Knowledge, attitudes, practices, and barriers regarding oral healthcare during pregnancy: a cross-sectional study among obstetricians in Guangxi, China.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Pregnancy Childbirth . 2026 Apr 22;26:615. doi: 10.1186/s12884-026-09116-y Knowledge, attitudes, practices, and barriers regarding oral healthcare during pregnancy: a cross-sectional study among obstetricians in Guangxi, China Wenyong Wang 1, 2, # , Leiming Yi 2, # , Jinmei Yu 2 , Qiuling Pang 2 , Lingshan Ran 2 , Xiaofeng Tan 2 , Ruofei Huang 2 , Yunxin Yang 2 , Hongxia Wei 2 , Yishan Zhang 2 , Fanghong Liu 2 , Jiangping Wei 1 , Rongmin Qiu 2, ✉ Author information Article notes Copyright and License information 1 Baise People’s Hospital, Baise, Guangxi 533000 China 2 College & Hospital of Stomatology, Guangxi Key Laboratory of the Rehabilitation and Reconstruction for Oral and Maxillofacial Research, Guangxi Clinical Research Center for Craniofacial Deformity, Guangxi Health Commission Key Laboratory of Prevention and Treatment for Oral Infectious Diseases, Guangxi Medical University, Nanning, Guangxi 530021 China ✉ Corresponding author. # Contributed equally. Received 2025 Dec 22; Accepted 2026 Apr 14; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13234960  PMID: 42021172 Abstract Background Maternal oral health is closely linked to pregnancy outcomes, yet its integration into prenatal care remains inadequate, particularly in resource-limited regions like Guangxi, China. Obstetricians, as primary caregivers for pregnant women, play a critical role in bridging this gap. This study aimed to evaluate their knowledge, attitudes, and practices regarding oral healthcare during pregnancy, identify service barriers, and analyze the interrelationships among these factors. Methods A cross-sectional, online questionnaire-based study was conducted from Nov 2024 to Jan 2025 among licensed obstetricians in Guangxi.The questionnaire assessed demographic characteristics and four key dimensions: knowledge, attitudes, practices, and barriers related to oral healthcare during pregnancy. Data were analyzed using multivariable descriptive statistics (frequencies, percentages) and inferential methods (Mann-Whitney U test, Kruskal-Wallis test, Spearman correlation, and multiple linear regression). Results Among 532 participants, 526 returned valid surveys (98.9% response rate). Only 179 (34.0%) had received oral health training. Mean scores were: knowledge 9.68/16, attitude 32.18/40, practice 18.61/30, and barriers 28.09/40. Knowledge strongly correlated with attitude ( r = 0.668, P <0.001), weakly with practice ( r = 0.116, P <0.001), and positively with barriers ( r = 0.341, P <0.001). Due to the cross-sectional design, causality cannot be inferred; notably, knowledge alone poorly predicts practice. The weak knowledge-practice association further indicates that knowledge alone is insufficient to predict service utilization. Conclusions Obstetricians in Guangxi demonstrated moderate knowledge and positive attitudes toward perinatal oral healthcare; however, their clinical engagement remained limited and substantial service barriers were reported. These findings underscore the urgent need for developing interdisciplinary clinical guidelines between obstetrics and dentistry, establishing specialized oral health training programs tailored for obstetricians, and systematically integrating oral health screening into routine antenatal care protocols to bridge the knowledge-practice gap and enhance the quality of perinatal oral health services. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-026-09116-y. Keywords: Maternal oral health, Obstetricians, Knowledge-Attitudes-Practices (KAP), Barriers to care, Cross-sectional study Introduction Maternal oral health during pregnancy is critically important, not only for the health of the mother but also as a key factor influencing fetal development. Research indicates that oral diseases, such as periodontitis, are associated with an increased risk of adverse pregnancy outcomes, including preterm birth and low birth weight [ 1 ]. Despite the relatively comprehensive maternal healthcare system in China, oral health management remains consistently overlooked. Although the government has continued to enhance reproductive health services, data show that approximately 35% of pregnant women report never having undergone an oral examination [ 2 ], and the treatment rate for oral diseases during pregnancy remains below 20% [ 3 ], highlighting a significant gap in care. Pregnant women often possess limited awareness of the importance of oral health. Symptoms such as gingival bleeding and tooth mobility are frequently dismissed as normal pregnancy-related changes, leading to low initiative in seeking dental care. At the same time, pregnant women generally express high levels of trust in healthcare providers and are inclined to follow their recommendations [ 4 – 5 ]. Obstetricians, being the most frequently visited health professionals during pregnancy, are uniquely positioned to provide education on oral hygiene and the importance of dental care throughout this period [ 6 ]. Their guidance plays a crucial role in influencing pregnant women’s decisions to seek oral health services [ 7 ]. Ideally, obstetricians should be able to identify common oral conditions, offer basic preventive advice, and make appropriate referrals to mitigate associated risks [ 8 ]. In practice, however, significant gaps exist in the provision of oral healthcare by obstetricians. A survey revealed that only 36.34% of pregnant women recalled receiving oral health advice from their obstetricians [ 9 ]. This issue is not unique to China; for example, in France, 33.2% of obstetricians reported never routinely advising dental visits during pregnancy [ 10 ]. Meanwhile, a survey in the United States revealed that 37% of primary care physicians rarely or never provide oral health consultations [ 11 ]. Similarly, a study conducted in Australia reported that only 29% of obstetricians and midwives performed oral examinations [ 12 ]. These findings underscore that, irrespective of healthcare system characteristics, the knowledge-practice gap in perinatal oral health represents a universal and persistent challenge.Several key barriers contribute to this shortfall. First, most obstetricians lack systematic training in oral health, leading to insufficient knowledge about oral care and limited awareness of its impact on pregnancy outcomes. Second, clinical priorities tend to focus on conventional obstetric concerns, relegating oral health to a peripheral role.However, oral health education is often not prioritized in antenatal care services, resulting in missed opportunities for prevention and treatment [ 13 ]. Heavy clinical workloads and the perception that oral care falls within the dentists’ scope of practice further diminish engagement [ 14 ]. Third, disparities in medical resources, especially in primary care settings, and the absence of established interprofessional collaboration mechanisms between dental and obstetric services hinder effective referral and management. These systemic barriers contribute to the primary bottleneck impeding the