Obstetrician Advice as a Key Determinant of Dental Visits During Pregnancy: A Cross-Sectional Study in China

Obstetrician Advice as a Key Determinant of Dental Visits During Pregnancy: A Cross-Sectional Study in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Obstetrician Advice as a Key Determinant of Dental Visits During Pregnancy: A Cross-Sectional Study in China Kaijia Xue, Jiaju Liu, Yi Lin, Liang Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8683366/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objectives To assess oral health knowledge, attitudes, and practices (KAP) among pregnant women in Fuzhou, China, and to identify factors associated with dental visits during pregnancy. Materials and Methods A cross-sectional survey was conducted from 10 September to 31 October 2025 at a tertiary obstetrics clinic in Fuzhou, China. Participants were recruited at Fuzhou University Affiliated Provincial Hospital. Using consecutive recruitment with trimester quota sampling (DEFF ≈ 1), 452 pregnant women completed a structured questionnaire covering demographics, oral health knowledge (7 items), attitudes (6 items), behaviors, barriers, and information needs. Internal consistency was assessed (Attitudes: Cronbach’s α; Knowledge: KR-20), and construct validity of the attitude scale was examined (KMO and Bartlett’s test). Spearman correlation and multivariable logistic regression were performed. Results Mean Knowledge, Attitude, and Practice scores were 4.29 ± 1.79 (0–7), 24.35 ± 4.38 (6–30), and 2.96 ± 1.88 (0–10), respectively. Overall, 13.1% (59/452) reported a dental visit during pregnancy, increasing by trimester (7.3% ≤12 weeks; 11.8% 13–27 weeks; 20.0% ≥28 weeks). While 68.6% brushed at least twice daily, only 14.4% used dental floss. Knowledge and attitudes correlated positively with practice (Spearman r = 0.248 and r = 0.178; both p < 0.001). Among non-attenders, the most common primary barrier was lack of obstetrician advice or referral information (53.2%, 209/393). In adjusted analyses, obstetrician advice/referral was the strongest predictor of dental visits during pregnancy (aOR 6.30; 95% CI 3.22–12.32). Higher household income was also associated with dental attendance (15,000–24,999 RMB: aOR 3.32, 95% CI 1.02–10.75; ≥25,000 RMB: aOR 6.09, 95% CI 1.61–23.04, vs. <8,000 RMB), as was having a dental check within 6 months prior to pregnancy (aOR 2.19; 95% CI 1.18–4.07). Late pregnancy (≥ 28 weeks) showed a borderline association with utilization (aOR 2.22; 95% CI 0.99–4.99; p = 0.054). Education was not independently associated after adjustment. Conclusions Despite generally positive attitudes, dental service utilization and several preventive behaviors remained low. Integrating obstetrician-delivered counseling/referral into routine antenatal care and addressing pregnancy-specific safety misconceptions may improve timely dental attendance. Clinical Relevance: Embedding oral health counseling and a streamlined referral pathway within antenatal visits could reduce missed opportunities for dental care during pregnancy. Trial Registration: This study was registered in the China National Medical Research Registration System with the registration number: MR-35-25-062116. Registered on September 8, 2025. pregnancy oral health dental attendance knowledge-attitude-practice obstetrician advice cross-sectional study Figures Figure 1 Figure 2 Figure 3 1. Introduction Pregnancy is accompanied by substantial hormonal and immunological changes that may increase susceptibility to oral diseases, particularly gingivitis and periodontal conditions [ 1 , 2 ]. Periodontal disease is common during pregnancy; a recent systematic review and meta-analysis reported a pooled prevalence of approximately 40% worldwide [ 3 ]. In line with this vulnerability, clinical evidence has also documented measurable immunological and microbiological shifts in the oral environment during and after pregnancy [ 4 ]. Beyond local symptoms, maternal oral infections have attracted attention because of their potential association with adverse pregnancy outcomes (APOs). Proposed pathways include hematogenous dissemination of oral microorganisms or their products to the feto-placental unit, and systemic spillover of inflammatory mediators that may contribute to uterine activation and membrane weakening [ 1 , 2 ]. Systematic reviews and umbrella reviews have reported associations between periodontitis and increased risks of preterm birth (PTB) and low birth weight (LBW), although heterogeneity in periodontal definitions, confounding control, and study quality remains a recurring concern [ 5 – 7 ]. The scope of concern may also extend beyond periodontitis: a systematic review suggests that apical periodontitis could be associated with APOs, albeit based on a limited evidence base [ 8 ]. Collectively, these findings underscore the clinical relevance of oral health within prenatal care. Whether periodontal treatment during pregnancy reduces APOs remains debated. While recent evidence syntheses continue to refine the field—highlighting differences in intervention components, timing, and baseline risk profiles—conclusions on PTB prevention are not fully consistent [ 9 ]. This uncertainty does not negate the importance of timely dental assessment and management of symptomatic oral disease during pregnancy. Accordingly, professional bodies increasingly advocate incorporating oral health into antenatal care. A recent Chinese expert consensus provides trimester-informed recommendations regarding the management of common oral conditions and the safety considerations of dental procedures during pregnancy, and calls for strengthened interprofessional collaboration [ 10 ]. Internationally, the FDI World Dental Federation emphasizes perinatal and infant oral health and the integration of screening and referral into maternal care systems [ 11 ]. In practice, however, dental service utilization during pregnancy is often suboptimal. A systematic review of maternal beliefs shows that misconceptions about the safety of dental care—particularly local anesthesia and radiography—are common and frequently reported as barriers to seeking care [ 12 ]. This pattern reflects an “attitude–practice gap,” where women may endorse the importance of oral health yet still defer dental visits. Such a gap has also been observed in China; for example, a cross-sectional study in Shanghai reported high endorsement of the importance of regular oral examinations but relatively low uptake of preventive behaviors and limited dental attendance during pregnancy [ 13 ]. These observations suggest that improving awareness alone may be insufficient to translate into care-seeking behavior. A potentially modifiable determinant is the role of antenatal care providers. Obstetricians and prenatal care teams are the most frequent and trusted point of contact for pregnant women, positioning them as practical “gatekeepers” for oral health counseling and referral. Nevertheless, evidence indicates that this opportunity is not fully leveraged. In Australia, almost all antenatal care providers agreed that maternal oral health is important, yet routine counseling and referral practices were limited [ 14 ]. More recent interprofessional studies similarly highlight gaps in guideline awareness and system-level barriers, including unclear referral pathways and limited training, which impede effective collaboration between antenatal and dental services [ 15 , 16 ]. Importantly, oral health promotion programs initiated in prenatal settings have shown potential to improve knowledge and, in some contexts, increase dental attendance, supporting the feasibility of embedding brief “ask-and-refer” strategies into routine antenatal workflows [ 17 ]. However, evidence quantifying the strength of association between obstetrician-delivered advice/referral and dental attendance among pregnant women in Fujian Province remains scarce. Therefore, this study aimed to assess oral health knowledge, attitudes, and practices (KAP) among pregnant women attending a tertiary hospital in Fuzhou, China, and to test whether receiving obstetrician advice/referral is an independent determinant of dental visits during pregnancy, using a pilot-tested questionnaire. 2. Materials and methods 2.1 Study design and setting This cross-sectional study was conducted from 10 September to 31 October 2025 at the Department of Obstetrics, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China. The survey assessed oral health knowledge, attitudes, and practices (KAP) and collected information on dental visits during the current pregnancy.. 2.2 Participants, recruitment and sampling Pregnant women attending routine antenatal visits were consecutively approached and invited to participate. To improve representativeness across gestational stages, recruitment was implemented with trimester-stratified quotas (≤ 12 weeks, 13–27 weeks, and ≥ 28 weeks). The recruitment process was therefore treated as approximately simple random sampling for analysis (design effect, DEFF = 1). Eligibility criteria were: (1) confirmed pregnancy; (2) age ≥ 18 years; and (3) ability to complete a self-administered questionnaire. Questionnaires were excluded if they failed the built-in attention check (item A7) or if the primary outcome (dental visit during the current pregnancy) was missing. A total of 452 questionnaires were included in the final analysis. 2.3 Questionnaire development and content validation Data were collected using the Pregnant Women Oral Health KAP Questionnaire (Version 1.1), developed for this study based on relevant literature, guideline/consensus recommendations, and clinical practice considerations. The initial item pool and wording were reviewed by a multidisciplinary panel (obstetrics and dental professionals) to evaluate item relevance, clarity, and comprehensiveness. Minor revisions were made before pilot testing and field implementation. The Chinese questionnaire used in this survey is provided as Online Resource 1, and an English translation is provided as Online Resource 2. 2.4 Questionnaire pre-testing Prior to the main survey, the questionnaire was pre-tested in 50 pregnant women to assess feasibility and comprehensibility. Based on participant feedback, minor wording refinements were made, and the final Version 1.1 was used for the formal survey. Reliability and validity were evaluated in the main sample; results from the pre-test were used only as supportive information. 2.5 Measures and scoring 2.5.1 Sociodemographic and obstetric characteristics Participants reported age group, gestational week and trimester, residence (urban/rural), gravidity, education level, occupation, and household monthly income. Oral health history included pre-pregnancy dental check within 6 months and self-reported oral problems before pregnancy. Obstetrician advice/referral was measured by asking whether, during this pregnancy, the obstetric provider had explicitly advised a dental visit or provided referral information (yes/no/don’t remember). 2.5.2 Knowledge (K) Knowledge was assessed using 7 items (K1–K7) addressing pregnancy-related oral conditions and the safety/timing of dental care (e.g., routine dental check-ups, scaling/restoration, local anesthesia, radiography under protection, and second-trimester timing). Each item had three response options (“Yes/No/Unclear”). As all knowledge statements were formulated as correct statements, “Yes” was scored 1, while “No/Unclear” was scored 0, yielding a total score ranging from 0 to 7 (higher scores indicating better knowledge). 2.5.3 Attitudes (A) Attitudes were measured using 6 items (A1–A6) on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Item content covered perceived importance of oral hygiene in pregnancy, perceived safety of dental care under professional protection, willingness to accept treatment if advised, and the desire for antenatal oral health guidance. The attitude total score ranged from 6 to 30. Item A7 was used as an attention-check and was not included in the attitude score. 