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Infant sleep and negative reactivity: The role of maternal adversity and perinatal sleep

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Abstract

Sleep during infancy contributes to the development and maintenance of infant regulatory functioning and may be an early risk marker for more difficult temperamental traits like negative reactivity. Further, maternal adverse childhood experiences (ACEs) may predispose individuals to greater sleep disturbances in adulthood and have been linked with sleep disturbances in both mothers and infants. Thus, examining maternal history of ACEs and maternal sleep difficulties during pregnancy and postpartum may provide insight into underlying risk factors affecting infant sleep difficulties and early temperament development. Fifty-nine mothers from a diverse, community sample (44% white) completed questionnaires on ACEs, maternal sleep, infant sleep, and infant temperament at 30-weeks gestation, 6-weeks postpartum, and 16-weeks postpartum. Results indicated that maternal ACES and sleep problems during pregnancy have long term implications for infant negative reactivity at 16-weeks, with significant indirect effects through maternal and infant sleep problems at 6-weeks. Addressing psychosocial functioning and prenatal sleep during pregnancy, particularly among women with high ACEs, may be a target of intervention to improve maternal and infant sleep health during the postpartum, and reduce the risk for difficult infant temperament.

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Background: Trauma-exposed women may be at magnified risk for posttraumatic stress (PTSS) and depression symptoms in the perinatal period, but few studies have examined symptomatology across the perinatal period in high-risk samples. Further, the role of sleep in perinatal symptomatology has been largely neglected in the violence literature, despite its well-established associations to mental health in other samples. This study aimed to examine the trajectory of PTSS and depression symptoms across the perinatal period and the effects of childhood adversity, intimate partner violence and prenatal sleep impairment on PTSS and depression symptoms across the perinatal period. Method: In a longitudinal, prospective study, 101 low-income pregnant women were interviewed during pregnancy, at 6-weeks postpartum, and 4 months postpartum. N = 83 women completed at least 2 interviews and were included in the analyses. Prenatal sleep, childhood adversity, and IPV exposure were assessed at the prenatal interview; PTSS and depression were assessed at all interviews. Results: Past year IPV was associated with elevated prenatal mental health symptoms and prenatal sleep difficulties were associated with a worsening trajectory in perinatal PTSS. Conclusions: Screening for IPV and prenatal sleep difficulties may be paramount in identifying those at risk for the development or exacerbation of mental health symptoms in the perinatal period.
Article
After childbirth, most American women are not scheduled for follow up care for 6 weeks, and this visit is poorly attended. Many new mothers feel unprepared for the common health issues they encounter and are uncertain of whom to contact. To improve care, the 4(th) Trimester Project is bringing together mothers, health care providers, and other stakeholders to explore what families need most from birth to 12 weeks postpartum. Eighty-seven individuals convened in March 2016 in Chapel Hill, NC. Four major topic areas emerged: (1) the intense focus on women's health prenatally is unbalanced by infrequent and late postpartum care; (2) medical practice guidelines often do not align with women's experiences and constraints; (3) validation of women as experts of their infants and elevating their strengths as mothers is necessary to achieve health goals; and (4) mothers need comprehensive care, which is difficult to provide due to numerous system constraints. Considerations for improving postpartum services include enabling more convenient care for families that is holistic, culturally appropriate, conversation-based, and equitable. Maternal health issues in the 4(th) Trimester intersect and can compound one another. Enhanced collaboration among health care providers may improve the focus clinical interactions to address the interrelated health issues most important to women.
Article
Infant sleep problems have been the focus of a growing literature over the last few years. The current review is based on literature searches of Pubmed and PsycInfo for studies published over the last few years including randomized controlled trials, systematic reviews and meta-analyses on infant sleep problems and resulting developmental effected, risk factors and interventions. Several risk/protective factors for sleep problems have been identified including health literacy, TV in the room, feeding, close contact and arousing activities at bedtime, intolerance for infant crying, co-sleeping, maternal depression and infant temperament. Cross-cultural differences have been noted both for infant sleep problems and parents’ perceived distress by those problems. A number of interventions have been tried to ameliorate infant sleep problems including consultations, teaching sessions on extinction and bedtime fading, internet-based interventions and nighttime massages by parents. Some of these studies have shown improvements and others have suggested only short-term or negligible effects. Significant methodological problems exist with this literature including the almost sole use of parent report as well as the mixed age samples and the potential confounding variables.
