Introduction

Perinatal loss is defined in the psychosocial and nursing literature as an umbrella term encompassing any involuntary loss of a pregnancy or death of an infant from conception up to 28 days after birth, including miscarriage, stillbirth, and neonatal death [1,2]. As a complex and potentially traumatic life event, perinatal loss not only causes great psychological trauma to the pregnant woman and her family but also has an impact on the next pregnancy. Studies have shown that women who experience perinatal loss have an increased risk of adverse pregnancy outcomes, such as stillbirth, preterm labour, placental abruption and neonatal death, and more prominent problems, such as sleep disorders, anxiety, depression and post-traumatic stress disorder (PTSD), when they become pregnant again compared with the general population [3–5].

A previous study by the group found that the prevalence of sleep disorders in late pregnancy was as high as 58.49% in women with a history of perinatal loss [6]. Poor sleep quality is an independent predictor of suicidal ideation among pregnant women [7]. Those with poor subjective sleep quality were 2.85 times more likely to experience suicidal ideation when compared with women who had good sleep quality. Studies in some countries have reported that short sleep duration during pregnancy is associated with a higher risk of preterm birth [8], low birth weight and small for gestational age [9]. Late pregnancy is a critical stage of pregnancy, and the quality of sleep is not only related to the health of the pregnant women themselves but may also have an important impact on fetal development and pregnancy outcomes [10,11].

In recent years, the sleep experiences in subsequent pregnancies of women with a history of perinatal loss during late pregnancy have not been sufficiently reported. Existing studies have mostly used quantitative methods to assess sleep quality and lack in-depth exploration of the subjective experience in this population. The present study comprehensively explores the sleep experience in late pregnancy of women with a history of perinatal loss through qualitative research methods, providing a basis for clinical healthcare professionals to develop effective interventions to improve the sleep quality of women and promote the health of mothers and infants.

Materials and methods

Results

A total of 18 participants were included in this study, aged 26–40 (32.67 ± 4.47) years and at gestational week 28–39 (32.20 ± 3.20). Previous causes of loss included miscarriages (n = 13), stillbirths (n = 3) and neonatal death (n = 2). The PSQI global scores ranged from 4 to 15, with a mean of 9.83 ± 3.24 and a median of 10 (IQR: 8–13). Using a cutoff of > 7 to define poor sleep quality, 14 participants (77.8%) were classified as having poor sleep quality. Participants were represented by A1–A18, and the general information is detailed in Table 1.

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Table 1. Demographic characteristics of the participants (N = 18).

https://doi.org/10.1371/journal.pone.0354895.t001

The researcher coded and refined the interview data, and finally summarised three themes: severe sleep disruption; diversified factors affecting sleep quality (distressing pregnancy symptoms, overloaded psychological load, behavioral and lifestyle factors, weak support from family and friends, and insufficient support from healthcare providers); and difficulties in self-coping with sleep problems.

Discussion

The results of the qualitative interviews showed that women with a history of perinatal loss have poor sleep quality and poor sleep experience in subsequent late pregnancy and that their sleep experience needs to be improved urgently. During late pregnancy, many women face sleep difficulties and fatigue due to changes in body size and increased cardiac load [16]. Pregnant women with a history of adverse maternal outcomes often require more complex treatments and more frequent prenatal visits, which further adds to their physical burden. In addition to pregnancy-induced physical exhaustion, this population also has to cope with the stress associated with high-risk pregnancies [17], all of which may exacerbate sleep problems by aggravating the psychological stress response of pregnant women.

During the interviews, some interviewees mentioned that they were concerned that insomnia would affect their unborn children, which indicates that some pregnant women place a certain degree of importance and concern on the quality of sleep during pregnancy. However, in late pregnancy, medical staff and family members are more concerned about the presence of pregnancy complications and the ability of the pregnant women to deliver their babies successfully, and sleep problems are not seen as an urgent or priority issue. Therefore, to improve the sleep experiences of women with a history of perinatal loss during subsequent pregnancies, healthcare providers should gain an in-depth understanding of their sleep needs, systematically analyse and understand the reasons for the occurrence of sleep problems and incorporate sleep quality into routine follow-up. Furthermore, they should assess pregnant women’s sleep by using sleep-related scales and sleep diaries, and provide the necessary assistance to optimise their sleep experience in late pregnancy.

