Experiences of labor in women undergoing induced and spontaneous onset of labor: Associations with depressive symptoms and sleep disturbances

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Induction of labor (IOL), depressive symptoms, and sleep disturbances may compromise the EOL. We evaluated whether EOL, depressive symptoms, and sleep disturbances are interrelated in women with IOL. Methods: The FinnBrain Birth Cohort with 2405 women comprising of 443 women in the IOL group and 1962 women in the spontaneous onset of labor (SOL) group. The Edinburgh Postnatal Depression (early pregnancy [pp 1 ], mid-pregnancy [pp 2 ] and late pregnancy points [pp 3 ]), the Basic Nordic Sleep Questionnaire (pp 1 , pp 2 , pp 3 and delivery point [pp 4 ]) and EOL were assessed, and the associations were investigated using logistic regression analyses. Results: Women reporting depressive symptoms at any point during pregnancy reported a more negative EOL (pp 1 p =0.004; pp 2 p =0.026; pp 3 p= 0.003). A more negative EOL was also reported by women with poor general sleep quality (pp 4 p =0.005), with higher Insomnia scores (pp 2 p =0.042; pp 4 p =0.007), and with higher Sleepiness scores (pp 2 p =0.001; pp 3 p =0.028; pp 4 p =0.034). At different pregnancy time points, several sleep disturbances, such as difficulty to fall asleep (pp 4 p =0.003) and nocturnal awakenings (pp 3 p =0.025) were associated with a more negative EOL. However, all of these findings were similar in both groups. Conclusions: Depressive symptoms and sleep disturbances were associated with a negative EOL independently of IOL. Our findings highlight psychological distress and sleep difficulties as distinct, clinically relevant determinants of EOL. Early identification and targeted management of these modifiable factors may improve EOL and maternal well-being. Trial registration number : ETMK 57/180/2011, meeting 14.6.2011 § 168. childbirth depression insomnia pregnancy sleep quality Figures Figure 1 Figure 2 Figure 3 Article Highlights Women who had induction of labor reported a more negative labor experience than those with a spontaneous onset of labor. Depressive symptoms and sleep disturbances during pregnancy were associated with a negative experience of labor. Associations of depressive symptoms and sleep disturbances with labor experience were independent of labor induction. Introduction The experience of labor (EOL) is highly important, because a negative experience can lead to detrimental consequences, such as a fear of childbirth (Dencker et al., 2019 ), postpartum depression (Rosseland et al. 2020 ; Waller et al. 2022 ), or the desire for a cesarean section (CS) in a subsequent labor (Gaudernack et al. 2020 ). A negative EOL is also associated with longer intervals between pregnancies, fewer subsequent offspring, and later intentional infertility (Gottvall and Waldenström 2002 ). Risk factors for a negative EOL include a long duration of labor (Joensuu et al. 2022 ; Ramlee et al. 2023 ), urgent CS (Joensuu et al. 2022 ; Ramlee et al. 2023 ), and labor pain (Karlsdottir et al. 2018 ). Furthermore, women who experience induction of labor (IOL) have a higher risk of a negative EOL than women with spontaneous onset of labor (SOL) (Joensuu et al. 2022 ). Good care during labor (Taheri et al. 2018 ), the IOL method used (Shechter-Maor et al. 2015 ), the IOL setting(Haavisto et al. 2021), and the length of the induction-to-delivery interval (Ramlee et al. 2023 ) also impact the EOL. Depressive symptoms and sleep disturbances deteriorate quality of life (Lagadec et al. 2018 ). During pregnancy, such symptoms can have widespread effects on maternal well - being, (Pietikäinen et al. 2019 ; Liu et al. 2022 ) and, may also influence infant outcomes (Newland et al. 2016 ; Rollè et al. 2020 ). The prevalence of depressive symptoms during pregnancy is between 8 and 20% (Biaggi et al. 2016 ) and with pre-pregnancy depression, the prevalence can be as high as 40% (Rae et al. 2025 ). Symptoms also increase as pregnancy proceeds (Bennett et al. 2004 ). Depressive symptoms during pregnancy have been shown to relate to a negative EOL (Whelan et al. 2023), for example through more intense labor pain or prolonged labor (Junge et al. 2018 ; Riutta et al. 2022 ). Sleep disturbances, particularly insomnia symptoms (Polo-Kantola et al. 2017 ; Aukia et al. 2020 ), also increase during pregnancy. Similar to depressive symptoms, sleep disturbances may interfere with negative experiences during pregnancy and labor, for example via higher levels of anxiety (van der Zwan et al. 2017 ), stress (Sanchez et al. 2020 ), and fear of childbirth (Dencker et al. 2019 ). Furthermore, depressive symptoms are related to sleep disturbances during pregnancy and postpartum and vice versa (Polo-Kantola et al. 2017 ; Biaggi et al. 2016 ; Tomfohr et al. 2015 ; Pietikäinen et al. 2019 ). Screening for maternal prenatal depressive symptoms, even without sleeping problems during pregnancy, would help identify women at an increased risk of a more negative EOL. Currently about one-third of labors are induced, and the rate of IOL is rising (Kruit et al. 2022 ). IOL is usually performed in the event of prolonged pregnancy, membrane rupture, or gestational diabetes mellitus. In so-called elective IOL, non-medical indications of IOL typically include maternal tiredness (Dögl et al. 2018 ; Coulm et al. 2016 ; Sørbye et al. 2020 ). Furthermore, women who prefer IOL often have higher levels of anxiety or depressive symptoms (Keulen et al. 2021 ). Accordingly, an understanding of the interplay between depressive symptoms and sleep disturbance during pregnancy is crucial, especially in cases of IOL. Despite the high incidence of maternal depressive symptoms and sleep disturbances during pregnancy, the literature on their possible interference with the EOL is scant. The current study focuses on the pregnancy, mood, and sleep of pregnant women and the factors influencing women’s EOL. We conducted a large prospective study and assessed depressive symptoms and sleep disturbances during pregnancy to investigate their relationships to EOL. We hypothesized that women with frequent depressive symptoms and sleep disturbances during pregnancy have a more negative EOL, and that this would be more pronounced in women undergoing IOL. Materials and Methods Data collection and participants This was a prospective follow-up study, that formed part of the Finnish FinnBrain Birth Cohort survey ( www.finnbrain.fi ) (Karlsson et al. 2018 ). The recruitment of pregnant women of all ages was conducted between December 2011 and April 2015 at Turku University Hospital and Åland hospital districts during routine early pregnancy appointments. The inclusion criterion was sufficient language skills to complete the study questionnaires. The FinnBrain Cohort survey involved 3808 women, of whom 3661 had a birth. Women who delivered at ≥ 38 gestation weeks (gwks) and had healthy pregnancies without severe pregnancy complications, such as gestational diabetes with pharmacotherapy, hypertension or pre-eclampsia, cholestasis of pregnancy, breech presentation fetus, multifetal pregnancy, early spontaneous rupture of membranes, or planned CS, were eligible. In addition, replying to the study questionnaires at least once was required. The responses were given in early pregnancy ( pp 1 : 11 + 2 to 16 + 6 gwks), in mid-pregnancy (pp 2 : 22 + 0 to 27 − 6 gwks), in late pregnancy (pp 3 : 32 + 0 to 38 + 0 gwks), and at delivery (pp 4 : 0–6 days postpartum). The early, mid-, and late pregnancy questionnaires were sent either by post or by e-mail, and if no reply was received in two to three weeks, two reminders were sent to the participant. The delivery questionnaire was assessed in the postpartum department. Altogether, 2405 women were included, of which 443 women had IOL (the IOL group) and 1962 women had a spontaneous onset of labor (the SOL group). The number of women with questionnaire data at each pregnancy point in both groups (IOL and SOL) is illustrated in Fig ure 1. Questionnaires Depressive symptoms were evaluated using the Edinburgh Postnatal Depression Scale (EPDS) (Rubertsson et al. 2011 ) in early, mid-, and late pregnancy with 10 questions that covered the previous week and were scored on a four-point Likert scale with 0–3 points per item (see Supplementary Information). A score ≥ 10 was considered a sign of clinical depression. Sleep disturbances in the previous month were assessed with the Basic Nordic Sleep Questionnaire (BNSQ) four times (early-, mid-, and late pregnancy and delivery; see Supplementary Information). In the BNSQ, 10 five-point sleep disturbance variables were dichotomized to differentiate between general sleep quality and the severity of sleep disturbances. Answers ranging from “1’’ to “3’’ represented no disturbances, and answers of “4’’ and “5’’ represented disturbances. In addition, “sleep duration’’ and “sleep need’’ were assessed, and “sleep loss* was calculated by subtracting “sleep need’’ from “sleep duration.’’ The sum scores of Insomnia (“difficulty to fall asleep/week,’’ “nocturnal awakenings/week,’’ and “too early morning awakening/week’’), Sleep Disordered Breathing (“snoring/week’’ and “witnessed apneas/week’’), and Sleepiness (“sleepiness in the morning/week,’’ “daytime sleepiness/week,’’ and “napping/week’’) were also calculated. The EOL was assessed with the question of “How was your experience of labor? (very positive/quite positive/quite negative, but I was able to cope soon/very negative)’’ after delivery in the postpartum department. In the statistical analysis, the EOL was dichotomized as positive (very positive/quite positive) or negative (quite negative/very negative). Together with the first questionnaire, background information was obtained, including age (in years), body mass index (BMI, kg/m 2 ), parity (primiparous/multiparous), and smoking (yes/no). The researchers obtained IOL information and the mode of delivery from the Finnish Medical Birth Register and rechecked it from medical records. Statistical analysis We conducted a descriptive analysis of the basic characteristics, EPDS scores (both continuous and categorical [≥ 10 points]) and sleep variables (both continuous and categorical), stratified into the two groups of IOL and SOL. Next, we studied whether EPDS scores at the three pregnancy points (early, mid- and late pregnancy) or sleep variables at the four pregnancy time points (early, mid-, and late pregnancy and delivery) were related to the EOL using a binary logistic regression model: experience of labor ~ Intercept + sleep variable + IOL + age + BMI + parity + smoking + EPDS +mode of delivery , where EOL (negative vs. positive), IOL (IOL vs. SOL), parity (multiparous vs. primiparous), smoking (yes vs. no) and mode of delivery (CS vs vaginal) were considered categorical. Age, BMI and EPDS scores were used as continuous variables (early pregnancy EPDS scores were entered for the sleep analysis). Thereafter, an interaction between EPDS scores or sleep variables and IOL was formed to examine whether the associations between EPDS or sleep variables and EOL differed depending on the group. All p -values were corrected using the Bonferroni correction. P -values (two-tailed) < 0.05 were interpreted as statistically significant. For the adjusted odds ratios (adjusted OR), 95% confidence intervals (95% CIs) were calculated. All analyses were performed in R (4.2.2, 2022) and figures were created using the ggplot2 library. Results Basic characteristics The mean age of the women was 30 years (range 17–46 years) with no differences between the groups. Compared to the women in the SOL group, more women in the IOL group were primiparous, had a higher BMI, and had more deliveries that resulted in urgent CS (Table 1). Maternal fatigue was cited as a reason for requesting elective IOL in 17 cases, representing 3.3% of all participants. The EOL for both groups is shown in Fig. 2. The EOL was better in the SOL group than in the IOL group. Of all the women, 32.7% (n=786) reported a negative EOL. Of the women who answered the EOL question, 6.0% (n=85) in the SOL group and 10.2 % (n=33) in the IOL group reported a very negative EOL. Of the answers provided, 18.9% (n=267) of women in the SOL group reported a very positive EOL, as did 5.9% (n=19) of women in the IOL group. Frequency of depressive symptoms and sleep disturbances Total EPDS scores, as well as the number of women with EPDS scores ≥10 remained stable during pregnancy in both the IOL and SOL groups. The mean EPDS score was 5, and an EPDS ≥10 was recorded in 13% of women in both groups (Table 2). The frequencies of sleep disturbances are shown in Table 2. General sleep quality worsened during pregnancy similarly in the IOL and SOL groups. Also, the Insomnia scores, as well as all distinct insomnia symptoms increased as pregnancy proceeded in both groups. The most frequently reported insomnia symptom was nocturnal awakenings/week. These were already common in early pregnancy, and at delivery, almost all women in both groups reported them. Of the sleep disordered breathing symptoms, snoring increased during pregnancy similarly in both groups, but at delivery women in the IOL group tended to have more snoring compared to women in the SOL group. In mid-pregnancy, the women in the IOL group had a shorter sleep duration, and more women slept for under seven hours. The Sleepiness scores showed a U-shaped change, being the highest in early pregnancy and at delivery in both groups. Of the distinct sleepiness symptoms, daytime sleepiness was the most commonly reported symptom in early pregnancy, while napping occurred most frequently at delivery. Associations between the experience of labor and depressive symptoms Regarding depressive symptoms, women with higher symptom scores at all recorded pregnancy points (early, mid- and late pregnancy) were more likely to report a negative EOL, similarly in both the IOL and SOL groups. A high depression score (EPDS≥10) was associated with a negative EOL only in late pregnancy (Table 3). Depression was not evaluated at delivery. The distributions of EPDS scores in the EOL groups are shown in Figure 3. Association between the experience of labor and sleep disturbances The associations between sleep disturbances and EOL are presented in Figure 3 and Table 3. In early pregnancy, there were no associations between sleep disturbances and EOL. In mid-pregnancy, women with higher Insomnia scores, higher Sleepiness scores, and more daytime tiredness were more likely to report a negative EOL. In late pregnancy, higher Sleepiness scores, more frequent nocturnal awakenings/week and more frequent morning sleepiness were related to a negative EOL. At delivery, women with higher Insomnia and Sleepiness scores, worse general sleep quality, and more frequent difficulties to fall asleep and morning sleepiness were more likely to report a negative EOL (Fig. 3). Sleep duration and sleep loss were not related to the EOL. Only one interaction between IOL and sleep disturbances was found: at delivery, women with greater sleep loss in the IOL group were more likely to report a negative EOL. Discussion Our study is one of the first to evaluate the associations between maternal depressive symptoms, sleep disturbances, and EOL. We found that women with depressive symptoms were more likely to report a negative EOL. This finding was constant throughout the pregnancy. In addition, women with sleep disturbances, especially insomnia and sleepiness symptoms from mid-pregnancy onwards, were more likely to report a negative EOL. However, sleep duration and sleep loss were not related to the EOL. Furthermore, women with IOL reported a more negative EOL than those with SOL. However, the associations between depressive symptoms, sleep disturbances and EOL were independent of IOL. Our findings highlight the importance of positive mood and high-quality sleep in promoting better EOL. Our results are in line with the results of a recent IOL study from Finland, which included 22 393 women with IOL and 72 658 women with SOL. That study showed that IOL was associated with a negative EOL (Joensuu et al. 2022 ). Women with IOL have been found to have more adverse delivery outcomes, such as longer labor duration (Lee and Gay 2004 ) and increased rates of operative vaginal deliveries (Souter et al. 2019 ), factors that may potentially worsen the EOL (Joensuu et al. 2022 ). The EOL can be negatively influenced by the fear of childbirth, which is more common in women with depressive symptoms (Demšar et al. 2018 ). A study by Whelan et al ( 2022 ) used the validated Labour Agentry Scale to evaluate women’s experiences of control