Sleep facilitators and barriers in gestational diabetes mellitus: a qualitative study

Abstract

Background

Sleep disorders can exacerbate abnormal glucose metabolism and increase the incidence of adverse pregnancy outcomes in women with gestational diabetes mellitus. However, data on sleep in gestational diabetes mellitus remain limited.

Objective

To explore the sleep facilitators and barriers in pregnant women with gestational diabetes mellitus to inform the development of interventions aimed at promoting maternal and child health.

Methods

This was a prospective qualitative interview study. Pregnant women with gestational diabetes mellitus who attended the obstetric clinic of a tertiary general hospital in Fujian Province from February 2024 to May 2024 were included. Participants were selected using purposive sampling and underwent one-on-one, semi-structured, in-depth interviews. Colaizzi’s content analysis method was used to identify themes.

Results

Eighteen participants were included in the study. Sleep facilitators and barriers in pregnant women with gestational diabetes mellitus were categorized into the following themes: 1. Disease effects; 2. Physiological and psychological changes during pregnancy; 3. Daily behaviors and environmental factors; 4. Family support; 5. Need for professional medical services.

Conclusions

Healthcare providers should consider enhancing sleep hygiene education and developing targeted interventions, such as relaxation training, based on the identified factors for patients with gestational diabetes mellitus.

Introduction

Gestational diabetes mellitus (GDM) is a condition characterized by an abnormality of glucose tolerance of varying degrees that is first detected during pregnancy [1] and is the most common metabolic disorder diagnosed during pregnancy [2]. According to the latest estimates from the International Diabetes Federation, GDM affects approximately 14.0% of pregnancies worldwide and impacts 20 million newborns annually [3]. A systematic review of 79,064 pregnant women revealed that the prevalence of GDM in China was 14.8% and has been increasing in recent years [4]. GDM increases the risk of prenatal and perinatal complications for mothers, including cardiovascular diseases, diabetes, obesity, and perinatal or postpartum depression [5]. Additionally, GDM can cause both short-term and long-term adverse health effects to the fetus. It can lead to conditions such as macrosomia, postnatal hypoglycemia, birth trauma, and shoulder dystocia, and it increases the risk of obesity and cardiometabolic risks in offspring during childhood and adulthood [6], thereby placing a heavy burden on China’s public health care.

Due to anatomical, physiological, pathological, hormonal, and psychological changes, pregnant women are prone to changes in sleep patterns and, in severe cases, sleep disorders [7]. Sleep disorders are defined as conditions in which normal sleep patterns are disturbed, affecting overall health, safety, and quality of life [8]. Na et al.’s research on Chinese pregnant women reported that the prevalence of sleep disorders in this population is 44% [9]. Peters et al.’s research on diverse populations found that about 50% of pregnant women with sleep disorders continue to experience these disorders up to two years postpartum [10]. Sleep disorders impair glucose homeostasis and metabolism through mechanisms such as dysregulation of energy balance, elevated oxidative stress, increased systemic inflammation, endothelial dysfunction, intermittent hypoxia, and activation of the hypothalamic–pituitary–adrenal axis [11], which, in the long term, increases the risk of GDM and preterm labor in pregnant women [12].

Recently, the impact of sleep on GDM has attracted widespread attention. The American Academy of Sleep Medicine (AASM) has developed scientific sleep guidelines [13] and collaborated with the Sleep Research Society to publish a sleep consensus. However, these guidelines only define regular nightly sleep duration and the adverse effects of sleep disorders on adults and adolescents in general [14] and lack specific standards for pregnant women. Given the importance of sleep in the health of patients with GDM, factors influencing sleep in these patients should be explored further, and sleep standards should be improved. Current studies on sleep in patients with diabetes have mostly focused on type 1 diabetes [15, 16]. A few studies have been conducted in women with GDM, but most of these have been quantitative studies using scales or questionnaires to investigate sleep patterns, sleep duration at different stages of pregnancy, and the risk of GDM [17,18,19,20]. However, it is difficult for such studies to comprehensively assess the experience of, and factors that promote and impede sleep in GDM from the perspective of pregnant women.

