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. 2022 Nov 30;17(11):e0274252. doi: 10.1371/journal.pone.0274252

Knowledge, attitudes, and practices (KAP) towards COVID-19 pandemic among pregnant women in a tertiary hospital in Karachi, Pakistan

Sumaira Naz 1, Syeda Dur e Shawar 1, Shamila Saleem 1, Ayesha Malik 1,*, Amir Raza 1
Editor: Prasenjit Mitra2
PMCID: PMC9710773  PMID: 36449555

Abstract

Background

The aim of this study was to evaluate the knowledge, attitude, and practices (KAP) of the pregnant population during the COVID-19 pandemic in a tertiary care hospital.

Methods

This cross-sectional study was conducted at Aga Khan University Hospital, Karachi, Pakistan. KAP towards COVID-19 was assessed using 21-item questionnaires. A score for each category was calculated and points were summed. The outcome variables of KAP were compared with demographic characteristics. Data were analyzed by using SPSS 19.

Results

A total of 377 patients participated in the study. The majority of the patients were multiparous (36.8%) in the age group of 30-40years (42.4%). More than 90% of patients were aware of COVID-19 symptoms and mode of transmission. They were aware of no cure for disease and optimum social distance. Although < 50% of patients truly answered the questions regarding the impact of COVID-19 on the risk of congenital malformation, vertical transmission, and the effect of infection on the mode of delivery. Regarding attitude and practices,> 90% of patients were anxious about fetal and personal safety, they are using a facemask, sanitizing their hands regularly, and avoiding social gatherings. Univariate and multivariable linear regression analysis showed statistically significant results among demographic variables (age, parity, family members, occupational status, and source of information).

Conclusion

Pregnant patients demonstrated inadequate knowledge regarding the impact of COVID-19 on pregnancy. However positive attitude and practices on preventive measures were good. This highlights the need for health education for pregnant women for COVID-19 to improve knowledge on a constant basis.

Introduction

Coronavirus disease 2019 (COVID-2019), is an ongoing pandemic caused by a highly infectious novel virus COVID-19 belongs ta o large family of coronaviruses [1]. On January 31st, 2020, this outbreak has been declared a serious global health emergency by the World health organization (WHO) [2].

The course of illness ranging from mild flu-like illness to severe diseases like pneumonia, acute respiratory distress syndrome (ARDS), aseptic shock, and multi-organ failure [3]. Presently there is no specific treatment available for this disease [4]. Despite the implementation of vaccination, the third wave of this pandemic has gripped the whole globe and resulted in thousands of new cases and death all over the world [5].

Pregnancy is an immune-compromised state, which predisposes pregnant women to infection. Because of this sudden outbreak of COVID-19, lots of stress and anxiety have been created among pregnant women in different parts of the world [6]. The main reason for this anxiety and fear is the lack of provision of accurate information regarding pregnancy with COVID-19 infection and its complications [7]. In addition, there are concerns regarding the impact of COVID-19 infection on pregnancy, fetal, and neonatal outcomes all over the world [8].

Therefore, it is important to identify their worries and help them to reduce fear by providing correct and evidence-based information regarding COVID-19 disease and its sound effects on pregnancy [9].

Literature suggests that pregnant women with hypertensive, cardiovascular, and respiratory system diseases are at higher risk of maternal mortality in COVID-19 [10]. Although national data on COVID 19 related to pregnancy have been lacking. Hence, there is an urgent need for the evaluation of pregnant women’s awareness regarding COVID-19 in developing countries like Pakistan to facilitate appropriate antenatal, intrapartum, and postpartum care. This Study explored the Knowledge, attitude, and practices (KAP) among pregnant patients attending during this COVID-19 outbreak.

Materials and method

This cross-sectional study was conducted with a non-probability convenience sampling method over a 3-month period from February 15, 2022, to April 15, 2022, among pregnant women in obstetrics and gynecology department of a tertiary care hospital, Aga khan university hospital (AKUH) Karachi during an outbreak of covid-19. Data was collected after approval of the ethical review committee with the reference number; 2020-4976-12883 at Aga khan university hospital Karachi, Pakistan.

The sample size calculated by the WHO calculator is 360 assuming a response rate of 50%, confidence interval (CI) of 95%, Z as 1.96, and margin of error d as 5% by assuming 5000 deliveries occurred per annum in obstetrics and gynecology unit as per unit annual statistics. Hence, the sample size was n = (Z) 2 P (1-P) N /d2 (N-1) + (Z) 2 P (1-P), by considering the incomplete responses, we included the target sample of 380 [11].

