Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana.

BACKGROUND: COVID-19 is a novel respiratory disease associated with severe morbidity and high mortality in the elderly population and people with comorbidities. Studies have suggested that pregnant women are more susceptible to COVID-19 compared to non-pregnant women. However, it's unclear whether pregnant women in Ghana are knowledgeable about COVID-19 and practice preventive measures against it. This study sought to assess the knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana.
METHODS: A cross-sectional study was conducted using a structured questionnaire in the Nabdam district in Ghana. A total of 527 pregnant women were randomly sampled from health facilities offering antenatal care services in the district. Multivariable logistic regression analysis was used to assess the association between the predictors and outcome variables.
RESULTS: The prevalence of adequate knowledge and good COVID-19 preventive practices were 85.6%, (95% CI: 82.57, 88.59) and 46.6%, (95% CI: 42.41, 50.95) respectively. Having at least a primary education, residing in an urban area, and receiving COVID-19 education at a health facility were positively associated with adequate knowledge on COVID-19. Factors positively associated with good COVID-19 preventive practices were older age, having at least a primary education, pregnant women with a chronic disease, and living in an urban area. Multiparity was negatively associated with good COVID-19 preventive practices.
CONCLUSION: Although majority of women had adequate knowledge of COVID-19, less than half of them were engaged in good COVID-19 preventive practices. Education of pregnant women on COVID-19 preventive practices should be intensified at health facilities while improving upon the water, sanitation and hygiene need particularly in rural communities.

Introduction

Coronavirus disease 2019 (COVID-19) is an emerging respiratory disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-COV2), which is a single-strand, positive-sense ribonucleic acid (RNA) virus [1]. Confirmed cases of COVID-19 usually present with clinical signs and symptoms of fever, dry cough, tiredness, and shortness of breath with an incubation period of 2–14 days after exposure to the virus [2-5]. The virus may cause morbidity in the range of mild respiratory illness to severe complications characterized by acute respiratory distress syndrome, septic shock, and other metabolic and hemostasis disorders, and eventually death [4, 5]. Most of the fatal forms of COVID-19 including acute respiratory syndrome occurred in older adults and people with underlying medical comorbidities [6-8]. A systematic review by Yang et al., found that individuals with hypertensive, cardiovascular, and respiratory system diseases were the most vulnerable groups associated with mortality due to COVID-19 [9].

As the outbreak of COVID-19 continues to unfold, major concerns are being raised about its effects on pregnancy and the potential risk of vertical transmission. Recent evidence suggests that the risk of maternal mortality appears to be high in COVID-19 pregnant women with severe disease [10]. There is limited evidence on intra-uterine transmission of COVID-19 from mother to child [11, 12]. Whilst some newborns have tested negative for COVID-19 after birth, some have tested positive after few days of life [13]. It is however unclear at what stage (pre, peri, or postnatal) the transmission might have occurred among newborns who tested positive [14]. In early studies from China, it was observed that some newborns were preterm and low birth weight when born to COVID-19 positive mothers, but the evidence linking these outcomes to the COVID-19 is unclear [15]. Although the impact of COVID-19 on pregnant women is not yet known, there is the need to consider pregnant women as a high-risk population in COVID-19 prevention and control strategies [16, 17].

Although vaccines for COVID-19 are now available, it is not clear if vaccines can prevent transmission of the virus [18]. Therefore, practicing COVID-19 preventive measures is critical in the control of the COVID-19 pandemic [19]. Accordingly, various interventions have been implemented globally such as partial lockdowns, contact tracing, and self-isolation or quarantine, and promotion of public health measures including hand hygiene, respiratory protocols, and social distancing to curb the spread of the virus [20].

Ghana reported its first case of COVID-19 on 12th March 2020 in its national capital, Accra [21]. Cases of COVID-19 have since spread to all regions of the country, and as of 8th April 2021, Ghana has recorded a total of 91,109 cases and 752 deaths [22]. Ghana has adopted several measures to fight the virus namely; testing, tracing, and treating, the partial lockdown of some major cities, and practicing COVID-19 safety measures [23]. It has also resorted to the use of geospatial technology in its effort to enhance contact tracing and improving decision making [24]. Successful control of COVID-19 infection will require a change of individual behavior, and this is influenced by people’s understanding of the characteristics of the disease and its preventive measures [25]. Studies on knowledge and preventive practices in Ghana are focused on health workers and the general public [26-28], but not pregnant women. Therefore, the study assessed the knowledge and preventive practices of pregnant women towards COVID-19 in the Nabdam district of Ghana.

