Maternal Factors Influencing Infant Oral Health Knowledge and Beliefs among Pregnant Women in Saudi Arabia: A Cross-Sectional Study

Abstract

Objective

This study aimed to assess the knowledge and beliefs regarding infant oral health care among Saudi pregnant women and identify influencing factors.

Materials and Methods

A cross-sectional study was conducted on 235 pregnant Saudi women attending prenatal clinics in AlAhsa, Eastern region of Saudi Arabia from November 2023 to March 2024. Data were collected using a validated, self-administered questionnaire assessing demographic information, infant oral health knowledge (IOK), and infant oral health beliefs (IOB). Data were analyzed using chi-squared tests and multiple linear regression.

Results

The mean age of participants was 29.27 ± 3.45 years, with 56.5% being multiparous. Most respondents (64.1%) had completed college or university education. Only 36.3% reported regular dental visits during pregnancy. Multiparous women demonstrated significantly higher IOK scores compared with primiparous women (p = 0.013), while IOB scores were comparable (p = 0.087). Regression analysis revealed that birth history and education significantly predicted IOK scores (R ² = 0.561; p < 0.001), while education, maternal age, and dental visits during pregnancy significantly predicted IOB scores (R ² = 0.266; p < 0.001).

Conclusion

This study highlights the significant influence of birth history, education, maternal age, and dental visits during pregnancy on maternal knowledge and beliefs regarding infant oral health. These findings underscore the need for targeted, culturally sensitive educational interventions and increased health care provider engagement to promote oral health awareness and behaviors among pregnant women in Saudi Arabia.

Keywords

infant oral health - pregnant women - knowledge - beliefs - birth history - parity

Introduction

Oral health during pregnancy is a critical component of overall maternal and infant well-being. However, many pregnant women may not be fully aware of the impact that oral health can have on their infants' oral development.[1] There is increasing evidence that poor maternal oral health, including issues such as untreated dental caries and periodontal diseases, may not only affect the health of the mother but can also have lasting consequences on the oral health of the expected child.[2] Poor maternal oral health awareness significantly impacts children's oral health and can lead to issues such as the transmission of harmful oral bacteria, failure to establish proper infant oral hygiene, and an increased risk of early childhood caries (ECC). Despite this, knowledge, attitudes, and beliefs surrounding oral health care during pregnancy remain underexplored in many populations. Pregnant women's perceptions and practices regarding oral hygiene, dietary habits, and dental visits play a significant role in shaping their own oral health outcomes as well as those of their infants.[3] [4] However, these beliefs and practices might be influenced by various psychosocial factors, including factors related to health behaviors, potentially increasing the risk of ECC and other oral health issues.[5]

Evidence in the literature suggests that many pregnant women lack awareness regarding the importance of early oral hygiene practices for their infants or children, and the potential impact of maternal oral health on their infants' future oral health outcomes. Additionally, myths and misconceptions, such as the belief that dental treatments are unsafe during pregnancy, can contribute to reduced dental visits and/or suboptimal oral health practices.[6] [7] [8] [9] While diverse cultural norms and health practices exist in Saudi Arabia, there is limited research on how pregnant women in the population view and understand the importance of maintaining good oral health. In particular, knowledge and beliefs of pregnant women about infant oral health are often not well understood. By identifying gaps in knowledge and understanding beliefs specific to Saudi culture, the study sought to inform targeted interventions that could enhance both maternal and infant oral health in this population. This study aims to explore knowledge and beliefs regarding infant oral health care among a cohort of Saudi pregnant women.

Materials and Methods

This study was part of a cross-sectional study that investigated the unmet oral health needs and patterns of dental care utilization by pregnant women in eastern Saudi Arabia. This observational study included a cohort of pregnant women who visited the outpatient department of the prenatal clinics in AlAhsa, Eastern region of Saudi Arabia. Saudi women belonging to different socioeconomic status usually attend the clinics to avail the maternity services provided by the government through these health centers. This approach ensured that the study was conducted without bias, across different socioeconomic and educational groups. The study protocol was reviewed and approved by the institutional review board, Deanship of Scientific Affairs, King Faisal University, and the study was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

