Pregnant women's unmet need to communicate with a health professional during the SARS-CoV-2 pandemic lockdown in France: The Covimater cross-sectional study.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic lockdown, communication between pregnant women and health professionals may have become complicated due to restrictions on movement and saturated health services. This could have impacts on pregnancy monitoring and women's wellbeing. We aimed to i) describe the unmet need of pregnant women living in France to communicate with health professionals about the pandemic and their pregnancy during the lockdown, ii) assess the socio-demographic, medical and contextual factors associated with this unmet need. The Covimater cross-sectional study, conducted in July 2020, includes data on 500 adult women's experiences of pregnancy during the first lockdown period in France (i.e., from March to May 2020). The women, all residents in metropolitan France, answered a web-based questionnaire about their conversations with health professionals during the lockdown, as well as their social and medical characteristics. A robust variance Poisson regression model was used to estimate crude or adjusted prevalence ratios (aPRs) for their unmet need to communicate with health professionals about the pandemic and their pregnancy. Forty-one percent of participants reported an unmet need to communicate with a health professional during the lockdown, mainly about the risk of transmitting SARS-CoV-2 to their baby and the consequences for the latter. Factors associated were: i) being professionally inactive (aPR = 1.58,CI95%[(1.14-2.21]), ii) having an educational level below secondary school diploma (1.38,[1.05,-1.81]), iii) having experienced serious arguments/violence (2.12,[1.28-3.52]), iv) being very worried about the pandemic (1.41,[1.11-1.78]), v) being primiparous (1.36,[1.06-1.74]) and vi) having had pregnancy consultations postponed/cancelled by health professionals during the lockdown (1.35,[1.06-1.73]). These results can be used to develop targeted strategies that ensure pregnant women are able to i) communicate with health professionals about the potential impact of the SARS-CoV-2 pandemic on their pregnancy, and ii) access up-to-date and reliable information on the consequences of SARS-CoV-2 for themselves and their child.

Introduction

Data from previous coronavirus epidemics in 2002 (SARS-CoV-1) and 2013 (Middle East respiratory syndrome-related coronavirus, i.e., MERS-CoV) showed that pregnancy was an aggravating factor in respiratory diseases, which in turn are associated with significant maternal-foetal morbidity [1, 2]. Moreover, when the SARS-CoV-2 pandemic began, for months, pregnant women were uncertain about the risk of developing severe forms of COVID-19, the disease caused by SARS-CoV-2, and/or transmitting the virus to their unborn children. Indeed, the first related scientific data published internationally presented contradictory conclusions. While some studies showed an increased risk of complications in infected pregnant women (such as admission to an intensive care unit, invasive ventilation, need for extra corporeal membrane oxygenation, preterm delivery or admission to a neonatal unit for their newborn) [3-5] and a greater possibility of vertical transmission of the virus [6], others found no increased risk compared with infected non-pregnant women [7-9] and no possible transmission of SARS-CoV-2 from mother to foetus [7, 9–12]. These contradictory findings may have generated an increased need for pregnant women to communicate with health professionals about the risks linked to infection (regarding themselves, their foetus or newborn), but also about the course of their pregnancy monitoring or childbirth.

However, such communication may have become more difficult given the spread of the pandemic, the strain it put on healthcare services, and the introduction of lockdown measures. In the United States, a survey conducted between mid-March and mid-May 2020 showed that almost one-third of pregnancy monitoring visits were changed, cancelled or postponed [13]. In France, half (48.9%) of the pregnant women included in the Covimater cross-sectional study reported at least one postponement or cancellation of a consultation or pregnancy check-up during the country’s first lockdown (from 17 March to 11 May 2020), whether on their own initiative (23.4%), or that of a hospital/health professional (36.3%) [14]. Another French study reported that 29.5% of pregnancy-related health consultations (mainly healthcare consultations and childbirth preparation sessions) were cancelled during the lockdown [15]. Following these initial cancellations/postponements, recommendations to reorganise and maintain pregnancy monitoring were quickly issued by the French National Authority for Health (HAS, Haute Autorité de Santé) [16]. In France, the primary reorganisation strategies were to monitor pregnancies by video or telephone (teleconsultation) and to group certain examinations and consultations [16].

Despite these changes, the overall unprecedented context may have had an impact on the ability of health professionals to respond to their patients’ questions. However, even before the pandemic began, several studies highlighted pregnant women’s perceived lack of communication from health care professionals about the course of pregnancy [17, 18]. This phenomenon may have increased during the pandemic and the lockdown. In the literature, pregnant women’s need to communicate with a health professional during the SARS-CoV-2 pandemic about the risks associated with their own infection or that of their foetus/newborn, about the course of pregnancy monitoring or about childbirth, is poorly documented. Yet descriptive information on this subject is necessary, particularly to characterise the women most at risk of having unmet communication needs, in order to develop targeted strategies to improve these women’s quality of life during pregnancy, a period of great vulnerability in terms of mental health.