Materials and methods

Study design, population, and setting

A population-based cross-sectional survey was conducted in health facilities using a quantitative approach. The study involved pregnant women who were 18 years and above, and accessed antenatal care services in the Nabdam District of Upper East Region, Ghana. The survey was conducted in October 2020.

Sample size and sampling procedure

The sample size for the study was estimated using EpiInfo Version 7.1 (STAT CALC). The prevalence of knowledge on COVID-19 was not known, therefore a 50% prevalence rate was used with a 95% confidence interval and 5% margin of error. The estimated minimum sample size was 407 including a 10% non-response rate. However, 527 participants completed our surveys. A pretest was conducted to ascertain the validity of the questionnaire.

A total of 16 health facilities that conduct antenatal care services in the district were purposively selected for the study. The selection of study participants from the health facilities was done using a simple random sampling method. Face-to-face interviews were conducted with a structured questionnaire.

Predictor variables

The predictor variables were age, parity, marital status, educational level, gestational age, has a chronic disease, the number of antenatal visits, residential area, and health education on COVID-19 at a health facility. These variables were categorized as age (18–22 years, 23-27years, ≥ 28 years); parity (0, 1, 2+); marital status (never married, married); educational level (no formal education, primary education, secondary or higher education); gestational age (first trimester, second trimester, third trimester); residential area (rural, urban); the number of antenatal visits (1–3, 4+); received COVID-19 education at a health facility (yes, no); and has a chronic disease (yes, no). Having a chronic disease was defined as having any one of the following diseases; hypertension, diabetes, sickle cell disease, asthma, cancer, chronic obstructive pulmonary disease.

Outcome variables

We assessed two outcome variables; knowledge of COVID-19 and COVID-19 preventive practices. Knowledge was assessed on a 10-item questionnaire adapted from Ah-Hanawi et al., [28], and the level of knowledge was adapted from Bloom’s cut-off point [29]. The questions were about clinical presentations, transmission, prevention, and control of COVID-19. Each correct response weighed 1 point and 0 for an incorrect response. A score of 6 points and above was considered adequate knowledge while 5 points and below was considered inadequate knowledge. Questions used to construct our outcome variable on knowledge of COVID-19 are shown in S1 Appendix.

COVID-19 preventive practices were assessed on a 5-item questionnaire derived from W.H.O. recommendations on preventive measures against COVID-19 [30] and cut-off points adapted from Bloom’s [29]. Each correct response weighed 1 point and 0 for an incorrect response. A score of 3 points and above was considered good COVID-19 preventive practices while 2 points and below was considered poor COVID-19 preventive practices. S2 Appendix also shows questions that were used to define COVID-19 preventive practices.

Data processing and analysis

Data analysis was done using SAS version 9.3 (SAS Institute, Cary, NC). Descriptive statistics were used to present the characteristics of study participants. Multivariable logistic regression analysis was used to assess the association between the predictors and outcome variables, while simultaneously controlling for predictor variables. A P-value <0.05 was considered statistically significant.

Ethical consideration

Approval was obtained from the Committee on Human Research, Publication, and Ethics at the School of Medical Sciences /Komfo Anokye Teaching Hospital (CHRPE/AP/369/20). Permission was also sought from the district management as well as heads of the various health facilities. Written informed consent was obtained from all the study participants.

Results

Characteristics of the study sample

The ages of participants were fairly distributed between pregnant women aged 18–22 years old (37.0%) and above 28 years old (36.1%). Pregnant women with more than one child formed the majority of the participants (44.0%). The proportion of pregnant women with a primary education was 46.9%, secondary or higher education (30.5%), and no formal education (22.6%). The majority of the pregnant women were in their second trimester (41.0%), and most (91.4%) had no chronic diseases. Women who made one to three antenatal care visits were 45.8% while four visits and above were 54.2%. More than half (65.6%) of the women had received COVID-19 education from a health facility (Table 1).

