To the best of our knowledge, our study is hitherto the first study performed in a South East Asian population of pregnant women. Factors like race, religion, education background and employment status can influence women’s attitude, practice and perception especially in an affluent country like Singapore. Our survey showed that Malay pregnant women are likely to practice safe distancing and sanitise their hands at a higher frequency compared to Chinese to minimise the spread of COVID-19. In addition, women attending ‘high-risk’ clinics are more likely to stay at home compared to women attending ‘general clinics’. A plausible explanation suggests that women with high risk pregnancies are more likely to stay at home to minimize themselves or their foetuses from being infected with COVID-19 when compared to women with low risk pregnancies.
Employed individuals who worked in front line services such as healthcare, hospitality have a lower tendency to stay home for social distancing, possibly driven by their more sociable or out-going characteristics when compared to those do not work in front line. Conversely, our study also showed that employed individuals with front line jobs are more likely to practice hand hygiene compared to those who do not to reduce the risk of infection. It is possible to attribute this to the nature characteristics of front-line jobs and these women are likely to have a high tendency to wash their hands more often compared to those who do not work in front-line jobs. In our study, women with previous history of miscarriage had a lower tendency to stay home for maintaining social distancing (Q19, β: -0.22) suggesting that obstetric experience did not make women more cautious to practice social distancing to protect themselves. The same inverse associations were observed for Q18,Q20, Q21 with no significance.
There are currently limited cross-sectional studies addressing the attitude and perception of COVID-19 among pregnant women. Anikwe et al showed that majority of pregnant women in their third trimester in Nigeria demonstrated good attitude and preventative practices of COVID‐19  by practising hand washing, wearing masks, avoiding face touching and quarantine infected people as good practices towards the prevention of COVID‐19 infection. These measures were performed without a ‘lock-down’ period unlike Singapore which implemented a colour-coded framework known as ‘Disease Outbreak Response System Condition’ (DORSCON) to guide the public on prevention and reducing the impact of COVID-19. There are four statuses namely Green, Yellow, Orange and Red of which Singapore is at orange currently which meant that the disease is severe but has not spread widely and is being contained . The Singapore government implemented a ‘circuit-breaker’ in different phases’ akin to lock-down period in other countries to curb the community spread of COVID-19 . A circuit breaker is a set of safe distancing measures akin to a lock-down to pre-empt the trend of increasing transmission of COVID-19 by reducing significantly movements and interactions in places . Safety measures implemented include staying mostly indoors and going outdoors only when necessary, practice social distancing at least one metre apart, wearing surgical masks in public places and adopting good hand sanitation practices to reduce the risk of community spread of COVID-19. Singaporeans are mostly compliant to the safe distancing measures as there are strict rules regarding social distancing with hefty fines and custodial sentences along with an effective enforcement ability.
Pregnant women should be appropriately educated on preventative measures to reduce the severity of COVID-19 associated illness. Pregnant women should also avoid missing prenatal appointments if well and limit interactions with others to reduce the risk of transmission. Symptomatic women should be urged to be tested early for COVID-19 by nasopharyngeal or oropharyngeal swabs and practice self-isolation to reduce the risk of vertical transmission [24,25].
Yassa et al focused on Turkish pregnant women in attitude, concerns and knowledge towards COVID-19 from 30 weeks gestation onwards  where Turkey was one of the most affected countries then with over 20,000 cases and 425 deaths in April 2020 . They showed that about 80% of women felt vulnerable towards the outbreak 45 % of women were confused or doubtful about the mode of delivery and 50% wasn’t sure if breast feeding was safe during the pandemic . This is similar to our findings where 74% of women were worried about being infected with COVID-19; 53% of women would choose having a caesarean section over a vaginal delivery and only 35% of women will choose to breast feed if they were diagnosed with COVID-19. These views reflect the vulnerability of pregnant women despite differences in race or culture as pregnant women want the best outcome for themselves and minimize risk of vertical transmission to their baby. Hence it is paramount for clinicians to reflect on the insecurities and worries of pregnant women towards COVID-19.
In our study, 46% of pregnant women believed they are more likely to go into pre-term labour when infected with COVID-19. Di Mascio et al showed that 41.1% of pregnant women with COVID-19 had preterm birth before 37 weeks gestation , however that study did not distinguish between spontaneous and iatrogenic preterm birth . A systemic review by A. Khalil et al also showed an 18.4% increase in iatrogenic preterm births before 37 weeks as these women were ill enough to require early caesarean deliveries . This emphasizes the importance of imparting knowledge and educating women to avoid unnecessary anxieties from non-evidenced based perceptions.
