Abstract
Objective
The effect of coronavirus disease-2019 (COVID-19) on pregnancy remains controversial. Currently, literature investigating levels of knowledge, behavior, and attitudes regarding COVID-19 among pregnant women is scarce. This study aims to determine the knowledge, attitudes, and awareness levels of pregnant women followed up at the obstetrics and gynecology clinic of a tertiary care hospital in Western Türkiye.
Methods
Pregnant women admitted to a tertiary care hospital in İzmir, a metropolitan city in Türkiye, between May 1 and June 30, 2020, were enrolled in the study. The researchers used a questionnaire to measure COVID-19 knowledge, attitudes, and awareness levels. Anxiety level was evaluated using the generalized anxiety disorder-7 scale. All analyses were performed using SPSS v.25 (IBM Corp., Armonk, NY) at a significance level of 0.05.
Results
The median COVID-19 knowledge score of the study group was 13.00 (12.00-15.00). Negative correlations were detected between the COVID-19 knowledge score and the number of pregnancies, live births, and children. Conversely, the knowledge score increased with higher education levels among pregnant women and their partners. Similarly, higher family income levels were associated with higher knowledge scores. Severe anxiety was detected in 109 (26.2%) pregnant women.
Conclusion
Pregnant women in the study had substantial COVID-19 knowledge levels. Knowledge level was positively correlated with positive behaviors, post-pandemic attitudes, higher education levels, and higher soci-economic status.
Introduction
Coronaviruses (CoVs) are a large family of viruses that cause a variety of diseases, ranging from the common cold to more serious conditions such as middle east respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV)(1). CoVs cause zoonotic infections; however, many CoVs detected in animals have not yet been transmitted to humans. The subtypes of coronavirus currently circulating in humans are HCoV-229E, HCoV-OC43, HCoV-NL63, and HKU1-CoV(2).
On December 31, 2019, the World Health Organization (WHO) reported pneumonia cases of unknown etiology in Wuhan, China. Through sequence analysis of samples, a previously unknown novel coronavirus was discovered and named 2019-nCoV(3). Soon after, this disease was defined as coronavirus disease-2019 (COVID-19) by the WHO(4). Due to its structural similarity to SARS-CoV, the novel coronavirus was named SARS-CoV-2(5). The first COVID-19 cases in Türkiye were reported on March 19, 2020(6).
The spectrum of infection ranges widely from mild to critical; however, most symptomatic infections are not severe(7). COVID-19 infection is characterized by a wide spectrum of clinical manifestations, ranging from completely asymptomatic cases to severe acute respiratory distress syndrome (ARDS). Approximately 5-10% of patients with COVID-19 develop severe ARDS(8). Severe infection and increased mortality rates are associated with older age or underlying comorbidities such as cardiovascular diseases, diabetes mellitus, hypertension, chronic lung disease, and cancer(9). Currently, no specific treatment for COVID-19 has been proven effective. Except for remdesivir, no antiviral drug has been fully approved, although many agents have been investigated in vitro and in some in vivo studies, showing promising results(10).
It is known that physiological changes in the immune system during pregnancy can affect susceptibility to and the severity of infectious diseases(11). In SARS and MERS-CoV experiences, pregnant women were observed to be a high-risk group for complications of coronavirus infections(12). However, data regarding the effect of COVID-19 on pregnancy remain limited(13-15). Most pregnant patients exhibit mild or moderate symptoms similar to non-pregnant women, and morbidity and mortality rates comparable to the general population have been observed(16, 17).
This study aims to determine the levels of knowledge, attitudes, and awareness regarding COVID-19 among pregnant women attending the obstetrics and gynecology clinic of a tertiary care hospital in Western Türkiye.
Materials and Methods
This cross-sectional study was conducted between May 1 and June 30, 2020. The survey was conducted in the clinic of obstetrics and gynecology at a tertiary care hospital in Western Türkiye. The target population, consisting of pregnant women who sought pregnancy follow-up or were hospitalized in wards during the study period, was estimated to be 600 individuals. An a priori power analysis was conducted, and the minimum sample size was calculated to be 316, assuming a type 1 error of 1% (99% confidence) and a confidence interval of 5%. The final study group consisted of 416 pregnant women. A total of 21 pregnant women who declined to participate were excluded.
