Perceptions,Uses of,and Interests in Complementary Health Care Approaches in Depressed Pregnant Women

Abstract

Depression affects up to 23% of pregnant women and is associated with adverse physical/mental health outcomes for both the mother and baby. Depressed pregnant women may be more likely to engage in unhealthy lifestyle behaviors that contribute to an increased risk for chronic disease. Little is known regarding depressed pregnant women’s perceptions, uses of, and interests in complementary health approaches. Study participants (mean age 28.7 ± 6.8; n = 1032) included pregnant women ≥8 weeks gestation who responded to a survey assessing physical and mental health and wellness practices. Of those completing the survey, depressed pregnant women (n = 272) had significantly higher levels of anxiety (P < .001) and stress (P < .001) and had poorer sleep quality (P < .001), mindfulness (P < .001), and social support (P < .001) compared to nondepressed pregnant women (n = 760). A majority (84%) of depressed pregnant women would consider using a complementary health approach for weight and/or stress management during pregnancy, and more than 50% were interested in yoga.

Keywords

complementary and alternative medicine depression pregnancy

Depression is the most common mental health disorder during pregnancy¹ such that 14% to 23% of pregnant women will experience depressive symptoms at some point during their pregnancy.² Sadly, depression and other mental health distress (eg, stress, anxiety) can often go unrecognized in pregnancy due to the overlapping symptoms similar to the physical and mental changes during pregnancy (eg, increased food consumption, weight gain, insomnia, worsened mood, fatigue), resulting in high rates of untreated and/or undertreated depression.^2,3 Studies report less than half of depressed pregnant women are identified and many fail to receive treatment for depressive symptoms,^4
–6 partially due to stigma⁷ and concerns about the safety of treatment (ie, medications) during pregnancy.² Furthermore, 50% to 62% of women who are not treated for depression during pregnancy continue to suffer from depression in the postpartum period,⁸ and symptoms may last for months to years after the birth of the baby.⁹ A 2014 report from the Harvard Review of Psychiatry suggested that 30% of women diagnosed with postpartum depression were still depressed up to 3 years after delivery.¹⁰

The presence of depression contributes to negative health implications for both the mother and fetus. The impact of depressive symptoms on the mother may include, but are not limited to, less optimal maternal-fetal attachment,¹ increased pregnancy complaints (eg, pain, nausea, dizziness, gastrointestinal symptoms, discomfort), preeclampsia, cesarean section, and even suicide.¹ For the fetus and/or child negative implications may include, but are not limited to, low birth weight, preterm birth, elevated fetal activity, difficult temperament (eg, frequent crying, irritability), attention deficit hyperactivity disorder,¹ elevated cortisol at birth, irregular sleep patterns, delayed cognitive and linguistic skills, and impaired emotional development.^3,8 These behavioral, developmental, and mental deficits among offspring may persist throughout childhood and adolescence.^11
–13

Pregnant women experiencing depressive symptoms are at risk for excessive gestational weight gain (GWG)^14,15 and are more likely to experience comorbid mental health problems such as stress and anxiety.¹⁶ Depressed pregnant women may also be more likely to engage in unhealthy lifestyle behaviors^3,8 such as poor sleep habits, self-care and nutrition,^8,17 and less physical activity,¹⁸ all of which increase risk for chronic disease (eg, diabetes, obesity, cardiovascular disease)¹⁹ and long-term negative health implications. Recent literature suggests that pregnant women with limited social support are at high risk for depression,²⁰ and limited social support during pregnancy is predictive of higher GWG and postpartum depression.^15,21 In addition, the link between depression and poor sleep quality has been well documented in nonpregnant populations; however, the relationship between sleep quality and depression during pregnancy is less understood as irregular sleep patterns are common during pregnancy due to changes in hormones, growth of the fetus, and frequent urination.^22,23 Because both depression and pregnancy both pose challenges with sleep quality, depressed pregnant women are more likely to suffer from increased sleep disturbances, which may lead to immune system disruption and increased inflammatory markers that contribute to a substantial increased risk for adverse pregnancy outcomes.¹⁵ Depression during pregnancy can affect the mother’s ability to function and/or participate in healthy lifestyle behaviors.⁸ An understanding of how these lifestyle behaviors are affected in depressed pregnant women may aid health care providers (HCPs; eg, obstetricians, midwives) in providing optimal prenatal care as well as determining better strategies to improve healthy lifestyle behaviors in depressed pregnant women.

Despite the negative health implications, many HCPs do not routinely assess or screen for depressive symptoms during pregnancy.²⁴ In a national survey by Dietrich and colleagues, only 9% to 12% of obstetricians and gynecologists routinely screened for depressive symptoms.²⁵ Similarly, a survey by Leiferman and colleagues found that even though 90% of HCPs thought it was their responsibility to recognize maternal depression only 60% assessed depression in their pregnant patients.²⁶ These data highlight that many pregnant women with depression go untreated, increasing their risk of the aforementioned maternal and fetal negative health implications.

Depression during pregnancy is commonly treated by individual/group psychotherapy, medications (eg, psychotropics, serotonin reuptake inhibitors), or a combination thereof.²⁷ However, women report cost, transportation, child care, stigma,^7,28,29 and fear of adverse reproductive outcomes as barriers to current treatment options.²⁹ Data from the 2005 to 2009 National Surveys on Drug Use and Health found 26.3% of pregnant women report stigma concerns as a treatment barrier to depression.²⁴ Goodman investigated pregnant women’s attitudes, preferences, and perceived barriers to treatment for maternal depression and found that 42% of pregnant women felt that they would be embarrassed if their friends knew they received professional help for mental health problems.⁷ Additionally, 66% of pregnant women report the use of psychotropic medications (ie, medication for mental health disorders that are capable of effecting the mind, emotions, and behavior)³⁰ to be unacceptable during pregnancy^28,31

–34 and desire nonpharmacological alternatives.^35

–38 Findings in a review by Bonari and colleagues suggested that pregnant women were reluctant to take psychotropic medications and those who used them often felt apprehensive (eg, anxious, guilty) and preferred other natural treatments such as herbal remedies.³⁴

Of late, complementary health care approaches have been increasing in popularity for the treatment of mental health disorders (eg, depression, anxiety)³⁹ in nonpregnant populations due to their nonpharmacologic nature.^39,40 Complementary health care approaches can be defined as a natural product (eg, herbs) or mind-body practice (eg, yoga, meditation, Tai Chi, Qigong), developed outside of mainstream Western (ie, conventional) medicine to improve health and wellness.⁴¹ Complementary health care approaches have been used in clinical practice to improve chronic disease symptomology including those with diabetes,⁴² heart disease,⁴³ and cancer.⁴⁴ Studies suggest that complementary health care approaches (ie, mind-body practices) may stimulate relaxation, reduce stress-signaling hormones, and increase dopamine levels, which play a role in controlling emotions, mood, and anxiety.⁴⁵ Practices such as yoga and meditation have been documented to be desirable⁴⁶ and improves somatic complaints (ie, pain) of depressed pregnant women, which may improve sleep, as pain is a highly cited reason for sleep disruption during pregnancy.⁴⁷ Recent research investigating the effects of yoga to reduce depressive symptoms in depressed pregnant women have reported that yoga is a safe, feasible, and an acceptable approach that may have advantages over standard depression treatment (eg, medications).^48
–50 Complementary health care approaches cultivate mindfulness (ie, paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally), a skill that encourages emotion regulation⁵¹ thereby reducing depressive symptoms.⁵² Additionally, mindfulness may facilitate positive social interactions and reduce social conflict, which may increase levels of social support in both the peri- and postpartum periods.²⁰ The benefits of mindfulness extend into the postpartum period and may increase a mothers’ self-efficacy and self-compassion, improve mental health distress, and may even have an indirect positive effect on child development.⁵³ Therefore, complementary health care approaches may be an appropriate strategy to improve depressive symptoms in pregnant women. However, the perceptions, uses of, and interests in complementary health care approaches during pregnancy are less understood, and research in this area is still in its infancy.