The results of this study showed that psychological overload and late pregnancy somatic symptoms are important factors affecting the quality of sleep in women with a history of perinatal loss. As a stressful event, perinatal loss causes persistent psychological trauma in pregnant women [18], leading to excessive tension, worry and sensitivity during subsequent pregnancy. For women with a history of perinatal loss who are pregnant again, the late stage of pregnancy not only involves a heavy physiological load but also a greater psychological pressure. One survey shows that PTSD rates following perinatal loss are up to seven times the rates among mothers of living infants [19]. Negative emotions such as worry or anxiety before bedtime can lead to sympathetic nervous system excitation, elevated cortisol levels and altered melatonin levels, resulting in circadian rhythm disruption and affecting the quality of sleep in pregnant women [20]. Analysis of the causes revealed that as the weeks of pregnancy increase, the uterus continues to grow and exerts increasing pressure on the bladder, which leads to an increase in the frequency of nocturnal urination and awakenings in pregnant women [21]. Lower back pain in some pregnant women may be related to relaxation of pelvic ligaments and intervertebral nodes and ligaments by relaxin secreted by the placenta, and musculoskeletal discomfort associated with fetal movement and musculoskeletal changes during pregnancy can also lead to sleep fragmentation. Multiple symptoms synergistically interact, significantly impairing sleep quality in women with a history of perinatal loss during subsequent pregnancy [22]. This suggests that medical personnel should strengthen the symptom management of subsequent late pregnancy for women experiencing perinatal loss, identify the somatic symptoms of the women in a timely manner and encourage them to report the symptoms and sleep status on their own. Moreover, the risk perception caused by sleep disorders and the distress of somatic discomfort should be improved, and targeted and effective strategies should be adopted, such as instructing pregnant women to adopt the left lateral position to alleviate and relieve the uterus’s pressure on the inferior vena cava and increase the venous reflux. Appropriate outdoor activities should be recommended to promote blood circulation, improve sleep and increase appetite, while drinking a lot of water before bedtime should be avoided to reduce the frequency of nighttime toilet visits, thereby enhancing the quality of nighttime sleep.

In addition, increased attention should be paid to the mental health of women with a history of perinatal loss during subsequent pregnancy. Health education should be strengthened to guide these women in managing emotions and stress effectively. Psychological elasticity plays an important role in stress coping. Individuals with higher psychological elasticity have a stronger ability to self-regulate and emotionally regulate in the face of adversity or stress, and are able to effectively alleviate anxiety and stress, thus improving sleep quality. Therefore, medical personnel can improve the psychological elasticity of pregnant women through a series of measures, such as emotional calming strategies [23] and positive thinking stress reduction training [24], to reduce pregnancy stress and promote psychological health, thereby improving sleep quality.

Poor sleep habits, irregular work routines, lack of sleep health awareness and serious sleep procrastination behaviours can affect the quality of sleep in women with a history of perinatal loss during subsequent pregnancy. On analysing the factors, the use of electronic products for leisure and recreational activities at night will clearly affect sleep, with the continuous light emitted by the devices interfering with the formation of circadian rhythms in pregnant women, leading to a misalignment of the individual’s perception of time, and, at the same time, inhibiting the production of melatonin, thus affecting sleep quality [25]. Furthermore, irregular work and rest schedules can disrupt the body’s biological clock, leading to unstable sleep quality, and excessive sleep during the day can lead to insomnia at night, forming a vicious cycle that affects sleep quality and quality of life [26]. It is suggested that nursing staff should guide pregnant women to create a good sleep atmosphere in advance, reduce the temptation of accessible networks, enhance their sleep health awareness and help them to establish a stable sleep schedule, such as regular sleep and wake-up times, as well as avoiding long naps. Continuing health education groups have been formed to provide pregnant women with online guidance and interactive learning through a variety of means, such as webcasting, microblogging platforms and multimedia, while a web-based follow-up platform has been established for regular follow-up visits.

