Elsevier

Sleep Medicine

Volume 59, July 2019, Pages 33-41
Sleep Medicine

Original Article
Postpartum fatigue, daytime sleepiness, and psychomotor vigilance are modifiable through a brief residential early parenting program

https://doi.org/10.1016/j.sleep.2019.01.012Get rights and content

Highlights

  • Sleep disturbance and sleep-related deficits in daytime functioning are common in the months after giving birth.

  • This is the first study showing postpartum daytime sleepiness and objectively measured sustained attention to improve through an intervention.

  • This is also the first study to assess self-report and objective sleep-related daytime functioning in a clinical sample and after three months postpartum.

  • It is important to recognise and address impairments in sleep-related daytime functioning during postpartum periods.

Abstract

Objective/Background

In the months after childbirth, women are vulnerable to sleep disturbances and sleep-related deficits in functioning, such as fatigue, daytime sleepiness, and attentional lapses. Currently there is limited evidence that these deficits are modifiable. Using both self-report and objective measures, this study examined changes in sleep-related daytime functioning among women attending a residential early parenting program for assistance with unsettled infant behavior and mild to moderate postpartum distress.

Methods

Participants were 78 women (age M = 34.16, SD = 4.16 years) attending a five-day program with their infants (age M = 8.67, SD = 4.82 months). Sleep was assessed via self-report. Sleep-related daytime functioning was operationalized as fatigue, sleepiness, and sustained attention, and measured using validated questionnaires (all women) and the 10-min visual Psychomotor Vigilance Test (PVT; subgroup of 47 women). All measures were administered on both admission (baseline) and discharge.

Results

On admission, participants reported elevated sleep disturbance (94%), fatigue (91%), as well as trait (54%) and state (67%) sleepiness. From admission to discharge, there were medium effect size reductions in fatigue and sleepiness, and large effect size improvements in sleep quality related domains such as increased sleep efficiency and reduced nighttime awakenings (all p < 0.001); changes in total sleep time were nonsignificant (p = 0.22). PVT reciprocal mean reaction times were also significantly faster (p = 0.001; medium effect size).

Conclusions

This study demonstrated that among women attending a brief residential early parenting program, fatigue, daytime sleepiness, and objectively measured psychomotor vigilance can be improved. Implications for further research and potential treatments are discussed.

Introduction

Sleep disturbance is a common experience for new parents. Both women and their partners can experience increased nighttime awakenings (NA), longer wake after sleep onset (WASO), reductions in total sleep time (TST) and reduced sleep efficiency (SE) in the weeks and months following childbirth [1], [2], [3], [4]. These disruptions to postpartum sleep patterns are evident in both self-report and objective measures such as actigraphy [3], and are associated with various forms of impairment in daytime functioning, including increased fatigue, daytime sleepiness, and impaired sustained attention [1], [3], [5], [6].

Fatigue is perhaps the most common form of impaired daytime functioning during the postpartum period. Between 40 and 60% of women report elevated fatigue during the first 18 months postpartum [7], [8]. Fatigue is a cluster of subjective physical and psychological symptoms that involve a sense of extreme tiredness or exhaustion and lessens individuals’ capacity to function to their expectations [9], [10]. Sleep disturbance caused by infant care and settling difficulties are major contributing factors to fatigue symptoms [5], [11]. Fatigue is also associated with many other adverse outcomes, including elevated depressive, anxiety, and stress symptoms [12], [13], [14], [15]. Both longitudinal and cross-sectional studies have shown that for many women, fatigue symptoms may persist for months into the postpartum period [1], [7], [16], [17].

Despite high prevalence and associated distress [18], postpartum fatigue symptoms have shown either little, or very small-sized response to interventions that specifically targeted fatigue symptoms [19], [20]. In comparison, interventions designed to treat both fatigue and distress, or to manage infant sleep and behaviors have shown greater efficacy. A telephone-based treatment for both fatigue and distress symptoms administered to women with elevated depressive symptoms at 2–3 months postpartum led to significantly greater reductions in fatigue compared to control [21]. Also, a residential early parenting program that provided multidisciplinary care and psychoeducation on infant settling for women with infants aged 4–12 months reported significant decreases in fatigue and other mood symptoms at 1- and 6-month follow-up [22].

Daytime sleepiness, although less studied than fatigue, may be just as prevalent as fatigue among women in the first months after childbirth [23], [24]. Sleepiness is the perceived likelihood of falling asleep when intending to be awake [25]. While mild transient feelings of sleepiness are normal, excessive sleepiness is problematic, particularly in safety-sensitive contexts (eg, driving). A study on community-dwelling women at three months postpartum showed that half of the sample reported elevated daytime sleepiness [23], and that a third of driving episodes occurred while experiencing elevated daytime sleepiness [24].

One longitudinal study showed that sleepiness as measured by the Epworth Sleepiness Scale [26] (ESS) reduced from being above the clinical cut-off towards the higher end of the normal range without intervention from 6 to 18 weeks postpartum in a community sample of women [23]. This suggests that sleepiness may increase after childbirth but decline over time naturally as maternal sleep disturbance gradually decreases [2], [23].

