Effectiveness of Smartphone-Based Mindfulness Training on Maternal Perinatal Depression: Randomized Controlled Trial

Background Despite potential for benefit, mindfulness remains an emergent area in perinatal mental health care, and evidence of smartphone-based mindfulness training for perinatal depression is especially limited. Objective The objective of this study was to evaluate the effectiveness of a smartphone-based mindfulness training intervention during pregnancy on perinatal depression and other mental health problems with a randomized controlled design. Methods Pregnant adult women who were potentially at risk of perinatal depression were recruited from an obstetrics clinic and randomized to a self-guided 8-week smartphone-based mindfulness training during pregnancy group or attention control group. Mental health indicators were surveyed over five time points through the postpartum period by online self-assessment. The assessor who collected the follow-up data was blind to the assignment. The primary outcome was depression as measured by symptoms, and secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear. Results A total of 168 participants were randomly allocated to the mindfulness training (n=84) or attention control (n=84) group. The overall dropout rate was 34.5%, and 52.4% of the participants completed the intervention. Mindfulness training participants reported significant improvement of depression (group × time interaction χ24=16.2, P=.003) and secondary outcomes (χ24=13.1, P=.01 for anxiety; χ24=8.4, P=.04 for positive affect) compared to attention control group participants. Medium between-group effect sizes were found on depression and positive affect at postintervention, and on anxiety in late pregnancy (Cohen d=0.47, –0.49, and 0.46, respectively). Mindfulness training participants reported a decreased risk of positive depressive symptom (Edinburgh Postnatal Depression Scale [EPDS] score>9) compared to attention control participants postintervention (odds ratio [OR] 0.391, 95% CI 0.164-0.930) and significantly higher depression symptom remission with different EPDS reduction scores from preintervention to postintervention (OR 3.471-27.986). Parity did not show a significant moderating effect; however, for nulliparous women, mindfulness training participants had significantly improved depression symptoms compared to nulliparous attention control group participants (group × time interaction χ24=18.1, P=.001). Conclusions Smartphone-based mindfulness training is an effective intervention in improving maternal perinatal depression for those who are potentially at risk of perinatal depression in early pregnancy. Nulliparous women are a promising subgroup who may benefit more from mindfulness training. Trial Registration Chinese Clinical Trial Registry ChiCTR1900028521; http://www.chictr.org.cn/showproj.aspx?proj=33474

Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if oqine products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms.

Does your paper address subitem 1a-i? *
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes, it's "a smartphone-based mindfulness training".

1a-ii) Non-web-based components or impo"ant co-interventions in title
Mention non-web-based components or important co-interventions in title, if any (e.g., "with telephone support").
subitem not at all important 1 2 3 4 5 essential 1b) ABSTRACT: Structured summary of trial design, methods, results, and conclusions NPT extension: Description of experimental treatment, comparator, care providers, centers, and blinding status.
Does your paper address subitem 1a-ii?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study No, we provided only basic health consolation for participants in both intervention and control group, which are not an important component for this trail.

1a-iii) Primary condition or target group in the title
Mention primary condition or target group in the title, if any (e.g., "for children with Type I Diabetes") Example: A Web-based and Mobile Intervention with Telephone Support for Children with Type I Diabetes: Randomized Controlled Trial Does your paper address subitem 1a-iii? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes, the target condition is "maternal perinatal depression". Mention key features/functionalities/components of the intervention and comparator in the abstract. If possible, also mention theories and principles used for designing the site. Keep in mind the needs of systematic reviewers and indexers by including important synonyms. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-i? * Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. The key intervention is "fully automated 8-week smartphone-based mindfulness training during pregnancy", and the comparator is "attention-controlled group".

