Abstract
The Coping with Sleep Problems Scale for Pregnant Women (CSPS-PW) is a psychometrically validated self-report instrument developed to assess the behavioral, cognitive, and psychosocial strategies employed by expectant mothers to mitigate sleep disturbances across various stages of gestation (Gokdemir & Yilmaz, 2023). Perinatal sleep disruptions—characterized by frequent nocturnal awakenings, insomnia, reduced sleep efficiency, and daytime fatigue—affect an estimated 60% to 80% of pregnant women due to complex anatomical, hormonal, and psychological shifts. Despite the high prevalence and documented consequences of poor maternal sleep on perinatal outcomes, validated instruments specifically targeting coping responses have historically been lacking. The CSPS-PW was developed through a rigorous three-phase methodological workflow: initial item generation from literature syntheses and extant measures (46 items), expert content evaluation and cognitive pilot testing reducing the pool to 36 items, and psychometric evaluation in a clinical sample of pregnant women (gestational age 8 to 42 weeks) in Turkey, yielding an 18-item final instrument. Exploratory factor analysis identified four underlying dimensions: Coping by Developing a Sleeping Habit, Coping by Performing Activities That Make Sleeping Easier, Coping by Seeking Social Support, and Coping by Thinking Positively, which collectively account for 47.987% of the total variance. The scale utilizes a five-point Likert-type response format. Psychometric analyses demonstrated strong internal consistency, with an overall Cronbach's alpha of .799 and subscale coefficients ranging from .614 to .763, alongside robust split-half reliability indices. The CSPS-PW fills an essential gap in perinatal nursing, clinical psychology, and obstetric care by providing a specialized tool to identify maladaptive versus adaptive sleep coping behaviors, evaluate sleep-hygiene psychoeducation, and guide non-pharmacological clinical interventions.
Keywords
Coping with Sleep Problems Scale for Pregnant Women, CSPS-PW, Sleep Disturbance, Perinatal Sleep, Pregnancy, Coping Strategies, Sleep Hygiene, Maternal Mental Health, Psychometrics, Factor Analysis, Midwifery, Obstetric Nursing.
Authors
The scale was developed and psychometrically evaluated by academic researchers in obstetric nursing and midwifery science in Turkey:
- Fulya Gokdemir, PhD, RN: Department of Obstetrics and Gynecologic Nursing, Faculty of Health Sciences, Artvin Coruh University, Artvin, Turkey. ORCID: 0000-0002-6089-3862. Email: [email protected] / [email protected].
- Tulay Yilmaz, PhD, RM: Department of Midwifery, Faculty of Health Sciences, Istanbul University-Cerrahpasa, Istanbul, Turkey. ORCID: 0000-0002-3706-3844.
Purpose
Sleep architecture undergoes profound alterations across human pregnancy. Elevated progesterone levels during the first trimester induce daytime somnolence and disrupt rapid eye movement (REM) sleep. As gestation advances into the second and third trimesters, mechanical and anatomical burdens—such as progressive uterine enlargement, fetal movements, diaphragmatic compression, nocturnal back pain, gastroesophageal reflux, and urinary frequency—foster sleep fragmentation, severe nocturnal awakenings, and insomnia. Epidemiological investigations consistently establish that chronic maternal sleep deprivation and poor sleep quality correlate with elevated risks of adverse maternal-fetal endpoints, including gestational diabetes mellitus, preeclampsia, prolonged labor duration, unplanned cesarean deliveries, and postpartum depression.
Despite this extensive clinical recognition, conventional assessment in perinatal medicine has overwhelmingly focused on measuring the *severity* of sleep disturbances—such as via the Pittsburgh Sleep Quality Index (PSQI) or general insomnia indexes—rather than systematically evaluating *how* women manage these nocturnal disruptions. Pregnant women frequently face unique contraindications regarding pharmacological sleep aids due to teratogenicity and neonatal withdrawal risks, making non-pharmacological, behavioral, and psychological self-regulation primary management strategies. Prior to the development of the Coping with Sleep Problems Scale for Pregnant Women (CSPS-PW), healthcare clinicians lacked an instrument specifically calibrated to assess pregnancy-specific coping mechanisms for sleep disruption.