However, currently no study has measured postpartum sleepiness using a validated scale after the first 18 weeks postpartum. Further, despite its importance to maternal daytime functioning, no study has examined whether sleepiness levels are responsive to interventions in the postpartum period. Current studies of daytime sleepiness in the postpartum period have also been restricted to community samples of healthy parents [23], [27], and findings are not necessarily generalizable to women who seek clinical support.

Sleep disturbance can also impair new parents' ability to sustain attention on tasks. To date, there is only one study that objectively measured sustained attention during the postpartum period. Insana et al., [27] showed that women between 2 and 13 weeks postpartum performed consistently worse on Psychomotor Vigilance Test (PVT) than matched controls, with slower average reaction times (RT's) and more lapses in attention (RT > 500 ms) [28], [29]. Across this early postpartum period, performance on the PVT gradually declined, even though women's sleep durations gradually increased, suggesting that adverse effects of sleep disturbance on performance may be cumulative [28]. Further, higher PVT attention lapses were associated with lower objectively measured TST and SE, greater self-report WASO, later and less stable sleep midpoints [27], [30].

No study has assessed PVT performance beyond the first few months postpartum, even though ongoing difficulties with self-report fatigue are frequently reported extend well beyond this period [7], [31]. Furthermore, the responsiveness of objectively assessed psychomotor vigilance to postpartum interventions remains unknown. In non-postpartum contexts, sleep and physical activity interventions were shown to improve PVT performance in adults with short (<6 h) sleep duration [32] and obesity [33].

The current literature consistently shows that parents in the post-childbirth period can be vulnerable to sleep disturbance and sleep-related deficits in daytime functioning, including fatigue, excessive daytime sleepiness, and deficits in sustained attention. However, this body of research, with the exception of fatigue, is restricted to the first three months postpartum [34], and parents with older infants are largely neglected. Further, it is unclear whether daytime sleepiness and deficits in sustained attention can be improved by intervention, and there is mixed evidence for improving postpartum fatigue symptoms. A further gap in the literature is that all existing studies with measures of sleepiness and the PVT have recruited physically and mentally healthy women in community samples [6], [27], [28]. Findings from these samples may not generalize to women seeking clinical support, who could potentially experience more significant sleep disturbance, more severe impairments in daytime functioning, and higher levels of psychological distress [35].

In this study, these gaps were addressed by assessing sleep, fatigue, sleepiness, and PVT performance among women attending residential early parenting programs. In Australia, these programs are available through both public and private healthcare settings, and service tens of thousands of families each year [36]. Following a medical referral, the residential programs provide admitted parents with clinical support, respite, and individualized training in managing unsettled infant behavior, which includes persistent and inconsolable crying, resistance to soothing, difficulties with settling to sleep, short sleep periods, and frequent nighttime awakenings [36], [37].

These residential early parenting programs have previously been found to reduce maternal depressive, anxiety, stress, fatigue symptoms, and improve infant sleep [22], [38], [39], [40]. Given that these programs tend to admit parents with older infants and clinically elevated fatigue and/or psychological distress symptoms [22], [39], they also serve as a unique opportunity to explore the potential modifiability of fatigue, daytime sleepiness, and sustained attention in a postpartum population with infants older than three months.

On this basis, this study aims to assess whether maternal sleep, fatigue, sleepiness, and PVT performance changed after a brief residential early parenting program. Associations between PVT and self-report fatigue and sleepiness were exploratory.

Section snippets

Setting and participants

Data collection was conducted at the Masada Early Parenting Centre (MEPC), Masada Private Hospital, a residential early parenting program service in Melbourne, Australia. The MEPC is a 20-bed residential unit that admits mother-infant dyads for addressing unsettled infant behavior, as well as maternal fatigue and distress (eg, symptoms of depression and anxiety) through a five day multidisciplinary intervention. The program involves increasing maternal and infant sleep opportunities,

Sample characteristics

A total of 85 women were recruited; 78 completed surveys at both T1 and T2 and were included in analyses. Among these, 75 provided consent for medical records extraction, and 47 opted in and completed the PVT component at both T1 and T2.

Details on maternal and infant demographics are shown in Table 1. Mean maternal age was 34.16 (SD = 4.16) years and mean infant age was 8.68 (SD = 4.82) months. In general, participants were highly educated, mostly spoke English, and were predominantly born in

Discussion

Women attending a brief residential program that assists with infant settling difficulties and mild to moderate psychological distress self-reported elevated sleep disturbance, fatigue, daytime sleepiness, and depressive symptoms upon admission to the unit. Upon discharge from the program, they reported significant improvements in all these domains, as well as faster reaction time on the PVT.

Funding and disclosure

Nathan Wilson was supported by an Australian Government Research Training Program Scholarship and has nothing to disclose.

Karen Wynter was supported by a Monash University Advancing Women's Research Success grant and has nothing to disclose.

Clare Anderson has received a research award/prize from Sanofi-Aventis, contract research support from VicRoads, Rio Tinto Coal Australia, National Transport Commission, Tontine/Pacific Brands, lecturing fees from Brown Medical School/Rhode Island Hospital,

Acknowledgements

The authors are grateful to the staff at Masada Early Parenting Centre, Masada Private Hospital for their support in data collection, Olivia Chung, Hilary Brown, and Hannah Gray for assisted with data collection, and to the women who most generously contributed data.

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