“It’s Not All About My Baby’s Sleep”: A Qualitative Study of Factors Influencing Low-Income African American Mothers’ Sleep Quality

Abstract

Low-income African American mothers are at particular risk for poor postpartum sleep. This study sought to understand facilitators and barriers that exist to getting a good night’s sleep among these high risk mothers. Semi-structured interviews with 18 low-income African Americans (3–6 months postpartum) were conducted. Most mothers described their own sleep quality to be poor, despite the fact that their babies’ sleep improved substantially from the newborn period. Mothers kept themselves awake due to their own internal worry and anxiety, along with external factors that were largely independent of babies’ sleep, including work/school commitments and the home environment. For the few mothers with good sleep quality, time management and family support were strong facilitators. Findings lay the groundwork for sleep improvement interventions.

Introduction

The majority of mothers experience profound sleep disturbances in the first six months after childbirth (Kennedy, Gardiner, Gay, & Lee, 2007; Lee, Zaffke, & McEnany, 2000). Sleep becomes highly fragmented and inefficient in the early postpartum period (Montgomery-Downs, Insana, Clegg-Kraynok, & Mancini, 2010), characterized by three times the number of nighttime awakenings and twice the level of daytime sleepiness compared to what is experienced in pregnancy (Nishihara & Horiuchi, 1998). More than half (55%) of postpartum mothers report poor sleep quality and commonly describe symptoms related to insomnia, including taking greater than 30 minutes to fall asleep (12.3%) and waking during the night or too early in the morning (37.0%) (Mindell, Sadeh, Kwon, & Goh, 2013).

Low-income African American mothers are at particular risk for poor postpartum sleep. Studies repeatedly show that compared to individuals of higher income or other races, low-income African Americans are the most likely to get shorter, more restless sleep (Mezick et al., 2008; Pigeon et al., 2011; Jackson, Redline, Kawachi, & Hu, 2013; Whinnery, Jackson, Rattanaumpawan, & Grandner, 2014). In the postpartum period, ethnic minority socioeconomically-disadvantaged mothers are more sleep inefficient and have a greater number of postpartum night awakenings than mothers from predominately Caucasian socioeconomically-advantaged backgrounds (Lee & Gay, 2011).

While a number of studies suggest that babies’ sleep is the largest contributor to maternal fatigue and sleeplessness in the first few months postpartum (Hunter, Rychnovsky, & Yount, 2009; Kennedy, Gardiner, Gay, & Lee, 2007; Wambach, 1998), these investigations are limited by lack of socio-economic and racial/ethnic diversity along with the use of closed-ended questions that may inhibit mothers’ responses. Little is understood about the contextual factors and beliefs influencing low income African American mothers’ sleep quality. This information is imperative for developing effective interventions to improve postpartum sleep among these high risk mothers. As sleep disturbances after childbirth have been linked to maternal depression, lapses in cognitive functioning, and weight retention (Insana, Williams, & Montgomery-Downs, 2013; Park, Meltzer-Brody, & Stickgold, 2013; Swain, O’Hara, Starr, & Gorman, 1997; Siega-Riz et al., 2009; Gunderson et al., 2008), these interventions could have profound effects on maternal health and well-being.

The objective of this study was to understand how low-income African American mothers perceive the quality of their sleep in the early postpartum period, specifically focused on what facilitators and barriers exist to getting a good night’s sleep. We used qualitative research methods to explore our study objective because these methods provide rich information regarding how an individual’s frame of reference and social context influence health-related behaviors. These methods are meant to generate coherent theories or hypotheses about a phenomena that is not well understood (in this case, how low-income African American mothers’ perceive sleep quality in the early postpartum period) and are not meant to test specific hypotheses (Giacomini & Cook, 2000).

