INTRODUCTION:

Pregnancy is the most beautiful period of women life.¹ Motherhood is a unique bio-psychosocial experience that reshapes a woman’s identity and extends her role into that of a mother.² These changes affect women's sleep quality and sleep patterns during pregnancy.³ Change in circadian rhythm or hormonal changes, such as higher levels of oestrogen and progesterone, are thought to contribute to insomnia.⁴ Sleep plays a vital role in maintaining overall health by supporting the body’s physiological processes.⁵ However, during pregnancy, normal sleep patterns are often disrupted, potentially altering these physiological functions.

Various studies have emphasised common complaints among pregnant women, particularly in the third trimester, including dyspnea, nausea, vomiting, lower back pain, haemorrhoids, insomnia, pelvic pain, dizziness, cramping in the abdomen and legs, frequent urination, acid reflux, and discomfort from painful and tense contractions.^4,6,7 Sleep disturbances and poor sleep quality are also among the most common minor ailments of pregnancy. Most discomforts are primarily associated with hormonal fluctuations or the physiological changes occurring in the uterus.^8,9 It has been reported that the prevalence of poor sleep quality during pregnancy ranges from 30% to 76% among women,^10–14 and it tends to get worse as pregnancy progresses, particularly in the later trimesters.^15,16 In addition to poor sleep quality, pregnant women also experience several other sleep disturbances, such as altered sleep duration, insomnia symptoms (33.4%), restless legs syndrome (58.2%), sleep-disordered breathing, and obstructive sleep apnea.^17,18 These minor ailments affect sleep quality; however, only 22.5% of mothers have good knowledge about their management.¹⁹

It is essential for pregnant women to get proper sleep, as it promotes the normal growth and development of both the mind and the body.¹³ Sleep disturbances also increase the chance of several adverse outcomes, including pre-eclampsia, gestational hypertension, gestational diabetes mellitus, caesarean delivery, preterm birth, large-for-gestational-age infants, and stillbirth.^17,20,21 Additionally, disturbances in subjective and objective sleep patterns are linked to nearly 70% of mental health disorders during pregnancy.¹³ Emerging evidence suggests that sleep quality during pregnancy and mental health are closely interconnected. Poor sleep quality has been identified as a potential risk factor for the development of depression, anxiety, and suicidal ideation among antenatal women.^22,23 It also leads to higher concentration of cortisol, which is responsible for stress, anxiety and distress.²⁴These findings suggest that sleep disturbances are not merely a minor discomfort, it may contribute to the increased risk of high-risk pregnancies and need special, individualised care as they account for most perinatal morbidity and mortality despite being a small group.²⁵

Antenatal mental health is affected by factors such as physical and hormonal changes, daily stress, past depression, domestic issues, and lack of social support, which can disturb emotional balance.²⁶ Conversely, psychological factors may also contribute to sleep disturbances during pregnancy.^27,28 A study conducted in Ethiopia has shown that depression (AOR = 4.26; 95% CI: 2.54–7.14) and stress (AOR = 1.85; 95% CI: 1.20–3.02) are significantly associated with poor sleep quality among pregnant women.¹⁴ It has been reported that around 70% of pregnant women experience depressive symptoms, whereas 10–16% develop major depressive disorder.²⁹ Furthermore, pregnant women who report higher level of pregnancy-related anxiety and fear of childbirth are more likely to experience poor sleep quality.²⁷

Despite growing research on sleep quality during pregnancy, most studies tend to examine either sleep disturbances alone or select mental health outcomes, without considering the broader interplay between them. Existing evidence largely examines these factors in only one direction, and relatively few studies have addressed the potential bidirectional relationship between sleep quality and mental health outcomes. This limited evidence highlights the need for a comprehensive synthesis to better understand the dynamics among these factors. Therefore, this narrative review examines the bidirectional relationship between sleep quality and mental health in pregnant women.

MATERIAL AND METHOD:

Data sources:

This review targeted studies that show the relationship between sleep quality and mental health in pregnant women. For a broad scope of literature, electronic databases such as Google Scholar and PubMed were extensively used. The scope was limited to English-language articles published between 2015 and 2026. Screening was done, and relevant articles were included. The initial search was conducted on 12 March 2026, followed by further investigation.

Inclusion and exclusion:

Articles were screened to identify a set that explicitly addressed the bidirectional relationship between sleep quality and mental health in pregnant women. The inclusion and exclusion criteria for the studies are explained comprehensively in Table 1.

