Association between maternal stress during pregnancy and child sleep quality: Mediation effect of parent–child relationship

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Methods This study included 4,830 mothers and their children. The mothers retrospectively reported stress during pregnancy, including negative mood and major life events that happened during pregnancy, using a four-item questionnaire. They also completed the Brigance Parent-Child Interactions Scale (BPCIS) and the Brief Infant Sleep Questionnaire (BISQ). A structural equation model was used to analyze the association between maternal stress during pregnancy and child sleep quality, with parent–child relationship as a mediator. Results Maternal stress during pregnancy was negatively associated with parent–child relationship ( β = −0.41, P < 0.01), parent–child relationship was positively associated with child sleep quality ( β = 0.04, P < 0.01), whereas maternal stress during pregnancy was negatively associated with child sleep quality ( ß = −0.11, P < 0.01). Furthermore, parent–child relationship mediated the association between maternal stress during pregnancy and child sleep quality, achieving a mediation effect rate of 13.19% ( P < 0.01). Conclusion Maternal stress during pregnancy was associated with negative parent–child relationship and child sleep disorders; In addition, a good parent-child relationship was positively associated with child sleep quality. Parent–child relationship mediate the association between maternal stress during pregnancy and child sleep disorders. This finding could provide a scientific basis for developing preventive strategies to improve child sleep quality. Maternal stress during pregnancy Sleep quality Parent–child relationship Preschool children Figures Figure 1 Background In recent years, research has focused on sleep disorders in children, which have an incidence rate of 18–61% [ 1 ]. Childhood is marked by rapid developmental changes in sleep patterns, and sleep problems are among the most commonly reported parenting issues today [ 2 ]. A growing body of evidence suggests that sleep problems in children are associated with adverse developmental outcomes, including physical, cognitive, emotional, and behavioral issues [ 3 , 4 ]. Chronic sleep disorders can impact brain tissues, causing impaired functional areas and psycho-behavioral problems in preschool children [ 5 ]. Identification of factors associated with sleep disorders in children is crucial in improving their physical and mental health. The earliest predictors of sleep problems in children can potentially be found in utero , particularly maternal stress during pregnancy, which includes hypervigilance and hyperarousal [ 6 , 7 ]. Some studies demonstrated that maternal negative emotion (depression, anxiety) during pregnancy increases the risk of sleep problems in infants and preschool children, especially sleep rhythm disorders and night awakenings [ 8 – 10 ]. Thus, exposure to maternal negative stress and emotion during pregnancy may be a risk factor for the development of early sleep problems in children. Some literature described how exposure of the hypothalamic–pituitary–adrenocortical (HPA) axis to maternal stress hormones (e.g., cortisol) can influence child sleep problems [ 11 ]. Some studies also examined alterations in fetal cerebellar–insular connectivity as a result of prenatal exposure to stress as intermediate mechanism underlying sleep problems in 3–5-year-old children [ 12 ]. Most studies to date have focused on stress physiological mechanisms that may underlie the association between high levels of maternal stress during pregnancy and child sleep disorders. What has been neglected mostly, however, is the influence that postnatal parenting factors may have on child sleep status. More specifically, a previous study demonstrated that particularly negative emotions during pregnancy was associated with lower expected parenting self-efficacy in pregnancy, suggesting that anxiety during pregnancy hampers optimal preparation for parenting [ 13 ]. Helen and Sydney found that young mothers with prenatal depression perceived more parent–child interaction difficulty than non-depressed mothers during pregnancy even after adjusting for postpartum depression [ 14 ], and prenatal depression predicted child development. Thus, mothers who experienced high levels of negative stress during pregnancy are also expected to encounter more difficulty in establishing good interaction with their offspring. While several studies have considered parenting factors as confounders, when looking at the predictive effect of maternal stress during pregnancy on child behavior [ 15 ], very little is known about how maternal stress during pregnancy may lead to parent–child relationship stress, which, in turn, could also affect child sleep. Maternal stress during pregnancy has been evaluated using a broad range of instruments under the following categories: negative emotion/mood status, perceived stress, daily hassles, psychological symptomatology, life events, specific socioenvironmental stressors, and pregnancy-specific stress to pregnancy [ 16 ]. In view of some longstanding approaches involve the assessment of negative emotion/mood during pregnancy, and stressful stimuli, especially major life events during pregnancy [ 17 , 18 ], are applied, thus, maternal stress during pregnancy in our study are focused on negative emotion/mood and major life event stress. Our study aimed to determine (1) whether maternal stress during pregnancy and parent–child relationship are associated with child sleep quality and (2) whether parent–child relationship mediates the association between maternal pregnancy stress and child sleep quality. The findings provide insight for interventions aimed at improving parent–child relationship stress and child sleep difficulties. Methods Participants Participants in this study were mothers of 4,830 children from 13 community health centers in Xinbei District, Changzhou City, China. Health surveillance and questionnaire data were analyzed. Inclusion criteria for children were age of 3–6 years old, parental voluntary participation, and willingness to sign an informed consent form. Alternatively, the exclusion criteria were incomplete questionnaires, presence of stunting or chronic diseases, and high-risk pregnancies. Of the 5,013 participants who completed the questionnaire, the demographic differences between the 183 excluded participants and the remaining sample were not statistically significant. Procedure and measures The participants completed paper questionnaires at the Children’s Health Screening Clinic located at 1 of the 13 community health centers in Xinbei District, Changzhou City, China. Completion of the questionnaire was voluntary and participation was not mandatory. Trained researchers collected the participants’ sociodemographic data and information regarding children’s lifestyles and mothers’ conditions during pregnancy using a structured questionnaire. The questionnaire covered child age, parental education and occupation, family structure, annual family income, child feeding, mother’s perceived stress during pregnancy, and child sleep problems. All the participants provided informed consent, and the study was approved by the ethics committee of Nantong University’s School of Public Health (approval no. (2022) 04). Children’s Sleep Habits Questionnaire The Children’s Sleep Habits Questionnaire (CSHQ) was compiled by American scholar Judith in 2000 and is currently one of the credible research tools used in the sleep research of children aged 3 to 12. It is completed onsite by parents based on their child’s sleep status during the previous week. The questionnaire was validated by a sleep diary and a wristwatch activity monitor, a standardized sleep measurement tool, and had a strong retest reliability (0.62 to 0.79) [ 19 ]. It was translated into Chinese and included in the guideline for child sleep hygiene by the National Health Commission of China [ 20 , 21 ]. Furthermore, it has been extensively used in research conducted throughout China and exhibited good reliability and validity. The CSHQ can be read and understood normally and filled out accurately by parents. The CSHQ questionnaire contains a total of 33 entries that measure Bedtime Resistance, Sleep Onset Delay, Sleep Duration, Sleep Anxiety, Night Wakings, Parasomnias, and Sleep Disordered Breathing, Daytime Sleepiness 8 dimensions of sleep problems. Five specific sleep questions from this questionnaire were analyzed: nighttime sleep duration, number of nighttime awakenings, sleep difficulties, regular sleep, and sleep latency. Maternal Stress Assessment The mothers retrospectively reported stress during pregnancy based on their medical records during pregnancy. Maternal stress, including negative mood and major life events during pregnancy, was assessed. The questionnaire comprises a total of four sections, one pertaining to major life events during pregnancy and three to negative mood during pregnancy. The negative mood score was used as the endpoint of Affectometer-2 [ 22 ]. Ten negative adjectives were determined and formed the negative mood subscales in Affectometer-2: lonely, helpless, impatient, depressed, hopeless, withdrawn, discontented, confused, tense, and insignificant [ 23 ]. The mothers’ negative mood was assessed using three items, namely, tense, depressed, and hopeless. Furthermore, their mood stress during pregnancy was rated on a four-point scale (from “hardly ever” [0] to “most of the time” [ 3 ]). The mean score of the summed items was used to reflect negative mood score and ranged between 0 and 3, with higher scores indicating greater experience of negative mood. The evaluation of life events stress during pregnancy is adapted from the Life Events Scale (LES) developed by Young Desen [ 24 ]. Items include life events that are likely to occur and have a high impact during pregnancy, including 9 items in family life stress (husband beating and scolding, separation of husband and wife, tension between husband and wife, serious illness or serious injury of family members, death of family