Considering the negative implications for both the mother and fetus associated with depression during pregnancy, the limitations to identifying and treating depression during pregnancy, and the lack of research in this area, there is a need to explore the perceptions, uses of, and interests in complementary health care approaches in depressed pregnant women. The purpose of this study was to (1) describe the differences in mental health (ie, stress, anxiety) and lifestyle factors (ie, physical activity, diet, sleep, social support, mindfulness) of depressed pregnant women as compared to nondepressed pregnant women and (2) describe the perceptions, uses of, and interests in complementary health care approaches in depressed and nondepressed pregnant women.

Methods

The institutional review board of a large university in the southwestern United States approved this study.

Participant Selection

Women were included in the study if they were (1) currently pregnant (≥8 weeks gestation), (2) 18 years and older, (3) a US resident, and (4) able to read and write in English.

Procedures

This was a descriptive, cross-sectional study using a purposive nonprobabilistic sample. Research staff contacted organizations (eg, mother and baby retail stores, hospitals, pregnancy websites) and asked them to advertise the study by posting provided recruitment information (eg, flyers, blurbs) to their social media sites and/or websites, emailing listservs, or by displaying flyers at their location. Local and national organizations agreeing to advertise for the study were sent recruitment information via email. Recruitment for the study occurred between April and June 2015 locally and nationally via social media (eg, Facebook, Twitter), listservs, and websites that cater to women who are pregnant.

Women who were interested in participating were asked to complete an online survey that assessed their general physical and mental health during pregnancy as well as their perceptions, uses of, and interests in complementary health care approaches. After women were confirmed eligible to participate, they were informed of how the data would be used, confidentiality of their responses, and that completion of the survey indicated their consent to be in the study. Women were also told that they were free to choose no as a response or skip questions. The online survey was labeled the Pregnancy and Wellness Survey (PAWS) and was implemented using Qualtrics (Provo, UT). The PAWS took women approximately 30 minutes to complete. Participants who completed the PAWS were offered a $10 Target gift card to compensate for their time participating in the study (limited to the first 350 due to funding). The remaining participants were entered into a drawing to win one Jawbone UP Band or Fitbit Flex (winner’s choice) as compensation for their time.

Survey

The PAWS consisted of 2 parts: (1) multiple reliable and valid scales to describe general physical health (eg, amount of GWG in each trimester), lifestyle factors (eg, physical activity, diet, sleep, social support, mindfulness), and maternal mental health (ie, stress, anxiety, depression) and (2) investigator-developed questions to identify the wellness practices (ie, perceptions, uses of, interests in complementary health care approaches) of pregnant women. Demographics were collected at the end of the survey.

PAWS Part 1

Pregnancy Risk Assessment Monitoring System (PRAMS)

To determine general physical health, the PRAMS Phase 6 Core Questionnaire⁵⁴ was modified and general health questions related to pregnancy were asked, prepregnancy body mass index was calculated using self-reported prepregnancy height and weight, and total GWG was reported in each trimester. Current physical activity behaviors (eg, Are you currently participating in regular exercise? What kind of exercise are you currently participating in?) throughout pregnancy and a general nutrition question (eg, What kind of diet best describes how you are currently eating?) were asked to determine physical activity and dietary habits of pregnant women.

Pittsburgh Sleep Quality Index (PSQI)

Sleep quality was assessed using the PSQI,⁵⁵ a 19-item questionnaire. Previous studies have reported Cronbach’s α = .83, and the value in the present study was α = .73. Seven component scores are produced to calculate a final global score ranging from 0 to 21. Higher global PSQI scores indicate worse sleep quality.

Modified Medical Outcome Study–Social Support Survey (mMOS-SS)

The 8-item mMOS-SS was used to determine available social support resources.⁵⁶ Compared to the original 19-item MOS-SS, the mMOS-SS has similar internal consistency with studies reporting α = .80 to .87 and good construct validity. Comparatively, the present study demonstrated a Cronbach’s α = .93. Scores range from 0 to 100, with higher scores indicating more support.

Mindful Attention Awareness Scale (MAAS)

The MAAS⁵⁷ includes 15 items to measures the extent to which individuals are able to maintain awareness of present-moment experience. The MAAS is a valid and reliable measure with good internal consistency (α = .80-.87). Our sample produced a Cronbach’s α = .93. Higher scores reflect higher levels of mindfulness.

Perceived Stress Scale (PSS)

The PSS⁵⁸ includes 10 items that measure the degree of self-appraised stress in one’s life within the past month. The PSS is a reliable and valid measure that has demonstrated Cronbach’s α = .84 and good construct validity in pregnant women.⁵⁹ Comparatively, our sample’s Cronbach’s α was .90. Higher scores indicate higher levels of perceived stress.

State Trait Anxiety Inventory-Short Form (STAI-S)

The STAI-S is a 6-item scale used to determine levels of state anxiety and produces scores similar to those obtained using the 20-item STAI state scale.⁶⁰ To mitigate participant burden, researchers implemented the 6-item STAI-S (compared to the original 40-item STAI). There is currently no short form for trait anxiety. The STAI-S has been reported to be reliable and valid measure with good internal consistency (α = .82) and concurrent validity. Comparatively, this study reported Cronbach’s α of .85. Scores range from 20 to 80, with higher scores indicating higher levels of anxiety.

Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is a 10-item scale used to assess participants at risk for perinatal depression⁶¹ and is a reliable (α = .87) and valid tool. For our current study, Cronbach’s α = .87. EPDS scores range from 0 to 30, with scores of 12 or greater indicating probable depression. For this study, a cutoff score of 12 was used in data analysis. For convenience of writing this article, those scoring 12 or greater were referred to as depressed and are not representative of a clinical diagnosis for depression.

PAWS Part 2

Wellness Practices

A 19-item survey was developed to assess participants’ perceptions, uses of, and interests in complementary health care approaches (eg, yoga, meditation, Tai Chi, Qigong).⁴¹ Questions were yes/no, Likert-type scale items with ordinal answers, multiple choice, open-ended, and check all that apply. Example questions include, “Have you ever participated in complementary health care approaches during pregnancy?” “What benefits do you like about using complementary health care approaches?” “Would you ever consider participating in complementary health care approaches to health care during pregnancy?” “What kinds of complementary health care approaches would you be interested in using during pregnancy?” The list of complementary health care approaches included yoga, meditation, mindfulness, Qigong, acupuncture, chiropractic, naturopathy, massage, aruveyda, Tai Chi, Chinese medicine, homeopathy, biofeedback, prayer, shamanism, and energy healing (eg, reiki), and participants were asked to select whether or not they used an complementary health care approach in a previous pregnancy, when they were not pregnant, and/or if they were currently using (see Table 3).

Table 1.

Demographics and Characteristics of Survey Respondents (N = 1032) by Depression Status.