Table 1

Characteristics of the study sample (n = 527).

Variable	N (%)
Age (years)
18–22	195 (37.0)
23–27	142 (26.9)
> 28	190 (36.1)
Parity
0	168 (31.9)
1	127 (24.1)
2+	232 (44.0)
Marital status
Never married	81 (15.4)
Married	446 (84.6)
Educational level
No formal education	119 (22.6)
Primary education	247 (46.9)
Secondary or higher education	161 (30.5)
Gestational age
First trimester	128 (24.3)
Second trimester	216 (41.0)
Third trimester	183 (34.7)
Has a chronic disease
No	481 (91.4)
Yes	45 (8.6)
Residential area
Rural	306 (58.1)
Urban	221 (41.9)
Number of antenatal visits
1–3	241 (45.8)
4+	285 (54.2)
Received COVID-19 education at a health facility
No	179 (34.4)
Yes	341 (65.6)

Prevalence of knowledge and COVID-19 preventive practices

More than two-thirds of the participants had adequate knowledge of COVID-19, 85.6% (95% CI: 82.57, 88.59). However, less than half of them were found to be engaged in good COVID-19 preventive practices, 46.6% (95% CI: 42.41, 50.95) [Fig 1].

Fig 1

Prevalence of knowledge and COVID-19 preventive practices.

Factors associated with knowledge on COVID-19 and COVID-19 preventive practices

Pregnant women with a primary education [Adjusted prevalence odds ratios (aOR): 3.40, 95% CI: 1.79, 6.46], and secondary or higher education (aOR: 10.61, 95% CI: 3.59, 31.33), had 3.40 times and 10.61 times respectively, the odds of having adequate knowledge on COVID-19 compared to those with no formal education. Women residing in urban areas had 119% higher odds of having adequate knowledge on COVID-19 compared to those living in rural areas (aOR: 2.19, 95% CI: 1.11, 4.35). Women who received COVID-19 education at a health facility had 112% higher odds of having adequate knowledge on COVID-19 compared to women who did not receive COVID-19 education at a health facility (aOR: 2.12, 95% CI: 1.18, 3.82). All other variables were not associated with knowledge on COVID-19 (Table 2).

Table 2

Factors associated with knowledge on COVID-19 and practice of COVID-19 preventive measures.

Variable	Knowledge of COVID-19	COVID-19 preventive practices
	Adjusted OR (95% CI)	Adjusted OR (95% CI)
Age (years)
18–22	1	1
23–27	1.31 (0.50, 3.44)	1.85 (1.04, 3.31) *
≥ 28	1.21 (0.44, 3.28)	2.12 (1.06, 4.23) *
Parity
0	1	1
1	0.84 (0.31, 2.28)	0.77 (0.44, 1.34)
2+	0.42 (0.15, 1.17)	0.46 (0.22, 0.95) *
Marital status
Never married	1	1
Married	0.97 (0.33, 2.91)	1.53 (0.88, 2.64)
Educational level
No formal education	1	1
Primary education	3.40 (1.79, 6.46) *	2.11 (1.22, 3.64) *
Secondary or higher education	10.61 (3.59, 31.33) *	4.11 (2.18, 7.74) *
Gestational age
First trimester	1	1
Second trimester	1.10 (0.55, 2.18)	0.72 (0.43, 1.23)
Third trimester	0.81 (0.32, 2.08)	0.87 (0.45, 1.69)
Has a chronic disease
No	1	1
Yes	2.72 (0.90, 8.28)	2.11 (1.09, 4.11) *
Residential area
Rural	1	1
Urban	2.19 (1.11, 4.35) *	1.89 (1.26, 2.83) *
Number of antenatal visits
1–3	1	1
4+	0.98 (0.46, 2.10)	1.25 (0.75, 2.06)
Received COVID-19 education at a health facility
No	1	1
Yes	2.12 (1.18, 3.82) *	1.22 (0.80, 1.87)

*P-value is less than 0.05.