Article
Objective Growing evidence suggests the deleterious consequences of exposure to childhood maltreatment (CM) not only might endure over the exposed individual’s lifespan but also might be transmitted across generations. The time windows, mechanisms, and targets of such intergenerational transmission are poorly understood. The prevailing paradigm posits that mother-to-child transmission of the effects of maternal CM likely occurs after her child’s birth. The authors seek to extend this paradigm and advance a transdisciplinary framework that integrates the concepts of biological embedding of life experiences and fetal origins of health and disease risk. Method The authors posit that the period of embryonic and fetal life represents a particularly sensitive time for intergenerational transmission; that the developing brain represents a target of particular interest; and that stress-sensitive maternal-placental-fetal biological (endocrine, immune) pathways represent leading candidate mechanisms of interest. Results The plausibility of this model is supported by theoretical considerations and empirical findings in humans and animals. The authors synthesize several research areas and identify important knowledge gaps that might warrant further study. Conclusion The scientific and public health relevance of this effort relates to achieving a better understanding of the “when,” “what,” and “how” of intergenerational transmission of CM, with implications for early identification of risk, prevention, and intervention.
Article
Objective: Research has demonstrated that exposure to violence and adversity has negative effects on both mental health and biobehavioral outcomes, such as sleep health. Research examining the relationship between past and recent violence exposure and mental health suggests that the effects of childhood adversity are especially pernicious, but to date, no studies have attempted to disentangle the direct, indirect and relative effects of past year versus childhood exposure to violence and adversity on sleep. The objective of the current study was to examine the direct effects of adverse childhood experiences (ACEs) and past year intimate partner violence (IPV) on different aspects of sleep health in pregnant women. Method: A sample of high-risk pregnant women (n = 101) were interviewed. Mediation analysis with bias-corrected, bootstrapped confidence intervals was used to evaluate direct and indirect effects. Results: Findings indicated that while ACEs had significant direct effects on mental health, past year IPV had stronger effects on sleep quality, latency, and efficiency. ACEs did, however, indirectly affect subjective sleep quality via past year psychological IPV. Conclusion: These findings suggest that sleep disturbance may be a regulatory stress response that is most clearly linked to past year violence and trauma. That is, though long-term sleep disturbance may be evident following childhood adversity, it is likely that this relationship is better explained by the role of childhood adversity in predicting adulthood revictimization or due to long-term mental health difficulties associated with early trauma. (PsycINFO Database Record
Article
Objective: To evaluate the feasibility and efficacy of a home-based cognitive-behavioral training program for sleep during late pregnancy. Methods: A nonrandomized quasiexperimental sample of nulliparous women who received the intervention during pregnancy (n=25) was compared with two control groups (n=76 and n=48) from other intervention studies at similar postintervention time points: approximately 1 month before childbirth and 1-2 months after childbirth. The home-based Sleep Enhancement Training System for Pregnancy consisted of 4 weeks of sound-enhanced audio relaxation programs, readings, and daily sleep diaries. Both control groups received dietary recommendations for improving sleep. Sleep duration (total sleep time) and sleep disruption (wake after sleep onset) were measured using wrist actigraphy for a minimum of 48 hours on consecutive weekdays. Results: The intervention group had significantly longer sleep duration and less sleep disruption than both control groups, particularly at the postpartum assessment. Intervention participants slept an average of 430 (95% confidence interval [CI] 397-464) minutes during pregnancy compared with 420 (95% CI 403-438) and 417 (95% CI 395-439) minutes for the two control groups. At the postpartum assessment, the intervention group slept 446 (95% CI 415-478) minutes compared with 390 (95% CI 373-408) and 370 (95% CI 348-393) minutes for those in the control groups. In terms of sleep disruption, women in the intervention group had 16.1% (95% CI 11.9-20.2%) wake after sleep onset during pregnancy, whereas women in the control groups had 13.4% (95% CI 11.2-15.5%) and 20.4% (95% CI 17.7-23.0%). Postpartum, the intervention group had 20.3% (95% CI 16.4-24.1%) wake after sleep onset compared with 26.6% (95% CI 24.5-28.8%) and 28.7% (95% CI 26.0-31.5%) among women in the control groups. Participant feedback about the intervention was generally positive, although intervention adherence was variable. Conclusion: This study provides evidence of the feasibility and efficacy of the Sleep Enhancement Training System for Pregnancy intervention for enhancing sleep that typically worsens during late pregnancy and after childbirth.