Methods

Study design and participants

We conducted semi-structured individual interviews with postpartum participants in 2011 and 2012. We targeted mothers that previously participated in a qualitative investigation exploring diet quality in pregnancy for enrollment into this study. Mothers were recruited from the waiting room of a single university-affiliated outpatient prenatal care clinic in Philadelphia, PA. Enrollment was restricted to those mothers who self-identified as African American, were at least 18 years of age, and received Medicaid (income proxy). A total of 24 participants completed the parent study. Recruitment details have been summarized previously (Reyes, Klotz, & Herring, 2013).

Between 3 and 6 months postpartum, these mothers were invited to additionally participate in the qualitative sleep study that is the focus of this article; 23 out of 24 mothers agreed to do so. Each participant provided written consent and was compensated for time/travel with $100 in cash. The institutional review board of Temple University approved the study protocol.

For the current analysis, we excluded mothers who had depressive symptoms (Edinburgh Postnatal Depression Scale scores > 9, n=5) (Cox, Holden, & Sagovsky, 1987), given the known relationship between depression and poor postpartum sleep (Hiscock & Wake, 2001; Park, Meltzer-Brody, & Stickgold, 2013). Thus, we were left with a final analytical sample of 18 participants.

Data collection

Postpartum interviews were conducted by two of the study authors (S.J.H. and N.R.R), both experienced in qualitative data collection with low-income women. Interviews lasted 60 to 90 minutes and were held in a private office near the mothers’ prenatal clinic. The interview guide and prompting questions were developed by the authors and informed by prior research in this area (Kennedy, Gardiner, Gay, & Lee, 2007). All study questions were pilot tested for clarity among a convenience sample of two low-income African American mothers.

Questions were divided into two broad categories: 1) sleep behaviors and 2) beliefs about sleep after childbirth. Sample sleep behavior questions included: “How has your sleep changed now that your baby is born?”; “Do you have a usual bedtime and/or wake time?”; “Do you have a specific routine before you go to bed? Has this changed since you’ve had the baby?” Sample sleep-related belief questions included: “How do you define a good night’s sleep?”; “What might stand in the way of you getting a good night’s sleep?”; “Do you feel like you have control over how much you sleep?” Specific probing questions, such as “Can you tell me more about that?” or “Can you help me understand that better?” were used to clarify participant responses and narrow the discussion. Sessions were audio-recorded and transcribed verbatim.

At the time of their interview, participants were also asked to complete a questionnaire assessing self-reported demographics, body weight, depressive symptoms (using the Edinburgh Postnatal Depression Scale) (Cox, Holden, & Sagovsky, 1987), maternal sleep quality (using the Pittsburgh Sleep Quality Index) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1988), and infant sleep problems (using the Brief Infant Sleep Questionnaire) (Sadeh, 2004).

Data analysis

Thematic coding and content analysis was performed using ATLAS.ti software (version 6.1, ATLAS.ti GmbH, Berlin, Germany). Following the review of the first three transcripts, two of the authors (D.N.Z. and S.J.H.) collaboratively developed an initial codebook that defined themes and was used to code the remaining transcripts. The codebook was then updated independently by the two authors using an inductive approach (Strauss & Corbin, 1998), as additional transcripts suggested new themes. The two authors met regularly to assess the level of concordance regarding emerging or new themes, review supporting comments, and check for completeness of the codes. Inter-rater reliability was assessed by calculating percent agreement of the matching codes between the two reviewers (Weber, 1990). Agreement was high (89%). Transcripts were coded and re-coded repeatedly until saturation of each theme was achieved. A third author (J.A.M.) provided input on combining similar themes into categories.