The odds of engaging in good COVID-19 preventive practices among women aged 23–27 years (aOR: 1.85, 95% CI: 1.04, 3.31), and 28 years and above (aOR: 2.12, 95% CI: 1.06, 4.23) were 1.85 times and 2.12 times respectively, the odds of good COVID-19 preventive practices compared to women aged 18–22 years old. Multiparous (i.e. more than 1 child) women had 54% lower odds of engaging in good COVID-19 preventive practices compared to nulliparous women (aOR: 0.46, 95% CI: 0.22, 0.95). Women with primary education (aOR: 2.11, 95% CI: 1.22, 3.64), and secondary or higher education (aOR: 4.11, 95% CI: 2.18, 7.74), had 2.11 times and 4.11 times respectively, the odds of engaging in good COVID-19 preventive practices compared to women with no formal education. The odds of engaging in good COVID-19 preventive practices were 111% higher in women who had a chronic condition compared to women without a chronic condition (aOR: 2.11, 95% CI: 1.09, 4.11), and women living in urban areas had 89% higher odds of engaging in good COVID-19 preventive practices compared to those in rural areas (aOR: 1.89, 95% CI: 1.26, 2.83). All other variables were not associated with COVID-19 preventive practices (Table 2).

Discussion

We investigated the knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Ghana. Our study found that more than 8 in every 10 pregnant women had adequate knowledge of COVID-19, however, less than half of the participants were engaged in good COVID-19 preventive practices. Having at least primary education, residing in an urban area, and women who received COVID-19 education at a health facility were positively associated with adequate knowledge on COVID-19. Good COVID-19 preventive practices were more prevalent among older pregnant women, pregnant women who had at least primary education, pregnant women who had a chronic disease, and those living in an urban area. Multiparity was negatively associated with good COVID-19 preventive practices.

Our study found that majority of the women had adequate knowledge of COVID-19, but less than half of the women were engaged in good COVID-19 preventive practices. This finding is corroborated in a similar study by Nwafor et al., in Nigeria [31]. The high prevalence of adequate knowledge may be attributed to intense information sharing through media and other platforms. For example, since the emergence of the disease, there has been constant sharing of information on COVID-19 by the Government of Ghana, civil society organizations, and individuals via social media, television, radio, and mobile van announcements [32]. Health education on COVID-19 has also been ongoing at the various health facilities. The low prevalence of good preventive practices could be due to several reasons. Inadequate face masks, challenges with water supply systems, and unavailability of soap for handwashing as well as the high cost of hand sanitizers might be the possible explanation for the low level of adherence to COVID-19 preventive practices [33].

Women who had at least primary education and women living in urban areas were positively associated with adequate knowledge on COVID-19. Our finding is supported by Nwafor et al. [31]. Having at least primary education is often associated with easier access to health information compared to individuals without a formal education [34], and this might explain why women with primary or higher education had adequate knowledge on COVID-19. Most educated pregnant women live in the urban areas [35], more so, the urban areas have good infrastructure such as internet connectivity and other media facilities compared to the rural areas, and this may account for the high prevalence of adequate knowledge on COVID-19 among women living in urban areas [36]. We also found that women who received COVID-19 education at a health facility had adequate knowledge on COVID-19 compared to those who did not receive COVID-19 education at a health facility. This confirms the key role that health workers play in disseminating information regarding COVID-19 at health facilities.

Although our study found a low prevalence of good COVID-19 preventive practices, older age women were positively associated with good COVID-19 preventive practices. Women who were 28 years old and above were more likely to engage in good COVID-19 preventive practices compared to women aged 18–22 years old. Studies have shown that older age is a risk factor for severe complications and fatality related to COVID-19 [7, 8]. This might be the reason why older women in our study were more engaged in good COVID-19 preventive practices to avoid getting infected with the disease. Pregnant women with at least a primary education were also associated with good COVID-19 preventive practices. Women with at least a primary education may be more exposed to health information especially regarding COVID-19 and are therefore likely to take positive measures to protect themselves against the disease [37].