All pregnant patients attending clinics, wards, and labor rooms in a latent phase were invited to participate in the study, who agreed to participate, and informed consent in writing has been taken. After the written consent study questionnaire was used to assess the Knowledge regarding COVID-19, also their attitude and Practices toward this outbreak. Patients not giving consent, who was in active labor, with acute emergencies were excluded.

All patients coming to the clinic had their vitals checked in the assessment Room. They were identified and approached in the assessment room and invited to participate in the study. Informed consent was taken in a history-taking room which was a separate room in the clinic.

Patients admitted to wards and labor room (latent phase), after taking Informed consent, are guided to a separate room (A2 teaching room located in between labor room and wards) to complete the questionnaire by themselves, whereas patients in the labor room (in latent phase) were approached in their assigned room (non-sharing) for consent. These rooms were used to ensure privacy and social distancing. One of the team members was available to facilitate the patients in case of queries related to the questionnaire. The time duration for filling one form was10–15 minutes.

Data was collected on the self-administered questionnaire, developed after a literature review and from WHO recommendation [12]. The questionnaire was prepared in English and then translated into the Urdu language with the assistance of language experts. The content of the questionnaire was grouped into various themes, including demographic characteristics, obstetric variables, knowledge, attitude, and practice of COVID-19-related questions. The questionnaire consisted of two parts: First part included demographic variables; age, parity, family members, education, source of information, employment, and area of residence. The age variable was categorized as: <30, 30–40, >40 years, and parity as a primigravida, para 1+0, para 2 to 4, and para 5+0 or more, whereas the number of households was taken as less than 4, 4–7, more than 7 members in family and education was categorized into no formal education, basic education (Matriculation), college and university level Employment status was considered an as a housewife and working. The area of residence was taken as rural and urban whereas the sources of information included health workers, friends and relatives, television, and the internet.

The second part included a total 21-item scale. Of the 21, twelve questions were regarding knowledge (clinical presentations, transmission routes, prevention of COVID-19) with additional 3 questions for attitude and 6 for practices against this outbreak.

Each question of the knowledge section had three options (Yes/No/ don’t know). The correct answer was given 1 score and the incorrect answer was given a zero score. Overall knowledge scores ranged from zero to twelve. Individual scoring of 10 and above was categorized as excellent whereas scores below 10 were considered as poor knowledge.

The attitude section consisted of three questions, and the response of each item was collected on a 3-point Likert scale as follows 0 (“Disagree”), 1 (“Neutral”), and 2 (“Agree”). The total score ranged from 0 to 6 with an overall greater score indicating more positive attitudes toward the COVID-19. A cut-off level of 5–6 was set for more positive attitudes towards the prevention of COVID infection [13].

Similarly, the practice section included 6 items to assess practice measures related to the COVID-19, and each of the six questions was answered as Yes, No, and Sometimes. Practice items’ total scores ranged from 0-to 6, with an overall greater score indicating more frequent practice towards the COVID-19. A cut-off level of ≥5 is set for more frequent practices [14].

The reliability of the questionnaire was assessed by using Cronbach’s alpha and the Cronbach’s alpha coefficient of the knowledge, attitude, and practice were 0.93, 0.98, and 0.85, respectively, and overall Cronbach’s alpha of KAP questions was 0.93, which indicates acceptable internal consistency. No data from the pilot study were included in the final analyses. A pretest was conducted for understandability, language clarity, and relevance of the questionnaire among pregnant women by taking 10% of the sample size.

Data was entered and analyzed using SPSS version 19. Descriptive analysis was done by treating age, parity, and family members as continuous variables, whereas education was analyzed as ordinal data. Employment status, source of information, and residence were categorized as nominal data. Frequencies and percentages were calculated for categorical variables. Mean and standard deviation was calculated for continuous variables.

Scoring categories of knowledge, attitude, and Practices were compared with different categories of age, parity, number of family members, employment status, source of information, educational status, and area of residence. Chi-square test or fisher’s exact test was used for Univariate analysis.

Multivariable linear regression analysis using all the demographic variables as independent variables and knowledge, attitude and practice score as the outcome variable were conducted to identify factors associated with knowledge. P≤0.05 was considered as significant.

Results

A total of 380 women participated in the study however, we excluded three participants due to missing data. A total of 377 pregnant women have considered for the final analysis and the response rate was 99%. Of the total, 55.2% of women were below 30 years of age and 42.7% of pregnant women were of 31 to 40 years. More than 80% of participants belong to urban areas. More than 90% of the women had an education at the university or college level. Most of the women were housewives (76.4%). Out of 377 women, around 38.5% were grand multiparous and multiparous, while 23.3% of women were nulliparous. The main sources of information for these women were the internet (37.75%) and television (26%), while 20% of participants’ source of information was health care workers (Table 1).