The study encompassed a total of 235 participants selected based on convenience sampling during a period from November 2023 to March 2024. The inclusion criteria were women of Saudi nationality aged at least 18 years, in any of the trimesters of pregnancy, attending the maternity clinics at the time of data collection, and those willing to participate. Women with a history of any systemic disease and those who do not wish to participate were excluded from the study. The data collection tool included a validated and tested questionnaire adopted from previous study in the literature.[10] [11] The questionnaire was slightly modified and translated into Arabic language, the local dialect, by an Arabic- and English-speaking health care specialist, reviewed and evaluated using the standard forward and back translation procedures. The questionnaire was face validated and pilot tested on a sample of 20 parents, and no additional modifications were needed. A QR code was created to make it easier for the participants to digitally fill out the questionnaire themselves, without any time constraints. Participation was voluntary and anonymous, and the submission of the completed questionnaire implied the participant's informed consent.

The self-administered questionnaire consisted of questions designed to evaluate participants' knowledge and beliefs regarding infant oral health, in addition to demographic details. Demographic data included maternal age, educational level, birth history (number of pregnancies), and dental visits during pregnancy. Monthly income of the participants was not considered as the health care system in Saudi Arabia is publicly funded by the government and hence provides it free of cost to all the citizens, irrespective of their socioeconomic status. Four questions, identified as indicators of infant oral health knowledge (IOK), were assessed with three possible responses: “true,” “false,” or “don't know.” Knowledge questions included the following: Gum problems, such as bleeding when brushing teeth, can influence the course of pregnancy and/or the health of the baby at birth (Q1). It is important to wipe a baby's gums after they drink from the breast or bottle (Q2). It is OK to let a baby sleep with a bottle of milk (Q3). Cleaning baby teeth is not important because they fall out anyway (Q4). Five additional questions, designated as indicators of infant oral health beliefs (IOB), were assessed using a using a 5-point scale (“strongly agree,” “agree,” “don't know,” “disagree,” and “strongly disagree”). Belief questions included the following: It is important to brush your child's teeth as soon as the teeth come in (Q5). Cavities in a child's teeth can lead to other health problems (Q6). Keeping my child's teeth healthy is important to me (Q7). A cavity in a baby tooth does not need to be filled unless it hurts (Q8). It is important to take a child to the dentist when the first tooth comes in (Q9). Correct responses to knowledge questions were counted and beliefs that promoted positive oral health behavior were considered, based on the context of the question and the strength of the response. Questions answered with “don't know” were considered incorrect.

Percentages were then calculated for women who answered individual knowledge questions correctly and held beliefs that favored positive oral health behaviors. A “knowledge score” was developed by assigning 1 point for each correctly answered knowledge question, with the lowest possible score being “0” and the highest possible score being “4.” Similarly, a belief score was calculated by assigning 1 point for each question answered in favor of a positive health belief. The average or mean score of these items was calculated to derive each participant's IOK and IOB scores.

The independent variables were birth history (primiparous vs. multiparous groups), maternal age, and dental visits during pregnancy, while maternal education level was the ordinal variable. The multiparous group included respondents having had at least one live birth or having a child in the household between the ages of 2 and 5 years. The primiparous group included respondents who reported of not having had any previous live births and not having any children in the household between the ages of 2 and 5 years. The primary outcome variables were the pregnant women's knowledge and beliefs about infant oral health.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL, United States). Frequencies and percentages were calculated, and the chi-squared test was used to determine significant differences between the expected frequencies and the observed frequencies in one or more categories. Independent sample t-test was used to compare the mean scores. Multiple linear regression analysis was performed to assess the influence of multiple variables as predictors (birth history, education, maternal age, and dental visits) of IOK or belief scores in pregnant women. A p-value of less than 0.05 was considered statistically significant.

Results

The final sample included a total of 223 pregnant women who had responded to the questionnaire. Twelve respondents were excluded from the final sample due to missing or incomplete data. All the pregnant women who responded were in the age range of 21 to 38 years, with an overall mean age of 29.27 ± 3.45 years (mean ± standard deviation [SD]). The mean age of the primiparous group was 27.62 ± 2.68 years, while in the multiparous group it was 30.54 ± 3.44 years. More than half of them (n = 126; 56.5%) had at least one child at home aged 2 to 5 years (multiparous), while 43.5% (n = 97) of them were pregnant for the first time (primiparous). The majority of the respondents reported completing college or university level education (64.1%; n = 143), while 35.9% (n = 80) of the participants completed at least high school education. Only 36.3% (n = 81) of the respondents reported visiting a dentist regularly or at least once during the pregnancy period ([Table 1]). The responses to the questionnaire and the results have been discussed elsewhere (unpublished data; [Supplementary Tables S1] and [S2], available in the online version).