2.5.4 Practices/behaviors (P) Oral health practices included brushing frequency, use of oral hygiene aids, routine preventive dental habits prior to pregnancy, and dental service utilization during pregnancy. A composite practice score (range 0–10) was constructed a priori by summing points assigned to (1) brushing frequency (0–3 points), (2) use of oral hygiene aids (toothbrush, electric toothbrush, dental floss, interdental brush; 0–4 points), (3) routine annual scaling/check habit prior to pregnancy (0–1 point), and (4) dental visit during pregnancy (0–2 points). Higher scores indicated better self-reported practices. 2.5.5 Barriers, facilitators, information sources and intention Among participants who reported no dental visit during pregnancy, the main barrier was recorded using a single-choice item (BR1). Facilitators (BR2; up to three selections), information sources (I1), receipt of antenatal oral health education (I2), and intended actions in response to toothache (E1) were also collected. An optional open-ended item captured suggestions regarding desired hospital services. 2.6 Outcome definition The primary outcome was dental service utilization during the current pregnancy, defined as a self-reported visit to dental/oral health services (including examination, scaling, restoration, or treatment) and analyzed as a binary variable (yes/no). Secondary outcomes included K, A, and P scores, and self-reported barriers/facilitators. 2.7 Reliability and validity assessment Internal consistency reliability was assessed for the knowledge scale using Kuder–Richardson Formula 20 (KR-20) and for the attitude scale using Cronbach’s alpha. Construct validity of the attitude items was examined using exploratory factor analysis based on the inter-item correlation matrix, with standard adequacy checks (KMO and Bartlett’s test) and factor loadings evaluated for interpretability. 2.8 Statistical analysis Analyses were conducted in SPSS (version 26.0). Categorical variables were summarized as frequency and percentage; continuous variables were summarized as mean (standard deviation) or median (interquartile range) depending on distribution. Associations with dental service utilization were examined using chi-square tests (or Fisher’s exact tests when appropriate) for categorical variables and appropriate non-parametric tests for score comparisons when distributional assumptions were not met. Spearman’s rank correlation was used to evaluate associations among K, A, and P scores. Multivariable logistic regression was used to identify independent predictors of dental visits during pregnancy, with adjusted odds ratios (aORs) and 95% confidence intervals (CIs) reported. A two-sided P < 0.05 was considered statistically significant. 2.9 Ethics This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Fujian Provincial Hospital (Approval No. K 2025-09-001). Written informed consent was obtained from all participants prior to participation. 3. Results 3.1 Participant flow and dental attendance during pregnancy A total of 480 questionnaires were returned. After excluding 28 questionnaires due to incomplete or invalid responses, 452 pregnant women were included in the final analysis (Fig. 1 ). Among the included participants, 59 (13.1%) reported at least one dental visit during the current pregnancy, whereas 393 (86.9%) reported no dental visit. Dental visit rates appeared to increase across gestational stages, as further illustrated in Fig. S2 (Online Resource 3) A total of 480 questionnaires were returned; 28 were excluded due to incomplete or invalid responses, and 452 were included in the final analysis. Among included participants, 59 reported a dental visit during pregnancy and 393 reported no dental visit. 3.2 Participant characteristics by dental visit status Participant characteristics stratified by dental visit status are presented in Table 1 . Dental attendance during pregnancy differed significantly by gestational stage (P = 0.004), household monthly income (P = 0.013), dental check within 6 months prior to pregnancy (P = 0.008), and receipt of obstetrician advice/referral during antenatal care (P < 0.001). In particular, the proportion reporting obstetrician advice/referral was higher among women who visited a dentist than among those who did not (61.0% vs 20.9%). No statistically significant differences were observed for age, residence, gravidity, education level, or occupation (all P > 0.05). Table 1 Participant characteristics and dental service utilization during pregnancy (n = 452) Characteristic Category Total (n = 452) Dental visit (n = 59) No dental visit (n = 393) P value Age (years) 18–24 45 (10.0) 4 (6.8) 41 (10.4) 0.246 25–29 177 (39.2) 30 (50.8) 147 (37.4) 30–34 163 (36.1) 20 (33.9) 143 (36.4) 35–39 59 (13.1) 5 (8.5) 54 (13.7) ≥ 40 8 (1.8) 0 (0.0) 8 (2.0) Gestational stage ≤ 12 weeks 150 (33.2) 11 (18.6) 139 (35.4) 0.004 13–27 weeks 152 (33.6) 18 (30.5) 134 (34.1) ≥ 28 weeks 150 (33.2) 30 (50.8) 120 (30.5) Residence Urban 357 (79.0) 48 (81.4) 309 (78.6) 0.758 Rural 95 (21.0) 11 (18.6) 84 (21.4) Gravidity First pregnancy 241 (53.3) 31 (52.5) 210 (53.4) 0.988 Second pregnancy 172 (38.1) 23 (39.0) 149 (37.9) Third or more 39 (8.6) 5 (8.5) 34 (8.7) Education Junior high or below 38 (8.4) 2 (3.4) 36 (9.2) 0.657 High school/technical secondary 70 (15.5) 9 (15.3) 61 (15.5) College/associate 111 (24.6) 16 (27.1) 95 (24.2) Bachelor 184 (40.7) 26 (44.1) 158 (40.2) Master or above 49 (10.8) 6 (10.2) 43 (10.9) Occupation Employed 349 (77.2) 46 (78.0) 303 (77.1) 0.732 Homemaker 56 (12.4) 8 (13.6) 48 (12.2) Student 12 (2.7) 0 (0.0) 12 (3.1) Unemployed 23 (5.1) 3 (5.1) 20 (5.1) Other 12 (2.7) 2 (3.4) 10 (2.5) Household monthly income (RMB) < 8000 65 (14.4) 4 (6.8) 61 (15.5) 0.013 8000–14999 185 (40.9) 18 (30.5) 167 (42.5) 15000–24999 155 (34.3) 26 (44.1) 129 (32.8) ≥ 25000 47 (10.4) 11 (18.6) 36 (9.2) Dental check within 6 months before pregnancy Yes 150 (33.2) 29 (49.2) 121 (30.8) 0.008 No 302 (66.8) 30 (50.8) 272 (69.2) Pre-pregnancy oral problems Any problem 305 (67.5) 45 (76.3) 260 (66.2) 0.290 None 110 (24.3) 11 (18.6) 99 (25.2) Uncertain 37 (8.2) 3 (5.1) 34 (8.7) Obstetrician advice/referral during antenatal care Yes 118 (26.1) 36 (61.0) 82 (20.9) < 0.001 No 288 (63.7) 17 (28.8) 271 (69.0) Not sure/Do not recall 46 (10.2) 6 (10.2) 40 (10.2) Notes : Data are presented as n (%). P values were calculated using the chi-square test (or Fisher’s exact test where appropriate). 3.3 Oral health knowledge, attitudes, and practices Overall KAP results are summarized in Table 2 . The mean knowledge score was 4.29 ± 1.79 (range 0–7). Knowledge was relatively high for pregnancy-related gingival inflammation (83.6%) and the potential link between severe gum problems and adverse pregnancy outcomes (75.2%). However, uncertainty was common regarding the safety and timing of dental care during pregnancy, including local anesthesia (41.4% “not sure”), dental radiography (39.2% “not sure”), and the second trimester as the safest period for dental treatment (48.2% “not sure”). Attitudes toward oral health during pregnancy were generally positive, with a mean attitude score of 24.35 ± 4.38 (range 9–30). In contrast, practice scores were comparatively low (mean 2.96 ± 1.88, range 0–9). Although 68.6% of participants reported brushing at least twice daily, use of interdental cleaning aids was uncommon (dental floss 14.4%; interdental brush 8.6%). The a priori scoring rubric used to derive the composite practice score is detailed in Table S2 (Online Resource 3). The distribution of the composite practice score by dental visit status is shown in Fig. S1 (Online Resource 3), and KAP score distributions across gestational stages are presented in Fig. S2 a (Online Resource 3). Table 2 Oral health knowledge, attitudes, and practices among pregnant women (n = 452). Domain Item/indicator Value Knowledge K1. Hormonal changes during pregnancy may aggravate gingival inflammation Yes 378 (83.6%); No 29 (6.4%); Uncertain 45 (10.0%) K2. Severe gum problems may increase the risk of preterm birth Yes 340 (75.2%); No 34 (7.5%); Uncertain 78 (17.3%) K3. Routine dental check-ups are permissible during pregnancy Yes 317 (70.1%); No 50 (11.1%); Uncertain 85 (18.8%) K4. Dental cleaning and fillings are generally safe during pregnancy under professional care Yes 251 (55.5%); No 45 (10.0%); Uncertain 156 (34.5%) K5. Local anesthesia may be used when necessary during pregnancy Yes 226 (50.0%); No 39 (8.6%); Uncertain 187 (41.4%) K6. Dental X-rays are usually safe during pregnancy with proper assessment and protection Yes 227 (50.2%); No 48 (10.6%); Uncertain 177 (39.2%) K7. The second trimester (13–27 weeks) is the safest period for dental treatment Yes 201 (44.5%); No 33 (7.3%); Uncertain 218 (48.2%) Attitudes A1. Keeping teeth clean is important for pregnancy health 4.35 ± 0.91 (1–5) A2. Dental visits are usually safe during pregnancy with professional assessment and protection 3.73 ± 1.21 (1–5) A3. If recommended by a doctor, I would accept treatment during pregnancy 4.03 ± 1.15 (1–5) A4. I would like to receive oral care guidance during antenatal visits 4.23 ± 1.03 (1–5) A5. I am willing to attend an oral health education session for pregnant women 3.80 ± 1.26 (1–5) A6. Pregnant women should have regular oral examinations 4.22 ± 1.06 (1–5) Practices Brushing frequency 0/day 26 (5.8%); 1/day 116 (25.7%); 2/day 162 (35.8%); ≥3/day 148 (32.7%) Brushing ≥ 2/day 310 (68.6%) Electric toothbrush 158 (35.0%) Dental floss 65 (14.4%) Interdental brush 39 (8.6%) No listed aids used 19 (4.2%) Gingival bleeding during pregnancy Often 29 (6.4%); Sometimes 277 (61.3%); Never 146 (32.3%) Routine annual scaling/check prior to pregnancy Yes 125 (27.7%); No 221 (48.9%); Not sure 106 (23.5%) Toothache during pregnancy 114 (25.2%) If toothache: visited a dentist Yes 54 (47.4%); No 53 (46.5%); Not sure 7 (6.1%) Dental visit during pregnancy (B7) 59 (13.1%) Total scores Knowledge total score (0–7) 4.29 ± 1.79; median 5 (IQR 3–6); range 0–7 Attitude total score (6–30) 24.35 ± 4.38; median 25 (IQR 21–28); range 9–30 Practice total score (0–10) 2.96 ± 1.88; median 3 (IQR 2–4); range 0–9 Notes : Data are presented as n (%) or mean ± SD. Total scores are presented as mean ± SD and median (IQR). Abbreviations : IQR, interquartile range; SD, standard deviation. 3.4 Psychometric properties and correlations among KAP scores Internal consistency was acceptable for the attitude scale (Cronbach’s α = 0.738) and modest for the knowledge scale (KR-20 = 0.609) (Table S4,Online Resource 3). Construct validity of the attitude items was supported by exploratory factor analysis (KMO = 0.823; Bartlett’s test of sphericity P < 0.001), with factor loadings ranging from 0.575 to 0.726 (Table S3 ,Online Resource 3). Spearman correlation analysis showed that knowledge and attitudes were positively correlated with practice (knowledge–practice ρ = 0.248; attitude–practice ρ = 0.178; both P < 0.001), and knowledge was positively correlated with attitudes (ρ = 0.283; P < 0.001) (Table S5,Online Resource 3). 3.5 Barriers and facilitators to dental visits among non-visitors Among the 393 women who did not visit a dentist during pregnancy, the most frequently reported primary barrier was lack of obstetrician advice/referral information (53.2%, 209/393). Other common barriers included being unaware that dental care is allowed during pregnancy (8.4%) and not knowing where to seek dental care (8.4%). Concerns about fetal harm (5.6%), cost/insurance issues (5.6%), and lack of time (5.3%) were also reported; full distributions are shown in Table 3 and visualized in Fig. 2 . Regarding potential facilitators (multiple response), the most frequently endorsed were family support/accompaniment (37.9%) and explicit recommendation from an obstetrician (31.6%), followed by a priority pathway for pregnant women (30.0%) and reimbursement of most costs (29.0%). Table 3 Barriers and facilitators for dental visits during pregnancy among non-visitors (n = 393). Item n % A) Primary barrier (single choice) No obstetrician advice/referral 209 53.2 Unaware dental care is allowed during pregnancy 33 8.4 Do not know where to seek dental care 33 8.4 Concern about fetal harm 22 5.6 Cost/insurance issues 22 5.6 Lack of time 21 5.3 Fear of dental treatment (pain/drilling) 17 4.3 Cannot find a trusted dental clinic 16 4.1 Symptoms not serious 12 3.1 Prefer postpartum treatment 6 1.5 Lack of family support 2 0.5 Other 0 0.0 B) Potential facilitators (multiple response; up to three options) Family support/accompaniment 149 37.9 Obstetrician explicitly recommends/requests 124 31.6 Priority pathway for pregnant women 118 30.0 Most costs reimbursed 114 29.0 Evidence that treatment is safe 105 26.7 Attended a relevant health lecture 89 22.6 Would not go under any circumstance 18 4.6 Notes : Data are presented as n (%). Percentages are calculated using the number of non-visitors as the denominator. Panel B is multiple response, percentages do not sum to 100%. 