There have been several respiratory virus epidemics in the last few decades, of which the COVID-19 pandemic was the most widespread and resulted in high mortality; it is likely that more will occur in the future. In most cases, specific vaccines are not available initially and reliance is placed on non-pharmaceutical measures. Vulnerable groups, of which pregnant women are one, are particularly at risk.
According to a population-based cohort study among 36 hospitals in South Africa that assessed pregnancy outcomes of hospitalised pregnant women with COVID-19, of the 673 infected hospitalised pregnant women, 32.2% were admitted for COVID-19 illness and for other indications, there were 39 deaths, 179 (35.4%) preterm births, and 25 (4.7%) stillbirths [13]. It is thus important to determine the uptake of these non-pharmaceutical interventions. Such information will inform the response to future outbreaks of severe respiratory viral illness.
The Royal College of Midwives recommendations suggest that women in labour should not be expected to wear face masks [14]. However, in LMIC countries where vaccine rollout and access is problematic even when a vaccine is available globally, this may be an important method of preventing transmission.
In our study, 78% of peripartum women used face masks effectively during the COVID-19 pandemic. Furthermore, 90% of respondents had adequate knowledge of face mask use and this knowledge was a significant predictor of correct use of face masks (p = 0.006). In exploring the reasons for effective face mask use, more than half the women used face masks because they felt susceptible to getting COVID-19 in hospital and the majority used face masks because they believed that they were effective in preventing COVID-19 and decreasing its spread to loved ones. The lowest rate of face mask usage was in the second stage of labour. Higher education levels were associated with a higher rate of face mask wearing.
The rate of face mask use in the peripartum period is relatively high, considering that the pain, energy expenditure, and emotion of labour was thought to be a possible deterrent to effective face mask use. Studies have shown rates of face mask use varying from 91.8% in an outpatient setting to 4% in a community setting during the SARS pandemic [15, 16]. The relatively good results in our study may relate to the fact that the study was conducted in the hospital at a time when there was widespread information about the need to wear face masks, coupled with the country’s directive for individuals to adhere to COVID-19 protocols.
The rate of knowledge of effective face mask use of 90% and the consequent association between knowledge and adequate face mask usage (4-fold increase; p = 0.006) concurs with the findings of a questionnaire-based cross-sectional study conducted in a primary health care facility in South Africa by Hoque et al. assessing knowledge, attitude and practices among pregnant women during the COVID-19 pandemic [17]. They showed that women with good knowledge were 7 times more likely to practice positively regarding COVID-19 (p = 0.019). A Kenyan study, however, showed that, while knowledge of the advantages of non-pharmaceutical interventions was high amongst a group of pregnant women (99%), this did not translate to good practice [18]. The reasons for non-use of face masks was that they were uncomfortable and expensive. In our study, face masks were made available free to all women attending the hospital. In contrast, research conducted among healthcare workers in Pakistan in April 2020 to assess their knowledge, attitude, and practices of face mask use in limiting the spread of COVID-19 revealed inadequate knowledge of the technique and practice of face mask use. Of 392 participants, only 43.6% knew how to wear the face masks properly, 68.9% recognised that there were three layers, and 75.5% knew the prescribed maximum wearing period [19]. Our study was conducted slightly later in the pandemic which may explain the difference as there would have been more time to disseminate information. A recent meta-analysis of knowledge, attitudes and practice of pregnant women in Africa regarding COVID-19 [20] reported a knowledge rate of 61.8% and positive preventative practices in 52.3% of women. The studies included were mainly from the Eastern and Western regions of Africa, with only one study [17] from southern Africa. These results also reflect regional differences with higher knowledge in the Western region. They recommend health education in antenatal clinics. In our setting, health education on COVID-19 was routinely made available during antenatal visits, sensitising women on the need for COVID prevention and face mask wearing.
In exploring women’s reasons for wearing face masks, more than half felt susceptible to contracting COVID-19 in hospital and the majority believed that COVID-19 was troublesome and could spread to loved ones and that wearing face masks was a way of preventing this (90.8% and 96%, respectively). The majority did not find it troublesome to wear a face mask and those who effectively wore their face masks did not do so because of pressure from mass media, but rather because of their knowledge and beliefs about the benefits of face mask use.
As in other studies, we found that face mask usage was greater in women with higher levels of education [21,22,23]. There is a need to make educational materials on effective face mask use and COVID-19 simple through public education and outreach programs to target this subgroup of the population with lower education levels. Consideration should be given to the use of easily accessible means such as television and addressing potential discomfort.
Effective face mask use was highest during the postpartum stage (83.1%) and lowest in the second stage of labour (64.3%) with the first stage of labour recording 81.1%. The relatively low prevalence in the second stage of labour is thought to be due to the pain and emotion that characterises this stage of labour and the potential discomfort that the face mask use may pose to the respondents, as the women are pushing and breathing heavily, and this can be hampered by wearing a face mask. However, this finding is significant because of the potential for the spread of COVID-19 at this stage of labour.
Consideration needs to be given to the high risk of SARS-CoV-2 transmission to delivery assistants and birth companions at the second stage of labour, emphasising the importance of appropriate PPE.
This study has some limitations. It was a single centre study and thus might not be generalisable. It is likely that similar results would be obtained in large urban hospitals but further research should be conducted in rural areas.
Based on the cross-sectional study design, associations found cannot be temporal or causal.
The observation of effective face mask use can be prone to observer bias. However, the robust statistical methods used in the conduct of the study make the findings empirically sound and can be compared to findings from similar contexts.