Healthy lifestyle during pregnancy: Uncovering the role of online health information seeking experience.

In the new era, many people seek their health-related information through the Internet due to the increasing access to this technology. Searching online health information can affect the health behavior. This study aimed to investigate the correlation between online health information-seeking behavior and a healthy lifestyle during pregnancy in a sample of Iranian pregnant women. This cross-sectional study was conducted among pregnant women admitted to health centers of Eghlid city, Fars province, Iran in 2019. A total of 193 women participated in the study. The required data were gathered using two validated questionnaires to measure the online health information-seeking behavior and the healthy lifestyle practices of the participants. The collected data were analyzed through descriptive statistics and Pearson correlation coefficient using SPSS version 22. Online health information experience and its subscales showed no statistical correlation with a healthy lifestyle. Age and education did not correlate with online health information-seeking behavior. Age had a statistical correlation with a healthy lifestyle, but education had the same correlation only with some subscales of a healthy lifestyle. The findings were surprising, suggesting that online health information-seeking behavior does not affect the lifestyle of pregnant women. These finding and probable explanations are discussed, but due to the limited literature on the subject, further studies are recommended to be conducted.

Introduction

Pregnancy is an important period of women’s life [1, 2]. Studies show that all women who are planning for pregnancy have at least one risk factor that can negatively affect pregnancy outcomes [3]. Many of these risk factors such as alcohol consumption, tobacco use, nutrition, and physical activity are lifestyle-related factors which can be modified [3]. The effects of lifestyle risk factors on pregnancy outcomes have been confirmed in many studies. A study on 385 pregnant women in Tabriz, Iran, (2010) has found that maternal nutritional status and physical activity during pregnancy are associated with birth weight [4]. Another meta-analysis has shown that maternal lifestyle factors such as pre-pregnancy Body Mass index (BMI), poor nutrition, and lack of physical activity are associated with poor maternal and neonatal outcomes [5]. It has been documented that positive healthy behaviors such as appropriate nutrition, adequate physical activity, vitamin intake, regular perinatal care, and health care utilization can have long-term positive effects on maternal and child health. In contrast, unhealthy behaviors can lead to a wide range of pregnancy complications and long-term adverse effects on maternal and child health such as preterm labor, mother’s obesity and overweight, low birth weight, preeclampsia, hypertension, sudden abortion, and emergency cesarean section [1, 3, 5, 6]. Therefore, health decisions during pregnancy are important and can affect the life of the mother and baby [1]. Thus, promoting lifestyle behaviors that can reduce the negative consequences of pregnancy and protect individuals during this critical period of life has become an important aspect of public health research [2]. In this regard, due to the confirmed relationship between lifestyle modification during pregnancy and pregnancy outcomes, many studies have examined the correlation of intention to pregnancy and lifestyle improvement practices among women. However, the results are different and, in some cases, confusing [6]. A study on 430 women with planned pregnancy in Belgium reported that 83% of the participants had at least one change in their lifestyle behaviors in preparation for pregnancy. The modifications included behaviors such as smoking, alcohol consumption, caffeine consumption, nutritional status, weight control, and folic acid multivitamin supplements intake [7]. A similar study on 283 pregnant women in the Netherlands has showed that actively preparing for pregnancy is associated with choosing a healthier lifestyle by women during the preconception period [3].

Although both these studies and the others have shown that pregnancy intention to conceive correlates with lifestyle changes, few women who have planned for pregnancy change their health behaviors [3]. Also, some studies have shown that women’s attempts to change their lifestyle for the purpose of preparing for pregnancy are affected by their socioeconomic status and medical history including education level, income status, perceived poverty, high-risk pregnancy, and abortion history [7]. Also, studies show that women who receive pre-pregnancy health information are more likely to modify their lifestyle behaviors during pregnancy than those not prepared for pregnancy [3]. Therefore, information-seeking behavior can be considered as a motivational facilitator for lifestyle improvements before and during pregnancy.

In recent years, the Internet has become a common source of health information for pregnant women [1, 8]. Various studies have shown that the Internet use is increasing among pregnant women due to some reasons such as availability and accessibility, ease of use, low cost, anonymity, ability to retrieve a large amount of information in a short time, and opportunity to find the support and live experiences of similar people [1, 2, 9, 10]. A study on 1347 pregnant women in India showed that 86% of the participants had used the Internet to retrieve pregnancy-related information [11]. A large multicenter study in Italy has found that almost all participants are pregnancy e-health users [9]. Also, a national survey in the United States has shown that about 75% of childbearing women search the pregnancy and infant information through the Internet [12]. Another study in Sweden has reported a similar prevalence of the Internet use among pregnant women. This study has reported the frequency of the Internet searching by pregnant women between one to 63 times a month [13]. Other studies from India [14], Turkey [15], Germany [16], US [17, 18], Saudi Arabia [19], China [20], and Australia [21] have also reported the same results. The results of three review articles have also confirmed these findings [1, 8, 12].

Studies in Iran also show that the use of the Internet to seek pregnancy-related information is increasing. A descriptive survey on 196 pregnant women in different months of pregnancy in Hamadan reported that 75% of the participants used search engines for seeking health information at least one or two times weekly [22]. Another qualitative study at 5 Gynecological hospitals in Tehran has shown that the Internet is one of the most important information sources for pregnant women [23]. Another study involving 188 pregnant women referred to health centers in Behshahr reported that approximately 70% of the participants had used online sources moderately to highly to find pregnancy information [24].