3.6 Factors associated with dental visits during pregnancy Multivariable logistic regression results are presented in Table 4 (full model in Table S1 ,Online Resource 3; Fig. 3 ).. After adjustment for residence and gravidity, obstetrician advice/referral was the strongest independent predictor of dental attendance. Compared with women who reported no advice/referral, those who reported receiving obstetrician advice/referral had substantially higher odds of visiting a dentist during pregnancy (aOR 6.30, 95% CI 3.22–12.32; P < 0.001). Higher household monthly income was also independently associated with dental visits: compared with < 8,000 RMB, women with 15,000–24,999 RMB (aOR 3.32, 95% CI 1.02–10.75; P = 0.046) and ≥ 25,000 RMB (aOR 6.09, 95% CI 1.61–23.04; P = 0.008) showed higher utilization. Additionally, a dental check within 6 months prior to pregnancy was associated with higher odds of dental visits during pregnancy (aOR 2.19, 95% CI 1.18–4.07; P = 0.013). Late pregnancy (≥ 28 weeks) showed a borderline association (aOR 2.22, 95% CI 0.99–4.99; P = 0.054). Points represent adjusted odds ratios (aORs) and horizontal lines indicate 95% confidence intervals. The vertical reference line indicates aOR = 1. The model was adjusted for residence and gravidity (see Table 4 ; full model in Table S1 ). Table 4 Multivariable logistic regression for dental visit during pregnancy (n = 452). Variable Category aOR 95% CI P value Obstetrician advice/referral (D10) No (ref) — — — Not sure/Do not recall 1.95 0.70–5.42 0.2 Yes 6.30 3.22–12.32 < 0.001 Household monthly income (RMB) < 8,000 (ref) — — — 8,000–14,999 1.89 0.57–6.29 0.298 15,000–24,999 3.32 1.02–10.75 0.046 ≥ 25,000 6.09 1.61–23.04 0.008 Gestational stage (weeks) ≤ 12 (ref) — — — 13–27 1.21 0.51–2.86 0.663 ≥ 28 2.22 0.99–4.99 0.054 Dental check within 6 months pre-pregnancy No (ref) — — — Yes 2.19 1.18–4.07 0.013 Education Junior high or below (ref) — — — High school/technical 2.82 0.53–15.07 0.225 College 3.08 0.62–15.40 0.17 Bachelor 2.53 0.53–12.15 0.245 Postgraduate 1.80 0.30–10.76 0.52 Notes : Model adjusted for residence and gravidity (full model shown in Table S1 ). 4. Discussion This cross-sectional study offers a detailed examination of the oral health knowledge, attitudes, and practices among pregnant women in Fuzhou, China, and highlights the factors influencing dental service utilization during pregnancy. Despite a generally positive attitude toward maternal oral health, the actual rate of dental attendance was surprisingly low, with only 13.1% of participants reporting a dental visit during pregnancy. This finding mirrors previous reports from both China and other countries, underscoring the ongoing issue of underutilization of dental care during pregnancy, even in settings where antenatal care access is relatively strong [13,18,19]. The dental attendance rate observed in our study aligns with findings from other regions in eastern China, though it is notably lower than the rates reported in some high-income countries. This disparity points to the significant role that contextual and healthcare system-related factors play in shaping care-seeking behavior [18,19]. Existing systematic reviews have consistently shown that factors such as socioeconomic status, perceived need, health beliefs, and the advice of healthcare professionals are key determinants of dental attendance during pregnancy, while knowledge alone is not sufficient to drive action[19]. Our results support this broader body of evidence, suggesting that although women may hold favorable attitudes toward oral health, these attitudes do not automatically lead to increased dental service utilization. One of the most significant and novel findings from this study is the strong correlation between obstetrician advice or referral and dental visits during pregnancy. Women who reported receiving advice from their obstetrician were over six times more likely to attend dental services, making this the most powerful factor identified in the multivariable model. This finding is consistent with prior research, which has demonstrated that recommendations from prenatal care providers can play a critical role in normalizing dental care during pregnancy and alleviating concerns regarding its safety[14,15,20]. Obstetricians are frequently the most trusted and accessible healthcare providers during pregnancy, and their recommendations may serve as a crucial prompt for patients to seek dental care, especially in contexts where misconceptions about dental treatment, anesthesia, and radiography are still widespread. Socioeconomic factors also contributed to disparities in dental attendance. Higher household income and a dental check within six months prior to pregnancy were independently associated with dental visits during pregnancy, reflecting the importance of continuity of preventive care and existing engagement with oral health services. Similar associations have been reported in other populations, where women with established dental care habits before pregnancy were more likely to maintain dental attendance during pregnancy [19,21]. In contrast, education level was not independently associated with utilization after adjustment, suggesting that formal education alone may be insufficient to overcome practical, perceptual, and system-related barriers to care. Within the KAP framework, knowledge and attitudes were positively correlated with oral health practices, although these associations were modest. This pattern reflects a persistent attitude–practice gap that has been documented in multiple studies of pregnant women, both in China and internationally [12,22,23]. While adequate knowledge and positive attitudes are necessary components of behavior change, they appear insufficient in isolation to prompt dental attendance during pregnancy. Our findings suggest that the translation of knowledge into action may depend heavily on reinforcing signals from healthcare providers and on the removal of structural barriers within the healthcare system. The analysis of barriers and facilitators further supports this interpretation. Among women who did not attend dental services, lack of obstetrician advice was the most commonly reported primary barrier, followed by uncertainty regarding the safety of dental care and limited awareness of service access. These barriers mirror those identified in systematic reviews and qualitative studies, which consistently highlight safety concerns, cost, time constraints, and unclear referral pathways as major impediments to prenatal dental care [12,16,19]. Conversely, the most frequently endorsed facilitators—explicit obstetrician recommendation, family support, priority access for pregnant women, and cost reimbursement—point toward actionable strategies that extend beyond individual education. Taken together, these findings underscore the importance of integrating oral health into routine antenatal care. Evidence from interprofessional and health promotion studies suggests that brief oral health screening, counseling, and referral delivered within prenatal care settings can improve knowledge and, in some contexts, increase dental attendance during pregnancy [17,24]. Our results add to this evidence by quantifying the magnitude of the association between obstetrician advice and dental visits, highlighting provider engagement as a particularly promising and modifiable intervention target. Of course, there are several limitations to this study. The cross-sectional design prevents us from making causal inferences, and self-reported data may be susceptible to recall bias or social desirability bias. Moreover, because participants were recruited from a single tertiary hospital, the generalizability of our findings to other regions or healthcare settings may be limited. Nonetheless, the use of a pilot-tested questionnaire, comprehensive assessment of KAP domains, and multivariable adjustments strengthen the validity of our conclusions. In conclusion, while attitudes toward oral health are generally positive, dental service utilization during pregnancy remains low in this population. Obstetrician advice and referral emerged as the most influential and potentially modifiable determinant of dental attendance. These findings support the integration of structured oral health counseling and referral mechanisms into routine antenatal care, serving as a practical strategy to bridge the attitude–practice gap and improve maternal oral health outcomes. 5. Conclusion Despite generally positive attitudes toward oral health, dental service utilization during pregnancy remains low among women attending a tertiary hospital in China. Obstetrician advice or referral emerged as the strongest determinant of dental attendance, highlighting the pivotal role of antenatal care providers in influencing oral health–related behaviors during pregnancy. Integrating oral health counseling and streamlined referral pathways into routine antenatal care may help reduce missed opportunities for timely dental care and improve maternal oral health during pregnancy. Abbreviations KAP - Knowledge, Attitudes, and Practices aOR - Adjusted Odds Ratio CI - Confidence Interval DEFF - Design Effect KR-20 - Kuder-Richardson Formula 20 Cronbach’s α - Cronbach's Alpha KMO - Kaiser-Meyer-Olkin SD - Standard Deviation IQR - Interquartile Range SPSS - Statistical Package for the Social Sciences α - Alpha Declarations 6.2 Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Fuzhou University Affiliated Provincial Hospital (Approval No. K 2025-09-001). Written informed consent was obtained from all participants before participation in the study. 6.3 Consent for publication Written informed consent for publication was obtained from all participants. 6.4 Availability of data and materials Data is available upon reasonable request. 6.5 Competing Interests The authors declare no competing interests. 6.6 Funding This paper was not funded. 6.7 Authors' contributions Kaijia Xue: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Visualization; Writing—original draft; Writing—review & editing. Jiaju Liu: Conceptualization; Supervision; Methodology; Writing—review & editing; Corresponding author. Yi Lin: Methodology; Supervision; Writing—review & editing. Liang Lin: Data curation; Formal analysis; Visualization; Software.11 Data Availability Statement 6.8 Acknowledgements The authors would like to thank the obstetricians and nurses at Fuzhou University Affiliated Provincial Hospital for their invaluable assistance during this study. Supplementary information The online version contains supplementary material. The Chinese questionnaire used in this survey is provided as Online Resource 1 , and an English translation is provided as Online Resource 2 . Additional tables and figures are provided as Online Resource 3 , including the full regression model (Table S1), the practice score rubric (Table S2), psychometric diagnostics (Tables S3–S5), and additional visualizations (Figs. S1–S2). References Bobetsis YA, Graziani F, Gürsoy M, et al. Periodontal disease and adverse pregnancy outcomes. Periodontol 2000. 2020;83(1):154–74. https://doi.org/10.1111/prd.12294 . Xu B, Han YW. Oral bacteria, oral health, and adverse pregnancy outcomes. Periodontol 2000. 