Prevalence of Insomnia and Related Factors among Pregnant Women in Zahedan City

¹ Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

² General Practitioner, Zahedan University of Medical Sciences, Zahedan, Iran

³ Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan, Iran

*Corresponding author: Erfan Ayubi, Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan, Iran. Email: aubi65@gmail.com

EXTENDED ABSTRACT

Background

Sleep disturbance is a frequent adverse experience during pregnancy, and both sleep quality and sleep quantity may decline as gestation advances [1]. Physiological, hormonal, and physical changes make pregnant women particularly susceptible to insomnia [2, 3], with previous studies reporting prevalence estimates that may exceed 50% [4, 5]. Insomnia during pregnancy has been associated with clinically important consequences, including depression and suicidal ideation [6], impaired neurobehavioral and daytime functioning [7], and adverse obstetric outcomes [8]. The occurrence of insomnia is also influenced by demographic and socioeconomic conditions [9–11], excessive gestational weight gain [12], and advancing gestational age, particularly in the third trimester [13]. Accurate assessment requires instruments appropriate for pregnancy; a Persian version of the Sleep Condition Indicator (SCI) has been validated for pregnant women [14]. However, information on the burden of insomnia and its determinants among pregnant women in Zahedan was limited. This study therefore aimed to determine the prevalence and symptom pattern of insomnia and to identify demographic, socioeconomic, and pregnancy-related factors associated with insomnia among pregnant women attending comprehensive health centers in Zahedan, Iran.

Methods

This cross-sectional study was conducted in Zahedan during 2021 among pregnant women attending urban comprehensive health service centers for routine antenatal care. Eligible women were 15-45 years old, literate, and beyond 16 weeks of gestation. Exclusion criteria included substance dependence or sedative use; physical disorders such as diabetes, asthma, renal disease, thyroid disease, or preeclampsia; psychiatric illness; and loss of a close family member during the preceding year. Because local prevalence data were unavailable, an expected prevalence of 0.50 was used for sample-size estimation; after accounting for the planned analysis of major predictors, 240 pregnant women were included. Zahedan was divided geographically into four regions, one health center was randomly selected from each region, and approximately 60 eligible women from each center were recruited by convenience sampling.

After written informed consent, participants completed a researcher-designed checklist covering age, occupation, education, household socioeconomic status, husband’s smoking, gestational age, gravidity, weight, unintended pregnancy, previous miscarriage, and stillbirth. Socioeconomic status was derived from household assets using principal component analysis and categorized into five levels from very poor to very rich. Insomnia was assessed with the nine-item Sleep Condition Indicator developed by Espie et al. [15]; the Persian version had previously demonstrated acceptable validity and reliability in pregnant women [14]. The SCI evaluates sleep quantity, sleep quality, concern about sleep, and effects on daytime functioning during the previous month, with total scores ranging from 0 to 36. The study used the article’s reported cut-off of 18 to classify clinical insomnia symptoms. Univariable and multivariable linear regression were used to evaluate factors associated with insomnia score. Variables with P≤0.10 in univariable analysis entered the multivariable model. Sensitivity to unmeasured confounding was assessed using the E-value framework proposed by VanderWeele and Ding [16] and implemented according to published methods [17]. Analyses were performed in Stata version 14, with P<0.05 considered statistically significant. The study was approved by the Ethics Committee of Zahedan University of Medical Sciences (IR.ZAUMS.REC.1399.304).

Results

A total of 240 pregnant women were analyzed. Mean age was 26.30 ± 6.24 years. Most participants were 21-35 years old (67.4%), were homemakers (89.6%), had middle-school education (64.6%), and were in weeks 24-36 of pregnancy (52.5%). Gravidity was three or more in 35.8% of participants. Approximately 28% weighed 58 kg or less, whereas 24% weighed more than 75 kg. Unintended pregnancy, previous miscarriage, and previous stillbirth were reported by 24.6%, 27.5%, and 9.2%, respectively.

Clinical insomnia symptoms were present in 113 women (47.1%). Sleep initiation and sleep maintenance problems were common: 56.3% reported taking more than 30 minutes to fall asleep, and 63.0% reported more than 30 minutes of wakefulness during the night. More than one third reported difficulty falling asleep on more than five nights per week. Overall, 113 participants (47.1%) rated their sleep quality as moderate or worse. Daytime consequences were also frequent: 57.5% reported that inadequate sleep affected mood, energy, or daily relationships, and substantial proportions reported impaired concentration, productivity, or ability to remain awake. The detailed distribution of SCI symptoms is shown in Table 2.

Table 2. Distribution of insomnia symptoms among pregnant women in the study.

In univariable analyses, better socioeconomic status, later gestational age, greater gravidity, weight above 75 kg, and history of miscarriage met the prespecified criterion for entry into the multivariable model. After adjustment, women in the middle socioeconomic category had an insomnia score 6.22 points higher than women in the very poor category (95% CI: 2.30-10.15; P=0.002), and women in the rich category had a 4.26-point higher score (95% CI: 0.15-8.37; P=0.04). Third-trimester pregnancy was associated with a 3.39-point higher insomnia score than second-trimester pregnancy (95% CI: 0.79-5.99; P=0.01). Women in the fourth weight quartile, corresponding to approximately 75 kg or more, had a 4.55-point higher insomnia score than those in the first quartile (95% CI: 0.57-8.54; P=0.02 in Table 3). Age, gravidity after adjustment, and miscarriage history were not statistically significant independent predictors. Significant adjusted associations had moderate standardized effect sizes, and E-values were relatively close to one, indicating that the observed estimates were not strongly influenced by the modeled degree of unmeasured confounding. Table 3 presents the complete adjusted regression and sensitivity analysis.

Table 3. Multivariable linear regression and sensitivity analysis among pregnant women in the study.

Conclusion

Insomnia was common among pregnant women in Zahedan, affecting approximately half of the study population and frequently interfering with daytime functioning. Higher insomnia scores were independently associated with middle or rich socioeconomic status, third-trimester pregnancy, and higher maternal weight. These findings support routine assessment of sleep during antenatal care, with particular attention to women in later pregnancy and those with higher weight or socioeconomic profiles associated with greater insomnia scores in this study. The cross-sectional design, self-reported measures, recruitment during the COVID-19 period, restriction to literate women, and absence of some potentially relevant factors such as depression and anxiety should be considered when interpreting the findings.

Keywords: Determinants, Insomnia, Pregnancy, Sleep Disturbances

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