The Effect of Sleep Disturbance on Quality of Life in Pregnant Women

This cross-sectional and descriptive study conducted in a State University Hospital Obstetrics Clinic in Ankara, Turkey. In the collection of data, Individual Information Form, Pittsburgh Sleep Quality Index and SF-36 Quality of Life Scale were used. To analyze the collection data, Man Whitney U test, Kruskall Wallis test and Pearson correlation test were applied.


Ethical approval
Ethical approval was obtained for the conduct of this study from the Research and Ethics Committee of the hospital. (No: KO11/00). The researcher introduced the questionnaire to participants and explained the coverage of the material. Participants completed an informed consent form in which they were assured of the confidentiality of their responses following which they provided informed consent that participation was voluntary and anonymous. Rules specified in the Helsinki Declaration were observed in the data collection phase.

Data analyses
Descriptive statistics were calculated for all variables. In the evaluation of the data, besides the number, percentage, mean and standard deviation representations of the variables, the Mann-Whitney U test was used when the data was not normally distributed in the two-group comparisons, the Kruskall-Wallis test was used in the comparisons with three or more groups, and the Pearson correlation test was used to examine the relationship between the two scales. A value of P < 0.05 was considered statistically significant.

Results
The average age of patients was 27.5 ± 4.9 years

Materials and Methods
Study type, design, setting, period, population, and sample size This descriptive and cross-sectional study was conducted during June-July 2015 in a State University Hospital, Obstetric Clinic in Ankara, Turkey. The universe of the study consisted of 1000 women who applied to the obstetric clinic of the hospital for routine control (in the last year). The sample of the study was determined according to the formula "calculating the sample size in case of a known universe" (n = t 2 .p.q/d 2 ) the sample size was determined as 267 pregnant women (95% CI, alpha = 0.05) [27].

Sampling selection criteria
1) Those who volunteer to participate in the study, 2) Who do not have an auditory or mental disability, 3) Who were open to cooperation and able to understand in Turkish language, 4) Who do not have a health problem requiring hospitalization, 5) Pregnant women applying to the polyclinic for routine control, and 6) Who do not have twin or triplet pregnancies.

Dependent and independent variables
Dependent variables; sleep quality and quality of life scores. Independent variables; 1) Socio-demographic characteristics of pregnant women (age, educational status, employment status, working status before pregnancy, income status, presence of social security, family type), 2) Medical and pregnancy-related characteristics (weight, height, weight before pregnancy, regularly used drugs, pregnancy week, existence of chronic disease, whether pregnancy is planned, number of pregnancies, number of living children, status of receiving social support, status of getting ready for childbirth education and health problems that occur with pregnancy, 3) Habits (smoking, alcohol, tea-coffee consumption, and exercising regularly).

Instruments
Three separate data collections: Individual Information Form, Pittsburgh Sleep Quality Index (PSQI) and SF-36 Quality of Life Scale (QLS) tool was applied by the researchers using face-to-face interview method. It took an average of 5-10 minutes to complete.

1.
Socio-demographic characteristics such as age, education, employment, income, social security and family type etc. disease during this period. Reported diseases were as follows, thyroid (53.8%), hypertension (17.3%), migraine (15.3%), and diabetes (11.5%). Women declaring pregnancy-related (min: 17, Max: 42). Some socio-demographic and medical characteristics and habits of pregnant women are presented in Table 1. 62.6% of the pregnant women were in their third trimester, 37.5% had their second pregnancy, 41.2% had a living child, 73% had a planned pregnancy, 82% received support from their spouse or social environment, 26.6% had received antenatal training, and 9.7% had pregnancy-related  In Table 4, the mean global score of the PSQI was 6.8 ± 3.6 (95% CI). The mean global score of the SF-36 QLS was 32 ± 12.8, which was below the average of the study population. The subgroups of the scale, respectively, physical function score was 36.9 ± 14.6, role difficulty (physical) score average was 21.6 ± 20.5, pain score average was 33.8 ± 18.5, general health score average was 35.3 ± 9.5, vitality (energy) score average was 34.1 ± 15.3, social function score average was 34.6 ± 14.7, role difficulty (emotional) score was 25.3 ± 20.0, and mental health score was 36.3 ± 10.4. According to the SF-36 QLS, the quality of life of the pregnant women was below the average. There was a negative correlation between the scores of pregnant women from PSQI and the sub-dimension of life quality scale (r = -0.386, p = 0.000), (Table 4). Also, the mean scores of physical function and role difficulties were decreasing as the insomnia increased ( Figure 1). Table 5 shows the total PSQI scores of pregnant women and their subscale scores in the last month. Even though the daily sleep duration of the pregnant women (mean: 7.2 hours ± 3.4) was found to be within normal limits, more than half of them had insomnia, which indicates their low quality of sleep. According to the PSQI, 68.5% of the pregnant women had insomnia. It is seen that the times of falling a sleep of most of the women with insomnia were longer than those with good sleep quality (p < 0.001). Women with good sleep quality have longer periods of sleep (p < 0.001).
In Table 6, several factors were determined to have an independent effect on sleep problems. There was a significant difference between age groups in terms of sleep quality, duration, efficiency and sleep disorder component (p < 0.05). Accordingly, it was observed that the older age group had more sleep problems. Sleep latency (difficulty falling asleep) is significantly higher in low-income groups (p < 0.05). Sleep duration, sleep disturbance, daytime dysfunction, global score were found to be significantly higher in those with co-morbidity than those without the diseases (p < 0.05). A stronger relationship was observed between obesity and insomnia (p < 0.05). As the week of gestation increased, sleep duration decreased, sleep quality decreased (p < 0.05). Women with high parity had difficulty falling asleep (p < 0.05). Sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, daytime dysfunction and global score scores of those who had pregnancy-related problems during pregnancy were found to be significantly higher than those who did not have pregnancy-related problems (p < 0.05).

