This study was conducted during the rise of the COVID-19 outbreak in Lebanon which is accompanied by a concomitant increase of pregnant women infected by COVID-19. To the best of our knowledge, this is the first national Lebanese study aiming to explore OBGYNs knowledge, attitudes and practices toward COVID-19 and, antenatal care. It also reveals OBGYN’s insights, doubts and, fears, hence allowing us to better understand the gaps and weak aspects in practices to be target in future interventions. A Similar topic was addressed by Awad et al., from the pregnant women point of view (23).
The baseline characteristics of the participants in our study defined a representative sample of Lebanese OBGYNs. Its main findings that the majority of respondents had a large experience (>10 years) and 38% of participating OBGYNs are working in the frontline during COVID-19 pandemic). Only 21.5% of them had a previous experience during an epidemic. Around half of OBGYNs have treated COVID-19 cases.
A finding of significant concern in this survey is that more than 28.3% of the respondents expressed their reluctance towards treating a pregnant woman with COVID-19. Given the unpredictability, novelty and infectiousness of COVID-19, in addition to the scarcity of data related to COVID-19 and pregnancy, the reluctance of OBGYNs should not be surprising and could be understood. However, this caused a moral dilemma between a duty to treat and a right to refrain. Our findings are consistent with a study conducted in Nepal where 35.9% of HCWs showed an unwillingness to work during the pandemic (24). In Bangladesh, it is reported that the reluctance of some physicians to treat patients suspected of COVID-19 infection, was due to personal risk assessment and not to reliable objection (25). Indeed, such hesitancy is not surprising as frontline health care workers have “more than three times the risk of COVID-19 infection than the general public” (26). However, these results highlight the importance of exploring the determinants of reluctance among Lebanese OBGYNs.
More than half of OBGYNs' respondents have cared for a COVID‐19 woman which is a percentage to take considerably, given that COVID‐19 cases escalate in Lebanon during the study period where wider community transmission is observed.
The majority of OBGYNs (65.6%) had an overall good level of knowledge and only 1% of them had a poor level of knowledge (<60%). This result is in line with that of Abou Abass et al., who reported that 89.5% of Lebanese physicians have a good knowledge regarding COVID-19 (27). Future plans should focus on improving the knowledge of OBGYNs with moderate knowledge levels. When looking in-depth at the knowledge domains, we found that most OBGYNs were cognizant of the different domains.
Most of OBGYNs were well-informed and updated in different knowledge domains. The highest knowledge scales were shown in the general knowledge part and the domain related to the delivery where OBGYNs had a knowledge level 91.8% of and 95% respectively. Despite the good level of knowledge specific to pregnancy and COVID-19, only 41.2% of OBGYNs were aware that the overall risk of COVID-19 infection in the pregnant patients is low. However, a new study from the University of Texas Southwestern has found that pregnant women who test positive for COVID-19 and their newborn babies have a low risk of developing severe symptoms (28).
In addition, around 40% of OBGYNs were not knowledgeable that pregnant patients with COVID-19 could develop respiratory complications requiring intensive care more than COVID-19 positive non-pregnant patients. This could be due to the swift generation of knowledge and its continuous update based on the availability and the emergence of new evidence based on the evolving nature of the disease which requires constant and regular upgrading of OBGYNs’ knowledge.
The breach in knowledge was ostensible in the domain related to the medicinal treatment of COVID-19, where only, nearly half of surveyed OBGYNs recognized that high doses of systemic corticosteroids should be avoided in confirmed or suspected COVID-19 cases. The divulged poor knowledge in the medicinal treatment domain was particularly related to the question concerning the use of non-steroidal anti-inflammatory drugs (NSAID), as ibuprofen, which could worsen COVID-19. However, to date, most COVID-19 clinical trials have excluded or included very few pregnant and lactating women. This limitation makes it difficult to generate evidence-based recommendation on the treatment of COVID-19 and potentially limit the treatment options (29, 30). Peculiar finding in this study that 26.9% of respondents consider cesarean section as an indication for delivery of pregnant COVID-19 patients.