The questionnaire was administered by the researchers via face-to-face interviews. The first part of the questionnaire contained 13 questions regarding demographic characteristics, pregnancy, and birth history. In the second part, the question “Have you heard of the epidemic of the new coronavirus (COVID-19) disease?” was asked to assess awareness. In the third, fourth, and fifth sections, knowledge levels regarding COVID-19 symptoms (5 questions, 3-point Likert scale), transmission pathways (4 questions, 3-point Likert scale), and treatment/prevention (9 questions, 2-point Likert scale, true/false) were evaluated. One point was awarded for each correct answer. The total COVID-19 knowledge score ranged from 0 to 18 points; higher scores indicated a higher level of knowledge.
In the sixth section, positive behaviors related to COVID-19 were evaluated using a 5-point Likert scale by asking about seven specific behaviors. The frequency of participants responding “I apply very well/well” was recorded, and correlations between this frequency and the COVID-19 knowledge score were analyzed. The seventh chapter examined participants’ self-perception of the sufficiency of their knowledge and their sources of information about COVID-19.
In chapter eight, changes in attitudes following the onset of the pandemic were evaluated using 16 questions. The first 4 questions related to increased anxiety, while the other 5 related to self-restraint in social life. For these questions, the frequency of participants responding “I strongly agree/I agree” was presented, along with correlations to the knowledge score. Additionally, information regarding childcare and the stocking of materials after the start of the pandemic was presented as frequencies.
The anxiety levels of participants were evaluated using the generalized anxiety disorder-7 (GAD-7) scale(18), which has been adapted to Turkish with proven validity and reliability(19). Total scores were categorized as follows: 0 points indicated “no anxiety”; 1-4 points indicated “mild anxiety”; 5-9 points indicated “moderate anxiety”; and 15 points and above indicated “severe anxiety”.
The study group was divided into three categories based on gestational age: 1st trimester (1-13 weeks), 2nd trimester (14-26 weeks), and 3rd trimester (27-40 weeks). Marital status was categorized as married, cohabiting, or single/divorced/separated. Professions were grouped into the categories: housewife, unemployed, blue collar, and white collar. Spousal profession was categorized similarly. Monthly family income was categorized based on multiples of the minimum wage: below the minimum wage, around the minimum wage, 2-3 times the minimum wage, and 4 times the minimum wage or above.
This study was approved by University of Health Sciences Türkiye, İzmir Tepecik Education and Research Hospital, Local Ethics Committee (approval no: 2020/6-20, date: 13.05.2020). All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee. All participants provided written informed consent. Confidentiality was maintained throughout the study.
Statistical Analysis
IBM SPSS® (Statistical Package for the Social Sciences) version 25.0 (IBM Corp., Armonk, NY) was used for statistical analyses. The Normal distribution was evaluated using Q-Q plots, histograms, skewness and kurtosis values, and the Shapiro-Wilk test. As the data did not conform to a normal distribution, non-parametric tests were used. Frequency values were presented as n (%), and average values as median (25th-75th percentile). Spearman correlation analysis was used to assess the relationships between variables. A p-value <0.05 was considered statistically significant.
Results
The median age of the 416 pregnant women in the study group was 28. Those in the third trimester of pregnancy accounted for 210 (50.5%) of the participants. Primigravida women (first pregnancy) constituted 108 (25.9%) of the group. The proportion of women with one live birth was 38.2% (n=159). The median (25-75%) values for the number of pregnancies, live births, and children were 2 (1-3), 1 (0-2), and 1 (0-2), respectively.