Article
The aim of this study was to examine the cross-sectional and longitudinal relationships among variables related to sleep patterns and both social-emotional problems (i.e., internalizing, externalizing, and dysregulation) and healthy social development (i.e., social competence). Assessments were completed at 6, 12, and 18 months across 5 cohorts of children for a total of 117 mother-child dyads. Mothers completed the Brief Infant Sleep Questionnaire at 6, 12, and 18 months, as well as the Infant Toddler Social Emotional Assessment at 12 and 18 months. Later bedtimes and less total sleep across the 24-hr period predicted higher internalizing problem scores, which includes indices of depression/withdrawal, general anxiety, separation distress, and inhibition. In contrast, sleep fragmentation was minimally associated with decreased social competence but not with any negative social-emotional outcomes. These results indicate that sleep patterns, primarily later bedtimes and less total sleep, appear to be associated with and predictive of social-emotional problem areas, namely, internalizing issues, in infants and toddlers. These findings add to the growing literature on the role of sleep in early social-emotional development and suggest that sleep schedule and duration should be addressed in clinical assessment and interventions for infant sleep.
Article
The current study prospectively examined the ways in which goodness of fit between maternal and infant sleep contributes to maternal depressive symptoms and the mother-child relationship across the first years of life. In a sample of 173 mother-child dyads, maternal prenatal sleep, infant sleep, maternal depressive symptoms, and mother-child attachment security were assessed via self-report, actigraphy, and observational measures. Results suggested that a poor fit between mothers’ prenatal sleep and infants’ sleep at 8 months (measured by sleep diary and actigraphy) was associated with maternal depressive symptoms at 15 months. Additionally, maternal depression mediated the association between the interplay of mother and infant sleep (measured by sleep diary) and mother-child attachment security at 30 months. Findings emphasize the importance of the match between mother and infant sleep on maternal wellbeing and mother-child relationships and highlight the role of mothers’ perceptions of infant sleep.
Article
Maternal adverse childhood experiences (ACEs) have been associated with negative physical and mental health outcomes in adulthood. Less is known regarding how maternal ACEs relate to perinatal depressive symptoms or the intergenerational effect of maternal childhood trauma history on birth outcomes and infant functioning. To address this gap, an at-risk sample of 398 pregnant women was recruited from Women, Infants, and Children health clinics. Participants completed a prenatal (M = 4.84 months before due date) and postnatal (M = 6.76 months after birth) assessment and provided birth outcome data. At the prenatal assessment, mothers completed an ACEs measure which assessed experiences of childhood maltreatment and household dysfunction. Self-report measures of maternal depressive symptoms were obtained at both time points. Mothers reported on infant socioemotional functioning at 6 months. Maternal ACEs predicted higher levels of prenatal depressive symptoms. Childhood maltreatment experiences, in particular, predicted higher postnatal depressive symptoms and a smaller reduction in depressive symptoms across the perinatal period. Regarding intergenerational associations, maternal childhood maltreatment directly predicted higher levels of maladaptive infant socioemotional symptoms, whereas maternal household dysfunction indirectly related to infant socioemotional symptoms through maternal age at first pregnancy and infant birth weight. Limitations and future directions are discussed.
Article
Infant sleep consolidates rapidly during the first half year of life in the context of a dynamic, bidirectional exchange between infant characteristics and the caregiving environment. The current study examined the relationship between mothers' emotional availability (EA) at bedtime and infant temperament, and objectively assessing infant sleep development from one to six months, particularly focus on whether infant temperament moderated linkages between EA at bedtime and infant sleep development. The sample consisted of 72 mother–infant dyads, and the measures included actigraphy-assessed infant sleep at one and six months, observed maternal EA coded from bedtime videos at 3 and 6 months, and maternal reports of infant temperament at three and six months. The analysis showed significant positive effects of maternal EA at bedtime on developmental changes in infant sleep minutes. Additionally, infant temperamental surgency moderated the influence of EA at bedtime on the increase in infant sleep minutes. In other words, highly surgent infants whose mothers were emotionally available at bedtime showed a greater increase in their sleep time than other infants. The results are discussed in terms of the transactional model of infant sleep development.
