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AbstractObjectiveTo determine whether a single low dose of esketamine administered after childbirth reduces postpartum depression in mothers with prenatal depression.DesignRandomised, double blind, placebo controlled trial with two parallel arms.SettingFive tertiary care hospitals in China, 19 June 2020 to 3 August 2022.Participants364 mothers aged ≥18 years who had at least mild prenatal depression as indicated by Edinburgh postnatal depression scale scores of ≥10 (range 0-30, with higher scores indicating worse depression) and who were admitted to hospital for delivery.InterventionsParticipants were randomly assigned 1:1 to receive either 0.2 mg/kg esketamine or placebo infused intravenously over 40 minutes after childbirth once the umbilical cord had been clamped.Main outcome measuresThe primary outcome was prevalence of a major depressive episode at 42 days post partum, diagnosed using the mini-international neuropsychiatric interview. Secondary outcomes included the Edinburgh postnatal depression scale score at seven and 42 days post partum and the 17 item Hamilton depression rating scale score at 42 days post partum (range 0-52, with higher scores indicating worse depression). Adverse events were monitored until 24 hours after childbirth.ResultsA total of 364 mothers (mean age 31.8 (standard deviation 4.1) years) were enrolled and randomised. At 42 days post partum, a major depressive episode was observed in 6.7% (12/180) of participants in the esketamine group compared with 25.4% (46/181) in the placebo group (relative risk 0.26, 95% confidence interval (CI) 0.14 to 0.48; P<0.001). Edinburgh postnatal depression scale scores were lower in the esketamine group at seven days (median difference −3, 95% CI −4 to −2; P<0.001) and 42 days (−3, −4 to −2; P<0.001). Hamilton depression rating scale scores at 42 days post partum were also lower in the esketamine group (−4, −6 to −3; P<0.001). The overall incidence of neuropsychiatric adverse events was higher in the esketamine group (45.1% (82/182) v 22.0% (40/182); P<0.001); however, symptoms lasted less than a day and none required drug treatment.ConclusionsFor mothers with prenatal depression, a single low dose of esketamine after childbirth decreases major depressive episodes at 42 days post partum by about three quarters. Neuropsychiatric symptoms were more frequent but transient and did not require drug intervention.Trial registrationClinicalTrials.gov NCT04414943.

Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity. We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61-1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13-1.96). The magnitudes of the coefficients indicated that a one-standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity. In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women's mental health should be explored.

Maternal depression is one of the most common prenatal complications, and prenatal maternal depression predicts many child psychopathologies. Here, we apply the fetal programming hypothesis as an organizational framework to address the possibility that fetal exposure to maternal depressive symptoms during pregnancy affects fetal development of vulnerabilities and risk mechanisms, which enhance risk for subsequent psychopathology. We consider four candidate pathways through which maternal prenatal depression may affect the propensity of offspring to develop later psychopathology across the life span: brain development, physiological stress regulation (hypothalamic–pituitary–adrenocortical axis), negative emotionality, and cognitive (effortful) control. The majority of past research has been correlational, so potential causal conclusions have been limited. We describe an ongoing experimental test of the fetal programming influence of prenatal maternal depressive symptoms using a randomized controlled trial design. In this randomized controlled trial, interpersonal psychotherapy is compared to enhanced usual care among distressed pregnant women to evaluate whether reducing prenatal maternal depressive symptoms has a salutary impact on child ontogenetic vulnerabilities and thereby reduces offspring's risk for emergence of later psychopathology.

The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development. We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on maternal depression and infant outcomes. We randomly assigned 40 Union Council clusters in rural Rawalpindi, Pakistan, in equal numbers to intervention or control. Married women (aged 16–45 years) in their third trimester of pregnancy with perinatal depression were eligible to participate. In the intervention group, primary health workers were trained to deliver the psychological intervention, whereas in the control group untrained health workers made an equal number of visits to the depressed mothers. The primary outcomes were infant weight and height at 6 months and 12 months, and secondary outcome was maternal depression. The interviewers were unaware of what group the participants were assigned to. Analysis was by intention to treat. The study is registered as ISRCTN65316374. The number of clusters per group was 20, with 463 mothers in the intervention group and 440 in the control group. At 6 months, 97 (23%) of 418 and 211 (53%) of 400 mothers in the intervention and control groups, respectively, met the criteria for major depression (adjusted odds ratio (OR) 0·22, 95% CI 0·14 to 0·36, p<0·0001). These effects were sustained at 12 months (111/412 [27%] vs 226/386 [59%], adjusted OR 0·23, 95% CI 0·15 to 0·36, p<0·0001). The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months (−0·83 vs −0·86, p=0·7 and −2·03 vs −2·16, p=0·3, respectively) or 12 months (−0·64 vs −0·8, p=0·3 and −1·10 vs −1·36, p=0·07, respectively). This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings. Wellcome Trust.