Therefore, we conducted a qualitative study aimed at exploring and analyzing the social, psychological, and physiological aspects of sleep among pregnant women with GDM, with the goal of providing a basis for the development of intervention programs to enhance sleep quality in GDM and to promote the health and quality of life of mothers and infants.

Methods

Research participants

This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Using a purposive sampling method, pregnant women with GDM who visited the obstetrics outpatient clinic of a tertiary general hospital in Fujian Province between September 2023 and April 2024 were selected for in-depth interviews. The inclusion criteria were as follows: (1) Age ≥ 18 years; (2) Diagnosis of GDM according to the diagnostic criteria of the International Association of Diabetes and Pregnancy Study Groups [21]; (3) Attendance at three or more prenatal visits at the obstetrics outpatient clinic; (4) Provision of informed consent and voluntary participation in this study; and (5) Good language expression and communication skills. Patients with psychiatric diseases, cognitive disorders, or serious comorbidities were excluded. Researchers could access detailed medical records of each patient and screened patients who met the research criteria through the specialized electronic medical record system at the obstetrics outpatient clinic. Two members of the research team independently reviewed the medical records to verify eligibility based on the inclusion criteria. Any discrepancies in their assessments were resolved through discussion or consultation with a third senior researcher. The screening was conducted for those who met the International Association of Diabetes and Pregnancy Study Groups’ OGTT diagnosis criteria. Pregnant women with GDM between 24 and 38 weeks of gestation were included in this study for interviews, which helped investigate the sleep experiences of GDM pregnant women at different stages of pregnancy. In combination with maximal variation sampling, demographic factors such as age, education, occupation, and other relevant characteristics were taken into account to ensure the representativeness of the study population.

The sample size was determined by saturation of the interview information. Data saturation was assessed through an iterative process of data collection and analysis. During the interviews, we continuously compared new data with previously collected data to identify recurring themes and patterns. Saturation was considered achieved when no new themes or insights emerged from three consecutive interviews. After saturation was reached, four additional pregnant women with GDM were interviewed to ensure the comprehensiveness of the data.

Ethical statement

The study obtained written consent from the pregnant women and was approved by the Ethics Committee of the Second Affiliated Hospital of Fujian Medical University (approval number: 2024 (153); approval date: February 27, 2024).

Research method

After conducting a thorough literature review and aligning with the objectives of our study, we developed an initial interview outline. Our team, consisting of six obstetric healthcare professionals, collectively discussed and revised this initial outline. Two of the six obstetric healthcare professionals involved in this study hold certifications in psychological counseling and have substantial experience in addressing the psychological and emotional needs of pregnant women, including those with GDM. Following the revision, we proceeded to conduct two rounds of pre-interviews with patients using the updated outline. Based on the feedback from these pre-interviews, our research team further modified and reviewed the outline, ultimately arriving at the final version. The final outline was as follows: (1) What changes in your sleep have occurred since the diagnosis of GDM? (2) How is your sleep? (3) What factors promote sleep? (4) What factors hinder sleep? (5) If you have sleep problems, what measures have you taken to improve your sleep? (6) From what channels would you like to receive help?

Data collection

Data were collected through semi-structured interviews. Prior to the interview, we communicated with the pregnant women to explain the purpose, significance, and main content of the interview, agreed on the time and place of the interview, and prepared the interview tools. We obtained consent from each research participant and selected a time when they were available to conduct face-to-face semi-structured interviews. The interviews were conducted in a quiet classroom within the hospital that was designated for health education.