The CSPS-PW serves distinct clinical and research purposes:
- Diagnostic and Clinical Profiling: It allows obstetricians, midwives, perinatal nurses, and mental health clinicians to systematically capture the behavioral, cognitive, and social strategies an expectant mother utilizes when confronted with insomnia or sleep fragmentation. Identifying these strategies differentiates adaptive coping mechanisms from dysfunctional or counterproductive behaviors.
- Intervention Guidance: By isolating specific dimensions—such as positive cognitive restructuring versus environmental sleep-hygiene behaviors—the instrument highlights distinct deficits in an individual's self-regulation toolkit, enabling tailored non-pharmacological interventions such as Cognitive Behavioral Therapy for Insomnia adapted for Perinatal populations (CBT-I).
- Empirical Research Application: The tool enables researchers to evaluate the efficacy of maternal health interventions, childbirth education curricula, mindfulness courses, and sleep hygiene protocols on self-efficacy and coping flexibility throughout gestation.
Psychological Construct
The Coping with Sleep Problems Scale for Pregnant Women assesses a multidimensional psychological construct grounded in behavioral self-regulation, cognitive reframing, and social coping deployed specifically to handle nocturnal disturbances. The operationalized construct comprises four interconnected yet distinct subdimensions:
1. Coping by Developing a Sleeping Habit
This subdimension measures the degree to which an expectant mother establishes, maintains, and regulates consistent sleep-wake routines and structured environmental conditions conducive to nocturnal rest. Rooted in classical sleep hygiene and stimulus control theory, this dimension reflects behaviors designed to stabilize the endogenous circadian pacemaker. Examples of construct manifestations include maintaining consistent bedtimes and rise times, preparing an optimal, stimulus-controlled sleep environment (e.g., controlling temperature, light, and ambient noise), and establishing pre-sleep sensory rituals that condition the central nervous system for sleep onset despite physiological discomfort.
2. Coping by Performing Activities That Make Sleeping Easier
This dimension captures the active, behavioral strategies implemented proximately before bedtime or during nocturnal awakenings to downregulate physiological and somatic arousal. Somatic hyperarousal is a primary barrier to sleep onset in pregnant women, exacerbated by fetal activity, muscular cramps, and restless legs syndrome. This subscale measures reliance on non-pharmacological bedtime rituals, such as performing muscle relaxation techniques, breathing exercises, engaging in light reading, consuming warm soothing beverages (e.g., decaffeinated herbal infusions or warm milk), taking warm baths, or utilizing specialized ergonomic positioning (such as maternal wedge pillows). These behaviors target autonomic relaxation without pharmacological reliance.
3. Coping by Seeking Social Support
Consistent with psychological coping models, social coping reflects the mobilization of interpersonal, emotional, informational, and instrumental resources to manage stress. In the context of perinatal sleep disturbance, seeking social support involves communicating sleep-related distress, pain, and daytime exhaustion to significant others, family members, or healthcare providers. It encompasses practical actions such as delegating daytime domestic or caregiving responsibilities to partners to facilitate maternal daytime rest, seeking emotional reassurance from peers or family regarding nighttime distress, and actively consulting midwives or obstetricians to clarify whether sleep difficulties represent physiological normalcy or underlying clinical pathology.
4. Coping by Thinking Positively
This dimension operationalizes cognitive reappraisal and positive psychological reframing specifically applied to nocturnal distress and intrusive daytime rumination. Nocturnal wakefulness in pregnant women frequently triggers catastrophic cognitions regarding daylight functional impairment, fetal well-being, or impending labor challenges. This subdimension captures cognitive efforts to minimize catastrophic appraisals, maintain an optimistic outlook, contextualize sleep disruption as a transient, normative adaptation to motherhood, and actively deploy calming, optimistic self-talk to counteract nighttime anxiety and cognitive hyperarousal.
