Partnering with Perinatal Community Workers To Improve Prenatal Sleep

About This Grant

Sleep disturbances are highly prevalent during pregnancy, with 42–60% of individuals experiencing clinically significant insomnia. These disturbances are associated with impaired daytime functioning and serious maternal health risks such as gestational diabetes, preeclampsia, and depression, as well as adverse infant outcomes including low birth weight and sleep problems. Despite the substantial and well-documented consequences of poor prenatal sleep, these problems often go untreated in standard perinatal care. Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line, evidence-based treatment for insomnia and poor sleep quality and has demonstrated efficacy during pregnancy. Yet access and engagement are limited. Approximately 40% of adults drop out of CBT-I prematurely, and it is typically delivered by clinical psychologists—only 6% of whom are trained in behavioral sleep medicine. This workforce limitation significantly constrains the scalability of CBT-I, particularly in communities that face challenges with health care access. Community-based delivery models offer a promising and innovative approach to expanding access to prenatal sleep care. Doulas—non-clinical, community-based perinatal support workers—are uniquely positioned to help address these gaps due to their sustained contact with families, shared community backgrounds, and growing integration into health systems, including via Medicaid. National surveys indicate strong interest among doulas in delivering mental health (81%) and sleep health (78%) interventions, and studies support their effectiveness in supporting maternal well-being. We aim to adapt and pilot a doula-delivered prenatal CBT-I intervention through a Human-Centered Design (HCD) implementation-focused process. We will first (HCD Discovery Phase; Aim 1) conduct a community sleep needs assessment to identify perinatal sleep-related strengths, assets, needs, challenges, and facilitators, engaging key stakeholders (patients, doulas, OBGYNs, sleep specialists) through focus groups and a Perinatal Sleep Day summit. Next (Aim 2), we will co-design a patient-centered adaptation of CBT-I for delivery by doulas. Using HCD design/build methods, we will engage an Implementation Workgroup in iterative co-creation sessions and assess usability, feasibility, appropriateness, and acceptability, followed by Theater Testing of the full intervention with target users. Lastly (Aim 3), we will conduct a pre-post feasibility and acceptability pilot trial of the adapted intervention, including recruitment and training of community doulas. We will use mixed methods to evaluate maternal sleep quality, insomnia symptoms, and mood, along with implementation outcomes guided by Proctor’s Framework and the Consolidated Framework for Implementation. Findings will inform the design of a subsequent hybrid type I effectiveness-implementation RCT study design, including feasibility of the study timeline, recruitment and training strategies, assessment processes, attrition and engagement, and estimates of effect size. This project will fill a critical gap in maternal health care by integrating evidence-based sleep interventions into community perinatal services, improving access and enhancing maternal and infant outcomes.