Factors associated with oral health behaviours during pregnancy in high-income countries: a systematic literature review

Oral health is a critical component of overall health and well-being, with particular importance during pregnancy due to the bidirectional relationship between oral health and pregnancy outcomes. Despite this increased vulnerability, studies consistently report low uptake of preventive dental services, and limited adherence to recommended self-care practices among pregnant women. As a group, pregnant women are influenced by distinguishable behavioural, social and system-level factors. The World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) conceptual framework provides a useful lens to understand these influences. However, its application to maternal oral health remains limited, and no synthesis has examined how determinants of oral hygiene behaviours align with structural and intermediary factors. This review aimed to address this gap. A systematic literature review was conducted and reported in accordance with PRISMA guidelines. MEDLINE, Embase, Scopus, PsycINFO, and the Dental & Oral Sciences Database (DOSS) were searched on 10 March 2025 for studies published from January 2015 to March 2025. The review included studies conducted in a defined set of countries with broadly comparable social and healthcare contexts. Eligible studies examined oral health behaviours during the current pregnancy, including self-care practices such as toothbrushing, interdental cleaning, and mouthwash use and/or dental service utilisation. Data were narratively synthesised, with the identified determinants mapped to the WHO CSDH conceptual framework. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). The database searches identified 11,458 studies, of which 22 were included in the final review. These studies identified structural determinants including healthcare coverage, income and employment, education, and ethnicity. Intermediary determinants encompassed biological factors (pregnancy-related changes, age, systemic and dental conditions), circumstances (cost and transport), psychological and behavioural factors (attitudes, fear, past behaviour, time and energy constraints, marital status), and health system factors (oral health promotion, service availability, and provider readiness). Most studies focused on dental visits as the primary outcome, with limited examination of home-based oral hygiene behaviours such as toothbrushing, flossing, and mouthwash use. Oral health behaviours during pregnancy are shaped by a complex interplay of psychological, social, and health system factors. Behaviours are influenced not only by individual beliefs and experiences, but also by competing demands and the accessibility, affordability, and responsiveness of health services. Improving maternal oral health, therefore, requires a combined approach that integrates behaviour change strategies with health care systems that enable better access to safe, affordable, flexible and coordinated care during pregnancy.