advancement of perinatal oral healthcare services. Further analysis indicates that only about 8.2% of obstetricians in China have received professional training on oral health during pregnancy [ 15 ]. There is a conspicuous lack of standardized instruction in undergraduate education, residency training, and major clinical textbooks (such as Obstetrics and Gynecology). Moreover, key national guidelines, including the Guidelines for Preconception and Prenatal Care (2018) [ 16 ] and the Standards for Residency Training Content (Trial) [ 17 ], do not incorporate oral health as a mandatory component of care or training. As a result, only 29.3% of obstetricians demonstrate familiarity with medication safety protocols related to dental treatment during pregnancy [ 18 ], reflecting a substantial professional competency gap. In contrast, the United Kingdom has explicitly integrated oral health assessments into routine antenatal care pathways within its pregnancy dental care policy [ 19 ]. However, deficiencies persist in undergraduate curricula concerning perinatal oral health education in other countries, including France, Brazil, India, and the United States [ 20 ]. Guangxi, located in southwestern China, is a region characterized by its multi-ethnic composition and a relatively underdeveloped economy with generally lower educational attainment. Deeply rooted familial values and a strong preference for larger family sizes contribute to a birth rate that consistently exceeds the national average. This demographic trend places sustained pressure on an already strained maternal and child healthcare system. Compounding this challenge is the significant urban-rural disparity in resource distribution: while urban centers are relatively well-equipped, many rural and remote areas—often inhabited by ethnic minority communities—face severe shortages of specialized medical personnel and facilities. This imbalance has created a pronounced “supply-demand” gap in specialized preventive services, such as antenatal oral healthcare, highlighting the urgent need for tailored regional strategies. The Knowledge-Attitude-Practice (KAP) model, comprising Knowledge (K), Attitude (A), and Practice (P), provides a theoretical framework for understanding how cognitive and affective factors translate into health-related behaviors. In this study, we applied the KAP model to perinatal oral healthcare to systematically evaluate obstetricians’ cognitive preparedness (knowledge), readiness to act (attitude), and actual clinical engagement (practice) regarding oral health during pregnancy [ 21 ]. Notably, we extended the traditional KAP framework by incorporating a fourth dimension—healthcare barriers—which addresses a critical gap in conventional KAP assessments. While the KAP model elucidates individual-level determinants of behavior, it does not account for structural and systemic constraints that may impede the translation of knowledge and positive attitudes into actual practice. Healthcare barriers, conceptualized from public health and health systems perspectives, refer to obstacles encountered by specific populations in accessing, receiving, or delivering effective, timely, and appropriate preventive and curative medical services [ 22 , 23 ]. These barriers encompass provider-level constraints (e.g., lack of clinical guidelines, insufficient training), patient-level factors (e.g., awareness deficits, safety concerns), and systemic challenges (e.g., resource limitations, interdisciplinary coordination gaps). By integrating barriers into our analytical framework, we aimed to identify not only what obstetricians know and believe, but also why their practices may fall short of their knowledge and attitudes—thereby providing a more comprehensive evidence base for targeted interventions that address both individual capacity and systemic enablers. This study aims to investigate the KAP of obstetricians in Guangxi concerning oral healthcare during pregnancy and to systematically examine the barriers to service provision. We hypothesize that significant gaps exist across these KAPB dimensions, and crucially, that these gaps are not uniform; they are likely shaped and exacerbated by the region’s unique demographic and developmental characteristics. The results will provide evidence for the development of region-specific intervention strategies, with the goal of improving maternal oral health outcomes across the underdeveloped regions. Materials and methods Study design This cross-sectional survey was conducted from Nov 2024 - Jan 2025 through the Wenjuanxing online platform. Using convenience sampling, questionnaires were distributed to obstetrician work groups in public hospitals and private institutions across all 14 prefecture-level cities of Guangxi. Inclusion criteria for participants were as follows: (1) Licensed obstetrician currently registered and practicing in Guangxi; (2) Currently engaged in obstetric clinical work; Exclusion criteria included: Declining to participate in the survey or failing to complete the questionnaire as required. Ethical approval This study was conducted in strict accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Medical Ethics Committee of the Affiliated Stomatological Hospital of Guangxi Medical University (Approval No. 2024082). The committee reviewed and approved all aspects of the study, including the research protocol, informed consent materials, and the questionnaire. Informed consent was obtained from all participants, who indicated their willingness by selecting "Yes" in response to the screening question: "Are you willing to participate in this survey?" The survey was administered anonymously, and no personally identifiable information was collected throughout the process. Sample size estimation The sample size for this cross-sectional study was calculated using the formula [ 24 ]: with the following parameters: ① N : Required sample size; ② P : Awareness rate (set at 45%). Based on a pilot survey of 13 obstetricians regarding the association between periodontal disease and adverse pregnancy outcomes, the awareness rate for "periodontal disease may lead to adverse pregnancy outcomes" was 53.9%. To ensure a conservative estimate and expand the sample size, P was set at 45%. Q = 1 − P . ③ d: Margin of error (set at 10% of P , i.e., d = 0.1× P ) ④ Confidence level: 95% (two-tailed), with t=1.96. Substituting the values into the formula: N = 1.96²×0.45×(1−0.45)/(0.1×0.45)² = 469. Considering potential invalid responses (estimated at 10%), the theoretical required sample size was 516 obstetricians. Questionnaire design The questionnaire was Self-designed, it was developed for this study based on a comprehensive review of domestic and international literature concerning oral healthcare during pregnancy and the KAP framework. The questionnaire consisted of the following five sections and was presented in the format of a supplementary questionnaire (Appendix 1). Demographic characteristics Demographic data collected from participants included gender, educational level, professional title, work experience, location of workplace, type of institutional registration, level of institution and training participation, whether they had