1b-ii) Level of human involvement in the METHODS section of the ABSTRACT
Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 1b-ii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. The intervention is "fully automated".
1b-iii) Open vs. closed, web-based (self-assessment) vs. face-to-face assessments in the METHODS section of the ABSTRACT Mention how participants were recruited (online vs. oqine), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials). Note: In traditional oqine trials, an open trial (open-label trial) is a type of clinical trial in which both the researchers and participants know which treatment is being administered. To avoid confusion, use "blinded" or "unblinded" to indicated the level of blinding instead of "open", as "open" in web-based trials usually refers to "open access" (i.e. participants can self-enrol). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 1b-iii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Participant were recruited oqine. "Pregnant adult women with potential risk of perinatal depression were recruited from obstetrics clinics." This was a purely webbased trial and only usergroups that were recruited were accessible to the application. Baseline data were collected in person while follow-up data were selfassessed through questionnaires. "Maternal mental health indicators were measured over four time points through postpartum by online self-assessed surveys." Through the procedure, only "the assessor who collected the follow-up data was blind to the assignment." 1b-iv) RESULTS section in abstract must contain use data Report number of participants enrolled/assessed in each group, the use/uptake of the intervention (e.g., attrition/adherence metrics, use over time, number of logins etc.), in addition to primary/secondary outcomes. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-iv?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "A total of 168 pregnant women were randomly allocated to MTPG (n = 84) or Conclusions/Discussions in abstract for negative trials: Discuss the primary outcome -if the trial is negative (primary outcome not changed), and the intervention was not used, discuss whether negative results are attributable to lack of uptake and discuss reasons. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-v?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Parity did not show signiPcantly moderating effect on intervention effect. But for nulliparous women, participants who received MTP showed signiPcantly improved depression symptoms than those who received ACG (Group × Time effect: 2 = 18.114, p = 0.001)." subitem not at all important 1 2 3 4 5 essential 2a-i) Problem and the type of system/solution Describe the problem and the type of system/solution that is object of the study: intended as stand-alone intervention vs. incorporated in broader health care program? Intended for a particular patient population? Goals of the intervention, e.g., being more cost-effective to other interventions, replace or complement other solutions? (Note: Details about the intervention are provided in "Methods" under 5) Does your paper address subitem 2a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes.
The main problems in this area are: 1) "Low-and middle-income countries (LAMICS) had a higher prevalence of prenatal depression than that in high-income countries (19-25% vs. 7-15%) [4]. However, the prevention and treatment of perinatal depression in LAMICS remains underrecognized, in part, due to limited resources to mental health services, greater priority to prevent obstetric complications and fetal anomaly [6] and fear of stigmatization [7]. Against this context, to provide accessible, low-cost and effective mental health services in LAMICS is a basic but signiPcant way to improve perinatal depression." 2)Long distance is a major reason of refusal in previous intervention studies [8,9].
Smartphone, nowadays, providing a right platform to solve this problem and disseminate accessible mental health services [10]. Smartphone applications were reported helpful for treating depression [11]." 3)"In the past three years, MBIs through internet or mobile devices were introduced into perinatal care. But for now, these studies either were in protocol and preliminary stage [22][23][24][25], or aimed at postpartum period only [26], or treated mindfulness as one component of integrated interventions [27], or used only prepost-test design [28]. Well-design smartphone-based RCT using large sample size and long-term follow-ups and aiming at improving perinatal depression was barely conducted yet." The target population of this study is pregnant women with potential risk of perinatal depression.
Goal of the intervention is "to provide accessible, low-cost and effective mental health services in LAMICS." subitem not at all important 1 2 3 4 5 essential 2a-ii) Scienti%c background, rationale: What is known about the (type of) system Motivation for the study: 1)"Low-and middle-income countries (LAMICS) had a higher prevalence of prenatal depression than that in high-income countries (19-25% vs. 7-15%) [4]. However, the prevention and treatment of perinatal depression in LAMICS remains underrecognized, in part, due to limited resources to mental health services, greater priority to prevent obstetric complications and fetal anomaly [6] and fear of stigmatization [7]. Against this context, to provide accessible, low-cost and effective mental health services in LAMICS is a basic but signiPcant way to improve perinatal depression." 2)"Long distance is a major reason of refusal in previous intervention studies [8,9].
Smartphone, nowadays, providing a right platform to solve this problem and disseminate accessible mental health services [10]. Smartphone applications were reported helpful for treating depression [11]." "Even more encouraging, smartphonebased interventions may be particularly adapted by pregnant women because recent studies found that majority expectant mother searched pregnancy-related information through internet and performed high appreciations [13,14]." The comparator in the current study is attention-controlled group, which can partly eliminated the social component bias and provided solid Pndings.
2b) In INTRODUCTION: Speci!c objectives or hypotheses METHODS 3a) Description of trial design (such as parallel, factorial) including allocation ratio Does your paper address CONSORT subitem 2b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "The Prst aim of the current study is to evaluate the effectiveness of mindfulness on depression remission at post-intervention in pregnancy women with potential high risk of perinatal depression compared to ACG. The second aim is to evaluate the longer-term difference on perinatal depression, and secondary outcomes (anxiety, perceived stress, positive and negative emotions, fatigue, sleep, memory and fear of childbirth) between mindfulness training in pregnancy group (MTPG) and ACG. And the third aim is to test whether the intervention effect will differ in nulliparous and multiparous women." 3b) Impo"ant changes to methods a#er trial commencement (such as eligibility criteria), with reasons subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 3a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "This study was a single-center, two-parallel-armed, assessor-blinded, 1:1 allocated, randomized controlled study with 32-week follow up. Pregnant women who scored at or above the threshold for positive depressive symptoms were randomly assigned to intervention group (receiving 8-week smartphone-based MTP) or control group (receiving 8-week regular WeChat health consultation)." Does your paper address CONSORT subitem 3b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "No important change was conducted after enrollment."