during delivery. They found that the mean scores were lower and the experiences more negative for women with a prior diagnosis of depression or anxiety. Moreover, Waldenström et al. ( 2004 ) showed that depressive mood, evaluated using the EPDS during early pregnancy, was associated with a negative EOL when asked two months postpartum. However, Ramlee et al. ( 2023 ) found no correlation between depression and satisfaction with labor among women with planned IOL. We found that depressive symptoms already present in early pregnancy were associated with a more negative EOL, independent of IOL. The different outcomes may be attributed to the distinct sample sizes and questionnaires used. Previous research on the relationship between sleep and EOL is limited. In the above-mentioned study by Ramlee et al. ( 2023 ), maternal satisfaction with IOL was independent of sleep quality measured using the Pittsburgh Sleep Quality Index (PSQI) upon admission. Instead, Abay et al. ( 2024 ) found that poor sleepers assessed using the PSQI had lower means in the birth process subscale score of the Childbirth Experience Questionnaire than good sleepers meaning a more negative EOL among poor sleepers (Abay et al. 2024 ). In our earlier study of 117 women with IOL, poor general sleep quality evaluated using the BNSQ was associated with a more negative experience of IOL (Haavisto et al. 2023 ). Furthermore, women having difficulty to fall asleep reported more pain and less relaxation during IOL, while those with higher sleep loss reported more anxiety and were less satisfied (Haavisto et al. 2023 ). In the present study, we confirmed the association between sleep disturbances and a negative EOL. Sleep disturbances occurring in early pregnancy were not associated with the EOL, but associations were found from mid-pregnancy onwards. While insomnia symptoms were important, sleepiness symptoms were even more consistently related to a negative EOL. Despite these unambiguous findings, the association between sleep disturbances and a negative EOL was independent of IOL. Multiple factors appear to contribute to a negative EOL. Previous studies have emphasized the importance of high-quality treatment and supportive interactions during labor and hospital stay (Taheri et al. 2018 ). Furthermore, it is well established that women highly value being listened to and receiving individualized care (Keulen et al. 2021 ). Based on our findings, fewer depressive symptoms and good sleep quality during pregnancy may serve as protective factors for a more positive EOL, regardless of whether labor is induced. Emotional resilience, positive attitudes towards labor, and effective coping strategies are also known to be associated with a more favorable EOL (Aune et al. 2015 ). Conversely, both physiological and psychological stress have been shown to negatively impact the labor process and, consequently, the overall EOL (Walter et al. 2021 ). Our study had strengths but also flaws. One of the major strengths was the large sample size. Furthermore, we used two validated questionnaires, the EPDS and the BNSQ, which are widely used in different populations, including pregnant women (Okagbue et al. 2019 ; Polo-Kantola et al. 2017 ; Pietikäinen et al. 2019 ; Hedman et al. 2002 ). Depressive symptoms are screened with the EPDS in primary health care in Finland, therefore, the EPDS is a suitable tool to distinguish women with these symptoms. The BNSQ comprises multiple detailed items that assess sleep disturbances, enabling differentiation between various symptoms of insomnia and excessive sleepiness. However, the fourth BNSQ questionnaire was completed after delivery, and thus the replies may have been influenced by labor even though the women were instructed to evaluate sleep during the entire previous month. Furthermore, we did not evaluate either pre-pregnancy depressive symptoms or sleep quality; therefore, we were unable to estimate the effects of plausible existing symptoms. No sleep architecture was measured, which could have provided another perspective on sleep quality. However, previous studies have shown that reports of subjective sleep quality are usually sufficient and more feasible in clinical work than objective measurements, which measure sleep during only one or several nights. Furthermore, the study population was relatively healthy with uncomplicated full-term pregnancies; therefore, our results cannot be generalized to women with preterm delivery and pregnancy complications. Conclusion Our findings underscore the significant role of depressive symptoms and sleep disturbances during pregnancy in contributing to a EOL. Psychological distress and sleep disturbances represented distinct and clinically meaningful contributors to diminished EOL. In particular, depressive symptoms, insomnia symptoms, and daytime sleepiness emerged as key factors associated with adverse EOL outcomes. Although IOL was linked to a more negative EOL relative to SOL, mood and sleep were equally associated with a negative EOL in both groups. Therefore, to improve EOL, systematic screening of maternal mood and sleep during pregnancy is required, followed by appropriate clinical intervention when warranted. Abbreviations delivery point, pp 4 ; early pregnancy point, pp 1 ; EOL, experience of labor; CS, Cesarean section; IOL, induction of labor; late pregnancy point, pp 3 ; mid-pregnancy point, pp 2 ; SOL, spontaneous onset of labor; gwk, gestation week; EPDS, Edinburgh Postnatal Depression Scale; BNSQ, Basic Nordic Sleep Questionnaire; BMI, body mass index; The Pittsburgh Sleep Quality Index, PSQI Declarations Ethics approval: The study was approved by the Joint Ethics Committees of the University of Turku and Turku University Hospital, Turku, Finland (number ETMK 57/180/2011, meeting 14.6.2011 § 168). Compliance with Ethical Standards Consent: Written informed consent was obtained from all participants. 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AOGS 99;1700–1709. https://doi.org/10.1111/aogs.13948 Souter V., Painter I., Sitcov K., Caughey A. B. (2019). Maternal and newborn outcomes with elective induction of labor at term. Am J Obstet Gynecol 220;273.e1-273.e11. https://doi.org/10.1016/j.ajog.2019.01.223 Taheri M., Takian A., Taghizadeh Z. et al (2018). Creating a positive perception of childbirth experience : systematic review and meta- analysis of prenatal and intrapartum interventions. Reprod Health 15;73. Tomfohr L. M., Buliga E., Hons B. A. et al (2015) Trajectories of Sleep Quality and Associations with Mood during the Perinatal Period. Sleep 38;1237–1245. van der Zwan J. E., de Vente W., Tolvanen M. et al(2017). Longitudinal associations between sleep and anxiety during pregnancy, and the moderating effect of resilience, using parallel process latent growth curve models. Sleep Med, 40;63–68. https://doi.org/10.1016/j.sleep.2017.08.023 Waldenström U., Hildingsson I., Rubertsson C., Rådestad I. (2004). A negative birth experience: Prevalence and risk factors in a national sample. Birth, 31:17–27. https://doi.org/10.1111/j.0730-7659.2004.0270.x Waller R., Kornfield S. L., White L. K. et al. (2022). Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression. Arch of Womens Ment Health, 25:985–993. https://doi.org/10.1007/s00737-022-01263-3 Walter M. H., Abele H., Plappert C. F. (2021). The Role of Oxytocin and the Effect of Stress During Childbirth: Neurobiological Basics and Implications for Mother and Child. Front Endocrinol 12;1–10. https://doi.org/10.3389/fendo.2021.742236 Whelan A. R., Recabo O., Ayala N. K. et al (2022). The Association of Perceived Labor Agentry and Depression and/or Anxiety. Am J Perinatol 40 ; 1047–1053. https://doi.org/10.1055/a-2051-2433 Tables Tables 1 to 3 are available in the supplementary files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-9047309","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614140887,"identity":"c474a8c3-ed23-463a-960f-848e88cada7d","order_by":0,"name":"Henna Lähde","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAn0lEQVRIiWNgGAWjYBACAwbmBmYGNhsw50MCcVoYQVrSGHgYGBhnkKLlMEQLUQ4zZ29s/FxQdj5xv0QCY8MDYrRY9hxslp5x7nZiD0gLcQ67kdggzdsG1sL+gDgt9x82/+ZtO0eSLYxtQFsOkKLlTGKbNc+5ZOOeMw8bidRy/PDh2zxldrLt7ckHG38QowUJMDaQqGEUjIJRMApGAU4AANmpNhtWwsaNAAAAAElFTkSuQmCC","orcid":"","institution":"University of Turku","correspondingAuthor":true,"prefix":"","firstName":"Henna","middleName":"","lastName":"Lähde","suffix":""},{"id":614140889,"identity":"029ea665-75c1-43b0-b0f2-499de17b11b2","order_by":1,"name":"Laura Perasto","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Perasto","suffix":""},{"id":614140890,"identity":"ccd1b1be-d1d3-4682-8992-18aea19aa2d3","order_by":2,"name":"Hasse Karlsson","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Hasse","middleName":"","lastName":"Karlsson","suffix":""},{"id":614140891,"identity":"6835c974-a0a2-4ba9-b771-acdfe91b962f","order_by":3,"name":"Linnea Karlsson","email":"","orcid":"","institution":"University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Linnea","middleName":"","lastName":"Karlsson","suffix":""},{"id":614140892,"identity":"42c87a04-64f5-4ee3-8022-2de2c579dc7c","order_by":4,"name":"Reetta Ilvonen","email":"","orcid":"","institution":"Turku University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Reetta","middleName":"","lastName":"Ilvonen","suffix":""},{"id":614140893,"identity":"81891e04-f469-4c37-80ea-05c32c348916","order_by":5,"name":"E.Juulia Paavonen","email":"","orcid":"","institution":"Helsinki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"E.Juulia","middleName":"","lastName":"Paavonen","suffix":""},{"id":614140894,"identity":"b80b8136-34a5-40a9-a739-31f5dd25d85b","order_by":6,"name":"Kirsi Rinne","email":"","orcid":"","institution":"Turku University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kirsi","middleName":"","lastName":"Rinne","suffix":""},{"id":614140895,"identity":"769444fc-3340-453d-a80d-5cb59d8d0341","order_by":7,"name":"Päivi Polo-Kantola","email":"","orcid":"","institution":"Turku University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Päivi","middleName":"","lastName":"Polo-Kantola","suffix":""}],"badges":[],"createdAt":"2026-03-06 07:24:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9047309/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9047309/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106003988,"identity":"491f42d5-0fe3-4e84-972e-425b1ee790c0","added_by":"auto","created_at":"2026-04-02 10:27:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157845,"visible":true,"origin":"","legend":"\u003cp\u003e\u0026nbsp;Flow chart of the study\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eWomen who responded to the Basic Nordic Sleep Questionnaire at the pregnancy point at the correct time\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eWomen who responded to the Edinburgh Postnatal Depression Scale at the pregnancy point at the correct time\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003ePregnancies under 38 gestation weeks, diabetes mellitus, gestational diabetes mellitus withpharmacotherapy, hypertension/pre-eclampsia, cholestasis of pregnancy, multiple pregnancy, breech presentation fetus, planned cesarean section\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9047309/v1/ea7c37572cd76cfd0600d4ce.png"},{"id":106003983,"identity":"43d7b032-1c1f-4066-87bf-c60a2093763d","added_by":"auto","created_at":"2026-04-02 10:27:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41241,"visible":true,"origin":"","legend":"\u003cp\u003eExperience of labor (EOL) in the spontaneous onset of labor (SOL, n=1416) and induction of labor (IOL, n=323) groups Missing answers to the EOL question: 546 (27.8%) in the SOL group and 120 (27.1%) in the IOL group\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9047309/v1/2dfadfba8db5dd5d19d56f7b.png"},{"id":106003980,"identity":"9686639b-b44f-451c-94ed-82af44027f5c","added_by":"auto","created_at":"2026-04-02 10:27:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":229424,"visible":true,"origin":"","legend":"\u003cp\u003eAssociations between experience of labor, depressive symptoms and sleep disturbances General sleep quality is shown with Barblot and other symptoms with Boxplot\u003c/p\u003e\n\u003cp\u003eLevel of statistical differences: \u003csup\u003ea\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, \u003csup\u003eb\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e\u0026lt;0.01, \u003csup\u003ec\u003c/sup\u003e\u003cem\u003e p\u003c/em\u003e\u0026lt;0.05 EPDS = Edinburgh Postnatal Depression Scale\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9047309/v1/36abce4a9a3a23d641382a36.png"},{"id":106095936,"identity":"84f76ac7-e9ce-435e-b24c-3128eb64f3f1","added_by":"auto","created_at":"2026-04-03 11:51:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":911382,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9047309/v1/312e8766-d1d5-41ab-a8bd-a7735ef70f38.pdf"},{"id":106095034,"identity":"a47be22b-6877-4dd3-9d71-0b978d8fa6ee","added_by":"auto","created_at":"2026-04-03 11:44:04","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":47104,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryinformation.doc","url":"https://assets-eu.researchsquare.com/files/rs-9047309/v1/98e322d4a36423f265b7576f.doc"},{"id":106003990,"identity":"a3e7fe09-fbfe-4777-bc97-0c820d2fd368","added_by":"auto","created_at":"2026-04-02 10:27:48","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":188060,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9047309/v1/3afe73e469343f0b1be4f15a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences of labor in women undergoing induced and spontaneous onset of labor: Associations with depressive symptoms and sleep disturbances","fulltext":[{"header":"Article Highlights","content":"\u003cul\u003e\n \u003cli\u003eWomen who had induction of labor reported a more negative labor experience than those with a spontaneous onset of labor.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDepressive symptoms and sleep disturbances during pregnancy were associated with a negative experience of labor.\u003c/li\u003e\n \u003cli\u003eAssociations of depressive symptoms and sleep disturbances with labor experience were independent of labor induction.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe experience of labor (EOL) is highly important, because a negative experience can lead to detrimental consequences, such as a fear of childbirth (Dencker et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), postpartum depression (Rosseland et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Waller et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), or the desire for a cesarean section (CS) in a subsequent labor (Gaudernack et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A negative EOL is also associated with longer intervals between pregnancies, fewer subsequent offspring, and later intentional infertility (Gottvall and Waldenstr\u0026ouml;m \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRisk factors for a negative EOL include a long duration of labor (Joensuu et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ramlee et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), urgent CS (Joensuu et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ramlee et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and labor pain (Karlsdottir et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, women who experience induction of labor (IOL) have a higher risk of a negative EOL than women with spontaneous onset of labor (SOL) (Joensuu et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Good care during labor (Taheri et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), the IOL method used (Shechter-Maor et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), the IOL setting(Haavisto et al. 2021), and the length of the induction-to-delivery interval (Ramlee et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) also impact the EOL.