{"paper_id":"0e7dabb8-0375-4e9d-a27a-53aa0f38705c","body_text":"Effect of Interactive Ultrasound Intervention on Moderate Depressive Symptoms and Maternal Attachment: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Interactive Ultrasound Intervention on Moderate Depressive Symptoms and Maternal Attachment: A Randomized Controlled Trial Henrika Pulliainen, Eeva-Leena Kataja, Eliisa Löyttyniemi, Kirsi Rinne, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6672112/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background We examined whether an interactive four-dimensional (4D) ultrasound intervention decreases prenatal and early postnatal depressive symptoms and improves maternal-fetal attachment. Methods This randomized controlled trial recruited pregnant women who scored 10–15 on the Edinburgh Pre-/Postnatal Depression Scale (EPDS), with half of them attending three interactive ultrasound examinations. Depressive symptoms and maternal attachment were the primary outcomes measured using the EPDS and the Maternal Antenatal/Postnatal Attachment Scale (MAAS/MPAS) from early pregnancy to postpartum. An independent FinnBrain Birth Cohort study group served as a control to compare the trajectories of depressive symptoms in women scoring 10–15 on the EPDS. Results A total of 53 women participated in the intervention and 52 in the control group. We found an interaction effect between groups and time (p = 0.018). Although maternal-fetal attachment followed a similar trajectory in both groups, the pattern of change in depressive symptoms differed, similar to the FinnBrain Birth Cohort Study. Participation in the intervention did not enhance the decrease in depressive symptoms or increase attachment in the overall study group. Conclusions Depressive symptoms decreased and maternal attachment increased during pregnancy in moderately depressed women, regardless of the intervention. Trial registration This study was registered at ClinicalTrials.gov (NCT 03424642) on January 5, 2018. 4D ultrasound interactive ultrasound maternal-fetal attachment prenatal depression mother-infant relationship Figures Figure 1 Figure 2 Background Depressive symptoms during pregnancy are common, affecting almost every fifth woman (1,2). Some studies have suggested that depressive symptoms tend to remain stable throughout pregnancy and continue into the postpartum period (1,3,4), while others have reported more variability (5,6). Prenatal depressive symptoms are associated with several maternal and child health outcomes, including impaired cognitive, behavioral and psychomotor development in offspring (7,8). Perinatal depression increases the risk for suicide, which is a major cause of maternal mortality in European countries (9). Prenatal depressive symptoms predict low maternal involvement in mother-infant interactions (10,11), lower maternal structuring behavior and lower maternal involvement in the child (12). Moreover, weak maternal prenatal attachment predicts postnatal depressive symptoms (13,14). Prenatal depressive symptoms may distort mothers’ representations of the infant and impending motherhood (15,16), and these representations often remain stable from pregnancy to postpartum (17,18). According to previous research, alleviating depressive symptoms alone does not improve mother–infant interactions (19–22). Non-pharmacological interventions are needed to prophylactically decrease prenatal depressive symptoms and improve mother-infant interactions. Ultrasound scans have been reported to enhance prenatal attachment by providing a visual image of the fetus, allowing the parents to see the fetus as an individual (23). Few studies have combined pregnancy ultrasound with psychological support (24–29) in which the fetus is observed with mother-initiated interaction (25), which has been shown to enhance maternal attachment and reduce general anxiety (24). Our study indicates that combining pregnancy ultrasound with psychological support promotes attendance in maternal health care in risk pregnancies (27,28). Pregnant women at risk of preterm delivery reported that the fetus felt more real and that their emotional connection increased (29). An interactive approach could be integrated into routine screenings and maternity clinic visits as ultrasound is widely used during pregnancy. We hypothesized that an interactive ultrasound intervention could improve maternal prenatal depressive symptoms and strengthen maternal prenatal attachment by providing vivid images of the fetus. Materials And Methods This study consisted of two groups. First, a randomized controlled trial (RCT) was conducted at the maternity unit of Turku University Hospital, in collaboration with the Department of Psychology and Speech-Language Pathology at the University of Turku. The study was registered on ClinicalTrials.gov (NCT 03424642) and approved by the ethics committee of the Hospital District of Southwest Finland (30). Second, to compare changes in the Edinburgh Pre/Postnatal Depression Scale (EPDS) scores from early pregnancy to 3 months postpartum, we used a cohort sample of women with EPDS scores of 10-15 from the FinnBrain Birth Cohort study as an independent control group, collected in the same region and during the same period. The study design and recruitment process are shown in the flowchart in Figure 1. Subjects The inclusion criteria for the RCT study were singleton pregnancy, EPDS score of 10-15, body mass index below 35, age over 18, and fluency in Finnish. The exclusion criteria included psychotic and self-destructive symptoms and fetal structural anomalies observed during ultrasound screening. Procedure The participants were recruited between September 2018 and February 2024. Overall, 377 pregnant women completed the electronic EPDS questionnaire, which was shared on social media and through brochures during routine ultrasound scans at 20-21 gestational weeks (gwks) (Figure 1). The researcher contacted the women who scored 10-15 points on the EPDS by telephone, confirmed the inclusion criteria, interviewed them about clinical depression using the depression module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR (SCID) (31,32), and scheduled the first representation interview (Working Model of the Child Interview) to assess prenatal attachment representations (33). Women who scored 16 or higher on the EPDS or reported suicidal ideation were contacted to determine their need for support and to refer them to medical care. A total of 105 (28%) women who met the inclusion criteria agreed to participate and provided their written informed consent. Randomization to the intervention or control group occurred after the first representation interview. Measures Depressive symptoms were assessed using the EPDS, a validated 10-item self-rating tool that screens for depressive symptoms over the past 7 days, with scores ranging from 0 to 30 points (34,35). Clinical depression was assessed at recruitment using the Depression Module of the SCID (31,32), a valid and reliable, semistructured diagnostic interview suitable for clinical screening and research, including telephone administration (32). Prenatal maternal emotional attachment was assessed using the validated 19-item Maternal Antenatal Attachment Scale (MAAS) with five-point response options (1-5). Higher scores indicate stronger attachment and relationship (36–38). The instrument has two dimensions: “quality of attachment” (10 items e.g. experiences of closeness, tenderness, pleasure in interaction, distress at fantasized loss and viewing the fetus as a “little person”). and “intensity/time spent in attachment mode” (8 items, e.g., time spent thinking about, talking to, dreaming about, or palpating the fetus, quality of involvement and intensity of preoccupation). An item assessing fetal dependence on the mother for well-being was excluded from the dimension but included in the global score. Postnatal maternal emotional attachment was measured with the Maternal Postnatal Attachment Scale (MPAS), a validated 19-item postnatal counterpart of the MAAS (36). The Maternal Fetal Attachment Scale (MFAS) was used in the FinnBrain Bitrh Cohort study to assess attitudes toward pregnancy, motherhood, and the baby. It is a 24-item self-report questionnaire using a five-point Likert scale (1-5), with a total score ranging from 24 to 120; higher scores indicate stronger attachment to the fetus. The MFAS includes five subscales: 1) role taking, 2) differentiating the self from the fetus, 3) interaction with the fetus, 4) attributing characteristics to the fetus, and 5) giving of self (38). Background information was collected at preintervention (Table 1). Table 1 Sociodemographic background. All N = 105 (100%) Intervention N = 53 (50.5%) Control N = 52 (49.5%) p Age, years (mean, SD, range) 32.2, 4.4, 20–50 32.4, 4.7, 22–50 31.9, 4.1, 20–39 0.57* Education n (%) 0.4074** Primary school 1 (1) 1 (1.9) 0 (0) Vocational school 24 (22.9) 13 (24.5) 11 (21.1) Secondary school graduate 4 (3.8) 4 (7.6) 0 (0) University of Applied Sciences 41 (39.0) 17 (32.1) 24 (46.2) Master's degree 35 (33.3) 18 (34.0) 17 (32.7) Main activity n (%) 0.8027** At work 80 (76.2) 39 (73.6) 41 (78.9) Unemployed/laid off 4 (3.8) 2 (3.8) 2 (3.9) Parental leave 8 (7.6) 6 (11.3) 2 (3.9) Student 8 (7.6) 4 (7.6) 4 (7.7) Long-term sick leave or retirement 0 (0) 0 (0) 1 (1) Other 4 (2.9) 2 (3.8) 2 (3.9) The family includes 0.1772** One parent 13 (12.4) 8 (15.1) 5 (9.6) Two parents 78 (74.3) 40 (75.5) 38 (73.1) New family of two parents 14 (13.3) 5 (9.4) 9 (17.3) Treatment for mental health problems before pregnancy 20 (19.1) 10 (18.9) 10 (19.2) 1.00*** Antidepressant medication before pregnancy 12 (11.4) 4 (7.6) 8 (15.4) 0.2356 *** Other mood medication before pregnancy 18 (17.1) 5 (9.4) 13 (25.0) 0.0408*** Antidepressant medication during pregnancy 7 (6.7) 3 (5.7) 4 (7.7) 0.7157*** Other mood medication during pregnancy 10 (9.5) 4 (7.6) 6 (11.5) 0.526*** Smoking before pregnancy 15 (14.3) 7 (13.2) 8 (15.4) 0.79*** * Age was compared assuming normal distribution and equal variances with two sample t-test showing p = 0.5682 (Levene p = 0.8805). ** Ordinal categorial varibles were compared using Cochran-Armitage trend test. *** Other categorial variables were compared using Fisher’s exact test two-tailed. Intervention The interactive ultrasound intervention published earlier (30) used an interactive approach to ultrasound led by an obstetrician and a psychologist specialized in psychotherapy and infant mental health. The session focuses on observing the fetus according to the woman’s wishes: observing fetal activity and facial expressions in the womb, working with mental images related to the fetus and the pregnancy, and listening to her thoughts about the fetus. Professionals comment neutrally on fetal behavior without interpreting it, and encourage women to reflect on their feelings. Sessions are structured and last approximately 40 minutes. Women participate alone. Independent control group The FinnBrain Birth Cohort study is a transgenerational prospective study investigating the effects of prenatal and early life stress