	Nondepressed, n (%)	Depressed, n (%)	Overall, n (%)
n	760 (73.64)	272 (26.4)	1,032 (100)
Age (M ± SD)	28.8 ± 7.4	28.4 ± 4.9	28.72 ± 6.8
Race (n = 933)
Caucasian	554 (81.0)	210 (84.3)	764 (81.9)
African American	45 (6.6)	15 (6.0)	60 (6.4)
Asian or Pacific Islander	27 (3.9)	7 (2.8)	34 (3.6)
American Indian	1 (0.1)	1 (0.4)	2 (0.3)
Two or more races	27 (3.9)	11 (4.4)	38 (4.1)
Other	30 (4.4)	5 (2.0)	35 (3.8)
Hispanic/Latino (n = 935)
Yes	81 (11.8)	27 (10.8)	108 (11.6)
No	604 (88.2)	223 (89.2)	827 (88.4)
Marital status (n = 940)
Single (never married)	117 (17.0)	56 (22.2)	173 (18.4)
Divorced/separated/widowed	14 (2.0)	13 (5.2)	27 (2.9)
Married	557 (81)	183 (72.6)	740 (78.7)
Income (n = 938)
<$10 000	40 (5.8)	15 (6.0)	55 (5.9)
$10 000-19 999	55 (8.0)	26 (10.3)	81 (8.6)
$20 000-34 999	87 (12.7)	40 (15.9)	127 (13.5)
$35 000-49 999	109 (15.9)	30 (11.9)	139 (14.8)
>$50 000	395 (57.6)	141 (56.0)	536 (57.1)
Education (n = 939)
Less than 12 years	17 (2.5)	4 (1.6)	21 (2.2)
High school/GED	77 (11.2)	27 (10.7)	104 (11.1)
Some college	214 (31.1)	68 (27.0)	282 (30.0)
College degree	231 (33.6)	114 (45.2)	345 (36.7)
Beyond college	148 (21.5)	39 (15.5)	187 (19.9)
Current trimester (n = 1032)
First (0-13 weeks)	50 (6.6)	21 (7.7)	71 (6.9)
Second (14-26 weeks)	237 (31.2)	104 (38.2)	341 (33.0)
Third (27+ weeks)	473 (62.2)	147 (54.0)	620 (60.1)
Prepregnancy BMI (n = 1032)
Underweight	22 (2.9)	47 (17.3)	69 (6.7)
Normal	313 (41.2)	102 (37.5)	415 (40.2)
Overweight	184 (24.2)	46 (16.9)	230 (22.3)
Obese	229 (30.1)	72 (26.5)	301 (29.2)
Currently exercising regularly (n = 983)
Yes	358 (49.4)	95 (36.7)	453 (46.1)
No	366 (50.6)	164 (63.3)	530 (53.9)
Counseling/therapy for depression (n = 99)
Yes	13 (30.2)	13 (23.2)	26 (26.3)
No	30 (69.8)	43 (76.8)	73 (73.7)
Ask for help for depression (n = 99)
Yes	7 (.92)	22 (8.1)	29 (2.8)
No	36 (4.7)	34 (12.5)	70 (6.8)
Clinically diagnosed for depression (n = 99)	43 (5.7)	56 (20.6)	99 (9.6)
Currently taking depression medications (n = 30)	14 (1.8)	16 (5.9)	30 (2.9)

Abbreviations: M, mean; SD, standard deviation; BMI, body mass index.

Table 2.

Mean Differences in Lifestyle Factors Between Nondepressed and Depressed Pregnant Women.

Lifestyle Factor	Nondepressed, M ± SD	Depressed, M ± SD	t	P	d ^a
Anxiety (STAI)	33.11 ± 10.61	48.6 ± 10.65	−20.57	<.001	1.46
Stress (PSS)	12.23 ± 6.12	21.47 ± 5.34	−23.3	<.001	1.61
Social Support (MOS-SS)	79.15 ± 20.75	59.18 ± 23.06	12.39	<.001	0.91
Mindfulness (MAAS)	4.43 ± 0.91	3.43 ± 0.83	16.06	<.001	1.15
Sleep	7.1 ± 3.26	9.01 ± 3.21	−8.33	<.001	0.59

Abbreviations: M, mean; SD, standard deviation; STAI, State Trait Anxiety Inventory; PSS, Perceived Stress Scale; MOS-SS, Medical Outcome Study–Social Support Survey; MAAS, Mindful Attention Awareness Scale.

^aCohen’s d.

Table 3.

Questions Pertaining to the Perceptions, Uses of, and Interests in Complementary Health Care Approaches.

Response	Question and Frequency
	Q1. Have you ever used a complementary health care health care approach (N = 984)?
	Nondepressed, n (%)			Depressed, n (%)			Overall, n (%)
Yes	260 (36.0)			69 (26.4)			329 (33.4)
No	463 (64.0)			192 (73.6)			655 (66.6)

	Q2. Type and time of complementary health care approach used:
	Previous pregnancy		Prepregnancy			Currently
	Nondepressed, n (%)	Depressed, n (%)	Nondepressed, n (%)		Depressed, n (%)	Nondepressed, n (%)		Depressed, n (%)
	N = 260	N = 69	N = 260		N = 69	N = 260		N = 69
Yoga	68 (26.2)	20 (29.0)	165 (63.5)		39 (56.5)	95 (36.5)		23 (33.3)
Meditation	29 (11.2)	11 (15.9)	85 (32.7)		27 (39.1)	67 (25.8)		20 (29.0)
Mindfulness	24 (9.2)	6 (8.7)	65 (25.0)		18 (26.1)	59 (22.7)		15 (21.7)
Qigong	0 (0.0)	1 (1.4)	6 (2.3)		2 (2.9)	0 (0.0)		1 (1.4)
Acupuncture	9 (3.5)	1 (1.4)	44 (16.9)		8 (11.6)	6 (2.3)		3 (4.3)
Chiropractic	51 (19.6)	9 (13.0)	101 (38.8)		28 (40.6)	67 (25.8)		12 (17.4)
Naturopathy	11 (4.2)	5 (7.2)	32 (12.3)		6 (8.7)	13 (5.0)		1 (1.4)
Massage	55 (21.2)	14 (20.3)	142 (54.6)		35 (50.7)	88 (33.8)		18 (26.1)
Aruveyda	0 (0.0)	0 (0.0)	12 (4.6)		5 (7.2)	1 (0.4)		0 (0.0)
Tai Chi	2 (0.8)	3 (4.3)	5 (1.9)		2 (2.9)	5 (1.9)		0 (0.0)
Chinese medicine	2 (0.8)	0 (0.0)	19 (7.3)		2 (2.9)	2 (0.8)		2 (2.9)
Homeopathy	24 (9.2)	3 (4.3)	58 (22.3)		8 (11.6)	35 (13.5)		6 (8.7)
Biofeedback	1 (0.4)	2 (2.9)	7 (2.7)		2 (2.9)	2 (0.8)		0 (0.0)
Prayer	81 (31.2)	18 (26.1)	113 (43.5)		28 (40.6)	117 (45.0)		30 (43.5)
Shamanism	2 (0.8)	1 (1.4)	4 (1.5)		3 (4.3)	2 (0.8)		0 (0.0)
Energy healing (eg, Reiki)	7 (2.7)	1 (1.4)	21 (8.1)		4 (5.8)	11 (4.2)		3 (4.3)

	Q2a. When using yoga, meditation, mindfulness, Tai Chi, or Qigong, was a meditative state encouraged and/or did you strive to achieve a meditative state (ie, focusing on breath, acknowledging the present moment)?
	Nondepressed, n (%)			Depressed, n (%)			Overall, n (%)
	N = 213			N = 59			N = 272
Yes	164 (77.0)			42 (71.2)			206 (75.74)
No	49 (23.0)			17 (28.8)			66 (24.26)

	Q2b. Reasons for using complementary health care approaches:
	N = 260			N = 69			N = 329
Relaxation	208 (80.0)			52 (75.4)			260 (79.0)
Stress reduction	182 (70.0)			53 (76.8)			235 (71.4)
Weight loss/management	36 (13.8)			16 (23.2)			52 (15.8)
Illness	21 (8.1)			5 (7.2)			26 (7.9)
Pain management	119 (45.8)			31 (44.9)			150 (45.6)
Allergies	12 (4.6)			1 (1.4)			13 (4.0)
Restore energy imbalances	37 (14.2)			6 (8.7)			43 (13.1)
Other	14 (05.4)			4 (5.8)			18 (5.5)

	Q2c. What benefits do you like about using complementary health care approaches?
	N = 260			N = 69			N = 329
Improved emotional health	160 (61.5)			43 (62.3)			203 (61.7)
Improved spiritual health	110 (42.3)			27 (39.1)			137 (41.6)
Improved mental health	150 (57.7)			46 (66.7)			196 (59.6)
Treating the whole person	99 (38.1)			27 (39.1)			126 (38.3)
Focus on prevention	77 (29.6)			14 (20.3)			91 (27.7)
Limited side effects	106 (40.8)			20 (29.0)			136 (41.3)
Stress reduction	178 (68.5)			46 (66.7)			224 (68.1)
Relaxation	203 (78.1)			45 (65.2)			248 (75.4)
Enjoyable	146 (56.2)			35 (50.7)			181 (55.0)
Weight loss/management	30 (11.5)			9 (13.0)			39 (11.9)
Physical strengthening	67 (25.8)			22 (31.9)			89 (27.1)
Other	8 (3.1)			3 (4.3)			11 (3.3)