Table 1. Inclusion and Exclusion criteria

Inclusion Criteria	Exclusion criteria
Studies involving pregnant women.	Studies on non- pregnant women or the general population.
Studies exploring the association or bidirectional relationship between sleep quality and mental health in pregnant women.	Studies that do not show the relationship between the sleep quality and mental health in pregnant women.
Observational studies, RCT.	Reviews, case reports, guidelines and editorial letters were not included.
Article published in the English language.	Article not published in English.
Studies published between 2015 and 2026.	Studies published before 2015.

Screening:

In the screening process, after removing duplicates and considering inclusion and exclusion criteria, a total of 25 studies were included in the review.

RESULT:

A total of 25 studies were included in this narrative review, comprising cross-sectional, cohort, case-control and longitudinal studies. The included studies primarily examined the relationship between sleep quality and mental health outcomes such as depression, anxiety and stress among pregnant women. The findings were synthesised into key themes to explore the bidirectional relationship between sleep quality and mental health.

Sleep Quality and Mental Health Outcomes:

Poor sleep quality during pregnancy is consistently and significantly linked with higher levels of depression, anxiety, and stress. Across studies, poor sleep, both in terms of shorter duration and reduced subjective quality, emerges as a consistent predictor of adverse mental health outcomes during pregnancy. Poor subjective sleep quality in the prenatal period is associated with an increased likelihood of postpartum depressive symptoms, indicating that affected women may have 2.66 times the odds of experiencing borderline depression.^30–32 Evidence also demonstrates that women sleeping less than 6-8 hours per day consistently are at a higher risk of depression across all trimesters,^31,33 along with an elevated risk of anxiety, particularly during early and mid-pregnancy.³¹ Additionally, prenatal sleep impairment has also been identified as a significant predictor of increased post-traumatic stress symptoms (PTSS) over time, indicating its role in elevating psychological distress during the perinatal period.^32,34

Several studies strongly support that women reporting poorer sleep have significantly higher odds of experiencing anxiety symptoms compared to those with good sleep quality.^32,35 Notably, anxiety symptoms often co-occur with sleep disturbances and, in many cases, are observed at higher prevalence rates than depression, highlighting a strong and closely linked relationship between sleep quality and anxiety during pregnancy.³⁶ Evidence also shows a long-term trajectory with poor sleep quality in later pregnancy linked to increased postpartum anxiety and depression, underscoring the enduring impact of prenatal sleep disturbances on maternal mental health.³⁷ Beyond direct associations, evidence also suggests a mediating pathway, wherein maternal anxiety symptoms link poor sleep quality to elevated evening cortisol levels in late pregnancy, indicating that psychological distress may underlie the physiological stress response associated with sleep disturbances.²⁴ In addition, subjective sleep perceptions are considered more strongly associated with mental health outcomes than objective sleep measures, underscoring the importance of perceived sleep quality for psychological well-being.²⁸

Emerging evidence also suggests that sleep disruption not only increases the risk of common mental disorders but also contributes to the persistence of existing mental health conditions, leading to a more prolonged course of illness into the postpartum period.³⁸ Supporting this, objectively assessed poor sleep efficiency in the first trimester has been shown to predict both elevated and persistent depressive symptoms throughout pregnancy, indicating that disrupted sleep in early pregnancy may have a lasting impact on maternal mental health trajectories.³⁹

Influence of Mental Health on Sleep Quality:

Studies indicate that depression, anxiety, and stress have a profound influence on sleep quality in pregnant women, where psychological distress acts as both a primary driver and an exacerbator of sleep disturbances.^40,41

Depressive and anxiety-related symptoms in late pregnancy were found to be cross-sectionally associated with sleep disturbances.⁴² Evidence also indicates that circadian misalignment, reflected as social jetlag, has been linked to increased stress and poorer sleep quality in primigravida women, suggesting that stress may disrupt circadian rhythms and impair sleep.³⁶ In line with this, emotional distress appears to moderate sleep perception, with higher levels of depression and anxiety strengthening the association between objective sleep measures and subjective sleep experience.²⁸ Consistently, prenatal maternal stress has also been significantly linked to poorer sleep quality among pregnant women (p<0.01).⁴³ Specifically, fear of childbirth is an independent predictor of poor sleep quality, particularly in the third trimester, and is associated with increased restlessness and inadequate nighttime sleep.²⁷ Studies reported that highly distressed women perceive sleep fragmentation as more detrimental, indicating a reduced tolerance to normal sleep disruptions during pregnancy.²⁸ This suggests that depression and anxiety may lower the threshold for tolerating the natural sleep disruptions that occur during pregnancy.

