Treating Insomnia During Pregnancy Improves Bedtime Procrastination, Rumination, Anxiety, and Positive Affect: A Randomized Controlled Trial of Cognitive-Behavioral and Mindfulness-based Therapies for Prenatal Insomnia

ABSTRACT Study Objectives Insomnia is common in pregnancy and is associated with maladaptive sleep behaviors and poor emotion regulation. Cognitive-behavioral therapy for insomnia (CBTI) and Perinatal Understanding of Mindful Awareness for Sleep (PUMAS) are effective interventions for alleviating prenatal insomnia. However, clinical benefits outside the primary target of sleep remain unclear. This randomized controlled trial (RCT) explored the effectiveness of CBTI and PUMAS on bedtime procrastination, insomnia-focused rumination, anxiety, affect, and mindfulness. Methods Secondary analysis of a single-site, three-arm RCT of N=64 pregnant women with clinical insomnia who were randomized to CBTI, PUMAS, or sleep hygiene education (SHE). Outcomes included the bedtime procrastination scale (BPS), daytime insomnia symptom response scale (DISRS), generalized anxiety disorder-7 (GAD-7), positive and negative affect schedule, expanded form-modified (PANAS positive and negative affect), and five facet mindfulness questionnaire (FFMQ). Patients provided treatment feedback. Results CBTI and PUMAS were associated with large reductions in BPS (Cohen’s ds≥1.02) and medium-to-large effects on PANAS positive affect (Cohen’s ds≥.60). In a subsample of patients with anxiety symptoms, CBTI and PUMAS produced large anxiolytic effects (Cohen’s ds≥.92). PUMAS reduced insomnia-focused rumination relative to SHE (Cohen’s d=.71), whereas CBTI did not. We observed no significant effects on negative affect or FFMQ. Patients identified behavioral sleep strategies, meditation, and honoring pregnancy as particularly helpful. Conclusions CBTI and PUMAS yield clinical gains beyond the primary target of insomnia. These findings highlight the benefits of improving sleep quality for the betterment of overall maternal wellbeing, thereby strengthening consideration of CBTI and PUMAS as first-line treatments for prenatal insomnia. Clinical Trial Registration Improving Negative Stressful Perseverations in Insomnia to Revitalize Expectant Moms (INSPIRE). https://clinicaltrials.gov/study/NCT04445805, National Library of Medicine ClinicalTrials.gov Registry: NCT04445805