7.
Daytime dysfunction 0.  did not (p < 0.05). However, our study revealed that most women did not go to the doctor for insomnia. Similarly, some authors reported that insomnia significantly linked with pregnancy-related problems [15,16,18,21,25]. Because of the complex and common co-morbid nature of insomnia, even if the problems related to pregnancy are minimized, the insomnia may not improve immediately. Several studies found that massage therapy was the non-pharmacological intervention most commonly preferred to pregnant women with low-back pain such as acupuncture, herbal, relaxation, exercise, yoga, and chiropractic, mindfulness, meditation, and physiotherapeutic counseling [17,36,37].
Significant relationship was detected between the state of smoking and insomnia (p < 0.05). Some authors identified that smoking pregnant women experienced sleep disturbances two times more frequently than those who did not [26,30,31]. In the present study, the score of sleep quality decreased significantly due to the stimulating effect of drinking tea (p < 0.05). The results of this study are consisted with other studies [33][34][35]. Physical activity is considered as a non-pharmacological approach to alleviating sleep problems [36]. In our study, sleep quality of those who exercise regularly during pregnancy was found to be better (p < 0.05). Similar result was obtained in previous studies [37,38].
Although motherhood is a natural event, it brings along many difficulties. Thus, women are vulnerable to some problems about individual or family role functions during pregnancy [3,7]. In our study, women's quality of life of score was generally low (32 ± 12.8), particularly in the subscale of physical role function ( Figure 1). Furthermore, there was significant inverse related between the quality of life score and insomnia (p < 0.05), so the H 1 hypothesis was confirmed. Similarly, recent researches indicated that the quality of life of pregnant women is related to their sleep quality [1,4,6,10,25].
The validity of the findings is dependent on the individual's memory and accuracy in reporting sleep problems. The sample in this study reflects only one area of Turkey and the findings should be limited to this population. However, our findings highlight the importance of considering the sociodemographic, medical, pregnancy-related characteristics and habits for each woman with pregnant to ensure correct approach for alleviating sleep problems. Also, the data of this cross-sectional study were based on clinically prognostic scale of the women by face-to-face interview instead of retrospective patient chart based reports.

Conclusion
Sleep problems was common in the majority of pregnant women. Also, quality of life decreased with increasing insomnia. In line with these findings, women should be thoroughly evaluated for insomnia symptoms including risk factors as part of usual antenatal care and treated timely with effective strategies such as improving sleep hygiene, behavioral therapies, and pharmacotherapy by healthcare professionals. Future research with larger group should examine various factors underlying poor sleep quality during pregnancy to improve women's quality of life.

Discussion
Pregnancy is a physiological challenge to virtually every organ system, in particular, the respiratory system. Thus, women are vulnerable to sleep disturbance during the perinatal period. A variety of sleep problems may worsen quality of life of the pregnant women [1][2][3][4][5][6][7][8][9][10][11]. In our study, it was determined that 68% of the women had insomnia. Recent studies also found that insomnia was common in the majority of pregnant women. These were as follows, Sedov Modifications in sleep pattern result from high circulating hormone levels and physical changes associated with pregnancy such as increased sympathetic activity, pulse rate, blood pressure and respiratory frequency with augmented alveolar oxygen gradient. All these changes contribute to the tiredness, fever, congestion, and respiration problems by the pregnant women [26,[29][30][31][32][33][34]. We found that the most common reasons of insomnia were fatigue (being obliged to continue their traditional roles in the family), back-pain, growing their fetus, reflux, irritability, stress, fever, nausea, leg cramps and frequent urination. Similarly, previous studies showed that sleep problems were frequently associated with polyuria, fetal movements, uncomfortable position while sleeping, pain, breathing problems, and restless legs, respectively [8,21,22,26,[35][36][37].
In the study, sleep quality has reduced significantly with increasing age (p < 0.05). According to the previous studies, advanced age was an important factor for insomnia [3,4,8,25,26]. Fatigue and other health problems that increase with age may cause sleep problems. In this study, it was found that uneducated women with poor income had more problems with sleep patterns (p < 0.05). Findings of this study are correlated with the literature [3,5,26,37]. However, Coban and Yanıkkerem, et al. (2010) did not detect a relationship between education level and quality of sleep in pregnant women. We found that sleep quality decreased significantly with the increase in the gestational age (p < 0.05). The related literature shows that insomnia is more common in the third trimester due to physical and psychosocial changes including anxiety, fetal growing, and respiratory distress [33][34][35].
In this study, obesity was an important modifier of sleep problems (p < 0.05). Obesity accompanied excessive soft tissue may narrow the pharyngeal airway and reduce lung volume. This situation may cause sleep problems along with apnea and snoring. Findings of this study are comparable with those in the literature [24,26,31,[33][34][35].
Mental and physical discomfort caused by pregnancy related problems such as pain, interruption of sleep at night, waking up early in the morning, and being sleepy during the day may cause insomnia [9,11,24,25]. This study detected that the participants who had pregnancy-related complaints had the risk of developing insomnia more than those who