In our study, 338 (93.3%) of the pregnant women were married, and 205 (49.3%) were primary- or secondary- school graduates. A large majority (n=398, 95.7%) lived in urban areas. Among the spouses of participants, 218 (52.4%) were primary or secondary school graduates, and 291 (70.0%) were blue collar workers. It was reported that 29.8% (n=124) of pregnant women had monthly incomes below the minimum wage. Socio-demographic characteristics of the study group are presented in Table 1.
All participants were aware of the COVID-19 pandemic. The three least-known propositions about the pandemic were: “People with the disease certainly have a complaint/finding” (27.2% correct); “All COVID-19 patients have serious symptoms” (31.5% correct); and “In order not to get COVID-19, we must try to stay at least 10 meters away from other people” (4.4% correct). Conversely, the most commonly known propositions were: “Touching the eyes, nose or mouth with dirty hands is risky” (90.9%); “Hands should be cleaned frequently with water-soap or alcohol-based disinfectants” (91.1%); “When coughing/sneezing, mouth/nose should be covered with tissue or elbow” (91.1%); “One should try to stay at home except in compulsory situations” (91.1%); and “As far as possible, we should avoid touching the eyes, nose and mouth with our hands” (91.3%). Questions and affirmative answers are presented in Table 2.
The median COVID-19 knowledge score of the study group was 13(12-15), with minimum and maximum values of 0 and 18, respectively. No correlation was found between the COVID-19 knowledge score and age (r=0.064; p=0.195). However, negative correlations were observed between the knowledge score and the numbers of pregnancies, live births, and children (r=-0.152, p=0.002; r=-0.162, p=0.001; and r=-0.169, p=0.001, respectively).
No relationship was found between the knowledge score and either marital status or residential area (rural/urban). However, the knowledge score increased with the education level of pregnant women and their partners (r=0.415, p<0.001; r=0.284, p<0.001, respectively). Similarly, scores were higher when pregnant women and their partners worked in white collar jobs. As the family income level increased, the COVID-19 knowledge score increased (r=0.288; p<0.001). Correlations between knowledge scores and socio-demographic characteristics are presented in Table 3.
In the study, 77.4% (n=322) of participants reported their level of knowledge regarding the pandemic as sufficient. A positive correlation was found between the COVID-19 knowledge score and self-perceived knowledge sufficiency (r=0.209; p<0.001). Sources of information were television (93.8%), internet (54.1%), health workers (40.6%), social media (40.6%), mobile news applications (33.4%), and friends/relatives (31.3%).
The frequency of participants who reported performing the seven positive behaviors as “very well/well” ranged from 92.8% to 96.4%. Positive correlations were found between the application of each positive behavior rated “very well/well” and the COVID-19 knowledge score (p<0.001 for each). Frequency distributions for positive behaviors are presented in Table 4.
Regarding changes in attitudes, 53.0% of participants reported, “My concerns about my children increased. No correlation was found between anxiety regarding children and knowledge level (p>0.05). However, correlations were found between other concerns and knowledge level (p<0.05). A positive correlation was found between self-restraint in social life (reported at >90% frequency) and knowledge level (p<0.05). The proportion of respondents stating “I try to stay away from the healthcare professionals I know” was 80.7%; no correlation was found between this avoidance and the knowledge score.
Among the 293 (70.4%) pregnant women with children, 70 (23.9%) reported needing additional childcare support during the pandemic. Of those not needing support, care was provided by themselves (17.9%), by older family members (20.6%), or by professional caregivers or friends (1.8%).
The median anxiety score (GAD-7) was 6.00 (2.00-10.00). Anxiety was absent in 68 (16.3%) women. Mild, moderate, and severe anxiety were found in 107 (25.7%), 132 (31.7%), and 109 (26.2%) women, respectively. No correlation was found between the anxiety score and the COVID-19 knowledge score (r=0.077; p=0.116).
Discussion
There is currently no evidence that pregnancy acts as a risk factor for COVID-19(14). Literature investigating the levels of knowledge, behavior, and attitudes among pregnant women is limited. Our study offers an opportunity to assess these parameters among pregnant women in Türkiye.
