Share child night duty, prioritize sleep and be flexible about feeding. These and other tips can help increase maternal sleep.
When one of my pregnant patients started feeling depressed during her third trimester, we both wondered — was it time to start an antidepressant? Despite her history of postpartum depression, she had been feeling well. But for three weeks, she had been crying frequently and feeling guilty, impatient and less resilient.
Depression during pregnancy is one of the biggest risk factors for postpartum depression, so it was time to intervene. Before writing a prescription, however, I had one more question: How is your sleep?
Her answer: not good. She had started waking during the night as her body accommodated the growing baby. Her toddler had also started waking her, and she was having trouble falling back to sleep. “Does your husband ever get up with him?” I asked her. No, she replied, she felt bad asking.
Her husband was no slouch; she had simply not prioritized her sleep. When I framed sleep as an important intervention for both her and their baby, she was able to talk to her husband, which led to a remarkable improvement — the resolution of her depression.
“I’ve had a lot better sleep since our last appointment,” she wrote. “I was able to hand off almost all the night wakings. Marked improvement in my mood — not getting overwhelmed or sad as easily, feeling less stressed, and generally more myself.”
Research on the consequences of sleep disruption outside of pregnancy and postpartum is substantial and compelling: Acute sleep disruption can be disabling. It’s why we have hour restrictions for jobs such as flying airplanes, driving trucks and practicing medicine, where the consequences of insufficient sleep can cause harm. We also know that chronic sleep disruption takes years off one’s life, increasing the risk of diabetes, cardiovascular disease, strokes and cancer.
Risk of depression after pregnancy is high
During and especially after pregnancy, when a biological window of increased risk for depression opens wide, women suffer acute and chronic sleep deprivation that goes on for weeks, months and sometimes years, with a shrug, as if to say, “What can you do?”
Despite an increasing awareness of and recommended universal screening for perinatal depression, most women, their families and their physicians expect the perinatal brain to recover from mental illness while toxically sleep deprived. We prescribe helpful interventions such as therapy and medications but expect them to perform a miracle if we think they can pry the brain out from under the 10,000-pound elephant in the room.
That elephant is infant night feedings. If a mother is not depressed, or her infant starts sleeping in four- to six-hour stretches, then standard interventions for postpartum depression will, with any luck, work. If a mother, however, is at high risk for postpartum depression, or already depressed, and for some evil purpose, we wanted to provoke or sustain mental illness, a simple recipe of wake-ups every one-hour to three-hours overnight for weeks on end would suffice.
What of the reverse experiment? Could restoring postpartum sleep treat severe postpartum depression?
A study of brexanolone, the first drug approved by the Food and Drug Administration for postpartum depression, hints that it might. To join this double-blinded, placebo-controlled trial, severely depressed postpartum women had to give up breastfeeding for seven days and receive an intravenous infusion in an inpatient setting.
Some women got brexanolone; others got saline without the drug. All must have had supportive families who figured out how to care for an infant overnight. Brexanolone, rightfully, won the headlines for dramatically reducing depression scores in 72 percent of women in a mere 60 hours and sustaining this effect 30 days out.
Yet in the placebo group, where severely depressed women got nothing but an opportunity to sleep and then return home to family that had developed a strategy for feeding baby at night without mom, 55 percent of women felt better and stayed better 30 days later.
Could restored sleep swiftly and sustainably resolve postpartum depression? My patients have been proving the efficacy of this remedy for years.
These are my time-tested tips on how to increase sleep after delivery. They target the postpartum (the hardest time to get consolidated sleep) but also apply during pregnancy or toddler wake-ups.
Sharing child night duty benefits the whole family
If a partner or family member takes responsibility consistently for just one infant wake-up and allows a mother to sleep through it, so that she gets a four- to five-hour chunk of sleep plus another two- to three-hour chunk of sleep before or after, this sleep consolidation could allow her to recover from or prevent depression.
The partner can get two to three hours plus four to five hours of sleep and can continue to function, too. Here’s how it might work: Say the baby goes to sleep at 8:30 p.m. and wakes every 2.5 hours. If the mother goes to sleep at 8:30 p.m. and a partner does the 11 p.m. feeding, by 1:30 a.m., when the baby next wakes, the mother will have gotten five hours of sleep and can take over, allowing her partner to sleep from 11:30 p.m. until the morning. Taking shifts allows another person to become competent at soothing the baby overnight, improving bonding.
Prioritize sleep over everything else
A common objection to Tip No. 1: “I have so many things to do — the only time to do them is when the baby sleeps!” Protecting postpartum sleep will require sacrificing something. I find, however, that when women experience the benefit consolidated sleep brings, they become converts to the gospel of quality time as a non-depressed mother over quantity time living under the shadow of depression. It’s worth leaving dishes undone and boxes unchecked. Your family wants you to feel yourself again, not to do more at the cost of suffering.
Use a protected sleep room
The next objection to Tip No. 1 is something like: “I wake up anyway whenever the baby wakes up, so I might as well be the one to do the feeding.” I recommend the person “on duty” sleep in the same room as the baby while the person getting “protected sleep” hides in a quiet separate room. After their shift ends, have your partner come into the quiet room and turn on a monitor or leave the door open so that the next time the baby wakes, you can hear that you are now “on.”
Be flexible about feeding
Use whatever combination of methods is most protective of your health and your ability to bond and connect with your baby. Depression makes it hard to connect.
Tip No. 1 is not compatible with exclusive feeding at the breast every time. Having a loving person take over one to two feedings does not impair mother-baby bonding. Postpartum depression does. Use whatever combination of breast feeding, pumping and formula protects you and your baby together.
For women awakened by their milk supply coming in before four to five hours of consolidated sleep, consider pumping when awakened and then delaying pumping by 30 additional minutes every three nights. With time, you can train your body to allow one 4-to-5-hour gap between letdowns. Add a pumping or feeding session during the day if concerned about total quantity of milk.
Protecting postpartum sleep is hard
Give yourself and your family a chance to fail, learn and get better. Try different solutions for two weeks and then reassess and make changes.
Finally, we need to improve maternal sleep as a society. Shockingly, maternal suicide is a leading cause of postpartum death in the United States, and postpartum depression is estimated to cost $32,000 per untreated mother-child pair. Night doulas, paid leave or other support for single parents cost considerably less. Can we afford to not make the investment?
