In this study, we explored the knowledge and expectations of perinatal and neonatal care among pregnant mothers during the current COVID-19 pandemic in Singapore. Our survey revealed that most participants were aware of the modes of SARS-CoV-2 transmission and the important transmission prevention strategies. There was significant variability identified in their understanding of the safe mode of delivery and of breastfeeding in mothers with COVID-19. Up to 60% of those surveyed were neutral or disagreed with alterations to pre-pandemic standards of perinatal care including the use of teleconferencing, separation of mother and infant after birth, restriction of in-hospital visitors and alterations to confinement practices.
There are limited current studies reporting on the perception and expectations of perinatal care by pregnant women’s during the current COVID-19 pandemic. In a recent study of the perception of the impact of COVID-19 on pregnancy and psychological impact on pregnant women, Ng et al highlighted the importance of timely, accurate information on the impact of COVID-19 on pregnancy and its effect on the psychological well-being of pregnant women . Knowledge gaps in this regard among antenatal women was associated with increased anxiety and depression during this current pandemic. In a national cross-sectional survey conducted in Italy, Ravaldi et al  reported significant changes in pregnant women’s expectations regarding childbirth where they expressed more fear, anxiety, pain and loneliness during this current pandemic. They also found that women with a history of psychological distress were significantly more likely to be overwhelmed by the situations caused by the COVID-19 pandemic [15, 16]. Another study on COVID-19 awareness among pregnant women revealed that social demographic factors such as maternal age, ethnicity, frontline jobs and attendance at high-risk clinics are likely to influence the attitudes and precaution practices among of pregnant women . All these studies highlight the importance of appropriate and targeted counselling to pregnant women on the potential effect of COVID-19 on pregnancy as a measure of psychological support. Our study adds to this by illustrating the potential importance of early and appropriate provision of evidence-based information to expectant mothers to reduce misinformation and moderate their expectations of perinatal and neonatal care during this current pandemic.
Much of the anxiety among pregnant women may be related to the variability of recommendations on perinatal and neonatal care that was available during the early phases of the pandemic. Most recommendations were based on expert consensus with limited evidence which were of variable and low methodological rigour [6–8, 18]. This was likely inevitable considering the speed and magnitude of the pandemic and the rapidly evolving nature of the evidence that was available. This is evidenced by the emerging evidence on transmission of SARS-CoV-2 in utero. Recent data have confirmed the possibility of in-utero transmission, even though this is likely a very rare occurrence[19–21]. This emerging information was reflected in the majority of our survey participants agreeing that in-utero transmission of SARS-CoV-2 virus to the unborn fetus was possible. This could also possibly be due to the widespread coverage of reports of newborns diagnosed and infected with COVID-19 shortly after birth [22, 23].
Delivery room practices are important considerations in mitigating the risk of perinatal viral transmission during the current pandemic [24–27]. Emerging reports have reported SARS-CoV-2 being detected in amniotic fluid, vaginal fluid and the placenta [20, 21], highlighting the possibility of infection in utero and during delivery. Systematic review of cases reported in the literature have indicated no substantial evidence for increased transmission risk during vaginal birth[28–31]. Even so, most of the women in our cohort had expressed uncertainty regarding the optimal mode of delivery in women with COVID-19. While only 22% of women held a definitive opinion, 6% would choose to have a caesarean Section and 16% would choose to have a vaginal delivery. This is in contrast to another earlier study  which showed that 53% of women would opt to have a Caesarean section over a vaginal delivery if infected with SARS-CoV-2. This may be a reflection of the evolving and emerging evidence, especially that being shared in the media and by international perinatal organizations [9, 10, 12]. This uncertainty should be addressed and communicated by the clinicians, as the evidence for the safety of routine obstetric indications for delivery of pregnant women with COVID-19 accumulates [13, 32].
Breastfeeding and the feeding of mother’s own breast milk by women with COVID-19 have also been areas of significant contention with significant variability in the initial guidelines [6, 7, 33]. Only 22% of our study cohort would choose to actively breastfeed their infant with active COVID-19, whereas the remaining 78% were unsure or would totally avoid breastfeeding altogether. This finding is consistent to that reported by Yassa et al , where 50% of the women surveyed was unsure if breastfeeding was safe during the pandemic. Breastfeeding and provision of breast milk, with its well-documented short and long-term health benefits, is an important aspect that needs to be addressed [11, 35]. The lack of viable virus detected in reverse transcription polymerase chain reaction (RT-PCR) positive breast milk  and the presence of SARS-CoV-2 specific immunoglobulin A response in breast milk  after COVID-19 provides suggests the low likelihood of transmission via milk.
While 46.6% of participants expressed concern about the risk of contracting COVID-19 during their hospital visits, only 37% were receptive to the idea of teleconferencing as an option. Notably, women who were nulliparous were less likely to agree. Teleconferencing confers increased autonomy to the patient but would also rely heavily on patient involvement and reporting . It is likely that nulliparous women are likely to have less confidence on self-monitoring and reporting of issues during her pregnancy. Pregnant women > 35 years were also less likely to agree to teleconferencing of hospital visits. This may be related to the perceived increased risk associated with advanced age pregnancies. With the potential need for ongoing social distancing procedures during this pandemic and beyond , there needs to be increased effort to improve the knowledge and increase the comfort level of pregnant women for home monitoring through the potential implementation of suitable monitoring devices and applications [40, 41].
Confinement is a unique postnatal practice specific to several Asian ethnicities and communities which involves the prohibition of performing certain daily tasks and the restriction of certain foods and diets. Local studies have previously shown that a negative postnatal confinement experience was a significant risk factor for postnatal depression . More than half of the women surveyed reported that their confinement plans were being affected by restrictions imposed due to the current pandemic. In this regard, physicians must be aware of the importance of confinement especially in the Asian context and its significant contribution to the overall pregnancy experience. Being cognizant of the different confinement activities practiced by different ethnicities  and how these activities may be affected by the COVID-19 pandemic, is important to provide tailored advice to pregnant women on the postpartum care for themselves as well as for their neonates. This would also aid in improving the doctor-patient relationship and the outcomes for both pregnant women and their neonates.
Our study is limited by our relatively small sample size as well as the conduct of the survey in a single hospital in Singapore. Even so, our study cohort was recruited from the largest perinatal center on the country and the ethnic distribution is well representative of the general Singaporean population. Our findings could have been influenced by selection bias as our survey was conducted on a voluntary basis and on an online platform requiring mobile devices. This could have inevitably excluded those less technologically savvy or pregnant women without mobile devices. To expand our study further, the translation of our survey into more languages and expanding the scope to neighboring South-East Asian countries to see if the findings are reproducible could be explored. In addition, a qualitative portion to the survey as well as focus group discussions could be included to elucidate the impetus behind the responses given by pregnant women.