Chinese pregnant women's knowledge, attitude, and practice of self-protection against coronavirus disease 2019 during the post-pandemic period: A structural equation modeling-based survey

Abstract

This study aimed to investigate the Chinese pregnant women's levels of knowledge, attitude, and practice (KAP) of self-protection against coronavirus disease 2019 (COVID-19) during the post-pandemic period, to aid the development of targeted health education. An online questionnaire was conducted for 2156 Chinese pregnant women from October 1, 2021, to December 31, 2021, to collect socio-demographic and KAP information. Structural equation modeling (SEM) was used to determine self-protection-related factors. The mean age of the participants was 30 ± 4.1 years. SEM indicated that pregnant women's level of knowledge can directly and indirectly affect the practice of self-protection (r = 0.23) through their belief, with a correlation coefficient of 0.56 and 0.46 between knowledge and belief and belief and practice, respectively. The “basic protection” and “hospital visits after infection” exerted the greatest impact on knowledge formation, with correlation coefficients of 0.85 and 0.89, respectively. Attitude had a direct effect on practice with a correlation coefficient of 0.46. “Awareness of prevention and control” and “family and social support” had the greatest impact on belief formation, with correlation coefficients of 0.77 and 0.73, respectively. Pregnant Chinese women were generally familiar with COVID-19 knowledge, and their levels of knowledge and beliefs particularly affect the practice of self-protection. Health education aimed at improving pregnant women's knowledge and belief toward self-protection against COVID-19 may be an effective way to guide them toward positive practices and promote their health and that of their babies.

1. Introduction

Recently, changes in lifestyle choices and fertility preferences have led to an annual decline in China's fertility rate, with increasingly severe accelerated aging and exacerbated low birth rate challenges [1]. In response to these challenges, China has introduced policies and measures to lift the cap on the number of births, including the “two-child” and subsequent “three-child” policies, allowing each family in China to have two or three children. However, these policies have failed to deliver significant improvements [2]. According to registered data on new births, the total number of newborns in China was 10.035 million in 2020, a precipitous decline of 4.6 million compared with that of 2019 [3].

Despite the declining annual number of births, the frequency of natural disasters has increased rapidly [4]. Globally, China is one of the countries that mostly experience natural disasters [5]. The coronavirus disease 2019 (COVID-19) pandemic, which has swept the globe since 2019, constitutes an immense public health threat, with great challenges to governments, medical systems, and individuals [6]. China has adopted several measures to effectively control this pandemic. The entire society is in the “post-pandemic era” with gradual recovery and reconstruction [7]. However, constantly emerging sporadic cases due to new mutated virus strains have led to ongoing small-scale epidemics in cities, counties, and communities [7]. These repeated outbreaks could result in health risks to perinatal women and their newborns. Having a vast knowledge about COVID-19 and the adoption of appropriate protective measures to cope with the epidemic are extremely important for individuals in the post-pandemic era. This could aid in disease prevention and the proper control of the spread of infection.

Overall, perinatal women were particularly vulnerable to COVID-19. The rapid increase in estrogen and progesterone concentrations during pregnancy could increase pregnant women's susceptibility to respiratory infectious diseases through the thickening of respiratory mucosa, leading to respiratory congestion and edema. The postpartum immunity level of mothers is low due to dramatic changes in their bodies and psychological systems following the pregnancy state. In addition, newborns are equally at risk during the pandemic because they are more vulnerable to infectious diseases due to the immaturity of their immune system and respiratory organs [8]. The susceptibility of perinatal women and their babies to COVID-19 demands a higher practice level of protection by perinatal women and their families against COVID-19. Awareness on the baseline self-protection techniques and requirements of pregnant women against COVID-19 could help determine the barriers to the promotion of civil protection and design schemes to combat the COVID-19 pandemic.

A few studies have Investigated the awareness level of the people regarding the appropriate protection against COVID-19. However, most respondents in such studies were healthcare professionals, representing the main forces behind infectious disease management in health fields, although their protection is extremely critical for public health [[9], [10], [11], [12], [13]]. To date, there have been no published reports on protection awareness in pregnant women.