received prior relevant training, and sources of knowledge acquisition. The knowledge dimension 16 items were used to evaluated obstetricians' awareness of oral healthcare during pregnancy. Participants answered each item with “True,” “False,” or “Uncertain.” Responses of “True” were assigned 1 point, while “False” or “Uncertain” responses received 0 points. The total knowledge score was the sum of all correct answers, ranging from 0 to 16, with higher scores reflecting better knowledge. The attitude dimension comprised 8 items rated on a five-point Likert scale from “Strongly Disagree” to “Strongly Agree,” scored from 1 to 5 points. Total scores ranged from 8 to 40, with higher values indicating more positive attitudes toward oral healthcare during pregnancy. The practice dimension included one item on clinical consultation experience and 6 items rated on a five-point Likert scale from “Never” to “Always,” each scored from 1 to 5 points. Total scores ranged from 6 to 30, with higher scores representing more proactive practices in oral healthcare. The barriers dimension consisted of 8 items rated on a five-point Likert scale from “Strongly Disagree” to “Strongly Agree,” scored from 1 to 5 points. Total scores ranged from 8 to 40, with higher scores indicating greater perceived barriers to providing oral healthcare during pregnancy. This dimension covered three domains: environmental factors (3items), physician-related factors (3items), and patient-related factors (2items). Scale reliability and validity testing The questionnaire was reviewed by 3 subject-matter experts (obstetrician-gynecologists and public health researchers).During the pilot phase, the questionnaire was distributed to 13 obstetricians selected via convenience sampling. Based on the pilot results and expert feedback, the questionnaire was revised. Meanwhile, to ensure the credibility, validity, and representativeness of the data collection, KR-20 was used to test the internal consistency of the knowledge scale.Reliability testing of the attitude, practice, and barrier scales requiring quantitative scoring in the questionnaire was conducted using Cronbach’s α coefficient. After multiple rounds of revision and deletion of questionnaire items, The KR-20 value of the knowledge scale was 0.92, the final Cronbach’s α coefficients for the attitude, practice, and barrier scales were 0.974, 0.950, and 0.973,respectively. Overall, this questionnaire demonstrates excellent consistency, high reliability, and the collected data are suitable for factor analysis, making them appropriate for research and analysis. Quality control Wenjuanxing is a widely used professional online platform in China designed for surveys, exams, and voting. Regarding its system architecture. It is a platform with a controlled backend and open distribution channels. We selected this software to assist in the survey and configured the backend settings to restrict the response area to “Guangxi” only, allowing each user to submit only one response to prevent duplicate entries. Additionally, all questions were set as mandatory to ensure completeness before submission. After generating a QR code or link through the software, we distributed them via the work groups of obstetrics department directors in various hospitals. The questionnaire QR code and link were also shared in the WeChat group of the Guangxi Obstetrics and Gynecology Medical Association members to ensure that all respondents were obstetricians. Following data collection, all questionnaires were manually verified by two reviewers. Based on the pilot survey results ( n =13), we determined that the average completion time was 120 seconds and established this as the threshold for data cleaning. Specifically, questionnaires completed in less than 120 seconds were excluded for the following reasons: (1) this duration was markedly shorter than the average completion time, suggesting that respondents may not have fully read the items or responded carelessly; and (2) in conjunction with the parallel exclusion criterion of "substantially identical or highly overlapping responses," this threshold effectively identified and eliminated low-quality or invalid questionnaires. Notably, this time standard was applied solely for post-hoc data cleaning and was not communicated to participants as an inclusion criterion beforehand, so as to avoid inducing time pressure or prompting respondents to deliberately adjust their answering behavior to meet the requirement, thereby ensuring the authenticity and naturalness of the data. Statistical analysis The independent variables considered included gender, education level, professional title, years of practice, institution location, institution registration type, institution level, and prior training. Variables showing an association with the dependent variable at P < 0.20 in univariate analyses were entered into the initial multivariate model. Bidirectional stepwise regression analysis was conducted to screen for independent variables. Data were analyzed using SPSS 27.0. Categorical data are expressed as frequencies and percentages, and continuous data as mean ± standard deviation. Non parametric tests (Mann Whitney U for two group comparisons and Kruskal Wallis H for multi group comparisons) were used for group comparisons. Spearman correlation analysis was conducted to assess relationships among knowledge, attitude, practice, and barrier scores. Multiple linear regression was employed to identify factors influencing KAPB scores, with variance inflation factor (VIF) used to evaluate multicollinearity. A P value < 0.05 was considered statistically significant. Results Demographic characteristics A total of 532 questionnaires were collected from obstetricians. After automated screening by the questionnaire platform and subsequent manual verification, invalid responses, such as those with a completion time of less than 120 seconds or irrational answers were excluded, yielding 526 valid questionnaires. The sample encompassed all 14 prefecture-level cities of Guangxi (Table 1 ).Variable classification and assignment description are presented in (Table 2 ). Table 1. Geographic distribution of obstetricians ( n = 526) Location N (%) Location N (%) Nanning City 73 (13.9) Qinzhou City 18 (3.4) Guilin City 20 (3.8) Guigang City 29 (5.5) Liuzhou City 36 (6.8) Baise City 110 (20.9) Wuzhou City 23 (4.4) Hezhou City 17 (3.2) Fangchenggang City 21 (4.0) Hechi City 34 (6.5) YulinCity 55 (10.5) LaibingCity 31 (5.9) Beihai City 27 (5.1) Chongzuo City 32 (6.1) Open in a new tab Table 2. Variable assignment description Variable Category/Assignment/Scoring Gender 1: Male 2: Female Education level 1: Below Bachelor 2: Bachelor 3: Master or above Professional Title 1: Junior or below 2: Intermediate 3: Senior Work Experience 1: <10 years 2: ≥10 years Institution Location 1: Low-economic-level area 2: High-economic-level area Institution Registration Type 1: Public 2: Private Level of Institution 1: Primary healthcare institution 2: Secondary hospital 3: Tertiary hospital Training Experience 1: Yes 2: No Knowledge Score 0–16 points (Continuous variable) Attitude Score 8–40 points (Continuous variable) Practice Score 6–30 points (Continuous