Table 1. Characteristics of pregnant women [n = 377].

Variables Frequency Percentage
Age Groups
≤ 30 208 55.2%
31–40 161 42.7%
>40 8 2.1%
Parity
Zero 88 23.3%
2–4 144 38.2%
≥5 145 38.5%
Area of Resident
Rural 53 14.1%
Urban 324 85.9%
Number of family members:
<4 155 41.1%
4–7 176 46.7%
>7 46 12.2%
Education status
No formal education 4 1.1%
Basic/Metric Level 25 6.6%
College Level 119 31.6%
University Level 229 60.7%
Occupational Status
Housewife 288 76.4%
Working women 89 23.65
Sources of Information
Health workers 77 20.4%
Friends and relatives 60 15.9%
Television 98 26%
Internet 142 37.75
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Less than 50% of the women responded that COVID19 infection developed the severe disease in pregnancy, it causes poor pregnancy outcome if occurs in the third trimester, affects the mode of delivery, it’s increased the abnormality of the fetus, and increases the risk of vertical transmission. Fifty-five percent of women replied that breastfeeding is safe for mild COVID 19 infections. More than 90% of the participants were aware of the symptoms, spread of infection, an optimum social distancing between individuals, and lack of optimal treatment of COVID19. There were 85% of women responded that health care workers should wear an N-95 mask all the time while 75% of women were that patients without symptoms can transmit the infection to others. Overall responses of knowledge regarding the COVID 19 are illustrated in (Fig 1).

Fig 1. Knowledge of pregnant women toward COVID-19. [n = 377].

Fig 1

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The average knowledge score was 6.63 ± 2.48 (Range: 0–12) (Table 2). There were only 13(3.4%) women who had excellent knowledge (Score: 11–12), 78 (20.7%) women had good knowledge (Score: 9–10) and most of the study participants 286(75.9%) had poor knowledge (Score Range: 0–8) (Fig 2).

Table 2. Mean KAP score of women toward COVID-19.

KAP Mean ± SD 95% CI for Mean Min-Max
Knowledge Score 6.63±2.48 6.38–2.48 0–11
Attitude Score 5.36±1.81 5.18–5.54 0–6
Practice Score 5.22±5.11 5.11–5.34 0–6
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Fig 2. Women’s KAP toward COVID-19.

Fig 2

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Nearly 88% of women had a positive attitude and the mean attitude score was 5.36±1.81 (Range: 0–6) as presented in (Table 2) & (Fig 2). Practices responses of women to limit the spread of COVID-19 are shown in (Table 3). Use of, a mask, sanitizer, and soap for hand washing, avoiding social gatherings, and maintaining a social distance of 6 feet was highly appreciated by study participants. The mean practice score was 5.22±5.11 (Range: 0–6) (Table 2).

Table 3. Women’s attitude and practice related to COVID 19 [n = 377].

Attitude Agree Disagree Undecided No answer
Are you anxious about your safety? 337(89.4) 31(8.2) 5(1.3) 4
Are you anxious about the safety of your fetus? 341(90.5) 17(4.5) 15(4) 4
Do you have confidence that PPE (personal protection equipment) and contact precautions can protect you against COVID-19 infection? 332(88.1) 36(9.5) 0(0) 9
Practices Yes No Sometimes No answer
Do you use a face mask? 374(99.2) 1(0.3) 2(0.5) 0
Do you use gloves? 180(47.7) 171(45.4) 25(6.6) 1
Do you use hand sanitizers? 361(95.8) 7(1.9) 9(2.4) 0
Do you use soap for hand washing? 364(96.6) 7(1.9) 3(0.8) 3
Are you avoiding large social gatherings 356(94.4) 12(3.2) 9(2.4) 0
Do you maintain a social distance of 6 feet with your peers? 334(88.6) 17(4.5) 26(6.9) 0
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Out of 377 women, only 91(24%) had excellent to good knowledge (Score: 9–12) and their attitude (score = 6), as well as practice score, was high (score: 5–6). Of 241(63.9%) had poor knowledge but their attitude and practice were above 90%. Two (0.5%) women had poor knowledge and negative attitude but the practice of these 2 women was appropriate (score = 4).

In Univariate analysis, regression coefficient showed that woman with age above 30 years (vs. ≤ 30, β = -2.87, p<0.01), grand multiparty (vs. no parity, β = -2.50, p<0.01), working women (vs. housewife, β = -4.29, p<0.01) and those women who had got information by internet (vs. others, β = -3.75, p<0.01) were significantly associated with low knowledge. In multivariate analysis, adjusted regression coefficient (by general linear model) showed that age above 30 years (vs. ≤ 30, β = -0.96, p<0.01), less family member<4 (vs. >7, β = -0.89, p<0.001), working women (vs. housewife, β = -1.58, p<0.01) and those women who had got information by internet (vs. others, β = -2.39, p<0.01) were significantly associated with lower knowledge score (Table 4).