exposure on child health and brain development (39). It is a well-characterized study and the courses of maternal depression in this general population sample have been presented (5). Data from the FinnBrain Birth Cohort study were used to show how EPDS scores develop through pregnancy in women from the same area scoring 10–15 points on the EPDS with no intervention. Pregnant women completed the EPDS and MFAS at 14, 24 and 34 gwks and at 3 months postpartum, comparable to the RCT. Data collection from the RCT The questionnaire data were collected at four time points (Fig. 1 ) using the Research Electronic Data Capture (REDCap) tools hosted at the University of Turku (40). Randomization was performed using random permuted blocks with a block size of 10 using SAS® software (version 9.4 for Windows). Power analysis A mean decrease of three points in the EPDS score was considered clinically relevant and was used for power calculations. A standard deviation (SD) of 3.5 points in the EPDS score used in power calculations was based on earlier studies in the Finnish population showing an SD of 3.7–4 (16). A power analysis with 80% power and a significance level of 0.05 (two-tailed) showed that 50 subjects were needed in both groups. Statistical methods Descriptive statistics were analyzed using JMP®, version 17 Pro. SAS Institute Inc., Cary, NC, 1989–2019). Continuous variables were evaluated assuming a normal distribution, despite one outlier. Other categorical variables were compared using Fisher’s exact test two-tailed. Significance level of 0.05 was used two-tailed. The ordinal variables were compared using the Cochrane-Armitage trend test. A linear mixed model for repeated measures analysis was conducted using SAS® software, (version 9.4 of the SAS System for Windows, SAS Institute Inc., Cary, NC, USA) to assess changes in the EPDS and MAAS/MPAS scores between the intervention and control groups over time. Additional repeated measures analyses were adjusted using participants’ medication information as an explanatory variable. Primary analysis was conducted at three time points–preintervention, postintervention and postpartum–to assess the efficacy of the intervention. A sensitivity analysis using four time points, including recruitment, was conducted to assess the consistency of the primary analysis. The EPDS and MFAS scores in the FinnBrain Birth Cohort study were examined using a paired t-test to examine changes over time. Results The mean age of the participants was 32.2 years (SD 4.4, range 20–50) and 34.3% were nulliparous. Overall, 18 (17%) participants reported clinical depression in the SCID interview, with seven (38.9%) in the intervention group and 11 (61.1%) in the control group. Antidepressants were used by four (7.6%) participants in the intervention group and eight (15.4%) in the control group, p = 0.24. The groups differed significantly in the use of other mood medications before pregnancy, p = 0.04: five (9.4%) in the intervention group and eight (15.4%) in the control group (Table 1 ). The EPDS scores were missing at preintervention for 18 subjects in the intervention group and 17 in the control group. Primary analyses The primary analyses are presented in Table 2 and in Fig. 2 . We found an interaction effect between groups and time (p = 0.018), indicating that EPDS scores changed differently over time in the intervention and control groups. Specifically, the decrease in EPDS scores from preintervention to postpartum differed significantly between the groups [p = 0.0008; intervention group 10.5 (95% CI 9.4–11.5) and 8.5 (95% CI 7.1–10.0); control group 12.0 (95% CI 11-13.1) and 7.3, (95% CI 5.8–8.8), respectively]. Despite randomization, there was a difference between the groups at preintervention (p = 0.038; intervention group 10.5; control group 12.0). Within group analyses showed that in the intervention group, EPDS scores significantly decreased from preintervention to postpartum (p = 0.0048, 10.5 and 8.5, respectively). In the control group, a significant decrease was observed between preintervention and postintervention (p = 0.0203; 12.0 and 7.3). Sensitivity analyses showed similar results (p = 0.015). A significant decrease in EPDS scores was found between preintervention and postpartum [p = 0.004; intervention group 10.4 (95% CI 9.4–11.5) and 8.5 (95% CI 7.1–10.0); control group 12.0 (95% CI 11-13.1) and 7.4 (95% CI 5.9–8.9)]. The MAAS scores increased similarly in both groups (Table 2 ): global MAAS [p = 0.43; intervention group from preintervention 69.2 (95% CI 67.2–71.2) to postintervention 75.4 (95% CI 73.6–77.1); control group 68.3 (95% CI 66.3–70.3) to 73.5 (95% CI 71.6–75.4)], quality dimension [p = 0.35; intervention group 42.2 (95% CI 41.1–43.3) to 45.2 (95% CI 44.4–46.0); control group 42.2 (95% CI 41.1–43.2) to 44.5 (95% CI 43.6–45.4)]; intensity dimension [p = 1.0; intervention group 22.9 (95% CI 21.8–24.1) to 26.1 (95% CI 25-27.1); control group 22.0 (95% CI 20.8–23.1) to 25.2 (95% CI 23.9–26.4)], respectively, indicating a strengthening of attachment. The MPAS scores were also similar in both groups [p = 0.44; intervention group 71.7 (95% CI 69.9–73.4) and control group 72.7 (95% CI 70.8–74.4)] (Table 2 ). Adjusted analyses Additional analyses were adjusted for participants’ medications information as an explanatory variable (Table 2 , Fig. 2 ). We found a similar interaction effect between the groups in a model adjusted for antidepressant use before pregnancy (p = 0.005) and in a model adjusted for the use of other mood medications before pregnancy (p = 0.022), which was consistent with the results of theprimary analyses. Despite the adjustment, no intervention effect was found. Sensitivity analyses showed similar interaction effect in participants using antidepressants (p = 0.009) and other mood medications before pregnancy (p = 0.029). The global MAAS and MPAS scores were higher in those using antidepressants before pregnancy at all time points: in the intervention group at preintervention 71.3 (SD 8.7; n = 4), at postintervention 75.8 (SD 6.9; n = 4) at postpartum 75.2 (SD 4.4, n = 5), and in the control group at preintervention 75.6 ( SD3.8; n = 5), at postintervention 74.3 (SD 5.2; n = 7), at postpartum 72 (SD 4.4; n = 4). MPAS scores were also higher in those using other mood medications 75.3 (SD 3.7; n = 8), but small sample size limited analysis. Table 2 Results. Intervention, n = 53 Control, n = 52 Model based means 95% CI Model based means 95% CI EPDS Preintervention 10.5 9.4–11.5 12.0 11-13.1 Postintervention 8.4 7.4–9.4 9.0 7.8–10.1 Postpartum 8.5 7.1–10.0 7.3 5.8–8.8 EPDS, adjusted with antidepressants used before pregnancy Preintervention 9.8 8.3–11.3 11.7 10.4–13.0 Postintervention 9.4 7.9–10.8 9.6 8.2–11.0 Postpartum 8.2 6.2–10.2 6.9 5.0-8.8 EPDS, adjusted with other mood medications before pregnancy Preintervention 10.2 8.9–11.6 11.9 10.8–13 Postintervention 9.0 7.6–10.4 9.3 8.0-10.6 Postpartum 7.9 6.0-9.8 6.9 5.3–8.6 MAAS Global Preintervention 69.2 67.2–71.2 68.3 66.3–70.3 Postintervention 75.4 73.6–77.1 73.5 71.6–75.4 MAAS Quality Preintervention 42.2 41.1–43.3 42.2 41.1–43.2 Postintervention 45.2 44.4–46.0 44.5 43.6–45.4 MAAS Intensity Preintervention 22.9 21.8–24.1 22.0 20.8–23.1 Postintervention 26.1 25.0-27.1 25.2 23.9–26.4 MPAS Global Postpartum 71.7 69.9–73.4 72.7 70.8–74.6 FinnBrain Birth Cohort study data The EPDS mean scores in the FinnBrain data were 11.7 (SD 1.55; n = 338) at 14 gwks, 9.0 (SD 4.25; n = 279) at 24 gwks, 8.7 (SD 3.93; n = 256) at 34 gwks, and 7.5 (SD 4.19¸n = 213) three months postpartum. The decrease was significant between 14 and 24 gwks, and between 14 and 34 gwks (p < 0.001). The MFAS increased from 87.1 (SD 10.5, n = 239) at 24 gwks to 92.9 (SD 8.9, n = 239) at 34 gwks and the increase was significant (p < .001). Discussion In this RCT study, we found a reduction in depressive symptoms and an increase in maternal-fetal attachment in both groups from preintervention to four months postpartum. Although maternal-fetal attachment followed a similar trajectory in both groups, the pattern of change in depressive symptoms differed. Contrary to expectations, the depressive symptoms decreased more in the control group than in the intervention group. Thus, ultrasound intervention was not associated with greater reductions in depressive symptoms or improved maternal-fetal attachment. In the primary analysis, we found no intervention effect of interactive ultrasound on depressive symptoms. Previous studies have shown promising results from the interactive use of pregnancy ultrasound in low-risk (24,25) and high-risk pregnancies (27–29), but our study was the first to focus on depressive symptoms. Jussila et al. (28) reported similar null findings on depressive symptoms in substance-using pregnant women. Inconsistent results have been reported in interventions targeting depressive symptoms and parenting support. A systematic review and meta-analysis found that parenting interventions for mothers with depressive symptoms had no effect on the parent-child relationship or child development (21), whereas group-based cognitive-behavioral therapy effectively reduced depressive symptoms and increased maternal-fetal attachment (41). Three-dimensional (3D) and 4D ultrasound scans may enhance mental images of the fetus and increase attachment (42,43). The use of 3D-printed images and models of the fetal face obtained from ultrasound scans during the second trimester in a randomized setting has also been shown to improve maternal-fetal attachment and reduce depressive symptoms in healthy pregnant women (44), but these studies did not include parenting interventions. Unlike in other studies, it is important to consider that Finnish pregnant women are served by the Finnish maternity and child health clinic system, which provides support, counseling, and screening for depressive symptoms (45). At pre-intervention, despite randomization, the control group had higher EPDS scores and were more likely to use mood medications other than antidepressants. When the models were adjusted for antidepressants or other mood medications use before pregnancy, similar interaction effects between group and time were observed, indicating that the finding was independent of the use of mood medication. Notably, depressive symptoms declined more steeply in the control group than in the intervention group. Several explanations may account for the lack of an intervention effect on depressive symptoms. First, despite the power calculations, the sample size may have been too small to detect the intervention effect. Second, despite randomization, the control group had a higher proportion of women with more severe depressive symptoms (Table 1 ). Third, the interactive ultrasound intervention may not be effective in decreasing depressive symptoms. We found a decrease in moderate depressive symptoms throughout pregnancy across all studied groups, which is consistent with previous research showing reductions in depressive symptoms from early prenatal periods to eight months postpartum for both mothers and fathers (46). In contrast, some studies have reported