The sleep prescription
an enticingly unattainable remedy for better health?
“Just telling a mother to sleep is as ridiculous as telling her to fly. Protecting her sleep requires challenging deep cultural and structural factors, both within families and within the medical establishment.” – Leistikow et al. 2022
I always thought that sleep disruption in the third trimester of pregnancy was the cruelest irony. Repeatedly hearing “better get your sleep before the baby comes!” lands in that special part of the brain that makes the heightened sensitivity towards wakefulness in this stage especially frustrating and stressful. Add in the discomfort of existing in a lopsided body that does not appreciate the usual sleep positions with the constant reminder that the most logical position – back sleeping – is ‘dangerous for the baby’.
Now that I have children old enough to sleep through the night but I still find myself wide awake at 3am, I realize, this is the cruelest irony. The frustrating alignment between finally settling into a sleep routine that does not revolve around small children – not having to wake up for a hungry baby or a potty training crib jumper or a night time wanderer who always ends up squeezing their way in to heat up your coveted nighttime space – and living in a body firing up the next phase of physiological changes that fuel all new drivers of sleep disturbance.
Ah yes, fun times cruising into perimenopause – when sleep disruption tends to spike between 3am and 5am. Hours that are important for deep sleep. Hours that are important for immune health. Hours that are most important for healthy aging. The hours that seem to pop up as the key to everything when anyone talks about the importance of sleep1.
Can you sense my stress levels spiking just wrapping my head around the narrative we are fed on the importance of sleep as someone having trouble getting through the night?!
Of course, as a 43 year old in a cycling body, my assumption (based on the explosion of perimenopause content I am getting fed right now) is that this version of sleep disruption is an early indication that my body is in a transitional state. But that might not even be at the root of it. It might just be stress. Or motherhood. Or a brain over-tuned to things going bump in the night. Or being a logical human in an illogical point of American history. Or a jumbled mess of all of it.
Sleep and stress have a bidirectional relationship. Stress affects sleep. Sleep affects stress. Physiologically and emotionally. Sleep is a key recommendation for decreasing stress load. And decreasing stress is a key recommendation for improving sleep quality.
Like stress, sleep disruption is generally accepted as a part of life, a part of parenting, a part of motherhood, a biological repercussion of the physiological changes in a cycling body. But there is little to no research to understand exactly how, or even which, physiological changes are responsible for sleep disruption across the female reproductive lifespan.
Like stress management recommendations, sleep hygiene advice falls into a similar narrative trap. Good ‘sleep hygiene’ revolves around the frustrating reminder that sleep disruption is your problem to fix. The world will acknowledge that you have a lot on your plate that increases your stress load and affects your sleep but skips right over that and points out how fixing it is your problem alone.
For example, from the NIH:
“The years of the menopausal transition are often a time when there are other changes in a woman’s life. You may be caring for aging parents, supporting children as they move into adulthood, taking on more responsibilities at work, and reflecting on your own life journey. Add symptoms of menopause on top of all this, and you may find yourself having trouble sleeping at night.”
This acknowledgement is followed by the usual advice – follow a sleep schedule, turn off devices, exercise during the day (not close to bedtime!), don’t drink caffeine or alcohol.
What about the woman who pushes her computer-based work hours into the cracks of early morning or late nights because she is taking on a bulk of family caregiving or child care during the day?
What about the exercise gender gap? Or the more general gender time gap that disproportionately restricts access to the tools for better sleep?
What about the disproportionate emotional weight or cognitive load related to the “children moving into adulthood” or the “caring for aging parents” that tends to fall onto women?
We don’t actually know all that much about the physiological changes during the menopause transition to link stress and sleep and health. But, sure, blame hot flashes and hormones and skip over everything else2.
The NIH post is careful to point out that “there are other changes in a woman’s life” before it launches into general sleep advice but does it have a similar tee up for information about sleep and men’s health or at least in a post on aging and sleep in general? Nope. Searching the NIH site for “sleep and aging” does not bring up a complimentary post and searching for “sleep and men’s health” surfaces exactly ZERO articles on that specific topic.
As already noted, despite acknowledging how the outside world could affect women’s sleep, the sleep recommendations fall into the same trap as stress and stress management – sleep is considered an individual problem with individual solutions.
This is false logic.
We need to flip the narrative and discuss protecting sleep as part of the strategy. Starting in the earliest days…
The sleep prescription for postpartum depression (and other mental health disorders)
In a 2022 Commentary piece in Biological Psychiatry, Dr. Leistikow and colleagues examine the connections between sleep and postpartum depression with a revolutionary idea – the key to improving maternal sleep does NOT need to revolve around controlling the baby OR around the mother “sleeping when the baby sleeps”. The most impactful intervention is maternal sleep protection.