Table 1 Descriptive data of the study variables according to birth history

Variables		Primiparous, n (%)	Multiparous, n (%)	Total, n (%)	p-value[a]
Maternal age	< 29 y	68 (30.5)	79 (35.4)	147 (65.9)	0.247
	≥30 y	29 (13.0)	47 (21.1)	76 (34.1)
Education	≤High school	36 (16.1)	44 (19.7)	80 (35.9)	0.735
	≥College/university	61 (27.3)	82 (36.8)	143 (64.1)
Dental visits during pregnancy	Yes	29 (13.0)	52 (23.3)	81 (36.3)	0.080
	No	68 (30.5)	74 (33.2)	142 (63.7)

^a Chi-squared test.

The mean IOK score for all respondents was 0.483, with multiparous women having a higher mean IOK than primiparous women (p = 0.013), while no significant difference was noted between them in the mean IOB values (p = 0.087; [Table 2]). Multiparous women possessed more knowledge of infant oral health compared with primiparous women, while the maternal IOB scores were comparable between both multiparous and primiparous women.

Table 2 Comparison of mean scores of outcome variables according to birth history

Outcome variable	Primiparous (n = 97) Mean ± SD	Multiparous (n = 126) Mean ± SD	Total (n = 223) Mean ± SD	p-value[a]
Mean IOK score	0.430 ± 0.230	0.523 ± 0.307	0.483 ± 0.279	0.013
Mean IOB score	3.645 ± 0.230	3.705 ± 0.274	3.678 ± 0.257	0.087

Abbreviations: IOB, infant oral health beliefs; IOK, infant oral health knowledge.

^a Independent sample t-test.

Regression analysis was performed to test if the maternal IOK and IOB scores can be predicted by the independent variables of birth history, education, maternal age, and dental visits during pregnancy ([Table 3]). The unstandardized coefficients (B) represent the actual change in the dependent variable for each 1-unit change in the predictor variable. The standardized coefficients (beta) show the strength and direction of the relationship between the predictor and the dependent variable, expressed in standard deviation units, allowing for easier comparison of the relative importance of predictors. The results showed that the variables birth history and education significantly predicted IOK (F(2, 220) = 140.347, p = 0.000), which indicates that those two factors had a significant impact on IOK scores. Moreover, the model explains 56.1% of the variance in IOK (R ² = 0.561) can be accounted for by the two predictors, collectively. The regression model revealed that education (p = 0.000; t = 16.338, B = 0.425) and birth history (p = 0.001; t = 3.341; B = 0.084) had a significant positive impact on maternal IOK scores. Maternal age (p = 0.185) and dental visits during pregnancy (p = 0.06) had no significant association with the IOK score. With regard to IOB, the variables education, maternal age, and dental visits during pregnancy significantly predicted the IOB (F(3, 219) = 26.431, p = 0.000). The model explains that the three predictors account for 26.6% of the variance in maternal IOB (R ² = 0.266). Women who visited the dentists or utilized dental services during pregnancy had higher IOB scores (p = 0.000). Maternal age (p = 0.000) and education (p = 0.002) tend to have a positive influence on IOB scores. Birth history had no significant influence on the maternal IOB scores (p = 0.246).

Table 3 Regression analysis of maternal infant oral health knowledge (IOK) and beliefs (IOB)

Parameter		Unstandardized coefficients		Standardized coefficients	t-value	Significance
		B	Standard error	Beta
IOK	Education	0.425	0.026	0.730	16.338	0.000
	Birth history	0.084	0.025	0.149	3.341	0.001
	Maternal age	–	–	0.060	1.330	0.185
	Dental visit	–	–	0.087	1.913	0.06
IOB	Education	–0.099	0.031	–0.186	–3.157	0.002
	Maternal age	0.170	0.034	0.311	4.99	0.000
	Dental visit	0.162	0.034	0.304	4.812	0.000
	Birth history	–	–	0.068	1.163	0.246

Discussion

This study aimed to examine maternal knowledge and beliefs about infant oral health among a cohort of Saudi pregnant women. The findings offer valuable insights into how factors such as birth history (parity), education, maternal age, and dental visits during pregnancy influence maternal knowledge and beliefs regarding infant oral health.

