A cross-sectional study, using the snowball sampling method, was conducted during the COVID-19 pandemic in five Arab countries (Lebanon, Palestine, Jordan, Saudi Arabia and Bahrain). A web-based questionnaire was disseminated through social media websites (available at the link https://www.palnut.org/frontend/web/index.php?r=survey/survey/index) to collect data from pregnant women. The questionnaire used in our survey was previously validated in two published data (6, 7). The current survey investigated pregnant women’s sociodemographic characteristics, maternal medical history, eating patterns, food consumption, physical activity patterns, anthropometric data, smoking, anxiety, and depression. The first section of the questionnaire inquired about pregnancy and its progression. It includes questions about the mother’s age, health status, and diseases. Moreover, the socio-demographic characteristics included education, residency, and economic situation. The second section questioned about the daily serving sizes from each food group (bread, pasta, cereal, vegetables, fruits, meat, poultry, fish, nuts, sweets, fast food, fats, and oils) consumed during the day and week prior to completing this survey. Participants were also asked about their mental health (anxiety and depression) and smoking habits, as well as any physical activities they engaged in. In the current study, we did not cover the pre-pregnancy period, but rather the period preceding the COVID-19 pandemic and the pandemic period only. The questionnaire had various questions, some with only one option for each topic and others with open-ended answers.

The following criteria conditioned the data collection: (i) pregnancy since the pre-COVID-19 pandemic period; (ii) pregnancy of normal course; (iii) the woman’s age > 18; (iv) place of residence—the listed five countries; (v) replying to all questions; (vi) consenting participating in the study. Moreover, the exclusion criteria were conception during the intra-COVID-19 pandemic period and some risk factors such as miscarriage.

The study design obtained written approval of the Ethics Committee in Scientific Research of Lebanese University (CUER#30-2020), as well as universities from all participating countries. Before completing the questionnaire, each participant was informed of the study’s goal and ensured the confidentiality of their information. The completion of the questionnaire was voluntary and anonymous. Consenting to participate in the study was considered as a necessary component.

Continuous variables were expressed as means and standard deviations (SDs), while categorical variables were shown as frequencies and percentages. Chi-square test was used to compare variables among the five countries, while ANOVA test was applied for continuous variables. The Paired sample t-test was used to compare continuous variables before and during the pandemic, while the McNemar test (a marginal homogeneity test for paired data) was used to compare categorical variables. The statistical significance level was set at p-value < 0.05, and the statistical analysis was carried out using IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.

Table 3 shows the dietary intake among pregnant women from the five countries before and during the pandemic.

The consumption of cereals, fruits, vegetables, dairy products and protein group increased significantly during the pandemic compared to the period before (p-value < 0.001; Table 3). Additionally, before and during the pandemic, women’s daily consumption of almost all food groups was lower than the USDA’s daily recommendations, with the exception of fruit consumption, which was higher than the daily standard.

According to Table 3, 83.8% of women in Jordan, 83.9% in Palestine, 86.5% of women in Lebanon, 91.5% in Saudi Arabia, and 82.1% in Bahrein showed poor adherence to the USDA’s recommendations before the COVID-19 pandemic. Nevertheless, the percentage of adherence increased significantly during the pandemic (p-value = 0.001). It increased of 3% in Jordan, 2% in Palestine, 3.4% in Saudi Arabia and 8% in Bahrein. However, it decreased of 3.1% in Lebanon (p-value < 0.001).

Otherwise, our findings concerning the increase in the consumption of all food groups were concordant with the findings of a longitudinal Chinese study which found that the consumption of vegetables, fruits, dairy products, and cereals was significantly higher among pregnant women during the pandemic (13). Furthermore, Hillier et al. revealed a substantial increase in the consumption of fruit and vegetable along with a decrease in egg, fried fast foods, coffee and tea consumption from pre-pregnancy period to during pregnancy in the pre-COVID-19 time (14).

Starchy carbohydrates and fiber containing whole grain cereals and vegetables are the fundamental of a healthy diet. According to the USDA guidelines, the intake of 18–24 g of fiber during the second and third trimester allow for good body’s functioning (5). Due to its richness in minerals, vitamins and dietary fibers, pregnant women are recommended to include wholegrain cereal products in their daily diet. Although the primary source of energy and nutrients should be derived from this food group and should be part of each main meal, 65% of the women in this study consume less than six portions per day from this food group.

A large number of antioxidants (vitamin A, C, and E, carotenoids and flavonoids) are derived from the inclusion of vegetables and fruits in pregnant women’s diets. They provide also folates, potassium and fiber. According to the USDA’s recommendations, an amount of 300 and 350 g per day in the first semester, and in the second and third trimester—300 g and 450 per day of fruits and vegetables, respectively, should be included in pregnant women’s diet (5). Similarly, according to WHO, the intake of vegetables and fruit in the diet of pregnant women should be of high-priority (15). In this study, women mostly consumed fruits in a way higher than the daily standard. In comparison with data from pre-COVID-19-time, our findings came hand by hand with the results obtained in the study conducted by Dere’n et al. (16), where the majority of the women consumed fruit between meals, and one third outstretched for sweets during pregnancy (16). Another study conducted by Kobiołka et al. (17) showed that, between meals, fruit was the most preferred snack consumed by pregnant women (17).