Results

Participant characteristics

On average, participants were 3.5 months postpartum (range 3 to 6 months postpartum) at the time of interview. The majority of mothers were multiparous (n = 15, 83%), overweight or obese (n = 17, 94%), and non-smokers (n = 14, 78%). Mean age was 24.8 ± 5.0 years. Over one third (n = 7, 35%) had not completed high school and more than half (n = 11, 61%) were unemployed. Only one mother reported that she exclusively breastfed her baby (the remaining participants [n = 17, 94%] fed their babies some combination of formula, breast-milk, and solid foods). Seventeen (94%) mothers reported they were single; however, all participants (n =18) lived with other adults or children (average number of persons in the home was 5). Almost all participants (n=16, 89%) slept in the same room as their babies (who most often slept in a crib next to mothers’ beds, n=15 [83%]). Even though 100% (n = 18) of mothers reported that their baby’s sleep was “not a problem at all”, and the majority described substantial infant sleep improvements from birth to 3 months postpartum (n = 13, 72%), mothers’ own sleep quality was poor (n = 15, 83%). Mean self-reported nighttime sleep duration was 6.6 ± 2.2 hours; mean sleep onset latency 27.9 ± 35.1 minutes. Two-thirds (n = 12) reported multiple awakenings at least one to two times per week. Less than 10% (n = 1) reported they had trouble sleeping because they snored or coughed loudly over the past month.

Themes

Ten themes emerged around internal and external barriers to and facilitators of getting a good night’s sleep. Internal factors were perceived as being under mothers’ control (e.g., psychological or motivational factors) and primarily influenced mothers’ ability to fall asleep. External factors were controlled by sources other than mothers (e.g., social or environmental factors) and most often influenced sleep maintenance or affected mothers’ bedtime and rise time. Overall, mothers perceived more barriers to (number of themes = 6) than facilitators of (number of themes = 4) getting a good night’s sleep. Themes and representative quotes supporting each theme are summarized below and in Tables 1 and 2.

Table 1.

Low-income African American mothers’ barriers to getting a good night’s sleep

Themes	Representative quotes
Internal Barriers
1. Worry and anxiety	“Sometimes I’m still laying there - like they [children] are asleep, but I still be laying there till 12 o’clock sometimes. I be so tired I can’t fall asleep or something. I be worrying about too much, most of the time.” “I’ll be dead sleepy, but my body just don’t permit me [to fall asleep], you know? And I guess it’s like, I have other things to do, and, you know, I just, I can’t relax enough… And then by the time I get to that point she’s [baby] awake again. So…” “Cause like when she [baby] goes to sleep, I don’t go right to sleep, because I always get the feeling she’s going to get up soon.”
2. Lack of bedtime routine/late bedtimes for mother and baby	“I don’t really have a routine. Usually, sometimes I just jump in the shower real quick. Then throw a robe on and that’s it.” “Um, shower. That’s basically it, shower [before bed]. We don’t really have no routine just yet” “We are late sleepers, so, usually, now it’s like 10:00, 11:00.”
External Barriers
3. Work or school	“I get about five hours of sleep a night. I have to get up at 5 am. I am so tired, but I manage to get up and I get myself clean and dressed first while my oldest one’s asleep, then I get them up, get them dressed, feed them, then out the door at 7:30 to get my oldest to daycare.” “Yeah, I have to get up early, my older son goes to preschool, I have to get him up and ready, you know, make his breakfast. And I’m in school also.” “I have a three-year-old, and he’s in preschool, so I have to get up early and get him ready.”
4. Household chores	“I don’t go down when she goes down. I go down about 11:00, 12:00, because once she lays down to go to bed, I’ll clean up, you know, if there’s something to be cleaned up.” “After she [baby] goes to sleep, I will straighten up the house a little bit, and then go upstairs and go to bed.” “I probably, I’ll be up. Washing clothes, getting uniforms together, ironing clothes… Cleaning the house, cleaning bottles, getting ready for lunch, making dinner. Just stuff like that.”
5. Television/electronics	“If I be, like, watching TV or something and it keeps going on commercial, I’ll just keep dozing off and then finally fall asleep.” “My TV helps me fall asleep. I leave it on. I fall asleep with the TV on.” “No, I don’t fall asleep right away. I’ll just lay there. Sometimes I’ll go on my phone on the internet.”
6. Other children disturb sleep	“She [my oldest child] normally wakes up at night. She’ll be screaming. I think she’ll be having nightmares. Like once a week she’ll wake up crying.” “I normally put him [my oldest child] in a deep sleep first, then I lay him in his bed. In the middle of the night, he’ll wake up and come back in in our room. And now it’s been harder since the baby’s here.” “The baby will wake up like two times… but then I have the 1 year-old, I can’t go to sleep because she’s running around so I got to keep an eye on her.”

