It's well established that a healthy diet and exercise are vital to a healthy pregnancy and delivery, but sleep is also crucial. Unfortunately, of the 300,000 women who give birth every year in Australia, one in three will likely experience significant sleep disturbance and symptoms of insomnia.

Worryingly, a lack of sleep during pregnancy and postnatally is linked to impaired daytime functioning, depression and anxiety, gestational diabetes, prolonged labour, higher rates of c-section and pre-term birth.

It's a situation that may soon improve with new research led by Dr Bei Bei, a Health Professional Research Fellow at Monash University, showing cognitive behavioural therapy for insomnia (CBT-I) may be key to better sleep in this group.

According to Dr Bei Bei, 60 per cent of women experience sleep disturbance during the latter parts of pregnancy due to physiological changes such as foetal growth, hormonal changes and restless leg syndrome. And for many women with insomnia during pregnancy, sleep issues could persist beyond two years after the birth.

"Sleep disturbance has negative consequences in new mothers, including mood disturbance, fatigue, lower daytime functioning, and pregnancy and birth complications," says Dr Bei Bei.

In the study, researchers studied 163 women who had not had a baby previously – in their last semester until two years post-birth, to determine whether a sleep intervention program using CBT-I improved their sleep over this time.

Half of the volunteers received the CBT-I, while the remaining women acted as controls without the sleep intervention.

The study revealed that receiving CBT-I in the latter part of pregnancy and the first five months of having a baby led to less severe insomnia, less sleep disturbance and less sleep-related impairment – fatigue, sleepiness – both at the end of pregnancy and two years after birth.

In particular, the participants who had significant insomnia at the beginning of the study benefited substantially from the CBT programs, compared to controls.

According to Dr Bei, "CBT is consistently shown to be efficacious in improving sleep and reducing symptoms of insomnia – comparable to medication short-term, but much better than medications long-term.

"However, CBT for better sleep is largely inaccessible, and currently, not part of current perinatal care."

Dr Bei Bei explained that CBT-I provides women with interventions that help change unhelpful sleep behaviours.

"We try to help women understand the differences between insomnia and sleep deprivation, which are quite common during the perinatal periods, and need different strategies.

"[The] "sleep when baby sleeps" is popular advice, and we tried to add a "catch" to it in case of insomnia - difficulty sleeping despite enough sleep opportunity.

"We ask women to "rest" instead because naps, especially long ones, can make it harder to sleep at night.

"In the case of sleep deprivation, we encourage women to nap when they can, but not napping in late afternoon or evening, and stop napping if it affects nighttime sleep."

Other unhelpful behaviours targeted include going to bed early to 'catch-up' on sleep when not tired, which only strengthens the association between being in bed and wakefulness and catastrophising after a night of poor sleep, leading to sleep anxiety.

The CBT-I interventions also involved relaxation, mindfulness, understanding the difference between insomnia and sleep deprivation, managing sleep initiation and maintenance difficulties, and balancing expectations and normalising some loss of sleep.

Melissa Hays, a paediatric nurse, midwife and holistic sleep coach, says while CBT for perinatal sleep is still largely inaccessible, the possibility of integrating it into perinatal care is exciting with many benefits for new parents.

"Sleep hygiene refers to the habits, behaviours, and practices that people undertake prior to going to sleep. It includes the bedtime routine and a positive association with the bedroom environment.

"The bedtime routine, going to bed, and the sleep space should be positively associated with calm and a rapid onset of sleep in less than thirty minutes."

Ms Hays says her top tips for improving sleep hygiene during pregnancy include:

• A set wake up and bedtime every day
• Pregnancy safe exercise during the day
• Nutritious and balanced meals
• Ensuring naps are not late in the day
• Avoiding caffeine or heavy meals close to bedtime
• Avoiding screens for 1-2 hours before sleep as the blue light emitted from the screen inhibits melatonin production
• A positive and calming sequence of predictable activities before bed, such as reading a book or taking a shower or bath
• A cool, dark and quiet bedroom
• Using a nightlight to keep the room mostly dark when getting up overnight to use the bathroom

Try to avoid the following pitfalls of sleep during pregnancy:

• Participating in activities at bedtime that are not conducive to calming down
• Watching screens before bed
• Not enough sunshine and activity during the day
• Bedroom environment is not associated with a rapid onset of sleep

Tips for improving sleep hygiene when caring for a newborn:

• Postpartum safe exercise during the day, such as taking a gentle walk outdoors
• Eat nutritious and balanced meals, ideally prepared by family, friends, or a postnatal food delivery service
• Avoid screens for 1-2 hours before sleep
• Keep the bedroom cool, dark and quiet, even during the day, so it is easier to sleep when the baby sleeps
• A positive and calming sequence of predictable activities before bed, such as reading a book or taking a shower or bath
• An early bedtime at approximately the same time every night to maximise your sleep whilst the baby is asleep
• Use a nightlight to keep the room mostly dark when getting up overnight to care for and feed baby
• Enlist the help of your partner, family, and friends to ensure you are meeting your own basic needs and making sleep a priority 

Pitfalls of achieving good sleep hygiene:

• Participating in activities at bedtime that are not conducive to calming down
• Watching screens prior to bed and when waking overnight to care for baby
• Turning on bright lights overnight when feeding and caring for baby
• Not enough sunshine and activity during the day
• Bedroom environment is not associated with a rapid onset of sleep

While existing literature has shown that CBT-I is effective as a treatment for clinically significant insomnia during pregnancy, there is limited data to show its potential to help all expectant individuals. 

Researchers are hopeful that future larger trials will help evaluate the potential to integrate CBT-I into routine perinatal care.