members, serious illness or serious injury of husband, housing stress, moving, and conflict with family members).There were 3 items in work and financial stress (job loss, husband job loss, family financial loss), and 3 items for social stress (tension with colleagues, tension with neighbors, involvement in legal disputes). The evaluation of pregnancy stress events included whether the life event occurred and the degree of impact on oneself (0: None, 1: Happened but had no impact, 2: Some impact, 3: Severe impact). The total score of the stressful life event score of the pregnant woman was added up, and the total score was divided into 0 points, 1 points, 2 points, and 3 points into 4 groups. In the present study, Cronbach’s alpha coefficient for the questionnaire was 0.78, with a KMO value of 0.75 ( P < 0.01 in Bartlett’s test). The questionnaire demonstrated good reliability and validity. Brigance Parent–Child Interaction Scale The Brigance Parent–Child Interactions Scale, a parent report questionnaire, was developed by researcher Frances Page Glascoe in 2002 to monitor parent–child interaction problems. This scale has been standardized in the USA with 382 families recruited (matching demographic characteristics). It was translated into Chinese and used in multiple studies across China. The scale consists of 20 questions, including 14 positive and 6 negative interaction questions. The questionnaire uses a three-point self-report scale that categorizes responses to each question into “rarely/inconsistent,” “sometimes,” and “often/concordant.” In this study, the scores of the questions were first summed up to obtain the total score. The total scores were ranked, and 25% of each group was taken as the high and low groups. The scores of the high and low groups on each question were compared using the independent samples t -test, and questions with no significant difference between the high and low groups were excluded. Delete questions with correlation coefficients < 0.3 between the scores of each question and the total score. The questions deleted at the end of the total item analysis were 3, 10, 13, 15, 16, and 17. Exploratory factor analysis was conducted on the remaining questions, and the KMO value was 0.797, suggesting that the questionnaire was suitable for factor analysis. Subsequently, factor extraction was performed via principal component analysis and orthogonal rotation with variance maximization, and questions with factor loadings < 0.4 were deleted to achieve division into three dimensions according to the dimensional factors of the original scale: Dimension 1: Guiding, which includes 2, 4, 9, 14, and 19; Dimension 2: Intimacy, which includes 1, 5, 7, and 8; and Dimension 3: Parental Efficacy, which includes 11, 12, 18, and 20. Statistical analysis Descriptive statistics, correlation analysis, t -tests, and one-way analysis of variance were conducted using IBM SPSS Statistics version 27.0. Continuous variables were expressed as means and standard deviations (SD) and categorical variables as percentages. To examine differences in categorical sociodemographic characteristics associated with child sleep quality, chi-squared tests and Student’s t -tests were employed. Structural equation modeling was used to analyze the mediation model. The model was developed using maternal stress during pregnancy as the independent variable, child sleep quality as the dependent variable, and parent–child relationship as the mediating variable. As all continuous variables exhibited normal distribution, great likelihood estimation was used as a comprehensive test of the model. The chi-squared statistic, root mean squared error of approximation (RMSEA), goodness-of-fit index (GFI), Tucker–Lewis fit index (TLI), comparative fit index (CFI), Parsimony-adjusted normed fit index (PNFI), and parsimony-adjusted goodness-of-fit index (PGFI) were used to evaluate the goodness of fit of the model. The acceptable values for model fit are as follows: RMSEA ≤ 0.08, GFI ≥ 0.90, TLI ≥ 0.90, CFI ≥ 0.90, TLI ≥ 0.90, PNFI ≥ 0.50, and PGFI ≥ 0.50 [ 25 ]. The researchers suggested using bootstrapping as a potent and efficient technique for testing the statistical significance of mediated indirect effects. Indirect effects were considered significant at the 0.05 level if the bias-corrected 95% confidence interval (CI) of 5000 bootstrap samples did not include 0 [ 26 ]. Results The demographic characteristics of the participants are presented in Table 1 . The mean age of the participating children was 4.27 years (SD, 0.69; range, 3–6 years), and 50.1% of them were boys and 49.9% were girls. About 14.8% of the families had a low mean gross annual income (≤￥80,000), 1.8% of the children were from single-parent families, and 67.2% of the children were exclusively breastfed up to 4 months of age. Child sleep status was categorized into good sleep quality (66.1%) and poor sleep quality (33.9%, characterized by short sleep duration, long sleep latency, and high number of night wakings) via cluster analysis. Child age was correlated with child sleep quality ( t = 3.85, P < 0.01). However, gender did not have a statistically significant effect on child sleep quality. In addition, child sleep quality significantly varied across different family structures (χ 2 = 46.04, P < 0.01) and feeding styles during the 4-month period (χ 2 = 6.33, P < 0.01). The study found a statistically significant difference ( P < 0.01) in child sleep quality associated with maternal stress during pregnancy. Specifically, various factors including tense mood during pregnancy (χ 2 = 82.61, P < 0.01), depressed mood during pregnancy (χ 2 = 46.10, P < 0.01), hopeless mood during pregnancy (χ 2 = 48.65, P < 0.01), and major life events during pregnancy (χ 2 = 10.17, P = 0.017) exerted varying degrees of influence on child sleep quality. The association between parent–child relationship and child sleep quality is presented in Table 2 . The children had a mean sleep duration of 9.34 ± 0.85 h, which was positively correlated with all three dimensions of parent–child relationship (all P < 0.01). Similarly, the mean sleep latency of the children was 0.57 ± 0.42 h, which was significantly associated with the intimacy and guiding dimensions of parent–child relationship ( P < 0.01), but not significant in the parental functional dimension( P = 0.38). The average number of night wakings among children was 0.49 ± 0.71, which was significantly correlated with the intimacy and guiding dimensions of parent–child relationship ( P < 0.01). Child sleep difficulties had a statistically significant impact on all three dimensions of parent–child relationship (all P < 0.01), as well as sleep regularity (all P < 0.01). The mediation model of parent–child relationship and the standardized coefficients for each variable are presented in Fig. 1 . The structural equation model depicts significant regression and correlation paths, whereby all path coefficients are statistically significant at P < 0.01. Acceptable fit indices were observed for the model: chi-squared test = 163.53, df = 48, RMSEA = 0.022, GFI = 0.994, PGFI = 0.612, CFI = 0.988, TLI = 0.984, and PNFI = 0.715. According to the model, the sleep qualities in children were significantly predicted by maternal stress during pregnancy and negative parent–child relationship. The standardized direct effect values of maternal stress during pregnancy and parent–child relationship on sleep qualities were − 0.19 ( P < 0.01) and 0.23 ( P < 0.01), respectively. Parent–child relationship was significantly impacted by maternal stress during pregnancy, with the standardized direct effect value being − 0.13 ( P < 0.01). Furthermore, the standardized indirect effect value of maternal stress during pregnancy on sleep qualities in children, through parent–child relationship, was − 0.029 (− 0.13 * 0.23). The bootstrapped 95% CI did not include 0 (− 0.026, − 0.010, P < 0.01) for the indirect effect of maternal stress during pregnancy on sleep quality through parent–child relationship, confirming the significant indirect effect. The standardized total effect value of maternal stress during pregnancy on sleep quality was − 0.220 (− 0.029, − 0.191). Thus, the mediation effect ratio was 13.18% (0.029/0.220 × 100%). Table 1 Characteristics of mother and child Variable (n = 4830) Good sleep quality Poor sleep quality t / χ 2 P Ages 4.30 ± 0.70 4.22 ± 0.67 3.85 < 0.001 Gender 0.45 0.502 Boy 1612 (50.5) 809 (49.4) Girl 1582 (49.5) 827 (50.6) Annual household income 0.69 0.707 Low(￥300,000) 487 (15.2) 235 (14.4) Family structure 46.04 < 0.001 Immediate Family 1518 (47.5) 926 (56.6) Nuclear Family 1532 (48.0) 621 (38.0) Joint Family 96 (3.0) 51 (3.1) Single Parent Families 48 (1.5) 38 (2.3) Feeding Within 4 Months 6.33 0.012 Breast-feeding 2188 (68.5) 1062 (64.9) Mix-feeding 1006 (31.5) 574 (35.1) Tense mood during pregnancy 82.62 < 0.001 Hardly ever 2584 (80.9) 1134 (69.3) Sometimes 339 (10.6) 288 (17.6) Often 257 (8.0) 205 (12.5) Most of the time 14 (0.4) 9 (0.6) Depressed mood during pregnancy 46.10 < 0.001 Hardly ever 2446 (76.6) 1104 (67.5) Sometimes 431 (13.5) 303 (18.5) Often 299 (9.4) 217 (13.3) Most of the time 18 (0.6) 12 (0.7) Hopeless mood during pregnancy 48.66 < 0.001 Hardly ever 2841 (88.9) 1338 (81.8) Sometimes 193 (6.0) 174 (10.6) Often 150 (4.7) 117 (7.2) Most of the time 10 (0.3) 7 (0.4) Major life events during pregnancy 10.17 0.017 Not happen 3080 (96.4) 1551 (94.8) Happened but had no impact 33 (1.0) 34 (2.1) Some impact 69 (2.2) 43 (2.6) Severe impact 12 (0.4) 8 (0.5) *The p-values were tested using the t-test and chi-square test; The bold part indicates P < 0.05 Table 2 Comparison of the parent-child relationship and child sleep quality Variable(n = 4830) Intimacy (13.93 ± 1.58) t/F P Guiding (9.65 ± 1.78) t/F P Parental Functional (9.23 ± 1.62) t/F P Sleep duration(h/d) 9.34 ± 0.85 30.94 < 0.001 59.78 < 0.001 10.25 0.001 Latency to fall asleep(h/d) 0.57 ± 0.42 63.35 < 0.001 24.02 < 0.001 0.77 0.381 Number of night wakings 0.48 ± 0.70 33.09 < 0.001 26.14 < 0.001 2.64 0.104 Difficulty in sleeping 1.58 ± 0.75 34.79 < 0.001 31.41 < 0.001 31.95 < 0.001 Regular sleep 5.36 < 0.001 5.11 < 