The results of this study show that a weak support system is also an influential factor in the quality of sleep in women with a history of perinatal loss during subsequent pregnancy. The interviewees noted that when they attempted to discuss their sleep problems with family members or medical personnel, they often did not receive adequate understanding and recognition, nor did they receive substantial help or solutions. One participant also mentioned that her friend‘s advice regarding sleep was unhelpful, though this was not a prevalent theme across the sample. The lack of information on ways to improve sleep quality, the use of hypnotic medications and so on can prevent pregnant women from effectively dealing with their sleep problems, leading to decreased sleep quality. Family support refers to the positive and favourable assistance provided by family members in the emotional, psychological and daily life aspects, which can maintain harmonious family relationships and promote efficient solutions to various problems [27]. One study also found that comprehensive family-centred interventions can alleviate pregnant women’s sleep disorders and help improve their quality of life in late pregnancy and maintain a healthy lifestyle [28]. It is suggested that medical personnel can build a family-centred multifaceted support system, pay attention to sleep assessment and provide personalised sleep advice and medication management to help pregnant women who have experienced perinatal loss to effectively resolve their sleep problems, thereby promoting the health of the mother and infant. Moreover, spouses and family members of pregnant women are advised to learn the contents and forms of family support, provide emotional and behavioral support for pregnant women and promote positive communication and exchange to improve sleep problems.

Notably, one participant described receiving emotional and physical comfort from her husband during episodes of sleep difficulty, suggesting that positive partner support may serve as a protective factor against sleep disturbances. However, this was not commonly reported across the sample, which may reflect the heightened sensitivity and vulnerability of this population, or a genuine gap in available support. Additionally, while peer support has been shown in previous studies to improve emotional well-being and sleep quality in perinatal populations [29], this was not directly reported by participants in our study and warrants further investigation.

This study also found that some pregnant women lacked effective coping knowledge and coping skills when they experienced sleep problems. A self-management model involves individuals adopting specific behaviours to maintain and improve their health, monitor and manage their physical and psychological symptoms, and treat their illnesses consistently [30]. Pregnant women experiencing insomnia can acquire the skills and methods of disease management, which can improve their confidence in coping with sleep problems. In addition, healthcare professionals can assist pregnant women in finding effective treatments to improve their sleep quality. Recent studies confirm that wearable technology can continuously and autonomously track adult sleep patterns while delivering quantifiable sleep parameters via digital interfaces [31,32]. It is suggested that caregivers can instruct pregnant women to wear portable health monitoring devices, such as smart bracelets, to track and monitor their health and living conditions, and to obtain more accurate information to optimise sleep patterns and provide more effective interventions, as well as to improve self-management.

Traditional Chinese medicine (TCM) therapies, such as footbaths and acupressure, may offer alternative approaches to managing insomnia during pregnancy [33], though their effectiveness in this specific population warrants further investigation.

Conclusion

In this study, 18 women experiencing perinatal loss were interviewed face to face about their sleep experience in late pregnancy. Three main themes were identified: serious sleep disruption; diverse factors affecting sleep quality (pregnancy symptoms, psychological overload, disturbed sleep patterns, and weak family and social support); and difficulties in self-coping with sleep problems. Healthcare professionals should improve the sleep quality of women experiencing perinatal loss during subsequent pregnancy through a series of measures. This could include timely recognition of somatic symptoms of pregnancy discomfort, attention to the women’s mental health status, change of irrational cognition, enhancement of sleep health awareness, establishment of diversified support and improvement of self-coping ability.

Supporting information

Acknowledgments

The authors express their sincere gratitude to all the pregnant women who participated in this study for their time and willingness to share their personal experiences. We also thank the staff of the Department of Obstetrics at Suzhou Municipal Hospital for their assistance with participant recruitment and data collection. Our appreciation extends to the research team members for their contributions to data analysis and interpretation. Additionally, we acknowledge the Nursing Department of Suzhou Municipal Hospital for their administrative support.