INTRODUCTION
The coronavirus-19 disease (COVID-19) due to the SARS-CoV-2 virus had a drastic impact on the world, including on pregnant women1. In Wuhan, China, the majority (64.6%) of the pregnant women were absent from their antenatal follow-up and did not use all the personal protective equipment as a preventive measure2. Even though the SARS-CoV2 affected all population groups, pregnant women are particularly vulnerable due to physiological changes and impaired cellular immunity during pregnancy, which increased their risk of respiratory infection3,4. Pregnant women often faced preterm delivery due to COVID-19, and preventive measures were reported to be considered5,6.
Restricting movements, physical distancing, routine screening, isolation of infected persons, sanitizers, hand hygiene, environmental monitoring, and appropriate use of personal protective equipment like face masks were recommended to mitigate the COVID-19 pandemic7. COVID-19 was reported to make pregnant women more susceptible to stress and depression, resulting in miscarriage, preterm birth, low birth weight, and potentially even fetal death8. When pregnant women became infected, they required more hospitalization, intensive care unit admission, and mechanical ventilation, which may have affected the mode of delivery, impacted breastfeeding uptake and increased the physical burden of the pregnancy, resulting in psychological-emotional challenges9.
In low- and middle-income countries, COVID-19 negatively affected maternal and newborn health by decreasing the number of pregnant women attending prenatal care and institutional delivery10. Increased knowledge of pregnant women aids in reducing their negative attitude and increases the preventive measures taken against COVID-1911. Knowledge regarding the pandemic was a determining factor for pregnant women to achieve an ideal pregnancy during the COVID-19 pandemic12. Adherence to COVID-19 preventive measures among pregnant women is insufficient; hence, studies are recommended to create awareness about COVID-19 through the media and health education13,14.
Therefore, the study aimed to assess the knowledge, preventive practice, and associated factors in regard to COVID-19, among pregnant mothers attending antenatal care at public health facilities in East Gojjam Zone, Ethiopia.
METHODS
Study setting, design, and period
A cross-sectional study was conducted from 1 to 30 December 2020, in the East Gojjam Zone public health facilities in the Amhara regional state, Ethiopia. With population projection from the 2007 census, East Gojjam Zone has a total population of 2153937, of whom 1087221 are women. East Gojjam Zone is divided into 19 districts and 468 kebeles.
The study’s sample size was determined by using a single population proportion formula based on the following assumptions. Considering a design effect of 2 and 10% non-response rate, the final sample size was 847.
A multistage sampling technique was used. The study area had 103 health centers, eight primary hospitals, and one general and comprehensive specialized hospital. First, stratification was done based on the level of the health facility. Then, one-third of each type of health facility was taken by simple random sampling technique using a lottery method. Then, the proportional allocation for each health facility was done to allocate the sample size based on the case flow seen in the last month’s registration report. Finally, each study participant was selected using a systematic sampling technique for every 2nd pregnant woman after randomly selecting the 1st sample from 1 and 2.
Measurements and operational definitions
The dependent variables were knowledge and preventive practice regarding the COVID-19 pandemic. Knowledge and preventive practice were assessed by asking pregnant women 28 and 9 ‘yes’ or ‘no’ item questions, respectively. One point was given for the correct response, while zero was given for the incorrect response. The knowledge assessment questions consisted of the transmission, risk perception, preventive measures, and the signs and symptoms of COVID-19. Better knowledge among pregnant women was considered when pregnant women scored greater than or equal to the mean values of knowledge-related questions within our study sample. Pregnant women who scored greater than or equal to the mean values of practice-related questions were categorized as having better preventive practices for COVID-19.
Data collection tools and procedures
An interviewer-administered questionnaire was used to collect data from study participants. The questionnaire was adapted from a literature review15-18 with modification and contextualized into the local setting. The questionnaires collected information on sociodemographic characteristics, the obstetric and reproductive history of the study participants, and knowledge and practice assessment questions regarding COVID-19. Under the supervision of MSc midwives, BSc midwives collected the study’s data.
Data quality control
The questionnaire was written in English, then translated into the study participants’ native tongue, Amharic, and finally back into English. Before data collection, the supervisors and data collectors received training. A pre-test was conducted on 5% of the estimated sample size at Finote Selam General Hospital to evaluate the suitability of phrasing, clarity of the questions, and responder attitude to the questions and interviewer. The questionnaire was reviewed and confirmed for completion.