In our study, 46% of pregnant women also believed they are more likely to miscarry when infected with COVID-19. A systematic review by Zaigham et al did not report any adverse outcomes relating to perinatal outcomes . Although results from the SARS epidemic did not suggest an increased risk of miscarriage or congenital anomalies associated with COVID-19 infection, more data is required before conclusions can be made on the risk of miscarriage .
In our study, almost three in four (74%) of women were worried and very worried about being infected with COVID-19 in pregnancy. Durankus et al showed that pregnant women scored higher on the Edinburgh Postpartum Depression Scale (EPDS) when compared to the control group . It is understandable for pregnant women to be anxious and this can be associated with a higher risk of depression . This highlights the importance of providing psychosocial support especially in a vulnerable group of pregnant women. Clinicians should work in tandem with clinical psychologists and psychiatrists in a multi-disciplinary setting. The care of pregnant women should be tailored individually for the mental health of women and their babies.
Most cases of COVID-19 have evidence of human-to-human transmission where the virus appears to spread through respiratory, fomite or faecal methods [33,34]. There is also emerging opinion that the fetus may be exposed during pregnancy. Perinatal infection may occur but its true incidence remains unknown. The likelihood of vertical transmission is low based on the United Kingdom Obstetric Surveillance System (UKOSS) interim study where six babies (2.5%) had a positive nasopharyngeal swab for SARS-CoV-2 within 12 hours of birth in severely affected hospitalised women. . Hence, the risk of vertical transmission in mild or asymptomatic patients is likely to be lower than that.
A case series published by Chen et al a tested amniotic fluid, cord blood, neonatal throat swabs and breast milk samples from COVID-19 infected mothers and all samples tested negative for the virus . Conversely, two reported cases of possible vertical transmission showed evidence of immunoglobulin M (IgM) for SARS-CoV-2 in the neonatal serum [37-38]. Although direct evidence of viral positive reverse transcriptase-polymerase chain reaction (RT-PCR) were mostly negative in large majority of reported studies, the paucity of published data is limited with small cohort numbers , limited sensitivity and specificity of swab tests and rapid evolution of COVID-19 infection. [39-42]. Hence, more data is needed about the risk of vertical transmission before definitive conclusions can be made.
The mode of delivery should be discussed adequately with pregnant women taking into consideration their preferences and any obstetric indications. In our study, 53% of women would choose to have a caesarean section over a vaginal delivery if they were diagnosed with COVID-19. A. Khalil et al showed that nearly half of pregnant women infected with COVID-19 had caesarean deliveries . As there is no convincing evidence of vertical transmission, vaginal delivery is not contraindicated in patients with COVID-19 [11,12]. Thus, Caesarean section is preferred over vaginal delivery in the face of maternal deterioration and fetal compromise where delivery is imminent. However, logistical issues can arise from the transfer of patients in hospital to labour ward or the availability of operating theatre to perform a caesarean section with negative pressure to minimize the risk of transmission. Hence, clinicians should counsel women on the appropriate mode of delivery as there is a lack of data and uncertainty surrounding the risk of perinatal transmission during vaginal deliveries.
In our study, only 35% of pregnant women will choose to breast feed if they were diagnosed with COVID-19. There is also limited data to guide the postnatal management of babies of mothers who tested positive for COVID-19 in the third trimester of pregnancy. Currently, possibility of infection from breast milk remain uncertain although there is recent evidence to suggest a small risk of transmission through breast feeding [43-45]. As breast feeding requires close contact, direct breast feeding may be of concern in infected mothers. Hence, infected mothers should be advised to wear surgical masks, cleaning their breast before expression via breast pumps to bottle feed their neonates to reduce the risk of neonatal transmission. Precautionary separation of mother and child is debatable and cause loss of physical bonding and emotional attachment which have a negative psychological impact in infected women.
We chose to perform an online survey as this is a rapid and convenient mode of administration. Furthermore, we used CHERRIES to ensure the quality of our web-based survey . Limitations of our study include small sample size and lack of internal consistency of questions without validation. A larger study would be essential to confirm our findings. Despite our small sample size , the data collected likely representative of our local population as the two large public hospitals which make up more than half of the number of pregnancies and deliveries in Singapore. In addition, our findings may be influenced by possible selection bias because participants needed a mobile device with applications to scan the QR code to access the survey. However , the large majority of the local Singaporean population own mobile devices which makes the online survey easily accessible for participation.
Ever-since the WHO declared COVID-19 a global pandemic, the world has seen an exponential number of rising cases and unprecedented death rates. Until a vaccine is found, herculean efforts rests on containing community spread of COVID-19 through means like testing for suspected cases, practising social distancing and maintaining good personal hygiene [47-49].