2022;89(1):181–9. https://doi.org/10.1111/prd.12436 . Chen P, Hong F, Yu X. Prevalence of periodontal disease in pregnancy: a systematic review and meta-analysis. J Dent. 2022;125:104253. https://doi.org/10.1016/j.jdent.2022.104253 . Meriç P, Silbereisen A, Emingil G, et al. Clinical, oral immunological and microbiological shifts during and after pregnancy. Clin Oral Investig. 2024;28:60. https://doi.org/10.1007/s00784-023-05408-1 . Padilla-Cáceres T, Arbildo-Vega HI, Caballero-Apaza L, et al. Association between the risk of preterm birth and low birth weight with periodontal disease in pregnant women: an umbrella review. Dent J (Basel). 2023;11(3):74. https://doi.org/10.3390/dj11030074 . Zhang Y, Feng W, Li J, et al. Periodontal Disease and Adverse Neonatal Outcomes: A Systematic Review and Meta-Analysis. Front Pediatr. 2022;10:799740. https://doi.org/10.3389/fped.2022.799740 . Montoya-Carralero JM, Ávila-Villasmil R, Sánchez-Pérez A, et al. Relationship between periodontal disease and preterm birth: a systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal. 2024;29(6):e857–65. https://doi.org/10.4317/medoral.26830 . Jakovljevic A, Sljivancanin Jakovljevic T, Duncan HF, et al. The association between apical periodontitis and adverse pregnancy outcomes: a systematic review. Int Endod J. 2021;54(9):1527–37. https://doi.org/10.1111/iej.13538 . Wu J, Wu J, Tang B, et al. Effects of different periodontal interventions on the risk of adverse pregnancy outcomes in pregnant women: a systematic review and network meta-analysis of randomized controlled trials. Front Public Health. 2024;12:1373691. https://doi.org/10.3389/fpubh.2024.1373691 . Zhang J, Zhou C, Zheng L, et al. Expert consensus on the treatment of oral diseases in pregnant women and infants. Int J Oral Sci. 2025;17:62. https://doi.org/10.1038/s41368-025-00370-4 . FDI World Dental Federation. Perinatal and infant oral health care (Policy statement). Int Dent J. 2024. https://doi.org/10.1016/j.identj.2023.10.009 . Kamalabadi YM, Campbell MK, Zitoun NM, et al. Unfavourable beliefs about oral health and safety of dental care during pregnancy: a systematic review. BMC Oral Health. 2023;23:762. https://doi.org/10.1186/s12903-023-03439-4 . Hu W, Wang Y, Chen R, et al. Oral Health Status and Literacy/Knowledge Amongst Pregnant Women in Shanghai. Int Dent J. 2023;73(2):212–8. https://doi.org/10.1016/j.identj.2022.06.005 . George A, Dahlen HG, Reath J, et al. What do antenatal care providers understand and do about oral health care during pregnancy: a cross-sectional survey in New South Wales, Australia. BMC Pregnancy Childbirth. 2016;16(1):382. https://doi.org/10.1186/s12884-016-1163-x . Vamos CA, Richardson Cayama M, Mahony H et al. Oral health during pregnancy: an analysis of interprofessional guideline awareness and practice behaviors among prenatal and oral health providers.BMC Pregnancy and Childbirth. 2023;23(1):721 https://doi.org/10.1186/s12884-023-06032-3 Ahmed S, Shah H, Hussain A, et al. Challenges in oral health referral during pregnancy: perspectives from antenatal and dental care providers. BMC Oral Health. 2025;25:858. https://doi.org/10.1186/s12903-025-06285-8 . Vamos CA, Walsh ML, Thompson E, et al. Oral health promotion interventions during pregnancy: a systematic review. Community Dent Oral Epidemiol. 2015;43(5):385–96. https://doi.org/10.1111/cdoe.12167 . Sun W, Guo J, Li X, et al. The routine utilization of dental care during pregnancy in eastern China and the key underlying factors: a Hangzhou City study. PLoS ONE. 2014;9(6):e98780. .https://doi.org/10.1371/journal.pone.0098780 . Rocha JS, Arima LY, Werneck RI, et al. Determinants of Dental Care Attendance during Pregnancy: A Systematic Review. Caries Res. 2018;52(1–2):139–52. https://doi.org/10.1159/000481407 . John S, AlMesmar H. Oral health status, oral hygiene practices and dental treatment utilization among pregnant women. Dubai Med J. 2021;4(4):320–8. https://doi.org/10.1159/000519294 . Boggess KA, Urlaub DM, Moos MK, et al. Knowledge and beliefs regarding oral health among pregnant women. J Am Dent Assoc. 2011;142(11):1275–82. https://doi.org/10.14219/jada.archive.2011.0113 . Hullah E, Turok Y, Nauta M, et al. Self-reported oral hygiene habits, dental attendance and attitudes to dentistry during pregnancy in a sample of immigrant women in North London. Arch Gynecol Obstet. 2008;277(5):405–9. https://doi.org/10.1007/s00404-007-0480-8 . Jojo AM, D’Souza P, Abraham A, et al. Knowledge and Practice of Dental Health among Pregnant Women in a Selected Hospital Mangaluru. J Health Allied Sci NU. 2024. https://doi.org/10.1055/s-0044-1793821 . George A, Johnson M, Blinkhorn A, Ellis S, Bhole S, Ajwani S. Promoting oral health during pregnancy: current evidence and implications for Australian midwives. J Clin Nurs. 2010;19(23–24):3324–33. .https://doi.org/10.1111/j.1365-2702.2010.03426.x . Additional Declarations No competing interests reported. Supplementary Files ESM1.pdf ESM2.pdf ESM3.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Reviewers agreed at journal 28 Feb, 2026 Reviewers invited by journal 25 Feb, 2026 Editor assigned by journal 23 Feb, 2026 Editor invited by journal 04 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 03 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8683366","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596799003,"identity":"bbcf80f3-4ed7-48dc-9860-4271560b1740","order_by":0,"name":"Kaijia Xue","email":"","orcid":"","institution":"Shengli Clinical Medical College of Fujian Medical University, Fuzhou University Affiliated Provincial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kaijia","middleName":"","lastName":"Xue","suffix":""},{"id":596799004,"identity":"042c3bbb-018d-4816-9ea4-401d2ca81174","order_by":1,"name":"Jiaju Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIie2RsQrCMBCGLxTSJeCazVdICNQlDxOXTA6KSzcDhboIXRV8iE7OhaAueYCOfQGhTyCmdHJpMwrmm+7gPu5+DiAS+UFQAcAgp4dq6LqhCVOcRBcDyKgQZfRKjeomVEmOSbcn2CbieVp1KpcCUnuvpw/DTBBiceYcN8rpDIjW7UwWr1BLsnbDzbq0Eqivp5W0F4RZKs7hCvFblGaMjkoWomz5tZGKusfu7LMIPJeFV88be72pWhyLuu9zyavUPqYVA/j7FXhqfGDpX9PNDUUikcif8wEAOEhCFz9P6AAAAABJRU5ErkJggg==","orcid":"","institution":"Shengli Clinical Medical College of Fujian Medical University, Fuzhou University Affiliated Provincial Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jiaju","middleName":"","lastName":"Liu","suffix":""},{"id":596799005,"identity":"f0fda701-e2a4-4dcd-98bd-15901543a9d8","order_by":2,"name":"Yi Lin","email":"","orcid":"","institution":"Shengli Clinical Medical College of Fujian Medical University, Fuzhou University Affiliated Provincial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Lin","suffix":""},{"id":596799006,"identity":"f727e8c3-41b3-454d-8a8f-175efe54d379","order_by":3,"name":"Liang Lin","email":"","orcid":"","institution":"Shengli Clinical Medical College of Fujian Medical University, Fuzhou University Affiliated Provincial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2026-01-24 03:08:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8683366/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8683366/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104400170,"identity":"832e36db-f593-4d61-8605-55424afa945f","added_by":"auto","created_at":"2026-03-11 12:09:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54467,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy flow diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/5dc3022e16665b1f7490e718.png"},{"id":104400641,"identity":"bf4bc127-3142-4532-9a3c-2ed2eb0926cc","added_by":"auto","created_at":"2026-03-11 12:10:36","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":429241,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBarriers and facilitators to dental visits during pregnancy among non-visitors (n = 393)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(a) Primary barriers (single choice). (b) Potential facilitators (multiple response; percentages do not sum to 100)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/2fc4b6635e910fed78c81349.jpeg"},{"id":104399880,"identity":"8cbb149a-e156-4d5d-b3f0-3268e191a152","added_by":"auto","created_at":"2026-03-11 12:08:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":48846,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFactors associated with dental visits during pregnancy: multivariable logistic regression (n = 452)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePoints represent adjusted odds ratios (aORs) and horizontal lines indicate 95% confidence intervals. The vertical reference line indicates aOR = 1. The model was adjusted for residence and gravidity (see Table 4; full model in Table S1).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/a367301c7e098711d5f4ed9c.png"},{"id":104407871,"identity":"9e2b76a0-b94c-4ea2-8694-42561e9c2ddd","added_by":"auto","created_at":"2026-03-11 12:40:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1999463,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/8f3e4108-a953-4c4e-a462-05f52a7062da.pdf"},{"id":103732211,"identity":"9c781cf7-4a4a-4c0a-8b43-d08c853cacba","added_by":"auto","created_at":"2026-03-02 09:21:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":139388,"visible":true,"origin":"","legend":"","description":"","filename":"ESM1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/e891460afb9f49a930b54d43.pdf"},{"id":104399790,"identity":"c9d5c542-48dd-4f38-b486-f546978aab95","added_by":"auto","created_at":"2026-03-11 12:07:37","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":149571,"visible":true,"origin":"","legend":"","description":"","filename":"ESM2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/c3e35859f7aca1beb8c0dbe5.pdf"},{"id":103732214,"identity":"217048d2-456e-4392-9b5d-8799c73aace6","added_by":"auto","created_at":"2026-03-02 09:21:56","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":220577,"visible":true,"origin":"","legend":"","description":"","filename":"ESM3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8683366/v1/8a27869fe0d4c71c39d480f0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Obstetrician Advice as a Key Determinant of Dental Visits During Pregnancy: A Cross-Sectional Study in China","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePregnancy is accompanied by substantial hormonal and immunological changes that may increase susceptibility to oral diseases, particularly gingivitis and periodontal conditions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Periodontal disease is common during pregnancy; a recent systematic review and meta-analysis reported a pooled prevalence of approximately 40% worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In line with this vulnerability, clinical evidence has also documented measurable immunological and microbiological shifts in the oral environment during and after pregnancy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond local symptoms, maternal oral infections have attracted attention because of their potential association with adverse pregnancy outcomes (APOs). Proposed pathways include hematogenous dissemination of oral microorganisms or their products to the feto-placental unit, and systemic spillover of inflammatory mediators that may contribute to uterine activation and membrane weakening [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Systematic reviews and umbrella reviews have reported associations between periodontitis and increased risks of preterm birth (PTB) and low birth weight (LBW), although heterogeneity in periodontal definitions, confounding control, and study quality remains a recurring concern [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The scope of concern may also extend beyond periodontitis: a systematic review suggests that apical periodontitis could be associated with APOs, albeit based on a limited evidence base [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Collectively, these findings underscore the clinical relevance of oral health within prenatal care.