Health Evidence™ hosted a 60 minute webinar examining the effectiveness of mindfulness-based interventions (MBIs) on maternal perinatal mental health outcomes. Click here for access to the audio recording for this webinar: https://youtu.be/NzStoRa87fY Dr. Angus MacBeth, CPsychol, AFBPsS, Lecturer in Clinical Psychology, Honorary Principal Clinical Psychologist, Department of Clinical and Health Psychology, School of Health in Social Science, The University of Edinburgh led the session and presented findings from their recent systematic review: Shi Z, & MacBeth A. (2017). The effectiveness of mindfulness-based interventions on maternal perinatal mental health outcomes: A systematic review. Mindfulness, 8(4), 823–847. Estimates suggest that at least 10% of pregnant women experience perinatal anxiety, 20% suffer prenatal depression and between 12 and 16% are likely to suffer postnatal depression. This review examines the effectiveness of MBIs in reducing the severity of perinatal anxiety and depression. Seven randomized control trials, 2 non-randomized control trials, and 9 treatment evaluations with 640 participants were included in this review. Maternal participation in an MBI was associated with reductions in perinatal anxiety of moderate to large magnitude. Results for the effect of MBIs on depression were less consistent, with pre-post treatment reductions of moderate magnitude, but no significant differences in depression scores when MBI was compared with a control group. There was some evidence that MBIs were associated with increased mindfulness.

1. Welcome!
Effectiveness of mindfulness-
based interventions on
maternal perinatal mental
health outcomes: What's the
evidence?
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4. What’s the evidence?
Shi Z, & MacBeth A. (2017). The effectiveness of
mindfulness-based interventions on maternal
perinatal mental health outcomes: A systematic
review. Mindfulness, 8(4), 823–847.
https://www.healthevidence.org/view-
article.aspx?a=effectiveness-mindfulness-
based-interventions-maternal-perinatal-
mental-health-30209

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14. Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcomes
5.Setting

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16. CPsychol, AFBPsS, Lecturer in Clinical
Psychology, Honorary Principal Clinical
Psychologist, Department of Clinical and
Health Psychology, School of Health in Social
Science, The University of Edinburgh
Angus MacBeth

17. Pregnancy and mental health
• Pregnancy and the postnatal period is a time of
rapid and significant change in a women’s life,
encompassing biological, social and psychological
changes.
• Estimates of the prevalence of anxiety and
depression:
– Perinatal anxiety affects ~10% of pregnant
women (Andersson et al. 2006)
– Antenatal depression ~20% of pregnant women
– Postnatal depression ~12 to 16% of women

18. Impact of perinatal mental
health
Parental
Mental
Health
Birth
Antenatal MH Postnatal MH
Perinatal MH
Influence
Of
Parental
MH
Health of Offspring
Prenatal MH

19. Mindfulness-based interventions (MBIs)
• Kabat-Zinn (1994)
– “paying attention in a particular way: on purpose, in
the present moment, and nonjudgmentally"(p. 4).
• Includes acceptance of situations, relationships as they
are.
• Facilitate compassionate, open minded approach.
• Impact on reduced anxiety and fear.
• Evidence-based reviews (Hoffman et al., 2010).
– Moderate effect size of MBIs on anxiety and mood reduction for
all participants.
– Strong effect size for reducing anxiety (g = 0.97) and mood (g =
0.95) symptoms for those participants with pre-existing anxiety
and mood disorders.
Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: a
meta- analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169–183.

20. Mindfulness interventions
• Different definitions:
– ‘mindfulness’
– ‘mindfulness techniques’
– ‘mindfulness approaches’
– ‘mindfulness-based cognitive therapy
(MBCT)’
– ‘mindfulness-based interventions/treatments
(MBI’s/MBT’s)’
– ‘mindfulness- based stress reduction (MBSR)’
– ‘mindful yoga’
– ‘mindful meditation’

21. Mindfulness & yoga in
pregnancy
• Yoga integrated with meditation has been
demonstrated to improve maternal physical health in
pregnancy and improve labor and birth outcomes
(Curtis et al. 2012; Narendran et al. 2005).
• Yoga practice in pregnancy reduces perinatal anxiety
and depression (Newham et al. 2014).
• Non-pharmacologic interventions in pregnancy such as
yoga and MBIs share overlapping common
characteristics such as meditation and regulated
breathing.

22. Aims of review
• Number of recent meta-analyses of MBI’s in pregnancy
(Hall et al. 2016; Taylor et al., 2016; Dhillon et al.,
2017).
– Varied in their approach to study designs,
assessment of risk of bias and definitions of MBIs.
• We sought to systematically review the evidence for
the effectiveness of MBIs (MBCT, MBSR and mindfulness-
informed yoga) on common mental health difficulties
(specifically anxiety, depression and stress) in
pregnancy.
– Focus on a narrative synthesis of the theoretical and
methodological challenges in the current literature
and methodological variance in the literature.