variable) Perceived Barrier Score 8–40 points (Continuous variable) Open in a new tab 1. The economic level classification of areas is based on the 2024 GDP ranking of Guangxi. The top 7 areas (Nanning, Liuzhou, Guilin, Yulin, Baise, Beihai, Qinzhou) were defined as high-economic-level areas; the remaining 7 areas (Wuzhou, Guigang, Hechi, Chongzuo, Fangchenggang, Laibin, Hezhou) were defined as low-economic-level areas 2. Primary healthcare institutions include township health centers, community health service centers, outpatient dental departments, and dental clinics. Hospital levels are defined according to the “Hospital Grading Standards and Regulations”: Primary hospitals are grassroots hospitals or health centers with ≤ 100 beds; Secondary hospitals are regional hospitals with 101–500 beds; Tertiary hospitals are supra-regional hospitals with ≥ 501 beds Scores of four dimensions Among the 16 knowledge items, the correct response rates for K4, K6, K7, K9, K10, and K11 were relatively low, ranging from only 28% to 59.1%. The correct response rates for the remaining items ranged from 61.2% to 75.5%, indicating that the overall knowledge of obstetricians in Guangxi regarding oral healthcare during pregnancy is moderate, with significant room for improvement. Detailed results are shown in (Table 3 ). Table 3. Obstetricians’ knowledge of oral healthcare during pregnancy ( n = 526) Variables N (%) K1 Oral health can affect overall health 397 (75.5) K2 Pre-pregnancy preventive oral examinations and treatments should be conducted 392 (74.5) K3 Pregnancy can exacerbate existing dental problems 357 (67.9) K4 Calcium is drawn from the mother’s teeth by the developing baby 147 (28.0) K5 Changes in dietary habits, increased eating frequency, and vomiting during pregnancy can elevate the risk of dental caries 386 (73.4) K6 Should pregnant women only receive emergency dental treatments? 262 (49.8) K7 Elective dental treatments should be postponed until after delivery 276 (52.5) K8 Pregnancy increases the risk of developing gingivitis 368 (70.0) K9 The use of lidocaine anesthesia is safe throughout pregnancy 233 (44.3) K10 Dental X-rays (periapical films) are safe during pregnancy when adequate head, neck, and abdominal protection is provided 311 (59.1) K11 Cariogenic bacteria in the mother’s oral cavity can be vertically transmitted to the fetus 223 (42.4) K12 Periodontal disease during pregnancy may lead to adverse pregnancy outcomes (such as preterm birth, low birth weight, preeclampsia, etc.) 329 (62.6) K13 Acetaminophen is the preferred analgesic for pain relief during pregnancy 385 (73.2) K14 Tooth germs for deciduous teeth begin to develop from the second month of pregnancy 322 (61.2) K15 The use of penicillin is safe during all trimesters of pregnancy 346 (65.8) K16 The second trimester is the relatively safest period for performing dental procedures during pregnancy 356 (67.7) Open in a new tab In the attitude dimension, aside from the statement "Treatment of periodontal disease during pregnancy has a positive impact on pregnancy outcomes," which received agreement from 78.0% of respondents, all other items achieved agreement rates exceeding 80% (Table 4 ). Table 4. Obstetricians’ attitudes toward oral healthcare during pregnancy ( n = 526) Variables N (%) Maintaining oral health during pregnancy is important 423 (80.4) Pregnant women should receive oral examinations during the pre-pregnancy period 420(80.0) Pregnant women are more likely to seek dental care if recommended by obstetricians 422(80.2) Treatment of periodontal disease during pregnancy has a positive impact on pregnancy outcomes 410(78.0) Improve the collaboration between obstetricians and dentists will be more benefit to the provision of dental care during pregnancy 430(81.8) Develop " Chinese Guidelines or Consensus on Oral Healthcare and Treatment During Pregnancy” for obstetricians and dentists is essential 426(81.0) Strengthen the training on knowledge about oral healthcare during pregnancy 425(80.8) Promoting oral healthcare during pregnancy requires joint efforts from the government, society, hospitals, healthcare professionals, and patients 429(81.5) Open in a new tab In the practice dimension, among the 404 respondents who had provided oral health consultations to pregnant women, the majority (approximately 60%) reported that they consistently communicated patient conditions with dentists, advised managing dental issues postpartum, and provided counseling on the association between periodontal disease and adverse pregnancy outcomes,as detailed in (Table 5 ). Table 5. Obstetricians’ oral healthcare practice during pregnancy ( n = 404) Variables N (%) Do you communicate with dentists about the condition when treating pregnant patients? 246 (61.0) Do you recommend pre-pregnancy women to undergo routine oral examinations? 256(63.4) If any dental problem arise during pregnancy, do you advise patients to address them after childbirth? 242(60.0) Do you inform pregnant patients about the importance of oral health and how to maintain oral care during pregnancy 274(67.7) Do you provide counseling on the relationship between periodontal disease and adverse pregnancy outcomes? 244 (60.3) Do you provide counseling on the prevention of dental caries during pregnancy? 242(59.8) Open in a new tab In the dimension of barriers, the top three factors that respondents strongly agreed as obstacles were: "pregnant women's lack of awareness about the importance of oral health" (78.8%), "lack of guidelines for oral healthcare and treatment during pregnancy" (75.5%), and "pregnant women's concerns about the safety of dental treatments" (73.8%), as shown in (Table 6 ). Table 6. Obstetricians’ perceived barriers to pregnancy oral healthcare ( n = 404) Variables N (%) environmental determinants The high cost of dental treatment procedures 280 (69.2) Tensions in doctor-patient relationships, with concerns about causing complications that may lead to medical disputes. 305 (75.5) China currently lacks “Guidelines for Oral Healthcare and Treatment During Pregnancy” for clinical practice. 247 (61.1) physician determinants Busy outpatient clinics, no time for such consultations. 