In addition, 17.6% were not conscious that COVID-19 cannot be transmitted through breast milk. This could be attributed to the scientific dilemma anticipated by the experts regarding this topic and the evolving nature of the disease.
The present study also revealed that more than 74.6% of the surveyed OBGYNs were afraid of getting infected with COVID‐19 due to their occupational exposure, and approximately all of them were afraid of transmitting COVID-19 to their family member in the case they got infected. Our results are in line with the findings of studies conducted in Lebanon, Egypt and, Denmark (27, 31, 32).
More than half of respondents feared being very sick in case they catch COVID-19 and many of them were frightened of working in facilities where COVID-19 positive patients are admitted and followed. This could be attributed to the fact that 37% of participants were aged more than 55 years old and the complications of COVID-19 anticipated with age (33). Indeed, a high range of anxiety and burnout were expected since this outbreak impacted every and daily personal life across this globe especially the aspects of life of health care providers. The current financial crisis in Lebanon heightens the situation. Thus, addressing OBGYN’s fears, and perceptions through psychological intervention would be necessary to help them to cope with daily stressors during the outbreak (34). Such finding stressed the importance of building and consolidating OBGYNs' confidence which is of paramount importance not only for the physicians at a personal level but for effective practice revealed by the increase of their willingness to treat COVID-19 pregnant women.
Impact of COVID-19 on OBGYN wellbeing:
COVID-19 has sternly negatively impacted the wellbeing of OBGYNs. Our findings revealed that 27.2% of OBGYNs considered that their anxiety and worries are affecting the quality of care anticipated to the patient and 42.3% of them felt overwhelmed and burned out by the workload during COVID-19 pandemic. Our findings were in line with the results displayed in many studies. A survey conducted in India about burnout among HCW during COVID-19 pandemic shown that the prevalence of personal burnout was 44.6% (903), and 52.8% had pandemic-related burnout (35). These results also shed light on the importance of perusing in-depth mental health issues among OBGYNs.
Concerning attitudes of OBGYNs towards government approach and response to COVID-19 pandemic, interestingly, 62.7% of the participants declared that policies and actions implemented by the ministry of public health. Our findings showed a decrease in the positive attitude towards the government response in comparison with a previous study conducted at the early phase of the pandemic among Lebanese physicians (27). However, the success of measures (lockdown, point of entry closure, school closure, curfew…) showed in the early phase in containing the outbreak, was time-bounded. It vanished gradually with the release of lockdown and the situation was aggravated after Beirut blast where a spike of cases was reported.
Nevertheless, only 51.9% of OBGYNs thought that the preventive measures applied by their health care facilities were appropriate and sufficient in fighting COVID-19 and to protect health care workers. This highlights the importance of improving infection prevention practices within the health facilities. On another hand, the majority of respondents (72%) believed that measures limiting the traffic of OBGYNs and medical staff between health facilities are rational since restraining the work circle could control the spread of COVID-19.
Attitudes of OBGYNs toward the pregnant woman with COVID-19
Surprisingly, a large number of surveyed OBGYNs admitted that some pregnant patients will hide their exposure to COVID-19 from them. Even though, the majority 81% of OBGYNs perceived that pregnant woman will hide their positivity from their social environment in order to avoid stigmatization (36). However, social stigma of contracting COVID-19 motivates the general public not to disclose possible infection when presenting for medical care and, therefore, place physicians and nurses at risk (37). Hence, 84% of the participants highlighted the importance of supporting the mental status of the pregnant patient with COVID-19 during antenatal care which is consistent with Awad et al results (23).