Pregnant women generally have different goals and motives for using the Internet as an information source, including overcoming barriers to accessing information, reassuring or supplementing traditional information sources, improving their understanding and knowledge promotion, better managing of the pregnancy risks, sharing information with others, social networking, and satisfying their informational needs [9, 11, 18, 19]. Also, they have different information needs. They seek various subjects from online sources [2, 25]. Studies show that some of the most important topics searched by pregnant women include fetal development, pregnancy sociology, general counseling about pregnancy time, nutrition during pregnancy, available social supports, pregnancy complications, diseases and risks during pregnancy, mental health, delivery methods, relationship with spouse and child, physical activity, pregnancy stages and changes, breastfeeding, maternity stories, maternal and child products sales, prenatal and personal health care, medications and supplements, tobacco use, and lifestyle [1, 2, 8, 11, 14, 15, 17, 19, 20, 23].

In summary, the results of studies regarding the most common topics searched by pregnant women indicate that although these topics change during pregnancy, lifestyle-related ones are among the most commonly searched topics. In this regard, a qualitative study in China reported that support for lifestyle modifications during pregnancy was one of the most important benefits of using the Internet from the perspective of pregnant women [20]. Another qualitative study in Iran has also shown that promoting a healthy lifestyle is one of the main reasons for Iranian women to seek online health information [26]. However, the overall effect of searching online pregnancy-related information on the actual changes in lifestyle during pregnancy has remained controversial. Although some studies have reported that online seeking pregnancy-related information affects lifestyle changes, other studies have not confirmed this relationship. Therefore, this study aimed to investigate the effect of online health information-seeking experience on the women’s lifestyle during pregnancy. As noted, pregnancy is a transformational period in the life of every woman. During this period, a woman’s body changes, and many questions arise about her own health and that of the infant as well as the lifestyle during pregnancy [1, 3, 27]. In the pregnancy, women want to be assured they will have a healthy pregnancy and therefore seek a lot of information. According to the documents, in this period, women use various sources of information including websites and social networks that are among the most common information sources for pregnant women [28]. Reports show that women are increasingly using the Internet for searching pregnancy-related information as well as sharing their information and experiences. Looking at the accessibility of the Internet indicates that nowadays maternal health information is easily and quickly accessible at any time and place [1-4]. The use of the Internet as a source of health information, among all groups of population including pregnant women has increased significantly during the Covid-19 epidemic due to restrictions such as limited face-to-face access to health professionals [29-31]. However, using the Internet also has many challenges. Leaving aside the issue of access to the Internet in some parts of the world, issues such as mothers’ ability to retrieve and evaluate online information, their confidence in online information in spite of the vast amount of misinformation being disseminated through the Internet, and the understandability of online information for mothers are the challenges in the effectiveness of this technology in promoting maternal health [3-7]. Therefore, health authorities and professionals should facilitate pregnant women’s access to online health information which can help in improving maternal health [9, 13]. This, requires awareness of the various aspects of pregnant women’s health information seeking behavior [9]. This study, provides such insights by examining the online health information seeking behavior of pregnant women in a religious and developing community. Therefore, it also has policy applications for health authorities.

Materials and methods

Participants, setting, and procedures

This study examined the correlation between online health information-seeking behavior and healthy lifestyle through a cross-sectional method during the first 6 months of 2019 among a sample of Iranian pregnant women. A total of 193 women participated in the study. Participants were recruited from 2 health centers of Eghlid city, Fars province using simple random sampling. All the participants were selected from the pregnant women who were in second and third trimester of pregnancy and had an active prenatal care record at the health center. Iran has an extensive primary healthcare network including the health centers at the first level. Health centers that have recently been renamed to Comprehensive Health Services Centers are affiliated to medical universities. These centers provide a comprehensive package of health services for the covered population including prenatal care for the pregnant mothers. Therefore, they are the most appropriate place to access the pregnant women. We recruited the study participants from these centers considering in case every pregnant woman had a pregnancy care record at the health center. The inclusion criteria were being in second and third trimesters of the pregnancy, having access to the Internet, and using it for pregnancy-related purposes at least once in the past month. The sample size was calculated for correlation studies using the results of a pilot study that was done prior to the main research. The required sample was calculated as 194, considering α = 0/05, β = 0/2 and r = 0/2. Given that the 2 study settings covered approximately equal population, the sample size was allocated to the centers equally. Questionnaires were administered by a member of the research team who attended the health center; after explaining the objectives of the research and obtaining a written consent, he distributed the questionnaires among the study candidates. The administration of the questionnaires was done in the waiting room of the centers on the day of pregnancy visit. A total of 210 questionnaires were distributed, of which 193 were analyzed and 17 were removed from the analysis due to the incomplete answers. None of the participants had complicated pregnancy considering that the high-risk pregnant women were referred to the second level of care and did not remain in the first level for receiving prenatal care.