\u003c/p\u003e \u003cp\u003eWhether periodontal treatment during pregnancy reduces APOs remains debated. While recent evidence syntheses continue to refine the field\u0026mdash;highlighting differences in intervention components, timing, and baseline risk profiles\u0026mdash;conclusions on PTB prevention are not fully consistent [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This uncertainty does not negate the importance of timely dental assessment and management of symptomatic oral disease during pregnancy. Accordingly, professional bodies increasingly advocate incorporating oral health into antenatal care. A recent Chinese expert consensus provides trimester-informed recommendations regarding the management of common oral conditions and the safety considerations of dental procedures during pregnancy, and calls for strengthened interprofessional collaboration [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Internationally, the FDI World Dental Federation emphasizes perinatal and infant oral health and the integration of screening and referral into maternal care systems [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn practice, however, dental service utilization during pregnancy is often suboptimal. A systematic review of maternal beliefs shows that misconceptions about the safety of dental care\u0026mdash;particularly local anesthesia and radiography\u0026mdash;are common and frequently reported as barriers to seeking care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This pattern reflects an \u0026ldquo;attitude\u0026ndash;practice gap,\u0026rdquo; where women may endorse the importance of oral health yet still defer dental visits. Such a gap has also been observed in China; for example, a cross-sectional study in Shanghai reported high endorsement of the importance of regular oral examinations but relatively low uptake of preventive behaviors and limited dental attendance during pregnancy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These observations suggest that improving awareness alone may be insufficient to translate into care-seeking behavior.\u003c/p\u003e \u003cp\u003eA potentially modifiable determinant is the role of antenatal care providers. Obstetricians and prenatal care teams are the most frequent and trusted point of contact for pregnant women, positioning them as practical \u0026ldquo;gatekeepers\u0026rdquo; for oral health counseling and referral. Nevertheless, evidence indicates that this opportunity is not fully leveraged. In Australia, almost all antenatal care providers agreed that maternal oral health is important, yet routine counseling and referral practices were limited [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. More recent interprofessional studies similarly highlight gaps in guideline awareness and system-level barriers, including unclear referral pathways and limited training, which impede effective collaboration between antenatal and dental services [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Importantly, oral health promotion programs initiated in prenatal settings have shown potential to improve knowledge and, in some contexts, increase dental attendance, supporting the feasibility of embedding brief \u0026ldquo;ask-and-refer\u0026rdquo; strategies into routine antenatal workflows [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, evidence quantifying the strength of association between obstetrician-delivered advice/referral and dental attendance among pregnant women in Fujian Province remains scarce.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to assess oral health knowledge, attitudes, and practices (KAP) among pregnant women attending a tertiary hospital in Fuzhou, China, and to test whether receiving obstetrician advice/referral is an independent determinant of dental visits during pregnancy, using a pilot-tested questionnaire.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and setting\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted from 10 September to 31 October 2025 at the Department of Obstetrics, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China. The survey assessed oral health knowledge, attitudes, and practices (KAP) and collected information on dental visits during the current pregnancy..\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants, recruitment and sampling\u003c/h2\u003e \u003cp\u003ePregnant women attending routine antenatal visits were consecutively approached and invited to participate. To improve representativeness across gestational stages, recruitment was implemented with trimester-stratified quotas (\u0026le;\u0026thinsp;12 weeks, 13\u0026ndash;27 weeks, and \u0026ge;\u0026thinsp;28 weeks). The recruitment process was therefore treated as approximately simple random sampling for analysis (design effect, DEFF\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003eEligibility criteria were: (1) confirmed pregnancy; (2) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; and (3) ability to complete a self-administered questionnaire. Questionnaires were excluded if they failed the built-in attention check (item A7) or if the primary outcome (dental visit during the current pregnancy) was missing. A total of 452 questionnaires were included in the final analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Questionnaire development and content validation\u003c/h2\u003e \u003cp\u003e Data were collected using the Pregnant Women Oral Health KAP Questionnaire (Version 1.1), developed for this study based on relevant literature, guideline/consensus recommendations, and clinical practice considerations. The initial item pool and wording were reviewed by a multidisciplinary panel (obstetrics and dental professionals) to evaluate item relevance, clarity, and comprehensiveness. Minor revisions were made before pilot testing and field implementation. The Chinese questionnaire used in this survey is provided as Online Resource 1, and an English translation is provided as Online Resource 2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Questionnaire pre-testing\u003c/h2\u003e \u003cp\u003ePrior to the main survey, the questionnaire was pre-tested in 50 pregnant women to assess feasibility and comprehensibility. Based on participant feedback, minor wording refinements were made, and the final Version 1.1 was used for the formal survey. Reliability and validity were evaluated in the main sample; results from the pre-test were used only as supportive information.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Measures and scoring\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.5.1 Sociodemographic and obstetric characteristics\u003c/h2\u003e \u003cp\u003eParticipants reported age group, gestational week and trimester, residence (urban/rural), gravidity, education level, occupation, and household monthly income. Oral health history included pre-pregnancy dental check within 6 months and self-reported oral problems before pregnancy. Obstetrician advice/referral was measured by asking whether, during this pregnancy, the obstetric provider had explicitly advised a dental visit or provided referral information (yes/no/don\u0026rsquo;t remember).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.5.2 Knowledge (K)\u003c/h2\u003e \u003cp\u003eKnowledge was assessed using 7 items (K1\u0026ndash;K7) addressing pregnancy-related oral conditions and the safety/timing of dental care (e.g., routine dental check-ups, scaling/restoration, local anesthesia, radiography under protection, and second-trimester timing). Each item had three response options (\u0026ldquo;Yes/No/Unclear\u0026rdquo;). As all knowledge statements were formulated as correct statements, \u0026ldquo;Yes\u0026rdquo; was scored 1, while \u0026ldquo;No/Unclear\u0026rdquo; was scored 0, yielding a total score ranging from 0 to 7 (higher scores indicating better knowledge).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.5.3 Attitudes (A)\u003c/h2\u003e \u003cp\u003eAttitudes were measured using 6 items (A1\u0026ndash;A6) on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree to 5\u0026thinsp;=\u0026thinsp;strongly agree). Item content covered perceived importance of oral hygiene in pregnancy, perceived safety of dental care under professional protection, willingness to accept treatment if advised, and the desire for antenatal oral health guidance. The attitude total score ranged from 6 to 30. Item A7 was used as an attention-check and was not included in the attitude score.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.5.4 Practices/behaviors (P)\u003c/h2\u003e \u003cp\u003eOral health practices included brushing frequency, use of oral hygiene aids, routine preventive dental habits prior to pregnancy, and dental service utilization during pregnancy. A composite practice score (range 0\u0026ndash;10) was constructed a priori by summing points assigned to (1) brushing frequency (0\u0026ndash;3 points), (2) use of oral hygiene aids (toothbrush, electric toothbrush, dental floss, interdental brush; 0\u0026ndash;4 points), (3) routine annual scaling/check habit prior to pregnancy (0\u0026ndash;1 point), and (4) dental visit during pregnancy (0\u0026ndash;2 points). Higher scores indicated better self-reported practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.5.5 Barriers, facilitators, information sources and intention\u003c/h2\u003e \u003cp\u003eAmong participants who reported no dental visit during pregnancy, the main barrier was recorded using a single-choice item (BR1). Facilitators (BR2; up to three selections), information sources (I1), receipt of antenatal oral health education (I2), and intended actions in response to toothache (E1) were also collected. An optional open-ended item captured suggestions regarding desired hospital services.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Outcome definition\u003c/h2\u003e \u003cp\u003eThe primary outcome was dental service utilization during the current pregnancy, defined as a self-reported visit to dental/oral health services (including examination, scaling, restoration, or treatment) and analyzed as a binary variable (yes/no). Secondary outcomes included K, A, and P scores, and self-reported barriers/facilitators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Reliability and validity assessment\u003c/h2\u003e \u003cp\u003eInternal consistency reliability was assessed for the knowledge scale using Kuder\u0026ndash;Richardson Formula 20 (KR-20) and for the attitude scale using Cronbach\u0026rsquo;s alpha. Construct validity of the attitude items was examined using exploratory factor analysis based on the inter-item correlation matrix, with standard adequacy checks (KMO and Bartlett\u0026rsquo;s test) and factor loadings evaluated for interpretability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Statistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were conducted in SPSS (version 26.0). Categorical variables were summarized as frequency and percentage; continuous variables were summarized as mean (standard deviation) or median (interquartile range) depending on distribution. Associations with dental service utilization were examined using chi-square tests (or Fisher\u0026rsquo;s exact tests when appropriate) for categorical variables and appropriate non-parametric tests for score comparisons when distributional assumptions were not met.\u003c/p\u003e \u003cp\u003eSpearman\u0026rsquo;s rank correlation was used to evaluate associations among K, A, and P scores. Multivariable logistic regression was used to identify independent predictors of dental visits during pregnancy, with adjusted odds ratios (aORs) and 95% confidence intervals (CIs) reported. A two-sided P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.9 Ethics\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Fujian Provincial Hospital (Approval No. K 2025-09-001). Written informed consent was obtained from all participants prior to participation.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant flow and dental attendance during pregnancy\u003c/h2\u003e \u003cp\u003eA total of 480 questionnaires were returned. After excluding 28 questionnaires due to incomplete or invalid responses, 452 pregnant women were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among the included participants, 59 (13.1%) reported at least one dental visit during the current pregnancy, whereas 393 (86.9%) reported no dental visit. Dental visit rates appeared to increase across gestational stages, as further illustrated in Fig. \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e (Online Resource 3)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA total of 480 questionnaires were returned; 28 were excluded due to incomplete or invalid responses, and 452 were included in the final analysis. Among included participants, 59 reported a dental visit during pregnancy and 393 reported no dental visit.