The duration of the interview was 20–60 min, and the entire interview was recorded with the consent of each pregnant woman. This study was conducted by two researchers (both female and holding a master’s degree) who obtained consent from the research subjects before proceeding with the interviews and audio recording. One of the researchers was responsible for using a well-functioning recording device to capture the interviews and for documenting the subjects’ non-verbal behaviors (such as laughter, silence, contemplation, gestures, etc.) with pen and paper. The other researcher conducted the interviews following the interview protocol.

Two researchers who have long been involved in qualitative studies on GDM in the obstetrics outpatient department and are responsible for prenatal checkups for some pregnant women have established a very familiar and trusting relationship with GDM patients. This relationship facilitates in-depth interviews and discussions about factors that promote sleep and obstacles that hinder sleep. However, to effectively ensure the principle of voluntary participation, the GDM participants included in this study were not patients of the researchers. During the interviews, researchers focused on listening to the participants, avoiding leading questions, and refraining from making right or wrong or tendency judgments of the interview content. They also avoided interrupting unnecessarily, recorded key information, and documented pregnant women's non-verbal behaviors, such as expressions, body language, and tone of voice.

Data analysis

Within 48 h after the end of the interview, the two researchers used a system to automatically transcribe the recordings. Then, they manually reviewed the transcribed text against the audio recordings, word for word, and marked the non-verbal actions of the research participants (such as laughter, silence, contemplation, and gestures) recorded during the interviews in the relevant sections. If there was any uncertain or ambiguous information in the transcription, they promptly communicated with the research participants to confirm and clarify. After the transcription was fully completed, they once again checked with the research participants to ensure the final transcription text was accurate.Two researchers conducted data analysis and completed multiple rounds of thematic refinement. Subsequently, a team of six experts discussed and modified the themes and coding. The coding and interview results were then presented to the research participants to ensure consistency with their interview content and to confirm the final themes. Colaizzi’s content analysis method [22] was used to refine the themes and codes, following these steps: (1) reading the interview data; (2) extracting meaningful statements; (3) refining the meanings; (4) forming thematic clusters; (5) linking the themes to the research phenomenon to provide a complete narrative; (6) summarizing statements constituting the essential structure of the phenomenon; and (7) seeking confirmation of the authenticity of the results from the interviewed pregnant women.

To ensure trustworthiness, member checking was conducted by sharing the transcribed data from interview recordings and non-verbal behavior records with participants to confirm whether these accurately expressed their intended meanings. Dependability was ensured through detailed documentation of the research process, and confirmability was supported by team-based data analysis involving six experts.

Acknowledging that researchers’ backgrounds and experiences may influence the study, we have strategically leveraged our team’s expertise—including years of GDM-related research experience and the psychological counseling certifications held by two members—to inform the study design, interpretation, and overall validity. To minimize bias, we held regular team discussions to critically examine our perspectives, ensuring the findings authentically represented participants’voices.

Results

General information of pregnant women

Eighteen women were included in this study. Their general characteristics are shown in Table 1. Our research team screened potential participants through the specialized electronic medical record system at the obstetrics outpatient clinic. A total of 21 pregnant women with GDM met the inclusion criteria and were invited to participate in the study. Among these, 18 women agreed to participate, while 3 women declined due to a lack of interest and privacy concerns. The consent rate was 85.71% (18 out of 21 eligible women).

Table 1 General information of pregnant women (N = 18)

Themes

Theme 1: Impact of illness on sleep

Impact of psychological changes on sleep after the diagnosis of GDM

Pregnant women demonstrated different levels of ascribed importance, cognition, and acceptance after receiving a GDM diagnosis, accompanied by the emergence of various emotions. Our study found that a positive mood promotes sleep and improves sleep quality, while anxiety and other negative emotions act as barriers to sleep. And the ability to regulate negative emotions is a key factor in maintaining good sleep. According to one participant, “The day I was first diagnosed, I was so anxious that I couldn't sleep and kept thinking about it.” (P18) Another woman recounted: “My blood sugar was also a little bit high with my first child, and when I was diagnosed during pregnancy with my second child, I felt as if it was nothing, I just went with the flow, and I did not have trouble sleeping at night because of the diagnosis.” (P11) One participant shared: “I also get anxious when my blood sugar is unstable. I looked for some ways to control sugar on the Internet, and now I do not worry, and the quality of my sleep is a little bit better after I understood it.” (P09).