3b-i) Bug %xes, Downtimes, Content Changes
Bug Pxes, Downtimes, Content Changes: ehealth systems are often dynamic systems. A description of changes to methods therefore also includes important changes made on the intervention or comparator during the trial (e.g., major bug Pxes or changes in the functionality or content) (5-iii) and other "unexpected events" that may have inruenced study design such as staff changes, system failures/downtimes, etc. [2].

4a) Eligibility criteria for pa"icipants
Does your paper address subitem 3b-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "The Spiritual Healing was debugging-Pxed for three times due to the adaptation of phone systems during this trial, but no change related to intervention content was made." Does your paper address CONSORT subitem 4a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes.
"Inclusion criteria for women to participate in the study: 1) aged 18 years and over; 2) in the 12th to 20th week of gestation; 3) singleton pregnancy; 4) no plan to terminate pregnancy; 5) receiving antenatal care and planning to deliver in the study hospital; 6) completion of junior high school education or above; 7) positive depressive symptoms screen with Edinburgh Postnatal Depression Scale (EPDS) > 10 or Patient Health Questionaire-9 (PHQ-9) > 5; 8) able to use application on smartphone for the study; 9) able to understand the questionnaire.
Exclusion criteria were: 1) at risk of suicide or self-harm; 2) currently receiving psychiatric treatment or use psychiatric medications; 3) history of substance abuse or addiction in the past 6 months; 4) prior experience with mindfulness meditation; 5) decline to participant." subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 4a-i) Computer / Internet literacy Computer / Internet literacy is often an implicit "de facto" eligibility criterion -this should be explicitly clariPed.
Does your paper address subitem 4a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Participants need to be "able to use application on smartphone for the study." 4a-ii) Open vs. closed, web-based vs. face-to-face assessments: Open vs. closed, web-based vs. face-to-face assessments: Mention how participants were recruited (online vs. oqine), e.g., from an open access website or from a clinic, and clarify if this was a purely webbased trial, or there were face-to-face components (as part of the intervention or for assessment), i.e., to what degree got the study team to know the participant. In online-only trials, clarify if participants were quasi-anonymous and whether having multiple identities was possible or whether technical or logistical measures (e.g., cookies, email conPrmation, phone calls) were used to detect/prevent these.
Does your paper address subitem 4a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes.
"According to the national policy requirements of the National Health Commission of China, all pregnant women are recorded as pregnant in the 12 gestational week and then should start prenatal visits regularly. Pregnant women were recruited from the pool of women recorded as pregnant, all of whom were required to report pregnancy-related information and to receive depression screening and baseline evaluation (T1) at their Prst regular visit in the obstetric clinic where the study was based. Informed consent for psychological assessment was Prstly obtained and then printed questionnaires including socio demographics, pregnancy-related characteristics and mental health indicators were distributed, and participants were required to complete and return them. All pregnant women were screened according to the inclusion and exclusion criteria, and eligible participants were then contacted by WeChat (a popular instant social networking software) or by phone within two weeks. Research assistants introduced them to the procedure and objectives of the trial, and obtained online informed consent if they agreed to participant this trial. Recruited participants were randomly assigned to intervention group (MTPG) or control group (ACG), where MTPG received 8-week MTP and ACG to received 8-week regular WeChat health consultations as attention control. Data collection and assessment of intervention effect took place over four time points in the follow-up period. T2 assessment took place at 4 weeks after allocation (intermediate period of intervention), T3 at 8 weeks after allocation (endpoint of intervention), T4 at 18 weeks after allocation (before childbirth), and T5 at 6 weeks after delivery. Follow-up assessments were collected by computer/smartphone assisted self-administered surveys. All participants were awarded 2 yuan when completing an assessment." The use of instant communication software, WeChat, made it impossible to hide behind anonymity for the participants.
subitem not at all important 1 2 3 4 5 essential 4b) Se$ings and locations where the data were collected 4a-iii) Information giving during recruitment Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results.