As existing evidence suggests [14] that pregnant women are at a high risk of contracting infections due to coronaviruses [including COVID-19, severe acute respiratory syndrome (SARS), and Middle Eastern respiratory syndrome (MERS)] and developing health complications, it is essential to promote their protective capability against COVID-19. A lack of evidence on pregnant women's levels of knowledge, attitude, and practice (KAP) of self-protection against the epidemic may hinder the design of supportive measures to improve pregnant women's protection capabilities. Thus, we conducted a cross-sectional survey to assess KAP levels during COVID-19 among pregnant women to provide a reference for developing strategies and measures for corrective and protective efforts.

According to the KAP theoretical framework, relevant knowledge and skills can be acquired via learning, to aid the gradual cultivation of relevant attitude and subsequently facilitate changes in practice [15]. Knowledge and attitude may influence one another and serve as the mediating variables. Other variables (such as socio-demographics) may directly or indirectly affect KAP. However, the correlation and degree of impact of knowledge on attitudes, attitude toward practice, and knowledge on the practice of self-protection of pregnant women against COVID-19 are unknown. It is difficult for nurses to assign training time for knowledge instruction, attitude cultivation, and operational demonstration, corresponding to KAP formation. Thus, structural equation modeling (SEM) was used to determine the associations between the elements of KAP to provide suggestions for designing training programs for pregnant women.

2. Materials and methods

2.1. Study participants

Women in the third trimester of pregnancy who visited clinics for antenatal care in a top-tertiary maternal and children's hospital between October 1 and December 31, 2021, were selected in this cross-sectional study. This tertiary hospital, located in Southwest China, has an obstetric clinic that serves nearly 226,000 outpatients annually, making it adequate for participant recruitment. A pregnant woman was included if she 1) received regular prenatal checkups at the hospital, 2) voluntarily participated in the study, and 3) had no known history of auditory, language, or cognitive problems. Women diagnosed with fetal malformations or death and participants with more than 20% missing data in the questionnaire items were excluded.

The sample size was determined using the following formula [16]:

$$\mathrm{N}={\mathrm{Z}}_{\alpha }^2\mathrm{P}(1-\mathrm{P})/{\mathrm{d}}^2$$

A confidence interval of 95% with a Z_α value of 1.96 was adopted and the acceptable error, d, was set at 3%. The proportion of pregnant women with appropriate protection measures was estimated at 41.7% according to existing studies on public preventive practices other than for COVID-19 in China, owing to a lack of evidence [17]. Thus, the sample size comprised 1037 pregnant women in their third trimester. Considering the missing rate and subgroup analysis, a final sample size of 1881 pregnant women was considered.

2.2. Measures

The participants were assessed using a self-designed questionnaire developed by researchers based on clinical experience, the KAP theory, and an extensive literature review. After three rounds of expert consultation, the final questionnaire, consisting of two parts (the general information and self-protection against COVID-19 items), was designed. The general information section comprised 17 items, which mainly included demographic data and medical history (such as age, education, pre-pregnancy body mass index [BMI], health status of family members, income, and obstetric history). The self-protection section covered three dimensions (KAP on self-protection against COVID-19) and included 51 items.

2.3. Data collection procedure

After data collection, to facilitate analysis, we integrated the knowledge, attitude, behavior, and other items in the questionnaire into several dimensions, as presented in Table 1 . Each questionnaire item was scored from 1 to 4 according to the different options. The knowledge score was classified, based on the modified Bloom's cutoff points, into poor (<60%), fair (60–79%), and good (≥80%) categories [18]. Similarly, the attitude score was classified into positive (≥80%), neutral (60–79%), and negative (<60%) categories, whereas the practice score was classified into appropriate (≥80%), acceptable (60–79%), and inappropriate (<60%) categories.

Table 1.

Classification of questionnaire items.

