Optimizing Cognitive-Behavioral Therapy for Insomnia for Pregnant and Postpartum Women

The researchers conducted a secondary analysis of 46 pregnant women who were treated with digital cognitive-behavioral therapy for insomnia in a randomized controlled trial.

Optimizing cognitive-behavioral therapy for insomnia (CBTI) for pregnant and postpartum women requires a tailored, creative approach, researchers found in a secondary analysis published in Behavioral Sleep Medicine of patients nearing or entering the third trimester of pregnancy. They also found that posttreatment short sleep and higher levels of cognitive arousal and depressive symptoms were associated with lack of response to digital CBTI.

Patients nearing or entering the third trimester of pregnancy had participated in a randomized controlled trial (ClinicalTrials.gov: NCT03596879) which compared the efficacy of digital CBTI to sleep education. Women who self-reported high-risk pregnancy were excluded from the trial.

The participants in the secondary analysis had been randomized to CBTI and completed the Sleepio program (which included behavioral sleep strategies, cognitive components, progressive muscle relaxation and sleep hygiene) and had access it until they either completed 6 sessions of digital CBTI or gave birth. Time in bed could not be prescribed as <6 hours. The 46 patients completed a median of 6 sessions and a mean of 4.83 sessions.

CBTI non-responders experienced poorer sleep quality (Cohen’s d=1.26) and shorter sleep (56 fewer minutes per night) after treatment. They reported more severe depressive symptoms (Cohen’s d=.63), more nocturnal cognitive arousal (Cohen’s d=1.41) and preservative thinking (Cohen’s d=1.17) compared with responders.

A total of 25 out of the 44 women who provided postpartum data estimated sleeping 6 hours, at most, per night. Poorer infant sleep was reported more frequently by women with shorter sleep duration than women with normal sleep duration (20%, 0% respectively; Cohen’s d=.69). Patients whose insomnia and depression symptoms levels decreased reported reductions in nocturnal cognitive arousal and preservative thinking.

Among the 26 patients who offered feedback on the treatment, more than 80% said they preferred online or telemedicine treatment and 76.9% said CBTI was sufficient treatment for their insomnia. However, only 57.7% said their sleep issues were resolved and less than half said it was helpful for postpartum sleep.

Patients mostly frequently said that the most helpful aspects of digital CBTI were sleep hygiene tips and sleep education (n=8) and reduction of sleep-interfering nighttime thoughts (n=6) while the most commonly noted drawbacks were that digital CBTI was not tailored for pregnancy (n=6) nor postpartum sleep challenges (n=6) and that the online program was too inflexible regarding sleep restrictions and schedule (n=7).

The researchers recommended providing psychoeducation on maternal and infant sleep, reducing cognitive arousal particularly at night, modifying behavioral sleep strategies to allow for more patient flexibility and sleep opportunity (which may include restricted and appropriately timed napping), reducing maternal burden for nighttime infant feedings and wakings by collaborating with both patient and partner to establish a concrete shift schedule, and teaching behavioral strategies to mothers that promote infant sleep.

Limitations of the study included limited generalizability due to solely collecting patient feedback from 26 of the 46 patients and the fact that treatment outcomes were self-reported and limited to maternal perceptions.

 “At this stage, telemedicine CBTI for perinatal insomnia offers a strong balance between increasing treatment access and clinician-led treatment personalization,” the study authors said.

Disclosure: Several study authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Kalmbach DA, Cheng P, Roth T, et al. Examining patient feedback and the role of cognitive arousal in treatment non-response to digital cognitive-behavioral therapy for insomnia during pregnancy. Behav Sleep Med. Published online March 15, 2021. doi: 10.1080/15402002.2021.1895793