Does your paper address subitem 4a-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Does your paper address CONSORT subitem 4b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "This study was conducted between March 2018 to January 2020 and participants were recruited in the obstetric clinic of a tertiary hospital in Jinan, Shandong, a city located in east of China. The hospital provides perinatal services for around 5,000 pregnant women each year." subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 4b-i) Repo" if outcomes were (self-)assessed through online questionnaires Clearly report if outcomes were (self-)assessed through online questionnaires (as common in web-based trials) or otherwise.
Does your paper address subitem 4b-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Depression screening and baseline evaluation (T1) was conducted through printed questionnaire in the obstetric clinic where the study was based." "Follow-up assessments were collected by computer/smartphone assisted self-administered surveys."

4b-ii) Repo" how institutional a!liations are displayed
Report how institutional axliations are displayed to potential participants [on ehealth media], as axliations with prestigious hospitals or universities may affect volunteer rates, use, and reactions with regards to an intervention.(Not a required item -describe only if this may bias results) 5) The interventions for each group with su%cient details to allow replication, including how and when they were actually administered subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 4b-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study

5-i) Mention names, credential, a!liations of the developers, sponsors, and owners
Mention names, credential, axliations of the developers, sponsors, and owners [6] (if authors/evaluators are owners or developer of the software, this needs to be declared in a "Conrict of interest" section or mentioned elsewhere in the manuscript).

Does your paper address subitem 5-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study No. The intervention content used in the current study was developed by our team and a technology company was hired to transfer the content into application.
subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 5-ii) Describe the history/development process Describe the history/development process of the application and previous formative evaluations (e.g., focus groups, usability testing), as these will have an impact on adoption/use rates and help with interpreting results.

Does your paper address subitem 5-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study

5-iii) Revisions and updating
Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial. Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b).
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 5-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study

5-iv) Quality assurance methods
Provide information on quality assurance methods to ensure accuracy and quality of information provided [1], if applicable.
Does your paper address subitem 5-iv?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential subitem not at all important 1 2 3 4 5 essential 5-v) Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing &owcha"s of the algorithms used Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing rowcharts of the algorithms used. Replicability (i.e., other researchers should in principle be able to replicate the study) is a hallmark of scientiPc reporting.

Does your paper address subitem 5-v?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study We only provide the screenshots of our application, but we do not keep the source code because that's a technical problem.

5-vi) Digital preservation
Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article). As pages behind login screens cannot be archived, consider creating demo pages which are accessible without login.
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 5-vi?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study The URL of the application is expired now.

5-vii) Access
Access: Describe how participants accessed the application, in what setting/context, if they had to pay (or were paid) or not, whether they had to be a member of speciPc group. If known, describe how participants obtained "access to the platform and Internet" [1]. To ensure access for editors/reviewers/readers, consider to provide a "backdoor" login account or demo mode for reviewers/readers to explore the application (also important for archiving purposes, see vi).
Does your paper address subitem 5-vii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Participants who were allocated to MTPG received the URL of the application through WeChat. They can use the application as long as they sign up. An assistant will assist with registering and activating the intervention." The application is free and they do not need to be a member of speciPc group because the URL of the

5-ix) Describe use parameters
Describe use parameters (e.g., intended "doses" and optimal timing for use). Clarify what instructions or recommendations were given to the user, e.g., regarding timing, frequency, heaviness of use, if any, or was the intervention used ad libitum.

Does your paper address subitem 5-ix?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "MTP lasted 8 weeks, with content provided 6 days per week and 15-25 minutes per day. A message to remind participants to follow the MTP was sent every week." "The training in MTP updated automatically every day and participants practiced according to their own schedules. A message to remind participants to follow the MTP was sent every week by WeChat."

5-x) Clarify the level of human involvement
Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 5-x?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. The 8-week mindfulness training used in the current study is fully automated.

5-xi) Repo" any prompts/reminders used
Report any prompts/reminders used: Clarify if there were prompts (letters, emails, phone calls, SMS) to use the application, what triggered them, frequency etc. It may be necessary to distinguish between the level of prompts/reminders required for the trial, and the level of prompts/reminders for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
Does your paper address subitem 5-xi? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "A message to remind participants to follow the MTP was sent every week by WeChat." subitem not at all important 1 2 3 4 5 essential 6a) Completely de!ned pre-speci!ed primary and secondary outcome measures, including how and when they were assessed 5-xii) Describe any co-interventions (incl. training/suppo") Describe any co-interventions (incl. training/support): Clearly state any interventions that are provided in addition to the targeted eHealth intervention, as ehealth intervention may not be designed as stand-alone intervention. This includes training sessions and support [1]. It may be necessary to distinguish between the level of training required for the trial, and the level of training for a routine application outside of a RCT setting (discuss under item 21 -generalizability. Does your paper address subitem 5-xii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "We provided basic perinatal health consultations in the entire perinatal period by WeChat app for all participants allocated." Does your paper address CONSORT subitem 6a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Depression assessed by the EPDS was the primary outcome in this study.
EPDS is a self-report scale which assesses depressive symptoms experienced If outcomes were obtained through online questionnaires, describe if they were validated for online use and apply CHERRIES items to describe how the questionnaires were designed/deployed [9].