Variables	Dimensions of each variable	Content of each dimension
Knowledge	Knowledge 1	Knowledge of basic protection
	Knowledge 2	Vaccine-related knowledge
	Knowledge 3	Knowledge of hospital visits after infection
Attitude	Attitude 1	Concerns about the epidemic
	Attitude 2	Awareness on basic protection
	Attitude 3	Impact of the epidemic
	Attitude 4	Awareness on vaccination
	Attitude 5	Family and social support
Practice	Practice 1	Strengthened self-protection
	Practice 2	Improved environmental protection requirements
	Practice 3	Changes in the status of life and work

2.4. Statistical analysis

All data were stored in Microsoft Excel and imported into IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA) for statistical analysis. Additionally, descriptive analyses and SEM were performed. For SEM, Amos21.0 (IBM Corp., Armonk, NY, USA) software was used to analyze the data structure. An equation model was constructed and verified, and the SEM parameters were estimated using the maximum likelihood method. In this way, SEM was utilized to determine the factors influencing the self-protection of pregnant women during the post-pandemic era and further elucidate the associations between the KAP elements of self-protection as well as the extent of their influence.

2.5. Research ethics

Written informed consent was obtained from the pregnant women before data collection. While the pregnant women awaited antenatal consultation, the researchers and their assistants provided them with study information and invited them to participate. Doubts or questions related to pregnancy were clarified. The ethical principle of confidentiality was strictly followed, and data were collected only for this study. The principle of non-maleficence was strictly followed, and no harm was caused. All participants were allowed to withdraw from the study at any time, and all questions were set as non-mandatory. The study was approved by the committee of West China Second University Hospital of Sichuan University (No. 2022.136).

3. Results

The individual-item content validity index (I-CVI) of our questionnaire ranged from 0.83 to 1.00; the scale (S)-CVI/universal agreement (UA) value was 0.96, and the S-CVI/average (Ave) value was 0.99. All these values, which were within the acceptable range, indicated good content validity of the questionnaire. The pilot study and formal questionnaire Cronbach's α coefficient were 0.85 and 0.94, respectively, suggesting good internal consistency. Our study revealed that pregnant women have different levels of knowledge, belief, and practice of self-protection against COVID-19. However, these parameters do not exist in isolation but interact and influence one another.

3.1. General participants’ information

Of the 2170 questionnaires distributed, 2156 were returned (response rate, 99.35%). The mean age of the participants was 30 ± 4.1 years. Other general information is presented in Table 2 .

Table 2.

General participants’ information.

Variables	Categories	Number of participants	Percentage
Residence	Cities	2061	95.6
	Villages and towns	55	2.6
	Rural areas	40	1.9
Ethnicity	Han nationality	2112	98.0
	Minority	44	0.2
Age (years)	≤30	989	45.9
	31–40	1146	53.2
	41–50	21	1.0
Education	Junior middle school or below	20	0.9
	Senior middle school polytechnic school	83	3.8
	Junior college	432	20.0
	Bachelor's degree	1153	53.5
	Master's degree	427	19.8
	Doctoral degree or above	41	1.9
Occupation	Public officials	105	4.9
	Clerks	898	41.7
	Teachers	253	11.7
	Health care workers	130	6.0
	Technician	259	12.0
	Service personnel	42	1.9
	Other	469	21.8
Marital status	Unmarried	32	1.5
	Married	2120	98.3
	Divorced	4	0.2
Monthly per capita income (yuan)	≤2000	28	1.3
	2001–5000	250	11.6
	5001–10,000	814	37.8
	10,001–20,000	713	33.1
	>20,000	351	16.3
Number of children	0	1657	76.9
	1	470	21.8
	2	28	1.3
	≥3	1	0.0
	Yes	69	3.2
Whether participant had been infected with COVID-19	No	2152	99.8
	Yes	4	0.2
Whether their partner had been infected with COVID-19	No	2155	100.0
	Yes	1	0.0
Whether participant had contacted confirmed cases of COVID-19	No	2151	99.8
	Yes	5	0.2
Whether their partner had contacted confirmed cases of COVID-19	No	2155	100.0
	Yes	1	0.0
Whether the participant had red or yellow health codes on their mobile phones	No	2,114	98.1
	Yes	42	1.9

COVID-19, coronavirus disease 2019.