260 (64.5) Worried about the potential negative impact of dental treatments on pregnant women and the fetus 293 (72.6) Lack of knowledge regarding oral healthcare during pregnancy and insufficient understanding of associated risks 268 (66.3) patient determinants Pregnant women’s concerns about the safety of dental procedures 298 (73.8) Lack of awareness among pregnant women regarding the importance of oral health 318 (78.8) Open in a new tab The mean scores for the four dimensions of KAPB were reported in (Table 7 ). Table 7. Demographic characteristics and dimension scores Variables N (%) Knowledge Attitudes N (%) Practice Barriers Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P Total 526 (100) 9.68 ± 3.78 32.18 ± 7.22 404 (100) 18.61 ± 4.98 28.09 ± 5.38 Gender < 0.001* < 0.001* 0.524* < 0.001* Male 97 (18.4) 5.90 ± 2.56 25.59 ± 5.83 59 (14.6) 18.03 ± 3.89 24.68 ± 4.64 Female 429 (81.6) 10.53 ± 3.48 33.68 ± 6.64 345 (85.4) 18.70 ± 5.14 28.67 ± 5.29 Education level △ < 0.001** < 0.001** 0.196** < 0.001** Below Bachelor 1 108 (20.5) 7.46 ± 3.71 29.28 ± 7.44 69 (17.1) 19.23 ± 4.88 26.04 ± 5.24 Bachelor 2 313 (59.5) 11.07 ± 3.13 34.37 ± 6.16 268 (66.3) 18.65 ± 5.03 29.05 ± 5.23 Master or Above 3 105 (20.0) 7.79 ± 3.78 28.66 ± 7.51 67 (16.6) 17.81 ± 4.87 26.34 ± 5.19 Professional Title▲ < 0.001** < 0.001** 0.072** 0.095** Junior or Below 1 155 (29.5) 8.36 ± 3.57 30.44 ± 7.27 112 (27.7) 19.51 ± 4.93 28.64 ± 5.34 Intermediate 2 159 (30.2) 10.32 ± 3.55 33.09 ± 7.33 129 (31.9) 18.40 ± 4.73 28.52 ± 5.24 senior 3 212 (40.3) 10.16 ± 3.88 32.78 ± 6.89 163 (40.4) 18.15 ± 5.16 27.36 ± 5.48 Work Experience 0.761* 0.31* 0.238* < 0.001* < 10 years 226 (43.0) 9.70 ± 3.55 32.43 ± 7.49 170 (42.1) 18.93 ± 4.99 29.15 ± 5.08 ≥10 years 300 (57.0) 9.66 ± 3.96 32.00 ± 7.01 234 (57.9) 18.37 ± 4.97 27.31 ± 5.48 Institution Location 0.003* < 0.001* 0.271* 0.397* Low Economic 187 (35.6) 8.99 ± 3.81 30.64 ± 7.25 134 (33.2) 18.25 ± 4.88 27.81 ± 5.27 High Economic 339 (64.5) 10.05 ± 3.72 33.04 ± 7.07 270 (66.8) 18.79 ± 5.03 28.23 ± 5.45 Institutional Registration Type < 0.001* < 0.001* 0.53* < 0.001* Public 432 (82.1) 10.58 ± 3.46 33.97 ± 6.41 349 (86.4) 18.68 ± 5.20 28.73 ± 5.36 Private 94 (17.9) 5.53 ± 2.07 23.99 ± 4.55 55 (13.6) 18.13 ± 3.24 24.02 ± 3.38 Level of institution◇ < 0.001** < 0.001** 0.073** 0.04** Primary 1 212 (40.3) 8.50 ± 3.86 30.55 ± 7.18 157 (38.9) 19.18 ± 4.87 27.36 ± 5.56 Secondary 2 127 (24.1) 9.30 ± 3.82 31.27 ± 7.88 95 (23.5) 18.66 ± 4.63 28.38 ± 5.03 Tertiary 3 187 (35.6) 11.26 ± 3.07 34.66 ± 6.06 152 (37.6) 17.97 ± 5.26 28.65 ± 5.36 Training Experience < 0.001* < 0.001* < 0.001* 0.004* Yes 179 (34.0) 8.60 ± 3.81 30.26 ± 7.62 132 (32.7) 20.29 ± 5.17 27.14 ± 5.98 No 347 (66.0) 10.23 ± 3.65 33.18 ± 6.80 272 (67.3) 17.79 ± 4.68 28.55 ± 5.02 Open in a new tab K△: P < 0.001for comparison between1 and 2, A△ P < 0.001for comparison between1 and 2, B△ P < 0.001for comparison between1 and 2 P = 0.550 for comparison between1 and 3, P = 0.590for comparison between1 and 3, P = 0.704 0.001for comparison between1 and 3 P < 0.001 for comparison between2 and 3. P < 0.001for comparison between2 and 3, P < 0.001for comparison between2 and3 K▲: P < 0.001 for comparison between 1 and 2, A▲ P < 0.001 for comparison between 1 and 2 P < 0.001 for comparison between1 and 3, P = 0.002for comparison between1 and3 P = 0.861 for comparison between 2 and 3. P = 0.514for comparison between2 and 3 K◇: P = 0.058 for comparison between 1 and 2, A◇ P = 0.194for comparison between1 and 2, B◇ P = 0.103for comparison between1 and 2 p < 0.001 for comparison between1and3, P < 0.001for comparison between1 and3, P = 0.014 0.001for comparison between1 and3 p < 0.001 for comparison between 2 and 3. P < 0.001for comparison between2 and 3, P = 0.604for comparison between2 and3 Factors related to KAPB Analysis of demographic variables revealed significant differences in knowledge and attitude scores across multiple factors, including gender, education level, professional title, work experience, location of work place, type of institutional registration, level of institution, and training participation (all P < 0.001 for knowledge and attitude, except hospital location: P = 0.003 for knowledge and P < 0.001 for attitude). Barrier scores also differed significantly by gender, education level, years of work experience, type of institutional registration, level of institution, and training participation ( P < 0.001 for most, with level of institution at P = 0.04 and training at P = 0.004). In contrast, practice scores showed a significant difference only in training participation ( P < 0.001) (Table 7 ). Multiple linear regression analysis revealed that, regarding knowledge scores, female obstetricians, individuals with bachelor's degrees, those holding senior professional titles, practitioners in economically developed regions, and medical staff in public or tertiary hospitals demonstrated significantly better performance than their respective reference groups. For attitude scores, females, bachelor's degree holders, practitioners in economically developed areas, and staff in public/tertiary hospitals exhibited more positive attitudes; notably, those without relevant training unexpectedly showed more favorable attitudes. Concerning practice scores, physicians lacking training scored significantly lower than their trained counterparts. With respect to perceived barriers, females and bachelor's degree holders reported greater obstacles, whereas practitioners with intermediate or senior professional titles, those in economically developed regions, and those in private hospitals perceived fewer barriers. All variance inflation factor (VIF) values were below 5, indicating no significant multicollinearity among the included variables (Tables 8 , 9 , 10 and 11 ). Table 8. Determinants of obstetricians’ knowledge on oral healthcare during pregnancy Variables Unstandardized Coefficients Standard Coefficients Standardized t p 95% CI Collinearity Statistics β Standard Error β Lower Bound Upper Bound Error Tolerance VIF Gender Male Female 2.43 0.36 0.25 6.86 0.000 1.74 3.13 0.79 1.27 Education level Below Bachelor Bachelor 2.12 0.33 0.26 6.37 0.000 1.47 2.78 0.56 1.79 Master or Above 0.31 0.39 0.03 0.78 0.438 -0.47 1.08 0.60 1.67 Professional Title Junior or Below Intermediate 0.42 0.33 0.05 1.27 0.204 -0.23 1.07 0.65 1.55 Senior 0.82 0.32 0.11 2.54 0.012 0.18 1.45 0.59 1.69 Work Experience < 10 years ≥10 years -0.17 0.26 -0.02 -0.63 0.527 -0.68 0.35 0.89 1.13 Institution Location Low Economic High Economic 0.75 0.26 0.09 2.89 0.004 0.25 1.25 0.99 1.01 Institutional Registration Type Public Private -2.84 0.36 -0.29 -7.86 0.000 -3.56 -2.14 0.78 1.29 Level of institution Primary Secondary 0.03 0.32 0.00 0.11 0.916 -0.60 0.67 0.79 1.27 Tertiary 1.09 0.30 0.14 3.63 0.000 0.51 1.68 0.72 1.39 Training Experience Yes No 0.42 0.27 0.05 1.56 0.119 -0.11 0.95 0.93 1.08 Open in a new tab Table 9. Determinants of obstetricians’ attitude on oral healthcare during pregnancy Variables Unstandardized Coefficients Standard Coefficients Standardized t p 95% CI Collinearity Statistics β Standard Error β Lower Bound Upper Bound Error Tolerance VIF Gender Male Female 3.87 0.71 0.21 5.45 0.000 2.48 5.27 0.79 1.27 Education level Below Bachelor Bachelor 2.41 0.67 0.16 3.61 0.000 1.10 3.72 0.56 1.79 Master or Above -0.44 0.79 -0.02 -0.56 0.577 -1.99 1.11 0.60 1.67 Professional Title Junior or Below Intermediate 0.16 0.66 0.01 0.25 0.806 -1.14 1.46 0.65 1.55 Senior 0.86 0.65 0.06 1.33 0.184 -0.41 2.13 0.59 1.69 Work Experience < 10 years ≥10 years -0.47 0.52 -0.03 -0.89 0.374 -1.50 0.56 0.89 1.13 Institution Location Low Economic High Economic 1.80 0.51 0.12 3.50 0.001 0.79 2.81 0.99 1.01 Institutional Registration Type Public Private -6.81 0.73 -0.36 -9.40 0.000 -8.24 -5.39 0.78 1.29 Level of institution Primary Secondary -0.57 0.64 -0.03 -0.89 0.374 -1.84 0.69 0.79 1.27 Tertiary 1.15 0.60 0.08 1.91 0.056 -0.03 2.33 0.72 1.39 Training Experience Yes No 1.06 0.54 0.07 1.97 0.050 0.00 2.11 0.93 1.08 Open in a new tab Table 10. Determinants of obstetricians’ practice on oral healthcare during pregnancy Variables Unstandardized Coefficients Standard Coefficients Standardized t p 95% CI Collinearity Statistics β Standard Error