therefore , prevalence of 
 depression , anxiety , phobia , and obsessive disorders are increased during 
 pregnancy .  
about 18% of pregnant women are depressed during pregnancy while 14% of them experience 
 depression for the first time during pregnancy .
anxiety is also other common disorder during pregnancy with a prevalence 
 of around 18% .  
the results of an interview - based study revealed that more than one 
 third of pregnant women had comorbid symptoms of depression and anxiety .   untreated gestational depression and anxiety can affect mothers relationships with their 
 infants and other family members and may 
 lead to different negative consequences for both mother and fetus .
for instance , they are 
 associated with intrauterine growth retardation , infant s depressive behaviors , depression during adolescence , low birth weight , 
 premature delivery , mothers postnatal 
 depression , and lower accountability 
 to infants .
anxiety can also predispose 
 children to behavioral , emotional , and cognitive disorders later in their life .  
given their high prevalence and negative consequences , effective and timely management of 
 depression and anxiety during pregnancy is of paramount importance .  
however , studies have shown that neither pregnant women nor psychiatrists pay attention to 
 the management of depression and anxiety .
chan et al . , reported that pregnant women 
 consider inattentiveness as a right option for management of depression .
currently , psychological problems are treated 
 mainly by using psychotherapy and drug therapy . given their unique conditions and their 
 concerns over the negative effects of medications on fetus , most pregnant women prefer 
 psychotherapy over drug therapy .   two effective psychotherapeutic interventions which have been used for pregnant women are 
 cognitive behavior therapy ( cbt ) and 
 interpersonal therapy .
however , these 
 interventions have not been developed for managing comorbid psychological problems such as 
 depression and anxiety .   in recent years
, mindfulness - based interventions were developed and used for managing 
 psychological problems among pregnant women .
one of these interventions is 
 mindfulness - integrated cognitive behavior therapy ( micbt ) which integrates mindfulness - based 
 techniques with cognitive behavior therapy .
it is a structured treatment strategy which trains 
 clients to internalize their attention in order to regulate their emotions and attention and 
 then externalize and use their regulated emotions and attention for managing their 
 problems .  
previous studies have shown the effectiveness of micbt in alleviating depression and 
 hyperglycemia among patients with type ii diabetes mellitus , reducing students procrastination , perfectionism , and 
 worry . however , to our knowledge , 
 the effects of micbt have not yet been evaluated among pregnant women .
the aim of present 
 study was to examine the effect of mindfulness - integrated cognitive behavior therapy on 
 depression and anxiety among pregnant women .
we used the cluster random sampling 
 method to select three healthcare centers from all healthcare centers which had the 
 necessary facilities for conducting the study and were located in kashan , iran .
study 
 population included of all pregnant women referring to akramian , taleghani , and ketabchi 
 health centers .
we referred to the study setting and compiled a list of all pregnant women 
 with a gestational age of one to six months .
as all pregnant women had already referred to 
 the health centers since the fifth week of their pregnancy to receive prenatal care 
 services , the lowest gestational age was six weeks .
on the other side , the length of our 
 intervention was eight weeks with a one - month follow - up and thus , the highest gestational 
 age was considered to be six months .
pregnant women with higher gestational ages were 
 excluded due to the likelihood of going into labor before the end of the follow - up period 
 and the probable confounding effects of labor on their mental status .
accordingly , we only 
 selected the pregnant women who had a gestational age of one to six months .  
then , midwives working in the study setting were asked to inform pregnant women about the 
 study .
the inclusion criteria consisted of pregnant women in the one to six months of gestational 
 age , had at least a high school degree , acquired a score of greater than 13 in the edinburgh 
 depression scale and a score of greater than 16 in the beck anxiety inventory , and had no 
 history of psychological disorders or chronic physical problems , have not received 
 psychotherapy or drug therapy during the last six months preceding the study , and women 
 whose depression and anxiety were not secondary to certain known causes such as grief , 