3.2. Pregnant women's level and sources of knowledge regarding protection against COVID-19

For knowledge dimension scores, the median score, range, and number of participants at each level are presented in Table 3 . The degree of knowledge acquisition was less than satisfactory (good level of knowledge = 0). Pregnant women had the best and worst grasp of basic knowledge (poor level of knowledge 1 = 34.6%) and vaccine-related knowledge (poor level of knowledge 2 = 68.6%), respectively. Each source of knowledge acquisition was assigned a score ranging from 0 to 10. As summarized in Table 4 , pregnant Chinese women acquired relevant knowledge mainly through the Internet, including webpages and online social media platforms, such as WeChat and Weibo. The highest-scored item was “online social media platform” (mean point, 8.31).

Table 3.

Pregnant women's knowledge scores related to COVID-19.

Variables	Median scores (min, max)	Levels	N (%)
Knowledge 1	22 (8, 32)	Poor	745(34.6)
		Moderate	731(33.9)
		Good	680(31.5)
Knowledge 2	4 (2, 8)	Poor	1478(68.6)
		Moderate	387(17.9)
		Good	291(13.5)
Knowledge 3	13 (6, 24)	Poor	1291(59.9)
		Moderate	500(23.2)
		Good	365(16.9)
Knowledge	28 (11, 44)	Poor	1859(86.2)
		Moderate	297(13.8)
		Good	0

COVID-19, coronavirus disease 2019.

Table 4.

Sources of knowledge.

Sources of knowledge acquisition	Minimum point	Maximum point	Mean point	standard deviation
Television	0	10	5.50	3.385
Web page	0	10	7.83	2.337
Lectures of medical staff	0	10	5.10	3.239
Public lecture of the community	0	10	5.16	3.144
Online social media platforms (such as WeChat)	0	10	8.31	2.022
Parenting classes	0	10	3.16	3.41
Consultation with experts	0	10	3.68	3.543
Books, newspapers, and magazines	0	10	4.54	3.458
Other sources	0	10	3.90	3.539

3.3. Attitudes regarding protection against COVID-19

Most pregnant women did not show negative attitude towards epidemic prevention and control (3.6%). Most pregnant women had positive awareness of epidemic prevention and control (positive attitude, 62.4%). However, their levels of awareness of active vaccination were low (positive attitude 4 = 10%). Other details are listed in Table 5 .

Table 5.

Pregnant women's attitude score related to COVID-19.

Variables	Median scores (min, max)	Levels	N (%)
Attitude 1	5 (3, 12)	Positive	157 (7.3)
		Neutral	260 (12.1)
		Negative	1739 (80.7)
Attitude 2	23 (6, 24)	Positive	1346 (62.4)
		Neutral	678 (31.4)
		Negative	132 (6.1)
Attitude 3	21 (13, 28)	Positive	540 (25.0)
		Neutral	1446 (67.1)
		Negative	170 (7.9)
Attitude 4	6 (3, 12)	Positive	215 (10)
		Neutral	472 (21.9)
		Negative	1469 (68.1)
Attitude 5	9 (3, 12)	Positive	951 (44.1)
		Neutral	819 (38.0)
		Negative	386 (17.9)
Attitude	67 (43, 88)	Positive	724 (33.6)
		Neutral	1355 (62.8)
		Negative	77 (3.6)

COVID-19, coronavirus disease 2019.

3.4. Practices regarding protection against COVID-19

The survey results suggested (Table 6 ) that a few pregnant women demonstrated inappropriate practices (1.8%). The protection requirements of pregnant women for their surrounding environment and personnel were improved (appropriate practice = 66.4%). However, a few women reported willingness to limit their number of children or change their working status due to the epidemic (inappropriate practice 3 = 24.6%, similar to the number reporting appropriate practice).

Table 6.

Pregnant women's practice score related to COVID-19.

Variables	Median scores (min, max)	Levels	N (%)
Practice 1	16 (5, 20)	Appropriate	1329 (61.6)
		Acceptable	739 (34.3)
		Inappropriate	88 (4.1)
Practice 2	11 (3, 12)	Appropriate	1432 (66.4)
		Acceptable	583 (27)
		Inappropriate	141 (6.5)
Practice 3	8 (3, 12)	Appropriate	584 (27.1)
		Acceptable	1041 (48.3)
		Inappropriate	531 (24.6)
Practice	35 (14, 44)	Appropriate	1032 (47.9)
		Acceptable	1085 (50.3)
		Inappropriate	39 (1.8)

COVID-19, coronavirus disease 2019.

