Racial/ethnic disparities in sleep in mothers and infants during the Covid-19 pandemic
Summary (3 min read)
Participants and study design
- All mothers who gave birth at Morgan Stanley Children's Hospital or Allen Hospital since March 22, 2020 and who had a confirmed SARS-CoV-2 PCR positive test result during pregnancy or a SARS-CoV-2 positive antibody test result with a confirmed or suspected infection onset during pregnancy were approached for inclusion in the COVID-19 positive group of COMBO.
- Prior to delivery, they were asked to complete the COVID-19 Perinatal Experiences (COPE) survey to collect information on maternal mental and physical health during pregnancy.
- These participants were subsequently enrolled in the postnatal arm of the COMBO study after giving birth and were enrolled regardless of COVID-19 status and without case-matching.
Race/ethnicity:
- The main exposure variable was maternal racial/ethnic background.
- The authors combined these 2 variables to obtain one single race/ethnicity variable as follows: non-Hispanic White (W), African American (AA), Hispanic (H), and other (O).
Sleep and mental health measures:
- The primary outcomes were mothers' report of their infant's sleep health as measured by the Brief Infant Sleep Questionnaire (BISQ), 35 and of their own sleep as measured by the Pittsburgh Sleep Quality Index (PSQI) questionnaire (Cronbach's alpha 0.83).
- 36 The entire cohort completed the BISQ infant sleep questionnaire.
- From the BISQ the authors extracted the following measures: 1) nighttime sleep duration, 2) daytime sleep duration, 3) total sleep duration, 4) number of night awakenings, 5) amount of wakefulness during the night, 6) sleep latency, 7) bedtime, and 8) infant's sleep perceived as a problem by the mother.
- One-hundred and forty-nine women out of the total sample of 238 women also completed the PSQI.
- This same subset of mothers also completed the Patient Health Questionnaire-9 (PHQ-9, Cronbach's alpha 0.851) 37 to assess severity of depressive symptoms, the Perceived Stress Scale (PSS, Cronbach's alpha 0.82) 38 to assess levels of perceived stress, and the post-traumatic stress PTSD Checklist for DSM-5 (PCL-5) adapted for COVID-19 (see Supplementary Material for this adapted scale).
Other measures:
- The authors collected information on infant sex, gestational age at birth, maternal age at delivery, and health insurance status (commercial versus Medicaid) from the electronic medical records.
- Positive indicated that the participant had tested positive by PCR or serology at any point during pregnancy.
- Negative indicated that participant had not had a known COVID-19 infection at any point in pregnancy and had tested negative for SARS-CoV-2 by PCR and/or antibody testing at the time of delivery.
- The subset of mothers who completed the PSQI, PHQ-9, PSS, and PCL do not include any pre-pandemic control participants.
Statistical analysis:
- The authors tested for normal distribution of continuous variables obtained from the BISQ.
- No adjustments were made for regression models predicting maternal sleep in Model 1.
- In Model 3, the authors adjusted for COVID-19 status, with control pre-pandemic mothers as reference group.
- The authors performed mediation analysis via the CMAverse R package 39 to assess whether PHQ-9, PSS and PCL scores were mediators in the relationship between race/ethnicity and maternal and infant sleep variables.
- The mediation was tested only for non-Hispanic White and Hispanic mothers.
RESULTS
- The racial/ethnic composition of the entire sample was 71 non-Hispanic White, 14 African American, 113 Hispanic and 40 other.
- The racial/ethnic composition of the subset of mothers who also completed the PSQI and the mental health questionnaires was 44 White non-Hispanic, 8 African American, 70 Hispanic and 27 other.
- The subset was not significantly different from the entire subset for any socio-demographic variable, except for infant's age at the assessment, with infants from the subset being younger (p<0.001) and COVID-19 status, since in the subset there were no pre-pandemic control mothers.
- Additional socio-demographics for the subset are presented in Table S1 .
Infants sleep by race/ethnicity
- Table 2 displays infant sleep variables across racial/ethnic groups.
- The results of the multivariable regression models for Model 1, with maternal race/ethnicity predicting infant sleep variables and infant's sex and gestational age at birth as covariates, indicated that compared to non-Hispanic.
- Time of the pandemic was associated only with sleep latency, with infants born in July-August having longer latency 4 shows statistical results for all infant sleep domains for the 4 models.
- Results from Model 2, in which the authors added health insurance as an indicator of SES in the model, showed that the estimates associated with race/ethnicity on latency, disturbances and daytime dysfunction did not change appreciably, while for other domains differences by race/ethnicity were not significant anymore.
Maternal sleep by race/ethnicity
- Results from Model 3, in which the authors added COVID-19 status to the model, showed that the estimates associated with race/ethnicity on latency, disturbances, and daytime dysfunction did not change appreciably.
- Results from Model 4, in which the authors added maternal time of delivery during the pandemic, showed that the estimates associated with race/ethnicity on latency and daytime dysfunction did not change appreciably.
- In addition, birth timing with respect to the pandemic was associated with several sleep domains.
- For results for Models 2, 3, and 4 see Supplementary materials for additional information on statistical results.