Table 2.

Low-income African American mothers’ facilitators of getting a good night’s sleep

Themes	Representative quotes
Internal facilitator
7. Time management	“I would say try hard to get on a routine once you can. That’s basically it [to help get more sleep].” “I like to have everything organized because mornings are hectic so it makes it easier. Everything is organization, preparation, like that would be the best way for a mom to get her sleep.” “Once she [baby] gets into this wail I’m up and I got her. Most of the nights, I’m prepared, so I’ll already have a made bottle in her crib, so I don’t have to wait for anything. Everything just moves like clockwork.”
External facilitators
8. Family support	“And, to be perfectly honest, I may fall asleep around 8:00pm and I couldn’t tell you when she went to sleep because Dad is on duty…so, all I know is I wake around 1:30am for a feeding.” Oh, my mom watches my older daughter. She be with my mom every day, so that gives me [an opportunity for] nap time…my mom got her while I got the little one. “Oh, we [my boyfriend and I] switch. It depends on if I’m tired that day, then I’ll pretend like I don’t hear. So, he’ll get up…about 3 times per week.”
9. Baby consolidates sleep	“Now he’s [baby] sleeping more. He only really wakes up one time at night.” “Well, she’s [baby] sleeping through the night now. So, that’s good. She’s been doing that for two weeks now. Yeah, I’m getting more sleep too.” “Just between the end of two months and into three, she just started sleeping through the night, no problem.”
10. Baby learns to self-soothe	“Well, he’s a good baby. He really is, thank God for that. He don’t really keep you- he falls asleep quick [on his own].” “On the good nights I’m able just to put her in her crib and eventually the music or the lights will soothe her [and she’ll go to sleep on her own].” “He’s a good baby. He’ll wake up at like 12:30 and I just have to make his bottle, and he’ll go right back to sleep until the morning. Yeah it makes me sleep more too so, it’s really nice.”

Barriers to getting a good night’s sleep

Internal barriers

Mothers often (n = 10, 55%) shared that they were unable to fall asleep or get a good night’s rest because they were worried and anxious (Theme 1). Frequently this worry and anxiety was not about their baby’s sleep: “I can’t fall asleep until like 2:00, 2:30 every night, then I wake right back up at 6:00. I just can’t go to sleep because I will be thinking about stuff I have to do.” Much of this anxiety stemmed from multiple life stressors, such as unemployment, housing issues, or just having a new baby: “I’ve been looking forever for a job, so that’s what I’m doing now. I gotta have more experience, but I’m fresh out of school. How do you expect me to have experience if nobody going to hire me? I’ve been looking everywhere. I’ve been looking for anything that can pay the bills.” Another mother shared, “I’m in the process of looking for a job. I really, really need a job. In any field - whether it’s McDonald’s, anything.” Several mothers (n = 6, 33%) reported that if they tried to force themselves to go to sleep, they would be more anxious, further delaying their sleep time: “Sometimes [I have trouble falling asleep and feel like] I’m forcing myself to fall asleep because I know it is midnight, or it’s getting a little past midnight, and I will have to get up soon.” For a few mothers (n = 4, 22%), however, their worry was influenced by babies’ sleep habits. “I’m worried, yeah. ‘Cause I know how her schedule is and how stuff is already. So if anything changed [in the baby’s sleeping patterns] I would get up and see what’s wrong.”

Many mothers (n = 11, 61%) also lacked a routine before bed, which made it more difficult to fall asleep and often pushed their bedtimes well past midnight (Theme 2). These late bedtimes coupled with early morning wake times promoted shorter nocturnal sleep duration and daytime fatigue: “Well, I go to bed late. And now I don’t really get that much sleep I don’t think. I feel really drained, especially if I get less than 7 hours of sleep, like just really tired. Like today, when I was at work, I just felt like I was going to fall asleep standing up.” The lack of a bedtime routine was associated with later bedtimes for baby as well: “We don’t really have a routine just yet. She [my baby] just usually goes to sleep around like 9:00.” Some infants had even later bedtimes “She goes to bed around 10:00, 10:30. Another mother said, “He will go down 10 to 11.” Additional quotes are found in Table 1.