0.001 2.70 0.007 Yes 4504 (93.3) 13.99 ± 1.49 9.69 ± 1.75 9.24 ± 1.59 No 326 (6.7) 13.40 ± 1.97 9.14 ± 1.89 8.99 ± 1.68 *The p-values were tested using the ANOVA or t-test; The bold part indicates P < 0.05 Figure 1 . Mediation model of parent–child relationship on maternal stress during pregnancy and child sleep quality (N = 4830). Age, family structure, and feeding approach were taken as covariates. The fit indices for the modified model were acceptable: χ2 = 163.53, df = 48, χ2/df = 3.41, RMSEA = 0.022, GFI = 0.994, PGFI = 0.612, CFI = 0.988, TLI = 0.984, PNFI = 0.715. Discussion This study investigated the sleep quality of 3–6-year-old children and the association between maternal stress during pregnancy, parent–child relationship, and child sleep quality. Cluster analysis revealed that 33.9% of children had poor sleep quality, characterized by short sleep duration, long sleep latency, and frequent night wakings. The results were consistent with those of a 2021 analysis in mainland China, which showed a proportion of 37.6% [ 27 ]. No significant difference was observed in sleep duration between both sexes. In terms of family environmental factors, the annual income level of the family was not significantly associated with child sleep quality in our study. A previous study demonstrated that low income could influence child sleep behavior because of family function or chaos [ 28 ]. It is likely that the children in our study were all from the city, and the influence of family socioeconomic status on children was relatively limited. However, the child sleep quality in the current study varied depending on the types of family structure. This finding is consistent with the report by W M Troxel and colleagues in Pennsylvania, who found that sleep duration was affected by various types of family structure among adolescents [ 29 ]. The present study also examined the association between breastfeeding and sleep quality in children and demonstrated that feeding practices during the first 4 months of life had an impact on child sleep quality. Our results indicated that children who were exclusively breastfed during this period had longer sleep duration and shorter sleep latency compared with those who received mixed feeding, a finding consistent with that of a recent research conducted in Singapore [ 30 ]. The present study suggests that the disparity in nighttime sleep duration could be due to the abundant hormones present in breast milk [ 31 ]. These components may have an effect on early infant biological regulation, thereby extending the length of nighttime sleep in children [ 32 ]. This study demonstrated that maternal stress during pregnancy was significantly associated with child sleep quality. The greater the mothers’ exposure to adverse emotions and life event stress during pregnancy, the poorer their children’s sleep quality. Maternal stress during pregnancy can influence the neurodevelopmental outcomes of a child which in turn can influence the child sleep quality. Due to the rapid fetal brain development, exposure to intrauterine psychological stress increases the susceptibility of the fetus to neuropsychiatric disorders [ 33 ]. Furthermore, it may affect the neurobehavioral development of the offspring of exposed mothers [ 34 ]; it has also been associated with an increased risk of attention-deficit hyperactivity disorder and autism in children. Therefore, it is important to consider the impact of maternal pregnancy stress on fetal brain development [ 35 ]. Research has demonstrated that psychological stress related to pregnancy has a greater impact on developmental outcomes in infants and toddlers, including preterm birth, cognitive and motor development, emotion regulation, brain morphology, and sleep quality than general psychological stress [ 36 , 37 ]. Maternal pregnancy stress exposure can potentially affect the intrauterine development of the fetus through poor maternal health behaviors, indirectly causing health problems in children [ 38 ]. This study showed that a good parent–child relationship had a positive effect on child sleep status, and each of the three parent–child relationship scores distinctly impacted child sleep quality. Parent–child relationship is widely acknowledged to significantly contribute to child sleep [ 39 , 40 ]. Frequent parent–child conflict in family life can serve as a chronic stressor and negatively impact child sleep quality [ 41 ]. It may also affect the body’s regulatory system and cause hormone secretion disorders, thereby impacting the duration and quality of sleep, which results in mental health issues [ 42 ]. Furthermore, a previous research demonstrated that the HPA axis and the parasympathetic nervous system could potentially contribute to the correlation between child sleep patterns and their familial connections [ 43 ]. One potential explanation is that a positive parent–child relationship within a family influences the HPA axis of children, decreasing cortisol levels before bedtime and increasing overall cortisol level fluctuations, which ultimately impacts child sleep patterns [ 29 ]. The present study also demonstrated that parent–child relationships played a mediating role in the association between maternal stress during pregnancy and child sleep quality. Maternal negative emotions during pregnancy was associated with lower expected parenting self-efficacy, which may hamper optimal preparation for parenting [ 13 ]. Previous studies found that mothers with prenatal depression faced more parent–child interaction difficulties even after adjusting for postpartum depression [ 14 ]. These findings are consistent with those of previous studies demonstrating that maternal pregnancy stress is an influential factor in parent–child relationship [ 44 ], and this relationship is associated with children’s mental and physical health status, which includes sleep quality [ 42 ]. Importantly, the study provides new insights into the impact of maternal pregnancy stress on child sleep quality by examining the mediating role of parent–child relationship. This study sheds light on the factors influencing sleep quality across different parent–child dynamics in the family environment. Parent–child relationship is of high interest to the general public as they strive to improve it in order to promote better sleep among children. These findings contribute to improved understanding of the association between emotional stress during pregnancy, parent–child relationship, and child sleep quality. They also provide new directions for the development of interventions to enhance child sleep quality. This study has several limitations that need to be acknowledged. First, the cross-sectional design limited the ability to confirm the causal association between maternal pregnancy stress, parent–child relationships, and child sleep quality. Longitudinal studies are warranted to examine the causal effect of prenatal maternal stress on child sleep quality. Second, the measure of children sleep were reported by children’s caregivers, thus, further research that adopts multiple methodologies for assessing sleep quality is needed. Third, maternal stress during pregnancy, which includes negative mood and major life events during pregnancy measure relied on retrospectively recalled, which may be recall biased for our study. However, there is some research suggesting that emotion or mood memories of past are long-lasting and likely to be accessible, and negative mood or life event memories can be easier to retrieve and more likely to influence mental health and behavior [ 45 , 46 ]. With this in mind, our questionnaire included entries on maternal negative mood and life event during pregnancy. To help mothers easier recall negative mood during pregnancy, only the three most common negative moods were chosen from the scales in Affectometer-2. This study had several strengths. This was a survey of a large sample population of pre-school children, and these findings may provide improved understanding of the role of parent–child relationship in the association between maternal stress during pregnancy and child sleep quality. They may also provide a new direction for the development of interventions to improve child sleep quality. Conclusions This study showed that maternal stress during pregnancy was associated with negative parent–child relationship and child sleep disorders; In addition, a good parent-child relationship was positively associated with child sleep quality. Parent–child relationship mediate the association between maternal stress during pregnancy and child sleep disorders. This finding could provide a scientific basis for developing preventive strategies to improve child sleep quality. Mothers who experienced greater stress during pregnancy should focus on the parent-child relationship to improve sleep disorders in children. Declarations Acknowledgments We thank all the children and their guardians, medical workers who participated in the questionnaire, and Changzhou Children's Hospital Affiliated to Nantong University who provided scientific and reasonable information for this survey. Authors’ contributions QY.L and YX.G developed the research question. CY.Z, YT.L, and QY.L drafted the main manuscript. CY.Z and YT.L ran the statistical analyses. All authors provided edits and feedback on the manuscript. F.Y, W.T, K.J, QY.L and YX.G secured funding and were responsible for study design. Funding statement This research was supported by 2021 Maternal and Child Health Research Project of Jiangsu Province (F2021-48). Ethics approval and consent to participate All protocols were approved by the Institutional Review Board of Nantong University, protocol number 2022-04. All participants were consented for this research study and the consent form was approved by the Institutional Review Board of Nantong University. All research was carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare there are no competing interests. References Hutchison BL, Stone P, McCowan L, et al. A postal survey of maternal sleep in late pregnancy. 