In the context of France’s first SARS-CoV-2 lockdown, we aimed to (i) estimate the frequency of pregnant women reporting an unmet need to communicate with health professionals, (ii) specify which pregnancy/delivery-related information they were unable to talk about with health professionals, and (iii) assess the factors associated with their unmet need to communicate with health professionals about the impact of the pandemic on their pregnancy/childbirth.

Materials and methods

Study design, setting and sample size of Covimater

At our request, a service provider (BVA group) interviewed its unpaid pre-pandemic internet panel of 15,000 future parents or parents of children under 3 years of age in order to create a pseudonymised non-probability sample of 500 pregnant adult women who met the inclusion criteria (described below) and volunteered to participate our survey. Covimater is a cross-sectional study using quota sampling, whereby the study sample was assigned a structure similar to that of the target population (i.e., all pregnant women in France) in order to increase the representativeness. The population of parents of children under 1 year old–as per the National Institute of Statistics and Economic Studies 2016 census–was used to set the quotas [19]. By its broad representation, the latter was judged as a good proxy for our target population of pregnant women in France. The quotas for mothers of children under 1 year old were used to calculate weightings using Newton’s algorithm in order to obtain weighted individual data for the statistical analysis presented herein [20]. Specifically, these quotas comprised age group, socio-professional category, region of residence, size of urban area, and parity.

Eligible women for Covimater (see below) were invited by BVA to answer a web-based questionnaire between 6–20 July 2020, i.e., two months after the end of the first lockdown in France (March to May 2020). The two-month interval was chosen to avoid the memory bias associated with a longer interval. Demographic/socio-economic data, pandemic and lockdown-related data, participants’ perceptions of the pandemic, data on their pregnancy, their health, and on pregnancy monitoring during first lockdown were collected.

We compared our sample to another data source (the National Medical and Administrative Database) in order to validate its representativeness. No significant difference in available data for age group, region of residence or parity was observed between the women participating in Covimater and women in the whole French population who gave birth in a hospital maternity ward in France in 2017 (i.e., 99% of pregnant women in France) [21]. Our study shows, with a power of 99%, a difference of at least 20% concerning the variable of interest (see definition below) between two subgroups of balanced/unbalanced women.

Participants

Inclusion criteria

Women who were pregnant during the first lockdown (17 March–11 May 2020), aged 18 years and over, and residents in metropolitan France.

Exclusion criteria

Women who were pregnant during the lockdown but with limited exposure to it: those who delivered in the first two weeks of the lockdown and those whose first week of gestation began during the last two weeks of the lockdown (deducted from the expected date of delivery reported by the women).

Issue of interest: Unmet need to communicate with health professionals

Women who reported an unmet need to communicate with a health professional (gynaecologist, nurse, generalist, midwife, etc.) were those who answered “I was not able to discuss this topic with a health professional but I would have liked to”, to at least one of six questions regarding: (i) the risk of being infected with SARS-CoV-2 and the possibility of having severe symptoms of COVID-19 disease, (ii) the risk of transmission of SARS-CoV-2 to their baby and the consequences for the latter, (iii) the course of their pregnancy monitoring during the pandemic, (iv) the delivery process in the context of the pandemic, (v) the course of their maternity stay, and (vi) the possibility of breastfeeding without risk to their child during the pandemic.

Women who answered “No, because I did not need it” or “Yes, I met with a health professional” to all six questions were considered to have had their need for communication with health professionals fully satisfied.

Comparisons

Explanatory variables were divided into five main themes:

Demographic and socio-economic: age, socio-professional category (SPC) reduced into SPC+ (self-employed women, managers, intermediate professions), SPC- (employees, blue-collar workers) and inactive women (students and other professionally inactives), educational level (equal to or higher than secondary school diploma, lower than secondary school diploma), perceived financial situation (comfortable, just getting by, difficult to make ends meet).

Pandemic and lockdown-related: child(ren) under six years of age (i.e., younger than school age in France) in the household during the lockdown, SARS-CoV-2 healthcare system severity as reported by the Ministry of Health on 1 May 2020 in their region of residence (coded as green, orange or red, reflecting increased epidemic pressure on the healthcare system) [22], professional workload (did not work, lighter than/same as usual, heavier than usual), self-perceived social support (from family, friends, etc.; Very good, Good, Little or None), having experienced serious disputes or violence (Very-often/Often, Sometimes/Rarely, Never), having COVID-19 type symptoms, family member or friends diagnosed with COVID-19 or had symptoms suggestive of the disease.

Self-perception of the pandemic during the lockdown: Two different scale-based scores were recorded: one for participants’ general level of worry about the pandemic situation in France, and another for their perceived vulnerability to SARS-CoV-2 infection (from 0 (not at all worried/vulnerable) to 10 (very worried/vulnerable)). Two dichotomous variables were then created for ‘worry’ and ‘vulnerability’, with 7/10 and 6/10 as the thresholds, respectively, corresponding to the average worry or vulnerability observed (7.0 +/- 0.1 and 6.2 +/- 0.1, respectively).