Interestingly, all surveyed OBGYNs acknowledged changes since the early phase of the pandemic. The majority of them (80.3%) had a good overall practice score. The highest score was observed in the domain related to the practices at a personal level (93.5%) which included regular hand hygiene, wearing PPEs including masks and gloves, changing gloves after each patient and, regular cleaning and disinfection of surfaces and equipment's (especially high touched surfaces). A study conducted in Bangladesh revealed that the proper use of face shields or goggles in addition to decontamination could significantly protect the physicians from COVID-19 (38). Such proper implementation of good practices would mitigate this problem(39).
Based on OBGYNs responses, 78,9 % of them had a good practice score at the clinic level. These good practices including requesting all the time from all visitors to wear a mask (98.2%) and requiring that all health staff at the clinic wear protective clothing (75.6%). These practices would enhance patient confidence and alleviate their fears during the pandemic.
Limiting the duration of the consultation strategy was adopted by OBGYNs. The majority of OBGYNs followed a reducing in-person visit and employing an extended hours strategy and 90.1% of them have made some modifications to the waiting room and clinic space to accommodate physical distancing. Also, they prioritized in-person visits for patients with the greatest medical needs for in-person examination while postponing non-emergent gynecologic or well women appointments. Hence, compliance and adherence of the OBGYNs to ACOG and other OBGYN societies recommended measures was well noticed.
The bulk of OBGYN performed pre-appointment screening of patients for in-person visits concerning potential exposure to COVID-19, symptoms and, temperature checking. Such measures are essentials to ensure patient and physician safety.
Since providing telehealth services was essential to their mission as physicians during the pandemic, shifting to Telemedicine and maximizing the use of the telehealth modalities (calls, video calls…) was acknowledged by a large number of OBGYNs. Consistently to the findings of a study conducted by Helou et al, regarding the use of telehealth by physicians in Lebanon showed an increase in physicians use of telehealth activities during the COVID-19 pandemic in the fields of telemedicine (40). Reliable remote payment and reimbursement services may prove to be an important barrier shortly, due to the uncertainty of Lebanon’s economy and lack of concomitant legislation.
Raising awareness and counseling:
Moreover, 86,7% of OBGYNs had a good practice score concerning their role in raising awareness and counseling. Also, they emphasized measures to prevent COVID-19 and their families Adherent to ACOG and other OBGYN societies’ recommendations, most OBGYNs instructed their patients to maintain prenatal care appointments and to take needed vaccines during pregnancy. This would reduce the misbeliefs of pregnant women during this critical period. However, poor adherence to the influenza vaccine has been noticed among Lebanese pregnant women (23). Despite that the majority of OBGYNs advised their patients, it is astonishing that 16.8% of them didn’t enlighten these methods. Our results were inconsistent with the study conducted among Lebanese pregnant women who reported that half of participants did not discuss methods of contraception with their physicians (23).
However, brochures, guidelines regarding COVID-19 and pregnancy were not distributed by nearly half of OBGYNs. This can be due to their availability at their clinics or health facilities due to inaccessibility and financial issue.
Considering the fear of the social stigma that may lead some pregnant women to hide their exposure and positivity for COVID-19, the majority of OBGYNs my patients to notify me and the health authorities of any potential exposure to COVID-19 (41).
4.2 Study limitations
Some limitations of this study should be acknowledged. First, our study relies on OBGYNs’ self-reported information, which may be a threat to internal validity. In fact, self-reporting could be influenced by social desirability and then intentionally modified to meet the norms. Furthermore, this online questionnaire might have favored a selection bias by since it might only allow the participation of OBGYN users who have access to online resources to participate. The findings of the present study should be considered in light of several limitations. No validated tool for the assessment of the knowledge, attitudes and, practices of OBGYNs was available. We have formulated items from ACOG guidelines. Based on a study exploring the characteristics of healthcare providers in Lebanon, less than 20% of Lebanese physicians are female (42), since then, an increase in the percentage of female physicians was noticed (current estimate of 25%). The demographic characteristics of our respondents show a higher percentage of male physicians (57% male vs. 43% female). The slight overrepresentation of female physicians in our sample could be attributed to our sampling method and the ability of participation of females more than males in such surveys.