 marital conflict , divorce , or unwanted pregnancy .  
the exclusion criteria were having no desire for continuing participation in the study , 
 having two or more absences from the study intervention sessions , and having a premature 
 delivery . with an alpha of 0.05 , a beta of 0.1 , and an effect size of 0.8 ( 25 ) , the cohen s 
 formula for sample size calculation revealed that 33 participants were necessary for each 
 study group .
however , by considering an attrition rate of 10% , we recruited 40 participants 
 to each group .
participants were randomly allocated into experimental and control groups 
 using block randomization method , by using units of 4 blocks .  
the study primary outcomes were depression and anxiety which were measured three times : 
 before the intervention ( t1 ) , immediately after ( t2 ) , and one month after intervention ( t3 ) . 
 the measurement tools were a demographic questionnaire , the edinburgh postnatal depression 
 scale , and the beck anxiety inventory .
the edinburgh postnatal depression scale ( epds ) had 
 been previously used for measuring pre- and postnatal depression among women .
items 1 , 
 2 , and 4 are scored from 0 to 3 while the other items are scored reversely .
the 
 cronbach s alpha of the persian epds has been reported to be 0.92 .
we also assessed the reliability of the epds which yielded a 
 cronbach s alpha of 0.82 ( n= 100 ) .  
the beck anxiety inventory ( bai ) is a 21-item questionnaire for measuring anxiety 
 severity .
each bai item represents one of the common manifestations of anxiety . on each 
 item ,
a respondent can choose one of the four points of  not at all , 
the cutoff scores of the bai are as follows : 07 : no or minimal anxiety ; 815 : mild 
 anxiety ; 1625 : moderate anxiety ; and 2663 : severe anxiety . the validity and the 
 reliability of the persian bai
we also found that the 
 cronbach s alpha of the inventory was 0.78 ( n= 1513 ) .  
the study intervention was a micbt program which was implemented in eight 90-minute 
 sessions .
an overview of micbt , the flow of the program , and the contents of the next 
 sessions ;   session 2.the basic principles of mindfulness , the components of cbt , and mindful 
 breathing ;   session 3.mindful breathing ( continued ) , step - by - step body scanning exercises , and 
 awareness of visceral sensations ;   session 4.body scanning exercises ( continued ) , behavior therapy techniques ( such as problem 
 solving ) , and the relationship of mindfulness with cbt ;   session 5.body scanning exercises ( continued ) ;   session 6.interpersonal skills , assertiveness , and role play ;   session 7.acceptance and management of suffering in daily life ;   session 8.review and evaluation .  
the intervention was performed by a msc in clinical psychology ( first author ) who had 
 received specialized training in this area under the supervision of a phd in clinical 
 psychology .
participants in the experimental group received micbt while participants in the control 
 group received only routine prenatal care services such as weight control , blood pressure 
 monitoring , and delivery - related educations . at the end of the study participants in control 
 group received training manual of intervention sessions .  
descriptive statistics measures such as frequency , mean , and standard deviation as well as 
 statistical tests such as repeated - measures analysis of variance ( anova ) were used for data 
 analysis by using spss ( version 11.5 ) software .  
this study was approved by the ethics committee of kashan university of medical sciences , 
 kashan , iran , with an approval code of p/13/0/3/4005 , december 17 , 2014 and is registered in 
 the iranian registry of clinical trials with the irct2015012920869n1 code . before 
 implementing the intervention ,
participants were asked to fill out and sign the informed 
 consent form of the study .
  eighty pregnant women participated in this study ( 40 person for each group ) .
ten 
 participants from the experimental were excluded due to their poor attendance at micbt 
 sessions . moreover ,
seven participants from the control were also excluded because of 
 developing pregnancy - related physical problems or their failure to complete the study 
 questionnaires at either t2 or t3 . finally , data analysis was performed on the data 
 retrieved from 63 participants ( 30 women in the experimental and 33 women in the control 
 group ) ( figure 1 ) .
chi - square and 
 independent - samples t - test were used for demographic variables ( age , body mass index and 
 gestational age were analyzedusing the t - test , and educational level , previous childbirth 
 and job were analyzed using the chi - square test).the of participants ' mean age in the 
 experimental and control groups were 26.0 ( 5.8 ) and 26.7 ( 4.5 ) , respectively ( p < 0.05 ) . 