We also found that women who had a chronic disease were more likely to engage in good COVID-19 preventive practices compared to those who have no chronic disease. As has been found in most COVID-19 studies, severe complications and fatalities occur in people with chronic diseases such as hypertension, diabetes, and respiratory chronic diseases [7-9]. It is therefore not surprising that women with such chronic diseases took more precautions in protecting themselves against COVID-19 compared to women without chronic disease. Good COVID-19 preventive practices were also associated with living in an urban area. Women living in urban areas had higher odds of engaging in good COVID-19 preventive practices compared to those in rural areas. In Ghana, the prevalence of COVID-19 has been high in the urban areas compared to the rural areas [38], and this might have been the reason why pregnant women in urban areas are more engaging in good COVID-19 preventive practices. Our study also found that multiparous women had lower odds of engaging in good COVID-19 preventive practices. This finding might be because multiparous women are associated with lower education and mostly reside in rural areas [39].

Our study had some strengths and limitations. Our findings are relevant to inform policymakers in channeling resources towards the fight against COVID-19. The data was self-reported and might have suffered recall bias. Also, the cross-sectional nature of our data does not allow for our findings to infer causality. Our findings may not be generalized to the entire country however, our findings are useful and are the first to assess the level of knowledge and preventive practices of pregnant women towards COVID-19 in Ghana.

Conclusion

Although knowledge on COVID-19 among pregnant women was high, this did not reflect into pregnant women engaging in good COVID-19 preventive practices. There is a need to institute measures to improve COVID-19 preventive practices among pregnant women in Ghana. One of the ways of achieving this is by extending the media campaign to rural areas, where access to electronic media is limited. Also, efforts should be made to improve water, sanitation, and hygiene systems in communities as well as the free supply of facemask to the underprivileged.

Questions on knowledge of COVID-19.

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Questions on COVID-19 preventive practices.

(DOCX)

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(XLSX)

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18 Feb 2021

PONE-D-20-33669

Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Ghana

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Reviewer #1: COVID-19 is a novel respiratory disease associated with severe morbidity and high mortality in the elderly population and people with comorbidities. Studies have suggested that pregnant women are more susceptible to COVID-19 compared to non-pregnant women. However, it’s unclear whether pregnant women in Ghana are knowledgeable about COVID-19 and practice preventive measures against it.

This manuscript I provides evidence of knowledge of covid -19 among pregnant women in Ghana. The Manuscript is technically sound, well written and data analysis supports the conclusion

Reviewer #2: The study was carried out in Ghana in the Nabdam district in the Northern part of the country. It sought to find out whether pregnant women we putting themselves at risk of COVID-19 in terms of following the stipulated COVID-19 preventive measures and also to find out whether they are in the known at all of these preventive measures.

Questionnaires were administered as the pregnant women visited the hospital for antenatal care. These are my concerns:

The northern part of Ghana in terms of demography and topology is totally different from the southern part so the title is misleading.

What informed in the selection of the particular health facilities. How many health facilities were selected and how dispersed were they. How can this be a representative study for the whole district. The scope of sampling is too small to generalize to the whole district. How is the attitude of the pregnant women in terms of attending antenatal.

The authors per the last paragraph states that no studies on knowledge and preventive practices are focused on pregnant women, but this is not so. So many studies on knowledge and preventive practices focused on pregnant women have been carried out by several people Nwafor et al 2020, Anikwe et al 2020, Fikadu et al 2021, Kassie et al 2021 among others. Authors should therefore state in clearer terms the novelty of the study.

Authors should check grammar , there are a lot of grammatical errors in the article

Authors should number the lines of the article to make it easier to make reference to.

The conclusion at the abstract section was just a result restated. Authors should conclude appropriately.

**********

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19 Feb 2021

Reviewer #1

COVID-19 is a novel respiratory disease associated with severe morbidity and high mortality in the elderly population and people with comorbidities. Studies have suggested that pregnant women are more susceptible to COVID-19 compared to non-pregnant women. However, it’s unclear whether pregnant women in Ghana are knowledgeable about COVID-19 and practice preventive measures against it.

This manuscript I provides evidence of knowledge of COVID -19 among pregnant women in Ghana. The Manuscript is technically sound, well written and data analysis supports the conclusion.

Response: We sincerely appreciate the reviews.

Reviewer #2

The study was carried out in Ghana in the Nabdam district in the Northern part of the country. It sought to find out whether pregnant women we putting themselves at risk of COVID-19 in terms of following the stipulated COVID-19 preventive measures and also to find out whether they are in the known at all of these preventive measures. Questionnaires were administered as the pregnant women visited the hospital for antenatal care.

