“Critical appraisal Journal” of Affective Disorders Review article

The effect of music, massage, yoga and exercise on antenatal

depression: A meta-analysis
M a te ri T ug as E le kt if

D os en P em b i mb in g :

Disusun Oleh :
1. Diya amanatur rohmah ( 202108005)
2. Umrotul Ustadah (202108006)
3. Nur Rahmawati (202108019)
4. Dinna Pinta Kori'ah (202108020)
5. Mieta Khusna Istiana (202108028)
6. Duwi Sariasih (202108034)
7. Nihayatur rosyidah ( 202108038)

PROGRAM STUDI S1 KEBIDANAN

FAKULTAS ILMU KESEHATAN
UNIVERSITAS BINA SEHAT PPNI KABUPATEN MOJOKERTO
TAHUN 2021
 KATA PENGANTAR

Segala puji syukur saya panjatkan kepada Tuhan Yang Maha Esa yang telah
memberikan rahmat dan hidayahNya sehingga kelompok dapat menyelesaikan tugas
Elektif Dalam Kebidanan tentang “Critical appraisal Journal” of Affective
Disorders Review article The effect of music, massage, yoga and exercise on
antenatal depression: A meta-analysis
Semoga critical appraisal dapat bermanfaat bagi pembaca, khususnya untuk
penulis, kritik dan saran dari pembaca akan sangat perlu untuk memperbaiki dalam
penulisan critical apprasial ini. Serta semoga critical appraisal ini tercatat menjadi
motivator bagi penulis untuk penulisan critical apprasial yang lebih baik dan
bermanfaat. Aamiin.

Mojokerto, 26 November 2022

Penulis

ii
 DAFTAR ISI
Halaman Cover.............................................................................................
Kata Pengantar.............................................................................................ii
Daftar Isi.......................................................................................................iii
Bab 1 Pendahuluan
1.1 Latar Belakang.............................................................................1
1.2 Tujuan .........................................................................................2
1.3 Manfaat .......................................................................................3
Bab 2 Pembahasan
2.1 Telaah Jurnal Dikaitkan Dengan Teori Konseling……………4
Bab 3 Penutup
3.1 Kesimpulan .................................................................................8
3.2 Saran............................................................................................8
Daftar Pustaka..............................................................................................9

iii
 BAB 1
PENDAHULUAN
1.1 Latar Belakang
Depresi adalah gangguan mental yang paling umum di antara
populasi umum, yang prevalensinya pada wanita dua kali lebih tinggi
daripada pria, dengan wanita yang melahirkan anak berisiko sangat tinggi.
Depresi prenatal mempengaruhi 20,7 persen wanita di seluruh dunia
sebenarnya mungkin lebih tinggi karena sering terlewatkan, dengan wanita
menganggap depresi sebagai bagian biasa dari respons kehamilan.
Depresi prenatal dikaitkan dengan kelahiran prematur, berat lahir
rendah dan skor Apgar, serta gangguan perkembangan kognitif, emosional
dan perilaku. Selanjutnya, depresi prenatal dianggap sebagai salah satu
prediktor depresi postnatal telah mengeksplorasi efek terapi pengobatan
komplementer dan alternatif pada depresi prenatal, termasuk pengobatan
herbal, probiotik, vitamin dan mineral, dll. Meskipun metode ini mungkin
berguna, aksesibilitasnya tidak tinggi, dengan risiko tertentu, pada
kenyataannya, studi lebih lanjut dengan ukuran sampel yang lebih besar
diperlukan untuk mengevaluasi efektivitas dan keamanan produk
alami.Mungkin ada preferensi di antara orang hamil untuk terapi perilaku,
seperti olahraga, musik, pijat, yoga. Di bawah bimbingan staf medis, terapi
perilaku semacam ini membutuhkan perawatan diri atau kerja sama dengan
anggota keluarga sebagai mode intervensi utama, yang sederhana dan
mudah dioperasikan. Mereka dapat digunakan sebagai sarana untuk
mempromosikan pemberdayaan individu, meningkatkan keintiman dan
meningkatkan kesehatan dan kesejahteraan secara keseluruhan, dan dapat
digunakan dalam konteks privasi dan keamanan, dengan sedikit atau tanpa
potensi efek atau risiko yang merugikan, yang dapat berkontribusi pada
pencegahan. dan pengobatan wanita yang berisiko atau mengalami depresi
prenatal. Beberapa tinjauan sistematis telah mengeksplorasi dampak terapi
perilaku pada depresi prenatal, namun penelitian yang ada mendukung

1
 yoga sebagai intervensi yang efektif untuk depresi prenatal, tetapi efek
komponen yoga (seperti teknik relaksasi, mindfulness, dan latihan) atau
jenis yoga tertentu pada gejala depresi masih belum jelas.
Nakamura dkk. (2019) menunjukkan latihan itu efektif, tetapi
sebagian besar penelitian yang dimasukkan bukan Uji Coba Terkontrol
Acak (RCT), menghasilkan kualitas bukti yang rendah.Wu dkk.
(2020)mengeksplorasi pengaruh Musik Lima Elemen Pengobatan Cina
pada depresi perinatal, tetapi sebagian besar penelitian berfokus pada
postpartum, kurang evaluasi efek intervensi pada periode prenatal, dan
penelitian hanya mengeksplorasi jenis musik khusus, dan tidak
menunjukkan perbedaan dengan jenis musik lainnya.
1.2 Rumusan Masalah
Bagaimana critical dari jurnal yang berjudul “Critical appraisal
Journal” of Affective Disorders Review article The effect of music,
massage, yoga and exercise on antenatal depression: A meta-analysis

1.3 Tujuan
1.3.1 Tujuan Umum
Mengaplikasikan teori dengan critical jurnal terkait gangguan
afektif “Efek musik, pijat, yoga, dan olahraga pada depresi
antenatal: Sebuah meta-analisis”
1.3.2 Tujuan Khusus
1. Memahami critical jurnal terkait gangguan afektif “Efek musik,
pijat, yoga, dan olahraga pada depresi antenatal: Sebuah meta-
analisis”
2. Menganalisis critical jurnal terkait gangguan afektif “Efek
musik, pijat, yoga, dan olahraga pada depresi antenatal: Sebuah
meta-analisis”

2
1.3.2 Manfaat
1. Mampu memahami critical jurnal terkait gangguan afektif “Efek
musik, pijat, yoga, dan olahraga pada depresi antenatal: Sebuah
meta-analisis”
2. Mampu menganalisis aplikasi critical jurnal terkait gangguan
afektif “Efek musik, pijat, yoga, dan olahraga pada depresi
antenatal: Sebuah meta-analisis.