Pregnancy and health: parity, gestational age at the end of lockdown, childbirth (during or after first lockdown), at least one pre-existing chronic disease, at least one pregnancy-related pathology (see details of pathologies in Table 1), overweight/obesity status before pregnancy (based on Body Mass Index≥25kg/m2; see details in Table 1).

Table 1

Description of pregnant women during the first COVID-19-related lockdown (March to May 2020) who participated in the Covimater survey (n = 500), France (July 2020).

	N (%) or mean (sd)*	[95%CI**]
Demographic and socio-economic characteristics
Age (in years)	31.4 (5.1)	[30.8–31.9]
Socio-professional category (SPC)a
SPC +	192 (38.4)	[33.9–43.2]
SPC -	180 (36.1)	[31.8–40.6]
Inactive	128 (25.5)	[20.5–31.2]
Educational level
Equal to or higher than secondary school diploma	391 (78.1)	[73.6–82.1]
Lower than secondary school diploma	109 (21.9)	[17.9–26.4]
Perceived financial situation
Comfortable	246 (49.2)	[44.2–54.2]
Just getting by	159 (31.7)	[27.2–36.6]
Difficult to make ends meet	95 (19.1)	[15.2–23.7]
Pandemic and lockdown related variables
Child(ren) under six years of age in the household during the lockdown	234 (46.8)	[41.8–51.8]
SARS-CoV-2 healthcare system severity (colour-coded) for the region of residenceb
Green zone	127 (25.4)	[21.1–30.2]
Orange zone	150 (30.0)	[25.7–34.7]
Red zone	223 (44.6)	[39.7–49.6]
Self-perceived social support
Very good	180 (36.0)	[31.3–40.9]
Good	231 (46.1)	[41.2–51.1]
Little or none	89 (17.9)	[14.5–21.8]
Serious disputes or violence
Very-often/ Often	11 (2.3)	[1.10–4.60]
Sometimes / Rarely	129 (25.8)	[21.7–30.4]
Never	360 (71.9)	[67.2–76.2]
Having had COVID-19 type symptoms	92 (18.4)	[14.9–22.6]
Family member or friends diagnosed with COVID-19 or had symptoms suggestive of the disease	171 (34.2)	[29.7–39.0]
Self-perception of the pandemic during first lockdown
Perceived a general worry about the SARS-CoV-2 pandemic (max.10; n = 485) > 7/10c	234 (48.3)	[43.3–53.3]
Perceived vulnerability to severe forms of COVID -19 disease (max. 10; n = 459) >6/10c	250 (54.6)	[49.4–59.6]
Pregnancy and health
Primiparous	203 (40.6)	[35.8–45.6]
Gestational age (weeks) at the end of first lockdownd
<10	34 (6.8)	[4.70–9.80]
10–20	177 (35.4)	[30.8–40.3]
20–30	180 (36.1)	[31.4–41.0]
30–40	77 (15.4)	[12.1–19.4]
> 40	32 (6.3)	[4.30–9.20]
Childbirth
During lockdown	34 (6.8)	[4.70–9.80]
After lockdown	466 (93.2)	[90.2–95.2]
Pre-existing Chronic disease(s)e	152 (30.3)	[25.8–35.1]
Pregnancy-related pathology(ies)f	119 (23.7)	[19.9–28.0]
Overweight/Obesity status before pregnancyg	212 (42.4)	[37.5–47.4]
Pregnancy monitoring during first lockdown
Cancelled/postponed pregnancy consultations or examinations at the initiative of a health professional	182 (36.3)	[31.6–41.3]
Forewent/postponed pregnancy consultations or examinations at the initiative of the womenh	117 (23.4)	[18.8–27.7]
Teleconsultations (video or telephone) for pregnancy monitoring	197 (39.4)	[34.6–44.4]
Change of health professional than the referring professional	74 (14.9)	[11.7–18.8]
Having an unmet need to communicate with health professionals about course of pregnancy/childbirth during pandemic
No	295 (59.0)	[53.9–63.8]
Yes	205 (41.0)	[36.1–46.1]

* Weighted and rounded values using Newton’s algorithm [20] for discrete or qualitative variables. For continuous variables, mean (standard deviation) were presented.