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Participant characteristics by dental visit status\u003c/h2\u003e \u003cp\u003eParticipant characteristics stratified by dental visit status are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Dental attendance during pregnancy differed significantly by gestational stage (P\u0026thinsp;=\u0026thinsp;0.004), household monthly income (P\u0026thinsp;=\u0026thinsp;0.013), dental check within 6 months prior to pregnancy (P\u0026thinsp;=\u0026thinsp;0.008), and receipt of obstetrician advice/referral during antenatal care (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In particular, the proportion reporting obstetrician advice/referral was higher among women who visited a dentist than among those who did not (61.0% vs 20.9%).\u003c/p\u003e \u003cp\u003eNo statistically significant differences were observed for age, residence, gravidity, education level, or occupation (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics and dental service utilization during pregnancy (n\u0026thinsp;=\u0026thinsp;452)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;452)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDental visit (n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo dental visit (n\u0026thinsp;=\u0026thinsp;393)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e177 (39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e147 (37.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e163 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e143 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150 (33.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139 (35.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026ndash;27 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e134 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;28 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150 (33.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e120 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e357 (79.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48 (81.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e309 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.758\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95 (21.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e84 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e241 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e210 (53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e172 (38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e149 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThird or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.657\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school/technical secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege/associate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111 (24.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e95 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184 (40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e158 (40.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaster or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e349 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e303 (77.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHomemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold monthly income (RMB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;8000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8000\u0026ndash;14999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e185 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e167 (42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15000\u0026ndash;24999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e155 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e129 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;25000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental check within 6 months before pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150 (33.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e302 (66.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e272 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-pregnancy oral problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAny problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e305 (67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45 (76.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e260 (66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e99 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUncertain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrician advice/referral during antenatal care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36 (61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e82 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e288 (63.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e271 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot sure/Do not recall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNotes\u003c/b\u003e: Data are presented as n (%). P values were calculated using the chi-square test (or Fisher\u0026rsquo;s exact test where appropriate).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Oral health knowledge, attitudes, and practices\u003c/h2\u003e \u003cp\u003eOverall KAP results are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The mean knowledge score was 4.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 (range 0\u0026ndash;7). Knowledge was relatively high for pregnancy-related gingival inflammation (83.6%) and the potential link between severe gum problems and adverse pregnancy outcomes (75.2%). However, uncertainty was common regarding the safety and timing of dental care during pregnancy, including local anesthesia (41.4% \u0026ldquo;not sure\u0026rdquo;), dental radiography (39.2% \u0026ldquo;not sure\u0026rdquo;), and the second trimester as the safest period for dental treatment (48.2% \u0026ldquo;not sure\u0026rdquo;).\u003c/p\u003e \u003cp\u003eAttitudes toward oral health during pregnancy were generally positive, with a mean attitude score of 24.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38 (range 9\u0026ndash;30). In contrast, practice scores were comparatively low (mean 2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88, range 0\u0026ndash;9). Although 68.6% of participants reported brushing at least twice daily, use of interdental cleaning aids was uncommon (dental floss 14.4%; interdental brush 8.6%). The a priori scoring rubric used to derive the composite practice score is detailed in Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e (Online Resource 3). The distribution of the composite practice score by dental visit status is shown in Fig. \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e (Online Resource 3), and KAP score distributions across gestational stages are presented in Fig. \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003ea (Online Resource 3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOral health knowledge, attitudes, and practices among pregnant women (n\u0026thinsp;=\u0026thinsp;452).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem/indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK1. Hormonal changes during pregnancy may aggravate gingival inflammation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 378 (83.6%); No 29 (6.4%); Uncertain 45 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK2. Severe gum problems may increase the risk of preterm birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 340 (75.2%); No 34 (7.5%); Uncertain 78 (17.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK3. Routine dental check-ups are permissible during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 317 (70.1%); No 50 (11.1%); Uncertain 85 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK4. Dental cleaning and fillings are generally safe during pregnancy under professional care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 251 (55.5%); No 45 (10.0%); Uncertain 156 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK5. Local anesthesia may be used when necessary during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 226 (50.0%); No 39 (8.6%); Uncertain 187 (41.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK6. Dental X-rays are usually safe during pregnancy with proper assessment and protection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 227 (50.2%); No 48 (10.6%); Uncertain 177 (39.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK7. The second trimester (13\u0026ndash;27 weeks) is the safest period for dental treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 201 (44.5%); No 33 (7.3%); Uncertain 218 (48.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAttitudes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA1. Keeping teeth clean is important for pregnancy health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA2. Dental visits are usually safe during pregnancy with professional assessment and protection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA3. If recommended by a doctor, I would accept treatment during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA4. I would like to receive oral care guidance during antenatal visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA5. I am willing to attend an oral health education session for pregnant women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA6. Pregnant women should have regular oral examinations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003ePractices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrushing frequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/day 26 (5.8%); 1/day 116 (25.7%); 2/day 162 (35.8%); \u0026ge;3/day 148 (32.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrushing\u0026thinsp;\u0026ge;\u0026thinsp;2/day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e310 (68.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElectric toothbrush\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDental floss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (14.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterdental brush\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo listed aids used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGingival bleeding during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOften 29 (6.4%); Sometimes 277 (61.3%); Never 146 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRoutine annual scaling/check prior to pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 125 (27.7%); No 221 (48.9%); Not sure 106 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eToothache during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIf toothache: visited a dentist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes 54 (47.4%); No 53 (46.5%); Not sure 7 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDental visit during pregnancy (B7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (13.