Effects of sleep quality, anxiety, and depression on miscarriage among pregnant women: a multi-center prospective observational study

This study aims to uncover the mechanisms and quantitative dose response relationships among sleep quality, anxiety, depression and miscarriage, as well as develop a comprehensive predictive model for the miscarriage rate. In this study, 1058 pregnant women in mainland China were recruited. We utilized both univariate, multivariate analyses and sensitivity analysis to investigate the relationship between sleep quality, anxiety, depression, and miscarriage. Then, we used mediation analysis and directed acyclic graph to explore how anxiety and sleep quality mediate the relationship between depression and miscarriage. We employed restricted cubic spline (RCS) to examine the dose-response relationship between these variables and constructed a nomogram model for predicting the occurrence of miscarriages. During our investigation, 16.4% of the participant had a miscarriage. Our results showed a significant association between sleep quality, anxiety, depression and miscarriage both unadjusted and multivariable multinomial logistic regression. Dose-response relationships showed that the miscarriage rate slowly increases with increasing PSQI, SAS and SDS scores at first. However, when a certain threshold is reached, even slight increases in the scores will lead to a sharp rise in the miscarriage rate. Anxiety mediated the effect of depression on miscarriage by 44% and sleep quality had a similar mediation effect (16%). The quantitative dose response relationships between PSQI, SAS, SDS, and the miscarriage rate are all positive. In the impact of depression on the miscarriage rate, anxiety and sleep quality also play significant mediating roles. By revealing high-risk pregnant women, early intervention can be provided, aiming to reduce the miscarriage rate.