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Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling , 1999, 6(1): 1-55. MacKinnon D P, Lockwood C M, Hoffman J M, et al. A comparison of methods to test mediation and other intervening variable effects. Psycho Methods , 2002, 7(1): 83. Chen X, Ke ZL, Chen Y, Lin X. The prevalence of sleep problems among children in mainland China: a meta-analysis and systemic-analysis. Sleep Med . 2021 Jul;83:248-255. Boles, R.E., et al., Family Chaos and Child Functioning in Relation to Sleep Problems Among Children at Risk for Obesity. Behav Sleep Med , 2017. 15(2): p. 114-128. Troxel W M, Lee L, Hall M ,et al.Single-parent family structure and sleep problems in black and white adolescents. Sleep Med , 2014, 15(2):255-261. Abdul Jafar N K, Tham E K H, Pang W W, et al. Association between breastfeeding and sleep patterns in infants and preschool children. Am J clin Nutr , 2021, 114(6): 1986-1996. Cohen, Engler, Hadash et al.Breastfeeding may improve nocturnal sleep and reduce infantile colic: Potential role of breast milk melatonin.European, Eur J Pediatr , 2012, 171(4):729-732. Sánchez C L, Cubero J, Sánchez J, et al. The possible role of human milk nucleotides as sleep inducers. Nutr Neurosci , 2009, 12(1): 2-8. Andersen S L .Trajectories of brain development: point of vulnerability or window of opportunity? Neurosci Biobehav Rev , 2003, 27(1-2):3-18. Niederhofer H , Reiter A .Prenatal maternal stress, prenatal fetal movements and perinatal temperament factors influence behavior and school marks at the age of 6 years. Fetal Diagn Ther , 2004, 19(2):160-162. Anders T F. Infant sleep, nighttime relationships, and attachment. Psychiatry , 1994, 57(1): 11-21. Davis E P, Sandman C A. The timing of prenatal exposure to maternal cortisol and psychosocial stress is associated with human infant cognitive development. Child Dev , 2010, 81(1): 131-148. Erath S A, Tu K M. The parenting context of children’s sleep. Sleep and development: Familial and socio-cultural considerations (pp. 29–47). Oxford University Press. Kuhlman K R , Repetti R L , Reynolds B M ,et al.Change in parent-child conflict and the HPA-axis: Where should we be looking and for how long? Psychoneuroendocrinology , 2016, 68:74-81. Zhang L , Yang Y , Liu Z Z ,et al.Sleep disturbance mediates the association between intrafamily conflict and mental health problems in Chinese adolescents. Sleep Med , 2018:S1389945718300765. El‐Sheikh M, Kelly R J. Family functioning and children's sleep. Child Dve Perspect , 2017, 11(4): 264-269. Sadeh A, Raviv A, Gruber R. Sleep patterns and sleep disruptions in school-age children. Dev Psychol , 2000, 36(3): 291. Kelly R J , Marks B T , El-Sheikh M .Longitudinal Relations Between Parent–Child Conflict and Children's Adjustment: The Role of Children's Sleep. J Abnorm Child Psychol , 2014,42(7):1175-1185. El-Sheikh M , Buckhalt J A , Keller P S ,et al.Children's objective and subjective sleep disruptions: links with afternoon cortisol levels. Health Psychol . 2008 Jan;27(1):26-33. Chen Y J, Strodl E, Hou X Y, et al. Parent-child interactions in early life mediating association between prenatal maternal stress and autistic-like behaviors among preschoolers. Psychol Health Med . 2023;28(8):2156-2168. Williams, S.E., J.H. Ford, and E.A. Kensinger, The power of negative and positive episodic memories. Cogn Affect Behav Neurosci , 2022. 22(5): p. 869-903. Burnell, R., A.S. Rasmussen, and M. Garry, Negative memories serve functions in both adaptive and maladaptive ways. Memory , 2020. 28(4): p. 494-505. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4808793","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333368400,"identity":"19f9a5ff-3c0d-4ff8-acd2-ceea4c50aa3f","order_by":0,"name":"Chaoyi Zou","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chaoyi","middleName":"","lastName":"Zou","suffix":""},{"id":333368401,"identity":"09189d5a-dfd0-4dce-b4b7-21e088576674","order_by":1,"name":"Yitong Lu","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yitong","middleName":"","lastName":"Lu","suffix":""},{"id":333368402,"identity":"ca734ea4-cfef-417b-bc57-05d177743c4e","order_by":2,"name":"Fang Yao","email":"","orcid":"","institution":"Changzhou Children's Hospital Affiliated to Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fang","middleName":"","lastName":"Yao","suffix":""},{"id":333368403,"identity":"24ff6787-b856-4617-8838-2abe2362435a","order_by":3,"name":"Wenjuan Tu","email":"","orcid":"","institution":"Changzhou Children's Hospital Affiliated to Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenjuan","middleName":"","lastName":"Tu","suffix":""},{"id":333368404,"identity":"57263e9f-8573-44d6-b777-71b4fc7540ff","order_by":4,"name":"Kaihua Jiang","email":"","orcid":"","institution":"Changzhou Children's Hospital Affiliated to Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kaihua","middleName":"","lastName":"Jiang","suffix":""},{"id":333368406,"identity":"2aeb1acc-e63c-41e7-992d-91fac7c4786d","order_by":5,"name":"Yuexia Gao","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuexia","middleName":"","lastName":"Gao","suffix":""},{"id":333368407,"identity":"3ce7f87e-a82b-417a-8e68-0cc385705f85","order_by":6,"name":"Qingyun Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYDACZghV38/e2PjgAylaGGf2HG42nEGKZYwbbqS3SXMQo5TvOO/h17xtd5gNbj5skGZgsJPTbSCgRfIwX5o1b9szNsnbiQ3GBQzJxmYHCGgxOMxjZszbdpiHD6gleQbDgcRtxGqRYLh5sOEwD5FajB8DtRgI3GBsbCZKiyTQFsY55w4nSPYkNjPOMCDCL3znzxh/eFN2OIGf/fjzHx8q7OQIamE4wMAmxYNwJyHlEC3MH38Qo3AUjIJRMApGLgAARI5HGgSThHUAAAAASUVORK5CYII=","orcid":"","institution":"Nantong University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Qingyun","middleName":"","lastName":"Lu","suffix":""}],"badges":[],"createdAt":"2024-07-26 14:35:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4808793/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4808793/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63809308,"identity":"3abf983c-55bf-4af2-9ad2-bdc4cddcb3ac","added_by":"auto","created_at":"2024-09-02 13:51:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":174154,"visible":true,"origin":"","legend":"\u003cp\u003eMediation model of parent–child relationship on maternal stress during pregnancy and child sleep quality (N = 4830). Age, family structure, and feeding approach were taken as covariates. The fit indices for the modified model were acceptable: χ2 = 163.53, df = 48, χ2/df = 3.41, RMSEA = 0.022, GFI = 0.994, PGFI = 0.612, CFI = 0.988, TLI = 0.984, PNFI = 0.715.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4808793/v1/703b59cba5af55de94623a66.png"},{"id":90444317,"identity":"23e7ede4-be0f-4af1-8f1c-3831131ac669","added_by":"auto","created_at":"2025-09-02 19:16:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1126169,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4808793/v1/5a823b8b-3684-45e5-bee2-64f9e1e182d6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between maternal stress during pregnancy and child sleep quality: Mediation effect of parent–child relationship","fulltext":[{"header":"Background","content":"\u003cp\u003eIn recent years, research has focused on sleep disorders in children, which have an incidence rate of 18\u0026ndash;61% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Childhood is marked by rapid developmental changes in sleep patterns, and sleep problems are among the most commonly reported parenting issues today [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A growing body of evidence suggests that sleep problems in children are associated with adverse developmental outcomes, including physical, cognitive, emotional, and behavioral issues [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Chronic sleep disorders can impact brain tissues, causing impaired functional areas and psycho-behavioral problems in preschool children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Identification of factors associated with sleep disorders in children is crucial in improving their physical and mental health.\u003c/p\u003e \u003cp\u003eThe earliest predictors of sleep problems in children can potentially be found \u003cem\u003ein utero\u003c/em\u003e, particularly maternal stress during pregnancy, which includes hypervigilance and hyperarousal [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Some studies demonstrated that maternal negative emotion (depression, anxiety) during pregnancy increases the risk of sleep problems in infants and preschool children, especially sleep rhythm disorders and night awakenings [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thus, exposure to maternal negative stress and emotion during pregnancy may be a risk factor for the development of early sleep problems in children. Some literature described how exposure of the hypothalamic\u0026ndash;pituitary\u0026ndash;adrenocortical (HPA) axis to maternal stress hormones (e.g., cortisol) can influence child sleep problems [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Some studies also examined alterations in fetal cerebellar\u0026ndash;insular connectivity as a result of prenatal exposure to stress as intermediate mechanism underlying sleep problems in 3\u0026ndash;5-year-old children [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Most studies to date have focused on stress physiological mechanisms that may underlie the association between high levels of maternal stress during pregnancy and child sleep disorders.\u003c/p\u003e \u003cp\u003eWhat has been neglected mostly, however, is the influence that postnatal parenting factors may have on child sleep status. More specifically, a previous study demonstrated that particularly negative emotions during pregnancy was associated with lower expected parenting self-efficacy in pregnancy, suggesting that anxiety during pregnancy hampers optimal preparation for parenting [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Helen and Sydney found that young mothers with prenatal depression perceived more parent\u0026ndash;child interaction difficulty than non-depressed mothers during pregnancy even after adjusting for postpartum depression [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and prenatal depression predicted child development. Thus, mothers who experienced high levels of negative stress during pregnancy are also expected to encounter more difficulty in establishing good interaction with their offspring. While several studies have considered parenting factors as confounders, when looking at the predictive effect of maternal stress during pregnancy on child behavior [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], very little is known about how maternal stress during pregnancy may lead to parent\u0026ndash;child relationship stress, which, in turn, could also affect child sleep.