Theoretical Framework
The conceptual architecture of the CSPS-PW integrates two primary psychological frameworks: Richard Lazarus and Susan Folkman's Transactional Model of Stress and Coping (Lazarus & Folkman, 1984) and Arthur Spielman's 3P Model of Insomnia (Spielman et al., 1987), situated within the broader biopsychosocial framework of perinatal health.
The Transactional Model of Stress and Coping
According to Lazarus and Folkman, stress is defined not merely by environmental events, but by an individual's cognitive evaluation of an event relative to their resources. This process involves two core appraisals:
- Primary Appraisal: The pregnant woman interprets sleep disruption (such as prolonged sleep latency or frequent nocturnal awakenings) either as a benign, temporary inconvenience or as an overwhelming threat to her physical health, emotional stability, and fetal development.
- Secondary Appraisal: The mother evaluates her available coping mechanisms and resources to respond to the disruption.
Within this paradigm, coping strategies are broadly divided into problem-focused coping (actions directed at altering the stressor itself) and emotion-focused coping (cognitive and emotional efforts aimed at regulating the emotional distress associated with the stressor). The CSPS-PW reflects both modalities: establishing sleep habits and performing facilitating activities represent active, problem-focused approaches designed to modify the sleep environment and somatic arousal; meanwhile, cognitive reframing (positive thinking) and seeking emotional support function primarily as emotion-focused regulatory strategies that lower psychological distress.
Integration with Spielman’s 3P Model and Cognitive Insomnia Models
Spielman's behavioral model posits that chronic sleep disturbances emerge from the interaction of Predisposing, Precipitating, and Perpetuating factors:
- Predisposing Factors: Genetic vulnerability, preexisting anxiety, and high baseline sensory sensitivity.
- Precipitating Factors: In pregnancy, acute physiological shifts (surges in estrogen, progesterone, and cortisol), anatomical changes, and visceral discomfort serve as potent precipitating factors triggering acute insomnia.
- Perpetuating Factors: Whether acute sleep problems transition into intractable insomnia depends on perpetuating factors—maladaptive compensatory behaviors such as irregular napping, excessive bed rest, catastrophic cognitive rumination, and bedtime performance anxiety.
The CSPS-PW evaluates whether a woman's response repertoire relies on positive behavioral routines (mitigating perpetuating factors) or fails to address cognitive hyperarousal. By measuring both behavioral habits and cognitive reappraisal, the instrument aligns with cognitive models of insomnia (Harvey, 2002), which demonstrate that misattributions, worry about sleep debt, and unrealistic sleep expectations amplify physiological arousal, creating a cycle that exacerbates sleep disruption.
Validity
The psychometric validation of the CSPS-PW involved content, construct, and criterion validity evaluations:
Content and Face Validity
Initial item generation yielded a pool of 46 candidate items derived from a systematic review of perinatal sleep literature, clinical guidelines, and existing general coping inventories. Content validity was evaluated using a panel of independent expert judges specializing in obstetric and gynecological nursing, midwifery, and sleep medicine. Judges assessed each item for clarity, maternal relevance, and construct congruence using a standardized Content Validity Index (CVI) framework. Following expert evaluation, items failing to achieve consensus were eliminated or linguistically refined, reducing the pool to 36 items. The Item-Content Validity Index (I-CVI) across the remaining items ranged from 0.85 to 1.00, and the overall Scale-Content Validity Index (S-CVI) was 0.91, surpassing the accepted psychometric benchmark of 0.80 (Polit & Beck, 2006). Subsequent pilot testing in an independent sub-sample of pregnant women confirmed high face validity, with respondents reporting clear comprehension of item semantics and response categories.