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTotal scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge total score (0\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79; median 5 (IQR 3\u0026ndash;6); range 0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitude total score (6\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38; median 25 (IQR 21\u0026ndash;28); range 9\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractice total score (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88; median 3 (IQR 2\u0026ndash;4); range 0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNotes\u003c/b\u003e: Data are presented as n (%) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. Total scores are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD and median (IQR). \u003cb\u003eAbbreviations\u003c/b\u003e: IQR, interquartile range; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Psychometric properties and correlations among KAP scores\u003c/h2\u003e \u003cp\u003eInternal consistency was acceptable for the attitude scale (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.738) and modest for the knowledge scale (KR-20\u0026thinsp;=\u0026thinsp;0.609) (Table S4,Online Resource 3). Construct validity of the attitude items was supported by exploratory factor analysis (KMO\u0026thinsp;=\u0026thinsp;0.823; Bartlett\u0026rsquo;s test of sphericity P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with factor loadings ranging from 0.575 to 0.726 (Table \u003cspan refid=\"MOESM3\" class=\"InternalRef\"\u003eS3\u003c/span\u003e,Online Resource 3). Spearman correlation analysis showed that knowledge and attitudes were positively correlated with practice (knowledge\u0026ndash;practice ρ\u0026thinsp;=\u0026thinsp;0.248; attitude\u0026ndash;practice ρ\u0026thinsp;=\u0026thinsp;0.178; both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and knowledge was positively correlated with attitudes (ρ\u0026thinsp;=\u0026thinsp;0.283; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table S5,Online Resource 3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Barriers and facilitators to dental visits among non-visitors\u003c/h2\u003e \u003cp\u003eAmong the 393 women who did not visit a dentist during pregnancy, the most frequently reported primary barrier was lack of obstetrician advice/referral information (53.2%, 209/393). Other common barriers included being unaware that dental care is allowed during pregnancy (8.4%) and not knowing where to seek dental care (8.4%). Concerns about fetal harm (5.6%), cost/insurance issues (5.6%), and lack of time (5.3%) were also reported; full distributions are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and visualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eRegarding potential facilitators (multiple response), the most frequently endorsed were family support/accompaniment (37.9%) and explicit recommendation from an obstetrician (31.6%), followed by a priority pathway for pregnant women (30.0%) and reimbursement of most costs (29.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers and facilitators for dental visits during pregnancy among non-visitors (n\u0026thinsp;=\u0026thinsp;393).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eA) Primary barrier (single choice)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo obstetrician advice/referral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaware dental care is allowed during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not know where to seek dental care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about fetal harm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost/insurance issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of dental treatment (pain/drilling)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCannot find a trusted dental clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms not serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer postpartum treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of family support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB) Potential facilitators (multiple response; up to three options)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily support/accompaniment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrician explicitly recommends/requests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePriority pathway for pregnant women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost costs reimbursed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvidence that treatment is safe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttended a relevant health lecture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould not go under any circumstance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNotes\u003c/b\u003e: Data are presented as n (%). Percentages are calculated using the number of non-visitors as the denominator. Panel B is multiple response, percentages do not sum to 100%.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/div\u003e \u003cbr\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Factors associated with dental visits during pregnancy\u003c/h2\u003e \u003cp\u003eMultivariable logistic regression results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e (full model in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e,Online Resource 3; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).. After adjustment for residence and gravidity, obstetrician advice/referral was the strongest independent predictor of dental attendance. Compared with women who reported no advice/referral, those who reported receiving obstetrician advice/referral had substantially higher odds of visiting a dentist during pregnancy (aOR 6.30, 95% CI 3.22\u0026ndash;12.32; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eHigher household monthly income was also independently associated with dental visits: compared with \u0026lt;\u0026thinsp;8,000 RMB, women with 15,000\u0026ndash;24,999 RMB (aOR 3.32, 95% CI 1.02\u0026ndash;10.75; P\u0026thinsp;=\u0026thinsp;0.046) and \u0026ge;\u0026thinsp;25,000 RMB (aOR 6.09, 95% CI 1.61\u0026ndash;23.04; P\u0026thinsp;=\u0026thinsp;0.008) showed higher utilization. Additionally, a dental check within 6 months prior to pregnancy was associated with higher odds of dental visits during pregnancy (aOR 2.19, 95% CI 1.18\u0026ndash;4.07; P\u0026thinsp;=\u0026thinsp;0.013). Late pregnancy (\u0026ge;\u0026thinsp;28 weeks) showed a borderline association (aOR 2.22, 95% CI 0.99\u0026ndash;4.99; P\u0026thinsp;=\u0026thinsp;0.054).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePoints represent adjusted odds ratios (aORs) and horizontal lines indicate 95% confidence intervals. The vertical reference line indicates aOR\u0026thinsp;=\u0026thinsp;1. The model was adjusted for residence and gravidity (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e; full model in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression for dental visit during pregnancy (n\u0026thinsp;=\u0026thinsp;452).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrician advice/referral (D10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot sure/Do not recall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70\u0026ndash;5.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.22\u0026ndash;12.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold monthly income (RMB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;8,000 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8,000\u0026ndash;14,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u0026ndash;6.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,000\u0026ndash;24,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u0026ndash;10.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;25,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.61\u0026ndash;23.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational stage (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;12 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.51\u0026ndash;2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u0026ndash;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental check within 6 months pre-pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.18\u0026ndash;4.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high or below (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school/technical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u0026ndash;15.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u0026ndash;15.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u0026ndash;12.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30\u0026ndash;10.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e \u003cb\u003eNotes\u003c/b\u003e: Model adjusted for residence and gravidity (full model shown in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis cross-sectional study offers a detailed examination of the oral health knowledge, attitudes, and practices among pregnant women in Fuzhou, China, and highlights the factors influencing dental service utilization during pregnancy. Despite a generally positive attitude toward maternal oral health, the actual rate of dental attendance was surprisingly low, with only 13.1% of participants reporting a dental visit during pregnancy. This finding mirrors previous reports from both China and other countries, underscoring the ongoing issue of underutilization of dental care during pregnancy, even in settings where antenatal care access is relatively strong [13,18,19].\u003c/p\u003e\n\u003cp\u003eThe dental attendance rate observed in our study aligns with findings from other regions in eastern China, though it is notably lower than the rates reported in some high-income countries. This disparity points to the significant role that contextual and healthcare system-related factors play in shaping care-seeking behavior [18,19]. Existing systematic reviews have consistently shown that factors such as socioeconomic status, perceived need, health beliefs, and the advice of healthcare professionals are key determinants of dental attendance during pregnancy, while knowledge alone is not sufficient to drive action[19]. Our results support this broader body of evidence, suggesting that although women may hold favorable attitudes toward oral health, these attitudes do not automatically lead to increased dental service utilization.\u003c/p\u003e\n\u003cp\u003eOne of the most significant and novel findings from this study is the strong correlation between obstetrician advice or referral and dental visits during pregnancy. Women who reported receiving advice from their obstetrician were over six times more likely to attend dental services, making this the most powerful factor identified in the multivariable model. This finding is consistent with prior research, which has demonstrated that recommendations from prenatal care providers can play a critical role in normalizing dental care during pregnancy and alleviating concerns regarding its safety[14,15,20]. Obstetricians are frequently the most trusted and accessible healthcare providers during pregnancy, and their recommendations may serve as a crucial prompt for patients to seek dental care, especially in contexts where misconceptions about dental treatment, anesthesia, and radiography are still widespread.\u003c/p\u003e\n\u003cp\u003eSocioeconomic factors also contributed to disparities in dental attendance. Higher household income and a dental check within six months prior to pregnancy were independently associated with dental visits during pregnancy, reflecting the importance of continuity of preventive care and existing engagement with oral health services. Similar associations have been reported in other populations, where women with established dental care habits before pregnancy were more likely to maintain dental attendance during pregnancy [19,21]. In contrast, education level was not independently associated with utilization after adjustment, suggesting that formal education alone may be insufficient to overcome practical, perceptual, and system-related barriers to care.\u003c/p\u003e\n\u003cp\u003eWithin the KAP framework, knowledge and attitudes were positively correlated with oral health practices, although these associations were modest. This pattern reflects a persistent attitude\u0026ndash;practice gap that has been documented in multiple studies of pregnant women, both in China and internationally [12,22,23]. While adequate knowledge and positive attitudes are necessary components of behavior change, they appear insufficient in isolation to prompt dental attendance during pregnancy. Our findings suggest that the translation of knowledge into action may depend heavily on reinforcing signals from healthcare providers and on the removal of structural barriers within the healthcare system.