\u003c/p\u003e \u003cp\u003eMaternal stress during pregnancy has been evaluated using a broad range of instruments under the following categories: negative emotion/mood status, perceived stress, daily hassles, psychological symptomatology, life events, specific socioenvironmental stressors, and pregnancy-specific stress to pregnancy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In view of some longstanding approaches involve the assessment of negative emotion/mood during pregnancy, and stressful stimuli, especially major life events during pregnancy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], are applied, thus, maternal stress during pregnancy in our study are focused on negative emotion/mood and major life event stress. Our study aimed to determine (1) whether maternal stress during pregnancy and parent\u0026ndash;child relationship are associated with child sleep quality and (2) whether parent\u0026ndash;child relationship mediates the association between maternal pregnancy stress and child sleep quality. The findings provide insight for interventions aimed at improving parent\u0026ndash;child relationship stress and child sleep difficulties.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e Participants in this study were mothers of 4,830 children from 13 community health centers in Xinbei District, Changzhou City, China. Health surveillance and questionnaire data were analyzed. Inclusion criteria for children were age of 3\u0026ndash;6 years old, parental voluntary participation, and willingness to sign an informed consent form. Alternatively, the exclusion criteria were incomplete questionnaires, presence of stunting or chronic diseases, and high-risk pregnancies. Of the 5,013 participants who completed the questionnaire, the demographic differences between the 183 excluded participants and the remaining sample were not statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedure and measures\u003c/h2\u003e \u003cp\u003e The participants completed paper questionnaires at the Children\u0026rsquo;s Health Screening Clinic located at 1 of the 13 community health centers in Xinbei District, Changzhou City, China. Completion of the questionnaire was voluntary and participation was not mandatory. Trained researchers collected the participants\u0026rsquo; sociodemographic data and information regarding children\u0026rsquo;s lifestyles and mothers\u0026rsquo; conditions during pregnancy using a structured questionnaire. The questionnaire covered child age, parental education and occupation, family structure, annual family income, child feeding, mother\u0026rsquo;s perceived stress during pregnancy, and child sleep problems. All the participants provided informed consent, and the study was approved by the ethics committee of Nantong University\u0026rsquo;s School of Public Health (approval no. (2022) 04).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eChildren\u0026rsquo;s Sleep Habits Questionnaire\u003c/h2\u003e \u003cp\u003eThe Children\u0026rsquo;s Sleep Habits Questionnaire (CSHQ) was compiled by American scholar Judith in 2000 and is currently one of the credible research tools used in the sleep research of children aged 3 to 12. It is completed onsite by parents based on their child\u0026rsquo;s sleep status during the previous week. The questionnaire was validated by a sleep diary and a wristwatch activity monitor, a standardized sleep measurement tool, and had a strong retest reliability (0.62 to 0.79) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It was translated into Chinese and included in the guideline for child sleep hygiene by the National Health Commission of China [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Furthermore, it has been extensively used in research conducted throughout China and exhibited good reliability and validity. The CSHQ can be read and understood normally and filled out accurately by parents. The CSHQ questionnaire contains a total of 33 entries that measure Bedtime Resistance, Sleep Onset Delay, Sleep Duration, Sleep Anxiety, Night Wakings, Parasomnias, and Sleep Disordered Breathing, Daytime Sleepiness 8 dimensions of sleep problems. Five specific sleep questions from this questionnaire were analyzed: nighttime sleep duration, number of nighttime awakenings, sleep difficulties, regular sleep, and sleep latency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eMaternal Stress Assessment\u003c/h2\u003e \u003cp\u003eThe mothers retrospectively reported stress during pregnancy based on their medical records during pregnancy. Maternal stress, including negative mood and major life events during pregnancy, was assessed. The questionnaire comprises a total of four sections, one pertaining to major life events during pregnancy and three to negative mood during pregnancy. The negative mood score was used as the endpoint of Affectometer-2 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Ten negative adjectives were determined and formed the negative mood subscales in Affectometer-2: lonely, helpless, impatient, depressed, hopeless, withdrawn, discontented, confused, tense, and insignificant [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The mothers\u0026rsquo; negative mood was assessed using three items, namely, tense, depressed, and hopeless. Furthermore, their mood stress during pregnancy was rated on a four-point scale (from \u0026ldquo;hardly ever\u0026rdquo; [0] to \u0026ldquo;most of the time\u0026rdquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]). The mean score of the summed items was used to reflect negative mood score and ranged between 0 and 3, with higher scores indicating greater experience of negative mood. The evaluation of life events stress during pregnancy is adapted from the Life Events Scale (LES) developed by Young Desen [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Items include life events that are likely to occur and have a high impact during pregnancy, including 9 items in family life stress (husband beating and scolding, separation of husband and wife, tension between husband and wife, serious illness or serious injury of family members, death of family members, serious illness or serious injury of husband, housing stress, moving, and conflict with family members).There were 3 items in work and financial stress (job loss, husband job loss, family financial loss), and 3 items for social stress (tension with colleagues, tension with neighbors, involvement in legal disputes). The evaluation of pregnancy stress events included whether the life event occurred and the degree of impact on oneself (0: None, 1: Happened but had no impact, 2: Some impact, 3: Severe impact). The total score of the stressful life event score of the pregnant woman was added up, and the total score was divided into 0 points, 1 points, 2 points, and 3 points into 4 groups. In the present study, Cronbach\u0026rsquo;s alpha coefficient for the questionnaire was 0.78, with a KMO value of 0.75 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 in Bartlett\u0026rsquo;s test). The questionnaire demonstrated good reliability and validity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eBrigance Parent\u0026ndash;Child Interaction Scale\u003c/h2\u003e \u003cp\u003eThe Brigance Parent\u0026ndash;Child Interactions Scale, a parent report questionnaire, was developed by researcher Frances Page Glascoe in 2002 to monitor parent\u0026ndash;child interaction problems. This scale has been standardized in the USA with 382 families recruited (matching demographic characteristics). It was translated into Chinese and used in multiple studies across China. The scale consists of 20 questions, including 14 positive and 6 negative interaction questions. The questionnaire uses a three-point self-report scale that categorizes responses to each question into \u0026ldquo;rarely/inconsistent,\u0026rdquo; \u0026ldquo;sometimes,\u0026rdquo; and \u0026ldquo;often/concordant.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn this study, the scores of the questions were first summed up to obtain the total score. The total scores were ranked, and 25% of each group was taken as the high and low groups. The scores of the high and low groups on each question were compared using the independent samples \u003cem\u003et\u003c/em\u003e-test, and questions with no significant difference between the high and low groups were excluded. Delete questions with correlation coefficients\u0026thinsp;\u0026lt;\u0026thinsp;0.3 between the scores of each question and the total score. The questions deleted at the end of the total item analysis were 3, 10, 13, 15, 16, and 17. Exploratory factor analysis was conducted on the remaining questions, and the KMO value was 0.797, suggesting that the questionnaire was suitable for factor analysis. Subsequently, factor extraction was performed via principal component analysis and orthogonal rotation with variance maximization, and questions with factor loadings\u0026thinsp;\u0026lt;\u0026thinsp;0.4 were deleted to achieve division into three dimensions according to the dimensional factors of the original scale: Dimension 1: Guiding, which includes 2, 4, 9, 14, and 19; Dimension 2: Intimacy, which includes 1, 5, 7, and 8; and Dimension 3: Parental Efficacy, which includes 11, 12, 18, and 20.