I wrote about this solution in relation to the stress of breastfeeding:
The path towards maternal sleep protection in the postpartum period requires solutions that exist beyond the lactating parent. It requires a narrative shift. It requires spreading out nighttime responsibilities. It requires resetting how we think about the priorities in our home, in relationship dynamics, and in our baby-feeding preferences.
In many ways, the connections between breastfeeding and PPD is a good example of how a sleep prescription matches the perfect storm of a gendered problem with a perfect solution to improve women’s health.
Breastfeeding is intertwined with gendered expectations. Psychologically, the “good mother/bad mother” narrative has permeated the “breast is best” discourse, fueling the guilt and shame related to feeding decisions with the perception of ‘failure’ (when breastfeeding plans go off course) likely adding to the stress load. When exclusive breastfeeding requires the lactating parent to take on 100% of wake up duty3, it also reinforces the assumption that only mom can feed the baby, which can result in mom being the one who wakes up at night4. For home (and work) dynamics there is a subtle acceptance that mom is the one who can afford to be tired during the day. Discrepancies in paid parental leave (especially for fathers) further fuel the gender divide – “his sleep is more important because he has work in the morning…”. This mentality can stick even if/when both parents are back at work5.
The sleep prescription is a perfect solution when it comes to PPD because the benefits of improved sleep for the mental health of the postpartum parent are exponential. The peripartum period is a sensitive window – physiologically and psychologically – and reducing the exposure to and the impact of stress is especially critical and impactful. Of course, now we’re right back where we started – sleep buffers stress, stress disturbs sleep, and round and round we go. Not surprising, early research on programs aimed at protecting maternal sleep has shown decreases in PPD symptoms.
Now - how do we make this case for the sleep prescription? More broadly – how do we change the dialogue to “YOUR sleep is most important because of YOUR health!”?
A great example of the sleep prescription in action comes from
and her story about receiving a sleep prescription for managing bipolar disease during and after pregnancy. Given the gravity of her risk level, Devika’s sleep prescription came with the very clear directive:“When I was expecting my first baby, my psychiatrist was unequivocal: She recommended that I not breastfeed — for my health and my son’s.” – Dr. Devika Bhushan
As she explains, breastfeeding = waking up through the night, waking up through the night = sleep disruption. Sleep disruption increases risk of mental illness episodes (e.g. depression, suicidal thoughts, mania, anxiety) especially during the postpartum period. Knowing that she was at a very high risk level, the recommendation was to just take breastfeeding off the table entirely. Formula feeding changes the equation for who wakes up during the night and how often. Formula feeding allowed her to fully protect her sleep which was critical for managing her bipolar disorder. Formula feeding was the best path forward for her family.
In fact, when she interviewed psychiatrists for her piece published in Slate, most mentioned that they routinely prescribe sleep through their recommendations against breastfeeding:
“Psychiatrists I interviewed for this piece routinely recommend against breastfeeding to protect maternal mental health in clear-cut cases—including for parents with serious mental illness, any illness known to be triggered by sleep loss, and those who have tried to breastfeed but have simply struggled with it too much.
‘I’m trying to cut out anything that’s going to increase that risk for destabilization,’ said Crystal Clark, a perinatal psychiatrist and associate professor at the University of Toronto.”
As Devika explains:
“If sleep deprivation could put you at risk for illness, consider all your feeding options — the only “right” choice is the one that allows you to be the best parent you can be.”
Of course, this discussion can still be an uphill battle. Those who explore/choose formula or combo feeding strategies for their own health still contend with the many ways the “breast is best” discourse surfaces as cultural pressure – from family or random social media influencers or even medical professionals. Even Devika faced questions and a bit of push back from her OB and pediatrician despite the fact that she is a pediatrician herself. And when she published this in Slate…. oh baby, did those judgement floodgates open!6
(Note: Devika’s piece also received some lovely comments from readers who felt seen, validated, and supported in their choices.)
What does this have to do with sleep later in life?
Here is where I venture into unknown territory. I’m relying on breastfeeding + sleep + stress as an example because it’s easier to point out all those elements of the perfect storm with the perfect solution. With this lens there is at least some understanding of how it works with some data to back up the connections and solutions.
How sleep disturbance relates to the cycling body or how things add up when you combine perimenopause/the menopause transition + sleep + stress is far more difficult because we know so little7. It might even go beyond hormone changes and female physiology. For example, we don’t know enough about how a brain, sensitized by caregiving, maintains a different level of awareness and vigilance in those wee hours. We know even less about the connections between these changes, emotional labor, and waking up in the middle of the night, though I do have thoughts on that one. Since that comes right back to traditional gender roles in the home and support (or lack of support) for early days of parenthood, this brings in an even more daunting challenge – the most impactful solutions may come right back to societal and cultural changes that facilitate equal care division in two-parent households, especially in those early days.