Impact of blood glucose fluctuation on sleep

Based on the experiences shared by participants in this study, blood sugar instability in some pregnant women can lead to negative emotions before going to bed, which can also change their physical state and affect the quality of sleep. As one woman put it, “When my blood sugar is higher, I feel that my whole body is more constrained; I feel as if my whole being is very bulky and heavy. When I try to sleep, I experience some difficulty breathing, which makes it hard to fall asleep.” (P15).

Theme 2: Impact of physiological and psychological changes in pregnancy on sleep

Impact of physiological changes in pregnancy on sleep

The study participants believed that the anatomical, physiological, and pathological changes they experienced during pregnancy could affect their sleep patterns and even cause varying degrees of sleep disorders, including insomnia and sleep disruption. Among these changes, frequent urination due to the enlarged belly in the third trimester, the need to change sleeping positions multiple times during the night, and pubic bone pain were identified as significant factors hindering sleep. One participant’s experience illustrates this point: “My belly is bigger, and sleeping is not so comfortable. I roll over, I urinate more frequently at night, and I feel that maybe my sleep is not as good as it used to be.” (P11) Reflecting on her experience, one interviewee said, “I recently have been experiencing pubic bone pain at this stage, and having to roll over constantly makes me sleep poorly.” (P04).

Effects of psychological changes in pregnancy on sleep

Participants in this study reported that anxiety about postnatal life, childcare, body changes, etc., tends to occur in the third trimester of pregnancy due to the proximity of labor, which can significantly impede sleep. The emotional impact was evident in one participant’s words: “It's just that I'm going to give birth soon, and now I have a little bit of that prenatal anxiety, and I sleep intermittently because I'm afraid of it.” (P16) Another participant highlighted her perspective: “The reason I was having trouble falling asleep earlier was because of my fear of life after giving birth.” (P18).

Theme 3: Impact of different daily behaviors and environment on sleep

Daily habits

According to the participants’ accounts in this study, bad habits such as waking up to use electronic devices before or in the middle of sleep, staying up late to play mahjong, having too many late-night snacks before going to bed, taking too long a lunch break, drinking milk tea, and eating fast food may impair sleep quality of pregnant women with GDM. Conversely, they noted that activities like fitness exercises or walking and other sports, listening to music before going to bed, soaking the feet, wearing a steam eye mask, drinking hot milk, and providing psychological suggestions can promote better sleep health. In the words of one respondent, “I sleep too much during my lunch break in the daytime, and I get too caught up watching TV dramas before bedtime (playing with my cell phone), so I cannot sleep at night.” (P14) One participant explained: “I walk for an hour after eating and I feel that I sleep better when I am tired from walking.” (P15) One interviewee mentioned: “I usually listen to some meditation music before bed … Then, after soaking my feet and using a steam-eye mask, I feel much better.” (P18).

Work

The pregnant women interviewed believed that work had a significant impact on sleep, particularly when work was not completed or when they worked late. These factors often led to a poor emotional state and reduced sleep quality, whereas engaging in more time-consuming tasks during the day or working from home could enhance sleep quality. One participant’s response revealed her coping mechanism: “If I don't do something on any day, then it might be on my mind, and I keep thinking about how to explain the plan. So, I usually complete my work on the same day, which makes me feel more at ease before going to bed.” (P08) Another individual expressed: “When I'm more tired from work, I do sleep quite well.” (P06).

