Sleep quality during pregnancy is an essential yet overlooked aspect of maternal and offspring psychopathology.^1,2,3 Approximately 40% – 62% of pregnant women globally report significant sleep disturbances with 57% in sub-Saharan Africa.^4,5,6,7 Restorative sleep is vital for metabolic regulation, neuronal homeostasis and foetal development.^1,8,9 However, pregnancy-related sleep disturbances arise from interplay of physiological and psychosocial factors that came along with gestation. Hormonal fluctuations characterised by progesterone-melatonin changes, physical discomforts (such as nocturia, back pain and respiratory challenges) and perinatal anxiety from ruminating over birth outcomes disrupt the sleep–wake cycle, elevating risk for neurodevelopmental and maternal mental health outcomes.^2,7,10,11

Emerging evidence supports a bidirectional relationship between poor sleep and maternal mental health, with chronic sleep activating psychoneuroimmunological pathways contributing to psychiatric outcomes.^3,12,13 These disturbances are linked to elevated cortisol from hypothalamic-pituitary-adrenal (HPA) axis dysregulation, increased pro-inflammatory cytokines (Interleukin-6 [IL-6], Tumour Necrosis Factor-alpha [TNF-α]) and altered neurotransmitter balance (Gamma-aminobutyric acid [GABA], serotonin, dopamine). These changes may impair amygdala-prefrontal cortex connectivity and emotional processing, creating intergenerational risks for neurodevelopmental disorders.^{3,11,12,13,14,15}

Psychosocial factors, especially anxiety and depression, can disrupt sleep architecture by affecting stress-responsive neurotransmitters like serotonin 5-hydroxytryptamine (5-HT), reducing sleep duration and efficiency and contributing to postpartum depression.^16,17,18 Maternal age also impacts sleep: younger women may have immature stress adaptation, while older women may experience insomnia related to age-associated obstetric risks.^19,20,21 Elevated pre-pregnancy body mass index (BMI) exacerbates sleep issues through metabolic dysregulation and chronic inflammation.^20,22,23 Similarly, maternal stress, social isolation, low perceived emotional support and late-night eating during pregnancy can further exacerbate sleep disturbances, especially as pregnancy progresses into the third trimester.^24,25,26,27 These intersecting factors cumulatively increase risks for adverse maternal and child outcomes.

In low-resource contexts like Malawi, where socio-economic challenges are exacerbated by poverty and health disparities, there is a risk of elevated sleep disturbances that may be normalised and dismissed as inevitable. Factors such as poverty, Malawi’s prevalent malaria in pregnancy, intimate partner violence and maternal mental health illiteracy could exacerbate sleep disturbances during pregnancy.^3,28,29 Despite evidence of pervasive lower back pain in pregnancy and high rates of adverse outcomes linked to poor sleep quality in Malawi,^30,31,32,33 research has predominantly focused on depression and anxiety while neglecting the significance of sleep quality, a modifiable risk factor. The absence of targeted sleep screening in antenatal care at Kamuzu Central Hospital (KCH) emphasises the urgency for research examining sleep quality in this context. This study aimed at assessing the prevalence and associated factors of insomnia disorder among pregnant women attending antenatal care at KCH in Lilongwe, Malawi.

All 110 questionnaires were retrieved and analysed, yielding a 100% response rate.

This study assessed insomnia disorder symptoms consistent with a PSQI score of less than 5, which signifies poor sleep quality than providing formal DSM diagnoses. The study reveals a concerning prevalence of insomnia disorder symptoms, represented with a prevalence of poor sleep quality of 79.1%, as high as figures reported in US,³⁷ India,³⁸ China³⁹ and sub-Saharan Africa^35,36 underscoring poor sleep quality in pregnancy as a global public health concern. The mean PSQI score of 8.77 at KCH indicates significant sleep disturbances, emphasising an area of perinatal mental health care that has been largely neglected yet poses risks of perinatal depression, anxiety disorders, suicidality and neurodevelopmental disorders in children overburdening families and the health care system.^10,11

Women in their first trimester exhibited lower odds of poor sleep (AOR = 0.21), suggesting less hormonal or psychological impact during this period. However, those in the second trimester faced a fivefold increased risk (AOR = 5.21), identifying this stage as a critical window for intervention. Regional factors such as endemic malaria may further exacerbate sleep disturbances, emphasising the need for context-specific maternal care approaches that address both biological and psychosocial influences.

Interestingly, married women reported higher instances of poor sleep, possibly due to increased household responsibilities and caregiver demands, while bed-sharing was significantly associated with sleep disturbances (OR = 5.28). The presence of a partner may disrupt sleep through movement or snoring, especially during pregnancy.^40,41

Despite the focus on insomnia disorder as a form of poor sleep quality rather than a clinical diagnosis, the study presents actionable insights. There is an urgent need to incorporate sleep health screenings into routine antenatal care practices. Educational initiatives focused on sleep hygiene for pregnant women and their partners could help mitigate the adverse effects of poor sleep on perinatal mental health and promote better outcomes for mothers and their children.

Limitations of this study include: The cross-sectional design, which prevents causal inference and cannot establish whether associated factors cause or result from insomnia. Sleep disturbances during pregnancy can vary across trimesters, and a single measurement may fail to capture these fluctuations. The exclusion of other sleep disorders, particularly obstructive sleep apnoea – especially given the high BMI in the sample – may have affected the accuracy of the ‘insomnia’ diagnosis. Additionally, reliance on self-reported PSQI scoring for poor sleep quality for a month, which does not fully capture insomnia disorder and has the potential to introduce bias and lurking psychological associated factors. Moreover, selection bias could have occurred due to the varied times of day and different trimesters, and a stratified sample might have minimised assumptions across trimesters.

This study highlights the high prevalence of insomnia disorder, characterised by poor sleep quality in pregnancy, as a modifiable risk factor for perinatal mental health issues in Malawi. Focusing on sleep health during antenatal care, especially in the second trimester, can improve maternal well-being and child developmental outcomes in resource-limited settings. Referring participants with severe sleep disturbances to other health services provides an opportunity for further investigation. Future research should utilise longitudinal approaches with objective sleep assessments, such as actigraphy, and consider the influence of psychological factors to explore the intricate relationships between sleep quality and mental health in this vulnerable population.