How are you sleeping?

In your practice, do you routinely ask women how they’re sleeping? And if you do, what do you do with that information? Do you use sleep-related questions as a way of triggering and exploring all manner of topics with women? Are there things that you say to all women and families about sleep and rest, or do you only discuss sleep if the woman raises the subject herself?

In my early years as a midwife, I mainly asked women about sleep in mid to late pregnancy and the postnatal period unless something they said prompted a discussion of this topic earlier. As my experience developed (and probably also as my own sleep patterns and experiences evolved), I began to realise that asking women about sleep could bring up discussion of all sorts of elements about their experience. I saw how sleep and rest could be fundamentally important elements of labour and incorporated discussions about sleep within the context of childbirth education as well. Asking women about their sleep helped me learn about their worries, their relationships, their fears, about what comfort meant to them, and much more on top.

The pathologisation of sleep?

I became aware a few years ago of a growth in the number of articles about sleep in pregnancy and the postnatal period, though barely any of these also considered the topic of sleep in labour, so I shall perhaps have to return to that another time. These articles tend to focus more on sleep problems, though. The topic of sleep-disordered breathing (SDB) in pregnancy, for instance, has received quite a bit of attention, with authors noting that symptoms of SDB may be more common in pregnant than non-pregnant women (Bourjeily et al 2011). Other studies have raised questions about the relationship of sleep to mental wellness (Sivertsen et al 2015). Many of the teams looking at these areas acknowledge that our understanding is still limited, so as much as I welcome more information on this important area, I also feel slightly concerned when I hear certain colleagues discussing the question of screening all pregnant women for possible sleep disorders.

In practice, most the women that I have attended who say that they have problems sleeping tend to be more concerned with a lack of sleep, or insomnia, although many of them see sleep-related issues as an inevitable part of pregnancy and parenting. Most (again only in my experience; yours may vary) are looking for no more than suggestions or even just the chance to offload their experiences rather than formal assessment and treatment.

Is routine assessment and treatment even warranted at this stage of our understanding? There exist physiological differences between pregnant and non-pregnant women, and many of the studies to date have been small (Tauman 2015). When it comes to pregnancy and the parenting years, as a recent longitudinal study by Sivertsen et al (2015) showed, normality may rapidly change. Such factors tend not, of course, to stand between tabloid journalists and fear-mongering headlines. As I write, a British newspaper has just run a story about a possible link between poor sleep quality and Alzheimer’s disease, which prompted a ‘let’s look at the facts behind the headlines’ response by the NHS Choices team (2015) in the hope of reassuring those who were worried.

The importance of balance

Could a balance to be struck in our approach to asking women about sleep? It’s one thing to use sleep as a starting point for conversation, and it’s clearly important to be aware of links between sleep, rest and mental wellness and respond appropriately where a woman is having problems or expresses real concern, but the past few decades have seen us veer ever further towards pathologising the everyday and defining what is – or might be – abnormal. Often, we are told to screen for problems without necessarily having an effective, warranted and/or compassionate solution.

There is rarely a stampede to apply the same level of scrutiny to looking at the parameters of normal in an area or to considering how people vary in their experiences. Often, simple and tiny adjustments are all that is needed to help regain balance. In the case of sleep problems, examples might include blackout curtains, daytime napping, pillows, social support, home remedies or the removal of smartphones from the bedroom.

Ancient and modern sleep

It may also be important to ask what we are measuring sleep – and indicators of poor sleep, such as insomnia – against. My own perception of what constitutes normal sleep changed after I read historian A. Roger Ekirch’s (2005) work, which suggests that our modern, Western ways of sleeping are rather new and different from those of even our recent ancestors. The idea that we should sleep for eight hours in a row, at night, and use electric light to help us work and do other things outside of (and, of course, in some cases during) the hours of darkness is barely two centuries old. Ekirch uncovered an abundance of evidence showing that, until recently, people practiced segmented sleep and had two sleeps a night rather than one long one. They snoozed off when darkness fell, slept for three or four hours and then woke up for an hour or so. During this time, according to the literary sources that Ekirch examined, people would chat, have sex, brew beer or visit with friends. If they were naughty, they might engage in a bit of petty theft before falling back to sleep for another few hours.

This revelation casts a rather different light on so-called ‘middle of the night insomnia’. I have shared my understanding of this with women, new dads, friends and colleagues, and some have read the book and changed their view of their own sleep patterns. That is, they no longer see them as problems but as more normal within the context of human development and evolution. If this is what we can learn from one (albeit very detailed) study, then I wonder what might we learn from reconsidering other elements of sleep? Especially if we could reconsider these other elements of sleep from a perspective that focuses on pregnant and new parents, places importance on cultural context as a key determinant of our ideas and actively embraces the notions of normalcy and balance.

References

Bourjeily G, Ankner G, Mohsenin V (2011). Sleep-disordered Breathing in Pregnancy. Clinics in Chest Medicine 32(1): 175–189

Ekirch AR (2005). At Day’s Close: Night in Times Past. London: Weidenfeld & Nicolson.

NHS Choices (2015). Poor sleep quality linked to Alzheimer’s disease. http://www.nhs.uk/news/2015/06June/Pages/Poor-sleep-quality-linked-to-Alzheimers-disease.aspx

Sivertsen B, Hysing M, Dørheim SK et al (2015). Trajectories of maternal sleep problems before and after childbirth: a longitudinal population-based study. BMC Pregnancy and Childbirth (2015) 15: 129 doi: 10.1186/s12884-015-0577-1

Tauman R, Zuk L, Uliel-Sibony S et al (2015). The effect of maternal sleep-disordered breathing on the infant’s neurodevelopment. AJOG 212(5): 656.e1–656.e7