3
 BAB 2
PEMBAHASAN
2.1 Critical Jurnal Dikaitkan Dengan Teori Konseling
1. Judul Artikel :
“Critical appraisal Journal” of Affective Disorders Review
article The effect of music, massage, yoga and exercise on antenatal
depression: A meta-analysis
Judul pada artikel penelitian ini sangat menarik,dimana judul ini
termasuk dalam kesehatan ibu hamil yaitu tentang Efek musik, pijat,
yoga, dan olahraga pada depresi antenatal: Sebuah meta-analisis Di Cina
2. Penulis / Authors :
Yuan Zhusebuah, Ruiwangb, Xiao Mei Tangc, Qianqian Lid, Gui Hua
Xusebuah,Aixia Zhange
3. Metode Pencarian :
Metode pencarian literature melalui journal homepage:
www.elsevier.com/locate/jad

4
5
4. Critical Of Introduction
a. Place and Time:
Penelitian ini dilakukan untuk meriview atau mengulas critical
jurnal “of Affective Disorders Review article The effect of music,
massage, yoga and exercise on antenatal depression: A meta-
analysis “ yang dilakukan di Cina pada tahun 2021
b. Population :
Sesuai dengan panduan Preferred Reporting Items for Systematic
Review and Meta-analysis (PRISMA) (Moher et al., 2009) dan
Buku Pegangan Cochrane (Higgins JPT, 2021).
c. Sample :
24 studies included in meta - analysis
5. Critical Of Objective
Tujuan dari penelitian ini untuk membandingkan keempat
metode terlebih dahulu untuk mengeksplorasi cara yang paling efektif.
Kami juga membandingkan berbagai jenis yoga dan musik, untuk
menemukan jenis intervensi yang paling efektif. Bahwa pada hasil
Penelitian ini menemukan bukti rendah hingga sangat rendah bahwa
yoga, olahraga, musik, dan pijat dapat mengurangi depresi antenatal.
Diantaranya, musik mungkin merupakan intervensi yang paling efektif,
dan yoga terpadu selain yoga sederhana akan memperbaiki depresi
prenatal.
6. Critical Of Material And Methods
a. Variable :
Variabel tergantung dalam studi itu inisiasi seksual. Berikut ini
adalah variabel independen: Depresi, Kehamilan, Latihan Yoga,
Pijat, Musik, Tinjauan sistematis, dan Meta-analisis.
b. Material & Method :
Pencarian literatur yang komprehensif dilakukan melalui enam
database pada uji coba terkontrol secara acak (RCT). Efek dirangkum
oleh model efek acak menggunakan perbedaan rata-rata dengan
interval kepercayaan 95%. Kualitas bukti dinilai menggunakan
kriteria Grading of Recommendations Assessment, Development,
and Evaluation (GRADE).

6
 Meta-analisis ini dilakukan mengikuti panduan Preferred
Reporting Items for Systematic Review and Meta-analysis
(PRISMA) (Moher et al., 2009) dan Buku Pegangan Cochrane
(Higgins JPT, 2021), yaitu melalui :
1) Sumber data dan penelusuran
2) Inklusi dan pengecualian
3) Garis besar studi
4) Penilaian resiko bias
5) Ekstraksi data
6) Penilaian ukuran efek keseluruhan
7) Bandingkan perkiraan ringkasan dari beberapa subgrub
8) Penilaian kualitas bukti
9) Penilaian bias publikasi

7. Critical Of Result
a. Are the result of the study valid ?
Hasil yang dipaparkan dalam penelitian sesuai dengan judul dan tujuan
penelitian awal namun pada abstrak ataupun isi tidak ada pemertegas
akan tujuan dari penelitian riview artikel diatas.
b. What are the result ?
Penelitian ini menemukan bukti rendah hingga sangat rendah
bahwa yoga, olahraga, musik, dan pijat dapat mengurangi depresi
antenatal. Diantaranya, musik mungkin merupakan intervensi yang
paling efektif, dan yoga terpadu selain yoga sederhana akan
memperbaiki depresi prenatal. Pengaruh Musik Lima Elemen
Pengobatan Cina mungkin lebih baik daripada musik biasa.
8. Critical Of Discussion
Depresi prenatal mempengaruhi 20,7 persen wanita di seluruh
dunia, dikaitkan dengan kelahiran prematur, berat lahir rendah dan
skor Apgar, serta gangguan perkembangan kognitif, emosional dan
perilaku. dilakukan tinjauan sistematis dan meta-analisis untuk
mengambil bukti terbaru dan terbaik tentang musik, pijat, yoga, dan
olahraga dalam pencegahan dan pengobatan depresi prenatal, dan
untuk membandingkan keempat metode terlebih dahulu untuk
mengeksplorasi cara yang paling efektif. Kami juga membandingkan
berbagai jenis yoga dan musik, untuk menemukan jenis intervensi
yang paling efektif.

7
9. Critical Of Conclusion
Berdasarkan hasil penelitian dan pembahasan maka dapat diambil
kesimpulan Penelitian ini menemukan bukti rendah hingga sangat rendah
bahwa yoga, olahraga, musik, dan pijat dapat mengurangi depresi antenatal.
Diantaranya, musik mungkin merupakan intervensi yang paling efektif, dan
yoga terpadu selain yoga sederhana akan memperbaiki depresi prenatal.
Pengaruh Musik Lima Elemen Pengobatan Cina mungkin lebih baik daripada
musik biasa. RCT yang dirancang lebih ketat dijamin untuk dukungan lebih
lanjut.
10. Disclosure :
Para penulis sendiri bertanggung jawab atas isi dan penulisan artikel.
Guihua Xu: Konseptualisasi, Metodologi, Administrasi proyek,
Penulisan - ulasan & penyuntingan. Aixia Zhang: Konseptualisasi,
Sumber Daya, Penulisan - ulasan & penyuntingan. Yuan Zhu: Kurasi
data, Analisis formal, Penulisan - draf asli. Rui Wang: Kurasi data,
Analisis formal, Penulisan - draf asli. Qianqian Li: Kurasi Data,
Analisis Formal, Metodologi. Xiaomei Tang: Investigasi, Sumber
Daya, Perangkat Lunak.
11. References :
a. Pemakaian referensi lebih banyak yang menggunakan kurang
dari 10 tahun, baik dari buku ilmiah maupun artikel atau
jurnal.
b. Penulisan daftar pustaka sesuai dengan standart internasional
dengan tanpa menuliskan gelar autor
c. Penggunaan literature dalam penelitian ini cukup banyak
sehingga dapat memperluas pengetahuan tentang bahasan
topic yang dibahas.

8
 BAB 3
PENUTUP
3.1 Kesimpulan
Berdasarkan hasil penelitian dan pembahasan maka dapat diambil
kesimpulan Penelitian ini menemukan bukti rendah hingga sangat rendah bahwa
yoga, olahraga, musik, dan pijat dapat mengurangi depresi antenatal. Diantaranya,
musik mungkin merupakan intervensi yang paling efektif, dan yoga terpadu selain
yoga sederhana akan memperbaiki depresi prenatal. Pengaruh Musik Lima
Elemen Pengobatan Cina mungkin lebih baik daripada musik biasa. RCT yang
dirancang lebih ketat dijamin untuk dukungan lebih lanjut.
3.2 Saran
Alangkah baiknya apabila penelitian riview diatas bisa lebih
diperjelas akan tujuan dari penelitian tersebut. Serta diakhir bisa lebih
diberikan saran mengenai literatur yang diriview kembali.
.