more maternal depressive symptoms in the first and third trimesters compared with the second (2,47). The observed decrease may indicate psychological adjustment: the first trimester involves early pregnancy stress, the second is more stable, and the third fosters positive expectations about childbirth and parenthood (48). A similar decrease in EPDS scores in both groups may reflect an overall improvement in psychological adjustment in women with depressive symptoms in early pregnancy, as observed in the FinnBrain Birth Cohort (5). In our study, the MAAS scores increased over time in both groups, indicating a strengthening of attachment, consistent with previous findings (49). There are no official cut-off values for the global MAAS score or its dimensions. However, compared with the estimated cut-off values from a recent study (50), the MAAS scores in this sample were below the midpoint of the distribution. A global MAAS score ≤ 75 indicates low attachment (49), suggesting that pregnant women in the control group had low attachment at all time points measured, whereas women in the intervention group were at the threshold. Stronger prenatal attachment may be associated with fewer depressive symptoms during pregnancy and postpartum (1,14), and vice versa: more depressive symptoms have been associated with lower scores (51). This study has several limitations. First, the use of self-report symptom scales rather than clinical interviews may not fully capture participants’ health and symptomology although the EPDS is a validated questionnaire for assessing depressive symptoms over the past 7 days. A large systematic review and meta-analysis found that an EPDS cut-off of ≥ 14 (9%) aligns with the SCID prevalence of major depression (52), which is consistent with our findings. Second, we did not systematically collect information about the participants’ other contacts and treatments regarding depression. Third, participation in the intervention study may have influenced the results (53). All participants attended the representation interviews, which can be considered an intervention in itself, as the interview systematically explores the parents’ thoughts, feelings, and perceptions about their baby and their relationship (18). Moreover, the opportunity for three free 4D-ultrasound examinations may have biased the self-report mood symptom scores at recruitment. Psychological interventions effectively treat perinatal depression and provide long-term benefits (54). Interventions that reduce depression while supporting maternal-fetal attachment may improve care for pregnant women with moderate depressive symptoms (19). Conclusions Our findings suggest that among moderately depressed women, depressive symptoms decrease and maternal attachment increases during pregnancy, regardless of the intervention. This may reflect an improvement in psychological adjustment as the women integrate motherhood into their identity and bond with their unborn child. Abbreviations 4D Four-dimensional EPDS Edinburgh Pre-/Postnatal Depression Scale MAAS Maternal Antenatal Attachment Scale MPAS Maternal Postnatal Attachment Scale MFAS Maternl-fetal Antenatal Attachmnet Scale gwks gestational weeks WMCI Working Model of the Child Interview REDCap Research Electronic Data Capture SCID Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR 3D three-dimensional RCT Randomized controlled trial SSRI selective serotonin reuptake inhibitor Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the Hospital District of Southwest Finland, case number 95/1801/2017, and conducted according to the ethical standards of the Declaration of Helsinki, 1964. Written informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. Availability of data and material Data from this study are available from the corresponding author upon reasonable request. Competing interests The authors have no relevant financial or non-financial interests to disclose. Funding This study was funded by the Varsinais-Suomi Regional Fund, the Turku University Foundation, the Finnish Medical Foundation, the State Research Funding and the Signe and Ane Gyllenberg Foundation. Author contributions All authors contributed to the study’s conception and design. Study planning, material preparation, data collection, and analysis were performed by HP, EE and SA-B. HP, EE, SA-B, E-LK, KR and NG contributed to data collection and conducted the intervention visits. Statistical analyses were performed by HP and EL. HP drafted the first version of the manuscript, and E-LK, EE and SA-B provided comments. HK and LK participated in planning in the use of the Finnbrain Cohort Study Data and reviewed manuscript. 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Substance-abusing pregnant women: prenatal intervention using ultrasound consultation and mentalization to enhance the mother–child relationship and reduce substance use. Infant Ment Health J. 2016;37(4):317–34. Jussila H, Ekholm E, Pajulo M. A New Parental Mentalization Focused Ultrasound Intervention for Substance Using Pregnant Women. Effect on Self-reported Prenatal Mental Health, Attachment and Mentalization in a Randomized and Controlled Trial. Int J Ment Health Addict. 2020; Jussila H, Pajulo M, Ekholm E. A Novel 4D Ultrasound Parenting Intervention for Substance Using Pregnant Women in Finland: Participation in Obstetric Care, Fetal Drug Exposure, and Perinatal Outcomes in a Randomized Controlled Trial. Matern Child Health J. 2020; Pulliainen H, Niela-Vilén H, Ekholm E, Ahlqvist-Björkroth S. Experiences of interactive ultrasound examination among women at risk of preterm birth: A qualitative study. BMC Pregnancy Childbirth. 2019; Pulliainen H, Sari-Ahlqvist-Björkroth, Ekholm E. Does interactive ultrasound intervention relieve minor depressive symptoms and increase maternal attachment in pregnancy? A protocol for a randomized controlled trial. Trials. 2022 Apr;23(1):313. Shankman SA, Funkhouser CJ, Klein DN, Davila J, Lerner D, Hee D. Reliability and validity of severity dimensions of psychopathology assessed using the Structured Clinical Interview for DSM-5 (SCID). Int J Methods Psychiatr Res. 2018; Osório FL, Loureiro SR, Hallak JEC, Machado-de-Sousa JP, Ushirohira JM, Baes CVW, et al. Clinical validity and intrarater and test–retest reliability of the Structured Clinical Interview for DSM-5 – Clinician Version (SCID-5-CV). Psychiatry Clin Neurosci. 2019; Zeanah CH, Benoit D, Hirshberg L, Barton ML, Regan C. Mothers’ representations of their infants are concordant with infant attachment classifications. Dev Issues Psychiatry Psychol. 1994; Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression scale. Br J Psychiatry. 1987; Bergink V, Kooistra L, Lambregtse-van den Berg MP, Wijnen H, Bunevicius R, van Baar A, et al. Validation of the Edinburgh Depression Scale during pregnancy. J Psychosom Res. 2011; Condon JT, Corkindale C. The correlates of antenatal attachment in pregnant women. Br J Med Psychol. 1997; Condon JT. The assessment of antenatal emotional attachment: Development of a questionnaire instrument. Br J Med Psychol. 1993; MS C. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res. 1981; Karlsson L, Tolvanen M, Scheinin NM, Uusitupa HM, Korja R, Ekholm E, et al. Cohort Profile: The FinnBrain Birth Cohort Study (FinnBrain). Int J Epidemiol. 2018; Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009; Alhusen JL, Hayat MJ, Borg L. A pilot study of a group-based perinatal depression intervention on reducing depressive symptoms and improving maternal-fetal attachment and maternal sensitivity. Arch Womens Ment Health. 2021; Wenstrom KD. Preexamination and postexamination assessment of parental-fetal bonding in patients undergoing 3-/4-dimensional obstetric ultrasonography: Commentary. Vol. 62, Obstetrical and Gynecological Survey. 2007. p. 165–6. Righetti PL, Dell’Avanzo M, Grigio M, Nicolini U. Maternal/paternal antenatal attachment and fourth-dimensional ultrasound technique: A preliminary report. Br J Psychol. 2005; Coté JJ, Badura-Brack AS, Walters RW, Dubay NG, Bredehoeft MR. Randomized Controlled Trial of the Effects of 3D-Printed Models and 3D Ultrasonography on Maternal-Fetal Attachment. J Obstet Gynecol neonatal Nurs JOGNN. 2020 Mar;49(2):190–9. Hakulinen Tuovi, Pakarinen Anni U-LH. Terveyden ja hyvinvoinnin laitos, Äitiys- ja lastenneuvola, EPDS-mielialalomake raskausajan ja synnytyksen jälkeisen masennuksen seulonnassa. 24.8.2021. Heron J, O’Connor TG, Evans J, Golding J, Glover V. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004 May;80(1):65–73. Pesonen A-K, Lahti M, Kuusinen T, Tuovinen S, Villa P, Hämäläinen E, et al. Maternal Prenatal Positive Affect, Depressive and Anxiety Symptoms and Birth Outcomes: The PREDO Study. PLoS One. 2016;11(2):e0150058. Brodén, Margareta Kivirauma M. Raskausajan mahdollisuudet: Kun suhteet syventyvät ja kehittyvät. Helsinki: Therapeia-säätiö; 2006. Rowe HJ, Wynter KH, Steele A, Fisher JRW, Quinlivan JA. The growth of maternal-fetal emotional attachment in pregnant adolescents: a prospective cohort study. J Pediatr Adolesc Gynecol. 2013 Dec;26(6):327–33. Kelmanson IA. Maternal Antenatal Attachment Scale (MAAS) reference values at different stages of pregnancy and their possible associations with major obstetric and demographic characteristics. Early Child Dev Care [Internet]. 2022 Jul 27;192(10):1673–84. Available from: https://doi.org/10.1080/03004430.2021.1925263 Göbel A, Lüersen L, Asselmann E, Arck P, Diemert A, Garthus-Niegel S, et al. Psychometric properties of the Maternal Postnatal Attachment Scale and the Postpartum Bonding Questionnaire in three German samples. BMC Pregnancy Childbirth. 2024 Nov;24(1):789. Lyubenova A, Neupane D, Levis B, Wu Y, Sun Y, He C, et al. Depression prevalence based on the Edinburgh Postnatal Depression Scale compared to Structured Clinical Interview for DSM DIsorders classification: Systematic review and individual participant data meta-analysis. Int J Methods Psychiatr Res. 2021 Mar;30(1):e1860. Nijjar SK, D’Amico MI, Wimalaweera NA, Cooper N, Zamora J, Khan KS. Participation in clinical trials improves outcomes in women’s health: a systematic review and meta-analysis. BJOG. 2017 May;124(6):863–71. Cuijpers P, Franco P, Ciharova M, Miguel C, Segre L, Quero S, et al. Psychological treatment of perinatal depression: a meta-analysis. Psychol Med. 2023 Apr;53(6):2596–608. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 11 Jun, 2025 Editor invited by journal 19 May, 2025 Editor assigned by journal 17 May, 2025 Submission checks completed at journal 17 May, 2025 First submitted to journal 15 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6672112\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":469937234,\"identity\":\"a5d60fed-d277-4024-9594-5e7fb4c89de6\",\"order_by\":0,\"name\":\"Henrika 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11:50:44\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":70643,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eflowchart.