The present study found that multiparous women had significantly higher knowledge about infant oral health than the primiparous women (p = 0.013), indicating that prior experience with childbirth may contribute to a better understanding of infant oral health. This finding aligns with previous studies,[11] [12] [13] which reported that multiparous women generally possess more knowledge about infant oral health, which could likely be due to previous exposure to health care services, prenatal education, and childcare practices. Furthermore, regression analysis, in this study, confirmed that birth history significantly predicted maternal IOK, further supporting the concept that prior exposure to health care systems and practices positively influences IOK scores. In contrast, Thomas et al[14] found that primiparous women demonstrated significantly higher IOK scores, while other studies reported no significant effect of birth history or parity on IOK levels in pregnant women.[9] [15] Previous research in Saudi Arabia[16] has shown that primiparous women are more likely to seek advice and information on infant oral health care compared with their multiparous counterparts. This highlights the need for targeted educational efforts for primiparous women, as well as the continuous reinforcement of knowledge for multiparous women.[17] Additionally, health care professionals, including dentists, midwives, and antenatal caregivers, should provide more evidence-based information on infant oral health care to both groups of women.[18]

Maternal education emerged as a significant predictor for both infant oral knowledge and IOB in this study. Specifically, women with a college or university education had higher IOK scores compared with those with only a high school education. The positive impact of education on both IOK and IOB aligned with previous findings, which suggested that women with higher education are more likely to possess better knowledge and hold more positive beliefs about infant oral health.[15] [19] [20] [21] Women with higher education are also more inclined to engage with health care services, understand the importance of preventive health measures including infant oral care, and adopt health-promoting behaviors, such as regular dental visits.[12] [13] [22] Cagetti et al[11] reported that the increased awareness of infant oral health in multiparous women was more attributable to their previous experiences than to their education level.

Studies have reported that women often tend to avoid or reduce dental visits during pregnancy due to various factors such as fear, anxiety, and concerns about the safety of both their own health and that of their unborn child.[7] [20] [23] Another recent study conducted among Lithuanian pregnant women revealed that more than half of the pregnant women did not visit an oral care specialist during pregnancy.[4] The present study found a positive association between dental visits during pregnancy and IOB. Women who visited the dentist during pregnancy had higher IOB scores (p = 0.000), indicating that engaging with dental professionals or accessing dental care during pregnancy provides valuable opportunities to enhance maternal beliefs about infant oral health. This finding is consistent with existing literature, which highlights the link between dental visits during pregnancy and increased awareness of oral health practices, as well as positive health beliefs regarding their child's oral health.[9] [24]

Maternal age was also identified as a positive predictor of IOB, with older pregnant women demonstrating more favorable beliefs about infant oral health. This may reflect a greater level of maturity and experience in managing both their own and their children's health. These findings align with studies showing that older pregnant women tend to have more positive beliefs on oral health practices.[10] This could be attributed to their greater life experience and increased exposure to health-related information over time.[14] [15] [19] The lack of a significant influence of maternal age on IOK scores is noteworthy. While maternal age has been shown to impact other aspects of health behavior or beliefs, its lack of association with IOK in this study may be attributed to the narrow age range of participants. This limited variation in maternal age may not have been sufficient to detect significant differences in IOK.

Additionally, the study found no significant impact of dental visits during pregnancy on maternal IOK. Although dental visits are generally considered valuable for providing in-formation and reinforcing healthy practices, this study found that they may not significantly influence maternal IOK. It is possible that factors such as the quality and content of the information provided during these visits, or the frequency of such visits, may not be sufficient to impact maternal knowledge significantly. On the other hand, dental visits during pregnancy had a positive effect on maternal beliefs (IOB). This suggests that while dental visits may not directly increase factual knowledge about infant oral health, they likely provide opportunities for women to engage with health care providers and discuss the importance of infant oral care, thereby reinforcing positive health beliefs and behavior.[9] [24]

Interestingly, birth history did not significantly impact maternal IOB scores (p = 0.246), suggesting that maternal beliefs about infant oral health may be more influenced by active health care experiences, such as dental visits, rather than passive learning from previous pregnancies. This implies that while multiparous women may possess more knowledge about oral health, this does not necessarily translate into stronger beliefs about the importance of infant oral health.