Dream changes

Participants in this study described how the frequency of dreams and the occurrence of nightmares could make patients with GDM wake up frequently at night. They were unable to fall asleep quickly after waking up, and this could even affect their mood and quality of life the following day. One woman’s experience was particularly telling: “If you have some nightmares …… you wake up suddenly, and you feel like you cannot fall asleep again.” (P13) A respondent noted: “ In late pregnancy, I often have nightmares,so I will wake up scared. Then, I comfort myself and go back to sleep.” (P18).

Environmental changes

As reported by participants in this study, changes in environmental factors, such as excessively high temperatures, high humidity, and bright lighting, can significantly disrupt sleep in pregnant women with GDM. Conversely, they found that a comfortable temperature, moderate humidity, dim lighting, and a quiet environment promoted better sleep. A participant elaborated: “I cannot sleep well if the humidity is too high on days with a southerly wind.” (P16) One woman’s account captured the environmental challenges::“I'm sensitive to light and sound, so I need blackout curtains……. because that way I fall asleep a bit faster.” (P18).

Theme 4: Impact of family support on sleep

Husband support

Pregnant women indicated that having a husband with them before bedtime can promote sleep, but if the husband has a habit of staying up late, waking up early for work, snoring, or arguing with them, it can become a barrier to sleep. One participant reflected: “It is all about my husband accompanying me to go for a walk together, and if he has the time, I go; if not, I stay by myself in the house lying on my bed, unable to sleep. Sometimes, when I argue with my husband, I get angry and end up playing on my phone until I fall asleep.” (P16).

Child support

Participants in this study mentioned that while having children nearby could improve their sleep, concerns about their children’s schooling or health, such as catching a cold at night, often negatively impacted sleep quality. Reflecting on her experience, one participant noted,“My child has just started first grade, which is also a very new stage for him, and it makes me worry so much that I can’t sleep well… But, every time I sleep with my son, I am very happy and can sleep more soundly.” (P14) As one participant described it: “Now that it is winter, I am afraid that my older childwill be cold. Occasionally, I will wake up to cover him with a quilt. My sleep is not so deep, it is a bit shallower.” (P12).

Theme 5: Demand for specialized medical services

Healthcare professionals'attention and guidance

According to the participants’ feedback in this study, healthcare professionals often pay little attention to and provide limited education on sleep-related issues for women with GDM. One participant explained: “The doctor's advice is mainly about controlling blood glucose and exercising, but sleep is rarely mentioned.” (P15) In her own words,“I usually tell the doctor that my blood sugar is a bit high, and he advises me to control it, but he doesn’t mention how to pay attention to sleep.” (P16).

Inadequate allocation of medical resources

Pregnant women with GDM should have access to comprehensive healthcare services to ensure safe delivery. When labor was imminent, the limited availability of hospital beds and the fear of not having a bed negatively affected participants’ sleep quality. One participant described: “But I am more worried now before I go to bed because I often see people saying that there are no beds in the hospital, and I get more scared.” (P16) Pregnant women also mentioned that the hospital had a limited number of daily registration slots, and they needed to secure these in advance every morning, which led to worsened sleep quality and a poor mental state the next day. One participant recounted her experience: “I often had to get up at 7 a.m. to book the hospital's appointment during that period. I wake up very early, feeling dizzy the next morning as if my whole body has been beaten.” (P18).

Discussion

Our study contributes to the evidence related to sleep in participants with GDM and provides a scientific basis for the development of intervention strategies to improve sleep quality by analyzing the factors that facilitate or hinder sleep in this population. The level of awareness, acceptance, and perceived importance of post-diagnosis glycemic management of GDM varies widely among pregnant women. This may be because some pregnant women have better psychological resilience, including optimism, cognitive flexibility, and high coping self-efficacy, which enable them to adapt positively to identity changes after diagnosis, maintain positive emotions, and achieve good sleep quality.