Measures

The required data were gathered using two validated questionnaires:

eHIQ (e-Health Information Questionnaire part 1 and 2): This scale was used to measure the online health information-seeking experience of the participants. The eHIQ, developed by Kelly et al. in 2015 as a tool to facilitate the measurement of the potential consequences of using websites containing different types of material across a range of health conditions, is a 2-part instrument with 37 items [32]. eHIQ-Part 1 includes 11 items related to general views of using the Internet in relation to health. 11 items of eHIQ-Part 1 have been grouped into 2 sub-scales named Attitudes towards online health information (5 items) and Attitudes towards sharing health experiences online (6 items). eHIQ-Part 2 includes 26 items related to the consequences of using a specific health-related online source. 26 items of eHIQ-Part 2 also have been grouped into 3 sub-scales, including Confidence and identification (9 items); Information and presentation (8 items), and Understanding and motivation (9 items). In our study, the participants were asked to respond to the 26 items of eHIQ-Part 2 regarding the online sources which they have sought during their pregnancy to find the required information. Also, the participants were asked to score all items of both parts on a 5-point scale ranging from ‘never’ to ‘always’ scored 1–5. We used a standard ‘forward-backward’ procedure to translate the eHIQ from English into Persian. To demonstrate the content validity, we used the content validity ratio to quantify the extent of the experts’ agreement. The reliability of the questionnaire also was confirmed before the study using Cronbach’s alpha.

LSQ (Lifestyle Questionnaire): The LSQ, which was developed by Lali et al. in 2012 to assess healthy lifestyle practices, consists of 70 items [33]. LSQ is a multidimensional scale consisting of ten factors including activities related to physical health, exercise and fitness, weight control and nutrition, illness prevention, psychological health, spiritual health, social health, drug and alcohol avoidance, accident prevention (safety behavior), and environmental health. The used LSQ is a Persian-originated tool which has been developed by Mohsen Lali, an Iranian psychologist, and his colleagues. They have confirmed its validity and reliability in their study.

Analysis

After completing the questionnaires, the collected data were analyzed through descriptive statistics (including means and standard deviations) and Pearson correlation coefficient using SPSS version 22.

Ethical considerations

All participants provided a written informed consent to participate in the study and were assured that their personal information would be kept confidential. The ethical written consent forms were obtained from the participants. All the participants read and signed the consent before filling the questionnaire and returned it to the researcher. The content of the consent forms and the procedure were all approved by the ethics committee. Also, all the study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki. Considering the ethical approval, the work was approved by the ethics committee of Shahid Sadoughi University of Medical Sciences, Yazd, Iran (Approval code: IR.SSU.SPH.REC.1399.022).

Results and discussion

The mean age of the participants was 31.3±6.61 years. Also, 16.1% of them had a high school degree, 47.3% had a diploma or some university degrees, 34.4% a bachelor’s degree, and 2.2% had a degree above the bachelor’s degrees. Also, 86% of the participants had at least one previous pregnancy experience.

The descriptive results of the studied women’s information-seeking behavior are presented in Table 1. As shown in this Table, understanding and motivation subscale that examines the extent of understandability of online health contents for the participants and the extent to which their online information-seeking experience encourage them to play a more active role in their health had the highest mean. On the other hand, the Confidence and Identification subscale that examines the extent to which online information-seeking experience makes the sense of confidence for the participants to explain their health concerns and discuss them with others gives them confidence that they are able to manage their health and the value they give to the online information had the lowest mean score.

Table 1

Online health information seeking scores of the participants.

Item	Mean ± SD
eHIQ-Part 1
Attitudes towards online health information	3.23±0.88
Attitudes towards sharing health experiences online	3.27±0.91
eHIQ-Part 2
Confidence and Identification	2.93±0.87
Information and Presentation	3.38±0.75
Understanding and Motivation	3.57±0.93
eHIQ (total)	3.29±0.74

Also, the descriptive results of the women’s healthy lifestyle are presented in Table 2. As shown in the Table, the participants had moderate to good scores regarding the healthy lifestyle subscales. Other findings regarding the healthy lifestyle showed that although age had a statistically significant correlation with a healthy lifestyle, education level had the same correlation with only three subscales, including social health, accident prevention behavior, and environmental health.

Table 2

Lifestyle scale and subscale scores of the participants.

Item	Mean ± SD
Physical Health	3.78±0.55
Exercises and fitness	3.15±0.80
Weight control and nutrition	3.63±0.69
Illness prevention	4.32±0.57
Psychological Health	4.08±0.73
Spiritual Health	4.34±0.65
Social Health	4.20±0.68
Drugs and alcohol avoidance	4.56±0.84
Accident prevention behavior	4.28±0.64
Environmental Health	4.25±0.68
Healthy life style (total score)	4.06±0.44

Additional tests showed that e-HIQ and its subscales had no statistically significant correlations with the participants’ age and education (Table 3).

Table 3

Correlations of e-HIQ and its subscales with age and education.

e-HIQ-Part 1 and 2	Age		Education
	r	Sig.	r	Sig.
eHIQ-Part 1	0.03	0.76	0.15	0.17
Attitudes towards online health information	0.06	0.58	0.16	0.14
Attitudes towards sharing health experiences online	0.03	0.77	0.13	0.21
eHIQ-Part 2	0.04	0.74	0.10	0.36
Confidence and Identification	0.06	0.61	0.01	0.90
Information and Presentation	0.00	0.99	0.09	0.39
Understanding and Motivation	0.03	0.78	0/09	0.38
eHIQ-Part (total)	0.00	0.98	0.13	0.23

The same tests showed that healthy lifestyle and its 2 subscales including “accident prevention behavior” and “environmental health” had a statistically significant correlation with age, while it did not correlate with education (Table 4).