Response

• We sincerely appreciate the reviews.

The northern part of Ghana in terms of demography and topology is totally different from the southern part so the title is misleading.

Response

• We have changed the title to reflect Northern Ghana. See lines 1 and 2.

What informed in the selection of the particular health facilities?

Response

• All health facilities in the district that conducts antenatal care services were selected for the study. See lines 113 and 114.

How many health facilities were selected?

Response

• 16 health facilities were selected. See lines 113 and 114.

How dispersed were they?

Response

• The health facilities were not so dispersed. The distance between health facilities ranged from three to seven kilometers.

How can this be a representative study for the whole district. The scope of sampling is too small to generalize to the whole district.

Response

• Although the health facilities were purposively sampled, they included all antenatal care facilities in the district. Furthermore, pregnant women were randomly sampled from all these health facilities in the district. We therefore think that our findings can generalized in the district although same may not be applied in the country. We have stated it in our limitations. See lines 255, 256 and 257.

How is the attitude of the pregnant women in terms of attending antenatal?

Response

• Our study did not assessed attitude of pregnant women towards antenatal care attendance. However, some of the authors are practitioners in the district and have observed that antenatal care attendance is high.

The authors per the last paragraph states that no studies on knowledge and preventive practices are focused on pregnant women, but this is not so. So many studies on knowledge and preventive practices focused on pregnant women have been carried out by several people Nwafor et al 2020, Anikwe et al 2020, Fikadu et al 2021, Kassie et al 2021 among others. Authors should therefore state in clearer terms the novelty of the study?

Response

• This study is the first of its kind in Ghana. We have appropriately stated that in the paper. See lines 97 and 98.

Authors should check grammar, there are a lot of grammatical errors in the article.

Response

• We have thoroughly read the paper and grammatical errors have been corrected.

Authors should number the lines of the article to make it easier to make reference to.

Response

• We have numbered all the lines of the article.

The conclusion at the abstract section was just a result restated. Authors should conclude appropriately.

Response

• The conclusion has been reconstructed appropriately. See lines 43,44 and 45.

Submitted filename: Response to Reviewers.docx

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9 Apr 2021

PONE-D-20-33669R1

Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana

PLOS ONE

Dear Author,

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Kind regards,

Ramesh Kumar, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

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

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: Yes

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: (No Response)

Reviewer #2: For the conclusion, state the type of education on COVID needed to be given pregnant women that is not being done already.

Abstract should emphasize on the Northern Ghana.

At the onset of the study there might not have been COVID-19 vaccines. Now there are, authors should kindly update this information in their introduction.

At the discussion section COVID-19 was mistakenly written as COVID-1, edit.

How does having at least primary education associate with easier access to health information compared to individuals without a formal education, explain further.

**********

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

[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.

9 Apr 2021

Reviewer #1: (No Response)

Response:

We sincerely appreciate your reviews.

Reviewer #2: For the conclusion, state the type of education on COVID-19 needed to be given pregnant women that is not being done already.

Response: Education of COVID-19 preventive practices at the health facility level has been emphasized. See page 3 line 44.

Abstract should emphasize on the Northern Ghana.

Response:

This has been edited. See page 2 line 27

At the onset of the study there might not have been COVID-19 vaccines. Now there are, authors should kindly update this information in their introduction.

Response:

This information has been updated. See page 5 lines 84-86 and lines 91-92.

At the discussion section COVID-19 was mistakenly written as COVID-1, edit.

Response:

This has been edited. See page 12 line 204

How does having at least primary education associate with easier access to health information compared to individuals without a formal education, explain further.

Response:

It exposes mothers to knowledge on health compared to mothers with no formal education. We have cited this sentence in page 13 line 221.

Submitted filename: Response to Reviewer.docx

Click here for additional data file.