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6672112/v1/99836449cf0ca38aa0b9a7cd.png\"},{\"id\":84556524,\"identity\":\"8d4d4320-406e-4407-9166-38fbc2cea21e\",\"added_by\":\"auto\",\"created_at\":\"2025-06-13 11:50:44\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":14681,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eResults.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6672112/v1/2f8b7ba9e085a9f2e77ae9e9.png\"},{\"id\":84558146,\"identity\":\"666d1c83-45fc-4038-a8fe-12d55362c1dc\",\"added_by\":\"auto\",\"created_at\":\"2025-06-13 12:14:44\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":788824,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6672112/v1/8538f3b9-69d1-4386-9ff3-649f6918cacc.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Effect of Interactive Ultrasound Intervention on Moderate Depressive Symptoms and Maternal Attachment: A Randomized Controlled Trial\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eDepressive symptoms during pregnancy are common, affecting almost every fifth woman (1,2). Some studies have suggested that depressive symptoms tend to remain stable throughout pregnancy and continue into the postpartum period (1,3,4), while others have reported more variability (5,6). Prenatal depressive symptoms are associated with several maternal and child health outcomes, including impaired cognitive, behavioral and psychomotor development in offspring (7,8). Perinatal depression increases the risk for suicide, which is a major cause of maternal mortality in European countries (9).\\u003c/p\\u003e\\n\\u003cp\\u003ePrenatal depressive symptoms predict low maternal involvement in mother-infant interactions (10,11), lower maternal structuring behavior and lower maternal involvement in the child (12). \\u0026nbsp;Moreover, weak maternal prenatal attachment predicts postnatal depressive symptoms (13,14). Prenatal depressive symptoms may distort mothers\\u0026rsquo; representations of the infant and impending motherhood (15,16), and these representations often remain stable from pregnancy to postpartum (17,18). According to previous research, alleviating depressive symptoms alone does not improve mother\\u0026ndash;infant interactions (19\\u0026ndash;22). Non-pharmacological interventions are needed to prophylactically decrease prenatal depressive symptoms and improve mother-infant interactions.\\u003c/p\\u003e\\n\\u003cp\\u003eUltrasound scans have been reported to enhance prenatal attachment by providing a visual image of the fetus, allowing the parents to see the fetus as an individual (23). Few studies have combined pregnancy ultrasound with psychological support (24\\u0026ndash;29) in which the fetus is observed with mother-initiated interaction (25), which has been shown to enhance maternal attachment and reduce general anxiety (24). Our study indicates that combining pregnancy ultrasound with psychological support promotes attendance in maternal health care in risk pregnancies (27,28). Pregnant women at risk of preterm delivery reported that the fetus felt more real and that their emotional connection increased (29). \\u0026nbsp;An interactive approach could be integrated into routine screenings and maternity clinic visits as ultrasound is widely used during pregnancy.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWe hypothesized that an interactive ultrasound intervention could improve maternal prenatal depressive symptoms and strengthen maternal prenatal attachment by providing vivid images of the fetus.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Materials And Methods\",\"content\":\"\\u003cp\\u003eThis study consisted of two groups. First, a randomized controlled trial (RCT) was conducted at the maternity unit of Turku University Hospital, in collaboration with the Department of Psychology and Speech-Language Pathology at the University of Turku. The study was registered on ClinicalTrials.gov (NCT 03424642) and approved by the ethics committee of the Hospital District of Southwest Finland (30). Second, to compare changes in the Edinburgh Pre/Postnatal Depression Scale (EPDS) scores from early pregnancy to 3 months postpartum, we used a cohort sample of women with EPDS scores of 10-15 from the FinnBrain Birth Cohort study as an independent control group, collected in the same region and during the same period.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe study design and recruitment process are shown in the flowchart in Figure 1.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSubjects\\u003c/p\\u003e\\n\\u003cp\\u003eThe inclusion criteria for the RCT study were singleton pregnancy, EPDS score of 10-15, body mass index below 35, age over 18, and fluency in Finnish. The exclusion criteria included psychotic and self-destructive symptoms and fetal structural anomalies observed during ultrasound screening.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eProcedure\\u003c/p\\u003e\\n\\u003cp\\u003eThe participants were recruited between September 2018 and February 2024. Overall, 377 pregnant women completed the electronic EPDS questionnaire, which was shared on social media and through brochures during routine ultrasound scans at 20-21 gestational weeks (gwks) (Figure 1). The researcher contacted the women who\\u0026nbsp;scored 10-15 points on the EPDS by telephone, confirmed the inclusion criteria, interviewed them about clinical depression using the depression module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR (SCID) (31,32), and scheduled the first representation interview (Working Model of the Child Interview) to assess prenatal attachment representations (33).\\u0026nbsp;Women who scored 16 or higher on the EPDS or reported suicidal ideation were contacted to determine their need for support and to refer them to medical care.\\u003c/p\\u003e\\n\\u003cp\\u003eA total of 105 (28%) women who met the inclusion criteria agreed to participate and provided their written informed consent. Randomization to the intervention or control group occurred after the first representation interview.\\u003c/p\\u003e\\n\\u003cp\\u003eMeasures\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDepressive symptoms were assessed using the EPDS, a validated 10-item self-rating tool that screens for depressive symptoms over the past 7 days, with scores ranging from 0 to 30 points (34,35).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eClinical depression was assessed at recruitment using the Depression Module of the SCID (31,32), a valid and reliable, semistructured diagnostic interview suitable for clinical screening and research, including telephone administration (32).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ePrenatal maternal emotional attachment was assessed using the validated 19-item Maternal Antenatal Attachment Scale (MAAS) with five-point response options (1-5). Higher scores indicate stronger attachment and relationship (36\\u0026ndash;38). The instrument has two dimensions: \\u0026ldquo;quality of attachment\\u0026rdquo; (10 items e.g. experiences of closeness, tenderness, pleasure in interaction, distress at fantasized loss and viewing the fetus as a \\u0026ldquo;little person\\u0026rdquo;). and \\u0026ldquo;intensity/time spent in attachment mode\\u0026rdquo; (8 items, e.g., time spent thinking about, talking to, dreaming about, or palpating the fetus, quality of involvement and intensity of preoccupation). An item assessing fetal dependence on the mother for well-being was excluded from the dimension but included in the global score. Postnatal maternal emotional attachment was measured with the Maternal Postnatal Attachment Scale (MPAS), a validated 19-item postnatal counterpart of the MAAS (36).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe Maternal Fetal Attachment Scale (MFAS) was used in the FinnBrain Bitrh Cohort study to assess attitudes toward pregnancy, motherhood, and the baby. It is a 24-item self-report questionnaire using a five-point Likert scale (1-5), with a total score ranging from 24 to 120; higher scores indicate stronger attachment to the fetus. The MFAS includes five subscales: 1) role taking, 2) differentiating the self from the fetus, 3) interaction with the fetus, 4) attributing characteristics to the fetus, and 5) giving of self (38).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eBackground information was collected at preintervention (Table 1).\\u003c/p\\u003e\\n\\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSociodemographic background.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAll\\u003c/p\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;105 (100%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eIntervention\\u003c/p\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;53 (50.5%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eControl\\u003c/p\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;52 (49.5%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ep\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge, years (mean, SD, range)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e32.2, 4.4, 20\\u0026ndash;50\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e32.4, 4.7, 22\\u0026ndash;50\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e31.9, 4.1, 20\\u0026ndash;39\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.57*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEducation n (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.4074**\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrimary school\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (1.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0 (0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVocational school\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e24 (22.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13 (24.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11 (21.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSecondary school graduate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (3.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0 (0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUniversity of Applied Sciences\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e41 (39.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17 (32.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24 (46.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaster's degree\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e35 (33.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e18 (34.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e17 (32.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMain activity n (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.8027**\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAt work\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e80 (76.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e39 (73.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e41 (78.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnemployed/laid off\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (3.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (3.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (3.