External barriers

Work or school commitments were perceived as strong external barriers to getting a good night’s sleep for many mothers (n = 12, 67%; Theme 3): “Well, I don’t think I really get that much sleep now because my new work schedule is so early in the morning.” These early rise times were often perceived as non-negotiable as work or school commitments couldn’t be adjusted: “I get home so late from work but I have to get up at 5am because my kids have school. I have to make breakfast and get them ready. So, I get about five hours of sleep a night. I am so tired.” However, going to bed earlier to increase total sleep time, was difficult for the majority of mothers (n = 10, 55%) given numerous household responsibilities (Theme 4): “After the baby falls asleep, I try to do little things that I can’t really do when I’m working. Probably like, making phone calls or washing clothes, stuff like that.” Mothers very rarely went to sleep immediately after their infants because that was the time when they felt the chaos of the day was gone and they could get things done around the house: “I guess it’s just my time where I finally can get things done, ‘cause I focus all my time on them during the day, so sometimes I just like to relax and catch one TV show, read a book, different things. And I make sure I clean before I go to bed. I try to wake up and have just everything cleaned… Yeah, I have to do everything at night, when they’re asleep.” Often, mothers felt alone in fulfilling these household responsibilities: “Even though my boyfriend is there, I have to do everything or it won’t get done - and I’m the only one that gets up during the night most of the time, not him.” One mother reported that she intermittently lived in a shelter due to financial constraints that fell solely on her shoulders.

Most mothers (n = 15, 83%) mentioned that they watched television or used other electronics before they went to bed or if they awoke during the night (Theme 5): “I would try to turn the TV on to fall asleep.” While the majority believed these electronic devices improved their sleep quality, these activities were often quite stimulating and instead prevented most mothers from falling or staying asleep: “Sometimes I fall asleep with it [TV] on, but when I turn the TV off, I actually can fall asleep pretty quickly.”

Mothers’ sleep quality was also affected by their other children and/or other adults in the home (n = 6, 33%; Theme 6): “A good night’s sleep would be my older son staying out of my bed. When he wakes up because of a bad dream or something he will come into my bed and he is a wild sleeper. After he falls back to sleep, I usually pick him up and put him back in his bedroom.” Other children often interfered with mothers’ rise times: “Once he [older son] gets up, he comes into the room. He’s like, ‘Mom, mom, mom!’ Even if his dad does get him dressed, he’s still in the habit of, ‘Mom! Mom! You want to eat?’ I’ll be like, ‘No.’ His dad will cook and get him dressed and brush his hair. He’s still, ‘Mom, mom! Bye, Bye!’ So, you’re like, ‘Okay, I’m up!’” Living with multiple other family/friends also disrupted many mothers’ sleep: “Sometimes if my television in my bedroom is off, I can still hear the TV downstairs because my brother’s a night owl, so he’s up like all night. He sometimes has it on extra loud and it interrupts my sleep.” Table 1 includes several other quotes describing external barriers to getting a good night’s sleep.

Facilitators of getting a good night’s sleep

Internal facilitator

For the few mothers who reported that their own sleep quality improved at 3 months postpartum (n = 3, 17%), time management played a key role in allowing mothers to experience a better night’s sleep (Theme 7): “You have to get them [baby and other children] on a schedule. You have to be organized.” Being scheduled and organized reduced the chaos and stress for these mothers so that they could relax and fall asleep more easily. A small number of mothers reported planning ahead and having feedings/meals ready for their children overnight so both mother and baby could quickly get back to sleep after night awakenings: “He’ll [baby] wake up, probably like about 12:00 or 1:00 and I’ll try to have all his stuff ready so he’ll fall back to sleep right away.” Table 2 details additional quotes related to this theme.