Article
The notion of an average expectable environment for promoting normal development proposes that there are species-specific ranges of environmental conditions that elicit normative developmental processes. This chapter provides a review of child maltreatment. Of particular salience is the growing contribution of neurobiological and genetic research to the study of child maltreatment, such that ontogenic development can be considered from both psychological and neurobiological perspectives. The ecological-transactional model of child maltreatment explains how processes at each level of ecology exert reciprocal influences on each other and shape the course of child development. The extent of variation in personality characteristics and personality organization among maltreated children represents an area of investigation that has recently gained attention in the maltreatment literature. The maladaptive trajectories of maltreated children diverge from those of nonmaltreated children over time such that maltreated children's problems become more severe as children get older, especially in peer relationships.
Article
Objective: This article presents a new formulation of the relationship between stress and the processes leading to disease. It emphasizes the hidden cost of chronic stress to the body over long time periods, which act as a predisposing factor for the effects of acute, stressful life events. It also presents a model showing how individual differences in the susceptibility to stress are tied to individual behavioral responses to environmental challenges that are coupled to physiologic and pathophysiologic responses.Data Sources: Published original articles from human and animal studies and selected reviews. Literature was surveyed using MEDLINE.Data Extraction: Independent extraction and cross-referencing by us.Data Synthesis: Stress is frequently seen as a significant contributor to disease, and clinical evidence is mounting for specific effects of stress on immune and cardiovascular systems. Yet, until recently, aspects of stress that precipitate disease have been obscure. The concept of homeostasis has failed to help us understand the hidden toll of chronic stress on the body. Rather than maintaining constancy, the physiologic systems within the body fluctuate to meet demands from external forces, a state termed allostasis. In this article, we extend the concept of allostasis over the dimension of time and we define allostatic load as the cost of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or chronic environmental challenge that an individual reacts to as being particularly stressful.Conclusions: This new formulation emphasizes the cascading relationships, beginning early in life, between environmental factors and genetic predispositions that lead to large individual differences in susceptibility to stress and, in some cases, to disease. There are now empirical studies based on this formulation, as well as new insights into mechanisms involving specific changes in neural, neuroendocrine, and immune systems. The practical implications of this formulation for clinical practice and further research are discussed.(Arch Intern Med. 1993;153:2093-2101)
Article
Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality that is associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, and/or awakening earlier in the morning than desired. Although progress has been made in our understanding of the nature, etiology, and pathophysiology of insomnia, there is still no universally accepted model. Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment. The aims of this report are (1) to summarize current knowledge on the pathophysiology of insomnia and (2) to present a model of the pathophysiology of insomnia that considers evidence from various domains of research. Working within several models of insomnia, evidence for the pathophysiology of the disorder is presented across levels of analysis, from genetic to molecular and cellular mechanisms, neural circuitry, physiologic mechanisms, sleep behavior, and self-report. We discuss the role of hyperarousal as an overarching theme that guides our conceptualization of insomnia. Finally, we propose a model of the pathophysiology of insomnia that integrates the various types of evidence presented.