Data processing and analysis
The collected data were rechecked, coded, and entered into a computer using Epi Data version 4.6. and exported to SPSS version 25.0 for analysis. Descriptive statistics were computed to determine frequencies and percentages to describe the study population regarding sociodemographic and other relevant variables. Bivariable logistic regression was used to check variables associated with the dependent variable. Then, those variables with a p-value ≤0.25 were fitted to multivariable logistic regression adjusted for covariates. A p-value <0.05 with a 95% confidence level was used to declare a significant association of independent variables with the dependent variable. The Hosmer-Lemeshow goodness of fit test checked the model fitness.
RESULTS
Sociodemographic and obstetric characteristics of study participants
Out of 847 sampled pregnant women, 806 responded to the questionnaires, resulting in a response rate of 95.2%. Among the participants, 285 (35.4%) were aged 25–29 years, and the mean age was 27.6 ± 6.1 years. The majority, 763 (94.6%) of the study participants were married. More than half, 426 (52.9%) of the study participants were urban residents. About 42.6% of study participants did not have any formal education. Nearly half (329; 40.8%) of the study participants reported that their monthly income worsened in the past three months before the study (Supplementary Table 1). In all, 501 (62.2%) and 327 (40.6%) study participants were multigravidas and nulliparous, respectively. About 70 (8.7%) of the participants had a history of abortion (Table 1).
Table 1
Obstetrics-related characteristics of pregnant women attending ANC at East Gojjam Zone, Northwest Ethiopia public health facilities, 2020 (N=806)
Knowledge of study participants towards COVID-19 pandemic
Every study participant (100%) had heard of COVID-19, and about four-fifths (81.6%) knew it was a viral disease; and 90.3% of the participants said that COVID-19 could not be transmitted during breastfeeding. Headache (38.3%), fever (67%) and cough (68.6%) were the three most frequently mentioned COVID-19 symptoms by the participants (Table 2).
Table 2
COVID-19 knowledge of pregnant women attending ANC at public health facilities of East Gojjam Zone, Northwest Ethiopia, 2020 (N=806)
Preventive measures of pregnant women against COVID-19
Of 806 pregnant women who reported COVID-19 preventive measures, 514 (63.8%) washed their hands using soap and water, 410 (50.1%) wore a face mask when they were in public, 156 (19.4%) maintained social distancing, and 361 (44.8%) did not participate in public meetings. Also, 354 (43.9%) (95% CI: 40.5–47.3) pregnant women reported good preventive practices for COVID-19 (Table 3).
Table 3
Practice of COVID-19 preventive measures among pregnant women attending ANC at public health facilities of East Gojjam Zone, Northwest Ethiopia, 2020 (N=806)
Factors associated with knowledge of pregnant women
Pregnant women residing in urban settings had 1.9 times better knowledge of COVID-19 than those living in rural areas (AOR=1.9; 95% CI: 1.3–2.8). The odds of having good knowledge of COVID-19 among pregnant women who were civil servants were 2.3 times more likely than pregnant women of other occupations (AOR=2.3; 95% CI: 1.2–4.4). Based on education level, the odds of having good knowledge of COVID-19 among pregnant women who had an education level of secondary school or college and above, were 2.0 (AOR=2.0; 95% CI: 1.1–3.4) and 3 (AOR= 3.0; 95% CI: 1.6–5.7) times more likely compared to those who had no formal education, respectively. Women with a favorable attitude towards preventative measures were 2.1 (AOR=2.1; 95% CI: 1.5–2.9) times more likely than those with an unfavorable attitude to have good knowledge of the COVID-19 pandemic (Table 4).