Cultural norms and socioeconomic factors play a significant role in shaping maternal knowledge and beliefs about infant oral health. However, this study did not consider socioeconomic status, as Saudi Arabia's publicly funded health care system provides free maternal and child health services to Saudi citizens, regardless of their economic status. In Saudi Arabia, as in many other Arab countries, there is a strong focus on general maternal health during pregnancy, but oral health may not be emphasized as prominently, which can lead to gaps in knowledge, particularly among primiparous women and those with lower educational levels.[19] [23] Contributing factors such as underutilization of health care services, insufficient guidance from health care providers, and cultural beliefs may further exacerbate disparities in maternal knowledge and beliefs regarding infant oral health. Although most women had at least a high school education, a significant proportion had limited exposure to oral health education, particularly concerning infant oral health. Al Khamis et al[25] had suggested that addressing cultural beliefs and practices surrounding oral health is essential to improving and maintaining positive oral health behaviors during pregnancy.

The findings from this study can guide public health decision-making, aiding the development of more effective dental health education programs for pregnant women. Targeted health campaigns could collaborate with prenatal clinics, midwives, and dentists to offer personalized oral health education during routine checkups promoting the importance of prenatal dental visits and infant oral hygiene practices could help address existing gaps. Such campaigns should be tailored to the educational background and cultural context of the target population to maximize their effectiveness. These initiatives could integrate dental care into existing prenatal or maternal health care programs, ensuring pregnant women receive comprehensive information on oral health for both themselves and their infants. Furthermore, emphasizing the role of health care professionals in encouraging regular dental visits and providing practical guidance on infant oral health during prenatal care could significantly enhance maternal awareness and health behaviors.[24]

Limitations of the Study

While this study offers valuable insights, the findings should be interpreted in the light of the few limitations. The cross-sectional nature of the study limits the ability to infer causality between dental visits, maternal age, and other factors with IOK and IOB. Second, the use of self-reported data may introduce recall bias, particularly regarding dental visits and health knowledge. While cultural factors were acknowledged, they were not comprehensively explored. The role of cultural beliefs and practices in shaping maternal knowledge and attitudes toward infant oral health could be further investigated. The publicly funded health care system in Saudi Arabia may limit the impact of socioeconomic status, but it could still play a role in shaping health behaviors and hence needs further exploration. Future longitudinal studies could provide a clearer understanding of how maternal knowledge and beliefs evolve throughout pregnancy and after childbirth, as well as the long-term impact of prenatal education on child oral health outcomes.

Conclusion

This study highlights the significant influence of maternal education, age, birth history, and dental visits during pregnancy on maternal knowledge and beliefs about infant oral health. While prior childbirth experience (multiparity) and maternal education were key predictors of knowledge, dental visits during pregnancy were more influential in shaping maternal beliefs about infant oral care. Notably, first-time mothers (primiparous women) exhibit lower levels of awareness and are at a greater risk of lacking essential oral health knowledge. The findings emphasize the need for targeted educational interventions, particularly for primiparous women, to improve their understanding of infant oral care. Integrating comprehensive dental care discussions into routine prenatal care is essential, ensuring that all pregnant women, both primiparous and multiparous, receive personalized, culturally sensitive information. Health care providers should be trained to actively promote oral health during prenatal visits, reinforcing the importance of both maternal and infant oral health. Future research should explore the quality and content of prenatal dental care to further enhance maternal and infant oral health outcomes.

Conflict of Interest

None declared.

Ethical Approval

This study was reviewed and approved by the Institutional Review Board, Deanship of Scientific Research, King Faisal University, Alahsa, Saudi Arabia (Ref: KFU-REC-2023-OCT-ETHICS1566). Written informed consent was obtained from all the subjects involved in the study.

Authors' Contributions

The concept and design of the study were developed by M.G.S. and A.E.A. Data acquisition was done by A.E.A. Data analysis and interpretation were done by M.G.S. and A.E.A. Drafting of the article was done by M.G.S. Revising article for important intellectual content was done by S.A. and Y.M.A. All the authors have critically reviewed and approved the final version of the manuscript and are responsible for the similarity index of the manuscript.

Data Availability Statement

Data are available upon reasonable request from the corresponding author.

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Publication History

Article published online:
25 April 2025