The aim of this study is to explore the impact of the COVID-19 pandemic on pregnant women’s anxiety and identify factors most strongly associated with greater changes in anxiety. An anonymous, online, survey of pregnant women (distributed April 3–24, 2020) included a modified pregnancy-related anxiety scale (PRAS) reflecting respondents’ perception of pregnancy anxiety before COVID-19 and a current assessment of pregnancy-related anxiety. The difference between these scores was used as the outcome variable. Data were analyzed using bivariate and multivariate linear regression analyses. Two thousand seven hundred forty pregnant women from 47 states completed the survey. 25.8% (N = 706) stopped in-person visits, 15.2% used video visits (N = 415), and 31.8% (N = 817) used phone visits for prenatal care as a result of COVID-19. Those planning a hospital birth dropped from 2641 (96.4%) to 2400 (87.7%) following COVID-19. More than half of women reported increased stress about food running out (59.2%, N = 1622), losing a job or household income (63.7%, N = 1745), or loss of childcare (56.3%, N = 1543). More than a third reported increasing stress about conflict between household members (37.5%, N = 1028), and 93% (N = 2556) reported increased stress about getting infected with COVID-19. Slightly less than half of respondents (either selves or family members) were healthcare workers (41.4%, N = 1133) or worked in essential services (45.5%, N = 1246). In multivariate analysis, those reporting higher agreement with COVID-19-related stressors had greater changes in pre- to post-COVID-19 pregnancy-related anxiety. The COVID-19 pandemic is profoundly affecting pregnant women’s mental health, and factors independent of pregnancy appear to be driving changes in pregnancy-specific anxiety.

Objective: Lifestyle intervention could help obese pregnant women to limit their weight gain during pregnancy and improve their psychological comfort, but has not yet been evaluated in randomized controlled trials. We evaluated whether a targeted antenatal lifestyle intervention programme for obese pregnant women influences gestational weight gain (GWG) and levels of anxiety or depressed mood. Design and subjects: This study used a longitudinal interventional design. Of the 235 eligible obese pregnant women, 205 (mean age (years): 29±4.5; body mass index (BMI, kg m − 2 ): 34.7±4.6) were randomized to a control group, a brochure group receiving written information on healthy lifestyle and an experimental group receiving an additional four antenatal lifestyle intervention sessions by a midwife trained in motivational lifestyle intervention. Anxiety (State and Trait Anxiety Inventory) and feelings of depression (Edinburgh Depression Scale) were measured during the first, second and third trimesters of pregnancy. Socio-demographical, behavioural, psychological and medical variables were used for controlling and correcting outcome variables. Results: We found a significant reduction of GWG in the brochure (9.5 kg) and lifestyle intervention (10.6 kg) group compared with normal care group (13.5 kg) ( P =0.007). Furthermore, levels of anxiety significantly decreased in the lifestyle intervention group and increased in the normal care group during pregnancy ( P =0.02); no differences were demonstrated in the brochure group. Pre-pregnancy BMI was positively related to levels of anxiety. Obese pregnant women who stopped smoking recently showed a significant higher GWG ( β =3.04; P =0.01); those with concurrent gestational diabetes mellitus (GDM) ( β =3.54; P =0.03) and those who consumed alcohol on a regular base ( β =3.69; P =0.04) showed significant higher levels of state anxiety. No differences in depressed mood or obstetrical/neonatal outcomes were observed between the three groups. Conclusions: A targeted lifestyle intervention programme based on the principles of motivational interviewing reduces GWG and levels of anxiety in obese pregnant women.

Binge eating is one of the most prevalent eating disorder behaviours in pregnancy, its risk factors and association with pregnancy-related outcomes has sparsely researched in this population. This study aimed to investigate: (hypothesis 1) the effectiveness of a lifestyle intervention in reducing binge eating; (hypothesis 2) the association between depressive symptoms and binge eating behaviours throughout the perinatal period; and (hypothesis 3) the association between binge eating, gestational weight gain and birthweight in a cohort of pregnant women with obesity. This is a planned secondary analysis of the UK Pregnancies Better Eating and Activity Trial (UPBEAT) randomized controlled trial. Exposures were trial arms (hypothesis 1); depressive symptoms (hypothesis 2); and number of weekly binge eating episodes and binge eating behaviours (hypothesis 3). Outcomes were number of weekly binge eating episodes and binge eating behaviours and cognitions (hypotheses 1 and 2), gestational weight gain and child’s birthweight (hypothesis 3). There was no evidence that the UPBEAT intervention was effective in reducing number of weekly binge eating behaviours (IRR .942; 95%CI .756, 1.174) or binge eating behaviours (IRR 1.005; 95%CI .861, 1.174). Increased levels of depressive symptoms were associated with a higher number of binge eating behaviours (IRR 1.031; 95%CI 1.015, 1.048) and its associated features (IRR 1.030; 95%CI 1.019, 1.041). There was evidence that more frequent binge eating behaviours lead to greater increase in gestational weight gain. (coefficient = .614; 95%CI .264, .964). There is a need for holistic interventions that promote maternal mental health and address binge eating behaviours. More work is required in the field to understand which interventions would prove efficacious.