	Q2d. What extent do you feel that complementary health care approaches help improve your condition(s)?
	N = 258			N = 68			N = 326
Very much	129 (50.0)			26 (38.2)			155 (47.5)
Somewhat	105 (40.7)			31 (45.6)			136 (41.7)
Undecided	17 (6.6)			8 (11.8)			25 (7.7)
Not really	4 (1.6)			2 (02.9)			6 (1.8)
Not at all	3 (1.2)			1 (1.5)			4 (1.2)

	Q2e. Do you use complementary health care approaches as an alternative (ie, instead of) to conventional health care?
	N = 255			N = 67			N = 322
Yes	23 (9.0)			14 (20.9)			37 (11.5)
No	232 (91.0)			53 (79.1)			285 (88.5)

	Q3. What are your reasons for not trying a complementary health care approach?
	N = 463			N = 192			N = 655
Nowhere to try it out	79 (17.1)			34 (17.7)			113 (17.3)
Injury	4 (0.9)			6 (3.1)			110 (16.8)
Soreness	9 (1.9)			15 (7.8)			24 (3.7)
Emotional trigger	4 (0.9)			27 (14.1)			31 (4.7)
Irritability	5 (1.1)			15 (7.8)			20 (3.1)
Cost	104 (22.5)			25 (13.0)			129 (19.7)
Boring	24 (5.2)			9 (4.7)			33 (5.0)
Don’t know much about it	308 (66.5)			90 (46.9)			398 (60.8)
Clashes with religious beliefs	8 (1.7)			1 (0.5)			9 (1.4)
Safety concerns	44 (9.5)			14 (7.3)			58 (8.9)
Other	22 (4.8)			4 (2.1)			26 (4.0)

	Q4. During pregnancy, have you ever thought of using complementary health care approaches to:
	N = 702			N = 256			N = 960
Manage weight only	37 (5.3)			22 (8.6)			59 (6.1)
Manage weight and stress	202 (28.8)			71 (27.7)			273 (28.4)
Manage stress only	149 (19.6)			88 (34.4)			237 (24.7)
Neither	314 (44.7)			75 (29.3)			389 (40.5)

	Q5. During pregnancy, would you ever consider using complementary health care approaches to:
	N = 704			N = 256			N = 960
Manage weight only	34 (4.8)			25 (9.8)			59 (6.1)
Manage weight and stress	362 (51.4)			118 (46.1)			480 (50.0)
Manage stress only	122 (17.3)			71 (27.7)			193 (20.1)
Neither	186 (26.4)			42 (16.4)			228 (23.8)

	Q6. What types of complementary health care approaches would you be interested in using to manage your weight during pregnancy? (n = those who selected manage weight only or manage weight and stress in Question 5)
	N = 396			N = 143			N = 539
Yoga	338 (85.4)			101 (70.6)			439 (81.4)
Meditation	137 (34.6)			53 (37.1)			190 (35.3)
Mindfulness	79 (19.9)			28 (19.6)			107 (19.9)
Acupuncture	71 (17.9)			22 (15.4)			93 (17.3)
Chiropractic	145 (36.6)			51 (35.7)			196 (36.4)
Naturopathy	30 (7.6)			14 (9.8)			44 (8.2)
Massage	255 (64.4)			72 (50.3)			327 (60.7)
Aruveyda	14 (3.5)			6 (4.2)			20 (3.7)
Qigong	9 (2.3)			1 (0.7)			10 (1.9)
Tai Chi	26 (6.6)			4 (2.8)			30 (5.6)
Any	63 (15.9)			35 (24.5)			98 (18.2)
Other	3 (0.8)			0 (0.0)			3 (0.6)

	Q7. What types of complementary health care approaches would you be interested in using to manage your stress during pregnancy? (n = those who selected manage stress only or manage weight and stress in Question 5)
	N = 484			N = 189			N = 673
Yoga	361 (74.6)			101 (53.4)			462 (68.6)
Meditation	235 (48.6)			70 (37.0)			305 (45.3)
Mindfulness	123 (25.4)			45 (23.8)			168 (25.0)
Acupuncture	88 (18.2)			36 (19.0)			124 (18.4)
Chiropractic	165 (34.1)			55 (29.1)			220 (32.7)
Naturopathy	27 (5.6)			13 (6.9)			40 (5.9)
Massage	335 (69.2)			78 (41.3)			413 (61.4)
Aruveyda	10 (2.1)			3 (1.6)			13 (1.9)
Qigong	6 (1.2)			1 (0.5)			7 (1.0)
Any	80 (16.5)			36 (19.0)			116 (17.2)
Other	3 (0.6)			3 (1.6)			6 (0.9)

Statistical Analysis

Data were entered into the Statistical Package for Social Sciences (SPSS) version 22.0 for analysis. Descriptive statistics (eg, mean ± SD, frequencies, and percentages) were used to describe the demographic characteristics, mental health, and lifestyle factors of the pregnant women. Independent t tests were conducted to examine mean differences in maternal mental health scores and lifestyle factors between depressed and nondepressed pregnant women. Cohens d was used to determine effect size, and values of .2, .5, and .8 indicated small, moderate, and large effect size, respectively.⁶² A P value ≤ .05 was considered statistically significant.

Results

Baseline Demographics and Characteristics

Table 1 illustrates demographics and characteristics of survey respondents (n = 1032). Overall, participants were 28.7 ± 6.8 years and primarily Caucasian (81.9%). A majority of the sample was married (78.7%), made more than $50 000 (57.1%), and had a college degree (36.7%). Approximately 60% of participants were in their third trimester (ie, ≥27 weeks gestation). Just over 26% (n = 272) of women screened positive for depression (eg, EPDS ≥12), but when asked if they had been clinically diagnosed with and currently suffering from depression only 21% said yes (n = 56). Eight percent of depressed pregnant women reported asking for help for depression from a doctor, nurse, or other health care professional; 23% were currently receiving counseling or therapy for depression; and 5.9% were currently taking medication for depression. About 46% of pregnant women reported meeting physical activity recommendations (≥150 min/week)⁶³; 36% (n = 95) of depressed pregnant women and 49.4% of nondepressed pregnant women. The majority of women reported a normal prepregnancy body mass index (40.2%), but a large amount was overweight (22.3%) or obese (29.2%).

Lifestyle Factors

Independent t test results indicated that depressed pregnant women had significantly greater mean scores for anxiety (mean [M] = 48.6, standard deviation [SD] ± 10.65), t(1020) = −20.6, P < .001; stress (M = 21.47, SD ± 5.34), t(534.5) = −23.3, P < .001; and sleep (M = 9.01, SD ± 3.21), t(1029) = −8.3, P < .001, indicating higher levels of anxiety, stress, and worse sleep quality when compared to mean scores in nondepressed women at M = 33.11, SD ± 10.61; M = 12.23, SD ± 6.12; M = 7.1, SD ± 3.26, respectively (see Table 2). Depressed pregnant women also had lower mean scores for social support (M = 59.18, SD ± 23.06), t(428.4) = 12.4, P < .001, and mindfulness (M = 3.43, SD ± 0.83), t(492.1) = 16.1, P < .001, indicating less available social support resources and lower levels of mindfulness when compared to mean scores in nondepressed pregnant women at M = 79.15, SD ± 20.75, and M = 4.43, SD ± 0.91, respectively (see Table 2).

Perceptions, Uses of, and Interests in Complementary Health Care Approaches

Women were asked whether or not they had ever used a complementary health care health care approach (n = 984), and follow-up questions were asked based on their answer (ie, yes/no). The findings presented below represent data gathered from the overall sample (n = 984) as well as the sample of depressed (n = 261) and nondepressed (n = 723) pregnant women (see Table 3).