Among study participants, we found that sleep was primarily influenced by physiological changes during pregnancy, daily behavioral habits, environmental factors, family support, and blood sugar fluctuations. As these women were in the special physiological stage of mid-to-late pregnancy, their sleep patterns were affected by frequent urination and pubic bone pain. In addition, some pregnant women were aware that blood glucose fluctuations cause discomfort and reduce their sleep quality. A study by Tiwari and colleagues [23] also showed that blood glucose stabilization is beneficial for sleep. Poor lifestyle habits before bedtime, such as staying up late, using electronic devices, drinking milk tea, eating too many late-night snacks, and playing mahjong, were identified as barriers to sleep, while the opposite was true for healthy sleep habits (HSHs), such as walking, listening to meditation music, soaking their feet, and using a steam eye mask. In current sleep research, there is less focus on GDM in pregnant women compared to other types of diabetes.Vézina-Im et al. [24] used open-ended questionnaires and qualitative studies to compare the perceptions of adults with and without diabetes regarding HSHs, and found that participants believe that HSHs can improve sleep, including avoiding electronic device use in bed, seeking social support, maintaining regular time management, etc. Our study suggests that some women with GDM also perceive these HSHs to be helpful in improving their sleep. In addition, our research participants reported that walks with their husbands and bedtime routines with their children contribute to more restful sleep for pregnant women.This may be because family members spend more time supporting each other in this way, and facing difficulties together may contribute to reducing emotional stress and enhancing psychological resilience among pregnant women. Timm et al. [25] also found that pregnant women felt that their partner’s motivation for behavioral changes, such as dietary changes and exercise, was beneficial for improving their quality of life. A cohort study of two ethnic groups showed that pregnant women with low levels of partner support experienced higher levels of prenatal anxiety, depression, and smoking, indicating that partner support may improve the emotional well-being and health behaviors of pregnant women [26].Therefore, women with GDM should actively cultivate more HSHs, and partners should provide sufficient family support whenever possible. Good behavioral habits of family members can indirectly influence pregnant women's behaviors and moods, and the beneficial effects on both sleep and blood glucose levels cannot be ignored.

We further analyzed the reasons for altered sleep quality due to barrier factors in GDM. These factors may elevate the level of perceived stress, leading to the development of negative emotions, such as anxiety, which in turn increase the frequency of dreams, particularly nightmares [27] and contribute to insomnia in pregnant women, resulting in sleep disorders. Ko et al. [28] confirmed that perceived stress can alter the quality of sleep. When stress activates cognitive–emotional activity, negative emotions, such as anxiety, are more likely to occur, which in turn increases the sensitivity of the sleep system, leading to nighttime awakenings and reduced sleep quality. This may be related to the hyperactivity of the hypothalamic–pituitary–adrenal axis and an increased cortisol arousal response [29]. In contrast, pregnant women with anxiety disorders are 2.855 times more likely to develop sleep disorders than those without anxiety [30]. A systematic review indicates that, compared to healthy pregnant women, pregnant women with GDM experience greater psychological stress, such as depression and anxiety [31]. Therefore, controlling and reducing stress to alleviate anxiety in GDM patients may be an effective way to improve sleep quality.

While physiological and psychological changes, daily behaviors and environment, and family support are important considerations for all pregnant women, these factors may take on heightened significance and could manifest uniquely in women with GDM. Our study suggests that GDM may potentially amplify the impact of these factors on sleep quality due to the additional burden of managing the condition. Physiological changes could be exacerbated by the physical demands of blood glucose control, while psychological stress might be intensified by concerns over fetal health and potential complications. Daily habits may become more critical as strict dietary and exercise regimens need to be maintained, and environmental sensitivities could be heightened. Furthermore, family support might play a particularly crucial role, as women with GDM often require additional assistance in managing their condition while balancing childcare responsibilities. These potential unique manifestations could underscore the need for targeted interventions addressing the specific sleep challenges possibly faced by women with GDM.