Table 4
Multivariable logistic regression analysis of the factors associated with the knowledge related to COVID-19 of pregnant women attending ANC at public health facilities of East Gojjam Zone, Northwest Ethiopia, 2020 (N=806)
| Variables | Knowledge | OR (95%) | AOR (95%) | p | |
|---|---|---|---|---|---|
| Yes | No | ||||
| Residence | |||||
| Rural ® | 139 | 241 | 1 | 1 | |
| Urban | 277 | 149 | 3.2 (2.4–4.3) | 1.9 (1.3–2.8) | 0.001* |
| Age (years) | |||||
| 15–19 | 27 | 33 | 1.5 (0.8–2.7) | 1.0 (0.5–2.4) | 0.931 |
| 20–24 | 107 | 93 | 2.0 (1.3–3.2) | 1.1 (0.6–2.0) | 0. 819 |
| 25–29 | 161 | 122 | 2.3 (1.5–3.6) | 1.3 (0.7–2.2) | 0.341 |
| 30–34 | 73 | 57 | 2.3 (1.4–3.7) | 1.5 (0.8–2.6) | 0.192 |
| ≥35 ® | 48 | 85 | 1 | 1 | |
| Employment status | |||||
| Housewife ® | 199 | 297 | 1 | 1 | |
| Civil servant | 127 | 24 | 7.9 (4.9–12.7) | 2.3 (1.2–4.4) | 0.012* |
| Merchant | 55 | 48 | 1.7 (1.1–2.6) | 1.0 (0.6–1.7) | 0.910 |
| Private sector | 35 | 21 | 2.5 (1.4–4.4) | 1.6 (0.8–3.1) | 0.142 |
| Education level | |||||
| No formal education ® | 118 | 225 | 1 | 1 | |
| Primary | 76 | 94 | 1.5 (1.1–2.2) | 1.1 (0.7–1.7) | 0.764 |
| Secondary | 66 | 39 | 3.2 (2.1–5.1) | 2.0 (1.1–3.4) | 0.015* |
| College and higher | 156 | 32 | 9.3 (6.0–14.5) | 3.0 (1.6–5.7) | 0.001* |
| Gravidity | |||||
| Primigravida | 176 | 129 | 1.5 (1.1–2.0) | 1.5 (0.7–3.2) | 0.323 |
| Multigravida ® | 240 | 261 | 1 | 1 | |
| Gestation age (weeks) | |||||
| <37 | 376 | 363 | 0.7 (0.5–0.9) | 1.0 (0.5–1.9) | 0.965 |
| ≥37 ® | 41 | 26 | 1 | 1 | |
| Parity | |||||
| Nulliparous | 186 | 141 | 1.8 (1.3–2.5) | 0.8 (0.3–1.7) | 0.535 |
| Primipara | 99 | 71 | 1.9 (1.3–2.8) | 1.2 (0.7–2.0) | 0.456 |
| Multipara ® | 131 | 178 | 1 | 1 | |
| Number of living children | |||||
| <3 | 233 | 319 | 3.5 (2.6–4.9) | 3.6 (0.5–5.2) | 0.426 |
| ≥3 | 183 | 71 | 1 | 1 | |
| Attitude | |||||
| Favorable | 254 | 158 | 2.3 (1.7–3.05) | 2.1 (1.51–2.9) | 0.000* |
| Unfavorable ® | 162 | 232 | 1 | 1 | |
Associated factors of COVID-19 preventive practices
Pregnant urban residents were 1.5 (AOR=1.5; 95% CI: 1.1–2.2) times more likely than non-urban residents to apply better COVID-19 pandemic prevention practices. The odds of having good prevention practices among pregnant women who were civil servants (AOR=1.8; 95% CI: 1.0–3.2), merchants (AOR=1.9; 95% CI: 1.2–3.0), and other occupations (AOR=2.0; 95% CI: 1.1–3.6) where higher than those of pregnant women who were housewives. Pregnant women who had medical problems were 1.7 (AOR=1.7; 95% CI: 1.1–2.7) times more likely than their counterparts to apply better preventive practices for COVID-19. Pregnant women with better knowledge were 1.8 (AOR=1.8; 95% CI: 1.2–2.3) times more likely to have good preventive practices than those with inadequate knowledge of COVID-19 (Table 5).