26 Apr 2021

PONE-D-20-33669R2

Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana

PLOS ONE

Dear Author,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 10 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ramesh Kumar, PhD

Academic Editor

PLOS ONE

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

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 #2: All comments have been addressed

Reviewer #3: 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 #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #2: (No Response)

Reviewer #3: 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 #2: Yes

Reviewer #3: No

**********

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 #2: Yes

Reviewer #3: 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 #2: (No Response)

Reviewer #3: This study aimed to assess the knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana. A cross-sectional study was conducted using a structured questionnaire in the Nabdam district in Ghana. A total of 527 pregnant women were randomly sampled from health facilities offering antenatal care services in the district. Multivariable logistic regression analysis was used to assess the association between the predictors and outcome variables. Although the majority of the women had adequate knowledge of COVID-19, less than half of them were engaged in good COVID-19 preventive practices. Education of pregnant women on COVID-19 preventive practices should be intensified at health facilities while improving upon the water, sanitation and hygiene need particularly in rural communities.

This study has merit and important in the context of Ghana. However, I have several comments on the content.

Major Comments:

1. “The sample size for the study was estimated using EpiInfo Version 7.1 (STAT CALC). The prevalence of knowledge on COVID-19 was not known, therefore a 50% prevalence rate was used with a 95% confidence interval and 5% margin of error. The estimated minimum sample size was 407 including a 10% non-response rate. However, 527 participants completed our surveys.” Why was there oversampling and how this might affect the study?

2. Line 139-140: “A score of 3 points and above was considered good COVID-19 preventive practices while 2 points and below was considered poor COVID-19 preventive practices.” Was this cut-off validated? Please provide reference of previous literature who used this score.

Minor Comments:

1. There are some typos in the manuscript. For example in line 90 “Ghana reported its first case of COVIG-19 on 12th March 2020 in its national capital, Accra [21].” Please change this to COVID-19.

2. Line 121: add the unit (years) after the age.

**********

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 #2: No

Reviewer #3: Yes: Rajat Das Gupta

[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.

27 Apr 2021

Reviewer #3:

This study aimed to assess the knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana. A cross-sectional study was conducted using a structured questionnaire in the Nabdam district in Ghana. A total of 527 pregnant women were randomly sampled from health facilities offering antenatal care services in the district. Multivariable logistic regression analysis was used to assess the association between the predictors and outcome variables. Although the majority of the women had adequate knowledge of COVID-19, less than half of them were engaged in good COVID-19 preventive practices. Education of pregnant women on COVID-19 preventive practices should be intensified at health facilities while improving upon the water, sanitation and hygiene need particularly in rural communities.

This study has merit and important in the context of Ghana. However, I have several comments on the content.

Response:

We sincerely appreciate your reviews.

Major Comments:

1. “The sample size for the study was estimated using EpiInfo Version 7.1 (STAT CALC). The prevalence of knowledge on COVID-19 was not known, therefore a 50% prevalence rate was used with a 95% confidence interval and 5% margin of error. The estimated minimum sample size was 407 including a 10% non-response rate. However, 527 participants completed our surveys.” Why was there oversampling and how this might affect the study?

Response:

The sample size of 407 was the minimum sample size required. A sample size of 527 will increase the precision of our estimates.

2. Line 139-140: “A score of 3 points and above was considered good COVID-19 preventive practices while 2 points and below was considered poor COVID-19 preventive practices.” Was this cut-off validated? Please provide reference of previous literature who used this score.

Response:

This cut-off was adapted from Bloom’s cut-off points. It was duly cited in our study. See page 7 line 139.

Minor Comments:

1. There are some typos in the manuscript. For example, in line 90 “Ghana reported its first case of COVIG-19 on 12th March 2020 in its national capital, Accra [21].” Please change this to COVID-19.

Response: This error has been corrected. See page 5 line 90. We have also read through the manuscript and made all the necessary correction of errors.

2. Line 121: add the unit (years) after the age.

Response:

Years has added accordingly. See page 6 lines 121-122.

Submitted filename: Response to reviewer.docx

Click here for additional data file.

7 Jun 2021

Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana

PONE-D-20-33669R3

Dear Author,

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,

Ramesh Kumar, PhD

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 #2: All comments have been addressed

Reviewer #3: 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 #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: 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 #2: (No Response)

Reviewer #3: The authors have addressed all the comments. I recommend this manuscript for publication. I wish the authors good luck.

**********

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 #2: No

Reviewer #3: Yes: Rajat Das Gupta

9 Jun 2021

PONE-D-20-33669R3

Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana

Dear Dr. Kumbeni:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ramesh Kumar

Academic Editor

PLOS ONE