Table 4

Correlations of LSQ and its subscales with age and education.

Life Style Subscales	Age		Education
	r	Sig.	r	Sig.
Physical Health	0.01	0.91	0.03	0.75
Exercises and fitness	0.01	0.94	0.00	0.95
Weight control and nutrition	0.01	0.90	0.14	0.19
Illness prevention	0.03	0.75	0.07	0.50
Psychological Health	0.10	0.36	0.13	0.21
Spiritual Health	0.18	0.09	0.15	0.18
Social Health	0.18	0.10	0.07	0.53
Drugs and alcohol avoidance	0.14	0.18	0.15	0.15
Accident prevention behavior	0.32	0.00*	0.16	0.13
Environmental Health	0.31	0.00*	0.07	0.51
Healthy life style (total score)	0.25	0.05*	0.03	0.76

*Sig. at P<0.05

The correlation coefficients of online health information-seeking behavior and its subscales with a healthy lifestyle are presented in Table 5. Based on the findings presented in this Table, eHIQ and its subscales showed no statistically significant correlation with a healthy lifestyle. This finding is surprising and suggests that accessing the Internet and seeking online health information did not affect the studied women’s lifestyle even in the pregnancy course.

Table 5

Correlations of online health information-seeking subscales with healthy lifestyle.

	Healthy lifestyle
	r	P value
Attitudes towards online health information	0.04	0.754
Attitudes towards sharing health experiences online	0.05	0.647
Confidence and Identification	0.12	0.274
Information and Presentation	0.15	0.159
Understanding and Motivation	0.21	0.055
eHIQ (total)	0.14	0.212

Discussion

Pregnancy is a potentially changing period in the women’s life that exposes them to new worries and responsibilities [34]. Maternal health status can affect pregnancy outcomes as well as short-term and long-term infant health [34].

Healthy lifestyle including physical activity, healthy eating, and weight control is the main predictor of health status [4, 5]. During pregnancy, women have a strong motivation to choose a healthy lifestyle to have a healthy infant. Even, some believe that pregnancy can be an opportunity for women to return to healthy lifestyle [34]. Therefore, supporting pregnant women in modifying their lifestyle is among the priorities and responsibilities of health care providers. Typically, health systems at different levels provide parts of these supports in routine prenatal cares such as pregnancy consults. Pregnant women have traditionally received the advice and information needed to improve their lifestyle during pregnancy from health professionals [5–7, 9, 13]. However, accessing and obtaining health information have changed dramatically in recent years. Today, many people, including pregnant women, receive vast amounts of health information related to lifestyle from the Internet and social media. They also share a lot of information and experience with others through the Internet [11, 15]. This change creates opportunities and challenges. Taking advantages of the potential opportunities requires having a clear picture of its various aspects, including preferred and common sources of health information of pregnant women, their information needs, information retrieval methods, information validation process and criteria, level of trust in the information obtained and understanding them, and ultimately the practical use of information for health promotion purposes [19-24]. In this study, some of these aspects and their correlations with the healthy lifestyle were studied in a sample of Iranian pregnant women.

The findings showed that study participants had a moderately positive feeling to use the Internet as a source of pregnancy-related information in their health decisions and to share their experience online. There are many studies which have revealed that the majority of pregnant women sought their needed health information through the Internet, but the results of studies on the willingness of pregnant women to share their experiences online were widely dispersed [13, 15, 19, 22, 23]. It seems that factors such as lack of trust in Internet information as well as incomprehensibility of online information affect these views [35]. Therefore, health care providers should pay attention to improvement of the view and trust of pregnant women in online pregnancy-related information. Empowerment of pregnant women to search the reliable information, sufficient attention to their information needs, the production and dissemination the need-based contents, social marketing of the online health platforms, and the active involvement of health professionals can improve the pregnant women’s perception and increase their confidence in online health information [34-36].

In this study, we found that the age and education level of the participants did not have any significant correlations with their views of online health information. Regarding this findings, some studies have reported that variables such as the perceived barriers, age, education, level of knowledge, occupational status, number of pregnancies, pregnancy care model, self-efficacy, gestational age, geography and ethnicity have significant relationships with the amount and type of information searched online [1, 11, 12, 14, 15, 20, 21, 37, 38]. However, some studies have not confirmed such relationships and have reported that women using online information do not have a specific profile [16].

Participants also believed that searching for online health information doid not give them the confidence that they could manage their health and share their health concerns with others. On the other hand, they thought that seeking online pregnancy-related information did not prepare them for what might happen to their health. Also, they valued online information as moderate. Trusting the accuracy of online information and also believing that seeking online information can help to improve the health care are among the most important affecting factors of online health information seeking behavior and using online information to promote health [34-36]. Therefore, confidence for online health information has been studied in many studies, and some have shown that the Internet users are suspicious about online information, while others have identified the Internet as a reliable source [9, 10, 12, 15, 22]. Empowering women to validate the retrieved online information, monitoring the online contents by regulatory bodies, and more active participation of health professionals in the production of online health information can improve public trust in such information [34-36]. The mean score of information and presentation subscale was also moderate in our study. This means that the respondents cannot use health websites and their contents easily. This is also one of the most challenging barriers to the effective use of the Internet as a source of health information, which has been reported in many studies [39, 40]. Online information should be presented in a way that can be used by target users [39]. Developing appropriate guidelines and presenting the pregnancy-related information according to them, taking into account the users’ views in designing health websites, providing information in a more systematic way, and using images and visual aids appropriately can be applied [35, 37, 38]. Mean score of the last subscale, named understanding and motivation, was moderate. This means that pregnancy-related information provided online for participants has not been fully understandable for them and has not encouraged them enough to play an active role in their health management. Generally, readability, understandability, reliability, and action-ability are the main criteria for evaluating the usefulness of online health information. Including visual aids such as simple images and charts in the online information to make them more understandable, using a common language, defining and explaining the terms appropriately, categorizing the information with specific titles, presenting information in logical sequence, and providing practical summaries can help to promote the understandability of online health contents for pregnant women, which can, in turn, encourage them to apply such information in their health promotion [39, 40].

