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Objectives: This study aims to examine the associations among fear of childbirth, psychological distress, resilience, and sleep quality among Chinese pregnant women. Methods: A cross-sectional survey was carried out between January 2022 to March 2022 among pregnant women who met the inclusion criteria and sought healthcare services at The First Affiliated Hospital of Guangzhou University of Chinese Medicine in Guangdong Province, Southern China. Data was collected using a structured questionnaire that included sociodemographic characteristics, childbirth attitudes questionnaires (CAQ), hospital anxiety and depression scale (HADS), Connor-Davidson resilience scale (CD-RISC), and Pittsburgh sleep quality index (PSQI). A generalized additive model and moderated mediation analysis were employed for data analysis. Results: A non-linear and negative association between fear of childbirth and sleep quality was found in the second trimester and antenatal period. Psychological distress significantly mediated the relationship between fear of childbirth and sleep quality (first trimester: β = 0.044, 95%CI:0.022–0.071; second trimester: β = 0.029, 95%CI:0.009–0.056; third trimester: β = 0.064, 95%CI:0.046–0.088; antenatal period: β = 0.050, 95%CI:0.037–0.063). The moderating role of resilience between fear of childbirth and sleep quality was significant (second trimester: β=-0.006, 95%CI:-0.012–0.001, P = 0.025; antenatal period: β=-0.004, 95%CI:-0.007–-0.001, P = 0.014), as well as between fear of childbirth and psychological distress (first trimester: β=-0.016, 95%CI:-0.026–-0.005, P = 0.004; antenatal period: β=-0.005, 95%CI:-0.009–-0.001, P = 0.014). Conclusions: Fear of childbirth, psychological distress, and resilience are three important factors affecting sleep quality in Chinese pregnant women. [ABSTRACT FROM AUTHOR]