β Lower Bound Upper Bound Error Tolerance VIF Gender Male Female -0.74 0.87 -0.04 -0.86 0.392 -2.45 0.96 0.79 1.27 Education level Below Bachelor Bachelor 1.04 0.81 0.07 1.28 0.202 -0.56 2.64 0.56 1.79 Master or Above 0.50 0.96 0.03 0.52 0.606 -1.40 2.39 0.60 1.67 Professional Title Junior or Below Intermediate 0.52 0.81 0.03 0.64 0.521 -1.07 2.11 0.65 1.55 Senior 0.62 0.79 0.04 0.78 0.434 -0.94 2.17 0.59 1.69 Work Experience < 10 years ≥10 years -0.29 0.64 -0.02 -0.45 0.654 -1.55 0.97 0.89 1.13 Institution Location Low Economic High Economic 0.28 0.63 0.02 0.45 0.655 -0.95 1.52 0.99 1.01 Institutional Registration Type Public Private 0.62 0.89 0.03 0.70 0.482 -1.12 2.36 0.78 1.29 Level of institution Primary Secondary 0.16 0.77 0.01 0.21 0.836 -1.38 1.71 0.79 1.27 Tertiary -1.20 0.73 -0.08 -1.64 0.103 -2.64 0.24 0.72 1.39 Training Experience Yes No -2.48 0.66 -0.17 -3.78 0.000 -3.77 -1.19 0.93 1.08 Open in a new tab Table 11. Determinants of obstetricians’ barriers on oral healthcare during pregnancy Variables Unstandardized Coefficients Standard Coefficients Standardized t p 95% CI Collinearity Statistics β Standard Error β Lower Bound Upper Bound Error Tolerance VIF Gender Male Female -0.10 1.19 -0.00 -0.08 0.935 -2.43 2.24 0.79 1.27 Education level Below Bachelor Bachelor 3.21 1.11 0.17 2.88 0.004 1.02 5.40 0.56 1.79 Master or Above 1.27 1.32 0.05 0.97 0.334 -1.32 3.87 0.60 1.67 Professional Title Junior or Below Intermediate 0.52 1.11 0.03 0.47 0.638 -1.65 2.69 0.65 1.55 Senior 0.00 1.08 0.00 0.00 0.995 -2.12 2.13 0.59 1.69 Work Experience < 10 years ≥10 years -0.60 0.88 -0.03 -0.69 0.492 -2.32 1.12 0.89 1.13 Institution Location Low Economic High Economic 0.09 0.86 0.00 0.10 0.920 -1.60 1.77 0.10 1.01 Institutional Registration Type Public Private -0.73 1.21 -0.03 -0.60 0.548 -3.11 1.65 0.78 1.29 Level of institution Primary Secondary 0.87 1.07 0.04 0.81 0.421 -1.25 2.98 0.79 1.27 Tertiary -0.14 1.00 -0.01 -0.14 0.891 -2.11 1.84 0.72 1.39 Training Experience Yes No -0.5 0.90 -0.02 -0.53 0.600 -2.23 1.29 0.93 1.08 Open in a new tab Sources of knowledge acquisition As shown in (Table 12 ), the primary source of knowledge acquisition regarding oral healthcare during pregnancy among obstetricians was consulting professional books and journals, followed by the internet (e.g., Douyin, short videos, and other platforms). Table 12. Sources of pregnancy oral health knowledge for obstetricians( n = 526) Variables N (%) Education Received During School 207 (39.35) Consulted professional books and journals 285 (54.18) The Internet (Douyin, short videos, etc.) 266 (50.57) Academic conferences, training courses, and seminars 182 (34.60) Consultation with supervisors/other obstetricians 201 (38.21) others 147 (27.95) Open in a new tab Correlation analysis among four dimensions Correlation analysis indicated significant positive correlations between knowledge and attitude (r = 0.668, P < 0.001), knowledge and practice (r = 0.116, P < 0.001), knowledge and barriers (r = 0.341, P < 0.001). Additionally, significant correlations were observed between attitude and practice (r = 0.197, P < 0.001),attitude and barriers (r = 0.431, P < 0.001), practice and barriers (r = 0.101, P < 0.001) (Table 13 ). Table 13. Spearman Correlations of KAPB Factors Domain Knowledge Attitudes Practice Barriers Knowledge 1.000 0.668** 0.116 0.341** Attitude 0.668** 1.000 0.197** 0.431** Practice 0.116 0.197** 1.000 0.101 Barriers 0.341** 0.431** 0.101 1.000 Open in a new tab ** indicates P < 0.01 (two-tailed) Discussion This study reveals a disconnect among knowledge, attitude, and practice (KAP) in the area of oral healthcare during pregnancy among obstetricians in Guangxi, China. Although most respondents held positive attitudes, substantial knowledge deficits and systemic barriers impeded the translation of attitudes into effective practice. This study reveals a significant fragmentation in knowledge regarding oral healthcare during pregnancy among obstetricians in Guangxi, China. While awareness was notably high concerning the increased risk of dental caries associated with changes in dietary habits, increased eating frequency, and vomiting during pregnancy, marked deficiencies were observed in several critical areas. These include limited recognition of the link between periodontal disease and adverse pregnancy outcomes, insufficient knowledge of critical clinical considerations (such as the safety of dental X-rays and Use of local anesthetics),which indicates increased confidence in dental procedural safety is crucial. And inadequate understanding of the vertical transmission mechanism of cariogenic bacteria which is a key risk factor of early childhood caries. This selective pattern of knowledge differs from data previously reported in previous contexts [ 25 – 28 ], indicating a systematic gap in pregnancy-related oral health content within China's medical education system. According to the U.S. Guidelines for Oral Health Care during Pregnancy [ 29 ], although routine screening X-rays are not recommended, essential diagnostic or therapeutic radiographs, when performed with abdominal shielding, carry minimal radiation risk and are not associated with fetal abnormalities or miscarriage. China’s standard textbook, Oral and Maxillofacial Medical Imaging Diagnostics [ 30 ], states that recommendations to avoid X-rays during pregnancy are based primarily on psychological considerations rather than actual radiation risk. This helps explain why many clinicians in China remain cautious regarding dental radiography for pregnant patients. Increased confidence in dental procedural safety is crucial. This "excessive caution" may lead to delays in necessary diagnostic examinations, thereby increasing the risk of progression of oral diseases during pregnancy. This finding suggests that knowledge updating should not only convey "what" but also clarify "why",in order to correct cognitive biases rooted in empirical knowledge. This study reveals a significant gap between attitudes and practice, with the lack of training being a primary contributing factor. Although 80.8% of obstetricians expressed strong willingness to learn and 80.4% acknowledged the importance of oral health during pregnancy, only 63.4% actually recommended pre pregnancy oral examinationsa finding consistent with international patterns reported in previous studies [ 31 , 32 ]. However, the nonlinear relationship among knowledge, attitude, and practice warrants in-depth exploration: In this study, knowledge and attitude exhibited a strong correlation (r=0.668), whereas attitude and practice showed only a weak correlation (r=0.116), and the direct association between knowledge and practice was even weaker (r=0.116). This finding challenges the core assumption of the traditional KAP model—that attitude serves as a key mediator in the translation of knowledge into behavior [ 33 ]. In highly specialized clinical settings where systemic barriers (e.g., absence of clinical guidelines, lack of interdisciplinary collaboration mechanisms) persistently exist, positive attitudes may fail to overcome institutional constraints, giving rise to the "high willingness-low action" paradox. This aligns with the revised