Table 5
Multivariable logistic regression analysis on factors associated with implementing COVID–19 preventive measures among pregnant women attending ANC at public health facilities of East Gojjam Zone, Northwest Ethiopia, 2020 (N=806)
| Variables | Measures adopted | OR (95%) | AOR (95%) | p | |
|---|---|---|---|---|---|
| Yes | No | ||||
| Residence | |||||
| Rural ® | 260 | 120 | 1 | 1 | |
| Urban | 192 | 234 | 2.6 (2.0–3.5) | 1.5 (1.1–2.2) | 0.020* |
| Age (years) | |||||
| 15–19 | 23 | 37 | 1.1 (0.6–1.2) | 0.6 (0.3–1.3) | 0.193 |
| 20–24 | 87 | 113 | 1.3 (0.8–2.0) | 0.7 (0.4–1.3) | 0.285 |
| 25–29 | 144 | 139 | 1.8 (1.2–2.7) | 1.1 (0.6–1.8) | 0.817 |
| 30–34 | 51 | 79 | 1.1 (0.7–1.8) | 0.7 (0.4–1.2) | 0.235 |
| ≥35 ® | 49 | 84 | 1 | 1 | |
| Employment status | |||||
| Housewife ® | 169 | 327 | 1 | 1 | |
| Civil servant | 97 | 54 | 3.5 (2.4–5.1) | 1.8 (1.0–3.2) | 0.043* |
| Merchant | 56 | 47 | 3.1 (1.50–3.5) | 1.9 (1.2–3.0) | 0.010* |
| Private sector | 32 | 24 | 2.6 (1.5–4.52) | 2.0 (1.1–3.6) | 0.030* |
| Education level | |||||
| No formal education ® | 108 | 235 | 1 | 1 | |
| Primary | 73 | 97 | 1.6 (1.1–2.4) | 1.2 (0.8–1.8) | 0.493 |
| Secondary | 52 | 53 | 2.1 (1.4–3.3) | 1.2 (0.7–2.0) | 0.525 |
| Gravidity | |||||
| Primigravida | 155 | 150 | 1.6 (1.2–2.1) | 0.7 (0.3–1.4) | 0.297 |
| Multigravida ® | 199 | 302 | 1 | 1 | |
| Parity | |||||
| Nulliparous | 170 | 157 | 1.8 (1.3–2.5) | 2.1 (1.0–4.6) | 0.560 |
| Primipara | 69 | 101 | 1.2 (0.8–1.7) | 0.71 (0.5–1.2) | 0.162 |
| Multipara ® | 115 | 194 | 1 | 1 | |
| Medical problems | |||||
| Yes | 53 | 49 | 1.5 (1.0–2.2) | 1.7 (1.1–2.7) | 0.024* |
| No ® | 301 | 403 | 1 | 1 | |
| Overall knowledge | |||||
| Adequate | 230 | 186 | 2.7 (2.0–3.5) | 1.7 (1.2–2.3) | 0.001* |
| Inadequate ® | 124 | 266 | 1 | 1 | |
| Attitude | |||||
| Favorable | 215 | 197 | 2.0 (1.5–2.7) | 1.7 (1.3–2.4) | 0.001* |
| Unfavorable ® | 139 | 255 | 1 | 1 | |
DISCUSSION
In Ethiopia, the health sector’s welfare of mothers, newborns, and children remains a top priority. Still, a significant proportion of women did not utilize maternity healthcare services during the COVID-19 pandemic. With this in mind, we conducted a multicenter institution-based cross-sectional study to determine knowledge and preventive practice of the COVID-19 pandemic and associated factors among pregnant women attending ANC at public health facilities of East Gojjam Zone.
The proportion of pregnant women with adequate knowledge of COVID-19 was 51.6%. This result is in line with the study conducted in Gondar (55%)19, Gurage (54.84%)20, and India (50.5%)21. The mean scores reported in the current study were lower than those obtained in Wollega (75.4%)22, Egypt (57.6%)23, low-resource African setting (60.9%)24, and in a defence hospital in India (75.3%)25. This discrepancy might be due to differences in sociodemographic characteristics (education level) of the study participants compared to other studies, as the majority of the participants in this study did not have any formal education, which directly affects the level of knowledge.
Conversely, our finding was higher than that of the studies in Debre Tabor (46.8%)26, South Africa (43.5%)27, and Iraq (28%)28. This discrepancy might be due to the difference in the study setting. The present study was facility-based compared to the study done in Debre Tabor26. When pregnant women go to health institutions, they get the opportunity to receive some information regarding the pandemic during their antenatal care follow-up. Furthermore, more than half of the study’s participants were urban residents who could easily update themselves on COVID-19 through social media and mass media. Indeed, urban resident pregnant women were more likely to be knowledgeable about COVID-19 than their rural counterparts. This could be because urban residents have greater access to new information and update themselves through various media than rural residents. Studies from Wollega, Ethiopia22 and India25 support this finding.
Regarding occupation, pregnant women who were civil servants were 2.3 times more likely than housewives to be knowledgeable about the COVID-19 pandemic. The possible reason for this might be that pregnant women are employed, educated, and work in close collaboration with the government to reduce this pandemic’s burden, thus increasing their knowledge. Studies conducted in Debre Tabor, Ethiopia26 support this finding.