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics, correlation analysis, \u003cem\u003et\u003c/em\u003e-tests, and one-way analysis of variance were conducted using IBM SPSS Statistics version 27.0. Continuous variables were expressed as means and standard deviations (SD) and categorical variables as percentages. To examine differences in categorical sociodemographic characteristics associated with child sleep quality, chi-squared tests and Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-tests were employed. Structural equation modeling was used to analyze the mediation model. The model was developed using maternal stress during pregnancy as the independent variable, child sleep quality as the dependent variable, and parent\u0026ndash;child relationship as the mediating variable. As all continuous variables exhibited normal distribution, great likelihood estimation was used as a comprehensive test of the model. The chi-squared statistic, root mean squared error of approximation (RMSEA), goodness-of-fit index (GFI), Tucker\u0026ndash;Lewis fit index (TLI), comparative fit index (CFI), Parsimony-adjusted normed fit index (PNFI), and parsimony-adjusted goodness-of-fit index (PGFI) were used to evaluate the goodness of fit of the model. The acceptable values for model fit are as follows: RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.08, GFI\u0026thinsp;\u0026ge;\u0026thinsp;0.90, TLI\u0026thinsp;\u0026ge;\u0026thinsp;0.90, CFI\u0026thinsp;\u0026ge;\u0026thinsp;0.90, TLI\u0026thinsp;\u0026ge;\u0026thinsp;0.90, PNFI\u0026thinsp;\u0026ge;\u0026thinsp;0.50, and PGFI\u0026thinsp;\u0026ge;\u0026thinsp;0.50 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The researchers suggested using bootstrapping as a potent and efficient technique for testing the statistical significance of mediated indirect effects. Indirect effects were considered significant at the 0.05 level if the bias-corrected 95% confidence interval (CI) of 5000 bootstrap samples did not include 0 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic characteristics of the participants are presented in Table \u003cspan\u003e1\u003c/span\u003e. The mean age of the participating children was 4.27 years (SD, 0.69; range, 3\u0026ndash;6 years), and 50.1% of them were boys and 49.9% were girls. About 14.8% of the families had a low mean gross annual income (\u0026le;￥80,000), 1.8% of the children were from single-parent families, and 67.2% of the children were exclusively breastfed up to 4 months of age. Child sleep status was categorized into good sleep quality (66.1%) and poor sleep quality (33.9%, characterized by short sleep duration, long sleep latency, and high number of night wakings) via cluster analysis. Child age was correlated with child sleep quality (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.85, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). However, gender did not have a statistically significant effect on child sleep quality. In addition, child sleep quality significantly varied across different family structures (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;46.04, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and feeding styles during the 4-month period (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;6.33, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The study found a statistically significant difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) in child sleep quality associated with maternal stress during pregnancy. Specifically, various factors including tense mood during pregnancy (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;82.61, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), depressed mood during pregnancy (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;46.10, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), hopeless mood during pregnancy (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;48.65, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and major life events during pregnancy (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;10.17, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017) exerted varying degrees of influence on child sleep quality.\u003c/p\u003e\n\u003cp\u003eThe association between parent\u0026ndash;child relationship and child sleep quality is presented in Table \u003cspan\u003e2\u003c/span\u003e. The children had a mean sleep duration of 9.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85 h, which was positively correlated with all three dimensions of parent\u0026ndash;child relationship (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Similarly, the mean sleep latency of the children was 0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42 h, which was significantly associated with the intimacy and guiding dimensions of parent\u0026ndash;child relationship (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), but not significant in the parental functional dimension(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.38). The average number of night wakings among children was 0.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71, which was significantly correlated with the intimacy and guiding dimensions of parent\u0026ndash;child relationship (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Child sleep difficulties had a statistically significant impact on all three dimensions of parent\u0026ndash;child relationship (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), as well as sleep regularity (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003cp\u003eThe mediation model of parent\u0026ndash;child relationship and the standardized coefficients for each variable are presented in Fig. \u003cspan\u003e1\u003c/span\u003e. The structural equation model depicts significant regression and correlation paths, whereby all path coefficients are statistically significant at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01. Acceptable fit indices were observed for the model: chi-squared test\u0026thinsp;=\u0026thinsp;163.53, df\u0026thinsp;=\u0026thinsp;48, RMSEA\u0026thinsp;=\u0026thinsp;0.022, GFI\u0026thinsp;=\u0026thinsp;0.994, PGFI\u0026thinsp;=\u0026thinsp;0.612, CFI\u0026thinsp;=\u0026thinsp;0.988, TLI\u0026thinsp;=\u0026thinsp;0.984, and PNFI\u0026thinsp;=\u0026thinsp;0.715. According to the model, the sleep qualities in children were significantly predicted by maternal stress during pregnancy and negative parent\u0026ndash;child relationship. The standardized direct effect values of maternal stress during pregnancy and parent\u0026ndash;child relationship on sleep qualities were \u0026minus;\u0026thinsp;0.19 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and 0.23 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), respectively. Parent\u0026ndash;child relationship was significantly impacted by maternal stress during pregnancy, with the standardized direct effect value being \u0026minus;\u0026thinsp;0.13 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Furthermore, the standardized indirect effect value of maternal stress during pregnancy on sleep qualities in children, through parent\u0026ndash;child relationship, was \u0026minus;\u0026thinsp;0.029 (\u0026minus;\u0026thinsp;0.13 * 0.23). The bootstrapped 95% CI did not include 0 (\u0026minus;\u0026thinsp;0.026, \u0026minus;\u0026thinsp;0.010, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) for the indirect effect of maternal stress during pregnancy on sleep quality through parent\u0026ndash;child relationship, confirming the significant indirect effect. The standardized total effect value of maternal stress during pregnancy on sleep quality was \u0026minus;\u0026thinsp;0.220 (\u0026minus;\u0026thinsp;0.029, \u0026minus;\u0026thinsp;0.191). Thus, the mediation effect ratio was 13.18% (0.029/0.220 \u0026times; 100%).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCharacteristics of mother and child\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable (n\u0026thinsp;=\u0026thinsp;4830)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGood sleep quality\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePoor sleep quality\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et /\u003cem\u003e\u0026chi;\u003c/em\u003e 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.502\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1612 (50.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e809 (49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1582 (49.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e827 (50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual household income\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.707\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow(\u0026lt;￥80,000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e458 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e240 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate(￥80,000\u0026ndash;￥300,000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2249 (70.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1161 (71.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh(\u0026gt;￥300,000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e487 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e235 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily structure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImmediate Family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1518 (47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e926 (56.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNuclear Family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1532 (48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e621 (38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJoint Family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle Parent Families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeding Within 4 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreast-feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2188 (68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1062 (64.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMix-feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1006 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e574 (35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTense mood during pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e82.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHardly ever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2584 (80.