Table 4. Univariate and multivariable linear regression analysis showing the factors associated with the knowledge score of pregnant women related to COVID-19.

Variables Unadjusted ß(SE) P-value Adjusted ß(SE) P-Value
Age Groups
≤ 30 Ref Ref
>30 -2.87(0.21) 0.0005 -0.96(0.24) 0.0005
Parity
≥5 -2.50(0.23) 0.0005 -0.64(0.36) 0.080
2–4 1.54(0.23) 0.0005 0.31(0.16) 0.049
Zero Ref Ref
Area of Resident - -
Urban -0.43(0.37) 0.24
Rural Ref
Family members:
<4 4.72(0.32) 0.0005 -0.89(0.27) 0.001
4–7 4.87(0.31) 0.0005 2.0(0.20) 0.0005
>7 Ref Ref
Education status - -
University/ College Level -0.40(0.47) 0.401
No/Basic Level Ref
Occupational Status
Working women -4.29(0.21) 0.0005 -1.58(0.19) 0.0005
Housewife Ref Ref
Sources of Information
Internet -3.75(0.18) 0.0005 -2.39(0.34) 0.0005
Health Workers/TV/Relative Ref Ref
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ß (SE) = Regression coefficient (Standard error)

Similarly, in univariate analysis for attitude and practice are showing that less than 30 years of age, nulliparous, less than 7 family members, basic level of education, housewives and sources of information by a health care worker, relatives, and television were significantly associated with a positive attitude and positive practice (Table 5).

Table 5. In Univariate analysis, factors associated with attitude and practice of pregnant women.

Variables n Attitude Frequent Practice
Positive n = 332 Negative n = 45 P-Value Yes n = 334 No n = 43 P-Value
Age Groups 0.0005 0.0005
≤ 30 208 208(100%) 0 208(100%) 0
>30 169 124(73.4%) 45(26.6%) 126(74.6%) 43(25.4%)
Parity 0.0005 0.0005
Zero 88 88(100%) 0 88(100%) 0
2–4 144 142(98.6%) 2(1.4%) 144(100%) 0
≥5 145 102(70.3%) 43(29.7%) 102(70.3%) 43(29.7%)
Area of Resident 0.001 0.001
Rural 53 53(100%) 0 53(10%) 0
Urban 324 279(86.1%) 45(13.9%) 281(86.7%) 43(13.3%)
Number of family members: 0.0005 0.0005
<4 155 155(100%) 0 155(100%) 0
4–7 176 176(100%) 0 176(100%) 0
>7 46 1(2.2%) 45(97.8%) 3(6.5%) 43(93.5%)
Education status 0.035 0.060
University/ College Level 348 303(87.1%) 45(12.9%) 305(87.6%) 43(12.4%)
No/Basic Level 29 29(100%) 0(0%) 29(100%) 0(0%)
Occupational Status 0.0005 0.0005
Housewife 288 287(99.7%) 1(0.3%) 287(99.7%) 1(0.3%)
Working women 89 45(50.6%) 44(19.7%) 47(52.8% 42(47.2%)
Sources of Information 0.0005 0.0005
Internet 142 97(68.3%) 45(31.7%) 99(69.7%) 43(30.3%)
Health Workers/TV/Relative 235 235(100%) 0(0%) 235(100%) 0(0%)
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Discussion

To date, few studies have been conducted to assess knowledge, attitude, and practices among pregnant women against COVID 19 pandemic [15]. Despite the implementation of the COVID-19 vaccine, this pandemic not only poses a significant threat to public health but also created a lot of fear and anxiety among pregnant women. This directs the importance of awareness and adherence of pregnant women to preventive measures. Hence this might be the first study, conducted in our country to evaluate Knowledge, attitude, and practices among pregnant women against COVID-19 disease during the third wave of this pandemic.

Our study findings showed most pregnant women had poor knowledge regarding the impact of COVID-19 infection on pregnancy, although they were aware of symptomatology, the spread of infection, use of N-95 mask, social distancing and lack of optimal cure of the disease to date.

Despite their lack of knowledge, they were found to have a good attitude and appropriate practices against COVID-19 infection (Table 2).