Thirty-three percent (n = 329) of the overall sample of pregnant women reported use of a complementary health care health care approach. Just over 59% of pregnant women had thought of using complementary health care approaches to manage their weight or stress, 41% had never thought of using complementary health care approaches to manage weight or stress, and 76% of women would consider using complementary health care approaches to manage their weight or stress during pregnancy. A majority of pregnant women (69%) were interested in using yoga to manage their stress during pregnancy. Of those who had used a complementary health care health care approach (n = 329), the top 5 most popular types were prayer (44%), yoga (36%), massage (32%), meditation (26%), and chiropractic care (24%). Most pregnant women who engaged in some sort of mind-body practice (ie, yoga, meditation, Tai Chi, Qigong; 76%) reported using a meditative state (ie, focusing on breath, acknowledging the present moment). Relaxation (79%) was the top reason for using complementary health care approaches, and the top benefit for use was stress reduction (68%). Most pregnant women (89%) felt that complementary health care approaches somewhat or very much helped improve their condition. Approximately 11% of pregnant women were using complementary health care approaches as an alternative (ie, instead of) to conventional health care. Of those who reported never using a complementary health care health care approach (n = 655), a majority (61%) reported not using because they did not know much about it.

Twenty-six percent (n = 69) of depressed pregnant women reported use of a complementary health care approach. About 71% of depressed pregnant women had thought of using complementary health care approaches to manage their weight or stress, 29% had never thought of using complementary health care approaches to manage weight or stress, and 84% would consider using complementary health care approaches to manage their weight or stress during pregnancy. A majority of depressed pregnant women (53%) were interested in using yoga to manage their stress during pregnancy. Of the depressed pregnant women who had used a complementary health care health care approach (n = 69), the top 5 most popular types were prayer (44%), yoga (33%), meditation (29%), massage (26%), and mindfulness (22%). Most depressed pregnant women who engaged in some sort of mind-body practice (ie, yoga, meditation, Tai Chi, Qigong; 71%) reported using a meditative state. Stress reduction (77%) was the top reason for using complementary health care approaches, and the top benefit for use was both improved mental health (67%) and stress reduction (67%). Most depressed pregnant women (84%) felt that complementary health care approaches somewhat or very much helped improve their condition. Approximately 21% of depressed pregnant women were using complementary health care approaches as an alternative to conventional health care. Of the depressed pregnant women who reported never using a complementary health care approach (n = 192), 47% reported not using because they did not know much about it. See Table 3 for the complementary health care approaches used in nondepressed pregnant women.

Discussion

The purpose of this study was to (1) describe the differences in mental health (ie, stress, anxiety) and lifestyle factors (ie, physical activity, diet, sleep, social support, mindfulness) of depressed pregnant women as compared to nondepressed pregnant women and (2) describe the perceptions, uses of, and interests in complementary health care approaches in depressed and nondepressed pregnant women. Just over 26% of pregnant women in our sample had clinically relevant symptoms of depression (≥12 on the EPDS), consistent with previous studies reporting depression rates during pregnancy between 9.8% and 28.3% (depending on study cohort and depression scale used).^45,64,65 Though a considerable proportion of pregnant women in our study screened positive on the EPDS for depression (≥12), when depressed pregnant women (n = 272) were asked if they had been clinically diagnosed with and currently suffering from depression only 21% said yes. Additionally, only a small amount (8.1%) of depressed pregnant women asked for help for depression from a doctor, nurse, or other health care professional. Just over 23% of depressed pregnant women were currently receiving counseling or therapy for depression and 5.9% were currently taking medication for depression. These data are consistent with the literature^{3,24,27,66,67} and highlight the significant amount of women with clinically relevant levels of depression that may not be receiving treatment. Pregnant women may have difficulty recognizing symptoms of depression during pregnancy,^3,8,27,68 which may play a role in their decision to seek treatment. Encouraging HCPs to assess and treat/refer for depression during pregnancy is warranted as well as exploring strategies to encourage pregnant women to seek help for depression.

Lifestyle Factors

Depressed pregnant women in our sample had significantly higher levels of anxiety and stress, as well as worse sleep quality, levels of mindfulness, and social support as compared to nondepressed pregnant women. These modifiable lifestyle factors may play a role in depression during pregnancy. Research suggests that pregnant women with high depression scores (≥12 on the EPDS) typically experience comorbid conditions such as anxiety disorders⁶⁹ and stress,⁷⁰ which complicate pregnancy outcomes and are strong risk factors for postpartum depression.⁸ In nonpregnant populations, depression and sleep have a strong association,⁷¹ but their relationship during pregnancy is complex. Findings in a study by Okun and colleagues suggest that depression and disturbed sleep during pregnancy interact to increase risk for adverse pregnancy outcomes and chronic disease (eg, cardiovascular disease, obesity) by increasing an exaggerated inflammatory profile.⁷² Our findings highlight that depressed pregnant women may be experiencing worse sleep quality compared to nondepressed pregnant women. HCPs may need to specifically address sleep disturbance in depressed pregnant women. The relationship between sleep and depression during pregnancy warrants further investigation.

High levels of mindfulness and social support have been shown in the literature to improve depressive symptoms and may be protective factors for depression during pregnancy.^73,74 The literature suggests that social support protects the emotional well-being of the mother by buffering the impact of life stress.⁷⁵ In our sample, depressed pregnant women had significantly lower social support scores. Though our study did not report on differences between low or high socioeconomic status, depressed pregnant women of low socioeconomic status have been reported to experience higher levels of depression and lower levels of social support.^76,77 Recently, social support has been the target of psychosocial interventions because of its emerging importance in depressed pregnant women and is a predictor of depression during pregnancy and postpartum. Hahn-Holbrook and colleagues found that social support biologically mitigates depression by reducing stress-releasing hormones, and researchers suggest that the timing of social support interventions is extremely important. Early social support interventions that target depressed pregnant women with low socioeconomic status are warranted.⁷⁸ Research on strategies to provide early social support is recommended.

Similarly, mindfulness may also be protective against depression in pregnancy. Depressed pregnant women in our sample had lower levels of mindfulness when compared to nondepressed pregnant women. Previous mindfulness interventions have shown that higher mindfulness levels are associated with lower depressive symptomology in pregnant women.⁷⁹ However, a limited number of mindfulness studies have been conducted in pregnant women with depression and have had small sample sizes with poor study designs. A review by Hall and colleagues found only 6 mindfulness interventions with depression outcomes in pregnant women and none of the studies were randomized controlled trials.⁷⁹ Of late, the mechanisms by which mindfulness reduces depressive symptomology has become of interest. Paul and colleagues suggest that mindfulness protects against depression by limiting rumination and negative bias (key risk factors for depression) and reducing automatic emotional responding to negative stimuli.⁸⁰ Mindfulness also cultivates self-compassion, which has been reported to be a beneficial factor that is protective against depression and relapse/recurrence.⁸¹ More research is needed, especially randomized controlled trials, to determine the efficacy of mindfulness interventions for depression and the pathways by which mindfulness protects against depression in pregnant women.

Depressed pregnant women often have unhealthy lifestyle behaviors (eg, poor sleep, low social support), which may spiral into even worse depression, may lead to subsequent postpartum weight gain and/or retention, and may contribute to the development of obesity in the postpartum period.^82,83 Not only is it important for HCPs to screen for depression during pregnancy, but screening and managing (ie, treating and/or referring to care) these modifiable lifestyle factors (eg, mental health, sleep, social support, mindfulness) may help inadvertently improve depression in pregnant women and enhance health in the postpartum period. Furthermore, identifying nonpharmacological strategies such as complementary health care approaches to help depressed pregnant women improve lifestyle behaviors should be explored further.

Perceptions, Uses of, and Interests in Complementary Health Care Approaches

In our study, depressed pregnant women felt the most benefit for use of complementary health care approaches was improved mental health and stress reduction. Similar to our study, in a recent nationally representative survey 86.1% of 34 525 adults aged 18 and older reported reduction of stress as the major reason for using yoga specifically.^84,85 Our data suggest that depressed pregnant women may experience symptoms of stress and anxiety simultaneously with depressive symptoms when compared with nondepressed pregnant women and use complementary health care approaches to relieve their stress for improved mental health many complementary health care approaches incorporate mindfulness,⁸⁶ which can help regulate emotions, a pathway by which mindfulness also promotes mental health.⁵¹ Emotion regulation is a process by which individuals control their emotions in response to external stimuli (eg, environmental demands),⁵¹ in turn decreasing circulating cortisol levels and providing behavioral therapy (eg, increasing motivation).⁸⁷ Complementary health care approaches may be a more acceptable intervention for the treatment of depression during pregnancy due to their nonpharmacologic nature and may help pregnant women recognize feelings and emotions of depression as well as alleviate symptoms through the application of mindfulness. Utilizing nonpharmacological strategies such as complementary health care approaches to help pregnant women manage and treat depression and its related mental health distress needs to be explored in future trials.