23. Method
• PRISMA review.
• Search from 1980 – end September 2016.
• Yoga interventions only included where there was
clear evidence from the intervention description
of several components consistent with integrated
mindfulness practice.
– e.g. techniques to encourage a non-
judgmental focus on sensation experienced in
the current moment, meditation, breathing,
body scan, deep relaxation)
• Not simply a description of yoga practices per se.

24. Inclusion criteria
• Prima- or multigravida.
• Measurement of depression and/or anxiety symptoms
using validated self-report or interview measures.
• Or met diagnostic criteria for a depressive or anxiety
disorder.
• Assessed either during pregnancy or during first year
after delivery.
• Aged between 16 and 45 years old.
• Compared MBI with a control group or without a control
group.
• Treatment component used either manualized
protocols, accredited facilitators or was delivered by
health professional with specific training in facilitation
of MBIs.

25. Exclusion criteria
• Participants had current psychosis or other
complex mental disorders.
• Depressive and/or anxiety symptoms were
comorbid symptoms with a specific physical
disorder.
• A priori identified as medically defined high-
risk pregnancies (e.g. multiple pregnancies).
• Qualitative studies, case studies, book
chapters and literature reviews.

26. Effect size calculation (Cohen,
1988)
• Revised Cochrane Risk of Bias tool used to
evaluate methodological biases (Higgins
et al. 2011).
Effect Size Convention
Trivial d ≤ 0.2
Small d > 0.2
Moderate d > 0.5
Large d > 0.8
Very Large d > 1.3

28. Characteristics and demographics
• 17 studies representing 18 cohorts.
• Designs:
– 7 RCTs
– 2 Non-randomized trials
– 9 Non-controlled evaluations
• N=640 participants; reporting on n=603
completers.
• Most studies conducted in USA (k=12),
Australia (k=4).

29. Types of intervention
• MBCT – 7 studies.
• MBSR – 9 studies.
• Mindfulness Yoga - 1 study.
• Prenatal Yoga - 1 study.
• Mean sessions = 8 weeks (range of 6-10).
• 2 hour mean session length.
• Engagement mostly high (except Zhang &
Emory 2015).

30. Effectiveness of intervention:
Depression
• Depression RCT/NCTs (6 studies):
– 3 studies showed significant reductions.
• Approximately d=0.4-0.5
• Mostly for MBCT
– 2 trend level change; 1 no significant diffs.
• Depression open trials (10 studies):
– 8 showed significant improvement.
– Moderate to large ES’s
• d=0.32 – 1.23

31. Effectiveness of intervention:
Anxiety
• Anxiety RCT/NCTs (7 studies):
– 5 studies showed significant reductions –
mostly moderate to large effects.
– No effect on pregnancy specific anxiety.
• Anxiety open trials (5 studies)
– Non-significant results but inconsistent effect
sizes.

32. Effectiveness of intervention:
Stress
• Stress RCT/NCTs (7 studies):
– Results equivocal
• 1 study reporting significant effect.
• 1 reporting clinical improvement.
• Stress open trials (4 studies)
– Similar findings
• However, large within-subjects effects
– Effects washed out in comparisons?

33. Mechanisms of change
• 13 studies evaluated change in
mindfulness:
– 5 RCTs reported significant change (moderate
to large effect).
– 1 NCT suggested positive trend.
– 5 of 6 open trials suggested change.
• Magnitude of effect varied.
• All studies used Five Facet Mindfulness
Questionnaire (FFMQ).

35. Our review vs Dhillon (2017)
Dhillon, A., Sparkes, E. and Duarte, R.V., 2017. Mindfulness-Based Interventions During Pregnancy: a Systematic Review and Meta-
analysis. Mindfulness, pp.1-17.
Overlap (k=9)
•Beddoe et al (2010)
•Duncan & Bardacke (2010)
•Dunn et al. (2012)
•Byrne et al. (2014)
•Goodman et al. (2014)
•Guardiano et al. (2014)
•Vieten & Astin (2008)
•Dimidjian et al. (2015)
•Dimidjian et al. (2016)
Shi & MacBeth (k=8)
•Muzik et al. (2012)
•Perez-Blasco et al. (2013)
•Woolhouse et al. (2014)
•Battle et al. (2015)
•Narimani & Musavi (2015)
•Miklowitz et al. (2015)
•Zhang & Emory (2015)
•Felder et al (2016)
Dhillon (k=4)
•Matvienko-Sikar & Dockray
(2016)
•Bowen et al. (2014)
•Shahtaheri et al. (2016)
•Muthukrishnan et al (2016)

36. Discussion
• Some evidence of effectiveness on
depression and anxiety:
– Effect washed out compared to control.
• Equivalence effects?
• For depression MBCT designed with
preventative function.
• For anxiety impact via cognitive and
physiological routes?

37. Discussion
• Methodological limitations:
– Sample size
– Treatment heterogeneity
– Sampling differences
– Measurement issues (self-reports)
• Implications:
– Targeting of treatment vs universal provision
– Sleeper effects?
– Methodological rigor in trials

38. THANK YOU
angus.macbeth@ed.ac.uk
Twitter: @gusmacbeth

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