** 95% Confidence Interval

a Women on maternity leave and unemployed women were classified according to their current SPC category or their most recent category prior to ending work, respectively.

b Estimated by the Ministry of Health on 1 May 2020 on the basis of two variables: i) Virus circulation level (i.e., percentage of emergency room admissions for suspected COVID-19) and ii) Strain on hospital intensive care unit capacity (i.e., occupancy rate of intensive care beds by patients with COVID-19), coded as green, orange or red, reflecting increased epidemic pressure on the healthcare system [22].

c Scores for participants’ general worry about the pandemic situation and for their perceived vulnerability to SARS-CoV-2 infection during the first lockdown (from 0 (not at all worried/vulnerable) to 10 (very worried/vulnerable)). Two dichotomous ‘low/high’ variables were then created for ‘worry’ and ‘vulnerability’, with 7/10 and 6/10 as the thresholds, respectively (see details in methods). No documented data for 15 and 41 pregnant women in terms of level of worry about the pandemic or level of perceived vulnerability to severe forms of COVID -19, respectively.

d At the end of the first lockdown (11 May 2020) or at the date of childbirth if women gave birth during lockdown.

e Diabetes, Overweight/Obesity status before pregnancy, High Blood Pressure, Asthma, Cardiac condition, Autoimmune disease, mental illness, inherited bleeding disorders.

f Gestational diabetes, pre-eclampsia, preterm labour, gestational hypertension.

g Body Mass Index≥25kg/m2.

h Also includes women who did not start monitoring despite a gestational age of 15 weeks.

Pregnancy monitoring during first lockdown: had a consultation/examination cancelled/postponed on a health professional’s initiative, change in health professional from the one who usually followed them, teleconsultation (video or telephone) for pregnancy monitoring.

Ethics and endpoint

Covimater received approval from the Saint Maurice Hospital Ethics Committee on 01/07/2020 (approval number n°2020–1). Internet panel volunteers included in the Covimater study were informed by mail of the study’s purpose then given the choice to participate in the survey. Only pseudonymised databases were transmitted to Santé publique France. The data are stored on Santé publique France’s servers, respecting the agency’s data security and confidentiality standards.

Statistical analysis

A robust variance Poisson regression model was used to estimate unadjusted and adjusted prevalence ratios (aPR) [23] for having had an unmet need to communicate with a health professional. Factors associated with this outcome which had a p-value<0.20 in bivariate analysis or which were judged clinically relevant (e.g., gestational age at the end of the lockdown period and parity) were introduced into the multivariable model. When several variables were possibly collinear, the model with the best likelihood score (lowest Bayesian Information Criterion) was selected. Fractional polynomials confirmed a linear relationship between continuous variables included in the models and the studied prevalence of the outcome. A manual stepwise descending approach was applied. The final model included all variables independently associated with the variable of interest (p-value<0.05) after epidemiological reflection and according to the clinical relevance of each variable at each step of the procedure. As indicated by Zou, PRs were interpreted in the same way as relative risks [24].

All statistical analyses were performed using Stata® software version 14.2 (Stata Corp., College Station, TX, USA).

Results

Characteristics of women included in Covimater (Table 1)

The mean age of the Covimater study sample (n = 500) was 31.4 years (sd = 5.1). The majority (78.1%) had a secondary school diploma or higher level of education, 36.1% were classified SPC-, 25.5% were inactive, 31.7% declared they just got by financially, while 19.1% reported that they could not make ends meet. Among the 500 women in the sample, 40.6% were primiparous. Nearly one in six women (17.9%) received little or no social support during the lockdown, 28% experienced serious arguments and/or a climate of violence, and almost one in two (48.3%) reported having a level of worry higher than 7 (out of 10) about the pandemic during the same first lockdown.

With regard to pregnancy monitoring during the first lockdown, 36.3% reported postponements or cancellations of consultations/examinations by their hospital or health professionals, and 39.4% had had teleconsultations. Furthermore, 14.9% of the women who had started their pregnancy monitoring during the first lockdown declared that they had changed health professionals from the one who usually followed them.

Pregnant women’s unmet need to communicate with a health professional during France’s first SARS-CoV-2 pandemic-related lockdown (17 March to 11 May 2020) (Fig 1)

Two in five (41%) participants in Covimater indicated that they had an unmet need to communicate with health professionals on at least one of the six themes studied concerning the SARS-CoV-2 pandemic, pregnancy care and delivery process. The two most frequent themes not discussed with health professionals were i) the risk of transmitting SARS-CoV-2 to their unborn child and the consequences for the latter (29.3%), and ii) the risk of being infected and having severe symptoms (27.4%). Approximately one in six women reported that they would have liked to have been able to talk with a professional about the delivery process (16.1%), the maternity stay (16.4%), and the possibility of breastfeeding during the SARS-CoV-2 pandemic (15.3%).

Proportion of women with an unmet need to communicate with a health professional. Among the 500 pregnant women during the lockdown, 102 had given birth at the time of completing the web-questionnaire.

Factors associated with unmet need to communicate with a health professional during the first SARS-CoV-2 pandemic lockdown (Table 2)

The following subgroups had a significantly higher prevalence of having at least one unmet need for information for the six themes addressed in the study: women who were professionally inactive (aPR = 1.58, CI95%[(1.14–2.21]), those with a level of education lower than secondary school diploma (1.38, [1.05–1.81]), those having experienced often or very-often violence or serious arguments during the lockdown (2.12, [1.28–3.52]), those very worried about the pandemic (1.41, [1.11–1.78]), those who were primiparous (1.36, [1.06–1.74]) and those who had a pregnancy consultation cancelled/postponed at the initiative of health professionals during the lockdown (1.35, [1.06–1.73]).