Article
Growing evidence suggests that toxic stressors early in life not only convey developmental impacts but also augment risk of proliferating chains of additional stressors that can overwhelm individual coping and undermine recovery and health. Examining trauma within a life course stress process perspective, we posit that early childhood adversity carries a unique capacity to impair adult psychological well-being both independent of and cumulative with other contributors, including social disadvantage and stressful adult experiences. This study uses data from a representative population-based health survey (N=13,593) to provide one of the first multivariate assessments of unique, cumulative, and moderated effects of adverse childhood experiences (ACEs) toward explaining 3 related yet distinct measures of adult mental health: perceived well-being, psychological distress, and impaired daily activities. Results demonstrate support for each set of hypothesized associations, including exacerbation and amelioration of ACEs effects by adult stress and resilience resources, respectively. Implications for services and future research are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
Sleep patterns and temperament in the first year of life are closely related. However, research utilizing objective, rather than subjective measurements of sleep and temperament is scarce and results are inconsistent. In addition, a relative lack of longitudinal data prevents inference of causality between the two constructs. In this study, infant sleep was objectively assessed among 95 infants at 3, 6, and 12 months-of-age with an actigraph in the home setting. Reactivity to sound, light, and touch, a specific aspect of temperament, was behaviorally assessed at 3 and 6 months, both during sleep (at home) and during waking (at the laboratory). Expected maturational trends were recorded in sleep, with a temporal increase in sleep efficiency and percent of motionless sleep. Quadratic (i.e., inverse U shape) relations were found, especially among girls, when predicting change in sleep by reactivity thresholds, suggesting that both hyposensitive and hypersensitive infants are at risk for poor sleep quality. These are the first research findings suggesting that low reactivity in infancy might be associated with compromised sleep quality. The observed nonlinear effects may account for null or inconsistent results in previous studies that explored only linear associations between temperament and sleep. Future studies should address both extremes of the temperament continuum when exploring relations with sleep patterns. © 2015 The Society for Research in Child Development, Inc.
Article
The aims of this longitudinal study were to examine (a) development of infant sleep and maternal sleep from 3 to 6 months postpartum; (b) concomitant and prospective links between maternal sleep and infant sleep; and (c) triadic links between paternal involvement in infant caregiving and maternal and infant sleep. The study included 57 families that were recruited during pregnancy. Maternal and infant sleep was assessed using actigraphy and sleep diaries for 5 nights. Both fathers and mothers completed a questionnaire assessing the involvement of fathers relative to mothers in infant caregiving. The results demonstrated moderate improvement in infant and maternal sleep percent between 3 and 6 months. Maternal sleep percent at 3 months significantly predicted infant sleep percent at 6 months. Greater paternal involvement in infant daytime and nighttime caregiving at 3 months significantly predicted more consolidated maternal and infant sleep at 6 months. These findings suggest that maternal sleep is an important predictor of infant sleep and that increased involvement of fathers in infant caregiving responsibilities may contribute to improvements in both maternal and infant sleep during the first 6 months postpartum. © 2015 The Society for Research in Child Development, Inc.
Article
Adverse childhood experiences (ACEs) represent substantial threats to public health and affect about 58% of youth in the US. In addition to their acute effects such as injury and physical trauma, ACEs are associated with an increased risk of several negative health outcomes throughout the life course. Emerging evidence suggests that sleep disorders may be one such outcome, but existing studies have not been systematically reviewed and summarized. We conducted a systematic review to summarize the evidence concerning the relationship between ACEs and sleep disorders and disturbances, with a focus on adult women. Original publications were identified through searches of the electronic databases MEDLINE, Embase, and Web of Science using the keywords "childhood," "adversity," "abuse," and "sleep" as well as searches of the reference lists of eligible studies. Studies evaluating ACEs that occurred before 18 years of age and sleep outcomes that were assessed at 18 years or older were adjudicated and included. A total of 30 publications were identified. Of the 30 studies, 28 were retrospective analyses and there was vast heterogeneity in the types of ACEs and sleep outcomes measured. The majority of retrospective studies (N = 25 of 28) documented statistically significant associations between sleep disorders including sleep apnea, narcolepsy, nightmare distress, sleep paralysis, and psychiatric sleep disorders with a history of childhood adversity. In many studies, the strengths of associations increased with the number and severity of adverse experiences. These associations were corroborated by the two prospective studies published to date. Notably, investigators have documented statistically significant associations between family conflict at 7-15 years of age and insomnia at 18 years of age (odds ratio, OR = 1.4; 95% confidence interval, CI = 1.2-1.7) and between childhood sexual abuse and sleep disturbances 10 years later in adult women (β = 0.24, p <0.05). There is a growing scientific body of knowledge suggesting an association between ACEs and multiple sleep disorders in adulthood. The available evidence indicates the need to develop treatment strategies such as trauma-informed care for survivors of abuse who suffer from sleep disorders and disturbances. Further, longitudinal studies among diverse populations are needed to improve the overall understanding of this association and to investigate potential gender and racial/ethnic disparities in the strength of the association. Copyright © 2014 Elsevier B.V. All rights reserved.