Furthermore, the results of the present study also showed that online health information-seeking behavior and its dimensions had nosignificant correlations with the participants’ lifestyle. This finding was the main objective of this study. The ultimate advantage of producing and disseminating online health information is using them in health promoting actions by users. However, our findings showed that online health information seeking is not playing such role among the study participants. One reason for this finding can be the participants’ low trust in online information. A study in the Netherland showed that women who had obtained pre-pregnancy health information were more likely to modify lifestyle behaviors than those who were not prepared for pregnancy [3]. Some other studies from different countries have reported the same findings; altogether confirming that pregnant women’s access to online maternal health information could encourage them to choose a healthier life style, which in turn improves maternal health [9, 11, 16, 20, 26, 41]. Overall, the present study showed that online health information-seeking behavior does not have a positive relationship with lifestyle behaviors during pregnancy. There are many explanations for this question that why the Internet search does not predict the lifestyle of pregnant women. Although the Internet search is widely used to retrieve health information by pregnant women, it also has its challenges and disadvantages. Some of the most important challenges can be as follows:

Unreliability due to the wide dissemination of health misinformation: The Internet technologies provide a wonderful opportunity to disseminate the accurate health information and facilitate the dissemination of health misinformation [42]. It is a growing concern that health information obtained from the Internet is not always reliable and up to date. Online health misinformation can be harmful, confusing, and uncomfortable. The existence of marketing incentives, conflict of interests and bias in the production and dissemination of information complicate this challenge [3, 16, 18, 43].

Inability to judge and interpret online health information: Many Internet users do not have enough ability and skill to understand and interpret the retrieved online information. This inability reduces the impact of access to the health information on health decisions/health outcomes and in some cases even imposes adverse effects [1, 8, 12, 23, 43].

Lack of a legal framework: The lack of a legal framework for producing, publishing, and monitoring online contents is also a major concern [9].

Confidentiality and information security: The development of digital technologies has raised concerns about the privacy of personal information. In legal frameworks designed to monitor online space, the privacy and confidentiality of personal information must specifically be addressed [20].

Given these challenges, it seems that developing effective strategies for the optimal use of online capacities for the improvement of pregnant women’s health is essential. Such strategies can be formulated at three levels:

User Level: Increasing pregnant women’s access to reliable online health information should be considered as a strategy. Empowering pregnant women through training health promotion, improving their internet skills and familiarizing them with search methods and specialized sources and websites are also helpful [22, 23].

Expert Level: Health professionals need to understand that many people today get their health information from online sources. Therefore, they should be prepared to support pregnant women in retrieving, interpreting and using online information [25]. They should encourage pregnant women to share information and discuss them [19].

Institutional Level: At this level, there is an urgent need to establish legal frameworks for regular monitoring and verification of the accuracy and validity of online health information [9, 42]. It is also helpful to strengthen the online culture through the use of social marketing and promotion of interventions [43]. Although Pemberton and Goldblatt (1998) pointed out that “in the digital age, the concept of knowledgeable person should be accepted and his web-surfing skill should be applied” [8], the Internet technologies can serve to promote health when online health information is accessible, reliable and understandable for all. Finally, further research is needed to fully understand the online health information-seeking behavior of pregnant women, including developing policies and reducing challenges and barriers.

This study had some limitations alongside its strengths and applications. First of all, a cross-sectional study was done; therefore, the results are subject to the limitations of cross-sectional studies; second, we did not have a control group in the study, while doing a study with a control group can provide a better picture; third, the data analyzed in this study are self-reported, and forth the study was done in a specific socio-economic and cultural context which limits the possibility of generalizing the findings to the other societies.

Conclusion

In this study, we found that the pregnant women moderately used the pregnancy-related online information in their health decisions and shared their experiences with others; they had a moderate trust in online health information. Also, they moderately understood the online health contents and those contents did not encourage them enough to play an active role in their health improvements. Also, we found that the online health information seeking behavior and its subscales had nostatistical correlations with lifestyle modification among the studied participants. These findings have many implications alongside its research and theoretical implications for the health authorities and professionals who are interested in using the potential of the Internet to improve the population health, especially pregnant women.

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Please also revise intensively the introduction and discussion section with respect to the current state of the art and integrate and discuss recent studies in the field appropriately.

Please do not hesitate to contact us if you have any questions regarding the

revision of your manuscript or if you need more time. We look forward to

hearing from you soon.