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParental leave\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6 (11.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (3.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStudent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (7.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLong-term sick leave or retirement\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0 (0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0 (0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1 (1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOther\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (2.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (3.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (3.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThe family includes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.1772**\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOne parent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13 (12.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (15.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5 (9.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTwo parents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e78 (74.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e40 (75.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e38 (73.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNew family of two parents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14 (13.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5 (9.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9 (17.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTreatment for mental health problems before pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (19.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (18.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10 (19.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.00***\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAntidepressant medication before pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12 (11.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e8 (15.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.2356 ***\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOther mood medication before pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e18 (17.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5 (9.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13 (25.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.0408***\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAntidepressant medication during pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (6.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (5.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (7.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.7157***\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOther mood medication during pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10 (9.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (7.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6 (11.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.526***\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoking before pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15 (14.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (13.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e8 (15.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.79***\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e* Age was compared assuming normal distribution and equal variances with two sample t-test showing p\\u0026thinsp;=\\u0026thinsp;0.5682 (Levene p\\u0026thinsp;=\\u0026thinsp;0.8805).\\u003c/p\\u003e \\u003cp\\u003e** Ordinal categorial varibles were compared using Cochran-Armitage trend test.\\u003c/p\\u003e \\u003cp\\u003e*** Other categorial variables were compared using Fisher\\u0026rsquo;s exact test two-tailed.\\u003c/p\\u003e \\u003cp\\u003eIntervention\\u003c/p\\u003e \\u003cp\\u003eThe interactive ultrasound intervention published earlier (30) used an interactive approach to ultrasound led by an obstetrician and a psychologist specialized in psychotherapy and infant mental health. The session focuses on observing the fetus according to the woman\\u0026rsquo;s wishes: observing fetal activity and facial expressions in the womb, working with mental images related to the fetus and the pregnancy, and listening to her thoughts about the fetus. Professionals comment neutrally on fetal behavior without interpreting it, and encourage women to reflect on their feelings. Sessions are structured and last approximately 40 minutes. Women participate alone.\\u003c/p\\u003e \\u003cp\\u003eIndependent control group\\u003c/p\\u003e \\u003cp\\u003eThe FinnBrain Birth Cohort study is a transgenerational prospective study investigating the effects of prenatal and early life stress exposure on child health and brain development (39). It is a well-characterized study and the courses of maternal depression in this general population sample have been presented (5). Data from the FinnBrain Birth Cohort study were used to show how EPDS scores develop through pregnancy in women from the same area scoring 10\\u0026ndash;15 points on the EPDS with no intervention. Pregnant women completed the EPDS and MFAS at 14, 24 and 34 gwks and at 3 months postpartum, comparable to the RCT.\\u003c/p\\u003e \\u003cp\\u003eData collection from the RCT\\u003c/p\\u003e \\u003cp\\u003eThe questionnaire data were collected at four time points (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e) using the Research Electronic Data Capture (REDCap) tools hosted at the University of Turku (40).\\u003c/p\\u003e \\u003cp\\u003eRandomization was performed using random permuted blocks with a block size of 10 using SAS\\u0026reg; software (version 9.4 for Windows).\\u003c/p\\u003e \\u003cp\\u003ePower analysis\\u003c/p\\u003e \\u003cp\\u003eA mean decrease of three points in the EPDS score was considered clinically relevant and was used for power calculations. A standard deviation (SD) of 3.5 points in the EPDS score used in power calculations was based on earlier studies in the Finnish population showing an SD of 3.7\\u0026ndash;4 (16). A power analysis with 80% power and a significance level of 0.05 (two-tailed) showed that 50 subjects were needed in both groups.\\u003c/p\\u003e \\u003cp\\u003eStatistical methods\\u003c/p\\u003e \\u003cp\\u003eDescriptive statistics were analyzed using JMP\\u0026reg;, version 17 Pro. SAS Institute Inc., Cary, NC, 1989\\u0026ndash;2019). Continuous variables were evaluated assuming a normal distribution, despite one outlier. Other categorical variables were compared using Fisher\\u0026rsquo;s exact test two-tailed. Significance level of 0.05 was used two-tailed. The ordinal variables were compared using the Cochrane-Armitage trend test.\\u003c/p\\u003e \\u003cp\\u003eA linear mixed model for repeated measures analysis was conducted using SAS\\u0026reg; software, (version 9.4 of the SAS System for Windows, SAS Institute Inc., Cary, NC, USA) to assess changes in the EPDS and MAAS/MPAS scores between the intervention and control groups over time. Additional repeated measures analyses were adjusted using participants\\u0026rsquo; medication information as an explanatory variable. Primary analysis was conducted at three time points\\u0026ndash;preintervention, postintervention and postpartum\\u0026ndash;to assess the efficacy of the intervention. A sensitivity analysis using four time points, including recruitment, was conducted to assess the consistency of the primary analysis. The EPDS and MFAS scores in the FinnBrain Birth Cohort study were examined using a paired t-test to examine changes over time.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe mean age of the participants was 32.2 years (SD 4.4, range 20\\u0026ndash;50) and 34.3% were nulliparous. Overall, 18 (17%) participants reported clinical depression in the SCID interview, with seven (38.9%) in the intervention group and 11 (61.1%) in the control group. Antidepressants were used by four (7.6%) participants in the intervention group and eight (15.4%) in the control group, p\\u0026thinsp;=\\u0026thinsp;0.24. The groups differed significantly in the use of other mood medications before pregnancy, p\\u0026thinsp;=\\u0026thinsp;0.04: five (9.4%) in the intervention group and eight (15.4%) in the control group (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The EPDS scores were missing at preintervention for 18 subjects in the intervention group and 17 in the control group.\\u003c/p\\u003e \\u003cp\\u003ePrimary analyses\\u003c/p\\u003e \\u003cp\\u003eThe primary analyses are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e and in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. We found an interaction effect between groups and time (p\\u0026thinsp;=\\u0026thinsp;0.018), indicating that EPDS scores changed differently over time in the intervention and control groups. Specifically, the decrease in EPDS scores from preintervention to postpartum differed significantly between the groups [p\\u0026thinsp;=\\u0026thinsp;0.0008; intervention group 10.5 (95% CI 9.4\\u0026ndash;11.5) and 8.5 (95% CI 7.1\\u0026ndash;10.0); control group 12.0 (95% CI 11-13.1) and 7.3, (95% CI 5.8\\u0026ndash;8.8), respectively]. Despite randomization, there was a difference between the groups at preintervention (p\\u0026thinsp;=\\u0026thinsp;0.038; intervention group 10.5; control group 12.0). Within group analyses showed that in the intervention group, EPDS scores significantly decreased from preintervention to postpartum (p\\u0026thinsp;=\\u0026thinsp;0.0048, 10.5 and 8.5, respectively). In the control group, a significant decrease was observed between preintervention and postintervention (p\\u0026thinsp;=\\u0026thinsp;0.0203; 12.0 and 7.3).\\u003c/p\\u003e \\u003cp\\u003eSensitivity analyses showed similar results (p\\u0026thinsp;=\\u0026thinsp;0.015). A significant decrease in EPDS scores was found between preintervention and postpartum [p\\u0026thinsp;=\\u0026thinsp;0.004; intervention group 10.4 (95% CI 9.4\\u0026ndash;11.5) and 8.5 (95% CI 7.1\\u0026ndash;10.0); control group 12.0 (95% CI 11-13.1) and 7.4 (95% CI 5.9\\u0026ndash;8.9)].