the mean of participants gestational age in the experimental and control groups were 
 respectively 15.0 ( 1.1 ) and 15 ( 1.2 ) weeks ( p < 0.05 ; table 1 ) .
study groups did not differ significantly from each other concerning 
 variables such as age , education , number of deliveries , gestational age , body mass index , 
 and employment status ( p < 0.05 ; table 1 ) .
clinical trial flowchart 
 data are presented as n ( % ) , bindependent - samples t - test was 
 used .
table 2 shows the mean scores of participants 
 depression and anxiety at the three measurement time - points of t1 , t2 , and t3 . at t1 ,
the 
 mean scores of depression and anxiety in the experimental and the control groups were 16.83 
 ( 2.7 ) vs. 16.33 ( 2.64 ) and 19.76 ( 6.33 ) and 20.24 ( 6.11 ) , respectively .
the differences 
 between the study groups regarding the pretest mean scores of depression and anxiety were 
 not statistically significant ( p<0.05 ) . however , the results of the repeated - measures 
 anova test for comparing the variations of depression and anxiety scores showed that at t2 
 and t3 , the mean scores of anxiety and depression in the experimental group were 
 significantly lower than the control group ( p < 0.001 ; table 2 ) .
 repeated measures anova variations of depression scores in the two study groups variations of anxiety scores in the two study groups
  the results of this study showed that mindfulness - based interventions produced positive 
 effects during pregnancy .
for 
 instance , vieten and astin implemented an eight - session mindfulness - based educational 
 program for women who were in the second or third trimester of their pregnancy .
, also conducted a pilot study to investigate the effects of mindfulness - based 
 training on psychological distress among ten multiparous pregnant women .  
3 the control groups were respectively in the 1228 and 
 1729 weeks of their pregnancy .
they used epds and the 
 depression anxiety stress scale ( dass ) for data collection and reported that mind 
 fulness - based intervention significantly reduced the epds and the dass scores .   in another study ,
duncan and bardacke employed a one - group non - controlled design and 
 implemented a mindfulness - based educational program for 27 pregnant women .
the women were in 
 the third trimester of pregnancy and most of them ( 92.6% ) were experiencing their first 
 pregnancy .
the findings 
 revealed that mindfulness was effective in alleviating depression , anxiety , and negative 
 affect and in enhancing positive affect and well - being .
given the facts that their study was 
 non - controlled and some of their participants had previously participated in yoga training 
 courses , the findings reported by duncan and bardacke might have been affected by 
 participants previous experiences .   recently , a study was conducted on 39 women with major depression disorder ( 27 women ) and 
 bipolar - spectrum disorder ( 12 women ) in order to assess the effects of an eight - week 
 mindfulness - based cognitive therapy .
the participating women either were pregnant ( 12 
 individuals ) , had planned for pregnancy ( 11 individuals ) , or were in their postnatal period 
 ( 26 ones ) .
the findings showed that mindfulness - based cognitive therapy significantly 
 alleviated major depression disorder and had no significant effect on bipolar - spectrum 
 disorder .  
as mentioned earlier , depression and anxiety are comorbid conditions.therefore , the effectiveness of treatments can 
 be enhanced through adopting treatment strategies which can alleviate both of them .
this is 
 of paramount importance to pregnant women because simultaneous and rapid alleviation of 
 mother s depression and anxiety can reduce the negative effects of these two conditions on 
 fetus .  
mindfulness is rather a new concept in psychotherapy and has attracted therapists and 
 researchers attention in recent years .
it teaches people to focus on the present moment , 
 identify their own experiences , cultivate a non judgment attitude , accept their experiences , 
 reduce reactivity towards them , and effectively manage them .  
mindful attention requires preventing habitual reactions and creating non judgment 
 attitude towards , acceptance of , and detach from internal experiences .  
people who receive cbt need executive functions such as keeping attention , deliberate 
 actions , affect regulation , behavior control , problem solving , and motivation in order to 
 get the most from cbt .
executive 
 functions are mainly performed in the prefrontal area of the brain . when people access their executive functions 
 and use them for self - regulation , their distress is reduced . on the other hand , people 
 suffering from depression experience distress due to having limited access to their 
 executive functions .
accordingly , during sensitive courses of emotional excitements such as 
 pregnancy , executive functions can be used and promoted for alleviating depression and 
 anxiety .
the effectiveness of 
 cognitive behavior therapies can be enhanced through integrating mindfulness - based executive 
 functions . moreover ,
emotional 
 dysregulation are related to the dysfunction of the front limbic region , i.e. where 
 prefrontal activity is reduced and amygdale is stimulated .
evidence shows that integrating cbt with mindfulness - based interventions produces more 
 significant results compared with single therapy . great effectiveness of 
 mindfulness - based interventions has required clinicians to use these interventions to 
 enhance the effectiveness of their treatments .
micbt is one of these interventions and 
 further investigations are still needed for assessing and confirming their 
 effectiveness .  
one of the study limitations was related to lack of 
 background knowledge about the study subject matter due to its novelty .  
 mindfulness interventions are among the most appropriate and effective strategies for 
 managing psychological problems . 
 nonetheless , given their novelty , few studies have been conducted so far on these 
 interventions .   moreover , we could not retrieve a random sample of pregnant women from all healthcare 
 centers located in kashan , iran .
we also were not able to assess the long - term effects of 
 micbt in the postnatal period .
future studies are recommended to perform long - term follow - up 
 assessments in order to evaluate the effects of micbt on different pregnancy - related 
 outcomes such as emotional well - being , postnatal depression , and mother - infant 
 relationships .
  the results of this study indicated that micbt is effective in alleviating pregnant 
 women s depression and anxiety even for one month after implementing it .
  we wish to thank the research deputy of kashan university of medical sciences , kashan , 
 iran , for financial supporting of this project .
moreover , authors are grateful to staffs of 
 akramian , taleghani , and ketabchi health centers , and dr .
 
 introduction : pregnancy can be associated with different 
 psychological problems such as depression and anxiety . 
 these problems are often neglected 
 and left untreated . this study aimed to examine the effect of mindfulness - integrated 
 cognitive behavior therapy on depression and anxiety among pregnant women . 
 
 methods : a convenient sample of 80 pregnant women were 
 selected . 
 participants were randomly allocated to either the experimental or the control 
 groups . 
 participants in the experimental group received mindfulness - integrated cognitive 
 behavior therapy while women in the control group only received routine prenatal care 
 services . a demographic questionnaire , the edinburgh postnatal depression scale , and the 
 beck anxiety inventory were used for data collection . 
 descriptive statistics measures such 
 as frequency , mean , and standard deviation as well as the repeated - measures analysis of 
 variance test were used for data analysis . 
 
 results : after the study intervention , the mean scores of 
 anxiety and depression in the experimental group were significantly lower than the control 
 group . 
 
 conclusion : mindfulness - integrated cognitive behavior 
 therapy can significantly alleviate pregnant women s depression and anxiety 
 . so 
 implementation of this method alongside with other prenatal care services is 
 recommended . 