Discussion

Nearly 41% of pregnant women in Covimater reported that they had tried in vain to communicate with a health professional on at least one of the six topics studied in the survey. The topics that pregnant women would have liked to discuss were mainly related to the risk and complications for them and their unborn/born baby in the event of SARS-CoV-2 infection, and the impact of the pandemic on their pregnancy monitoring or delivery. Primiparous women, those professionally inactive, those with an educational level below secondary school diploma, those who had experienced violence during lockdown, those very worried about the pandemic, and finally, those whose pregnancy consultations had been postponed or cancelled at the initiative of a health professional were all more likely to have had an unmet need to communicate with a healthcare professional.

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions [25].

Greater health literacy is associated with better health [26]. One of the most important determinants of health literacy is education level [26]. According to our results, pregnant women who did not have a secondary school diploma were more likely to report an unmet need to communicate with a health professional. Because of poor health literacy, these women may have had more difficulties to express their need and therefore to obtain answers to their questions when they talked to the health professionals; accordingly, they were more likely to be dissatisfied.

In Covimater, primiparous women were more likely to attempt to communicate with health professionals, particularly concerning the process of delivery and their stay in the maternity ward. On this subject, the National Perinatal Survey (NPS) carried out in France in all maternity units in 2016 reported that birth and parenthood preparation sessions were more often attended by primiparous women [27]. Primiparous women may have been more likely to have unmet need to communicate with a healthcare professional than their multiparous counterparts.

In our analyses, postponements/cancellations of consultations/examinations by health professionals were associated with a higher likelihood of reporting an unmet need to communicate with healthcare professionals during France’s first lockdown. Several studies have underlined the importance of the patient/caregiver relationship in medical monitoring (compliance with care, treatment, and health examinations). It is therefore crucial, even outside the context of the pandemic and lockdown, to maintain personalised monitoring of pregnant women as much as possible [28].

In Covimater, pregnant women who were very worried about the pandemic in general were more likely to have had an unmet need to communicate with a health professional during the first lockdown. The self-reported reasons for worry were mainly related to their pregnancy, the risk of infection of their vulnerable relatives, the risk of being infected themselves and of transmitting the virus to their unborn child (article submitted for publication). In our analysis, the topics which women would have liked to talk about but could not overlapped with some of these most frequent reasons for worry: the risk of being infected and having a severe form of COVID-19 disease; the risk of transmitting the virus to their unborn child, and the consequences for the latter, the course of the delivery, and the stay in the maternity ward. The need to communicate with health professionals on these subjects reflects the initial worldwide uncertainty about the consequences of infection and COVID-19 disease for pregnant women throughout the medical and scientific community during the first international lockdowns [3, 6, 7, 9].

Our results showed an association between having experienced violence during the first lockdown and pregnant women’s unmet need to communicate with health professionals. Although the percentage of pregnant women that reported violence or serious arguments during the first lockdown was high (28.1%), it was significantly lower than that obtained for women of childbearing age (18–49 years) in the CoviPrev study (32.9%, p = 0.03), a repeated cross-sectional study in the French general population using the same methodology and conducted at the same time as Covimater [29]. Some studies but not all reported a higher risk of violence in pregnant women than in non-pregnant women [30, 31]. With regard to prenatal care, several studies have shown that pregnant women experiencing domestic violence were more likely to delay antenatal visits; for some, this was because partners prevented or discouraged them from having visits, while others felt embarrassed about the possibility of being judged in public because of obvious signs of violence [32, 33]. A study conducted in the United States showed that pregnant women who experienced domestic violence (vs those who did not) were 1.8 times more likely (CI95%[1.5–2.1]) to delay entry into prenatal care [32]. This may partly explain why, in our analysis, pregnant women who experienced violence during France’s first lockdown were more likely to have an unmet need for communication with health professionals. Efforts to detect violence against women at an early stage of pregnancy should be continued to prevent its harmful impact on health.

Health professionals are not the only sources of information for the general population; many health promotion campaigns have demonstrated their impact in recent years [34-37]. One example is the ‘Antibiotics are not automatic’ campaign conducted in France in 2002. This slogan was strongly featured on social networks, television and newspapers, and halved the number of false responses in surveys concerning the use of antibiotics. In addition, this campaign created a need for information and knowledge among patients; more specifically, 55% of the participants felt that the campaign made them want to know more [35]. In May 2020, during the COVID-19 pandemic in France, the following message targeting patients and vulnerable populations including newborns and pregnant women was broadcast on television and radio: “During the pandemic, whatever your health problem, make sure you get care” [38]. It is essential to continue to use these communication channels to inform and reassure populations during a health crisis.

Our work therefore highlighted the importance of maintaining or promoting communication between health professionals and pregnant women during the pandemic. Specific information campaigns could also be enhanced and circulated through diverse media channels (e.g., radio or television) to help reassure this population during the pandemic.