\\u003c/p\\u003e \\u003cp\\u003eThe MAAS scores increased similarly in both groups (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e): global MAAS [p\\u0026thinsp;=\\u0026thinsp;0.43; intervention group from preintervention 69.2 (95% CI 67.2\\u0026ndash;71.2) to postintervention 75.4 (95% CI 73.6\\u0026ndash;77.1); control group 68.3 (95% CI 66.3\\u0026ndash;70.3) to 73.5 (95% CI 71.6\\u0026ndash;75.4)], quality dimension [p\\u0026thinsp;=\\u0026thinsp;0.35; intervention group 42.2 (95% CI 41.1\\u0026ndash;43.3) to 45.2 (95% CI 44.4\\u0026ndash;46.0); control group 42.2 (95% CI 41.1\\u0026ndash;43.2) to 44.5 (95% CI 43.6\\u0026ndash;45.4)]; intensity dimension [p\\u0026thinsp;=\\u0026thinsp;1.0; intervention group 22.9 (95% CI 21.8\\u0026ndash;24.1) to 26.1 (95% CI 25-27.1); control group 22.0 (95% CI 20.8\\u0026ndash;23.1) to 25.2 (95% CI 23.9\\u0026ndash;26.4)], respectively, indicating a strengthening of attachment. The MPAS scores were also similar in both groups [p\\u0026thinsp;=\\u0026thinsp;0.44; intervention group 71.7 (95% CI 69.9\\u0026ndash;73.4) and control group 72.7 (95% CI 70.8\\u0026ndash;74.4)] (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAdjusted analyses\\u003c/p\\u003e \\u003cp\\u003eAdditional analyses were adjusted for participants\\u0026rsquo; medications information as an explanatory variable (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). We found a similar interaction effect between the groups in a model adjusted for antidepressant use before pregnancy (p\\u0026thinsp;=\\u0026thinsp;0.005) and in a model adjusted for the use of other mood medications before pregnancy (p\\u0026thinsp;=\\u0026thinsp;0.022), which was consistent with the results of theprimary analyses. Despite the adjustment, no intervention effect was found.\\u003c/p\\u003e \\u003cp\\u003eSensitivity analyses showed similar interaction effect in participants using antidepressants (p\\u0026thinsp;=\\u0026thinsp;0.009) and other mood medications before pregnancy (p\\u0026thinsp;=\\u0026thinsp;0.029).\\u003c/p\\u003e \\u003cp\\u003eThe global MAAS and MPAS scores were higher in those using antidepressants before pregnancy at all time points: in the intervention group at preintervention 71.3 (SD 8.7; n\\u0026thinsp;=\\u0026thinsp;4), at postintervention 75.8 (SD 6.9; n\\u0026thinsp;=\\u0026thinsp;4) at postpartum 75.2 (SD 4.4, n\\u0026thinsp;=\\u0026thinsp;5), and in the control group at preintervention 75.6 ( SD3.8; n\\u0026thinsp;=\\u0026thinsp;5), at postintervention 74.3 (SD 5.2; n\\u0026thinsp;=\\u0026thinsp;7), at postpartum 72 (SD 4.4; n\\u0026thinsp;=\\u0026thinsp;4). MPAS scores were also higher in those using other mood medications 75.3 (SD 3.7; n\\u0026thinsp;=\\u0026thinsp;8), but small sample size limited analysis.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eResults.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eIntervention, n\\u0026thinsp;=\\u0026thinsp;53\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c5\\\" namest=\\\"c4\\\"\\u003e \\u003cp\\u003eControl, n\\u0026thinsp;=\\u0026thinsp;52\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eModel based means\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95% CI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eModel based means\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e95% CI\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEPDS\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9.4\\u0026ndash;11.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e12.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11-13.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.4\\u0026ndash;9.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7.8\\u0026ndash;10.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostpartum\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.1\\u0026ndash;10.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e7.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5.8\\u0026ndash;8.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEPDS, adjusted with antidepressants used before pregnancy\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.3\\u0026ndash;11.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10.4\\u0026ndash;13.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.9\\u0026ndash;10.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8.2\\u0026ndash;11.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostpartum\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6.2\\u0026ndash;10.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5.0-8.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEPDS, adjusted with other mood medications before pregnancy\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.9\\u0026ndash;11.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10.8\\u0026ndash;13\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.6\\u0026ndash;10.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8.0-10.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostpartum\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6.0-9.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5.3\\u0026ndash;8.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMAAS Global\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e69.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e67.2\\u0026ndash;71.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e68.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e66.3\\u0026ndash;70.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e75.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e73.6\\u0026ndash;77.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e73.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e71.6\\u0026ndash;75.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMAAS Quality\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e42.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e41.1\\u0026ndash;43.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e42.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e41.1\\u0026ndash;43.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e45.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e44.4\\u0026ndash;46.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e44.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e43.6\\u0026ndash;45.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMAAS Intensity\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e22.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e21.8\\u0026ndash;24.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e22.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e20.8\\u0026ndash;23.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostintervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e26.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e25.0-27.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e25.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e23.9\\u0026ndash;26.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMPAS Global\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostpartum\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e71.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e69.9\\u0026ndash;73.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e72.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e70.8\\u0026ndash;74.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eFinnBrain Birth Cohort study data\\u003c/p\\u003e \\u003cp\\u003eThe EPDS mean scores in the FinnBrain data were 11.7 (SD 1.55; n\\u0026thinsp;=\\u0026thinsp;338) at 14 gwks, 9.0 (SD 4.25; n\\u0026thinsp;=\\u0026thinsp;279) at 24 gwks, 8.7 (SD 3.93; n\\u0026thinsp;=\\u0026thinsp;256) at 34 gwks, and 7.5 (SD 4.19\\u0026cedil;n\\u0026thinsp;=\\u0026thinsp;213) three months postpartum. The decrease was significant between 14 and 24 gwks, and between 14 and 34 gwks (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e \\u003cp\\u003eThe MFAS increased from 87.1 (SD 10.5, n\\u0026thinsp;=\\u0026thinsp;239) at 24 gwks to 92.9 (SD 8.9, n\\u0026thinsp;=\\u0026thinsp;239) at 34 gwks and the increase was significant (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn this RCT study, we found a reduction in depressive symptoms and an increase in maternal-fetal attachment in both groups from preintervention to four months postpartum. Although maternal-fetal attachment followed a similar trajectory in both groups, the pattern of change in depressive symptoms differed. Contrary to expectations, the depressive symptoms decreased more in the control group than in the intervention group. Thus, ultrasound intervention was not associated with greater reductions in depressive symptoms or improved maternal-fetal attachment.\\u003c/p\\u003e \\u003cp\\u003eIn the primary analysis, we found no intervention effect of interactive ultrasound on depressive symptoms. Previous studies have shown promising results from the interactive use of pregnancy ultrasound in low-risk (24,25) and high-risk pregnancies (27\\u0026ndash;29), but our study was the first to focus on depressive symptoms. Jussila et al. (28) reported similar null findings on depressive symptoms in substance-using pregnant women. Inconsistent results have been reported in interventions targeting depressive symptoms and parenting support. A systematic review and meta-analysis found that parenting interventions for mothers with depressive symptoms had no effect on the parent-child relationship or child development (21), whereas group-based cognitive-behavioral therapy effectively reduced depressive symptoms and increased maternal-fetal attachment (41). Three-dimensional (3D) and 4D ultrasound scans may enhance mental images of the fetus and increase attachment (42,43). The use of 3D-printed images and models of the fetal face obtained from ultrasound scans during the second trimester in a randomized setting has also been shown to improve maternal-fetal attachment and reduce depressive symptoms in healthy pregnant women (44), but these studies did not include parenting interventions. Unlike in other studies, it is important to consider that Finnish pregnant women are served by the Finnish maternity and child health clinic system, which provides support, counseling, and screening for depressive symptoms (45).\\u003c/p\\u003e \\u003cp\\u003eAt pre-intervention, despite randomization, the control group had higher EPDS scores and were more likely to use mood medications other than antidepressants. When the models were adjusted for antidepressants or other mood medications use before pregnancy, similar interaction effects between group and time were observed, indicating that the finding was independent of the use of mood medication. Notably, depressive symptoms declined more steeply in the control group than in the intervention group.\\u003c/p\\u003e \\u003cp\\u003eSeveral explanations may account for the lack of an intervention effect on depressive symptoms. First, despite the power calculations, the sample size may have been too small to detect the intervention effect. Second, despite randomization, the control group had a higher proportion of women with more severe depressive symptoms (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Third, the interactive ultrasound intervention may not be effective in decreasing depressive symptoms.\\u003c/p\\u003e \\u003cp\\u003eWe found a decrease in moderate depressive symptoms throughout pregnancy across all studied groups, which is consistent with previous research showing reductions in depressive symptoms from early prenatal periods to eight months postpartum for both mothers and fathers (46). In contrast, some studies have reported more maternal depressive symptoms in the first and third trimesters compared with the second (2,47). The observed decrease may indicate psychological adjustment: the first trimester involves early pregnancy stress, the second is more stable, and the third fosters positive expectations about childbirth and parenthood (48). A similar decrease in EPDS scores in both groups may reflect an overall improvement in psychological adjustment in women with depressive symptoms in early pregnancy, as observed in the FinnBrain Birth Cohort (5).