Insomnia During Pregnancy

Roughly four in ten pregnant people experience insomnia symptoms, and sleep problems rank among the most common complaints of pregnancy. Many go untreated, because sleeping pills are often not a good choice during pregnancy.

How common it is

A 2024 systematic review and meta-analysis, pooling studies that used standardized questionnaires and diagnostic criteria, put the overall prevalence of insomnia symptoms during pregnancy at 43.9%.1

That figure covers insomnia symptoms, which is a broader category than meeting the full criteria for chronic insomnia disorder.

The criteria do not change

Chronic insomnia disorder is difficulty falling asleep, staying asleep or waking too early; three or more nights a week; for three months or more; with a daytime consequence; and not explained purely by inadequate opportunity or circumstances for sleep.2 Those criteria are the same whether or not you are pregnant.

The one that does most of the work in pregnancy is the last. Being woken repeatedly by discomfort or by needing the bathroom disrupts sleep. Whether that is insomnia depends on what happens next: whether you drift back off, or lie awake for an hour afterwards.

The medication conversation

Outside pregnancy, someone with chronic insomnia has medication and over-the-counter products available as short-term tools. In pregnancy, every one of those decisions — prescription, over-the-counter, supplement, melatonin included — belongs with your pregnancy care provider, weighed alongside everything else about your pregnancy.

That narrows one set of options. It does not leave you without any, because the first-line treatment is not a drug.

What actually helps

CBT-I holds the only strong recommendation in the AASM's 2021 behavioral guideline for chronic insomnia in adults.3 And unusually for this site, it has been tested in pregnancy specifically — three randomized trials.

Key terms

• Insomnia Severity Index (ISI) — a seven-question score from 0 to 28. Higher means worse insomnia; 15 to 21 is moderate. We explain the bands on the ISI page.
• Remission — symptoms drop low enough that insomnia no longer counts.
• Active control — a comparison group given a different, non-CBT-I program rather than nothing at all.

The first, in 2019, enrolled 179 women between 18 and 32 weeks and assigned them to five sessions of CBT-I or to an active control. Insomnia severity scores fell from 15.4 to 8.0 — moderate insomnia down to subthreshold — against 15.9 to 11.2 in the control group. Sixty-four percent reached remission versus 52%, and reached it faster: a median of 31 days against 48.5

A 2020 trial tested a digital format. 208 women were assigned either to six weekly online sessions of about twenty minutes, or to standard treatment, which left them free to seek medication or therapy on their own. Remission: 44.0% against 22.3%. They spent less time awake in bed and rated their sleep quality higher. Total sleep time did not differ. The gains held at follow-up about two months after the program ended.6

A third trial, also digital, enrolled 91 women near or entering the third trimester and compared CBT-I against digital sleep education. Insomnia severity fell by about five points and nightly sleep rose by 32 minutes during pregnancy, while the control group's sleep did not change. Six weeks after birth, the CBT-I group was still sleeping around 40 minutes more a night, with better sleep maintenance.7

What these studies share is a consistent direction: across in-person and digital delivery, CBT-I improved sleep in pregnancy.

On depression the picture is mixed. The 2019 trial found a small but significantly greater reduction in depression scores, and the 2020 digital trial found greater improvement in depressive and anxiety symptoms.56 A follow-up of that digital trial found fewer women screening positive for probable major depression at three months postpartum.8 The third trial found no effect on depression, before or after birth.7

Trial evidence is not a guideline

Worth being precise about what the above is and is not. There is no AASM clinical practice guideline specific to pregnancy. What exists is trial evidence in this population, which is a step short of a recommendation.

What this means practically

CBT-I involves no medication, so there is no fetal drug exposure to weigh against the benefit.

If you are pregnant and not sleeping, the question to bring to your pregnancy care provider is whether CBT-I is available to you — in person, through a structured program, by referral, or through telehealth or a digital format.

One caveat to raise in the same conversation: sleep restriction, the component that usually drives the improvement, narrows time in bed. How that should be handled during pregnancy is a clinical decision, not something to improvise.