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1134 (69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e339 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e288 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOften\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e257 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e205 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMost of the time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepressed mood during pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHardly ever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2446 (76.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1104 (67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e431 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e303 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOften\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e299 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e217 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMost of the time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHopeless mood during pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHardly ever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2841 (88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1338 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e193 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e174 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOften\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e150 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMost of the time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor life events during pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot happen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3080 (96.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1551 (94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHappened but had no impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSome impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*The p-values were tested using the t-test and chi-square test; The bold part indicates \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eComparison of the parent-child relationship and child sleep quality\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"11\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable(n\u0026thinsp;=\u0026thinsp;4830)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntimacy\u003c/p\u003e\n \u003cp\u003e(13.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et/F\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGuiding\u003c/p\u003e\n \u003cp\u003e(9.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et/F\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParental Functional\u003c/p\u003e\n \u003cp\u003e(9.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et/F\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep duration(h/d)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLatency to fall asleep(h/d)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.381\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of night wakings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty in sleeping\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegular sleep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4504 (93.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e326 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*The p-values were tested using the ANOVA or t-test; The bold part indicates \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan\u003e1\u003c/span\u003e. Mediation model of parent\u0026ndash;child relationship on maternal stress during pregnancy and child sleep quality (N\u0026thinsp;=\u0026thinsp;4830). Age, family structure, and feeding approach were taken as covariates. The fit indices for the modified model were acceptable: \u0026chi;2\u0026thinsp;=\u0026thinsp;163.53, df\u0026thinsp;=\u0026thinsp;48, \u0026chi;2/df\u0026thinsp;=\u0026thinsp;3.41, RMSEA\u0026thinsp;=\u0026thinsp;0.022, GFI\u0026thinsp;=\u0026thinsp;0.994, PGFI\u0026thinsp;=\u0026thinsp;0.612, CFI\u0026thinsp;=\u0026thinsp;0.988, TLI\u0026thinsp;=\u0026thinsp;0.984, PNFI\u0026thinsp;=\u0026thinsp;0.715.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the sleep quality of 3\u0026ndash;6-year-old children and the association between maternal stress during pregnancy, parent\u0026ndash;child relationship, and child sleep quality. Cluster analysis revealed that 33.9% of children had poor sleep quality, characterized by short sleep duration, long sleep latency, and frequent night wakings. The results were consistent with those of a 2021 analysis in mainland China, which showed a proportion of 37.6% [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. No significant difference was observed in sleep duration between both sexes. In terms of family environmental factors, the annual income level of the family was not significantly associated with child sleep quality in our study. A previous study demonstrated that low income could influence child sleep behavior because of family function or chaos [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It is likely that the children in our study were all from the city, and the influence of family socioeconomic status on children was relatively limited. However, the child sleep quality in the current study varied depending on the types of family structure. This finding is consistent with the report by W M Troxel and colleagues in Pennsylvania, who found that sleep duration was affected by various types of family structure among adolescents [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The present study also examined the association between breastfeeding and sleep quality in children and demonstrated that feeding practices during the first 4 months of life had an impact on child sleep quality. Our results indicated that children who were exclusively breastfed during this period had longer sleep duration and shorter sleep latency compared with those who received mixed feeding, a finding consistent with that of a recent research conducted in Singapore [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The present study suggests that the disparity in nighttime sleep duration could be due to the abundant hormones present in breast milk [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These components may have an effect on early infant biological regulation, thereby extending the length of nighttime sleep in children [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study demonstrated that maternal stress during pregnancy was significantly associated with child sleep quality. The greater the mothers\u0026rsquo; exposure to adverse emotions and life event stress during pregnancy, the poorer their children\u0026rsquo;s sleep quality. Maternal stress during pregnancy can influence the neurodevelopmental outcomes of a child which in turn can influence the child sleep quality. Due to the rapid fetal brain development, exposure to intrauterine psychological stress increases the susceptibility of the fetus to neuropsychiatric disorders [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Furthermore, it may affect the neurobehavioral development of the offspring of exposed mothers [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]; it has also been associated with an increased risk of attention-deficit hyperactivity disorder and autism in children. Therefore, it is important to consider the impact of maternal pregnancy stress on fetal brain development [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Research has demonstrated that psychological stress related to pregnancy has a greater impact on developmental outcomes in infants and toddlers, including preterm birth, cognitive and motor development, emotion regulation, brain morphology, and sleep quality than general psychological stress [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Maternal pregnancy stress exposure can potentially affect the intrauterine development of the fetus through poor maternal health behaviors, indirectly causing health problems in children [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study showed that a good parent\u0026ndash;child relationship had a positive effect on child sleep status, and each of the three parent\u0026ndash;child relationship scores distinctly impacted child sleep quality. Parent\u0026ndash;child relationship is widely acknowledged to significantly contribute to child sleep [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Frequent parent\u0026ndash;child conflict in family life can serve as a chronic stressor and negatively impact child sleep quality [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. It may also affect the body\u0026rsquo;s regulatory system and cause hormone secretion disorders, thereby impacting the duration and quality of sleep, which results in mental health issues [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Furthermore, a previous research demonstrated that the HPA axis and the parasympathetic nervous system could potentially contribute to the correlation between child sleep patterns and their familial connections [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. One potential explanation is that a positive parent\u0026ndash;child relationship within a family influences the HPA axis of children, decreasing cortisol levels before bedtime and increasing overall cortisol level fluctuations, which ultimately impacts child sleep patterns [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study also demonstrated that parent\u0026ndash;child relationships played a mediating role in the association between maternal stress during pregnancy and child sleep quality. Maternal negative emotions during pregnancy was associated with lower expected parenting self-efficacy, which may hamper optimal preparation for parenting [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Previous studies found that mothers with prenatal depression faced more parent\u0026ndash;child interaction difficulties even after adjusting for postpartum depression [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These findings are consistent with those of previous studies demonstrating that maternal pregnancy stress is an influential factor in parent\u0026ndash;child relationship [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and this relationship is associated with children\u0026rsquo;s mental and physical health status, which includes sleep quality [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Importantly, the study provides new insights into the impact of maternal pregnancy stress on child sleep quality by examining the mediating role of parent\u0026ndash;child relationship. This study sheds light on the factors influencing sleep quality across different parent\u0026ndash;child dynamics in the family environment. Parent\u0026ndash;child relationship is of high interest to the general public as they strive to improve it in order to promote better sleep among children. These findings contribute to improved understanding of the association between emotional stress during pregnancy, parent\u0026ndash;child relationship, and child sleep quality. They also provide new directions for the development of interventions to enhance child sleep quality.