Non-pharmacological Interventions for Improving Sleep Quality During Pregnancy: A Systematic Review and Meta-Analysis

Paulino, Daiane Sofia Morais; Borrelli, Carolina Bicudo; Faria-Schützer, Débora Bicudo; Brito, Luiz Gustavo Oliveira; Surita, Fernanda Garanhani

doi:10.1055/s-0042-1746200

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Revista Brasileira de Ginecologia e Obstetrícia

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Review Article • Rev Bras Ginecol Obstet. 44 (08) • 2022 • https://doi.org/10.1055/s-0042-1746200 copy

Non-pharmacological Interventions for Improving Sleep Quality During Pregnancy: A Systematic Review and Meta-Analysis

Intervenções não-farmacológicas para melhoria da qualidade do sono durante a gravidez: Uma revisão sistemática e metanálise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To investigate the effect of non-pharmacological interventions to improve sleep quality during pregnancy.

Data sources

A search was made in the NCBI/PubMed, ClinicalTrials.gov, Embase, BVS, and Web of Science databases. There were no limitations regarding language, sample size, and type of non-pharmacological intervention. We have included prospective clinical trials between July 2014 and July 2019.

Selection of studies

This study was registered in the Prospective International Registration of Systematic Reviews (PROSPERO) database was performed. Publication bias was also assessed with funnel plots. the primary outcome was the total score in the Pittsburgh Sleep Quality Index (PSQI) before and after intervention. Risk of bias and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were used for assessing methodological quality. From the 28 retrieved studies, we have selected 8 for qualitative analysis and 6 for meta-analysis.

Data collection

Two independent reviewers performed the study selection. In the case of disagreement, a third senior reviewer was consulted. The study was initially assessed based on the title, followed by abstract. Lastly, the full text was assessed to be included.

Data Synthesis

A significant improvement on the sleep quality (PSQI score) was observed when all interventions were grouped (MD = -3.03, 95%CI -4.15 to -1.92, n= 623, i²= 84%, p< 0.001). Analysis by subgroup (music listening: MD = -1.96, 95% CI -3.27 to -0.65, n= 207, i²= 67%, p= 0.003 and other interventions: MD = -3.66, 95% CI -4.93 to -2.40, n= 416, i2 = 80%, p< 0.001) showed an improvement, with high heterogeneity. Risk of bias has shown performance and detection bias for almost studies, and GRADE evidence was very low for all analyzed variables.

Conclusion

Non-pharmacological interventions—listening to music, physical exercise, relaxation exercises, lettuce seed, sleep hygiene, and acupressure—are effective for improving sleep quality during pregnancy.

Keywords
sleep quality; non-pharmacological interventions; pregnant women; systematic review; meta-analysis