According to many international dietary standards, protein intake should be increased throughout pregnancy, particularly in the second and third trimesters. Referring to the USDA guidelines, 165–195 g (second and third trimester) of protein sources allow for a proper functioning of the body (5). Protein is required for the tissue and placenta of both the mother and the fetus (18). Primary sources of protein could be derived from animal sources (red, lean meat and its products, skimmed milk and its products, fish and poultry). Thus, the daily intake should increase of 1, 8, and 26 g in the first trimester, the second trimester, and in the third trimester of pregnancy (19). Our findings revealed that a significant proportion of respondents consumed poorly this food group (70% in pre-COVID-19 period compared to 65% in the intra-COVID-19 period). Our results are tied well with the literature where Abd-Elmohdy Emara (20) investigated that 37, 31, and 27% of pregnant women consumed white meat 3–4 times per week, 2–3 times per week, and at least once per day, respectively. Furthermore, according to the same study, 43, 12, and 33% of women ate red meat 3–4 times per week, 2–3 times per week, and occasionally, respectively (20).

Moreover, during pregnancy, the body’s demand for iron rises, and red meats are a rich source of iron (21). Because of their increased vitamin B₁₂ and iron content, pregnant women should have white and red meats in their weekly diet. Our findings indicated that a significant proportion of respondents consumed poorly this food group (70% in pre-COVID-19 period compared to 65% in the intra-COVID-19 period), which may result in anemia in the short term and low birth weight in the long term (22). Our results backs up findings from a systematic analysis by Caut et al. (23), which found that in 91 and 55% of included studies, pregnant women were not adhering to iron and calcium dietary recommendations, respectively (23).

Dairy products, rich in protein, riboflavin and calcium, are essential for pregnant women, alongside bread, vegetables, fruits, and meat (24). According to WHO, a dietary intake of 1,200 mg/day of calcium for pregnant women is recommended (15). To meet this need, a pregnant woman should drink daily three cups of skimmed milk (5). Fermented milk drinks, rich in nutritious protein, vitamin B₂, and calcium are widely recommended in the diets of pregnant women because they provided probiotic bacteria (3). According to our findings, pregnant women’s diets have a low percentage of milk and dairy products. In our study, 80% of the subjects were drinking milk and fermented milk drinks less than three servings per day. The research of Kobus-Cisowska et al. (25) and Suliga (26) yielded similar results (25, 26). Likewise, 43% of pregnant women in the study by Dere’n et al. (16), consumed dairy products once a day, and 48% more often (16). Regular physical activity during pregnancy, known to be beneficial to both physical and mental health, in addition to a balanced diet, has an impact on the mother’s and child’s short and long-term health (27–29). Nevertheless, most pregnant women in our study (64%) show usually high levels of physical activity. According to WHO, at least 150 min of moderate intensity physical activity per week is recommended for adults (30). Unless there are medical restrictions, regular and moderate exercise is recommended for pregnant women (27–29). Due to the need to adapt the physiological and psychological changes during pregnancy, pregnant women may struggle with the sedentary behavior and become physically inactive (3). Finally, despite the well-known health benefits related to practicing regular physical activity during pregnancy, over 40% of women do not adhere to the recommendations.

To our knowledge, no data was published among Arab countries that investigate the consumption patterns of pregnant women amid the COVID-19 pandemic. Thus, our findings were compared to many data published in which the food consumption was reported for the whole population. In Lebanon, the findings of a national study aligned our findings in which a significant increase in the number of meals consumed per day during the pandemic compared to before the pandemic (all p < 0.001) was observed (31). However, there was a significant decrease in physical activity engagement during the lockdown compared to before the pandemic (all p < 0.001) (31). Another study in Lebanon showed that home isolation due to COVID-19 induced an increase in the consumption of legumes and pulses (3.2%, p-value = 0.001) and whole wheat groups (2.8%, p-value = 0.03). In contrast, a decrease of 5.4, 6.9, 5.8, 5.1, 3.1, 3.4, and 2.8% was observed in the consumption of fruits (p-value = 0), vegetables (p-value = 0), processed meats, poultry, and fish (p-value = 0) and other dairy products (p-value = 0), respectively. In Lebanon, since the ordeals of COVID-19, economic crisis, and the Beirut port explosions, food insecurity became an immediate problem for households in Lebanon. Between November 2020 and March 2021, 9 in every 16 households ate less than two meals per day and more than 70% of them skipped their meals to spare food. This explains the difference in term of food consumption among Lebanese pregnant women compared to other countries (32). At the Arab countries level, a recent study conducted in 10 countries including Jordan, Palestine, Lebanon, Saudi Arabia and Bahrain showed that, before and during the pandemic, most food groups were consumed less or equal to four times per week which indicated a poor dietary diversity among the countries’ population (33). This finding along with our findings describe the nutritional situation and food consumption patterns among pregnant women on one side and the whole population on the other side.

This study has some limitations. First, this study was conducted online through convenience sampling that could probably lead to skewed sample characteristics in some countries. Second, respondents were asked to recall the food categories’ consumption patterns prior to lockdown, which could have caused recall bias. Third, although this sampling method does not always guarantee the generalizability of the results, it can remain an effective method for estimating the likelihood of potential relationships between variables (34–36). Finally, although it is necessary that all Arab countries adhere to evidenced-based guidelines, multiple factors can limit guidelines’ adherence, including income, food availability and affordability, individual beliefs and preferences, cultural traditions, and educational, social, geographical, and environmental aspects.