External facilitators

Family support was perceived as the strongest external facilitator of getting a good night’s sleep for many mothers (n = 12, 67%). Family played a critical role in helping mothers get to bed earlier and maintain a steady state of sleep during the night by alleviating much of the household responsibilities (Theme 8): “My mom, her uncles, my brothers were helping me, you know, as much as they could so I could go to sleep.” Family members also watched other children at home during the day so mothers could take naps, increasing mothers’ total sleep time: “Whenever she [baby] would take a nap I would usually take a nap. I had support from family; they would watch my son so I would be able to have the time to relax while she slept.” Most mothers (n = 11, 61%), however, described limited external support, promoting poor maternal sleep because of the numerous responsibilities that fell solely on mothers’ shoulders: “It’s hard trying to take care of the baby and my oldest son by myself. Like, trying to feed them both, watch them both, tend to both of them at the same time.” Another mother stated: “Me and my two kids live with my mom and sister. They will help me with them if I need it, but I don’t really like to ask for their help. I don’t just want to throw my baby off on them. My kids are my responsibility.”

Once the baby’s sleep consolidated around 3 months of age, a few mothers (n = 3, 17%) reported that they were able to get more sleep because their baby would sleep less during the day and sleep longer at night (Theme 9): “She’s [baby] gotten better. She doesn’t really wake up, like she wakes up probably twice a night.” Another mother shared: “I’m sleeping good, extra good now. She [baby] started sleeping a little longer. She just wakes up during the middle of the night like one or two times now.” For these few mothers, babies’ sleep played a pivotal role in improving their own sleep quality.

In addition, some mothers (n = 4, 22%) mentioned that their baby’s ability to self-soothe facilitated a better night’s sleep for both of them (Theme 10). “Yeah, he [baby] knows how to self-soothe. He’ll just wake up and open his eyes, turn, look, and close them back up…He’ll go right back to sleep. I’m so happy he does that. Sometimes he’ll wait for 10 minutes, but then he’ll go right back to sleep, and I don’t have to pick him up, soothe him, or give him a bottle or anything.” Another mother stated, “It’s like she [baby] doesn’t even need me. ‘Okay, you changed me and gave me a bottle. Alright, bye. I can do the rest on my own!’” The baby’s ability to self-soothe allowed these mothers to quickly go back to sleep and experience more consolidated sleep throughout the night. Table 2 contains more quotes describing external facilitators to getting a good night’s sleep.

Discussion

In this qualitative study of 18 low-income African American mothers, we found that most mothers described their own sleep quality to be poor at 3–6 months postpartum, despite the fact that their babies’ sleep improved substantially from the newborn period. Babies’ sleep was therefore not the primary barrier to getting a good night’s sleep. Rather, it was the mothers who kept themselves awake due to their own internal worry and anxiety, along with external factors that were largely independent of babies’ sleep patterns, including work/school commitments, household chores, the home environment, and television viewing. For the few mothers whose sleep quality improved by 3 months postpartum, time management and family support were strong drivers of a good night’s sleep.