\\u003c/p\\u003e \\u003cp\\u003eIn our study, the MAAS scores increased over time in both groups, indicating a strengthening of attachment, consistent with previous findings (49). There are no official cut-off values for the global MAAS score or its dimensions. However, compared with the estimated cut-off values from a recent study (50), the MAAS scores in this sample were below the midpoint of the distribution. A global MAAS score\\u0026thinsp;\\u0026le;\\u0026thinsp;75 indicates low attachment (49), suggesting that pregnant women in the control group had low attachment at all time points measured, whereas women in the intervention group were at the threshold. Stronger prenatal attachment may be associated with fewer depressive symptoms during pregnancy and postpartum (1,14), and vice versa: more depressive symptoms have been associated with lower scores (51).\\u003c/p\\u003e \\u003cp\\u003eThis study has several limitations. First, the use of self-report symptom scales rather than clinical interviews may not fully capture participants\\u0026rsquo; health and symptomology although the EPDS is a validated questionnaire for assessing depressive symptoms over the past 7 days. A large systematic review and meta-analysis found that an EPDS cut-off of \\u0026ge;\\u0026thinsp;14 (9%) aligns with the SCID prevalence of major depression (52), which is consistent with our findings. Second, we did not systematically collect information about the participants\\u0026rsquo; other contacts and treatments regarding depression. Third, participation in the intervention study may have influenced the results (53). All participants attended the representation interviews, which can be considered an intervention in itself, as the interview systematically explores the parents\\u0026rsquo; thoughts, feelings, and perceptions about their baby and their relationship (18). Moreover, the opportunity for three free 4D-ultrasound examinations may have biased the self-report mood symptom scores at recruitment.\\u003c/p\\u003e \\u003cp\\u003ePsychological interventions effectively treat perinatal depression and provide long-term benefits (54). Interventions that reduce depression while supporting maternal-fetal attachment may improve care for pregnant women with moderate depressive symptoms (19).\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eOur findings suggest that among moderately depressed women, depressive symptoms decrease and maternal attachment increases during pregnancy, regardless of the intervention. This may reflect an improvement in psychological adjustment as the women integrate motherhood into their identity and bond with their unborn child.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003e4D \\u0026nbsp;Four-dimensional\\u003c/p\\u003e\\n\\u003cp\\u003eEPDS \\u0026nbsp; Edinburgh Pre-/Postnatal Depression Scale\\u003c/p\\u003e\\n\\u003cp\\u003eMAAS\\u0026nbsp;Maternal Antenatal Attachment Scale\\u003c/p\\u003e\\n\\u003cp\\u003eMPAS \\u0026nbsp;Maternal Postnatal Attachment Scale\\u003c/p\\u003e\\n\\u003cp\\u003eMFAS \\u0026nbsp;Maternl-fetal Antenatal Attachmnet Scale\\u003c/p\\u003e\\n\\u003cp\\u003egwks \\u0026nbsp;gestational weeks\\u003c/p\\u003e\\n\\u003cp\\u003eWMCI \\u0026nbsp;Working Model of the Child Interview\\u003c/p\\u003e\\n\\u003cp\\u003eREDCap\\u0026nbsp; Research Electronic Data Capture\\u003c/p\\u003e\\n\\u003cp\\u003eSCID\\u0026nbsp; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR\\u003c/p\\u003e\\n\\u003cp\\u003e3D \\u0026nbsp;three-dimensional\\u003c/p\\u003e\\n\\u003cp\\u003eRCT \\u0026nbsp;Randomized controlled trial\\u003c/p\\u003e\\n\\u003cp\\u003eSSRI\\u0026nbsp; selective serotonin reuptake inhibitor\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was approved by the Ethics Committee of the Hospital District of Southwest Finland, case number 95/1801/2017, and conducted according to the ethical standards of the Declaration of Helsinki, 1964. Written informed consent was obtained\\u0026nbsp;from all individual participants included in the study.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and material\\u003c/p\\u003e\\n\\u003cp\\u003eData from this study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting interests\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no relevant financial or non-financial interests to disclose.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was funded by the Varsinais-Suomi Regional Fund, the Turku University Foundation, the Finnish Medical Foundation, the State Research Funding\\u0026nbsp;and the Signe and Ane Gyllenberg Foundation.\\u003c/p\\u003e\\n\\u003cp\\u003eAuthor contributions\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors contributed to the study\\u0026rsquo;s conception and design. Study planning, material preparation, data collection, and analysis were performed by HP, EE and SA-B. HP, EE, SA-B, E-LK, KR and NG contributed to data collection and conducted the intervention visits. Statistical analyses were performed by HP and EL. HP drafted the first version of the manuscript, and E-LK, EE and SA-B provided comments. HK and LK participated in planning in the use of the Finnbrain Cohort Study Data and reviewed manuscript. E-LK wrote the sections related to the FinnBrain Cohort Study Data. All authors read and approved the final manuscript. EE and SA-B share the last authorship.\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgements\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to express our gratitude to all the participants and the hospital personnel carrying out this study, with special thanks to the graduate students in psychology, who carried out the representation interviews. We also gratefully acknowledge The Hospital District of Southwest Finland/The Wellbeing Services County of Southwest Finland, the Finnish Medical Foundation, the Varsinais-Suomi Regional Fund, Signe and Ane Gyllenberg Foundation and University of Turku for funding this research.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eGoecke TW, Voigt F, Faschingbauer F, Spangler G, Beckmann MW, Beetz A. The association of prenatal attachment and perinatal factors with pre- and postpartum depression in first-time mothers. Arch Gynecol Obstet. 2012;286(2):309\\u0026ndash;16. \\u003c/li\\u003e\\n\\u003cli\\u003eMarchesi C, Bertoni S, Maggini C. Major and minor depression in pregnancy. Obstet Gynecol. 2009; \\u003c/li\\u003e\\n\\u003cli\\u003eLeigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry. 2008; \\u003c/li\\u003e\\n\\u003cli\\u003eUnderwood L, Waldie K, D\\u0026rsquo;Souza S, Peterson ER, Morton S. A review of longitudinal studies on antenatal and postnatal depression. Archives of Women\\u0026rsquo;s Mental Health. 2016. \\u003c/li\\u003e\\n\\u003cli\\u003eKorja R, Nolvi S, Kataja EL, Scheinin N, Junttila N, Lahtinen H, et al. The courses of maternal and paternal depressive and anxiety symptoms during the prenatal period in the finnbrain birth cohort study. PLoS One. 2018; \\u003c/li\\u003e\\n\\u003cli\\u003eSlade A, Cohen LJ, Sadler LS, Miller M. The psychology and psychopathology of pregnancy: Reorganization and transformation. In: Handbook of infant mental health, 3rd ed. New York, NY, US: The Guilford Press; 2009. p. 22\\u0026ndash;39. \\u003c/li\\u003e\\n\\u003cli\\u003eKingston D, Tough S, Whitfield H. Prenatal and postpartum maternal psychological distress and infant development: A systematic review. Child Psychiatry and Human Development. 2012. \\u003c/li\\u003e\\n\\u003cli\\u003eTuovinen S, Lahti-Pulkkinen M, Girchenko P, Lipsanen J, Lahti J, Heinonen K, et al. Maternal depressive symptoms during and after pregnancy and child developmental milestones. Depress Anxiety. 2018; \\u003c/li\\u003e\\n\\u003cli\\u003eDiguisto C, Saucedo M, Kallianidis A, Bloemenkamp K, B\\u0026oslash;dker B, Buoncristiano M, et al. Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study. BMJ. 2022 Nov;379:e070621. \\u003c/li\\u003e\\n\\u003cli\\u003eSiddiqui A, H\\u0026auml;ggl\\u0026ouml;f B. Does maternal prenatal attachment predict postnatal mother-infant interaction? Early Hum Dev. 2000;59(1):13\\u0026ndash;25. \\u003c/li\\u003e\\n\\u003cli\\u003eDubber S, Reck C, M\\u0026uuml;ller M, Gawlik S. Postpartum bonding: the role of perinatal depression, anxiety and maternal\\u0026ndash;fetal bonding during pregnancy. Arch Womens Ment Health. 2015; \\u003c/li\\u003e\\n\\u003cli\\u003eHakanen H, Flykt M, Sinerv\\u0026auml; E, Nolvi S, Kataja E-L, Pelto J, et al. How maternal pre- and postnatal symptoms of depression and anxiety affect early mother-infant interaction? J Affect Disord. 2019 Oct;257:83\\u0026ndash;90. \\u003c/li\\u003e\\n\\u003cli\\u003eRoll\\u0026egrave; L, Giordano M, Santoniccolo F, Trombetta T. Prenatal attachment and perinatal depression: A systematic review. International Journal of Environmental Research and Public Health. 2020. \\u003c/li\\u003e\\n\\u003cli\\u003ePetri E, Palagini L, Bacci O, Borri C, Teristi V, Corezzi C, et al. Maternal-foetal attachment independently predicts the quality of maternal-infant bonding and post-partum psychopathology. J Matern neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2018 Dec;31(23):3153\\u0026ndash;9. \\u003c/li\\u003e\\n\\u003cli\\u003eTambelli R, Odorisio F, Lucarelli L. Prenatal and postnatal maternal representations in nonrisk and at-risk parenting: Exploring the influences on mother-infant feeding interactions. Infant Ment Health J. 2014; \\u003c/li\\u003e\\n\\u003cli\\u003eAhlqvist-Bj\\u0026ouml;rkroth S, Korja R, Junttila N, Savonlahti E, Pajulo M, R\\u0026auml;ih\\u0026auml; H, et al. Mothers\\u0026rsquo; and fathers\\u0026rsquo; prenatal representations in relation to marital distress and depressive symptoms. Infant Ment Health J. 2016;37(4):388\\u0026ndash;400. \\u003c/li\\u003e\\n\\u003cli\\u003eAmmaniti M, Tambelli R, Odorisio F. Exploring Maternal Representations During Pregnancy in Normal and At-Risk Samples: The Use of the Interview of Maternal Representations During Pregnancy. Infant Ment Health J. 2013; \\u003c/li\\u003e\\n\\u003cli\\u003eBenoit D, Parker KCH, Zeanah CH. Mothers\\u0026rsquo; representations of their infants assessed prenatally: Stability and association with infants\\u0026rsquo; attachment classifications. J Child Psychol Psychiatry Allied Discip. 1997; \\u003c/li\\u003e\\n\\u003cli\\u003eStein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. The Lancet. 2014. \\u003c/li\\u003e\\n\\u003cli\\u003eForman DR, O\\u0026rsquo;Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Dev Psychopathol. 2007; \\u003c/li\\u003e\\n\\u003cli\\u003eRayce SB, Rasmussen IS, V\\u0026aelig;ver MS, Pontoppidan M. Effects of parenting interventions for mothers with depressive symptoms and an infant: systematic review and meta-analysis. BJPsych open. 2020 Jan;6(1):e9. \\u003c/li\\u003e\\n\\u003cli\\u003ePoobalan AS, Aucott LS, Ross L, Smith WCS, Helms PJ, Williams JHG. Effects of treating postnatal depression on mother-infant interaction and child development: Systematic review. British Journal of Psychiatry. 