In our study, less than 50% of respondents, were unaware of the impact of COVID-19 infection on pregnancy and its possible feto-maternal outcomes. About half of the women reported that they think breastfeeding is safe for mild diseases (Fig 1). Similar findings have been debated in the literature and raised a lot of concerns in pregnant women related to their pregnancy and unborn babies [16]. We propose that their concerns can be addressed by upgrading their knowledge regarding the impact of COVID-19 infection on pregnancy by taking comprehensive antenatal counseling sessions on booking antenatal visits and by sharing appropriate and reliable evidence of this pandemic correlating with pregnancy.

However, most of the obstetric participants (> 90%) correctly identified the symptoms, mode of transmission social distancing, and lack of specific treatment for this infection. (Fig 1). These findings are consistent with a study conducted in Bangladesh [17]. The probable reason for good awareness regarding these questions may be the mass media (Internet and television), as most of the participants (76.4%) disclosed the mass media as the commonest source of information and the second reason may be the demographic variation as most of the participants belongs to the urban region (85.9%) with a higher level of education (90%). These findings were comparable to the study performed in Kenya [18].

Univariate and multivariable linear regression analysis shows the factors; the age of more than 30 years, grand multiparity working women, and sources of information by internet associated with poor knowledge score of pregnant women. (Table 4). These findings are consistent with one of the studies conducted in Nigeria [19].

Despite having poor knowledge regarding the impact of COVID 19 on pregnancy, study participants showed a positive attitude shown in Table 2 and Fig 2. This might be because of fear, anxiety, and concerns of pregnant women for their unborn babies, as most of them reported that they felt vulnerable and predominantly concerned about themselves (89.4%) and their unborn baby’s health (90%). These findings are almost comparable to the study conducted in Iran and Malaysia [20, 21] Though these results contrast with another study that proposed negative emotions, anxiety, and panic affect their attitude [22].

In our study respondents showed good practices (88,6%) Fig 2, with a mean practice score of 5.22±5.11 (Range: 0–6) (Table 2). These findings are also comparable to other studies done in Pakistan that also revealed a good level of practice (88.7%) [23]. The reason of good practices might be the difference in educational status, as most of the respondents (92.3%) had tertiary level education. The only difference was the study participants, we recruited pregnant women, whereas health care workers were the participants in a comparable study. The other possible reasons for good preventive practices (mean of 88.6%) among pregnant women were the absence of high-quality evidence regarding the safety of vaccines during pregnancy, so the absence of high-quality evidence, that they are more inclined toward preventive practice.

Univariate analysis showed age, parity, type of residence, family size and mass media were found to be the significant predictors of positive attitudes and good practices among pregnant women. (Table 5).

Conclusion

Pregnant patients demonstrated inadequate knowledge regarding the impact of COVID-19 on pregnancy. However, they showed a positive attitude and good practices in preventive measures. This highlights the need for community-based health education for pregnant women for COVID-19 to improve knowledge on a constant basis and further studies are required to see the impact of COVID-19 on pregnancy and feto-maternal outcomes.

Strengths and limitations

The strength of this study is that it is the first study to evaluate the KAP and its association with socio-demographic variables against coronavirus infection among pregnant mothers in Pakistan. As this study has been conducted in a single tertiary care center and targeted only pregnant women. Hence, the result of this study limits the generalization of the study findings. Further, a multicenter study may be considered to understand the pregnant women’s KAP so that the results can be generalizable for an action plan.

Supporting information

S1 Data. Data sheet.

(XLS)

Click here for additional data file. (287KB, xls)

Acknowledgments

Declarations our gratitude and appreciation go to the data collectors, pregnant women participants, physicians, and authorities of Aga Khan University Hospital.

Data Availability

All relevant data are within the paper and its Supporting Information file.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Prasenjit Mitra

22 Dec 2021

PONE-D-21-19464Knowledge, attitudes, and practices (KAP) towards COVID-19 pandemic among pregnant women in a tertiary hospital Karachi, PakistanPLOS ONE

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We look forward to receiving your revised manuscript.

Kind regards,

Prasenjit Mitra, MD, CBiol, MRSB, MIScT, FLS, FACSc, FAACC

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

3. Please state whether you validated the questionnaire prior to testing on study participants. Please provide details regarding the validation group within the methods section.

4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

5. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

6. Please include a separate caption for each figure in your manuscript.

7. Please ensure that you refer to Figure 2 in your text as, if accepted, production will need this reference to link the reader to the figure.

8. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files".

9. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. Sample size calculated by WHO calculator is 380 assuming a response rate of 50%, confidence interval (CI) 95%, Z as 1.96, and margin of error d as 5% by assuming 5000 deliveries occurred per annum in obstetrics and gynecology unit as per unit annual statistics – VERIFY AND INCLUDE THE CALCULATION IN THE TEXT

2. Explain the sampling method

3. Individual scoring of 10 and above were categorized as excellent whereas score below 10 were considered as poor knowledge – HOW WAS THE CUT OFF DETERMINED

4. QUESTIONNAIRE – 21 ITEM QUESTIONNAIRE – Explain the validation process

5. The attitude section consisted of three questions, and the response of each item collected on a 3 point Likert scale as follows 0 (“Disagree”), 1 (“Undecided”), and 2 (“Agree”) – UNDECIDED CATEROGRY IN LIKERT SCALE IS NOT UNIVERSALLY FOLLOWED, BETTER TO BE CONVERTED AS NEAUTRAL

6. The total score ranged from 0 to 6 with an overall greater score indicates more positive attitudes towards the COVID-19. A cut off level of ≥ 5 was set for more positive attitudes towards the prevention of COVID infection – HOW WAS CUT OFF ARRIVED?

7. The reliability of the questionnaire checked by conducting a pretest among pregnant women by taking 5% of the sample size. From the pretest, understandability, clarity, and organization of the questionnaire will be checked and reviewed – IF RELIABALITY WAS DONE – WHATS THE CRONBACH’S ALPHA VALUE AND ITEM ANALYSIS TO BE EXPLAINED

8. STUDY TOOL – The 21 item questionnaire – Validation process is not explained in the article.

9. Data was entered and analyzed using SPSS version 21. Data was analyzed by using SPSS 19. – DESCRIBE THE VERSION CLEARLY AND MENTION THE LICENSE AGREEMENT

10. Calculated sample size is 380, but the results were given only for 377 due to 3 missing data which is less than optimum sample size – Author has to view this seriously as sampling and sample size determines the internal and external validity of any quantitative study.

Reviewer #2: Summary:

The study is a well-grounded scientific research to assess the Knowledge, attitude and practice regarding COVID 19 among pregnant mothers. The findings of the study will be useful in identifying and filling the gaps in knowledge regarding COVID 19 among pregnant mothers.

Background:

1. WHO, ARDS and KAP has to be expanded for the first time in the manuscript before using them as abbreviations thereafter.

2. Since study has been completed the phrase “study has been planned” can be avoided. Instead “Study was done” can be used.

3. Grammatical errors are present throughout the background section which needs to be addressed.

4. COVID – 19 has to be represented uniformly in capital letters throughout the manuscript.

5. The Justification for the study could be explained in more detail with detailed statistics regarding COVID 19 related deaths among preganant mothers - Globally, Nationally and in the area of study.

Methods:

1. More explanation is required regarding the sample size calculation. (Eg: Reference for WHO sample size calculator)

2. Since the questionnaire is self-made and not standardised, Cronbach alpha and rationale behind choosing the cut-off has to be mentioned in the manuscript. The author could explain whether they used median/mean or interquartile range of the scores to choose the cut-offs.

3. In page 5, line 115, terms like “will be checked and reviewed” has to be avoided as the study is completed.

4. Sampling method and study duration are not mentioned in the methods section.

5. The author could provide details regarding the language in which questionnaire was used.

6. Details regarding the mode of interview could be provided by the author. They could mention whether the participants filled on their own or an investigator asked questions and filled the form.

Results:

1. In the results section, Table 1 could to be cited in Page 6, Line no:115 to give readers that the details are present in frequency table.

2. In figure 1, the numbers looks pixelated and not visible. The authors could provide an image with good clarity so that, the numbers looks readable.

3. The authors could give details regarding the participants who gave no answer in attitude and practice section and how those responses were used in analysis.

4. The authors could interpret the beta coefficients in details to add value to the interpretation of the findings.

5. In table 5, since 0 is present in many of the cells, the authors could give details on the statistical test in the univariate analysis used to establish association between variables.

Discussion:

1. Repetition of findings mentioned in the results could be avoided in the discussion. Instead a gist can be given and discussed in detail with relevant study comparisons.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Nov 30;17(11):e0274252. doi: 10.1371/journal.pone.0274252.r002

Author response to Decision Letter 0

22 Jun 2022

RESPONSE TO REVIEWER

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

Manuscript style including file name is corrected

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

Data was collected on the self-administered questionnaire, developed after a literature review and from WHO recommendation [ ]. The content of the questionnaire was grouped into various themes, including demographic characteristics, obstetric variables, knowledge, attitude, and practice of COVID-19-related questions.

3. Please state whether you validated the questionnaire prior to testing on study participants. Please provide details regarding the validation group within the methods section.

A pretest was conducted to ascertain the validity of the questionnaire. Mentioned in manuscript

4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Link of Data set is created in Manuscript before references

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

5. Please include your full ethics statement in the ‘Methods section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Data was collected after approval of the ethical review committee (Reference number; 2020-4976-14204) of (Aga khan university hospital (AKUH) Karachi, Pakistan. Anonymity and confidentiality of data were maintained.

