Advancing Postpartum Sleep for Maternal and Infant Wellbeing
Duke Nursing faculty Bonnie Hepler and her colleagues emphasize the need for better postpartum sleep, starting in the hospital, for the wellbeing of caregivers and their infants.
The Need for Protected Postpartum Sleep
For newly postpartum parents, sleep is critical to the wellbeing of both themselves and their newborns—but unsurprisingly, it is often difficult to come by. School of Nursing Assistant Professor Bonnie Hepler, RN, MSW, MSPH, PhD, is using her research to advocate for protected sleep for birthing individuals and partners or caregivers, especially in those first crucial hours between birth and hospital discharge.
“No human can function well on 50 minutes of sleep in a 24-hour period, but that is all that some parents are able to get in the hospital after birth,” said Dr. Hepler. “And then they’re receiving vital information on postpartum and neonatal warning signs for health issues that can really go wrong—yet we know from the literature that, less than about four hours of sleep, people are not able to process information in a reliable way, which puts them and their baby at risk.”
Building on her dissertation research, which she conducted as a PhD student at Duke University School of Nursing, Dr. Hepler partnered with UNC-Chapel Hill faculty Kristin Tully, PhD, and Alison M. Stuebe, MD, MSc, to publish findings on inpatient postpartum sleep. Together, they analyzed video and audio recordings collected in 2020 through the Agency for Healthcare Research and Quality-funded Postnatal Patient Safety Learning Lab, documenting how much sleep patients got during the 24-hour period following childbirth before being discharged from the hospital. They found that the median amount of sleep during the observation period was only 2.8 hours over a 24-hour period.
Dr. Hepler and her colleagues found that many patients struggled to get to sleep due to physical and emotional discomfort, and that they were often woken by sounds from the newborn, their companion, health care team members, or the general environment.
“We showed patterns quantitatively, such as how much sleep they’re getting, who's waking them up, and what’s happening in their environment,” said Dr. Hepler. “But we also documented their stories, and the reasons why people struggled started to come to light, like undermedicated pain, shame around substance use exposure, or desperation when they were unable to console their crying baby.”
Dr. Hepler added that one of the primary predictors of long-term postpartum mental health disorders is not being able to get protected sleep, which in the postpartum period amounts to at least three to four consolidated sleeping hours plus additional small amount of rest. And while some interruptions are unavoidable, hospitals could help out in a number of ways—such as providing anticipatory guidance about sleep strategies, adjusting postpartum rounding schedules to avoid waking sleeping patients, and offering patients more autonomy and flexibility in the support they receive.
“Family-Friendly” and Holistic Postpartum Care
Hepler, who has two small children, draws from her own experience with early motherhood to inform her work. She also takes inspiration from her decade of research, prior to becoming a nurse, in the field of global maternal and child health, having witnessed communal practices of postpartum care in regions like the Middle East and sub-Saharan Africa.
“The focus in the US tends to be on pregnancy, labor, and birth, and then postpartum is an afterthought,” said Dr. Hepler. “As soon as birth occurs, the focus is on the baby, but the wellbeing of the parents is so intricately tied to the wellbeing of the infant—and the parents still matter as individuals, too.”
To that end, Hepler said she hopes to partner with the Baby-Friendly Hospital Initiative, a global program launched by the World Health Organization and the United Nations Children’s Fund, to encourage health facilities to make their breastfeeding support measures more compatible with protected sleep.
"The focus in the US tends to be on pregnancy, labor, and birth, and then postpartum is an afterthought. As soon as birth occurs, the focus is on the baby, but the wellbeing of the parents is so intricately tied to the wellbeing of the infant—and the parents still matter as individuals, too.”
~ Bonnie Hepler, Assistant Professor
“That initiative has done an incredible job at increasing lactation rates, but this has also meant that rooming-in—keeping the baby in the room with the mother throughout her stay—is a standard practice for baby-friendly hospitals,” said Dr. Hepler. One drawback of this practice within the current structure is that exhausted caregivers can feel “trapped in the room” with a crying infant with no recourse to sleep, especially if there are also policies against walking infants down the hallways so as not to disturb other patients.
“I’d love to partner with this initiative to think about: how do we build on this incredible work and make it more family-friendly? How do we ensure that the infant’s feeding cues are not being missed, but there are opportunities for caregivers to get sleep?” said Dr. Hepler. Access to infants within the room is one of the noted areas.
As Dr. Hepler continues this work, sleep is one of the interrelated components of her focus, which centers on postpartum care more holistically.
“This is about human dignity, and caring for one another in an incredibly vulnerable time,” said Dr. Hepler. “There’s going to be crying and tears, right? It’s postpartum. But these are the moments when people are forming their identity as caregivers, and they’re attaching a lot of meaning to it. I really want to help make this a kinder, gentler space.”