In the literature, little information was available on patients’ needs for communication with health professionals, even less in the context of the ongoing SARS-CoV-2 pandemic. Covimater brought new insight to this important topic and identifies specific groups of women who should be targeted by public policies, which constitutes the study’s primary strength. Secondly, Covimater included women with different gestational ages, unlike studies from other countries that mostly focus on the third trimester of pregnancy during the current pandemic. Furthermore, Covimater succeeded in identifying significant associations with the variable of interest despite the fact that some of the groups compared were unbalanced in size (with consequently reduced power).

Covimater also had some limitations. First, the use of a panel of volunteers and quota sampling could imply an inclusion bias in the pregnant women who accepted to participate for the survey. However, no alternative method available would have permitted the study to take place in sufficient time to avoid a significant recall bias. The further away the lockdown was, the more difficult it would have been to collect reliable information from women about their behaviour and feelings during the period. Consequently, greater caution is required when interpreting the statistical inference of our results than would be needed for random sample studies. Second, sampling bias could explain the poor estimation of the percentage of pregnant women with pre-existing chronic diseases like diabetes or obesity (1.5 vs 0.5% and 2.4 vs 12% in Covimater vs NPS study, respectively). Third, as the study questionnaire was self-administered, there is a risk that respondents misinterpreted questions, as well as a risk of recall biases or potential social desirability. However, there is no reason why any of the study’s above-mentioned limitations should only affect a particular sub-group of pregnant women.

Conclusions

During the first SARS-CoV-2 pandemic lockdown in France, a high proportion of pregnant women declared an unmet need to communicate with a health professional. The Covimater study made it possible to identify pregnant women who were at particular risk of this unmet need, with a special focus on women who were victims of violence. Our results underline the importance of public policies aimed at preventing this communication deficit, for example, by promoting access for pregnant women to healthcare/patient communication channels and by increasing the availability of information on the different types of media used by these women.

29 Oct 2021

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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

Reviewer #1: I am glad to assess this study entitled, " Pregnant women's unmet need to communicate with a health professional during the SARS-CoV-2 pandemic in France: the Covimater cross-sectional study."

I suggest some minor corrections to check the typo errors in writing to enhance the English quality to reach the scientific merit for the publication of this study. I will this article after the following modifications.

This present study explains that

When the pandemic started, healthcare systems throughout the world rapidly reorganised to respond to what was an unprecedented situation. We aimed to i) describe the unmet need of pregnant women living in France to communicate with health professionals about the pandemic and their pregnancy, ii) assess the socio demographic, medical and contextual factors associated with this unmet need I am in favor of this study and will recommend for publication. However, the authors need to revise the manuscript and work according to my suggestions to enhance the quality. I will accept this paper for publication after these minor changes as suggested below.

Introduction and literation sections

I recommend the authors add suggested articles in the introduction and literature sections. These research articles have identified health-related topics I believe it will improve the quality of your work. I strongly suggested them to improve this section a bit more. I advise authors to revisit their introduction and literature sections of the recommended studies and cite these studies to enhance your research study's quality to reach scientific merit for publication.

Wang, C., Wang, D., Abbas, J., Duan, K., & Mubeen, R. (2021). Global financial crisis, smart lockdown strategies, and the COVID-19 spillover impacts: A global perspective implications from Southeast Asia. Front Psychiatry, 12, 1-14. doi:10.3389/fpsyt.2021.643783

Abbas, J., Hussain, I., Hussain, S., Akram, S., Shaheen, I., & Niu, B. (2019). The Impact of Knowledge Sharing and Innovation upon Sustainable Performance in Islamic Banks: A Mediation Analysis through an SEM Approach. Sustainability, 11(15), 4049. doi:10.3390/su11154049

NeJhaddadgar, N., Ziapour, A., Zakkipour, G., Abolfathi, M., & Shabani, M. (2020, Nov 13). Effectiveness of telephone-based screening and triage during COVID-19 outbreak in the promoted primary healthcare system: a case study in Ardabil province, Iran. Z Gesundh Wiss, 1-6. https://doi.org/10.1007/s10389-020-01407-8

Literature

I want to see publish this creative study after some corrections. I have endorsed this study as; it deserves the merit for publication. However, I suggest the authors make minor corrections according to my advice. Please read the suggested studies and cite them in the introduction, literature, and method sections. How corporate social responsibility, innovation and social media and internet use is helpful. Add few lines in the introduction and literature sections. How companies are practicing CSR, business, entrepreneurial networks with innovation and knowledge sharing to improve the business performance and provide better healthcare medicines?