Current evidence on sleep interventions for GDM is extremely limited. The AASM recommends that clinicians select specific behavioral and psychological therapies for the treatment of chronic insomnia in adults [13]. Among these, Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia in adults. It includes sleep hygiene education, relaxation therapy, cognitive therapy, sleep restriction, and stimulus control [32]. Kyle et al. [33] conducted a randomized controlled trial in adults with sleep disorders, comparing the intervention effects of CBT-I and sleep hygiene education after 6 months of intervention, using the Insomnia Severity Index. They concluded that the treatment effect of CBT-I was more pronounced. Scholars have conducted relaxation training for pregnant women without GDM and found that it can improve sleep during pregnancy [34]. This approach could potentially be applied to GDM in the future to track both immediate and long-term effects. It has been suggested that pregnant women may benefit from relaxation training, as they often experience worrying thoughts, which can prevent them from achieving sufficient relaxation to fall asleep and disrupt their circadian rhythms [29]. A systematic evaluation showed that relaxation training can influence the physiological and psychological stress systems of pregnant women and help reduce stress and anxiety [35].Abbreviated progressive muscle relaxation (APMR) works by systematically tensing and relaxing 16 muscle groups to induce deep relaxation. It enhances the activity of the parasympathetic nervous system, reduces the excitability of the cerebral cortex and central nervous system, decreases oxygen consumption and cortisol secretion, and promotes the anabolism and secretion of hormones related to the anti-stress response. This, in turn, reduces an individual's stress response and increases positive emotions [36]. APMR may be an effective strategy for improving sleep in women with GDM, who represent a medium- to high-risk pregnancy group with heavier psychological and physical burdens compared to healthy pregnant women. Additionally, interventions should be targeted and designed based on sleep-facilitating and sleep-disabling factors.

The education provided by medical staff during prenatal checkups for women with GDM seldom includes sleep health education or specific guidance on measures to improve sleep. Sleep disorders can disrupt glucose homeostasis by increasing oxidative stress, systemic inflammation, and endothelial dysfunction [37], thereby exacerbating preexisting metabolic abnormalities in GDM. Consequently, for women with GDM, maintaining good sleep quality is a crucial factor in effective glycemic management.

Rezaei et al. [38] showed that sleep health education can improve sleep quality in pregnant women. In 2020, it was estimated that over 2 million pregnant women in China were diagnosed with GDM. Providing scientific and effective management guidance for this large population of pregnant women with GDM in China remains a challenge for healthcare professionals [39]. For both pregnant women and clinicians, sleep disorders can be easily overlooked but are also treatable.Therefore, healthcare professionals should place greater emphasis on sleep during antenatal counseling and healthcare services. Individualized management and guidance for GDM could be provided by establishing a public GDM telephone hotline to disseminate knowledge about self-management, forming multidisciplinary teams, organizing offline and online healthcare consultations for follow-up supervision and management, and launching nutrition clinics. Enhancing sleep health education for pregnant women and their families, creating comfortable environments, and improving the sleep quality of pregnant women may contribute to reducing the occurrence of adverse pregnancy outcomes for both mothers and infants.

Limitations and future research directions

The participant sample included in this study was recruited from only one tertiary general hospital, which may limit the generalizability of the findings. A multicenter, large-sample study should be conducted to validate the influencing factors. In addition, although this qualitative study collected limited data for a quantitative assessment of causality, it could provide a foundation for future quantitative or clinical trials to incorporate objective indicators of sleep and glucose management in patients with GDM. In the present study, patients with GDM were more likely to identify facilitators and barriers to sleep, most of which represent potential targets for intervention. These findings may guide future sleep hygiene health education and behavioral interventions aimed at improving sleep as well as promoting maternal and child health.

Conclusions

The facilitators and barriers to sleep in GDM include disease effects, physiological and psychological changes during pregnancy, variations in daily behaviors and environments, family support, and the need for specialized healthcare services. Patients with GDM should develop good HSHs to enhance their sleep quality. In addition, the effects of interventions such as APMR on sleep quality and health indicators, including blood glucose, should be evaluated.