9
 DAFTAR PUSTAKA

journal homepage: www.elsevier.com/locate/jad

10
 Journal of Affective Disorders 292 (2021) 592–602

Contents lists available at ScienceDirect

Journal of Affective
Disorders

Review article

The effect of music, massage, yoga and exercise on antenatal

depression: A meta-analysis
a, 1 b, 1
Yuan Zhu , Rui Wang , Xiaomei Tang c, Qianqian Li d, Guihua Xu a,*
, AiXia Zhang e,*

a
School of Nursing, Nanjing University of Chinese Medicine, Jiangsu, China
b
School of Nursing, Nanjing Medical University, Jiangsu, China
c
Department of Nursing, Xinghua Maternity and Child Healthcare centre, Taizhou, Jiangsu, China
d
Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
e
Department of Nursing, Women’s Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Jiangsu, China

A R T I C L E I N F
O A B S T R A C T

Keywords: Background: Prenatal depression affects 20.7 percent of women worldwide, which was associated with
Depression preterm birth, low birth weight and Apgar score, as well as cognitive, emotional and behavioral
Pregnancy development disorders. We conducted a systematic review and meta-analysis to retrieve the latest and
EXercise best evidence about music, massage, yoga and exercise in the prevention and treatment of prenatal
Yoga
depression, and to preliminarily compare the four methods to explore the most effective means. We also
Massage
compared different types of yoga and music, in order to find the most effective type of intervention.
Music
Methods: A comprehensive literature search was carried out through siX databases on randomized
Systematic
review Meta- controlled trials (RCTs). Effects were summarized by a random effects model using mean differences
analysis with 95% confidence intervals. Evidence quality was assessed using the Grading of Recommendations
Assessment, Development, and Evaluation (GRADE) criteria.
Results: This research found low to very low evidence that yoga, exercise, music and massage could
reduce antenatal depression. Among them, music may be the most effective intervention, and
integrated yoga other than simple yoga would improve prenatal depression. The effect of Chinese
Medicine Five Element Music may be better than ordinary music.
Conclusion: It is important to support prenatal depression patients to make informed decisions about
their behavior therapy.

1. Introduction
Depression is the most common mental disorder among
the general population, of which the prevalence in women is
twice as high as in men, with childbearing women at
particularly high risk (Simavli et al., 2014). Prenatal
depression affects 20.7 percent of women worldwide (Yin et
al., 2021), actually it may be even higher as it is often
missed, with women considering depression as a usual
part of pregnancy response (Austin et al., 2013). Prenatal
depression was associated with preterm birth, low birth
weight and Apgar score, as well as cognitive, emotional and
behavioral development disorders. (Eastwood et al., 2017;
Lefkovics et al., 2014; Sanchez et al., 2013). Furthermore,
prenatal depression is regarded as one of the predictors of
postnatal depression (Biaggi et al.,
2016). Taken together, performing intervention for prenatal
depression is the top priority.
For prevention and treatment of prenatal depression,
many different options exist for pregnant women.
Psychological choice is usually rec- ommended as a first-
line prevention and treatment (Austin et al., 2013), however,
women may fail to achieve therapy, including time
restraints, absence of childcare, and stigma (Dennis and
Chung-Lee, 2006; Goodman, 2009; Sockol et al., 2011).
Although anti-depressant medi- cation has curative effect
on moderate to severe depression, the treat- ment tends to
be discontinued since women often feel worried about the
development of the fetus (Goodman, 2009), and the safety of
anti-depressant medication has not well-proved, which cannot
eliminate risks of fetal exposure (Boath et al., 2004). In
addition, some studies

11
 * Corresponding authors.
E-mail addresses: guihua.Xu@njucm.edu.cn (G. Xu), zhangaiXia@njmu.edu.cn (A. Zhang).
1
Yuan Zhu and Rui Wang Contributed equally to the work.

https://doi.org/10.1016/j.jad.2021.05.122
Received 1 March 2021; Received in revised form 2 May 2021; Accepted 31 May 2021
Available online 8 June 2021
0165-0327/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

12
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

(Deligiannidis and Freeman, 2014; Smith et al., 2019) have Library, PubMed, CNKI, WanFang, Web of Science, Embase
explored the effect of complementary and alternative Database from inception to April 2021. Medical subject
medicine therapies on prenatal depression, including herbal heading (MeSH) terms and text
remedies, probiotics, vitamins and min- erals, etc. Although words were used as follows: (“antepartum” OR “ante-partum”
these methods may be useful, the accessibility is not high, OR “prenatal” OR “pre-natal” OR “antenatal” OR “ante-natal”
with certain risks, in fact, further studies with larger OR “maternal ” OR “perinatal” OR “peri-natal” OR
sample sizes are needed to evaluate the effectiveness and “peripartum” OR “peri-partum” OR “pregnan*” OR
safety of natural products (Curry et al., 2019; Nishi et al., “prepartum” OR “pre-partum” OR “mother*”) AND (“music”
2019). OR “exercise” OR “yoga” OR “massage” OR “physical activit*”)
There may be a preference among pregnant persons for AND (“depression” OR depressive disorder” OR “depress*”).
behavioral therapy, such as exercise, music, massage, yoga. Specific details of search algorithm are available in
Supplementary material 1. In
Under the guidance of medical staff, this kind of behavioral
addition, we also searched references and citations from
therapy takes self-care or cooper- ation with family
included studies, relevant reviews, or meta-analyses.
members as the main intervention mode, which is simple
and easy to operate. They can be used as means to promote 2.2. Inclusion and exclusion
in- dividual empowerment, improve intimacy and promote
overall health and well-being, and can be used in the Studies would be enrolled in the meta-analysis if they met
context of privacy and safety, with little or no potential the PICOS criteria as follows. P(Participants): pregnant
adverse effects or risks, which may contribute to the women, including women
prevention and treatment of women at risk or experience
prenatal depression (Woolhouse et al., 2016).
Some systematic reviews (Gong et al., 2015; Hall et al.,
2020b; Nakamura et al., 2019; Wu et al., 2020) have
explored the impact of behavioral therapy on prenatal
depression, however, the existing re- searches have
shortcomings. Gong et al. (2015) supported yoga as an
effective intervention for prenatal depression, but the effects
of com- ponents of yoga (such as relaxation techniques,
mindfulness and prac- tice) or specific types of yoga on
depressive symptoms remain unclear. Nakamura et al.
(2019) showed exercise was effective, but most of the studies
included are not Randomized Controlled Trials (RCTs),
resulting in low quality of evidence. Wu et al. (2020)
explored the influence of Chinese Medicine Five Element
Music on perinatal depression, but most of the studies
focused on postpartum, lacking the evaluation of inter-
vention effect in prenatal period, and the study only
explored a special type of music, and did not show the
difference with other types of music. Hall et al. (2020b)
explored the effect of massage on prenatal depres- sion, but
the sample size was small. All the studies above did not
grade the quality of evidence using the Grading of
Recommendations Assess- ment, Development, and
Evaluation (GRADE) criteria. Therefore, our study attempts
to retrieve the latest and best evidence about music,
massage, yoga and exercise in the prevention and treatment
of prenatal depression, and to preliminarily compare the
four methods to explore the most effective means. We also
compared different types of yoga and music, in order to find
the most effective type of intervention.