perspective of the Theory of Planned Behavior: the translation of behavioral intention into actual practice is moderated by "perceived behavioral control." When physicians perceive substantial systemic obstacles, even favorable attitudes may result in suppressed practice intentions [ 34 ]. The study further uncovers context specific barriers in China: a severe lack of formal oral health training during undergraduate or postgraduate education (66.0% received no relevant training), with doctors relying predominantly on professional books and fragmented online information (e.g., short video platforms) for knowledge acquisition, while academic conferences and systematic training programs were underutilized.This finding stands in stark contrast with international experiences. In the United States, the establishment of standardized perinatal oral health protocols through multi-state collaborations—including clear referral pathways and insurance coverage policies—has enhanced the frequency of oral health consultations provided by obstetricians [ 35 ]. Similarly, the 2012 Pregnancy Care Guidelines published by the Australian Department of Health recommends that all antenatal care providers assess pregnant women's oral health, offer preventive advice, and consult with dental professionals [ 36 ]. In contrast, the absence of localized and operable clinical pathways in China contributes to inconsistencies in practice and raises concerns regarding medico-legal risks. The policy implication of this finding is that continuing education cannot rely solely on physician initiative but requires the establishment of institutionalized training systems. It is recommended that oral healthcare during pregnancy be integrated into the mandatory modules of standardized residency training and continuing medical education. Additionally, targeted training programs should be implemented for primary care institutions (including private hospitals and community health centers) to mitigate disparities in knowledge distribution. For the tertiary hospital obstetricians, the training emphasis should be on the management of complex cases, while for primary care physicians, the focus should be on basic screening procedures and referral pathways. A key finding of this study is the positive correlation between perceived barriers and knowledge level, the more knowledgeable the physicians, the stronger their perception of systemic barriers (e.g., lack of guidelines, insufficient interdisciplinary collaboration). This seeming paradox, which reflects a state of cognitive dissonance where high competence meets an unsupportive practice environment, reveals a deeper issue: improving individual knowledge without corresponding systemic support may not only fail to improve practice but could exacerbate professional frustration by heightening awareness of the constraints. In contrast to the United States, where the American College of Obstetricians and Gynecologists (ACOG) and the American Dental Association (ADA) jointly established comprehensive national guidelines as early as 2012 [ 37 ], China currently lacks a comparable regulatory framework. The U.S. guidelines mandate that all pregnant women receive comprehensive oral health services, encompassing assessment, counseling, referral, and coordinated care. Consequently, China faces a triple structural challenge in the provision of prenatal oral healthcare: (1) Guideline vacuum: the absence of localized, actionable clinical pathways leads to inconsistent practices and concerns over medico legal risks; (2) Collaboration gap: only 61.0% of obstetricians maintain communication with dentists, and referral mechanisms are underdeveloped; (3) Patient awareness deficit: 78.8% of obstetricians identified “low awareness among pregnant women” as the primary barrier, creating a vicious cycle of “physician caution patient neglect-limited service provision.” Drawing on relevant international experiences [ 38 ], it is recommended that the Chinese Stomatological Association and the Perinatal Medicine Association jointly develop Clinical Guidelines for Oral Healthcare During Pregnancy, clarifying key issues such as appropriate timing for treatment, medication safety, and indications for radiographic examinations. To develop a perinatal oral health risk assessment tool and integrate it into the antenatal care handbook. Additionally, a two way referral pathway between obstetrics and dentistry should be established, and oral health assessments should be incorporated into routine prenatal care [ 22 ].To establish referral alerts within the in-hospital electronic medical record (EMR) system; to develop a regional oral health referral network outside the hospital, connecting tertiary hospital dental departments with primary care obstetric units through an integrated healthcare delivery system, thereby fostering interdisciplinary collaboration. This study confirms the applicability of the KAP model in the domain of oral healthcare during pregnancy; however, it also reveals a notable deviation—the mediating role of attitude is limited (knowledge correlates only weakly with practice, r=0.116). This finding substantially diverges from the linear “knowledge → attitude → practice” pathway postulated by the conventional KAP model. According to the knowledge–action gap theory, the translation of knowledge into practice is not an automatic process but is instead modulated by multilevel contextual factors. The knowledge-to-action cycle model proposed by Graham et al. [ 39 ] explicitly identifies a systematic disconnect between knowledge creation and action application, emphasising that effective translation requires specific knowledge tools and facilitating factors. In the present study, although obstetricians possessed a reasonable knowledge base, they lacked both the opportunity structures (e.g:guideline support, referral pathways) and reflexive motivation necessary to translate knowledge into practice, thereby preventing attitude from exerting its expected mediating function. From the perspective of the Behaviour Change Wheel (BCW) model [ 40 ], behaviour change depends on the synergistic interplay of capability, opportunity, and motivation. Here, obstetricians may have exhibited psychological capability (knowledge) but were deficient in physical opportunity (e.g., collaborative mechanisms) and reflexive motivation (e.g., professional role identity), which in turn hindered the knowledge-to-behaviour translation. This interpretation is highly consistent with the Consolidated Framework for Implementation Research (CFIR) [ 41 ], which posits that implementation outcomes are shaped by multiple dimensions, including intervention characteristics, the outer setting, the inner setting, and other contextual factors. The systemic barriers identified in this study constitute a powerful contextual filter that significantly attenuates the likelihood of translating individual knowledge into practice. Furthermore, Social Cognitive Theory (SCT) [ 42 ] highlights the critical role of the interaction between self-efficacy and environmental reinforcement in facilitating behaviour change. In this study, obstetricians may have lacked prior training experiences, role modelling by