While prior studies among similar populations are sparse, data consistently show that Non-Hispanic Whites get more and better quality sleep than Blacks (Mezick et al., 2008; Pigeon et al., 2011; Jackson, Redline, Kawachi, & Hu, 2013; Whinnery, Jackson, Rattanaumpawan, & Grandner, 2014). Much of the disparities in sleep quality are thought to be due to differences in socioeconomics – lower-income individuals are more likely to experience stress, work odd hours, or live in chaotic, noisy environments that may interfere with sleep (Friedman et al., 2007; Mezick et al., 2008). Not surprising then, is our finding that low-income African American mothers experience poor sleep in the early postpartum period that is largely independent of babies’ sleep patterns. Instead, internal (psychological) and external (environmental) factors associated with living in poverty and raising children - often multiple children - had the greatest influence over mothers’ sleep quality. Mothers’ distracting home environments, often chaotic and filled with multiple family/friends, were a symptom of mothers’ limited financial freedom and affected mothers’ bed times and sleep maintenance. Additionally, mothers’ in our study often felt alone in fulfilling financial or household responsibilities, despite living with several other adults in the home. This pressure to fulfill multiple roles, a pressure that is commonly reported among low-income women (Morris & Levine Coley, 2004; Rose Black, Mcbride Murry, Cutrona, & Chen, 2009), led to chronic worry and anxiety which significantly affected mothers’ ability to fall asleep at night. Doering (2013) found similar results when she explored the influence of the physical and social environment on low-income mothers’ sleep quality over the first 8 weeks postpartum. Factors such as emotional distress relating to work/family/relationship issues, television use, and environmental sounds strongly influenced socially disadvantaged mothers’ ability to get a good night’s sleep.

In addition to extending prior work linking the social environment to sleep and health (Grandner, Hale, Moore, & Patel, 2010), our findings lay the groundwork for interventions designed to improve the sleep quality of low-income mothers. Interventions focusing on skills training about time management, relaxation strategies, modifications to the home environment, and sleep schedules may enhance mothers’ sleep quality and have the potential to produce substantial physical and psychological benefits for both low-income mothers and their children. Involving family members in discussions around sleep is also essential, as family support was a strong facilitator of good sleep quality. For example, testing a strategy such as substituting televisions in mothers’ bedrooms for sound machines to mask home environmental noise or setting bedtime alarms to promote sleep schedules, with ample discussion among other household members about ways to promote these strategies and remedy barriers, may facilitate improved sleep quality among low-income mothers. Without family buy-in, modifications to the home environment may be difficult because of the inherent resource restrictions that low-income mothers face. Our results also suggest that health care providers may want to focus most of their sleep-related advice around mothers’ own internal and external issues, rather than on baby’s sleep.

Several limitations of this qualitative study should be considered. We focused on a small number of low-income, urban, African American mothers, who were recruited from one prenatal clinic, limiting our generalizability to mothers of higher income, rural surroundings, or different racial/ethnic groups. We had very few mothers in our sample who exclusively breastfed or were primiparous, variables that have been linked to poor sleep quality in prior studies, and thus, it is unclear whether our results apply to mothers who are not primarily using formula to feed their babies or to first time mothers. Our small sample size limited our ability to stratify analyses by feeding modality and parity. Nevertheless, many US cities have large numbers of low-income, African American mothers, similar to our sample, to whom our findings may apply. We also lacked a comprehensive assessment of sleep before and during pregnancy, and thus, we cannot be certain that the external barriers we found are unique to the postpartum period or persist chronically. Additionally, all mothers in our sample reported that their baby’s sleep was “not a problem at all” which may have introduced bias. We did not query mothers about alcohol consumption or illicit drug use which may be important confounders of the perceptions we found. Moreover, the vast majority of participants were overweight or obese, putting them at high risk for sleep disordered breathing, which may have affected mothers’ sleep quality. We did not ask mothers a standard questionnaire to screen for sleep apnea. However, only one mother reported she had trouble sleeping because she snored or coughed loudly over the past month (via the Pittsburgh Sleep Quality Index), and thus, there is a lower likelihood that sleep disordered breathing influenced our results.

Conclusions

In summary, our qualitative study uncovered many more barriers to than facilitators of getting a good night’s sleep. These barriers were largely independent of babies’ sleep. Given the paucity of qualitative work examining sleep behaviors and beliefs among low-income African American mothers, our study provides important insight into the facilitators and barriers that exist to getting a good night’s sleep in the early postpartum period. This information is critical to the design of effective interventions to improve sleep quality among low-income mothers, for whom the prevalence of disturbed sleep after childbirth is high. Interventions aimed at overcoming the obstacles we found to obtaining a good night’s sleep may improve low-income African American mothers’ sleep quality, and thus, lead to beneficial health outcomes for both mothers and their babies.