Kind regards,

Manuela Bombana

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

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

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

Reviewer #1: 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: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

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

Reviewer #1: The study “Healthy Life Style During Pregnancy: Uncovering the Role of Online Health Information Seeking Experience” is interesting. In this study the authors observed that Online health information-seeking does not affect women's lifestyle during pregnancy. Secondly, Online pregnancy-related information moderately encourages and motivates women to play an active role in their health improvement. Thirdly, Pregnant women's attitudes towards online health information and sharing experience online can be improved. Fourthly, Pregnant women did not have good confidence in online pregnancy-related information. Lastly, Online pregnancy-related information is not fully understandable and reliable for pregnant women.

However, the author must elaborate the contribution of this work in the introduction section. The motivation behind this work and how it will solve the real word problems. I would recommend the authors add some more explanations and also describe the innovation of this paper in the introduction section and a new section of conclusion must be added.

Moreover, attention should be given to the following highlighted points before resubmitting.

1. Attention should be given to the authors affiliation it must follow the journal standard.

2. The work presented in the discussion section is basically not discussion. This is the literature or may put in the introduction section. For reference “As to online information sharing, a study in Turkey reported that about half of its participants had shared the sought information with health professionals (15). A similar study in Hamedan, Iran, found that more than 75% of the pregnant women had shared their retrieved online information with others including health professionals, friends, and family members (22). Another study in Tehran, Iran, reported that all the studied participants tended to share information with others and assisted them in obtaining information (23). A similar study has also reported that 80.2% of its participants were eager to share the information they found (19). In contrast, Larsson's (2009) study showed that most women, who had searched online information, did not talk to others about the retrieved information (13). The ratio of pregnant women who share the retrieved pregnancy-related online information in a study in Saudi Arabia has been reported as 26.7%. This study has concluded that participants generally have a positive feeling about online information and think that the Internet information is easily understandable and interpretable (19).” The authors discussed their own work in the discussion section.

3. The paper may be proof read by a native speaker because it has many grammatical mistakes.

4. The contribution should be further enhanced in the introduction section.

5. The new section of conclusion may be added before the references.

All in all, I suggest accepting the paper after revision.

Reviewer #2: GENERAL. The manuscript is not paged for ease of assessment.

ABSTRACT: Under methods, line 3,is it valid or validated questionnaire? There is no need to include references in the abstract and abbreviations should 1st be written in full.

INTRODUCTION: The 2nd sentence line 1-2, paragraph 1 should be referenced. BMI should be written in full 1st also US. In paragraph 2,line 12,what do the authors mean by intention to pregnancy? The last sentence is too long and can be separated.

METHODS. This section should should be much more detailed. How many health facilities were used or the study, what were the facilities and what type of health facilities were they? What informed the choice of these particular facilities? How did the authors determine their sample size and select their study population? where specifically in the facilities were the interviews held, who administered the questionnaires and how was this done? Where there no inclusion or exclusion criteria? The eHIQ questionnaire by Kelly should be referenced .Which Medical University's ethical review committee approved the study? There is no information related to pregnancy with reference to the participants

RESULTS: It not clear where the statistically significant correlation between age with a healthy lifestyle and education with the 3 subscales is shown.

DISCUSSION: Did the study have any limitations?

**********

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

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

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

Reviewer #1: No

Reviewer #2: No

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

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

4 Jan 2022

Dear editor

Hi and many thanks for your work on our submission, hope to be well.

Respectfully, all the editors and reviewers' comments were considered carefully, the requested corrections were done as followings and highlighted in the submission file. Also, regarding the editor’s request for language editing, the manuscript was edited by Dr. Nasrin Shokrpour (Professor of teaching English at Shiraz University of Medical Sciences: https://isid.research.ac.ir/Nasrin_Shokrpour.) The English editions also, are track changed in the submission file. If any more revisions will be needed we are ready to do.

Journal requirements:

Comment: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: It was done based on the journal style requirements.

Comment: Please amend your current ethics statement to address the following concerns: a) Did participants provide their written or verbal informed consent to participate in this study? b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure.

Response: It was done; all of the requested descriptions were added to methods under the sub-title of “Ethical considerations”.

Comment: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. "Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter.

Response: The data sheet of the study is submitted as supporting information.

Comment: Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Response: It was done. All the requested explanations were added in methods under the sub-section of “ethical considerations”.

Comment: We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: https://www.researchsquare.com/article/rs-19224/v1, https://medinform.jmir.org/2020/12/e23854/. The text that needs to be addressed involves the first paragraph of the results. In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

Response: Thanks for your comment. It was considered carefully. The first paragraph of results was completely rewritten. Also, all the manuscript body was rechecked for this concern. For your more information I would like to explain that this manuscript is one of our series of works on the online information seeking behavior of different population groups. To date we have done more than 10 works on different groups including students; pregnant women; hospital patients, oral care consumers and other ones. Each of these works has defined as a unique research with its own design and unique ethics code. The first one was published in JMIR medical informatics which had been done on a sample of female high school students to examine the correlation of online information seeking behavior and the quality of life. Although, these works may overlap slightly; but they are independent studies on the different population groups. Thanks again.

Editor's comments:

Comment: Dear authors, Your manuscript has been reviewed by experts in the field. The paper should undergo major revisions. Please find the referee reports below. Please revise your manuscript according to the referees’ comments. One of the referees has suggested that your manuscript should undergo extensive English revisions. Please address this issue during revision. Please revise specifically the methodological part of the study with regard to the referees comments (ethics approval, sample size calculation, recriting and selection of participants etc.). Please also revise intensively the introduction and discussion section with respect to the current state of the art and integrate and discuss recent studies in the field appropriately.