senior physicians, and institutional incentives. Consequently, even when possessing relevant knowledge, they remained unlikely to engage in the desired practices. Attitude, as an individual cognitive factor, naturally has limited predictive power in the absence of systemic support. Therefore, this study proposes an Institutional Mediation Model as a context-sensitive revision of the KAP model. This model argues that in highly specialised clinical environments, the translation of knowledge into practice must be achieved through institutional mediating mechanisms—including evidence-based guidelines, continuing education and training, multidisciplinary collaboration mechanisms, and institutional incentives—rather than relying solely on changes in individual attitudes. This theoretical contribution extends the application boundaries of the KAP model in healthcare behaviour research, suggesting that in clinical contexts characterised by high systemic complexity, behaviour change theories should shift from an individual-centred approach to an ecological-systems perspective. Future research should adopt multilevel strategies that target both individual cognition and the healthcare system. Simple educational interventions are likely to have limited effects; bridging the knowledge–practice gap effectively will require combining guideline development, process optimisation, and incentive mechanism design. Strengths and limitations of the study Currently, research in China on obstetricians' knowledge, attitudes, and practices (KAP) toward oral healthcare during pregnancy, along with barriers to service delivery, remains limited. Existing studies are predominantly concentrated in economically developed regions. Conducted in the multi-ethnic border area of Guangxi, this investigation represents the first of its kind in this setting, thereby holding notable significance. Nevertheless, the study is subject to several limitations.First, although the self-developed questionnaire was validated through expert review and pilot testing, the absence of comprehensive psychometric evaluation means that measurement error cannot be entirely excluded. Second, convenience sampling limits external validity and may introduce selection bias and non-response bias. Furthermore, the distribution of the survey within specific healthcare institutions may induce clustering effects, violating the assumption of observational independence. Third, the cross-sectional design precludes causal inference, and self-reported data are susceptible to recall bias and social desirability bias. Fourth, stepwise regression, as a data-driven method, may overfit sample-specific fluctuations, and the lack of rigorous correction for multiple comparisons (e.g., Bonferroni) increases the risk of Type I errors. Finally, the geographic restriction to a single province (Guangxi) limits the generalisability of the findings. Therefore, future research should employ probability sampling, multi-centre designs, longitudinal or experimental methods, coupled with rigorous psychometric validation and statistical corrections, to validate the findings of this study. Conclusion This study identified several interrelated challenges among obstetricians in Guangxi regarding the provision of oral healthcare services during pregnancy. Compared with their international counterparts, the participating obstetricians exhibited potential deficiencies in relevant knowledge, attitudes, and clinical practices, alongside systemic barriers that may limit service delivery. Based on these correlational findings, the following hypothetical directions are proposed for future exploration: establishing a collaborative network involving government agencies, communities, healthcare institutions, healthcare providers, and pregnant women may be positively associated with improved service accessibility; developing authoritative clinical guidance documents may serve as a potential strategy to standardise practice behaviours; within-hospital multidisciplinary collaboration mechanisms and streamlined referral pathways may represent feasible directions for improving service provision; systematic professional training may be associated with narrowing the knowledge–skill gap among obstetricians; integrating oral healthcare into routine antenatal care warrants pilot studies to explore its feasibility; and enhancing pregnant women's oral health literacy may be a potential entry point for early prevention of oral diseases. However, the effectiveness of each of these proposed strategies requires rigorous validation through interventional studies, implementation science research, or prospective investigations. The cross-sectional design of this study precludes the establishment of causal relationships, and the findings are based on a region specific sample, warranting caution in generalisability. Future research should employ rigorous experimental designs to inform evidence based decision making. Supplementary Information Supplementary Material 1. (32KB, docx) Acknowledgements Acknowledgements The author thanks all the obstetricians who participated in this survey. Abbreviations KAPB Knowledge, Attitudes, Practices, and Barriers to Service BCW Behaviour Change Wheel CFIR Consolidated Framework for Implementation Research SCT Social Cognitive Theory ADA American Dental Association Authors' contributions W.W. and L.Y. were major contributors to the writing of the manuscript. J.Y., Q.P. conducted the study and defined the inclusion and exclusion criteria, L.R., X.T., R.H., Y.Y. and H.W. conducted the data collection. Y.Z., F.L, and J.W. analysed and interpreted the data .R.Q. planned the study. All the authors edited and reviewed the draft manuscript and read and approved the final manuscript. Funding This work was supported by Guangxi Medical and Health appropriate Technology Development and Promotion and Application Project (NO. S2020041 and S2024121). Self-funded research project of the Health Commission of Guangxi (NO. Z-L20251674). Data availability Data is provided within the manuscript or supplementary information files. Declarations Ethics approval and consent to participate All procedures performed in this research were in accordance with the ethical standards of the Scientific and Ethics Commissions of the College of Guangxi Medical University (NO.2024082) . Informed consent was obtained from all individual participants included in the study. The analysis of the collected human data in this study adheres to the Helsinki Declaration. Consent for publication Not applicable to this article. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Wenyong Wang and Leiming Yi contributed equally to this work. References 1. Machado V, Ferreira M, Lopes L, et al. Adverse pregnancy outcomes and maternal periodontal disease: an overview on meta-analytic and methodological quality. J Clin Med. 2023;12(11):3635. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Wu Sansan M, Shuai S, Zhongzhou. t al. Analysis of oral health care behavior and associated factors among women in the 1st trimester. Chin J Health Manage. 2019;13(6):504–509. [ Google Scholar ] 3. Zhu Yan-yan, Liu Lin, Bao Guang-jie. 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