Data were collected during the full quarantine in March and April 2020.

Pregnant patient attending obstetric clinics for consultation were asked to participation in the study, who agreed for participation an informed consent in writing has been taken before completing questionnaire.

6. Please include a separate caption for each figure in your manuscript.

Incorporated in manuscript

7. Please ensure that you refer to Figure 2 in your text as, if accepted, production will need this reference to link the reader to the figure.

Incorporated in manuscript

8. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files".

9. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table.

Incorporated in manuscript

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

________________________________________

5. Have the authors made all data underlying the findings in their manuscript fully available?

Provided in Covering letter and as a supplementary file with name of S1 Data sheet

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. Sample size calculated by WHO calculator is 380 assuming a response rate of 50%, confidence interval (CI) 95%, Z as 1.96, and margin of error d as 5% by assuming 5000 deliveries occurred per annum in obstetrics and gynecology unit as per unit annual statistics – VERIFY AND INCLUDE THE CALCULATION IN THE TEXT

1. The sample size calculated by the WHO calculator is 360 assuming a response rate of 50%, confidence interval (CI) of 95%, Z as 1.96, and margin of error d as 5% by assuming 5000 deliveries occurred per annum in obstetrics and gynecology unit as per unit annual statistics. Hence, the sample size was n= (Z) 2 P (1-P) N /d2 (N-1) + (Z) 2 P (1-P), by considering the incomplete responses, we included the target sample of 380. 2.

2. Explain the sampling method

Non-Probability convenience sampling method

3. Individual scoring of 10 and above were categorized as excellent whereas score below 10 were considered as poor knowledge – HOW WAS THE CUT OFF DETERMINED

Above and equal to 80% (10/12) was considered excellent to good knowledge.

4. QUESTIONNAIRE – 21 ITEM QUESTIONNAIRE – Explain the validation process

The validity of content was reviewed for appropriateness, relevance, applicability, and accuracy by two senior faculty members, epidemiologist and educationist. Long statements were rephrased and make them clear, and unambiguous. Items that need exclusion were highlighted and removed.

5. The attitude section consisted of three questions, and the response of each item collected on a 3 point Likert scale as follows 0 (“Disagree”), 1 (“Undecided”), and 2 (“Agree”) – UNDECIDED CATEROGRY IN LIKERT SCALE IS NOT UNIVERSALLY FOLLOWED, BETTER TO BE CONVERTED AS NEAUTRAL

UNDECIDED have been replaced into Neutral

6. The total score ranged from 0 to 6 with an overall greater score indicates more positive attitudes towards the COVID-19. A cut off level of 6 was set for more positive attitudes towards the prevention of COVID infection – HOW WAS CUT OFF ARRIVED?

Above and equal to 80% (5/6) was considered good attitude.

7. The reliability of the questionnaire checked by conducting a pretest among pregnant women by taking 5% of the sample size. From the pretest, understandability, clarity, and organization of the questionnaire will be checked and reviewed – IF RELIABALITY WAS DONE – WHATS THE CRONBACH’S ALPHA VALUE AND ITEM ANALYSIS TO BE EXPLAINED

Incorporated in methodology

Cronbach’s Alpha for Knowledge = 0.93 (12 item)

Cronbach’s Alpha for attitude = 0.98 (3 item)

Cronbach’s Alpha for practice = 0.85(6 item)

8. STUDY TOOL – The 21 item questionnaire – Validation process is not explained in the article.

Same as question 4

9. Data was entered and analyzed using SPSS version 21. Data was analyzed by using SPSS 19. – DESCRIBE THE VERSION CLEARLY AND MENTION THE LICENSE AGREEMENT

SPSS 19 version Used

10. Calculated sample size is 380, but the results were given only for 377 due to 3 missing data which is less than optimum sample size – Author has to view this seriously as sampling and sample size determines the internal and external validity of any quantitative study.

Also Incorporated in manuscripts

The sample size calculated by the WHO calculator is 360 assuming a response rate of 50%, confidence interval (CI) of 95%, Z as 1.96, and margin of error d as 5% by assuming 5000 deliveries occurred per annum in obstetrics and gynecology unit as per unit annual statistics. Hence, the sample size was n= (Z) 2 P (1-P) N /d2 (N-1) + (Z) 2 P (1-P), by considering the incomplete responses, we included the target sample of 380.

Reviewer#2: Summary:

The study is a well-grounded scientific research to assess the Knowledge, attitude and practice regarding COVID 19 among pregnant mothers. The findings of the study will be useful in identifying and filling the gaps in knowledge regarding COVID 19 among pregnant mothers.