2. Methods

This meta-analysis was performed following the Preferred

Reporting Items for Systematic Review and Meta-analyses
(PRISMA) guidelines (Moher et al., 2009) and Cochrane
Handbook (Higgins JPT, 2021).

2.1. Data sources and searches

A comprehensive search was performed on Cochrane

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Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

with suspected or confirmed depression; I(Intervention):
music, exer- cise, massage, and yoga, performed during
pregnancy; C(Comparison): waiting-list control, usual care,
or active controls (e.g, health educa- tion); O(Outcomes):
antenatal depression was focused on as the primary outcomes
of interest, secondary outcome was antenatal anxiety.
S(Study design): We included RCTs, which are the gold
standard for clinical effectiveness studies. Studies would
be excluded if: (1) depression caused by alcohol abuse or
non-alcoholic psychoactive substances; (2) depressive
episodes caused by somatic diseases; (3) not containing
available outcome information; (4) not written in Chinese or
English; (5) unpublished documents.
2.3. Study outline
After removing duplications, all titles and abstracts were
screened according to eligibility criteria by two reviewers
(ZY and WR) inde- pendently, the third reviewer (LQQ) was
invited to discuss and decide on the controversial ideas.
Next, the full texts of potentially eligible were read. Finally,
studies containing useful information were selected for
meta-analysis. The inter-rater, coefficient of internal
consistency(kappa coefficient) (Landis and Koch, 1977) is
an important index to evaluate the consistency of
judgment, kappa 0.75 shows good consistency, 0.75
>kappa 0.4 shows general consistency, kappa < 0.4
shows poor
consistency.
2.6. Assessment of overall effect size
Statistical analyses were conducted in Review Manager
(RevMan V.5.3; Cochrane Collaboration, OXford, UK). We
base our analyses on the between-group difference in
change scores, if only the baseline and post intervention
mean and standard deviation were described in the original
study, we converted the original data according to the
Cochrane manual (Higgins JPT, 2021). For continuous
outcomes, when the mea- surement method of the same
intervention is identical, the weighted mean
difference(WMD) should be selected, otherwise, the
standardized mean difference(SMD) should be selected. The
above analyses were considered with 95% confidence
intervals (CIs). In self-management
model, an effect size<0.2 is regarded as a small effect,
0.2-0.5 is
≥
≥

2.4. Assessment of risks of bias

Two reviewers(ZY and WY) independently assessed the risk

of bias of included studies using the Cochrane Risk of Bias
Tool (Higgins JPT, 2021), which included the following
rating items: randomization pro- cedure, generating
random sequence, allocation concealment, blinding of
implementers and participators, blinding of outcome
evaluator, incomplete outcome information, selective
reports, and other biases. In Cochrane collaborative
network, the risk assessment of each evaluation item is
described in detail, and the specific criteria are divided into
low risk, high risk and unclear risk (Higgins JPT, 2021).
For self-management programs (Lorig, 2003), it is usually
hard to blind participants or health-care providers,
therefore, we considered blinding of outcome assessors as
adequate. The kappa coefficient of consistency between
evaluators was calculated and third reviewer (LQQ) was
invited to discuss and decide on the controversial items.

2.5. Data extraction

With a standardized form, two investigators (ZY and WR)

indepen- dently extracted data including: author, year of
publication, country where the study was performed,
gestational weeks, sample size, inclu- sion criteria,
intervention modes, length, frequency,and duration,
measurement time, and reported outcomes. It must be
strongly emphasized that we preferred to extract the
outcome data from the Intention To Treat analysis (ITT) if one
study used multiple data analysis methods.

59
Y. Zhu et al.
moderate, and>0.5 is large (Saragiotto et al., 2016).
Statistical hetero- geneity of the intervention effects was
assessed by using the chi-squared test, corresponding to a
P value and I2 statistic, the random-effects model was
adopted while I2>50%, or the fiXed-effects model was
adopted.
2.7. Compare summary estimates of different subgroups
We also conducted subgroup analyses according to the
different characteristics of the included studies. For the
types of yoga, there are mainly two categories: integrated
yoga (including meditation, breath, mindfulness, et al.) and
simple yoga (only including easy postures). For the types of
music, according to whether the formation of the music has
theoretical system, we divided it into Chinese Medicine Five
Element Music and ordinary music. We would like to know
whether there is any difference between the types of some
specific interventions on improving depression and anxiety.
We compared summary estimates of different subgroups
by observing whether the 95% CI of the subgroups are
overlapped. If there is no overlap, it can be considered that
the difference is statistically significant (Cumpston et al.,
2019).
2.8. Assessment of evidence quality
The overall quality of the evidence for each outcome was
rated by two reviewers(ZY and WR) using the Grading of
Recommendations Assessment, Development, and
Evaluation (GRADE) criteria (Brozek et al., 2009). In the
system, according to five domains: limitations of
59
Journal of Affective Disorders 292 (2021) 592–
602
design, inconsistency, indirectness, imprecision, publication
bias, qual- ity of the evidence varies from four levels: high
quality, moderate quality, low quality, and very low quality
(Brozek et al., 2009). The between-rater kappa was
calculated.
2.9. Assessment of publication bias
We explored the publication bias by drawing funnel plots,
for a single intervention, if the number of studies is more
than or equal to 10, we will conduct funnel plot (Egger et
al., 1997).
3. Results
3.1. Search process
Fig. 1 presents the search process. A total of 2183
studies were identified through siX databases. After
removing duplicates, remaining 2183 studies were screened
by title and abstract, resulting in 92 studies for a full-text
review. Among them, 72 studies were excluded for several
reasons. Also, by tracing the references of the full text, we
have included four new articles. Finally, 24 included studies
contained 26 useful outcome data were included in our
meta-analysis. During the stages of screening
titles/abstracts and full texts, the kappa coefficients
were
85.4%(P<0.001) and 82.1(P<0.001), respectively, which
indicated that
the opinions of the raters on the literature were almost
identical.
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

Fig. 1. PRISMA flow diagram.