Despite 71% of depressed pregnant women who had thought of using complementary health care approaches to manage their weight and/or stress during pregnancy, only 26% had used or were currently using them.³ However, 84% of depressed pregnant women would consider using a complementary health care approach to manage their weight and/or stress during pregnancy and more than half were interested in using yoga. Our data suggest that depressed pregnant women are interested in using complementary health care approaches for weight and/or stress management during pregnancy, particularly yoga, yet many do not use them. Forty-seven percent of depressed pregnant women reported not using them because they did not know much about them. Complementary health care approaches that apply a movement component (eg, yoga, Tai Chi, Qigong) especially may encourage GWG management due to the combination of both physical activity and application of mindfulness and relaxation techniques.⁴⁴ Movement-based complementary health care approaches may increase energy expenditure during practice, facilitate exercise outside of practice (due to reducing back and joint pain), heighten mindfulness, improve mood, reduce stress, reduce food intake, increase connection to body, and enhance awareness of feelings of fullness.⁸⁷ In a recent review by Gong and colleagues, researchers concluded that depressed pregnant women who participated in integrated yoga (physical postures, breathing exercises, meditation, mindfulness) had better mental health outcomes as compared to depressed pregnant women who participated in exercise-based yoga (ie, physical postures only) and may be a better choice for pregnant women.⁸⁸ Findings in a study by Larkey and colleagues suggest that meditative movement exercises (eg, yoga, Tai Chi, Qigong) may achieve weight loss without perceived hard work of vigorous physical activity and dietary restrictions. Additionally, mindfulness-based interventions may reduce stress-related emotions (eg, anxiety, depression), body mass index, metabolic imbalance, and disordered eating by focus on body awareness, emotional self-regulation, and attention to inner “wisdom” cues.⁸⁹ Because depressed pregnant women in our sample exhibited unhealthier lifestyle behaviors compared with nondepressed pregnant women, complementary health care approaches utilizing a movement component (eg, yoga, Tai Chi, Qigong) may be an effective approach to simultaneously manage GWG, depression, and related mental health distress (eg, stress, anxiety). Future research is necessary to test the effectiveness of complementary health care approaches in the simultaneous management of GWG and depression and determine which types are most beneficial in pregnant women. To our knowledge, no such intervention exists.

Interestingly, only 54% of nondepressed pregnant women (as compared to 71% of depressed pregnant women) had thought about using complementary health care approaches to manage their weight and/or stress during pregnancy. As reported above, nondepressed pregnant women have lower stress and anxiety levels when compared to depressed pregnant women. As a result, many nondepressed pregnant women may not consider looking for stress management techniques because they simply do not feel stressed. On the other hand, depressed pregnant women experience heightened mental health distress and may look for resources to help manage their mental health distress, thereby increasing their interest for using complementary health care approaches. Future research utilizing yoga as a modality to manage weight and improve mental health in depressed pregnant women may be an acceptable and preferred method and should be tested to determine its acceptability and efficacy.

Limitations

Despite this study being one of the first to explore the perceptions, uses of, and interests in complementary health care approaches in women with depressive symptoms, there were a few limitations to note. First, because the majority of participants in this study were pregnant, Caucasian, and middle class, the generalizability of the findings are limited to these populations. Second, administering a survey presents inherent self-report limitations⁹⁰ including biased results, participant burden resulting from length of survey, potential data errors, and incorrect interpretation of survey questions. Third, the design of this study was cross-sectional; therefore, no causal relationships can be determined from analyses. For the differences found between depressed and nondepressed pregnant women regarding lifestyle behaviors, use of complementary health care approaches could be explained as behavioral choices affecting mental health; conversely, it could be that preexisting depression influences these behavioral choices. It would be important to explore these relationships temporally and learn how to mitigate this challenging cluster of behaviors and mental health.

Conclusion

Few interventions have used complementary health care approaches to reduce mental health distress (eg, stress, anxiety, depression) in depressed pregnant women and many are limited in sample size and study design.^91

–94 Research in this area during pregnancy is lacking. Sixty-one percent of pregnant women (independent of depression status) in our sample report not using complementary health care approaches because they do not know much about them. Sadly, there is literature to suggest that HCPs do not provide physical activity and/or stress management resources to patients.²⁶ This provides a unique opportunity to educate pregnant women and their HCPs about the benefits of using complementary health care approaches to treat and prevent excessive GWG and maternal mental health during pregnancy. Perhaps education about what complementary health care approaches are, types to consider trying, and the benefits of using them may help encourage the use of complementary health care approaches and thus manage GWG and symptoms of mental health distress. HCPs could provide recommendations and/or information to pregnant women regarding GWG, stress, and how to manage both using complementary health care approaches. Since pregnant women have frequent interactions with their HCPs, this may be an opportune time to disseminate information about the use of complementary health care approaches for managing GWG and mental health during pregnancy. Pregnant women may be more receptive to recommendations from their HCPs and may be more willing to try complementary health care approaches.^95,96 Furthermore, rigorous screening for depression and assessment of lifestyle factors is recommended in early pregnancy. Additionally, data related to complementary health care approaches to simultaneously reduce mental health distress and GWG in pregnancy is nonexistent. The known benefits of complementary health care approaches on mental health are well established,^97,98 as well as their potential for weight management in nonpregnant populations.^87,89 Because of the safety and low cost⁹⁹ of complementary health care approaches and preference for nonpharmacological interventions in pregnant women,^35,37,38 there is a need to explore the efficacy of complementary health care approaches as a strategy for maternal mental health and GWG management in depressed pregnant women to improve pregnancy and birth outcomes. More research is needed to inform future interventions targeted to improve physical and mental health outcomes for the mother and fetus. Future interventions should design trials to test the effectiveness of complementary health care approaches to simultaneously manage maternal mental health (ie, depression) and GWG in depressed pregnant women.

Footnotes

Acknowledgments

The authors would like to acknowledge Lauren Martinez at Arizona State University for her assistance in manuscript preparation.

Author Contributions

JM developed the idea for the study, acted as project coordinator on the study, drafted the initial manuscript, and prepared the manuscript for publication. JLH contributed to conceptualization of the study, provided feedback on revisions of the manuscript, and served as a mentor on this study. JAL contributed to the conceptualization of the study design and provided feedback and revisions to the manuscript. DM provided feedback and revisions to the manuscript and assisted with data analyses. LKL provided feedback and revisions to the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Athletics Research Grant from Arizona State University Sun Devil Athletics Department.

Ethical Approval

This project was approved by the Institutional Review Board at Arizona State University Office of Research Integrity and Assurance (Ethical approval number: STUDY00002406).

References

Satyanarayana

Lukose

Srinivasan

. Maternal mental health in pregnancy and child behavior. Indian J Psychiatry. 2011;53:351–361.

Yonkers

Wisner

Stewart

. Depression during pregnancy: treatment recommendations. http://www.acog.org/About-ACOG/News-Room/News-Releases/2009/Depression-During-Pregnancy. Published August 21, 2009. Accessed March 22, 2016.

Marcus

Heringhausen

. Depression in childbearing women: when depression complicates pregnancy. Prim Care. 2009;36:151–165.

Vesga-Lopez

Blanco

Keyes

Olfson

Grant

Hasin

. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65:805–815.

Farr

Bitsko

Hayes

Dietz

. Mental health and access to services among US women of reproductive age. Am J Obstet Gynecol. 2010;203:542.e1–e9.

Le Strat

Dubertret

Le Foll

. Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. J Affect Disord. 2011;135:128–138.