Background High levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention. Method Between May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here. Results 1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine ( n  = 339) women were randomised (intervention n  = 170; controls n  = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n  = 91; controls n  = 93). Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p  = 0.27) and emergency CS rates (18 % vs 25 %, p  = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p  = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p  = 0.05). Postnatally women who received psycho-education reported that the ‘decision aid’ helped reduce their fear (53 % vs 37 %, p  = 0.02). Conclusion Following a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies. Trial registration Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012

Sleep deficiency is common during pregnancy, with consequences for maternal and fetal health. This pilot study assessed the efficacy, feasibility, and acceptability of a six-week, online, mindfulness-based intervention (OPTIMISM) in pregnant women with sleep deficiency. Participants were randomized to either mindfulness (self-directed learning modules about mindfulness meditation, sleep challenges in pregnancy, and behavioral strategies) or education-only control conditions. Participants completed surveys and wore an actigraph with daily sleep diaries for 8 days at baseline and post-intervention. The primary outcome was sleep quality. Secondary outcomes included actigraphy, sleep-related impairment, sleep disturbance, fatigue, depression, anxiety, postnatal depressive symptoms, well-being, and quality of life. Exploratory outcomes included feasibility, acceptability, self-management, and behavior change. Efficacy was estimated with analysis of covariance, comparing mean post-test scores corrected for baseline. Of the 351 women screened, 163 were eligible, 64 enrolled, and 59 were randomized. 45 participants (OPTIMISM, 23; control, 22) completed post-intervention assessments and were included in the analysis. The mean satisfaction with the OPTIMISM was higher than the control group (OPTIMISM, 4.1; control, 3.8). The mean sleep quality score was significantly improved in the OPTIMISM group compared to that in the control group after adjusting for baseline score (OPTIMISM, 5.4; control, 7.6; p =.008; partial h 2 =.157). There were similar improvements in sleep-related impairment, sleep disturbance, fatigue, and depressive symptoms, but no differences in other outcomes. Findings suggest that OPTIMISM improves subjective sleep quality and psychological distress, including fatigue, depression, and anxiety during pregnancy and should be tested in larger trials with longitudinal follow-up. Trial registration: ClinicalTrials.gov, NCT04016428. Registered on 11 July 2019.

Pregnancy is a vulnerable period for women, with an increased risk of mental health issues such as depression and anxiety. The perinatal period is particularly important, as maternal mental health significantly impacts maternal physical health, pregnancy outcomes, postnatal outcomes, and fetal and infant development. Psychotherapeutic interventions for depression are essential, especially given the limitations of medication use during pregnancy. However, perinatal women experiencing depression often encounter barriers to accessing these interventions. Digital health interventions may offer a promising approach to overcome these barriers. This study aimed to (1) evaluate the effectiveness of Avecmom, a self-help, mindfulness-based mobile intervention, in reducing depression severity among pregnant women with mild to moderate depression; (2) examine its impact on emotional well-being and maternal-fetal attachment; and (3) explore whether the effect on mental well-being is mediated by increased mindfulness and reduced depression severity. Participants were recruited both online and offline. Of 158 screened individuals, 90 met the inclusion criteria and were randomly assigned to either the intervention or control group. The intervention group used both the Avecmom and Big 4+ apps, while the control group used only the Big 4+ app. Depressive symptoms, anxiety, and stress were assessed as primary outcomes at baseline and postintervention. Mindfulness, mental well-being, positive and negative emotions, and maternal-fetal attachment were assessed as secondary outcomes. Analysis of covariance (ANCOVA) was conducted with postintervention scores as the dependent variable, adjusting for baseline scores. To estimate the mechanism of change following Avecmom mobile app use, the bootstrapping technique with PROCESS Macro Model 6 was employed, applying the difference score from postintervention to baseline. A total of 86 pregnant women (intervention group: n=42; control group: n=42) completed the study and were included in the final analysis, reflecting an overall dropout rate of 4% (4/90). At postintervention, the intervention group demonstrated lower depression severity scores (F1,84=5.69; P=.02; partial ƞ2=0.06) and higher scores of mindfulness (F1,84=11.18; P=.001; partial ƞ2=0.12), maternal-fetal attachment (F1,84=5.54; P=.02; partial ƞ2=0.06), mental well-being (F1,84=8.79; P=.004; partial ƞ2=0.10), and positive affect (F1,84=7.21; P=.009; partial ƞ2=0.08) compared to the control group. Serial mediation analysis revealed that Avecmom app use influenced mental well-being through sequential improvements in mindfulness and decreases in depression severity (standardized β=.33; Boot SE=0.12, 95% CI 0.12-0.58). Mindfulness-based mobile app interventions tailored for pregnant women may be more effective than self-monitoring alone in improving perinatal depression. These findings suggest that mindfulness-based mobile app interventions may help improve mental well-being in pregnant women, potentially by enhancing mindfulness and reducing depression severity.