2007. \\u003c/li\\u003e\\n\\u003cli\\u003eSkelton E, Webb R, Malamateniou C, Rutherford M, Ayers S. The impact of antenatal imaging on parent experience and prenatal attachment: a systematic review. J Reprod Infant Psychol. 2024 Jan;42(1):22\\u0026ndash;44. \\u003c/li\\u003e\\n\\u003cli\\u003eBoukydis Z. Ultrasound consultation to reduce risk and increase resilience in pregnancy. In: Annals of the New York Academy of Sciences. 2006. p. 268\\u0026ndash;71. \\u003c/li\\u003e\\n\\u003cli\\u003eBoukydis CFZ, Treadwell MC, Delaney-Black V, Boyes K, King M, Robinson T, et al. Women\\u0026rsquo;s Responses to Ultrasound Examinations During Routine Screens in an Obstetric Clinic. J Ultrasound Med [Internet]. 2006;25(6):721\\u0026ndash;8. Available from: http://doi.wiley.com/10.7863/jum.2006.25.6.721\\u003c/li\\u003e\\n\\u003cli\\u003ePajulo H, Pajulo M, Jussila H, Ekholm E. Substance-abusing pregnant women: prenatal intervention using ultrasound consultation and mentalization to enhance the mother\\u0026ndash;child relationship and reduce substance use. Infant Ment Health J. 2016;37(4):317\\u0026ndash;34. \\u003c/li\\u003e\\n\\u003cli\\u003eJussila H, Ekholm E, Pajulo M. A New Parental Mentalization Focused Ultrasound Intervention for Substance Using Pregnant Women. Effect on Self-reported Prenatal Mental Health, Attachment and Mentalization in a Randomized and Controlled Trial. Int J Ment Health Addict. 2020; \\u003c/li\\u003e\\n\\u003cli\\u003eJussila H, Pajulo M, Ekholm E. A Novel 4D Ultrasound Parenting Intervention for Substance Using Pregnant Women in Finland: Participation in Obstetric Care, Fetal Drug Exposure, and Perinatal Outcomes in a Randomized Controlled Trial. Matern Child Health J. 2020; \\u003c/li\\u003e\\n\\u003cli\\u003ePulliainen H, Niela-Vil\\u0026eacute;n H, Ekholm E, Ahlqvist-Bj\\u0026ouml;rkroth S. Experiences of interactive ultrasound examination among women at risk of preterm birth: A qualitative study. BMC Pregnancy Childbirth. 2019; \\u003c/li\\u003e\\n\\u003cli\\u003ePulliainen H, Sari-Ahlqvist-Bj\\u0026ouml;rkroth, Ekholm E. Does interactive ultrasound intervention relieve minor depressive symptoms and increase maternal attachment in pregnancy? A protocol for a randomized controlled trial. Trials. 2022 Apr;23(1):313. \\u003c/li\\u003e\\n\\u003cli\\u003eShankman SA, Funkhouser CJ, Klein DN, Davila J, Lerner D, Hee D. Reliability and validity of severity dimensions of psychopathology assessed using the Structured Clinical Interview for DSM-5 (SCID). Int J Methods Psychiatr Res. 2018; \\u003c/li\\u003e\\n\\u003cli\\u003eOs\\u0026oacute;rio FL, Loureiro SR, Hallak JEC, Machado-de-Sousa JP, Ushirohira JM, Baes CVW, et al. Clinical validity and intrarater and test\\u0026ndash;retest reliability of the Structured Clinical Interview for DSM-5 \\u0026ndash; Clinician Version (SCID-5-CV). Psychiatry Clin Neurosci. 2019; \\u003c/li\\u003e\\n\\u003cli\\u003eZeanah CH, Benoit D, Hirshberg L, Barton ML, Regan C. Mothers\\u0026rsquo; representations of their infants are concordant with infant attachment classifications. Dev Issues Psychiatry Psychol. 1994; \\u003c/li\\u003e\\n\\u003cli\\u003eCox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression scale. Br J Psychiatry. 1987; \\u003c/li\\u003e\\n\\u003cli\\u003eBergink V, Kooistra L, Lambregtse-van den Berg MP, Wijnen H, Bunevicius R, van Baar A, et al. Validation of the Edinburgh Depression Scale during pregnancy. J Psychosom Res. 2011; \\u003c/li\\u003e\\n\\u003cli\\u003eCondon JT, Corkindale C. The correlates of antenatal attachment in pregnant women. 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A pilot study of a group-based perinatal depression intervention on reducing depressive symptoms and improving maternal-fetal attachment and maternal sensitivity. Arch Womens Ment Health. 2021; \\u003c/li\\u003e\\n\\u003cli\\u003eWenstrom KD. Preexamination and postexamination assessment of parental-fetal bonding in patients undergoing 3-/4-dimensional obstetric ultrasonography: Commentary. Vol. 62, Obstetrical and Gynecological Survey. 2007. p. 165\\u0026ndash;6. \\u003c/li\\u003e\\n\\u003cli\\u003eRighetti PL, Dell\\u0026rsquo;Avanzo M, Grigio M, Nicolini U. Maternal/paternal antenatal attachment and fourth-dimensional ultrasound technique: A preliminary report. Br J Psychol. 2005; \\u003c/li\\u003e\\n\\u003cli\\u003eCot\\u0026eacute; JJ, Badura-Brack AS, Walters RW, Dubay NG, Bredehoeft MR. Randomized Controlled Trial of the Effects of 3D-Printed Models and 3D Ultrasonography on Maternal-Fetal Attachment. J Obstet Gynecol neonatal Nurs JOGNN. 2020 Mar;49(2):190\\u0026ndash;9. \\u003c/li\\u003e\\n\\u003cli\\u003eHakulinen Tuovi, Pakarinen Anni U-LH. Terveyden ja hyvinvoinnin laitos, \\u0026Auml;itiys- ja lastenneuvola, EPDS-mielialalomake raskausajan ja synnytyksen j\\u0026auml;lkeisen masennuksen seulonnassa. 24.8.2021. \\u003c/li\\u003e\\n\\u003cli\\u003eHeron J, O\\u0026rsquo;Connor TG, Evans J, Golding J, Glover V. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004 May;80(1):65\\u0026ndash;73. \\u003c/li\\u003e\\n\\u003cli\\u003ePesonen A-K, Lahti M, Kuusinen T, Tuovinen S, Villa P, H\\u0026auml;m\\u0026auml;l\\u0026auml;inen E, et al. Maternal Prenatal Positive Affect, Depressive and Anxiety Symptoms and Birth Outcomes: The PREDO Study. PLoS One. 2016;11(2):e0150058. \\u003c/li\\u003e\\n\\u003cli\\u003eBrod\\u0026eacute;n, Margareta Kivirauma M. Raskausajan mahdollisuudet: Kun suhteet syventyv\\u0026auml;t ja kehittyv\\u0026auml;t. Helsinki: Therapeia-s\\u0026auml;\\u0026auml;ti\\u0026ouml;; 2006. \\u003c/li\\u003e\\n\\u003cli\\u003eRowe HJ, Wynter KH, Steele A, Fisher JRW, Quinlivan JA. The growth of maternal-fetal emotional attachment in pregnant adolescents: a prospective cohort study. J Pediatr Adolesc Gynecol. 2013 Dec;26(6):327\\u0026ndash;33. \\u003c/li\\u003e\\n\\u003cli\\u003eKelmanson IA. Maternal Antenatal Attachment Scale (MAAS) reference values at different stages of pregnancy and their possible associations with major obstetric and demographic characteristics. Early Child Dev Care [Internet]. 2022 Jul 27;192(10):1673\\u0026ndash;84. Available from: https://doi.org/10.1080/03004430.2021.1925263\\u003c/li\\u003e\\n\\u003cli\\u003eG\\u0026ouml;bel A, L\\u0026uuml;ersen L, Asselmann E, Arck P, Diemert A, Garthus-Niegel S, et al. Psychometric properties of the Maternal Postnatal Attachment Scale and the Postpartum Bonding Questionnaire in three German samples. BMC Pregnancy Childbirth. 2024 Nov;24(1):789. \\u003c/li\\u003e\\n\\u003cli\\u003eLyubenova A, Neupane D, Levis B, Wu Y, Sun Y, He C, et al. Depression prevalence based on the Edinburgh Postnatal Depression Scale compared to Structured Clinical Interview for DSM DIsorders classification: Systematic review and individual participant data meta-analysis. Int J Methods Psychiatr Res. 2021 Mar;30(1):e1860. \\u003c/li\\u003e\\n\\u003cli\\u003eNijjar SK, D\\u0026rsquo;Amico MI, Wimalaweera NA, Cooper N, Zamora J, Khan KS. Participation in clinical trials improves outcomes in women\\u0026rsquo;s health: a systematic review and meta-analysis. BJOG. 2017 May;124(6):863\\u0026ndash;71. \\u003c/li\\u003e\\n\\u003cli\\u003eCuijpers P, Franco P, Ciharova M, Miguel C, Segre L, Quero S, et al. Psychological treatment of perinatal depression: a meta-analysis. Psychol Med. 2023 Apr;53(6):2596\\u0026ndash;608. \\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-pregnancy-and-childbirth\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"prch\",\"sideBox\":\"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/prch/default.aspx\",\"title\":\"BMC Pregnancy and Childbirth\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"4D ultrasound, interactive ultrasound, maternal-fetal attachment, prenatal depression, mother-infant relationship\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6672112/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6672112/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eWe examined whether an interactive four-dimensional (4D) ultrasound intervention decreases prenatal and early postnatal depressive symptoms and improves maternal-fetal attachment.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis randomized controlled trial recruited pregnant women who scored 10\\u0026ndash;15 on the Edinburgh Pre-/Postnatal Depression Scale (EPDS), with half of them attending three interactive ultrasound examinations. Depressive symptoms and maternal attachment were the primary outcomes measured using the EPDS and the Maternal Antenatal/Postnatal Attachment Scale (MAAS/MPAS) from early pregnancy to postpartum. An independent FinnBrain Birth Cohort study group served as a control to compare the trajectories of depressive symptoms in women scoring 10\\u0026ndash;15 on the EPDS.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eA total of 53 women participated in the intervention and 52 in the control group. We found an interaction effect between groups and time (p\\u0026thinsp;=\\u0026thinsp;0.018). Although maternal-fetal attachment followed a similar trajectory in both groups, the pattern of change in depressive symptoms differed, similar to the FinnBrain Birth Cohort Study. Participation in the intervention did not enhance the decrease in depressive symptoms or increase attachment in the overall study group.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eDepressive symptoms decreased and maternal attachment increased during pregnancy in moderately depressed women, regardless of the intervention.\\u003c/p\\u003e\\u003ch2\\u003eTrial registration\\u003c/h2\\u003e \\u003cp\\u003eThis study was registered at ClinicalTrials.gov (NCT 03424642) on January 5, 2018.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Effect of Interactive Ultrasound Intervention on Moderate Depressive Symptoms and Maternal Attachment: A Randomized Controlled Trial\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-06-13 11:50:40\",\"doi\":\"10.21203/rs.3.rs-6672112/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-06-11T07:21:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-05-19T05:39:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-05-17T09:07:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-05-17T09:05:12+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Pregnancy and Childbirth\",\"date\":\"2025-05-15T11:19:47+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-pregnancy-and-childbirth\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"prch\",\"sideBox\":\"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/prch/default.aspx\",\"title\":\"BMC Pregnancy and Childbirth\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"021f2018-fffd-4382-8fdf-dc2c6dbf7175\",\"owner\":[],\"postedDate\":\"June 13th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-06-13T11:50:40+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-06-13 11:50:40\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6672112\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6672112\",\"identity\":\"rs-6672112\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}