\u003c/p\u003e \u003cp\u003eDepressive symptoms and sleep disturbances deteriorate quality of life (Lagadec et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). During pregnancy, such symptoms can have widespread effects on maternal well\u003cb\u003e-\u003c/b\u003ebeing, (Pietik\u0026auml;inen et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Liu et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and, may also influence infant outcomes (Newland et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Roll\u0026egrave; et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The prevalence of depressive symptoms during pregnancy is between 8 and 20% (Biaggi et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and with pre-pregnancy depression, the prevalence can be as high as 40% (Rae et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Symptoms also increase as pregnancy proceeds (Bennett et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Depressive symptoms during pregnancy have been shown to relate to a negative EOL (Whelan et al. 2023), for example through more intense labor pain or prolonged labor (Junge et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Riutta et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Sleep disturbances, particularly insomnia symptoms (Polo-Kantola et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Aukia et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), also increase during pregnancy. Similar to depressive symptoms, sleep disturbances may interfere with negative experiences during pregnancy and labor, for example via higher levels of anxiety (van der Zwan et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), stress (Sanchez et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and fear of childbirth (Dencker et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Furthermore, depressive symptoms are related to sleep disturbances during pregnancy and postpartum and vice versa (Polo-Kantola et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Biaggi et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Tomfohr et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Pietik\u0026auml;inen et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Screening for maternal prenatal depressive symptoms, even without sleeping problems during pregnancy, would help identify women at an increased risk of a more negative EOL.\u003c/p\u003e \u003cp\u003eCurrently about one-third of labors are induced, and the rate of IOL is rising (Kruit et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). IOL is usually performed in the event of prolonged pregnancy, membrane rupture, or gestational diabetes mellitus. In so-called elective IOL, non-medical indications of IOL typically include maternal tiredness (D\u0026ouml;gl et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Coulm et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; S\u0026oslash;rbye et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Furthermore, women who prefer IOL often have higher levels of anxiety or depressive symptoms (Keulen et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Accordingly, an understanding of the interplay between depressive symptoms and sleep disturbance during pregnancy is crucial, especially in cases of IOL.\u003c/p\u003e \u003cp\u003eDespite the high incidence of maternal depressive symptoms and sleep disturbances during pregnancy, the literature on their possible interference with the EOL is scant. The current study focuses on the pregnancy, mood, and sleep of pregnant women and the factors influencing women\u0026rsquo;s EOL. We conducted a large prospective study and assessed depressive symptoms and sleep disturbances during pregnancy to investigate their relationships to EOL. We hypothesized that women with frequent depressive symptoms and sleep disturbances during pregnancy have a more negative EOL, and that this would be more pronounced in women undergoing IOL.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection and participants\u003c/h2\u003e \u003cp\u003eThis was a prospective follow-up study, that formed part of the Finnish FinnBrain Birth Cohort survey (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.finnbrain.fi\" target=\"_blank\"\u003ewww.finnbrain.fi\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.finnbrain.fi\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (Karlsson et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The recruitment of pregnant women of all ages was conducted between December 2011 and April 2015 at Turku University Hospital and \u0026Aring;land hospital districts during routine early pregnancy appointments. The inclusion criterion was sufficient language skills to complete the study questionnaires. The FinnBrain Cohort survey involved 3808 women, of whom 3661 had a birth. Women who delivered at \u0026ge;\u0026thinsp;38 gestation weeks (gwks) and had healthy pregnancies without severe pregnancy complications, such as gestational diabetes with pharmacotherapy, hypertension or pre-eclampsia, cholestasis of pregnancy, breech presentation fetus, multifetal pregnancy, early spontaneous rupture of membranes, or planned CS, were eligible. In addition, replying to the study questionnaires at least once was required. The responses were given in early pregnancy ( pp\u003csup\u003e1\u003c/sup\u003e: 11\u0026thinsp;+\u0026thinsp;2 to 16\u0026thinsp;+\u0026thinsp;6 gwks), in mid-pregnancy (pp\u003csup\u003e2\u003c/sup\u003e: 22\u0026thinsp;+\u0026thinsp;0 to 27\u0026thinsp;\u0026minus;\u0026thinsp;6 gwks), in late pregnancy (pp\u003csup\u003e3\u003c/sup\u003e: 32\u0026thinsp;+\u0026thinsp;0 to 38\u0026thinsp;+\u0026thinsp;0 gwks), and at delivery (pp\u003csup\u003e4\u003c/sup\u003e: 0\u0026ndash;6 days postpartum). The early, mid-, and late pregnancy questionnaires were sent either by post or by e-mail, and if no reply was received in two to three weeks, two reminders were sent to the participant. The delivery questionnaire was assessed in the postpartum department. Altogether, 2405 women were included, of which 443 women had IOL (the IOL group) and 1962 women had a spontaneous onset of labor (the SOL group). The number of women with questionnaire data at each pregnancy point in both groups (IOL and SOL) is illustrated in Fig\u003c/p\u003e \u003cp\u003eure 1.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuestionnaires\u003c/h3\u003e\n\u003cp\u003eDepressive symptoms were evaluated using the Edinburgh Postnatal Depression Scale (EPDS) (Rubertsson et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) in early, mid-, and late pregnancy with 10 questions that covered the previous week and were scored on a four-point Likert scale with 0\u0026ndash;3 points per item (see Supplementary Information). A score\u0026thinsp;\u0026ge;\u0026thinsp;10 was considered a sign of clinical depression.\u003c/p\u003e \u003cp\u003eSleep disturbances in the previous month were assessed with the Basic Nordic Sleep Questionnaire (BNSQ) four times (early-, mid-, and late pregnancy and delivery; see Supplementary Information). In the BNSQ, 10 five-point sleep disturbance variables were dichotomized to differentiate between general sleep quality and the severity of sleep disturbances. Answers ranging from \u0026ldquo;1\u0026rsquo;\u0026rsquo; to \u0026ldquo;3\u0026rsquo;\u0026rsquo; represented no disturbances, and answers of \u0026ldquo;4\u0026rsquo;\u0026rsquo; and \u0026ldquo;5\u0026rsquo;\u0026rsquo; represented disturbances. In addition, \u0026ldquo;sleep duration\u0026rsquo;\u0026rsquo; and \u0026ldquo;sleep need\u0026rsquo;\u0026rsquo; were assessed, and \u0026ldquo;sleep loss* was calculated by subtracting \u0026ldquo;sleep need\u0026rsquo;\u0026rsquo; from \u0026ldquo;sleep duration.\u0026rsquo;\u0026rsquo; The sum scores of Insomnia (\u0026ldquo;difficulty to fall asleep/week,\u0026rsquo;\u0026rsquo; \u0026ldquo;nocturnal awakenings/week,\u0026rsquo;\u0026rsquo; and \u0026ldquo;too early morning awakening/week\u0026rsquo;\u0026rsquo;), Sleep Disordered Breathing (\u0026ldquo;snoring/week\u0026rsquo;\u0026rsquo; and \u0026ldquo;witnessed apneas/week\u0026rsquo;\u0026rsquo;), and Sleepiness (\u0026ldquo;sleepiness in the morning/week,\u0026rsquo;\u0026rsquo; \u0026ldquo;daytime sleepiness/week,\u0026rsquo;\u0026rsquo; and \u0026ldquo;napping/week\u0026rsquo;\u0026rsquo;) were also calculated.\u003c/p\u003e \u003cp\u003eThe EOL was assessed with the question of \u0026ldquo;How was your experience of labor? (very positive/quite positive/quite negative, but I was able to cope soon/very negative)\u0026rsquo;\u0026rsquo; after delivery in the postpartum department. In the statistical analysis, the EOL was dichotomized as positive (very positive/quite positive) or negative (quite negative/very negative). Together with the first questionnaire, background information was obtained, including age (in years), body mass index (BMI, kg/m\u003csup\u003e2\u003c/sup\u003e), parity (primiparous/multiparous), and smoking (yes/no). The researchers obtained IOL information and the mode of delivery from the Finnish Medical Birth Register and rechecked it from medical records.