Does your paper address subitem 6a-i?
Copy and paste relevant sections from manuscript text 6a-ii) Describe whether and how "use" (including intensity of use/dosage) was de%ned/measured/monitored Describe whether and how "use" (including intensity of use/dosage) was dePned/measured/monitored (logins, logPle analysis, etc.). Use/adoption metrics are important process outcomes that should be reported in any ehealth trial.
subitem not at all important 1 2 3 4 5 essential 6b) Any changes to trial outcomes a#er the trial commenced, with reasons Does your paper address subitem 6a-ii?
Copy and paste relevant sections from manuscript text Yes. "Logs of practice on formal mindfulness training were recorded and used to evaluate the Pdelity of mindfulness training. At least 3 days of practice per week in this study was considered a completed training week. And at least 4 completed training weeks were considered as completing the MTP. Completion rate in this study is the percentage of participants who completed the MTP divided by participants who received intervention." 6a-iii) Describe whether, how, and when qualitative feedback from pa"icipants was obtained Describe whether, how, and when qualitative feedback from participants was obtained (e.g., through emails, feedback forms, interviews, focus groups).

Does your paper address subitem 6a-iii?
Copy and paste relevant sections from manuscript text 7a) How sample size was determined NPT: When applicable, details of whether and how the clustering by care provides or centers was addressed subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 6b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. No important change related trail outcomes was made in the trail. However, 14 participants in MTPG and 11 participants in ACG lost to follow up at T2 due to researcher's omission, which was marked in row chart.

7a-i) Describe whether and how expected a'rition was taken into account when calculating the sample size
Describe whether and how expected attrition was taken into account when calculating the sample size.

Does your paper address subitem 7a-i?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "In the above meta-analysis of self-help mindfulness [33], on average 27% of participants were lost to follow up in the post-intervention assessment.
Considering a 30% attrition in the follow-up, a Pnal sample size should reach 168 with 84 individuals in each group." 7b) When applicable, explanation of any interim analyses and stopping guidelines 8a) Method used to generate the random allocation sequence NPT: When applicable, how care providers were allocated to each trial group 8b) Type of randomisation; details of any restriction (such as blocking and block size) Does your paper address CONSORT subitem 7b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study No. We have conducted a pilot study. Then no interim analyses was made in the formal trail.
Does your paper address CONSORT subitem 8a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes."This trial used a simple randomization approach. The random number sequence was generated by a researcher who didn't participate this study using Random Number Generators function in SPSS 23.0. Random number sequence was kept in sealed, opaque, numbered envelopes. When each participant was enrolled, a research assistant opened the envelop in sequence and assigned the participant. Participants received allocation according to the order of enrollment." 9) Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned 10) Who generated the random allocation sequence, who enrolled pa"icipants, and who assigned pa"icipants to interventions Does your paper address CONSORT subitem 8b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes."This trial used a simple randomization approach." Does your paper address CONSORT subitem 9? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "The random number sequence was generated by a researcher who didn't participate this study using Random Number Generators function in SPSS 23.0.
Random number sequence was kept in sealed, opaque, numbered envelopes. When each participant was enrolled, a research assistant opened the envelop in sequence and assigned the participant." 11a) If done, who was blinded a#er assignment to interventions (for example, pa"icipants, care providers, those assessing outcomes) and how NPT: Whether or not administering co-interventions were blinded to group assignment subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 10? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "The random number sequence was generated by a researcher who didn't participate this study." The person who enrolls participants and assigns participants is the same person. "When each participant was enrolled, a research assistant opened the envelop in sequence and assigned the participant.
Participants received allocation according to the order of enrollment." 11a-i) Specify who was blinded, and who wasn't Specify who was blinded, and who wasn't. Usually, in web-based trials it is not possible to blind the participants [1, 3] (this should be clearly acknowledged), but it may be possible to blind outcome assessors, those doing data analysis or those administering co-interventions (if any).
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 11a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Throughout the RCT procedure, the assessor who collected the follow-up data did not know the assignment. Considering the use of smartphone application, the participants were able to infer the assignment." 11a-ii) Discuss e.g., whether pa"icipants knew which intervention was the "intervention of interest" and which one was the "comparator" Informed consent procedures (4a-ii) can create biases and certain expectations -discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator".

