregnant women. The results of this systematic review and meta-analysis might help stakeholders and policymakers to implement different programs and healthcare initiatives aimed improving sleep quality and quantity of pregnant women.
Discussion
This systematic review and meta-analysis was employed to estimate the pooled prevalence of sleep disturbance and predictors among pregnant women in Ethiopia. As a result, half of pregnant women in Ethiopia have a disturbed sleep pattern. This finding underlines the significance of timely screening, early diagnosis and providing proper intervention of sleep disturbance among pregnant women.
The pooled estimate of sleep disturbance among pregnant women in Ethiopia was 50.43%, (95% CI: 38.21–62.65). This study finding is in line with previous studies 45.7% [
35] and 54.2% [
36]. However, the results of this meta-analysis were lower than a systematic review and met analytic study conducted on association between sleep disorder during pregnancy time and risk of postpartum depression in China76% [
37].
The possible reasons for this variation might be due to the difference in the socioeconomic status of the study participants including the difference in the prevalence of prenatal depression and stress.
This review identified that third trimester pregnancy, multigravidity, unplanned pregnancy, depression, stress, anxiety, and poor sleep hygiene were the factors statistically associated with sleep disturbance among pregnant women in Ethiopia.
This research found an association between third trimester pregnancy and sleep disturbance. This finding is supported by previous reviews [
3,
35,
37]. The possible reasons of sleep disturbance during the third trimester might be due to the physiologic changes because of the pregnancy including urinary frequency, fetal movement, lower back pain, leg cramps, heartburn, easily fatigability and abdominal discomfort [
14]. Furthermore, when the pregnant woman approaches to her expected date of delivery, she might worry about the mode of delivery, labor, birth outcome and financial issues which all could negatively affect the sleep pattern.
Multigravidity has a significant association with sleep disturbance. This may be explained by the fact that maternal sleep quality is disturbed as a result of being overstressed about having extra roles after childbirth and the way they incorporate the new role and responsibilities as a mother. In addition, multigravid pregnant mothers complained that their sleep pattern is depend on their children’s sleep awake cycle. If children frequently wake up at night, mothers will have a disturbed sleep pattern.
The review also showed that unplanned pregnancy has a significant association with sleep disturbance which is consistent with another study [
38]. This may be due to inadequate preparation for pregnancy and childbirth leading mothers to feel stressed with all the changes and challenges.
The odds of sleep disturbance were about more than three times greater among pregnant women with depression when compared with their counterparts. Another study supports this finding [
39]. This could be due to mood and emotional disturbance results sleep disturbance as depression and sleep disturbance have a bidirectional relationship [
40]. Furthermore, evidence has indicated that prenatal depression is one of the most possible psychological factors contributing to sleep disturbance during pregnancy [
9,
39].
This review also showed that stress has an association with sleep disturbance which is supported by previous studies [
41,
42]. These may be due to stress is thought to increase cognitive and somatic arousal which negatively affects sleep primarily by decreasing sleep duration and results pregnant women to have a fragmented sleep pattern [
43]. Moreover, it could be due to the direct effect of stress during pregnancy on sleep quality might be related to arginine vasopressin hormone, which is involved in the stress response and circadian regulation of the sleep-wake cycle [
44,
45].
The findings of this review showed that anxiety has a significant association with sleep disturbance which is consentient with another study [
46]. The odds of sleep disturbance were more than three times higher among pregnant women with anxiety as compared with their counter parts. The possible reason might be due to emotional and physiological arousal caused by anxiety and worries, which would result in more attention to environmental and personal stimuli, and these can lead to experience sleep disturbance [
47,
48].
Furthermore, poor sleep hygiene practice has a significant association with sleep disturbance among pregnant women which is supported by another previous studies [
3,
12]. The possible justification for this might be lack of healthy sleep habits, behaviors and environmental factors that can help pregnant women to have adequate sleep for instance drinking caffeinated drinks, performing dynamic physical activity and inconsistent sleep awake time.
Limitation of the study
Even though this is the first systematic review and meta-analysis of sleep disturbance among pregnant women in Ethiopia, it is not without limitations. This review may not be representative for all regions as the included studies were done in some regions of Ethiopia. In addition, the causal association between outcome variable and factors couldn’t be established since all the included studies were cross-sectional in nature. As a result of limited number of studies, publication bias and subgroup analysis were not performed for each identified factors though heterogeneity was observed in some analyses.
Conclusion and recommendation
This systematic review and meta-analysis found that about half of pregnant women have disturbed sleep pattern. Third trimester pregnancy, multigravidity, unplanned pregnancy, depression, stress, anxiety, and poor sleep hygiene were identified factors statistically associated with sleep disturbance. Thus, implementation of interventions for sleep disturbance after screening pregnant women is needed with collaborative effort of policy-makers and stakeholders. Moreover, public health interventions targeted at the prevention of unintended pregnancy, depression during pregnancy and considering other identified risk factors should be implemented.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.