Construct Validity
Construct validity was evaluated via Exploratory Factor Analysis (EFA) using Principal Component Analysis (PCA) conducted on data gathered from pregnant women spanning gestational ages 8 to 42 weeks in Turkey. Statistical tests of sampling adequacy confirmed the data's factorability (Kaiser-Meyer-Olkin measure and Bartlett's Test of Sphericity were statistically significant). The factor structure demonstrated that 18 items successfully converged into four clinically interpretable factors with eigenvalues greater than 1.0. All retained items exhibited strong factor loadings exceeding accepted thresholds, supporting construct validity.
Criterion Validity
Criterion-related validity was examined by evaluating bivariate correlations between the CSPS-PW and the Turkish validated short form of the Patient-Reported Outcomes Measurement Information System® Sleep Disturbance scale (PROMIS–Sleep Disturbance–Short Form; Yüzeren et al., 2017). The correlational analyses yielded the following findings:
- Total CSPS-PW score vs. PROMIS Sleep Disturbance: r = .079, p = .131 (non-significant).
- CSPS-PW Subdimension 2 (Activities Making Sleeping Easier) vs. PROMIS Sleep Disturbance: r = .057, p = .273 (non-significant).
- CSPS-PW Subdimension 4 (Positive Thinking) vs. PROMIS Sleep Disturbance: r = −.010, p = .845 (non-significant).
While standard psychometric protocols often anticipate correlations between symptom inventories and coping efforts, the absence of a significant linear correlation between coping strategy utilization and sleep disturbance severity highlights an important psychometric distinction: the CSPS-PW measures the presence and mobilization of coping strategies, rather than the raw severity of nocturnal symptoms. An expectant mother may deploy active coping mechanisms (e.g., maintaining routines, cognitive reframing) regardless of whether her physiological disturbance is mild or severe. Conversely, another woman with marked sleep impairment may possess limited coping behaviors. These findings provide evidence for divergent construct independence: coping mechanism deployment is conceptually distinct from symptom burden.
Reliability
The CSPS-PW demonstrates satisfactory to strong internal consistency and split-half reliability across its total scale and subscales:
Internal Consistency
For the final 18-item instrument, the overall Cronbach's alpha coefficient was .799, demonstrating good overall internal consistency for clinical and research purposes. Across the individual subscales, Cronbach's alpha coefficients were:
- Coping by Developing a Sleeping Habit: α = .763
- Coping by Performing Activities That Make Sleeping Easier: α = .712
- Coping by Seeking Social Support: α = .678
- Coping by Thinking Positively: α = .614
The Corrected Item-Total Correlations (CITC) for all 18 items ranged from .286 to .538. All item-total correlation values met or exceeded acceptable thresholds (typically ≥ .25 to .30), confirming that each retained item contributes meaningfully to the overall measurement of maternal sleep coping.
Split-Half Reliability
Split-half reliability analyses confirmed internal scale stability across divided halves:
- Reliability of the first half: r = 0.734
- Reliability of the second half: r = 0.714
- Guttman split-half coefficient: 0.625
- Spearman-Brown split-half coefficient: 0.625
Methodological Context: Test-Retest Reliability and CFA
The original authors noted a study limitation: due to health system disruptions and logistical restrictions during the COVID-19 pandemic, prospective longitudinal follow-up was impeded. Consequently, test-retest reliability across fixed intervals and Confirmatory Factor Analysis (CFA) in an independent cohort could not be performed during the initial validation study. Future research is warranted to verify temporal stability and confirm structural invariance across gestational trimesters via CFA.
Factor Analysis
The dimensionality of the CSPS-PW was analyzed using Exploratory Factor Analysis (EFA) via Principal Component Analysis (PCA) with orthogonal rotation.