Does your paper address subitem 11a-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. The participants were informed that this trial contained two groups: application group and WeChat group. The WeChat is a popular instant communicating software in China, which is not special for the participants. Then, the participants might be able to infer the intervention of interest.
11b) If relevant, description of the similarity of interventions (this item is usually not relevant for ehealth trials as it refers to similarity of a placebo or sham intervention to a active medication/intervention) 12a) Statistical methods used to compare groups for primary and secondary outcomes NPT: When applicable, details of whether and how the clustering by care providers or centers was addressed Does your paper address CONSORT subitem 11b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study No. Because the two interventions are different in this study.
Does your paper address CONSORT subitem 12a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Statistical analyses were performed with SPSS 23.0. The primary analysis used intention-to-treat (ITT) approach. Normality of outcomes at baseline were visually examined, and NA, sleep and PM were transformed by log due to nonnormal data distribution. No more than Pve individuals for each measure at T1 had single entry missing, which were considered as missing at random and were imputed with median of item. Independent sample t test and chi-square test were used to compare the baseline characteristics between MTPG and ACG. In order to assess the intervention effect on depression remission at post-intervention (T3), positive depressive symptoms at T3 and EPDS reductions from T1 to T3 were compared between intervention and control groups using logistic regression models, adjusting EPDS score at baseline and between-group imbalanced factor (intended pregnancy) after randomization. To assess MTPG vs ACG intervention effect on longer-term outcomes, multilevel linear models within Generalized Estimating Equations (GEE) were performed. In GEE, the participants and assessment timepoints were designated as subject variables and within-subject variable, respectively, with exchangeable working correlation matrix and full maximum likelihood estimation applied. The continuous outcome variables in Pve timepoints were the dependent variable. Main effects of group, time, and Group × Time interaction effect were examined." subitem not at all important 1 2 3 4 5 essential 12b) Methods for additional analyses, such as subgroup analyses and adjusted analyses 12a-i) Imputation techniques to deal with a'rition / missing values Imputation techniques to deal with attrition / missing values: Not all participants will use the intervention/comparator as intended and attrition is typically high in ehealth trials. Specify how participants who did not use the application or dropped out from the trial were treated in the statistical analysis (a complete case analysis is strongly discouraged, and simple imputation techniques such as LOCF may also be problematic [4]).

Does your paper address subitem 12a-i? *
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes.
For the single entry missing: "no more than Pve individuals for each measure at T1 had single entry missing, which were considered as missing at random and were imputed with median of item." "For T2 and above, the web-based survey included rules that eliminated missing items on questionnaires. So, no item missed at follow-up due to the requirement of web-based survey." For lost-to follow-up data: "To address our second aim on MTPG vs ACG intervention effect on longer-term outcomes, multilevel linear models within Generalized Estimating Equations (GEE) were performed. This approach has been recommended because it is able to handle missing data appropriately and can keep stable in different correlation matrix."

X26) REB/IRB Approval and Ethical Considerations [recommended as subheading under "Methods"] (not a CONSORT item)
subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 12b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "As [35] suggested, several sensitivity analyses were conducted. Firstly, the longer-term between-group differences were analyzed in ITT group, per-protocol (PP) group and as-treated (AT) group (referred as the PP-IC group in the current study; IC: "intervention completed"). Secondly, adjusted GEE models with baseline imbalanced factor (intended pregnancy) were also performed. Thirdly, longer-term intervention effect based on GEE were also conducted in participants who completed different times of follow-up. In addition, subgroup analysis by parity (primipara/multipara) were also conducted. In the subgroup analysis, p value of less than 0.025 was considered statistically signiPcant after Bonferroni multiplecorrected."

X26-i) Comment on ethics commi'ee approval
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem X26-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study

x26-ii) Outline informed consent procedures
Outline informed consent procedures e.g., if consent was obtained oqine or online (how? Checkbox, etc.?), and what information was provided (see 4a-ii). See [6] for some items to be included in informed consent documents.