Until data catches up, the maternal stress map might as well double as a maternal sleep map.
Despite NIH acknowledging external sources of stress that impact sleep in the menopause transition, we have not disentangled the impact of shit that weighs on women/mothers more than men/fathers in the middle of the night.
As a daytime problem, we know that mental load has a clear gender divide (Eve Rodsky, Dr. Darby Saxbe, and colleagues have outlined the disproportionate division of cognitive labor here). Though gendered cognitive labor has yet to be quantified as a nighttime issue, personally, I know my brain loves a good bout of mental load gymnastics at 3am. Which begs the question – is it just the sheer number of cognitive tasks we hold or are there other elements of that load that linger in our sleeping maternal brain?
Also – is this where emotional labor comes in? For example, research on the most pressing concerns that parents have about their kids, puts children’s mental health at the top of the list. These are forward-thinking, anticipatory fears that parents carry around all day. But how do they affect our sleep quality? Does this anticipatory stress affect mothers and fathers differently? Is there a specific maternal panic button set to go off at the precise hour we are primed to wake?
How do we protect maternal sleep in this context of mental load and forward thinking?
I don’t have a clear answer. Looking at the stressor map as a sleep map, the opportunities for protecting maternal sleep likely exist within the nodes and between them. Reducing the weight, the gravity, with broad solutions – e.g. paid family leave, child care stability, supportive workplace cultures, financial stability, housing, health care access, elder care – could broadly improve sleep for so many women. But, let’s be honest, it’s hard to be optimistic about policy change right now.
In the meantime, we need to start smaller – work towards sharing the load while also changing the narrative that protecting maternal sleep is a key part of improving women’s health.
Culture change drives policy (eventually). Let’s start with an eye on those early days — encouraging non-birth parents to take leave or demand leave, share nighttime responsibilities, and split care tasks in those early days (I really do think this sets a trajectory that carries throughout life). Let’s remind moms that their sleep is equally, if not more, important. Let’s lean into equal partnership and away from maternal martyrdom throughout the parenting journey. Let’s stop perpetuating the “just suck it up” mentality that normalizes shitty sleep as a price of motherhood.
Let’s adopt the language of protection when we talk about the importance of sleep and sleep strategies, especially for women in all seasons of life.
Ok, the exact hours of 3-5am may reflect a recency bias thing -- I feel like I hear this specific window everywhere but I cannot for the life of me find a good reference (as it relates to perimenopause or general sleep quality)!
Maybe you know of a good reference(s)?
Personally, I haven’t had any temperature issues and the beneficial effects of HRT on sleep and other symptoms might not actually relate to estrogen/progesterone regulation.
Of course, this is not true for every household. In our house, I did breastfeed during the night but we did what we called “baby roulette” – if baby refused to go to sleep after a feed or woke up but wasn’t hungry, my husband was in charge of soothing for as long as it took.
This clearly represents the scenario for opposite sex couples. I am going to go out on a limb to assume non-hetero couples are far more egalitarian in their approach but it is still hard to avoid the lactating parent taking on a bulk of night time feeding when they are exclusively breastfeeding. And it is still hard to avoid the cultural expectation that the parent who does not have paid work to do in the morning is the one who can "afford” to lose more sleep.
Many many anecdotal stories for this one. I have yet to hear "my sleep is the most important. He can be tired at work."
there were some very lovely and encouraging comments but also plenty along the theme: "If you think your sleep is more important than a baby, then don't have kids"
lack of research and lack of funding for that research, and well, historical lack of interest in studying women's bodies and women's health.
Great piece on sleep protection, Molly! I especially love this part:
"Let’s start with an eye on those early days — encouraging non-birth parents to take leave or demand leave, share nighttime responsibilities, and split caregiving tasks in those early days (I really do think this creates a divergent neurobiological path that carries throughout life). Let’s remind moms that their sleep is equally if not more important. Let’s lean into equal partnership and away from maternal martyrdom throughout the parenting journey. Let’s stop perpetuating the “just suck it up” mentality that normalizes shitty sleep as a price of motherhood."
YES, YES, and YES!
Thanks for including my story, and I'm looking forward to our conversation next week.
Another thing that would be helpful is for co-sleeping, something that's safe if done safely, to stop being demonized by the medical establishment. Once I tried it (3rd kid), I realized that we're doing this to ourselves.