Response: All were done carefully.

Reviewers' comments

Reviewer 1:

Comment: The study “Healthy Life Style During Pregnancy: Uncovering the Role of Online Health Information Seeking Experience” is interesting. In this study the authors observed that Online health information-seeking does not affect women's lifestyle during pregnancy. Secondly, Online pregnancy-related information moderately encourages and motivates women to play an active role in their health improvement. Thirdly, Pregnant women's attitudes towards online health information and sharing experience online can be improved. Fourthly, Pregnant women did not have good confidence in online pregnancy-related information. Lastly, Online pregnancy-related information is not fully understandable and reliable for pregnant women. However, the author must elaborate the contribution of this work in the introduction section. The motivation behind this work and how it will solve the real word problems. I would recommend the authors add some more explanations and also describe the innovation of this paper in the introduction section and a new section of conclusion must be added. Moreover, attention should be given to the following highlighted points before resubmitting.

Response: Thanks for the comment. The contribution of the work, its research and policy implications for health authorities and professionals and the motivation behind it were added to introduction (lines 137-166). Also, a new section of conclusion was added after the results and discussion. For these revisions, references were also updated.

Comment: Attention should be given to the authors' affiliation it must follow the journal standard.

Response: It was done.

Comment: The work presented in the discussion section is basically not discussion. This is the literature or may put in the introduction section. For reference “As to online information sharing, a study in Turkey reported that about half of its participants had shared the sought information with health professionals (15). A similar study in Hamedan, Iran, found that more than 75% of the pregnant women had shared their retrieved online information with others including health professionals, friends, and family members (22). Another study in Tehran, Iran, reported that all the studied participants tended to share information with others and assisted them in obtaining information (23). A similar study has also reported that 80.2% of its participants were eager to share the information they found (19). In contrast, Larsson's (2009) study showed that most women, who had searched online information, did not talk to others about the retrieved information (13). The ratio of pregnant women who share the retrieved pregnancy-related online information in a study in Saudi Arabia has been reported as 26.7%. This study has concluded that participants generally have a positive feeling about online information and think that the Internet information is easily understandable and interpretable (19).” The authors discussed their own work in the discussion section.

Response: Thanks for the comment. The discussion section was revised and rewritten again. It was improved substantially.

Comment: The paper may be proof read by a native speaker because it has many grammatical mistakes.

Response: the manuscript was edited by Dr. Nasrin Shokrpour (Professor of teaching English at Shiraz University of Medical Sciences: https://isid.research.ac.ir/Nasrin_Shokrpour.)

Comment: The contribution should be further enhanced in the introduction section.

Response: Thanks for the comment. The contribution of the work, its research and policy implications for health authorities and professionals and the motivation behind it were added to introduction (lines 137-166).

Comment: The new section of conclusion may be added before the references.

Response: A new section of conclusion was added before the references.

Comment: All in all, I suggest accepting the paper after revision.

Response: Thanks for the kind decision, reviewers' comments contributed highly in the submission improvement.

Reviewer 2:

Comment: GENERAL. The manuscript is not paged for ease of assessment.

Response: Sorry, it was done.

Comment: ABSTRACT: Under methods, line 3,is it valid or validated questionnaire? There is no need to include references in the abstract and abbreviations should 1st be written in full.

Response: The corrections were made.

Comment: INTRODUCTION: The 2nd sentence line 1-2, paragraph 1 should be referenced. BMI should be written in full 1st also US. In paragraph 2, line 12,what do the authors mean by intention to pregnancy? The last sentence is too long and can be separated.

Response: The reference of 2nd sentence, paragraph 1 was added. The words are written in full 1st. Regarding the term "intention to pregnancy, "most often, pregnancies are characterized as either “intended” or “unintended.” Intended pregnancies are those wanted at, or sooner than, the time they occurred. Unintended pregnancies include unwanted and mistimed pregnancies". (URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734627/.). There are some studies which show that the mothers' intentions to pregnancy affect their health behaviors. The last sentence of introduction has been replaced in this version due to the revisions made to introduction section.

Comment: METHODS. This section should be much more detailed. How many health facilities were used or the study, what were the facilities and what type of health facilities were they? What informed the choice of these particular facilities? How did the authors determine their sample size and select their study population? Where specifically in the facilities were the interviews held, who administered the questionnaires and how was this done? Where there no inclusion or exclusion criteria? The eHIQ questionnaire by Kelly should be referenced .Which Medical University's ethical review committee approved the study? There is no information related to pregnancy with reference to the participants.

Response: Thanks for the comment. All were done. Study setting (including the number and type of health facilities that used to recruit the participants and the reason to choose them); sample size calculation and sampling method; the administration procedure of questionnaires; inclusion criteria and some information related to the pregnancy were explained in the "participant, setting and procedures" subsection of methods. The references of both questionnaires were added to" measures" subsection of methods and the references list were also updated. The name of ethical approval committee was added to "ethical consideration" subsection of methods.

Comment; RESULTS: It not clear where the statistically significant correlation between age with a healthy lifestyle and education with the 3 subscales is shown.

Response: We added 2 new tables for the related results including:

Table 3. Correlations of e-HIQ and its subscales with age and education and

Table 4. Correlations of LSQ and its subscales with age and education.