\u003c/p\u003e \u003cp\u003eThis study has several limitations that need to be acknowledged. First, the cross-sectional design limited the ability to confirm the causal association between maternal pregnancy stress, parent\u0026ndash;child relationships, and child sleep quality. Longitudinal studies are warranted to examine the causal effect of prenatal maternal stress on child sleep quality. Second, the measure of children sleep were reported by children\u0026rsquo;s caregivers, thus, further research that adopts multiple methodologies for assessing sleep quality is needed. Third, maternal stress during pregnancy, which includes negative mood and major life events during pregnancy measure relied on retrospectively recalled, which may be recall biased for our study. However, there is some research suggesting that emotion or mood memories of past are long-lasting and likely to be accessible, and negative mood or life event memories can be easier to retrieve and more likely to influence mental health and behavior [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. With this in mind, our questionnaire included entries on maternal negative mood and life event during pregnancy. To help mothers easier recall negative mood during pregnancy, only the three most common negative moods were chosen from the scales in Affectometer-2. This study had several strengths. This was a survey of a large sample population of pre-school children, and these findings may provide improved understanding of the role of parent\u0026ndash;child relationship in the association between maternal stress during pregnancy and child sleep quality. They may also provide a new direction for the development of interventions to improve child sleep quality.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study showed that maternal stress during pregnancy was associated with negative parent\u0026ndash;child relationship and child sleep disorders; In addition, a good parent-child relationship was positively associated with child sleep quality. Parent\u0026ndash;child relationship mediate the association between maternal stress during pregnancy and child sleep disorders. This finding could provide a scientific basis for developing preventive strategies to improve child sleep quality. Mothers who experienced greater stress during pregnancy should focus on the parent-child relationship to improve sleep disorders in children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the children and their guardians, medical workers who participated in the questionnaire, and Changzhou Children\u0026apos;s Hospital Affiliated to Nantong University who provided scientific and reasonable information for this survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQY.L and YX.G developed the research question. CY.Z, YT.L, and QY.L drafted the main manuscript. CY.Z and YT.L ran the statistical analyses. All authors provided edits and feedback on the manuscript. F.Y, W.T, K.J, QY.L and YX.G secured funding and were responsible for study design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by 2021 Maternal and Child Health Research Project of Jiangsu Province (F2021-48).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll protocols were approved by the Institutional Review Board of Nantong University, protocol number 2022-04. All participants were consented for this research study and the consent form was approved by the Institutional Review Board of Nantong University. All research was carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare there are no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHutchison BL, Stone P, McCowan L, et al. A postal survey of maternal sleep in late pregnancy. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e,2012;12(1):144.\u003c/li\u003e\n\u003cli\u003eZhang Y，Sanders M，Feng W，et al. Using epidemiological data to identify needs for child-rearing support among Chinese parents: a cross-sectional survey of parents of children aged 6 to 35 months in 15 Chinese cities. \u003cem\u003eBMC Public Health\u003c/em\u003e,2019,19(1):1470. \u003c/li\u003e\n\u003cli\u003eTham EK，Schneider N，Broekman BF. 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Epidemiological survey on sleep health and influencing factors of preschool children in Shanghai.\u003cem\u003eChin J Woman Child\u003c/em\u003e, 2022,33(03):9-14. \u003c/li\u003e\n\u003cli\u003eYU J,GUAN J,YAN M.Research progress and nursing enlightenment on sleep quality among obese children.[J].\u003cem\u003eChin J Nurs\u003c/em\u003e,2023,58(10):1269-1274.\u003c/li\u003e\n\u003cli\u003eRichard, R. Kammann, and Flett, Affectometer 2: A scale to measure current level of general happiness. \u003cem\u003eAust J Psycho\u003c/em\u003e, 1983. 35(2): p.259-265.\u003c/li\u003e\n\u003cli\u003eDennerstein L, Lehert P, Burger H, et al. Mood and the menopausal transition. \u003cem\u003eJ Nerv Ment Dis\u003c/em\u003e, 1999, 187(11): 685-691.\u003c/li\u003e\n\u003cli\u003eYang Desen. \u003cem\u003eBehavioral Medicine\u003c/em\u003e. Changsha: Hunan Normal University Press(China), 1990:285-286.\u003c/li\u003e\n\u003cli\u003eHu L, Bentler P M. 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Parent-child interactions in early life mediating association between prenatal maternal stress and autistic-like behaviors among preschoolers. \u003cem\u003ePsychol Health Med\u003c/em\u003e. 2023;28(8):2156-2168.\u003c/li\u003e\n\u003cli\u003eWilliams, S.E., J.H. Ford, and E.A. Kensinger, The power of negative and positive episodic memories. \u003cem\u003eCogn Affect Behav Neurosci\u003c/em\u003e, 2022. 22(5): p. 869-903.\u003c/li\u003e\n\u003cli\u003eBurnell, R., A.S. Rasmussen, and M. Garry, Negative memories serve functions in both adaptive and maladaptive ways.\u003cem\u003e Memory\u003c/em\u003e, 2020. 28(4): p. 494-505. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maternal stress during pregnancy, Sleep quality, Parent–child relationship, Preschool children","lastPublishedDoi":"10.21203/rs.3.rs-4808793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4808793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo investigate the association between maternal stress during pregnancy, parent\u0026ndash;child relationships, and child sleep quality and determine whether parent\u0026ndash;child relationship mediates the association between maternal stress during pregnancy and child sleep quality.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study included 4,830 mothers and their children. The mothers retrospectively reported stress during pregnancy, including negative mood and major life events that happened during pregnancy, using a four-item questionnaire. They also completed the Brigance Parent-Child Interactions Scale (BPCIS) and the Brief Infant Sleep Questionnaire (BISQ). A structural equation model was used to analyze the association between maternal stress during pregnancy and child sleep quality, with parent\u0026ndash;child relationship as a mediator.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMaternal stress during pregnancy was negatively associated with parent\u0026ndash;child relationship (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;0.41, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), parent\u0026ndash;child relationship was positively associated with child sleep quality (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), whereas maternal stress during pregnancy was negatively associated with child sleep quality (\u003cem\u003e\u0026szlig;\u003c/em\u003e = \u0026minus;0.11, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Furthermore, parent\u0026ndash;child relationship mediated the association between maternal stress during pregnancy and child sleep quality, achieving a mediation effect rate of 13.19% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMaternal stress during pregnancy was associated with negative parent\u0026ndash;child relationship and child sleep disorders; In addition, a good parent-child relationship was positively associated with child sleep quality. Parent\u0026ndash;child relationship mediate the association between maternal stress during pregnancy and child sleep disorders. This finding could provide a scientific basis for developing preventive strategies to improve child sleep quality.\u003c/p\u003e","manuscriptTitle":"Association between maternal stress during pregnancy and child sleep quality: Mediation effect of parent–child relationship","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 13:43:24","doi":"10.21203/rs.3.rs-4808793/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9ded7e1-752f-4e1f-be2b-d861753ea706","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-02T19:08:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-02 13:43:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4808793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4808793","identity":"rs-4808793","version":["v1"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}