Does your paper address subitem X26-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential RESULTS 13a) For each group, the numbers of pa"icipants who were randomly assigned, received intended treatment, and were analysed for the primary outcome NPT: The number of care providers or centers performing the intervention in each group and the number of patients treated by each care provider in each center

X26-iii) Safety and security procedures
Safety and security procedures, incl. privacy considerations, and any steps taken to reduce the likelihood or detection of harm (e.g., education and training, availability of a hotline) Does your paper address subitem X26-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "For safety and de-stigmatization, participants were reminded that this APP is not equivalent psychotherapy and professional supports need to be reached when necessary." 13b) For each group, losses and exclusions a#er randomisation, together with reasons subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 13a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "A total of 1140 pregnant women were reached and a Pnal sample of 168 was allocated." "Of the 84 participants allocated to MTPG, 10 of them did not activate the Spirit Healing, which was considered refusing the allocation." Details are shown in row chart.
Does your paper address CONSORT subitem 13b? (NOTE: Preferably, this is shown in a CONSORT &ow diagram) *

14a) Dates de!ning the periods of recruitment and follow-up
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 13b-i?
Copy and paste relevant sections from the manuscript or cite the Pgure number if applicable (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Of the 84 participants allocated to MTPG, 10 of them did not activate the Spirit Healing, which was considered refusing the allocation. All the remaining participants received MTP. On the basis of ITT sample, the mean number of completed training weeks was 3 weeks (SD: 2.701). As a whole, 44/84 participants completed at least 4 weeks training and the total completion rate was 52.4%. In all, 7/84 (8.3%) participants completed the whole 8-week training." Does your paper address CONSORT subitem 14a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Recruitment begun in March 2018 and ended in June 2019, and follow-up assessments ended in January 2020."

14a-i) Indicate if critical "secular events" fell into the study period
Indicate if critical "secular events" fell into the study period, e.g., signiPcant changes in Internet resources available or "changes in computer hardware or Internet delivery resources" 14b) Why the trial ended or was stopped (early) 15) A table showing baseline demographic and clinical characteristics for each group NPT: When applicable, a description of care providers (case volume, qualiPcation, expertise, etc.) and centers (volume) in each group Does your paper address subitem 14a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Does your paper address CONSORT subitem 14b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study No. The trial did not stop halfway. It ended as long as the sample size reached 168.
Does your paper address CONSORT subitem 15? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. These information was shown in Table 1. In ehealth trials it is particularly important to report demographics associated with digital divide issues, such as age, education, gender, social-economic status, computer/Internet/ehealth literacy of the participants, if known.

Does your paper address subitem 15-i? *
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Age, education, gender and social-economic status were reported in Table 1.

16-i) Repo" multiple "denominators" and provide de%nitions
Report multiple "denominators" and provide dePnitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at speciPc pre-dePned time points of interest (in absolute and relative numbers per group). Always clearly dePne "use" of the intervention.
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 16-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study

16-ii) Primary analysis should be intent-to-treat
Primary analysis should be intent-to-treat, secondary analyses could include comparing only "users", with the appropriate caveats that this is no longer a randomized sample (see 18-i).
17a) For each primary and secondary outcome, results for each group, and the estimated e&ect size and its precision (such as 95% con!dence interval) subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 16-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. ITT group, per-protocol (PP) group and as-treated (AT) group (referred as the PP-IC group in the current study; IC: "intervention completed") were all used to analyze in the current study.
Does your paper address CONSORT subitem 17a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Estimated effect size and its precision were reported in appendix.

17a-i) Presentation of process outcomes such as metrics of use and intensity of use
In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational dePnitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is dePned (e.g., timeout after idle time) [1] (report under item 6a).
17b) For binary outcomes, presentation of both absolute and relative e&ect sizes is recommended 18) Results of any other analyses pe'ormed, including subgroup analyses and adjusted analyses, distinguishing pre-speci!ed from exploratory Does your paper address subitem 17a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Does your paper address CONSORT subitem 17b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Does your paper address CONSORT subitem 18? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Results related to subgroup analysis (parity) and three kinds of sensitivity analyst were conducted.

18-i) Subgroup analysis of comparing only users
A subgroup analysis of comparing only users is not uncommon in ehealth trials, but if done, it must be stressed that this is a self-selected sample and no longer an unbiased sample from a randomized trial (see 16-iii).
Does your paper address subitem 18-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 19? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Only one pregnant woman in MTPG reported psychological burden caused by mindfulness training after 2 days practice, and discontinued the training. No other adverse event was reported associating with MTP directly.

19-i) Include privacy breaches, technical problems
Include privacy breaches, technical problems. This does not only include physical "harm" to participants, but also incidents such as perceived or real privacy breaches [1], technical problems, and other unexpected/unintended incidents. "Unintended effects" also includes unintended positive effects [2].