Abbas, J., Raza, S., Nurunnabi, M., Minai, M. S., & Bano, S. (2019). The Impact of Entrepreneurial Business Networks on Firms’ Performance Through a Mediating Role of Dynamic Capabilities. Sustainability, 11(11), 3006. doi:10.3390/su11113006

Azizi, M. R., Atlasi, R., Ziapour, & Naemi, R. (2021). Innovative human resource management strategies during the COVID-19 pandemic: A systematic narrative review approach. Heliyon, 7(6), e07233. doi:10.1016/j.heliyon.2021.e07233

Abbas, J., Zhang, Q., Hussain, I., Akram, S., Afaq, A., & Shad, M. A. (2020). Sustainable Innovation in Small Medium Enterprises: The Impact of Knowledge Management on Organizational Innovation through a Mediation Analysis by Using SEM Approach. Sustainability, 12(6), 2407. doi:https://doi.org/10.3390/su12062407

Azadi, N. A., Ziapour, A., Lebni, J. Y., Irandoost, S. F., & Chaboksavar, F. (2021). The effect of education based on health belief model on promoting preventive behaviors of hypertensive disease in staff of the Iran University of Medical Sciences. Archives of Public Health, 79(1), 69. doi:10.1186/s13690-021-00594-4

Materials and Methods

The results section of the paper presents a good view of the study. This work presents a notable investigation on a selected topic. I suggest the authors to present high quality graphs. By including some graphical presentations will improve the quality of this study. Please see the proposed studies and see the graphical representation. Improve your work like these studies and cite them in this section.

Paulson, K. R., Kamath, A. M., Alam, T., Bienhoff, K., Abady, G. G., . . . Kassebaum, N. J. (2021). Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019. The Lancet, 1-36. doi:10.1016/s0140-6736(21)01207-1

Hussain, T., Wei, Z., & Nurunnabi, M. (2019). The Effect of Sustainable Urban Planning and Slum Disamenity on The Value of Neighboring Residential Property: Application of The Hedonic Pricing Model in Rent Price Appraisal. Sustainability, 11(4), 1144. doi:10.3390/su11041144

Abbas, J., Aman, J., Nurunnabi, M., & Bano, S. (2019). The Impact of Social Media on Learning Behavior for Sustainable Education: Evidence of Students from Selected Universities in Pakistan. Sustainability, 11(6). https://doi.org/10.3390/su11061683

Mubeen, R., Han, D., Abbas, J., & Hussain, I. (2020). The Effects of Market Competition, Capital Structure, and CEO Duality on Firm Performance: A Mediation Analysis by Incorporating the GMM Model Technique. Sustainability, 12(8), 3480. doi:10.3390/su12083480

Discussion

I suggest the authors to discuss the effects of the COVID-19. I suggest you to cite these studies. Read the proposed studies to improve your results and discussion section. See the recommended studies and improve your sections. How companies are practicing CSR, business, entrepreneurial networks with innovation and knowledge sharing to improve the business performance and provide better performance?

Su, Z., McDonnell, D., Wen, J., Kozak, M., Šegalo, S., . . . Xiang, Y.-T. (2021). Mental health consequences of COVID-19 media coverage: the need for effective crisis communication practices. Globalization and Health, 17(1), 4. doi:10.1186/s12992-020-00654-4

Abbas, J., Mahmood, S., Ali, H., Ali Raza, M., Ali, G., Aman, J., . . . Nurunnabi, M. (2019). The Effects of Corporate Social Responsibility Practices and Environmental Factors through a Moderating Role of Social Media Marketing on Sustainable Performance of Firms’ Operating in Multan, Pakistan. Sustainability, 11(12), 3434. doi:10.3390/su11123434

Aqeel, M., Shuja, K. H., Rehna, T., Ziapour, A., Yousaf, I., & Karamat, T. (2021). The Influence of Illness Perception, Anxiety and Depression Disorders on Students Mental Health during COVID-19 Outbreak in Pakistan: A Web-Based Cross-Sectional Survey. International Journal of Human Rights in Healthcare, 14, 1-14.

Abbas, J. (2020). The Impact of Coronavirus (SARS-CoV2) Epidemic on Individuals Mental Health: The Protective Measures of Pakistan in Managing and Sustaining Transmissible Disease. Psychiatr Danub, 32(3-4), 472-477. https://doi.org/10.24869/psyd.2020.472

Conclusion

I suggest you make a separate heading of the conclusion and do not mix it with implications.

Policy Recommendations

I again recommend you to make a separate heading of the Policy Recommendations.

The conclusion section is acceptable. Overall, this presents a good piece of research work. I recommend that authors do a little more work and revise this article accordingly. I suggest the authors check English quality and fix some weak sentences. If you have already taken English editing service, ask them to recheck the quality to meet scientific merit for publication. I endorse this manuscript for publication after minor corrections, as suggested.

Abbasi, K. R., Abbas, J., & Tufail, M. (2021). Revisiting electricity consumption, price, and real GDP: A modified sectoral level analysis from Pakistan. Energy Policy, 149, 112087. doi:10.1016/j.enpol.2020.112087

Local Burden of Disease, H. I. V. C. (2021, 2021/01/08). Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems. BMC Medicine, 19(1), 4. https://doi.org/10.1186/s12916-020-01876-4

Pay attention of English quality to reach scientific merit. I suggest to cite these six studies to improve the quality of the Introduction, Literature and Methods sections. I accept and endorse this manuscript for publication after the suggested minor corrections.