59
Y. Zhu et al.
3.2. Risks of bias
The assessment of risk of bias is illustrated in
Supplementary mate- rial Fig. 1. Among all studies, 14
studies had low risk of random sequence generation and 10
studies were assessed as unclear risk due to insufficient
reporting. Seven studies were assessed at low risk with
allocation concealment and 17 studies had unclear risk
because of insufficient reporting. Eight studies had low risk
of blinding of outcome assessment and 16 studies were
assessed as unclear risk. As for
“incomplete outcome data”, 10 studies had low risk and 14
studies had
unclear risk because of insufficient reporting. All studies
were assessed as unclear risk at reporting bias and other
bias due to the lack of necessary information. The kappa
coefficients of=seven items ranged from 100.0% (P 0.003)
and 75.8% (P 0.004), illustrating substantial or almost
perfect between-rater agreements. The 24 RCTs showed
moderate quality in risk of bias.
3.3. Study characteristics
The characteristics of included studies are presented in
Table 1. There were seven from China, eight from USA, two
from UK, and one from each of the following: India, Saudi
Arabia, Spain, Colombia, Australia, Iran, and one from
English speaking country. Thirteen included studies had
been conducted since 2015.
The sample size of the included studies ranged from 20
to 282, and the intervention started at 9 to 34 weeks of
gestation. The characteristics of participants varied in
mental state and judgement criteria from study to study.
For details, please refer to Table 1.
The antenatal depression was measured in 24 studies
using the short form Depression: Anxiety and =Stress Scale
(DASS-21) (n 1), the Center for Epidemiological = Studies-
Depression Scale (CES-D) (n 9), the Phys-
ical Health Questionnaire-9 (PHQ-9) = (n 1), the Hospital
Anxiety
Depression Scale (HADS) = (n 1), the Self-Rating Depression
= (SDS) (n 1), the Hamilton Depression Scale (HAMD) (n 2)
Scale
=
and the Edinburgh Postnatal Depression Scale (EPDS) (n 9),
while antenatal anxiety was assessed in 16 studies using
the short form Depression, the Hamilton
Anxiety Scale (HAMA) (n=2), the Self-Rating Anxiety Scale
(SAS) (n=2),
the State and Trait Anxiety Inventories (STAI) (n=11). All
studies were
measured immediately after intervention except one study
at one week
after intervention.
Interventions were grouped into massage therapy = (n 4),
=
music therapy = yoga (n 10) and exercise (n 4) with
(n 6),
control groups that=included other cares differing from their
corresponding interventions such as standard care,
perinatal health education, parenting education attention
control, social support and home-based program. The
details of interventions were discussed in Table 1.
3.4. Quantitative analysis
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Journal of Affective Disorders 292 (2021) 592–
602
Compared with control group, a significant moderate effect was
found in favour of the yoga on antenatal depression [SMD = -
0.45, 95%CI –0.69,
-0.22, p = 0.0002, I2 = 43%, Chi2 = 15.89, p = 0.07] (Fig. 2).
3.4.1.2. Massage. Of the 24 studies, four studies (Field et al.,
2009a, 2009b, 2008; Hall et al., 2020a) including five available
data were included on massage intervention, they were carried
= weeks, weekly (n 3) or twice/week (n 2) and 20
out for 5-14
minutes for each interven- tion. Three studies were applied by
partners while the remains were performed by therapists. The
massage was administered in the following sequence with women
in a side-lying position (each side for 10 min, total session for 20
min): (1) head and neck; (2) back; (3) arms; (4) hands; (5) legs
and (6) feet. Moderate pressure was recommended during
massage therapy. Compared with control group, a significant
moderate effect was
found in favour of the massage on antenatal depression
[SMD = -0.43, 95%CI -0.79, -0.06, p = 0.02, I2 = 55%, Chi2
= 8.86, p = 0.06] (Fig. 2).
3.4.1.3. Music. Of the 24 studies, siX studies including seven
available data were included on music interventions (Chang et
al., 2008; Jabbari et al., 2020; Nwebube et al., 2017;Li et al.,
2016a, 2016b; Liu et al., 2017), they were applied for
=
multiple weeks (3-12weeks), twice/day and siX days/week (n
3) or daily (n 3). The music intervention in one study lasted 20
minutes while four studies lasted 30 minutes, and the duration
was not reported in one study. Compared with control group, a
significant large effect was found in favour of the music on
antenatal depression [SMD = -1.35, 95%CI -1.87, -0.84, p
<0.00001, I2 = 92%,
Chi2 = 73.05, p <0.00001] (Fig. 2).
3.4.1.4. Exercise. Of the 24 studies, four studies (Bose, 2015;
Perales et al., 2015; Robledo-Colonia et al., 2012; Yan, 2019)
were included on exercise intervention, they were applied for
30-60 minutes each time, three times/week, lasting for 4-31
weeks. The type of exercise in one study was dancing for birth,
with moderate intensity. The contents of exercise in other three
studies were consistent including walking (10 min), aerobic
exercise (30 min), stretching (10 min), and relaxation (10 min),
with moderate to vigorous intensity. Compared with control
group, a significant large effect was found in favour of the
exercise on
antenatal2 depression [SMD = -0.66, 95%CI -1.00, -0.31, p =
0.0002, I 2
= 69%, Chi = 9.79, p = 0.02] (Fig. 2).
3.4.1. Effects of the interventions on antenatal depression
24 RCTs including 26 available data were included for
meta-analysis on interventions on antenatal depression.
Considering I2>50%, the random effects model was
adopted. Compared with control group, a
significant large effect was found in favour of the
intervention group on antenatal depression [SMD = -0.74,
95%CI -0.98, -0.5, p <0.00001, I2 = 86%, Chi 2 = 176.60,
p<0.00001] (Fig. 2).
3.4.1.1. Yoga. Of the 24 studies, 10 trials ((Davis, 2014);
Bershadsky et al., 2014; Field et al., 2013, 2012; Mitchell et al.,
Y. Zhu et al.
2012; Newham et al., 2014; Satyapriya et al., 2013; Uebelacker
et al., 2016; Shu et al., 2019; Zhang et al., 2016) were included
on yoga intervention, the intervention was applied for 6-32
weeks with certified prenatal yoga instructor
teaching, weekly (n=5) or twice/week (n=2) or daily (n=1),
and not reported(n=2). The duration of each time was 20
min (n=3), 60 min (n=2), 75 min (n=3), 90 min (n=1),
and not reported in one study.
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Journal of Affective Disorders 292 (2021) 592–
602
3.4.2. Compare summary estimates of different subgroups on depression
As shown in Table 2, it can be seen that the 95%
confidence interval of the effect size of music and yoga
intervention has no overlap, the same to music and
massage intervention, so the effect of music intervention is
significantly better than that of yoga and massage. The 95%
confidence interval of music and exercise has overlap, it can
be considered that the effect of music intervention maybe
better than that of exercise.
3.4.3. Effects of the interventions on antenatal anxiety
15 RCTs containing 17 useful data examined the effect of
in- terventions on antenatal anxiety. Considering I2>50%,
the random ef- fects model was adopted. Compared with
control group, a significant
large effect was found in favour of the intervention group on
antenatal anxiety
= [SMD -1.06, 95%CI -1.53, = -0.58,
p<0.0001, I2 95%, Chi2 =
297.86, p<0.00001] (Fig. 3).
3.4.3.5. Yoga. Of the15 RCTs, siX studies (Field et al., 2013,
2012; Newham et al., 2014; Satyapriya et al., 2013; Shu et al.,
2019) were included on yoga intervention. Compared with
control group, a signif-
icant large effect was found in favour of the yoga on
antenatal
= anxiety [SMD -0.87, 95%CI
= -1.52,
= -0.23, p 0.008,
I2 89%, Chi2 43.87, =
p<0.00001] (Fig. 3).
3.4.3.6. Massage. Of the15 RCTs, four studies (Field et al.,
2009a, 2009b, 2008; Hall et al., 2020a) were included on
massage intervention.
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