\u003c/p\u003e\n\u003cp\u003eThe analysis of barriers and facilitators further supports this interpretation. Among women who did not attend dental services, lack of obstetrician advice was the most commonly reported primary barrier, followed by uncertainty regarding the safety of dental care and limited awareness of service access. These barriers mirror those identified in systematic reviews and qualitative studies, which consistently highlight safety concerns, cost, time constraints, and unclear referral pathways as major impediments to prenatal dental care [12,16,19]. Conversely, the most frequently endorsed facilitators\u0026mdash;explicit obstetrician recommendation, family support, priority access for pregnant women, and cost reimbursement\u0026mdash;point toward actionable strategies that extend beyond individual education.\u003c/p\u003e\n\u003cp\u003eTaken together, these findings underscore the importance of integrating oral health into routine antenatal care. Evidence from interprofessional and health promotion studies suggests that brief oral health screening, counseling, and referral delivered within prenatal care settings can improve knowledge and, in some contexts, increase dental attendance during pregnancy [17,24]. Our results add to this evidence by quantifying the magnitude of the association between obstetrician advice and dental visits, highlighting provider engagement as a particularly promising and modifiable intervention target.\u003c/p\u003e\n\u003cp\u003eOf course, there are several limitations to this study. The cross-sectional design prevents us from making causal inferences, and self-reported data may be susceptible to recall bias or social desirability bias. Moreover, because participants were recruited from a single tertiary hospital, the generalizability of our findings to other regions or healthcare settings may be limited. Nonetheless, the use of a pilot-tested questionnaire, comprehensive assessment of KAP domains, and multivariable adjustments strengthen the validity of our conclusions.\u003c/p\u003e\n\u003cp\u003eIn conclusion, while attitudes toward oral health are generally positive, dental service utilization during pregnancy remains low in this population. Obstetrician advice and referral emerged as the most influential and potentially modifiable determinant of dental attendance. These findings support the integration of structured oral health counseling and referral mechanisms into routine antenatal care, serving as a practical strategy to bridge the attitude\u0026ndash;practice gap and improve maternal oral health outcomes.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eDespite generally positive attitudes toward oral health, dental service utilization during pregnancy remains low among women attending a tertiary hospital in China. Obstetrician advice or referral emerged as the strongest determinant of dental attendance, highlighting the pivotal role of antenatal care providers in influencing oral health–related behaviors during pregnancy. Integrating oral health counseling and streamlined referral pathways into routine antenatal care may help reduce missed opportunities for timely dental care and improve maternal oral health during pregnancy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eKAP\u003c/strong\u003e - Knowledge, Attitudes, and Practices\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e - Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u0026nbsp;\u003c/strong\u003e- Confidence Interval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDEFF\u003c/strong\u003e - Design Effect\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKR-20\u0026nbsp;\u003c/strong\u003e- Kuder-Richardson Formula 20\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCronbach\u0026rsquo;s \u0026alpha; -\u0026nbsp;\u003c/strong\u003eCronbach\u0026apos;s Alpha\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKMO -\u003c/strong\u003e Kaiser-Meyer-Olkin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD -\u003c/strong\u003e Standard Deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e - Interquartile Range\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSPSS\u0026nbsp;\u003c/strong\u003e- Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026alpha;\u0026nbsp;\u003c/strong\u003e- Alpha\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e6.2 Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Fuzhou University Affiliated Provincial Hospital (Approval No. K 2025-09-001). Written informed consent was obtained from all participants before participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.3 Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.4 Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.5 Competing Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.6 Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper was not funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.7 Authors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKaijia Xue:\u0026nbsp;\u003c/strong\u003eConceptualization; Methodology; Investigation; Data curation; Formal analysis; Visualization; Writing\u0026mdash;original draft; Writing\u0026mdash;review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJiaju Liu:\u0026nbsp;\u003c/strong\u003eConceptualization; Supervision; Methodology; Writing\u0026mdash;review \u0026amp; editing; Corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYi Lin:\u0026nbsp;\u003c/strong\u003eMethodology; Supervision; Writing\u0026mdash;review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiang Lin:\u0026nbsp;\u003c/strong\u003eData curation; Formal analysis; Visualization; Software.11 Data Availability Statement\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.8 Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the obstetricians and nurses at Fuzhou University Affiliated Provincial Hospital for their invaluable assistance during this study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSupplementary information\u003c/strong\u003e The online version contains supplementary material. The Chinese questionnaire used in this survey is provided as \u003cstrong\u003eOnline Resource 1\u003c/strong\u003e, and an English translation is provided as\u003cstrong\u003e\u0026nbsp;Online Resource 2\u003c/strong\u003e. Additional tables and figures are provided as \u003cstrong\u003eOnline Resource 3\u003c/strong\u003e, including the full regression model (Table S1), the practice score rubric (Table S2), psychometric diagnostics (Tables S3\u0026ndash;S5), and additional visualizations (Figs. S1\u0026ndash;S2).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBobetsis YA, Graziani F, G\u0026uuml;rsoy M, et al. Periodontal disease and adverse pregnancy outcomes. 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J Clin Nurs. 2010;19(23\u0026ndash;24):3324\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.https://doi.org/10.1111/j.1365-2702.2010.03426.x\u003c/span\u003e\u003cspan address=\".10.1111/j.1365-2702.2010.03426.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pregnancy, oral health, dental attendance, knowledge-attitude-practice, obstetrician advice, cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-8683366/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8683366/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo assess oral health knowledge, attitudes, and practices (KAP) among pregnant women in Fuzhou, China, and to identify factors associated with dental visits during pregnancy.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted from 10 September to 31 October 2025 at a tertiary obstetrics clinic in Fuzhou, China. Participants were recruited at Fuzhou University Affiliated Provincial Hospital. Using consecutive recruitment with trimester quota sampling (DEFF\u0026thinsp;\u0026asymp;\u0026thinsp;1), 452 pregnant women completed a structured questionnaire covering demographics, oral health knowledge (7 items), attitudes (6 items), behaviors, barriers, and information needs. Internal consistency was assessed (Attitudes: Cronbach\u0026rsquo;s α; Knowledge: KR-20), and construct validity of the attitude scale was examined (KMO and Bartlett\u0026rsquo;s test). Spearman correlation and multivariable logistic regression were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean Knowledge, Attitude, and Practice scores were 4.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 (0\u0026ndash;7), 24.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38 (6\u0026ndash;30), and 2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 (0\u0026ndash;10), respectively. Overall, 13.1% (59/452) reported a dental visit during pregnancy, increasing by trimester (7.3% \u0026le;12 weeks; 11.8% 13\u0026ndash;27 weeks; 20.0% \u0026ge;28 weeks). While 68.6% brushed at least twice daily, only 14.4% used dental floss. Knowledge and attitudes correlated positively with practice (Spearman r\u0026thinsp;=\u0026thinsp;0.248 and r\u0026thinsp;=\u0026thinsp;0.178; both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among non-attenders, the most common primary barrier was lack of obstetrician advice or referral information (53.2%, 209/393). In adjusted analyses, obstetrician advice/referral was the strongest predictor of dental visits during pregnancy (aOR 6.30; 95% CI 3.22\u0026ndash;12.32). Higher household income was also associated with dental attendance (15,000\u0026ndash;24,999 RMB: aOR 3.32, 95% CI 1.02\u0026ndash;10.75; \u0026ge;25,000 RMB: aOR 6.09, 95% CI 1.61\u0026ndash;23.04, vs. \u0026lt;8,000 RMB), as was having a dental check within 6 months prior to pregnancy (aOR 2.19; 95% CI 1.18\u0026ndash;4.07). Late pregnancy (\u0026ge;\u0026thinsp;28 weeks) showed a borderline association with utilization (aOR 2.22; 95% CI 0.99\u0026ndash;4.99; p\u0026thinsp;=\u0026thinsp;0.054). Education was not independently associated after adjustment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite generally positive attitudes, dental service utilization and several preventive behaviors remained low. Integrating obstetrician-delivered counseling/referral into routine antenatal care and addressing pregnancy-specific safety misconceptions may improve timely dental attendance.\u003c/p\u003e\u003ch2\u003eClinical Relevance:\u003c/h2\u003e \u003cp\u003eEmbedding oral health counseling and a streamlined referral pathway within antenatal visits could reduce missed opportunities for dental care during pregnancy.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003eThis study was registered in the China National Medical Research Registration System with the registration number: MR-35-25-062116. Registered on September 8, 2025.\u003c/p\u003e","manuscriptTitle":"Obstetrician Advice as a Key Determinant of Dental Visits During Pregnancy: A Cross-Sectional Study in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 09:21:51","doi":"10.21203/rs.3.rs-8683366/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-06T11:37:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130406091547063089295385308587318491232","date":"2026-03-04T13:53:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210391017779186290171858711352454230751","date":"2026-03-02T02:19:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73426846009313005397617675936981097925","date":"2026-02-28T14:45:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-25T08:47:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T11:56:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-04T07:20:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T23:19:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-02-03T23:15:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6393c4ef-2aeb-420b-980b-947d7f849068","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T09:21:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 09:21:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8683366","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8683366","identity":"rs-8683366","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}