Item Reduction Process
The initial questionnaire draft comprised 46 candidate items. After content validity evaluation reduced the pool to 36 items, EFA was performed on the empirical dataset. Items demonstrating cross-loadings across multiple factors (with differences < .10), low primary loadings (< .40), or insufficient item-total correlations were systematically removed. This process produced a clean, parsimonious 18-item final structure distributed across four factors.
Factor Extraction and Variance Explained
The four extracted components accounted for a cumulative 47.987% of the total variance, with each factor contributing a balanced proportion of explanatory power:
- Factor 1: Coping by Developing a Sleeping Habit: Accounted for 13.401% of the variance (eigenvalue > 1.0). This factor groups items related to regularizing bedtimes, wake routines, and sleep hygiene practices.
- Factor 2: Coping by Performing Activities That Make Sleeping Easier: Accounted for 12.119% of the variance. This factor groups items reflecting somatic down-regulation and soothing bedtime activities.
- Factor 3: Coping by Seeking Social Support: Accounted for 11.298% of the variance. This factor captures items addressing communication, partner involvement, and healthcare provider consultations.
- Factor 4: Coping by Thinking Positively: Accounted for 11.169% of the variance. This factor captures cognitive items concerning positive reframing, calming thoughts, and avoidance of catastrophic expectations.
The relatively uniform distribution of explained variance across the four factors (each between 11.1% and 13.4%) indicates that maternal coping with sleep problems relies on a balanced set of behavioral, somatic, interpersonal, and cognitive mechanisms, rather than a single dominant strategy.
Instrument / Measurement Tool
The technical parameters and administrative properties of the CSPS-PW are structured as follows:
- Instrument Name: Coping with Sleep Problems Scale for Pregnant Women (CSPS-PW)
- Original Language: Turkish (Gebelikte Uyku Problemleri ile Başa Çıkma Ölçeği)
- Instrument Type: Self-report questionnaire / psychometric assessment scale
- Target Population: Adult pregnant women across all gestational trimesters (studied across gestational ages 8 to 42 weeks)
- Number of Items: 18 items
- Underlying Factors / Subscales (4):
- Subscale 1: Coping by Developing a Sleeping Habit
- Subscale 2: Coping by Performing Activities That Make Sleeping Easier
- Subscale 3: Coping by Seeking Social Support
- Subscale 4: Coping by Thinking Positively
- Response Scale: Items are rated on a five-point Likert-type response scale
- Administration Time: Approximately 5 to 8 minutes
- Scoring System: Individual subscale scores are computed by summing or averaging the items corresponding to each of the four dimensions; a total scale score can be obtained by summing all 18 items. Higher scores reflect a higher frequency and wider repertoire of adaptive coping strategies utilized to manage sleep disturbances during pregnancy.
Permissions & Fee and Test Year
The Coping with Sleep Problems Scale for Pregnant Women was officially published in 2023 in the Journal of Advanced Nursing. The instrument is intended for non-commercial academic and clinical research purposes.
- Commercial Status: Non-commercial; no testing fee is required for clinical or academic investigations.
- Permissions: Researchers wishing to utilize, translate, or adapt the CSPS-PW must obtain formal written permission from the corresponding author, Dr. Fulya Gokdemir ([email protected] / [email protected]).
References
- Gokdemir, F., & Yilmaz, T. (2023). Development and psychometric properties of the Sleep Problems and Coping with Sleep Problem Scales for Pregnant Women. Journal of Advanced Nursing, 79(6), 2378–2392. https://doi.org/10.1111/jan.15592
- Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869–893. https://doi.org/10.1016/S0005-7967(01)00077-8
- Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
- Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what's being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489–497. https://doi.org/10.1002/nur.20147
- Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10(4), 541–553. https://doi.org/10.1016/S0193-953X(18)30532-X
- Yüzeren, H., Civan, B., & Demir, G. (2017). Turkish validity and reliability study of the Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance and Sleep-Related Impairment Short Forms. Turkish Journal of Physical Medicine and Rehabilitation, 63(3), 209–218.