Table 1
Characteristics of the included
studies.
Inclusion Criteria Intervention Modes,Length,Frequency,and DurationMeasure time Main outcome:
Authors.Year,Country Gestational
weeks
(weeks),Sample size Treatment group Control outcome
(randomized)/ group measures
Sample size
(analyzed)

(Hall et al.,
28-32,44/ 24 self-reported: Partner delivered Self-directed immediately antenatal
2020a),
women with EPDS massage lasting 20 stress after depression:DAS
Australia ≥ 13 or positive minutes per week for 5- management intervention S- 21
score in 14 weeks training program
question 10 were
excluded
Field et al., 2008, USA 20,57/47 depressed women Massage therapy lasting standard care antenatal
20 depression:CES-
minutes twice a week for immediatel D antenatal
12 weeks y after anxiety: STAI
interventio
n
Field et al., 16-20,200/149 depressed women Massage therapy lasting standard care immediately antenatal
2009b, USA 20 after depression:CES-
minutes twice a week for intervention D antenatal
12 weeks anxiety: STAI
Field et al., 18-22,112/43 depression: SCID Massage therapy with Interpersonal immediately antenatal
2009a, USA group Psychotherap after depression:CES-
Interpersonal y group intervention D antenatal
Psychotherapy lasting 20 anxiety: STAI
minutes per week for five
weeks
Liu et al., 2017, China 28-32,100/100 pregnant women Chinese Medicine Five standard care immediately antenatal
Element Music lasting after depression:SDS
30 minutes twice/day intervention antenatal
and siX days/week for anxiety: SAS
siX weeks
Nwebube et al., NR,222/36 pregnant women music therapy lasting standard care immediately antenatal
2017, English 20 minutes daily for 12 after depression:EPD
speaking weeks intervention S antenatal
countries anxiety: STAI
(Jabbari et al., 25-28,168/165 self-reported: Holly Quran Voice With standard care one week antenatal
2020)., 2017, UK except those or Without Translation after depression:EPD
EPDS≥13 or history daily for three weeks intervention S antanatal
of anxiety: S-STAI
mental problems
Chang et al., 18-22 or 30-34,241/236 pregnant women music therapy lasting 30 standard care immediately antenatal
2008, China minutes daily for two after depression:EPD
weeks intervention S antenatal
anxiety: S-STAI
Li et al., 2016a, China 20-27,120/120 pregnant women Chinese Medicine Five standard care immediately antenatal
Element Music lasting after depression:HAM
30 minutes twice/day intervention D antenatal
and seven days/week anxiety: HAMA
for two weeks
Li et al., 2016b, China 20-27,240/240 pregnant women Chinese Medicine Five antenatal
Element Music lasting standard care immediately depression:HAM
30 minutes twice/day after D antenatal
and seven days/week intervention anxiety: HAMA
for two weeks
Zhang et al., 18-22,164/77 self-reported: yoga lasting 75 minutes standard care immediately antenatal
2016, China CES- D>16 twice a week for eight after depression:CES-
weeks intervention D
(Uebelacker et 12–26,20/18 self-reported: yoga lasting 75 minutes perinatal immediately antenatal
al., 2016), USA 7<QIDS per week for nine weeks health after depression:EPDS
<20 education intervention
Shu et al., 10-28,86/78 self- mindfulness-based yoga standard care immediately antenatal
2019, reported: lasting 60 minutes per after depression:EPD
China EPDS≥9.5 week for siX weeks intervention S antenatal
anxiety: SAS
Satyapriya et 22-24,105/96 pregnant women Integrated approach of standard immediately antenatal
al., 2013, yoga antenatal after depression:D-
India therapy (IAYT) lasting exercises intervention HADS
60 minutes daily for antenatal
12-14 weeks anxiety:
S-STAI
Field et al., 2012, USA 18-20,84/56 depression: SCID IG1: yoga IG2: standard care immediately antenatal
massage
after depression:CES-
lasting 20 minutes for
intervention D antenatal
12 weeks

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Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
anxiety: STAI 602
Mitchell et al., 20,24/24 depression: SCID yoga lasting 20 parenting immediately antenatal
2012, USA minutes twice/week education after depression:
for 12 weeks attention control intervention CES- D
Field et al., 2013, USA NR,92/79 depression: SCID yoga lasting 20 minutes social support immediately antenatal
per after depression:CES-
week for 12 weeks intervention D antenatal
anxiety: STAI
Davis et al. 2014,USA <28,46/39 self-reported:EPDS > yoga lasting 75 minutes standard care immediately antenatal
9 per week for eight weeks after depression:EPD
and/or S-STAI > 25 intervention S antenatal
and/or T-STAI > 35: anxiety: S-STAI
(continued on next page)

59
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602

Table 1 (continued )

Authors.Year,Country Gestational weeks Inclusion Criteria Intervention Modes,Length,Frequency,and Duration Measure time Main outcome:
(weeks),Sample size Treatment group Control group outcome
(randomized)/ Sample measures
size (analyzed)

Newham et al., 2014, 15-16,59/45 pregnant women yoga for eight weeks standard care immediately after antenatal
UK intervention depression:EPDS
antenatal anxiety:
S-STAI
Bershadsky et al., 15-16,51/41 self-reported: women Prenatal Hatha yoga lasting standard care immediately after antenatal
2014, USA diagnosed with 90 minutes at least once intervention depression: CES-D
depression were weekly for 10 weeks
excluded
Robledo- IG:18±2/ pregnant women exercise lasting 60 standard care immediately antenatal
Colonia et CG:17±1, 80/74 minutes after depression: CES-D
al., 2012, three times/week for 12 intervention
Colombia weeks
Perales et al., 9-12,184/176 pregnant women exercise lasting 55-60 standard care immediately antenatal
2015, Spain minutes three after depression: CES-D
times/week for 27-31 intervention
weeks
(Yan, 2019), China ≥28,282/212 self-reported: dancing for birth lasting standard care immediately antenatal
women ≥30 after depression:EPDS
diagnosed minutes three-four intervention
with times/ week for nine
depression weeks
were excluded
(Bose, 2015) ≥14 and <28,60/54 depressed women exercise lasting 40-60 home-based immediately antenatal
Saudi Arabia minutes four times/week program after depression:PHQ-
for 27-31 weeks intervention 9

Note: Abbreviations: DASS-21: the short form Depression, Anxiety and Stress Scale; CES-D: the Center for Epidemiological Studies-Depression Scale;
SCID: Structured Clinical Interview for Depression; PRAQR: the Pregnancy-Related Anxiety Questionnaire Revised; SAS: Self-Rating Anxiety Scale;
SDS: Self-Rating Depression Scale;
HADS: Hospital Anxiety Depression Scale; PHQ-9: Physical Health Questionnaire-9; STAI: State-Trait Anxiety Inventory; S-STAI: State Inventory of
State-Trait Anxiety
Inventory; T-STAI: Trait Inventory of State-Trait Anxiety Inventory; IG: Intervention Group; CG: Control Group; NR: Not Referred; HAMA: Hamilton
Anxiety Scale; HAMD: Hamilton Depression Scale.