All participants were aware of the COVID-19 pandemic. The average knowledge score was 13 out of 18, indicating a knowledge level of over 70%. In a study by Nwafor et al.(13) in Nigeria, the knowledge level regarding preventive measures was reported as good in 60.9% of pregnant women. Similarly, another study found that the majority of respondents had adequate knowledge about COVID-19 infection(20).
In our study, the level of knowledge decreased as the number of pregnancies, live births, and children increased. Although this could be affected by age, no correlation was found between age and knowledge level. Multiparity was also a factor reducing knowledge levels in the Nigerian study(13). In Türkiye, multiparity is frequently observed in women with lower socio-economic status and lower education levels. This may be due to various cultural factors, as well as insufficient knowledge of, or access to, birth control methods.
Our results indicated that higher levels of COVID-19 knowledge were associated with higher education levels, white collar professions, and higher family income (Table 3), aligning with the results of the Nigerian study(13).
Mass media were the primary sources, whereas the proportion obtaining information from healthcare workers was relatively low (40%). Another study similarly reported that most participants received information from mass media, while only 20% received information from healthcare workers(20). This suggests that healthcare professionals should increase educational efforts to provide adequate disease information.
The positive correlation between the study group’s acceptance of their knowledge as “sufficient” and their actual knowledge scores suggests that participants consciously obtained information and followed pandemic developments. Knowledge level is a critical factor influencing attitudes and practices. Several studies have presented a positive correlation between knowledge levels and attitudes/practices regarding COVID-19(21, 22). Similarly, our study showed a positive correlation between knowledge level and the adoption of protective behaviors (Table 4). Conversely, the Nigerian study reported insufficiencies in the development of positive behaviors(13).
Anxiety, depression, and self-reported stress are common psychological reactions to the pandemic(23). In this study, concerns about personal health, the unborn baby, and elderly relatives were high. Although vertical transmission and transmission via breast milk appear possible, current data have not yet definitively demonstrated COVID-19 positivity in fetal samples(24). While correlations were observed between general anxiety and knowledge level, 53% of participants expressed concern for their children regardless of their knowledge level. Another study similarly found heightened anxiety regarding older relatives, children, and unborn babies among pregnant women(25).
Approximately a quarter of pregnant women with children reported needing childcare support during the pandemic. This need should be addressed by governmental and non-governmental organizations, individually or jointly.
Our results showed that approximately 90% of pregnant women complied with social restrictions as suggested by the Turkish government and WHO(26, 27), with compliance correlating with knowledge levels. Healthcare workers on the front lines may face stigma and discrimination(28), which may intensify as cases and mortality rates rise. Approximately 80% of our participants preferred to avoid contact with healthcare workers. Interestingly, as the level of knowledge increased, stigmatization decreased (Table 5). Disseminating precise information may help mitigate COVID-19-related stigma.
Managing health anxiety is crucial during pandemics(29). Prenatal maternal distress can have negative impacts. Increased levels of anxiety and psychiatric symptoms have been reported in pregnant women during the pandemic(30). Saccone et al.(31) found that more than half of pregnant women (53%) experienced severe psychological impacts. In our study, moderate-to-severe anxiety was observed in approximately 60% of participants. No correlation was found between anxiety levels and knowledge levels. However, Wang et al.(32) reported that while accurate health information was associated with lower stress levels, female gender and poor self-rated health were associated with higher psychological impact.
Study Limitations
Because of the rapid progression of the pandemic, a validity and reliability study of the questionnaire could not be conducted. Furthermore, this was a cross-sectional, single-center study. However, given the limited number of publications measuring knowledge, attitudes, and awareness among pregnant women, this study makes a significant contribution to the literature.
Conclusion
Little is known about the effects of COVID-19 on pregnancy. The COVID-19 knowledge levels of the pregnant women in this study were found to be substantial. Positive correlations were found between knowledge levels and positive behaviors, post-pandemic attitudes, education level, and socio-economic status. To protect the physical and psychological well-being of pregnant women and their babies, continuing education for health professionals is recommended. These results also highlight the need to focus on groups with lower knowledge levels.