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe conducted a descriptive analysis of the basic characteristics, EPDS scores (both continuous and categorical [\u0026ge;\u0026thinsp;10 points]) and sleep variables (both continuous and categorical), stratified into the two groups of IOL and SOL. Next, we studied whether EPDS scores at the three pregnancy points (early, mid- and late pregnancy) or sleep variables at the four pregnancy time points (early, mid-, and late pregnancy and delivery) were related to the EOL using a binary logistic regression model: \u003cem\u003eexperience of labor\u0026thinsp;~\u0026thinsp;Intercept\u0026thinsp;+\u0026thinsp;sleep variable\u0026thinsp;+\u0026thinsp;IOL\u0026thinsp;+\u0026thinsp;age\u0026thinsp;+\u0026thinsp;BMI\u0026thinsp;+\u0026thinsp;parity\u0026thinsp;+\u0026thinsp;smoking\u0026thinsp;+\u0026thinsp;EPDS +mode of delivery\u003c/em\u003e, where EOL (negative vs. positive), IOL (IOL vs. SOL), parity (multiparous vs. primiparous), smoking (yes vs. no) and mode of delivery (CS vs vaginal) were considered categorical. Age, BMI and EPDS scores were used as continuous variables (early pregnancy EPDS scores were entered for the sleep analysis). Thereafter, an interaction between EPDS scores or sleep variables and IOL was formed to examine whether the associations between EPDS or sleep variables and EOL differed depending on the group. All \u003cem\u003ep\u003c/em\u003e-values were corrected using the Bonferroni correction. \u003cem\u003eP\u003c/em\u003e-values (two-tailed)\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were interpreted as statistically significant. For the adjusted odds ratios (adjusted OR), 95% confidence intervals (95% CIs) were calculated. All analyses were performed in R (4.2.2, 2022) and figures were created using the ggplot2 library.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eBasic characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of the women was 30 years (range 17\u0026ndash;46 years) with no differences between the groups. Compared to the women in the SOL group, more women in the IOL group were primiparous, had a higher BMI, and had more deliveries that resulted in urgent CS (Table 1). Maternal fatigue was cited as a reason for requesting elective IOL in 17 cases, representing 3.3% of all participants.\u003c/p\u003e\n\u003cp\u003eThe EOL for both groups is shown in Fig. 2. The EOL was better in the SOL group than in the IOL group. Of all the women, 32.7% (n=786) reported a negative EOL. Of the women who answered the EOL question, 6.0% (n=85) in the SOL group and 10.2 % (n=33) in the IOL group reported a very negative EOL. Of the answers provided, 18.9% (n=267) of women in the SOL group reported a very positive EOL, as did 5.9% (n=19) of women in the IOL group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFrequency of depressive symptoms and sleep disturbances\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTotal EPDS scores, as well as the number of women with EPDS scores \u0026ge;10 remained stable during pregnancy in both the IOL and SOL groups. The mean EPDS score was 5, and an EPDS \u0026ge;10 was recorded in 13% of women in both groups (Table 2).\u003c/p\u003e\n\u003cp\u003eThe frequencies of sleep disturbances are shown in Table 2. General sleep quality worsened during pregnancy similarly in the IOL and SOL groups. Also, the Insomnia scores, as well as all distinct insomnia symptoms increased as pregnancy proceeded in both groups. The most frequently reported insomnia symptom was nocturnal awakenings/week. These were already common in early pregnancy, and at delivery, almost all women in both groups reported them. Of the sleep disordered breathing symptoms, snoring increased during pregnancy similarly in both groups, but at delivery women in the IOL group tended to have more snoring compared to women in the SOL group. In mid-pregnancy, the women in the IOL group had a shorter sleep duration, and more women slept for under seven hours.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Sleepiness scores showed a U-shaped change, being the highest in early pregnancy and at delivery in both groups. Of the distinct sleepiness symptoms, daytime sleepiness was the most commonly reported symptom in early pregnancy, while napping occurred most frequently at delivery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssociations between the experience of labor and depressive symptoms\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding depressive symptoms, women with higher symptom scores at all recorded pregnancy points (early, mid- and late pregnancy) were more likely to report a negative EOL, similarly in both the IOL and SOL groups. A high depression score (EPDS\u0026ge;10) was associated with a negative EOL only in late pregnancy (Table 3). Depression was not evaluated at delivery. The distributions of EPDS scores in the EOL groups are shown in Figure 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssociation between the experience of labor and sleep disturbances\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe associations between sleep disturbances and EOL are presented in Figure 3 and Table 3. In early pregnancy, there were no associations between sleep disturbances and EOL. In mid-pregnancy, women with higher Insomnia scores, higher Sleepiness scores, and more daytime tiredness were more likely to report a negative EOL. In late pregnancy, higher Sleepiness scores, more frequent nocturnal awakenings/week and more frequent morning sleepiness were related to a negative EOL. At delivery, women with higher Insomnia and Sleepiness scores, worse general sleep quality, and more frequent difficulties to fall asleep and morning sleepiness were more likely to report a negative EOL (Fig. 3). Sleep duration and sleep loss were not related to the EOL. Only one interaction between IOL and sleep disturbances was found: at delivery, women with greater sleep loss in the IOL group were more likely to report a negative EOL.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study is one of the first to evaluate the associations between maternal depressive symptoms, sleep disturbances, and EOL. We found that women with depressive symptoms were more likely to report a negative EOL. This finding was constant throughout the pregnancy. In addition, women with sleep disturbances, especially insomnia and sleepiness symptoms from mid-pregnancy onwards, were more likely to report a negative EOL. However, sleep duration and sleep loss were not related to the EOL. Furthermore, women with IOL reported a more negative EOL than those with SOL. However, the associations between depressive symptoms, sleep disturbances and EOL were independent of IOL. Our findings highlight the importance of positive mood and high-quality sleep in promoting better EOL.\u003c/p\u003e \u003cp\u003eOur results are in line with the results of a recent IOL study from Finland, which included 22 393 women with IOL and 72 658 women with SOL. That study showed that IOL was associated with a negative EOL (Joensuu et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Women with IOL have been found to have more adverse delivery outcomes, such as longer labor duration (Lee and Gay \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) and increased rates of operative vaginal deliveries (Souter et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), factors that may potentially worsen the EOL (Joensuu et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe EOL can be negatively influenced by the fear of childbirth, which is more common in women with depressive symptoms (Demšar et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). A study by Whelan et al (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) used the validated Labour Agentry Scale to evaluate women\u0026rsquo;s experiences of control during delivery. They found that the mean scores were lower and the experiences more negative for women with a prior diagnosis of depression or anxiety. Moreover, Waldenstr\u0026ouml;m et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) showed that depressive mood, evaluated using the EPDS during early pregnancy, was associated with a negative EOL when asked two months postpartum. However, Ramlee et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found no correlation between depression and satisfaction with labor among women with planned IOL. We found that depressive symptoms already present in early pregnancy were associated with a more negative EOL, independent of IOL. The different outcomes may be attributed to the distinct sample sizes and questionnaires used.