3.5. SEM

Based on the results of the initial model, we adapted and modified the initial model to obtain the final model. The final model and its parameters are shown in Fig. 1 and Table 7 , respectively. The “e” represents the residual, which is the difference between the actual observed and estimated (fitting) values. The Chi-square fit statistics/degree of freedom (CMIN/DF) was 13.50, although, in normal conditions, CMIN/DF is required to be less than 3. Nevertheless, we considered other indices because of the large sample size (>2000).

Fig. 1.

The final constructed equation model.

Table 7.

Model fitness indices for the modified model.

Indices	ideal standards	Measurement values
CMIN		51.156
DF		38
CMIN/DF		13.504
GFI	>0.90	0.955
AGFI	>0.80	0.921
RMSEA	<0.08	0.076
IFI	>0.90	0.936
TLI	>0.90	0.907
CFI	>0.90	0.936

CMIN/DF, Chi-square fit statistics/degree of freedom; GFI, goodness-of-fit index; AGFI, adjusted goodness-of-fit index; RMSEA, root mean square error of approximation; IFI, incremental fix index; TLI, Tucker-Lewis index; CFI, comparative fix index.

4. Discussion

4.1. Knowledge and its sources of protection against COVID-19 among pregnant women

This survey showed that knowledge of COVID-19 prevention was relatively good among pregnant women in China during the post-pandemic period, regardless of their occupation and education level. Moreover, the main source for pregnant women in China to obtain relevant knowledge is the Internet, including website information, WeChat, Micro-Blog, and various other online social networking platforms. Furthermore, most of these women have a good understanding of specific daily protective measures, such as mask-wearing and hand hygiene, which is consistent with a study on the Chinese public during the epidemic period [19,20]. Nie et al. suggested that over 85% of the general population was aware of COVID-19 epidemiologic characteristics, pathogenic features, and prevention [19]. The National Center for Women's and Children's Health conducted a series of surveys during the peak period of the pandemic on the KAP of COVID-19 among pregnant women and parents. They showed that pregnant women and parents possessed slightly higher knowledge levels than the rest of the Chinese population [[20], [21], [22], [23]]. Therefore, we can infer that practices such as routine mask-wearing are likely to persist for a relatively long period or even become the norm during the post-pandemic era, which is consistent with China's epidemic prevention and control work.

In addition, the present results show that pregnant women still lack knowledge regarding vaccines and post-infection treatment. This may be related to the fact that pregnant women do not pay much attention to vaccine-related information, hence the increased risk of being infected with the virus. Due to the lack of effective treatment, the promotion of COVID-19 vaccination is an important strategy to control the outbreak of “new crown pneumonia” with COVID-19. Pregnant and lactating women were excluded from the initial phase 3 clinical trial of the COVID-19 vaccine; thus, current data on the efficacy and safety of the COVID-19 vaccine in pregnant and lactating women are very limited [24]. Based on comprehensive evidence, expert consensus on COVID-19 vaccination for peri-pregnancy women in China recommends that women who plan to conceive do not have to delay their pregnancy plan because they have been inoculated with the COVID-19 vaccine [25]. Moreover, termination of pregnancy because conception occurred after vaccination or vaccination occurred without the knowledge of the pregnancy status was not recommended. In these situations, experts recommended regular examinations and follow-ups. Similarly, timely vaccination for pregnant women presenting with symptoms of infection was recommended [26,27]. Therefore, increasing pregnant women's knowledge of vaccination against COVID-19 should become the focus of research in the post-epidemic period.

Our study showed that pregnant women's mastery of medical knowledge after infection is unsatisfactory. Overall, 59.5% of the pregnant women had no knowledge of the need for hospital visits after exposure to COVID-19. This may be related to insufficient attention of pregnant women in this area of knowledge. To control the spread of the epidemic, it is necessary to ensure that all patients with COVID-19 receive appropriate and timely treatment. China's medical institutions are committed to continuously reviewing and improving diagnosis and treatment processes. A few COVID-19 hospitals are designated for the diagnosis of patients suspected with “new crown pneumonia.” These hospitals have a more advanced epidemic prevention environment and sufficient protective materials and human resources [28]. Medical staff should provide quality medical services and ensure the implementation of epidemic prevention and control measures at the hospital. If pregnant women who are exposed or suspected of being exposed to COVID-19 do not know how to access timely medical treatment, early diagnosis and treatment may be delayed, adverse birth outcomes may result, and the disease may spread.