Comment: DISCUSSION: Did the study have any limitations?

Response: Limitations were added to the end of discussion.

With bet regards

________________________________________

Submitted filename: Response to reviewers.doc

Click here for additional data file.

24 May 2022

Healthy Life Style During Pregnancy: Uncovering the Role of Online Health Information Seeking Experience

PLOS ONE

Dear Dr. Bahrami,

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 Jul 07 2022 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.

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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: https://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,

Vanessa Carels

Staff 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 #1: All comments have been addressed

Reviewer #2: (No Response)

**********

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: (No Response)

Reviewer #2: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: I Don't Know

**********

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: (No Response)

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: (No Response)

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: INTRODUCTION: Line 76-78 should be recasted. The sentence in lines 148-150 does not seem complete. In lines 157 -159 , grammatical error should be corrected.

METHODS: The statement in lines 171-172 is not clear (who had referral; do the authors mean who were referred?). If so, this is at variance with the information in lines 176-177 which states that participants were recruited from 2 heath centres, hence the authors should clarify how and were the participants were recruited. If the sample size of the study was 194 (line 187), why did the authors distribute 210 questionnaires (line 193). It is not clear why the statement in lie 197 is in the methods section.

Line 199,what do the authors mean by valid questionnaires are they referring to validated questionnaires? Lines 201-204 and 219-220 should be referenced. Lines 238-239, where is the institution that granted the authors ethical approval for conduct of the study located?

RESULTS: Lines 243-244 is not clear, what's the difference between some University degrees and a bachelor degree?

DISCUSSION: The is no sub-heading titled discussion. It is not clear, whether the information after table 5 is a continuation of the results. Lines 386-398- In the the whole of this portion, the authors are just citing other studies and not discussing their findings and comparing them to others. This is just lengthening the discussion, hence this portion can be deleted.

**********

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.

25 May 2022

Dear editor:

Hi and hope to be well; with thanks to the editors and reviewers of our submission, all the reviewers’ comments were carefully revised as followings. If, any more revisions will be needed we will ready to do.

Reviewer #1: All comments have been addressed

Reviewer #2:

INTRODUCTION:

Comment: Line 76-78 should be recanted.

Response: Thanks, it was done.

Comment: The sentence in lines 148-150 does not seem complete.

Response: Thanks, It was done.

Comment: In lines 157 -159, grammatical error should be corrected.

Response: Thanks, it was corrected.

METHODS:

Comment: The statement in lines 171-172 is not clear (who had referral; do the authors mean who were referred?). If so, this is at variance with the information in lines 176-177 which states that participants were recruited from 2 heath centres, hence the authors should clarify how and were the participants were recruited.

Response: Thanks, It was done.

Comment: If the sample size of the study was 194 (line 187), why did the authors distribute 210 questionnaires (line 193).

Response: Given that response rate is not always 100% and all the distributed questionnaires are not returned completely, we distributed 210 questionnaires (more than the needed sample size) to achieve the target of 194 completed ones.

Comment: It is not clear why the statement in lie 197 is in the methods section.

Response: Thanks, the sentence was moved to the results section.

Comment: Line 199, what do the authors mean by valid questionnaires are they referring to validated questionnaires?

Response: Yes it is true, the correction was done.

Comment: Lines 201-204 and 219-220 should be referenced.

Response: It was done (the references number 32 and 33)

Comment: Lines 238-239, where is the institution that granted the authors ethical approval for conduct of the study located?

Response: It was added.

RESULTS:

Comment: Lines 243-244 is not clear, what's the difference between some University degrees and a bachelor degree?

Response: We used some university degree for Associate degree, it was corrected.

DISCUSSION:

Comment: The is no sub-heading titled discussion. It is not clear, whether the information after table 5 is a continuation of the results.

Response: Thanks, it was corrected.

Comment: Lines 386-398- In the whole of this portion, the authors are just citing other studies and not discussing their findings and comparing them to others. This is just lengthening the discussion, hence this portion can be deleted.

Response: It was done.

With best regards;

Correspondence

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

12 Jul 2022

Healthy Life Style During Pregnancy: Uncovering the Role of Online Health Information Seeking Experience

PONE-D-21-21672R2

Dear Dr. Bahrami,

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,

Aniekan Abasiattai

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

The reviewer's have completed their reviews and the manuscript is acceptable for publication. The 2nd reviewer has noted some grammatical errors which should be corrected.

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: (No Response)

**********

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: I Don't Know

**********

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: No

**********

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: GENERAL: There are still several grammatical errors that should be corrected before publication. Some are:

INTRODUCTION: Lines 74-75 should be ---Netherlands has showed that---. Lines 77-78 --intension to conceive correlates with---. Lines 78-80 should be ---change their lifestyle for the purpose of preparing for the pregnancy---. Line 140-150 should be -- their confidence in online information---.

METHODS: Line 173 should be --the inclusion criteria were being in---.

DISCUSSION: lINE 343 SHOULD BE --- the educational level of the participants did not have any----.347 health are should be health care. 349--CONFIDENCE FOR ON-LINE---. 353 should be ---more active participation of health---. 385 ----altogether confirming that---. Lie 388 should be --behavior does not have a---

**********

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

**********

20 Jul 2022

PONE-D-21-21672R2

Healthy Lifestyle during Pregnancy: Uncovering the Role of Online Health Information Seeking Experience

Dear Dr. Bahrami:

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