A Prenatal Mentalization-focused 4D Ultrasound and a Pregnancy Diary Intervention for Substance-abusing Women
A Prenatal Mentalization-focused 4D Ultrasound and a Pregnancy Diary Intervention for Substance-abusing Women
Objective: This randomized and controlled trial was aimed at exploring the effect of a new
 mentalization-focused 4D interactive ultrasound and a week-by-week pregnancy diary
 intervention with substance-abusing pregnant women.

 Method: Pregnant women referred to the hospital maternity outpatient clinic from primary
 health care due to substance abuse were recruited to participate in a randomized and
 controlled study. At admission, a psychiatric nurse offered all eligible women an opportunity
 for participation. A written informed consent was obtained from all participants included in
 the study. The participants were randomized into the intervention and control groups using a
 computer-generated block-randomization with block size of four. A separate randomization
 assignment was used for women in medication-assisted treatment for opioid dependence.

 The intervention group subjects were offered three mentalization-focused interactive 4D
 ultrasounds at 24, 30 and 34 gestational weeks and a mentalization-focused week-by-week
 pregnancy diary combined with three antenatal sessions and an option for one diary session
 after delivery. The control group received active treatment as usual in an obstetric tertiary
 setting.

 The pregnant woman and the child were followed-up until the child was one year old. The
 primary outcome was prenatal maternal depressive symptoms post-intervention, and secondary
 outcomes were anxiety symptoms, prenatal parental mentalization, maternal-fetal attachment
 and substance abuse. Other outcomes were utilisation of prenatal care, perinatal outcome,
 neonatal withdrawal symptoms and neonatal neurobehavior, postnatal maternal depressive and
 anxiety symptoms, parental mentalization, experienced stress from parenting and experienced
 social support, and emotional connection and commitment with the baby.

 The study was conducted at the hospital maternity outpatient clinic for substance-abusing
 pregnant women at Turku University Hospital (Finland) between October 2011 and December 2015.
 The registration of the trial is made retrospectively, but the research plan and outcomes are
 reported in this registration as they were originally documented in the research plan
 approved by The Joint Ethics Committee of the University of Turku and the Hospital District
 of Southwest Finland on 14th of June 2011.
Objective:

 The aim of this controlled trial was to explore the effect of a new mentalization-focused 4D
 interactive ultrasound and a week-by-week pregnancy diary intervention with substance-abusing
 pregnant women.

 Method:

 This trial was conducted at the maternity outpatient clinic for substance-abusing pregnant
 women at Turku University Hospital, Finland, between October 2011 and December 2015. At Turku
 University Hospital there is a specialized antenatal outpatient clinic for pregnant women
 with substance abuse problems. Pregnant women referred to this facility from primary health
 care due to substance abuse were invited to participate the trial.

 At admission, a psychiatric nurse offered all eligible women an opportunity to participate in
 the randomized trial. A written informed consent was obtained from all individual
 participants included in the study. The participants were randomized into the intervention
 and control groups using a computer-generated block-randomization with block size of four,
 and a separate randomization assignment was used for women in medication-assisted treatment
 for opioid addiction. In post-intervention phase at 35 gestational weeks, all participants
 were compensated with a 20 euros gift card targeted to the infant's needs. The research plan
 was approved by The Joint Ethics Committee of the University of Turku and the Hospital
 District of Southwest Finland on the 14th of June 2011.

 Description of the intervention and the control condition:

 The intervention group subjects were offered three mentalization-focused interactive 4D
 ultrasounds at 24, 30 and 34 gestational weeks and a mentalization-focused week-by-week
 pregnancy diary combined with three prenatal sessions and option for one diary session after
 delivery. Detailed intervention method description including a theoretical background of the
 intervention is already published and available (Pajulo et al. 2016).

 1. Mentalization-focused interactive use of 4D ultrasound imaging:

 Three interactive 4D ultrasound sessions were offered for the intervention group
 participants at 24, 30 and 34 gestational weeks at the maternity outpatient clinic. The
 pregnant women participated in the sessions alone. The ultrasound sessions took around
 20-30 minutes, and were performed by an experienced obstetrician and an infant mental
 health professional working in cooperation. The sessions were based on the intervention
 method called "ultrasound consultation" (Boukydis & Stockman, 2012; Boukydis, 2006)
 where the idea is to observe the fetus together with the parent(s); the fetal features,
 position, sleep-awake rhythm, personal characteristics, activities in the uterus and
 responses to mother's initiatives for interaction.The aim is to evoke the mother's
 active interest in this particular child and hence to enhance parental mentalization and
 maternal-fetal attachment.