Article
Emotions are biologically-based responses that help an organism meet challenges and opportunities, and involve changes in subjective experience, behavior, and physiology. Emotions arise when something important to us is at stake. Although many factors have been associated with healthy emotional regulation, the role of sleep in this process has been largely ignored. Recent studies, however, have begun to delineate how sleep critically affects emotional functioning. Nighttime sleep affects daytime mood, emotional reactivity and the capacity to regulate positive and negative emotions; conversely, daytime experiences affect sleep. Hence, there is a complex interplay between sleep and emotional regulation. The objective of this article is to examine this interplay in adults. This objective is addressed by utilizing a framework that identifies key aspects of the relationship between sleep and emotion. We propose that the connectivity between the emotional centers of the brain - the prefontal cortex and the amygdala - is in part dependent on the homeostatic sleep system such that connectivity between these brain networks is higher when rested and lower when sleep deprived. High connectivity drives more efficient executive functioning, while a disconnect leads to poor executive functioning capacity including emotional reactivity and impulsivity. The cognitive effects of the homeostatic system are couple with the mood regulation effects of the circadian system together dictating the degree to which one experiences emotional regulation or dysregulation. Further, the affective brain systems of individuals with clinical symptomology and/or pathology are suggested to be more vulnerable to homeostatic pressure and circadian lows or misalignment resulting in increased affective clinical symptomology. We review empirical evidence that supports this framework and explore the implications of this framework. Finally, we describe future directions for this type of work.
Article
Background: Pregnant women with complications including pregnancy-induced hypertension (PIH) and gestational diabetes mellitus (GDM) often experience disrupted sleep patterns because of activation of the sympathetic nervous system. These pathologies are aggravated by sympathetic nervous system activation and may be related to stress. The present study aimed to clarify the characteristics of and changes in sleep quality and stress in pregnant women with PIH and GDM during the second and third trimesters. Methods: We enrolled 56 women in their second or third trimesters who were diagnosed with PIH or GDM. Participants completed questionnaires, including the Pittsburgh Sleep Quality Index (PSQI) and the Perceived Stress Scale (PSS). Secretory immunoglobulin A (SlgA) concentrations were measured as a biological indicator of stress. Results: PSS scores and subjective stress parameters were significantly higher than those reported from previous studies of healthy pregnant women (15.2 points and 15.1 points for the second and third trimesters, respectively). Mean one-day values for SIgA were 168.3 and 205.7 μg/mL for the second and third trimesters, respectively. During the second and third trimesters, SIgA scores were higher than those reported for healthy pregnant women in previous studies. The PSQI component scores sleep disturbance (C5) and sleep duration (C3) in follow up case were significantly higher in the third trimester than in the second trimester. Discussion: This investigation suggests that pregnant women with PIH and GDM experience higher stress levels than do non-pregnant women and healthy pregnant women. Further, our results indicate that sleep quality worsens during the third trimester compared with the second trimester.
To evaluate the effect of socioeconomic status on measures of sleep quality, continuity, and quantity in a large cohort of pregnant women. Prospective, longitudinal study. One hundred seventy (170) pregnant women at 10-20 weeks gestation. Sleep quality was assessed with the Pittsburgh Sleep Quality Index. Sleep duration and continuity (sleep fragmentation index [SFI]) were assessed with actigraphy at 10-12, 14-16, and 18-20 weeks gestation. Because sleep did not significantly differ across time, averages across all three time points were used in analyses. Socioeconomic status (SES) was defined by self-reported annual household income. Linear regression analyses were used to model the independent associations of SES on sleep after adjusting for age, race, parity, marital status, body mass index (BMI), perceived stress, depressive symptoms, and financial strain. On average, women reported modestly poor sleep quality (M = 5.4, SD = 2.7), short sleep duration (391 [55.6] min) and fragmented sleep (SFI M = 33.9, SD = 10.4. A household income < $50,000/year was associated with poorer sleep quality (β = -.18, p < 0.05) and greater sleep fragmentation (β = -.18, p < 0.05) following covariate adjustment. Low SES was associated with poorer sleep quality and fragmented sleep, even after statistical adjustments. Perceived stress and financial strain attenuated SES-sleep associations indicating that psychosocial situations preceding pregnancy are also important to consider.