\u003c/p\u003e \u003cp\u003ePrevious research on the relationship between sleep and EOL is limited. In the above-mentioned study by Ramlee et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), maternal satisfaction with IOL was independent of sleep quality measured using the Pittsburgh Sleep Quality Index (PSQI) upon admission. Instead, Abay et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) found that poor sleepers assessed using the PSQI had lower means in the birth process subscale score of the Childbirth Experience Questionnaire than good sleepers meaning a more negative EOL among poor sleepers (Abay et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In our earlier study of 117 women with IOL, poor general sleep quality evaluated using the BNSQ was associated with a more negative experience of IOL (Haavisto et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Furthermore, women having difficulty to fall asleep reported more pain and less relaxation during IOL, while those with higher sleep loss reported more anxiety and were less satisfied (Haavisto et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In the present study, we confirmed the association between sleep disturbances and a negative EOL. Sleep disturbances occurring in early pregnancy were not associated with the EOL, but associations were found from mid-pregnancy onwards. While insomnia symptoms were important, sleepiness symptoms were even more consistently related to a negative EOL. Despite these unambiguous findings, the association between sleep disturbances and a negative EOL was independent of IOL.\u003c/p\u003e \u003cp\u003eMultiple factors appear to contribute to a negative EOL. Previous studies have emphasized the importance of high-quality treatment and supportive interactions during labor and hospital stay (Taheri et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, it is well established that women highly value being listened to and receiving individualized care (Keulen et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Based on our findings, fewer depressive symptoms and good sleep quality during pregnancy may serve as protective factors for a more positive EOL, regardless of whether labor is induced. Emotional resilience, positive attitudes towards labor, and effective coping strategies are also known to be associated with a more favorable EOL (Aune et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Conversely, both physiological and psychological stress have been shown to negatively impact the labor process and, consequently, the overall EOL (Walter et al. \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study had strengths but also flaws. One of the major strengths was the large sample size. Furthermore, we used two validated questionnaires, the EPDS and the BNSQ, which are widely used in different populations, including pregnant women (Okagbue et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Polo-Kantola et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Pietik\u0026auml;inen et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Hedman et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Depressive symptoms are screened with the EPDS in primary health care in Finland, therefore, the EPDS is a suitable tool to distinguish women with these symptoms. The BNSQ comprises multiple detailed items that assess sleep disturbances, enabling differentiation between various symptoms of insomnia and excessive sleepiness. However, the fourth BNSQ questionnaire was completed after delivery, and thus the replies may have been influenced by labor even though the women were instructed to evaluate sleep during the entire previous month. Furthermore, we did not evaluate either pre-pregnancy depressive symptoms or sleep quality; therefore, we were unable to estimate the effects of plausible existing symptoms. No sleep architecture was measured, which could have provided another perspective on sleep quality. However, previous studies have shown that reports of subjective sleep quality are usually sufficient and more feasible in clinical work than objective measurements, which measure sleep during only one or several nights. Furthermore, the study population was relatively healthy with uncomplicated full-term pregnancies; therefore, our results cannot be generalized to women with preterm delivery and pregnancy complications.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings underscore the significant role of depressive symptoms and sleep disturbances during pregnancy in contributing to a EOL. Psychological distress and sleep disturbances represented distinct and clinically meaningful contributors to diminished EOL. In particular, depressive symptoms, insomnia symptoms, and daytime sleepiness emerged as key factors associated with adverse EOL outcomes. Although IOL was linked to a more negative EOL relative to SOL, mood and sleep were equally associated with a negative EOL in both groups. Therefore, to improve EOL, systematic screening of maternal mood and sleep during pregnancy is required, followed by appropriate clinical intervention when warranted. \u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003edelivery point, pp\u003csup\u003e4\u003c/sup\u003e;\u0026nbsp;early pregnancy point, pp\u003csup\u003e1\u003c/sup\u003e; EOL, experience of labor; CS, Cesarean section; IOL, induction of labor; late pregnancy point, pp\u003csup\u003e3\u003c/sup\u003e; mid-pregnancy point,\u0026nbsp;pp\u003csup\u003e2\u003c/sup\u003e; SOL, spontaneous onset of labor; gwk, gestation week; EPDS, Edinburgh Postnatal Depression Scale; BNSQ, Basic Nordic Sleep Questionnaire; BMI, body mass index; The Pittsburgh Sleep Quality Index, PSQI\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThe study was approved by the Joint Ethics Committees of the University of Turku and Turku University Hospital, Turku, Finland (number ETMK 57/180/2011, meeting 14.6.2011 \u0026sect; 168).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe study was financially supported by the Finnish Government (research funds from specified government transfers), Turku Clinical Research Centre, the Research Council of Finland #308589, #308588, #342747, #342748, Finnish Medical Association and the Signe and Ane Gyllenberg Foundation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbay H., \u0026Ouml;zt\u0026uuml;rk G\u0026uuml;lmez, B. and Kaplan S. (2024). The effect of maternal sleep quality in late pregnancy on prenatal, birth and early postnatal outcomes. J Sleep Res 33:e14218. https://doi.org/10.1111/jsr.14218\u003c/li\u003e\n \u003cli\u003eAukia L, Paavonen EJ, J\u0026auml;nk\u0026auml;l\u0026auml; T. \u0026nbsp;et al. (2020). Insomnia symptoms increase during pregnancy, but no increase in sleepiness - Associations with symptoms of depression and anxiety. Sleep Med \u003cem\u003e72\u003c/em\u003e;150\u0026ndash;156. https://doi.org/10.1016/j.sleep.2020.03.031.\u003c/li\u003e\n \u003cli\u003eAune I., Marit Torvik H., Selboe S. T. et al. (2015). Promoting a normal birth and a positive birth experience - Norwegian women\u0026rsquo;s perspectives. Midwifery \u003cem\u003e31\u003c/em\u003e;721\u0026ndash;727. https://doi.org/10.1016/j.midw.2015.03.016\u003c/li\u003e\n \u003cli\u003eBennett H. A., Einarson A., Taddio A. et al. (2004). Prevalence of depression during pregnancy: Systematic review. 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AOGS\u003cem\u003e\u0026nbsp;\u003c/em\u003e96;198\u0026ndash;206. https://doi.org/10.1111/aogs.13056\u003c/li\u003e\n \u003cli\u003eRae C., Leigh L., Holliday E., Chojenta C. (2025). Perinatal relapse or recurrence rates in women reporting preconception anxiety and / or depression : a longitudinal study using linked data. Arch Womens Ment Health 18:1621\u0026ndash;1631.