59
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
Fig. 2. Forest plot of the effect on antenatal depression. 602

59
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

Table 2
Summary of subgroup analysis of antenatal depression.
Sub-group Category ES of intervention on prenatal
depression
ES 95% CI p values
Behavior therapy yoga -0.45(-0.69, -0.22)
massage -0.43(-0.79, -0.06)
music -1.35(-1.87, -0.84)
exercise -0.66(-1.00, -0.31)
Compared with control group, a significant mederate effect
was found in favour of the massage on antenatal anxiety
[SMD = -0.26, 95%CI -0.49,
-0.02, p = 0.03, I2 = 0%, Chi2 = 1.35, p = 0.72] (Fig. 3).
3.4.3.7. Music. Of the15 RCTs, siX studies (Chang et al., 2008;
Jabbari et al., 2020; Nwebube et al., 2017; Li et al., 2016a,
2016b; Liu et al., 2017) including seven data were included on
music interventions. Compared with control group, a
significant large effect was found in
favour of the music on antenatal depression [SMD = -1.63,
95%CI -2.48,
-0.77, p= 0.0002, I2 = 97%, Chi2 = 178.29, p<0.00001]
(Fig. 3).
3.4.4. Compare summary estimates of different subgroups on anxiety
As shown in Table 3, it can be seen that the 95%
confidence interval of the effect size of music and massage
intervention has no overlap, so the effect of music
intervention is significantly better than that of mas- sage.
The 95% confidence interval of music and yoga has overlap,
it can be considered that the effect of music intervention
maybe better than that of yoga.
into integrated yoga and simple yoga. Compare with control
group, simple yoga had no better effect [SMD = -0.48,
95%CI -1.29, 0.33, p=0.25, I2 = 81%, Chi2 = 5.26, p=0.02],
while integrated yoga reported
a large significant effects[SMD = -1.07, 95%CI -1.91, -0.23,
0.0002 p=0.01, I2
0.02 = 89%, Chi2 = 27.15, p<0.00001] (Fig. 5).
<0.00001
0.0002
3.4.6. Subgroup analyses of different types of music
For antenatal depression, siX studies including seven
data on music were divided into Chinese Medicine Five
Element Music and ordinary music group, the results
showed it was both significant in Chinese
Medicine Five Element Music group[SMD
= -1.84, 95%CI -
2 2
2.24, -1.44, =p<0.00001,= I 67%, Chi 6.00, p 0.05] and
ordinary
= music group [SMD= -0.97,
= 95%CI
= -1.58, -0.35, p
0.002, I2 89%, Chi2 26.87,=
p<0.00001] (Fig. 6).
For antenatal anxiety, the same studies above showed it
was both significant in Chinese Medicine Five Element
Music group [SMD =
-2.31, 95%CI -3.02, -1.59, p<0.00001, I2 = 88%, Chi2
= 16.75,
p=0.0002] and ordinary music group [SMD -1.11, 95%CI –
2 2
2.14,-0.09,
= = p 0.03, I 96%, Chi 68.88, p<0.00001] (Fig. 7).
The 95%= confidence interval of Chinese Medicine Five
Element Music and ordinary music has overlap, it can be
considered that the effect of Chinese Medicine Five Element
Music intervention on prenatal depression and anxiety
maybe better than that of ordinary music.
3.5. Rating the body of evidence

3.4.5. Subgroup analyses of different types of yoga Tables 4 and 5 summarize the quality of evidence. Kappa
For antenatal depression, 10 studies on yoga between raters was 100.0% (P = 0.001), indicating that
intervention were divided into integrated yoga and simple the raters were
yoga. Compare with control
group, simple yoga had no better effect [SMD
= -0.27, 95%CI Table 3
Summary of subgroup analysis of antenatal anxiety.
-0.58, =0.05, p= 0.10, I2 =
61%, Chi2 5.07, p 0.08], while
integrated yoga= reported a large =significant effect [SMD Sub-group Category ES of intervention on prenatal anxiety
ES 95% CI p values
-0.55, 95%CI -0.76, -0.34,
2 2
p<0.0001, I = 31%, Chi= 8.64, p 0.20] (Fig. 4). Behavior therapy yoga -0.87 (-1.52, -0.23) <0.0001
For antenatal anxiety, massage -0.26 (-0.49, -0.02) 0.03
= siX studies on yoga intervention
were divided music -1.63 (-2.48, -0.77) 0.0002

59
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

Fig. 3. Forest plot of the effect on antenatal anxiety.

59
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

Fig. 4. Forest plot of subgroup analysis based on the effects of two types of yoga on antenatal
depression.

Fig. 5. Forest plot of subgroup analysis based on the effects of two types of yoga on antenatal
anxiety.

Fig. 6. Forest plot of subgroup analysis based on the effects of two types of music on antenatal
depression.

completely consistent. The quality of evidence varies from and anxiety. For massage, very low quality of evidence
low to very low. For yoga, low to very low quality of evidence showed a clinically important effect on prenatal depression
showed a clinically important effect on prenatal depression and anxiety. For music, low quality of evidence showed a

59
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602
clinically important effect on prenatal depression and
anxiety. For ex- ercise, low quality of evidence showed a
clinically important effect on prenatal depression.

59
 Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602

Fig. 7. Forest plot of subgroup analysis based on the effects of two types of music on antenatal
anxiety.

Table 4
GRADE Summary of findings for self-care strategies on antenatal depression.
2
Analyses Affect estimate) No of studies no of i (%) Quality of evidence
95%( participants

Yoga -0.45)-0.69, 10 553 43 ⊕⊕○○low)High risk of bias in design; Inconsisitency(

-0.22(
Massage -0.43)-0.79, 5 318 55 ⊕○○○ very low)High risk of bias in design;
-0.06(
Inconsisitency; imprecision(
Music -1.35)-1.87, 7 942 91 ⊕⊕○○ low)High risk of bias in design;
-0.84( Inconsisitency(
EXercise -0.66)-1.00, 4 507 69 ⊕⊕○○ low)High risk of bias in design; Inconsisitency(