4.2. Current attitude status of the pregnant women on the protection against COVID-19

This survey revealed that adherence to regular physical exercise and daily protective measures was considered effective for pandemic prevention and control among most pregnant women. However, despite higher protection requirements and standards for their relatives, friends, and even in public places, pregnant women remain worried that they or their babies might contract COVID-19, which might affect their quality of daily life. Similar studies and reports in China and other countries [8,11] showed that pregnant women were more susceptible to mental health problems than the rest of the population during the pandemic owing to pregnancy-specific physiological changes [8,9]. During pregnancy, women usually experience hormonal fluctuations, physical discomfort, cumbersome prenatal care check-up procedures, and psychological stress induced by multiple triggers. In the COVID-19 pandemic era, society's functioning has been profoundly affected, prompting an even harder life for pregnant women [29]. This problem compromises the physical and mental health of pregnant women and places a tremendous burden on families and society. Moreover, the anxiety level of pregnant women is closely associated with their level of social and family support [30]. This is consistent with our findings. Hence, there is a need to promote cross-sectoral collaborations, attach importance to the physical and mental health of pregnant women, devote more effort to education and proper counseling, and address mental health issues by ensuring that proper measures to alleviate anxiety and stabilize their mental health status are taken by pregnant women. These measures include acquiring authoritative and credible information from the authorities, maintaining regular daily routines, avoiding catastrophizing, developing new interests and hobbies, and facilitating effective family communication. During pandemics, pregnant women should undergo more physical activities, maintain good relationships with family members, enhance family cohesion, and develop a positive and optimistic attitude towards life. Meanwhile, the survey revealed that pregnant women still hold a wait-and-see attitude towards COVID-19 vaccines; therefore, more education is warranted.

4.3. The practice of protection against COVID-19 among pregnant women

As this study suggested, most women took more cautious protective measures and imposed higher requirements of protective measures on their close contacts and in public places after pregnancy. According to Cao et al. the percentage of Chinese people (≥99%) wearing face masks outdoors during the pandemic was markedly higher than that during non-pandemic periods (16.05%) [4]. These data suggest that COVID-19 substantially changed the public's mask-wearing practices, and pregnant women were more aware of the need for protection against the disease as a special population, which is consistent with the findings of general public surveys in China [30]. Moreover, we showed that a quarter of pregnant women practiced some negative behaviors, such as having fewer children because of the pandemic, which can exacerbate the current problems of aging and low birth rates in China and pose a serious challenge to economic and social development, especially for the demographic structure. Therefore, to encourage more births, misgivings about the pandemic should be dispelled among women of child-bearing age, and more comprehensive support and education should be provided during the post-pandemic era. These should include more family centered perinatal education, remote medical consultations, smart health care, psychological counseling, art therapy, a green corridor for a hassle-free medical experience, and the establishment of maternity care foundations during COVID-19.

4.4. The correlation and extent of KAP toward self-protection among pregnant women in the post-pandemic period

The current study showed that knowledge can directly and indirectly affect practice by influencing attitudes. In the SEM, knowledge and attitude directly affected behavior (correlation coefficients, 0.23 and 0.46, respectively). Knowledge can indirectly affect behavior by influencing attitudes (correlation coefficient = 0.56). Thus, in addition to the study of epidemic prevention, knowledge and control awareness are crucial to forming protective behavior.

4.4.1. The influence of knowledge of COVID-19 prevention on belief and practice among pregnant women

Knowledge of basic protection and hospital visits after infection (two dimensions) influenced the formation of knowledge systems among pregnant women the most (correlation coefficients, 0.85 and 0.89, respectively). These findings suggest that focusing on training and educating women on basic protection and hospital visits could contribute to increase in the practice of self-protection among pregnant women. This is consistent with a study by Zhang et al. on the knowledge of the general public and healthcare workers [13,31]. Aghababaei et al. reported the perceived risk and protective behaviors regarding COVID-19 among pregnant women and suggested that risk perception is an independent predictor of protective behaviors related to COVID-19 and that the risk perception of pregnant women regarding COVID-19 can predict their protective behavior [32]. Hence, it is essential to educate pregnant women about pandemic prevention and control during the post-pandemic period.