Does your paper address subitem 19-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. Of all the MTPG participants, two did not complete the training due to APP bug, and one discontinued the training due to the phone being damaged, and one uninstalled the APP due to insuxcient phone storage.
subitem not at all important 1 2 3 4 5 essential DISCUSSION 22) Interpretation consistent with results, balancing bene!ts and harms, and considering other relevant evidence NPT: In addition, take into account the choice of the comparator, lack of or partial blinding, and unequal expertise of care providers or centers in each group 19-ii) Include qualitative feedback from pa"icipants or observations from sta$/researchers Include qualitative feedback from participants or observations from staff/researchers, if available, on strengths and shortcomings of the application, especially if they point to unintended/unexpected effects or uses. This includes (if available) reasons for why people did or did not use the application as intended by the developers.

Does your paper address subitem 19-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential 22-i) Restate study questions and summarize the answers suggested by the data, sta"ing with primary outcomes and process outcomes (use) Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use).

Does your paper address subitem 22-i? *
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Responding to the need of depression remission for pregnant women with potential risk of perinatal depression, smartphone-based mindfulness training led to lower rate of positive depression at post-intervention and greater decline in depression symptoms from baseline to post-intervention relative to attention control group. Results also support the longer-term effects of smartphone-based mindfulness training for the reduction of prenatal depression and anxiety and enhancement of positive affect. However, parity is only suggested as a potential moderator due to its dePcient statistical signiPcance.

20-i) Typical limitations in ehealth trials
Typical limitations in ehealth trials: Participants in ehealth trials are rarely blinded. Ehealth trials often look at a multiplicity of outcomes, increasing risk for a Type I error. Discuss biases due to non-use of the intervention/usability issues, biases through informed consent procedures, unexpected events.
Does your paper address subitem 20-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "Second, we have to notice that 10 of 84 participants in intervention group did not activate mindfulness training even after they have signed the informed consent and agreed to participate this program. The high proportion of inactive participants in intervention group weakens the strength of RCT design. Third, participants in this study are able to infer their allocation and are unblinded. And the multiple assessment of outcomes increases risk for a Type I error." subitem not at all important 1 2 3 4 5 essential 21-i) Generalizability to other populations Generalizability to other populations: In particular, discuss generalizability to a general Internet population, outside of a RCT setting, and general patient population, including applicability of the study results for other organizations Does your paper address subitem 21-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. This intervention is good to generalize outside of a RCT setting. "This study expands on the Pndings of mindfulness training in pregnancy in several key areas. First, it shows that the prenatal mindfulness training can be extended through smartphone-based delivery, which is able to lead reductions in both demand on therapists and service costs [46]. It is especially a preferable choice for LAMICS." However, on the other hand, the intervention content in the current study contains some professional knowledge related to pregnancy and perinatal care, which are not applicable to general internet population. Discuss if there were elements in the RCT that would be different in a routine application setting (e.g., prompts/reminders, more human involvement, training sessions or other co-interventions) and what impact the omission of these elements could have on use, adoption, or outcomes if the intervention is applied outside of a RCT setting.

Does your paper address subitem 21-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study 24) Where the full trial protocol can be accessed, if available 25) Sources of funding and other suppo" (such as supply of drugs), role of funders Does your paper address CONSORT subitem 23? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "This trial is retrospectively registered in Chinese Clinical Trial Registry (Registration number: ChiCTR1900028521) due to unawareness of requirements for trial registration before enrollment." We had obtained the ethical approval before the Prst enrollment but they did not address the registration before enrollment. We were confused that to register at any time was acceptable. So we did not register prospectively but did it before analyzing the data.
Does your paper address CONSORT subitem 24? * Cite a Multimedia Appendix, other reference, or copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study No. The protocol of this study was not published. This is the Prst study that introduce this trail in English. We have described the trail as speciPc as possible in the current study.

X27) Con(icts of Interest (not a CONSORT item)
subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 25? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study Yes. "This study was funded by the Chinese National Funding of Social Sciences (Grant Number: 17BSH054). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. We also thank the China Scholarship Council for the support in one of our authors' (Yaoyao Sun) studying aboard."

X27-i) State the relation of the study team towards the system being evaluated
In addition to the usual declaration of interests (Pnancial or otherwise), also state the relation of the study team towards the system being evaluated, i.e., state if the authors/evaluators are distinct from or identical with the developers/sponsors of the intervention.

Does your paper address subitem X27-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briery explain why the item is not applicable/relevant for your study As a result of using this checklist, did you make changes in your manuscript? * What were the most impo"ant changes you made as a result of using this checklist?
To add more details related to the application and the implementation process.
How much time did you spend on going through the checklist INCLUDING making changes in your manuscript *

Six hours.
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