-0.31(

4. Discussion
Table 5
GRADE Summary of findings for self-care strategies on antenatal
anxiety.
4.1. Main findings
Analyses Affect No of no of 2
i (%) Quality of
estimate studie participant evidence
) 95%(
We conducted a comprehensive search of siX databases
s s
to provide the latest evidence that massage, music, yoga
and exercise during
Yoga -0.87)- 6 393 89 ⊕○○○ very low)High
1.52,
pregnancy contribute to the prevention and treatment of
risk of bias in
-0.23( design; prenatal depression.
Inconsisitency; In the aspect of improving prenatal depression, we found
imprecision(
that the effect of music intervention is significantly better
Massage -0.26)- 4 294 0 ⊕○○○ very low)High
0.49, risk of bias in than yoga and mas- sage, and may be better than exercise.
-0.02( design; In the aspect of improving pre- natal anxiety, the effect of
imprecision;
music intervention is significantly better than massage, and
Music -1.63)- Inconsisitency(
2.48, 7 942 97 ⊕⊕○○low)High risk
may be better than yoga.
-0.77( of bias in In the subgroup analysis of yoga, the results showed that
design; compre- hensive yoga intervention had significant effect on
Inconsisitency(
improving prenatal depression and anxiety, but simple yoga
intervention had no effect. In
Note: 95%CI: 95% confidence interval. was small. Funnel plot is showed in Supplementary material
GRADE: Grading of Recommendations Assessment, Development, and 2.
Evaluation.
the subgroup analysis of music, the effect of Chinese
Medicine Five Element Music intervention may be better than
3.6. Publication bias test
that of ordinary music on improving prenatal depression and
anxiety.
Among the four interventions, only yoga intervention
4.2. Possible mechanisms of the findings
effect on depression reached 10 articles. Funnel plot was
drawn to test the pub- lication bias of yoga intervention on
The results showed that music, massage, yoga, exercise
prenatal depression. The results showed that the
may play a positive role in improving prenatal depression
distribution of each research point was basically sym-
and anxiety. Music therapy may stimulate the cerebral
metrical, suggesting that the possibility of publication bias
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Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602
cortex in many ways, reduce preg-
nant women’s perception of the outside world and arouse
their thoughts
and emotional connection to happiness (Chang et al.,
2008). Aerobic exercise can promote the secretion of
endorphin, serotonin and norepinephrine, and relieve
depression (Perales et al., 2015). And yoga can increase
individual serum brain-derived neurotrophic factor (BDNF)
and reduce serum cortisol level to relieve physical and
psychological discomfort (Naveen et al., 2016). Other
studies have also found that massage can reduce the
maternal cortisol levels in saliva and urine, and

600
Y. Zhu et al.
the cortisol levels of newborns also lower than the control
group (Field et al., 2005; Melville et al., 2014), and massage
by partner could improve the relationship.
The effect of music intervention on prenatal depression
and anxiety seems to be better than others, maybe it has the
highest feasibility, the lowest difficulty in implementation,
and it is easier to devote to wholeheartedly, while the
compliance of patients with other in- terventions may be low.
We need to explore more mechanisms to further demonstrate
this conclusion.
Integrated yoga could improve the physiology,
psychology, emotion and spirit of pregnant women, to
achieve the harmonious unity of body, mind and spirit. Yoga
with only a few simple postures is just a low- intensity
activity, which has limited effect on prenatal depression.
However, because of fewer participants in simple yoga
group, the evi- dence needs to be verified.
The Chinese Medicine Five Element Music is the first
attempt to combine the theory of Yin Yang and five element
in traditional Chinese medicine, the unity of heaven, earth
and human with music (Wu et al., 2020). It is designed,
created and carefully recorded by experts in the fields of
music, traditional Chinese medicine and Qigong. Therefore,
more studies need to be included in the future to explore the
interven- tion effect of Chinese Medicine Five Element Music
and ordinary music without theoretical system on prenatal
anxiety and depression.
4.3. Strengths and limitations
This study has several strengths. Firstly, the
interventions have high feasibility and accessibility,
pregnant women or their family members can cooperate at
home or anywhere under the guidance of medical staff.
Secondly, included studies are all RCTs, which increases the
reliability of our results. Thirdly, the data we compared
between intervention group and control group is the
difference pre- and post-intervention, elimi- nating the effect
of baseline. Fourthly, we used the framework of GRADE system
to assess the quality of evidence so that conclusions can be
drawn more objectively and explicitly.
This study also has some limitations. Firstly, the number
of eligible studies was small, especially at some specific
types of interventions when meta-analyses included
relatively very few studies. Therefore, the conclusions should
be viewed preliminary. Secondly, we only made a simple
comparison of different interventions, if more papers with
the same outcome indicators are published in the future, we
will compare various interventions through network meta-
analysis. Thirdly, because the inclusion and exclusion
criteria of the included studies are relatively broad, it is
difficult to distinguish the normal, suspicious and diagnosed
depression population, so we can not analyze the effect of
intervention and prevention separately. Fourthly, the quality
of evidence is low or very low, so it should be considered
carefully when recommending evidence.
60
Journal of Affective Disorders 292 (2021) 592–
602
4.4. Implications of nursing practice
It is important to support prenatal depression patients to
make informed decisions about their behavior therapy. We
should realize that some behavior therapies are still lack of
sufficient evidence. When the clinical symptoms of patients
are not improved, we should seek medical treatment in time
and change the treatment plan to prevent the deteri- oration
of the disease.
5. Conclusion
This research found low to very low evidence that yoga,
exercise, music and massage could reduce antenatal
depression. Among them, music may be the most effective
intervention, and integrated yoga other than simple yoga
would improve prenatal depression. The effect of Chinese
Medicine Five Element Music may be better than ordinary
music. More rigorously designed RCTs are warranted to
further support our conclusions.
Authors’ contribution
Guihua Xu: Conceptualization, Methodology, Project
administration, Writing - review & editing. AiXia Zhang:
Conceptualization, Resources, Writing - review & editing.
Yuan Zhu: Data curation, Formal analysis, Writing -
original draft. Rui Wang: Data curation, Formal analysis,
Writing - original draft. Qianqian Li: Data curation, Formal
analysis, Methodology. Xiaomei Tang: Investigation,
Resources, Software.
Funding
There is no funding support for this work.
Ethical approval
Not applicable.
CRediT authorship contribution statement
Yuan Zhu: Data curation, Formal analysis, Writing -
original draft. Rui Wang: Data curation, Formal analysis,
Writing - original draft. Xiaomei Tang: Investigation,
Resources, Software. Qianqian Li: Data curation, Formal
analysis, Methodology. Guihua Xu: Conceptualiza- tion,
Methodology, Project administration, Writing - review &
editing. Aixia Zhang: Conceptualization, Resources, Writing -
review & editing.
Declaration of Competing Interest
We declare that we have no financial and personal
relationships with other people or organizations that can
inappropriately influence our work, there is no professional
or other personal interest of any nature or kind in any
product, service and/or company that could be construed
as influencing the position presented in, or the review of,
the manuscript
entitled “ The effect of music, massage, yoga and exercise
Y. Zhu et al. Journal of Affective Disorders 292 (2021) 592–
602
on antenatal depression: a meta-analysis.”

Acknowledgement

None

Supplementary materials

Supplementary material associated with this article can

be found, in the online version, at
doi:10.1016/j.jad.2021.05.122.

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