Knowledge can indirectly affect behavior by influencing beliefs. Pregnant women acquire knowledge, assume greater responsibility to protect their health and others’ through thoughtful consideration, and form beliefs that shape protective health behaviors. Health educators can impart knowledge regarding pandemic protection as well as the spread and outcome of COVID-19 in pregnant women via different methods and means, such as when, where, and how to adopt protective measures and what actions to take after the infection. A few studies have revealed that sex and age are factors influencing public awareness of epidemic prevention [33]. Given that there are currently few such studies on pregnant women, the present study can provide a theoretical basis and evidence for the management of pregnant women during the post-pandemic period and for further implementation of policies to promote population growth in China during the pandemic.

4.4.2. The influence of attitude regarding COVID-19 prevention on practice among pregnant women

Belief directly affects practice; however, it is influenced by knowledge. We demonstrated that items on the awareness of basic prevention and control measures, as well as family and social support (two dimensions), influenced the formation of belief regarding self-protection among pregnant women the most. Belief refers to judgment, opinions, or views held by a person about something [34], and is characterized by complexity, stability, persistence, and diversity [15]. Consciousness refers to the awareness of internal and external representations in the human brain. Hence, consciousness is essential to the formation of beliefs [34]. For pregnant women, the strongest social support comes from their husbands [35,36]. A few existing surveys suggest that pregnant women with low marital satisfaction and support and help (especially support from their husbands) harbored more negative emotions and were more susceptible to depression [37]. Therefore, the healthcare system should create a positive and harmonious social environment and promote health education strategies targeted at husbands to change the protective behaviors of pregnant women. All sectors of society play an important role in constructing a strong healthcare system for families. For example, the public is currently adopting a positive attitude towards a few COVID-19 policies, including free COVID-19 treatment, which is instrumental in the cultivation of positive beliefs and attitudes among the public.

4.5. Limitation

First, there is no reference scale to provide a more comprehensive quantitative evaluation of KAP protection in pregnant women. The questionnaire used in this study was designed by researchers. However, a small-scale pre-survey pilot study was conducted before the actual survey. Furthermore, the questionnaire was modified based on the results of the pilot study to address the purpose of the survey. Second, the survey population was mainly pregnant women in our hospital; therefore, there might have been a selection bias. However, the results showed that respondents’ age groups, educational levels, and occupations differed. Therefore, this study still has a certain guiding significance for health education in the future.

5. Conclusion

The KAP of pregnant women influenced one another directly and indirectly. Knowledge, the main influencing factor, directly affected the behavior and indirectly affected behavior by influencing attitude. Among the three dimensions of knowledge, basic protection knowledge and post-infection treatment influenced knowledge the most, while the hospital visit after infection dimension was the weakest link in pregnant women's knowledge. These findings are worthy of great attention and serve as a key link to strengthen publicity, education, and interventions in the future.

Over time, COVID-19 has become more than a healthcare crisis affecting every aspect of our lives. The entire society has responsibility to safeguard women's rights and interests and prioritize children's growth and development during the post-pandemic era. Therefore, cross-disciplinary collaborations should be promoted to help pregnant women acquire knowledge regarding pandemic prevention and reinforce their belief in self-protection to encourage proactive protective behaviors. These protective behaviors can thus be helpful in effectively controlling the spread of COVID-19, alleviating the anxiety of pregnant women, reducing wasteful utilization of healthcare resources, boosting confidence in the use of measures against the pandemic, creating a positive and harmonious social and family environment, promoting births, and improving the population's overall quality of life.

Funding

This work was supported by a research project titled “studies and clinical validation of key technologies for monitoring and correction of posture in pregnant women” under the National Key Research and Development Program of China and the Science and Technology Plan of Sichuan province [grant number 2020YFS0083] and a research project at this department of Sichuan University titled “studies on the efficacy and mechanism of light touch massage in labor pain alleviation” [grant number HLBKJ202035]. The funders had no role in the study design; in the collection, analysis or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.