Translating Evidence into Obstetric Care: Developing a Best Practice-Informed Stepped-Care Clinical Algorithm for the Management of Gestational Insomnia

Background and Aims: Insomnia during pregnancy is potentially associated with adverse outcomes, including gestational diabetes mellitus, pre-eclampsia, cesarean delivery, preterm birth, and depression. This study aimed to synthesize available evidence on the management of gestational insomnia and develop a clinical algorithm to inform obstetric care practice. Methods: Based on the best available evidence, a clinical algorithm was developed as follows. First, a systematic search was conducted following the 6S evidence pyramid, including clinical practice guidelines, expert consensus statements, evidence summaries, and algorithms or decision aids published from database inception to January 2026. Second, four reviewers independently screened and appraised the literature. Third, two sleep medicine physicians extracted and synthesized the evidence using the JBI Grading of Evidence and Recommendation System. Finally, the clinical algorithm was constructed based on the synthesized evidence. Results: Nineteen publications were included, i.e., nine expert consensus statements, eight clinical guidelines, one clinical decision aid, and one evidence summary, from which 31 practice recommendations were derived. These recommendations fit within five key domains: (1) overarching principles emphasizing symptom control, stress management, and family support; (2) lifestyle-based interventions; (3) CBT-i and its digital delivery modalities; (4) pharmacotherapy; and (5) complementary and alternative medicine (CAM). Collectively, they create a stepped-care management pathway for gestational insomnia, beginning with lifestyle modifications, followed by CBT-i for patients with more severe symptoms (which can be supplemented by CBT-i Coach app to enhance self-management during treatment), and finally considers pharmacotherapy (at the lowest effective dose and shortest feasible duration) or CAM therapies (e.g. acupuncture) for women who respond poorly to psychotherapy or present with comorbid somatic/emotional disorders. Conclusion: This study proposes a stepped-care algorithm for managing gestational insomnia. As it is based on evidence synthesis rather than prospective clinical validation, its real-world effectiveness remains to be established. Furthermore, its implementation should be tailored to patient preferences and local healthcare resources to ensure contextual relevance and clinical feasibility.