Goodman

. Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009;36:60–69.

Bonari

. Perinatal risks of untreated depression during pregnancy. Can J Psychiatry. 2004;49:726–735.

Rogge

. Postpartum depression. http://www.nlm.nih.gov/medlineplus/ency/article/007215.htm. Accessed March 22, 2016.

10.

Vliegen

Casalin

Luyten

. The course of postpartum depression: a review of longitudinal studies. Harv Rev Psychiatry. 2014;22:1–22.

11.

Austin

Leader

. Maternal stress and obstetric and infant outcomes: epidemiological findings and neuroendocrine mechanisms. Aust N Z J Obstet Gynaecol. 2000;40:331–337.

12.

Beebe

Jaffe

Buck

. Six-week postpartum maternal depressive symptoms and 4-month mother-infant self- and interactive contingency. Infant Ment Health J. 2008;29:442–471.

13.

Murray

Cooper

Wilson

Romaniuk

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression 2. Impact on the mother-child relationship and child outcome. Br J Psychiatry. 2003;182:420–427.

14.

Webb

Siega-Riz

Dole

. Psychosocial determinants of adequacy of gestational weight gain. Obesity. 2009;17:300–309.

15.

Hartley

McPhie

Skouteris

Fuller-Tyszkiewicz

Hill

. Psychosocial risk factors for excessive gestational weight gain: a systematic review. Women Birth. 2015;28:e99–e109.

16.

Ertel

Rich-Edwards

Koenen

. Maternal depression in the United States: nationally representative rates and risks. J Womens Health (Larchmt). 2011;20:1609–1617.

17.

Pina-Camacho

Jensen

Gaysina

Barker

. Maternal depression symptoms, unhealthy diet and child emotional-behavioural dysregulation. Psychol Med. 2015;45:1851–1860.

18.

De Wit

Jelsma

JGM

van Poppel

MNM

. Physical activity, depressed mood and pregnancy worries in European obese pregnant women: results from the DALI study. BMC Pregnancy Childbirth. 2015;15:158.

19.

Byrn

Penckofer

. The relationship between gestational diabetes and antenatal depression. J Obstet Gynecol Neonat Nurs. 2015;44:246–255.

20.

Westdahl

Milan

Magriples

Kershaw

Rising

Ickovics

. Social support and social conflict as predictors of prenatal depression. Obstet Gynecol. 2007;110:134–140.

21.

Morikawa

Okada

Ando

. Relationship between social support during pregnancy and postpartum depressive state: a prospective cohort study. Sci Rep. 2015;5:10520.

22.

Skouteris

Germano

Wertheim

Paxton

Milgrom

. Sleep quality and depression during pregnancy: a prospective study. J Sleep Res. 2008;17:217–220.

23.

Chang

Chen

. A comparative study of sleep quality between pregnant and nonpregnant Taiwanese women. J Nurs Scholarsh. 2010;42:23–30.

24.

Farr

Dietz

Robbins

. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009. J Womens Health (Larchmt). 2012;21:830–836.

25.

Dietrich

Williams

Ciotti

. Depression care attitudes and practices of newer obstetrician-gynecologists: a national survey. Am J Obstet Gynecol. 2003;189:267–273.

26.

Leiferman

Dauber

Heisler

Paulson

. Primary care physicians’ beliefs and practices toward maternal depression. J Womens Health (Larchmt). 2008;17:1143–1150.

27.

Yonkers

Wisner

Stewart

. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31:403–413.

28.

Marcus

Flynn

Blow

Barry

. Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt). 2003;12:373–380.

29.

Patel

Wisner

. Decision making for depression treatment during pregnancy and the postpartum period. Depress Anxiety. 2011;28:589–595.

30.

Jonas

Albertorio-Diaz

. Psychotropic medication use among adolescents: United States, 2005-2010. http://www.cdc.gov/nchs/data/databriefs/db135.htm. Published 2013. Accessed March 22, 2016.

31.

Sleath

West

Tudor

Perreira

King

Morrissey

. Ethnicity and depression treatment preferences of pregnant women. J Psychosom Obstet Gynecol. 2005;26:135–140.

32.

Boath

Bradley

Henshaw

. Women’s views of antidepressants in the treatment of postnatal depression. J Psychosom Obstet Gynecol. 2004;25:221–233.

33.

Whitton

Warner

Appleby

. The pathway to care in post-natal depression: women’s attitudes to post-natal depression and its treatment. Br J Gen Pract. 1996;46:427–428.

34.

Bonari

Koren

Einarson

Jasper

Taddio

Einarson

. Use of antidepressants by pregnant women: evaluation of perception of risk, efficacy of evidence based counseling and determinants of decision making. Arch Womens Ment Health. 2005;8:214–220.

35.

Cohen

Altshuler

Harlow

. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295:499–507.

36.

Dennis

Ross

Grigoriadis

. Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database Syst Rev. 2007;(3):CD006309.

37.

Petersen

Gilbert

Evans

Man

Nazareth

. Pregnancy as a major determinant for discontinuation of antidepressants: an analysis of data from the Health Improvement Network. J Clin Psychiatry. 2011;72:979–985.

38.

Marcus

Flynn

. Depression, antidepressant medication, and functioning outcomes among pregnant women. Int J Gynecol Obstet. 2008;100:248–251.

39.

Srivastava

Talukdar

Lahan

. Meditation for the management of adjustment disorder anxiety and depression. Complement Ther Clin Pract. 2011;17:241–245.

40.

Yadav

Magan

Mehta

Mahapatra

. A short-term, comprehensive, yoga-based lifestyle intervention is efficacious in reducing anxiety, improving subjective well-being and personality. Int J Yoga. 2012;5:134–139.

41.

National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name? https://nccih.nih.gov/health/integrative-health. Accessed March 22, 2016.

42.

Malhotra

Singh

Tandon

Sharma

. The beneficial effect of yoga in diabetes. Nepal Med Coll J. 2005;7:145–147.

43.

Innes

Bourguignon

Taylor

. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga: a systematic review. J Am Board Fam Pract. 2005;18:491–519.

44.

Larkey

Weihs

Lopez

. BMI reductions in a Qigong/Tai Chi easy trial with breast cancer survivors. Poster presented at: Society for Behavioral Medicine meeting; April 24, 2012; New Orleans, LA.

45.

Louie

. The effectiveness of yoga for depression: a critical literature review. Issues Ment Health Nurs. 2014;35:265–276.

46.

Battle

. Prenatal yoga and depression during pregnancy. Birth. 2010;37:353–354.

47.

Beddoe

Paul Yang

Kennedy

Weiss

Lee

. The effects of mindfulness-based yoga during pregnancy on maternal psychological and physical distress. J Obstet Gynecol Neonat Nurs. 2009;38:310–319.

48.

Battle

Uebelacker

Magee

Sutton

Miller

. Potential for prenatal yoga to serve as an intervention to treat depression during pregnancy. Womens Health Issues (Larchmt). 2015;25:134–141.

49.

Kinser

Masho

. “I just start crying for no reason”: the experience of stress and depression in pregnant, urban, African-American adolescents and their perception of yoga as a management strategy. Womens Health Issues (Larchmt). 2015;25:142–148.

50.

Uebelacker

Battle

Sutton

Magee

Miller

. A pilot randomized controlled trial comparing prenatal yoga to perinatal health education for antenatal depression [published online September 18, 2015]. Arch Womens Mental Health. doi:10.1007/s00737-015-0571-7.

51.

Desrosiers

Vine

Klemanski

Nolen-Hoeksema

. Mindfulness and emotion regulation in depression and anxiety: common and distinct mechanisms of action. Depress Anxiety. 2013;30:654–661.

52.

Berking

Wupperman

. Emotion regulation and mental health: recent findings, current challenges, and future directions. Curr Opin Psychiatry. 2012;25:128–134.

53.

Perez-Blasco

Viguer

Rodrigo

. Effects of a mindfulness-based intervention on psychological distress, well-being, and maternal self-efficacy in breast-feeding mothers: results of a pilot study. Arch Womens Mental Health. 2013;16:227–236.

54.

