This study was conducted with the aim of providing an insight into the knowledge, attitude and practices of pregnant women regarding COVID-19 infection. Pregnant women form a unique vulnerable group due to the immunological suppression during pregnancy and measures should be taken to prevent COVID-19 infection in this subgroup. This is crucial particularly in developing nations like India where the health infrastructure is not as strong as in developed countries.
Respondents had an overall correct knowledge rate of 68.5% (22.6/33*100), demonstrating that majority of pregnant women were knowledgeable about coronavirus but previous study in China among general population showed greater correct knowledge rate (90%) . Overall, mean knowledge score (22.5) of the participants was adequate which is similar to knowledge level among pregnant women in previous study . The adequate knowledge could be attributed to robust efforts by GOI in spreading information and increasing awareness since the beginning of pandemic. Therefore, it is not surprising that mass media (television, radio and internet) were the primary sources of information about COVID-19 for majority of the study participants (92%) which is similar to the study results among pregnant women in a low-resource African setting . Significant predictor of knowledge was occupation (p-value = 0.030) with higher scores observed in health care workers as expected. There was no significant correlation of knowledge score with education, religion or area of distribution by COVID-19 status which is in contrast to previous studies [9, 10]. Commonly known COVID-19 related symptoms were fever (98%), cough (98%) and breathlessness (96%) but pregnant women were comparatively less aware about myalgia/weakness (77%) which is similar to the results of study in Iran by Erfani et al.  and this could be possible as myalgia and weakness are considered as physiological symptoms in pregnancy.
Health crisis situation like this also demands efforts towards correcting misleading information and misguided perceptions of the general public. This study discovered various misconceptions among pregnant respondents regarding the duration of handwashing, additional risk of COVID-19 in pregnancy and feeding options for the baby. Less than half (48%) of the participants correctly answered ideal duration of handwashing. Majority of the participants (73%) believed that COVID-19 poses additional risk of infection to pregnancy due to effect on the foetus (17%), antenatal complications (9%), delivery-related complications (3%) or all of the above (25%) whereas 18% answered that more research was required on this topic while 28% did not answer. These concerns can lead to unnecessary apprehension among pregnant mothers as revealed by other studies [13, 14]. Majority of the pregnant mothers (71%) were aware that there was no clinically approved treatment for COVID-19 and 13% thought that vaccine was the available treatment of choice . Around half (47%) of the participants believed that formula feed was the feeding option of choice for COVID-19 positive mothers followed by expressed breast milk (25%) and direct breastfeeding (17%) while 23% participants did not answer. Also, mode of delivery was another less known area among the respondents as only 23% correctly answered that there was no effect on the method of delivery. These are potential areas for health education programmes and mass media coverage for reducing the gap of knowledge among pregnant women in order to enhance their attitude and practices.
Overall, the respondents showed positive attitude regarding seriousness for following preventive measures against COVID-19 (96%) and visiting health care facility when suspected to have COVID-19 related symptoms (86%). 86% pregnant women believed that India could emerge victorious in the fight against this health emergency. These findings are in line with recent studies by Zhong et al. and Al-Hanawi et al. where the results showed positive attitude among general public [9, 16]. Positive attitude and confidence in control of COVID-19 among pregnant mothers could be a reflection of the government's relentless actions, stringent steps such as nationwide lockdown and suspension of routine activities such as schools and universities, domestic and international flights .
It is a common consensus that more educated people comply better with preventive and treatment measures but there was no significant statistical correlation (p-value 0.590) in this study between overall knowledge score and the practices followed. Participants (64%) were overall following good practices (mean score = 15.5, median score = 15) for prevention of COVID-19 infection. This could be due to constant reinforcements by GOI through mass media coverage regarding good practices for prevention such as social distancing, wearing masks and hand hygiene . Around 87% of pregnant women reported increased frequency of handwashing during COVID-19 pandemic and it was significantly increased (r = 0.150, P-value 0.034) among those who were aware about communicable nature of the disease. Also, this group of pregnant women frequently practiced increased safety measures such as wearing masks (98%), avoiding crowded places (95%), avoiding handshakes (91%), social distancing (89%) and washing vegetables before storing them (89%) which could be explained by their awareness of mode of spread of disease. It is similar to level of practice observed in the study among pregnant women by Kamal et al. . These preventive measures were followed more by those who had good knowledge about common symptoms of COVID-19 (r-0.205, P-value 0.004). Also, awareness about increasing trend of COVID-19 in India had a significant increased impact (r-0.183, P-value 0.009) on the frequency of handwashing. Awareness about effective preventive measures for COVID-19 had significantly negative impact on use of herbal or traditional medicines among participants. This could also be explained as a practice of avoiding unnecessary herbs/traditional medicines during pregnancy owing to possible adverse effects of these on foetus .
This study results could help the authorities in formulating policies directed towards the pregnant women with a special focus on those with low KAP (example—non-health care workers) who are at higher risk of contracting the disease. The areas that need to be focussed possibly include duration of handwashing and preferred method of breastfeeding in COVID-19 mother. Pregnancy is a landmark requiring extra attention and dissemination of information regarding knowledge and right practices will help diminish the anxiety and apprehension among the pregnant women and their relatives and will enhance positive attitude.
To the best of our knowledge, this is one of the initial studies providing insight into KAP among pregnant women in India. The questionnaire had been designed based on standard RCOG guideline and WHO resources and it evaluated various aspects of COVID-19 disease. This study was specific to pregnant population and hence, data might be helpful in formulating health policies targeting this subpopulation. Also, good knowledge, right practices and positive attitude are the only pillars of prevention with novel coronavirus variants, rising number of cases and uncertain future . Due to evolving evidence on this topic, answers to the questionnaire may change with time. Furthermore, it is a single centre study and may not be generalised to the entire population. In future, multicentric research is warranted for better KAP assessment of pregnant women.