- Table 5 shows statistical results for all infant sleep domains for the 4 models.
Mediation analysis
- The authors found no associations between race/ethnicity and scores on the PHQ-9, PSS, or PCL-5-COVID.
- Results from mediation analysis showed no significant result.
DISCUSSIONS
- Compared to white non-Hispanic infants, AA infants had longer sleep latency and went to bed later.
- In that study, assessment occurred earlier than their study (4-12 weeks postpartum) and Hispanic women were excluded.
- 44 Thus, their results extend knowledge from studies of the general population which indicate that racial/ethnic-minority adults in the United States are at increased risk for poor sleep health, filling a gap in the literature regarding racial disparities in sleep during the specific post-partum period.
- Other studies that have investigated sleep after natural disasters like 2005 Hurricane Katrina 52 and 2011 Great East Japan earthquake and tsunami 53 also found long lasting effects of posttraumatic stress on sleep health.
- In summary, their study shows racial/ethnic disparities in sleep in infants and mothers at 4 months postpartum across several sleep domains, and these disparities persist after controlling for SES and are not mediated by differences by race/ethnicity in maternal mental health.
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Frequently Asked Questions (16)
Q2. What did the authors think of the COVID-19 pandemic?
The authors had hypothesized that maternal depression, stress, and symptoms of trauma related to the COVID-19 pandemic would be higher in racial/ethnic minorities, thereby mediating disparities in sleep.
Q3. What is the importance of sleep for the infant?
For the infant, the early postnatal period is characterized by rapid development of sleep and wake patterns, marking a major neurobiological milestone.
Q4. What race/ethnic group did the infants sleep longer?
White infants, African American infants had longer sleep latency (β=1.2±0.6 p=0.03, OR 3.4 CI 1.1-10.5) and African American, Hispanic and infants from other race/ethnicities had later bedtimes (AA: β=1.9±0.6, p<0.001, OR 6.7 CI 2.2-20.2, H:β=1.7±0.3, p<0.001, OR 5.3 CI 2.9-9.8, O: β=0.9±0.4, p=0.01 OR 2.6 CI 1.2-5.3).
Q5. What was the criteria for the COVID-19 study?
Control mothers must have had negative SARS-CoV-2 PCR and antibody testing at admission to labor and delivery, no history of COVID-like symptoms, and no history of a positive COVID-19 test at any point during pregnancy.
Q6. What was the average PSS score for the mothers?
Mothers reported an average PSS score of 18.2 (sd 7.6), with 23.8% of the mothers reporting significant levels of perceived stress (PSS score ≥25)40.
Q7. What is the definition of sleep health?
Sleep health is an essential component of general health and it is associated with numerous mental and physical health outcomes in the general population.
Q8. What is the relationship between maternal mental health and sleep?
Regarding the relationship between maternal mental health and maternal sleep, higher PSS scores were associated with poorer subjective sleep quality (β=0.08±0.02, p<0.000), longer sleep latency (β=0.06±0.02, p=0.002), more sleep disturbances (β=0.1±0.02, p<0.000), more daytime dysfunction (β=0.1±0.02, p<0.000), and overall higher global PSQI scores (β=0.08±0.02, p<0.000).
Q9. What did a study assessing parents’ sleep health find?
a study assessing parent perspectives of their infants’ sleep in a predominantly low SES African American sample found that while children’s average sleep duration was below recommended for their age group and overall sleep difficulty was high, most mothers reported that their children had normal sleep.
Q10. What other studies have found long lasting effects of posttraumatic stress on sleep health?
Other studies that have investigated sleep after natural disasters like 2005 Hurricane Katrina52 and 2011 Great East Japan earthquake and tsunami53 also found long lasting effects of posttraumatic stress on sleep health.
Q11. What did the authors find in their study?
Their findings indicated that parent behaviors related to sleep, such as bedtime routine consistency, sleep associations, were the primary mediators, although they might not be completely independent from SES.
Q12. What was the p-value for the infant and maternal sleep measures?
After Bonferroni adjustments for multiple comparison analyses, the adjusted p-values for analyses on infant and maternal sleep measures was p=0.006.
Q13. What is the standardized measure of sleep?
From the BISQ the authors extracted the following measures: 1) nighttime sleep duration, 2) daytime sleep duration, 3) total sleep duration, 4) number of night awakenings, 5) amount of wakefulness during the night, 6) sleep latency, 7) bedtime, and 8) infant’s sleep perceived as a problem by the mother.
Q14. What is the relationship between poor sleep and perinatal health?
In the perinatal period, poor sleep has been associated with numerous maternal physical and mental outcomes, such as changes in interpersonal relationships, risk of postpartum weight retention, and perinatal mood disorders.
Q15. What are the limitations of this study?
54 Limitations of this study included the sparse information about additional behavioral and socioecological factors, such as marital status and social support, that may also interact with young children's sleep and the absence of objective sleep measures.
Q16. What did the participants do after giving birth?
These participants were subsequently enrolled in the postnatal arm of the COMBO study after giving birth and were enrolled regardless of COVID-19 status and without case-matching.