Centers for Disease Control and Prevention. PRAMS questionnaires. http://www.cdc.gov/prams/questionnaire.htm. Accessed March 22, 2016.

55.

Buysse

Reynolds

3rd Monk

Berman

Kupfer

. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213.

56.

Moser

Stuck

Silliman

Ganz

Clough-Gorr

. The eight-item modified Medical Outcomes Study Social Support Survey: psychometric evaluation showed excellent performance. J Clin Epidemiol. 2012;65:1107–1116.

57.

Brown

KKW

. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822–848.

58.

Cohen

. Perceived stress in a probability sample of the United States. In: pacapan

Shirlynn

Oskamp

Stuart

, eds. The social psychology of health. Thousand Oaks, CA, US: Sage Publications. 1988.

59.

Roberti

JJW

. Further psychometric support for the 10-item version of the Perceived Stress Scale. J Coll Couns. 2006;9:135–147.

60.

Marteau

Bekker

. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(pt 3):301–306.

61.

Cox

Holden

Sagovsky

Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786.

62.

Cohen

. Statistical Power Analysis for the Behavioral Sciences. Mahwah, NJ: Lawrence Erlbaum; 1988.

63.

ACOG. Physical activity and exercise during pregnancy and the postpartum period. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co650.pdf?dmc=1&ts=20160322T0741508442. Accessed March 22, 2016.

64.

Dennis

Allen

. Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression. Cochrane Database Syst Rev. 2008;(4):CD006795.

65.

Verreault

Da Costa

Marchand

Ireland

Dritsa

Khalife

. Rates and risk factors associated with depressive symptoms during pregnancy and with postpartum onset. J Psychosom Obstet Gynaecol. 2014;35:84–91.

66.

Centers for Disease Control and Prevention. Use of medication in pregnancy. http://www.cdc.gov/pregnancy/meds/treatingfortwo/data.html. Accessed March 22, 2016.

67.

Cooper

Willy

Pont

Ray

. Increasing use of antidepressants in pregnancy. Obstet Gynecol. 2007;196:544.e1–e5.

68.

Rallis

Skouteris

McCabe

Milgrom

. A prospective examination of depression, anxiety and stress throughout pregnancy. Women Birth. 2014;27:e36–e42.

69.

Lydsdottir

Howard

Olafsdottir

Thome

Tyrfingsson

Sigurdsson

. The mental health characteristics of pregnant women with depressive symptoms identified by the Edinburgh Postnatal Depression Scale. J Clin Psychiatry. 2014;75:393–398.

70.

O’Hara

. Social support, life events, and depression during pregnancy and the puerperium. Obstet Gynecol Surv. 1987;42:160–161.

71.

Nutt

Wilson

Paterson

. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci. 2008;10:329–336.

72.

Okun

Luther

Wisniewski

Wisner

. Disturbed sleep and inflammatory cytokines in depressed and nondepressed pregnant women: an exploratory analysis of pregnancy outcomes. Psychosom Med. 2013;75:670–681.

73.

Muzik

Hamilton

Lisa Rosenblum

Waxler

Hadi

. Mindfulness yoga during pregnancy for psychiatrically at-risk women: preliminary results from a pilot feasibility study. Complement Ther Clin Pract. 2012;18:235–240.

74.

Byrne

Hauck

Fisher

Bayes

Schutze

. Effectiveness of a mindfulness-based childbirth education pilot study on maternal self-efficacy and fear of childbirth. J Midwifery Womens Health. 2014;59:192–197.

75.

Elsenbruch

Benson

Rücke

. Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome. Hum Reprod. 2007;22:869–877.

76.

Yağmur

Ulukoca

. Social support and postpartum depression in low-socioeconomic level postpartum women in Eastern Turkey. Int J Public Health. 2010;55:543–549.

77.

Seguin

Potvin

St-Denis

Loiselle

. Depressive symptoms in the late postpartum among low socioeconomic status women. Birth. 1999;26:157–163.

78.

Hahn-Holbrook

Dunkel Schetter

Arora

Hobel

. Placental corticotropin-releasing hormone mediates the association between prenatal social support and postpartum depression. Clin Psychol Sci. 2013;1:253–265.

79.

Hall

Beattie

Lau

East

Anne Biro

Mindfulness and perinatal mental health: A systematic review. Women Birth. 2016;29:62–71.

80.

Paul

Stanton

Greeson

Smoski

Wang

. Psychological and neural mechanisms of trait mindfulness in reducing depression vulnerability. Soc Cogn Affect Neurosci. 2013;8:56–64.

81.

Oppen

Huijbers

Ruhe

. Preventing relapse in recurrent depression using mindfulness-based cognitive therapy, antidepressant medication or the combination: trial design and protocol of the MOMENT study. BMC Psychiatry. 2012;12:125.

82.

Herring

Rich-Edwards

Oken

Rifas-Shiman

Kleinman

Gillman

. Association of postpartum depression with weight retention 1 year after childbirth. Obesity. 2008;16:1296–1301.

83.

Wright

Bilder

DeBlasis

Mogul

Rubin

Shea

. Psychosocial factors associated with gestational weight gain in a low-income cohort. J Health Care Poor Underserved. 2013;24:332–343.

84.

Cramer

. Prevalence, patterns, and predictors of yoga use. Am J Prev Med. 2016;50:230–235.

85.

Stussman

Black

Barnes

Clarke

Nahin

. Wellness-related use of common complementary health approaches among adults: United States, 2012. Natl Health Stat Report. 2015;(85):1–12.

86.

Kabat-Zinn

. Mindfulness-based interventions in context: past, present, and future. Clin Psychol. 2003;10:144–156.

87.

Bernstein

Bar

Ehrman

Golubic

Roizen

. Yoga in the management of overweight and obesity. Am J Lifestyle Med. 2013;8:33–41.

88.

Gong

Shen

Jiang

. Yoga for prenatal depression: a systematic review and meta-analysis. BMC Psychiatry. 2015;15:14.

89.

Larkey

Vega-López

Keller

. A biobehavioral model of weight loss associated with meditative movement practice among breast cancer survivors. Health Psychol Open. 2014;1:1–10.

90.

Wright

. Researching Internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. J Comput Mediated Commun. 2005;10(3). doi:10.1111/j.1083-6101.2005.tb00259.x.

91.

Adamo

Ferraro

Goldfield

. The Maternal Obesity Management (MOM) Trial Protocol: a lifestyle intervention during pregnancy to minimize downstream obesity. Contemp Clin Trials. 2013;35:87–96.

92.

Bogaerts

Devlieger

Nuyts

Witters

Gyselaers

Van den Bergh

. Effects of lifestyle intervention in obese pregnant women on gestational weight gain and mental health: a randomized controlled trial. Int J Obes. 2013;37:814–821.

93.

Davis

Wambach

Nelson

. Health behavior change in pregnant women: a two-phase study. Telemed J E Health. 2014;20:1165–1169.

94.

Farajzadegan

Pozveh

. The design of maternal centered life-style modification program for weight gain management during pregnancy—a study protocol. J Res Med Sci. 2013;18:683.

95.

Kirzinger

Cohen

Gindi

. Health care access and utilization among young adults aged 19-25: early release of estimates from the National Health Interview Survey, January-September 2011. http://www.cdc.gov/nchs/nhis/releases.htm. Accessed March 22, 2016.

96.

Taffel

Keppel

. Advice about weight gain during pregnancy and actual weight gain. Obstet Gynecol Surv. 1987;42:433–434.

97.

Field

Diego

Hernandez-Reif

Figueiredo

Schanberg

Kuhn

. Sleep disturbances in depressed pregnant women and their newborns. Infant Behav Dev. 2007;30:127–133.

98.

Satyapriya

Nagendra

Nagarathna

Padmalatha

. Effect of integrated yoga on stress and heart rate variability in pregnant women. Int J Gynecol Obstet. 2009;104:218–222.

99.

Manocha

Black

Sarris

Stough

. A randomized, controlled trial of meditation for work stress, anxiety and depressed mood in full-time workers. Evid Based Complement Alternat Med. 2011;2011:960583.