\u0026nbsp;doi: 10.1007/s00737-025-01631-9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRamlee N., Azhary J. M. K., Hamdan M. et al (2023). Predictors of maternal satisfaction with labor induction: A prospective observational cohort study. Int J Gynecol Obstet 163;547\u0026ndash;554. https://doi.org/10.1002/ijgo.14848\u003c/li\u003e\n \u003cli\u003eRiutta K., Ekholm E, \u0026nbsp;Scheinin N. et al. (2022). The influence of maternal psychological distress on the mode of birth and duration of labor : findings from the FinnBrain Birth Cohort Study. Arch Womens Ment Health 25:463\u0026ndash;472. https://doi.org/10.1007/s00737-022-01212-0\u003c/li\u003e\n \u003cli\u003eRoll\u0026egrave; L., Giordano M., Santoniccolo F., Trombetta T. (2020). Prenatal attachment and perinatal depression: A systematic review. Int J Environ Res Public Health \u0026nbsp;17;2644 https://doi.org/10.3390/ijerph17082644\u003c/li\u003e\n \u003cli\u003eRosseland L. A., Reme S. E., Simonsen T. B. et al (2020). Are labor pain and birth experience associated with persistent pain and postpartum depression? A prospective cohort study. Scand J Pain 20;591\u0026ndash;602. https://doi.org/10.1515/sjpain-2020-0025\u003c/li\u003e\n \u003cli\u003eRubertsson C., B\u0026ouml;rjesson K., Berglund A. et al (2011). The Swedish validation of Edinburgh Postnatal Depression Scale (EPDS) during pregnancy. Nord J Psychiatry 65;414\u0026ndash;418. https://doi.org/10.3109/08039488.2011.590606\u003c/li\u003e\n \u003cli\u003eSanchez S. E., Friedman L. E., Rondon M. B. et al (2020). Association of stress-related sleep disturbance with psychiatric symptoms among pregnant women.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eSleep Med 7\u003c/em\u003e0;27\u0026ndash;32. https://doi.org/10.1016/j.sleep.2020.02.007\u003c/li\u003e\n \u003cli\u003eShechter-Maor G., Haran G., Sadeh-Mestechkin D. et al (2015). Intra-vaginal prostaglandin E2 versus double-balloon catheter for labor induction in term oligohydramnios. J Perinatol 35;95\u0026ndash;98. https://doi.org/10.1038/jp.2014.173\u003c/li\u003e\n \u003cli\u003eS\u0026oslash;rbye I. K., Oppegaard K. S., Weeks A. et al (2020). Induction of labor and nulliparity : A nationwide clinical practice pilot evaluation. AOGS 99;1700\u0026ndash;1709. https://doi.org/10.1111/aogs.13948\u003c/li\u003e\n \u003cli\u003eSouter V., Painter I., Sitcov K., Caughey A. B. (2019). Maternal and newborn outcomes with elective induction of labor at term. Am J Obstet Gynecol 220;273.e1-273.e11. https://doi.org/10.1016/j.ajog.2019.01.223\u003c/li\u003e\n \u003cli\u003eTaheri M., Takian A., Taghizadeh Z. et al (2018). Creating a positive perception of childbirth experience : systematic review and meta- analysis of prenatal and intrapartum interventions. Reprod Health 15;73.\u003c/li\u003e\n \u003cli\u003eTomfohr L. M., Buliga E., Hons B. A. \u0026nbsp;et al (2015) Trajectories of Sleep Quality and Associations with Mood during the Perinatal Period. Sleep 38;1237\u0026ndash;1245.\u003c/li\u003e\n \u003cli\u003evan der Zwan J. E., de Vente W., Tolvanen M. et al(2017). Longitudinal associations between sleep and anxiety during pregnancy, and the moderating effect of resilience, using parallel process latent growth curve models. Sleep Med, 40;63\u0026ndash;68. https://doi.org/10.1016/j.sleep.2017.08.023\u003c/li\u003e\n \u003cli\u003eWaldenstr\u0026ouml;m U., Hildingsson I., Rubertsson C., R\u0026aring;destad I. (2004). A negative birth experience: Prevalence and risk factors in a national sample. Birth, 31:17\u0026ndash;27. https://doi.org/10.1111/j.0730-7659.2004.0270.x\u003c/li\u003e\n \u003cli\u003eWaller R., Kornfield S. L., White L. K. et al. (2022). Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression. Arch of Womens Ment Health, 25:985\u0026ndash;993. https://doi.org/10.1007/s00737-022-01263-3\u003c/li\u003e\n \u003cli\u003eWalter M. H., Abele H., Plappert C. F. (2021). The Role of Oxytocin and the Effect of Stress During Childbirth: Neurobiological Basics and Implications for Mother and Child. Front Endocrinol 12;1\u0026ndash;10. https://doi.org/10.3389/fendo.2021.742236\u003c/li\u003e\n \u003cli\u003eWhelan A. R., Recabo O., Ayala N. K. et al (2022). The Association of Perceived Labor Agentry and Depression and/or Anxiety. Am J Perinatol 40\u003cem\u003e;\u003c/em\u003e1047\u0026ndash;1053. https://doi.org/10.1055/a-2051-2433\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the supplementary files section\u003c/p\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":"childbirth, depression, insomnia, pregnancy, sleep quality","lastPublishedDoi":"10.21203/rs.3.rs-9047309/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9047309/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eA negative experience of labor (EOL) may have long-term adverse effects on maternal well-being. Induction of labor (IOL), depressive symptoms, and sleep disturbances may compromise the EOL. We evaluated whether EOL, depressive symptoms, and sleep disturbances are interrelated in women with IOL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The FinnBrain Birth Cohort with 2405 women comprising of 443 women in the IOL group and 1962 women in the spontaneous onset of labor (SOL) group. The Edinburgh Postnatal Depression (early pregnancy [pp\u003csup\u003e1\u003c/sup\u003e], mid-pregnancy [pp\u003csup\u003e2\u003c/sup\u003e] and late pregnancy points [pp\u003csup\u003e3\u003c/sup\u003e]), the Basic Nordic Sleep Questionnaire (pp\u003csup\u003e1\u003c/sup\u003e, pp\u003csup\u003e2\u003c/sup\u003e, pp\u003csup\u003e3\u003c/sup\u003e and delivery point [pp\u003csup\u003e4\u003c/sup\u003e]) and EOL were assessed, and the associations were investigated using logistic regression analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWomen reporting depressive symptoms at any point during pregnancy reported a more negative EOL (pp\u003csup\u003e1\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.004;\u0026nbsp; pp\u003csup\u003e2\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.026; pp\u003csup\u003e3\u003c/sup\u003e \u003cem\u003ep=\u003c/em\u003e0.003). A more negative EOL was also reported by women with poor general sleep quality (pp\u003csup\u003e4\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.005), with higher Insomnia scores (pp\u003csup\u003e2\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.042; pp\u003csup\u003e4\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.007), and with higher Sleepiness scores (pp\u003csup\u003e2\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.001; pp\u003csup\u003e3\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.028; pp\u003csup\u003e4\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.034). At different pregnancy time points, several sleep disturbances, such as difficulty to fall asleep (pp\u003csup\u003e4\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.003) and nocturnal awakenings (pp\u003csup\u003e3\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e=0.025) were associated with a more negative EOL. However, all of these findings were similar in both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eDepressive symptoms\u003cstrong\u003e \u003c/strong\u003eand sleep disturbances were associated with a negative EOL independently of IOL. Our findings highlight psychological distress and sleep difficulties as distinct, clinically relevant determinants of EOL. Early identification and targeted management of these modifiable factors may improve EOL and maternal well-being.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration number\u003c/strong\u003e: ETMK 57/180/2011, meeting 14.6.2011 § 168.\u003c/p\u003e","manuscriptTitle":"Experiences of labor in women undergoing induced and spontaneous onset of labor: Associations with depressive symptoms and sleep disturbances","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-02 10:26:44","doi":"10.21203/rs.3.rs-9047309/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":"f0156f8f-6325-47b5-bfe0-548262596a00","owner":[],"postedDate":"April 2nd, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"65113239077036161216205461722406203684","date":"2026-04-29T16:21:20+00:00","index":29,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-02T10:26:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-02 10:26:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9047309","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9047309","identity":"rs-9047309","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}