Study ID	Country	Year	Sample size, N		Participant criteria	Intervention		Instrument
			Intervention	Control		Strategies/Intervention	Duration
Özkan and Rathfisch²³23 Özkan SA, Rathfisch G. The effect of relaxation exercises on sleep quality in pregnant women in the third trimester: A randomized controlled trial. Complement Ther Clin Pract. 2018;32:79–84. Doi: 10.1016/j.ctcp.2018.05.008 https://doi.org/10.1016/j.ctcp.2018.05.0...	Turkey	2018	42	42	3rd trimester, ≥ 20 y, primiparous, singleton, HRP, GA 28–34 weeks, pre-pregnancy BMI ≤ 25 kg/m², neck circumference < 38 cm, and no RLS.	Listening to a relaxation exercises CD before sleeping. The CD comprised a 4-minute introduction, 10-minute of information on deep relaxation PE and points to consider during PE, 30-minute introduction to relaxation, and the last 30 minute includes relaxation music.	4 weeks	PSQI
Pour et al.²⁴24 Pour ZS, Hosseinkhani A, Asadi N, Shahraki HR, Vafaei H, Kasraeian M, et al. Double-blind randomized placebo-controlled trial on efficacy and safety of Lactuca sativa L. seeds on pregnancyrelated insomnia. J Ethnopharmacol. 2018;227:176–180. Doi: 10.1016/j.jep.2018.08.001 https://doi.org/10.1016/j.jep.2018.08.00...	Iran	2018	50	50	20–45 y, singleton pregnancy, GA 12–36 weeks, with insomnia and PSQI score > 5.	IG received capsules containing 1000 mg of lettuce seed daily. CG received placebo capsules containing starch.	2 weeks	PSQI
Rodriguez-Blanque et al.²²22 Rodriguez-Blanque R, Sánchez-García JC, Sánchez-López AM, Mur-Villar N, Aguilar-Cordero MJ. The influence of physical activity in water on sleep quality in pregnant women: A randomised trial. Women Birth. 2018;31(01):e51–e58. Doi: 10.1016/j. wombi.2017.06.018 https://doi.org/10.1016/j.wombi.2017.06....	Spain	2018	67	67	GA 12–20 weeks, without any absolute contraindications for PE^* ** Involved general perception of sleep quality and quantity, number of awakenings, difficulty falling asleep, insomnia, restless sleep, snoring, diurnal sleep, and consequences of inadequate sleep. .	IG took part in the SWEP program, performing three 1-hour sessions/week water exercises. CG followed the usual recommendations, including emphasis on the positive effects of PE.	17 weeks	PSQI
Sönmez and Derya²⁵25 Sönmez A, Aksoy Derya Y. Effects of sleep hygiene training given to pregnant women with restless leg syndrome on their sleep quality. Sleep Breath. 2018;22(02):527–535. Doi: 10.1007/ s11325-018-1619-5 https://doi.org/10.1007/s11325-018-1619-...	Turkey	2018	64	64	Diagnoses of RLS, literate, at 3rd trimester, HRP, using iron supplementation, without sleep disorder.	IG received sleep hygiene training. A sleep hygiene training booklet was issued after training, and 2 weeks later, during a home visit, participants received a counseling service on sleep hygiene.	4 weeks	PSQI
Kocsis et al.¹⁹19 Kocsis I, Szilágyi T, Turos J, Bakó A, Frigy A. Effect of a gymnastics program on sleep characteristics in pregnant women. Taiwan J Obstet Gynecol. 2017;56(02):204–209. Doi: 10.1016/j.tjog.2017. 02.001 https://doi.org/10.1016/j.tjog.2017.02.0...	Romania	2017	79	53	HRP, 18–40 y, GA 18–22 weeks, BMI < 35 kg/m², parity < 3.	IG followed a specific PE program under strict instruction by a PE training specialist. The PE program structure involved 2-hour training sessions twice a week. PE included posture correction, preserving muscle tone, and strengthening pelvic and posterior muscles, breathing exercises, and relaxation techniques.	10 weeks	CDQ^ Involved general perception of sleep quality and quantity, number of awakenings, difficulty falling asleep, insomnia, restless sleep, snoring, diurnal sleep, and consequences of inadequate sleep.
Neri et al.¹⁸18 Neri I, Bruno R, Dante G, Facchinetti F. Acupressure on selfreported sleep quality during pregnancy. J Acupunct Meridian Stud. 2016;9(01):11–15. Doi: 10.1016/j.jams.2015.11.036 https://doi.org/10.1016/j.jams.2015.11.0...	Italy	2016	134	101	HRP, singleton pregnancy, ability to understand Italian, with feelings of anxiety and poor sleep quality.	IG was advised by a midwife (trained by an expert acupuncturist) to wear a soft rubber pin kept in place by an adhesive plaque able to exert acupressure on Point 7 of the heart meridian.	2 weeks	PSQI
Shobeiri et al.²⁰20 Shobeiri F, Khaledi S, Masoumi SZ, Roshanaei G. The effect of music therapy counseling on sleep quality in pregnant women. Int J Med Res Health Sci.. 2016;5(9S):408–416	Iran	2016	42	44	PSQI score > 5, 18–35 y, GA 30–34 weeks, singleton pregnancy, no drug addiction, not taking drugs affecting sleep quality, avoiding antidepressants use, without mental/physical disorders, access to an audio player at home.	IG received music therapy counseling in two weekly sessions, with each session lasting 60 minutes, in groups of 5–7 people. The music therapy method was passive music-listening (instrumental music by Kitaro, a Japanese composer and performer).	4 weeks	PSQI
Liu et al.²¹21 Liu YH, Lee CS, Yu CH, Chen CH. Effects of music listening on stress, anxiety, and sleep quality for sleep-disturbed pregnant women. Women Health. 2016;56(03):296–311. Doi: 10.1080/03630242. 2015.1088116 https://doi.org/10.1080/03630242.2015.10...	Taiwan	2016	61	60	PSQI score > 5, > 18y, GA 18–34 weeks.	IG was instructed to listen to at least one disc (30-minute) of the five prerecorded CDs compiled by the researcher or a minimum 30 minute of their preferred music per day at bedtime for 2 weeks. CG received the usual prenatal care.	2 weeks	Chinese version of the PSQI

Certainty assessment						Participants, n (before and after)		Absolute effect (95% CI)	Certainty
Number of studies	Study design	Risk of bias	Inconsistence	Indirect evidence	Imprecision	IC	CG	Absolute effect (95% CI)	Certainty
Non-pharmacological interventions - Music listening
2	Randomized clinical trial	Severe^a	Severe^b	Not severe	Severe^c	103	104	MD −1.96 (−3.27 to −0.65)	⊕⚪⚪⚪ Very low
Non-pharmacological interventions - Other interventions
4	Randomized clinical trial	Severe^a	Severe^b	Too severe^d	Severe^c	208	208	MD −3.66 (−4.93 to −2.4)	⊕⚪⚪⚪ Very low

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[1] Address for correspondence Fernanda Garanhani Surita, Professor of Obstetrics (Full), R. Alexander Fleming, 101, 13083-881, Campinas, SP, Brazil (surita@unicamp.br).