Participants who completed secondary school or college were 2.0 and 3.0 times, respectively, more knowledgeable about COVID-19 than those who did not attend formal education. The possible reason for this might be education is crucial and one of the most determinant factors in knowing and understanding adequately. Educated pregnant women can search, read, and follow social media, contributing to increased knowledge about the pandemic. The finding is supported by studies in Wollega22 and India25.
Pregnant women with a favorable attitude were 2.1 times more likely than those with an unfavorable attitude to be knowledgeable about the COVID-19 pandemic. The possible reason might be that the pregnant women’s positive attitude made them eager to hear, read and know about the coronavirus.
In all, 43.9% of the pregnant women had good preventive practices for COVID-19. This is in line with the study conducted in Wollega (43.6%)22. But this finding is lower than studies from Debre Tabor (47.6%)26, Gondar (47.4%)19, Guraghe (76.2%)20, South Africa (76%)27, the defence hospital in India (92.7%)25 and another study in India (69.8%)21. In low-income countries such as Ethiopia, a lack of knowledge and access to resources leads to poor pandemic prevention practices. Variations in pregnant women’s social lives across countries may have contributed to the discrepancy.
The mean scores reported in the present study were higher than the study conducted in Egypt (12.4%)23, in a low-resource African setting (30.3%)24, and Iraq (32.75%)28. The disparity could be attributed to a difference in the study period, as this study was conducted during the peak of COVID-19 in the country, causing pregnant women to be concerned about becoming infected and taking appropriate COVID-19 pandemic precautions. Furthermore, most study participants in the previous research studies were farmers and rural residents, which may result in poor prevention practices due to a lack of awareness about the severity of the COVID-19 pandemic. Pregnant women who reside in urban settings had better preventive practices for COVID-19 compared to their counterparts. This might be due to urban residents’ pregnant women having better access to information, being more educated, and being able to search for COVID-19 prevention methods. Studies in Guraghe, Wollega, low-resource African settings, and India20,22,24,25 supported this evidence.
Regarding occupation, pregnant women who were civil servants, merchants, and employed in the private sector were 1.8, 1.9, and 2.0 times more likely to practice COVID-19 prevention measures than housewives, respectively. This might be because pregnant housewives do not know what preventive measures need to be taken to avert the spread of COVID-19.
Pregnant women with medical problems were 1.7 times more likely to practice the prevention of COVID-19 when compared to their counterparts. The reason could be that pregnant women with medical problems may receive special attention and attempt to implement preventive measures against the COVID-19 pandemic.
Pregnant women who had adequate knowledge about COVID-19 practiced 1.7 times more preventive measures than pregnant women with inadequate knowledge. A possible explanation for this might be knowledge is a prerequisite for applying preventive measures for the COVID-19 pandemic. Studies in Ethiopia, South Africa, and India19,21,27 supported this finding.
The study revealed that pregnant women with a favorable attitude were 1.7 times more likely to practice good prevention of COVID-19 methods compared to those without medical problems. The reason might be that when pregnant women have a good feeling about COVID-19 prevention, they are more likely to implement the techniques of the global infection prevention strategies.
The COVID-19 pandemic might be the most intense and emotional experience in pregnant women’s lives. Good knowledge and practice of pregnant women regarding COVID-19 contribute to filling the gap in preventive measures. One of the most critical segments in managing COVID-19 is focusing on vulnerable targeted groups like pregnant women by assessing their knowledge and preventive practices.
Strengths and limitations
The study covered many study locations and all types of health facilities, which helped to generalize the representativeness of the population. Despite this, the study has some limitations. The cross-sectional study design in this study cannot attribute a cause-effect relationship of the factors. Due to the parallel occurrence of the COVID-19 infection, the study had a low response rate. Additionally, interviewer bias might have been introduced.
CONCLUSIONS
The findings of this study show that adequate knowledge and preventive practices against the COVID-19 pandemic among pregnant women attending antenatal were 51.6% and 43.9%, respectively. This information can be used within the context of future respiratory pandemics. Intensified education and enforcement of preventive measures will be required to interrupt the transmission chain, since knowledge level may not always translate to actual practice of preventing a pandemic. Mass media program mobilization and health education should be considered for those who have medical problems, do not have any formal education, are housewives, and are rural residents in developing countries. Additional future qualitative and observational studies that include pregnant women attending private health institutions might be advisable.