 2. The mentalization-focused week-by-week pregnancy diary:

 To keep the fetus more actively in the mother's mind across pregnancy, a new
 mentalization-focused pregnancy diary was designed for the intervention group. Three prenatal
 meetings (45 minutes) with the infant mental health professional were offered for reflecting
 the mother's experiences on using the diary. The diary contains short sections for each
 pregnancy week including information about pregnancy, fetal development and health promoting
 practices. The key elements in the diary are the mentalization-focused questions and tasks
 encouraging the pregnant woman to reflect on her fetus and pregnancy and becoming a parent.

 The control condition:

 The intervention and control group received active treatment as usual in an obstetric
 tertiary setting, and treatment as usual formed the control condition for the intervention.
 The treatment was offered by a multidisciplinary team consisting of an obstetrician, a
 midwife, a social worker and a psychiatric nurse . The patients were referred to addiction
 and psychiatric treatment when needed. The Child Protection Services were involved in
 prenatal phase in accordance with the Finnish legislation.

 Data collection:

 The primary outcome was prenatal maternal depressive symptoms post-intervention, and
 secondary outcomes were anxiety symptoms, prenatal parental mentalization, maternal-fetal
 attachment and substance abuse. Other outcomes were utilisation of prenatal care, perinatal
 outcome, neonatal withdrawal symptoms and neonatal neurobehavior, postnatal maternal
 depressive and anxiety symptoms, parental mentalization, experienced stress from parenting
 and experienced social support, and emotional connection and commitment with the baby.

 The pregnant woman and her child were followed-up until the child was one year old. The data
 was collected from multiple sources: standardized measures, questionnaires constructed for
 the study and information available from hospital medical records. As a part of routine
 clinical practice, the pregnant women were interviewed by the psychiatric nurse and the
 social worker. The interviews based on the European Addiction Severity Index-questionnaire
 (EuropASI) (Kokkevi & Hartgers, 1995), where the items regard maternal physical and mental
 health, substance abuse, employment and income, legal status and close relationships.
 Sociodemographic data was obtained by a ten-item questionnaire at baseline. Information
 regarding maternal psychiatric diagnosis and/or history was based on documented self-report
 or medical records. Information regarding maternal substance abuse was obtained through the
 medical records, and was based on maternal self-report or clinical documentation
 (intoxications, urine screening results, marks indicating intravenous substance abuse).
 Meconium sample was collected after birth for detection of illicit drugs. Data regarding
 utilisation of obstetric care and perinatal outcome was obtained from hospital medical
 records.

 The standardized measures used to assess maternal depressive and anxiety symptoms,
 maternal-fetal attachment and parental mentalization were administered during pregnancy at
 two time points, i.e. before and after intervention (< 24th and > 34th gestational weeks,
 respectively). Routine postnatal follow-up visits at the socio pediatric unit were conducted
 when the infant was at 3 months and 1 year age. Standardized measures were administered
 during those follow-up visits to assess maternal postnatal depressive and anxiety symptoms,
 parental mentalization, experienced stress from parenting and experienced social support, and
 emotional connection and commitment with the baby. Medical records concerning health and
 psychosocial situation of the mother and infant were available, based on informed consent,
 until the child was one year old. The assessment time points and measures were the same for
 both groups.

 The registration of the trial is made retrospectively, but the research plan and outcomes are
 reported in this registration as they were originally documented in the research plan
 approved by The Joint Ethics Committee of the University of Turku and the Hospital District
 of Southwest Finland on 14th of June 2011.
Inclusion Criteria:

 Pregnant women referred to the hospital maternity outpatient clinic from primary health
 care due to substance abuse were recruited to participate in a randomized and controlled
 study. The subjects were referred from primary health care due to:

 1. documented or self-reported illicit drug use, misuse of prescription medication or
 alcohol within three years prior to or during this pregnancy,

 2. and/or sum score ≥ 3 points on TWEAK alcohol screening (Russell, 1994).

 The inclusion criteria included also:

 3. pregnancy duration < 22 gestational weeks (gwks) at referral

 4. singleton pregnancy.