Reviewer #2: Abstract:

- Add a short background explaining the study question.

- The period of the study is confusing "July 2020" and "March to May 2020". Clarify

- Add detailed data about the participants and their criteria.

- The conclusion should be precise. Add the future directions.

Introduction:

- Define "SARS-COV-2 and its negative effects on pregnant women" in detail.

- Explain the measured variables.

- The significance of the study needs more details. What will the study add to the knowledge?

- Add the study hypothesis.

Methods:

- The study design, ethics, and setting are not clear.

- How and who administrates the data collection?

- How did you achieve the validity and reliability of the outcome measures?

- Please, reframe the components (SPICES) for methods

i. Study design, setting, sample size

ii. Participant (inclusion and exclusion criteria"

iii. Issue of interest (exposure)

iv. Comparisons

v. Ethics and endpoint

vi. Statistical analysis

- Mention the settings and locations where the data were collected.

- How was the sample size determined?

- Who enrolled participants?

- Who assigned participants?

Discussion:

- The strengths should be demonstrated in detail.

- Add your recommendations with study implications.

- The main limitation of the study is not demonstrated.

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Reviewer #1: No

Reviewer #2: Yes: Walid Kamal Abdelbasset

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19 Feb 2022

Dear reviewers,

Thank you very much for all the questions you have asked, highlighting the need for clarification and also helping to improve this manuscript.

Unfortunately, we submit our revisions to the comments of Reviewer 2 only (see attached document) as we assume that the remarks of Reviewer 1 correspond to another article.

Yours sincerely,

Alexandra Doncarli for the co-authors.

Submitted filename: Response to Reviewers_vf.docx

Click here for additional data file.

1 Apr 2022

Pregnant women's unmet need to communicate with a health professional during the SARS-CoV-2 pandemic in France: the Covimater cross-sectional study

PONE-D-21-31849R1

Dear Dr. Doncarli,

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.

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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: (No Response)

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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: (No Response)

**********

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

Reviewer #2: Yes

Reviewer #3: (No Response)

**********

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 Response)

**********

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: (No Response)

**********

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: Appreciating the authors for their responses to my previous comments. All comments have been addressed. Congrats

Reviewer #3: (No Response)

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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.

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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: Yes: Walid Kamal Abdelbasset

Reviewer #3: Yes: Navid Rabiee

7 Apr 2022

PONE-D-21-31849R1

Pregnant women's unmet need to communicate with a health professional during the SARS-CoV-2 pandemic lockdown in France: the Covimater cross-sectional study

Dear Dr. Doncarli:

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.

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on behalf of

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Academic Editor

PLOS ONE

Table 2

Factors associated with an unmet need to communicate with a healthcare professional about course of pregnancy or childbirth during the first SARS-CoV-2 pandemic lockdown, Covimater survey (n = 500), France (July 2020).

	N (%) or mean (sd)*	Adjusted PR [95% CI] **	p-value**
Age (in years)	30.6 (5.4)	0.98 [0.96–1.00]	0.137
Gestational age (in weeks)a	23.4 (8.9)	0.99 [0.98–1.01]	0.477
Socio-professional categoryb
SPC+	65 (33.8)	1
SPC-	74 (41.1)	1.05 [0.79–1.40]	0.716
Inactive	66 (51.5)	1.58 [1.14–2.21]	0.007
Parity
Primiparous	93 (45.8)	1.36 [1.06–1.74]	0.014
Multiparous	112 (37.7)	1
Educational level
Equal to or higher than secondary school diploma	145 (37.1)	1
Lower than secondary school diploma	60 (55.0)	1.38 [1.05–1.81]	0.022
Serious disputes or violence during the lockdown
Never	137 (38.0)	1
Sometimes / Rarely	61 (47.3)	1.29 [1.02–1.63]	0.033
Very-often/ Often	7 (63.6)	2.12 [1.28–3.52]	0.004
Self-perceived general worry about the SARS-CoV-2 pandemic (max.10)c
Score less than or equal to 7	90 (35.8)	1
Score above 7	113 (48.3)	1.41 [1.11–1.78]	0.004
Cancelled/postponed pregnancy consultations or examinations at the initiative of a health professional
No	116 (36.5)	1
Yes	89 (48.9)	1.35 [1.06–1.73]	0.016

* Weighted and rounded values using Newton’s algorithm [20] for discrete or qualitative variables. For continuous variables, mean (standard deviation) were presented.

** Adjusted Prevalence Ratio (aPR), 95%Confidence Interval (95%CI) and p-value obtained with robust variance Poisson regression model.

a At the end of the first French lockdown (11 May 2020) or at the date of childbirth if women gave birth during lockdown.

b Women on maternity leave and unemployed women were classified according to their current SPC category or their most recent category prior to ending work respectively.

c 15 women did not document their general worry score whose 2 with an unmet need to communicate with a healthcare professional.