Background:

1. WHO, ARDS and KAP has to be expanded for the first time in the manuscript before using them as abbreviations thereafter.

Corrected

2. Since study has been completed the phrase “study has been planned” can be avoided. Instead “Study was done” can be used.

Corrected

3. Grammatical errors are present throughout the background section which needs to be addressed.

Corrected

4. COVID – 19 has to be represented uniformly in capital letters throughout the manuscript.

Corrected

5. The Justification for the study could be explained in more detail with detailed statistics regarding COVID 19 related deaths among preganant mothers - Globally, Nationally and in the area of study.

Mentioned in manuscript

Methods:

1. More explanation is required regarding the sample size calculation. (Eg: Reference for WHO sample size calculator)

Mentioned above and Incorporated in manuscript.

2. Since the questionnaire is self-made and not standardized, Cronbach alpha and rationale behind choosing the cut-off has to be mentioned in the manuscript. The author could explain whether they used median/mean or interquartile range of the scores to choose the cut-offs.

Incorporated in manuscript

3. In page 5, line 115, terms like “will be checked and reviewed” has to be avoided as the study is completed.

Done

4. Sampling method and study duration are not mentioned in the methods section.

Mentioned above and in manuscript

5. The author could provide details regarding the language in which questionnaire was used.

The questionnaire was prepared in English and then translated into the Urdu language with the assistance of language experts. Mentioned in manuscript

6. Details regarding the mode of interview could be provided by the author. They could mention whether the participants filled on their own or an investigator asked questions and filled the form.

Participant filled themselves. And one of the team members was available to facilitate the patients in case of queries related to the questionnaire. Mentioned in manuscript

Results:

1. In the results section, Table 1 could to be cited in Page 6, Line no:115 to give readers that the details are present in frequency table.

Corrected in manuscript

2. In figure 1, the numbers looks pixelated and not visible. The authors could provide an image with good clarity so that, the numbers looks readable.

Corrected in manuscript

3. The authors could give details regarding the participants who gave no answer in attitude and practice section and how those responses were used in analysis.

Participant who did not respond were used in denominator in analysis and listed in table 3. For attitude, we observed 9 participants in which 4 did not respond in all three questions and five participants did not response 1 out of 3 questions of attitude.

For Practice, we observed three participants in which two participants did not response 1 out of 5 questions and one participants did not response 2 out of 5 question. See table 3, we included in the analysis

4. The authors could interpret the beta coefficients in details to add value to the interpretation of the findings.

Following lines also incorporated in results text

In Univariate analysis, regression coefficient showed that woman with above 30 years of age(vs. ≤ 30, β= -2.87, p<0.01), grand multiparty (vs. no parity, β= -2.50, p<0.01), working women (vs. housewife, β= -4.29, p<0.01) and those women who had got information by internet ( vs. others, β = -3.75, p<0.01) were significantly associated with low knowledge. In multivariate analysis, adjusted regression coefficient (by general linear model) showed that above 30 years (vs. ≤ 30, β= -0.96, p<0.01) , less family member<4 (vs. >7, β= -0.89, p<0.001), working women (vs. housewife, β= -1.58, p<0.01) and those women who had got information by internet ( vs. others, β = -2.39, p<0.01) were significantly associated with lower knowledge score (table 4). Corrected in manuscript also.

5. In table 5, since 0 is present in many of the cells, the authors could give details on the statistical test in the univariate analysis used to establish association between variables

Corrected in manuscript: Chi-square test or fisher’s exact test was used for Univariate analysis. . P≤0.05 was considered as significant.

Discussion:

1. Repetition of findings mentioned in the results could be avoided in the discussion. Instead a gist can be given and discussed in detail with relevant study comparisons.

Corrected in manuscript

________________________________________

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Corrected in manuscript.

Attachment

Submitted filename: RESPONSE TO REVIEWER.docx

Click here for additional data file. (31.1KB, docx)

Decision Letter 1

Prasenjit Mitra

25 Aug 2022

Knowledge, attitudes, and practices (KAP) towards COVID-19 pandemic among pregnant women in a tertiary hospital Karachi, Pakistan

PONE-D-21-19464R1

Dear Dr. malik,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Prasenjit Mitra, MD, CBiol, MRSB, MIScT, FLS, FACSc, FAACC

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. Check and verify the references - whether its in recommended

2. The reference articles mentioned in the discussion part are not done in the pregnant women population for comparison except one study from africa

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

Acceptance letter

Prasenjit Mitra

16 Nov 2022

PONE-D-21-19464R1

 Knowledge, attitudes, and practices (KAP) towards COVID-19 pandemic among pregnant women in a tertiary hospital in Karachi, Pakistan

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