A mobile-delivered mindfulness-based intervention for women during perinatal period

Abstract

Background: Perinatal depression and anxiety are crucial public health issues, and the identification of effective interventions is a global imperative. While the efficacy of the mindfulness-based intervention (MBI) in reducing perinatal depression and anxiety has been indicated, the evidence suggesting its effect is not consistent. With the second-generation MBI emerged, the question remains unanswered: whether, by enhancing MBI with wisdom, MBI delivered through mobiles can maximize its potential in perinatal care.

Objectives: This thesis aims to address the critical research question: whether MBI can effectively reduce perinatal depression and anxiety. The objectives are threefold 1. to investigate the effectiveness of existing MBIs for perinatal depression and anxiety; 2. to evaluate the efficacy of a mobile-delivered four-immeasurable MBI - “Thriving in Pregnancy” (iMBI) on perinatal depression and anxiety; 3. to examine the intervention mechanism.

Methods: The thesis encompassed two studies. Study I was a meta-analytic review, aggregating data from existing randomized controlled trial (RCT) evaluating the effectiveness of MBIs for perinatal depression and anxiety. Study II included two parts: clinical studies and analyses of the intervention process. Part 1-study II – clinical studies conducted an open trial pilot study examining the acceptability and feasibility of iMBI. An RCT was conducted afterward, recruited 75 pregnant women in the second trimester. Participants were randomly assigned to either iMBI (n=38) or iPE group (n=37). Primary outcomes were measured by: Edinburg Postpartum Depression Scale, Hospital Anxiety and Depression Scale-Anxiety. Trait mindfulness and equanimity were assessed as the process outcomes. Secondary outcomes included obstetric, neonatal and various psychological outcome. Outcomes were assessed at baseline, end of intervention, 37-week gestation, and 1-month postpartum. Intervention effects were analyzed using linear mixed models under intention-to-treat principle. Study II second part – further analyses examined intervention process: what works for whom. Using time-lag mediation and moderation analyses, the hypothesized intervention working model and the moderating effect of basal symptoms were tested.

Results: Study I identified and analyzed 19 RCTs, including a combined total of 1830 women with diverse symptom profiles during pregnancy and up to one year postpartum. The pre-post effects of MBI on improving perinatal mood were significant and large for depression (g=-0.87, 95% CI = [ -1.30, -0.44]) and anxiety (g=-1.56, 95% CI = [ -3.08, -0.04]) compared with controls. The MBIs’s significant effect relative to controls on perinatal depression (g=-0.84, 95%= [-1.53, -0.15]) was sustained up to one year postpartum. In study II- clinical studies, the times by group interaction were significant in depression [F (3, 211) = 5.5, p <.000] and anxiety severity [F (3, 209) =-4.4, p<.001], and depression caseness [z =-4.4, p<.001], suggesting iMBI significantly reduced perinatal depression and anxiety. Consistently, significant positive effects relative to controls were found in trait mindfulness, equanimity and other secondary outcomes. In particular, iMBI significantly reduced the risk of emergent cesarean delivery [X2(1) =5.3, p= .021] and increased newborns’ Apgar scores (t=2.1, p= .036). Study II-further analyses revealed patterns of mediation consistent with the theorized intervention working model. First, depression and /or anxiety changes during pregnancy mediated intervention effect on emergent cesarean delivery and infant Apgar score, accounting for 22-44% of the total effect. Second, trait mindfulness and equanimity jointly mediated subsequent depression and anxiety reduction, explaining 34-54% of the total effect. With the integration of equanimity, the parallel mediation model increased 8-22% of the predicting value than the model of trait mindfulness alone. Third, baseline depression and anxiety symptoms significantly moderated intervention effects on their improvements across assessment time-points, with the higher baseline symptoms predicting greater improvement.

Discussion: Existing MBIs have demonstrated promising potentials compared with well-established interventions in the perinatal period. In particular, the present mobile-delivered MBI, integrating the four-immeasurable meditations, demonstrated comparable short-term and more robust long-term efficacy to prior digital MBIs and previous MBIs using other models on perinatal depression and anxiety. The finding suggests a promising MBI model enhanced with wisdom that can be delivered through mobile. It is also one of the few psychological intervention studies that found positive results in obstetric and neonatal outcomes. By integrating equanimity into the current MBI working model, the predicting validity can be enhanced, underscored the importance of incorporating equanimity into mindfulness construct operationalization.

Conclusion and Implications: The thesis provides strong evidence addressing the critical research question that MBI can be feasible and effective for perinatal women. The “Thriving in Pregnancy” can be especially promising for perinatal depression and anxiety in the long run, mitigating the risk of emergent cesarean delivery, and enhancing neonatal physical health. The thesis provides significant theoretical insights concerning the linkage between intrauterine-environment and neonatal health and the mechanistic model of MBI. (758 words)