Several studies reported that depression across pregnancy shows a shifting association with sleep, being linked to longer sleep latency in early pregnancy and to increased nighttime disturbances in the third trimester.⁴⁴ It has also been observed that women with a lifetime diagnosis of major depressive disorder (MDD) experience significant sleep disturbances starting as early as the first trimester.⁴⁵ In addition, studies also highlighted that pregnant women with comorbid depression are significantly more likely to experience poor sleep quality, with one study finding them at a 4.26 times higher risk.⁴⁶ The symptoms of depression can begin during pregnancy, especially in women where there has been a poor episode of postpartum depression.⁴⁷

Taken together, depression, anxiety, and stress act as major contributors to poor sleep quality throughout pregnancy, highlighting the importance of addressing maternal mental health for optimal sleep.

Bidirectional relationship between sleep quality and mental health:

Emerging evidence suggests a bidirectional relationship between sleep and mental health, where sleep disturbances and psychological distress frequently act as both predictors and outcomes of each other. Fig.1

Evidence supports the idea that this interaction often creates a vicious cycle of sleep disruption, in which elevated evening cortisol, associated with eveningness, increases sleep latency, thereby perpetuating the cycle and potentially persisting throughout the perinatal period.³⁶

Consistent with this, stress-related sleep disturbances have been associated with increased risk of a range of adverse mental health outcomes, including depression, anxiety, post-traumatic stress, and psychotic symptoms.⁴⁸ This suggests that psychological stress not only disrupts sleep quality but also indirectly contributes to poorer maternal mental health during pregnancy. Moreover, antenatal sleep quality has been shown to predict postpartum mental health outcomes, also highlighting the enduring impact of prenatal sleep on maternal well-being.³⁸

Evidence shows that sleep and psychological distress mutually reinforce one another. Overall, the relationship between sleep and mental health during pregnancy is complex and bidirectional, with disturbances in one domain often precipitating or aggravating problems in the other.

DISCUSSION:

This review highlights a complex, bidirectional relationship between sleep disturbances and maternal mental health during pregnancy. Poor sleep quality consistently predicts adverse psychological outcomes, including depression, anxiety, stress, and post-traumatic stress symptoms, while maternal psychological distress in turn exacerbates sleep disturbances. These findings underscore the interdependence of sleep and mental health and the importance of addressing both in prenatal care.

This reciprocal relationship is explained by several concepts. Elevated evening cortisol levels and misaligned circadian rhythms in pregnant women can prolong sleep latency and reduce sleep quality, forming a vicious cycle that affects both sleep and mental health disturbances.^24,36 Similarly, psychological stress may lower the tolerance to natural sleep disturbances, affecting both subjective and objective sleep parameters.²⁸

The impact of sleep and psychological distress appears to vary across pregnancy. Poor sleep elevated the risk of anxiety, particularly during early and mid-pregnancy.³¹ In contrast, women who sleep less during pregnancy are consistently at a higher risk of depression throughout pregnancy.³³ This suggests that the timing in pregnancy may influence which mental health outcomes are most affected. This pattern might be due to heightened vulnerability to stress and hormonal fluctuations in early pregnancy that exacerbate anxiety, whereas cumulative sleep loss across gestation contributes more consistently to depressive symptoms.

Implication and Future Research:

Sleep quality and maternal mental health exert a bidirectional influence on each other. So, proper assessment and management of both sleep and psychological well-being during the antenatal period may help minimise the reciprocal effects. This will improve both the maternal and fetal outcomes. Addressing these factors and implementing proper strategies will also reduce the risk of postpartum depression, anxiety and other adverse outcomes.

Further studies should be conducted to explore non-pharmacological interventions to improve sleep quality and mental health during pregnancy. Additionally, qualitative studies could provide insight into women’s lived experiences and their expectations from healthcare professionals, which may help tailor more effective and patient-centred prenatal care strategies.

LIMITATION:

The scope of this review was limited to studies available online in English, and the literature search was conducted using only two databases.

CONCLUSION:

The sleep quality and mental health condition of women are often affected during pregnancy. Various factors affect the sleep quality of antenatal women, and mental health conditions such as depression, anxiety, stress and post-traumatic stress disorder are among them. Similarly, mental health disorders also influence the sleep quality of women, representing the bidirectional and cyclical pattern between them. Further research is needed to provide stronger evidence.

ACKNOWLEDGMENTS:

The author would like to thank the Library of AIIMS, Bhopal, Madhya Pradesh, India.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

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Received on 23.03.2026 Revised on 13.05.2026

Accepted on 20.06.2026 Published on 27.07.2026

Available online from August 01, 2026

Asian J. Nursing Education and Research. 2026;16(3):173-178.

DOI: 10.52711/2349-2996.2026.00035

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.